War Doctor

Surgery on the Front Line

David Nott

• Publisher: ABRAMS Press
• Year: 2020
• ISBN:
  9781683359067
• Topic: Médecine
• Subtopic: Biographies de médecine

#1 International Bestseller: A frontline trauma surgeon tells his "riveting" true story of operating in the world's most dangerous war zones ( The Times ). For more than twenty-five years, surgeon David Nott has volunteered in some of the world's most perilous conflict zones. From Sarajevo under siege in 1993 to clandestine hospitals in rebel-held eastern Aleppo, he has carried out lifesaving operations in the most challenging conditions, and with none of the resources of a major metropolitan hospital. He is now widely acknowledged as the most experienced trauma surgeon in the world. War Doctor is his extraordinary story, encompassing his surgeries in nearly every major conflict zone since the end of the Cold War, as well as his struggles to return to a "normal" life and routine after each trip. Culminating in his recent trips to war-torn Syria—and the untold story of his efforts to help secure a humanitarian corridor out of besieged Aleppo to evacuate some 50, 000 people— War Doctor is a heart-stopping and moving blend of medical memoir, personal journey, and nonfiction thriller that provides unforgettable, at times raw, insight into the human toll of war. "Superb... You are constantly amazed that men such as Nott can witness the extraordinary cruelties of the human race, so many and so foul, yet keep going." — Sunday Times "Gripping and fascinating medical stories." — Kirkus Reviews

1
THE BOMB FACTORY

The London 2012 Summer Olympics were in full flow, with Team Great Britain winning a record number of medals and the country basking in the reflected glory of our athletes and a successful Games. It was hard to imagine that only a few hours’ flight away an entire country was descending into violent anarchy.

I was busy with my day job for the National Health Service. For most of the year I work at three hospitals in London: St. Mary’s, where I am a consultant vascular (blood vessels and circulation, from the Latin vas, for vessel) and trauma surgeon; the Royal Marsden, where I help the cancer surgeons from various specialties such as general surgery, urology, faciomaxillary, and gynecology remove large tumors en bloc, which then require extensive vascular reconstruction; and the Chelsea and Westminster, where I am a consultant laparoscopic (keyhole) and general surgeon. But alongside this work, in most years since the early 1990s I’ve also done a few weeks’ trauma surgery in a war zone. I monitor the news avidly, keeping an eye out for developing hotspots, knowing at some point soon an aid agency is likely to ask me to help.

When I get such a call, my heart begins to race and I develop an irrepressible urge to remove any obstacle that might prevent me from going. My immediate response is always, “Give me a couple of hours and I will come back to you.” The call might come while I’m operating or assisting a colleague, or I might be holding a routine outpatient clinic. Wherever I am and whatever I am doing, the desire to go is always intense and almost overwhelming. But I can’t say yes every time. I might get a couple of requests a month from different agencies, and could easily be a full-time volunteer, but I have to earn a living, too. I do receive £300 or so for a month’s fieldwork, but mostly that’s spent on everyday expenses.

Before agreeing to anything, I call the surgical manager at Chelsea and Westminster, where my contract is held, and explain that there’s a humanitarian crisis in which I’ve been asked to help. I then request immediate unpaid leave for the time I’ll be away. There is usually no objection, “as long as you can sort out your clinics and your operating and your on-calls.” Indeed, I have never yet been turned down. No doubt the carrot of taking unpaid leave while maintaining all my commitments helps to allay any anxieties the NHS might have!

So I didn’t need asking twice when, during the summer of 2012, a call came from the head office of Médecins Sans Frontières (MSF) in Paris, asking if I would be prepared to work in a hospital they’d set up in Syria. I made the usual arrangements at home, packed my things, and got on a plane to Turkey.

Like most people, I knew Syria was a country in the Middle East that had steered clear of the conflicts that had beset many of its neighbors—three of the countries it borders are Iraq, Lebanon, and Israel, hardly oases of calm. For most of my lifetime Syria had been a closed, slightly secretive sort of place, but peaceful, where more adventurous Western tourists sometimes went on holiday, with a population known for its warm and hospitable nature.

