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So our next uh speaker, MS Elham Abdelaziz is the consultant breast surgeon and S es advocate at United Lincolnshire Hospitals, NHS Trust. Um M Abdela focuses on addressing the psychological impact of the conflict. And today her talk is um in the face of terror, it will provide invaluable insights of mental health strategies in such challenging settings and her reflection on resilience and recovery in the face of for this. Thank you very much. Thank you. If you want, I would like just to start my two by passing my thanks to the, my doctor in UK for inviting me to speak in this meeting and of course to the Royal College to make it happen. And my name is um EMA Plaz. I am a breast surgeon. Um uh I start working in UK in 2008. And so then I am employed in the NHS. Uh I finished my training as a breast surgeon in 2015 and as many surgeon would uh would be aware that uh breast is not a standalone speciality. We still have to go through general surgical training to be qualified as a breast surgeon then. So um in 2009, I was um employed in, uh in the NHS in, um, in northern Ireland. And I'm just sharing my experience there with you. So, um, on Saturday the seventh of March, uh 2009 in Northern Island Antrim area, um there was um, um, a military Barrack, uh which is like an, an in a military installation which was three miles away from the hospital where I used to work. Um, um, the occasion was that, that some off duty soldier was to be deployed to Afghanistan the next morning, they are having a small party before, um, their travel to Afghanistan and they ordered some pizza. Um, what happened is that, um, four off duty soldiers, um, they were unarmed, uh, they went out to the gate of the bar to have, um, to, to get their order pizza. There was also two guard men on the gate. So a total of six of them, plus the two delivery pizza delivery men who were, uh, Polish and Catholic. I'm not sure if many of you would know the conflict or the trouble that was in northern Ireland for years since the late sixties, uh, where the, um, uh, the Catholic minority had what looked like a civil, um, um, right movement asking for equal opportunity for housing and jobs and this was actually treated by, um, operation from the northern is mostly Protestant police. In 1969. The British have deployed forces on the ground in northern Ireland. And they went through the case of violence. Luckily in April Twin, in 1998 they reached what they call a, a good Friday agreement. And for almost 11 years, they had no violence in northern is so it was very quiet. No one expected any violence to happen. And actually the Barack, the military, Barrack was just like an um, a gathering of the soldier that get prepared to be deployed to different area, frontiers through the, the whole world where the British having military forces. So it was not an active military institution at the time. And eventually it was closed, I think few, few years later, I think 2011 or 22 permanently closed. So in this occasion, two masked men, gunmen, a nearby car went with a semiautomatic rifle and start shooting uh the four of shooting soldier and the two gate men and the two delivery boys. And um some of them actually had some fatal injury because my husband was only three miles away. All the casualty was sent to us. And on this occasion, I was on call, it was Saturday night and whoever know the Irish would know that Saturday, uh there's a happy hour mostly after 7 p.m. And uh yes, it was um one of called surgical consultant, a lady myself, the registrar and um on all surgical literature was also a young lady. Two of us, the two consultants standing on my shoulder, just telling me what to do before this, we had uh an open thoracotomy resuscitation in A&E on one of the soldiers and many of you would know now through the atl s, the indication for open thoracotomy resuscitation is quite limited for the gunshot, not for any blunt trauma. And because we are dealing with very young victims, we are talking 21 23 24 we had to do something. So we had to do open thoracotomy, gestation and A&E and at this point, my was on the ground and I haven't seen her for the rest of the night. She fainted and she couldn't participate on anything. So I was left with my consultant. We had to open to a theater. The rest of the colleague were standing behind us just to guide us. Many laparotomies were done. Uh I operated on one of the delivery feeds points and uh he was shot in the perineum. Very strange. No one would ever think that someone would be shot on the perineum, but he was shot on the perineum. And um I had to do laparotomy. I had to do a Hartmann procedure on him. Splenectomy. I think I did on him as well. Uh I had to debride his uh reum skin, a part of his scrotal skin. And eventually I had to do a fasciotomy for his lower legs because he had some compartment syndrome. Um It's easy now to remember and tell you what happened. But actually the trauma on the time was too much health support, asking how I'm feeling if I'm having any night terrors or, uh, nightmares, if I'd like to speak to anyone about what I have faced. But that's it. I can't remember any other supple. Of course, my colleague, uh, was looking at me in different ways and then he treated me like a stone. My situ had a long break from her professional career. She couldn't come back. Uh The rest, it was too much irritable environment because for the first time I give something called retaliation. Everyone thought that will face something called retaliation. Uh They thought that they uh the police will spread in the streets and there will be some action to be taken against Catholics. So everyone was