Then, about thirty miles ahead, loomed the great iron mountain of Buchwa, with its mine. It looked as big as Snowdon from our angle. Soon we picked up the railway, which led to the mine on its way to South Africa. By following it we should come to the wreck we were seeking.
Then, there it was, in a cutting. A mass of trucks, which looked as if a giant, or a petulant child with his toys, had thrown them into a heap. It was not sabotage, we learned. There had been a fault on the permanent way.
We landed and were met by other people. About twenty police reservists had been called out to guard the wreck, and were sitting on top of the cutting, in their camouflage, holding their rifles.
Jock and I climbed over the tumbled trucks, following a guide. And then we found him. A young white man. He had been taking a shower in the caboose, when the crash caught him. He was hanging in the wreckage in the crucified position, in nothing but his drawers. His head was on his chest, and he was quite unconscious. He had been hanging there all night. The sister from the mine clinic had come out and given him pethidine and set up a drip. It was this that must have saved him from death by crucifixion.
When we climbed down to him, I saw that he had a compound dislocation of his right foot. His left leg was buried up to the hip in the wreckage.
I realised this was going to be tricky. For a start, I was worried about giving him Pentothal, which I feared might finish him off. Nor could I see how I was going to get at his leg. I thought I would try and get him into a handier position.
I asked the railway people to lower a rope. They found one and did so. I got it under the man’s arms and round his chest, and made a bowline, as I still remembered from the Boy Scouts.Then I told them to lift.
They did so, and his leg came free without a mark on it!
Surely, we must be told somewhere in our medical training, never to take a third party’s word for granted!
We got him onto a stretcher and into the chopper, where there was now less room than before. The gunner kindly let me have his seat in the forward bubble. He sat on the edge of the floor, and swung his legs in the air. They told me cheerfully, you can’t fall out of a helicopter, because of the upward thrust, or something.
As we sped towards Shabani, I told the pilot on the intercom that we could land at the hospital, as we had a helipad there. He asked me, where was the hospital? We were then flying west, towards Bulawayo. ‘On the Selukwe road,’ I shouted.
He banked the machine to 450, and swung north. I found myself staring down the chimneys of the Nilton Hotel.
We landed in front of the hospital, and I was grateful for terra firma and my own familiar operating theatre. The foot did not present much difficulty: a good wash-out, and the tarsus slipped together like a Rubik’s cube. I closed the skin without tension.
A few days later, he went out with a plaster and crutches. He lived in Salisbury, so I referred him a with letter to his own doctor, and never saw him again.
Nor did I tell him about the amputation he so narrowly escaped.
7 - War Surgeon
Early in 1977, the war came to Shabani. I heard for the first time the shattering roar and whistle of a helicopter, bringing in the wounded, or ‘casevacs’, as they called them: a sound that my stomach never got used to over the next three years.
The first was a civilian (they were mostly civilians), ‘caught in the cross-fire’. A man of forty, shot through the thigh: the bone smashed and the artery severed. I had not then learned how to do a vein graft, or I would have attempted it. Later, a surgeon was to teach me, verbally - at the annual bush doctors’ refresher course at Bulawayo.
(In Africa, the old adage, ‘an ounce of practice is worth a ton of theory’, is reversed. The man with the knowledge in his head can do something: the man without it, nothing.)
I took the man’s leg off with eleven centimetres to spare: I could barely get the tourniquet above his wound. He needed nine pints of blood, but he lived.
(By now, as the risks of hepatitis became better known, we drew our blood supplies for transfusion exclusively from the National Blood Transfusion Service.)
I was sitting in a friend’s house one Sunday afternoon. I got a call from the hospital: a woman with a gunshot wound of the arm. My friend was a medic with the TA, so I took him along for the experience. The upper arm bone was shattered, but nerves and arteries were intact: a relatively simple wash-out, debridement and packing, and application of a U-plaster and sling. My friend, a mechanic, was most impressed. When we got back to his house, he told his wife: ‘Warren just did his job like I do mine.’
