Syrian American Surgeon Describes Amputations, 'Doctor-of-War Mentality' After Mission in Gaza
May 07 2024
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On the eve of the sixth month of Israel’s genocidal campaign in Gaza, Israeli Occupation Forces (IOF) ended their two-week siege of Al-Shifa Hospital. The once-beating heart of Gaza’s medical infrastructure was burned to a crisp. Hundreds of Palestinians were massacred in the hospital complex that once housed over 30,000 displaced people and treated thousands of patients. Israel’s systematic targeting and dismantlement of Gaza’s infrastructure has created a medical apocalypse, compounding upon famine. All but 10 of Gaza’s 36 hospitals remain “partially functioning.”  

In January of 2024, Dr. Bara Zuhaili entered Gaza on a two-week medical mission with a U.S.-based organization, Rahma Worldwide. Dr. Zuhaili dedicated most of his time to Shuhada’ Al-Aqsa Hospital in Deir Al-Balah, central Gaza. While this was not his first experience in a wartime or crisis setting — he had undertaken medical missions in Syria and was in southern Turkey during the earthquake — it proved to be his most horrific. As a vascular surgeon, he was tasked with assisting Gazan doctors in one of the ugliest tasks of this war: amputations. 

A generation of amputees has emerged, with over 10 children losing one or more limbs per day, on average, since the beginning of the war. Dr. Ghassan Abu-Sittah called it “the biggest cohort of pediatric amputees in history.” Even this statistic, reported by UNICEF in December of 2023, is now outdated. The true number of men, women, and child amputees remains unknown, with estimates ranging upwards of 10,000 people. It is a number that will continue to rise as new and unknown weapons destroy tissue and bone, crumbling medical infrastructures and scarce supplies force constant life-and-death decisions, while infections and chronic illnesses — largely ignored — silently kill or handicap thousands. 

In this interview, Ayah Kutmah spoke with Dr. Bara Zuhaili about his experience in Gaza, the magnitude of amputations and injuries he witnessed, the effects of the siege and war, and what rehabilitation and reconstruction could entail. The interview has been transcribed and edited for clarity and brevity. 

Is this the first time you’ve worked in a war zone or in a humanitarian crisis? Did any of them prepare you for this?

It was not the first time. Unfortunately, I had experience in Syria, working in the underground hospitals in the besieged areas of Aleppo and Idlib. There, the healthcare facilities were also under constant attack by the Syrian regime. But Gaza was unlike anything I had seen before. To start, the supply chain was completely broken. Supplies were extremely limited in Deir Al Balah, where I was based for most of my stay. The hospital functioned at only 5-10% capacity compared to any similar hospital in the Middle East—I’m not even talking about an American hospital. Then, there were the number of patients. Just to give you an idea: Shuhada’ Al-Aqsa Hospital in Deir Al Balah is only equipped for 150 patients. Under extreme circumstances, they could maybe stretch to accommodate up to 200 patients. When I arrived, there were 950 patients, in addition to over 20,000 refugees sleeping in the corridors of the hospital and its complex. Every time we experienced a bombardment, we had anywhere from 20 to 60 patients rushing in simultaneously, in addition to the patients already being treated. It was completely overwhelming and overcrowded. 

The third issue had to do with the type of injuries. I’ve seen a lot of trauma before — traumatic injuries are not new to me — but the level of trauma I saw was something I’ve never witnessed in my entire life. When I was in the operating room, I would get a call from the ER saying someone was shot in the leg and they needed me as soon as possible. In my mind, someone shot in the leg with a bullet would have an entry size of about five to six millimeters and an exit wound size of about two centimeters long. That is what I was familiar with. What I saw in Gaza — which I had never seen before — was literally as if an explosion, an RPG, had exploded into the leg. The entry wound would be about five to 10 centimeters wide and the exit wound would be almost 30 centimeters wide. One bullet would destroy a diameter of 10-15 centimeters… all of the muscle, bone, arteries, and nerves were all gone, destroyed. 

I’m not a military expert, I don’t know much about weapons. But I don’t know what kind of bullet can cause that much destruction. With a bullet wound in the U.S., I could get away with doing a bypass to salvage the leg. In Gaza, there was nothing anyone could do to salvage the leg. The amount of tissue damage forced me to do amputations almost every single time. 

