Ammar Darwish Interview

Patrick:

Welcome back to behind the knife. This is Patrick George off trauma and acute care surgeon at Duke university.

Patrick: And we've got a really special episode for you today. One I've been looking forward to for quite some time. And the reason I'm so excited is because of our guests, Dr. Amar Darwish, someone I admire very much and thrilled to have on behind the knife Amar, welcome to the podcast. Thank you very much, Patrick.

Patrick: And thank you very much for the invitation. And to be honest, I'm a huge fan. And I follow the work of your work and the team of Behind the Knife. And it's a great pleasure to be with you here. Amar is a general and major trauma surgeon at Manchester University NHS Foundation Trust, which is the major trauma center in Manchester, UK, and he has extensive surgical humanitarian field experience and major trauma surgical training in conflict zones, having been deployed to over 50 global humanitarian missions over the last 15 years.

Patrick: He is obviously passionate about helping

victims of conflict and natural disaster. And he does so by equipping the doctors in the area. training them up and providing some really amazing education that we're going to talk about today. Now, you may have recognized Dr. Darvish's name from the David Knott Foundation, where he serves as the medical director and lead global faculty.

Patrick: And the David Knott Foundation was established in 2015 by Dr. David Knott. And we had Dr. Knott, who is the author of the book, War Doctor, Surgery on the Front Lines on the podcast.

Patrick: And that was in July, 2020. If you're interested in listening, it's episode 303. And I got to say, I highly recommend you take a listen because if you haven't, Dr. Nod is really an incredible human being who has been through some really unbelievable things and he shares them on the podcast. And Dr.

Patrick: Darwish met Dr. Nod in Syria. And Ammar has been part of the David Nod Foundation really since the beginning. And this is when it was established back in 2015. And he has been deployed with Dr.

Patrick: Nod to places like Syria, Iraq,

Yemen, Ukraine, West Bank, and even Gaza most recently.

Patrick: So Dr. Darwish, without further ado. Let's get started. So you were born in Syria and you made your way into medicine. Was your early childhood like, and how did you find yourself on the path towards surgery and who influenced you the most? Gosh where can I start Patrick?

Patrick: So since a very young age, I knew that I was so interested in medicine and I wanted to be a doctor. The main reason because I was born into a family of doctors. So my father's a pediatrician and my grandfather was also a general practitioner and at those days, when I was in Syria, my granddad was very passionate about his work.

Patrick: He used to hold my hand during holidays and weekends and take me with him to his practice, GP practice. And he used to show me how to do things. And I used to watch him and

admire the way he cared about his patient, the way he was passionate. towards them and the relationship between the patient and him how it's developed, the respect they had for him, the the appreciation that they had for the work that he was doing.

Patrick: He taught me so many things, he even He taught me how to give injections at that time I was still a child, he used to have a big x ray machine and in the 70s and the 80s, x ray machines they were very big, you need to fit them in a big room, and he used to have one in his surgery, and he taught me how to take x rays, and you need to hide in a smaller room to avoid the x rays, and then take those films, and develop them in a dark room and he used to teach me all of that and I used to be amazed look at the x ray and I say oh wow you can look at the human body from the inside and this is so nice little I knew that when you become a surgeon actually you can

deal with it with your own eyes exactly so he was a role model for me he was My hero.

Patrick: And later in life, I came to know that patients who were poor and not able to afford their treatment. He used to treat them for free and go and buy the medicine for them and give them the medicine and a little bit of money on top of that to support them a little bit or their families. They come back after two or three weeks to him.

Patrick: They're so happy. They're feeling better. They're so grateful to him. And that really embedded something inside my heart about volunteer work, about a humanitarian work. When he died, when I was 12, it was big shock to me really, and really affected me because like I said, he was my hero. Went to the UK with my family and my dad was specializing in the UK as a pediatrician, but also I

realized that my dad himself had similar values and he was also my role model.

Patrick: He used to do a lot of work to help in the hospital, the NHS, but also In the community and used to volunteer with charities, especially children's charities to support them, give them the medical advice that they need in the UK and even back home. And my mother was so supportive to him and always tells us the stories of his work and encourages to be passionate about.

