'War Doctor' David Nott: Treating COVID-19 Is Like Fighting An Invisible Enemy : Shots - Health News Trauma surgeon David Nott has volunteered in war zones and disaster areas around the world. Now he's treating COVID-19 patients in London. He calls the pandemic a "disaster zone for the whole world."
NPR logo

'War Doctor' Says Treating COVID-19 Is Like Fighting An Invisible Enemy

  • Download
  • <iframe src="https://www.npr.org/player/embed/824703205/826035789" width="100%" height="290" frameborder="0" scrolling="no" title="NPR embedded audio player">
  • Transcript
'War Doctor' Says Treating COVID-19 Is Like Fighting An Invisible Enemy

'War Doctor' Says Treating COVID-19 Is Like Fighting An Invisible Enemy

  • Download
  • <iframe src="https://www.npr.org/player/embed/824703205/826035789" width="100%" height="290" frameborder="0" scrolling="no" title="NPR embedded audio player">
  • Transcript

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. My guest is a world-renowned trauma surgeon who has worked in war zones around the globe. The war he's fighting now is against the coronavirus in London, where he lives. And he is applying some of what he learned working in other peoples' wars and disasters. For 25 years, David Nott spent several weeks each year volunteering in some of the world's most dangerous conflict zones, including Syria, Afghanistan, Congo, Iraq, Yemen and Sarajevo. He's also worked in countries after natural disasters.

When he started to question how many times he could cheat death, he decided to start changing the nature of his work by training front-line surgeons in conflict and natural disaster zones around the world. He does this work through the David Nott Foundation and the Royal College of Surgeons. He also works at two London hospitals. Queen Elizabeth awarded him the title Officer of the British Empire for his medical work in war zones.

His memoir, "War Doctor: Surgery On The Front Line," has just been published in the U.S. He spoke to me by Skype from one of the hospitals in London that he works in. Just as we were about to start recording, Dr. Nott got an emergency phone call from one of his international medical contacts about a young woman in Syria who needed a cesarean and was being evacuated to a doctor. But the doctor had never performed a cesarean and needed Dr. Nott to guide him by phone. We started our interview as he waited to hear about the next step.

DAVID NOTT: So this call that you heard a few minutes ago was a desperation call from a refugee camp in Syria asking me whether I would help to take somebody through a cesarean section - somebody who has never done a cesarean section before - and to give them the ways how to do it over the phone. And I'm not quite sure yet because, as I said before when we started this interview, it may be such that I may have to go onto Skype to see the patient. Or we may have to do it over the phone.

But it has happened to me several times before that I have had to help people do procedures which they've never done before. This one can be particularly dangerous because, apparently, it's a 19-year-old girl in a refugee camp with an obstructed labor. And she's critically ill. And so it's a matter of I just need a bit more information, which I should get that very shortly, about the state of the mother, the state of the baby and how much clinical knowledge does the person that wants to do the cesarean section.

It's very unusual that I'm helping somebody that doesn't have huge surgical skills. But you cannot turn those people down and say, I'm sorry. I don't trust who you are or what you're going to do. You just need to get a bit more information. And that's, in fact, what I'm waiting for in the next few minutes.

GROSS: Yes. And if our interview has to be interrupted so you can save the mother's life and the baby's life, we will all understand. So let me ask you about the work you're doing now with COVID-19. I know everyone at your foundation is working at home now. Are you in touch with doctors around the world dealing with the virus?

NOTT: Well, yes and no. I work at Imperial College in London. And there are lots of people that work here as well. And there's lots of epidemiologists, statisticians. And people are working very hard on modeling systems and so on. They're in contact, really, with most of the people throughout the world. They're in contact with people in the U.S., Italy, Spain, China, Germany, Iran, France and so on and so forth. And I think they're really getting a grip of the situation, which is, unfortunately, still out of control and escalating rapidly.

So I'm offering my clinical help to my colleagues on the ground almost on a one-to-one basis rather than offering a great amount of epidemiological skills, which I don't have. But the skills I do have are working in disaster zones and war zones. And I had a discussion with the government, British government, a couple of days ago, a face-to-face discussion with them, about that, of course, in war zones and disaster zones, there are still people that aren't affected by the problems associated with the tsunami of viruses and so and so forth. And those people need, also, to be looked after. And you need to be regularly in contact with them on the phone.

