Category Archives: Medical

Arts, Books, Medical, Society, Syria

Book Review – War Doctor: Surgery On The Front Line

MEMOIR

Syria, 2012 – Location: Atmeh. A woman was rushed to the operating theatre with severe bomb damage to her leg.

Dr David Nott, a trauma surgeon, clamped the artery to prevent her from bleeding to death and gently pressed a finger into the gaping hole above her knee joint. He felt an object. It was probably some kind of shrapnel, but it was strangely smooth and cylindrical.

Dr Nott grabbed it with his fingers – “very carefully”, he recalls – and pulled it out. Once extracted he held it up to examine it. His Syrian helper took one look and went visibly pale; he obviously knew what was being presented and blurted out, “Mufajir!” before turning tail and leaving the room.

Nott and the anaesthetist locked eyes in panic. Was this some kind of bomb? The room fell silent, bar the hiss of the patient’s ventilator. The anaesthetist backed away and Nott felt his hand begin to shake so vigorously, he was in danger of dropping the thing.

Then the Syrian helper rushed back in with a bucket of water and motioned for Nott to place the metal object carefully into the bottom of it. He later learned that “mufajir” means “detonator” and it could have blown off his hand.

The woman was injured when a bomb her husband had been making in their kitchen had prematurely detonated, killing him instantly.

You can sense Dr Nott’s frustration and anger at the speed with which the Syrian civil war escalated. It had begun in March 2011, when a peaceful protest against the oppressive regime of Bashar al-Assad was met with shocking brutality.

By chance, Nott had met al-Assad in the early 1990s, when the dictator-in-waiting was working as an ophthalmic senior house officer at the Western Eye Hospital, London.

“He seemed very pleasant and respectful,” recalls the surgeon who would later treat Assad’s victims, including a heavily pregnant woman whose unborn child had been shot through the head by a sniper.

In his devastating memoir of more than two decades volunteering his services in some of the world’s most dangerous places, Nott doesn’t speculate on what changed al-Assad’s attitude to his fellow human beings.

He does, however, pinpoint the precise moment that a shy boy from rural Wales realised he wanted to become a “war doctor”, his epiphany occurring in 1985 when he first qualified as a surgeon. His parents took him to the cinema to see The Killing Fields (Roland Joffe’s 1984 drama about the civil war in Cambodia).

Nott’s father, also a doctor, was born in Burma and Nott had endured racist bullying as a child.

“The film lit a torch in me,” he says. “I could relate to its themes of innocent people being bullied, pushed around or dismissed. It gave a vivid depiction of the horrors of war. But, more than that, the film depicted the incredible power of human love in the face of unimaginable adversity.”

Some eight years later, Nott was standing over an operating table in Sarajevo. He had taken a month’s unpaid leave from the NHS to volunteer for the French aid organisation Médecins Sans Frontieres. The Bosnian civil war opened his eyes to a new medicine, in which decisions had to be made quickly, without the diagnostic tests and specialist equipment on which he had come to depend.

“I had never seen injuries like the ones that were coming in every hour.”

 

THE damage inflicted by bombs and high-velocity bullets was of an entirely different order from those received in even the most catastrophic trauma car accidents.

Multiple limbs were often missing. Many patients were dead on arrival, accompanied by relatives begging for help that Nott could not provide.

When he could attempt surgery, the hospital generators would often fail, and the team would have to wait until a porter brought in a wheelbarrow full of car batteries to get the theatre functioning again.

When bombs fell on the hospital itself, Nott’s team fled, leaving him alone in the dark, his hands around the failing heart of a teenage boy.

Stumbling from the room, soaked in his patient’s blood, Nott felt angry and betrayed. But he soon learned that, as an aid worker, his first duty was to keep himself alive so that he could help more people.

It was the first of many difficult moral choices he would have to make in Afghanistan, Sierra Leone, Chad, the Ivory Coast, Libya, Gaza, the Democratic Republic of Congo, Iraq and Pakistan.

In his scrubs, would you defy the Taliban policeman forbidding you to treat a woman bleeding to death in childbirth? Would you save the life of an ISIS fundamentalist likely to kidnap you on recovery? Would you give money to the children of dead patients?

Dr Nott had to make all these calls under extraordinary pressure.

He describes numerous near-death experiences and there was some terrible emotional fallout.

After returning from one mission, Nott found himself unable to bear the complaints of a British patient fretting about her “unsightly” thread veins and began a screaming, feigned sciatic attack until she left his consulting room.

He also had a panic attack when invited to a private lunch with the Queen. Overwhelmed by the contrast between the luxury of Buckingham Palace and the desolation he had seen in Syria, Nott found himself unable to answer Her Majesty’s questions.