Patrick: What he does. So I decided to do medicine. And I remember when I was 18 years old preparing for my exams, college exams to go into university. And at that time, I mean, till now, you open the door. the news, and you look at the natural disasters, you look at the wars here and

there, conflict everywhere, and you just feel frustrated.

Patrick: I was so frustrated that I really wanted to help, I really wanted to do something, and I was telling my mother that, and with a nice, calming voice, she told me, look, Hama, finish your studies. Finish medicine, specialize, and you can go and help. This is where you'll be able to help the most. Do your speciality and then go and help.

Patrick: That's the time where you'll be the most you know, beneficial to these people. And I took her advice and really helped me through my medical school. And that what made me decide when I graduated to go and do two years to work in North Africa. And that really opened my eye to the how much people are suffering in these countries, the limited resources, and how they struggle to get treatment and medicine.

Patrick: And embedded in me, again, that

Humanitarian work, voluntary work is absolutely crucial in our field, that we can share our expertise, we can share our knowledge, and we can, you know, deliver these skills and deliver these practices to doctors and to help our patients in these areas. I continued my work and came back to the UK.

Patrick: to do my surgical specialties. I was so fixed at that. I remember during my housemanship, I had excellent surgeons and excellent doctors who used to train me as a house officer. I was trained. Yeah. And how did you decide on surgery as a specialty as surgery is not the first choice and specialty in terms of Maybe public health or humanitarian impact that people might think of.

Patrick: Now, certainly it has a massive impact, but you could have been an internal medicine doctor and infectious disease specialist, the pediatrician, et cetera, with a more direct path to

impact large populations and underserved. And when you were choosing surgery, how did you link those two to what you knew was going to be a career that was focused at least a part of not wholly on this really amazing humanitarian work?

Patrick: Really good question, Patrick. During my work in North Africa, I was doing my housemanship and spent two years there doing that. And I did different specialties. But I felt surgery was the one that attracted me the most. You are faced with very sick patients, very ill patients, sometimes life threatening emergencies, and you need to take, make a decision and act there and then.

Patrick: You operate, you deal with the problem, you come out, and hopefully your patient will get better. And I love that about surgery. Don't get me wrong. Other specialties are amazing and other doctors in different specialties, medicine, pediatrics, obstetrics. Again, they do their

work with passion and they help their patients so much, but I felt.

Patrick: surgical specialty was the one that I wanted and that attracted me the most. I had excellent teachers and excellent surgeons teaching me taking me through doing emergency laparotomies. Even I remember as a house officer, I was doing cesarean sections, emergency cesarean sections with the consultant there because I was on call with the consultant and I was on call with the main man there.

Patrick: And in the night they go home and it's only me guarding the the hospital or department. So you went on with your training in the UK, and then at a certain point you found yourself. In Syria. And I guess this is a good point to just as a reminder, because we're going to use this as a takeoff point is the Syrian war.

Patrick: So, the Syrian war began in 2011. Yeah, sparked by the anti government protests during the

Arab spring. And this quickly, obviously escalated into a full scale civil war. And that's resulted in a devastating humanitarian crisis, hundreds of thousands of people dead. Millions displaced and truly widespread destruction.

Patrick: And there have been efforts at peace. But despite that, the conflict remains unresolved to this day. With ongoing violence and political instability, how did you get into Syria? And you met Dr not in Syria

Patrick: I was still interested in doing your material work and I've already done a little bit of work before 2011. I even went to on one of the medical missions there. So when the Arab Spring started, we are watching the news and learning about what's happening in Syria because of my background, because I still had family at that time there.

Patrick: And the demonstration started. It was initially peaceful demonstrations people going out on the street. Demonstrating peacefully for basic human rights,

freedom to have education, health system fairness in their treatment, and to be able to provide for their families. Unfortunately, after six months of peaceful demonstration, they were faced with brutal response from the government forces and from the secret police in Syria.

Patrick: And we started to see the images and the videos of the gunshot wounds, the injuries, and people trying to help who are non medical and causing more harm. And that really felt bad. wrong to me. I appreciate that they're trying to help, but they didn't know the right thing to do. And I felt that I could help.

Patrick: This is something I really can contribute to and help. So as a British Syrian doctors and surgeons in the UK, we decided to start on doing charity and we organized our first mission

medical mission to Syria in 2012. And we through donations from the public bought several ambulances, filled it with equipment, medical equipment, ventilators, defibrillators, surgical equipment.

