Knife Edge: Life as a Special Forces Surgeon (36 page)

Not all treatments in Madhya Pradesh require a surgeon. As with many Third World countries, local quacks and medicine men abound. One remarkable individual is the bone setter, based 160 kilometres south of Padhar. As Vincent and I sat in the various interminably long hospital out-patient clinics, we saw several patients who had been treated by the man. It was Vincent who made the first, complimentary remark.

‘He seems to be doing a good job, Richard. Look — this patient has a broken thigh bone that has now mended perfectly.’ He indicated a young railway worker who had walked 120 kilometres simply to show us the excellent results of his treatment. Three months earlier he had broken the bone in a road accident. Now, he was able to walk with barely a limp. Vincent thrust the large celluloid X-ray films on to the flickering illumination box. I could see the outline of a perfectly united bone and nodded my approval. The result was good. ‘Let me show you the bone setter,’ Vincent added. Within an hour we were on our way in the hospital Volvo, bumping and thumping along even dirtier roads, penetrating further into the countryside.

The bone setter’s clinic, if that is what one can call it, was a primitive affair. We had arrived unannounced, so it was impossible for the man to prepare. Low ramshackle buildings surrounded a dusty courtyard. Mangy dogs and sleepy, thin cows were everywhere. The fresh, clean, disinfected smell of clinics so frequently found in the West was not a feature there. Mostly we weaved our way past animal droppings and the general detritus of an impoverished society. Within the gloom of the most ramshackle dwelling of all I could see the shadow of a man hard at work. Vincent strode through the open door, shouting a greeting at the fellow. They knew each other well, though both were at different extremes of the bone-disease spectrum. Through Vincent as my interpreter, I greeted the man and then peered further into the gloom, inspecting him as closely as I dared. The bone setter was perhaps fifty years of age, unshaven, untidy, with gums stained red from incessant chewing of betel. Dressed in dirty, baggy, dishevelled garb, he smiled a half-toothless smile as we entered, indicating we should stand quietly to one side of the room. To call it a room is an exaggeration. The house was half twig, half mud, with an earthen ground floor to its one room. The front door hung precariously from its one remaining hinge, the air inside penetratingly dank.

We had arrived at an ideal moment. On the crumbly ground lay a ten-year-old boy. I could see the youngster was in pain. The lower end of his left shin bone was angled alarmingly as a result of a break - a fracture - several days earlier. The bone setter indicated I should examine the leg before he commenced treatment. I bent down slowly, taking care to make no sudden movement. I did not wish to frighten the boy. No sooner had my hand come within an inch of the broken area, it had not even touched it, than the boy began to whimper. Gently, with barely any pressure whatsoever, I laid my hand on the deformed bone. Instantly, the lad let out a violent scream - ‘Eeeaargh!’ In the close confines of the shadowy room, the noise was deafening.

I lurched backwards, removing my hand rapidly, as if electrocuted. ‘I’m sorry,’ I whispered, not that the boy could understand. ‘Let me try again. I won’t hurt you. I promise.’

It was no use. Whatever I did, however I tried to examine the broken limb, I could not get close. Each time I so much as brushed the broken area with my fingers, however gently, the boy would thrash his head from side to side and deliver a piercing scream. ‘Eeeaargh! Eeeaargh!’ It was not a good demonstration of British bedside manner.

Vincent leaned towards me in the half darkness. ‘Let the bone setter show you, Richard. Watch how he does it.’

As if on theatrical cue, the bone setter held up the palm of his right hand towards the boy, who immediately fell silent. It was as if the man was saying ‘Don’t worry - I’m in control now. The Englishman doesn’t know what to do anyway.’ He was probably right. The only way I could have dealt with the situation was to put the lad to sleep with anaesthetic first. Western medical training relies heavily on certain basic items of equipment being available. The bone setter had nothing except his hands, a pile of rotting rags and some seeds in a small heap on the ground nearby.

‘I see 400 patients every month, Dr Richard,’ explained the bone setter, via Vincent’s interpretation, as he stretched out a rag on the ground to his front. ‘I charge them nothing, though sometimes they will give me small gifts in exchange. Chickens, pots and pans, that sort of thing.’ As he talked, he retrieved a large, smooth oval stone from the shadows, moving it nearer to him. From deep inside his baggy, stained clothing he produced a small piece of pale root, no more than an inch long.

