Angry Planet - What It's Like to Work in a Gazan Hospital

Episode Date: November 15, 2023

This week on the show we talked with Canadian-Palestinian doctor Tarek Loubani about his work as an emergency room doctor in Gaza. Loubani helped pioneer the use of 3D printers in Gaza to produce low-cost medical equipment like stethoscopes. In 2018, he was shot in the legs by the IDF while delivering medical supplies.In this wide ranging conversation, he talks about the importance of low cost medical supplies, the 3D printing revolution, and what it’s like to work in a hospital under siege.The Glia ProjectMakers of 3D-Printed Medical Equipment Struggle to Save Lives In Gaza Under SiegeIsrael Bombs Emergency Medical Equipment 3D-Printing Facility in Gaza (Published 2021)Angry Planet has a Substack! Join to get weekly insights into our angry planet and hear more conversations about a world in conflict.https://angryplanet.substack.com/subscribeAngry Planet has a Substack! Join to get weekly insights into our angry planet and hear more conversations about a world in conflict.https://angryplanet.substack.com/subscribeSupport this show http://supporter.acast.com/warcollege. Hosted on Acast. See acast.com/privacy for more information.

Love this podcast. Support this show through the ACAST supporter feature. It's up to you how much you give, and there's no regular commitment. Just click the link in the show description to support now. Can we talk about the GLEA project and some of your experiences on the ground in the past and how important tourniquets are? Yeah, absolutely. I mean, the Glea Project basically came up during the 2012 war. And the origin story, as it is, is that I was taking care of all these patients. I had this beautiful litmus stethoscope, which I brought with me from Canada. And as it happened, I was the only one with a stethoscope in that emergency. Basically, for one reason or another, litmus weren't available. They're very, very expensive. At that time, it was about a month's salary for a doctor. and also they were just very hard to get in because the blockade was going full steam. And so really the only stethoscopes that were available to most doctors were so poor in quality that they're basically useless.

And so during the war, especially when they're explosive injuries, the way that they work, they can sometimes end up for, like just to make it simple for your audience, popping a lung. This is called a pneumothorax. And pneumothorax, in certain cases, can kill you. mention of orthoravs. And so this is something that's very easy to treat if you identify it correctly and fatal if you don't. It's very high risk, sort of high risk, high reward condition. And, you know, at that time, I was the only one with this stethoscope. There'd be maybe 100 people come in at a time and there'd be 10 of us working in the emerge and I'd have the only stethoscope and so we'd pass it around. And when you needed to figure it out, if you didn't, if you

the guy with the stethoscope or the woman with the stethoscope, then you'd put your ear to the patient's chest, which was often bloody. It's not like everything is blood and then their chest is fine. And then we would walk around. You'd have like a little bit of blood on your ear because like you listened. And I used to, because obviously I was in a teaching role, I would teach my patients because they'd say, I don't want to do that.

Be like, your patient might die. Getting a little bit of blood on your ear is not a problem. Like, go the fuck up. And so, you know, you'd kind of know who was just dealing with it. And sometimes just obviously there's a lot of gallows humor. He's like, yeah, doctor, did he have attention to me withorex or not? You know, they tell you, I put it in the chest too, but al-hameda-l-l-Land-a. So when I went home, obviously, I was feeling a lot like I think a lot of us are feeling now, just so depressed.

I felt depressed actually in a different way from kind of how we all feel depressed now. I felt like I didn't deserve to be alive. I don't want to die. I'm not suicidal. I never have been. But I couldn't explain to myself why all of these people who I had treated, you know, I saw almost everybody who died in that particular war. It was short. It was eight days.

And I couldn't explain to myself why I was the one who was not only alive. But then after the war got to go home and drink cold orange juice with the lights on 24 hours a day. You know, that first week back from that particular war, I didn't even turn on the lights. I like, in the stupidest act of solidarity known to man, I was just like, I'm just not going to turn out the lights this week. Oh, stupid is that? And I went to sort of get myself out of this moment. I went to visit my brother who lives in the same town. And his young son sort of approaches me,

kind of sees that I'm down, like, very good at picking up the vibe. And he's like, oh, Amo, are you sick? I'm like, yeah, I guess. And so he is basically like, okay, well, if you're sick, I know what to do. He goes and grabs this. toy stethoscope that his father had bought him. His father, my brother is also a doctor. And so he comes over with this toy stethoscope and starts listening. And I'm like,