Some doctors in Africa show their friends operations as a form of entertainment. Needless to say, this is unethical, and although I may have done it in my earlier days, I soon realised this and stopped it. People like military medics, Red Cross, etc, I regarded as students, and would allow them to watch. It was well understood that all government hospitals took students.
However, one Saturday night, I was in the mine club with Koos when a call came: another gunshot wound.
‘Man!’ pleaded Koos. ‘I’ve always wanted to see an operation.’
Well, I reflected, he sees active service in the TA: gunshot wounds are his business. I decided to bend my rule. ‘But you’d better pretend you’re an army medic.’
On the ward, I studied the X-rays: a forearm wound this time. I showed them to Koos. ‘You can see the joint is not involved. That’s very important.’
Koos took the X-rays from my hand. He pointed them out to the nurses who were present. ‘You see, the joint is not involved. That is very important.’
I said, ‘Cool it, Koos. You’re supposed to be an army medic, not a visiting consultant.’
Koos donned boots, mask and gown, and stood well back in the theatre, like a good boy, very interested. When it was over, we met Sister Feldwebel, outside the theatre. She was a German lady of the ‘old school’, meaning the ram-rod type. Koos greeted her in what he thought was German, and got a cup of coffee for us in the duty room.
The telephone rang. It was Koos’s wife, Anita, cooling her heels in the club.
‘Is my husband there?’
‘Yes, he’s been watching an operation with me.’ Something innocent, of course.
‘Just remind him he’s got a wife, will you. I’ve been sitting here like a sausage for the last two hours.’
I passed the message on to Koos. Sister Feldwebel said, ‘I’ll unlock the front door for you.’
She had trouble finding the key. She need not have bothered. Koos had left the room. When we got to the front doors, we found them swinging in the breeze. Koos had opened them like any other rhinoceros would have done.
‘Just look at that!’ shouted Sister Feldwebel, who knew Koos of old. ‘And you call that your friend? You, a doctor - an educated man!’ She stomped away. ‘As for him pretending to speak German!’
By now I had learnt (theoretically, as I said) to perform a vein graft, and I got my opportunity: a little girl of eight, shot through the upper arm. The bone was intact, but the main artery was severed. There was no pulse at the wrist.
The operation has to be done within six hours of the time of injury. If I transferred her to Bulawayo, this time, already short, would be lost. Also, we had a rule not to transfer cases after four o’ clock in the afternoon, as that was when the shooting season started, when the guerrillas could mount an ambush and have the rest of the night to get away. In the early days of the war, the security forces would pursue by night, but in the total African darkness of moonless nights, they got lost and sometimes fired on their own members.
I debrided the wound and trimmed the ends of the artery. Then I dissected out a section of the long vein of the leg in the lower part, carefully tying off all the little branches. I flushed out the graft and the distal (outer) section of the artery with heparin/saline solution, and stitched in the graft. I released the tapes and a column of blood pulsed down the graft - and stopped half-way.
To my desp
air I realised that I had forgotten to reverse the graft. A vein has valves opening towards the heart: a vein graft must be reversed, as an artery conducts away from the heart. I had even marked the graft with large and small forceps - north and south. In removing them, I had still failed to reverse the graft. I had been at work two hours. I was nearly dropping with fatigue in the hot night. I must get a grip on myself. Now I had to start the whole business again, taking a graft from the other leg.
First, I cut out the original graft. Good job I did so, for, to my relief, blood spurted from the distal section of the artery. The collateral circulation was intact. Resuscitation and the anaesthetic had restored the flow of blood. The wrist pulse was now palpable. I had no more to do than ligate the ends of the artery. The little patient made a good recovery.
I had a good excuse for my absent-mindedness. As I walked back to my house, I felt a pain in my groin. When I got home, I found a scab on my thigh and tender glands. My temperature was 38 0C. I realised I had contracted tick bite fever (African typhus). I must have been near to collapse in theatre.
