Written by Dr Chris Hook, Emergency Physician, Bristol Royal Infirmary
Edited by Silas Webb & Charlotte Nichols
Trigger warning – this post contains descriptions of injuries and fatalities which some readers may find especially difficult to read
Dr Chris Hook is a Bristol-based emergency and pre-hospital medicine doctor. He recently returned from working in the Gaza strip as a Médecins Sans Frontières (MSF) medical team leader.
Having spent time in South Africa following his foundation years and undertaken an MSc in International Health, Chris began working in the humanitarian sphere for both MSF and the International Committee of the Red Cross (ICRC). Over the next five years he gained experience working in disaster and conflict zones within Yemen, Nigeria, South Sudan, Bangladesh and the Democratic Republic of Congo.
Becoming an MSF medical team leader in Gaza
Prior to 2023, I had worked in Gaza twice: I spent 9 months there with the ICRC doing emergency department (ED) development work and 6 months with MSF as a medical team leader. The latter involved coordinating projects involving burns and major trauma management following The Great March of Return in 2019.
During that time, I developed skills in humanitarian medicine and got to know Gaza pretty well. I have worked in nearly every government hospital in Gaza in some fashion, and have visited most other health structures. As I am also an emergency medicine (EM) doctor, it meant that I could, if needed, support clinical work.
Most importantly I have people in Gaza who I consider genuine friends, and stay in touch with regularly. The suffering they were going through when the conflict started felt quite personal, and it felt difficult just staying in the UK when there might be an opportunity to provide help in person.
First days in Gaza
By the time we arrived on 14th November 2023 it was 5 weeks since the start of the war. Almost all MSF activities had stopped. Gaza City and the north had been cut off, effectively, separating it from the south. We decided we would go straight to Nasser Hospital in Khan Yunis, where MSF had worked a lot before.
Taken from: https://msf.org.uk/issues/israel-hamas-conflict
We were a team of 13 international staff; 3 surgeons, 2 anaesthetists, an EM doctor, an intensive care doctor, an EM nurse, a pharmacist, 3 co-ordinators and one logistician. For the first few days, we slept on the floor of the MSF clinic. During those first weeks, our job was to support increasing medical capacity. We helped to build surgical capacity for wounds and burns by providing supplies, opening another operating theatre and recruiting more local staff. We supported the Nasser Hospital surgical project, but we also supported other primary and secondary facilities. When I was not focusing on logistics I would help in the ED when needed, mainly during mass casualty incidents in the resuscitation area with major trauma cases.
We had initially planned for the team to sleep in the operating theatres in the hospital, but the mass casualty incidents were so abominable that it was felt people needed time away from the hospital to decompress. Debriefing was a massive part of what we did. What the staff were experiencing was psychologically brutal, the wounds they were seeing, the type of incidents they were involved in, combined with their frustrations about how little they felt they could impact the situation. A big part of my role was to try and help them through those feelings, and take on some of that burden to get them ready for the next day of full-time clinical work.
As the conflict evolved, the situation changed. Gaza has been divided into lots of small blocks which were recorded on a map. Everyday the Israel Defense Force (IDF) would say “These blocks now need to evacuate, they are now in an area where we intend to continue operations.” Unfortunately, a couple of the healthcare clinics that we were working in fell into those blocks and so could no longer function. Whilst having been very close to the bombs before, once you find yourself in the place where you are told you must evacuate you have to take it seriously. This meant that we were constantly looking for new places where we could work and help. We opened another clinic just south of Khan Yunis which we had planned to expand to have 50 inpatient beds, but had to close it 5 days later as the IDF moved across the south meaning that the project was no longer feasible.
We had also put all of our stock in two big warehouses south of Khan Yunis when we first arrived. This area was declared no longer safe by the IDF, so we had to find ways to retrieve all of our stock, find new places to store it and task staff to go through everything. We had to keep bouncing, moving, and looking for new places and ways to work.