It’s a truism I’ll return to that many of the countries I’ve volunteered in have collapsed into chaos after a challenge to authoritarian rule. Nature might abhor a vacuum, but warmongers love them. In Syria’s case the authoritarianism was provided by the Assad family, who had ruled over the country since taking power in a bloodless coup in 1970. The current president, Bashar al-Assad, had taken over after the death of his father, Hafez, in 2000—winning 99.7 percent of the vote that confirmed his assumption of power. The Assad family are leading lights in the minority Alawite sect, a branch of Shia Islam in a country where nearly three-quarters of the population are Sunnis. There was something of a cult of personality around them, with pictures of Hafez and Bashar the decor of choice in many offices and stores. Their grip on power was, in time-honored fashion, reinforced by a notoriously brutal secret police, conspicuous in their ubiquitous sunglasses and leather jackets.

My acquaintance with Syria went back a long way: my father had had a Syrian trainee called Dr. Bourak in the 1970s, whom my dad said was the best resident he had ever worked with, and I had also met a young Dr. Bashar al-Assad while he was an ophthalmic resident at the Western Eye Hospital in London in the early 1990s. We were discussing a patient who had eye problems from a small clot that had come off the carotid artery. He seemed very pleasant and respectful—little did I know that our paths would cross again many years later.

In Syria the plates had begun to shift in 2010, the year demonstrators in Tunisia took to the streets to complain about a host of grievances including high levels of corruption, unemployment, and lack of freedom of expression. Early in the new year Tunisia’s long-serving president was deposed, and others across North Africa and the Middle East, experiencing similarly bad government, began to take notice. There were sustained protests in Morocco, Algeria, and Sudan throughout early 2011, and then across to Iraq, Lebanon, Jordan, and Kuwait. And in five other countries—Libya, Egypt, Yemen, Bahrain, and Syria—the phenomenon that became known as the Arab Spring led to serious insurgencies, the toppling of regimes, or full-blown civil war. So far, only Tunisia has managed to turn the turmoil into positive democratic change: many of the other countries are arguably much worse off than before.

In Syria, suppression of the protests calling for President Assad’s removal was particularly brutal. In my opinion the whole civil war could have been avoided, or quickly curtailed, if the regime had responded to the protests in a more moderate way. In March 2011 some children sprayed anti-government graffiti on walls in the southern city of Daraa; Assad’s response was to have his security forces detain the children and torture them. Thousands of protesters took to the streets in response. On March 22, Assad’s forces stormed the hospital in Daraa and occupied the building, positioning snipers on the roof. As the protests escalated, the snipers began their work. A surgeon named Ali al-Mahameed was killed as he tried to attend to the wounded, and when thousands of mourners turned up at his funeral later that day, they too were shot at. Snipers would remain stationed on the roof for another two years, firing on sick and injured people who were simply trying to get treatment.

As protests erupted all over Syria, the country’s medical system became a lightning rod for the divisions tearing Syrian society apart. Those opposing the regime—mostly Sunnis, from among whom the Free Syrian Army emerged—found that seeking treatment for injuries sustained in the fighting became almost as dangerous as the fighting itself.

The healthcare system was weaponized by the regime. Government-run hospitals functioned as an extension of the security apparatus: it was reported that staff still loyal to Assad would routinely deal with minor injuries by carrying out amputations as a form of punishment. Protesters who had been wounded and were awaiting treatment were often taken from the wards and spirited away to be tortured and killed.

In the first year of the uprising a documented fifty-six medical workers were either targeted by government snipers or tortured to death in detention facilities. In July 2012, Assad passed a new law against failing to report anti-government activity, in effect making the medical treatment of anyone not actively supporting Assad a criminal offense. This was the kind of pressure medical staff across the country were having to face simply to do their job.

I flew to Istanbul and then on to Hatay, the airport near to Reyhanlı, the closest Turkish town to the Syrian border. I was then taken to the MSF safe house in Reyhanlı and given a briefing on the mission, the latest security alerts and escape routes in case of emergency evacuation. The following day I was picked up by a Syrian driver and a local Syrian logistician and taken to a checkpoint just before the border where I was given a false name and signed in as such and was given some papers. The driver then took me to the border, which was under the watchful eye of the Turkish military, who also checked my papers. We crossed the border, which at that time was just a barbed-wire fence, and waited for the Syrian car to take me to the MSF hospital in Atmeh. We passed the fledgling refugee camp, which had a few thousand people in ragged tents with poor sanitary conditions. Although the tents were disheveled, I was surprised to see the people inside were very well-dressed with clean shoes, and must have taken pride in their appearance. I am sure that they did not realize that their refugee status was just the beginning of a miserable existence that they were to endure for years to come. Médecins Sans Frontières (known as Doctors Without Borders in the US), a medical humanitarian organization with which I had worked on several occasions, had taken over a large walled villa in the town and converted it into a hospital, code-named Alpha, as it was the first such facility they set up in Syria. The house was large and well-proportioned and belonged to a man who happened to be a surgeon himself who was working in Aleppo. The rooms had been repurposed in anticipation of growing demand: the dining room became our operating room, the living room was our emergency room, where patients were first assessed, and the kitchen housed the sterilization unit. The first and second floors became our wards, with about twenty beds, and the staff accommodation was on the top floor—although when I arrived it was so warm we used to sleep on the roof, under mosquito nets. A mix of Syrians and foreign volunteers like me, we’d lie up there, exhausted after a nonstop shift, watching the jets streaking overhead and staring up at the stars in the inky night sky.

