War Doctor

David Nott with his wife, Elly and their elder daughter, Molly

Preface

The Geneva Conventions: 日内瓦公约
MSF: Médecins Sans Frontières (Doctors Without Borders), is a humanitarian medical non-governmental organisation (NGO) or charity of French origin known for its projects in conflict zones and in countries affected by endemic diseases. 无国界医生.

Chapter 1. The Bomb Factory

When anybody comes in to an emergency department the first thing we do is called the primary survey – looking at the basic parameters that can save lives, which we code as CABCDE.

C: catastrophic haemorrhage.
  stop it by direct pressure or using a tourniquet （止血带）
A: airway. 
  whether theres is obstruction to the flow of oxyen to the lungs.
B: Breathing. lungs expand properly and provide oxygen to the body.
C: general circulation and a quick assessment of the blood pressure by feeling the pulses
D: Disability, the most likely being neurological disability caused by head injuries.
E: exposure – checking the rest of the patient and also understanding the temperature of the environment.

Chapter 2. Two Epiphanies

In brain trauma there are two types of haemorrhage. Because an extradural haematoma only causes pressure on the brain from outside the dura, if it’s relieved quickly then the patient will make a complete recovery, because there is no actual brain injury. The bleed that occurs under the dura is called subdural and can be due to actual brain injury and therefore does not have such a good overall prognosis.

extradural haematoma: 硬膜外血肿，由外伤导致血肿压迫大脑，如果及时手术治疗预后较好。
subdural haematoma: 硬膜下血肿。大脑自身已经受到损伤。预后较差。

Space Invaders: 《太空侵略者》為日本太東公司於1978年發行之一款街机遊戲。是街机游戏时代最流行的游戏，对以后的游戏业界影响深远。

First epiphany: 硬膜外血肿开颅减压术(最基本的脑外科手术，日剧《仁医》里主角穿越到江户时代后做的第一个手术)
Second epiphany: The Killing Fields film (杀戮战场)

Chapter 3. Welcome to Sarajevo

That boy’s death, and in particular the way my colleagues reacted to the attack, changed me. Like many doctors and nurses I had always been very sympathetic and empathetic to my patients back home, taking bad outcomes very personally. But this experience taught me two things: first, I’d have to toughen up; second, I also had to take care of myself. Not just because there was no one else there who was going to do that for me, but because I wouldn’t be helping anyone if I was dead.

Sarajevo was my first taste of this, and I knew I wanted more. It was a strange mix of altruism, wanting to help others, and pure selfishness – chasing the high of intervening to save lives, but also of living my own life closer to the edge. At home I lived alone – I had a few girlfriends, but nothing serious. It was a bit of a monastic existence and I had few material needs. But after Sarajevo I had to acknowledge that this was something I needed in my life. There was another world out there, one in which I could use my skills to change the outcomes of people’s lives for the better – but also one in which I could experience the sheer thrill of being plunged into situations most people can’t begin to imagine. The endorphin rush of hearing and feeling bullets and missiles whizz overead was like nothing I’d encountered before, and everyday life seemed humdrum by comparison.

这种极端环境反而使作者“兴奋”(High)。而非通常的类 PTSD 反应。很多战地记者(war correspondents)等有类似的人格和心理特征。

Chapter 4 Damage Control

United States Ship (abbreviated as USS or U.S.S.):  a ship prefix used to identify a commissioned ship of the United States Navy and applies to a ship only while it is in commission.

Royal Auxiliary Air Force (RAuxAF), formerly the Auxiliary Air Force (AAF), together with the Air Force Reserve, is a component of His Majesty's Reserve Air Forces。英国皇军空军预备役的一个组成部分。

Jon-Allan Butterworth

外伤导致的大量失血会导致器官缺氧(lack of oxygen)，产生一系列 trauma triad of death 症状
  - 引起体温降低(hypothermia (cold))，因为细胞无法产生足够能量维持体温。
  - 由于叶酸(lactic acid)堆积导致酸中毒(acidosis (raised acidity))，引起凝血功能障碍(coagulopathy)从而进一步加重失血，因为凝血酶(clotting enzymes)不再工作（生化反应需要正常体温和中性酸碱度）。
  - 引起心衰，进一步导致器官缺氧。

在伊拉克战争等冲突期间发展起来的创伤管理技术和诊疗规范显著提高了这类严重外伤患者的生存率和预后。美国医生 Atul Gawande 写的 Better: A Surgeons Notes on Performance 里的战地医生章节写的是同样主题，但内容更加翔实。

Chapter 5. Under African Skies

Darfur: a province in the west of Sudan. 苏丹达尔富尔人道主义危机。主要是（政府军）北部穆斯林阿拉伯人对南部基督教黑人的种族屠杀。

General anaesthesia: 全身麻醉。作用于中枢神经系统，使其受到可逆性的抑制从而使得使用者的意识、感觉，特别是痛感消失，便于进行外科手术。
Local anesthesia (Regional anesthesia, Conduction anesthesia), 局部麻醉，阻断神经冲动的传导。
  - Spinal anaesthesia: 腰椎麻醉。进行下肢手术和脐部以下手术時常用的一种局部麻醉。

scorched-earth policy: 焦土政策

R&R: R&R, military slang for rest and recuperation (or rest and relaxation or rest and recreation or rest and rehabilitation), is an abbreviation used for the free time of a soldier or international UN staff serving in unaccompanied (no family) duty stations.