What types of injuries did you primarily work on? What was notable about them? What might they say about the weapons that were used?

Most of the injuries were either gunshot wounds or explosions. We discussed gunshot wounds and how one shot to the leg or abdomen was able to cause significant tissue loss. The second type of injuries were caused by explosions. I was shocked when paramedics bringing in patients would tell us that they came from three buildings away from the site of a missile attack. While I assumed there would be injuries from that distance, I was shocked to see the amount and level of injuries. Because of the severity of the explosion, even a small piece of shrapnel or debris — traveling at such high speed — caused significant damage. I saw someone whose abdominal wall was completely destroyed — literally half of their torso — and they told me it was from a small brick that flew from an explosion three buildings away. 

You have to ask, what kinds of bombs and what types of missiles were they using to create such high velocities to completely destroy someone’s torso or abdomen with just a small piece of debris, something as big as my hand? I cannot speak to the actual types of weapons; I’m not an expert. I only know that whatever they were using was of such high impact that it was causing significant destruction and tissue loss for people almost half-a-mile away from the explosion. 

Were there ever attempts or discussions between doctors or others to figure out what was being used?

No, we were barely fighting for survival. We didn’t have the time or luxury to sit down and discuss anything. Everyone was concerned with their own survival. For the local Gazan doctors, the survival of their families was paramount. 

Can you describe what a single day would look like? 

As a rule, anytime a bombardment happened, we would wait between four to eight hours before we received any injured people. In Deir Al-Balah, we would see the missile hitting two to three kilometers away and we knew that there were many casualties, but it would take these people —  who were only three kilometers away from us — four to eight hours to reach our location. The IOF (Israeli Occupation Forces) prevented any ambulances from entering the scene, and anyone attempting to help or approach would be shot. I had many cases where the ambulance driver would come to me holding two or three kids. They were dead, and he would swear to me they were alive four hours ago. We lost a lot of lives just waiting to reach us in the hospital. 

Our days typically began around seven in the morning, and even though the night was filled with attacks and bombardments, no casualties would reach us before the morning. By then, we would go to the ER and try to start the triage process: determining who needs to go to the OR first and who could afford to wait. We would then perform surgeries throughout the day, often not finishing until one or two in the morning. Sometimes, if I had time, I would do my rounds to check on the patients, and by late afternoon, we would have more bombardments and injuries coming in until midnight. Usually, by midnight, things slowed down… not because there was no bombardment, but because they couldn’t reach us anymore. 

Can you describe the magnitude of amputations and limb injuries in the current war? How are they amplified by the effect of the siege and the dwindling resources and destruction of the health sector in Gaza?

When I first entered Gaza, I carried a small notebook to track the surgeries I was doing for my recordkeeping. By day four, I realized I had done more amputations in Gaza than I did in two years in the U.S. I stopped counting, I couldn’t handle it anymore. 95% percent of the amputations were done on children. I’ve done amputations on a child as young as three months, which was absolutely horrifying. I’ve done amputations on women and men.

The most difficult part about the amputations was that they were almost always contaminated wounds, which means that every time we closed the skin, it would get infected and need a higher amputation. I had to change my practice from what I did in the U.S. I ended up not closing the skin after the amputation, which is miserable for the patient, because by not closing the skin, all the muscle — and sometimes the bone — is exposed, causing them extreme pain. But it was the only way to prevent infection and, even then, because of the lack of sterility and limited resources, there were a lot of infections. 

On my fifth day, it was fairly quiet, so I took the opportunity to do rounds around the hospital, checking up on patients and asking them when was the last time their dressing was changed. As a point of comparison, here in the U.S., you need to change bandages at least once a day, maximum every two days. One patient told me he had his dressing on for six weeks: no one was able to change it because they were so overwhelmed. I took my scissors and began cutting the dressing to find worms and maggots coming out of his leg: they were eating his flesh. It was so badly infected that I had to amputate his leg. 

As a doctor, you must contend with constant life-or-death decisions. In your case, they are also decisions of scale — whether that life could be saved with this amputation, and if it could be a life lived “meaningfully.” Was there a particular decision that stood out to you?

