by Ray Wiss
JULY 21 | Michelle and Mariam
I had finished eating dinner around 1715 and my thoughts were turning to the pleasant experience I would soon have of hearing the voices of my wife and daughter. Michelle is usually full of energy in the morning, eager to tell me her plans for the day.
Mariam probably woke up the same way. She had come from Kandahar City to visit her grandfather. He lives in Bazaar-e-Panjwayi, the village beside FOB Ma’Sum Ghar. Like Michelle, Mariam would have been excited at the dawning of a new day. A trip like this would have been quite an adventure for her.
Mariam would have spent the day exploring her new surroundings. Bazaar-e-Panjwayi is a lot poorer than Kandahar City, but children do not focus on things like that. I imagine Mariam’s attention was drawn more to the big mountains right beside the village. For a little girl from Kandahar City, this is “the country.” It may be poor, but it is full of new sights and sounds that fascinate the young mind. No doubt she also spent a good deal of time today snuggling up to her grandfather. He may have been a fierce Pashtun in his youth, but age has mellowed him. I have no trouble seeing him doting on his granddaughter. This gives the two girls something else in common: my parents adore Michelle and love her almost as much as I do.
When one looks for hope in a place as desperate as Afghanistan, it is almost a cliché to look at the children. Will they have the wisdom and the strength to do a better job than we have? Will they find a way to bring peace to this land? I hope Michelle becomes the kind of person who could contribute to this process. Mariam, tragically, will never get the chance to do so.
Around 1800 hours, one of our patrols was checking things in Bazaar-e-Panjwayi. These “presence patrols” show the enemy that we are keeping our eye on things and that there is no place we cannot go. The patrol entered the marketplace, where more people than usual were shopping and walking around.
This was neither a good thing nor a bad thing. The presence of many civilians does not guarantee that the Taliban will not detonate a mine or launch an ambush, as we have seen countless times in the past. Occasionally, the local population will get some warning of an impending Taliban attack. This makes it a very bad sign to see villagers scatter as we approach. This is called a “combat indicator,” and our troops go on high alert when that happens.
Whenever our troops are out and about, they maintain a security bubble into which no civilian can penetrate without showing due cause and harmless intent. After IEDs, suicide bombers are the most lethal weapon at the Taliban’s disposal. We want to make it difficult for them to get close enough to us to launch their attacks.
Taliban suicide bombers wear civilian clothing and are indistinguishable from the innocent. That is why Coalition forces have made strenuous attempts to educate the population. Signs on the roads and on our vehicles admonish civilians that they must never approach our patrols, checkpoints or convoys in a threatening manner. After eight years of war, a civilian would have to be mentally deficient not to be aware of this.
At approximately 1815, a man on a motorcycle drove towards the patrol. As he approached, the patrol made hand signals that clearly indicated the driver had to stop. The driver ignored these signals and kept driving, passing an Afghan police vehicle at the head of the patrol and getting even closer to the Canadians. This led to an “escalation of force”: the patrol aimed its weapons at the motorcyclist. That did the trick, and the driver stopped at a safe distance from the patrol. He was apprehended by the Afghan police and taken away. People who approach Coalition patrols are so likely to be motivated by nefarious intent that they are inevitably questioned and, almost as inevitably, released for lack of evidence.
The patrol had gone only a few metres farther when a second man approached, also on a motorcycle. He circled the patrol four times, just outside the security bubble. He stopped and turned his motorcycle directly towards the patrol and gunned the engine several times. Then he sped forward.
The two soldiers closest to the motorcyclist had already discussed what they would do if they had to go beyond hand signals. One of them carried a C9 light machine gun and the other carried our standard C7 rifle. The C7 is capable of firing a single, well-aimed shot, whereas a single pull of the trigger on the C9 sends several bullets into a rough general area. The soldiers had therefore agreed that any warning shots would be fired by the rifleman to minimize the risk to the civilians.