what's he listening to? I put it on my ears. I, what must have cost 30 cents to produce? I put it on myself. And I'm like, oh, this stethoscope isn't shit. Now, like Matthew, if you had to guess what are the three priorities, the engineer, probably somebody from China, India, designing that particular stethoscope. Are any of them quality and patient care? Absolutely not. Absolutely not. And all I could think to myself is, holy shit, this engineer with no priority towards patient care was able to do something this good. Like, what can I do if I turn my Western medical education and institution towards the problem of low-cost medical devices? and off we went 3D printers,

research and development, grants, all of it, Health Canada certification, all of it, all of it, all of it. And we were able to design the stethoscope that was as good as anything out there. And of course we released it as open source. Of course we did. You know, like, I'm a,

I'm from the Richard Stallman School of Free Software, you know. There was never even a mild conception that I wasn't going to release this thing as open source. And most of all it was because I didn't want to be in the business of stethascopes the rest of my life. Like, you don't like it? Help me. Help me make it better. You can't do that with the commercial models. And what we did was we ushered in this model that now I think it's accepted that you can make high quality medical devices that are open source.

You can make them at low cost. I think we've broken through this facade, a different kind of propaganda that the pharmaceutical and medical device companies have, that nothing is accessible unless it comes from us, that everything costs $2 billion to develop, and that's why you have to pay your left leg to do anything. And you can make them on site with 3D printers. Well, that's the thing. Yeah, that's the thing.

3D printers just made it possible. But of course, back then, you know, you're talking about 2012 when we started this project. 2014 when we released our first version. 2017, by the time we had it proved out, and it took time. It took time. But that's because I didn't know what the hell I was doing, mostly. Now we can usually get a device all the way through the entire pipeline in about a year. So we're working on higher-end devices.

We have a pulse oxymeter, which we're looking for some help with if some of you're listeners are in that domain, we have electrocardiogram, which is ready to go to clinical trials as soon as we get the ethics approved for it. You know, we are basically ready to tool up. And while we were doing that, the most important thing about this project, which I knew the moment it started, is that it was never going to be a Canadian project. It was always going to be a low resource country project, you know, in Gaza or right now there's other projects in other parts of the world, like Zambia. So what they did in Gaza, once you got them the 3D printers and once you started making

stethoscopes, they're like, yeah, yeah, yeah, this is nice. But you know what? Is killing our people right now bleeding from gunshots? Do you think we can do something about that? And it was, I'm proud to say that I was not involved at all in the initial research and development of the tourniquet. We just made the resources available. actually the doctor who led the project had nothing to do with Glea.

He came in because they had done an analysis and it turned out in 2014, I'm going to use very rough numbers. Please do not hold me to these numbers. They're very rough. These are not accurate numbers. Go look at up the United Nations numbers are probably the best ones. Approximately 2,000 people, Palestinians died in 2014. And of them about half died of exanguination.

We love fancy terms that people can't understand. that just means bleeding to death. And of those, about half took at least 30 minutes to die. That group of people, you know, a quarter of the 2000, let's call them 500, that group of people is what we would consider highly preventable deaths. If it takes you 30 minutes to bleed out, you didn't need to bleed to death. And so they weren't interested in 3D printed tourniquets. They wanted to buy the finest tourniquets in the world.

and import them, and the Israelis wouldn't let it happen. The tourniquet is called the Combat Application Turniquet. I mean, I tried to get a striker bed through with a Y to German company, and the Israeli like customs, I guess, guy on the border, when they finally interviewed us about it, it was like, it's called Stryker. What's it striking? It's a fucking bed. So, you know, combat application tourniquet was bound to be rejected, and it was ultimately.

They never allowed them in. There's never been a tourniquet enter Gaza sort of officially. And so, and the other thing too was that they would cost about 40 US dollars. The team there locally developed the tourniquet, made it from start to finish, and then deployed it into the field. It was rushed into the field because of the Great March of Return, where something like 6,000 people were shot. There were 22,000 casualties, but not a little more gunshots.