just on their tip toes. And two days later, we had the Prime Minister coming to our hospital. I think it was Gordon Brown just to check on the on the injured people and to see how we are, how we are doing. And uh it was difficult time. I'm sure you would all understand. Um I developed some connection with the, with the one of the the injured patient because he stayed with me for almost eight weeks. I was doing resting on his perineal wound on his fasciotomy wounds before I managed to transfer him to have some grafting and some flaps. And one day, one of my nurses asked me to go to his room because he wanted me to be there and I went and he wanted me to be there when he proposed to his pregnant partner. And it shocked me that he was still not recovered. He doesn't know what's gonna happen to him. His stoma is permanent. Uh If someone had a gunshot to his pernia, most likely he will not live a normal life. But yet he wanted to marry his partner who's pregnant with his child and he wanted me to be there. And it was so emotional because we developed this connection. And uh a few months later, I met him in one of the shopping mall. He was walking with his crutches after having his gastrotomy done. And um his partner is carrying a baby and actually, it will tell you that yes, even in the dark time, hope will come one day. And uh and that's it. So actually coming out from this experience and what really shocked me that people actually react differently to trauma to such a trauma. And actually this was a, a small incident I was in, in the comfort of my colleague around me and feeling safe. I went back home. I had some shoulder to cry on for how people in the conflict zone, how people actually on the war zone, I never had the privilege to go to one of these area where there is a conflict or war zone areas to help and uh I was still traumatized. And until now, actually, um you, when you remember this time, it's really emotional. And then I know everyone, the, everyone got his ghost and we learn to live with our ghost. But I don't believe how people in the, in the middle of the world and in this conflict area. All my respect to the, the first speaker, Mr Koko, who was just running a hostel in the forest. I don't know how we manage if we are here and we still complain. So what really affected me that my ho decided to take a career break and, and the the injured Polish boy decided just to live on his life and to get married and to continue with life, which was was very impressive. So I start looking at um at the psychological impact and, and then we have to remember that actually, the traditional gender um rules that men actually are ashamed to tell that they are psychologically traumatized still applies. And men don't like to tell how, how they are feeling. And as a breast surgeon now, I'm seeing many, many cancer patients and actually, it's quite traumatizing as well to tell someone you got cancer and you look at their eyes and you see the change in the life immediately when you tell the news that you got cancer, especially for a woman with uh with worry about her body image, her relationship with her husband, her partner and you see the psychological effect immediately and people are different in actually showing their emotion. And even if, if the patient will hide it, sometimes the partner and the husband cannot hide it and you see the the doom and gloom immediately come on their faces. So we usually offer um psychological support even to the partner of, of our cancer patients and looking on the literature about what happened when for people who was actually facing trauma. Um And we start just looking at the, as I mentioned that men don't actually declare the weakness because they are worried uh to say that they are experiencing emotional stress, that they will, they will be labeled as, as weak and this actually will address their emotion. And the overall a availability of men requesting help actually is less than women. So women are actually more prone to tell. But men, most of the time they, they hold their emotion and you wouldn't tell. And because there are many other problems that they are facing, especially in the war zone, they lost their houses whole, the whole life is not running the same. So this is what I got from the literature. I I'm not a psychiatrist but this I'm facing every day with the cancer patient as well in a different level. Uh So people suffer from depression from uh obsessive compulsive disorder and anxiety disorder, eating disorder addiction. And actually, I've seen this in many of the female um patient who's actually ex-military. And many of them will tell me that they are um discharged on medical reasons because they cannot cope with what they have seen in the war zone. And these are the victorious soldier. So you can imagine what happened to the war victims. We are human after all, all of us, regardless. What's our road, we have the same structure, we have the same blood, we have the same emotion. So um it's very frightening actually when you deal with this situation. So this is what I got from the literature that one professional soldier soldier are trained to come in terms with the stress of killing another human being. Still, there are survivor guilt. There are they are becoming physically disabled and difficulty in um readjusting. Um for civilian life. On the contrary, civilian may find it impossible actually to go with killing other human beings. Um identification and diagnosis of mental health issues uh during the uh uh the conflicts and war time is crucial task. And actually it's it's very daunting challenge because as I said, it's not only your emotion, you have lost your house, your life is never