作者在刚果内战期间作为MSF医生在非洲工作，期间母亲病重并去世。

Chapter 6. Flying In

taxi 的另一个释义: (指飞机）在地面或水面滑行（尤指起飞前或降落後）: The plane taxied/was taxiing along the runway. 飞机在跑道上滑行.

hepatic veins : 肝静脉。流向下腔静脉(Inferior vena cava)。
  vena cava: 回流向心脏。

3-0 suture:
From 0 to 11-0, each extra zero corresponds to a unit decrease in diameter (e.g. 0, 00, 000, etc. until the smallest size of eleven 0s is reached)
ie.more zeros means smaller (and weaker). The larger the suture diameter, the relatively stronger it is.
医疗中常用 3-0 强度的缝合线。日剧《Doctor X》里经常出现。

Another close shave, and perhaps another of my nine lives gone. Why did I keep putting myself in these situations? Once they’ve had a brush with real danger, I guess some people shiver and think, Never again, while others think, Wow! I had discovered I was definitely in the latter camp. I can’t deny I get a kick out of taking the controls of a plane or a helicopter, or performing surgery in a war zone: the risk is part of the appeal. And it is undeniably addictive. It is a physiological reaction, as well as an emotional one. The trick is knowing when to stop, as any ex-junkie will tell you.

读完这章我决定（暂定）给这本书打4星。

Chapter 7. Trauma School

作者在利比亚内战期间作为志愿者的经历使他认识到对医生进行教育（在冲突区域这种极端环境下治疗现代武器造成的严重外伤）的重要性

Surgical Training for Austere Environments (STAE)

Chapter 8. Syria again

When you press your skin and it blanches, it is because the blood circulating below the skin is driven out. If you’re stuck underneath a collapsed building, and can’t move, then your skin won’t receive any blood and the muscle below will die. This dead muscle then breaks down and minuscule particles enter the bloodstream, eventually blocking the tiny capillaries in the kidney. If this isn’t addressed, renal failure and death follow. Maintaining kidney function is therefore one of the first life-saving manoeuvres after rescuing any survivor pulled from a fallen building. It is also why bed-bound patients need to be turned from side to side every few hours, to stop pressure being applied to one particular area of the skin for too long.

作者从海地地震灾害带回英国手术的 Haiti baby girl: Landina。这个孩子最终与母亲重逢。整个故事被英国 Channel 4 报道。

triage

P1 (Priority 1) injuries are those that require immediate treatment without which the patient will die because of breathing obstruction or massive haemorrhage.
P2 injuries can be delayed for an hour or two before they go
to the operating theatre.
P3 are the walking wounded. // 轻伤员
P4 are the dead or those beyond saving.

It’s often said that there are different pulse pressures in the radial (arm), femoral (thigh) and carotid (neck) arteries. It is very difficult to know exactly where to feel for these pulses if one is not properly trained. Of them all, the most important is the radial pulse in either arm. If you can feel a radial pulse, then the pressure is around 90 mmHg systolic. This is sufficient to ensure that all the major organs such as the brain, heart, liver and kidneys will be well supplied with blood. Even if the patient is significantly injured, if he is in this category then he is P2. The P1 injured are those with obvious difficulty in breathing and who do not have a radial pulse pressure. These are the patients who need urgent care and attention, although everyone requires constant review as those who are P2 may suddenly become P1.

Aleppo 阿勒颇 叙利亚北部城市。2012-2016年間，阿勒颇的东、西两部分分别由反政府武装和叙利亚政府军控制。城市被围困，缺少供水、供电和医疗设施。2016年12月中旬，阿勒颇戰役以叙利亚政府军獲勝結束。作者2013年期间曾来到这里的反政府武装控制区提供医疗人道服务。

Chapter 9. Sniper City

omentum [解剖] 网膜This is a big, fatty, apron-like membrane in the gut, which can be wrapped around inflamed organs (eg. liver) to seal them off (to stop it from bleeding, etc)

作者当时（2023）仍然未婚。
//In 2015 Nott married Eleanor Jupp, and their daughter was born in the same year. Eleanor, known as "Elly", was formerly an analyst with the Institute of Strategic Studies.

