Medical innovation put to the test amid chaos, violence

Schulich Medicine & Dentistry professor Dr. Tarek Loubani provided these images, alongside a first-hand account, of the scene that played out as he and other medical professionals attended to wounded Palestinians during recent protests in Gaza. During the course of his work, Loubani suffered a gunshot wound in his left leg.

*Posted May 14th on his personal blog*

A few days ago, I wrote about our first day of field trials for an open source 3D-printed tourniquet in Gaza. The Glia team worked overtime to address and fix the problems we identified. Thanks to help from the 3D printing, engineering and open source communities, we got lots of feedback and felt that we were ready for today.

Good news first: The tourniquets worked well

The only bit of good news in this report has to do with the tourniquets. We left the packaging issues to later (Failure #2), and instead focused on the mechanical issues we identified (Failures #3 and #4). We pulled all old models and tested buckles to see if they would break — we thought this issue was a low likelihood of recurrence, even though we will be testing alternative buckle designs later.

The tourniquets worked well. We recovered the 100 units given to Hayat Center for use in the field, giving us an inventory of 200 deployed units. One hundred units were distributed in the field today, and one hundred held in reserve for May 15. Seventy-eight tourniquets were deployed to patients who met criteria. There were no failures of the device in any cases.

Failure #1 rules supreme: Unsafe conditions for medical personnel

Failure #1 in our previous report was that “there are no ideal operating conditions.” This made optimizing the device important. We did that as much as we could.

The unspoken part of this is optimizing safety. To ensure the safety of first responders, we all dressed in clearly identifiable medical garb. Most paramedics wore fluorescent high visibility jackets. I wore a hospital green top and bottom so I could both be identified as medical staff and a physician.

Despite our efforts to clearly identify ourselves as first responders, several of our medical team were wounded by Israeli live fire. One paramedic, Musa Abuhassanin, was killed while attempting a victim rescue under fire. One hour before he was shot in the thorax and killed, Musa was one of my rescuers when I was shot by live ammunition. I sustained a moderate injury to my left leg and a minor one to the right leg. Musa was also the paramedic who discovered and reported the failed buckle in our previous report. He had a great laugh and was a good paramedic.

Anatomy of my gunshot wound

I am still collecting details of the shootings of Musa and other members of the medical team. In the meantime, I can contribute an account of my injury. The scene in eastern Gaza was bad since early morning. There was so much live fire the first responder services stood outside the protest area and only approached when needed. In general, we approached with high visibility clothing and hands up until we arrived at the incident. We did not run to patients, but we definitely ran out. We did not attempt to tourniquet or treat patients on site.

I was shot toward the end of the morning, and we had already run out of our first supply of tourniquets. I had just resupplied with 8 units, one of them unpacked in my pocket. We were standing well away from the main protest area. The snipers in the three sniper outposts all had clear views of us.

There was no fire or smoke near us. We were standing still, and I was facing in a southerly direction talking to a colleague. The snipers were situated east of us. I was wearing visible full hospital greens. There was no active shooting from the Israelis immediately before or after. There were no protesters in our immediate vicinity.

I heard a loud bang and found myself on the ground. The bullet had entered my left proximal calf on the lateral side, exited on the medial side (moderate) and pierced my right knee superficial to the patella (minor). I yelled ‘fuck.’

The paramedics initiated treatment within five seconds, and asked me if I needed a tourniquet. The wound had about 100cc of blood lost on the scene but didn’t look to be bleeding dangerously. I believe I was shot with a regular bullet and not the exploding bullets that are causing severe injuries reported today and on other days. Knowing the shortage, I stopped the application of the tourniquet, and was instead given a pressure dressing. There was no live fire before or after my incident.

I was transported to hospital, stabilized and discharged after X-Rays showed no bony injury.

Conclusions

At the time of writing, there were 52 people killed and 2,410 wounded during today’s peaceful Palestinian protests. 1,204 were struck by live ammunition. Seventeen paramedics were wounded and one killed.

The tourniquets appear to be feature-complete and usable as is. We will continue to monitor and develop the tourniquets, especially thanks to the community support offered in improving the design.

However, it is clear conditions remain suboptimal for tourniquet deployment by paramedics at this time. One possible solution is the wide deployment and routine training of the general Palestinian population in the use of tourniquets, such as in Basic Life Support courses.

Dr. Tarek Loubani is a professor in the Schulich School of Medicine & Dentistry, an emergency physician at London Health Sciences Centre and Shifa Hospital (Gaza). He is a member of the Glia team making open medical devices.