Dressing Station: A Surgeon's Chronicle of War and Medicineby Jonathan Kaplan
The Dressing Station is a searing portrait of devastation on the battlefield that "illuminates the consequences of war and the ambiguities of relief work at a time when these issues couldn't matter more." (Caroline Fraser, Outside) From treating the casualties of apartheid in Cape Town to operating on Kurdish guerrillas in northern Iraq at the end of the Gulf War,
The Dressing Station is a searing portrait of devastation on the battlefield that "illuminates the consequences of war and the ambiguities of relief work at a time when these issues couldn't matter more." (Caroline Fraser, Outside) From treating the casualties of apartheid in Cape Town to operating on Kurdish guerrillas in northern Iraq at the end of the Gulf War, Jonathan Kaplan has saved (and lost) lives in the remotest corners of the world in the most extreme conditions. He has been a hospital surgeon, a ship's physician, an air-ambulance doctor, and a trauma surgeon. He has worked in locations as diverse as England, Burma, Eritrea, the Amazon, Mozambique, and the United States. In this story of unforgettable adventure and tragedy, Dr. Kaplan explores the great challenge of his career -- to maintain his humanity even when that option does not seem possible. The Dressing Station is a haunting and elucidating look into the nature of human violence, the shattering contradictions of war, and the complicated role of medicine in this modern world. "A unique mix of biography and reportage, both personal and clinical," it is "a rare insight into the mind of a surgeon." -- Sue Cullinan, Time "Eloquent ... Beautifully written ... Provides a startling glimpse of battlefield surgery in those conflicts that CNN does not cover." -- Abraham Verghese, The New York Times Book Review "Kaplan ... has a keen sense of the smaller moments that leaven the agonies of daily life." -- Julian B. Orenstein, The Washington Post
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I am a surgeon, some of the time. In certain clinical situations -- penetrating wounds, massive bleeding -- there remains no treatment but the knife. I have been fortunate, at times, to have saved the lives of patients who reached me on the threshold of death. Much of my work has dealt with trauma; among people changed abruptly from wholeness to injury, with all the fear of sudden mortality. Some of it has taken place in extreme circumstances -- with only the most basic of resources -- against a backdrop of dislocation and despair. I have seen people die, of wounds or disease or deprivation, and been unable to help.
All doctors have their ghosts. Sometimes they jostle me: the ones I couldn't save, the ones I killed. For all of us -- even the most dedicated and skilled -- the dead pile up, the results of decisions swayed by fatigue or hubris or blind bad luck. And there are those who are simply the inexorable casualties of the system, for medicine is not always benign or balanced, or even practised necessarily to the benefit of the suffering. Every loss diminishes us, yet with clinical detachment -- and with exhilaration, fear and fatalism -- we continue, always in the hope of redemption.
I have practised medicine in diverse fields: as a hospital surgeon, a flying doctor, a ship's medical officer. I have operated on wounded straight off the battlefield, treated people with rich strains of tropical disease raging in their bloodstreams, and tried to help those afflicted by occupational illness from industrial toxins or workplace stress. I have run research programmes funded by corporate finance -- that met the needs of shareholders before they benefited any patients -- and I've cared for children wasted by the diseases of famine and war. Like most doctors, I have seen my craft used and abused; been a part of its successes and witnessed its failings. It is by the terms of this unforgiving arena that we struggle to define ourselves.
No clinician can give an objective account of that work: the interaction between doctor and patient is mutual and intimate, and in the end comes down to something between us that is a fragile thing, as fragile as life. All we can do is the best we can in the war against death and against despair, including our own. For at its extremes the practice of medicine is a succession of front lines, and each victory is only a temporary respite. Perhaps you wonder what it's like to stand at that intense interface. Perhaps you believe in the existence of some profound morality, some metaphysical awareness that is vouchsafed by contact with the texture of suffering and the aura of pain. I guarantee nothing; you will have to find out for yourself. Come and see.
