There is a certain moral simplicity to medicine: a person with a set of skills helps another who is suffering. In contrast, in war men inflict suffering on each other. War and medicine, though both ancient practices, are odd bedfellows reflecting opposing facets of humanity. Few people have experienced these facets as closely as David Nott, a trauma surgeon who has worked in war zones from Afghanistan to Yemen.

His book, War Doctor, is not for the faint hearted. It is a repository of unimaginable horror, of flesh and limbs torn by barrel bombs and bullets, of young girls raped and families decimated by missiles and shrapnel, of pregnant women and unborn children murdered by snipers. In a chapter on his time in Aleppo, Syria, Nott describes seeing a 5-year-old boy, lying face down on a hospital trolley, with ‘both his buttocks and the backs of his thighs…completely blown off’ and ‘bits of what appeared to be cobwebs of tissue and dust and fragments of wire coming out of his wounds.’ The nurses turned him over: ‘he was still alive, but was completely silent as he gazed around the room. On his face and hair were blobs of grey-white tissue I could not identify. One of the nurses pulled his hair back from his face and started to comb it gently with her fingers.  That was all we could do for him; we had run out of morphine.’

It is in this hell that Nott and his medical colleagues sought to offer whatever medical assistance they could, limited as they were by drugs, blood, equipment, facilities, and staff. By 2013, 95% of the doctors in Aleppo had left the city. 

The threat of a violent death was not restricted to combatants and the local civilians.  It was also palpable for the medical staff. Nott describes in chilling detail his own brushes with death, from bullets that missed by inches to narrow escapes at checkpoints manned by ISIS or trigger-happy child soldiers.  He treated the severely injured brother of a furious ISIS commander, who peered over him with a gang of armed men, waiting to see if his brother survived. He operated on a 7-year old girl with blast injuries despite an instruction to evacuate the hospital immediately due to an impending attack on the hospital.  Nott, at that time unmarried and with no dependents, stayed behind to complete the operation with an anaesthetist in an eerily silent hospital. He operated, waiting for the shells that never came: ‘In the grand scheme of things, it didn’t much matter whether I lived or died.’  

Eager to impart his knowledge with others, Nott created the David Nott Foundation, a charity that finances and trains clinicians for work in disaster situations.  In the final part of the book, Nott recounts his gargantuan and ultimately successful efforts to allow the safe passage of civilians out of Aleppo, no doubt saving many more lives.

War Doctor documents Nott’s war against the wounds of his patients, his battle to stay alive amidst the barbarism and lawlessness of war zones, but also his internal struggle to make sense of why such horrors occur.  Sadly, the book does not address how Nott reconciles his Christian faith, referred to several times in the book, with a lived experience that few, thankfully, will ever share.

The endless waves of catastrophically injured patients, the long hours at the operating table with little sleep, and the constant threat of death eventually took a toll on Nott, who suffered from a mental breakdown on his return to London in 2014.  With the help of a psychiatrist and the support of his wife, Elly, he recovered and returned to his humanitarian work.

War Doctor may not have the same poetic quality as Jonathan Kaplan’s Dressing Station or Contact Wounds, but it is a haunting, disturbing, and uplifting addition to the genre.

Daniel Sokol is a medical ethicist and author of ‘Tough Choices: Stories from the Front Line of Medical Ethics’ (2018).  He has provided ethics training to the military doctors of the Defence Medical Services and published on the ethics of disaster medicine.

 

Daniel Sokol is a medical ethicist and author of “Tough Choices: Stories from the Front Line of Medical Ethics” (Book Guild, 2018).

Competing interests: None declared.