War Doctor: Surgery on the Front Line

by David Nott

War can make an already difficult existence impossible.

For reasons I will try to explore in this book, I have for over two decades now spent much of my time volunteering to go to dangerous places to help those who have been affected by events that are, very often, utterly beyond their control. I have ventured into other people’s wars many times – in Afghanistan, Sierra Leone, Liberia, Chad, the Ivory Coast, the Democratic Republic of the Congo, Sudan, Iraq, Pakistan, Libya, Gaza and Syria to mention a few.

Why do I keep going back to areas of pure misery and heartache? The answer is simple: to help people who, like you and I, have a right to proper care at this most precarious time of their lives.

But actually it’s quite simple: I don’t get to choose who I work on. I can only try to intervene to save the life of the person in front of me who is in desperate need of help. Usually I have no idea who they are or what they have done until afterwards anyway – but even if I did know, nothing would change.

But where does that urge come from? I suspect it was laid down long ago, and triggered by two formative events experienced by a young man just beginning his career in medicine.

Malcolm was born in the city of Mandalay, right in the middle of what was then Burma, the son of an Indian army officer and a Burmese mother.

One of my reports even went as far as to say that I would turn out to be a failure. I felt nobody really cared for me. But far from being a bad thing, I have remembered that feeling all my life and it has shaped my personality – I know what it is like to not be wanted and to feel abandoned.

I still hold a single-engine piston rating, a multi-engine piston rating, an instrument rating and an instructor rating, and a helicopter licence, all current.

I’d even scrubbed up to assist him a couple of times when he was operating on private patients – something that would never be allowed to happen today, but I can’t deny I was fascinated by those early experiences.

Some people don’t ever get used to it, though, and decide to focus on a different aspect of medicine or do something else entirely. But that was never going to be me.

Even now, after being a surgeon for nearly thirty-five years, I still have to steel myself, to an extent, before making that first incision: it is a violent act, after all.

The following day I discovered that the lady had died on the operating table. It was an enormous shock – I can see her smiling face to this day. It was the first time in my life that someone I knew had died.

I will never know why the examiner made it so easy for me; perhaps he sensed there were better things to come.

the end of that year, we were allowed to go on an ‘elective’ – a chance to study overseas. I chose to go to Singapore, Malaysia, Thailand and Burma, mainly because I wanted to see Changi jail in Singapore, where my grandfather had ended up during the Second World War, and also to visit the Thanbyuzayat war cemetery in Burma, to lay a wreath given to me by my father for his brother Herbert, who was laid to rest there. It was a wonderful trip, on which I learned a lot – and not only about medicine.

Surgery in the 1980s was a trial of sleep deprivation, of how much you could take before you broke.

‘Do you know who you’re talking to, sonny?’ came the reply. ‘You are lucky I haven’t started. I’ll send them down and they will be with you soon. A word of advice: stay calm.’ I couldn’t believe it – here I was, the most junior surgeon in the hospital, being given such great encouragement from the most senior. I had no idea how profound those two words were to become, and how they would resonate throughout my life.

I’d been drilling on the wrong side of the head.

But that was minor compared with the breathtaking nature of the intervention, the saving power of surgery if you have acquired the necessary techniques to resolve or prevent the effects of a particular physical problem.

she was nearing the end of the line. Her summary of the situation was stark, filled with warnings about the dangers from snipers and the various friends she’d known who had been killed. She seemed traumatized, perhaps literally shell-shocked. After the briefing I never saw her again.

lives and deaths were synonymous with despair. Another shock to the system

But once the initial shock had faded, I had to confront another emotion that was more surprising, even a little disturbing. I felt elated, exhilarated, euphoric. I had never felt more alive; it was as if I had been reborn.

At home I lived alone – I had a few girlfriends, but nothing serious. It was a bit of a monastic existence and I had few material needs. But after Sarajevo I had to acknowledge that this was something I needed in my life.

There was another world out there, one in which I could use my skills to change the outcomes of people’s lives for the better – but also one in which I could experience the sheer thrill of being plunged into situations most people can’t begin to imagine.