I grew up with the expectation that I would serve. One of my mother's brothers went through the Somalia campaign as a regimental surgeon in the King's African Rifles; he'd been commended for bravery. The other had been an army engineer, clearing German minefields under fire in the Western Desert. My father spent five years in uniform, in Africa and Europe, treating casualties in tented field hospitals. His medical colleagues -- our family friends -- had been there too. His anaesthetist received a medal for diving off the deck of a hospital ship in the shark -- thick Mozambique Channel to rescue an African soldier, maddened from a head-wound, who had thrown himself overboard. Even my dentist had a covert fame, from the time when he had worked in an army hospital in North Africa and replaced his uniform badges with ones cast in gold ('Fillings, Officers, for the use of'), easily convertible to cash during abandoned weekends in Cairo's brothels and bars.
We were a medical family: my father the orthopaedic surgeon, his brother the virologist; my mother the pathologist, her brother the urologist. In Durban, as we walked along the beachfront, we got respect. People would approach my father, expecting that he should instantly remember the history of their pain and survival. He used the trick (I have since used it myself) of asking to see their scars, and from the track of the knife he would recall first the operation, then the problem, and often, finally, their names. Among these erstwhile patients, as well as among the nurses and doctors I met as I trailed my father on his rounds through the hospital wards, the assumption was clear: I too would become a doctor, and serve. Exactly what form that service would take was uncertain: with the prospect of political change in South Africa apparently remote, there seemed no great, impending conflict in which I would be tested.
I was accepted by the School of Medicine at Cape Town University and, beneath the loom of Table Mountain, found a new burden of tradition. The university library contained the same leather-bound volumes by Wells and Kipling that my father had read. In the chemical reek of the dissecting rooms I studied the same intricate anatomy texts, and laughed at the old practical jokes involving cadaver fingers slipped into the lunch boxes of the unsuspecting. The senior anatomist -- an elderly rake who wore a linen suit and sported the Panama hat, white goatee and moustache that a brand of fried chicken was later to make famous -- had been there for four decades, and talked wistfully of the 'gentlemen' he had taught before the war. He would hold tea parties in his office for groups of old ladies, trying to coax them into leaving their bodies to science. Afterwards he led them on a tour of the dissecting rooms, warning us in advance to be on our best behaviour.
'Think of yourselves resting here, girls,' he would say, patting the enamel tables, 'in the hands of these young men,' and the ladies would giggle and gasp, and, presumably, be seduced.
These first years of study were basic blood and bones: anatomy, physiology, pathology and bacteriology, pharmacology. Some took their studies seriously, attending every lecture and reading textbooks into the night, but for myself and my friends there were too many diversions to learn any more than we needed to get through the examinations. The sun shone for nine months a year and white beaches surrounded us, washed on one side by green Indian Ocean breakers and on the other by the cold swell of the Atlantic. There was surfing and diving and cinemas and parties and pinball bars, and the all-night clubs near the harbour frequented by prostitutes and drunken sailors. On weekends we would leave the city to stay on farms in the wine lands or in beach cottages along the striking coastline.
It was extraordinary how frivolously we lived: in student paradise. Cape Town was a cosmopolitan outpost at the continent's tip, created by the first European settlers. Africa began beyond the city, on the bleak sand-plain known as the Cape Flats. This was the site of racially classified townships that supplied labour for the factories, and the domestic servants who maintained white homes to a standard envied by overseas visitors. Few white South Africans -- apart from policemen and officials -- even ventured inside the townships, where garbage burned on the streets and the silhouette of Table Mountain shimmered in the summer's heat.
We weren't really callous, or blind to the iniquities of a political system that denied the basic freedoms of most of the country's people. It dictated the identities of our classmates: the university's intake was controlled by government quotas that limited 'non-white' students to ten percent, few of whom could surmount the deficiencies of their segregated schooling to meet the entrance requirements for medical studies. There were groups trying to raise political awareness on campus, meeting with underground black trade union organizers and discussing revolutionary theory, but such activities seemed of little value in the face of the state's pervasive grip.
Politics had been a significant issue when my father was a medical student. In 1937 he and a friend had decided to go to Spain as volunteers to join the International Brigades fighting for the Republic. They went to tell a much-respected professor of their decision. The man had served in the Great War, and knew something of the impatience of youth. He too had been watching events unfold in Europe.
