Knife Edge: Life as a Special Forces Surgeon (43 page)

When you first visit such a place, where to go in safety, if there is such a thing, and how to do it, is confusing. No one briefed us where the Serbs were to be found, nor on how to stay alive should we venture on to the streets of Sarajevo. I had given the team a short talk in Ancona, before our ordeal with Maybe Airlines, explaining the basic principles of avoiding death during war. Cross intersections at a sprint, peer round corners at ground level rather than standing up, vary your speed of travel to make it difficult for a sniper to hold his aim. Do not wear bright clothes, and use dead ground - areas the enemy cannot see — as liberally as you can. Though such advice is better than nothing, there is no substitute for experience. Unfortunately, for most team members, war experience was something they lacked. A skeet shoot was an unfamiliar event, let alone life under genuine fire.

The locals did their best to make life difficult for snipers. Ropes were attached to the first floor of buildings each side of the narrow streets and blankets suspended from them to disrupt the sniper’s view. Certain no-go areas were commonly known. It was sometimes safe to walk down one side of a street, but lethal to walk on the other. Bev nearly died one day, returning from another city hospital after completing her assessment of operating-theatre facilities. She had been fortunate to beg a lift in an APC, a rare occurrence for aid workers, even with ODA blessing. The APC driver had refused to go near the Swiss Cheese Hospital, claiming it was too dangerous. Bev was left, 300 metres from the hospital, dressed in a bright yellow T-shirt. She could not have offered a better target if she had tried. I should have warned her to wear dark, inconspicuous clothing. Off she set on foot, only days into her first visit to her first war zone, in full view of every Serb sniper for miles around. I have no idea why she was not shot. Perhaps it was the opposition being kind to the fair sex - many snipers were themselves female - perhaps it was simple good luck. It took her several minutes to realize everyone else was walking on the opposite pavement to herself and that the old lady on the other side of the road was wildly gesticulating at her for a reason. Bev sprinted hastily to safety. I imagine several dozen telescopic sights were trained on her by then. She now gives an excellent description of what it sounds and feels like when a high-velocity bullet passes by, millimetres from your left ear. APCs were a dirty word that day.

Added to snipers, Sarajevans were regularly bombed. Not by aircraft, but from mortars. As many as 600 mortar bombs could land in a day, though this had reduced to about thirty during our time there. Firing a mortar is now an accurate art, so I could not understand how bread queues, schoolchildren or marketplaces could be hit without absolute intent to do so. As a surgeon in Sarajevo you rarely dealt with wounded soldiers. The majority of patients were unarmed civilians. My first ward round with our host was an education in this respect. Virtually all the hospital’s 250 beds were full. Patients lay in curtainless wards, each window again shattered by blast or gunshot. Even a patient in bed was fair game for a sniper. Women, children and the elderly, lay motionless, many paralysed and dozens without an arm or leg. People like Mika, a beautiful twelve-year-old Bosnian girl, the victim of rape on two occasions, who lay stranded without legs in her ward. Her parents had been murdered months earlier. For many of the patients I saw, perhaps even her, death would have been a blessing.

War has a habit of creating multiple injuries, rather than damaging one part of the body at a time. This can sometimes cause immense problems for medical staff. Take Viktor as an example. It was nine o’clock in the morning and had been a busy night. More than twenty major explosions near the hospital had kept the operating theatres permanently active.

A few minutes after breakfast a massive blast shook the hospital to its core, jolting free the few remaining shards of glass that hung loosely in the multitudinous, damaged window frames. Seconds later came the sound of frantic shouts from outside the casualty entrance. It was Viktor, caught within several metres of a mortar blast, again an innocent civilian. His two children, lovely twin girls aged no more than eight years, were hanging desperately to the bleeding body of their father as two burly friends dragged him to the entrance. Long, bloody smears on the chipped pavement tracked their course as they manhandled their colleague to the hospital. Viktor’s crime had been to accompany his children to a makeshift school. ‘For their protection,’ he muttered through a blood-soaked mouth. ‘Their mother was shot last week.’

