Knife Edge: Life as a Special Forces Surgeon

by Villar, Richard

  I had gone to see for myself whether patrol reports of a measles outbreak had been correct. Measles in the Bedouin had an unusual appearance and it was possible their diagnosis had been wrong. In fact they were correct. I should not have doubted it for a moment, but it was refreshing to escape the packed dispensary at Haruj if nothing else. It was getting dark as I drove the open-top Land Rover along a narrow rocky track, within a short, low gulley that briefly blinded me from the desert around. The track turned sharply to the left at the gulley’s end. As I heaved on the steering wheel to negotiate the bend I saw before me two figures, one on either side of the track. I thought they were large boulders at first. The figure to my right raised his arm, indicating I should stop. The one to my left was lying prone and motionless behind a few scattered, low rocks. I could see the glint of an ancient machine-gun pointing at me. An ambush? Who the hell were these guys anyway?

  I looked again at the figure to my right. Dressed as a typical Bedouin, his face was cracked and weatherbeaten, his teeth chipped and broken. In his arms he held an AK47 rifle, partially levelled at my chest. He began to chatter loudly, and aggressively, in a dialect I could not understand. My sweating palms gripped the steering wheel tightly. I tried to stay calm by taking small, short breaths. I did not want the Arab to see how I really felt. As I could not comprehend him, I shrugged my shoulders and waited for his next move. I had no idea what he wanted. Then, suddenly, he stopped talking, took one step back and aimed his weapon directly at me. I braced for what I was sure would come next. There was nothing else I could do, stuck behind the steering wheel of the Land Rover.

  For what felt an interminable period I sat very still, hands in full view on the steering wheel, waiting to be shot. In reality it was probably less than a minute. No shot came. Then, very slowly, the Arab lowered his weapon and started to talk incessantly again. He was still incomprehensible. Walking across to my Land Rover, he looked into the driver’s compartment, still talking. As before, I remained motionless, not wishing in any way to upset either him or his companion, still lying prone to my left. I could tell I was being sized up, his gaze flicking from one side to the other of the compartment. As the Arab talked, his eye caught a paperback novel I had been reading, wedged on the narrow dashboard to my front - Jeffrey Archer’s Kane and Abel. He raised his eyebrows quizzically, as if to say ‘What’s that?’

  ‘Jeffrey Archer,’ I replied. I could not think of an Arabic translation for his name.

  The response, however, was instant. ‘Jeffrey Archer?’ replied the battered Arab, in an accent that made the name barely recognizable. I nodded, very slowly and very cautiously. Then stretching out one hand, the Arab indicated I should hand the book to him. Gingerly, holding it very obviously between finger and thumb, just like plastic explosive, I passed it over. No sooner had I done so than the Arab grabbed it, clutched it tightly to his chest and repeated the words ‘Jeffrey Archer!’ once more. Then with a flourish from his AK47 he waved me on.

  To this day I have no idea who those two men were or what they had planned. Nor do I know if they had genuinely intended to harm me. All I do know is that Jeffrey Archer, now Lord Archer, did both the Arab and me a service that day.

  As a doctor to the Bedouin I had to turn my hand to many things. Human illness was only part of the task. Animals featured highly, in particular the local goats. I was glad I had guessed correctly before leaving UK, though my Melton Mowbray training was not a great help. Herriot’s All Creatures Great and Small certainly was. It was one lunchtime, three weeks into Globe Trotter, that an elderly Bedouin woman brought me her goat. Black, scraggy and becoming bald in places, it was obviously unwell. The story the woman gave was one of having insufficient water for the beast and feeding it a local form of Coca-Cola instead. I could well imagine it. There appeared to be an endless supply of a dark, sweet, fizzy liquid for all to drink. Genuine water supplies were frequently contaminated, as both animals and men drank from the same source. This was an open well, without any protection from the outside world, not a deep dark hole in the desert. I would frequently see camel droppings floating on the water’s surface.

