Surgery under fire

Many of us have had the experience of surgery in a hospital, either for ourselves or people around us. The routine may be familiar if fraught: nurses briskly entering and leaving, vital signs checked at apparently random intervals, those bright white lights, the hospital beds with their various handles and adjustments. Imagine, then, surgery without those sterile conditions, or without electricity, with minimal medical supplies, and with shells bursting overhead.

This is the environment that David Nott thrives in, and describes in the autobiographical War Doctor. An English doctor who works with the NHS, he works at several hospitals in multiple areas: vascular surgery, general surgery, urology, gynecology, and keyhole surgery.

But alongside this work, in most years since the early 1990s I’ve also done a few weeks’ trauma surgery in a war zone.

What led to this vocation? He traces it to watching the film The Killing Fields, set in Khmer Rouge Cambodia, which has an inspiring scene set in a Phnom Penh hospital. Once he completed his medical training in 1993, he applied to Médecins Sans Frontières (Doctors Without Borders), during the Yugoslav civil war period. By the end of that year, he was on his way to Zagreb (capital of the newly independent Croatia), from where he was headed to Sarajevo.

As we approached Sarajevo we went into a shockingly sudden descent, practically a nosedive — the protocol was to descend as rapidly as possible and then circle tight in a kind of corkscrew motion to make the plane more difficult to hit with a rocket or missile. [..]From the blown-out windows and shell-damaged airport buildings, with the control tower half destroyed, it was clear we’d left the relative security of Zagreb behind.

Nott is stationed in a large central hospital (nicknamed ‘Swiss Cheese’ because it has so many holes in it) along with a handful of surgeons, nurses and anesthesiologists who are all exhausted and demoralized.

Some of the injuries were too ghastly to describe here, but the main difference from my work in the UK was that so many casualties had missing body parts.

Each incoming patient poses quandaries: which person to operate on first, what operation to perform, whether it is too late already for that patient, whether they should get some of the small store of blood and medical supplies.

An elderly lady who looked to be in her mid-seventies, who had lost both legs, one above the knee and one below, and also an arm, all blown off by shrapnel. [..] It was likely she would not survive a lengthy operation or a series of different procedures. We also had a finite amount of blood to give her. Should she get it? Or would tomorrow bring a more worthy recipient? Who was I to decide who was more worthy anyway?

The working conditions are unimaginable: working hours depended on the situation but were always lengthy, sleep was sometimes under tables in sleeping bags, It was also bitterly cold in Sarajevo, and the operating rooms were reliant on generators which could sometimes fail.

And yet, the work leaves him exhilarated.

a strange mix of altruism and pure selfishness — chasing the high of intervening to save lives, but also of living my own life closer to the edge.

There is a surprise in the second chapter. David Nott’s father, it turns out, was born in Mandalay, “the son of an Indian army officer and a Burmese mother”, and thus Nott himself is part South Asian. (The origins of the name ‘Nott’ remain a mystery)

Obstetrics/gynecology, it turns out, was one of the most important disciplines for a war-zone surgeon, and performing Cesarean sections was one of the skills he needed to learn.

But I didn’t learn [it] in the safety of a London teaching hospital. I learned the procedure in Kabul [..] in 1996.

Nott was back in Afghanistan in 2001, this time in Kandahar, where among other patients, he treated one of Osama bin Laden’s wives for a fibroid problem.

The list of countries Nott worked in over the next thirty years sounds like a list of world catastrophies: the Congo, Sierra Leone, Sudan, Rwanda, Iraq, Gaza, Syria…

While Doctors Without Borders is apolitical, Nott himself does comment on the politics that led to the horrific conflicts and injuries and deaths in these war zones. But regardless of his own opinions, he operates on whichever patients come in, no matter what side they are on.

I am often asked how I can square my humanitarian work with saving the life of someone who might go on to make something that kills British soldiers or innocent civilians. It’s a valid point, of course, and every war surgeon has to wrestle with the conundrum at some point. But actually it’s quite simple: I don’t get to choose who I work on. I can only intervene to save the life of the person in front of me. Usually I have no idea who they are or what they have done [..] I rationalize it by thinking Maybe that Taliban guy or ISIS fighter will find out his life was saved by a Western, Christian doctor, and that might make him change his outlook. Some people may consider this naive, but that’s how it is.

A single man can do only so much, so Nott set up a training program for surgeons in war zones, and then later a foundation that would pay for surgeons from all over the world to attend.

Such work takes its toll, of course, and towards the end of the book Nott is clearly suffering from PTSD. Some of the people he worked with have died or vanished in mysterious circumstances. Many of his patients died before he could operate, during the operation, or after — these are hard stories to read but obviously even harder for the surgeon to live through. There are successes and failures: for example, telemedicine might seem like a promising approach, but a 2016 surgery consultation via Skype led to Syrian rebels targeting the operating room with even greater accuracy.

Henry Marsh, another great writer and doctor, wrote the foreword to War Doctor, and ends with: