BMJ No 7120 Volume 315
Education and debate Saturday 29 November 1997
Walk in peace: banish landmines from our globe
Eoin O'BrienIn Memoriam: Diana, Princess of Wales
These words are dedicated to the memory of Diana, Princess of Wales. She, perhaps more than any other individual, in reaching out to the ravaged victims of landmines, advanced the growing demand for a total ban on these vile weapons. Her courage in exposing the hypocrisy of governments, her own included, and her compassion for the suffering in mine infested countries, must not be to no avail. Rather it is for us to continue and to accelerate the impetus she gave to banishing landmines from our globe, so that we can then begin to cleanse the 60 nations in which more than 100 million mines have been scattered, and permit the people - the children in particular, so much loved by Diana - to walk again in peace.The sun, deepest red at first then shimmering to gold rising over the hills of the plains, casts the father, his young son, and their dog into black relief against the sky brightening gently, imperceptibly, and reluctantly, from the dark of night to the gold of dawn. Their silhouettes slowly emerge from the darkness; the tall gaunt figure of the father, staff in one hand, a sackbag over his shoulder, the boy hopping lightly beside him holding his other hand, and the dog gambolling along between them. The father and his son are clothed scantily, both are barefoot, and their skeletal transparency betrays the hardship of chronic malnutrition. Yet the figures carry a dignity, an almost biblical majesty, as they move gracefully on their way. They are heading for a small plot from which they eke a frugal existence, that is when the crop does not fail, or war and strife does not force them to move onwards. But an uneasy stability in their region has allowed them to make this journey to their plot daily for some years.
| A movement ahead attracts the dog, which darts suddenly from the man
and boy to chase a field rat. The morning sky is rent with red as the
body of the dog is sundered against the blueness, and the morning
stillness of the plain is shattered by the blast. Before the father can
react to the danger he knows so well, his son is running from the path
to save his beloved dog and another ghastly blast rents the air. The
father in anguish rushes headlong towards his boy, who lies moaning
where he has been thrown, like a rag doll against the stump of a tree,
one leg shattered. The third blast fells the father just as he reaches
his son and shrapnel pierces the eyes of the boy.
As the smoke and dust settle the scene of carnage becomes clear to the gathering villagers clustered on the edge of the path from which the trio had departed. The dog's entrails and limbs are strewn over a wide area. The boy has crawled whimpering from the tree stump, leaving a trail of blood as he drags his shattered limb along the soil. But he has reached his unconscious father, both of whose legs have disappeared. Here they lie, pathetic crumpled vestiges of humanity. |  |
One of the younger men from the village discusses with another the path the stricken pair had taken and then advancing inch by inch, probing the ground ahead and on either side with metal rods, they slowly reach them, and as slowly drag them back, probing the ground inch by inch in reverse until they reach the path. Both father and son are now unconscious. The father is losing blood rapidly from one of his shattered legs, from which the bone protrudes obscenely. The son's leg oozes blood. The women wrap the stumps in rags moistened in a nearby rivulet from which cattle drink and in which the villagers wash. One of the men uses another piece of rag as a tourniquet to staunch the systolic ejaculations from the father's left stump.
A team of young men begin the journey to the only hospital 20 miles away. The boy is strapped to the back of one of the men and two others take the ends of a makeshift hammock on which the father is lain. This is better than a stretcher, even had such been available, as it allows them to ascend and descend the many hills between the village and their destination. Another two carry frugal supplies and some water. Ten hours later they reach the huts comprising the hospital that serves a region of some 400 square miles. The boy is in profound shock and the father is delirious.
The only surgeon to the hospital decides the boy is the more critical of the two. Two nurses tend to the father. The left leg, which had been shattered in its lower third, is now gangrenous from the tourniquet, which had not been released, and this will have to be amputated from the thigh. It may be possible to perform a below knee amputation of the right leg. The genitalia have been badly wounded by ascending shrapnel and there are a series of infected puncture wounds along the right side of the thorax. Debridement will take many hours. A unit of blood is all that the hospital can spare for the man.
The surgeon takes the young boy to theatre and looks with sadness and anger at what he has seen so often. He thinks of his own son and begins to work. The boy is shocked and dehydrated and it can be taken for granted that the wounds are severely infected. There are no intravenous antibiotics, but out of date penicillin solutions kindly donated by a charity in a far away country of affluence is administered by nasogastric tube. The surgeon orders that two units of blood be given, even though the hospital ruling is that only one can be given in all save the most extreme emergencies: this he deems to be such. Anaesthesia like everything else being scarce, is given sparingly, and fortuitously is little needed at this stage. Apart from the shattered leg there are multiple wounds all over the frail frame. Both eyes are beyond salvage, but the shrapnel and soil must be removed. A penetrating wound like a stab wound from a knife on the left side of the jaw, on closer inspection, extends ominously into the palate and possibly further, leaving the surgeon to wonder whether, if he repairs this tragic wreck, all will be lost later from meningitis.
But he has to start and he does so with the facial and body wounds, probing for the plastic and metal components of these cruel weapons, made all the more deadly by the soil, grass, and grit which contaminates them. Finally, he gives his attention to the stump, deciding that such will be the advantages to this child in future life of having a prosthesis below the knee that the risks of saving the joint are worthwhile, though he does not like the look of the badly shattered tibia that extrudes beneath the coagulated contaminated tissue. As he works he thinks of the blind child's future as a cripple. He knows only too well that as the boy grows older, the bone of the amputation stump will grow more rapidly than the surrounding skin and soft tissues and he will need multiple reamputations. He knows that frequent infection of the amputation stump with recurrent pain will render a prosthesis intolerable and add to the child's decrepitude. He asks the nurse to give more anaesthesia as he saws off the shattered bone to leave a clean sunken shaft around which he can mould the soft tissues and skin.
| He has been operating for three hours. As he works he reflects that if
this boy - What age could he be? No more than 10? - was to be granted a
life expectancy of another 40 years, which might be about right for
these parts, he will probably need 25 prostheses in his lifetime. But
the child was not so destined and he died on the operating table an
hour later.
His father survived. Let us use that word literally. He survived and returned to his wife and family without his son and dog in a straw chair with scant hope of receiving even a rudimentary prosthesis, the stumps protruding hideously, a constant memory of an awful moment, a legacy from a war that had ended 12 years earlier and one in which he had not been involved other than as one of thousands who, with his family, had had to flee from one district to the next, in the ethnic wave that had swept his land. He was destined now to an even more uncertain existence than before and without a son to support him in his old age. He never laughed again, or cried, as he suffered the pains of his wounds, but it was the inner pain that scorched his mind, where it burned so incessantly as to all but consume him in its intensity. Humanity in ruins but, alas, not annihilated. |  |
Royal College of Surgeons in
Ireland Medical School,
St Stephen's Green,
Dublin 2
Eoin
O'Brien, consultant cardiologist
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