Knife Edge: Life as a Special Forces Surgeon (37 page)

All went well at the start. Suraj was soundly asleep, under anaesthetic, and positioned on his side on the operating table for surgery. I knew I had to operate quickly as the operating theatre did not have a special anti-infection airflow within it. The longer a surgical wound lay open, the higher the chances of infection. Bacteria are everywhere, even in the most advanced operating theatres. For major surgery units in the West, air is forcibly blown through the operating theatre so that bacteria are directed away from the surgical wound, not into it. No such luck in Padhar. Such air systems are hugely expensive. Operating quickly was a good second best. There would be less time for air bacteria to land in the wound and infect it.

I started by making the typical long, slightly curved incision in the skin. As I did so I felt something was not right. I could not tell at first. It was more an uncomfortable gut feeling - nothing specific. Then, four minutes into surgery, I realized Suraj’s blood was turning blue before my eyes. No longer did the arteries spurt forth bright red streams as I cut through and around them. The blood was a dark, purplish blue - cyanosis, like Peter on Everest. ‘Damn it!’ I shouted, not a good thing to say in an Indian mission hospital. ‘We’ve got problems! There’s no oxygen in Suraj’s blood!’

As I spoke, my voice raised and distressed, I could see the anaesthetist move quickly. ‘Come on!’ he said. ‘Stop operating, and turn him on to his back! We’ve got to resuscitate him fast!’

At such times you cannot delay. Fancy stitching is inappropriate and takes too long. Quickly, without asking, I grabbed two large gauze swabs from the theatre sister’s instrument trolley and forced them hard into the wound. Their pressure would control the bleeding sufficiently to allow us to resuscitate Suraj if we could. I would worry about stitching later.

In one swift movement, we turned Suraj on to his back to start heart massage, thumping up and down on his fragile chest. I could feel the ribs break as I pushed with all my strength, each shove squirting vitally needed blood to his oxygen-starved brain. I knew immediately the hip replacement operation must be abandoned. Saving life was now the priority. The anaesthetist pumped furiously on his breathing bag, delivering the oxygen to Suraj’s lungs. I would massage the heart six times for every one of his bag squeezes. It was no use. However hard we tried, Suraj continued to decline. We failed. After eight hours of continuous resuscitation, by which time the entire theatre team was physically and emotionally exhausted, Suraj died. The spondylitis had so affected his spine that he had been unable to breathe, whatever we did to save him. The extra stress of a major operation had tipped him over the edge. His weakened frame had been unable to cope.

After Suraj died I was mortified. To have a patient perish on the operating table is a most terrible experience for a surgeon. I could see Vincent, his charming wife Meenakshi and the anaesthetist, all feeling the same. We knew it was possible Suraj would have died anyway, so advanced was his disease. That is not the point. When a patient is asleep on the operating table, he is
your
responsibility. You have talked to him beforehand, you have met his family, you have encouraged him to proceed. For a brief moment, during surgery, he hands himself to you in faith you will do your best. When your best kills a patient, it is something you never forget.

Louise and I returned to Cambridge from India very impressed. We had seen doctors work for almost zero pay in conditions that can, at best, be described as primitive. The dedication to their task is astonishing. I sometimes wonder if patients fully understand the enormous sacrifices such people as Vincent and Meenakshi make when they choose to set up shop in the Third World. I doubt the patients spare it a thought. With their skills, many Third World doctors could earn what they liked, wherever they liked. They choose, driven by enormous personal force, to stay where they are.

Once it becomes known you like working in outlandish parts of the globe, offers come from everywhere. For most civilian agencies, my time with the SAS was an unknown quantity. They did not know what to make of it. The moment I returned from Padhar, the situation changed. I had earned my Third World civilian wings and suggestions poured in. For a period I worked in Bulawayo, a two-month attachment to Mpilo Hospital. Here, HIV was again a problem. The first surgeon to die of the disease in the UK probably acquired the condition in that hospital. The day he pricked his finger while working inside the belly of an HIV-positive patient has now become hospital legend. My first stop on returning to Cambridge from Bulawayo was the virology laboratory for an HIV test. I was negative, I am relieved to say.