About 6,000 were shot and about, 85% of those were extremity shots, shot in the extremities and the arms or legs. These are what we would consider the highly salvageable. And of that really large number, only two people died, 0.3% of the total count. And this is all WHO numbers. This one you can quote me on. And those two people who died represent a fraction of what I'm pretty sure, would have died if not just the Trinicke, but the entire Stop the Bleed campaign hadn't been launched. The number from the U.S. military is about 10% of extremity gunshots end up dying. Now, it's not an apples to apples comparison, but it gives you an idea. We went from this

expected number to 0.3%. It's a whole campaign, trinickets are one part of it, but the reality is trinickets are a big part of it, like it's a big part of a stop the bleed campaign. And so now, of course, There's a lot of interest in the U.S. Because guess where else? There are random gun massacres. And in some of these places where there's lots of conflict. When Ukraine happened, I went there. I worked there last year in one of the frontline hospitals.

And of course, I had a huge need for tourniquets. And I remember I was sitting there when they brought a patient in. And after they finished, took the tourniquet off, I saw somebody go and wash it and then hang it up on an IV pole to dry. And I was like, yeah, that's what we do too. It's what everybody does in low-resource settings, right? You wash and you dry and then you reuse. And I recognized that I was able to give them some of our knowledge from Gaza.

Some of our work in Ukraine has gone back to Gaza. It's been such a beautiful open source project in that way. So what makes a good tourniquet? The thing that makes a good tourniquet is a good person applying it. training. A triniquet itself has to, has very simple function, has to be tight and it has to be consistent. If you can have the tourniquet become tighter because of leverage, that's currently the accepted theory in how trinickets work best. So that's why almost every tourniquet you see has what's called a windlass, the stick that sort of turns. So our current belief is that the

windlass is needed to kind of tighten up the tourniquet. Any turnicet will generally do so long as it cuts off bleeding. And so you can, you know, the old movie belt will work if you're strong enough. But the real advantage of the cat style tourniquets, the ones that people probably think of that they think of turniquets, is that they'll give even small children and women the leverage to do it. So basically, it has to be reliable, has to not break, it has to be easy to apply, and it has to stay put once you put it on there. How long does it take to 3D print one tourniquet? It's about three hours.

The 3D printing is the longest part of the process. It's about three hours because, you know, there are things like you would want to do. Like, wouldn't you love to print, I assume, Matthew, that you've got some fluency in 3D printing. Is that right? Just a touch, yeah. Just a touch. So in terms of 3D printing, would you ever choose to print something that was round on the bed?

Of course not. So, you know, our first move was to basically flatten out the bottom so that we could have it adhere to the bed better. And then we realized that that actually makes the application difficult and inconsistent. We have to make design decisions that were impossible. And so we have to print it round. It takes time to print. But the other thing that takes time is to sew it

and then to quality assure it. These two things are very time intensive. Not as time intensive, but they're the things where the labor actually has to happen. You know, a 3D printer, you're not laboring for three hours. The printer's laboring for three hours. But for the other stuff, you're the one doing the work. That is, it's life-saving, but it's also a lot of time for one tourniquet, right? Yeah.

Yeah, it is. And, you know, we've thought about it and how to do it. Basically, there is injection molding in Gaza. I went and I visited several injection molding spots. I can send you some photos. But essentially, they're all, they get bombed essentially every time the Israelis fly. So these factories get bombed regularly. They are out of commission most of the time.

They're very hard. They're undependable. And so during most wars, we're actually producing at the time. Very often, we have a serious funding problem. People don't think about tourniquets until there's a war. And then all of a sudden you're like, well, I want to produce for you, but the Israelis just bombed my production center. What do you want me to do right now? You know, we, and also the Israelis aren't letting people move.

