Bad Medicine

by Terry Ledgard

  Throwing on the nearest pair of boots and shirt that I could find, I almost forgot my 9-millimetre pistol, as Tropical Cyclone Terry burst out the door to the Hilux that was idling patiently in anticipation for the short trip down to the American compound. Inside the trauma surgery, we worked at breakneck speed, quickly preparing IV bags and other emergency trauma gear for the onslaught of blood and gore that was due at any minute. Information on the casualties was scant; all we knew was that three Afghan trauma patients were on their way. I ran through the most likely emergency scenarios in my mind. There was a good chance that the patients would be hypovolemic (suffering major blood loss). Maybe they had head injuries or other forms of non-compressible haemorrhage (internal bleeding). I mentally rehearsed my treatment protocols, adrenaline pumping as the minutes passed.

  All of a sudden, stretchers burst through the door, accompanied by an entourage of stretcher-bearers, interpreters and chopper medics. The surgery was an instant hive of activity, people scurrying around the room grabbing bandages and pulse oximeters and needles. Vital statistics flew across the room in short, matter-of-fact statements from the chopper transfer crew. Verbal and physical shit was flying everywhere. It was a mission just to hear the information pertaining to my casualty, let alone block out all the other white noise.

  From what I could gather, the three Afghan patients had suffered significant lower-body trauma, presumably from an explosive force. But according to the chopper medic their story didn’t quite stack up. The guys were dressed in Afghan Police uniforms, but their particular injuries closely resembled those you’d expect from a stoush with allied friendly forces. The running theory was that they were Taliban combatants who’d been in contact with Dutch forces earlier that day. Not that this changed the nature of our medical treatment, but it provided valuable insights into their ‘mechanism of injury’ and clues as to the treatment they might need.

  My casualty was the most critical of the trio. While the others were moaning in pain, my bloke didn’t know who he was or what the hell was going on. His face was caked in a thick layer of dry, black blood and his eyes were swimming aimlessly inside his skull, unable to focus on anything. My triage team screamed out a set of baseline observations: pulse, respirations, blood pressure and all the rest. He was in bad shape; his blood pressure was dangerously low and dropping with each passing minute.

  While all this madness was going on, I cut away his clothing and assessed the extent of the injuries. His upper body and abdomen seemed to be okay, but his legs were another story. One of the team got IV access and pumped in a tsunami of fluids to raise his blood pressure. On the left thigh, he had a large, gaping hole, where I could see one of the quadricep muscle bundles taper away into a whitish tendon that had been harshly torn and cauterised by a hot piece of frag. There didn’t seem to be too much blood, so I moved on.

  Further down his leg, I saw that his foot had been blown to smithereens. There was another gaping hole on the top of his lower left appendage, through which I saw two exposed white, fleshy ligaments connecting to the internal structure of his toes. Three ligaments were severed and rolled up into the wound like tape measures. Underneath was a pulpy mess of blood, severed tissue and mashed bone. Again, not much blood was seeping out of the wound, so it probably wasn’t life-threatening at this stage. But by the time I’d progressed to rolling the patient over to inspect his back, the American surgeon watching over me was growing impatient. My primary survey was taking too long.

  The UM course had stressed the importance of taking an extra few minutes to fully assess the situation, but emergency mass-casualty situations were an entirely different beast. The imperative was to run a rapid-fire primary survey, take an educated guess as to what was going on and move the patient on to surgery – a bit like a production line. As I worked my hand down the casualty’s back, feeling for spinal abnormalities and bruising, the super-experienced overwatching surgeon grew increasingly restless. ‘Check the anal tone, check the anal tone now. And while you’re there, you might as well check the prostate,’ he urged, prompting the shorthand version of my primary survey.

  Checking the old boy’s dirty dot was a tried and true method for assessing spinal damage – if his sphincter didn’t pucker, he probably had a spinal injury. But asking me to check the prostate was a tad weird, especially in an emergency. I had my reservations, but I didn’t question the surgeon; in hindsight this was probably a hazing tradition. I took a deep breath and steadied my nerves, before diving in with both fingers. Fuck’s sake, I thought as I unceremoniously probed the poor fucker’s colon – jamming my fingers up someone’s arse was definitely not how I was expecting this day to turn out.

