by Ray Wiss
I then returned to the first patient. Dominic the Medic had cleaned off the extruded bowel and replaced it in the man’s abdomen, then bandaged the wound. The patient’s level of consciousness was still diminished, so I proceeded with the intubation I had planned for him.
We had just gotten these two patients loaded onto the medevac helicopter when another casualty reached us from the second convoy attack. He also had a gunshot wound to the chest, and ultrasound confirmed blood and air in his chest cavity. He also got a chest tube. We called for yet another helicopter, and he was away in less than twenty minutes.
My medic team performed admirably throughout this period, and I felt as well surrounded as I am in the Level 1 trauma centres I have practised in back home. This was all the more impressive because this group had not been led by an emergency specialist prior to my arrival. They had to work more quickly and more intricately than before. Master Corporal Guay, for instance, had seen chest tubes placed during her few weeks at the FOB, but never under sterile technique. She immediately understood that this additional step would help to achieve the best outcome and figured out how to assist me with the procedure.
Later in the day I called Lieutenant Colonel Ron Wojtyk, the highest-ranking doctor of the task force, to asKAFter my patients. Ron, who is a visionary physician, had been a student of mine on a couple of emergency ultrasound courses before we deployed. He is quite senior to me in rank, but we are close in age and careers and we have become good friends. He informed me that my patients had fared well. Two of them had required emergency surgery, but both were now on a regular ward. They will all be going home in a week or so.
Ron then asked me what I thought of the day. I replied that it had been very satisfying. Again, lots of blood and lots of life-saving procedures, everybody alive and doing well at the end. It had been pure emergency medicine, and it doesn’t get any better than that.
JUNE 12 | Political Science Lesson (or, Not Much Going On)
To understand what is going on in Afghanistan, it is necessary to understand another country: Pakistan. The fates of both nations are inextricably linked.
Let’s start with a bit of geography, since politics so often derives from the land. I mentioned earlier that the Taliban are almost exclusively drawn from the Pashtun tribe of southern Afghanistan. But while it is true that most Afghans living in the south are Pashtuns, it is not true that most Pashtuns are Afghans. The legacy of colonialism here, as in so many places, has split a tribe between two countries.
All through the 1800s, Great Britain and Russia vied for influence in Central Asia (roughly present-day Iran, Afghanistan, Turkmenistan, Uzbekistan, Tajikistan, Kyrgyzstan, Kazakhstan and Pakistan). Occasionally they would invade, but more often they would try to establish alliances with local warlords through bribes of money, weapons or other inducements. This went back and forth in what came to be called “the Great Game.”
Warlords controlled one main city and the surrounding countryside. By the mid-1800s, the territory that would be roughly recognized as present-day Afghanistan came to be controlled by a single king-like entity, an emir. The British wanted to demarcate where Afghanistan ended and where their own colony of India began. Sir Mortimer Durand, at the time the foreign secretary of the British Indian government, mapped out the line that to this day is the border between the two countries. The only difference is that, in 1947, the Muslim part of India became Pakistan. So the Durand Line is now the border between Afghanistan and Pakistan. The problem is that the Durand Line followed physical features such as rivers or watersheds. In doing so, it divided the Pashtun tribe.
Afghanistan’s government, long dominated by Pashtuns, has never recognized the Durand Line. The tribe longs to be reunited in a “Greater Pashtunistan.” One could argue that Pashtunistan already exists. Pakistan has never exerted much influence or control over those of its provinces that lie next to Afghanistan. The border is a nonentity, and Pashtuns pass effortlessly in both directions.
This state of affairs served Pakistan and the United States well during the Russian occupation of Afghanistan. The Pashtun provinces of Pakistan were training grounds, rest areas and logistics bases for the mujahedeen fighters who were being armed by the CIA. The situation in Afghanistan today stems in large part from the different goals held by America and Pakistan in the war against the Russians.
