Life after war-related extremity amputations A retrospective, descriptive clinical follow-up study from Gaza, occupied Palestine Gaza City, January 2016. Photo: Hanne Heszlein-Lossius Dissertation for the degree of Philosophiae Doctor The Arctic University of Tromsø, Norway (UiT) Faculty of Health Sciences Department of Clinical Medicine 2019 - Palestinian people are in love with life Mahmoud Darwish (1941-2008) Hanne Heszlein-Lossius Gaza City, occupied Palestinian territory (oPt) June 21th 2019 2 CONTENTS ACKNOWLEDGEMENTS .................................................................................................................................... 5 CONFLICTS OF INTEREST................................................................................................................................... 6 ABBREVIATIONS ............................................................................................................................................... 8 LIST OF PAPERS ................................................................................................................................................ 9 SUMMARY ..................................................................................................................................................... 10 ABSTRACT ...................................................................................................................................................... 13 ARABIC ABSTRACT ......................................................................................................................................... 15 1. INTRODUCTION..................................................................................................................................... 17 1.1. THE EPIDEMIOLOGY OF WAR-RELATED TRAUMATIC INJURIES ......................................................................... 17 1.2. THE LOSS OF LIMB(S) IS LIFE CHANGING ................................................................................................... 17 1.3. MORE WAR-WOUNDED SURVIVE, BUT WITH AMPUTATIONS ......................................................................... 18 1.4. SIEGE AND BLOCKADE IN GAZA ............................................................................................................. 18 1.5. FOUR MAJOR MILITARY INCURSIONS ....................................................................................................... 19 1.6. COMBATANTS, NOT CIVILIANS RESEARCHED .............................................................................................. 19 1.7. GAZA – A DIFFERENT SITUATION ............................................................................................................ 19 1.8. DRONES AND MODERN WARFARE .......................................................................................................... 20 1.9. AIMS OF THE THESIS ........................................................................................................................... 20 2. MATERIALS AND METHODS .................................................................................................................. 21 2.1. STUDY POPULATION ........................................................................................................................... 21 2.2. THE ARTIFICIAL LIMB AND POLIO CENTER (ALPC) ..................................................................................... 22 2.3. LANGUAGE AND TRANSLATION .............................................................................................................. 22 2.4. LEVEL OF EXTREMITY AMPUTATION AND COMORBIDITY ............................................................................... 23 2.5. SOCIOECONOMIC STATUS .................................................................................................................... 23 2.6. LOST FAMILY MEMBERS AND LOST HOMES ............................................................................................... 23 2.7. MECHANISMS OF INJURY ..................................................................................................................... 24 2.8. SEVERITY OF INJURY: ONE OUTCOME MEASURE ......................................................................................... 24 2.9. LOCAL EXPERTICE .............................................................................................................................. 25 2.10. ASSESSMENT OF PAIN ......................................................................................................................... 25 2.11. CLINICAL AND RADIOLOGICAL WORK-UP OF A SYMPTOMATIC SUBGROUP ......................................................... 26 2.12. POWER ANALYSIS: ATTAINED POWER ...................................................................................................... 26 2.13. STATISTICS....................................................................................................................................... 27 2.14. ETHICAL CONSIDERATIONS ................................................................................................................... 28 3. RESULTS ................................................................................................................................................ 30 3.1. PAPER I .......................................................................................................................................... 30 3.1.1. Demographics .......................................................................................................................... 30 3.1.2. Major amputations .................................................................................................................. 32 3.1.3. Rehabilitation and use of artificial limbs ................................................................................... 32 3.1.4. Medical comorbidity ................................................................................................................ 33 3.1.5. Increased workload on the exhausted healthcare system .......................................................... 33 3.2. PAPER II ......................................................................................................................................... 35 3.2.1. Mechanisms of injuries ............................................................................................................. 35 3.2.2. Amputating injuries following drone strikes .............................................................................. 36 3.2.3. Drone strikes and needs for surgical treatment ......................................................................... 38 3.2.4. Periods of military incursions versus periods of ceasefire .......................................................... 39 3.3. PAPER III ........................................................................................................................................ 40 3.3.1. Psychological distress and unemployment ................................................................................ 40 3.3.2. Pain and poverty ...................................................................................................................... 41 3.3.3. Psychological distress and pain ................................................................................................ 41 3.4. MEDICAL FINDINGS (UNPUBLISHED MATERIAL).......................................................................................... 42 3.4.1. Study participants referred for further medical investigations ................................................... 42 3.4.2. Radiology results ...................................................................................................................... 42 4. GENERAL DISCUSSION ........................................................................................................................... 45 4.1. PRINCIPAL FINDINGS .......................................................................................................................... 45 3 4.2. THE EXTREMITY-AMPUTATED SURVIVOR OF MILITARY INCURSIONS ................................................................. 45 4.2.1. Young, well-educated males with large financial responsibilities ............................................... 45 4.3. DRONES.......................................................................................................................................... 46 4.3.1. “Zanana” ................................................................................................................................. 46 4.3.2. The IDF and drones .................................................................................................................. 46 4.3.3. Increasing the workload of the local healthcare system ............................................................ 47 4.4. PSYCHOSOCIAL HEALTH AND WELLBEING AMONG TRAUMATIC AMPUTEES IN GAZA ............................................. 48 4.4.1. Pain ......................................................................................................................................... 48 4.5. MEDICAL FINDINGS REQUIRE FUTURE STUDIES .......................................................................................... 49 4.5.1. Embedded weapon shrapnel(s)................................................................................................. 49 4.6. RESEARCH DIFFICULTIES IN OCCUPIED TERRITORY