Emergency care in Gaza
When we arrived, the hospitals were under immense pressure. Everything being heard about Gaza, and people living in hospitals as displaced people is all true. Nasser Hospital, for example, has thousands of people living in the corridors, cupboards, and any spare space, including temporary shelters in the car parks. It is a hub for everyday life, any marketplaces that are happening are around the edges of the hospital, because it feels safer with so many people there. It is obviously not at all safe.
To give some context to the emergency care system in the last few years the ministry of health have developed their own EM training scheme. It takes 4 years and trainees rotate in a similar fashion to the UK – anaesthetics, ICU, ENT, acute specialties. The scheme is producing some excellent EM physicians, where previously it was a couple of medics and surgeons sent down to the ED to directly triage individuals. Now there are trained individuals who practise dedicated EM.
Working conditions are distressing. To begin conceptualising it, imagine the busiest you’ve ever seen any ED in the UK: people on trolleys everywhere, every bed full, resus full, not a single space available. Then imagine, at that moment, you are expected to receive 20 major trauma cases. Then add the fact that this is a resource-limited setting at the very best of times. There is a resuscitation room with 4 beds and 4 monitors, but without 4 ventilators and with only one resus trolley. Whilst there is most of the equipment you might need there is not enough of it e.g. only one laryngoscope and drugs are limited so if you have 20 major trauma patients arriving at one time, those drugs run out pretty quickly.
As an example, when I was in the car park at Nasser Hospital, we heard an explosion. The building shook, and a big cloud of smoke rose close by. I heard the ambulances set off and knew that in a few minutes a lot of sick patients would arrive. In the ED at that point a call went out; “All doctors! All doctors to the ED”. Intensive care doctors, surgeons and radiologists all got ready to support the emergency physicians. We arranged some pre-drawn ketamine and suxamethonium to perform rapid sequence intubations (RSIs). However there was only enough for 10 patients, and there remained only 4 resus beds. It became very busy very quickly because many of the patients were pulled from the rubble by non-emergency responders nearby. In these circumstances patients arrive in cars, in trucks – some in ambulances, but often they are simply carried in by brave bystanders.
Triage is exceptionally difficult. The team have an amazing experience of mass casualty triage, sorting people into green, yellow and red areas. However, anybody with a pulse who can’t walk is likely tagged as a “red” patient and obviously following these explosions this triage category encompasses the majority of patients. Suddenly 15 patients have been brought through to this four-bedded resuscitation unit. Some of them clearly have unsurvivable injuries from massive trauma, or are peri-arrest, and you do not have the resources to deal with this. But they are still there, so you find yourself working around dying people who have to be put on the floor whilst another space is found for them. But of course there is no other space – everywhere is full. So you might have 2 children on a trolley, one being intubated from one end, and one being intubated from the other. Meanwhile you are having to step over dead children to even be able to get to these children who might survive. You just do it, because you have to. You treat people who may well die in the end, but you are trying your best to save them.
People are doing whatever they can, and there is a good attempt at a system. For example one of the EM doctors is designated to FAST scan everybody. They use a butterfly ultrasound and are highly skilled because they are constantly learning – in the same way they are excellent at performing RSIs because they have so much experience. But you can imagine the equivalent of CT1/CT2 in EM being given a 10-year-old child who’s been exploded, he’s unconscious and has a partially amputated leg and they have to deal with the case on their own – that’s the level at which they are having to cope. Added to this, they are dealing with the busiest, most hectic environment possible, with people dying, or already dead, on the floor next to them. There are limbs amputated. There is blood everywhere. And they deal with that. And they get through it – they do an amazing job, and then they start to clean up. And then of course there’s another explosion, and there’s another call, the shout goes out “All doctors to the ED!” and they go through it again. And they get through it again. And this is not just for a week or 2 weeks. Over 100 days of war. With fewer and fewer resources each day.
The day I left, I remember a young man was shot in the chest not far from the hospital. He was intubated on the floor in the ED because there was not a single trolley or mattress left. He was ultrasound scanned, given bilateral thoracostomies and kept alive. He was carried on a plastic board to the CT scanner, taken up to theatre, had his operation, and went to ICU. To be able to achieve this in the current situation feels utterly incredible. But how can it continue?