'This is just the first round in the war against fascism,' he told them. 'It will go on for years, right across the world. You want to go and help the people of Spain. As soldiers [he had the kindness not to call them cannon-fodder] you may kill some of the enemy, or be killed. But, if you really wish to help, you can do much more as trained doctors. There are going to be many sick and wounded who'll need your care.' Persuaded, they had finished their studies, graduating at the end of 1940 and going directly into uniform.
For us the equivalent might have been to leave the country and join the ANC in exile, but few of us had that sort of commitment. I don't think we had much comprehension of being useful in any worthwhile way; we hadn't even seen a patient yet, and would only do so when we started our clinical training a year later. So the first time I got blood on my hands had little to do with my studies. It began, improbably, in the middle of a dull basic-sciences lecture.
A small group of students had marched through the centre of Cape Town that morning, carrying banners calling for an end to apartheid. By lunchtime they were ranged on the steps of the Anglican cathedral near the Parliament buildings, their banners aloft, when the police arrived. A stand-off ensued in the warm sunshine, with motorists steering carefully along the road between the opposing groups. Though the police seemed uncertain about taking action against the students in such a public place, riot squad reinforcements were gathering in the sidestreets, and student messengers were sent to the campus to ask for help.
I was drowsing over my lecture notes when there was a bustle in the corridor outside, and the sound of running feet. The door to the lecture hall opened with a crash. A face peered in and addressed us, ignoring the man at the podium.
'There's going to be trouble at St George's Cathedral; hundreds of cops and riot trucks. We need lots of people there; they can't arrest everyone.'
'Young man!' shouted the lecturer, but the messenger had already left to spread the word. A few of my friends stood up. I joined them. Perhaps ten, in that class of a hundred, made for the door. Some of our classmates hissed at us. The lecturer glowered, and a Catholic girl crossed herself. Outside it was clear that there had been a much better response from the liberal arts faculties, for all over campus students streamed out of the buildings and jostled for lifts, piling into cars and pickups and VW buses that roared off down to the highway that led to town.
We approached the cathedral from the rear, through public gardens unusually empty of sweepers and gardeners and nannies with their charges. From ahead came a thready chanting and a thumping sound that I couldn't identify. Rounding the building, we came to where the battle lines were drawn. A host of students, men and women, occupied the stone steps of the cathedral and the pavement in front of it. Across the street, drawn up in solid rows, stood a phalanx of riot police. Steady as a heartbeat, they struck their batons against the Perspex shields they carried. The crowd flinched at each resounding blow, shrinking back towards the cathedral steps. Then a police colonel stepped to the front of the line, sunlight blinking off the braid on his cap. In one hand he held a yellow megaphone.
'This is a prohibited gathering.' The metallic warp cut through the sudden silence. 'You have thirty seconds to disperse.'
He stood there in his dark uniform, the bright yellow cone raised to his mouth.
'It's Daffy Duck!' yelled a wag in the crowd, and a roar of laughter drowned out the colonel's next words. He turned to the police lines, raising an arm. There was a cracking sound and tear -- gas canisters lofted skyward, trailing arcs of haze. They struck the street, squirting smoke as they rolled towards us. A student scooped one up and flung it back into the police ranks, where it fumed under their feet. Gagging and swearing, the riot cops reeled, then charged in a body, their long batons raised. The banner-holders in the front went down under a storm of blows and were dragged across the roadway to the waiting trucks. The rest of us fled up the cathedral steps, gas canisters churning white clouds under our feet. We kicked them off the top step and stared, horrified, at the melee below, where people screamed and choked in the rising smoke and knots of students cowered under flailing clubs.
Men and women leapt up the steps, their arms outstretched towards us, while red-faced cops grabbed at their clothes and hurled them down, kicking them as they fell. In front of me a grisly tugging match ensued as we dragged at the hands of a girl while a policeman continued to rain blows on her back and legs. There was a shouted command and she fell, sobbing, into our arms. The police line retreated, stair by stair, exposing a wasteland of blood-splashed stone and lost shoes. We stood at the top of the stairs between the open cathedral doors. My eyes streamed; the gas stung my lips and smarted where it found moisture on my sweating face. People retched and coughed. Some helped to pass our injured to the rear, and carry them inside the nave. Others screamed insults at the police, calling them slime and filth and Boer baboons.
