The War Surgeon
Dr Jonathan Kaplan on hacking off skin with razor blades, dealing with horrific flashbacks, and sticking his hands in people’s guts…
Who actually employs you?
I’ve worked in my time for five international humanitarian agencies. It’s a fairly loose arrangement, I get contacted if there’s a situation developing that needs the sort of medical cover that I can provide. It’s voluntary work, but on the occasions that I’ve been offered a salary, I’ve generally given that salary back to the agency I’ve been working for.
When you’re on the frontline, will the enemy genuinely try not to shoot you because you’re a medic?
When I first started doing this sort of work, back in 1991 in the Kurdish uprising at the end of the first Gulf War, there was a general feeling that medical workers would not be shot at (or at least targeted). However, the most recent war I’ve been involved in was in Baghdad in 2003 and things have changed dramatically. It’s quite possible that you’ll become a target. Oddly enough, my real fear was being shot by American troops and not Iraqi insurgents.
How many limbs have you removed in one day?
It’s difficult to be sure because things become overlaid one on top of another when you’re dealing with lots of casualties. But in Angola I’ve probably done six amputations in one day – that’s because of landmines. It all depends where you are. In Eritrea, I spent all day opening chests and abdomens.
What’s been your most difficult operation?
I was working in Angola in a town that was besieged by the rebels. My first patient was a woman who was anemic – everyone’s anemic there because of malnutrition – she had a fever from malaria – everyone has malaria there too, mind you – she also was eight months’ pregnant and had been caught in an ambush. A bullet had caught her in the back of the neck and blown out her right eye. I don’t have a lot of experience in facial surgery but she clearly needed help, so we took her up to the operating theatre where the anaesthetist gave her some anaesthetic and she promptly stopped breathing. In that situation you put a face mask on the patient and pump oxygen into them. Trouble is, because the shotgun wound had broken the bone between the eye socket and her nose, the air was just bubbling up through the bloody hole where her eye should have been. She survived though and a couple of weeks later her baby was born.
What was your first job in the field?
The first war I was ever in was Kurdistan and I was separated from the rest of the group. Alone, I found my way to the Iraqi/Turkish border and walked over a ridge and found myself in a refugee camp for perhaps 100,000 Kurds who were squatting in these muddy, snow-filled ravines and dying of exposure, dysentery and altitude sickness. The first thing I had to do was walk through and not tell anyone that I was a doctor because I had no materials or equipment, I was all alone and there was nothing I could have done. It was very very upsetting.
Is it like on M*A*S*H where you’re in tents with music on in the background, and bombs falling outside?
It varies enormously. In Northern Iraq I was in tent hospitals – with no music or anything, just helicopters passing over every now and then – the operating table would be a stretcher on top of some ammunition boxes out in the open between the tents. In Baghdad I’ve worked in hospitals that were once been the most advanced medical services in the middle east, but are now worse than any tent hospitals – the floor would be 6-8 inches deep with old dressings and discarded surgeons’ gloves, there was no water, it absolutely stank and it was better to operate outside. We’d sterilise the equipment on a fire made of bashed up ammunition boxes.
What sort of makeshift tools have you used on the job?
There are several specific examples, but for instance, when I was working in Burma, in an area that was under attack by the Burmese army, I ended up treating young soldiers that belonged to the local warlord. One of the big problems there was jungle ulcers, which would cause the loss of a large area of skin, and become chronically infected. I converted a shaving razor into a skin graft knife so that I could take patches of skin from other parts of the body to cover the ulcers and allow them to heal.
What do you say to people you know will die? "You'll be OK!" etc?
It’s a very very difficult situation. They may be in such a degree of physical shock (in other words their blood pressure is so low because they’ve lost a lot of blood), they may have breathing difficulties or head injuries, they’ll be confused. It’s hard to communicate with people when they’re in that situation – lucid conversation is seldom an option. We give them pain relief, oxygen and basic life support.
Ever been tempted to get stuck into the morphine yourself?
No, I’m saving that for when it’s really necessary.
Do any armies have trademark ways of killing?
Well, sort of. In South Africa there were lots of knife wounds and shotgun wounds because the police tended to use shotguns. In war zones it’s mainly high velocity rifle wounds and fragmentation wounds from mortars or shells. In Angola, landmines are a big problem because they also blow a lot of earth up into the wound causing lots of contamination and tissue damage. That’s a very destructive type of injury.
What’s easiest to deal with, a gunshot wound, a knife wound or a severe burn?