As visions of limbless children filled his head, she placed her hand gently on his and encouraged him to pet her dogs. “There,” she said. “That’s so much better than talking, isn’t it.”

These days, the 63-year-old medic still travels the world to help victims of disaster. But his priorities changed after meeting his wife, Elly, at a charity event for Syria Relief in 2013.

The relationship came as a “bolt from the blue” to the man with a “monastic existence”. But, before they could arrange a first date, Nott made a trip to Gaza, where he elected to stay in the operating theatre to save the life of a little girl called Aysha, even though he had been ordered to evacuate the hospital because an airstrike was expected in minutes.

It was a story that Dr Nott told on Radio 4’s Desert Island Discs in 2017, reducing listeners to tears as he described how he still treasures the photograph he has of her, smiling as she recovered.

David married Elly in 2015 and welcomed daughter Molly the same year. Elly – an Oxford graduate with an MA in international relations – was the chief executive of the David Nott Foundation (a charity training surgeons to work in conflict zones) until the beginning of 2019.

Although as a husband and father, Nott tries harder to avoid danger, he finds it hard to be optimistic about the situation in Syria.

But he remains committed in continuing to train doctors working there.

On the final page of his book, Nott quotes the Koran: “Whoever saves a life, it shall be as though he had saved the lives of all mankind.”

– (Memoir) War Doctor: Surgery On The Front Line by David Nott is published by Picador for £18.99, 304pp

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Medical, Psychology, Science

(Quantum Leaps): Sigmund Freud

1856–1939

“The interpretation of dreams is the royal road to the unconscious activities of the mind.” – Freud

SIGMUND Freud’s popular impact remains profound even today. Yet for a scientist who changed the world, some critics would argue that his methods were at best unscientific and at worst downright reckless. Indeed, later thinkers in the fields of psychology and psychiatry have long since discredited many of his conclusions but still the Austrian’s influence pervades. Whatever the rights or wrongs of his ‘scientific’ deductions, Sigmund Freud remains the benchmark by which others working in the same field must compare themselves and compete against.

Medical Beginnings

Freud’s entry into science was far less controversial. He began by studying medicine at the University of Vienna in 1873 and went on to take up a position at a hospital in the same city from 1882. It was time spent working with the French neurologist Jean-Martin Charcot (1825–93) in Paris 1885, however, which set him on the path of his future career. Here he worked with patients suffering from hysteria and began to analyse the causes of their behaviour. Additional research with Josef Breuer back in Vienna during the early 1890s helped develop the basis for all of his future work, culminating in the publication of Studies in Hysteria in 1895.

The Idea of ‘Free Association’

In common with views generally held at the time, at the heart of Freud’s conclusions was a belief that mental illness was normally a psychological rather than a physical brain disease. Once one accepted this premise then Freud’s introduction of the idea of “psychoanalysis” for diagnosing the causes of mental disorder (and indeed ultimately to explain all mental behaviour) was a logical one.

One of the innovative tools he developed to aid in this was the idea of “free association”. Rather than hypnotise people as was traditional, Freud advocated this method whereby patients enunciated thoughts or ideas which came into their consciousness without prior contemplation or analysis.

Dream Theory

From this Freud believed he could make an insight into the “unconscious” of a patient and, in particular, the “repressed” thoughts and emotions (often related to past negative experiences) which their “conscious” prevented from being articulated or enacted upon. For Freud, having a patient understand and acknowledge their repressed desires was a route to therapy and ultimately the treatment of a mental disorder. He also believed that dreams offered a major insight into repressed thoughts held in the unconscious mind. This is shown in his most prominent work – which fully established his revolutionary approach – and which is entitled The Interpretation of Dreams, published in 1899.

While many critics were able to bear with – if not necessarily agree with – Freud’s interpretations up until this point, he caused an outcry with his 1905 Three Essays on the Theory of Sexuality. His conclusions included the explanation that most repressed behaviour was in essence suppression of sexual impulses and, most shockingly, this activity began in infancy. It was here that he also introduced the now notorious concept of the Oedipus complex, a phrase used by Freud to describe feelings of sexual attraction of a child for its parent of the same sex, and hostility to the parent of the other sex. This phrase, Freud claimed, speculatively at best, was one that all children passed through.

Gradually, however, Freud’s analyses would gain credibility, if not necessarily with everyone, and certainly by the 1920s they had entered the popular consciousness on a global scale. He wrote many other texts including the 1923 The Ego and the ID. Freud effectively redefined the “unconscious” as the “ID”, an intangible collection of base impulses such as instincts and emotions present in the mind from birth. With experience, living and structure, aspects of the ID would gradually help formulate a person’s “ego”.