The Americans wanted the Russians to hemorrhage blood and treasure. This was done out of revenge for their losses in Vietnam. Russia invaded Afghanistan less than five years after the Vietnam War had ended. America’s sixty thousand dead, many of them killed by weapons supplied by Russia, still constituted a raw wound in the American psyche. It was only much later, when the Afghans began to inflict serious damage on the Red Army, that the Americans began to think of this as a proxy war they could win.
When the war was won and the last Russian soldier had left, the Americans lost interest in Afghanistan. They had won a skirmish in the Cold War. That war was ongoing, and their attention turned to where they thought the next battles would take place. No one was predicting that within two years the stresses caused by Russia’s defeat here would provoke the disintegration of the Soviet Union.
Pakistan’s goals were radically different. With CIA money, Pakistan was training and advising the Afghans as they prosecuted all-out war against the Russians. As Muslims, most Pakistanis had no love for the atheist communists and it suited them to help their co-religionists. The war raging to the west also served to better prepare them to confront the far more serious enemy they faced to the east: India.
Since India and Pakistan’s independence, there have been three full-blown wars and countless skirmishes between these two countries. But whereas India sees Pakistan as a constant irritant, Pakistan sees India as an existential threat. A glance at the map explains why: India is gigantic. You may think of it as a Third World nation, but that would be inaccurate. It is the regional superpower. Its economy dwarfs that of Pakistan, it has five times Pakistan’s population and its army is much larger and better equipped.
The Pakistani army, on its best day, could never do more than conduct raids into Indian territory. The Indian army, on the other hand, has a large number of tanks and troops massed across the border at Pakistan’s midpoint. As the bomber flies or the tank drives, it is two-to three-hundred kilometres to the Afghan border. If Indian troops capture that central part of Pakistan, they will cut the country in half. The capital, Islamabad, would be cut off from the port of Karachi, the economic hub of the country. Pakistan would disintegrate.
This equation changed in 1997 when both countries became nuclear-armed (each detonated five warheads that year), but old habits die hard. Pakistan’s fear of invasion remains the same, even though it can now inflict such damage on India that New Delhi would never order such an attack.
This fear dictated Pakistan’s goal during the Afghans’ war against the Russians and in the civil war that followed: to establish a friendly government in Afghanistan that would give Pakistan “strategic depth.” In theory, Afghanistan would serve as a backstop for Pakistan, allowing the Pakistani army to continue to retreat westward in the face of the Indian onslaught. This would give the Pakistani army time to regroup and counterattack while leaving the Indian army at the end of a long and vulnerable supply line.
Although this has been advocated by the Pakistani military for decades, it is a lunatic concept. Afghanistan has minimal transportation infrastructure, and while the Pashtuns on either side of the border have an affinity for each other, it does not follow that the Afghans would welcome the retreating Pakistani army with open arms. The best the Pakistani army could hope for would be for a few of its members to hide in the caves of western Afghanistan. For Pakistan’s generals to cling to “strategic depth” as a matter of policy shows how detached from reality they are.
Whatever the logic of the matter (or lack thereof), that was the motivation for Pakistan’s support of the anti-Soviet resistance in Afghanistan. There is
a further complication: “Pakistan” cannot be taken to mean a nation-state in the sense that Canadians use the term. Pakistan is not one country; it is three countries.
One Pakistan is run by the civilian government. It has institutions that look like our parties, prime minister and parliament. Although influenced by the Islamic character of most of its citizens, it is nonetheless nominally secular. Think of the United States before Kennedy was elected president. It was a huge deal, in 1960, for a Catholic to even run for this office, much less win it. And yet, the unbroken string of Protestant presidents elected before then would have described their country as having a separation between church and state. Religion was not an official government policy, but it informed people’s decisions. Pakistan’s civilian governments would identify with this.
Another Pakistan is run by the army. This goes beyond the regular military coups that have overthrown the civilian government. Even when it is not in power, the Pakistani army exists as a national entity unto itself. It has its own economic base: it runs thriving import-export businesses in a wide range of fields; it owns hotels and shopping malls; it runs several factories. Even more astoundingly, it conducts its own foreign policy.
