Cases of head trauma and spinal cord injuries requiring surgical intervention are common in any busy health system. In Gaza, however, the need for quality neurosurgery services is increased by the repeated incidence of these injuries resulting from Israel’s repeated attacks and use of explosive weapons in densely populated urban environments.
Despite this, surgeons in blockaded Gaza have limited opportunities to enhance their skills and are often cut off from learning about advances in technique and best practice.
Dr Hazem Kuheil is a Neurosurgeon at the Shifa Hospital in Gaza. He has been a surgeon for 15 years and has focused on neurosurgery for the last five years. Due to his experience and skills, Dr Hazem was nominated by the Palestinian Ministry of Health to attend a four-week clinical observership, to accompany and share experiences with medical staff, at King’s College Hospital in London. His visit was supported by Medical Aid for Palestinians (MAP), as part of our commitment since 2017 to support the development of neurosurgery in Gaza.
During his observership this February, Dr Hazem was supervised by Dr Sinan Barazi, Consultant Neurosurgeon. Dr Barazi runs a fellowship course focused on skull base surgery, pituitary surgery, and spine and facial pain at King’s College Hospital. He recently joined his first MAP medical mission to Gaza from 4-9 March.
Throughout his observership, Dr Hazem was exposed to the very high level of neurosurgical care offered at King’s College Hospital. He witnessed the best standards of modern neurosurgery navigation technology being used, and experienced a busy neurosurgery department, where 20 to 30 cases a day are discussed and treated.
Importantly, he was involved in complex surgical case discussions in the almost daily multidisciplinary team meetings (MDTs), where patients’ care is discussed and agreed. He found these discussions useful and will be applying his experience to improve the way regular MDTs at Shifa Hospital are run. He observed the work of nurses and anaesthetists, and has recommendations to take back to Shifa Hospital regarding the quality of care.
Due to the unavailability of services, many neurosurgery cases must be referred out of Gaza and patients must travel to hospitals in the occupied West Bank, including East Jerusalem, or abroad. But to travel, patients must navigate an arduous and opaque application process to receive permission from the Israeli authorities. This procedure is characterised by frequent, arbitrary rejections and excessive delay.
Israel’s three-day military offensive on Gaza in August 2022 resulted in a high number of major head trauma and complex spinal cord injuries which caused a number of medical referrals outside Gaza, in addition to the regular caseload from cancers, accidents, and other injuries. According to the World Health Organisation, from January to September 2022, there were 406 permit applications to the Israeli authorities for patients referred for neurosurgery, of which 40% were denied or delayed.
A key objective of Dr Hazem’s observership was to gain skills in pituitary surgery as this is not currently conducted in Shifa Hospital, and pituitary cases therefore have to be referred outside of Gaza. He described to MAP a few cases observed during the month which were particularly useful for his learning.
One was a woman who underwent a successful endoscopic pituitary cancer surgery and recovered well. This was Dr Hazem’s first time seeing this type of surgery using endoscopy to remove the tumor. The second was an urgent endoscopic surgery for a patient with pituitary apoplexy (hemorrhage of the pituitary gland). In transnasal transsphenoidal endoscopic surgery, a surgical instrument is placed through the nostril and alongside the nasal septum to access a pituitary tumor. The patient experienced a severe deterioration in their vision due to the expansion of the tumor. This surgery was also successful in removing the tumor.
Dr Hazem aims to be able to do this type of surgery himself at Shifa Hospital in the future, with the support of Dr Barazi, as it is an advanced, but minimally invasive surgery. But additional equipment would be needed for these types of surgeries including endoscopes and Surgiflo, which is used to control bleeding during surgery.
As well as training and developing the skills of Palestinian neurosurgeons in Gaza, MAP has provided essential medical equipment and supplies to hospitals. Our support for neurosurgery services had previously focused on the European Gaza Hospital but, from 2022, our work has expanded to include support to Shifa Hospital which sees a large volume of patients.
Dr Hazem was hugely appreciative of Dr Barazi and other colleagues at King’s College Hospital for their support during his time there. “I would like to thank MAP and its supporters for the opportunity to attend this clinical observership,” he said.
“It was a very fruitful and meaningful experience, and I learned a lot from the UK consultants I have been working with here at King’s College Hospital, and observing the system in the UK. This will help to make neurosurgery services at Shifa Hospital more effective and sustainable.”
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Photo: Sinan Barazi, Consultant Neurosurgeon (left), Dr Hazem Kuheil (centre) and Nicholas Thomas, Consultant Neurosurgeon (right) at King’s College Hospital, London.