Knife Edge: Life as a Special Forces Surgeon (40 page)

‘You’re fighting with that? With a hip replacement?’

‘Of course. You look surprised. Is it a problem?’

I had to admire him. The mercenary’s life can be a perilous one - I have many friends who do it - but a hip replacement is not normally associated with successful soldiering. In the British Army, a hip replacement in a soldier would often mean medical discharge from the Services. Yet for more than ten years this huge man had done just that. Fighting for other people’s causes with an artificial hip, albeit well paid. When I X-rayed the leg, it did not surprise me to find the replacement had come loose. Instead of being tightly fixed to the man’s own bones, it was flopping about inside them. Any normal person would have been unable to walk.

The mercenary was desperate for help. In his precarious existence, when life could be snuffed out at any time, he had to be able to fight well. I suspected he was not qualified for anything else. I contacted our operating theatre staff and told them we needed to reattach a loose hip replacement. Though this is major, complex surgery, it has now become almost routine in the UK. In my mind, the job was as good as done.

‘We cannot do it,’ the theatre administrator replied.

‘What do you mean? This man is in terrible trouble.’

‘That may be so. But it is not possible for us. We do not have the equipment.’

‘If he gets into battle again, he could easily die. There is no way he can run for cover or dash from building to building as he is.’ As I spoke I could see the mercenary stagger around my consulting room, supported by the pole that bent alarmingly each time he applied his weight.

‘Doctor,’ the administrator answered finally. ‘We cannot afford it. Funds do not exist. You will have to leave him.’

I wanted to argue, to insist the soldier’s only hope of life was through my services. I knew it was hopeless. I was expecting too much - the door had been shut. The surgery was too involved and too expensive. I hate turning people down for treatment. I have always felt it was my job to keep going to the bitter end. Naturally a patient can turn me down, but not the other way round. It is an awkward realization as a surgeon that some treatments are not possible, due to the costs involved. It happens at home too, but it is difficult when you are the one who must tell the patient. When I told the man there was nothing I could do, I was worried how best to explain the situation to him. I started to mumble, to um and to ah. The mercenary was not daft. He could see me hesitate, stumbling my words, and understood immediately.

‘No money, Doctor?’ he said bitterly, walking awkwardly to the consulting-room door. ‘I thought that might happen. I guess my time is over.’ With a brief look of hatred and resentment over his shoulder, he disappeared through the door. I shall remember that look to the end of time. If he had been armed that day I would surely have been shot.

For many years the Palestinians have existed in refugee camps at various locations throughout Lebanon. The original intention had been for these camps to be temporary. Before I visited, I imagined a camp would be line upon line of tents, communal water stands, poor sanitation and the like. I had in my mind an image of displaced people living under canvas for years. However, Palestinian camps can be thriving institutions, with schools, health centres, shops - a wide variety of modern conveniences. Some are very well cared for. Well-constructed buildings, running water, decent sanitation, are often found. This surprised me. Life has not been made easy for the Palestinians, irrespective of which side you support. At all levels they are a people who have had obstructions put in their way, whether it be negotiating a peace accord or buying a spare part for a dilapidated car. Full credit to these people for creating such an organized life in the face of such resistance, when all around refuse to help. I was very impressed.

Leadership is a vital part of this success against such difficult odds. A strong people needs equally strong control. One morning, searching for more surgical cases in a frenetic camp clinic and under Miranda’s discerning eye, I came across firm leadership first hand. Fred and I had travelled south, near the beautiful harbour town of Tyre, to a Palestinian camp beside the Israeli Occupied Zone. Such camps are now in the firing line, being close to the Israeli border. You never refer to ‘Israel’ when discussing borders with a Palestinian. To them, Israel is Palestine.

The clinic was in full swing with Fred and me working in separate parts of the small camp hospital. Miranda had done, as usual, superb homework before we arrived, filtering out only the most severe cases for us to see. I had examined more than twenty patients in the first hour and my mind was spinning with ideas. Fatimah, meanwhile, was interpreting well. Hospitality was immaculate. I was being plied with soft drinks regularly, as many as I could consume. The inevitable occurred. My bladder distended - I had to relieve myself.

