by John Nichol
Under the circumstances, they had all done brilliantly. It was the justifiably proud boast of the Ajax Bay medics that they did not lose a single soldier or Marine who arrived at the field hospital alive. Their achievement was all the greater, given that the hospital’s role had been intended to be much more of a transitory one. The original plan was that the hospital ship Uganda and the sick bay on Canberra would be where the bulk of the serious surgery was done. In the event, a shortage of helicopters – largely because a dozen were lost when the container ship Atlantic Conveyor was hit by Argentinian Exocets – meant there was no swift and certain evacuation of casualties off the island. Ajax Bay had to double up as both an accident and emergency department and a surgical centre. In all, it handled 722 patients, nearly half of them Argentinians, and carried out more than 200 operations under general anaesthetic.
However, the fact that everyone who reached the hospital survived begged an important question. One hundred and seven British servicemen died in the land battles. Could some of them have been saved if they had arrived on the operating table sooner? The truth was, as Hugh McManners recalled, that ‘the marginal cases had already died in the extreme cold and wet while waiting hours (and sometimes days) for evacuation.’17 A ‘buddy care’ approach to battlefield casualties, allied to ‘scoop and run’ evacuation, meant that often those who were first on the scene – such as stretcher-bearers, of whom there were precious few anyway – did not have the medical skills to save the lives of the seriously wounded. In civilian life, ambulance drivers were morphing from chauffeurs with flashing blue lights and a siren into paramedics experienced in dealing with life-threatening emergencies. Clearly, the same development had to happen in the military. The suspicion had to be, too, that those with life-saving surgical skills needed to be closer to the action, if not at the very heart of it, if they were to be more effective.
In the reassessment that followed the conflict, it was clear to some that a new sense of purpose was needed in the whole field of military medicine. McManners was of the controversial opinion that the rethink did not go anywhere near as far as it should have done and that the British infantryman was in fact short-changed in what followed. ‘The British army made a number of unfortunate deductions from the Falklands,’ he wrote. ‘In Vietnam, the US achieved excellent levels of survival through having thoroughly trained medics forward with the fighting troops and getting helicopters in quickly to evacuate men to surgical hospitals. The British military establishment decided that it could not afford to deploy enough high-grade medics forward with the fighting troops and that, because of the vulnerability of helicopters to ground fire, flying up to the front line to collect casualties was too dangerous. In the Falklands it seemed that the men’s own first-aid skills had been enough. It was decided that the high levels of medical aid provided for US troops would not be given to British troops.’ Besides, the main theatre of operations, as far as the generals and the politicians were concerned, was still on the plains of northern Germany, where, if the Cold War ever went hot, the first battles with the Soviet Union would be fought. The Falklands had come out of left field and been dealt with, and no one envisaged an out-of-area operation like that happening again in a hurry. Now the army and air force could get back to the front line that really mattered. For the medics, normal service was resumed, treating in-growing toenails in sick bays in Osnabrück and Fallingbostel and, on the surface, everything returned to the way it had been before the successful foray down in the South Atlantic.
Some in the field of military medicine, however, reflecting on what had and what had not been achieved on the long haul to Port Stanley, felt a wind of positive change from the experience, blowing away the cobwebs on accepted practice. ‘The Falklands War was a watershed,’ declared Ryan. ‘Never again would surgical teams operate in disused factories dressed in khaki flannel shirts with no gowns or theatre linen.’ Recruitment and training were upgraded. The service went on to a more prized and more professional footing – even if some key questions, such as the easy availability of rescue helicopters, the use of tourniquets18 and where precisely it was best to locate the ‘front-line’ surgeons, remained (and remain) matters for continuing debate. Men fighting decades later in Iraq and Afghanistan would benefit more than they would ever know from the tough lessons learned at Goose Green, Bluff Cove and Mount Longdon.