The blast had created terrible damage. His right leg was a bloody stump below the knee - a traumatic amputation - though reasonably clean. Strangely, he was not bleeding badly from the injured area as the blood vessels had constricted tightly to control the blood loss. It is one of Nature’s miracles that arteries contain muscle in their walls. Cut one and the muscle will immediately clamp down to prevent excessive bleeding. Viktor’s other leg was also a bloody mess - mangled bone, dead muscle, tendons flapping uselessly through destroyed skin. Small particles of grit, or perhaps shrapnel, peppered the area, a large piece of jagged metal protruding visibly from the depths of the wound. It was tempting to remove it. You could easily grasp it between finger and thumb and pull, but if you did so there was real danger bleeding could increase. Remove a foreign body and the arteries have nothing to clamp down upon. I have seen patients nearly die as a result. Never remove such things, however tempting it may be, until the patient is safely inside the operating theatre and an intravenous drip is running fast to allow instant blood transfusion.

Added to his leg injuries, small pieces of shrapnel had peppered Viktor from neck to groin, though his face had largely been spared. Some of the wounds were deep, some superficial, but there must have been thirty separate wounds in all. You could see it was going to take some time to save Viktor, if he could be saved at all.

Apart from his visible injuries, it was difficult to be certain whether or not the blast had damaged internal organs, such as liver, kidney or spleen. Viktor was therefore treated by ‘peritoneal lavage’, sterile fluid being injected through his abdominal wall and allowed to circulate before being removed again. The normally clear fluid was tinged red. ‘Damn!’ That meant he was bleeding into his belly. Not only would surgery have to deal with his legs, and the multiple shrapnel wounds, his abdomen would have to be opened as well. Two macerated legs, thirty shrapnel wounds, and an abdominal operation were injuries only the strongest could survive.

Viktor was taken immediately to the operating theatre, his two children crying inconsolably as they saw their father being wheeled down the hospital corridor away from them. It was a heart-rending sight. There was no one to help, no one to cuddle or console them. Medical staff were too busy struggling to keep Viktor alive. Large iodine-soaked dressings were slapped firmly in place by the casualty staff, heavy pressure being applied to control any bleeding. Arterial spasm does not last forever. Two drips were set up, one in each forearm, to allow rapid transfusion, though whether enough blood existed in Sarajevo for Viktor’s needs was in doubt. His problems did not end there. No one was available to operate on him. Everyone was busy dealing with other casualties, and all surgical staff were operating in theatre. Viktor had to be left on his trolley in the theatre reception area, unaccompanied, without painkilling medication as supplies had been exhausted long ago. His pain was immense, soon overwhelming his initial self-control. He screamed, and he screamed - a horrible penetrating cry. You could not avoid it, it struck to the core. ‘Please God,’ you prayed, trying hard to concentrate on the patient before you, ‘Somehow, anyhow, please release Viktor from his agony.’ But release did not come, nor death. Viktor was a strong man, an agricultural worker in more normal times. He lay on the trolley, eyes tightly closed, uninjured hands gripping the side of the battered mattress and continued his incessant cry.

It took an hour to finish the previous case, a simple bullet wound through the upper arm in a Bosnian soldier, one of the few military casualties that day. Then it was Viktor’s turn. The moment he was wheeled into the operating theatre, his screaming stopped, his eyes opened and he looked up imploringly at the masked surgical team now poised to help him. You could tell he was certain he would die. ‘Look after my children,’ he slurred as the general anaesthetic took hold. Then there was silence, blissful peace, as work commenced.

For Viktor’s right leg there was little to be done except tidy damage the blast had created. This meant sawing away a few more centimetres of tibia bone to a smooth end and closing muscle and skin over it. It seemed safe to close the skin on this occasion as the blast had not heavily contaminated the tissue. The left leg was different. Engrained with dirt, it took two hours to remove each piece of shrapnel — more than fifty — and a further hour to cut away damaged muscle and skin. While one team dealt with Viktor’s legs, another opened his belly, an operation known as ‘laparotomy’. A long, vertical incision was made to one side of his belly button, from ribs to groin. Rapidly this cut was deepened to enter the abdominal cavity itself. Then the search for a bleeding point began. It is not as easy as it sounds. Viktor’s bowels, bruised from the blast, were still wriggling. Each time you push guts to one side, they always slither back to their original position, making it hard to obtain a good view of every nook and cranny inside a belly. It was a slow process, but it was eventually apparent that Viktor had not damaged an abdominal blood vessel at all. The red tinge obtained at peritoneal lavage had probably come from general, mild bruising. This was good news, if there was such a thing in Sarajevo. At least Viktor’s belly would recover. His abdomen was thus closed and attention turned to the many shrapnel wounds dotted over his body. Each needed to be carefully cleaned, each one sutured. It was a laborious task.

