Making the golden hours count: WHO trains Syrian health staff to treat chemical exposure and severe trauma


A Syrian doctor uses a dummy to practice intubation during a trauma training course run by the WHO field office in Gaziantep in south-eastern Turkey.

Muhanad, a surgeon in northern Syria, happened to be visiting his nephew not far from the town of Khan Sheikhoun on 4 April 2017. During the visit, he was called to a local field hospital that was receiving emergency cases of patients exposed to gas. He realized their symptoms weren’t what he was used to seeing with similar incidents. “More than 30 patients came in the afternoon,” he says. “They were in convulsions. That’s not a chlorine gas symptom.”

“I froze.”

He didn’t freeze for long. He and others set to work decontaminating the patients in an area outside the building. “I protected myself and the patients were washed well,” he says. He asked for a tank of water so the hospital wouldn’t run out. Of the patients they treated, one died.

Muhanad and other health-care staff in northern Syria are familiar with treating chlorine gas symptoms, but the nerve agent used on 4 April was new to them.

Many knew the basics: remove contaminated clothing and wash the patient thoroughly with soap and water; use atropine to counteract the symptoms; refer patients to intensive care when needed so they can receive oxygen and ventilation.

Some knew more, because WHO’s field office in Gaziantep, Turkey, has been training Syrian doctors in treating chemical exposure since 2016.

Specialized training for complex cases

The trainings are a part of broader trauma care courses that WHO provides across the border in Turkey. Doctors learn to manage not only chemical exposure, but also severe trauma including burns and crush injuries. After a week of specialized training, they return to their hospitals and clinics in northern Syria able to apply their knowledge.

The courses cover what to do before the patient gets to a hospital, as well as after. “We call them the ‘golden hours’ of the pre-hospital phase,” says Dr El Gazzar, referring to the short window of time that health responders have to save a life. “If we don’t provide proper care, they could die.”

“I learned how to help injured people buried under the rubble. We usually pull them out immediately,” says Abulaman,* a doctor from the area of Idlib. “Now we must change this. First we give them intravenous fluid [normal saline]. If there’s a crush injury, I must put on a tourniquet.” Then it is safer to pull the patient out, explains Dr Mohammed El Gazzar, Surgery and Trauma Management Health Officer in the WHO Gaziantep office.

During the trainings, participants take part in hands-on work using dummies to practice skills like intubation. Sometimes they role-play as patients. After a burn management session, a doctor named Mouhib explained why the training was so useful: “We’re seeing more burns from old-fashioned stoves. When people don’t have electricity or fuel, they use them for heating and cooking.”

The WHO trainings help first responders stay safe and save lives. “We learn how to deal with a patient when we’re under fire,” says Muhanad, who took a WHO course in spring 2017. “You stop the bleeding, put on a cervical collar, and get out.”

Protecting first responders

WHO has purchased specialized suits, masks, gloves and other equipment for northern Syria’s health workers. The permeability varies depending on the product. “It’s to protect the medical staff,” says Dr El Gazzar. “If they respond without wearing personal protective equipment, there will be more casualties.”

At a hands-on training held inside Syria, ambulance teams, civil defence and forensic workers learn about proper decontamination protocols after chemical attacks. In a large white tent with a water hose running along the top, participants in bright orange suits practice hosing down a patient, then getting rid of contaminated clothes. Dr El Gazzar monitors the course and its trainers via a video call from Turkey.

“Before this training, I didn’t know what to do with victims of chemical attacks,” says Yasmin*, a community health worker who took the hands-on training in the tent. WHO is working to overcome the gender gap in trainings, often related to cultural expectations that women will travel with male relatives to take courses. “There aren’t enough female staff to do decontamination,” says Yasmin. In Syria, depending on the context, it can be more culturally appropriate for women to provide hands-on care to women. “Every woman should know this – laypeople too.”

After each weeklong course in Turkey, participants take a quiz with questions such as “What is the treatment for a patient with signs of pupil constriction?”, “When should you start physiotherapy for a burn patient?” and “When should you use a tourniquet as a first choice?” They’re given materials they can share when they are back in Syria.
“We need this kind of training,” says Muhanad. “I work in a paramedic college. We have about 100 students in our college, we can do a workshop. I travel to other places to give trainings.”

“Our knowledge is old. Here we get updated information,” he continues. “We need education. We must teach others in Syria immediately.”

WHO’s trauma trainings are funded by European Civil Protection and Humanitarian Aid Operations (ECHO).

* Name has been changed for security reasons.