Patrick: I remember people driving these ambulances to the Turkish Syrian borders. And then we went in with the medical equipment. convoy into Syria to the non governmental areas. And there I was struck by the true brutality of this war. The whole health system was collapsed in the northern areas because the government withdrew all the support to it.

Patrick: So the charities has just had to step in and Take it, take its place. So with a field hospitals established in Aleppo, where we went and these hospitals, they're very limited with resources, very limited with the doctors and the medics there. They've never

seen. Were injuries before they're just normal.

Patrick: Doctors, surgeons who did their normal elective work day-to-day that we see here in the UK or in the states. And it was shock to them to see all these injuries, so we started to support them and help them. We did a bit of training for the first responders and they're non paramedics by the way.

Patrick: They're like engineers. teachers who volunteered to go and be first responders. So we taught them first aid. We taught them a little bit about the trauma, advanced trauma life support and so forth. And we came back to the UK and I felt something you know, has changed in me. I felt that this is what I want to do.

Patrick: This is where I'm suited the best. This is the through line to your, through line to your family, your history, your father, your grandfather, your mother. Absolutely. Absolutely. Absolutely. And I wanted to

take that path and continue in that path. And I always used to think and ask. Do you know anyone who does this kind of work here in the U.

Patrick: K.? And the name David Mott was mentioned to me, but I never knew who David Mott was at that time, till the Syrian conflict started when I met David. And so, when, did you actually, so did you meet David in Syria, or were you back in the U. K.? And did you guys did you chat on the phone, meet in person?

Patrick: You said, hey I'm here. I'm here. I'm passionate about this. I'm, you know, I have this family in Syria, I'm seeing what's happening and how did you get connected? And then from there, did you, did the knot foundation just spring up as something, or did you both travel back for missions and how did that play out?

Patrick: Yeah it's really interesting. So when we got back from our first mission in Syria, as Syrian, registered surgeons, we were invited to

the Royal College of Surgeons of England to do the STAY course. The STAY course stands for the Surgical Training in the Australian Environment in the Royal College. So when we went there, Of course, who's the, who's in charge of the course and who's the course director?

Patrick: Professor David Knot. And that's how we, how, that's how I met David in the course. We talked about Syria, and apparently he was in Syria at the same time where when we were in Aleppo, but in a different city. He was with MSF Doctors Without Borders. Right. But we didn't know that. And we talked about it. And he said, Look, I want to go to Syria.

Patrick: He contacted one of my colleagues in Action for Humanity, which is Syria Relief, the charity that we went with, and we continue to work with in Syria. So, and he said, I want to go with you. We want to go together to Syria again with Action for Humanity. And few

weeks after the course, we're off to Syria again with David, with Action for Humanity.

Patrick: And that's it. Since then, we've never stopped. We went on all our missions together, apart from, I think I missed two of his missions. But yeah, went to Syria several times, Syrian Turkish borders, Yemen several times, to Libya, to Iraq Cameroon, Kenya. We went to West Bank and Gaza. So several places, all these missions, and to Ukraine, several times to Ukraine.

Patrick: All these missions we went together, and it was really eye opening, and I felt I was the, you luckiest surgeon to be there with David, working with him. And I've learned so much from him. And you played a starring role in his book again, war doctor surgery on the front lines. And I know a lot of folks listening, I've read the

book but for those who haven't, you share a couple of stories from your time in Syria so let me talk about when we were, when I worked with David. So we went to Syria together and every time we go, we stay for six weeks up to three months, we take unpaid leave from the NHS and we go there.

Patrick: and do this work. We stay with the local surgeons there in Aleppo or in Bab al Hawa, and we live in the hospital itself, sharing a room with the Syrian, local Syrian surgeons, living day to day, eating with them, operating with them, teaching them in the evenings when there is a bit of time. And during that time, I've learned so much from David, operative wise, skill wise.

Patrick: And even from his personality David is a unique human being. He

is so passionate about his work, so passionate about his patient, so passionate about teaching and delivering his knowledge that he's gained over the years from going to war zones to deliver it to the doctors that They were there with him.

