Adventures in Human Being

by Gavin Francis

  The military doctors taught me how to take my own X-rays with a portable unit designed for the battlefield, reset broken bones and drill holes in the skull in case of coma following head injury – all skills they applied in war, but that they thought I might need in Antarctica. I was sent to traditional military establishments: dental anesthesia at an air-force base, logistics at an infantry barracks. I took a course called “Disaster Relief Operations” and sat in a room with thirty doctors, paramedics and nurses, all recently returned from battle zones. We learned how to build dressing stations near a front line, dig cholera-busting latrines, and other things that might be more useful on polar expeditions: satellite communications, improvised life support, and how to protect fragile drugs and equipment in transit. I developed an unanticipated respect for the military medics, and realized how much their predecessors had advanced our understanding of the body. Antiseptic surgery revolutionized the survival rates of soldiers during the Boer and First World Wars, while the advent of antibiotics had a similar effect in the Second World War. Charles Bell had learned much attending the soldiers of Waterloo; the Roman surgeon Galen had been physician to the gladiators. Perhaps the anatomical knowledge shown in The Iliad was part of this long, often unacknowledged tradition.

  THE WORD “ARMS” is dual-use: parts of our bodies and weapons of war. “Armed,” “armor,” “army” – our vocabulary bears witness to bodily violence, and humanity’s attitude to killing is written into our figures of speech. Someone skilled in violence is often known as “a strong arm,” and soldiers with a common cause “brothers in arms.” In Latin, armus means simply “shoulder,” while arma can mean any weapon, from a root meaning “that which is fitted together.”

  A historian of military medicine, P. B. Adamson, once read The Iliad with more care and attention than most surgeons bring to the closing of wounds. While acknowledging that it is an epic poem and not a historical record, he noted every cut, together with the weapon that had dealt it and whether the wound turned out to be a fatal one. He then compared the results with a similar exercise on Virgil’s Aeneid and concluded that at the time of the Trojan War spears were the most fatal weapons, but by the Roman period, which Virgil was describing, swords had the advantage. Stones were the least successful weapons in terms of killing people – 41 percent of those hit by a stone end up dead. (Teucer’s life wasn’t in danger when his arm was paralyzed – after Hector disables him in Book VIII he pops up to fight again in Book XII.) To be an archer like Paris or even Teucer is, according to the subtext of The Iliad, to be slightly cowardly – archery delivers death from a distance as well as poorer accuracy: 74 percent mortality as opposed to 100 percent for swords and 97 percent for spear thrusts. Adamson makes the point that in antiquity as today, armor encourages fierce engagement because it is reinforced toward the front but pitifully weak on the back. To turn on the battlefield and run has always been a mortally dangerous choice.

  Adamson noticed that the legs are rarely injured in The Iliad, perhaps because the men often fought thigh-deep in the bodies of their fallen comrades, from the back of a waist-high chariot or even from within the protection of the hulls of their ships. He also notes that the head, neck and trunk are the parts of the body aimed for. When upper limbs are damaged in The Iliad it’s usually because those arms are being raised in defense, or injured while they are themselves raised in violence. These Homeric patterns of injuries are still encountered every day in emergency departments: doctors assessing victims of domestic abuse often check women’s forearms, as it is these that bear the brunt of warding off an attacker. A midshaft fracture of the ulna, the long bone of the forearm, is still known as a “nightstick fracture” because it’s most commonly encountered in those who’ve been beaten with a policeman’s nightstick.

  The pattern of wounds described by Homer remained broadly similar for almost three millennia after the siege of Troy – it was only after the widespread adoption of gunpowder, and the increasing distance between belligerents that it facilitated, that the pattern began to change. As weapons became more powerful, mortality figures paradoxically began to fall. Adamson compares the mortality and injury rates described in ancient texts with those that have been gathered from some of the most awful wars of the nineteenth and twentieth centuries.

