‘We rushed him to theatre and slit him open like a lamb for slaughter. Within three months, he was showing off his scar in a nightclub’

Getting stabbed isn’t a great experience and the victims of knife and gun violence are never easy to deal with.

In time, medical staff come to expect verbal abuse as a matter of routine. The less seriously wounded often become abusive during questioning, threatening further violence if they aren’t seen promptly.

In my early days as a medical student, I remember seeing a sign on the wall in A&E and it took me by surprise. It reminded me of a sign I had seen in the London Overground. Something along the lines of “do not feed the pigeons”, only in this case, it was trying to discourage verbal abuse against the staff.

On that day, I just assumed it was a left over from a rag week stunt. In time, I would come to realise that it was entirely necessary. Whether or not it actually achieved anything though, I’m not sure. Many of the thugs to whom it was primarily directed seemed to have a reading age of nine.

Why do these people threaten us? Well, in the first instance, it’s important to remember that most of them are very young and quite a lot of them are completely legless from excessive alcohol. They may have been taking other substances too. It’s usually very late and you don’t know what they were up to in the earlier part of the evening.

Oddly though, in all the years they ever screamed abuse, I never really took offence from these people, only the buzz.

I did a solid year in a major trauma centre and I have to admit, it was pretty dramatic stuff. Best of all was the time when the helicopter landed. There was a sense of excitement and anticipation you just don’t really get in your average outpatient clinic. Indeed, you never really knew what you were about to get.

One time, we had an Asian lad on the table. He’d been airlifted in from some far from salubrious neighbourhood after having been stabbed. Later that night, when I finally left the unit, I remember stalling on my way to the car park. A&E had been surrounded by Asian youths and it seemed they were preparing to charge the doors. Not to be outdone, the police had positioned about 10 burly men in blue by that same entrance and I guess there was a standoff of sorts. I can remember diverting suddenly to the right, desperate to get back to my vehicle and free of the hospital grounds.

That day had been so filled with fights and casual violence that I had had this feeling that the world outside was a war zone, a place of ongoing conflict. The assailant had been of Caribbean origin and we’d been treating him too. His injuries weren’t too bad and there was talk of transferring him to another – unnamed – unit. From a medical perspective, he didn’t need to be moved, but there was a genuine fear of violence in our unit.

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Quite a lot of the more seriously injured people come in off the chopper. Nobody really knows whether helicopter evacuation really reduces death rates, but for peacetime trauma medics it certainly adds to the thrill of it all.

In the resuscitation room, we cut the patients free of their clothes. When you roll the guy over and check for penetrating trauma on their back, you can usually shuffle them free of their outer garments. For a motorcyclist in a one-piece leather suit, I remember looking down at the floor in resuss and thinking it was the hide of a skinned animal lying there. In his case, the carcass was already on its way to theatre.

Major trauma in Britain is assessed roughly in accordance with the influential American trauma course and manual ATLS (Advanced Trauma Life Support). Doctors start by assessing the airway and then work their way down through breathing and circulation. Verbal abuse is always reassuring. If the guy can still shout then his trachea must be patent and his lungs are still on line. Having said that, I’ve seen people who were shouting right up to the moment their blood pressure collapsed and their brain function fell to nil.

In resuss, we’ve completely renounced the Green Party: recycling just doesn’t come into it. Just about every piece of equipment is abandoned the moment we first use it and the red smears across the floor are mopped away, ready for the next patient.

When I worked in Liverpool we admitted a man in his late teens with a gunshot wound to his thigh. He had been sitting in a waiting room at the probation service, waiting to see his probation officer when another young man entered the room very suddenly and shot him with a handgun. The bullet entered his thigh, hit the femur and disintegrated within the surrounding muscle.

I was new to this kind of thing back then and found the x-ray rather shocking. How could a bullet be less sturdy than a single human bone? At the time, I was keen to explore the thing in theatre but my senior colleagues held me back: we could treat him with intravenous antibiotics for a few days and things would settle down. It worked and we discharged him in the space of a week.

Assuming he’s still alive, he’s now wandering around the place with the bullet fragments inside him, just waiting to surprise some young unsuspecting casualty officer who decides to x-ray his femur.

As my career progressed, I realised that this kind of shooting was a bad sign. One attack begets another in that kind of place; a unit could soon be overrun with a spate of minor gunshot wounds, none of them fatal, all of them pretty horrifying.