When I first entered Gaza, I held onto an American mindset that prioritized saving every life possible. However, I quickly learned the hard way that this approach was not applicable here. 

One heartbreaking case involved a child, whose exact age we would estimate to be around nine to ten months old, who came with his arms impacted by a missile attack almost half a mile away. The left arm was completely cut, there was no way to save it. His right arm was cut at the fourth and fifth finger, and the third finger was semi-functional. We rushed him to the operating room, I finished the amputation on the left arm, then I worked really hard to save the third finger on his right hand. I thought, at least, when he grows up, he would have three fingers to feed himself. I was so happy I managed to save the third finger and I went out to find his family and tell them it had been a successful effort. As I’m leaving to tell them, they tell me his entire family is gone. All of them — his parents, his siblings, uncles, aunts, the entire family was erased from the registry. He’s the only survivor of that family. I think that’s when it hit me that maybe saving this child’s life wasn’t the most efficient way to use the limited resources we had. Who would take care of him now? For the rest of his life? We saved his life, but that is when I started questioning my decision to save every life. 

Another incident happened soon after that, when someone came in, still alive, with half of their face destroyed. You could see their brain through the hole in their eye orbit, but their mouth and eye were completely destroyed. Saving that one life would not have given him any meaningful life. He likely sustained significant brain damage, couldn’t eat on his own, and would be in a vegetative state for the rest of his life. We had to leave him be and he died hours later. That is when I had to switch from an American mentality to the local doctor-of-war mentality, where we were, unfortunately — I’m not proud to say it — liberal on letting people go. That’s something I’ve never done, not in any other wartime setting. 

How did medical and rehab teams in Gaza manage these kinds of injuries before this war? Is there anything notable about the health structures or personnel in Gaza in this regard considering the long experience of bombardment campaigns amid a long and brutal siege? 

Actually — and this was surprising to me — they were very organized and efficient. In terms of physical preparation, I don’t think anything could ever prepare them for such a destructive war. Mentally, I was extremely humbled by their defiance and resilience. The healthcare workers always maintained a calm demeanor, even as they struggled to secure food and water for their own families, who were sheltering nearby. Almost all of them lost homes, family members, colleagues, and friends. I talked to many surgeons who were captured, tortured, and imprisoned by Israeli forces just because they were treating Gazans. Gazan doctors who were captured in Al-Shifa Hospital were interrogated and tortured for three to four days, just to get any information out of them. 

Before this war, there was a whole separate building next to Al-Shifa Hospital dedicated to prosthetics and rehab. Unfortunately, it was one of the first buildings destroyed. All the main prosthetics and rehab centers were destroyed early on in the war. There is zero rehabilitation capacity in Gaza right now — zero. It’s not even about rehab: injured patients are unable to get routine wound care. The hospitals are functioning just to keep people alive, nothing more. 

What are the dangers of the continued war, destroyed infrastructure, chronic illnesses, and medicinal and food shortages on the current population of amputees?

In Gaza, I’ve witnessed patients who died in front of me from a simple diabetic complication because we didn’t even have insulin. To have insulin, you need a fridge… and to have a fridge, you need electricity. They don’t have that. I can’t tell you how many patients came to us between bombardments with a worsening of their diabetic situation leading to a coma, worsening infections, or non-healing wounds. Because they weren’t traumatic injuries, no one was able to give them the attention they needed, and we didn’t have the resources to treat them. Basic chronic illnesses like diabetes and hypertension were killing people acutely, because they were largely ignored for more than four months. 

Is there anything being done now to address chronic illnesses?

We are trying to. Currently, there is a project between UOSSM Canada and UOSSM USA to collect commercially available hypertension and diabetes medication in Jordan and work on purchasing them to get them into Gaza. That is the first part. The second is working on a simplified algorithm written by experts here for the treatment of hypertension and diabetes. The idea is to create a simplified version that anyone, any nurse in the ER, can look at, so as to determine what medication to give them without needing to consult physicians who are busy elsewhere. It’s a two-pronged effort: giving them the medications and getting them the algorithm and knowledge of how to apply them so we can lower the mortality of these illnesses. 