Patrick: Doctors were dealing with casualties on the front line. And he's so knowledgeable and his surgical skills are just absolutely great. And all of these, and you have a very humble, down to earth man that really, you know, capture your respect. So I've learned so much from him during these first missions to Syria, and I continue to learn from him every time we go there.

Patrick: The conflict in Syria was so complex and still very complex. And I remember once we were after a very long day,

and operating through the night, we went to the room and we tried to get some sleep. And then David was called down to theatre because there was a gunshot wound injury to her chest. A young man was shot in the chest.

Patrick: And they wanted to open the chest and they never done that before. So David was the person to teach them and show them how to do that. So David went down and then immediately I followed David. And in theater while we were operating, trying to stop the bleeding, did a clam shell. Someone else enters the theater and apparently this was an ISIS fighter that was brought to the hospital and his brother or his teammates or with their guns stormed into theater and wanting to know what's going on with their with the patient and is he going to survive and who's operating on him?

Patrick: Yeah, that is extremely.

because if they knew that there are two British surgeons there. That would have been a disaster. So I just try to in my own way, try to reassure David. And I spoke with my Syrian colleague to these people and in, in an Arabic accent, telling them, look, we're operating on him.

Patrick: You need to leave theater to enable us to treat him. Once we're done, we'll let you through and you can see him. But for now, please leave the operating theater. And it was a very scary moment. That's an understatement. And another story that I remember, again, it wasn't in theatre. We were going from Aleppo to another city with the Aleppo Medical Council in a small minibus, moving to another city to try and do some work and support them there.

Patrick: And we had a flat tire. And we stopped. We had

to stop. And we didn't know where we stopped. Still an open fields with a hill. And on the top of the hill there's a post. Like a small room that people can look onto the road. And one of the Syrian doctors said, look, we need to do it quickly because this is most likely an ISIS area.

Patrick: We need to get out of here as quickly as possible. So I told David, stay in the minibus, lie on, lie down on the chair at the back of the minibus, cover yourself completely, do not come out of the minibus, whatever happens. And within minutes, we can see a car coming towards us, a jeep with a black flag on it.

Patrick: And they stopped, and immediately in a very aggressive way, they said, What are you doing here? And who are you? So we spoke to them, we told them, look, we're the medical council from Aleppo, and we're doctors, we just had a flat tire, and

we're going to repair it and move on to another hospital. And they said, Okay.

Patrick: And they said, immediately, you have to leave as soon as you finish. If we come back and we find you here, you'll be detained. And they left. And trust me, that was the quickest and the fastest flat tire change I've seen in my life. And we left. So, we had so many close moments that we looked danger in the eye, but we survived it.

Patrick: We survived it together. We survived it looking out for each other and supporting each other. And really, that's what I love about these missions and in particular missions like the Syria mission. You have this coherence, you have this relationship that you do, you build and you develop friendship between the whole team and you become like one family.

Patrick: And it's amazing. It's truly amazing.

How do you balance the risk to yourself and your colleagues with the important work that you're doing? You know, you have to be alive to do that work and to continue on with these humanitarian missions. And so how does that balance out? It's very difficult. It's really difficult to balance that. But from before, from we prepare before when we prepare for the mission, we try to make it as safe as possible. We do security checks. We do security assessment.

Patrick: And we have local teams on the ground that we trust. And we try to have a low profile. I can't even remember in Aleppo, instead of calling David, we used to call, gave him an Arabic name, Abu Dhabi. So people, when you call him that name, people don't think, Oh, there's a foreigner here. Oh, there is actually.

Patrick: So you try and do that,

do your best to make it as safe as possible. But in spite of all that you can only try. You can't guarantee that you won't get be, you won't get shot abducted. Your hospital bombed, and unfortunately that happened several times. You get sniped on the way from one place to another.

Patrick: And I remember once when we used to, in Aleppo, when we used, there were like four or five field hospitals. And when I say field hospitals, it's a small building that turned into a small hospital. And we usually operate underground because of the barrel bombs. And sometimes they need us in another hospital.

Patrick: They, over the walkie talkie, they tell us, can you come? We need you there. We've got an urgent case. So we get into a small car with the local doctor and we drive and it's in the night. You cannot put the lights on. It's completely dark because if you put your lights on, there are Aircrafts and jet fighters in

the air circulating the skies and indiscriminately launch on the ground.

