The view through the windscreen of my vehicle is quite alarming – there are six armed men in the back of a pick up truck in front of me, all armed with automatic weapons.

Fortunately, they are here to protect me. I am returning after a week of operating in Yemen, which is currently enduring a savage and long running civil war. The injuries that I have seen are all related to weapons of war – bullet injuries and bomb blast injuries. 

From the moment that we arrived, we could see men and women in the streets with crutches, negotiating their way through an obstacle course that is their daily life on the dusty streets.

Yemen is an enigma. There is a war going on and there is a front line between warring groups, but civilians do cross the front line frequently – sometimes as part of a commute to work.

Yemen has oil fields – we passed them in the armoured car, and this is the focus for the current battles near Marib. Yet as well as wealth, Yemen has much extreme poverty. There are refugee camps where malnutrition is rife, and feeding programmes are required to keep children nourished. We saw some of the children in the hospital, small for their ages and looking thin and forlorn.

Yemen has varied and spectacular terrain. There are canyons and plains and mountains and deserts, sometimes looking like a lunar landscape and sometimes vast, flat and intimdating. There is also a rich and ancient history – the Queen of Sheba lived in Marib and her palace and temple ruins are still there, as well as Shibam Hadramawt – the ‘Manhattan’ of the desert comprising a vast city of 500 year old high rise buildings that are still inhabited today.

Yet despite all these dichotomies, there is a war in Yemen. This was our focus – to treat people injured in a terrible war. Most patients that have survived to get to hospital have limb injuries. Many head, chest and abdominal injuries are fatal immediately, or within a few hours. Those with limb injuries survive, but suffer contaminated wounds, missing flesh and bone, and a lack of resources and skills to manage the initial injuries well enough to mitigate the disability optimally.

In the conflict zones I have worked in, it is frequently the case that patients treated with plates and nails have had subsequent infection, which can often make the problems faced by the patient worse. These may be the only means of treatment available for local doctors, and they are doing their best. This is why we are here. To help the local doctors offer their patients modern orthopaedic limb reconstruction surgery and provide training.

Luckily, we came prepared with our own orthopaedic hardware to allow us to treat patients with external fixation – which has much lower risks of contaminating or perpetuating infection in wounds. It is paradoxically more uncomfortable for the patients, with metalwork around their limbs instead of hidden inside, but ultimately safer. I was warned that patients would not tolerate external fixation.  However most accepted the treatment offered, many having had several operations previously and hoping for a better outcome.

The journey here was convoluted with little sleep over a 32 hour period. The final leg, after three flights, was an overnight 6 hours marathon drive from the airport to Marib. We must have passed through two hundred Yemeni Army check points each way. The variably dressed sentries with their head lights stop each car and check documents. For the most part, they wear sand coloured fatigues and desert boots, but some also wear coats over the top, and some wear the Arabic keffiyeh, wrapped around their heads and necks.

Eventually, we arrived at the city of Marib, home to 3 million, and possibly another 3 million internally displaced persons  – what we call refugees in their own country. It is much bigger than I had imagined and strangely adorned with neon lit hotels and other buildings. What a bizarre sight. This is a city that is supposed to be in the middle of a civil war.

There are random missile attacks on Marib – I am not sure if they are guided or not. The week before our mission, there was an attack on a key infrastructure element – the mobile phone mast. Another missile landed in a refugee camp in the middle of nowhere. These didn’t seem random – very much guided – but other attacks seemed to be ‘dumb’ missiles that just appeared to land in random locations, to terrify the local population. Yet life goes on, and people walk in the streets and street vendors open their shops and shoppers haggle at the market to negotiate a price.

The road was atrocious going to the hotel, but the hotel has just been refurbished and was surprisingly comfortable apart from a lack of running water. We sat down to a very late meal, with the security detail on the next table, and their AK47s nonchalantly piled on a table next to them. It was surreal. There was friendly Arabic conversation, with lots of smiles and laughing. I don’t speak Arabic, but it all sounded convivial.

