In the initial throes of April 2020, shortly after the United Kingdom’s Prime Minister, Boris Johnson, proclaimed the nation’s inaugural pandemic lockdown, an urologist named Archie Fernando embarked on a momentous collaboration with her colleague Nadine Hachach-Haram. Their affiliation transpired within the confines of Guy’s and St Thomas’ hospital, one of the nation’s most bustling medical establishments. During this tumultuous epoch, when the relentless onslaught of Covid-19 claimed nearly a thousand lives per week, most surgeries were deferred. Exceptions were only granted to cases involving a peril to life or limb, as well as exigent oncological interventions.
Hachach-Haram, a reconstructive plastic surgeon, vividly recollects her profound sense of helplessness during those harrowing times. She recalls, “I would just stroll through the wards, earnestly inquiring of the nurses how I might be of assistance. I took on multifarious roles, including portering and patient positioning, all in pursuit of ameliorating their respiratory distress.”
Notably, Hachach-Haram also held the mantle of CEO at a fledgling health-tech startup named Proximie. The enterprise had ingeniously conceived an augmented reality platform facilitating remote collaboration among surgeons. Their web-centric software empowered surgeons to engage in real-time discourse while sharing a live surgical feed encompassing up to four distinct camera angles and medical imaging, further enriched by a computer-generated overlay conducive to annotative directives on the shared interface.
Fernando harboured aspirations to employ Proximie for an intricate and time-sensitive procedure. Her patient, Mo Tajer, a 31-year-old cancer survivor, had previously undergone chemotherapy for testicular cancer. The malignancy had disseminated into his abdominal region, manifesting as a formidable 5-centimetre tumour enmeshed with the aorta and the inferior vena cava, two of the body’s largest vascular conduits. The surgical removal of this neoplasm posed a formidable challenge. Ordinarily, Fernando would have resorted to an open surgical approach. However, this would have necessitated a protracted two-week postoperative convalescence in the intensive care unit, an untenable scenario amidst the pandemic’s zenith. As Hachach-Haram explicates, “Such an environment would be decidedly inimical to an immunocompromised patient. It was imperative to expedite his hospital discharge.”
The safer recourse entailed the adoption of minimally invasive robotic-assisted laparoscopy. Regrettably, Fernando lacked the requisite proficiency in this specialised procedure. Nevertheless, the advent of Proximie proffered a lifeline; it offered her the guidance of a seasoned counterpart, the US-based surgeon, Jim Porter. Porter, who served as the medical director for robotic surgery at the Swedish Medical Center in Seattle, not only pioneered this genre of surgery but also stood as one of the foremost laparoscopic surgeons of his era.
The pivotal operation was convened on May 21. Adorned in full personal protective equipment, Fernando presided over the surgical robot’s console, stationed a distance of two metres from the patient. The robot, sporting four articulated arms, three of which bore surgical instruments, with the fourth bearing a slender tube housing a camera, offered Fernando an internal view of Tajer’s abdominal cavity upon insertion. Simultaneously, Porter, ensconced in the comfort of his Seattle residence, accessed an identical perspective on his laptop screen. Over a duration of five hours, he adeptly mentored Fernando through every intricate surgical step, conducting a virtual symphony of guidance, elucidating anatomical landmarks, and sketching annotations to demarcate precise incision sites.
Hachach-Haram, a rapt observer of this landmark procedure via the digital conduit, found herself utterly spellbound. She recollects, “I was rendered speechless by their unflappable composure.” This occasion marked the first instance, since the advent of the pandemic, when Proximie was enlisted to facilitate a surgical intervention. As she bore witness to this extraordinary feat of medical prowess, the gravity of her invention’s role in enabling this life-saving surgery overwhelmed her, and she was moved to tears.
In Akin Fashion to Most Surgical Practitioners, the Pedagogical Odyssey of Nadine Hachach-Haram Followed the Time-Honoured Tenets of “Observation, Execution, and Pedagogy.” This Age-Old Paradigm Dictates That Trainees, After Avidly Observing a Given Surgical Procedure or the Utilisation of Specialized Equipment, Should Progress to the Act of Performing It Themselves.
