15 Mar 2019

Doctors saving lives and risking death in war zones

From Nine To Noon, 10:06 am on 15 March 2019

Dr David Nott is a British surgeon who has been to 27 different war zones in the past 25 years treating people on the frontline of extreme danger. 

He’s operated in combat zone field hospitals in Sarajevo, Chad, Cameroon, Afghanistan, Sierra Leone, Dafur, Yemen, Gaza and Aleppo. In recent years medical staff and hospitals are being targeted more and more in war. And it’s an experience he’s lived through. 

War Doctor: Surgery on the Frontline is his new book and he joined Kathryn Ryan to discuss his incredible career.

Warning: Graphic content

Dr Nott says he was drawn to the work because he wanted to treat people and felt there were plenty of doctors for the people of the UK and Europe, but very few out in the field helping people who really needed it.

“Those are the ones where, if there was nobody there, they would die. So, it gives me great pleasure to do that. Although, it has been quite harrowing and has been quite difficult throughout the years and you do see the most awful sights and terrible cases of people being mortally wounded… It does take toll on you.”

He describes early in his career in Sarajevo having ice around his heart to keep him unemotional and able deal with the casualties that came in. 

“The cases that you do see are so pitiful and so pathetic and so heart wrenching that sometimes you really have to close yourself off to things that you do see. You just have to concentrate on the patient on the operating table in front of you, you have to be able to treat them and do your very best for them in the most dire situations. 

“If you became emotional about it, then it would be very difficult to continue. In Aleppo in 2014, when there were so many barrel bombs being dropped, whole families were coming in completely destroyed, you really have to fixate on just looking after the patient in front of you, and dealing with the next one, and the next one and the next one. If you became emotional, you’d be an emotional wreck and you wouldn’t be able to continue.

He says that whereas in places like Sierra Leone and Liberia where he dealt with mainly gunshot wounds, more recent warfare in places like Aleppo and Afghanistan sees patients with bomb blast injuries which cause significantly more bodily trauma and can be difficult to treat. Because multiple people are affected by bomb blasts in the same moment, he says tough decisions have to be made about which people to treat or which to not. 

“That’s a problem with war surgery: when you’re in an isolated environment, in a field hospital or something like that, your making those very, very difficult decisions.”  

Working within military settings and war zones has allowed Dr Nott to learn and pioneer innovations such as understanding how much blood a patient can survive on in settings where there’s little blood available. He now teaches this to colleagues from places like Doctors Without Borders and runs a course at the Royal College of Surgeons. He’s also started the David Nott Foundation which provides full scholarships for doctors, surgeons, and nurses to learn about treating trauma victims. 

When people aren’t able to come to the course, the foundation takes the course to them. He’s just spent three weeks in Yemen teaching 54 Yemeni surgeons techniques and skills involved in treating patients in a war zone. A few months before that they were in Cameroon Boko Haram area. 

The forgotten war

Dr Nott says Syria has been a particularly difficult frontline to treat patients because health workers and hospitals have become part of warfare, where by removing them blocks healthcare to thousands of people.

“When I was there, it was so obvious that hospitals were being targeted, health care workers were being targeted… We used to have hospitals underground because all the hospitals were bombed, either barrel bombed or rocketed.”

In one instance, Dr Nott was in London training surgeons in Aleppo in how to reconstruct a jaw over an eight hour surgery. He suspects the Skype coordinates were discovered and gave away the location of the underground hospital.

“The operating theatre was targeted by a bunker busting bomb, right in the centre of exactly where the coordinates were for Skype operation. That hospital was completely destroyed. I was part of that and it makes you think, well, you can’t really help anybody anymore, because if hospitals are being targeted and you’re trying to help people and you’re Skype coordinates are used as a focal point for dropping bombs then it’s just dreadful. You felt that you couldn’t even help because you didn’t know who was watching.”

Syria’s borders are completely closed now so journalists and doctors cannot get in. Dr Nott says this also means aid has dried up and his colleagues in the country are struggling to finance hospitals and receive necessary materials. 

“We’re just sitting and wondering what on Earth people can do about it. It is the forgotten war. Because it’s not reported anymore and because there’s not much information coming in and out, we’re don’t see it anymore. But is a terrible and dire situation.”