So even if I do produce for you, you know, it's very hard to get them to where they need to be. The theory that we have for tourniquets in Gaza right now as part of this thing called the Stop Them League campaign is that we need to do what's called pre-positioning. So we think it's a population of at the moment 2.3, 2.4 million, depending, I guess, on the death toll in the end and the people who become refugees. But it's probably going to be 2 million at the end of this. And we think we need about 100,000 tourniquets to take care of the population properly. That's not to say 100,000 people will be shot or wounded, but you need the tourniquet available when it's ready for use, which means that, you know, you've got to preposition it. And so the goal is to put 1,000,000 people. turnicates in every school, every major business, you know, the Palestinian equivalent of Walmart, these kinds of relatively large centers, to put a few hundred in every mosque. Think of everywhere you see an AED in the United States and imagine that in Gaza we would make sure that there's a thousand tourniquets there too. Why, it seems like this is a basic medical device, why can it not make it through the embargo? It is, the embargo is not supposed to catch medical

devices. Right. And that is like clear. The Israelis are consistent and clear about that. The embargo has gone through, you know, we're using the word embargo. The official language is blockade. You know, the blockade is basically in its third or fourth iteration right now. The first iteration, they didn't issue a white list or a blacklist. And so organizations, human rights organizations, would issue gray lists. We're pretty sure these things sometimes come in, sometimes don't They would issue what they thought were whitelist and they would issue things that had been banned recently, what they would consider the blacklists. But the blacklist included cinnamon for a while. Like, what's the military purpose of cinnamon?

I don't know. Like, it included chocolate for a while. What's the military purpose of chocolate? The gray list are the things that are useful, but that the Israelis for one reason or another have told us we can't have. So, for example, solar panels are on the gray list. And you can go a year, two years, three years trying to get solar panels in. And then suddenly they'll be like, yeah, you can get them in now. And then you get them in.

Same with batteries. Lithium ion is a total no-no. We're never going to get lithium ion in on a major scale. But they allow us to bring in lead gel sometimes. Most of the time it's rejected. You can't plan a project anymore because you don't know if it's going to make it in or not. But, you know, that's kind of gray list. Turnicates end up being on the de facto black list because I'm theorizing here.

But I theorize that the people who are looking at them consider them a tool for people who are shot. And they think everybody who's shot needs to be shot or should be shot. Like it's almost a guiding principle of theirs. and so we just have had no success with tourniquets at all. We have not much success with most things. For example, at the best of times, the stores have what's called a stockout list, and about 40% of what we consider essential medications are stocked out. There's lots of times when I can't get amoxicillin, like pain control, like morphine.

I mean, I think I could get a nuclear bomb easier than I can get pain control sometimes. So even in the emergency, I use this medication. this is going to mean virtually nothing to you, Matthew. Your medical listeners, their jobs are going to hit the ground. I intubate patients with thionopental and phenobarbital. And the reason for that is that propofal also doesn't make it in. Again, this is going to make no sense to you. It's your colleagues, only the ones who are probably older than the internet

who will know what those drugs are. Is phenobarbital, is that truth serum? Is that, or what we used to call it in bad fiction in the 40s? I guess so. I don't know that use of it. But it's a sedative that's so dangerous that like, why would you use it? But, you know, it's, so it's not like the Israelis can't allow things in. Like, if you're going to allow me to have thiopental, then why can't you allow me to have propothal?

No, it's a bar, I'm wrong. It's barbiturate. Yeah, wow. I didn't even know people still made that. Yeah, yeah, they're in glass vials. It won't surprise you. So the ones that you break.

Anyway, point there being that I want tourniquets to be allowed in. Turnicists should be allowed in. No medical device should be blocked. And probably if they were allowed in, it would kill our project. We'd move on to something else. Happily, by the way.

Happily. I want Glea to be at a business. but the reality, if you want to talk a little bit more about Glea and Glea's guiding ethos, the reality is that a project like Glea that opens up medical devices is both good during occupation and also good the morning after occupation. So imagine a peak medical system. I'm sorry I'm going to have to not say the United States, you know, but in a peak medical system, you still have devices and equipment that is too expensive for people to access or so expensive that governments have to ration their purchases of it.

So take as an example, let's take an American example, insulin, people rationing its use. Take as an example, dialysis machines. Probably we could stand to have many more of those around, but they're so expensive. So a project like Glea will convince people that there is a place for open medical devices. And so the day after occupation, when all of these people descend, right now, Siemens won't do business in Gaza. I don't know. It's a random company that I picked. I'm sure they don't.