A thing like that would not stop me working. I gave myself a short course of tetracycline, and in a few days was better.
But I reckoned I could chalk up my vien graft as a theoretical success. And if I could do it on the tiny vessels of a child, I could do it on an adult.
That was my first (and last) vein graft; but I nearly had another.
One Sunday afternoon, I was getting a book out of the white hospital library, when I saw Jock (who was on duty) examining a patient in one of the wards. I looked in out of interest. It was a white soldier with a gunshot wound of the thigh. I had heard no helicopter because the man had been brought in by road by his friends. It turned out the femoral artery was severed. It needed a graft, and most of the six-hour ‘golden period’ had been lost. Jock meant to send the man to Bulawayo. I debated in my mind whether to offer my services: I had to balance my slender advantage in time against the superior skills of the surgeon in the Central Hospital.
Colleagues who have worked together as close as Jock and I have an intuitive relationship. This was Jock’s case: I knew he wanted to send the man away. There was no point in arguing, especially in front of the patient, even if I felt that sure of myself. So, with uncharacteristic modesty, I said nothing.
In the event, the man arrived too late. The surgeon operated, but the graft did not take, and the leg had to come off next day. The man was very bitter about it, but the surgeon wrote to his lawyer (for it had come to that) that Jock had done well to keep him alive, and so he had.
Later, I learned from one of his friends how the man had come by his injury. They were ‘bounty-hunters’. Not satisfied with their statutory duties in the TA, etc, these desperadoes went in for the sport of man-hunting, which, apart from the pleasure Sir Garnet Wolseley so enthused about in West Africa, was here profitable. In short, if they brought back a communist weapon from their expeditions they got $1000 for it. And no doubt it was an exciting substitute for the other shooting and fishing they used to do, which the war had curtailed.
So, on the Saturday afternoon, they drove out into the countryside (a party of half-a-dozen, or so), left their vehicle, and marched off into the bundu, arriving under cover of darkness at a spot they had marked beforehand: a kopje overlooking a village. There they fed and watered, and lay up till next day.
After sunrise, they watched the village for any sign of guerrillas. The sun mounted to its furious zenith in that part of the country, bordering the Lowveld: and they ran out of water.
They got thirsty. Around midday, our patient (I will call him George), to the astonishment of his comrades, and before they could stop him, staggered out of cover and down the hill to the village, carrying his rifle and his water-bottle.
Whether he found water, I did not ask. The guerrillas, the seemingly ordinary peasants, sitting around, found him and knew he had not come from nowhere and alone. They let him walk back again up the kopje. Then they pulled their rifles out of the thatch and did a bit of field-craft of their own.
They took up a position on another kopje, higher than the first, and the first thing George and his companions knew about it was when they were fired on from above - an indefensible position.
George was the only one hit as they evacuated, and it says much for the devotion of his friends that they got him out alive.
One night, a police reservist was brought in, shot in the chest in an ambush. I noted he was the same age as myself then - 49. He was nearly bled out. He was still conscious and said he could not move his legs.
We transfused him. The chest X-ray showed the left side full of blood and a foreign body in the spine. The communist bullet had a copper coat and contained lead and a gun-metal cylinder, called the tumbler. The bullet would shatter on hitting bone, but the tumbler would penetrate deeper and fly anywhere. The FB in the spine was the tumbler.
The patient needed an immediate operation (on second thoughts, all he needed was a chest drain). This was going to be a tricky anaesthetic. I called one of the mine doctors who was a skilled anaesthetist. He got a tube down the windpipe and I opened the chest.
I evacuated the blood and reached my hand deep inside. I could feel the tip of the tumbler buried deep in the spine, impossible to remove; nor would that have served much useful purpose.