A breeze turned the scraps of paper in the street, thinning the tear-gas haze. The noise of the city returned, and I could hear the voices of office workers watching us from the windows of the buildings opposite. Then the colonel's megaphone screeched again.
'You are all under arrest!'
From our step came ragged laughter and shouts of defiance.
'Come and get us, you fuckers!' screamed a girl in a torn coat, then fell silent. Fresh police files were wheeling into line in the street below and lock-up trucks were backing up, their mesh doors open. The colonel waved his swagger-stick; the cops charged and the students recoiled. Those who could fled back into the church, the press of bodies carrying me with it. Over their heads I could see the flash of falling batons and hear the crack as they made contact. A tear-gas canister was bowled through the opening and then the doors shut with a crash on the daylight outside. Some students sprinted down the aisles to escape through the transepts, but those doors too were slammed shut before they reached them. We were sealed inside. From the street came cries, and the sounds of beatings.
The gloomy nave seemed filled with people. Some sobbed, or dashed about frantically, their chests heaving. Others staggered where they stood, their hair matted from bleeding scalp wounds. The shock of confrontation had revealed us for what we were: a bunch of self-styled rebels without cohesion. Someone had clapped a cleaner's bucket over the tear-gas canister, but trails of smoke leaked along the floor around its edge. It was not only the gas that made our eyes burn. I collapsed on a pew and lit a cigarette, my hands trembling.
'Not a fastidious churchgoer, I see,' said a voice beside me. I looked up and recognized the speaker, a medical student in the year ahead of me. Stefan gazed around at the defeated mob and shook his head. 'Looks like Casualty on a Saturday night,' he said. 'Smoke up, and we'll do something constructive.'
This was my first taste of trauma, but Stefan seemed to know what to do. He stood on a pew and addressed the refugees, his voice cutting through the moans and whimpers.
'Let's get the injured seen to,' he said. 'Anyone got some clean cloth?'
A girl pulled a blouse from her bag and held it up. Someone else produced a white lab-coat, and a couple of handkerchiefs were handed forward.
'Bring all those who've been hurt here to the front,' said Stefan, and he began, with the help of a penknife, to tear the fabric into strips. A cavalcade of wounded were assisted from the shadows; limping, shoeless, with bloodied faces and lacerated heads. I looked at their ragged cuts and thought I might faint. I set to work nervously, folding the cloth into pads and holding them against gashed scalps to stanch the bleeding. Other volunteers came forward to help. Stefan appeared at my side.
'Reassure them,' he said softly. 'Tell them head wounds always bleed a lot, but they soon stop. Tell them it's going to be OK.'
Stefan had gathered the worst tear-gas victims at the font. Some, their faces scorched by the irritant gas, could hardly see between their swollen eyelids. He spoke to them gently as he bathed the blistered skin. 'Don't worry, it burns at first when the water reacts with the chemicals. It'll stop after a few seconds.' His voice worked like a tranquillizer, and I began to understand a little of what healing involved.
I had treated my first casualties, however minor, and embraced my first cause. 'The Siege of St George's' they called it in the papers the next morning, and those of us who had been there gained a brief notoriety. A few went on to make names for themselves as political activists. One of them was my friend Stefan. For a while I occupied a student squat with him and Neil and Nils; the Marxist-Lentilists, who shared an admiration for Albanian communism and a conviction that meat or fruit, or anything but the most rigorous of subsistence diets signified bourgeois softness and a betrayal of the oppressed masses. They shared their spartan meals with some coloured children who slept rough in the cemetery behind the house, and laughed when our possessions were regularly stolen -- 'redistributed' -- by the most enterprising among them.
I didn't really mind the absence of luxuries. I was short of money and augmenting my living allowance by working as a mechanic, rebuilding the engines of the VW buses and Beetles that were the most popular student transport. And my social life had improved. Our kitchen was always full of people talking socialism through the night. A number of them were young women, attracted to the aura of revolutionary virility that hung around the house. With a few gallon jugs of proletarian wine the gatherings became parties. Though I didn't pretend to be an activist, some of the girls would try to expand my political consciousness through slippery sex, augmented by potent buds of marijuana.