Patrick: Absolutely. Absolutely. And so you can't really make it a hundred percent safe. But you can always try, do your best. And when you go and see the amount of the benefits that these patients get from such expertise, from such work people like David you think it's definitely worthwhile and you go again and again.

Patrick: Right. That has to be the case, right? That the benefit is so extraordinarily great that you see the worker doing is. So important that when it comes to weighing those risks and benefits that the risk is high as that is. But the benefits still outweigh that , once you go and see the benefits, see how people are benefiting, patients, doctors, locals you would think definitely it's worth it.

Definitely the benefits overweighs the dangers and the risks.

Patrick: End. You wanted to amplify that benefit farther. And one of the best ways to do that is to train local populations of surgeons. Take, for example, Syria, you mentioned the lack of exposure to some of these horrible traumatic injuries,. And you can only be there so much.

Patrick: Dr. Knott can only be there so much. And so one of your missions through the Knott Foundation is to train surgeons and other medical providers to become skilled in delivery of care so what's the not foundation up to now? What are some of the. The highest performing, I guess, or most sought after courses. And what are you most proud about in terms of the work you're doing through the foundation?

Patrick: Yeah, it's, I mean, the foundation, like you mentioned earlier, started in 2015 and the idea came from Ellie Knott and Ellie is David's wife. She's a very wise humanitarian, very passionate about this work,

very passionate about helping people. people in such circumstances. And she's very passionate about the foundation itself.

Patrick: And she just said to David, look, you've got all this experience. You've got all this knowledge. Why don't you start a foundation or charity? That does that think that it does this training, deliver this training to the people who need it the most. And that's how the foundation is started. And I was privileged to be with them from day one during the early days of the foundation and we started to go, it's really good and well to go and operate for a couple of weeks and come back.

Patrick: But really what's more important is you go and operate, you train the surgeons, you train the medics there on how to do these procedures, you come back, you stay in touch with them, you go back again and you do an assessment and you support them again with extra knowledge, extra skills,

till they're confident.

Patrick: to do the work themselves and to be trained as themselves. And that's the aim of the main goal of the foundation is to build capacity, to train the local surgeons in conflict zones on how to deal with such complex injuries. And once they're trained, when they're happy, then they'll be able to train their colleagues and so forth.

Patrick: And that's exactly what we did in Syria. We stayed with these doctors, with these surgeons, so many weeks, months, we went there again and again, we did the training for them, we did the assessment, and eventually, when the foundation was started, we started doing these courses, which I'll explain about the courses in a minute, but we formed a local faculty.

Patrick: in Syria of the David Knott Foundation. So the last two missions to Syria, they were delivered by local faculty

in Arabic to their colleagues. We just went there to support them. And this is really the aim that we want to do. We want to make them self sufficient. And it's exactly what we're doing in Ukraine at the moment.

Patrick: We've done so many missions in Ukraine. We're training doctors, we're training surgeons. And in our last course that we did in the Royal College of Surgeons of Edinburgh, We trained six or seven Ukrainian surgeons on delivering the course in Ukraine, and they went and they did the first training there.

Patrick: So we're hoping to achieve the same goal in Ukraine, hoping to do the same in Yemen, in Libya, and so forth. So for the foundation, really, this is the most important aim, and this is what we're proud of. It's a unique product that we have. I don't think there's any charity or big organization that has this

kind of training knowledge, equipment, and planning and that's what we're proud of, really. And to talk about the training that we do in the foundation. So initially we were doing the training as part of the college of surgeons at Edinburgh, the state course, which is surgical training and the austere environment where the foundation was sponsoring surgeons and doctors to come to the UK.

Patrick: do the course and then they go back. So they cover their expenses, their travel, their visas, their accommodation, the course fees, and they go back to train their colleagues. And that's a cadaver based course, correct? Exactly. That's the cadaveric course. Five days, very intense. We teach on damage control surgery, damage control resuscitation.

Patrick: We do abdominal trauma, cardiothoracic trauma, vascular trauma. We do plastics for trauma. We do obstetrics. in

trauma patients. We do maxillofacial. And we do neurosurgery. So very intense five days. We show that the candidates, the operations we give them is a scenario or case based teaching. So we show them a case.