And we're doing clinics on the phone. I did a clinic this morning on the phone just to check on my patients to make sure that they were OK. And one wasn't OK. So I asked them to come along. And so it's a matter of providing that sort of health care and support to other people.

Of course, there are people with colorectal cancers and chemotherapy and lots of other illnesses - cardiac and vascular problems - that are still having an ongoing problem. And those patients have been put to one side at the moment to make space for the COVID-19. But we mustn't forget those patients. And we must offer them help as well. And that's what I was in the government meetings on Friday discussing, ways of managing that problem.

GROSS: So do you have protective gear? There are a lot of doctors and nurses in the U.S. who don't have masks and who don't have the right gowns. And doctors are really risking their lives in the U.S. to take care of coronavirus patients. Are doctors in London in the same situation?

NOTT: I'm afraid so. We are struggling at the moment to get our protective equipment. It is coming. And we are just using normal face masks and plastic aprons, which isn't good enough. And there's lot of edicts coming out from various authorities on what sort of personal protective equipment you should have.

We've all been tested to get the right face masks for us. And when we go to the operating theater, we do have the right face masks. And we have the right visors and so on. But there's not enough equipment at the moment. And we're hopeful - in the next day or two or three - that that will come. So you've got to appreciate that it really has taken the world by storm. And we do need to have a degree of realism when it comes to getting our PPEs, which I'm sure will happen very shortly.

GROSS: Are there aspects of treating the pandemic that doctors who aren't medically or psychologically trained for war zones are unprepared for? Because doctors are, in a way, risking their lives taking care of patients. It's not bombs or guns that's going to kill them. But it's the virus itself that puts medical workers at risk. So are you talking to doctors about doing this, at this point, very risky work?

NOTT: Yes. And, in fact, last week, the Intensive Care Society from the U.K. asked me to make a video for the intensive care doctors, because, I mean, when I go to a war zone or when I go to a catastrophe area, I volunteer to go. It's not that it's part of my job. I take time off my job. And I go and volunteer to go and work in those places because it's something that I feel I have - a reason for going is that I really want to help people.

But everybody in this pandemic, in the U.S. or in the U.K., has not volunteered to go. We're just there. And so, it's a huge change in the way that your brain works. And you will see things that you have never seen before. You will make decisions which you've never made before. You will have to make very difficult decisions, which are those difficult decisions which you actually make in war zones about saving somebodies life if you've got, you know, one pint of blood.

But if you can't save somebody else's life who need five pints of blood because you haven't got five pints of blood, then you have to let that patient die even if that patient is fit and well. And it's, again, making those very difficult decisions, which we all have to make now because of the aspect of the ventilators, that we don't have enough ventilators. Or, you know, we're worried that we're going to run out of ventilators. And, of course, then it's making those very difficult decisions on which patients you should ventilate because the virus is so contagious. There are reports from your country, from the U.S., that between 70% to 90% of people that go on a ventilator eventually die. We have reports at the moment in the U.K. - and it may be that we - not putting everybody on a ventilator - that about 50% or 60% of those that go on a ventilator will be - will, unfortunately, pass away after two weeks or so. So it's then making those decisions on which patient, depending on the morbidity and - that that patient actually has, whether that patient should have that ventilator. Because if you have somebody who's 82 on a ventilator and then you get somebody who's 35 with exactly the same problems and you haven't got that ventilator for that 35-year-old, you know, the 35-year-old will die.

In fact, we shouldn't think that this is an emergency. It's a world disaster. It's a disaster zone for the whole world. And that's the way - also, we were discussing with the government on Friday that that's the sort of head that you need to put on your shoulders. It's a different mindset compared to what a simple emergency would be.

And I made this video. And it's been seen, I think, by hundreds of people now about how you feel psychologically as well, that you will feel dreadful. And you'll go home, and you'll, you know, you'll cry sometimes because the stress is just too much. And you must talk to your family members. And you must get help.

GROSS: How are you talking to doctors and nurses about dealing with the sense of guilt when they have to let one patient go to let another survive?