Freud By Name, Freudian By Nature

Freud’s legacy remains as much in the tools of language that he has bestowed on the modern world as anything else. Terms he introduced or of which he altered the meaning to give them our now common understanding, include: psychoanalysis, free association, the ID, the ego, neuroses, repression, the Oedipus complex and, of course, the Freudian slip. The structured, systematic approach he brought to analysing an inherently difficult-to-quantify subject also pervaded the work of his successors in the field.

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Medical, Research, Science

How Do Our Genes Make Us Human?

MOLECULAR BIOLOGY

Intro: One thing common to all life on Earth, from bacteria to blue whales to bonobos, is a genetic code contained within strands of DNA. This leads to the perplexing question of how our DNA creates human beings.

LONG sections of genetic code are identical across the entire span of life. About 50 per cent of our own DNA sequence is the same as bananas’, while we share 98 per cent of our DNA with chimpanzees. So, what makes us different?

In April 2003, a major milestone in the study of human genetics was reached with the publication of the complete human genome. An enormous collaborative project worked on by scientists in 20 different countries, it may well come to be regarded in the same light as the great scientific landmarks. Principal among these was the work of the Augustinian monk Gregor Mendel – often referred to as the “father of genetics” – which he carried out in the 1850s and ‘60s and which first established the rules of heredity, as well as James Watson and Francis Crick’s 1953 description of the molecular structure of DNA as the now-famous double helix.

Gene Expression

The published genome contains the sequence of some three billion so-called base pairs, which constitute the genetic code in our DNA. The translation of the code made up by these base pairs is used to build up 20 different essential amino acids which, together with other amino acids we get from our food, combine in numerous different ways to form all the different proteins we require in our bodies. Geneticists used to think that the role of DNA was almost entirely concerned with providing a template for the manufacture of these proteins, but the complete genome showed that the sections of DNA which perform this function, our genes, only account for about two per cent of the total.

The function of the remaining 98 per cent, sometimes known as “junk DNA”, is not entirely known, but it has become increasingly apparent that much of it is not junk at all. It plays a role in, among other things, gene expression. This is the actual process by which the information contained in our genes is used to make up all the different tissues and organs in our body, through the process known as cell differentiation. Here, stem cells divide to produce different types of cells, such as liver cells or nerve cells. Unravelling the way in which one type of cell divides to produce a wide variety of different cells has proved to be extremely difficult and is currently one of the principal areas of genetic research.

The basic functioning of DNA in producing amino acids from the genetic code is relatively straightforward: the double-stranded DNA molecule effectively unzips, splitting apart the base pairs and revealing the code that is then copied by single-stranded RNA and used to assemble amino acids. But the control of this process, in which the required genes are activated and those not needed switched off, appears to be extremely complicated. Each advance in our knowledge of gene expression uncovers a whole new level of complexity that has to be unravelled. Beyond that, there is also the equally tricky problem of determining how, during the process of protein folding, the proteins made from genes assume the three-dimensional shape that determines their functions. The potential applications of our advancing knowledge of gene expression and protein folding are wide, not least in increasing our understanding and ability to treat diseases which have a genetic basis, prominent among which are many forms of cancer.

The Difficulties of Cloning

Another landmark in genetic research was achieved in 1996, when the first mammal (known as Dolly the Sheep) was cloned by geneticists at the University of Edinburgh in Scotland, using a technique called somatic cell nuclear transfer. This involves the removal of a nucleus containing genetic material from a cell of the animal to be cloned, and its introduction into an egg from which the original nucleus has been removed. The egg is then implanted into a surrogate mother and, in theory at least, will develop into an embryo with DNA identical to the animal from which the nucleus was taken.

Needless to say, if it were as easy as that, cloning would be a common occurrence today. In reality, it has proved much more difficult, in part because of the complications which arise as a consequence of gene expression. In some successful cloning experiments, for instance, the observable traits, or phenotype as it is known, of the cloned offspring are not always the same as those of the original animal. So, despite being genetically identical, the offspring looks different from the parent. In order to produce exact copies of the original, the process of cloning has to solve the complicated issues involved with gene expression, including the role of junk DNA in regulating genes. We are, it appears, a long way from seeking flocks of cloned sheep.

Alternative Theories

In recent years, it has become increasingly apparent that gene expression is not controlled solely by DNA but is also influenced by a number of external factors collectively known as epigenetics. This is a new field of scientific research and the details of how it works are disputed, but, in essence, it implies that the environment in which DNA replication occurs during cell division can influence the activity of genes and, in doing so, can have an effect on the resulting phenotype. This is thought to occur at a molecular level, through environmental factors modifying the actions of those proteins that surround strands of DNA and influencing the switching off or activation of genes. These epigenetic modifications do not change the DNA sequence of base pairs, so are not inherited by future generations, even if those generations may then be subjected to the same environmental conditions as the parent, resulting in similar epigenetic modifications.

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