At a handful of intensive care units in rebel-held Syria, where doctors, medicine, and daily essentials are in short supply, telemedicine is saving lives.

Remote-operated webcams allow doctors working in the safety of countries like the United States to assess the best course of action for critical patients in Syria, now in its fourth year of conflict. They then relay their instructions to medical workers in the field.

“Before the era of telemedicine so many patients died because of the deficiency in the treatment and lack of experience,” says Dr. Abd al-Aziz al-Adel, head of the health office in rebel-controlled areas of Aleppo.

The telemedicine initiative was started last year by the Syrian American Medical Society (SAMS). It is a direct response to the shortage of doctors in Syria. In their absence, complex trauma cases often fall in the hands of nurses and technicians.

Dr. Tamer Hassan, who heads the SAMS field office in Gaziantep, a border town that is a hub for Syrian refugees and relief organizations, runs monthly trainings for Syrian medical workers in a bid to close the gap.

“We have a real shortage in all specialties so of course we don’t have [Intensive Care Unit] doctors,” he says. “We only have ICU technicians and nurses. Those guys are not real experts, especially when it comes to complex, difficult cases."

Dr. Adel, who uses a pseudonym for security reasons, says the telemedicine initiative has improved the treatment of patients in ICU units. But for field hospitals in rebel areas like Aleppo and Idlib Province, which come under frequent attack by Syrian regime forces, the conditions are still far from ideal.

Most of the ICU patients that Adel and his colleagues treat are victims of aerial bombardment, mainly barrel bombs dropped from helicopters or planes. These cheap improvised devices are typically metal barrels packed with chemicals or explosives and scraps of metal.

Webcams, monitors, Skype

Working in shifts, a team of doctors scattered across Canada, England, the United States, and Saudi Arabia monitor Syrian patients in real time using three webcams connected to the ICU. The supervising medical practitioner moves the cameras to check the monitors, ventilators, and the patient himself.

Based on the data collected, the doctor prescribes treatment and oversees its implementation, counseling his juniors along the way. Skype is used as a platform for communication.

“The ICU technician has a direct, 24-hour connection with a team of on-call doctors,” says Adel, a general surgeon, who has had to carry out 12 heart surgeries, half of them successful, due to the shortage of specialists.

Hospitals and medical staff have been a constant target of regime attacks in Syria. At the onset in spring 2011, when the regime violently cracked down on peaceful protests, doctors risked torture, death, and detention to treat wounded demonstrators and army defectors.

Now, with Syria in the grips of a brutal conflict, field hospitals in rebel-controlled areas operate underground in a bid to escape aerial bombardment. Adel, who experienced several close calls, shows on an i-Pad the rubble-filled remains of his bedroom in the Aleppo M1 hospital.

“This is my room after the attack,” he says, pointing to a mattress covered in debris.

He swipes the screen to another picture showing a bombed part of the hospital, which is still operational in other sections. In the picture, a glaring neon ambulance is parked outside. That was the giveaway, Adel says.

Medical workers in crosshairs

His latest lucky escape came on June 7 after he slipped back into Syria. Two air-to-ground missiles landed near the Bab Al-Hawa Hospital, close to the border with Turkey, which he had just crossed on his way to Aleppo. That hospital treats an average of 2,000 patients per month, according to Syria Relief, one of the charities running the facility.

In September, a missile attack destroyed an entire field hospital in Al-Bab, a rebel base on the outskirts of Aleppo. The attack killed 11 people including two doctors and four nurses. SAMS said it was the third hospital destroyed in Al-Bab in two years.

Hundreds of Syrian health professionals have lost their lives in the line of duty. Many died when regime forces shelled their medical facilities or homes, though rebels have also been accused of attacking hospitals, some of which were being used as military bases.

Physicians for Human Rights, a New York-based organization, has collected data for an interactive map showing that Syrian government forces carried out 90 percent of 156 confirmed attacks on medical facilities since March 2011.

“Syrian forces have systematically attacked the health care system in opposition-held areas over the past three years, resulting in the death of more than 460 health professionals and widespread destruction to hospitals and clinics,” it said in a statement.

The group's executive director, Donna McKay, says Syria “is among the worst examples of targeting medical care as a weapon of war.”

Continuity in patient care

Given these risks, many doctors and nurses — along with millions of civilians — have fled Syria. Those who remain are completely overwhelmed. In a bid to pace himself, Adel spends three out of four weeks per month in Aleppo, returning to Gaziantep to rest and visit his pregnant wife.

“We are exhausted. It’s not just a matter of surgery, it’s also a matter of follow-up,” says the doctor, who exudes energy despite the bags under his eyes and greying hair.

Three hospitals on the rebel side of divided Aleppo, currently use telemedicine to treat critical patients. Another two are operational in Idlib Province and further facilities are in the pipeline, including an underground hospital complex in central Syria.

The main challenge to scaling up operations is securing Internet access and finding staff willing to stick it out in high risk zones, the two doctors said. One benefit of telemedicine is that it allows for continuity in patient care even after they are transferred to a new facility in the network.

“Most of the patients are barrel-bomb victims. Maybe 90 to 95 percent of these patients are civilians because of the random dropping of barrel bombs,” says Adel.

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In general, says the doctor, ICU patients are transferred to other medical facilities as soon as possible because it is very difficult to evacuate a hospital when it is under attack, especially for ICU patients who are teetering between life and death.

“I’m very happy to know my patients are in safe hands, even if it is remotely,” he says. “Telemedicine has given us a golden opportunity to save lives.”