Knife wounds are the easiest because the injury is confined to the line of the blade. Gunshot wounds are horrific because they cause a huge build up of pressure inside the tissues, they make a cavity and shockwaves can travel up the bones to create further injuries, and when that cavity collapses again there’s more injury – because it sucks air and dirt into the wound which causes contamination. Burns depend on the area and the extent of the damage. They can cause long term damage and may need repeated surgery.
Ever done an operation pissed?
Believe me, there have been times when it seemed like a wonderful idea, but no.
What’s the most gruesome tropical illness you’ve ever come across?
A lot of the places where I’ve worked have had a lot of endemic tropical illnesses – in Mozambique and Angola so many people had malaria it was almost normal. In Zululand one of the problems was that people had huge numbers of long worms in their guts. That would make operating on stab wounds quite difficult because when you opened them up, all the worms would migrate to the stab wound in the intestines and be making their way around the abdominal cavity. That was quite horrific.
Ever seen a scene so horrific it's hard to work out which bits to sew back onto whom?
No, the difficulty is when people come in with lots of holes in them. It’s hard to know where to start – people who’ve been injured in the abdomen but need their chest opened first, or people who’ve got a bullet wound in the groin but have an exit wound in the shoulder. It’s quite often the situation. You’ve got to make a judgement to make the best use of your time.
What's the worst weapon we use?
The worst injuries I’ve seen have been from napalm or cluster bombs. Cluster bombs have lots of very very fine razor-like fragments that are very difficult to treat because people come in full of holes.
Are you afraid of death?
I’m not scared of being dead, but there are certain ways of dying that I wouldn’t choose. I wouldn’t like to die of rabies. It’s a horrific way to die that involves violent convulsions and tremendous difficulty breathing – there’s no treatment, it’s terrifying to see.
Ever treated someone who you thought deserved to die?
I’ve undoubtedly treated people who have been guilty of atrocities, but that’s not a moral dilemma that any doctor has to make. When you have a patient in front of you, you have to treat them and their injuries to the best of your ability. That’s as far as it goes.
Does it piss you off when you’ve worked your nuts off on someone and they still die?
It’s always distressing, but not because of the amount of work you put in. It’s because you form very intense relationships with people – the most intense relationship you can have with another human being is when you have your hand inside their guts. If they die, the hopes you had have been dashed and that stays with you.
Presumable in crappy field hospitals, they're dirtier than back home. Does dirt actually not matter that much - are we here in the UK all a bunch of weeds?
No not at all, hygiene over here in NHS hospitals needs to be improved significantly we’ve got a real problem with infection. The level of visible dirt over here in hospitals is pretty shocking.
Have you ever given patients booze to ease the pain like in the films?
I might do that, but not to ease the pain. It would be to make them too confused to resist the saw coming to their leg or something like that.
Is it easy or hard for a man to die? Are we surprisingly resilient?
It varies. From the physiological point of view, doctors know when the survival systems stop working – when a certain amount of blood is lost or when a certain degree of blood pressure is reached. However, the Zulus, for example, are extremely resilient, they’re as tough as nails. They come back from the most horrific injuries. The distressing thing is that children die so easily. They accept things unquestioningly in the way that adults don’t. They don’t know that you’re supposed to fight death. They just quietly slip away and accept their fate.
Who’s the bravest man you’ve met?
The bravest people I’ve ever met were my Iraqi doctor colleagues. They were looking after these neighbourhood GP clinics and when law and order broke down and the looting started, these doctors would stand there shouting at people trying to shame them into not stealing the drugs and the provisions. Then they started being killed or receiving death threats because they were considered to be collaborators. Or they’d run the risk of being shot by the Americans because their cars used to have ‘ministry of health’ written on the side in what some Americans called ‘Islamic writing’.
Ever get flashbacks?
The first time it happened was when I came back from Kurdistan. I started finding that I’d walk into the local shop and I’d be talking to this guy and I’d recognise him as someone I’d operated on. It was clearly him in my mind, but I was having hallucinations. Or after I came back from Eritrea when I was living under the flightpath for Heathrow, I’d suddenly find myself throwing myself under the sofa because I’d heard a plane that had the same engine note as a bomber.
Is there anywhere in the world you won’t go?
At the moment, the idea of going back to Iraq terrifies me. I think it’s almost impossible to work there as a humanitarian worker. There are also areas of the Ivory Coast where it’s very dangerous right now because they’ll target Westerners thinking they’re all French – the French military have been involved in the current unrest over there.
War, what is it good for?
Well, war is bad in every regard. But if somebody said to me we could banish all war and it would never happen again, I’d hesitate a moment. Because some of the most intense experiences I’ve ever had, some of the most worthwhile as well as the most damaging experiences have been inside war zones.
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