By eight o’clock that evening, surgery was complete. Everyone was exhausted, having operated continuously for more than fourteen hours. Importantly, Viktor was alive, and would now survive, despite appalling multiple injuries. After a long period in theatre, feeling so physically drained, it is sometimes difficult to realize why you do these things. For Viktor there was no mistake. It was as he was being wheeled out of theatre that a tear came to each man’s eye. His two little girls had found their way to the reception area, unbeknown to anyone, and had sat patiently throughout Viktor’s operation, hugging each other tightly. They had nowhere else to go. Instinct told them they should stay as close as possible to their father. Hour upon hour they had sat on the cold, plastic bench, tears streaming down their faces. All they had was each other. The moment they saw Viktor on his trolley, squeaking slowly by, they leapt to their feet, squealing with delight. Huge, happy smiles stretched across their faces as they whispered, ‘Daddy, Daddy, Daddy,’ clenching his semi-conscious hand tightly for extra security. Such occasions make surgery very worthwhile.

For many, the severity of their wounds meant that infection was unavoidable. Contamination by high-velocity missiles, combined with lying in the dirt for hours before rescue, and an inadequate supply of appropriate antibiotics, made it commonplace. At such times, a surgeon should not sew up the wound. After cleaning, damaged areas should be left open for several days, however big they are, until the wound looks healthy. Surgical closure is then safe. Otherwise, bacteria are trapped in the wound when it is sewn up and gas gangrene is the result.

Nerve damage was common. This was not always full paralysis, as happens when a bullet passes through the spinal cord, but more localized trouble. One pleasant, middle-aged woman, a teacher in peacetime, showed me her paralysed arm. A bullet had passed clean through her shoulder, dividing the nerves to her arm and hand by destroying an area called the brachial plexus. The damage had been so great that repair was not possible. Her right arm flopped uselessly by her side, the feeling absent from her fingers. She looked at me appealingly, grasping my white coat with an intact left hand. ‘Please help me,’ she pleaded, in faltering English. ‘I must have my right arm.’

I could do nothing, but how can you say so to a patient who believes that miracles are possible? I knew that nerves sometimes recover, but very rarely fully. For her, any improvement would be astonishing. She would have to wait at least two years to see, as nerve regrowth is agonizingly slow. All I could do was to look her sympathetically in the eyes, squeeze her uninjured hand and smile. She knew from my expression there was nothing I could do.

Nerves to the leg were also vulnerable, particularly a large one that passes behind the knee - the lateral popliteal nerve. Several patients had injured it due to gunshot wounds or shrapnel. The nerve’s job is to lift the toes and foot upwards. When it is damaged the foot flops downwards as the patient walks, making it easy to trip over - the ‘footdrop’ deformity. One way of immobilizing a prisoner, if you are so inclined, is to smash the outside of the knee with a rifle butt. That damages the lateral popliteal nerve so the prisoner cannot run away. Again, it is a matter of time and good fortune to see if the nerve is going to recover. Healing is only rarely complete.

There were also tales of great heroism. Benyic was an example. A mortar bomb had landed on a Sarajevan street in the midst of a gathering of children, but failed to explode. Benyic, a young man aged only twenty-four years, saw the danger immediately. Without any hesitation he barged his way through the terrified children, picked up the bomb and ran with it, preparing to throw it as far away as he could. As he started to run, the device exploded in his hand. His action saved the life of everyone present, as his body shielded them from the blast. Benyic had not fared so well. His right hand, and both legs, were missing. Unable to pass urine due to the enormous damage created by the bomb, he now relied on a thin catheter passing up his penis into the bladder. That one astonishing act of bravery, over within seconds, would remain with Benyic for life. It is so vital people like him are never forgotten. Throughout Sarajevo similar stories could be told. For most, the world will never hear of them.