Lifelong wounds: How Munjed Al Muderis operates in developing countries

By Charlotte Grieve, Tom Steinfort and Natalie Clancy

Karar Protez Uzun, an Iraqi patient of Munjed Al Muderis.

In July 2017, celebrity Australian surgeon Munjed Al Muderis told an Iraqi bomb-blast victim he would be walking within six months. For Karar Protez Uzun, who’s left leg had been amputated, and right foot was permanently damaged from the war injury, the promise seemed like a miracle.

Five years later, the 29-year-old remains bound to a bed.

“I can’t do much. I do not work,” says Karar Protez Uzun through an interpreter.

In 2017, Al Muderis agreed to travel back to the country he left as a refugee in 1999. It was a medical military mission with a humanitarian edge – Australia’s celebrity refugee-turned-doctor, a former NSW Australian of the year, would perform his signature procedure, osseointegration, on Iraqi soldiers and civilians who had lost limbs while fighting terrorist group ISIS.

Osseointegration involves inserting a titanium rod into the bone of the residual limb of an amputee. The rod fuses with the bone and protrudes through the skin to connect to a prosthetic. At best, it restores people’s ability to walk without the discomfort of a normal “socket” prosthetic.

Protez Uzun says some of his friends had success with the surgery. They can walk and drive. Protez Uzun received osseointegration for his amputated left limb first, and later the surgeon returned to amputate the right foot and insert another rod. He struggles with infection, pain and side effects from medication, including vomiting, and other people he knows are trying to travel to Iran to have the implants removed because they do not know where else to turn.

He has no direct connection to Al Muderis, and must go through another surgeon in Baghdad to relay his problems. His main concern, he says, is the lack of aftercare provided by the Sydney surgeon.

“For me, the biggest issue is, I wish we had more training, more information about this particular surgery for after the surgery. I can’t get in contact with him [Al Muderis],” he says.

“Can you guys help me?”

Money said to be ‘no issue’

It was a cool autumn evening in May 2017 when Al Muderis and his associates dined with the Iraqi ambassador at Sydney’s classic French bistro, Restaurant Hubert. The Iraqis were not fluent in English so Al Muderis, who had fled Saddam Hussein’s Iraq as a refugee in 1999, translated. One attendee, who spoke on the condition of anonymity, says the Iraqis told the surgeon they wanted him back in his home country doing operations. They conveyed the message that “money was no issue”.

“It wasn’t like we were having side conversations. He was the translator. It was coming from Munjed’s mouth,” they said.

On the guest list was local prosthetics firm APC director Stefan Laux, a senior executive from global prosthetics firm Ossur, Al Muderis’ head nurse Michelle Nairne, and patient representative Mitch Grant, among others. They were told those who agreed to travel would receive business-class airfares and have all their expenses paid, including accommodation in the palatial Prime Minister’s Guest House in Baghdad.

That night it was decided that Al Muderis and a team would go to Baghdad for three to four weeks at a time. It would be the first time he had been to his home country since, according to his well-known story, he had fled the regime of Saddam Hussein after being ordered to cut off the ears of army deserters. The following month he was in Iraq, the first of many trips.

It was a huge marketing success. Al Muderis was followed by the ABC’s Foreign Correspondent program, which, in December that year, published its story.

“Tonight, 10 days in a Baghdad hospital, with a man transforming lives and bringing hope to a shattered country,” the program told its viewers. “People have come from all over Iraq, pinning their hopes on the man they call Dr Munjed.”

One of those patients was Amane Nasser, a young Iraqi woman who lost both legs after a heater fell on her as a child. Nasser has become something of a celebrity in Iraq for her sporting achievements, after competing in athletics at the Paralympics and becoming the inspirational face of the country’s disability community. But, like many wheelchair users, she always wanted to walk again.

During the ABC documentary, Al Muderis was filmed saying that he could fulfil this dream. “If we do osseointegration for her, she will walk, for sure,” he told a room packed with emotional relatives.

But like in Australia, once the cameras were switched off, medical professionals and patients say aftercare was inconsistent and the surgeon became difficult to reach.

Five years later, despite the operation and the media attention, Nasser remains in a wheelchair. Al Muderis performed the surgery on her legs and personally covered the costs, but it was a failure.

Where before Nasser was a below-the-knee amputee, her amputation is now higher. She declined to be interviewed at length for this investigation but said complications meant her implants needed to be removed.

Al Muderis has told The Age, The Sydney Morning Herald and 60 Minutes he remains confident that one day she will walk. She is now trialling traditional socket prosthetics, but Al Muderis is prepared to try osseointegration on her once again.

“He gave me hope. I just wish he would come back and finish the job.”

Thanks to Al Muderis, Iraq now ranks among nations with the highest number of osseointegration patients. He claims he has performed 188 operations over a number of trips.

Orthopaedics resident doctor at Ibn Sina Hospital in Baghdad, Qutaiba Al-Maawi, said that, of these patients, 15 now need continuous pain management, 20 per cent had infections, one had died, two had fractures requiring hospitalisation and two patients needed their implants removed. These figures were in line with average complication rates, Al-Maawi said.