Patrick: from real life that we faced and we dealt with, we operated on in the field and we told them, what do you do? What do you think the next step would be? And we teach them a systematic way in approaching such cases. And then we show them the video, how to operate on after they've seen the video, they go to Heston, which is our human size mannequin that you saw in Belfast, which is popular the most famous part of our foundation.

Patrick: And now you're moving to Heston for everyone listening, it's a, it's truly life size. It's a silicone model, right? But it's extraordinarily unique in the sense that the foresight that was put into his design,

it is so useful. Every inch of that model is used and it's incredible for all the different exposures, all the different skill sets. And we mentioned before the other courses is cadaver based you can travel with Heston, right? You take Heston with you to some of these more austere environments.

Patrick: Is that correct? Absolutely. So Heston is a human size mannequin that has all the normal organs inside it. And it has all the 30 or 40 emergency trauma operations and exposures on it. So you can, like I said, you can do bear holes, you can see extradural, subdural hematomas and how you deal with that.

Patrick: You can do surgical airway, you can do a clam shell lung twist you can do trauma laparotomy, you can do plastic surgery on Hestan, and for obstetrics we have separate. Mannequin for that, in particular, like obstructed labor or emergencies in the area section and so forth.

And once they have seen that, and correctly, like you mentioned, for the Austrian environment, we developed the HES course.

Patrick: So people who cannot come to the to the UK to do the training, which is. Hundreds, if not thousands of them are not able to make it to the UK to do the HEST course we decided to take the course with us, make it into a mobile course, and we call it Hostile Environment Surgical Training.

Patrick: We take Heston with us, the whole team goes to do the training. We have a model that we've developed. For example, we have a model of a heart. and a pericardium. And once they've seen how to deal with cardiac injuries, how to repair a penetrating injury to the right ventricle, for example, they see it on Heston, and they go and practice it on the models that they have.

Patrick: And all of these, including Heston, they're all handmade specifically. for the course for the foundation.

Yeah. And this is what makes art and skill that went into that model is truly amazing. It's, it is one of a kind. It's the best I've seen anywhere in the world. And again, the the, for the planning into each of those organ systems and exposures is truly magnificent.

Patrick: It is. And it took about two to three years to develop it. I believe that. And we're still developing Heston. We're still adding things to Heston. And Max the artist who did Heston, of course, with the supervision of David does all these models too, and prepare them for each mission.

Patrick: So each mission we go, we carry all this equipment with us. We carry like about 12, 13 bags of equipment, including, in addition to Heston, which has his own special bag. And the funny thing is, Patrick, when you go and into these countries, you know, in, into countries where war zones or in the Middle East, and the custom officer asks you what's inside this bag.

Patrick: Sure. And you tell him

there's you know, there's a mannequin that you train surgeons on. Oh, open it. I need to see it. Are you sure? Yes, open it. Definitely. And we opened the bag and he looks at Heston and it's so funny to see the shock on their faces. It's absolutely hilarious. But again, that's part of the fun of these missions to watch the customs officer looking at squirm a little bit.

Patrick: Yeah. All right. So you were recently in Gaza and you're going back to Gaza again shortly. I understand it. Was very challenging in regards to the extent of destruction and human suffering. How do you feel when you go on these missions? How do you cope when you're there? Because the emotions have to be. Overwhelming. Gosh, that's a difficult question. Yes. I've been

to Gaza with the WHO and that was the beginning of this year because of what we do and the expertise that we have. We've been asked to deploy there to support the local teams.

Patrick: And to be honest, it was one of the most difficult missions that I've done. I've done many of them, but this was one of the most difficult ones because of the suffering you go inside there, the amount of displacement, huge long queues of children waiting to get clean water, some food, you go into the hospital is surrounded by makeshift tents of thousands of families because they've been displaced running away and they thought that the hospital is a safe place to stay in and you walk inside the hospital again it's full of families living there because there's no place for them to go very limited resources in the UK in our hospital we might

have a mass casualty once in a year Or twice in a year there every day there's a mass casualty coming into the hospital and with the limited resources, with a limited manpower, you tend to make very difficult decisions on who you're going to operate on and who you're going to leave.

Patrick: It's very hard decision. You make these decisions with the local doctors. Of course, it's not a single decision. And I still remember the faces of these children that we couldn't, we said, we can't do anything for them. And we didn't do anything, just left them to die. because we couldn't do much. We only had limited number of beds, limited number of theatres, sutures, materials, surgical equipment, antibiotics, very limited antibiotics, all wounds there were infected, all of it.