  The goat was unable to walk and panting furiously. The only abnormality I could find was a massively swollen abdomen, distended like a huge bass drum. There is a medical technique called percussion where you rest one finger face down, flat on the surface of any of the body’s cavities, such as abdomen or chest, striking it sharply with a fingertip of the opposite hand. It allows you to hear whether the cavity is full of fluid, or air, or is perhaps a solid expanding tumour. The technique is used all the time. I tried it on the goat. Bang-bang-bang! Percussion confirmed the animal’s belly was most likely distended with air, perhaps even bowel gases. I next listened to the abdomen with my stethoscope. Could I hear the gurgling sounds of bowel activity? With many human abdominal problems, the bowel sounds disappear altogether, particularly when a piece of intestine has burst, resulting in life-threatening peritonitis. But the goat did have bowel sounds, faint, tinkly ones - very high-pitched in nature. Such noises are, in the human, classically associated with bowel obstruction. For whatever reason, the intestines can occasionally become blocked. Perhaps they twist, or a tumour begins to grow, or even a lump of excrement fails to move on. This can cause massive distension of the guts upriver from the blockage. If the distension is not resolved, the guts can burst like a balloon. The pressure build-up can be enormous.

  Once, when working for one of the UK’s top bowel surgeons, I was helping in the operating theatre to relieve an elderly woman’s blocked lower bowel. To do this the patient was anaesthetized and laid supine on the operating table with legs held elevated and to the side, out of the way. Deftly, my boss inserted the sigmoidoscope, a shiny steel cylinder about eighteen inches long, up the woman’s tail end. As he did so there was an enormous explosion. I was sure it could be heard in the pub across the road. Faeces went everywhere, and certainly hit both my boss and the far wall of the operating theatre. The surgeon had simply, and skilfully, slipped the sigmoidoscope past the patient’s lower bowel obstruction, releasing days of increasing pressure taking place higher up.

  With my goat diagnosis made - intestinal obstruction - I had to act. Fascinated by my diagnostic methods, I had by now gathered a throng of Bedouin onlookers, perhaps a hundred altogether. Nearest to me was the elderly woman, visibly distressed by her animal’s plight. Goats are valuable assets to a Bedouin. The animal panting before me would cost her a local fortune to replace.

  I was stuck without any idea of what to do. I assumed my diagnosis was correct, though had no way of proving it. I certainly could not ask the animal and could barely understand the emotional outbursts from the owner that were becoming increasingly frequent. Gradually I could hear the low rumble of voices from the assembled crowd become louder. There was obviously intense discussion taking place between individuals, and an air of increasing dissatisfaction.

  ‘You’re going to have to do something, Doc’, whispered Trooper B, one of our most capable Regimental medics. ‘**** knows what this lot will do if you don’t.’ He indicated the restless crowd behind me as I knelt on the sand beside the breathless animal, wondering what to do next. I nodded. Trooper B was right. I had to perform.

  Before leaving the UK I recalled seeing a film, or perhaps a television series, where a vet thrust a large metal cannula, a form of surgical tube, into an animal with a swollen abdomen. I believe it was a cow. Well, I thought, if it is good enough for cows, and the BBC, it is certainly good enough for this goat. I knew also, for the restless Bedouin crowd and the now hysterical owner, I would have to make a ceremony of what I did. I rose to my feet and turned to the crowd, trying to look each one of them in the eye as I spoke. ‘I am now,’ I shouted, ‘going to save the life of this poor animal. It has suffered too long.’

  For a brief moment the throng fell silent, then a few heads nodded their agreement as the voices began once more. With a flourish I slipped on a pair of surgical glove
s from my medical bag, not an easy task when under stress, and produced a needle and cannula with a grand gesture. As I did so, I whispered out of the corner of my mouth to Trooper B, ‘For God’s sake help me! What the **** do I do next?’

  ‘Stick it in, Doc. You know, just stuff it in. We’ve both seen it on the telly. The bloody animal’s buggered if you don’t.’

  He was right. I was going to do it anyway but felt I needed moral support to help me with the task. Together the two of us knelt down beside the animal, the poor beast’s abdomen swelling visibly by the second. It was in desperate straits. Eyes now closed, its mouth was open as it panted in agony. Trooper B held the goat steady while I made a great show of what I was about to do. The crowd fell silent. You could have heard a pin drop. Even the desert wind appeared to stop blowing for the occasion.

