The first thing I realised when I saw J was that he was dying. All that remained of this 16-year-old's arm was six inches of skin; the rest had been shot off when he became caught in gunfire between the Congolese army and rebel forces. A further amputation had left him open to infection, and now he was facing the prospect of an awful, agonising death over a period of several days – hallucinations, dehydration, his kidneys packing up, his breathing going and then, finally, his heart.
It was my first day in the Democratic Republic of Congo, working with Medecins Sans Frontieres (MSF). I had been offering up my services as a vascular surgeon to aid agencies for 14 years – working in places as diverse as Bosnia, Afghanistan, Sierra Leone, Chad, Darfur, Liberia, the Ivory Coast and southern Sudan. Congo was by far the most beautiful country I had been to, but it was obviously also very dangerous - heaven and hell rolled into one.
I arrived at the beginning of October, when the latest bloody conflict started building. I was assigned to a mission hospital in Rutshuru, which was basically a building plonked in the middle of the jungle. It was very basic, manned by a few MSF volunteers and some local staff. The post-operative "ward" was just some tents outside. One day, we received 75 patients with gun shot wounds – men, women and children. There was a two-year-old who had been shot in the chest; the bullet had missed her heart but it had passed straight out the other side and her lung had collapsed. There were only eight staff in total working that day, and we were there for 22 hours. Quite unbelievably, nobody died.
Even more remarkable, though, was the story of J. His mother and father had been killed in the conflict, his siblings had fled into the jungle. He was all alone and I knew that the only way to save him would be to perform a forequarter amputation – removing what remained of his arm, and his shoulder. It is an incredibly difficult operation and only about ten people in the UK undergo it each year. There are only two or three surgeons in the UK who are able to do it, and I was not one of them. Fortunately, I knew somebody who was.
Professor Meirion Thomas is the head of cancer surgery at the Royal Marsden hospital in London. I had done operations with him before and I decided to text him to ask if he thought it a good idea to carry it out. I was just not sure that it was the right thing to do. I couldn't ask J because of the language barrier and even if I could, he was so ill he would not have known what I was talking about. The quality of life in DR Congo is so poor, and he was so alone, that I wondered if it would not be better off for him to die. But the local staff gleaned from him that he wanted to live – which is unusual in the region. The Congolese do not mind dying. They expect it. J did not.
Prof Thomas texted me the instructions for the operation. Though the procedure was tricky, his instructions were crystal clear – it was like reading the ingredients for baking a cake. He signed off the text with a playful "easy!" but I was concerned. Nobody in the hospital, including myself, had ever carried out an operation on this scale. They all thought I was a mad foreigner. And we barely had any blood. We probably needed five or six units but only had one. I told myself that it would better for J to die on the operating table under anaesthetic than conscious and in immense pain.
We did the operation on the afternoon of my third day. It took three hours and went smoothly; Professor Thomas' text was absolutely spot on. But the worry was whether or not J would recover. Would he have enough blood in him? Would it clot? Would he get further infections? We pumped him full of fluids and antibiotics and we waited and we hoped.
And he has survived. I was astonished when I saw a picture on the MSF website of him looking so well. He has been discharged now, and I do worry for him, because what hope does anyone have in DR Congo at the moment, let alone a teenage boy with only one arm and no social backup? But God works in mysterious ways, and I must have faith that Prof Thomas' text was God's will.
THE TEXT DAVID NOTT RECEIVED
Start on clavicle. Remove middle third. Control and divide subsc art and vein. Divide large nerve trunks around these as prox as poses. Then come onto chest wall immed anterior and divide Pec maj origin from remaining clav. Divide pec minor insertion and (very imp) divide origin and get deep to serrates anterior. Your hand sweeps behind scapula. Divide all muscles attached to scapula. Stop muscle bleeding with count suture. Easy! Good luck. Meirion
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