I dashed next door to the tiny toilet. As I stood there, I heard the gentle scuffing of feet outside the door as a number of people filed past into the adjacent consulting room. It was a relief to hide from the chaos outside in this tiny, cramped haven of temporary tranquility. I am a leg specialist at home, so the majority of patients I saw had leg problems. To assess them I naturally need the patient’s trousers down, or skirt lifted. As I walked back into the consulting room my head was for some reason bowed, my eyes on the floor. ‘OK. Take your trousers down,’ I instructed, aware that another patient had entered the room while I had been absent. ‘Let’s have a look at you. Hop up on the couch,’ I added.

As I spoke, I looked up to see Fatimah standing quietly, and very humbly, in the corner shaking her head from side to side. It was her way of saying, ‘Not now, Dr Villar! Just shut up and keep quiet!’ Beside her sat a smartly dressed man, small worry beads in his hand, wearing a perfectly pressed grey suit. Impenetrable sunglasses covered much of his clean-shaven face. As he looked at me he did not smile. To either side stood two tall bodyguards, each armed with an AK47 assault rifle. The man in the sunglasses, whoever he may be, was important. If you merited bodyguards, you were very important indeed. He indicated an empty plastic seat to his left. ‘Sit,’ he instructed in English. That was all. His voice was clear.

Obediently, like a domestic pet, I did what I was told. I could sense the power in the room. It was obvious that Mr Big, for that is what I will call him, was in control. I glanced across at Fatimah, raising my eyebrows quizzically, and as surreptitiously as I dared. She understood immediately, mouthing the silent letters ‘PLO’ back at me. PLO, the Palestinian Liberation Organization, was not something I knew much about.

Mr Big turned to look at me, his face breaking into the tiniest of smiles. Suddenly I felt very alone. Fred was still busy with his clinic elsewhere in the hospital, unaware of what was taking place. Nobody knew we were in the camp. We could disappear and no one would be any the wiser. Civilian aid workers, of which I was now one, take grave risks at times. Mr Big spoke.

‘I have just one question for you, doctor,’ he said, ‘it is simple, but it is important.’

I could feel a tight hand gripping my chest as he spoke. That same hand seems to have travelled with me to many parts of the world, appearing suddenly and without warning. I could tell Mr Big was not a man accustomed to lengthy negotiations.

‘What is it?’ I asked, my mouth dry and barely able to speak. There was silence around us. Out of the corner of my eye I could see one of the burly guards quietly shift the position of his AK47. The muscles of my thighs began to shake minutely as my whole frame began to be overcome by an uncontrollable fear. Thank God I was sitting down. I felt I would physically have been unable to stand.

Mr Big spoke quietly. ‘Doctor, tell me one thing. Are you here because your Government sent you or are you here of your own accord?’

What was I to say? There was obviously something very important about the question. Mr Big had travelled a long way, with his guards, to ask me this. I had now learned Palestinian politics are not easily understood by those outside. It is difficult enough for the people involved. What one man finds acceptable is, to another, a declaration of war. Would it be better to claim British Government involvement to lend authority, and hence safety, to my presence? The temptation was strong. However, the British Government had no idea one of their surgeons was currently absent without trace in southern Lebanon. The truth it would have to be.

‘No, sir,’ I replied, trying hard to penetrate the dark, forbidding, sunglass wall. ‘I am here of my own accord. My Government hasn’t a clue.’

The moment I answered, I felt the tension disappear in the air. The guard’s hand shifted from his AK47 to a more relaxed position near his pocket and Mr Big smiled - a huge, broad smile. ‘Good,’ he said, ‘that is the correct answer.’ Then, instantly, he sprang to his feet and left the room, taking his entourage with him. ‘Give him all the help he needs,’ he ordered as he departed. I had been given Mr Big’s blessing. A near miss? I have no idea.