I debrided the wound and inserted a water-sealed drain - a tube that goes into a bottle of water to release air and blood from the chest and prevents air returning. I closed the chest and the anaesthetist re-inflated the lung.
There remained the problem of the paralysis. There were two possibilities: one probable, the other just possible. Most probably, the spine was severed. On the other hand, perhaps it was merely compressed by a haemorrhage into the spinal canal which might be relieved by the operation of laminectomy - removing some of the spinal arches: something beyond my judgement, if not my skill. It might be done even by a general surgeon at Bulawayo, but no time should be lost to avoid progressive paralysis, even death.
As I have explained, our policy was not to transfer people by night, because of the risk of ambush. I never required this of our ambulance drivers, to say nothing of exposing the patients.
I put the matter to the man’s comrades, and a gallant police officer volunteered to take him in his car. In the event, I learned many years later, the ambulance driver got to take him, with the police officer riding shotgun.
As it happened, next day, one of the country’s two neurosurgeons, based on Salisbury, was on his regular visit to Bulawayo. He took one look at the X-rays and decided that further operation would be profitless.
But we had the satisfaction of saving the man’s life, and for ten years he pursued a courageous and useful career in business and civic affairs, before succumbing to his injuries.
What seemed the bitter irony of this case was that someone left open the back door of the armoured personnel carrier they were travelling in, and our patient received a bullet through the fatal gap. Later, I learned that these vehicles were so intolerable in the hot weather that the door was invariably left open. Very human, and very sad!
The brave police officer who escorted him came to a sad end. He survived the war, but in the disturbed conditions which followed, was killed by a bandit when attempting to arrest him. And it was so much later that I learned about his gallantry, that I was unable to thank or even identify the plucky ambulance driver. Let me do so now.
I had five brain shots in the three years of total war, three of which I saved.
The first was a white corporal, shot through the forehead, just above the right eye, which was shattered also.
This case was also admitted at night. I called the mine anaesthetist, Ben Theron, to this case too. It was a parlous case in a white man, and I knew that the African nurse-anaesthetists, for reasons which the reader may appreciate, were nervous of such: it was unfair and unwise to expose them to something they were not happy with. In other European cases, whe
re I was confident myself, they gladly obliged.
After resuscitation and intubation, I opened his head and washed out most of the right frontal lobe of the brain. I instructed the scrub nurse to stem the copious haemorrhage with a surgical towel, while I prepared a muscle graft. This is simply a piece of meat taken from the patient’s thigh, beaten flat, and applied like a dressing to the bleeding area. It sticks like a postage stamp in ten minutes, and effectively arrests the haemorrhage, before becoming eventually absorbed. I have saved many lives by this method in cases of head injury from what used to be called ‘uncontrollable haemorrhage’.I then closed the scalp without drainage. At the same time, I removed the shattered eye.
I sent the man to Bulawayo next day, where no further intervention was found necessary. I never saw him again. He was discharged from the army, and returned to his home in Salisbury; but I heard from his friends who told me that he was well enough but his personality had changed. He never became depressed and he never became excited. The frontal lobe is the part of the brain used for worrying. The bullet had inflicted a pre-frontal leucotomy, an operation which used to be performed in cases of intractable anxiety, but has since been abandoned. I hope he suffered no worse after-effects.
Another case was a carbon copy of this one, except for the eye injury, in which I operated on an African with a satisfactory result.
The third was an African lad of about sixteen, shot in the side of the head: the motor area. He survived, but was left with some lameness of his right leg and a paralysed right arm. His speech was affected, but mercifully, not much.
I did less well with abdominal shots, of which I had about half a dozen. There is a lot to go wrong in a television set. One succumbed to thrombosis, and at least two others to infection. I had only one clear success: a man whose bowels were riddled with mortar-bomb splinters. It was a simple matter of sewing up all the holes, followed by a wash-out. I was barely learning the abdominal trade when the war ended.
Across the Wide Zambezi: A Doctor's Life in Africa Page 29