Patrick: And, you know, I can tell you stories, one of the boys who was injured before we arrived in a month before we arrived. They had to do a laparotomy because of fragment injury to the abdomen and the wound dehiscence. So the wound opened and started to leak from his bowels, so had multiple fistulas.

Patrick: So anything he eats or drinks comes out straight from his abdomen and the boy didn't eat for a whole month. So I went to see him. He was like skin on bone and it was, we thought he's going to die. Yeah, if he doesn't get any treatment or taken out of Gaza, this boy will die. We gave him a lollipop, you know, sweet and his face just lightened up.

Patrick: He was so happy to have this sweet. It's really heartbreaking. And unfortunately we had to cut Our

mission short because of an incident in the safe house that we're staying in the whole team, we are British, four British surgeons and one Canadian the house was de conflicted, which means the WHO, the UN, everyone has the coordinates of this house and agreed that it's a safe house for this emergency medical team under the WHO to stay in and it's a green zone at six o'clock in the morning when we're preparing to go back when we took a break and we went to go back again to the hospital.

Patrick: We were hit by an airstrike, and this airstrike just hit the outside wall of the building, and luckily the sand absorbed the explosion and the fragments, and if that rocket was three meters closer, I wouldn't have been here speaking to you today. So it's like I said, it's one of the most difficult missions I've done. And I'm sure when I go now, it will

be much worse. And I don't know what to expect, but we've been asked to go and there's a huge need for that. So let's see what happens. Maybe when I'll come back, I'll let you know. I think we'd all like to know, how do you prepare mentally to go back to a situation like that where you were mere meters away from being blown up by a rocket and where you as a visitor have to absorb that human suffering, knowing that you have limited resources.

Patrick: I'm assuming a significant number of these injuries could be dealt with in a well resourced area.

Patrick: How do you think about that? let's pray and hope you make it there and back, but you still, you have to come back and leave those people behind and I'm sure that tears at you. And so how are you preparing for all this?

Patrick: There's a lot of feelings in surgery and there's a lot of feelings in surgery and a well resourced, non austere.

Patrick: environment in

which there's not a terrible war going on. It's, again it's really difficult, but again, once you see the amount of suffering and how much you can benefit these people, then you start to think about that, concentrate on that try to not to think too much about the dangers that you will be facing try to re, I try to reassure myself that everything is set up awfully to be safe for our team to be deployed there and to come back.

Patrick: It's frustrating to have limited resources because a lot of these injuries can be dealt with here in the UK, and I'm sure same thing in the States. If one patient come as a trauma, you have the whole trauma team there, you have seven, eight specialists dealing with that one person. There you have one doctor dealing with ten major

injuries.

Patrick: Again it's difficult, but then you think about. Saving one life is worth it, and this is what makes the whole thing worthwhile. If I go there and contribute into saving even one life, one child, I think that's good enough for me to go back again. And it's, you asked about feelings, really.

Patrick: It's difficult to describe it, Patrick because it's, in one way, it's very rewarding. If you see your patients getting better, your child, the child that you operated on or the man or the woman that they were almost dying. And after a few days, they're walking out of the hospital, smiling and saying, thank you and goodbye.

Patrick: That means the whole world to me, and I think that is

worth everything, really. And that's the rewarding thing. The relationship, the friendship that you build with the doctors there, with your teammates, with the surgeons and the medics in the hospital that you're working in, it's lifelong friendship. And really, you cannot compare it with anything else.

Patrick: But on the other hand, it is quite stressful when you think about it, and I try not to think about it too much, because you're going, and there's a risk of injury, there's risk of death and you've got your family, and you need to let, you need to let your family, you know, You know, they should be on your side supporting you.

Patrick: And I've been really blessed with a very supportive family. My mother bless her. She's always supportive. And I know she worries a lot. My children. My

daughter, Cheddar, who's 19 now doing psychology worries a lot and sometimes she cries and send me messages. My son, the same thing. He's always messaging me.