  Despite the appalling squalor and brutality of the Crimean War, the mortality rate from injuries was just 26 percent – five and a half thousand deaths among twenty-one thousand British combatants. Proportions were similar for British troops in the First World War: of two and a quarter million soldiers, just under six hundred thousand died as a result of their injuries. Adamson shows that at their worst, shells and bombs turn up a mortality rate of 29 percent (First World War), which is less than the rate for thrown stones described in The Iliad. The proportion of injuries sustained to the limbs versus those of trunk and head had entirely reversed: only 20 percent of injuries in the ancient epics were to the limbs, but in the last century, injuries to the limbs make up 70 to 80 percent of all those sustained in combat. As weapons grow more sophisticated, and kill at ever-greater distances, limbs started to become mutilated more often than soldiers were killed.

  THERE ARE VARIOUS DEGREES of nerve injury. If the nerves behind the collarbone have been wrenched out of the spinal cord itself, there is almost no chance of recovery. If they’ve been ruptured, there’s a small chance that some may heal, and nerve transplants sometimes help regain some weaker function. Nerves are in some respects similar to copper wiring surrounded by plastic insulation sheathing: a nerve that has been severely stretched may regrow if its outer sheath has remained intact and only the inner “axon,” corresponding to the copper of the wire, has split.

  Two months after his motorbike crash I saw Chris McTullom waiting in line for the neurosurgical review clinic. He still carried his right arm in a sling. The muscles of his upper arm that had been so pulpy and swollen were now withered and limp, but he had regained some movement in them.

  “How are you getting on?” I asked him.

  He took his arm from the sling, and slowly flexed his biceps. “It’s coming back,” he said. “I’m not fit for duty yet, but perhaps in another couple of months.”

  “And what then?” I asked him.

  “Back to my unit,” he said. “Afghanistan, probably.” He slowly curled the fingers of his right hand, stiff with disuse, as if to take hold of a trigger.

  THE WORD “ARM” might be embedded in our terms for weaponry and violence, but is also at the root of the language we use for friendship and affection. “Embrace” means “in arms.”

  When the Greek and Trojan armies meet in Book VI of The Iliad, the Greek warrior Diomedes finds himself facing up to a Trojan named Glaucus, dressed in such magnificent armor that Diomedes thinks he must be one of the gods. “What great man are you, among us mortals?” he shouts across the battlefield. “At the threat of my long-shadowed spear you show yourself braver than the rest.”

  “Why ask about my parentage?” Glaucus shouts back. “Men are like leaves, they fall to the ground when their season ends, and spring brings new buds on the trees. So the generations of men die but new generations come to take their place.”

  But after having initially refused to name his parents, Glaucus goes on to describe his ancestry: he is of Greek lineage; his grandfather was driven from Greece many years ago and settled in the lands of the Trojans. Diomedes realizes that his own grandfather and Glaucus’s grandfather had been friends, and because of that friendship he resolves to make peace: “Let’s stay away from one another’s spears in the battle – there are many more Trojans for me to slaughter if the gods let me outrun them, and many Greeks for you to slay if you can.”

  Standing apart from the hell of death that surrounded them, the two men leapt down from their chariots and clasped arms.

  10

  WRIST & HAND: PUNCHED, CUT & CRUCIFIED

  and (glancing at my own thin, veinèd wrist)

  In such a little tr
emor of the blood

  The whole strong clamour of a vehement soul

  Doth utter itself distinct

  Elizabeth Barrett Browning, Aurora Leigh

  SATURDAY NIGHT SHIFT in the emergency department: payday weekend. The double doors onto the street have been like a storm drain, all the madness and misery of humanity pouring through them. At the end of my shift I navigate my way toward the changing room, between the old ladies on gurneys and lines of paramedics, handcuffed prisoners and policemen. Ambulance sirens are getting closer, a roar of shouts is coming from the waiting room, and from the noises in the resuscitation room I hear they’re working on a cardiac arrest.