  But my fingers were pointing the wrong way! The prostate is located anterior to the butthole, not posterior.

  THE PROSTATE

  The prostate is a gland that produces an alkaline bodily fluid to lubricate the urethra during the male ejaculation. Prostate cancer ranks as the most deadly form of cancer in males. The prostate is a walnut-sized growth that can be felt through the rectum, and is never palpated in an emergency situation.

  Not unlike hitting the G-spot, or eyeballing a unicorn, finding the prostate can be surprisingly difficult – especially if you’re two-knuckles-deep inside the balloon-knot of your sworn enemy and the fucker’s clenching tight in a last-ditch display of defiance.

  Despite my best efforts, the prostate exam only revealed that I needed to burn my gloves to ash and wash my hands thoroughly afterwards. I felt so dirty.

  I’d never rammed my digits into anyone’s arse before, so I didn’t know what a healthy prostate felt like, let alone a damaged one. The surgeon was unhappy with my assessment so he gloved up and forcibly offered his second opinion, no lube. I didn’t know whether I should be embarrassed that I forgot the anatomical position of the prostate or happy that penetrating another bloke’s asshole was undoubtedly not my area of expertise.

  After the time-pressure of the situation wore off, my casualty began to stabilise. His blood pressure had risen to a life-sustaining level and started to plateau. His vitals were stable for now, and it was time to start looking at the individual wounds. The Yank surgeons assessed the mangled mess of bone and tissue where his foot should have been. It was certain at this point that serious nervous and vascular damage had been done, but the extent was still unknown. Some tissue still looked viable, so the foot was bandaged tight for the ‘wait and see’ game. His thigh looked to be in better nick. Under the surgeon’s watchful direction, I excised dead tissue from the gaping thigh hole with a scalpel, suturing closed the fleshy gaps when all the debris was finally cleared away. We needed to make sure that no necrotic tissue was left in the wound to create a festering abscess after the skin was closed. It was a long, painstaking process that lasted well into the night.

  While this was happening, Vinny, the cool-as-a-cucumber commando nurse, noticed a small, pimple-sized nodule of dried blood on the bloke’s nose. It looked like a zit. Following his gut, Vinny demanded a full head scan of the patient, which revealed that a piece of frag had entered his nose and played bouncy castles in his sinuses, where it finally came to rest. Removing the tiny piece of metal would’ve been riskier than it was worth, and since it wasn’t life-threatening, the bloke was doomed to the same fate as a can of spray paint – he’d hear a rattling sound when he blew his nose forever more.

  In the days that followed, the patient’s foot slowly started to deteriorate. The ashen-grey skin and bluish-grey tissue inside the wound screamed that his foot was dying. There was no point trying to save it because it was clearly deceased and becoming an infection and gangrene risk.

  We had to amputate.

  With the surgical room meticulously sterilised and prepared, the patient was wheeled into the breach. Under the watchful eye of the Yank anaesthetist, I sedated and intubated him. Before he could even count to three, he was off with the fairies, a machine now tasked to conduct the most basic of human functions and breathe
for him. While two of the more senior surgeons discussed where they were going to amputate, a third surgeon decided that this would be a great opportunity for an anatomy lesson. With a bunch of engrossed medics watching attentively, the surgeon grabbed a pair of forceps and gently tugged on one of the intact ligaments that could be seen from the open hole in the foot. The corresponding toe slowly started to curl and relax in unison with the forceps. It was macabre and fascinating at the same time. I felt a tad queasy, but couldn’t look away either. The decision was made that the foot would be amputated mid-lower leg. This would leave enough viable calf muscle to fold over as the padding for the stump while ensuring that all the dead tissue would be eliminated.

  So began the scalpel action.

