At the sharp end of city life

Many people have been shocked by the spate of gun crimes that has hit the headlines in recent weeks. But for inner-city surgeons such as Dr Alex Beatty, violence is now all in a typical day's work

It's unusual for a man to be shot in broad daylight. Because of this, my day usually begins in the civilised environment of the outpatient clinic and progresses through a leisurely lunch break in the post-graduate centre to a series of planned operations in the afternoon. Then, with night approaching, I wander down to casualty and find a different sort of patient.

It's unusual for a man to be shot in broad daylight. Because of this, my day usually begins in the civilised environment of the outpatient clinic and progresses through a leisurely lunch break in the post-graduate centre to a series of planned operations in the afternoon. Then, with night approaching, I wander down to casualty and find a different sort of patient.

Gunshot victims are rarely dead on arrival. For that matter, many of them are wide awake. Even today a firearm is a special weapon and their use is premeditated. When they arrive in the unit, the patients are usually surrounded by a small crowd of bored police officers wearing flak jackets. Very often, at least one of the police officers will be brandishing a firearm.

At medical school they teach you to take a history before the examination. In clinical practice we tend to merge these two things together. "What happened?" I ask the gunshot victim.

"Dunno, Doctor, this bloke I never met before just walked up to me in the middle of the street and just shot me in the leg and ran off."

"Who was he?"

"Dunno, Doctor."

Peeling off the dressings, I inspect the hole and wonder how much work it will involve. Some of the skin around the margins has been burnt. His assailants had pressed the pistol into his flesh before they pulled the trigger. Glancing at the other thigh, I notice a well-healed scar in much the same place.

"What happened there?"

"It's a funny thing, Doctor," he tells me. "But last year, exactly the same thing happened."

"How did that happen?"

"Dunno, Doctor. Guess I'm just unlucky."

For many of the victims in this world, it's just an occupational hazard and they live with it. Occasionally, as in the case of the two girls in Birmingham on New Year's eve, a complete innocent may be butchered, but that's just one of those things.

We get into theatre and he soon settles down for a good snooze under anaesthetic while I get scrubbed up. Having managed to keep me awake all night he returns to haunt me on the ward round. The nurses have put him in a side room. A bunch of obviously armed and obviously bored police officers have surrounded the entrance and settled down to look throughMarie Claire magazine. My patient isn't expected to escape, it's more a matter of follow-up attacks. What if his assailants decide they hadn't tried hard enough the first time and turn up in the unit to finish him off? Once we've got him better he can be discharged without any escort.

"What happens then?" I ask the coppers, but they don't seem bothered.

And suddenly, I am reminded of the old story about the British doctor who skipped off to the States on a fact-finding visit to an inner-city trauma unit. "I was interested," he is reported to have asked. "I was interested to know how many shootings you had in the department last year."

"Last year?" His American host paused and then quickly produced an answer. "Last year I would say about 35."

"Really!" Our visiting Brit was impressed. Maybe American cities weren't as violent as they said. "That's quite interesting because we got about 20 or so in Leeds last year." But his American host had made a mistake, and, after a few seconds, he grinned and owned up to it.

"Oh, I'm sorry," he said. "I thought you meant in the department."

He gestured to the uniformed security guards standing at either end of the waiting room, each carrying a sub-machine gun. "As you can see we've taken action to bring that figure down."

But you don't have to work in a trauma unit for long these days to start realising what it's all about. Few, if any of the modern-day shootings, beatings and stabbings are designed to kill. Even when these attacks skirt on the very edge of barbarism, there is still a logical thought process at work. Gangs of men with clubs and flick knives are acting under the auspices of a genuine command structure. Stabbing wounds to the chest are usually directed to the right-hand side, consciously reducing the risk of a penetrating injury to the heart. Heavier blows may be struck with heavier instruments but these would tend to be directed at the peripheries rather than the head, neck or trunk. A significant proportion of these victims already bear the scars of an earlier encounter with their colleagues and what we are looking at here are carefully targeted punishment beatings, designed to send a political message to their opponents on the street. Just as the superpowers consciously held themselves back from direct nuclear confrontation, so too, most of these gangs will hold back from the use of deadly force.

A guy turns up with a combination of gunshot wounds and multiple knife wounds.

"Who shot you?"

"Couldn't say, Doctor?"

They never say. At least not directly. You might hear: "It was too dark." They might tell you: "These blokes in black." But they rarely, if ever, say. Sometimes, when you inspect them again under anaesthetic, it starts to look different. There are patterns, some of them specific to the ethnic groups that direct them. Gangs of Bosnians like to mutilate people in a different way to the Serbs, Croats and Turks and for a while the police were able to target the criminals in this way. In the course of time, each group learns lessons from the others and they may prefer to maim in the style of their rivals.

Some of the victims are consciously waiting until they are well enough to go home, and can contact their associates and organise a counterattack. Why rely on the law when you can rely on a baseball bat. Or a gun.

Many of them seem unaware of the scale of the punishment they have inflicted on their bodies. "When will it get better doctor?" they ask and I don't think I've ever told them, "It won't get better. Not ever."

At the very least you'll always have that scar. The lacerated tendons will never pull again. Severed nerves will come back on line with a distant fuzz, but not real feeling. Many of the muscle groups will never function again. While you're young you'll hop along with undiminished vigour but as the years take their toll, you'll find it harder and harder to compensate.

The predominance of black and Asian people in this population is not lost on the medical staff. Although the staff are schooled in the philosophy of cultural enrichment through racial integration, many give way to the odd moment of cynicism.

De-scrubbing after a hard night with a shotgun victim, a colleague checked for witnesses and then said: "I think we've had enough enrichment for one week."

And so it goes on. Years ago, I remember reading that the British army had decided to rotate two military surgeons through a trauma unit in South Africa. During the Falklands war, they had ran into trouble because none of the doctors had had any previous experience of gunshot wounds. By shifting two guys through Johannesburg every six months there would always be officers with the appropriate experience for that unexpected war. A great experience for the surgeons involved, with ample opportunity to visit the regional game reserves. How much longer, I wonder, before that particular arrangement becomes unnecessary? South London, Moss Side and east Birmingham – these places may soon replace South Africa, but for the off-duty fun, they'll never have quite the same appeal.

The writer is a surgical registrar in an inner-city hospital