Knife Edge: Life as a Special Forces Surgeon

by Villar, Richard

  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.

  Some of the bravest were the ambulance drivers. Proper ambulances did not function in Sarajevo. They had either broken down or been destroyed months earlier. Battered, high-mileage civilian estate cars were used instead. These were painted in camouflage colours, plying between front line and hospital whenever they could. It appeared the Serbs regarded such vehicles as legitimate targets, so driving an ambulance car was one of the more dangerous tasks in Sarajevo. Daylight evacuations were rare events, they were simply too hazardous. Most casualties would therefore be held over until nightfall when the drivers would make their way at full speed, and under fire, from the front line. You could hear them. Suddenly, as if from nowhere, the sound of a high revving engine would break the night air. This would be followed by the screeching of tyres as the ambulance car hurtled furiously through the narrow alleyways to the hospital. As it drove you could hear the intense sound of Serb automatic gunfire trying to stop it in its tracks. In the pitch dark, the ambulance cars would arrive, no lights, no sirens, no horns and discharge their grizzly cargoes at the casualty front doors. Often these were the dead bodies of young soldiers killed in action. It was a pitiful sight — another life finished in this futile war.

  Food in Sarajevo was in short supply. The population was kept alive largely by outside aid. The Serbs had long ago prevented other supplies entering the city. What did filter in was often in poor condition, limited quantity and cost a fortune in Black Market Deutschmarks. Bosnian money was worthless. Each morning I would see the long lines of Sarajevans standing in their bread queues, those at the tail end invariably being disappointed. In the hospital we fed on aid rations. These were appalling and insufficient to keep an adult alive for long. Most meals would comprise two small slices of bread, yellow tasteless paste masquerading as butter and pale brown liquid pretending to be tea. Rumour had it the tea was boiled cardboard, though I never dared ask. In contrast, the French troops billeted in the PTT wined and dined like royal
ty. As much food as you could eat and a bottle of wine with your meal. No wonder Sarajevans regarded the UN with suspicion.

  Water was scarce. The hospital received only two hours’ supply each day. This made washing difficult and it became a challenge to see how little you needed to clean yourself from head to toe. I managed it on one occasion with an egg cupful, including teeth, but the acrobatics I had to go through were unrepeatable. Generally, a litre was sufficient for most hygiene purposes throughout the day, though in the operating theatres more was required. Because of water scarcity, the incidence of waterborne disease steadily increased within Sarajevo. People simply did not have enough to wash their hands as often as they should, and disease was the end result. Hepatitis and gastroenteritis were particularly common. In one month alone 2000 cases of gastroenteritis were reported.

  A major reason for our visit to Sarajevo was not only to help surgically, and to prepare an appreciation, but to show its people we genuinely cared. Simon did staunch work with the media, ensuring frequent bulletins on Bosnian Radio and keeping our profile as high as he could. By taking up residence in the Swiss Cheese Hospital we ran the risk of being seen by the Serbs as taking sides. I had repeatedly stressed to anyone I met that, as medical professionals, we could not be seen to support one side more than the other. I tried hard to arrange a crossing of the front line to show our faces to the Serbian opposition, but on each occasion failed. In practice I am sure we were supporting those most in need, but it was important we were regarded as neutral, if there is such a thing in genocidal war. Sarajevo, of course, wished us to be viewed as an entirely Bosnian arrangement.

  Local Sarajevans helped us as much as they could, as we gradually amassed evidence from throughout the city of appalling medical conditions and shortages. For most local people there was only one ambition - to escape by whatever means possible. There were few avenues left open to them. One route was as a medical evacuee. Each month, sometimes more often, a medical evacuation committee would meet to consider the plight of often 300 applicants at a time. Rarely more than four would be chosen. It was a desperately distressing task for those having to decide. Sarajevans who, before the war, were in well-paid professional jobs would do anything that might lead to an opportunity for escape. Those working for the United Nations were the most fortunate, being in frequent contact with those in influential positions.

  I talked to many Sarajevans when there. For most, they would have done anything to escape. One, an attractive woman, had been an eminent academic in her own right before the conflict. Her job, and position in Sarajevan society, had gone long ago.

  ‘Everything changes in war,’ she explained. ‘Your standards change, you forget those you love, your morals and behaviour reach rock bottom. Even so, I intend to survive and I intend to get out. Whatever it takes.’

  I did not ask for more detail as it seemed inappropriate, though I was clear in my mind what she meant. She had a young daughter to care for and wanted her evacuated by any means. Her tactics, whatever they were, worked eventually. Two months after I left the city, I received a message from a central European location that she had escaped and all was well. Not everyone was so lucky or, for that matter, so determined.

