by Iain Overton
All in all, getting shot is a terrible lottery. The odds might be in your favour, but it’s one bet never worth taking. Thank God, then, for doctors.
In a closed room behind a steel-barred door the medic and I sat and talked. The room was lit with an ugly sterility, the overhead lights gave off a low buzz, and all around was chrome and glass, instruments wrapped in stark, sterile packages. A bleach-white smell clung to this place. For two years, Dr Taylor, a petite and vivacious young woman, had been the head of the trauma unit here in this rising, brick-built oasis of South African care: Tygerberg Hospital.
Tygerberg. It sounded like the tiredness and despair that had long ago infected the slums surrounding this place. Each month up to 2,000 patients passed into Dr Taylor’s world, fresh from the poverty of the Cape Town flats. And what she saw, endlessly, was the trauma wounds of penetration – gunshots and gunshots and gunshots.
‘In the past we got stab wounds, but now it’s gun wounds. It’s all to do with drug crimes and gangsters.’
She was thirty-four. One of those bright young doctors whose sparkle gives you faith in this world, one who had always wanted this sort of work. She was from South Africa’s Free State and had that matter-of-fact way about her that defines people. But these gunshots, this was new to her. Back home, back in Bloemfontein, a place of long pastoral lands and the languid time of rural life, it was all stab wounds and car accidents. Not like here in the Cape Flats.
We were in the controlled section of the hospital. Only the staff and the dying and those clinging to life went back here: an unseen world the gun helped create. A world of sterile swabbed pain. We had walked through clanging doors and down long lines of scuffed corridors that glowed in the off-white light and turned into a windowless room. There we sat at a metal desk surrounded by blood pressure gauges and ventilators, IV lines and machines whose purpose you didn’t want to know. Drugs lay in quick-grasp handfuls in cabinets that hung upon the scrubbed walls. Adrenaline, Etomidate, Furosemide, Atropine – alien and painful-sounding words. There were ugly things that caused pain. Scissors. Scalpels. Large-bore catheter needles, sixteen gauge. They spoke of one thing: that the pain caused by guns does not end with the pulling of the trigger. That’s just the start.
Her patient population was predominantly, almost exclusively, young black and coloured men. And the gunshot wounds were predominantly low-velocity and multiple. No AK47 rounds here; rather, small handguns and bang, bang, bang. People getting shot four, five times even.
‘One guy was shot thirty times,’ she said. ‘Mostly flesh wounds, but he survived.’ She tapped the desk. She was frustrated with the lack of resources. She wanted to help so badly, but things were never just about desire here. ‘In the US you have full body scans. Full diagnostics, all on hand for you there. All in fifteen minutes. But here – we see so much violence and we’ve only just got an ultrasound.’
Computerised tomography scans and X-rays here can take twenty-four hours to get back, and this made for hard decisions. The other day a patient came in – shot in the abdomen. They put forty units of blood and blood products back into him, but by then he had suffered renal failure, so he went on a ventilator and then into an intensive care unit for four weeks. This meant others were refused intensive care, there just weren’t enough beds – and by others she meant children with acute appendicitis or cancer. One life saved here, even if it’s the life of a killer, means another life lost.
This is the stark reality of trauma surgery in a land of scarce resources. The ratio of public doctors to patients can be as low as 3 for every 100,000 in the South African health system.11 Such state medics care for about 85 per cent of the nation’s trauma cases and these men and women in white clearly don’t have enough resources to cope.
The gun has hardened her, she said. No longer does she want to be told about the background of her patients. ‘I am not interested in knowing anything more than that they were shot. I don’t need to know that one guy, a guy we’ve spent a long time helping and given lots of resources to, that he then brags about how many women he has raped. That’s too hard to hear. I don’t want to know, because, you know, lots of them have raped and killed.’