But I was becoming aware of the political aspects of studying medicine in South Africa, as one of the select minority who qualified. The ironies of this privilege became apparent when we started our clinical training. Our professors adhered to the exacting standards of the English medical schools from which most of them had graduated. They had been drawn to the University of Cape Town's Groote Schuur Hospital because it was an international centre of excellence; it was here that the world's first heart transplant had been performed in 1967, and overseas doctors considered themselves honoured to work in the department of cardiac surgery and other specialties. One day we too would enter that elect society of healers, and begin to make a difference to humanity. Our medical training was rigorous and complete, for what we had in abundant supply was 'clinical material': the disinherited and oppressed from the townships and bleak rural homelands.
We would see pathology that had all but disappeared in the developed West. TB patients coughed up bloody sputum, their heaving chests resonant from cavities where the disease had corroded their lungs. On the neurology ward a patient, asked to stand, would reel when he closed his eyes, and walk with stamping, uncertain feet. 'Come now,' our tutor challenged, 'are we looking at Beriberi or General Paresis of the Insane?' and we would strain our diagnostic faculties to try to distinguish vitamin-deficient dementia from delusions of grandeur, and to identify the vacant face and irregular pupils of advanced syphilis. Schizophrenics would be admitted to the psychiatric wards with florid catatonia, holding for hours the positions in which their ductile limbs were placed. By the time some cancer patients reached us from the rural areas their tumours would be huge and ulcerating and beyond hope: graphic opportunities for the surgeons to demonstrate to us their cutting skills.
There was also exposure to more acute surgical crises. Violence seemed to be the main export of the Cape Flats townships. Those of us who wished could spend nights working in the accident and emergency department, clamping arteries and stitching wounds. An excitable camaraderie embraced us all -- nurses, orderlies, students and casualty officers -- facing that steady tide of perforated bodies, as we worked together to stop bleeding and stabilize vital signs. I began to gain a little more confidence in my skills and judgement, but remained in awe of the registrars and consultants who stood solid in that workshop of pain, making life -- saving decisions. It was terrifying to imagine that I might ever have to shoulder such responsibilities myself.
Other experiences invoked a vertiginous awareness of our own mortality. We saw patients pass through the terminal stages of illness, and followed the hospital cardiac arrest teams to hover at the fringes of unsuccessful resuscitations. Learning clinical pathology, we crowded around the autopsy tables to see the face of victorious disease. Probably for the first time, I truly realized that one day I would die. It was disturbingly easy to imagine myself on the slab, sliced and gutted, with the pathologist opening my chest with a buzzsaw and his assistant sluicing away the blood clots. Most graphic were the sights in the police mortuary, where, during our study of forensic medicine, we would see every permutation of unnatural death.
The white bodies tended to be tidier. There was a regular attrition among young men in that society, who went scuba diving and hang-gliding and rock climbing, or drove too fast on winding mountain roads. A few, beaten down by loneliness or the fear of failure, would hang themselves or take fatal overdoses. In the 'non-white' mortuary (here too the principle of racial segregation was observed) the corpses were less reposeful: dead from spear-thrust, gunshot and axe. Bodies were disembowelled, bled dry from multiple chop-wounds, or contracted and charred by fire. They came from a place beyond the frontier of our known lives, where other rules of death appeared to prevail.
What we felt about that place was a sort of horror. People slaughtered each other there in a malevolent frenzy. One day, on the autopsy table, lay the body of a young woman. She was exquisitely beautiful. Even the coarse line of undertaker's stitches that ran from her neck down between her breasts to her pubic hair could not diminish her perfection. She had bled to death; gang-raped and then dispatched with a bottle kicked up her vagina that had shattered, slashing the arteries in her pelvis. The social theorists would explain such incidents as the product of economic despair, or rage at the impotence that apartheid had produced among the dispossessed. I felt dizzy, terrified at the thought of such contemptuous destruction. The only way to deal with that fear was to keep it at bay through clinical detachment, clinical study.
So we lay on the beach and studied, slept and studied, fell in love and studied. A number of my classmates were pairing off, getting married, setting up medical partnerships for the future. Others were planning to specialize, dreaming of a secure future of private practice and social standing. When I visited Durban my parents' friends smiled at me, and nodded their approval.