Pretty safe bet. These companies won't do business in Gaza, but they will eventually. And when they show up, they're going to start. start trying to blow smoke up everybody's ass about how only their device is the best and why you have to pay, you know, a million dollars for something that could be manufactured for so much less. And so a project like Glea is also inoculating the healthcare system so that they engage with these, you know, relatively parasitic medical device producers in a way that is more favorable. So imagine, for example, if the Ministry of Health in, let's say, Gaza or anywhere else,

is negotiating with a company about buying dialysis machines. The company says $20,000. And you say, well, but I can make the same machine for $1,000. Like, why don't you give me a more reasonable number? I don't want to make it, but I can't. Please don't make me make it, you know? and then you're able to put downward pressure on these commercial proprietary manufacturers where our work isn't just creating medical devices.

It's also fundamentally altering the economy to depress the costs and thereby make medical devices more accessible to everybody. Right. There's these knock-on effects here that I think are so, so important. I think everyone who has touched any kind of health care. system or any of these medical device companies in their entire life, knows how frustrating and nightmarish it can be. Any of these middlemen, right, really kind of put the screws to people.

And the Glea project is, shall we say, a tech disruptor in the space, right? Another thing that I found quite fascinating is that Glea is kind of pioneering the collection of data information about a lot of of these medical devices, right? So one of the ways that these companies kind of prevent people from getting cheap and easy access to care or their machines is by sitting on the manuals, right? So you're also, Glea is also kind of helping to create databases of medical device information, right? It's full spectrum. It has to be full spectrum. You can imagine that to be, to be, make a device, you actually have to generate a lot of data just in collecting how the device

works, calibrating the device. I'll give you an example we're going through right now. We've been collecting data on pulse oxymetry. Pulse oxymetry is the clip you put on your finger to tell you how much oxygen there is in there. A commercial device easily costs $1,000, and a glia device costs maybe $50. So the data, firstly, the data is generally racist. the FDA requires you only really to test it on more or less white people, and you have to throw in.

There's now a number, a minimum number of people with different skin tones you have to throw in. But what we've noticed in our own work is because we're comparing the hardcore data, the blood readings through the gold standard, we're comparing that to our device and to the gold standard market device. and what we've noticed is that when we put a white middle-aged guy in the machine, the numbers are perfect. They match up exactly. And when we put somebody with any other skin tone, they don't match up. It's not usually a huge problem, but when it gets to the points where the data isn't very good in the lowest parts of the spectrum, then it becomes much, much worse.

So how do you calibrate a pulse oxymeter? You take a human being, because this is actually, I shit you not, we don't have a better way to do this. You take a human being like you, and in fact, I invite you to come and have this procedure done, you put a cannula, a tube into their artery, and then so that you can pull blood off at regular intervals, and then you suffocate them. You just choke them out until their oxygen. is that falls to a point that we consider ethical, 70%, and then we stop. Because that's the limit, that means that we have no data below 70%.

And I would argue to you that that's actually the most important data there is. No pulse oxymeter has that data set yet. And so by not just, in collecting the data, we're not just collecting the data and making it available. We're creating a framework for the data. So what's going to happen is once this pulse oxymeter is good to go, once we get it through all of the health Canada stuff, the calibration, the validation, all of that, then we're going to put it in intensive care units. And we're going to say, hey, look, you have patients who are dying anyway, and you're measuring them anyway. So we're going to use ours. And as you draw off blood samples, because they do that regularly, we're going to match that moment in time to the reading that our machines have, and we're going to contribute that data to a data bank.

creating probably the only data bank of, definitely the only public, but I think actually the only data bank of critical care results. So, you know, that's the funny thing about open source. Like, what's Windows's web server nowadays? I guess it's IIS, if you want to say like not Azure. Yeah, not Azure is a good, is a good way to say it, I think, actually. When Apache started, I'm not sure that it was better than IIS. But there's no question now that open source has overtaken. That's because it builds in a way that's more or less inexorable. And if we put these devices out and let these data banks collect,

we're not just as good as the gold standard. We're very quickly going to become much, much better. And I strongly suspect that within 10 or 15 years, these open source data banks, which by the way, anyone can use, like I invite the manufacturers to use them too. These open source data banks are probably going to mean much better care for critically ill people. Can we switch gears again, if that's all right? Yeah. I know I'm meandering with you, Matthew. No, this is a, this is a meander show. This is what we do. We go all over the place, we ramble, all the guests.