During the war the alternative – ‘normal’ life – seemed very tame. I had no desire whatsoever to be someone safe in London, commuting to work, knowing what I would be doing and when months in advance. In Sarajevo I felt free . . . That part of it, the feeling of living on the edge, was fun. The only constraint was making a mistake that could get you wounded or killed, which was straightforward in a way that I liked.

they were very vulnerable and it is the vulnerability of human life that – when it is stripped down to its basics – makes us all the same.

But to be granted that God-given ability to help people in their time of need was the most joyous gift that I could ever have imagined.

One of the many disciplines I knew I’d need to get better at was obstetrics, which covers pregnancy, childbirth and the postnatal care of both mother and baby.

Over the years I came to appreciate that being able to perform a safe emergency caesarean section or manage post-partum bleeding was one of the most useful, even essential, skills for a humanitarian surgeon.

Afghanistan was a place where conflict seemed to be a semi-permanent state.

the real struggle for control of Kabul took place in September 1996.

The organization’s founding principles – humanity, impartiality, neutrality, independence, voluntary services, unity and universality – were drummed into me.

Sitting in a quiet classroom, it’s easy to gloss over how profound such ideas are, but out in the field they are the essential commandments that allow the ICRC to work almost anywhere in the world.

treated his wife for a fibroid problem, and the ICRC surgeon before me had treated bin Laden himself for kidney stones.

also couldn’t believe that what purported to be legal in Sharia law was nothing more than outright murder and torture.

Therefore the consequences of losing a lot of blood are that we become cold and bleed more, because the clotting enzymes don’t work. Having a cold circulation with high acidity also affects the heart, which begins to fail and does not pump adequately,

The combination of hypothermia (cold), coagulopathy (impaired ability of the blood to clot) and acidosis (raised acidity) is called the ‘trauma triad of death’.

‘Damage control’ surgery is, in

effect, a temporizing measure to reverse the effect of hypothermia, coagulopathy and acidosis.

The patient is on the operating table for a much shorter initial time, and can then be taken to the intensive care unit to be warmed up.

A major advance was the development of damage-control resuscitation, which involves replacing lost blood with preheated blood, thus minimizing the effects of cold and poor clotting. These techniques have now been adopted by all the major trauma centres in the developed world.

the hospital there had amazing results: 98 per cent of all those who were shot or who had major injuries from IEDs survived. It was a remarkable achievement, as some of the casualties had terrible wounds such as the complete loss of both legs and, in some cases, also an arm, the so-called triple amputation.

Once people start blindly obeying irrational authority and conforming in both mentality and dress, it becomes easier to dehumanize your enemies.

The person holding the needle is just one small part of the bigger picture.

The situation for Syria’s civilian population was critical – they were caught up in the fighting and demonized by their own government.

They operated a strict ‘two strikes and you’re out’ policy. The security scare at Alpha, when the jihadis had threatened to overrun the hospital because they’d seen me take photos of the sunset, had been strike two. I had known about the rule not to take

any pictures, but, as I have described, everyone routinely ignored it, and MSF seemed quite happy to turn a blind eye to all my priceless training videos, which were technically also in breach of the rule.

many of the more senior doctors and surgeons had already left – as many as 95 per cent of Aleppo’s physicians had seen which way the wind was blowing and found a route out. Those who remained were brave and committed, but there were very few of them. In the face of the regime’s targeting of healthcare workers and those seeking medical help, one of these courageous doctors had set up a network of secret hospitals to treat people injured in the war.

Volunteers would bring wounded protesters to the safe houses, and then leave before Dr White took over, to preserve his anonymity.

the UK coroner’s court deemed that he had been murdered by the Syrian regime in December 2013. The authorities denied this, claiming that he had hanged himself, but nobody believed them.

Abdulaziz told me that he’d heard that the snipers were playing a game: they were being given rewards, such as packs of cigarettes, for scoring hits on specific parts of the anatomy.