‘Who taught you your methods?’ I asked.

‘My father. Before him his father. And before him his father. This has been with my family for generations.’ Carefully, deliberately, he placed the root on the large oval stone, reaching behind him to retrieve another, smaller stone. My eyes had by now become accustomed to the shadows.

The bone setter continued talking as he worked. ‘I crush the root like this, into a fine white powder.’ Deftly, within seconds, the root had disappeared as he thumped and kneaded it between the two stones.

‘Then I take some oil — sunflower oil — that I have made from these seeds.’ He indicated the mound of small black seeds I had seen earlier. I saw him dip one finger in a small pot of oil and make a tiny smear on the ground beside him.

‘What’s that?’ I asked.

‘In memory of my father’s God. It is part of the treatment.’

I was not one to argue. The whole procedure was alien to me, though I could see the young boy was equally fascinated. He remained silent, watching the bone setter’s every move. Vincent, too, was quiet. He had seen this before and I could tell was interested in my reaction.

The bone setter picked up the fine powder between finger and thumb, sprinkling it on the surface of the thick oil. Then he set to, mixing it vigorously with a small stick until the powder had disappeared. ‘Once it is mixed,’ he continued, ‘I pour it on to the bandage like this.’

I smiled at his use of the word ‘bandage’ to describe the thin rag on the ground before him. Skilfully he poured the mixture on to the cloth, in a narrow line from one end to the other. ‘Then I take the bandage and wrap it around the boy’s leg. Watch.’ As he spoke I could see the lad lean backwards in fear and anticipation. Instantly the bone setter detected the worry, again holding up the palm of his right hand in reassurance. Visibly, the boy relaxed. Then slowly, very carefully, the bone setter wrapped the now- impregnated rag around the broken shin bone. The moment the oily cloth touched the skin I saw a transformation come over the boy’s face. Instantly the pain settled, his eyes relaxed and the etched lines of distress disappeared. The bone setter smiled. ‘There, what did I tell you,’ he whispered. ‘It’s better already.’ I was not sure who he was addressing. Me, Vincent or the boy. The effect was astonishing. He had achieved instant pain relief using little more than his hands and a crushed root.

‘How do you
do
that?’ I asked.

The bone setter turned, giving a half wink. ‘That, Dr Richard, is my secret.’

The result was miraculous. As soon as the oily bandage was fully applied I could pick up the boy’s leg, press it, manipulate it and be rough if I wished to. Pain was not a feature. He lay stationary, without symptoms, well able to tolerate anything I wanted to do.

I was dumbfounded. The bone setter also claimed he could make a broken bone mend within three days. In the West such things take twelve weeks minimum. Months later, on my return to the UK, I took some of the root with me, handing it to the scientists at London’s Kew Gardens to see if they could identify it. I was sure, if I could find the secret, I would become a millionaire overnight. Ideas for scientific trials, and subsequent marketing, flashed through my mind. I nearly formed a company - ‘Fractures Unlimited’ I was going to call it. No such luck. Kew Gardens could not help and the bone setter was not letting on. He is one competitor I am delighted lives thousands of miles from Cambridge. He could knock spots off me without trying.

It was not only orthopaedic conditions that were treated in such novel ways, as Louise’s experience with the community midwife demonstrated. In the developed world it is often regarded as abnormal to deliver your baby at home. In Madhya Pradesh the opposite applies. Community midwives travel throughout the villages, delivering children as they go. The workload is often so great that they cannot see every delivery, local elders coping with most routine births admirably. One problem at childbirth is splitting of the vagina. At the back, near the anus, is a thin bridge of skin and some very important muscles. At the
moment critique,
the child’s head squeezes past, distending the vagina enormously. This is the time when the skin bridge, and the tiny muscles, can split. If they do so, the woman can be incontinent of faeces for the rest of her days. This is not a welcome complication. The community midwife’s solution was simple - the birthing stone. A smooth, flat, palm-sized stone is pressed hard against the skin bridge and anus during delivery, particularly when the mother pushes to expel the child. This counterpressure significantly reduces the chances of splitting. The device, if that is what it can be called, was the midwife’s only item of equipment. No forceps, no syringes, no modern medicines - just a birthing stone. I often see Louise looking longingly at the rocks and boulders of our flowerbeds at home, wondering if she ought to demonstrate the technique to our Cambridge obstetricians. She knows, as I do, what their response will be. A Cantabrigian birthing stone would not succeed. Perhaps, one day, who knows?