NOTT: Well, it's really difficult. And we're all in this together. And you don't make those decisions on your own. You make them with a team. And the team has to realize that we have - we call them pods, really. So there's five of - we all look after about five ventilated patients in our pod. We have a senior who's in charge of the whole ICU. So that person, then, is in charge. And you go up to that person, say, look; I've got this problem. And so you work at it as a team rather than individual. And that seems to have a significant - make it easier to take the stress on board.

But, of course, everybody goes home with their individual problems. And it's recognizing that somebody is not coping on the medical nursing floor that you need to be aware of. And sometimes it's quite insidious. Sometimes it will take a while for that to develop. And I'm sure after the end of this in the U.S. and in the U.K., there'll be a whole host of people with post-traumatic stress after this.

And at the time, you work, like, 20 hours a day. And you come home. And you go back to work. And you're all in it together. And the good thing about it is it's very collegiate. You work together. You're in it together. And it's like a band of brothers, almost. And that's what war is like, too. You're in a band of brothers that people understand. And sometimes, when you come back from a war and there are those people there that don't understand, that's when it becomes very difficult. And that's really when the post-traumatic stress comes in - when you feel isolated and alone.

GROSS: Let me reintroduce you here. If you're just joining us, my guest is David Nott. His new memoir is called "War Doctor: Surgery On The Front Line." We'll talk more after we take a short break. This is FRESH AIR.

(SOUNDBITE OF AVISHAI COHEN SONG, "GBEDE TEMIN")

GROSS: This is FRESH AIR. Let's get back to my interview with Dr. David Nott, who spent several weeks a year for 25 years in war zones, including Syria, Afghanistan and Yemen. He now trains doctors in conflict and natural disaster zones, and he works at two hospitals in London, where he's now treating people with COVID-19. His new memoir is called "War Doctor: Surgery On The Front Line."

You've had to protect yourself, as a trauma surgeon in war zones, protect yourself from extremists, from militias, from child soldiers, from the Taliban. And now it's like it's a germ that is putting you at risk. It's a virus. And the patients that you treat are potential risks because they're contagious. Can you compare what it's like to deal with a virus as opposed to dealing with a war, where people are shooting and bombing each other?

NOTT: Well, it is quite similar, I would say, as regards to the risks to the surgeon himself. I mean, when you're in a war zone and you're operating on somebody, then at any moment, the hospital could get blown up, or people could come into the operating theater with guns and hold you at ransom and so on. And it's very similar, really, with the virus, because you have to appreciate that it is an invisible enemy. And you have to make sure that the invisible enemy doesn't get you. So you change the way that you operate on patients.

So now, of course, the majority of all our general surgery is done by laparoscopic surgery, putting in carbon dioxide and blowing up the tummy and allowing us to have access to various organs. But, of course, we can't use laparoscopic gas anymore because the virus would go into the gas and come out into the air. And then it might go - you might inhale it or go into your conjunctiva, in your eyes, or something like that. So we've stopped doing laparoscopic surgery now, and we've gone back to the basics of surgery.

And then also, very similar to - you can't operate on somebody that - do a massive operation that that patient would routinely require elective surgery then go to an intensive care unit and be ventilated for three or four days. We can't do that now. And that's, again, very similar in a war zone. You have to make very difficult decisions on what sort of surgery you do. So if somebody comes in now with a obstructing colorectal cancer, for example, then we wouldn't, probably, go for a major operation to excise the tumor and try and join up the bowels or try and do something fairly heroic. All we'd do now is do a defunctioning ileostomy, which is bringing out a piece of bowel onto the skin's surface to act as a vent to get past the obstruction. So we're doing things now which are very similar as, like, damage control. We would do an operation on the patient on the operating table, which probably lasts under an hour, and it would have to be an important operation that would save that patient's life for that moment. And then, fingers crossed - and again, it's like a war zone - that patient will get further treatment somewhere else.

So they'll - if you can't do the surgery in a war zone, then they'd go to a different hospital and have the surgery completed. And that's what we're going to do here as well. We would wait now for three to four months and then bring that patient back and complete the surgery.

GROSS: There are some medical innovations that have come out of doctors working in war zones. An example you give in your book is warming up blood before a blood transfusion. Can you talk about why that's done and how it came out of - I think it was the war in Iraq?