  All the soft tissue was systematically sliced and diced away, leaving a three-centimetre gap to access the bone. The lower-leg ligaments and tendons are under an incredible amount of tension, so as the scalpels severed the last few strands of soft tissue, the rigid structure of the foot suddenly released and sagged with an audible twang that shook the surgical table. An Australian commando medic called Jim was assigned the grisly task of separating the bones, which is done with a garrotte-like medical instrument known as a bone saw. It is essentially two hand toggles with a thin, serrated wire in between. Jim, who was funnier than a fart in an elevator, put his game face on and got straight down to business, moving the toggles up and down like a seesaw.

  Zzzt, zzzt, zzzt, zzzt, pop went the tibia as it separated, releasing the build-up of pressure inside the bone cavity.

  Zzzt, zzzt, zzzt, zzzt, pop went the fibula, as it followed suit.

  The foot was now a free agent, completely separated from the leg and held up by one of the attendants. All three forceps that had supported the foot during the surgery now hung limply from the curled toes they were clamped to. This was the most unnatural spectacle you could ever encounter. After washing away the damp white and reddish pulp of bone offcuts and softening the edges of the bones with a medical file, the surgeons tucked the calf-muscle flap back over the wound to create the stump, closing the whole mess up with some seriously heavy-duty sutures. Orthopaedic surgery looked a lot like carpentry to me, but it seemed to work.

  Our suspicions about the nature of the casualties’ injuries were later confirmed. According to reliable sources, the trio were fully-fledged Taliban insurgents who’d had their asses kicked by allied forces earlier that day. Gravely injured, the three had been taken in by a local police chief, who treated their wounds and dressed them in Afghan Police clothing to expedite their medical treatment (by the same forces they’d been fighting against, I might add). This is not to say that the local police chief was a Taliban sympathiser, or that he was corrupt; he might very well have had tribal and cultural obligations to these blokes – such was the complexity of figuring out who the ‘bad guys’ really were in this ambiguous and complicated environment.

  This kind of shit was a notorious Taliban tactic. They were very adept at undermining the political support of opposing developed nations by blurring the line between innocent punters and true Taliban forces. They were experts in the art of the ‘grey area’. If they could sway support away from the war on terror among the peace lovers and tree huggers back home, they’d cut our allied forces’ legs right out from underneath us on the home political front. Very subtle and sneaky stuff.

  This tactic was never more apparent than in the medical realm. We had an obligation to treat everyone, regardless of motive or military affiliation. That’s why, from day one, I tried my best to remove emotion from the equation when treating casualties. I saw everyone as a job, not as a person. I couldn’t afford to get emotionally invested; I needed to remain objective, almost like a robot. They were a lump of living meat. It was my job to keep that meat as fresh as possible for as long as possible, and then move on to the next patient when my job was finished.

  Easier said than done.

  6

  PRIOR PREPARATION DOESN’T PREVENT PISS-POOR PERFORMANCE

  Regardless of the occasional drama that surfaced at the FSB, the Tarin Kot base was a picture of serenity. I’d wake up in the morning, procure the requisite tall coffee and sit on the front step of my room, sparking a cigarette and contemplating the meaning of life through the lens of the tall bomb barriers that obscured sight of the distant mountain ranges. My room typically housed six to eight other medics, all of whom believed that waking up at six in the morning was cool. It was impossible to sleep in, even though there was no formal time to start work.

  The base was a makeshift holiday retreat; a far cry from the living conditions of warzones past. Most rooms were made of plywood or steel containers but all had air-conditioning. The mess produced some of the best grub you could possibly ask for – procured from the ass-end of the American supply system, yet it never failed to exceed expectations. If you were lucky, and had the right connections, a local Afghan entrepreneur would magically appear on the scene and upgrade the room’s TV reception to include seventy-seven different channels of pornography and debauchery. Medics are a highly ethical breed, sworn under oath to uphold the loftiest standards of morality, so, of course, we never bought the extra channels.

  Pfft . . .

  Trust medics with your life, not your money or your wife.

  We were the first to buy the extra channels.