It's funny how often guests comment on it. It's, uh, it's, uh, it's interesting. Like, you let me talk so long. I was like, well, yeah, it's a podcast. That's what we do here. You know, the most popular podcast in the world is two guys getting stoned and rambling for three hours, right? Yeah. Anyway, can you tell me, I really want the audience to understand what it is like to be an ER doctor in Gaza.

Can you kind of describe your experiences for us? Okay, since you don't mind me, Neandering, I'm going to tell you a story that's been on my mind this whole time. And I don't know why it's like an intrusive thought. And I actually told the story for the first time yesterday and hadn't really thought about ever sharing it publicly before that. but there was this one guy. So because I'm usually the senior medical doctor in almost any hospital that I go to in terms of trauma experience,

I usually get one of the most sensitive posts, which in most of these mass casualty situations is triage. The triage post is when you stand at the door and you direct people. Either you don't think they need treatment at all, You send them home. And by the way, like, somebody with a bone poking out their leg might not need treatment if the situation is severe enough. Or you think that they're not surviving, they're going to die.

So you send them in a direction or they're already dead. Or you sort of send them into the actual hospital. So you're there at the first post. and I remember this one time I was standing there and patient comes in, his son's with him. They had come in in a personal, I think it was a personal vehicle. I actually forget exactly right now what vehicle they came in,

but his son was with him. And they come in and I point them to my right. And so his son starts walking in that direction, looks there, and he's just like, where are we going? And so I say to him this saying, this Muslim saying,

Inna to Allah, and inna ilihe, Rajahum. And so he looks at me and he's like, doctor, but he's alive. The saying is a saying

you say when somebody has died. And I just repeated it. Inna to Allah and Allahe Rajaham. You're over there. And I remember thinking that if we were in Canada, this guy wouldn't just be salvageable, he would be easily salvageable. Please forgive the medical terminology. Salvageable doesn't sound like something that

should be used for human beings and it's not. But at the end of the day, I'm vaccinated in medicine, so I use these terms. But I knew that with my crew on that day, with the patient load as it was, that this patient would not survive. And the technical term for that is expectant, expectant to die. And so off he went in Naldao and Elida and Ere Jerome. And that position, that specific post, and the thing that I only really realized this week, I'd like blocked out of my memories so well, that specific post is so traumatic because the dead look at you and they beg you to do something and to help them.

They're screaming. They're in pain. You know? And you know that there's nothing that can be done. And in fact, as a necessity of being in that terrible situation, I dehumanize them. I don't think of them as Abdallah or Ahmed or whatever. I think of them as that 98% burn.

I think of them as that like over-exanguinated femur. So that's, I think, a way to put a bit of a picture about what it's like. You make terrible decisions that you know you didn't need to make. Most of my students, most of my residents now, they've only trained in Gaza. Many of them were small children when the blockade began. But all of the doctors, my age and older, they all trained outside, all of us. They trained in Ukraine. They trained in Russia.

They trained in London. They trained in New York. They trained in Wisconsin. They trained in Canada. and so they know that in any one of these places, you wouldn't be saying in that L'Ana, once you make it in, once you're through the door, then it becomes this bustle, this chaos,

this scene of, I guess, like a bazaar, an absolute bizarre because of course everybody nobody gets in there unless they're severely injured everybody's hurting

there are obviously a lot of women and children who you have to disconnect yourself from you cannot look at a child and see a child

you will not survive the shift or load the war you just can't you know these are bodies to be treated as bodies

and that's it that's the only you've got to disengage it's not the time for for your humanity in that moment. And the doctors are doing their best.

And in that moment, you know, at the beginning of the 2012 war, at the beginning of the 2014 war, at the beginning of the 2018 engagement, at the beginning of the 2021 war, at the beginning of the 2023 war, at the beginning of all of these wars that I have been there for, not necessarily attended personally, but most of them I have at this point,

the beginning of all of those wars, that's the training you have. That's the equipment you have. That's the hospital you have. That's it. It's never going to get better than that. It's only going to get worse from that day forward. And so they're doing the best that they can

based on the training that we gave before then. We do a lot of training. We do a lot of drilling and trauma. We do a lot of work in all of these fields to kind of make sure that everybody gets to gets to participate. And the only kind of training that we do in that moment is what's called just in time ATLS,

which the system has now broken down in Gaza, but it's a system that kind of was developed in Gaza, co-developed with some really wonderful doctors in Canada too. And this system basically is in the morning, when bombings are usually down, then you can sit there and do some training in the resuscitation room. and then in the afternoons when bombings go up and obviously over the nighttime, then you take that training and you use it to try to care for patients under some supervision.