12. Bitter Pills
For army medic Mick Jennings, the lesson of the Falklands was not one of inspiration but of disillusionment. The charred, disfigured bodies of the Galahad casualties were imprinted on his mind. ‘I hated the way that the war had affected all those young lives. All the way back home to England, I was determined to leave the army.’ His plan was to study computer science at night school and build an entirely different career for himself. But, in the end, he couldn’t face losing the military camaraderie that had been the centre of his existence since leaving school. He realized how much he would miss ‘the lads and the crack’, and so he stayed.
In 1990, as a thirty-five-year-old sergeant major, he found himself preparing for war again, for what was billed as ‘the Mother of all Battles’. This was going to be as different from the South Atlantic campaign as it was possible to imagine. The battleground was closer by some five thousand miles, hotter by a hundred degrees, and the risk of catching anthrax or tetanus came not from dead sheep but from deadly weapons the enemy were believed to possess. At least British forces were not alone this time. They were part of an international, US-led coalition to seize back the city-state of Kuwait, which the soldiers of the Iraqi dictator Saddam Hussein had overrun, in defiance of the United Nations. A force of hundreds of thousands assembled in the desert to take back what he had stolen.
Saddam’s army, it was feared, would not be easy to dislodge. His elite Republican Guards had a reputation for ruthless efficiency, but the biggest danger was that the Iraqi leader would fight back with weapons which the world had dangerously flirted with during the First World War but never dared to exploit fully – chemical and biological ones. If that happened, the coalition forces might have to resort to their own doomsday arsenal of tactical nuclear missiles – ‘dropping a bucket of sunshine’ on Saddam, as the squaddies put it. Either way, it seemed a near-certainty that casualties could well be unprecedented in scale and in type. The British medics prepared themselves for a war ranging over long distances – reminiscent of the Desert Rat days in North Africa half a century earlier – involving close fighting on a large scale with the Iraqi army. Armoured field ambulances would go forward to assist the surgical teams attached to each armoured brigade. Casualties would be ferried back as quickly as possible to massive field hospitals in the rear, in Saudi Arabia or on its borders.
For Jennings, the Falklands seemed a puny affair by comparison, its primitive field hospitals and tiny surgical teams old-fashioned and dwarfed by the massive medical operation now swinging into action in safe areas far away from the front line. The make-and-mend days of Ajax Bay were gone. A system as extensive and layered as any civilian hospital trust was in place and, with his rank, Jennings found himself more of an administrator than a medic. The only casualties he ended up actually treating were troops with burns from over-enthusiastic sunbathing. But over the whole enterprise hung an air of menace – the possibility of attacks spreading choking, blistering phosgene gas or, worse still, disease-laden bugs. The fear was very real, Jennings recalled. ‘It wasn’t a game. When the Scud missiles were flying, we really did expect to be hit by this stuff and to be dealing with mass casualties.’ Medics – including, for the first time in a front-line position, women – were busy sticking needles containing cocktails of prophylactic drugs into arms and thighs. Everyone drilled in cumbersome NBC (nuclear, biological and chemical) protective suits and respirators. They were issued with syringes of anti-nerve-gas serum to inject themselves with in the event of a chemical attack.
The size of the medical teams deployed was an indication of how seriously the threat was bei
ng taken. Reservists were called up. Hundreds of musicians, including the RAF’s renowned dance band, the Squadronaires, stowed away their trombones and clarinets and switched to stretcher-bearing. Along with Puma helicopters, they would be a vital link in the evacuation chain from front-line dressing stations to a base in Saudi Arabia and then back to the UK. The system was geared up to shift 1,600 casualties a day if necessary, with non-stop streams of helicopters and Hercules transporters. For RAF nurse Frank Mincher, who joined up after the Falklands, the nearest he had expected to come to front-line action was when he was posted to the Greenham Common air base, which was under siege by women camped at its edge in a prolonged protest against cruise missiles. The first Gulf War changed that. ‘We expected mass casualties. I heard a worst-case figure of thirty thousand.’
