Born in Gaza to a family of refugees who fled their village of Hamama in 1948, I carry a refugee status that has shaped my understanding of both loss and resilience in the face of ongoing conflict.
Practicing Medicine Under Siege
I studied, practiced, and taught medicine in Gaza’s hospitals, working in facilities like Al-Shifa, Nasser, Al-Aqsa, and the European Gaza hospitals. These experiences taught me the art of practicing medicine with minimal resources—often lacking basics like IV fluids and skin staplers. Even gauze, ironically first made in Gaza, was frequently in short supply.
Despite these challenges, my mentors—dedicated and passionate professors of medicine and surgery—communicated to me not just clinical knowledge but also wisdom and the importance of being tenacious and exhibiting an unwavering commitment to patient care.
The constraints of practicing medicine in Gaza have always demanded innovative solutions. When I left in 2017 to pursue surgery abroad, I knew the best way to care for my people was to gain expertise that could bridge the growing gaps in medical care.
During my postgraduate studies at Oxford in 2018, I co-founded OxPal 2.0, an online, tele-educational platform supporting medical schools in the occupied Palestinian territory with high-quality teaching in clinical subjects and research.
The military operation in Gaza that began in October 2023 resulted in the destruction of healthcare infrastructure and loss of life. It drove us, out of necessity, to create our most innovative initiative yet. As hospitals came under attack and healthcare workers were killed or detained, the situation became increasingly dire.
According to the United Nations Office for the Coordination of Humanitarian Affairs, more than 1,700 healthcare workers have been killed in Gaza since October 2023. Healthcare Workers Watch reported in its October 2024 report the names of at least 13 surgeons or surgical trainees and 37 medical students who were killed. Among them were people I knew personally, dedicated professionals like Professor Omar Ferwana, the former dean of my medical school, and Dr. Medhat Saidam, a plastic and burn surgeon, who had inspired my own career path.
We also lost promising young colleagues like Dr. Israa Al-Ashqar, an anesthesia resident, and Dr. Ibtihal Al-Astal, an outstanding intern. The loss of these healthcare workers created a double tragedy: the immediate crisis of fewer hands to heal and the long-term void of missing the very educators needed to train future physicians and surgeons. Selfless medical students stepped up to fill the positions of their clinical mentors and faculty who were missing or killed.
Innovation Amid Devastation
Along with the recently graduated Dr. Khaled Alser, the sole remaining general surgeon at Nasser Hospital in southern Gaza, we recognized the urgent need for a new approach to trauma care. In this moment of crisis, we turned to technology to bridge the devastating gap in surgical expertise, creating an innovative virtual network that would connect isolated doctors with global surgical expertise. In essence, we created the territory’s first comprehensive telemedicine initiative for trauma care.
The heart of our innovation was surprisingly simple yet transformative: A WhatsApp group chat grew to more than 1,000 healthcare workers worldwide, including surgeons from various specialties, intensivists, and emergency providers.
Setting up this network presented unique challenges. We had to establish protocols for patient privacy, develop systems for rapid response times, and create guidelines for sharing critical information despite unreliable internet connections. The platform evolved to include standardized templates for case presentations, ensuring that local doctors could quickly communicate essential details even in crisis situations.
This digital lifeline became especially useful for recent graduates suddenly thrust into managing complex trauma cases. Many of these young doctors, though well-trained in basic medicine, had never handled the types of injuries they were facing daily.
Through our network, they could receive real-time guidance from surgeons who had worked in similar conflict zones around the world. These experienced practitioners didn’t just offer medical advice, they also shared practical solutions for working around resource limitations and improvising with available materials.
The success of this approach was demonstrated through numerous cases, but one particularly stands out as an example of the innovation it fostered.
A 35-year-old OR nurse at Nasser Hospital sustained a gunshot wound to the chest while on duty. The patient needed a chest tube for a hemopneumothorax, but the hospital lacked wall suction, leading to dangerous desaturation episodes.