  With the needle and cannula held in both hands I raised my arms well above my head. There was a gentle murmur of fascination from the crowd as I briefly glanced over my shoulder to see them still frozen to the sand. I looked back towards the animal, identified the most distended spot, and thrust the needle and cannula firmly downwards. I was like some ancient Aztec priest in the process of sacrificing his first human victim of the day. The needle and cannula thumped home with a resounding ‘pop’, followed by the steady hiss of a deflating balloon. As I struck, for a brief moment the animal opened its eyes, then gave a loud, agonized ‘Baaaa!’, and died. I was horrified. My theatrical performance had gone badly wrong. For perhaps a minute my Bedouin audience remained silent, uncertain as to what had happened. Then, one by one, they realized Doc Villar had skewered their prize goat. The elderly owner fell to her knees, sobbing in the sand, while discontent in the voices of the crowd began to reappear. There was no way I could escape what I had just done.

  After my disaster with the goat, the clinics became quieter for a while. I had made the cardinal error of any bush doctor — allowing a patient to die on my doorstep. The patient may only have been a goat, but there is an unwritten contract in Third World medicine. If you agree to take a case on you must get it right. What I should have done was to tell the animal’s owner that the beast was going to die and not attempted to save it at all. Like many things in the SAS, they are often learned the hard way.

  As well as general medicine and animals, teeth and eyes are common causes for local complaint. Though it would horrify an ophthalmologist, an excellent way of winning over the hearts of a population is to arrive laden with assorted pairs of spectacles. You do not need to be obsessive about the exact power of each lens. It is the elderly male population in particular that likes these things. Partly it is because it allows them to see better but, more importantly perhaps, it makes them appear dignified. If a tribal elder wishes to be seen as statesmanlike and wise, a pair of glasses goes a long way to help him. Spectacles are a simple way of ensuring the help of those who make the decisions in local society.

  Teeth are a different matter. I had always wondered why it takes dentists so long to train when all they are dealing with are thirty-two tiny white structures crammed into the human mouth. Now I have tried basic dentistry myself, with all its associated hazards, I understand. The Bedouins’ teeth were terrible. Brushing them was a technique they had never heard of, while chewing and gnawing sickly sweet dates were commonplace. When I opened the average tribal Bedouin mouth, I was faced with a sea of holes, stains and awful breath. Abscesses were two-a-penny. I exhausted tube after tube of temporary dental filling. Some mouths would need more than twelve holes filled at a time.

  Lighting for dentistry - achieving illumination of the little nooks and crannies at the back of the mouth — was a problem. Without good lighting much of dentistry is impossible. My solution was to hold a pen torch in my own mouth so I could direct the light accurately into the patient’s. This worked well unless the treatment was particularly lengthy. With the pen torch between my lips I was unable to swallow, which meant my own dribble ran down the pen torch into the patient. It was unpleasant for both of us, though fortunately not too many patients noticed.

  Tooth extractions were great fun. If I had removed every rotten tooth I would have been clearing almost all Bedouin mouths of anything within them. It was important to be selective as I had no way of making false teeth. The only extractions therefore I undertook were for the most decayed. The average tooth is locked in tight and special instruments are needed to remove it. Each type of tooth, be it canine, molar or whatever, has a specific design of grasper dedicated to its removal. The principle is to push rather than pull at first. By pushing in you break its tight connections to the bone. If you pull before the connections are broken there is a chance you will chip off a piece of root. With a root left behind, the patient is likely to develop an abscess around it. By the time I had finished in Haruj I had nevertheless performed more than 400 extractions. A few, I confess, had shattered roots, not a fact of which I am proud.

  With the SAS hard at work in the Ramlaat Bawiti, there was intense interest within the country’s Government as to what we were doing. No more so than from the Minister of Health. He was a pleasant, ambitious man, with whom I had liaised before leaving Koussi. When I had first asked him what the Government expected of us, he had replied that so little was known of the Ramlaat Bawiti that anything we could do would be fine. Once we had looked at fish smuggling and recruited a local firquat, of course. He did promise to visit us.

  The day he arrived at Haruj we were four weeks into the job. I had gone totally Bedouin, with a lightweight cotton pyjama suit, shimaagh Arab headdress, and moderately respectable beard. I would walk either barefoot, or in sandals. The SAS operatives were looking similarly tribal, although the occasional vestige of military uniform still remained, such as khaki shorts or battered suede desert boots. The latter, fondly called ‘desert wellies’ were favoured items in the Regiment and always in short supply. When worn in Hereford, in combination with civilian clothes, they represented a type of badge of action. A label that said ‘I’ve been there and you haven’t’. Anyone wearing desert wellies in Hereford, bearing in mind the strong desert associations of the Regiment, was definitely the bee’s knees.