We once had this guy who had flown back from vacation in Jamaica with a hole in the palm of his right hand. A group of men in a bar had held him down, pressed the muzzle of a weapon into the centre of his palm and pulled the trigger. There were burn marks on the skin and minor wooden splinters around the exit wound. I guess the table didn’t enjoy being shot. To be fair, the doctors in Jamaica had already cleared most of the wood and wrapped him in a bandage on the general surgical ward, prior to formal exploration. Of the 24 men on his ward, 22 had been shot.

In the end, he discharged himself, returned to England and presented at hospital, demanding an operation. He wanted us to stitch his median nerve back together. Quite a lot of gunshot victims are like that. First they demand an operation, then they threaten the staff. As if we’d be more likely to treat them well if we fear some sort of physical retribution against ourselves. As if we might push them aside and leave them to fester unless under threat ourselves. As if the patient has no connection of any kind as to how professional people in the modern world behave.

When we took down the dressings, there was an unpleasant smell but the hand has an excellent blood supply and was likely to do well. You could see the blackened skin around the entry wound where a spurt of flame had cindered his flesh.

If any of these angry idiots think they’re making a good impression, they are sorely mistaken. Years ago, as a young surgical registrar, I remember attending a trauma seminar in the midlands where a series of knife and shooting cases were presented to an audience of medical professionals. After the first case, there was a ripple of laughter in the room. By the last one, there was open hysterics. Surgical seminars can get pretty dull and it’s good to have a bit of light relief.

It’s not the sort of thing they’d show on television. On television, medics in action are all very serious. When people know they’re on camera, they tend to alter their behaviour and at the time, it did throw me a bit. It wasn’t just the physical discomfort that seemed to call out for mockery, it was the sheer mindlessness that came with the behaviour of those who had ended up being hurt. The audience was laughing at the sheer madness of the world on display. I guess there’s an element of them and us too and laughter is a form of release. The amount of heartache many of these “victims” cause us by their abuse – even though we are trying to help them – is beyond description.

For the most part, violence has no rhyme or reason. Many left of centre commentators try to establish patterns and then draw some sort of message from them. Who knows, perhaps we have failed victims as a society.

Meanwhile, voices on the right sound tough and speak of heftier punishments.

What most people haven’t grasped is that most of the young men who live in this violent world, and who end up stabbing or shooting – or being stabbed or shot – have little real insight of any kind. They aren’t thinking about consequences. They couldn’t even guess at the likely sentence for their crimes, if they are the ones committing them. Most probably can’t even point to a map of the world and tell you what city they’re in. Violence is almost a passing phase for many of them, although we shouldn’t underestimate the role and influence of organised crime on their journey.

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So, what if it really happens? What if you’re walking down the street and some poor sod gets shot in front of you? It’s tempting to spend time stabilising the patient. After all, the paramedic of today is much more than an ambulance driver. He or she should insert lines, make the patient comfortable, maybe initiate a blood transfusion in the field before putting the stretcher in the ambulance.

Right? Wrong, not any more.

Data from the US shows that for gun and knife crime your best chance of survival comes with immediate transfer to A&E. Turn the blue light on and don’t stop for anything. If you find a stabbing or shooting victim in the street throw him in the back of your car and drive to the hospital as fast as you can. Every second you delay increases the chance of failure – and for failure, read death. The only thing that can save him is getting onto the resuscitation trolley in A&E and having the full ATLS protocol. A brisk transfer to the operating theatre might well be sensible too.

Years ago, before I’d even heard of the trauma unit, they called me to see this kid in resuss. We were a small unit without the benefits of a full on-call team. Initially, it felt like a pretty sedate little place and I never expected to see anything worse than a twisted thumb. When the call went out I was scrubbing to remove an appendix. Taking out an appendix is a major rite of passage for the wannabe surgeon and I used to keep track of the number of cases I’d done.

At that very moment, word came through that they’d just admitted the victim of a stabbing in A&E. I called my registrar and asked him to replace me in theatre from the outset as, if the appendix case was too difficult for me, then I’d have to call the registrar anyway to bail me out. In that scenario, there would be nobody left to assess the stabbing. The reg agreed and I stormed down to resuss ready to punch the guy as a punishment for denying me one appendectomy in my logbook.

I walked in in a fit of rage and saw a young man, naked to the waist, telling the A&E officer to “f**k off”. They always tell the A&E officer to “f**k off”. These days, it wouldn’t surprise me if there was a special hospital management office, specifically to chastise A&E officers who’ve been told to “f**k off” by stabbing victims, to explain how it’s their own fault for not saying something sufficiently soothing when they first introduce themselves.