The most remarkable example of this occurred in the spring of 1999. Pervez Musharraf, then the chief of the army’s land forces, decided to attack India at a place called Kargil. Only a few thousand Pakistani soldiers were involved, so this was never going to be more than a raid that penetrated a few kilometres into Indian territory. Nonetheless, it was a blatant act of war, and it could have provoked India to retaliate and perhaps have led to a nuclear exchange. Musharraf decided to do this on his own. He did not even discuss it with the then prime minister, Nawaz Sharif,* much less any other members of the civilian government.
In Canada, our country has an army. It is beholden to our elected civilian leaders. In Pakistan, as in a lot of developing-world nations, the army has a country; the elected civilians serve only as long as the army allows them to.
Finally, there is a third Pakistan. This one is run by the spies. Their organization is called the Inter Services Intelligence, or ISI. Think of this as a combination of the CIA, the FBI and military intelligence in the United States.
The ISI is a power unto itself. The civilian government (when there is one) is not even allowed to know what the ISI’s budget is. Like the army, the ISI runs a number of businesses to support its activities. And it is even more aggressive in the foreign policy arena than the army is.
During the Russian occupation of Afghanistan, the ISI controlled the CIA money that flowed to the Afghan resistance. Being largely run by Islamic fundamentalists, the ISI favoured those resistance groups who shared their theological beliefs.
This continued during the civil war that followed the Russian withdrawal and when the Taliban conquered the country. Despite the Taliban’s behaviour while in power, Pakistan did not sever its links with the Taliban until after 9/11. Even after that, the ISI continued to arm, train and otherwise support the Taliban for many years, even as the Coalition fought them in Afghanistan.
Pakistan is the piece of the puzzle that George W. Bush never addressed. Since Afghanistan is landlocked, Coalition forces have to ship most of their heavy supplies via Pakistani airports and harbours. In exchange for this access, the Bush White House ignored the overwhelming evidence that a proportion of the Pakistani military and intelligence establishments were helping the Coalition’s enemies. Instead, it kept praising Musharraf as a vigorous leader in the war against the Taliban. Musharraf would thank Bush for the compliment . . . and continue to pretend that his country was not playing both sides of the fence.
Until Pakistan is cajoled/encouraged/pressured/assisted to do its part in bringing responsible government to this area, our mission here will not have succeeded.
Addendum: The best review of the situation in Pakistan today is Descent into Chaos, a book by Ahmed Rashid, a Pakistani journalist who has covered Central Asia for two decades.* Rashid is critical of all sides in this mess. The difference, which he recognizes, is that his criticisms of the Coalition side will stimulate debate, which has a chance of leading to policy changes. His criticisms of the Taliban, on the other hand, have only led to death threats against him.
JUNE 13 | Combat Psychology, Combat Psychologist
The CF tries hard to identify those who will not be able to withstand the rigours of combat and to weed them out ahead of time. For the soldiers who make it into combat, the CF does everything it can to support them psychologically. Here’s an illustration of how far we go to make this happen.
For the past four days we have been joined in the camp by a social worker, Captain Josiane Giroux, who is posted to KAF. She has a master’s degree in counselling and does a lot of the critical-incident debriefing sessions for our troops. She will spend a week at our FOB, counselling any soldier who feels the need to talk. Her timing could not have been better. She arrived the day of the ramp ceremony for Private Alexandre Peloquin, twenty-four hours before Bravo Company came back to the FOB.
A number of soldiers, including some commanders, have come to see her. This is good to see. If our troops are no longer worried about discussing their anxieties, it means that the stigma attached to these feelings is nearly gone. This bodes well for the ongoing mental health of Canadian soldiers.
