As we pull up to the hospital, Dr. Faslic hurries out to welcome us. He is a short, energetic man in his fifties, whose gait is a quick hobble because of a bullet lodged deep in his right ankle. Dr. Faslic is the only plastic surgeon in the Tuzla region of Bosnia, but now his specialty is war surgery. When the war broke out in March 1992, he left his practice to set up and staff field hospitals. He now travels with a small team of doctors, nurses, and technicians to help out wherever they are needed. Today Dr. Faslic is helping set up a new field hospital near the front lines.
I, too, try to help where I can--I’m a physician working for Doctors Without Borders, an international aid organization that provides medical care wherever needed, regardless of individuals’ political loyalties. Today I am delivering supplies.
Dr. Faslic is especially pleased that I could bring him the portable operating room lamp he had requested. The hospital still lacks equipment, he says, but the lamp will be a big help. Haris, my Bosnian assistant, and I have also brought our usual stock of supplies--gauze, antibiotics, painkillers, anesthetics, and disinfectants. As Haris unloads the supplies, Dr. Faslic shows me around the hospital.
Most of Bosnia’s field hospitals are in converted private homes, old chicken farms, or hunting lodges. But this one has been built in a low building roofed with heavy timber and sunk into the base of a cliff. It looks more like a bomb shelter than a hospital. But for a facility less than a kilometer from the front and well within reach of Serb heavy artillery, its cavelike design is prudent preventive medicine.
Just as we go through the hospital’s thick doorway, we hear two low thuds. Nobody flinches, not even me, because the shells have landed about 300 yards away. They’ve started in on the town again, says Dr. Faslic, gesturing toward the hills. I nod. I realize I’m not wearing my bulletproof vest.
I hadn’t expected to be here, or anywhere near here, for that matter; my original assignment had been to run a small field hospital in Somalia. You must be crazy, my friends said. It’s dangerous over there. I had replied with a nervous laugh, Come on, it’s not so bad--at least I’m not going to Bosnia.
But a twist of fate brought me to Tuzla. When I arrived at the medical organization’s European headquarters in April 1993, I learned that the Somalia team had just been evacuated. I was quickly reassigned, and four days later I boarded a plane to Bosnia, carrying a satellite fax machine and a suitcase containing a bulletproof vest. In Bosnia, I soon learned that BP did not stand for blood pressure but for the dark, heavy vest filled with ceramic plates that provided a sometimes sweaty sense of security near the front lines.
This was not my first mission. I had spent four months coordinating the health care of 50,000 Burmese refugees who had fled to neighboring Bangladesh. We had started a vaccination program and set up clinics to treat mothers and their children. And we had cared for patients with severe malaria, cholera, diphtheria, and pneumonia in a hospital with bamboo walls and a dirt floor. I’d figured people must be pretty desperate to seek refuge in Bangladesh. I’d been right.
Bosnia is different. Unlike Bangladesh, Bosnia has a healthy population and plenty of well-trained doctors and nurses. The problem here is logistic: in the areas surrounded by opposing forces, hospitals have no way to get supplies or equipment. Thus our task--on all sides of the conflict--was to figure out what supplies doctors needed and then find a way to make damn sure they got them.
Surrounded on three sides by Serb forces, the Tuzla region depends on supplies that must pass through a fiercely contested corridor controlled by the Bosnian government. The new field hospital is being set up on this narrow strip so that patients won’t have to spend their first hour after injury, the critical golden hour, in the back of a car trying to survive the journey to the nearest surgeon. I had agreed that Doctors Without Borders would equip the new hospital.
To reach the hospital we passed along a stretch of road nicknamed Bomb Alley. Just a week after my arrival in Tuzla a British convoy leader was hit by a Serbian shell while trying to repair a truck, but over the past few weeks the road has been quiet.
Dr. Faslic and I are standing just outside the hospital when two small cars come screeching up, their horns blaring. The two shells we heard had struck near a stream where four people were gathering water. Two were killed on the spot; the other two--a man and a woman--are severely injured. The staff acts swiftly, hauling them out of the cars and carrying them into the hospital. The room brightens as the generator starts up.
Shrapnel has nicked the young man’s spinal cord, and the young woman’s right leg is badly mangled. Dr. Faslic attends first to the young man, whose injuries are more serious. He delicately slides a breathing tube into his patient’s windpipe so that a nurse can pump air into his lungs. But the staff cannot do more for him here. This man needs a respirator to do the work his diaphragm will never do again. Death from pneumonia will probably follow in a few days. Nonetheless, he is readied for transfer to a hospital in Tuzla. Bosnian doctors do not like to give up.
I try to comfort the young woman, whose name is Alma. Although her right thigh has been nearly destroyed, the bleeding has been controlled, and with intravenous fluids her blood pressure returns. I make sure that her IV lines are flowing and that she receives medication to relieve her pain. But then, although I am trained in general surgery, I step back. Surgery is not my job here, and I have earned the trust of the doctors in the Tuzla region by not telling them what to do.
I pass my hand through Alma’s hair, trying to brush the terror out of her eyes. I speak to her calmly. Though she cannot understand my English, I believe my presence comforts her. I know if we amputate immediately, she will live.
From a sheerly technical standpoint, amputating a leg is simple. In fact, the surgical technique has changed very little since the U.S. Civil War. Still, in other ways it is among the most difficult operations a surgeon can perform. You decide whether the leg must be severed above or below the knee and then use a scalpel to cut down to the bone. You pause for a moment to clamp and tie the leg’s major artery and vein. Then, using a foot-long serrated wire that looks as if it belongs in a carpentry shop, you saw through the bone, being careful to leave a flap of healthy skin, usually from the back of the leg, to fold over and cover the wound.
