Proximie: Redressing inequities in surgical healthcare during the pandemic

By Martin Armstrong

In between shifts at Guy and St Thomas’ Hospital beside London’s Westminster Bridge, Dr Nadine Hachach-Haram FRCS (Plast), BEM, reflects on the growth of her business, Proximie, during the current COVID-19 pandemic.

Proximie is a digital platform which is on a mission to save lives by sharing the world’s best clinical practice. Hachach-Haram launched Proximie in 2016. In 2018 she was awarded the British Empire Medal for her contribution to surgery and medicine.

“Last year we did 1,200 procedures. By the end of September this year we’d already done about 5,500. Looking widely at the numbers we’ve grown about 900% from last year in terms of users,” says Hachach-Haram.

“We launched in the USA in April and it already forms nearly 40% of our business. We just broke another record this month — we have done about 780 procedures.”

Expansion during the pandemic

At a time of uncertainty and change brought about by the COVID-19 pandemic, Proximie’s innovative platform provides a neat and effective solution to problems posed to traditional surgical practices, stepping in to facilitate vital services.

Proximie enables clinicians to support colleagues in the operating room from anywhere in the world via an interactive audio-visual display beamed live in both locations. This allows an expert working remotely to provide notes, and annotations during proceedings and place their hands in the surgical field for further instruction. Successful surgeries are then compiled in an ever-growing database which can be consulted at the click of a button.

The platform has been used in orthopaedic trauma, emergency cardiac, general surgery, neurosurgery and spinal emergency surgery. Additionally, its use has expanded this year to provide remote expertise to clinicians working in Intensive Care Units, while the application has also been used in conflict zones where medics are often physically isolated from peer support.

Confronting inequity in healthcare

Hachach-Haram developed Proximie having spent 10 years working as a surgeon on global health initiatives around the world.

While the experience was rewarding, Hachach-Haram found herself keen to do more to confront the global inequities in healthcare she came face to face with working in the field.

“After you’ve been doing it (global health initiatives) for 10 years you start to look back and see what impact you’ve had and how much you’ve actually been able to scale expertise or support independent delivery of care locally,” reflects Hachach-Haram.

“When I looked at the Lancet Commission that published that five billion people globally lack access to safe surgery, I realised that we were only scratching the surface. That it was really about building scalable, sustainable models of support and delivery so I started to look at technology.”

From Pokemon Go to Augmented Surgery

Hachach-Haram is a self-described “techie” and had previously worked with medical device companies helping them with their product training and launches, knowledge and expertise she used to good effect when developing Proximie.

“My Dad is a computer engineer and I was a gamer as a kid. I liked to put computers together,” says Hachach-Haram. “In telehealth there was not really any multi-sensory experience. I needed to be able to point out and demonstrate and give audible and visual instructions.”

“People had begun to speak about the possibility of augmented surgeries, and Pokemon Go had come out. That shaped our thinking as well,” continues Hachach-Haram, who speaks with a restless enthusiasm about improving access to safe and effective surgery like it is a personal mission.

She cites her upbringing as a central influence in this ongoing endeavour.

Growing up in post-war Lebanon

Hachach-Haram spent her early childhood in California. Her parents emigrated to the United States during Lebanon’s protracted Civil War (1975–1990). They returned to Beirut in the early 90s.

“I got involved in global health initiatives because in some ways it resonated with my upbringing in those difficult environments,” says Hachach-Haram, reflecting on life in post-war Lebanon in the 1990s. “But, ultimately it didn’t feel enough.”

Seeing the human impact conflict exacted on her homeland had a profound influence on Hachach-Haram.

“You would see a lot of deformities, people with arms and legs injured and missing. Things that perhaps you shouldn’t see as a teenager,” says Hachach-Haram.

“Because of the economic situation in Lebanon my father moved to Saudi and worked from there. We lived in Beirut with my Mum and grandmother,” says Hachach-Haram, who became involved in humanitarian initiatives in her teens, due in large part to the influence of her grandmother.

“She was a very independent woman. She ran a number of charities helping and empowering women and families, and would involve us all.”

Pursuing a career in surgery

Reflecting on her teenage years Hachach-Haram recalls events such as the Qana Massacre as pivotal in her decision to pursue a career in surgery.

In April 1996, over a hundred civilians, seeking refuge in a UN facility in the Southern Lebanese town of Qana from clashes between the Israeli Defence Force and the Lebanese paramilitary group Hezbollah, were killed when Israeli artillery fire struck the building they were sheltering in.

“My Mum’s family is from Qana, and we used to spend our weekends and summers there. At that point I started to get interested in the ability to help patients and to look for opportunities.”

“Soon afterwards, when I was 14 a family friend who was a plastic surgeon was going down to Sidon (a city 40km south of Beirut on Lebanon’s Mediterranean Coast) to do some reconstruction for some young trauma patients who had deformities in their legs from burns, contractures, and blast injuries. He was probably surprised I wanted to go with him,” remembers Hachach-Haram.

“I was mesmerised. After that, any time I could get into an operating room I wanted to see what was going on,” says Hachach-Haram, pausing momentarily. I still love it. It’s very humbling, you are in an operating room, the patient is asleep, you have a team around you trying to make a positive difference in a patient’s life.”


In August Proximie’s Beirut office suffered extensive material damage when a catastrophic explosion caused by the accidental ignition of fertilisers at the city’s port ripped through the heart of the Lebanese capital causing over 100 deaths and billions in material damage.

Hachach-Haram says she was left devastated by the event, though ultimately relieved that her colleagues and family were largely unscathed.

Since, Proximie has been utilised in a number of surgeries in Beirut. In September a surgeon at the American University of Beirut Hospital successfully performed a toe-to-thumb transplant for one of the blast victims.

The surgery was broadcast to a group of plastic surgery trainees in London, helping to expand their knowledge and understanding of a delicate surgical procedure.

“It is a great thing to be able to dial into someone else’s operating room and see how they are doing the case,” says Hachach-Haram, before commenting on the sense of legacy building that her grandmother instilled in her.

“From my grandmother I learnt this idea of legacy building, making a difference for people. When I started in surgery all I wanted was to restore form and function, help patients, give them a better quality of life. After a while I felt it wasn’t enough,” says Hachach-Haram with a steely determination that dovetails with a smile of genuine warmth and compassion.

“I think that is what Proximie ultimately gave me, that ability to do something that can scale and build legacy independently of me at some time.”

Proximie — The Future

Before returning to her duties at Guy and St Thomas’ Hachach-Haram comments on what the near future holds for Proximie, and surgical practice more generally.

“We have operated in 35 countries to date working with partners in Europe, North America, The Middle East, and Asia, and we will be working with partners in Latin America,” says Hachach-Haram.

“I think surgery is continuing to adapt,” notes Hachach-Haram, reflecting on the changes to her profession this year, and the role Proximie can play in its evolution.

“We wrote the commission on The Future of Surgery, what it is going to look like in the next 5–10–15 years, and definitely it is going to be more connected, more data-driven, and increasingly amplified through different pools and mechanisms that exist.”

“The patient surgeon interface is changing so quickly and as we layer on AI into different applications, having access to real-time insights will improve patient care.”

“Building on this it is exciting to think about how I was told that this problem was too big for a practicing surgeon and first time CEO to solve. We’re now in advanced discussions to solve the global connectivity problems in healthcare through 5G and Space Technology. Watch this space.”

“At our heart, though, is everyone working towards giving every patient the best care and absolutely, Proximie will be part of this future.”

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