The BEARR Trust Lecture

Surgery on the front line in Ukraine: David Nott in conversation with Bridget Kendall

Ross Gill, BEARR Trustee
June 2022

David Nott is one of the world’s most experienced trauma surgeons. Since the conflict in Bosnia-Herzegovina in 1992, he has been on some 27 missions to war zones around the world, supporting local doctors in treating war casualties. Together with his wife Ellie, he established the David Nott Foundation in 2013, which has so far trained over 1,000 war doctors worldwide.

Since the Russian invasion of Ukraine, David has supported doctors in Dnipro, Kyiv and Kharkiv. In June, he spoke in conversation with Bridget Kendall, the BBC’s former Moscow and Diplomatic Correspondent and a patron of the BEARR Trust, about his inspirational work amid the brutality of war. You can watch the full recording of their conversation on our YouTube channel here.

As a young registrar at Manchester Royal Infirmary, David remembers going with his father to see the 1984 film The Killing Fields, set in the time of Khmer Rouge regime in Cambodia. At the end of the film, the two journalists at the centre of the plot meet at a Red Cross refugee camp: at that point, the ‘penny dropped’ and he knew his vocation in humanitarian work.

A few years later, in 1992, he became a consultant at Charing Cross Hospital as the Bosnian war worsened. With the medical situation on the ground deteriorating, he approached Médecins sans Frontières and asked if he could help: MSF asked if he could go the following day, and Bosnia became his first mission. Since then, his work has taken him to war zones in Afghanistan, Sierra Leone, Liberia, Ivory Coast, Yemen, Syria and elsewhere, working alongside aid agencies.

This year, Ukraine sadly became his latest theatre of conflict. He knew from his experiences in Syria how the “complete lack of humanity” of Russian bombardment had destroyed Aleppo and could see the same happening again in Ukraine. With the help of the neurosurgeon Henry Marsh, who has worked extensively in Ukraine, he engaged with over 500 doctors remotely, before arriving in Ukraine in April. Since then, he trained some 36 doctors in Dnipro through the David Nott Foundation’s Hostile Environment Surgical Training (HEST) course, and over 30 in Kharkiv. Currently, the Foundation is in discussions with the Ukrainian Ministry of Health to run a ‘train the trainers’ course, training local doctors to deliver training to others.

Blast injuries of the type endured in war are outside of most surgeons’ experience, as is the pressure of triaging multiple, often horrific, casualties following a bomb attack. For many medics, the ‘normal’ experience of conventional elective surgery is replaced by injuries of a much greater order of magnitude. David’s direct support and training helps doctors to respond. But empathy is vital as well: many of the doctors David worked with in Dnipro already had previous experience from the conflict in the Donbas, but reassurance and understanding was important alongside training.

David and his team in June 2022 delivering HEST courses in Dnipro and Kharkiv.

New technology and human empathy

Since David’s work in conflict zones started, technology has moved on at pace: he has been able to direct operations via Skype, much advice can be given over WhatsApp and other channels, and opportunities for people with experience in conflict zones to network and exchange good practice across multiple countries has increased greatly.  However, this doesn’t compensate for being present in the field, which remains central to David’s work. Demonstrating commitment and solidarity supports the morale of the doctors in the front line, and in an intense working environment, it is also important to build up close relationships with co-workers and to understand the specifics of the situation that they face. That can take three to four weeks of working alongside colleagues in a hospital, in situations where language barriers present a further obstacle.

Getting the right equipment is obviously important as well. In general, David has found that the hospitals in Ukraine have been better equipped than those in Yemen or Syria – as might be expected, given the relative ease of importing equipment from the west. But hospitals in the east of the country face greater challenges, and the nature of war means that supplies can be quickly exhausted. The Foundation has left some specialist equipment with hospitals in Ukraine, and charities in the UK and elsewhere are doing an important job in getting first aid and other equipment out to where it is needed. However, equipment to support the David Nott Foundation’s training course is costly: tens of thousands have been invested in ‘HESTON’, the Foundation’s ‘model human’, with development of an enhanced version underway.

Meet HESTON, the David Nott Foundation’s life-sized replica human crafted from silicon.

Accounting for war crimes

There is evidence of war crimes in Ukraine, including the targeting of hospitals. In multiple war zones, David and his colleagues have accumulated evidence of crimes against civilians, but he is sceptical that the perpetrators will see justice: in the UK, he spoke to several MPs about the atrocities he witnessed in Syria, but to date, there has been limited progress. In the case of Ukraine, Russia’s permanent membership of the UN Security Council limits the action likely to be taken until there is domestic political change – but in the meantime, it remains important to “keep banging the drum and being angry” and to document and draw attention to the evidence.

The NHS connection

Although David is best known for his international humanitarian work, he continues his work as a consultant at St Mary’s Hospital, London: he was at work at St Mary’s the day after returning from Kharkiv earlier this year, and described his continuing commitment to and enthusiasm for the NHS at home. Gaining experience and expertise through the NHS remains the route into humanitarian medical work: it is with experience at consultant level that expertise becomes valuable, although there is a need for a wide range of medical specialisms.

Personal challenges

Supporting surgeons and doctors in conflict zones is intense and often traumatic. The mental health consequences both for those in the frontline of support and for the victims of war are often profound, and through its Ukraine Appeal, the BEARR Trust is supporting several organisations providing psychological support. It can be hard for people to recognise their own mental health needs, as David recounted from personal experience.

Working in very dangerous situations also presents its own stark moral challenges. In Gaza, David was about to operate on a seven-year-old girl, whose condition was critical, when he was advised to evacuate the hospital in anticipation of imminent attack. He stayed: the operation on the girl was successful, and the attack never materialised. The right choice, then: but there are many difficult and profound choices in extreme circumstances.

For all that, David’s commitment to thirty years’ humanitarian work shines through. The enthusiasm is constantly there: in doing the best for patients and fellow medics in the worst of times, “I’ve never felt so elated in my life”.

All funds raised from David Nott in conversation with Bridget Kendall will be donated equally to the BEARR Trust and the David Nott Foundation.

David Nott, ‘War Doctor: Surgery on the Front Line’ (Pan Macmillan, 2020) is available in paperback, price £9.99.

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