NOTT: Yes. I was very fortunate, actually, to be involved in the war in Iraq in the military. Most of the time I'm an NGO surgeon. But I spent some time working in Afghanistan and Iraq with the military and learned a lot about damage control and damage control resuscitation. And basically, when a patient who's lost a lot of blood comes into the hospital, they start to respire in a different way and use their oxygen in a different way, and the cells turn off, and rather than producing lots of energy compounds, they produce very few energy compounds. And of course, if you produce very few energy compounds, then you don't keep your heat up, and you become hypothermic; that is, you become cold.

And this was sort of known about over years, but it's only in Iraq and Afghanistan that it really came to light that what we need to do is to, rather than give patients cold blood if they come in with an injury because they're already - their temperature is lower than normal. So their temperature may be 35 or something like that Centigrade, which I think is probably about 94 Fahrenheit - something like that - then your heart doesn't work properly, and you start to - your blood pressure goes down. So on top of the injuries that you have, your blood pressure doesn't help with the circulation. And so what - if you give cold blood as well on top of that, then you become even more colder, and you'll die on the operating table.

So one of the things I was able to bring to war zones was that you must - every time you give blood to a patient, it has to be nice and warm; it has to be at least body temperature. And so what we were doing in Syria, sometimes we were using buckets of hot water and boiling the kettle, pouring the hot water into the bucket, putting the blood in the bucket and warming it up and then giving it to the patients. And that seemed to have a significant impact and reduce the - reduce bleeding time significantly and has a good effect on outcomes.

GROSS: You know, during this pandemic, doctors and nurses are so worried, rightfully, about bringing the virus home to their families. Some of them are trying to stay at hotels. And I should mention your family has left London so that you're not bringing the virus home to them.

You write about how, in war zones, life changed for you. Once you were married and had two children, you became more reluctant to risk your life in war zones. And you say that in war zones, it's usually the junior doctors who stay and do the work, whereas the older doctors who have families that they need to take care of and that they don't want to be at risk, those doctors tend to flee if they can. Can you talk about that a little bit?

NOTT: Yes, and it's very true. In war zones, you very rarely see senior doctors around. Most of them have fled because they've got their families. They've - they want to look after them. And of course, the most important thing in anybody's life is your family, and so that's what they do. And so it's usually the young doctors that are left, the 24- up to 29-year-olds that are left to carry the can, basically. And of course, those junior doctors aren't very well trained. They can't really do the operations.

And the surgery that you have in a war zone is intense. You've got patients with blast injuries, fragmentation injuries, bullet wounds - all sorts of really difficult operating that requires somebody with a lot of skill to be able to do or knowledge and experience. And of course, those patients are presented directly to those young surgeons or young doctors who haven't got that experience. So your mortality is going to be significant.

And so one of the ways which I felt was really the right thing to do going into a war zone and just being a single surgeon and operating on lots of patients and then coming home really wasn't the right way how to go around it, and I wanted to have a - almost like a legacy. So what I would start doing was going into war zones and then get all the local surgeons and train the local surgeons on how to do the very difficult surgery. And then you leave your legacy, and then you move on to the next war zone and do that.

GROSS: If you're just joining us, my guest is David Nott. He's a trauma surgeon who has worked in conflict and natural disaster zones around the world. He works at two London hospitals and is now treating patients with COVID-19. He has a new memoir that's just been published in the U.S. called "War Doctor: Surgery On The Front Line." We'll talk more after we take this short break. I'm Terry Gross, and this is FRESH AIR.

(SOUNDBITE OF COLIN VALLON, PATRICE MORET AND SAMUEL ROHRER'S "NOREIA")

GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to my interview with Dr. David Nott, who has treated patients in war and conflict zones around the world and now trains doctors in those zones through his David Nott Foundation and The Royal College of Surgeons in London. He works at two hospitals in London now, where he's now treating patients with COVID-19. Queen Elizabeth awarded him the title officer of the British Empire for his medical work in war zones. His new memoir "War Doctor: Surgery On The Front Line" has just been published in the U.S.