From Bulawayo it was off to Romania, in the wake of the Ceauçescu regime. This time, instead of orthopaedic surgery, it was my knowledge of medical appreciations that was required. A full report of a Transylvanian hospital, in the town of Zalau, was needed. It could have been the Third World. Facilities were appalling, training neglected, and one X-ray specialist had already died of leukaemia, a bone-marrow disease. I could never prove it, but I suspect this was due to the leakage of X-rays over many years. X-rays destroy bone marrow and doctors take great care to avoid unnecessary exposure as a result. An astonishing, highly motivated Cambridge character, Patrick Colquhoun, turned my recommendations into reality. The hospital was transformed. A remarkable man.

I did miss one thing, however. It is a terrible thing to say. It is, of course, entirely the fault of the SAS. I missed war. I hate it and yet I love it. I hate the misery it creates and yet I love sorting it out. I hate the worry it gives me and yet I love the challenge to control my fears. It is completely illogical and I cannot explain it. What I needed was another war zone to keep my system honed.

I could see alarm on Fatimah’s face as the Arab voices became louder. Rapidly, nervously, she shifted from one foot to the other, side to side, tilting her head to gather each word spoken.

‘I hope there is not going to be trouble,’ she said, craning her neck to see through the small, high window. No sooner had she spoken than the air was broken by two massive explosions, shaking the very fabric of the building in which we stood. My ears rang, a high-pitched whine, as the explosions died. AK47 shots at close quarters, fired in a confined space, make a terrible noise. Military training took over. Instinctively, I dived for cover under the examination couch beside me, flicking off the light switch as I fell. This was southern Lebanon, near the Israeli Occupied Zone, in the heart of Rashidiyeh Refugee Camp.

As I lay on the cold concrete floor, waiting for whatever might happen next, I looked up at the patient I had been examining before fighting broke out. He was an elderly man, perhaps seventy- five years old, with a previous gunshot wound to his elbow. His arm now stiff and immobile, he wanted me to return his elbow’s movement. I had explained, through the good offices of Fatimah, my interpreter, that undoing the damage of war is often impossible. I had been about to suggest surgery, with all its limitations, when the shooting had started. The old man had seen it all before. Unlike Fatimah and me, he was unperturbed by the fighting and sat nonchalantly on the edge of the couch, one leg swinging impatiently to and fro. He looked disdainfully down at me grovelling on the floor and pointed at the stiff elbow with his good hand. I could see his eyes rolling Heavenwards. Briefly he said a few words in his deep, gruff voice. Despite my SAS Arabic training years earlier, I did not understand one syllable. Fatimah translated from behind her chosen cover, a rickety medicine cabinet in one corner of the consulting room.

‘Dr Richard,’ she mumbled, her voice trembling and unclear, ‘he says, “Forget the shooting — what about my elbow? That’s the only important thing here.” What do you want to reply?’

Lebanon had seemed a good idea at the time, but as I lay on the damp floor I confess to having second thoughts. I had responded to a plea for help from Medical Aid for Palestinians, MAP, an enthusiastic and efficient charity based in London. When at home, I had been completely unaware of the enormous political and medical implications of such a task. The Palestine-Israel problem was not something I understood. Television broadcasts showed violence in both Lebanon and the Gaza Strip. Quite why it should occur had never crossed my mind. It was someone else’s war, in someone else’s country. To most of us, it meant little more than that.

It was only by going to Lebanon that I recognized the passionate views held by either side. Furthermore, it is my opinion that
we,
the British, have much to answer for. Somehow I do not think Winston Churchill liked Arabs. The scene was set before his time, with the Balfour Declaration of 1917, publicly proclaiming British support for a Jewish homeland. In the few years after the Second World War, and with British Government acceptance, almost one million Arab Palestinians left that part of Palestine the United Nations had decreed should become Israel. The majority left due to terror of what would happen if they stayed. They took with them their front-door keys, title deeds, insurance documents and a promise they could soon return. They never did and have been a people without homeland ever since. I can understand why emotions run so high. ‘Why do you come to help us when your people caused the problem?’ was said to me on numerous occasions in Lebanon. It was a difficult question to answer and a subject I tried to avoid.