For an impoverished people, and for many charities, cost is a limiting factor. My experience with the African mercenary had already shown me this. Furthermore, there is always someone who attempts to make a quick dollar from the situation. Take Mohammed, a fourteen-year-old Palestinian who had been shot in the hip joint two years earlier. He survived the bullet, but the damage it created was so severe that arthritis set in. By the time he was fourteen, pain was crippling him. He could barely walk. I looked at the poor lad in the clinic, racking my brains as to what I could do to help. There were many alternatives, but the safest would be fusing the hip joint straight. We call such an operation arthrodesis. It is a big procedure, involving a large incision over the front of the hip and the damaged bone being cut away with a high-speed, compressed air saw. Once the damaged area has been removed, the remaining healthy bone is fixed together until it heals. Though surgery only takes two hours, the subsequent healing takes three months. The hip area must be held rigid during this period, so a large metal plate, with multiple screw holes, is needed. The plate is fixed to the pelvis above and the thigh bone below, bridging the hip area. It is an unusual operation to do, so the metal plate must be specially designed. It is shaped like a cobra snake and is called, not surprisingly, a cobra plate.

The moment I saw Mohammed, and made the decision arthrodesis was correct, I requested a cobra plate be obtained. It is not something you would expect to find in every hospital’s storeroom. Even in the UK, a cobra plate would most likely be specially ordered. Several days passed, Lebanon being searched from north to south, without one being found. It appeared the only way of obtaining one would be an appeal directly to the manufacturers in Switzerland. This would be too expensive, so it was beginning to look as though Mohammed would join the mercenary and be deprived of his operation. Then, unexpectedly, a mysterious benefactor came to our rescue, or so I thought at the time. A cobra plate had been found and would be available whenever I wanted it, but would cost US$1000 for the plate alone. A thousand dollars! I could not believe it, but Mohammed’s needs were great. Without it he was destined to spend the rest of his days in either a wheelchair or walking with crutches. To the credit of MAP, they never blinked. Without hesitation they agreed to pay.

It was on the day of surgery the plate arrived. I carefully unwrapped it from its green cloth towel to inspect it. I could not believe what I saw. The plate was appalling — scratched, chipped, bent and burnished. It was not a new one at all. Our so-called benefactor, already charging a thousand dollars, had most likely given us a second-hand plate. The device had already been used in someone else. For all I knew it could have come from a dead body. ‘How could anyone charge a thousand dollars for this rubbish!’ I shouted, tempted to throw the thing wildly away in disgust. Even worse, how could anyone imperil a fourteen-year-old boy, just to make a buck? I would have to do the best I could. Mohammed was in too much trouble to be left untreated.

Later that day we had surgery under way. With the patient asleep under anaesthetic I made the incision, clotting all the haemorrhaging blood vessels with an electrical coagulation device as I worked. Blood transfusions were in short supply, so it was vital to be sure a patient did not bleed unnecessarily during surgery. Once I had removed a number of muscles from their attachments, the hip joint appeared. I could see the terrible damage the bullet had created. The gristle had become eroded and soft, huge lumps and knobs had appeared around the edges of the joint. This was a hip on its very last legs. It was a quick job to cut it away with the compressed-air saw, blood splattering everywhere as I did so. I turned to the theatre sister and asked for the cobra plate.

I looked at the plate again, still horrified by its condition. I placed it in Mohammed’s wound, holding it this way and that, trying hard to find a suitable position to screw it home. It was no use. However much I prayed otherwise, the plate was too damaged to do its job well. How could I give it to young Mohammed? So battered and bashed had it become, it would not have held the hip joint rigid for long and might well have broken before healing was complete. Eventually, I improvized by taking a metal plate designed for the shin bone and refashioning it during surgery to fit the hip. Unquestionably a second best. My only consolation was our so-called benefactor did not receive his thousand dollars. I heard months later that Mohammed did well.

A common request when working overseas is to perform a demonstration operation for local surgeons. I am always happy to oblige, provided I am not expected to do something too unusual. Hamsharry requested I demonstrate a hip replacement operation. As I do hundreds, if not thousands, of the things back home it seemed simple enough. Fresh in my mind, however, was the memory of a similar operation in Teheran, the previous year. There, with cameras in the operating theatre around me, a simple operation nearly turned to disaster when the thigh bone fractured in mid-surgery. Fortunately we spotted the problem at an early stage. We managed to salvage the situation, and complete the operation, without anyone else realizing what had taken place. It was not an easy task and certainly not a performance I wished to repeat in Hamsharry.