I quickly settled into a rhythm and began to feel useful. We’d get up early, have a meeting with the project manager, who would brief us on the security situation that day, where the latest fighting was concentrated, and so on, and then we’d do our ward rounds. I was very pleased to see that Pete Matthew, an excellent doctor I’d worked with before, was there, too. A consultant neurosurgeon from Dundee, Scotland, Pete had some years earlier been very keen to try his hand at humanitarian work. Back in 2002, with my colleagues Pauline Dodds and Jenny Hayward-Karlsson, I had run a training course sponsored by the British Red Cross to train British surgeons to work in war zones and Pete had been one of the delegates. We became great friends and had stayed in touch ever since.

After the ward round in Atmeh we’d have breakfast and then start on any scheduled operations: to begin with, in this early stage of the war, we were not overrun with casualties and there was still time to do elective or follow-up surgery for people whose lives were no longer in immediate danger.

But things soon heated up, and before long there was a great deal of significant emergency surgery going on—we began to see lots of gunshot wounds and fragmentation injuries as the regime began shelling civilian homes and firing rockets from helicopters. People were facing not only the primary risk of a direct hit, perhaps killing them outright or resulting in a catastrophic amputation, but also the secondary risk of fragmentation or shrapnel injuries as the metal shell casings flew in all directions and bits of buildings hit by a missile became deadly projectiles.

Every now and then, at any time of day or night, we might hear the blaring of a car or pickup truck’s horn in the distance, getting louder and louder as the vehicle sped toward us with its cargo of victims. The horns acted as a siren, and we’d know to get the emergency room ready so we could assess the patients and decide who needed to go straight into surgery. On one occasion, the first patient to need our help turned out to be the wife of a local bomb-maker. At that time there were a lot of small factories opening up in Atmeh that were making explosives. These were fairly crude devices and few of the people making them knew what they were doing—they were mostly working at home, making it up as they went along, and putting their own families at terrible risk.

The woman’s husband had apparently been making a bomb in their kitchen when it had detonated prematurely. The whole house was destroyed, the bomb-maker killed, and his wife rushed to us with a fragment injury to her lower left leg. She was hemorrhaging significantly from the wound, which required a tourniquet to be placed immediately on the thigh.

The anesthesiologist took a quick blood sample and put it through our very basic hemoglobinometer, a device which measures the red cell count in blood. It confirmed that she had a hemoglobin of 4 grams per liter (the normal amount of hemoglobin—the stuff that carries oxygen in the blood—is between 12 and 15g/L). It was clear she had lost a great deal of blood. He quickly established her blood group and then went to get a pint of fresh blood of the right type from our dwindling supplies. Then, on the other arm, he set up a saline drip to replace some of the fluid that she had lost.

All this happened on the operating table in the dining room. The nurse in charge set up the gurney with sterile drapes and instruments as the patient was given general anesthesia. It was impossible to assess the wound properly as there was arterial bleeding, most likely from the superficial femoral artery in the leg. There was a large dressing on the top, which was acting as a local compression. I scrubbed up and prepared to operate.

One of the Syrian assistants, who didn’t speak much English, was helping to lift the leg. As I prepped the limb with iodine, I asked the helper to take off the pressure dressing. The bleeding by this time had stopped, and there was a large clot overlying the wound. With the patient now draped and prepped, I started the procedure by making an incision below the tourniquet, high on the leg, so that I could get a clamp on the artery before exploring the wound. After gaining proximal control of the blood vessel I then went down to have a proper look. I tentatively put my finger into a large hole just above her knee joint and felt an object in there which I assumed was a piece of metal—a fragment from the bomb, or maybe a bit of her house.