This time, the hand signals and the raised weapon that followed had no effect on the driver’s behaviour. The motorcyclist kept moving towards the patrol. The rifleman then fired a warning shot into the ground several metres in front of the motorcycle. The motorcyclist turned and fled.
The patrol formed into a perimeter, scanning 360 degrees for any further threats. Then it noticed a body lying on the ground. The soldiers rushed over to see if they could help, but there was nothing to be done.
The bullet had skipped off the ground and hit Mariam in the forehead. The back of her head had exploded, and most of her brain ended up on the ground beside her. She died in the blink of an eye.
“Junior” Cappelli Horth was the medic on the patrol. He bandaged Mariam’s head, picked up her skull and brain matter and put them in a plastic bag, loaded her into a vehicle and rushed back to the FOB. He did not attempt CPR. This was the perfect way to deal with this horrible situation. Junior had treated the patient with dignity and professionalism. Even across cultural divides, families can see that.
The “right thing” to do, however, depends on whether one is in Canada or in the developing world. Back home, I have run a number of resuscitations on children who I knew were long gone. By the time I go to tell their parents the bad news, I can show them all the things we did to try to save their child. Parents in the West accept that even if the doctor does everything right, the resuscitation attempt might fail. They have seen enough T V shows in which that happens that it has become part of their reality. Even when it is obvious their loved one is dead, Canadians are comforted when they believe the doctor “did everything that could be done.”
People in the developing world, on the other hand, are exposed to death much more often than we are. Between 10 and 20 per cent of their children die before age five, and elderly family members often die at home. Because of this, they accept that various diseases and injuries lead inevitably to death. Conversely, they often have an unrealistic view of what modern medicine can do. The things we achieve seem so miraculous to them that they can have trouble accepting the fact that our best efforts are sometimes not enough. The futile resuscitation attempt we undertake in Canada to ease parents into the grieving process is sometimes seen in the developing world as a failure that has at least an element of physician error involved. It is wiser to forgo any such attempt if the conclusion is preordained.
Tracer bullet ricocheting
(Photo courtesy Master Corporal Julien Ricard)
That was what I had in mind when Mariam arrived at the UMS. A quick exam determined that she had no pulse, was not breathing and had fixed and midrange pupils. I loosened her bandage and felt her skull. It felt like picking up a bag of marbles. Although there was only a tiny hole in her forehead, everything behind her face was shattered.
I turned to her grandfather and told him that I was terribly sorry, but there was nothing I could do. I told him I deeply regretted his loss, but it looked like he was past that. He seemed to have already accepted the death of his granddaughter. His questions had to do with the details of getting her body back to his home. Nonetheless, I asked the interpreter to explain to him that Mariam had not suffered. I say the same thing to bereaved families I deal with in Canada. It seems to help.
When Mariam and her grandfather had gone, I turned my attention to the Canadians. I told Junior that he had done an outstanding job. He seemed okay. I spent a long time after that talking to the shooter. He is a sensitive and sophisticated man. By the time we were done talking, I think he had settled into the healthiest and most appropriate emotional reaction t
o this incident. He was distraught, but he recognized that his actions had been correct under the circumstances. Had he failed to defend the patrol, he might have allowed a suicide bomber to get close enough to kill several of his comrades.
The second motorcyclist, the one who caused all this, was not caught by the Afghan police. He has to have been a Taliban sympathizer, if not an active fighter. He was testing the patrol to see at what range our soldiers would fire warning shots, in an attempt to analyze its defensive procedures. In doing so, he deliberately provoked the patrol into shooting when there were numerous civilians around. He recklessly endangered those civilians and caused Mariam’s death. I doubt he feels as bad about that as the shooter does.
It is now a little after 2100. I am going to call home and talk to Michelle. I will ask her what she is doing, and we will laugh together for a few minutes. Then I will try to fall asleep while thinking about her face and not the one I saw tonight.
