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 were 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
