Knife Edge: Life as a Special Forces Surgeon (39 page)

Sometimes, when a patient walked into my consulting room I could sense the power inside him. Take Kayed, for example. He was both leader and fighter, standing high in local society; he came surrounded by several tall, heavily armed bodyguards. Running a clinic with Kalashnikovs in the room takes some getting used to. Fatimah, my young interpreter, did her best to translate.

‘My knee,’ said Kayed, his voice little more than a growl as he rolled up one trouser leg to mid-thigh. ‘I cannot bend it. Please cure me.’ His request made it appear as if success was a foregone conclusion. His guards nodded their heads silently in sympathy and agreement as they toyed ostentatiously with their weapons.

‘How did the knee get like this?’ I asked, trying hard to bend the stiff leg at the joint. It would not move. The skin was scarred and pockmarked like a Beirut wall.

‘Israelis,’ he replied. I could see the hatred in his eyes. ‘I managed to kill several before they did this to me.’ I knew I was on dangerous ground. It was important to take neither one side nor the other. I could see he was searching for compliments. I stuck to my trade, kept my head down and looked intently at the knee. However hard I looked, the thing would not budge. If he was to walk normally again, I would somehow have to free the knee up.

From a large, tatty, brown envelope one of the bodyguards produced two equally tatty X-ray films. Holding them to the dim window light I could see the white, metallic specks of shrapnel still buried deep inside the leg. Much of the thigh bone was missing, though time had done its best to fill the gap with irregular, thickened scar tissue. I nodded as sagely as I could.

‘It’s bad,’ I said. ‘Very bad. But I think I can help.’

‘Can you make it normal?’

‘No. That is impossible. But I can help you bend it slightly.’

‘Can you be certain you will succeed?’

‘No.’

‘Why not? The people say your team is the best in Europe.’

‘The damage is too great,’ I replied, not wishing to be drawn into discussion as to whether we were good, hopeless or indifferent. ‘There are some things even we cannot achieve,’ I added, capitalizing on whatever reputation was being given us behind the scenes.

It never pays to bluff in surgery. In many countries patients will travel from surgeon to surgeon, physician to physician, faith healer to faith healer. Each will give a different opinion. Some will offer guarantees that are scientifically impossible. Being truthful and open is always best.

For a brief moment Kayed fell silent, then glanced either side to his bodyguards. All three nodded quietly. ‘Then you must do it,’ he eventually replied. ‘You must do what you can.’

Kayed’s problem was a straightforward one, despite the horrible appearance of his knee. He had been caught in a mortar burst two years earlier, a large number of shrapnel slivers, over twenty, penetrating his leg. The bigger fragments had been removed at the time, the wounds healing over the remainder, now lying deep inside him. The residual shrapnel was best left where it was, it was doing no harm. It is a common misconception that it needs to be removed. Trying to find tiny metal shards deep inside a bleeding wound is difficult. A surgeon’s efforts may do more harm than good as the messy tissue makes it so easy to cut the wrong thing. Kayed’s stiffness was due to much of the muscle having been destroyed at the time of the injury. His previously muscular thigh was now wasted and thin. When tissue is damaged, by whatever means, the body tries to heal the area. It does this by the formation of scarring. Though we normally talk about scars on the skin, they also occur anywhere in the body that damage has previously occurred. That includes muscle. In Kayed’s case, scar tissue had replaced the muscle and scar tissue does not bend. If he was to bend the knee again, all scarring had to be removed - surgically excised.

Fred performed the operation while I looked on. It took ages. With a scalpel he made a long, vertical cut down the front of Kayed’s thigh and knee, dividing the skin to expose the underlying bone and scar tissue. Scar is white in colour, like a tight, inelastic band covering a joint. You have to cut transversely across it first, so it is completely divided, then you force it further apart, bending the joint by hand. It requires both surgical dexterity and muscle power. You must be strong enough to grasp a large knee in both hands, bending it until it gives way. Orthopaedic surgery is not for the faint-hearted. Painstakingly slowly the knee began to flex, degree by degree. By the end of the operation the once stiff joint was able to move to a right angle or more. It was a masterpiece of surgery.