  The changing room is windowless. Laundered green scrubs are stacked in piles on shelves, and a large bin of dirtied ones leans against one wall. The scrubs are made of some synthetic blood-proof cloth, and as they slide over my head they crackle with static electricity. I open my locker, throw in my name badge, and sift out my clothes from the discarded blood tubes, pens, surgical gloves and disposable scissors that have accumulated over the months. A colleague is changing into clean scrubs, beginning his ten-hour day shift. “Good luck,” I say to him. “You’ll need it.”

  Standing in the shower at home, scrubbing off the dried blood from my cheek and the smell of hospital disinfectant from my hands, I do a mental tally of the people I attended through the night: the overdosed and toxic, psychotic and broken, burned and convulsed. Seen from the corridors of an emergency department, the world is mad, bad and, like the poet said, incorrigibly plural. “How can you face it?” a friend asked me. “So many of the people you see must have brought their misery on themselves.” Does that matter? I remember thinking. Few of us manage to be who we aspire to be. I like that in the emergency department life is extreme and unfiltered: there is no preferential treatment for those with power and money. Everyone sits together on the same hard plastic chairs and is stitched up in the same curtained cubicles. There is an unarguable democracy to “triage”: being prioritized on the basis of medical need, rather than influence.

  Once out of the shower I notice it is 9 a.m. and tumble into bed the way a shipwrecked sailor would throw himself onto a beach. There are eight hours before I have to go back. The shifts come in a relentless tide: fourteen-hour night shifts, ten-hour day shifts, a couple of days off then straight back to the nights. All the time I work in adult emergency medicine I reverse my body clock through twenty-four hours every week or so.

  The idea behind my training there was to learn how to approach every injury and intoxication that humanity can inflict on itself, but what I didn’t bargain for were the stories. As I collapse into bed, my body twitching with fatigue, my neck and shoulders already tense at the thought of the next shift, it is those stories that keep me from sleep.

  A MAN LIES on a gurney trembling, a hospital gown over his legs and chest. Beneath the pressed institutional cotton his body has a toned, athletic form, well tanned with the musculature of someone who doesn’t waste his gym membership. At the entrance to his cubicle I glance down at the clipboard: “Mr. Adrianson?” I say to him. He nods and I walk in, pulling the curtain closed behind me.

  Dish towels are wrapped around his left forearm. Once a dirty white, they are now a deep and lustrous scarlet. The topmost one, a souvenir from Majorca, has come partly undone and lies loosely at his elbow. Blood is pouring over his skin like a wet sunset, pooling in the crevice formed by his buttock and the rubber gurney mattress. “I’m bleeding,” he says pointlessly as I reach to rewrap the arm with the towel, and begin to press hard.

  “You’re going to be fine,” I say, though I’ve no idea what’s under the towels yet. Maybe he won’t be; maybe the arteries are severed and the tendons too. Into the undamaged crook of his right elbow I push a sixteen-gauge cannula – as thick and long as a hat pin – pulling out the steel introducer as I nudge in its clear plastic conduit. Once the plastic wings of the cannula are taped down I draw off blood samples for hemoglobin and crossmatching, then hook up an IV drip of plasma substitute. “Are you left-handed?” I ask him. He nods. “What’s your job?”

  “I’m a pickpocket,” he says with a wry smile, “what’s it to you?”

  “Just checking you’re not a concert pianist.”

  “I fell through a window,” he says and looks away, though the nurses have already told me another story. When the paramedics arrived at his house there was a woman sobbing in the corner, who told them that he’d been about to punch her but punched a door instead. The window panels of the door shattered badly, and I wonder if he has fractured the bones of his hand in the punch. As I press on the forearm I lift his hand and glance at his fingertips: nice and pink, so there’s plenty of blood still getting down to them. I press hard on the pulp of his thumb, release the pressure, and count the number of seconds it takes to pink up. It’s less than two, so inwardly I relax a little. The knuckles are in bad shape though, and as expected, his little finger looks shorter than it should, and turned in at an unnatural angle. He has snapped the bone in the hand that supports it: a “boxer’s fracture.”