  Within a few weeks in Afghan, a mission began to manifest. Rumour had it that we were going to do a hit on some medium-to-high-value targets. Shit was getting real, so we started planning accordingly. The planning for an operation took much longer than you’d probably expect, and was carried out on a personal level as well as a group one. I potentially had six different weapon systems that I might need to use, so I familiarised myself with the unique personality traits of each weapon and the layout of spare ammo and other odds and sods that were different for each vehicle that the weapons were mounted on. I needed to prepare for every situation, military and medical. What emergency medical scenarios might happen? How prepared were the advanced first-aiders in my team? What skills and stores did they have? Could we share resources so that I didn’t have to carry so much gear? Were there any drugs or medical devices that had multiple uses so I could cut down on weight and storage space? As an example of the anal-retentiveness needed for a decent prep, this was my usual ammo readiness routine.

  BULLET PREP

  Load bullets into magazine, magazine into gun, pull the trigger, bad guy drops. Sounds simple, right? There’s a hell of a lot more to it than that.

  Start with the standard M4 magazine. Although you can cram thirty 5.56-calibre bullets into the sucker, twenty-eight was recommended to reduce spring compression and minimise the risk of stoppages, or jams. Moreover, the magazine needed periodical release to reduce the pressure on the spring, again to minimise stoppages. Both the spring and rounds needed a bit of cleaning TLC every so often, especially in dusty conditions.

  The M4 magazine can be a bitch and a half to grasp in a tight, sweaty clinch, so I put a sticky-tape tab on the end of every mag. Moving on to the mag pouch, I melted the male side of the velcro closing strap with an iron to minimise the ripping noise, but this left me with only one button stud to stop the mags from falling out of the pouch. A cost I’d have to bear. I organised the mags so that their curvature favoured my left, non-dominant hand. My right hand should be focused on my gat (rifle) and trigger operations. Each pouch could comfortably house two mags, but they tended to rattle around inside the pouch, creating a clinking noise that might expose my position. So I stuffed some cleaning cloth between the mags.

  How many mag pouches should I have? Too many and I’d be weighed down – too few and I’d be useless in a gunfight. I chose four pouches, eight mags in total. I tested this configuration by jumping all around, up and down. I still had a rattle somewhere. I rejigged and tried the new configuration from all conceivable firing positions: standing, sitting and lying. The pouches were too low; I couldn’t get to them while on my gut
s. Time for another readjustment.

  This was all well and good when I was using the mags, but what about when they were spent? My panic pouch needed work. A panic pouch is a rolled-up bag on the body armour, released by pulling on a velcro tab that opens the wide mouth of the bag to drop spent magazines into during a gunfight when you’re too preoccupied to worry about fitting the mag snugly into a pouch. I positioned the panic pouch on my lower left side; I might need discarded empty mags to house rounds if all else went to shit and I had to restock. Also, I’d be sure to tuck in my shirt so that I could stuff the spent suckers down my front if I needed to.

  What about spares? I had a grab-bag for emergencies, but how accessible were my bullets? I needed them to sit at the top of my grab-bag. Should I stock full mags (and carry more weight) or roll speed-loaders (which had less weight but took more time to load)? How many spares should I even have?

  I think you get the picture by now; obsessive-compulsive worrying was a positive thing.

  The Six Ps – prior preparation prevents piss-poor performance – was certainly a mantra during the mission-preparation stage, but it didn’t guarantee success, as I later learnt. Several days out from the mission proper, we ran a few dry runs, testing out different scenarios. I felt that I was all over it. No nasty surprises popped up and I only needed a few minor adjustments to my kit. I was confident that I’d accounted for every likely eventuality.

  The green light for the mission came quickly enough, and I soon found myself on the back of a long-range patrol vehicle, or LRPV for short. I was ‘outside the wire’ for the very first time, and I kept jumping at my own shadow. Through the dim green glow of my night-vision goggles (NVGs), I fully expected to see the big bad Taliban jump out from behind a rock at every turn. The adrenaline was pumping and my imagination was working overtime. Before long, we stopped at the lay-up point (LUP), which is where we would gather the troops and organise the attack. The commandos and SAS had grouped together for this hit.