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Saturday, December 31, 2005

The Atlanta Journal and Constitution


Iraqi doctors learn in Atlanta 3 surgeons also teach lessons here


Edition: Home

Section: Atlanta & The World

Three Iraqi surgeons who spend most days reattaching fingers and arms blown off by bombs recently watched a face-lift surgery in Buckhead while wealthy women in the waiting room sipped tea and sat on Victorian-style chairs, soothed by a harpist on the stereo.

The scene was a jolting juxtaposition. But the plastic surgeons from Baghdad had practical reasons for visiting the posh Paces Plastic Surgery last week. They were learning a breast reconstruction technique developed in Atlanta, in hopes of allowing Iraqi women who have had mastectomies for breast cancer to feel better about themselves.

They were also picking up tips on nose jobs, tummy tucks and face- lifts to better serve Iraq's small but steady cosmetic surgery market. That source of income is prized by physicians there, who are paid less than taxi drivers for their public sector work.

The Iraqis also were sharing their trauma surgery experiences with hundreds of doctors gathered in Atlanta for a symposium on breast surgery. The organizer of the event, the Southeastern Society of Plastic and Reconstructive Surgeons, brought the Iraqis to Atlanta for a week of medical and cultural exchange.

"Medicine doesn't have the same boundaries nations have," said Dr. Mark Codner of Paces Plastic Surgery, who arranged the visit. "You invariably end up learning more than you teach."

A fourth Iraqi surgeon arrived late last week. The four are at the University of Alabama-Birmingham this week before returning to Baghdad, possibly in time for Iraq's elections Sunday. Because they fear retribution from Iraqi insurgents for their U.S. trip, they are being identified here only by a single initial.

Beneath a pricey chandelier in the elegant library of Paces Plastic Surgery, the Iraqis displayed pictures of bombing victims they have treated. A recent patient's leg was missing pounds of flesh. They took muscle from his abdomen and attached it to the leg to let him walk again.

They said supplies that American doctors take for granted often can't be found in Iraq. Titanium screws, routinely used to repair broken bones here, aren't available there, they said. Even sutures, catheters, intravenous fluids and blood for transfusions can be hard to come by.

The surgeons spoke of fear for their own safety: car bombings on the road to work, death threats from insurgents, other doctors fleeing the country to wait out the war.

One day in November, they said, another doctor walked out of their hospital only to receive five bullets to the head. One of several bombs that killed a reported 26 people in Baghdad last Wednesday exploded just outside the hospital.

"It's like playing Russian roulette; you never know when or how you might be next," said Dr. N.

"But you can't stop working," said another surgeon, Dr. J. "People need surgery."

Most of their patients are civilians with war wounds.

"These days, it's mostly bombings and bullets," said Dr. N.

Sometimes full repairs are impossible because bones are crushed or tissue is riddled with debris. "You salvage what you can," explained the third surgeon, Dr. A.

'Depressed for life'

The doctors, in their 30s and early 40s, envision a time when they won't see so much war-related trauma. That's why they're learning the TRAM flap, a breast reconstruction technique pioneered 25 years ago by Dr. Carl Hartrampf of Atlanta. TRAM stands for transverse rectus abdominus muscle.

The procedure doesn't rely on implants to create breasts, like some reconstructions. Instead, an oval section of skin, fat and muscle is taken from the abdomen and slid up through a tunnel to the chest, where it is shaped into a breast. Patients get a tummy tuck and a new breast at the same time.

In the United States, many women with breast cancer now get lumpectomies, in which the tumor is removed but the breast is saved. In Iraq, nearly all women with breast cancer still get complete mastectomies: removal of the breast and surrounding lymph nodes. It can be difficult for Iraqi women to get to a hospital, and when they do, surgeons want to be sure to remove all the cancer, Dr. J explained.

Most Iraqi women who have had mastectomies don't think positively about trying to go on with their lives, the doctor said. "They are convinced that cancer is disastrous. They think they will be depressed for life, so they don't care how they look or feel." That could change if Iraq becomes more open, he said.

Once a medical model

Dr. N said Iraq was known for premium medical care in the 1960s and 1970s, when the government spent $1.2 billion a year on its national medical system. Under dictator Saddam Hussein, that annual spending fell to $200 million, the doctor said. With more commitment from the present Iraqi government and increased international aid, the medical budget is up to $900 million, he said.

Construction has started on a dozen of a planned 150 primary care centers, said Richard Garfield, a professor of nursing at Columbia University who visited Iraq's Ministry of Health this month and has assessed its medical system for the World Health Organization and UNICEF.

But security concerns stifle progress, Garfield said. "You don't get much built when people are standing there with guns instead of a hammer."

For the Iraqi surgeons who visited Atlanta, even medical textbooks are rare. They are too expensive, so they smuggle them in from other countries and make copies.

While in Atlanta, the doctors observed a variety of procedures, watching carefully.

"We're seeing things here we have only read about in the books," said Dr. J. "Now we can go back and do surgery even better."



Atlanta plastic surgeons Drs. Mark Codner (left) and Farzad Nahai

meet with Dr. J (foreground) from Baghdad, whose identity is being

shielded because of potential reprisals./ BILLY SMITH II / Staff

(Copyright, The Atlanta Journal and Constitution - 2005)