“There’s no doubt Assad has won the war, but he won it through Russia, he won it through destroying the whole country, really. It’s a real mess.There is no solution at the moment.”

'David, we have to leave now'

Dr Nott has, of course, faced terrible danger while working in war zones. In once case he refused to evacuate while he was performing surgery on a child in Gaza. 

“It was during the heaviest bombardment I’ve ever been in. There was a little girl, about 7-years-old, in the operating theatre who’d been blown up with fragmentation injuries. Her guts were spilling out and she had holes in her tummy and arms and legs. She was dying, there was no doubt about it.

“She went of the operating table, and as she did so the security person from the International Red Cross told me, ‘David, we have to leave now because the hospital’s going to be blown up in five minutes.’ At the time I didn’t have any family, I didn’t have parents, I had nobody like that, and I just felt I had seen enough. I had seen enough of terrible acts and I just couldn’t bare it any longer, and I thought ‘I’m not going to leave this girl, I’m not going to be bullied by people telling me I need to leave her on the operating table and walk out and just watch her from a distance, or not watch her but expect her to die. I’m just not going to do it’.”

“When you’ve seen so much and you’ve just had enough of being bullied around, I thought, ‘no, I’m not going to leave her, I’m going to stay with her.’ Why should she have to die on an operating table with no one around her, no parents, no family or anything like that. I said to the anaesthetist ‘you can go, but I’m not going to go,’ and he said, ‘no, David I’ll stay with you.’ So the two of us stayed. 

“He put her to sleep and I prepped her for surgery in the full knowledge that, within the next three or four minutes, the whole place was going to be totally destroyed. But, it was quite miraculous really, we continued the operation and five minutes went by, then ten minutes went by, then half an hour went by, and she survived. I had my photograph taken with her about three days later. She was a beautiful little girl and I’m glad I didn’t get bullied and leave her. I’m really pleased that I stayed. You just get to a stage sometimes where you’ve seen so much and you’ve just had enough of letting people die when they shouldn’t do.”

Since that incident, in which he was fully prepared to die, Dr Nott has got married and had children and he says it’s changed his outlook. 

“When you’re a single person you can choose what you want to do with your life and I loved that sort of life. I really enjoyed going to places and helping people and putting myself on the line. I didn’t have any responsibilities for anybody. When I came back from Gaza, I met Ellie who became my wife and who I fell in love with very rapidly.

“I can’t do what I used to do, but that’s why I now really enjoy training people and teaching people. Not on the front line, but close to the front line. Certainly I wouldn’t put myself in that position again, and I wouldn’t put myself in that position again, because I do have responsibilities now.”

'She just spat at me'

The situation that almost broke him was seeing rape used as a weapon of war against women and young children. In Chad, he treated many children who were pregnant by rape and too young to give birth, unless by caesarean. 

“I was working on the Chad-Dafur border where there were eight million refugees who were queueing for miles to get food. Not only that, but it was a time when there was raping of young girls by soldiers. In my little hospital, which turned into the most desperate place I’ve ever worked in my whole life, we would have children aged 9, 10, 11 in labour and they, of course, didn’t have pelvises which were developed and all there children would be in obstructive labour. They were coming in desperately ill. Some of them had malaria, they were anaemic, and it was the most pitiful sight I think I’ve ever seen. 

“It really did break me. You’re operating, basically, on 10-year-olds who were pregnant. It was so heartbreaking, not only to lose the child on the operating table - the mother - but then to lose the baby as well. It was just like being in hell. I remember the anaesthetist writing ‘this is as close to hell as we’ll ever get’.”

“I remember there was a girl, who was probably about 12, who I went to see because she was in obstructive labour and the midwife said she needed a caesarean pretty quick. I looked at her and I smiled and she just spat at me because, of course, she hated men. I walked away and I came back about 20 minutes later to see again whether or not she’d go for an operation and by the time I’d come back, she was dead.”

He says that, while it’s extremely upsetting to discover, he wanted readers to know the full truth. 

“We forget, in war, what really goes on. It is the most inhumane way that man behaves in all aspects. This is all written down in the book because I want people to realise that things like this do happen.”