‘You carry on because you’re saving somebody else’s life’

British surgeon David Nott has spent two decades operating on thousands of people in war zones, making life and death decisions under fire. Now he hopes to pass his hard-earned skills on to a small army of frontline volunteers

There’s a simple reason why I keep going back: I feel sorry for those who are caught up in conflict. Everyone needs access to healthcare, and I try to be the person to provide it.

I first volunteered in the besieged city of Sarajevo, Bosnia, in 1993 after seeing TV coverage of the conflict. What happened to me there changed my life. I’ve worked in conflict and catastrophe zones ever since: from Liberia and Darfur, to Haiti, Syria and Yemen.

In places wracked by war or natural disaster, there are few surgical provisions. There are limited blood supplies, few drugs and no diagnostic aids to speak of, so you rely on your medical skill. Yet, in war, most of the senior surgeons will have fled and it is the junior medics who are left behind. They may know basic surgical techniques, but they are faced with the most difficult wounds imaginable, from gunshots, snipers, IEDs and mines.

I take part in up to three missions a year with organisations such as Syria Relief, Médecins Sans Frontières (MSF) and the International Committee of the Red Cross (ICRC). I go for three weeks at most if it is a really hot war zone; six weeks if the frontline is further away.

If there are no casualties from the night before, my day starts around 7am, with a security briefing at 7.30am. I take an hour to visit patients and from 9am there are either new patients to see in the clinic or, if there are casualties in the emergency room, I begin operating. I can be doing that all day and sometimes all night. At my longest stretch, I operated for 22 hours. You forget the time, although you’re absolutely worn out. You carry on because you’re saving somebody else’s life – and then somebody else and somebody else. You sleep where and when you can.

"In war zones, you have to hope you will be among the lucky ones who come back"In quieter periods, I teach. In Syria, for example, there are lots of junior surgeons who are not particularly well trained. They accompany me in the operating room and we do the surgery together. I show them first, and then they pick up the knife, scissors and forceps. Speed and accuracy are very important. I teach techniques to limit blood loss, and quick procedures. You get very engrossed in surgery – even though you are in a war zone, your mind is utterly focused on the job at hand.

War surgery is all to do with decision-making. There isn’t enough time or resources to treat everyone. You need the insight to see what the problem is and how you could treat it. But you also need foresight; to think ahead to after the operation – is there an intensive care unit? Is the patient going to have chest problems as a result? If there are likely to be post-operative complications, then the right thing is not to start at all. You need to preserve blood and provisions for people with injuries you can possibly save.

You have to be unemotional. If you become emotional you can’t make rational decisions. But sometimes it is impossible, such as when a child comes in very badly blown up and there is nothing you can do.

In war zones, you just have to hope you will be among the lucky ones who come back. So far, I’ve been that person. Five of my colleagues in Aleppo were killed going from hospital to hospital. You must always have your wits about you and be extremely neutral.

While in Aleppo, a group of ISIS fighters came into surgery with their Kalashnikovs and surrounded the table as I was operating on one of their group who had a gunshot wound to the chest. It was very tense. I just had to try and ignore them and continue. You are a humanitarian surgeon there to save lives – not to be political or pass judgement.

Sometimes the difficulties are more prosaic, such as getting sick yourself. If you need to go to the toilet every 20 minutes while trying to operate that is very challenging; never mind the bombs in the distance.

"People put their hands up for humanitarian work but few do it where it is needed most – on the frontline"In 2014, I treated a 4-year-old boy injured by a barrel bomb in Aleppo. It took out all the blood vessels in his lower leg and foot. It would have been easy to amputate, but all the surgeons got together and I showed them how to take a vein from one leg, make it into an artery and put it into the damaged leg, and then cover it with a plastic surgical skin flap. It was a very difficult operation. But we saved his leg and he was walking in two months. The Syrian surgeons sent me a Whatsapp picture of him playing football – what a fantastic feeling.

The idea for the foundation came in 2011, when I was in Libya. The surgeons were struggling to manage the very severe injuries that came in, so I held lectures and courses, and this gave rise to the idea of training surgeons for the frontline. The David Nott Foundation launched in February. We offer a course three times a year at the UK’s Royal College of Surgeons, and around 30 surgeons from all over the world attend to learn 50 operations they will need in war or disaster situations. Most volunteer with MSF and ICRC. The course costs £2,000 (about $2,640) and the foundation aims to pay for those who can’t afford it.

I also run a three-day satellite course that takes the training to local surgeons. The course is free for participants, but costs the foundation anything from £20,000 to £75,000 to run, depending on the location. In April, we ran one in Gaziantep, Turkey, for 30 Syrian surgeons. Yemen and Jordan are planned for later this year.

People put their hands up for humanitarian work but few do it where it is needed most – on the frontlines. It is the local doctors and surgeons who are left to manage. I hope to help them.

Photo credit: Philanthropy Age/ Jason Dutch