The Gaza shootings: a massive orthopaedic crisis and mass disability

I am the Head of Plastic and Reconstructive Surgery in Gaza and I am writing in follow-up of the rapid response “The Maiming Fields of Gaza” of 4 May. (1) As of 18 May, the death and injury toll, rising every day, is 117 dead, including 13 children, and no less than 12,271 injured. 6,760 have been hospitalised, including 3,598 with bullet wounds. 19 clearly identified medics have been shot to date. (2)

The humanitarian agency Medecins Sans Frontieres (MSF) has been operating in Gaza and says that people have been shot with bullets that have caused fist-sized wounds of “unusual severity”. Marie-Elisabeth Ingres, head of MSF Palestine says in their report that “half of the more than 500 patients we have admitted in our clinics have injuries where the bullet has literally destroyed tissue after having pulverised bone”. (3) This is what we are facing. I have seen a great deal of physical trauma in Gaza following Israeli attacks but have not seen these kind of injuries before. From the appearance of the wounds there appears to have been systematic use by Israeli Defence Force snipers of ammunition with an expanding ‘butterfly’ effect.

There are currently between 300 and 350 high energy compound tibial fractures in Gaza as a result of live fire. These are the most difficult of all open fractures to treat. Complex lower limb injuries of this severity may require between 5 and 7 surgical procedures, with each operation taking 3-6 hours. Even with state-of-the-art reconstruction, healing takes 1-2 years. Most of these patients will develop osteomyelitis. A steadily increasing toll of secondary amputations is inevitable. They will also need intensive rehabilitation, but the only rehabilitation hospital in Gaza was destroyed by Israeli bombing in 2014 and has not been re-built. Mass lifelong disability is now the prospect facing Gazan citizens, largely young, who were merely gathering in unarmed protest about Israeli occupation and siege that has rendered their political and social futures impossible.

To reconstruct such injuries is entirely beyond the capabilities of Gazan medical services already depleted by the 12 year Israeli siege described in the earlier rapid response. Shifa hospital is anyway swamped and there are no beds. Moreover the level of expertise required for such reconstructive surgery is beyond that generalist orthopaedic surgeons, requiring dedicated Limb Salvage Teams. I am sure that if over 6000 injured patients, more than half with bullet wounds, required admission to hospitals in London over a short period of time, your services would be stretched even though you are fully resourced. I am told that no single limb reconstruction service in the UK has ever been confronted with such mass leg casualties. How are we here in Gaza to manage this situation?
I understand there is now the question of an investigation by the International Criminal Court.
We in Gaza cannot but ask why has no European government spoken out about events which if they had happened elsewhere would surely have been called an international outrage and probable war crime?

1. https://www.bmj.com/content/349/bmj.g6644/rr
2. https://www.democracynow.org/2018/5/17/meet_tarek_loubani_the_canadian_doctor
3. http://www.msf.org/en/article/palestine-msf-teams-gaza-observe-unusually-severe-and-devastating-gunshot-injuries

Email: nafiz2000@hotmail.com

06 June 2018

Nafiz Abu-Shaban
Plastic and reconstructive surgeon
Shifa Hospital, Gaza