The initial attempts are supervised, ultimately leading to autonomous execution. Once an adequate reservoir of firsthand experience is amassed, it is incumbent upon the surgeon to impart these skills to the succeeding generation. Hachach-Haram’s recollections of her maiden surgical observance remain vivid; at the tender age of 14, she bore witness to a pivotal surgical intervention. This momentous event transpired following her family’s relocation to Beirut from her native San Diego in 1990. The Lebanese civil war had subsided, but the tumult between the Israeli military and the Lebanese paramilitary organisation Hezbollah persisted, resulting in a litany of injuries and fatalities among the civilian populace. She reflects, “It was undeniably an inauspicious time to be growing up in Lebanon. Tragic sights of individuals afflicted with grievous burns, deformities, and lost limbs were regrettably commonplace.”
One fateful day, a family friend, a plastic surgeon hailing from New York, paid them a visit. This compassionate surgeon routinely journeyed to Lebanon to perform reconstructive procedures on trauma victims. Hachach-Haram’s intrigue led her to persuade him to permit her attendance at one of his surgeries. What unfolded before her eyes left an indelible impression. She was entranced as he conducted an operation on a young girl afflicted with foot contracture, a severe dermal condition that severely limited her mobility.
Hachach-Haram recollects, “Her foot bore the scars of a bomb blast. The surgeon executed a Z-plasty, a surgical technique involving geometric incisions to liberate the contracted tissue, enabling the repositioning of skin and the revision of scars. I was utterly astounded by his ability to restore her ability to walk simply by reconfiguring skin from one area to another. That transformative moment crystallised my life’s purpose. I aspired to emulate that New York-based plastic surgeon, someone willing to traverse 9,000 kilometres across the globe to provide essential surgical care to those in dire need. I yearned to extend the gift of hope to individuals worldwide.”
It took twelve more years for Hachach-Haram to participate in her first surgical procedure. As a first-year medical student in London, she assisted a senior surgeon in the removal of a thyroid gland. She subsequently specialised in reconstructive plastic surgery for breast and pelvic cancer, sharing her knowledge with aspiring surgeons as she continued her own training. In 2006, she commenced volunteering for global health charities, travelling to locales such as Peru, Vietnam, and Lebanon to train local medical practitioners. For a time, she derived fulfilment from her efforts. However, over the years, a nagging sense of insufficiency began to take root—a feeling that her contributions were somehow inadequate.
One particular day in April 2015, this sense of frustration reached a zenith. Hachach-Haram, heavily pregnant with her third child, found herself alone in an operating theatre. She had just returned from another gruelling overseas mission and was scheduled for yet another in the near future. The Lancet, a reputable medical journal, had published a disheartening report, revealing that a staggering nine out of ten individuals in low- and middle-income countries lacked access to rudimentary surgical care. This stark statistic landed like a gut punch, as she puts it, “I had been labouring tirelessly to improve access, provide aid, and make a meaningful impact, and suddenly, it all felt futile.”
As she reflected on her experiences as a teacher, a revelation struck her: her prior approach had been flawed. “I would train individuals, but I would never see them again,” she lamented. “I had no insight into how they adopted the techniques or whether they were employing them correctly.” This inefficacy, she realised, was an inherent flaw of the conventional “observe, execute, and teach” pedagogical model. “It was antiquated,” she proclaimed. “It simply cannot be scaled.”
Henceforth, Hachach-Haram envisioned a surgical ecosystem equipped with a digital interface—an operating system that could unite surgeons during live procedures, facilitating observation, learning, collaboration, and the exchange of expertise, unhindered by geographical constraints. Her mental imagery conjured an image of a spinning globe dotted with interconnected operating rooms spanning the world.
Assisted by a software engineer, she developed an application by the close of 2015, enabling surgeons to remotely share a visual feed of their surgical field, embellished with simple illustrations and annotations that could be inscribed directly onto the shared interface. To field-test this concept, she enlisted the services of a California-based surgeon who volunteered for the Global Smile Foundation, an organisation dedicated to cleft palate surgery for children. Traditionally, this surgeon journeyed to Trujillo, Peru, every three months to provide training to a local doctor. However, in that year, he adopted Hachach-Haram’s prototype, facilitating weekly remote training sessions. She recounted, “Within a year, the Peruvian doctor’s skill set improved significantly. Not only did she become more efficient, but her decision-making also quickened.”
