The Impact of the Syrian Civil War on One Department in an Israeli Hospital

Abstract

During the Syrian civil war, Syrian refugees crossed the Israeli border to receive medical treatment. During this time, Galilee Medical Center (GMC) became the main center for multidisciplinary treatment of these war-wounded patients. This retrospective study compares the demographics of local Israeli and refugee Syrian patients, as well as the volume and types of procedures each group received over a 5-year period. From January 2013 to December 2017, 963 unique patients underwent 1,751 procedures in the GMC Plastic Surgery Department. Of these patients, 176 were Syrian—including 42 children—and 787 were Israeli. These groups underwent 393 and 1,358 procedures, respectively, for a procedure-per-patient ratio of 2.23 versus 1.72, respectively. On average, Syrian patients tended to be younger than Israeli patients (23.6 vs. 49.25 years), had longer median hospitalization time (50 vs. 8 days), longer median operative times (102 vs. 85 minutes), and higher incidence of infection with multidrug-resistant bacteria (52.2 vs. 5.8%). Further, Syrian patients had more trauma-related procedures, such as skin grafts, wound debridement, and microsurgery, than Israeli patients. Through this process, GMC's plastic surgery department gained unprecedented exposure to a variety of complex procedures.

The onset of civil war in Syria in March of 2011 triggered widespread devastation, dubbed the “the greatest humanitarian disaster of the past two decades” by the United Nations High Commissioner for Refugees. ¹ The conflict caused Syrian refugees to seek medical treatment at the Israeli border; by 2013, plastic and reconstructive surgeons played a major role in the administration of trauma care as part of a multidisciplinary team. ¹ The care provided ranged from primary closure to complex reconstructive procedures for burns and other injuries. ^{2 3 4 5}

Galilee Medical Center

The Galilee Medical Center (GMC) is located at Nahariya, a coastal city in Northeastern Israel, approximately 10 km from the Lebanese border where it serves Galilee's 650,000 residents ( Fig. 1 ). The hospital serves a diverse population, comprising both military and civilian members, of the Jewish, Christian, Muslim, and Druze population. Established in 1985, the Department of Plastic Surgery primarily served the Israeli population; however, as a result of the war, plastic surgeons have become increasingly involved in managing Syrian casualties of war. The Department of Plastic Surgery itself mirrors the local population and in 2014, it was recognized as an academic teaching center affiliated with the Bar-Ilan University Faculty of Medicine.

Fig. 1.

Border map of Northern Israel, Lebanon, and Syria. ²

Due to its location and capabilities, the GMC became the main center for treating casualties of war. ^{6 7} The influx of Syrian refugees brought about significant change to the volume and type of procedures performed at GMC over a 5-year period. In this study, we discuss these differences and their associated implications for GMC.

Methodology

All patients who were admitted to the Department of Plastic Surgery or who received treatment by GMC plastic surgeons between January 2013 and December 2017 were included in this retrospective review of electronic medical records. Ambulatory procedures and patients were excluded. Data on patient demographics, procedure type, and procedure frequency were recorded. The study was approved by the GMC ethics committee.

Results

A retrospective review from January 2013 to December 2017 resulted in a total of 1,358 surgical procedures that met our inclusion criteria. Of these cases, 787 were Israeli patients and 393 were Syrian patients ( Fig. 2 ).

Fig. 2.

Study population.

The Department of Plastic Surgery saw an increase in the overall number of cases performed during this time ( Fig. 3 ). Most of these patients (82.3%) underwent one or two operations. The remainder needed three or more operations, up to a maximum of 15 procedures ( Fig. 4 ). Syrian patients on average received more surgeries than their Israeli counterparts, with 27.4% of Syrian patients receiving three or more procedures while only 15.2% of Israeli patients did so ( Fig. 5 ). There was a statistically significant difference in the distribution of these two groups ( p  < 0.009). Roughly, half of the Israeli population were male, compared to the Syrian group with 86% male patients ( Fig. 6 ). However, the gender difference between these two groups was much smaller in patients younger than 18 years ( Fig. 7 ). On average, the adult Syrian patients were much younger than the adult Israeli patients (23.6 vs. 49.25 years).

Fig. 3.

Number of procedures per year.

Fig. 4.

Number of plastic surgery operations per patient.

Fig. 5.

Number of procedures per patient, Syrians and Israeli groups.

Fig. 6.

Gender division between the Israeli and Syrian adult patients.

Fig. 7.

Pediatric patients gender division.

The median length of stay in the hospital was much longer for Syrian patients as compared with the Israeli patients (50 vs. 8 days). Additionally, median intraoperative time (102 vs. 85 minutes) and median operation duration (64 vs. 51 minutes) were significantly longer in the Syrian patients ( p  < 0.01).

Syrian patients also suffered from a high multidrug-resistant bacteria (MDR) rate of 52.2% (96 cases). This was 10 times higher than the rate in the Israeli patients (5.8%, 51 cases). Among pediatric patients, only one (0.9%) Israeli child was positive for MDR as compared with 30 Syrian children (71.4%). We saw a very strong correlation between the length of hospitalization and the patient's positive MDR test ( p  < 0.0001).

Procedures performed on the Israeli study group were diverse and included tumor excisions, breast operations, trauma-related treatments, and semiesthetic procedures such as abdominoplasties, body contour, peeling, and liposuction. The procedures in the Syrian group were almost exclusively related to trauma conditions such as skin grafts, flaps, and dressing changes under general anesthesia ( Table 1 ; Figs. 8 and 9 ).