In this kind of scenario it is always important to go very carefully, putting your finger into the wound slowly and cautiously because there may be fractured bone, which can be as sharp as shards of glass—the last thing you want is a needlestick injury without knowing the blood status of the patient. In this environment there was perhaps less concern about HIV or hepatitis, but it is a common mistake not to assume the worst.

Probing gently with my finger, it didn’t appear to be the usual jagged piece of metal or fragment but a smooth, cylindrical object. Very carefully I grabbed it with my fingers and pulled it out. I held it up to examine it, and the Syrian helper who was with me took one look and went pale. He obviously knew what I was holding and blurted out, “Mufajir!” before turning tail and leaving the room.

The anesthesiologist and I looked at each other. Was I holding some sort of bomb? In that instant, I froze as I wondered what on earth I should do next. It became extremely quiet—all I could hear was the soft hiss of the ventilator pumping oxygen into the patient’s lungs. The anesthesiologist shuffled away, moving across to the corner of the room behind one of the cabinets. By now my hands were shaking, I was in danger of dropping whatever it was, and I realized I had to do something. I decided to take a deep breath and walk out of the operating room as carefully and slowly as I could. I needed the anesthesiologist to open the door for me and jerked my head in its direction to show him what I wanted, hardly daring to speak. He said to wait, as he was sure somebody was going to come very shortly—thankfully he was right, and as I deliberated for a few more seconds the door opened and in came the Syrian helper with a bucket of water. He put the bucket on the floor next to me and he and the anesthesiologist ran to the safety of the next room. With my heart pounding, I carefully put the object into the bottom of the bucket, feeling the cold water seeping into the sleeve of my green scrubs, and very gingerly took it outside.

Mufajir means “detonator.” It was hard to tell if it was live or not. I was told later that it probably would not have killed me, but it would most likely have blown off my hand—not the end of my life, maybe, but certainly the end of my career, and at the time the two were much the same thing.

It wasn’t the last time I had a run-in with homespun explosives. Most of the fragmentation wounds from bombs that we were receiving were from the effects of amateur bomb-makers. Several times throughout the mission, we would receive young girls and boys at the hospital who had lost one or both of their hands. Some had severe facial injuries as well, and, even more pitifully, some had dreadful eye damage that rendered them blind. Many times I would go to the ward and hear the sobbing of parents holding their five- or six-year-old, who would never see them again or touch them with their fingers. It was utterly heartbreaking.

Although all around us there were people coming to terms with being at war, in the house we felt pretty safe. We didn’t really take much notice of the building opposite, which seemed to be full of young men in dark combat fatigues, often carrying weapons. I suppose if I thought about it at all, I assumed it was some sort of training facility for the Free Syrian Army. We used to watch them kneeling after the mosque’s call to prayer began at around 4:30 in the morning, and knew that they could see us going about our business, too. There was something very romantic about that moment; I would lie awake on the roof, listening to the beautiful voice singing from the mosque. The air at that early hour was sweet with a crisp coldness—there was a sense of complete tranquility as the sky gradually lightened. By seven o’clock in the morning it was too hot to lie awake on our rubber mattresses, which made it easy for us all to get up and wait our turn for the shared toilet and shower in the building.

The sunsets were equally beautiful. More often than not the evening sky was just a vast swathe of deep blue, with the occasional wispy cloud. The sun cycled through an array of startling colors as it sank down and set between two small mountains on the horizon; it was a wonderful spectacle to watch.

On one such evening, the rest of the team had gone down to the village swimming pool. Feeling self-conscious and a little overweight at the time, I decided not to join them and to go upstairs to the roof for a rest. The sunset was particularly striking, so I decided to take a photograph of it. I’d been doing these missions for many years by this time, and I knew the rule that one should never take photos on a mission with MSF. However, over the years I have always taken clinical photographs and videos for teaching purposes—with the patient’s permission, of course—often using a GoPro camera mounted on a headband. And I am very pleased that I did, because without doubt this archive of images has become a major educational tool for the teaching work I do now. And everyone took pictures, all the time—the rule, such as it was, was very widely ignored.

I set up my camera and spent quite a bit of time fiddling with the time-lapse function to get the best shot. As I was doing so I looked down into the street below and noticed someone I recognized—Dr. Isa Rahman, whom I had met at the Turkey-Syria border a few weeks before. I waved to him and he waved back. He had recently qualified from Imperial College and was working with a charity called Hand in Hand for Syria, which had set up a clinic in Atmeh.

I turned back to my camera, which was on the wall overlooking the street and the ...