It is one thing making a knee bend under anaesthetic, as in Kayed’s case. It is another to ensure the patient maintains the improvement once he wakes up. Bending a knee that has been stiff for two years, and has required radical division of scar tissue, is very painful. The natural temptation is for the patient to lie motionless after surgery, not daring to move his leg for pain. Within a few days the scar tissue reforms if the knee is not kept moving. Fred’s work would have been in vain.

Our plan had been for Miranda, or a Hamsharry physiotherapy colleague, to provide intensive treatment once surgery was complete. We had not reckoned on Kayed’s demands. He felt his bodyguards would do the job better. Perhaps he had something to prove. No sooner had he regained consciousness, back in bed on the hospital ward, than his men set to work. Ignoring their leader’s cries for mercy, they worked the long stiffened knee to and fro. Straight and bent, straight and bent, straight and bent. You could almost hear Fred’s carefully placed stitches breaking, one by one. It is difficult to argue with an armed physiotherapist, even if he is unqualified, but within a day the careful surgery had been ruined. Try as I might to explain to the bodyguards that operations of this nature needed careful handling after surgery, they would not listen. The result, within forty-eight hours, was that Kayed needed his operation repeated. This second time the bodyguards stayed their distance and Kayed’s knee was a success.

Not all injuries in war are caused by bullets. Mines, particularly antipersonnel mines, are major problems. To a doctor they represent an unforgivable act of war. So often the injured are defenceless civilians. Should you see a civilian in a war zone minus an arm or leg, you can be fairly certain a mine has caused it.

The Hamsharry clinics were full of women and children with horrific injuries. It is immensely distressing to see a beautiful six-year-old girl, radiating health and charm in every way, yet absent a leg. Staggering into my consulting room on crutches, young Lamia was a pitiful sight. Her wide brown eyes begged me to do something that might help. ‘Can I have another leg?’ she asked. I could only say no, tears stinging my eyes. The best I could offer was a lifetime with an artificial limb. Hamsharry highlighted the immense civilian toll of the Palestinian-Israeli conflict. More than 90 per cent of the patients we treated were civilians. People without any clue as to how a weapon should be handled.

You only have to see an amputee child in a war zone once to hate mines for life. There are millions scattered worldwide. They are of two sorts: anti-tank (AT) and anti-personnel (AP). As an ex-soldier, the former I can understand, the latter I cannot. The object of anti-personnel mines, from a military viewpoint, is to deny certain areas to an enemy. For example, should you have to withdraw from a building or trench system, scattering antipersonnel mines is a quick, simple method of being certain the enemy cannot use the same building or trench for his own ends. Being small, the mines may also be used for booby-traps. For example, under toilet seats, behind doors, under doormats. Once the enemy moves on, the AP mine stays behind. Children frequently play on wasteland and derelict areas, favoured locations for mines, and are prime victims for AP injuries.

The object of an AP mine is to maim, though some are designed to kill. The intent is to place as much strain on the enemy’s logistics as possible, by having to evacuate the wounded. There are two sorts of AP mine: blast mines and shrapnel mines. Blast mines are normally buried in the ground, requiring the victim to step on the device in order to trigger it. The dreaded Black Widow mine from Russia is barely two inches high and five inches wide, and needs only three kilograms of pressure to set it off. It can kill, but will certainly cause major leg injuries to above the knee. Amputation is likely.

Shrapnel mines are designed to maim or kill over a wider area, perhaps up to twenty metres from the device, often injuring more than one unfortunate at a time. They can be activated by pressure or a trip wire and will frequently spring to chest height before exploding. They are manufactured in many countries, including China, Portugal, the Czech Republic and, I am afraid, the United Kingdom.

Once a blast AP mine explodes, the human damage it causes is immense. Bones do not break cleanly, they shatter. Skin does not split smoothly, it rips. You are faced with a mangled mess that is impossible to reconstruct. If a bone breaks cleanly in two, it is simple enough to screw a metal plate across the break, or pass a metal rod down the centre of the bone, across the damaged area, supporting it until healing occurs. Orthopaedic surgeons do such things all the time. With AP mine damage, all you can do is tidy up what is left, maybe skin-grafting defects where the blast has blown the victim’s skin away; and this usually requires amputation as well.