If it came to this, then Andy Smith, another post-Falklands medical recruit to the RAF, would be better prepared than most. As part of the ‘crash and smash’ team called to the scene of aircraft accidents to, literally, pick up the pieces, he was intimately aware of the gruesome side of the business. Down on his hands and knees, combing through scattered wreckage for human remains, was a hard and hardening experience for a nineteen-year-old. ‘High-speed crashes make an awful mess of bodies. The biggest thing you’re likely to find is half a femur or half a skull. We had to pick up as much as we could before the birds got them, and lay them out on a tarpaulin.’1 Sometimes the bodies were those of people he’d known. ‘Perhaps you’d done their aircrew medical a few days before and chatted to them, and now you were picking up tennis-ball-size bits of their body. I once found a glove with the hand still inside. It wasn’t nice. You learn very quickly about the fragility of life.’ Here was a side of a medic’s duties few realized, a world away from the relative glamour of saving lives.
Smith had moved on to more advanced work by the time the Gulf crisis blew up and was fully trained for medical emergencies. Lying in his tent reading one day, a massive explosion seemed to be the start of all he feared. ‘I thought it was a mortar attack or an IED [improvised explosive device – a bomb]. I grabbed my medical snatch bag and ran towards the sound of screaming.’ In the kitchen, a pressure cooker had blown apart, and one of the chefs was badly hurt. ‘His arm was hanging off, held on by two inches of skin at the elbow. I put a line in and got some fluids into him. He also had bits of metal in his leg.’ To Smith, it seemed like a dress rehearsal. Much worse lay ahead, surely? Everyone was on edge with expectation.
In the early hours of a January morning in 1991, the first planes took off into the dark desert sky and headed for Baghdad. ‘It’ was on, and nobody could be sure what had just been unleashed. One pilot remembered sitting in his cockpit, the engines firing, and wondering whether he was about to initiate World War III.2 At the RAF hospital in Bahrain, the commander calmed his young team of WRAF medics, but the prayers of the chaplain put the fear of God into some of them. Air-raid warnings sounded, and they took cover in sand-bagged shelters wearing protective suits, rubber gloves, respirators, boots and helmets. The charcoal in the suits turned their skin as black as coalminers’; the claustrophobia turned their stomachs.
Five weeks of air bombardment paved the way for the ground attack, a massive onslaught in which thousands of vehicles sped across the desert, meeting very little resistance. Experienced Territorial Army surgeon David Rew, ex-SAS and ex-Para reservist, boarded a Bedford field ambulance and took his place towards the front of the column as part of the unfortunately acronymed Forward Advanced Resuscitation Team – FART for short, though the name was quickly changed. ‘Our role was not to get into anything complex with casualties but to stop bleeding, clear airways, all the basics so they could be transported back to the field hospitals.’3 He didn’t feel he was doing anything radically new. Surgeons, he knew, had operated this far forward in the desert battles in North Africa in the Second World War. ‘The instruments don’t change, nor does the anatomy and the physiology. Back in the 1940s they were in Austin trucks, whereas we were in Bedfords, and they had glass bottles for blood transfusions rather than plastic bags, and wooden stretchers instead of gurneys. Everything else was pretty much the same.’
There was some truth in this when applied to far-ranging desert warfare and special operations, as the adventures of RAMC doctor Lieutenant Malcolm Pleydell behind the German lines in Libya in 1942 showed.4 But the battlefield order in the Second World War had generally placed the most experienced doctors well to the rear. It was from the Falklands that the lesson had been learned that quick access to the best medical care was the key to saving lives. Now it was deemed right for someone of Rew’s seniority to be pushed well forward. This, however, didn’t apply to more than a handful of doctors. It was still considered prudent to concentrate the bulk of the surgical resources well behind the lines, in hospitals geared up to receive large numbers of casualties. But Rew’s FART, out rounding up casualties rather than waiting for them to be delivered, was the blueprint for the MERT (Medical Emergency Response Teams) of the future.