Addendum, July 31: The press reports in Canada have been reasonable about this incident, with the exception of one news outlet in Montreal that implied we had fired several rounds at civilians without explaining the threat our troops had faced. There has been a thorough investigation, which I will write more about in a later entry. It goes without saying that the family will be compensated.
Our procedures have been reviewed, and all troops have been ordered to fire warning shots into the air from now on. This is not as effective as firing into the ground. A shot into the air generates only a loud noise, whereas a shot into the ground also produces the visual stimulus of the dust kicking up where the bullet strikes. Firing into the ground is a much more powerful deterrent. It is also awkward and time-consuming to move to a “shoot to kill” position after having fired into the air. Nonetheless, we will use this method to increase the population’s safety.
Now, some context. The UN has issued a report on civilian casualties in Afghanistan over the first six months of 2009. There have been more than a thousand such deaths, over 70 per cent of them caused by the Taliban. These numbers are the opposite of what insurgencies should produce. Look at the civilian casualty rates in Sudan, El Salvador, Rhodesia and many others. Poorly armed rebel forces try to earn the trust and co-operation of the civilian population and cause few casualties among them. Entrenched powers use heavy weapons in sometimes indiscriminate ways and cause a lot of civilian casualties. Here, the proportions are completely inverted.
The report also accuses the Taliban of taking advantage of Pashtun culture, specifically nanawati (see the June 9 entry), to coerce civilians into giving them shelter and then attacking Coalition forces from those same dwellings. According to the report, this sometimes tricks Coalition forces into attacking the area and causing civilian casualties. This is something we are trying very hard to avoid.
Addendum, August 1: This is rich! Within twenty-four hours of the UN report coming out, the Taliban issued a statement saying they would “stop using suicide bombers to avoid harming Afghan civilians.” Eight years of war and thousands of civilian deaths later.
JULY 22 | Rules of Evidence, Rules of War
We had only one war casualty today, a fifteen-year-old who took a bullet to the shoulder. His injuries were not life-threatening, the care was straightforward and the medevac helicopter came quickly. I met his father at the gate after the helicopter had left and assured him his son would be returned to him shortly and in good health.
The most important aspect of the case had nothing to do with the medicine. The boy had been brought in after FOB Zettlemeyer, an ANP outpost a kilometre north of here, had been attacked. He told us he had been catching small crabs in the Arghandab River when he was shot. The problem with his story is that he was discovered north of the outpost whereas the river is to the south, between the FOB and the outpost. For his story to be true, he would have had to have walked close to one kilometre through the bush with his gunshot shoulder. This is very difficult to believe, as this would have meant he had walked away from the FOB, to which he claimed to have requested to come when he was found by the ANP.
Although still a juvenile, the patient fell into the category we call FA M, a fighting-age male (the Taliban make extensive use of child soldiers). We all had a gut feeling that this guy was wrong somehow. That is not enough. He was sent to Kandahar without any restrictions on his future movements. He was not even questioned by our military intelligence people.
We have had people about whom our suspicions of Taliban affiliation were much stronger but who were also released for lack of sufficient evidence. Some soldiers are frustrated when that happens, because it is likely that these individuals will go right back to their Taliban units and be attacking us the next day. Whenever I sense that this might be the case, I tell the aggravated soldier that the ones we let go are living proof that, despite the savagery of our enemies, we continue to fight this war in a clean and honourable way.
I say the same thing when a soldier expresses frustration with our rules of engagement, the criteria we must satisfy before we open fire. The rules are different for different weapons, with the most restrictive criteria being reserved for the heaviest weapons, the ones most at risk of killing innocent bystanders. The combat troopers who are getting shot at from one family compound sometimes resent it when a commander, safe at KAF, denies them an air strike because it might damage a neighbouring compound. It speaks volumes about the discipline and professionalism of these men that they follow these rules.