Patrick: Are you okay? What did you do today? He doesn't want to scare me, but he tried to, you know, get a reply from me to say, well, I'm good. Don't worry. I'm okay. And you know, when I operate being a father, put thing in prospect for me. So when I operate, I had a, one of the patient that I had was a girl and a young girl, and that was in Syria.

Patrick: And she was at that time, the age of my daughter, and she had a blast injury where fragments injury to the abdomen and to the bottom area. So we had to operate Repair the the injured bowel and bring a stoma out. Defunction her because of the injuries at the bottom end. And every time I looked at that girl, I thought

of my daughter being there.

Patrick: Every time that girl cried, Always in pain. I felt that my daughter is crying and in pain, similar with my son. I had a five or six year old boy who came with a fragment chest injury that we had to do a thoracic abdominal incision to repair the chest and injured lung, the diaphragm and repaired, took the spleen out because of the fragment.

Patrick: And that boy, when he woke up, he didn't have any family around him. And I'll tell you in a minute what, why he didn't have a, his family around his father brought him to us and then disappeared. And when that child walk woke up, I found a small toy and I took it to him to, you know, just to cheer him up a little bit.

Patrick: He looked at me and this is the first time I see. A child crying without a sound. His

tears were coming down and he didn't say a word. He looked at me, took the toy and just turned his face away. That broke my heart. I imagined my son is there in his position. And I felt so bad. After a couple of days, he didn't have any of his family.

Patrick: So the patient next to him, his mother, the child next to him, his mother starts to look after this boy. After two days, the father came back and he said, Oh, I'm asking about my son. So I was really frustrated with the dad said, wait, where did you go? Where did you leave your son and go? He said, I'm so sorry, doctor, when I brought him.

Patrick: The barrel bomb hit our house or a building. I brought him to you and I knew that he's going to be safe in the hospital. I went back to my house to dig out my daughters and my wife and I just managed to get them out and I buried them and I came back for my son.

I just sat down in tears to be honest. So it's difficult.

Patrick: It's really difficult. But having supportive family, having, you know, they understand what you do. My kids understand that, and they support me, and I'm so grateful for this. My wife, Alaa, is a humanitarian psychologist. and herself. She does a lot of humanitarian work and support in war zones and have a lot of trouble.

Patrick: So between us, we understand our work and we support each other. So every time I go on a mission, she understands she's there supporting the family. When she goes on a mission, I'm supporting the family and supporting her. And that makes a huge difference. Not just that having friends and colleagues like David, like people who we have in Syria, in Yemen in all these countries that we traveled to in

Ukraine we know that we have a big family and we support each other.

Patrick: And also having a supportive workplace. And I'm really grateful for my work the Manchester University NHS Foundation Trust, from the management to my colleagues. They've been absolutely fantastic and supportive. They understand the work that we do in the foundation. They support my leave. And when I come back, they're always, you know, very supportive and happy to see me back.

Patrick: And that makes a huge difference, really.

Patrick: Oh, well, Dr. Darwish, you are truly an exceptional human. Your family is exceptional. The Knott Foundation, Dr. David Knott, Ellie, everyone there is doing such important work and I'm so grateful you were able to share it on Behind the Knife and I hope a lot of people hear this.

I hope a lot of people also look into the David Knott Foundation.

Patrick: We'll put the link, it's davidknottfoundation. com into the show notes. So that if folks want to support the work you're doing, they can, and there's lots and lots of different ways to do so. Again, we thank you for your time and wish you the safest of travels on your upcoming trip back to Gaza. Just one last thing.

Patrick: Thank you very much for having me, Patrick. Like I said, I'm a huge fan of Behind the Knife, and I look forward really to build and working with yourself and with your team in the future really with the David Knott Foundation. We have a lot of partners like Action for Humanity, the WHO. Awesome. And.

Patrick: We cherish and we value these partnership and we try to reach as much people as we can. You know, we're really privileged as medical professions.

We have the knowledge, the expertise to save lives, to elevate the suffering and We should really be using this and helping people to you know, to cure people and get get them better.

Patrick: All of us, even if you're not a medic, you can still be a true humanitarian. The way you deal with your patients. family, your workplace, your neighbors, your community, the way you are nice to them. As long as your aim is to stop the suffering, you are a true humanitarian. And just last thing is, you know, for our, for my colleagues who are interested, please go out there, do your best, do no harm, and elevate the suffering and dominate the day.