On the bloody front line of London's gang wars, doctors go to Soweto for training in gun wounds

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On the graveyard shift, six gunshot victims is a quiet night

It was barely lunchtime in the Accident & Emergency ward of Homerton hospital, east London, when the genial banter among nurses and junior doctors catching up on paperwork was abruptly halted.

Amid a blur of fluorescent coats and Tannoy announcements, an ambulance crew flung open the double doors to deliver a young man, writhing in agony and pleading for a bullet, lodged near the base of his spine, to be removed.

Set among the high-rises of Hackney and a five-minute ambulance dash from "Murder Mile", a notorious battleground for drug-related violence which stretches along Upper Clapton and Lower Clapton roads just east of Hackney, Homerton has become the frontline hospital of London's brutal gang war.

Day in, day out, the hospital's medical team deals with more gunshot and knife-inflicted wounds than any other in Britain. When staff refer to themselves as the "Seventh Cavalry", it is only partly in jest.

The A&E department – staffed by a team of 20 consultants, middle-grade doctors and senior house officers – treats an average of five gunshot cases a month and 50 stabbings. About a third of major trauma cases in casualty are gun and knife-related – representing an increase of about 40 per cent since 1996. And if the experience of the past two years is anything to go by, the grim procession of wounded will peak in July and August as the drug war hots up along with the weather.

But, as Donal Shanahan, a senior consultant surgeon, admits, this is not merely a numbers game. He talks with something akin to nostalgia of the mid-1990s, when he joined the hospital. Back then, the appearance in casualty of a Metropolitan police officer turned heads – now they are a near constant presence. Patient confidentiality prevents the use of CCTV in casualty, and officers are frequently called to stand guard over a potential witness should anyone unexpectedly turn up to attend to unfinished business. Recently, a man arrived to visit his injured "brother", although he didn't even know his name.

Five years ago, bullet wounds were an extreme rarity at Homerton and a knifing was typically nothing deeper than superficial slashes. Now bigger knives are commonand the cuts – aimed at the chest and abdomen – are much deeper.

Thigh wounds are particularly vexatious, according to Dr Laurance Gant, the consultant who heads A&E. He said: "Muggers tend to stab in the leg or thigh because their victims can't run away and their assailant's conscience tells them it's not as dangerous. That's a total misconception because of the major arteries in that area and the chance of dying of blood loss."

Shots are most commonly aimed at the torso, a nightmare for surgeons who have to prise open the chest of otherwise healthy young men in search of the bullets, repairing damaged arteries as they go. Shots to the head remain rare. "They are easy to deal with because the victim is normally dead," Mr Shanahan said. He has become increasingly concerned about the effect of such extreme violence on his twenty-something junior doctors, and debriefings have necessarily become more frequent. "It would be a tragedy if these young people stopped going out because of what they see, but a lot of it would turn the stomach of a billy goat."

He and the directors of the Homerton NHS Trust have decided the hospital needs to improve the depth of its expertise in "battle surgery". Mr Shanahan believes London hospitals will eventually be forced to follow the American model of employing more surgeons who specialise in chest, abdominal and vascular injuries.

"They will be trained to do everything to save a life before another specialist comes along to deal with the refinements. I have seen a gradual increase in beatings, shootings and stabbings in this area. The consultants may have the expertise but the doctors need a crash course in penetrative injuries."

With a mixture of excitement and trepidation, Mr Shanahan, who is among the hospital's most senior surgeons and who helped treat the late PC Yvonne Fletcher after she was shot outside the Libyan embassy in London in 1984, will next month begin a six-week secondment to a trauma team in Soweto, the crime-ridden township outside Johannesburg, to help him devise new emergency guidelines for London's registrars.

Soweto's Baragwanath hospital was chosen after taking advice from police ballistics experts and trauma teams in the United States because it best replicated the challenge facing doctors in the East End. It treats young men – often drunk or under the influence of drugs – who have been stabbed or have sustained low-velocity gunshot wounds. Wounds from low-velocity guns sold on the streets of Britain, often ex-Eastern bloc military ware, pose a particular problem to surgeons because the bullets "tend to bounce and don't come out", Mr Shanahan said.

The surgeons' work is often complicated further by the reticence of patients, if they are involved in drug dealing. Often they arrive unaccompanied and give false names. Two months ago an ambulance crew watched in amazement as a car swung into the hospital forecourt, dumped a man bleeding from the stomach and drove away at high speed. They observed wryly that if the practise caught on they may find themselves out of work.

The killing on the streets of east London has too often been portrayed as a regrettable but insoluble "black-on-black" crime war, fuelled by drugs and orchestrated from Jamaica. While it is true that many of its victims are involved in the drugs trade, others are simply innocent victims of a youth subculture in which violence is a first instinct rather than a last resort. Recently, Mr Shanahan treated a young man stabbed for treading on someone's toes at a local nightclub.

But those involved in clearing up the bloody aftermath cannot afford to speculate on the causes of crime. As Richard Hurry, the station officer of the Homerton branch of the London Ambulance Service, said: "There is no such thing as a good or bad patient." But last month, the Homerton branch introduced personal safety training, including police "talk-down" tactics used to defuse violent situations.

Back at the hospital, in a curtained-off section of the resuscitation room of Homerton's A&E department, a "crash team" – made up of an anaesthetist, senior house officer and consultant surgeon – hurry into position around their patient. The attempts they make in the first five minutes to stabilise him are critical. Theirs is a carefully choreographed procedure that betrays their familiarity in dealing with gunshot victims. Soon the young man's condition has been stabilised and when Dr Gant is satisfied he will survive, the patient is taken upstairs on a trolley, where he will remain under observation.

A couple of miles away, police forensic teams remove the car in which he was found shot after jumping out of the window of his flat in Clapton Common, the northern end of "Murder Mile". The medical team quickly turn their attention to a critically-ill child delivered in the arms of his frantic parents.

Outside in the car park the on-call ambulance crews are gripped by an impending sense of doom. "You often get a second shooting within hours. Retaliation is part of the pattern," Mr Hurry says.