Her voice slipped a little in the white room. I noticed an edge of anger. I suspected that she, her heart so full of care, couldn’t comprehend how others did not feel the same desire to change matters, to help. But the thing she found the hardest was that those whose lives were marked by violence – the gangsters, the young thugs – often survived the terrible wounds caused by guns. It was the passer-by – the innocent caught in the crossfire who never expected this – who died with a look of surprise on their face, unprepared for the sudden descent. That bothered her.
She had seen a change in her personality. Now she is more clinical, dispassionate. ‘Don’t come and cry on me.’ This was what this brave doctor said to people. And she looked a little guilty at what this had done to her relationship with her patient boyfriend, an engineer and a man who never had to hold a dying teenager or an infant with a gaping gun wound in his back. Other things slip, too. After days of bloody surgery, everyday chores like tax forms and bill payments and driving licence renewals just fade out. Death captures her attention like a demanding child.
‘There are days when nothing happens. Then a whole number of gun-trauma victims come in at the same time. It’s 0 per cent to 100 per cent. In those days when nothing is happening, you pace the corridors; you get bored. You find yourself only functioning when something happens – when you are on adrenaline,’ she said.
She had been soaked in blood, head to toe, several times in the last year alone. So I asked her about HIV in this land where about 10 per cent of the population are infected, and her answer was as brutally logical as her other answers. She didn’t think about it – she took the necessary precautions with double gloves and all the rest. But it’s not possible to avoid blood. If there was cause for concern, she would take antiretroviral drugs and to hell with it.
‘They aren’t good. They make you tired, give you diarrhoea. You vomit. So you ask yourself – what are the chances of getting an infection? You treat all patients with caution but you can’t discriminate.’
Blood was nothing to her. But, then again, she couldn’t watch horror films. She was scared of the dark.
I ask about what would be the worst type of gunshot, and she was quick with her answer. ‘The head. If the head is involved and the bullet has gone through – well, it’s a very poor prognosis. If vasculature is involved, if you get shot in the neck, chest, abdomen and it is close to a vessel – all of these have poor outcomes.’
‘In fact,’ she said, ‘we don’t get to see a lot of large vessel abdominal injuries because those shot there just die.’
If you are shot in the limbs, she went on, you can get devastating trauma to nerves, or you get complex fractures, and then young men lose their legs. But what is most horrific is a spinal injury: C3 fractures, quadriplegics, tetraplegics. They end up in care homes and lie there, and no one turns them. No one cares for them, until their own foreshortened death.
She descended into talking about sepsis and perianal wounds and genital trauma. But her mind drifted back to those she felt most powerless about. It was the bleeders that stuck in her mind, those shot in the portal vein, the retrohepatic inferior vena cava, the aorta. They die there on the table, and you ask yourself: ‘Did I do the best I could?’ Holding these nameless men as they slip into unconsciousness and beyond has meant she has begun to take sleeping tablets to help her sleep. Or she turns off her phone and goes for a run and just, well, just tries to live a life of the living.
‘In the end,’ she said, patient and calm and answering my questions as best she could, ‘you really just want people to survive.’
The man’s face had the look of wax; his eyes were glazed and unfocused. He had sustained a vicious beating, and it was unlikely he would survive the night. His leg moved in small, grotesque, primal jerks. The man beside h
im was breathing in short, sharp gasps. That one making urgent noises with a bloody drip coiled up and away from his chest had been stabbed with a screwdriver.
The night after my conversation with Dr Taylor, I had driven back through the streets of Cape Town, through patches of contained light cast upon the empty dark roads, to witness what a weekend night brought to this hospital. To see people on the edge of surviving and to see which way they’d fall.
On this midnight watch, the waiting area outside Tygerburg’s trauma unit was filling up. A small boy lay silent, supine in his mother’s arms. His thumb had been ripped off, and the nurse was telling the mother they would not be able to save it. Later, the mother was to ask me if I was able to help him, because I was white and she assumed I was a doctor.
The paint was coming off the ochre walls in thick strips around the four ugly hooks that hung there. They were for saline drips; the numbers of wounded here was so great that no space was left inside the unit.