  That morning it was, as usual, bright baking sunshine. The clinic had been uncontrollable and I was exhausted. Suddenly, at about 11 a.m., I heard the sound of a helicopter approaching. It was not a Huey, but was certainly white and spotlessly clean. I could see that, even as it descended from around two thousand feet. It was sparkling. Transfixed to the spot and wondering who this could be, I waited in the sand to greet the newcomers, hand to my forehead as I squinted into the sun. I had not noticed that my SAS operative colleagues had, to a man, disappeared.

  It took another two minutes for the helicopter to land, by which time I could clearly see the Royal crest emblazoned on its side. As the Minister of Health stepped from the machine, closely followed by several aides, I began to feel exposed. I was filthy. So keen had I been to integrate myself completely into Bedouin life that, to an outsider, I must have looked disgusting. Having not had a bath since we arrived, I also smelt revolting. As the Minister crossed the fifty metres of sand between me and the helicopter I could see confusion in his expression. Where were those famous soldiers about whom he had heard so much? At one stage I saw his gaze strike me and then move on. He even started to turn back. Then, after a brief hesitation, his expression brightened as he turned in my direction once more. This was associated with an obvious shuffling in the sand either side of me - my SAS colleagues. Each had dashed back to his tent, quickly donned a spotless uniform and was now standing in even rank to my left and right. Rigidly to attention and looking every bit the perfect British soldier, it had been like an actor’s quick change at a Christmas pantomime. Of the entire base team, eight of us in all, I was the only one to look dishevelled, unkempt and dirty. The smartness of those beside me made my own appearance even worse. To the credit of the Health Minister, he ignored the insult, though what he would have told his masters in Koussi I do no
t know. With a brief handshake he looked me firmly in the eyes and asked, ‘Would you kindly take me round?’

  The visit lasted little more than ten minutes. I could tell he was in a hurry, so concentrated on showing him priority problems. In particular, the communal water well that was littered with camel droppings. A young Bedouin girl also obliged by squatting in the sand to one side of the Ministerial party and opening her bowels, right in the centre of the tiny village. I could not have had a better display of poor hygiene if I had tried to set one up. Cat sanitation, defecating in the sand, was the only thing available to the Bedouin.

  In hot sunshine the fresh motion would sterilize and dehydrate quickly, but the flies loved it. They would hop from there to your food. It was a perfect way of transmitting disease.

  During that short tour, every point I made was absorbed silently by the Minister, who then turned to his aides behind and snapped his fingers. As if using some hidden code, one of them would write furiously on a tiny clipboard. I realized rapidly that the Minister was actioning everything I asked. Within those ten minutes, the village had been promised a new well, proper sanitation, a new dispensary and a measles vaccination campaign. How I wish I had such direct Ministerial connections in my current employment in the UK. It would normally take years to negotiate such things.

  With the Minister gone, life returned to its usual cycle of clinic and village visits. Slowly we built up the confidence of the Ramlaat Bawiti Bedouin. It was a lonely job, though I had become accustomed to such feelings working full time with the SAS. However friendly one’s military colleagues, as a doctor it is useful to have medical people available with whom you can discuss cases and treatments. Otherwise it is easy to make the same mistake repeatedly. Moreover, when working alone, no one can tell you whether or not you are doing a good job. I began to feel very lonely in Haruj, despite Rosie and my SAS colleagues. I started to find it difficult to get out of my sleeping bag in the morning or to go to the clinic, and noticed it was taking me longer to make medical decisions. I decided the only way out was to add an extra dimension to my life - marathon running. I cannot explain why as it is a singularly mad idea to dream up in the middle of a desert. Each day, however, and for sanity’s sake alone, I would put on a pair of trainers and running shorts. Off I would go into the desert, up sand dunes and along gravelly tracks, training for the first marathon race I could find once I returned to the UK. It was my salvation. Every man needs his escape in life, whatever that may be. Marathon running was mine.