Al Muderis’ staff who attended the Iraq program were not paid wages. However, the Iraqi government paid $US20,000 per implant used, according to Al-Maawi, netting millions of dollars for the surgeon’s company, which owns the implant patent.

Al Muderis worked long days, maximising the number of patients he could see and surgeries he could perform, according to medical staff who attended.

“He always care[s] about doing surgery and very quickly without any deep investigation before surgery,” says one source working in a major Iraqi prosthetic company, who asked not to be named. “After surgery he was never ever answer anybody to follow-up patients. This issue was making me so angry.”

Another patient feeling this acutely is Aitham, who lost his hand and leg in a bomb blast fighting ISIS. Aitham praised Al Muderis’ work in the country, saying he wished the surgeon could train other doctors in his country to perform the procedure as it had helped many people.

However, Aitham said Al Muderis operated on his hand in 2017 and never completed the procedure, meaning he still cannot use his hand, and he has been unable to contact the surgeon.

“He gave me hope. I just wish he would come back and finish the job,” he says. “I’ve tried calling and contacting him, but, unfortunately, there’s no answer. Or when they do answer, they say he’s too busy.”

Fierce defenders

Like in Australia, there is a sharp division among Al Muderis’ patients. He has his detractors, but also a cohort of fierce defenders. Military patient Fityan Ali said he would not accept attacks on Al Muderis, praising his work in Iraq. “Dr Munjed saved our lives,” he said.

Al Muderis says he provides his personal phone number to every single patient he treats, but acknowledged there are a “handful” of patients who feel abandoned after the procedure. He said there were many reasons he did not answer calls.

An Iraqi soldier walks past a wall of debris on June 30, 2017, during the violent campaign to retake the city of Mosul from ISIS.Credit:Kate Geraghty

“If I’m operating on a patient and I’m in the middle of surgery, I can’t answer the phone because that’s not fair for the person that I’m operating [on]. Of course … certain patients are in a different time zone, and I may not be in the same. I may be asleep. My phone is turned off, but I do my best,” he says.

“When I wake up, I read my messages and I respond to them. My staff do the same. We instruct every single individual in the team to respond to patients as promptly as possible. We are not perfect, but we do our best to not make anyone abandoned.”

“If I had known that I would suffer the lifelong wound, I would have not received the surgery.”

Al Muderis also said recent unrest in the region meant it was more difficult to return to Iraq, but said he was confident with the outcome of the mission. “The success in Iraq has been remarkably higher than the success rate in Australia,” he said.

Prior to Al Muderis’s missions to Iraq, osseointegration was not performed on smokers. But in a country where around one-third of men smoke – this barrier was removed.

Al-Maawi said smokers “are doing well but non-smokers are doing better”. Smokers do not heal as fast and are more likely to develop infections, he says.

Global expansion dreams

Iraq was not the first time Al Muderis had flown to a developing country to perform osseointegration. In about 2015, he was invited by Dr Jim Gollogy to travel to Cambodia to treat locals who had lost their limbs. Al Muderis has patients in the UK, US, Canada, Iraq, Cambodia and hopes to expand the procedure globally.

“My goal is that the day comes before I die that this technology become available to people who need it. Most people who cannot afford it, people who live on $1 a day, that was always the focus and always the dream of my life,” Al Muderis says.

This masthead has tracked down two of the four patients who were operated on in Cambodia. Both described ongoing complications with their implants and both said they would not recommend the surgery to other amputees.

One, Eang Srey Da, a farmer living outside of capital city Phnom Penh, agreed to the surgery after she was shown a video of a successful patient and told it would be easier to walk.

“They said it would be better after the surgery,” she says through an interpreter. “But I did not know that I would have such a lifelong wound.”

Srey Da says her wound, known as a stoma, causes her daily pain. “I did not seem to know there would be pus,” she says. “If I had known that I would suffer the lifelong wound, I would have not received the surgery.”

Once the pain became so severe that Srey Da sought out Al Muderis’ help through a Cambodian doctor.

“I did not know what they were talking about. They took me for an X-ray and they said I was fine. After the examination, they asked me to go back home.”

She would not recommend the procedure to others. “No one wants to hurt themselves,” she says.

Another Cambodian patient, Pril Sina, describes a similar experience of being shown a video of a patient walking with the implant.

“They asked me was I interested in it? And I thought that it would be better than the prosthetic socket,” Sina says.

While Sina says the surgery has improved her mobility, she also deals with chronic pain. “The big problem for now is that I get hurt every day, the pus and fluid comes out every day,” he says.

“Sometimes, the blood comes out a lot, sometimes not. [But] I need to clean the wound every day.”

Despite the signs of infection, Sina says he does not take antibiotics or medication and rather uses massage to alleviate the discomfort because she cannot afford the treatment. “I can bear with it, I get used to it.”

Similarly, Sina says the last he heard from Al Muderis was in 2016. Like the other patient, he also would not recommend the surgery to others.

“I think there is no need to receive this kind of surgery because we cannot get much benefit from it.”

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