Let's talk about some of your experiences treating injuries in war zones, dealing with situations unlikely to happen outside war zones, such as the time in Syria when you were treating a shrapnel wound and found a detonator in the wound. Would you tell us what happened?

NOTT: Yes. And in fact, it's not unusual. There are lots of ordnance that people find in various people's bodies that have being brought in. In the Yemen, I was shown a picture of a patient that had a whole rocket through their body and been brought in. So in my circumstance, there was - I was operating on a lady who, in fact, her - she was the wife of somebody who was building bombs back in 2012. And the whole house had blown up, and she came into the hospital having had a severe injury to her left leg. And above the knee joint, she was exsanguinating, bleeding a lot through this hole.

So we put a tourniquet on, which is the right thing to do, and then stopped the bleeding with the tourniquet, and then took her to the operating theater where I prepared her for surgery. And making the incision - often when you make your incision, you put your finger in very carefully on most operations 'cause you don't know what you're going to find in there. There could be a piece of fragment, or there could be something. But when I put my finger in, I felt this sort of round object which felt a bit unusual. And so I got both fingers around it just pulled it out.

And suddenly, the whole attitude in the operating theater just went silent when the interpreter, Syrian interpreter who was standing next to me, shouted mufajir, which means detonator. And so I was holding up this detonator in my hand. My leg started to shake, thinking, you know, if it was going to go off, then it would significantly cause a problem - probably wouldn't kill me, but it would certainly blow my hands off. And we managed to put it into a bucket of water and gingerly take it out of the operating theater. But it's one of those very dangerous moments that you often find in war zones that you would never find elsewhere.

GROSS: One time in Syria, you were treating a whole family because a bomb-maker's bomb had accidentally detonated, and everybody in the family was injured, including of course the bomb-maker. And while working on the bomb-maker's wounds, a bomb fell out of his pocket. And the way you describe it, one of the Syrian interpreters kind of got it out of the room. It didn't blow up, right?

NOTT: Again, that was a bomb without a detonator inside it. And this was a tragic incident, really, where the man was - had these bombs in his pockets without putting the detonators in them and was praying. And as he bent down to pray, one bomb did fall out, and I don't quite know what happened, but the whole place blew up. And it killed his six members of his family, plus his wife. And he was brought in with this other bomb in his pocket.

And of course, it's very important that - and in fact, the ICRC are really on top of this. When I was working in Peshawar in northern Pakistan, anybody that ever came into the hospital, you made sure there were metal detectors underneath the car and metal detectors all over you to make sure that no - an ordnance was brought in. And there we were just at a very small hospital, and things were happening all the time. So we didn't take that much of security, and of course, the problem is, then, that that bomb did fall out of that man's pocket and could have had a detonator in it and could have killed us all.

So again, it's, like, the fact that you - if you let your guard down too easily, then things really bad could happen. And it's like letting your guard down with this virus; if you let your guard down, then things could really happen badly to you. So, you know, this is very similar on both sides.

GROSS: Let me reintroduce you here. If you're just joining us, my guest is David Nott. His new memoir is called "War Doctor: Surgery On The Front Line." We'll talk more after we take a short break. This is FRESH AIR.

(SOUNDBITE OF PHIL KEAGGY AND HOLT VAUGHN'S "BITTER SUITE")

GROSS: This is FRESH AIR. Let's get back to my interview with Dr. David Nott, who spent several weeks a year for 25 years in war zones, including Syria, Afghanistan and Yemen. He now trains doctors in conflict and natural disaster zones, and he works at two hospitals in London, where he's now treating people with COVID-19. His new memoir is called "War Doctor: Surgery On The Front Line."

You, I'm sure, had to ask yourself about the ethics of saving people's lives who were preparing to take other people's lives. I mean, you even once worked on saving a man who was the brother of a Chechen ISIS fighter who came in and then was really upset you were working on his brother. You thought you'd be killed. So when you're working on someone who turns out to be a bomb-maker or who turns out to be an ISIS fighter, how do you feel about the ethics of saving their life?

NOTT: You go in as a humanitarian surgeon, and your role there, really, is to help the human being that's in front of you. And you will do everything possible to save the life of somebody in front of you, if it's possible to save.