JULY 23 | Investigations
I spent a good deal of time yesterday describing the circumstances of Mariam’s death with a representative of the CF National Investigation Service (NIS). Any incident of this severity is investigated by NIS. Its members are senior members of the military police and serve as the detectives of that branch.
It is common for emergency physicians to have to discuss cases with police and lawyers, both in and out of court. I have had to do so several times and no longer feel any anxiety during the process. Although I had never met an NIS man before, much less been interviewed by one, this did not feel any different. Once the tape recorder was turned on, I gave my statement in one long speech. The investigator asked a few more questions and we were done. I had to go through the same process again today because of an incident that occurred this morning.
An Afghan policeman had been standing near the front gate of the FOB when one of our armoured vehicles came in. The Canadians indicated their intention to come in and turn to the left. However, it seems that the policeman did not know that tracked vehicles do not turn in the same way a wheeled vehicle does. To turn a tracked vehicle, you make one track go forward while the other one goes backward. As a result, the vehicle pivots, more or less in the same place. Unfortunately, the policeman did not wait for the vehicle to pass but rather walked right into its blind spot, whereupon his head was crushed between the vehicle and a wall. He was rushed to the UMS.
When he arrived, his head was covered with a sheet and he was not moving. One of the policemen accompanying him, perhaps a family relation or close friend, was distraught and screaming. He was controlled by the camp sergeant-major and removed from the premises.
I took half a second to steel myself before removing the sheet. Given the mechanism of injury and the other man’s emotional state, I thought I was going to be looking at a skull that had been squashed like a grape. Somewhat to my surprise and very much to my relief, the patient started talking as soon as I exposed his head. He had multiple facial lacerations and a skull fracture of the right forehead. His right eye socket had caved in and his eye was “extruded”—it went much further forward than it should have. The optic nerve, the thing that connects the eyeball to the brain, had been stretched a considerable distance. His pupil did not react at all when a light was shined into it.
This case gave me a chance to do some on-the-spot teaching. Everyone in the UMS, medics included, was focusing on the facial wounds. These are very distracting for medical personnel because the fa
ce is such a big part of who we are as human beings. You can lose a hand or a leg and, once your prosthesis is in place, people will barely notice the difference. A mangled face, however, dramatically changes how people see you.
I therefore took a minute to show my crew that, as bad as these injuries were, none of them was life-threatening. The patient was breathing on his own, he had good air entry into both lungs and his vital signs were stable. You could see that he was protecting his airway because he was spitting up the blood that pooled in his mouth. He also appeared neurologically intact because he was moving all four limbs and was able to speak coherently. He needed maxillofacial and plastic surgery procedures, but these could be safely delayed for hours.
I like to say that these patients are “stable in their instability.” So long as nothing else goes wrong, they are likely to remain stable for quite some time. It would be a terrible mistake, however, to assume that will be the case when a helicopter transfer is imminent. We therefore proceeded with a standard emergency department intubation, giving additional drugs to protect the brain as well as the usual ones to put the patient to sleep and paralyze him. We protected his cervical spine while we did this—always a good habit when the patient has a head trauma. We had barely finished securing the tube when the helicopter arrived to take him to KAF.
No more than an hour had gone by when another helicopter arrived at the FOB. This one carried a different member of the NIS, sent to investigate today’s incident.
I have a number of friends who are senior police officers, and the two NIS men came across the same way my buddies do: professional, very good at their jobs, completely ethical and determined to get to the truth. Both of them are investigating incidents in which the actions of Canadians have injured Afghans. Having spoken to the men involved, I am convinced that both occurrences were tragic accidents. I am equally convinced that the investigators will only reach that conclusion themselves when they have examined all the evidence and interviewed all the witnesses. And re-interviewed them, if necessary: the NIS man in charge of the investigation into Mariam’s death called me back to confirm which side of the forehead the bullet had entered, because there was disagreement among the witnesses. This may seem trivial, but it shows how badly this guy wanted to get the story absolutely right.