Table 1. Comparison of procedures among Israeli and Syrian patients.

	All Israeli		All Syrian
	n	%	n	%
Skin graft	315	23.2	132	33.6
Flaps	71	5.2	93	23.7
Debridement	175	12.9	59	15.0
Multidisciplinary	158	11.6	46	11.7
Dressing replacement	7	0.5	23	5.9
Scar and wound revision	36	2.7	13	3.3
Face	59	4.3	11	2.8
Nerve	0	–	6	1.5
Primary closure	27	2.0	5	1.3
Other	5	0.4	5	1.3
Tumor excisions	256	18.8	0	–
Breast	174	12.8	0	–
Semiesthetic procedures	75	5.4	0	–
Total	1,358		393

Note: A comparison of all procedures over the 5-year study period, grouped by types, in Israelis versus Syrian patients. Semiesthetic procedures include abdominoplasties, liposuction, peeling, body contour surgeries. Multidisciplinary procedures include cooperative efforts with teams from the departments of neurosurgery, orthopaedics, maxillofacial surgery, and urology. Face surgery includes rhinoplasty, cleft lip, blepharoplasty, facelift, ears, and lip repairs. Nerve type includes complicated nerve repairs and reconstructions.

Fig. 8.

Syrian patient who arrived 4 days after shrapnel-packed missile attack.

Fig. 9.

A 3-year-old child who arrived three days after being severely burned falling into boiled-milk pot, total body surface area (TBSA) of 30%, septic and hypovolemic shock.

Discussion

Demographics

In addition to the normal load of Israeli patients at GMC's Department of Plastic Surgery, the Syrian civil war brought with it an increasing number of multitrauma cases and severely injured patients. This increase in patient volume and complexity posed a significant challenge to a department with limited resources. Indeed, this complexity is highlighted by the increased number of procedures performed per patient among the Syrian group (2.23 procedures per patient) as compared with the Israeli group (1.72 procedures per patient). One reason for this difference between the groups may be that Syrian patients with simple injuries or illness were possibly treated in their homeland, with only the most seriously wounded being brought to GMC for treatment. Many of these patients received initial, often life-saving medical care at the Israeli field hospital set up on the Israel–Syrian border. Little has been revealed about how the Syrian patients were transferred to Israeli hospitals, other than that the Israeli Defense Forces were responsible for the technical side of the operation. ¹

We noted that the Syrian patients were on average younger and more likely to be male than patients in the Israeli group; this difference points to many of the Syrian patients' injuries likely being due to war activity.

Hospitalization Time

The lengthy hospitalization time for many of the Syrian patients was likely due to the complexity and severity of their injuries. However, this difference in hospital stay length was magnified by the fact that, unlike Israeli patients, Syrian patients had to remain in our medical center until their medical issues were completely resolved. This is due to the complex logistics involved in transporting Syrian patients across the Israeli border. These patients required special military convoys to transport them between the hospital and Syria; they were thus unable to leave and return for further treatment or follow-up surgery. We therefore preferred to keep the Syrian patients hospitalized until they completed the entire necessary medical process, including the fitting of prosthetics.

Multidrug-Resistant Bacteria Infections

We also identified higher rates of MDR infection in Syrian patients than in Israeli patients. Of note, similar findings were made by the Department of Pediatrics in our medical center which showed higher rates (79–83%) of resistant bacteria carriage among Syrian children compared with 15% among Israeli children. ^{8 9} The source of MDR organisms in war-associated injuries remains uncertain, possibly including nosocomial transmission, particularly through prior contact with severely compromised health systems. ^{10 11} Another possibility is fecal colonization with extended-spectrum β-lactamase–producing gram-negative bacteria. An additional etiology may have been the widespread availability of antimicrobial drugs without prescription in Syria during this conflict. ^{12 13} It should be noted that the low rates of MDR bacteria in the Israeli patients may also be explained by selection bias that every Syrian patient admitted to the hospital went through a screening panel for resistant bacteria. This screening panel was applied to only some Israeli patients.

Differences in Procedures Performed

Our data show that the Syrian group underwent many more complicated procedures with flaps, skin grafts, change of dressings under general anesthesia, scar revision, debridement to treat contaminated or infected wounds, open wounds, severe burns, and severe contractures. Our department was further challenged by an increasing necessity for procedures to treat damaged nerves (e.g., nerve grafts and neurorraphy) and for procedures to care for neonates (i.e., to address congenital anomalies such as cleft-lip and meningomyelocele). In contrast, Israeli patients were more likely to receive simple treatments like primary closure for clean and uncomplicated wounds. Other procedures that were more common in the Israeli patient group included excisions for skin cancer, peeling, body contouring, and liposuction for esthetic or oncologic reasons.

Conclusion

The influx of Syrian refugees presented to our department showed a wider range of complex emergency cases than we normally see in our Israeli population. Continuing to provide for the local population while treating these new and complicated cases arriving from Syria required our medical center to make adjustments including altering its work management strategy and recruiting more physicians and staff members. The exposure to this complex patient population challenged our department, resulting in new professional knowledge and experiences that can be applied to improve future patient outcomes.

The conflict in Syria has created tremendous suffering for those involved. We are acutely aware of the challenges faced by the patients we treated at our medical center, many of whom had families who remained in an active war zone. This crisis created an opportunity for Arab and Jewish health care providers to work together with Arab and Jewish patients despite historical tensions that have traditionally existed.