Another project focuses on addressing wound care. I mentioned the story of the man whose dressing hadn’t been changed in over six weeks: there are thousands like him. We are trying to create mobile wound clinics, almost like a tent, where the local nurse and physician can have patients wait in line, walk in, without appointments, to have their dressings changed and then be on their way. It’s not addressing the major issue — someone with wounds will need reconstructive surgery — but at least it’s preventing infections and preventing them from losing their limbs unnecessarily, almost serving as a temporary solution to get them through the war. The hope is that reconstruction efforts can be addressed at a later stage. 

How do you imagine rehabilitation and reconstruction in Gaza, particularly with such a massive population of amputees? What would it take in terms of physical infrastructure, equipment, human resources, training needs, and the community structures and links that enable effective management of these types of injuries? 

The rebuilding of Gaza must be done at a state and international level. With all due respect to NGOs and relief organizations, I really don’t think this is something that can be done by one, two, or 10 organizations. Everything is destroyed, all the buildings and structures are destroyed, and, as I said, hospitals are barely functioning at 5% or 10% capacity of any comparable hospital in the region. 

There needs to be something temporary, and, at the same time, there need to be larger structures built for the long-term rehabilitation of amputees. The only silver lining is that, in terms of human resources, they definitely exist. From what I witnessed in Gaza, doctors, nurses and even volunteers have incredible experience, stamina, and resilience. What we need to do is support them materially, financially, and with some expertise to rebuild what’s been destroyed and have them take care of their own people. 

Most hospitals as they currently stand are not able to handle any rehabilitation. At least, for the short-term, there need to be temporary structures, buildings, tents, or even in the open air, to begin rehabilitation. I don’t think we should wait until we rebuild actual buildings to do that, and I don’t think it’s fair to expect hospitals to do that when they are barely functioning. There must be a focus on wound treatment, followed by providing some physical and psychological therapy. This is in the short-term. At the same time, as those three things are happening, there needs to be a focus on rebuilding rehabilitation centers and facilities to account for all the patients scattered throughout the Gaza Strip. 

Is there a parallel you see anywhere in the world that could serve as a model for post-war rehabilitation and reconstruction — however ‘post-war’ looks like? 

You know, I think northwest Syria is a really decent example to go by in terms of “post-war” reconstruction. Similar to Gaza, all the healthcare facilities were destroyed, there was no recognized governance in control of the area, and there was a massive influx of patients at the same time. Years later, here we are in northwest Syria with rebuilt and functioning healthcare infrastructure. The major difference is that, in Syria, there was absolutely no governance: any NGO could go in and do some work, good work, without being held accountable. In Gaza, there is still some level of governance — I met with the Minister of Health — where the local government would be leading the charge in coordinating relief and reconstruction efforts.  

What did Gaza teach you? Do you plan on returning? 

Definitely. I’m still working on a few projects and I’m hoping to go back once some of the logistics are set up.

What did Gaza teach me? One word: resilience. In Gaza, I witnessed levels of resilience and heroism unlike anything I’ve seen before. These are nurses and doctors and volunteers who lost everything, but are still, somehow, functioning to save lives. To me, they are the real heroes of our time. As a matter of fact, I’m working on a project in collaboration with a few doctors at Johns Hopkins and local contacts in Gaza to record their stories, write them down, and share them so that their acts of heroism are known for generations to come. They have redefined everything we know of resilience and heroism in the medical community, and in this world. That is what I learned from Gaza.

Dr. Bara Zuhaili with children in Gaza. The feature photo in this article also shows Dr. Zuhaili performing surgery with colleagues.
About The Author: 

Ayah Kutmah is a writer and researcher with a focus on prisoners’ and human rights in the Middle East. She is a former visiting research fellow at Birzeit University, and previously worked with Addameer Prisoner Support and Human Rights Association. Ayah currently works on a defense team representing a detainee held in Guantánamo Bay, Cuba. 

Dr. Bara Zuhaili is a full-time vascular surgeon and dual board-certified in general and vascular surgery. He holds a medical degree from Damascus University and a Master of Public Health from Johns Hopkins. Dr. Zuhaili is an accomplished scholar with a special interest in global health and has participated in multiple medical missions overseas in Syria, Turkey, Uganda, and Palestine. Dr. Zuhaili is an affiliate with the Johns Hopkins Center for Humanitarian Health and teaches at Michigan State University. 

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