And if you do have the amount of equipment that you could use to save that person's life and it's the right thing to do, then you - your job as a surgeon, as a medical person, is to offer the - your human being that's in front of you the best chance of life. And that's my ethos, really, wherever I go. I don't know whether that person, what - I can imagine what he would have done in the past, but again, I have the feeling that if I was to save that person's life, that he may well realize that his life was saved by somebody who had no feelings of malice against him and had - was completely apolitical, and maybe I might change that man's life again. I don't know. But this is the way that I feel about when I go and operate on people, that I'm doing it purely as a humanitarian act.

And I'm hopeful, in one respect, that this pandemic at the moment, which has occurred throughout the whole world, will change people's minds to realizing that we are all human beings, that we are all here to help each other, and we must stop killing each other. And the warring factions in Saudi and Yemen now have stopped fighting. The warring parties in Syria have stopped fighting. And I hope, then, that they will - you know, that they will readjust to a new life.

GROSS: Have they stopped fighting because of the virus, because of the pandemic?

NOTT: Yes. Yes. They've stopped fighting because of the pandemic. And if they can do that - because of the pandemic, at the moment because everybody is sort of self-isolating, the Saudis are self-isolating, everybody's self-isolating, nobody wants to go and everyone wants to save themselves, and so the wars have, at this moment, stopped. And so this is a golden opportunity to say, OK, we're all in it together. Let's not restart them. Let's talk. Let's communicate.

GROSS: I heard you got a ping. Is that an emergency?

NOTT: Let me just check.

The situation is worse there, actually. So they're saying that the - has so little experience and has performed a cesarean section on a dead woman before. OK, that's not good. And the only anesthetic set they have is local anesthetic - so doesn't look very promising at all. So anyway, we'll wait for some further information.

GROSS: So this is a follow-up to a call you got...

NOTT: Yeah.

GROSS: ...Just before the interview started, about the emergency cesarean.

NOTT: Yeah.

GROSS: So they think the patient's going to die? Is that...

NOTT: It looks like it. It looks like it. It looks like mother and baby might die.

GROSS: Oh, I'm sorry. But this is giving us a glimpse of what your life is like - getting emergency calls from around the country, wanting you to help surgeons who've never done procedures before do things with you guiding them on a video app and phone. You know - and that was a cesarean. You learned how to do a cesarean the hard way. You were in a war zone. You'd never done a cesarean before. It wasn't part of your training. Tell us how you learned how to do it.

NOTT: Well, I was - as part of a - as being a medical student, you're - you do have an obstetric attachment. And I really enjoyed obstetrics when I was a medical student, but of course, I had never done a cesarean section. Well, there was a - when I went off to Afghanistan back in 1996, I was a trained surgeon but, again, had never done a cesarean. Section. And one of the surgeons in the Red Cross hospital and the senior Red Cross surgeon said to me, had I ever done a cesarean section? And I said, no, I haven't, actually.

And with that - I remember it vividly, the eyes - his eyes rolling to the back of his head and said - and then a few hours later, a lady who was in obstructed labor came in requiring a cesarean section. And so I went and knocked on his door, and grumpily, he got up at 4 o'clock in the morning. We both went to see the patient. And he told me to scrub with the scrub nurse and, basically, didn't scrub and used a long pair of forceps to show me where to make the incision, how to, what to do next and where to put my fingers in and where to make the incision on the uterus and how to get the baby out and so on, so forth.

And it was one of the most exhilarating moments, I think, of my whole life. It's a fantastic experience to be able to deliver a baby and save that baby's life and then save the mother's life. It was an amazing feeling. But I have - since that time, it's surprising, but every time I've ever been on a mission anywhere in the whole world, I've always had to do cesarean sections. And I went off to the Nepal earthquake, and I went to Kathmandu and then went to Arughat Bazaar working for Medecins Sans Frontieres as a trauma surgeon.

But the first thing I had to do when I got out of the seven-hour journey through very difficult roads and precipices getting to Arughat Bazaar was a lady came - one of the midwives came up to me and said, David, David, you need to come quickly because there's a lady in labor, but there's a foot hanging out of her. So what that meant was that she was in - having a breech delivery. But the baby was stuck, so I had to do an emergency cesarean section and then ended up spending three weeks just running the obstetric unit in that country.