A sixteen-year-old walked over and sat next to me. He had been stabbed in the neck over a 100 rand payment – about $10. His mother sat opposite. It was the first time he had been stabbed, and he laughed when I asked him what he was going to do about it.
‘Payback,’ said another man. The boy with the ripped thumb drifted to sleep.
A consulting doctor came over and talked to the boy and then turned to me. This young medic had been here ten hours already, and he’d seen things, he said. Like when a man had come in with six bullet wounds in his knee, and when they raised his thigh to get a look, the rest of his leg had just stayed on the table. Or the one who had had the top of his head cut off with a buzz saw.
He led me to the doctor’s area – a quiet room at the back behind a scuffed door and away from the noise of those in pain. Inside were other doctors, huddled in close, like fishermen sheltering from a storm. One was from Switzerland: a handsome man who had travelled to over eighty countries and whose girlfriend, who once skied professionally, was also a doctor here. They were an impossibly attractive couple in this ugly place. His words tumbled out; in trauma units time is of the essence, and there is no space for languid talk.
If you are a trauma surgeon, you don’t want to work in a quiet hospital, he said. So, you come here to see what guns can do, for there are few other places like this in the world. Doctors like him come from Holland, Sweden, the US, the UK. Some have never seen such penetrating trauma. An eighteen-month-old hit in the crossfire. A mother raped and shot as her two-year-old played beside her. These doctors had learned much. Like how to drain a heart with just a needle, or perform three laparotomies in a row, or hold a dying man so he did not go into the darkness alone.
‘Without a doubt,’ another said, a big man in a white coat and a solid voice, ‘South Africa is a violent nation. It’s like a civil war. I’ve spoken to guys in Iraq and it’s like this here on a Saturday night.’
Then an emergency call came in, and they solemnly filed out, back into corridors swathed in dull electric light.
I was left alone, and I thought how the gun had transformed these medics. How it made them stronger surgeons, more confident, more able. The harm that firearms wreak had caused them to develop skills and tools to bring people back from the edges of life. And they, unlike the men and women I had seen in the morgues of Central America, could offer hope in a landscape of despair and death.
A pile of papers lay to one side, and I picked one up – a medical magazine, Trauma. Its reports were revealing.
Initial surgical management of a gunshot wound to the lower face.
Non-operative management of abdominal gunshot wounds.
The European Trauma Course: Using experience to refine an educational initiative.
The last title showed just how much the trauma community is tied together by a singular response. Bearing witness to horror, they must learn from it. And this impulse to learn has transformed the course of medical history. For without learning from the history of the screams of men like the ones who lay shot outside this room, the gun truly would have won. Else it would have only taken and not given back a single thing.
War and violence have been the engines of creativity for many things that we take for granted. A material called Cellucotton, for instance, first used in the First World War to patch up gun wounds, was so absorbent that it caught the nurses’ eyes, and the sanitary towel was invented. The Great War also saw the creation of, or at least popularised, the tea bag, the wristwatch, the zip and stainless steel. But war, most pointedly, has been a constant driver of medicine.
As guns have evolved through the centuries, so too have medical responses to the injuries sustained from them. And the injuries have been terrible. In the fourteenth century, gunpowder’s arrival onto the battlefield made the treatment of trauma wounds far more complex. No longer the splice of a sword or the pierce of an arrow. Rather, embedded bullets, gunpowder burns and gaping holes in flesh changed forever the nature of wounds.
The early modern doctor was ill equipped to deal with such complex trauma. For a time gunpowder’s ability to take life so easily was even put down to the belief it was poisonous and that bullets were contaminants. This led to the medieval practice of burning the wound to rid the body of poison.12 Of course, such treatment probably took more lives than it saved, but it was not until the mid sixteenth century, when the French military surgeon Ambroise Paré, in the thick of battle, ran short of hot oil to cauterise wounds, that anyone challenged this practice and, more importantly, wrote about it. Paré improvised: egg yolk, rose oil and turpentine were used instead, and the benefits were marked. Many more survived under his care.13 But innovation takes time to find roots, and the technique of pouring boiling oil into wounds continued for another 200 years.