For the patients who make it to theatre, the post-operative care is almost impossible. This is a hospital with 230 inpatient beds, and they now record close to 800 inpatients. Nobody knows where these people are. I tried everyday to find the list of about 100 patients under the care of the plastic surgeons, and everyday we found 60, sometimes 80. Patients realise they haven’t been seen by a doctor for a couple of days, so they go home (to wherever they now call ‘home’) with no follow up plan. There are people with exposed bone and large wounds just living out in the community. There are people with external-fixators in place for 3 months and infected amputation stumps. MSF clinics are seeing people who need urgent plastic surgery but there is no capacity to provide it. It is a sad fact that even if you are fortunate enough to survive that initial injury, the long-term sequelae will be devastating.
This only takes into account the major trauma. Each day people are still having heart attacks and getting infections; elderly people are still becoming unwell and children are still getting pneumonia. Primary health care is collapsing, if it hasn’t already collapsed. People are decompensating from their chronic conditions because they are not getting access to their medications. All of the things that we see every day in the ED, appendicitis, bowel obstructions – there is no space for them.
It doesn’t end there, new challenges are coming. Incidence of diarrhoea in children is exponential in comparison to previous years, because people are displaces living under plastic tents in the rain and cold. Pneumonia cases will similarly sky-rocket because people have no access to primary health care
Conditions for healthcare workers in Gaza
Now, the Nasser Hospital is next to the blocks that have been told to evacuate. It has been hit by a mortar. Most of the staff have been displaced so cannot get to work. Before I left, the head of the ED was on his own for 24 hours because the IDF cut off the road. Everybody believed that Nasser Hospital was about to be besieged. This is what they’re dealing with. They are living in fear. They are not paid and haven’t been paid for a couple of months. You’ve got to be one of the bravest people imaginable to keep going to that hospital at the moment, to keep working there, to keep turning up day in, day out.
The doctors there, the nurses, pharmacists, nurse assistants, every member of health care staff that are still able to work- they are heroes. These people, they are fighting to the bitter end to provide whatever care they can. Everyday we tell the team in Nasser Hospital “It cannot be safe there, you must leave”, and everyday they say “Yeah, okay. I think we can do more. I think we can stay.” I’m not sure I know a single UK practitioner who would cope with these conditions. I don’t know any department that would still be functioning at all.
It is depressingly unique in Gaza that there is truly nowhere for people to go. They were displaced from Gaza City and told to go south to where it would be safe: so they moved south. Now that area has been declared as no longer safe, so they move further south, where there are still airstrikes. I cannot think of another circumstance where this has been the situation. Where you are told to move, but there is simply no way out. This population cannot become refugees because they are already refugees. They are a refugee population who have now been internally displaced. They cannot cross the border into Egypt. They are tightly packed and being squeezed into smaller and smaller areas, and they cannot get away from the fighting.
We were living in the ‘safest’ area in Gaza, on the coast. Nevertheless, all night long you can hear bombs, ships firing from the sea and tanks firing from the land – the building literally shakes. One strike hit the maternity unit at Nasser Hospital: clearly the safest parts of Gaza are truly, truly unsafe. The sheer number of people injured as a result of this conflict is escalating quicker than anyone has ever seen anywhere. These are heavy, heavy bombs being used in densely populated areas. To have that number of patients in such a small number of hospitals has never existed – neither is it possible for it to exist in any effective way.
So far in my career, this is, without any doubt, the most brutal thing I have ever witnessed. Certainly within MSF it is the most I’ve ever seen us concerned about how we even manage our own security. MSF convoys have been attacked in Gaza City and since I have been back in the UK, the MSF shelter in Khan Younis has been hit by a shell, resembling that used by IDF tanks, killing a 5 year old family member of our local staff.
A daily decision is being made about whether MSF can function in Gaza – and this is the organisation known for being the one that ‘leaves last’. I have never seen the organisation needing to think like this. Can we even be here? Is the value that we can add on a daily basis enough to justify the risks that people are taking whilst trying to help?