The food was tasty and filling. I especially appreciated the ready sweetened tea and the fresh grape juice.

Unlike the SUV, the air conditioning in the hotel was working, albeit rather noisily, but the noise didn’t stop me from getting to sleep in preparation for the first real day of the mission.

The next day, the journey to the hospital wasn’t long – about 10 minutes. We entered through an archway flanked by armed guards with AK47s, but then, who hasn’t got an AK47 here? Other cars were lining up to enter the hospital grounds, but we skirted around the queue and were immediately allowed in.

The cars weaved in and out of throngs of people, some of whom were on crutches or in wheelchairs – our prospective patients. As we left the cars, some of them seemed to recognise that we were the visiting team, and some of us had xrays thrust in our faces, and one mother was baring her daughters scarred forearm for one of us to inspect.

We squeezed through the throng and followed our contact into the hospital. We were scheduled to meet the Hospital Director first. We were sat down in a large room – his office – in comfortable chairs and offered drinks – cold water, fruit juice in cans and cups of warm sweet tea.

I got out pen and paper and we started the clinic. The first patient was a middle aged man with his xrays tucked under his arm. He had a shoe raise and a lumbar support belt on. We went through his xrays and his story. To cut a long story short, all the patients had all been injured by bomb blasts or gunshot injuries. He had been treated in Egypt and then in Saudi Arabia. In Saudi, they had made his femoral fracture unite, but his right leg was shorter than the left. He also complained of multiple discharges from the leg. At first we believed that this was the result of a bone infection from the injury, but his discharging areas were in his groin and well away from his injuries and previous treatment. The bone had healed, although it was short 4cm, and it seemed more likely that the discharging areas were the result of groin abscesses from other causes. He was advised by my Arabic speaking colleagues that he didn’t need surgery and that the shoe raise seemed to be doing a satisfactory job of equalising his leg lengths.

Some of the patients had been to Egypt or had been promised a trip to Egypt to see a doctor there. This created a real problem for us. They may have been given information that we would contradict. They may also have had surgery that we didn’t agree with. This can be confusing for patients as they have no idea who is right, if anyone at all is right in their advice.

The next patient had been injured by a bomb blast. He had an abdomen like a chess board as there were so many scars, but he had managed to survive and also have a normally functioning bowel. His right leg was also injured. The bone had healed up, but with significant shortening from overlapping of the bone ends, and he also had a deformity with a knock kneed position of his right leg. We studied the xrays and his limb – he had limited movement but functional enough. Without surgery, his knee would wear out prematurely on the outer side. We formulated a plan to correct the deformity and get it to heal – limited goals considering the environment. My colleagues wanted to use a plate to secure the new position. I am not comfortable with metal plates for war injuries, but there was no sign of infection from the last 2 years and we have limited equipment available to us. The plate has to be purchased as well as the accompanying screws. I didn’t really learn who was going to pay for it all, but I assume that it isn’t the patient, as it wasn’t demanded of him.

The next patient was a gunshot wound to the foot and ankle. His foot had an open wound on the inner side, possibly due to infection as it had been three months since the injury. We had brought treatment options for dealing with infection, so this was not now an issue. However, the joints were damaged as well, and this is something for a later date.

Our next patient had suffered a knee injury from a gunshot wound. He had a gap in his bone that needs filling but his knee had not moved for 7 months due to his emergency external fixator to stabilise the bone. We decided on just dealing with the bone loss, which could also possibly be infected, to leave the filling of the defect until later, when the possibility of infection would have been lowered further by debriding or scratching at the surface of the bone to remove dead and infected tissue, and then filling the space with a form of putty with antibiotics in it to kill any bacteria contaminating the area. This type of treatment isnt available here, so we had a better chance of clearing the infection.

Over the morning, we saw a total of 19 of these complex patients with typical chronic war injuries, which were preventing them from functioning normally. Some of them were open to our suggestions and others became agitated, with several walking out as the treatment options offered were not to their liking.