A few months later, a colleague in Gaza urgently summoned Hachach-Haram’s assistance. An 18-year-old had sustained severe hand injuries while attempting to dismantle an unexploded ordnance. The young man had endured six unsuccessful surgeries performed by local surgeons, and due to the Israeli blockade, he was unable to seek treatment abroad.
While Proximie had yet to be deployed in a live surgical procedure, Hachach-Haram called upon a trauma surgeon in Beirut to offer remote assistance to the local surgeon. “I was exceedingly apprehensive,” she confessed. “The prospect of transforming this young man’s life held immense importance to me. It was akin to my dream from the age of 14 coming to fruition.”
The triumphant outcome of that surgery emboldened Hachach-Haram to elevate her research project into a fully-fledged company. She secured funding, assembled a team dedicated to technological development, and spent the subsequent couple of years fervently advocating the merits of the digital operating room at conferences worldwide. She reminisced, “I would embark on ten-hour flights just to deliver a ten-minute presentation.” In 2019, Proximie was poised for its commercial debut.
When the Covid-19 pandemic swept across the UK a year later, Proximie had already played a role in over 1,200 surgeries spanning 30 countries. Hachach-Haram initially adhered to the prevailing industry trend, announcing to shareholders that the company would prioritise mental well-being and mere survival. However, a mere week later, she experienced a change of heart. “I realised that this was precisely when people would need our technology,” she asserted. She convened another shareholder meeting, declaring, “Discard our previous plan. We shall accelerate our efforts.” In a mere six months, the user base swelled tenfold, with surgical sessions increasing to 5,500. Presently, over 20 percent of NHS hospitals have adopted the software. “Previously, we were regarded as a speculative concept with latent potential,” she mused. “Suddenly, we became the sole viable option.”
In light of the suspension of routine surgical procedures during the pandemic, Hachach-Haram endured several months without participating in a single operation. She noted, “Upon our return to surgical procedures, our confidence was shaken. We sought camaraderie, pairing up with colleagues and soliciting their guidance when possible.”
When physical presence was unfeasible, many turned to Proximie to receive remote assistance. The erosion of skills and confidence during the pandemic posed a particular concern for junior surgeons. Official data indicated that NHS trainees experienced a 50 percent reduction in surgical training opportunities. Hachach-Haram expounded, “Many trainees at the pinnacle of their education were deprived of 18 months of practice. We couldn’t afford a protracted ten-year training period. We had to contemplate how Proximie could expedite this process.”
For instance, the Society of American Gastrointestinal and Endoscopic Surgeons dispatched anatomically realistic porcine tissue models to trainees working from home. These models facilitated practice in abdominal wall hernia repair, complemented by remote expert guidance. The Hip Preservation Society, on the other hand, instituted a regular virtual education program, encompassing live surgical demonstrations viewed by over 500 individuals across the globe. Hachach-Haram remarked, “Traditionally, only a select few trainees would gain access to such procedures. Now, hundreds could observe the few cases that transpired.”
Presently, over 95 percent of surgical sessions employing Proximie are archived in an online repository. This repository empowers surgeons to edit and tag recorded footage for subsequent training or debriefing. With over 20,000 surgical videos, it has evolved into the largest database of its kind. Hachach-Haram elucidated, “Initially, we envisaged solely the live surgery feature. However, we soon recognized the need for post-operative feedback and performance reviews. Hence, we constructed the library.” Viewing her own surgical footage revealed enlightening insights; she identified her assertive disposition during surgeries, even when trainees were present. Consequently, she adapted, consciously relinquishing control of surgical instruments, clasping her hands close to her chest, and retreating from the operating table in similar scenarios. “I’ve learned to respect their space,” she affirmed. “I merely provide them with the room they require.”
Hachach-Haram’s pioneering vision of a digital operating room, catalysed by Proximie, has not only revolutionised surgical education but has also proven indispensable in the face of global challenges like the Covid-19 pandemic. Through tireless dedication and unwavering resolve, she has elevated her dream from a distant aspiration to an indispensable reality, bridging geographical gaps and bringing the collective expertise of the medical world closer together.
In conclusion, the narrative of Nadine Hachach-Haram exemplifies the fusion of medical innovation, unwavering commitment, and the relentless pursuit of excellence. It serves as a testament to the remarkable possibilities unlocked when visionary minds harness the power of technology for the betterment of humanity.