Under normal operating conditions, you then stitch the wound closed. But when the wound is messy and dirty, you stitch the tissue just enough to hold the flap in place, leaving the edges loose to allow the wound to drain, helping prevent infection. Then you must dispose of the limb. And that is what makes the operation so difficult. There is an air of death about a severed limb, and it is one you know you have created.
Dr. Faslic now turns to Alma. He does not want to amputate, he tells me, because he feels the new hospital is not yet prepared for operations. Because I have helped equip the hospital, I believe they have what they need to save her. Among the supplies I provided is an amputation kit containing a small saw and an anesthetic called ketamine. Commonly used in war-torn areas served by relief workers, ketamine is an excellent anesthetic that puts patients to sleep without slowing their breathing. Its only drawback is that patients anesthetized with ketamine sometimes awaken with hallucinations. When operating during a war, however, you trade unpleasant side effects for improved patient survival. Bosnian doctors, though, don’t like ketamine. They consider it a Third World drug.
Bosnian doctors are so accustomed to providing sophisticated medical care that they are often extremely reluctant to adjust their methods to the grim realities of the war. It is an attitude I am loath to criticize, for I share their desire to do the very best for their patients. But I am caught in the middle. Emergency relief organizations, which provide the supplies I distribute, will send only the basics--gauze, painkillers, antibiotics, amputation kits, and ketamine. It is not appropriate, the donors say, to provide sophisticated equipment in a war zone. Maybe they are right. But what is not appropriate, I sometimes want to shout, is to allow a war to drag on for nearly three years, anywhere, in 1994.
Fifteen minutes after the two patients arrive, they are ready to be moved. The young man, if he survives, will arrive at a Tuzla hospital in about two hours. Alma will be taken to another field hospital nearby, where there is a vascular surgeon and a functioning operating room. She looks alert as she is whisked out the door, and I hope she will survive the 45- minute ride. Will they amputate, I wonder, or will the surgeon try to save her leg?
Dr. Faslic and I resume our tour of the hospital. He points out the hillside site where they are building a pharmacy and housing for the staff. As we finish up, he mentions that he needs tools--surgical drills, screws, and bolts--for repairing complicated arm and leg fractures. I take note of his needs and promise to return in a few weeks.
Haris has finished unloading the supplies, so we can be on our way. As we pull away from the hospital, Haris slips in a tape of Bob Marley. Everything’s gonna be all right, goes the ragged refrain. I cannot help thinking of Alma. Did Dr. Faslic transfer her because he was not satisfied with the level of care they can provide in the new hospital, or because he hopes the vascular surgeon can save her leg?
Haris, do you think they will try to save her leg? Haris is only 23, but he has the wisdom acquired from months spent on the front and in a Serb concentration camp. I value his advice for every big decision I make.
I don’t know, Michael, I’m just a driver, he says dryly, referring to the title on his ID card. That is his stock reply when he is uncomfortable with my questions. I find myself hoping that the vascular surgeon does not try to save Alma’s leg. It would require a long, complicated operation, difficult even in the most sophisticated hospital setting. Field hospitals can provide rudimentary care, but they lack equipment to monitor the heart and lungs, and without such equipment the risk of dying in a long operation rises steeply. But I say nothing. I do not want to appear to criticize Bosnian doctors.
Halfway back to Tuzla we stop at the field hospital where the young woman was taken. The doctor’s wife invites us in for a cup of coffee. In Bosnia, where coffee prices can soar to $80 a pound, this is a rare pleasure. On our way in, I step into the operating room. The vascular surgeon looks up from the table and says with satisfaction that he has succeeded in grafting a vein from the young woman’s good leg into her damaged leg. Now there is good blood flow, he says. Her leg is saved. I congratulate him, for I am truly pleased when my medical judgment is wrong and a patient does better than I expect. I didn’t think her leg could be saved. Although there has been no way to monitor her heart during the operation, she seems to be doing fine. After all, she has youth and health on her side.
Haris and I thank the staff for their hospitality and return to the road. We would like to get back to Tuzla before dark.
Several weeks later we stop by the underground hospital to deliver the supplies Dr. Faslic requested. The hospital is now fully functioning, and the staff proudly displays the log of operations they’ve performed. As we are leaving I ask if they know how Alma is doing. The room is quiet. She had a heart attack on the operating table at the end of the six-hour operation, says Dr. Faslic.
We will never know why Alma died. When a patient has lost a lot of blood, there are many reasons the heart would fail during a long, unmonitored operation. Monitoring a patient’s heart looks simple: all it takes are a couple of leads to detect an irregular heartbeat well before the heart actually stops. And it takes just a small clip on the finger to learn how much oxygen the lungs are sending out to the body. But these leads are attached to machines that cost thousands of dollars, and no field hospital around Tuzla has them. Without them, it would be impossible to know when to give the fluids, blood, or drugs that might have stabilized her heart and saved her life. If her leg had been amputated--a much shorter and simpler operation--I think Alma would have survived.
But it is not my task to tell my Bosnian colleagues how to treat their patients, even if I believe their efforts to provide state-of-the-art medical care can cost lives. And I am unable to convince aid organizations to buy expensive equipment for use in a war zone.
Many patients have died in this war, in spite of the brave efforts of my friends and colleagues in the front-line field hospitals. Still, Alma’s death is frustrating. I just do not know what more I could have done. But that is the tragedy of Bosnia.
Haris and I are silent on the drive to Tuzla. It is almost dusk. The way back takes us past steep gorges, thick forests, and small family farms. In all that is said about Bosnia, nobody ever bothers to mention that it is incredibly beautiful.