Bloody death after bloody death, though, has a horror that cannot be ignored, and the impulse for doctors to learn and to understand remained. Clearly much of that was by trial and error. So the American War of Independence in 1775 saw the surgeon John Hunter suggesting that, if a gunshot wound was to be sewn up, a piece of onion was best put inside, and then the wound reopened after two days. But during the Crimean War in the 1850s, a connection between mortality rates and sanitation was to become firmly established. There Florence Nightingale ‘was to thoroughly scrub the hospital, provide clean bedding, improve ventilation and sewage disposal’, with notable impact on patient mortality – it dropped almost immediately from 52 per cent to 20 per cent.14 This vicious war also saw the widespread use of chloroform to alleviate pain, and plaster of Paris to treat bones shattered by grapeshot.
But, just when it was thought medical discovery was catching up with weapons technology, the Minié ball came along. The round balls used before this tended to remain lodged in the flesh and muscle. The Minié ball, on the other hand, cut straight through, leaving a gaping, haemorrhaging exit wound; the metal rarely remained in the body. If a Minié ball was to strike your bone, it often caused it to shatter, causing damage severe enough to require amputation. It turned mass infantry assaults into mass slaughter.15 Fatality rates shot up; penetrating gunshot wounds to the abdomen reached a mortality rate of 87 per cent. There were over 50,000 amputations in the American Civil War, and infections followed, the spectre of death hard on their tail.16 Tetanus had a mortality rate of 89 per cent and pyaemia, a type of septicaemia, killed 97 per cent of those who developed it.17
So devastating were these odds that, by the Spanish-American War of 1898, the medical profession recognised the urgent need for antisepsis. After reading findings by Louis Pasteur, Joseph Lister carried out experiments using carbolic acid and found it helped massively reduce the patient’s chances of dying if applied following amputations.18 Antiseptic dressings on the battlefield and saline solutions to hydrate patients were also brought into play – innovations conceived on the bloody, ragged fields of war.
Roentgen’s discovery of the X-ray in 1895 further revolutionised trauma medicine. In previous wars, unwashed fingers and metal probes wer
e shoved into screaming men to locate bullets and metal shards. Lost pieces of cloth could be lethally dangerous, suppurating and causing gangrene to topple a man, but the use of X-rays in the field helped pinpoint fabric, bullets and bone fragments. The need for amputation and the subsequent risk of infection were greatly reduced – so much so that what happened to the mortality rates of the US wounded in the Spanish-American War was nothing short of revolutionary: 95 per cent of wounded men recovered.19 It was a far cry from the carnage that had defined the American Civil or Crimean Wars.
Then came the First World War. Those fixed lines of carnage brought their own rat- and slime-filled horror, but they also meant that those who were not caught dying upon rusting barbed wire had a fighting chance of survival. The rapid evacuation of casualties from the front line massively improved a wounded soldier’s chances of living. There was a mortality rate of 10 per cent if those hurt were casevaced within the hour. If you were out in no man’s land for eight hours, your chances of death rose to 75 per cent.20 The Great War also saw the wide-scale use of the tetanus antitoxin, and deaths from lockjaw dropped from 9 per 1,000 wounded to 1.4 per 1,000.21 But perhaps the most significant medical innovation was the first blood bank, established by Captain Oswald Robertson in 1917.22
The Second World War added to this: the development of blood banks continued through the early 1940s, as well as the rapid evacuation of the wounded and the production of penicillin on an industrial scale.23
By the time the Korean War began, things had improved beyond recognition. Casualties were being evacuated by helicopter, and plastic bags had been introduced to replace the glass bottles used to transport blood for transfusions. The conflict also saw the development of mobile army surgical hospital (MASH) units, which brought surgeons to the front lines. They were literally life-changing. A wounded soldier who arrived at a MASH unit had a 97 per cent chance of survival.24