为什么我们能够允许像叙利亚这样的暴行发生？美国和整个自由世界存在道德义务去制止这些暴行——用一切手段。联合国这种机构的授权（或缺乏授权）没有任何意义。

a groin flap 腹股沟皮瓣。用于治疗手部（背侧或手掌表面）、手腕或前臂直至肘部的大组织缺损。

Chapter 10. Lifeline

The X-ray of the pregnant
woman’s near-full-term foetus, clearly showing the bullet lodged in its head

作者拍摄的反映2013年叙利亚内战人道主义灾难的这张著名X光片。
The picture was published on the front page of The Times in October 2013 with the headline ‘Assad’s snipers target unborn babies’.

Conflict work really was the only thing that made me feel alive.

In academic terms, there are four categories of blast injuries.

Category one is the effect of the initial shockwave that is generated when a bomb goes off. There is an instantaneous blast which creates an air shockwave that travels at supersonic speed and dissipates quickly over distance. When this shockwave goes through a human body it causes conditions such as shock lung, whereby the small blood vessels within the lung burst into one another and patients drown in their own blood. There may
be no marks on the patient’s body at all; all the damage is done inside

Category two is the effect of shrapnel from the bomb itself or fragments of rubble from buildings damaged by the explosion. This is the kind of injury I had seen so often in Syria and elsewhere.

The original shockwave creates a vacuum. As it moves, the area behind rapidly fills up with fast-moving air, which gives rise to the so-called ‘blast wind’. This is the category three effect. The blast wind can be so strong that it can lift a man up and throw him against a wall or other hard surface, and can sometimes cause traumatic amputation, literally taking off an arm
or a leg. 

The other effects of the bomb, such as severe burns, or the effect of crush injuries due to falling debris, are category four.

Most of our patients were suffering in all four categories. To make things worse, infected flying debris and soil put them at risk of rapid death from septicaemia. The treatment of blast injuries is extremely complex and challenging.

本章叙述了作者与后来的妻子的馴れ初め。最初源于作者在加沙战争极限环境下以为自己随时就要死了时候给她发的短信。

Chapter 11. The Razor’s Edge

重返叙利亚

Chapter 12. Physician, Heal Thyself

STAE: (UK) Surgical Training for Austere Environments course at the Royal
College of Surgeons

When President Obama had talked in 2013 about ‘crossing the red line’ after four hundred children were killed by a chemical weapons attack in Ghouta, outside Damascus, he was awaiting the outcome of a vote on military action in the British Parliament. The vote was close, but in the end 285 MPs against 272 decided not to proceed with strikes against the Syrian regime. Unfortunately the debate seemed to be more about politicking between the prime minister, David Cameron, and the leader of the opposition, Ed Miliband, rather than what was the right thing to do. It was, in some ways, a reaction to Tony Blair’s support for the US invasion of Iraq a decade earlier. The aftermath of that war has left a toxic legacy: the British people just didn’t want to become embroiled in someone else’s war in a faraway place of which they knew very little. But I have no doubt that if the West had shown strong leadership at that point, the Syrian military hierarchy would have collapsed.

vocal MP: vocal outspoken 用言语自由表达意见或感情的; 直言的: vocal criticism╷ support 坦率的批评、支持。MP: Member of Parliament。国会议员。

俄罗斯是世界和平最大的威胁。我们应该把俄罗斯逐出联合国安理会。

Chapter 13. Escape from Aleppo

本章主旨与上一章后半部分相同：俄罗斯是人类毒瘤。

本书以叙利亚内战中最血腥的阿勒颇战役结束和各方协议成功实现的人道主义疏散作为终结。
She, and all the other children and innocent victims of conflict
the world over, is the reason I do what I do.

Afterword by Eleanor Nott (作者妻子)

Heroism is a consistent theme in the stories human beings tell one another: people of great strength doing remarkable things.

Second only to stories of romantic love, the tale of the hero undertaking a mission, overcoming adversity and emerging triumphant has adorned cave walls and filled library shelves for centuries. Heroic stories give us hope, make us feel better about our sometimes wretched world, and serve as inspiration and aspiration. We may not have those qualities ourselves, but knowing they are out there gives us comfort.

Desert Island Discs: BBC 广播节目。本书作者是 June 2016 期节目的主角。当期节目引起了巨大反响。

Surgery hasn’t had the profile of other health issues such as communicable or preventable diseases. Yet surgically treatable conditions kill 17 million people each year; more than tuberculosis, malaria and HIV/AIDS combined, according to a study in The Lancet. We therefore seek to promote the skilful and safe practice of surgery in low-resource or war-torn settings as well as advocate for the rights of the medical victims of conflict and the doctors who strive to care for them.

David embodies the truly heroic, if we will but allow our heroes the vulnerability and humanity that make them real people. A wise priest at the Catholic church where I was baptized and confirmed once said, ‘Go for the best and be prepared to work for it.’ It has always stuck with me. I wouldn’t want our daughters to miss real love in search of a romantic mirage; I am glad I didn’t either.

A hero all the more worthy of love because of his vulnerabilities. My extraordinary, complicated, beloved David.

The David Nott Foundation