gonna back the same. Um There's no healthcare facilities when MG was presenting her uh presentation about Gaza, most of the hospital in Gaza is now gone. All the hospitals are targeted, the healthcare professional as Mr Coo told us are targeted in Myanmar. So there's no health care facilities. Most of the time caring for the family, basic needs for Children, there's no water, there's no food and even us as the rest of the world community would like to help. We don't know how to help. We would like to send them help. We would like to send them aid. We would like to send them money, but we don't know even whatever we are providing is reaching the victims or not. And I'm, I'm sure everyone in the same position, um the victims are not able to process or channel or express their feelings. They are um because scenario are changing, they are not even safe in their position in shelters, the shelter might be any time. Um This leads to suppression of any emotion. No one's thinking about his emotion on the war time, everyone just thinking about survival. So everyone just regress, depress his emotion, all his thinking just to survive and for his loved one to survive. Of course, this leads to uh suppression of the emotion, potential development of neuropsychiatric condition. Additionally, patient may not uh reveal or be able to recall the trauma experience until they will go into treatment before of shame and fear diagnosis. How we diagnose in terms to diagnose a neuropsychiatric condition. Uh There is a consensus among practitioner how to assess uh the common disorder of the victimized population. Apart from comprehensive clinical evaluation, there are many questionnaire I came through plenty of questionnaire just to diagnose uh the posttraumatic stress syndrome, the depression and anxiety disorder. And I'm sure I II looked on the agenda and I see, I think some of the coming uh talks will be talk through this. So managing the uh psychological impact on health care uh providers in conflict area, the two main elements that should be considered are the wellbeing of the healthcare providers and the quality of care provided uh to the conflict victims. As MG said also in her uh in her talk, she said that this program are usually provided are done in a hurry and, and many of them don't look at the aspect of the optimum care or everyone in the war zone or the w on the conflict area. They are looking about doing that the best necessary damage control. As one of the speaker also talked about the damage controlled procedure, the damage controlled operation, the healthcare providers are working under high stress area are subjected to severe challenging, leading to long, long term mental effect. Um like chronic stress, like compassionate fatigue, like posttraumatic stress disorder, like moral dilemmas, aces, separations, like traumatic symptoms, how we manage this psychological impact um psychological first aid and peer support. So immediate psychological support, peer support program, the briefing session. So honestly, what helped me when I faced this is my consultant colleague because all of them went through the trouble. So they have been years and years through this trouble, they have seen killing. They have seen injuries. So they were quite supportive. And how are you feeling how you handle? This was great. It was very good. Sometimes we have to lose lives. So they were very optimistic because they've been through the wars and they've seen the wars saying so they were quite worried about the repercussion of what happened, but actually just talking about what happened helped a lot. So this immediate psychological support was quite important. I think it's imperative in this situation. The mental health resources and counseling, access to mental health professional, uh telehealth is very important. But this also depends on having internet, having wi fi all this will be important. And we can't guarantee that this will happen in the war time in the world and the conflict zones, trauma focused therapy, um crisis management and resource allocation. I think with supplies and equipment is not guaranteed, especially if all the war and conflict zones are under siege under the control of the oppressors. We can guarantee that the supplies we send will arrive there or not clear crisis protocol. Uh focus on work life balance. This is for people like us who actually face one off time of crisis, encouraging time for family time for personal wellbeing. Sadly, it's a luxury for those who live in the war and conflict zones. Uh supervision and leadership support, leadership development, regular check in and assessment of the recovery progress, peer led mental health initiatives, training, peer leader, some people who actually trained to deal with trauma management. And eventually just, it's just very, very scary, but that human beings have not learned the lesson over the year over since we've been created that killing each other and shedding each other blood is not gonna help anyone but still people do it. And the only thing we can do actually is just to have in this more life is just to raise awareness because you will not believe that many, many of the Western population does not know what's happening anywhere else. So we need to let them know and you've seen what's happening now, many, many administration everywhere in Europe about what's happening in Gaza, his government have not changed their position, but we need to let them that their people are not happy with, with what they are doing. The same with Myanmar, the same with Sudan, the same with young. I think people need to stand together to stop what's happening. And maybe one day we will thank you very much.