'You'll do orthopaedics, like your father,' they suggested. 'You can join his practice. One day he'll need someone to carry on his work.'
The idea seemed quite improbable. The charm of the city's avenues of jacaranda trees, the genteel respect of my father's patients, even his worthy work at the black leper hospital up the coast, appeared irrelevant and transitory. Something apocalyptic was about to happen.
In 1975 the South African army invaded Angola. Late the previous year there had been a coup in Portugal, led by junior officers against a senile military government. The officers objected to the slaughter of so many young conscripts in the Portuguese colonies of Angola and Mozambique, where they were fighting an unwinnable conflict against black independence movements. Their first move on taking power was to divest Portugal of its overseas possessions. Suddenly the colonial authorities were gone, along with many of the white settlers. Units of the main Angolan independence force, the MPLA (Popular Movement for the Liberation of Angola) entered the capital. Shortly afterwards there was heavy fighting to the south of the city, and a column of tanks and troops rolled in; white men speaking Afrikaans. The South African army was operating outside its country's borders for the first time since the Second World War.
I expected, like all white males in South Africa, to do National Service. Call-up came directly on leaving school at sixteen or seventeen to spend a year in desolate base towns in the Karoo or the Highveld, being bullied through drill and inspections by Permanent Force sergeants. For farm kids it represented a chance to experience the sophisticated delights of tinned food and a daily change of socks. City boys aimed for the navy, where they might have a chance to polish their surfing skills in Cape Town or Durban. You could apply for deferment to go to university, at the end of which you were called up anyway, to apply your tertiary education in mysterious ways: accountants would be sent to repair tanks, engineers to army intelligence, linguists to the quartermaster's arm. For most young men, service in the South African Defence force offered the prospect of a long period of dullness, enlivened only by the opportunity for some gratuitous damage to government property such as rolling a Bedford truck. The army had a high rate of serious motor accidents. Only graduating doctors could find any merit in this; drafted into the medical corps once you'd finished your year of hospital internship, you might see some vehicle trauma between treating conscripts' athlete's foot.
Now all that was changed. The Angolan invasion had been repelled by Cuban troops airlifted in to help the MPLA. Driven back to South West Africa, the army dug in along the Angolan border. The 'operational zone' extended from the Atlantic coast in the west to Rhodesia, where Ian Smith's government was losing its own war against black guerrilla forces. It was in the operational zone that you now did your service, which was extended to two years. From the border district of Ovamboland the army launched regular attacks into Angola. Even Ovamboland was enemy territory: the populace were supporters of SWAPO, the South West African Peoples' Organization, whose military wing was waging its own struggle against the South African occupiers.
The next year things got worse. In 1976 the Pretoria government decided that all black schoolchildren across South Africa should be taught in Afrikaans. There was enormous resentment against the decree. It was pointed out that few children, or their teachers, knew the language. Petitions were submitted, school deputations sent to the government. All were ignored. The children poured out of their schools onto the streets of Soweto, waving rough placards. The police opened fire, killing some kids and wounding many others. The accumulated pressures of almost thirty years of apartheid could no longer be contained. Pupils, parents and workers marched on every symbol of the hated system -- schools, administration offices, government beerhalls -- and burned them to the ground. Roads were blocked with flaming tyres. For two days the police couldn't enter Soweto, until they came in armoured cars. It took months to crush the uprising in the townships around Johannesburg, by which time it had spread across the country.
Many hundred of blacks died, and a few whites; killed by mobs as they drove too near to the townships and were caught in the conflagration. Suddenly all those atavistic fears of ravening black hordes seemed about to become reality. As unrest became endemic, the tacticians of apartheid declared that the 'Total Onslaught' was upon us, and a 'Total Strategy' was needed to counter it. The army, already aggressively committed along the borders, would now also serve in the townships. The war was everywhere, but it hadn't yet touched me directly. In the temporary stillness of the storm's center I concentrated on learning my art.
Excerpted from THE DRESSING STATION. Copyright © 2002 by Jonathan Kaplan. Reprinted with permission from Grove Atlantic, Inc. All rights reserved.
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