Through our telemedicine network, a trauma surgeon from South Africa and an ER physician from Canada suggested a creative solution: creating an improvised one-way flutter valve using surgical gloves. This simple yet ingenious adaptation worked remarkably well, stabilizing the patient’s respiratory status.
The impact of our telemedicine initiative extended far beyond individual cases. Our study, presented at ACS Clinical Congress 2024 and published in the August 2024 issue of The Lancet, analyzed 12 representative cases from Nasser Hospital.
The patients ranged from 3 to 70 years old, with more than 90% presenting with penetrating injuries. In each case, the global surgical community provided crucial guidance that influenced treatment decisions and improved patient care.
These cases revealed patterns of innovation that would prove valuable for future crisis response. For instance, when traditional wound closure materials were unavailable, surgeons shared techniques for using alternative materials safely. When standard monitoring equipment failed due to power outages, the network suggested manual assessment techniques that could provide reliable patient monitoring. Each challenge became an opportunity for collaborative problem-solving, with solutions documented and shared across the WhatsApp group for future reference.
Beyond immediate patient care, the initiative became a platform for sharing knowledge about resource-conscious medicine. Experienced surgeons taught techniques for conserving scarce supplies, methods for sterilizing and reusing certain materials safely, and approaches to triage that could maximize limited resources.
This knowledge exchange went both ways, as local doctors shared their innovations for practicing medicine under extreme constraints, contributing valuable insights to the global surgical community.
Our experience has shown that creative solutions often can be found in settings with limited resources. We’ve learned to adapt standard protocols, develop improvised medical devices, and create simplified decision-making algorithms for complex trauma cases. Perhaps most importantly, we’ve demonstrated that meaningful surgical education and support can continue even in the most challenging circumstances through remote mentorship.
Building a Future Through Collaboration
Looking ahead, we see immense potential in expanding this model. We’re working to develop standardized protocols for remote surgical consultation and create a comprehensive database of improvised medical solutions for resource-limited settings.
This database will include detailed instructions for creating emergency medical devices from locally available materials, protocols for adapting standard procedures to austere conditions, and guidelines for maintaining surgical standards despite severe resource constraints.
We’re also developing a formal curriculum for “crisis innovation” in medicine and surgery, drawing on the lessons learned through our telemedicine network. This program will teach healthcare workers not just medical procedures, but also creative problem-solving skills essential for working in resource-limited environments. Topics will include improvising medical devices, adapting standard protocols for crisis situations, and maintaining effective communication networks during emergencies.
Most urgently, we’re working to establish a comprehensive remote medical education platform—from undergraduate fundamentals through graduate surgical training—that can function while Gaza’s physical infrastructure is rebuilt. We cannot afford to wait.
Patients will still need emergency cesarean sections and acute appendectomies tomorrow, regardless of the state of these buildings. Their survival depends on our ability to train the next generation of healthcare providers now, with a particular focus on trauma care.
Furthermore, we’re establishing partnerships with medical institutions worldwide to create a more permanent infrastructure for remote surgical support. This approach includes developing secure digital platforms for medical consultation, creating standardized templates for case presentation and discussion, and building a network of volunteer specialists willing to provide remote consultation in crisis situations.
The success of our telemedicine initiative highlights a crucial truth—that even in the most difficult circumstances, innovation and collaboration can save lives. As surgeons and healthcare providers, we have a fundamental duty to uphold the mission of the ACS, which is to improve the care of surgical patients and safeguard standards of care.
In Gaza and beyond, we’re proving that the spirit of surgical innovation can flourish even in the most challenging circumstances, powered by global collaboration and the unwavering dedication of healthcare workers worldwide.
Acknowledgment
The author thanks Tanya Zakrison, MD, MPH, FACS, and Sami Kishawi, MD, for their help with this article.
Disclaimer
The thoughts and opinions expressed in this column are solely those of the author and do not necessarily reflect those of the ACS.
Dr. Osaid Alser is chief general surgery resident and global surgery researcher at Texas Tech University Health Sciences Center in Lubbock. He also is the Resident Liaison for the ACS Board of Governors Surgical Training Workgroup and ACS Advisory Council for Plastic and Maxillofacial Surgery.