It is appropriate and indeed necessary to be tough and unemotional when the bullets are flying. To be otherwise would put oneself and one’s comrades at risk. After the shooting is over, many people will benefit from being able to vent their feelings. Often soldiers will seek out friends or trusted leaders to do so. The CF also provides well-trained mental health professionals to those who want to avail themselves of that service.
Things are markedly different than they were even ten years ago. It used to be that soldiers who admitted they were scared were seen as weaklings. Discussion of one’s fears was subtly (and sometimes not so subtly) discouraged. Like all pendulums, this can go too far the other way. One of the men on the FOB asked to see Captain Giroux, saying that he had been ordered to talk about his feelings. He had been involved with our KIA—killed in action—and someone in the chain of command thought he was doing the right thing by shoving this soldier on the social worker. I am sure the commander’s heart was in the right place, but his actions were overzealous. Some people come through a combat experience with no emotional damage whatsoever, and others are not ready to talk about their feelings. Both types of individuals should be left alone until they feel the need for help.
Captain Giroux spent some time with me discussing the relaxation and visualization techniques she uses to coax the emotionally wounded back to health. She has had good success with these techniques, but she worries about the few individuals who have not responded. I can’t blame her. When my treatments fail, my patient’s suffering has ended; when her treatments fail, her patient’s suffering is only beginning.
JUNE 14 | EOD: Explosive Ordnance Disposal
Another day of heavy fighting all around the FOB.
The Taliban managed to pull off three attacks right after we had finished breakfast, one to the west and two to the east of our position. Two of these were ambushes of civilian convoys, and one was an attack on a police substation. ANA units and our own quick reaction force headed out to engage the enemy.
The first reports of casualties came in one hour later. There was one patient with a gunshot wound from the fighting to the west, and possibly other casualties to the east. We got ourselves revved up and ready to receive them. This involved calling all the medically trained personnel on the camp, especially the combat medics who are assigned to each platoon, to join us in the UMS. They are trained to the same level as Dominic, the Bison medic, so they are superb.
The other resources available to us in a MasCal event are the soldiers who have taken a course called Tactical Combat Casualty Care, or TCCC. They can perform basic emergency procedures and, most importantly, can help us control life-
threatening bleeding. They do this with a number of different kinds of sophisticated bandages, modern tourniquets and an ingenious substance called Combat Gauze, a dressing impregnated with a substance that accelerates the formation of blood clots. Using this dressing to pack a large open wound greatly decreases the speed with which the patient loses blood. Blast injuries can also give you a tremendous amount of blood loss from diffuse oozing. Combat Gauze is invaluable in these situations.
Combat Gauze has largely replaced its predecessor, Quick Clot. This was a substance we used liberally during Roto 4. It produced an exothermic reaction when it came in contact with blood or any other source of moisture. When you sprinkled it into a wound, it got so hot it cooked the torn flesh. This sealed off the bleeding vessels.
Sounds like a wonder drug, eh? It turns out to be, like so many things doctors have tried over the centuries, a beautiful theory that gets killed by an ugly fact. Since Quick Clot would burn itself into the tissues, it was often necessary to “debride” (cut away) more tissue than would otherwise have been the case. Combat Gauze has the advantages of Quick Clot without the drawbacks.
We also put the word out for two of the senior non-commissioned officers (NCOs) to join us. These two men handle the flow of information from me to the KAF Tactical Operation Centre, or TOC, which marshalls the medevac choppers and provides a summary of the incoming patients’ injuries to the receiving physicians. There is no physician-to-physician contact.
This may strike those familiar with Canadian medicine as aberrant, but in this setting it works well. Battlefield injuries, though devastating to the victim, are straightforward to manage. There’s a hole in the front and a hole in the back? The part that has to be fixed is in between the two holes. The leg is ripped off? Try to save as much of it as you can. The thorough description of the patient’s history and physical exam that is so crucial in civilian emergency medicine is not necessary here. In a MasCal, it would be an inappropriate use of my time—I have to focus on treating and stabilizing patients.