Back then, we weren’t burdened by such things and as I approached the guy and saw a couple of minor lacerations on his belly and chest, I managed to convince myself that there was nothing wrong with him and that he’d dragged me from my favourite part of the day, just to tell me to “f**k off” too. And then I heard him grunt one more time in a sitting position before collapsing precipitously onto the Sorbo rubber trolley as his blood pressure plummeted and the last vestiges of conscious thought deserted his mind.

He had decompensated. In spite of all the fluids the staff had pumped into his body, in spite of the reckless anger in his youth, his body had lost the ability to maintain an adequate blood pressure and as pressure dropped below 60 millimetres of mercury, his brain had gone off line. Doubtless his kidneys would soon follow. I called our consultant a couple of times: the first time, he sounded confused and hung up; the second time, he showed recognition and said he was driving in.

We rushed him to theatre and slit him open like a lamb for slaughter. The incision ran from beneath the top of his pants to the base of his sternum and as soon as we made it to the abdominal cavity, the blood was spilling over. As if some huge fat guy had leapt into a tub of the stuff.

We sucked the rest of it out, most of his blood volume surely (he probably started out with five litres, but we’d run in at least another four). There was a hole in his liver and the boss stitched it up. All visible spurting stopped and I began to see discernible organs in the abdomen. Nurses began to sigh. I thought we were winning, but his pressure was still falling.

Looking back at the wound, I realised that there was something odd about his diaphragm. The diaphragm was bulging from above. We aspirated something through the chest and saw that it was full of blood. There was a small wound in his diaphragm on the left and this was the path that the knife had taken, plunging through his abdominal wall and into the heart.

The boss called for a jiggly saw. I’d never seen a jiggly saw before but I was about to discover what it did. Threading the thing under the sternum and punching it out at the root of the patient’s neck, he began to jerk it backwards and forwards until it cut through the sternum from below and cracked open his entire thoracic cage. The patient was already intubated and the pressure from the anaesthetics machine would sustain his lungs.

We could see his heart now, all wrapped up in its surrounding membrane. You could see blood spurting out of it like a miniature fountain. The membrane was full of blood too: just about as soon as we slit it open, the stuff was coming out in buckets and straight away I remembered there was a name for this condition: tamponade. The heart bleeds but the blood is trapped in a bag. In time, the heart surrounds itself with a reservoir of blood. The same reservoir crushes the heart and prevents further function.

This guy was about as close to being dead as you can get but in that moment the boss stitched up the hole in the beating muscle using some sturdy synthetic sutures. It worked and he threaded a finer suture through the pericardium and started to plan his sternal closure, using a flexible wire as a stitch.

It was an operation like no other. I could see all the anatomy in the body that mattered. Everything but the head and neck. The appendix – that thing I’d almost glimpsed that same evening in another patient – was there on display, wriggling around at the base of the caecum. The liver, the gall bladder, the pounding heart itself. Outside of the post mortem room, I’ve never seen the human body like that, either before or since.

Later that day, a colleague would claim to have used the procedure repeatedly for organ harvest. But there was a lot of talk that day, with just about everyone in the unit claiming to have done the same before. As far as I was concerned, there was only one hero in the room and that was the man I was working for at the time.

I watched him detach the chest retractor. It was a huge unwieldly thing and just as it broke free, we saw something new. The heart itself was beating very strangely: an assymetric rhythm that the anaesthetists tried to correct with some more bicarb. It seemed to settle down right until the point at which the sternum was stitched up and there was only the skin left. And then the guy shut down completely. Strange alarms began to sound. The consultant anaesthetist – who had only arrived halfway through and was dressed in jogging kit and outdoor shoes – started to shout for the defib.

In all the arrest calls I ever saw, hardly anyone ever came back from the dead, but this kid did. Just one shock and he came back round. As if we’d thrown a bucket of cold water on a man’s face in a John Wayne movie. The rhythm came good and the anaesthetists started talking about blood chemistry.

The boss spoke to the lad’s parents that same evening. They seemed like entirely respectable people.

After two days in intensive care, the patient survived. Within three months, he had been seen in a popular night club, pulling up his T-shirt in front of girls and showing them the scar. I never found out what he’d been fighting about or why his assailant had attacked him. He’d almost gone the same way as Mercutio, but this time, they really did fetch a surgeon.