In our civilised society we are spoiled rotten, however deprived we may say we are. It is fashionable to criticize healthcare in the West by saying patients will die due to lack of equipment, or drugs, or staff, or whatever. That may be true, but such shroud waving is frequently an exaggeration, particularly when much of the world has to cope with so little. Improvization in rural India is essential. You are unlikely to be given the same instruments to do the job that you would receive at home. Compressed air may not be available for your bone saw, so doing it by hand is the only way. Gauze swabs for mopping up blood may be in short supply, so are reboiled between cases, used for any number of patients until incapable of the job. Needles and knives are used repetitively until they will cut or pierce no more.

Improvisation does not only apply to surgeons, as Louise’s experience with tiny, two-month-old Srina shows. The little girl had developed awful pneumonia. Lips blue, breathing raspy and shallow, her ribs strained visibly for every breath. Death was not far away. Again, the mother looked on impassively, as local paediatricians fought to keep the baby alive. The father had long since lost interest. In his mind she was, after all, a girl not a boy. At such times it is vital the child receives oxygen. The lungs, blocked with pus and phlegm, cannot absorb enough from the surrounding air. The concentration in normal air is too low. It must be delivered in high quantities for sufficient to reach the blood. For an adult there is no problem. A mask is applied to the face and high concentrations of oxygen are delivered this way. For a tiny baby, keeping a mask in place is difficult, even if one can be found to fit. Such minuscule items were not available in Padhar, being both expensive and in short supply. Louise improvised instantly by manufacturing a substitute on the spot - a headbox. Once an established method of delivering oxygen to tiny babies, it had long since faded into oblivion in Western paediatric circles. It pays to know something of medical history when working in the Third World. On one side of a biscuit tin she cut a head-sized arch, while in the other she made a small hole. Placing the biscuit tin over Srina’s gasping head, and a small-calibre oxygen tube in the hole, allowed high concentrations of oxygen to reach the infant’s lungs. Instantly her breathing became settled, more regular, less laboured. A tin of chocolate biscuits had saved the day. We never did learn who ate the contents.

The type of surgery required in the Third World is different to that seen at home. Illnesses in rural India are similar to illnesses in the West at the beginning of the century. Your surgical style must be similarly ancient. Modern techniques and fancy up-to-date textbooks are of little use. My favourite book for Padhar was written in 1939, a comprehensive manual of archaic operations that worked brilliantly for the Gond. Many procedures I had never seen before, let alone performed. Vincent was well used to this existence and was often able to teach me what was required. Despite an extensive experience both with the SAS and civilian practice at home, I would still find myself out of depth. Sometimes even Vincent was stumped. When that happened we would both leap into uncharted territory, doing the best we could. If we did not operate, no one else would. Padhar was the Gond’s only hope. There were many successes. Little Sunita, for example, with her dislocated hips. At four years old, the balls of her hip joints had never once been in their sockets since birth. The poor thing could barely walk. Slowly, and over a period of two years, we put her hip joints into their rightful positions. Sunita, and her parents, were delighted. In a society where the marriage prospects of a young girl are a feature of success, these operations transformed her life. Taking risks sometimes pays off.

Sometimes risk-taking does not pay. All surgeons live with such events on their conscience. No more so than my experience with Suraj. It started as a simple hip replacement, an operation I have performed more times than I care to remember. Suraj was a lovely man, about thirty years old, but totally crippled with spondylitis. Spondylitis is an inflammation of the spine and hips that slowly bends a patient over until he can only stoop. It can become so bad that it is impossible for the patient to look forwards. He can only look downwards, at the ground. To get a patient vertical, one way is to replace the hips so they can stand more upright. That is what I planned for Suraj.