If you have to do this terrible operation, it is best to make the decision quickly, as soon as the injured patient presents. The shock of the moment is so great, you can capitalize on it and remove the limb rapidly, before the patient starts to worry how he or she is going to manage the rest of life without a leg. In reality, life with a good artificial leg is a thousand times better than life exposed to a sequence of major operations, trying to preserve a totally shattered limb. If the leg is not removed, two years later the victim can be jobless, spouseless and depressed—the result of repeated admissions to hospital with a still unsatisfactory result by the end.

The higher up a leg you perform an amputation, the worse the result. If you must lose a leg, best choose a below-knee amputation, rather than above-knee. Modern artificial limbs are so good that it is sometimes impossible to tell someone has had a below-knee amputation without very close inspection. They walk almost normally, sit naturally and do all manner of things like skiing, climbing and scuba diving. Amputate through the thigh, or worse still through the hip, the dreaded hindquarter amputation, and the situation is very different. Walking properly is impossible, often requiring a stick for support, and the artificial leg is a much bulkier arrangement. In short, do not step on an AP mine. It will upset you and certainly upsets me.

Throughout my time in Hamsharry I was impressed by the intense and close friendships between hospital staff. These were people who had witnessed more than anyone should see in a lifetime. War is a horrific institution, particularly when large numbers of civilian casualties are involved. No doubt the official line would be that civilian casualties are unavoidable in war. At times it was difficult not to think civilian targets were the prime object, so many innocent folk did we see. For some the psychological effects of war were extreme. After my experiences during the Falklands conflict I had to sympathize. Some would twitch, or scream, or simply breathe deeply the moment gunfire was heard. At times I felt like taking such people to one side, putting an arm around them, in an attempt to reassure. They were a pitiful sight — psychologically and physically shattered.

Bomb and blast injuries are a major cause of death or injury in war. These come from high explosive, delivered by guns, grenades or mortar. As well as creating shrapnel, high explosive causes blast. This is a huge pressure of air flying ahead of the shrapnel. If the metal does not get you the blast surely will. Because blast is an air effect rather than due to solid matter, hiding behind a wall will not help you. The only way of protecting yourself from blast is distance. The further you are away from the explosion, the less likely it is you will be harmed. The concept of blast causing damage is difficult for many people to understand. Imagine a massive shock to one side of the body, from top to bottom, only lasting a millisecond. The skin may stay intact, but the shock is transmitted deep into the body itself. The solid organs, bones particularly, can remain unaffected. Those containing gas or fluid, such as lungs, heart, ears or guts, can rupture as they are compressible. Eardrum rupture is particularly common, with permanent hearing damage not unknown.

‘Blast lung’ was a well-recognized condition in the Second World War. This develops after the explosion, often several days later and quite unexpectedly. Damage occurs to the lung tissue, reducing the body’s ability to absorb oxygen from the air. Fluid also pours into the lung cavity, making it still harder to breathe. Victims require urgent Intensive Care treatment to survive, but in a war scenario such facilities are rare. You can therefore withstand metal shards flying past you, and think the blast was not a problem, only to perish later. Blast lung, should it happen, can be a killer.

Hamsharry Hospital showed us all of this, and more. Fighters, and defenceless civilians, would attend the clinics we held. Day and night theatre staff would pack, repack and sterilize the instruments we needed for our operations. It was an exhausting task. Not everyone we treated was Palestinian. The conflict has attracted its fair share of soldiers of fortune - mercenaries. One morning a tall, powerful African stumbled into my clinic, barely supported by a long wooden pole. Like his associates he had a hard, impassive gaze that looked directly through you. His problem was a hip replacement that was going wrong. Many years earlier he had injured his hip, the only solution then being to replace rather than repair it. Quietly he looked at me, his eyes unable to show pain, whatever he might be feeling.

‘I can’t move sometimes, doctor,’ he said. ‘My leg becomes stuck and I have to stay where I am until it loosens. It’s a problem with the fighting.’