  As I push on the forearm, trying to get the oozing to stop, I’m thinking of another boxer’s fracture I dealt with earlier in the week. The metacarpal in question had belonged to a prison warder’s fist, and only moments before assessing him I’d diagnosed his prisoner with a broken jaw. The two men sat in adjacent cubicles. The connection between the injuries was so obvious that it seemed almost discourteous to mention it. The warder had told me he’d been interrogating the prisoner about a disturbance and had his hands over the back of a chair, when the prisoner had kicked a desk that slid across the floor and made a bull’s-eye collision with his knuckles. “Is there any other way you can get a fracture like this?” he had asked me, nervously.

  “No,” I’d said firmly. “It’s called a boxer’s fracture. It happens when you punch something harder than the bones of your fist – or someone.”

  The blood wells up more slowly now, so I pull back the dish towel and peep underneath. There is a long gouge in his forearm extending onto the wrist, as if he’d been mauled by a lion. And within the wound lie his muscles and tendons, glistening.

  The nurses had already ordered an X-ray, and from looking at it I know that there is a sickle-shaped spicule of glass embedded somewhere in the wound. I elevate the skin around that wound now, dabbing with gauze and looking for the piece of glass. At last I find it, by touch rather than by sight, marbled with strings of clotting blood and tearing into the tissues like a poisoned thorn. I hold up the shard to the strip light and then walk over to the light box where the X-ray images are displayed. The bones of the forearm – the radius and ulna – are outlined in ghostly elegance as if etched on glass. I can see that his fifth metacarpal, the bone that supports the little finger within the heel of the hand, is fractured but not so badly that I’ll have to twist it straight. I hold the shard up to the sickle-shaped opacity on the light box and find that the two shapes match one another completely.

  “Good news,” I tell Adrianson. “There are no more bits of glass.”

  I sit down at the side of his gurney, and look down on the muscles of his forearm as they gather toward the wrist. The tendons of the superficial finger flexors glint in the light: the thick bands of collagen are like the quills of a feather, but in place of the barbs and vanes of a feather are fleshy chevrons of muscle. I ask him to flex his fingers, and marvel at the sight of the muscles bunching – the extraordinary intricacy of the pulley systems that control the fingers. How mechanical we are. The tendons are all intact; he can grip my fingers as strongly on the left as on the right, and I can’t see any nicks in the surface of the tendons as they move in and out of view.

  “When can I go home?” he asks.

  “Just as soon as I’ve stitched these wounds and strapped up your broken finger.”

  As a doctor, I talk all day, taking histories and giving explanations. Sometimes I get to the end of a shift or a clinic and feel
the need to be silent for hours, just to restore a balance. The verbal process of diagnosis works through sieves of possibilities, question and answer, weighing and measuring the patient’s responses and deciding when to question further, and when to move on. It’s a skill that takes years to develop: a medical history can take a student an hour, but as a GP or hospital consultant we have to try to make a decision within minutes. Practical tasks like stitching wounds or putting plaster of Paris on a broken limb offer a rare opportunity to spend time talking with a patient without that urgency, without directing the conversation toward a goal. There’s a deep pleasure in performing a skill that’s purely technical, with little of the intellect involved. Stitching is a technique, and like all techniques it can be done well or it can be done badly. Doing it well requires a level of focus that comes as a relief after the constant distractions of the emergency room floor.

  I set up a sterile tray of instruments and suture thread, syringes of local anesthetic, swab out his wounds again with antiseptic, and begin to stitch. He might need thirty or forty sutures, so this could take a while.

  In the emergency room I’ve never seen someone die from slashing open the arteries of the wrist – generally they don’t bleed enough to risk death. The only person I’ve seen die after slashing her radial artery had also taken a knife to her own throat, and managed to cut her carotids as well. Arteries are only two or three millimeters wide at the wrist, and when they’re sliced open they often close themselves off as if in self-defense. But I have seen hundreds who scratch and cut their wrists not necessarily through a desire to die, but in an attempt to relieve extreme personal anguish, and demonstrate their rejection of the life they’re obliged to live.