In reality, they had little to do in that first Gulf war, which quickly turned into a rout of Saddam’s reluctant-to-fight soldiers. Coalition casualties were few and mainly came from booby traps left in deserted Iraqi bunkers. They were generally helicoptered straight to hospital, before Rew’s team, chasing to catch up with the fast-moving attack force, got anywhere near them. For all the drama of being close to the front line – and on one occasion even straying ahead of it into the enemy’s line of fire – Rew had little to do. ‘I saw lots of desert, lots of tents, lots of burnt-out tanks and lots of Iraqis surrendering,’ he recalled. ‘But the only surgery we did in the whole of the four-day ground war was a single Iraqi soldier with multiple fragment wounds in his legs. There was no helicopter immediately available to evacuate him, so we parked three ambulances around to form a little amphitheatre, laid out a stretcher table, put the chap to sleep, debrided his wounds and cleaned up his legs.’
It fell to Andy Smith to see the full horrors of that war. As the Iraqi army abandoned Kuwait and retreated back across the desert to its own borders, it was pounded from the air. The road to Basra became a highway of destruction and death, littered with bodies and wrecked vehicles. Burnt and twisted corpses leaned out of the turrets of armoured cars in macabre poses. Smith was in a team following behind this trail of devastation when he saw an Iraqi running towards him. ‘I pulled out my pistol and cocked it. I was a second away from shooting him when I realized that he was trying to give us a present. He was trying to trade his video recorder for his life. I calmed him and handed him over to the Military Police at a checkpoint down the road. I suppose you could say I actually captured an Iraqi – not what you’d expect when you’re a medic, is it?’
The experience disturbed him. ‘I’d always wanted to be in a battle, ever since I joined up, but coming that close to actually killing somebody really scared me. I still think about that now, seventeen years later, and I’m glad I didn’t shoot him. Of course, I could have been wrong. If he’d been carrying a bomb or a weapon, I could have been dead.’ It was a life-or-death decision that, in the years ahead, many British soldiers would face as they battled phantom armies of guerrillas and insurgents who were indistinguishable from the civilian populations they emerged out of and melted back into. In the wars of the future, the humanitarian streak that ran through medics such as Andy Smith and was the basis of their calling would be severely put to the test.
*
Tim Hodgetts did not make the cut for the Gulf war. A junior doctor in the RAMC, he had to remain behind in the UK, stuck in a dreary posting in Northern Ireland while the vast majority of his colleagues were shipped to the Middle East. Yet it was in cold, murky Belfast rather than the hotspot of Arabia that he would be inspired to begin the process of transforming the army’s medical services, fitting them for the wars of the twenty-first century.
He was sitting in the officers’ mess of the military wing at Musgrave Park Hospital in Belfast in Novembe
r 1991 watching the rugby world cup final between England and Australia on television when a Semtex bomb planted by the IRA in a service tunnel exploded, devastating the staff social club. The ground floor collapsed into the basement. Not only were casualties trapped in the rubble amid fire and smoke, but the facilities to treat them, namely the emergency and resuscitation departments, had been wiped out. Hodgetts, though junior in rank, was the most senior clinician present. He took charge, commandeering equipment and rooms in the adjacent civilian wards and treating casualties on the spot because of fears that evacuating them might lead them into more danger from booby traps or snipers.
For five hours he directed operations, working out what he had to do as he went along, because, as he rapidly discovered, there was no emergency plan in the event of the hospital’s own facilities being out of action. Though two soldiers were killed and eleven other people injured, he did a good job. But, as he saw it, not good enough. His mind was made up: firstly, he wanted to specialize in emergency medicine; and, secondly, he wanted to set up comprehensive procedures and train others how to deal with similar extreme situations. Musgrave Park had become, in essence, a battleground that day. The lessons from the bombing could carry over into casualty treatment anywhere. Emergency medicine as a separate discipline for military doctors was soon to become a priority. No longer would the assumption be that general surgeons and physicians could just turn their hands and their skills to dealing with battlefield injuries when necessary. Military medicine not only needed a distinct training all of its own but a set-up with its own specialist casualty department to respond to emergencies.