Psychological impact on health care workers
The psychological damage that has been done to my colleagues is immense. Almost everybody there now has been displaced, they’ve lost their homes and many of them have lost family members. Imagine you are living in a plastic sheet tent or a hospital corridor. Your brother, sister, mum, dad, cousin, maybe even your child, has been killed or injured and you’re trying to go to work, faced with countless amputated children or children with 80% burns. It is brutally hard.
Many of the healthcare staff are completely burnt out but they keep turning up, desperately trying to do what they can. I know some of the most incredible doctors in Gaza who have told me they will never be able to work for the Ministry of Health again. It is devastatingly sad that they have had to go through this. I suspect that a large part of this terminal moral injury comes from the fact that they are not treating grown men in balaclavas carrying guns. The people they are treating are children who just happened to be in or next to a targeted building.
Many of those who are carrying out the ED work everyday are equivalent to those at CT1/2 level. They are just trying to start a career, build a life, feed their families, have a safe place to live, and they are doing that on the background of having lost family members or their home. They can see that their patient group are civilians and not fighters and it is devastatingly sad. And of course, everyday their home could be hit, they could be exploded or they could be shot walking through the streets. It has become winter since this war started. Imagine if you had to go to work everyday, and by the time you were there you were freezing cold, and whilst at work you were freezing cold. How do you function? You are hungry and worried about finding food, and you are worried about your family, and you have left them to go to work. The fact that these people are able to keep going at all is beyond remarkable.
Response of the international community
This is a highly emotive conflict, but I think, because of the political situation between the Occupied Palestinian Territories and Israel, people have found it hard to take a strong position. Through the political fog, what is clear is the response from emergency humanitarian organisations. When I arrived in Cairo, before I was able to get into Gaza, I was surrounded by people from all over the world who immediately knew that they needed to try and provide some form of support to the Gazan population. The willingness of people to do so at their own risk and put themselves in that situation is quite something.
Whatever anyone’s politics, I think anybody who does not unconditionally believe that this situation needs to end now, and in fact needed to end 4 months ago, needs to reflect deeply as to how they reconcile that with their role as emergency care practitioners whose professional purpose is to reduce human suffering. Over 24,000 people have been recorded as dead and there are over 60,000 injured. The death toll does not not include those hidden beneath the rubble. This does not include those yet to succumb to their injuries. I understand both ends of the political spectrum – why it has started and why it continues. However, to believe that the situation in Gaza should continue, to believe that there is any reason at all for it to continue, in my mind places someone on the wrong side of history.
The war needs to stop, we need to gain humanitarian access, there needs to be improved supplies, hospitals, we need more staff and medications, the population needs more food, clothing, blankets, shelter – everything. People should have a right to return to their homes and safely rebuild their lives in the Gaza Strip. However, before any of this is even possible, we need to see an end to the indiscriminate killing of civilians.
UK emergency medical community role
Practically it is very difficult to provide direct help, because there is no straightforward physical access to Gaza. When the time comes, and the Occupied Palestinian Territories, in whichever form it exists at the end of this, there will be a lot of need for physical support, and people with the right skill set and experience to provide help.
At present we need to keep talking about it, maintaining people’s awareness and advocating for the conflict to stop. Whatever political belief you might hold about the rights and wrongs of any aspect, share the message that this cannot continue. It is difficult to keep momentum when other events inevitably take place and suddenly the situation in Gaza drops out of the media cycle – but for the sake of Gazans, we must keep the advocacy going.
I find it helps to keep remembering that it is by sheer luck that we live where we live and that we work in the conditions that we work. When we think our lives are really tough – and I know working in UK EM is a really difficult job – let us try to maintain that solidarity with people not just in Gaza, but around the world who are trying to achieve the same thing. We must remember them. And we must never stop fighting for them.
Chris Hook in Gaza with ICRC colleagues Sanaa Rajab and Ico Bautista Garcia GECCo thanks Chris for sharing this deeply difficult experience – please email us on contactgecco@gmail.com or leave a comment if you wish to get in touch.