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.