So I'll monitor doctors who are psychiatrists, who are endocrinologists, you know. These are doctors who probably went into those fields because they had no appetite for trauma. And I'll train them or, you know, the system will train them to know what to do with trauma. The equipment is obviously completely absent and as the numbers go up your use of equipment goes down. By now

basically every medical disposable is gone and so you start guarding things like for example you'll guard needles or give them to somebody so that if a family member of theirs comes in you can reuse it on that family member and that

becomes an accepted like think about it if you have only dirty needles how do you manage that. Obviously, there's lots of blood donation going on, and we do blood donations the same way. There's no, the place with the reagents to test for HIV and blood got bombed almost immediately in the last war, and I'm not sure where it is now, but I'm going to guess that they don't have the capacity to test as many units as are needed. So, you know, you kind of have their family members donate to them, and then kind of hope for the best. Every, everybody there knows their blood type. It's like here's someone in the military or anyone in the police knows.

They're like, you can ask a 10-year-old and they probably know their blood type. And by now, things have degraded so much that you stop writing on paper. You write on the patient. So that as the patient goes through their journey, their medical record is their usually their abdomen. Depends on what's not injured. It could be their life. The nice thing is that people are kind of aware.

so many people will write their names on their forearms. And, you know, if you pick them up, you don't know who it is. You'll very often kind of see the name. And that's usually, like, family members will write the name on the patient's forearm. And that's, as I understand it, that's been happening a lot now with people writing identification before getting injured, just so that if they're injured, they can do it. Once I'm done with them, that's kind of the end of my role. role as the emergency and stabilization, then we send them up to the operating room. Almost all

the patients who hit us will need some kind of surgery. Not every patient who's a victim of bombing needs surgery, but the people who you're going to allow into the triage are usually the ones who need advanced care, who will die if they're not treated within half an hour or an hour. And almost all of those are going to be surgical cases. So, you know, you kind of send them up to surgery and I honestly, I went up to the surgery suite during war once and never again, never again. I just, I don't need that. I don't need that trauma. I don't need to see it. It's devastating to watch it because at least, you know, I can live with this myth that like, all I need to do is stabilize them, then the OR. The OR is the god of every hospital, right?

Like, my job is to get them to OAR and then everything's fine. And here, like, the The OR is just so bad. They're currently one of the surgeons, who's usually based in the United Kingdom, has been reporting that they're using vinegar to sterilize their surgical equipment now. That's for two reasons. One is they're almost completely out of sterile water. Obviously, because of the electricity situation, they can't run the ovens to sterilize the equipment because those are so energy expensive. but on the other side also like they kind of have to turn it around quickly and sterilization takes about an hour, you know, on a good day. So they have to turn things around quickly so they finish their surgery, they dump it in the bucket of vinegar, wash it off as best they can and get going.

When were you there last? A year ago in August 2022. And since then, I tried to enter three times in November. in February and in May. And, oh, actually, in August too, so I guess four times. And each time I was denied by the Israelis each time.

The reality is that the medical system doesn't just experience the hot wars. It experiences a constant state of blockade and degradation. And so when I don't show up, my residents don't get taught. I don't get to implement. part some of the experiences that I have. I don't get to check what they're doing, make sure they're

doing it well. And as much as we've moved as much as we can to Zoom at the end of the day, having my hand on the hand of a surge of an emergency resident while he's cutting something is so much more valuable and impossible to reproduce any other way. So the fact that I haven't been able to make it in. It's a huge cost. And of course, I'm willing to try four or five times before I make it in. On the flip side, most people have fixed vacations. They try to go on a timeline. The Israelis have raised the cost so that it's almost impossible for any of us to go and help out. So the last time we talked, I asked you a question towards the end of the conversation. I want to ask it again, but in a different way.