It is difficult to travel that middle line, taking neither one side nor the other. I have both Israeli and Palestinian friends, some of whom are very longstanding. I hold them all extremely dear and wish desperately they could somehow reconcile their differences. I fear it will be a long and painful road before it happens.

My visit to Lebanon fortunately coincided with a phase of relative quiet on the battle fronts. This was important as it allowed opportunity for the after-effects of war to be treated. One naturally imagines that to be shot means death. In practice this is infrequent. More often, to be shot means permanent injury or handicap, not death. To correct damage caused by warfare represents some of the most demanding surgery known. There is no standard recipe for success. Each case is different, each patient a challenge. The combination of earlier SAS experience, and orthopaedic surgery, put me in the fortunate position of knowing how to handle both the immediate, and the after-effects, of war. These were the skills MAP sought.

Bullets quite naturally cause a significant degree of damage to the body. In order to appreciate why they can cause serious after-effects, a surgeon needs to understand how they cause their damage in the first place. There are two types of bullet - high and low velocity. High-velocity bullets are fired from modern rifles and machine-guns, travelling at speeds over 1100 feet per second. Low-velocity bullets come from handguns and older rifles, at speeds less than this. When a high-velocity bullet hits you it makes a small entrance hole in the skin, but explodes the flesh beneath to form a huge cavity - cavitation. From the outside, you can be unaware cavitation is present. All you can see is the bullet wound in the skin, the real damage being deeper inside. Cavitation only lasts a fraction of a second, but in that period sucks in dirt and debris from outside, contaminating the flesh. The bullet then travels onwards, often leaving a large, gaping exit wound. Occasionally it can ricochet off a bone, making it possible for a bullet to enter a thigh, for example, but exit the chest. Along this tortuous path everything cavitates. The damage such an injury causes is enormous and the shock to the body extreme. You do not have to be shot through a vital organ, such as the heart, to die. Shoot someone in the upper arm with a high-velocity bullet and it is quite possible shock and impact will be sufficient to kill outright, even if the bullet passes directly through. Should you be unlucky enough to be shot in the first place, that is.

Low-velocity bullets cause much damage, as one might expect, but no cavitation. Their effect on flesh is less and contamination is not a major problem. That is why it is vital to the success of early treatment to obtain an accurate idea of what weapon caused the injury. Looking at the entrance wound is of no value. Low and high-velocity bullets can have entrance wounds that look identical. The two bullet types are handled in different ways. High-velocity injuries require radical surgery. The surgeon must cut open the whole bullet track, from one end to the other. If the bullet has entered the foot and exits the shoulder, for example, the patient is surgically opened from top to bottom. It is the only way to remove flesh contamination. If you then close the wound immediately, it is possible a small quantity of contaminated tissue can be left behind as it is very difficult to see each tiny piece of damaged flesh with the naked eye. Sometimes tissue continues to die
after
a bullet injury has occurred. For this reason, surgeons leave the track open for several days and then stitch it up later. If you do not do this, bacteria in the contaminated flesh can multiply and create a horrifying condition called gas gangrene. A particularly poisonous bacterium causes it, rotting the flesh and destroying the kidneys. Death is almost assured.

Low-velocity injuries, provided nothing major has been perforated, still require the surgeon’s knife, but in a less radical way than their high-velocity cousins. It is often sufficient to clean and close entrance and exit points, and leave the track alone.

Once you realize that a bullet wound is not always a simple matter of two holes being created, one on the way in and one on the way out, with a perfectly clean track between the two, it becomes easier to understand why serious after-effects occur. Cavitated muscle may not recover, nerves that cause fingers and toes to move can be destroyed, or tissue can be so damaged that amputation is the only solution. Whole bones and joints can be shattered beyond any hope of reconstruction. On two occasions I have seen patients where the bullet has ended up inside the ball and socket of the hip. Both later developed arthritis as a result. Another, a ten-year-old girl, was shot in the head, survived, but developed a gradually expanding lump above her right eyebrow. For two years this became bigger until someone thought to X-ray her. The lump was a piece of bullet slowly working its way out of her skull.