  One of our most important tasks was a simple one. To talk and make friends with local medical staff. For so long they had felt abandoned, their hopes repetitively raised and dashed by consecutive ceasefires. They had no idea what people felt in the outside world and were unaware of the enormous wave of sympathy and understanding that dominated the thinking of so many other countries. Long into the night we would talk. Complex, convoluted, political discussions that ended nowhere but made everyone feel better. One night in particular I remember well. We had found an ancient guitar in a bombed-out building. Despite a long split down its back, its tatty strings were still able to play a semblance of a tune. At great expense, I persuaded the PTT to use its satellite fax for selected sheet music to be sent from England. My secretary, with wonderful enthusiasm, could not decide which songs were best, transmitting everything I possessed. She dominated the fax machine for the best part of an hour.

  It was worth it. That night, by the light of a candle, our team sat round a hospital table with local Sarajevan medical staff. We took it in turns to sing or play a tune. One of their surgeons, a habitual chain smoker whenever he could obtain cigarettes, had once sung at the Llangollen Eistedfodd. He gently strummed the guitar, sniper rounds and blast noise in the background, singing a Bosnian love song in a most wonderful, penetrating tenor voice. It overwhelmed us at the time. It was the first opportunity any of them had been given to develop new friendships and behave normally since the war began. Of anything we did in Sarajevo, such social activities were perhaps the most vital.

  Before we had arrived in the city I was uncertain what to expect as far as local surgical skills were concerned. The tatty letter I had received highlighted lack of equipment, but made no mention of medical or surgical abilities. The moment I went on that first ward round I knew I was in the company of professionals. These people were excellent at their job. When it came to war surgery they could teach me far more than I could ever teach them. They had been unable to publish their experience in the medical journals, but there can be few professionals in the world with the expertise of Sarajevan surgeons and I can only pray that in time international surgery can learn from them. One technique in particular was widely used - the operation of external fixation. This is best for gunshot wounds that have totally shattered the bones. Implanting metal plates and screws directly on to the fragmented bone to reconstruct it is technically straightforward, but leaves metal inside the patient. Bacteria love metal, so the chances of infection after surgery are high.

  External fixation involves placing long pins through the skin, directly into the underlying bone and connecting the outer ends of the pins with a thick metal bar. Nothing is permanently implanted inside the patient, as the bar and pins are removed once the shattered bone has healed. It is an excellent way of reducing the chance of infection while still allowing bone to mend. External fixation is used worldwide, but not many have the experience of Sarajevo. By the time we arrived, the city’s surgeons had used the technique on over 1100 patients. With equipment in short supply they had been forced to design and manufacture their own fixation devices — improvization at its best. The ‘Sarafix’ had been born.

  Equipment shortages meant surgery had to be kept simple. Fancy techniques, with the implantation of expensive pieces of metal, were not appropriate. Even scrubbing up at the start of surgery had to be undertaken with care. Without functioning taps, an assistant had to pour water from a plastic container over your hands as you washed furiously with an iodine solution. Operations had to be as quick as possible to reduce the amount of anaesthetic used, the patient being put to sleep on the operating table rather than in a room next door. You would also prepare the patient’s skin, and apply the surgical towels, before anaesthesia was performed. Patients would cooperate with this fully. It is not surgical behaviour that would be regarded as acceptable by many in our peaceful United Kingdom. War forces you to challenge established practice. It is only right that it should do so.

  Josip, a twenty-two-year-old former student, was a particularly difficult case. He had been wounded in the thigh by a high-velocity missile, probably a sniper’s bullet. An area of the city had come under mortar attack while he had been walking through it. It was bad luck, nothing more, as Josip had survived the siege for many months by becoming war-wise. As the first bombs landed, he had hidden behind a small wall, but in his panic had not noticed one leg protruding from cover. Though Josip was dressed obviously in civilian clothes, a sniper had taken aim and shot. The bullet had entered his upper thigh and exited his lower shin bone, macerating and destroying everything in its path. Damage was immense. Several centimetres of bone were lost, much of the muscle and the major blood vessel to the leg was divided.

  Despite the pain, Josip had used his own belt as a t
ourniquet around the upper thigh, keeping blood loss low until he could be taken to hospital. Carried and dragged by friends once the attack had finished, he was dumped unceremoniously on the hospital doorsteps. Then the surgical work began. The on-call team had its work cut out to save the leg. More than four hours without an intact blood supply and it is simpler to amputate. Tissues will not survive for much longer without blood. By the time Josip reached the operating theatre, his leg had been bloodless for two and three-quarter hours. By using an undamaged vein, stripped from his healthy leg, it was turned upside down and joined to each end of the damaged artery. The direction of blood flow in the vein has to be reversed as veins contain valves that only allow flow in one direction. Arteries do not. Almost four hours to the minute after injury, blood was returned to Josip’s leg. Then the damaged muscle had to be cut away. Typically, the high-velocity bullet had caused cavitation, destroying tissue for a wide radius along its path. Once muscle is killed, it cannot recover and must be surgically excised, or it becomes a perfect focus for infection. By the time all damage had been cut from Josip’s leg, an operation called ‘debridement’, more than half of his leg muscle had been removed.