So my knowledge of obstetrics is, really, fairly basic, but it's obstetrics that saves people's lives and babies. So I would have no hesitation in taking somebody through a cesarean section because I've done so many of them.

GROSS: I so appreciate the work you do. The first war zone you were in was in Sarajevo, and once in the middle of trying to save a patient who was bleeding out, you called for help from other doctors and nurses and realized everyone had left to take shelter and no one had bothered to warn you. And you say it made you realize you had to watch out, and no one else would do that for you and that it also taught you you had to toughen up. How did that experience change you and challenge your idealism?

NOTT: Well, you know, as a young man, you always feel that you're protected by people around you. You know, you have your mother and father. You come from a family. You go out some place; you always feel that there may be people around you that will also look after you. You have this sort of image of longevity almost, really, and being immune to anything that could harm you.

And I remember operating in Sarajevo. I was working in a hospital called the State Hospital, which was nicknamed the Swiss Cheese Hospital because it was bombed all the time, and it had shells coming through it, and it had big holes in it. That's why it was called the Swiss Cheese. And often, I would be on my own in the operating theater with a nurse, scrub nurse, and the lights would go off, and a man would come holding big lights with car batteries in a wheelbarrow, and we'd continue the operation. There was anesthetists there and so on.

And I felt, at that time, quite secure. But then on that particular occasion, there was an enormous explosion on the roof of the hospital where a bomb had fallen on the top of the roof. And the whole hospital shook. And the lights went out. And at that time, I was operating on a young lad who had had a - a young boy who had a shrapnel injury to his abdomen. And the shrapnel had gone into one of his major blood vessels. And the lights suddenly went out.

And when this enormous explosion occurred - and I had my hands wrapped around his blood vessels and just removing this big piece of shrapnel. And fortunately, I - it was pitch-black because we were in an underground operating theater, completely pitch-black. And I was there for five or 10 or 15 minutes. And I was calling out to people because I could feel this boy's blood pressure going down and down and down. And suddenly, he died in this pitch-blackness.

And about 15 minutes later, I was still standing there with my hands on his tummy. And the lights suddenly flickered on. And then I realized I was the only person in the operating theater and everybody else had just run off. And it made me realize, really, that, you know, that you're on your own, really, when you go to these places, that people aren't there to really help you and protect you if you're in such an extreme circumstance.

GROSS: Let me reintroduce you here. If you're just joining us my, guest is Dr. David Nott. He's a trauma surgeon whose new memoir is called "War Doctor: Surgery On The Front Line." We'll be right back after a break.

This is FRESH AIR.

(SOUNDBITE OF RACHEL GRIMES' "WATER FROM THE SAME SOURCE")

GROSS: This is FRESH AIR. Let's get back to my interview with Dr. David Nott, who spent several weeks a year for 25 years in war zones, including Syria, Afghanistan and Yemen. He now trains doctors in conflict and natural disaster zones. And he works at two hospitals in London, where he's now treating people with COVID-19. His new memoir, just published in the U.S., is called "War Doctor: Surgery On The Front Line."

When you were working under Taliban rule in Afghanistan, you sometimes needed to get permission from, like, a Taliban police officer to perform an operation. You once even had to go to Mullah Omar, who was, at the time, the leader of the Taliban, and ask him for permission to operate on a woman. When you went to Mullah Omar to ask permission to save this woman's life, how did you handle it? What prevented you from saying, how dare you stand in the way of saving somebody's life?

NOTT: Well, it wasn't just me, actually. It was a Norwegian head nurse called Ingrid (ph). And she was one of the toughest women I have ever met. And she was in charge of the hospital. And I went to her when the Taliban policeman in the theater told me that I wasn't able to operate on this lady who was suffering, bleeding following the birth of her baby. And she was really bleeding a lot, called a postpartum hemorrhage, and was hemorrhaging and hemorrhaging. And she needed an operation within the hour. Otherwise, she - you know, she wouldn't make it.