How are you feeling right now not being there? Oh, boy. I mean, I wish I was there. I wish I was there for them, and I wish I was there for me. It's a two-way thing, and it's very, very difficult to pull that question apart in a way that recognizes my personal ego and recognizes my personal uterus. I am useful as a doctor in a place where doctors are few and they're exhausted. You know, these places with these thousands of patients, you assume they've got hundreds of doctors, but functionally the emergency is running on between five and ten doctors,

and they're rotating as fast as they can, they're doing as much as they can, these people have families who are dying, they're exhausted, they're wiped out. being a doctor who's there totally unencumbered by family is in and of itself a huge gift. I can work more than other people because I don't have to carry that cognitive load. So I would be useful there. I should be there. And it is part of the problem that me and people like me, there's, you know, frankly, there's probably only about 100 doctors who can do what I do in, in, war situations like that.

And that's not to say that I'm doing anything extraordinary, it's just that it requires a lot of experience, you know, to see that stuff. And lots of people who do that work burn out very quickly because it's fucking traumatic. So there is utility. I wish I was there. At the same time,

I always knew, I always knew that they have to go into war with the system that we build, not with the people who we have. It's a systems issue. It's always a system's issue. And I am so insanely proud. When I see them, you know,

they send me photos of some of the work that they're doing to sort of both have me check in on them and tell them if things are going the way that I would have taught them. And also to kind of like show me what the situation is like. And they're doing things as amazing.

amazingly as possible, they are carrying a system in a way that I don't think would have happened if they hadn't done all of that work building up their system. And so I think it's important to recognize that the effort to make the Palestinian healthcare system better is Palestinian. It's not United Nations-based or Canadian or anything. It's Palestinian. And we participate in it. And I'm so proud of my role participating in their building up of their capacity.

and I'm energized by their bravery. Like at this point, every one of them has had somebody die, and they're immediate or at the very least, their sort of next degree, relative family, everybody. And yet they report to work, and yet they work hard, and yet they sort of do what they can. And when I talk to them, I feel that they are obviously devastated in a lot of ways,

but that they have clarity of purpose. And that gives me a clarity of purpose. Right here, right now, I have three jobs. The first one is to do everything I can to make sure that they have the tools they need to treat their patients. The second one is to do everything I can to make sure that when the ceasefire does happen, that they end up better than they are today. right the next war can't be like this war they have to be better set up the system has to improve

we have to identify all of the holes and I have the luxury of being able to identify problems and write them down and record and all of that like that's my job right now and the third thing is to try to stop the bodies from going into the river if you know that particular analogy

you know doctors are always told your job is to pull bodies of the river. But at some point you've got to start asking, like, why are these bodies going into the river? And how can I stop that? And the best way I could treat a patient at a time, or if we can contribute to a ceasefire, to a humanitarian corridor, to pressure sort of being exerted on the Israelis so that they don't shoot ambulance, they don't destroy ambulances, then that's even more helpful. And that's currently one of my job. numbers, by the way, there have been 23 ambulances destroyed as of today.

There have been at least 10 paramedics killed, at least 20 wounded, at least three or four doctors as well. So all of these, the paramedics that I'm talking about are all active duty. The numbers of non-active duty are much, much, much higher. These are people who were in ambulances when they got shot. They were rescuing patients when they got bombed. So it's one of those things where we all have our roles. And right now, whether I like it or not, I'm not there.

So my role is to do the best I can for the humanitarian situation from here. Dr. Thank you so much for coming on to Angry Planet and walking us through this. Where can people learn more about the GLEA project and your work and get involved if they want to? Glea is available on basically all social. media, G-L-I-A, you can go to a website, gleea.org. If you have medical device expertise, please be in touch, especially people who are either in industry or have been in industry, because you are invaluable in trying to get this to happen. Similarly, you know, if you're a person who has production

capacity in terms of tourniquets, then get in touch. That would be plastics and that would be sewing. And we're, we obviously can't produce in Gaza right now. So we're producing as much as we can outside and trying to get what we can in. Obviously, there's a lot of quality assurance, but we'll work it out. So support the work that way. People can donate. They can spread the word. They can get involved.

Or even just, I guess, thinking about it and talking to their friends about the situation and trying to make it better for everybody. Thanks for listening to another episode of. Angry Planet. The show is produced with love by Matthew Galt and Jason Fields, with the assistants of Kevin Medell. This is the place where we ask you for money. If you subscribe to us on substack.angriplanet.com, it means the world to us. The show, which we've been doing for more than seven years now, means the world to us,

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