And I remember going - asking the Taliban policeman, you know, to operate. And he said, no. And so I then flew out of the operating theater and found Ingrid. And I said to Ingrid, Ingrid, he won't let me operate. So she said, come with me. So the two of us got into this ICRC van and flew down into Kandahar, the center of the Taliban stronghold. And we burst into Mullah Omar's office - well, Ingrid did. And it was the - (laughter) it was the most bizarre experience I'd ever had, because I was standing there with Ingrid, who basically was so strong and so forceful that Mullah Omar, sitting in his chair, sort of leant back a little bit.

And Ingrid said, you know, that we are here to help you. We are here to help you and your people. And you are going to help us. And with that, I think, he was so surprised. And I was so surprised to find myself standing next to Mullah Omar, the most, I would say, dangerous - I'm not sure if the word is dangerous, but the person in charge of the whole of the Taliban - to get his approval. And then we just marched off, got back in the car and got back to the hospital. And by time we got there, the Taliban policeman was told that, you know, he mustn't stop us from operating. And so it was a bizarre experience.

GROSS: In your memoir, you write, I am not religious. But there have been times when I've felt the need to turn to a higher being. If you don't mind my asking, if it's not too personal, when are those times? And what is the higher being you turn to? What is the nature of your prayer?

NOTT: Well, it is true. I don't pray every day. I'm not particularly religious. I don't go to church that often as I probably should do. But it's interesting. When you're in such a dreadful situation, and when you realize that your life may be coming to an end very rapidly, and the situation is such that the stress is so much that you need to turn to somebody - and, of course, you haven't got your parents there. You haven't got your loved ones there. And there's nobody there. So who do you turn to?

And it's quite funny that there is no doubt in my mind that there is a higher being there. There's no doubt because on occasions where my life has been almost on the line, where I've felt that within, you know, split second, I'm going to die here, that I do turn - something happens in my head. And I start to pray. And I feel like I have a frequency band on the radio in my head that I turn onto. And I do go onto that frequency and I feel that I am able to talk to God. And I do feel that he is listening to me. And he's listening to my severe anxieties that I'm discussing with him. And it gives me enormous comfort to realize that I am talking to him and that he is giving me some strength back.

And it's surprising how you get this - you feel this almost strength come back into your body. And a couple of times, I've felt - once, there was a priest in Aleppo who put his hand on my head. And again, the same thing happened to me. I was - I thought I was going to die there. And he put his hand on my head and I could feel the radiation going through my body. It was a very odd experience. But that's getting close to God.

GROSS: Through our interview, we've heard about the woman in Syria who needed an emergency cesarean. And you got a call asking you to walk the surgeon through it 'cause this was a doctor who'd never performed a cesarean. In the middle of the interview, we learned that the patient was probably dying and that your help would probably not be needed because of that. What happens next? Will you get a phone call updating you about what happened?

NOTT: Yes. I've just had a text message back from a doctor who was trying to contact me, saying the connection is a bit flaky still and they will come back to me as soon as they can. So I'm still waiting to hear what will happen about that. And I'll just wait to hear and do exactly what I can to help.

GROSS: Dr. David Nott, thank you so much for the work that you do. Thank you so much for this interview. I feel bad taking some time away from your patients. I really appreciate you so much spending some time with us. I wish you good luck. I wish your patients good luck. Thank you so much.

NOTT: Thank you for having me. Thank you.

GROSS: David Nott spoke to us from London, where he's now working in two hospitals. His new memoir is called "War Doctor: Surgery On The Front Line." His foundation that trains trauma surgeons in conflict zones is the David Nott Foundation.

FRESH AIR'S executive producer is Danny Miller. Our interviews and reviews are produced and edited by Amy Salit, Phyllis Myers, Sam Briger, Lauren Krenzel, Heidi Saman, Therese Madden, Mooj Zadie, Thea Chaloner and Seth Kelley. Our associate producer of digital media is Molly Seavy-Nesper. Our technical director is Audrey Bentham. She and Adam Staniszewski were our engineers this week. Roberta Shorrock directs the show. I'm Terry Gross.

We'll close today with music by pianist Ellis Marsalis who died Wednesday of complications of the coronavirus. He was 85. He was a musician and educator and the father of musicians Wynton, Branford, Delfeayo and Jason Marsalis.

(SOUNDBITE OF ELLIS MARSALIS' "JUST SQUEEZE ME (BUT DON'T TEASE ME)")

Copyright © 2020 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.