by John Nichol
Rosell, as if he hadn’t had enough violence that day, relaxed by watching the cult Vietnam war movie Full Metal Jacket on a big outdoor screen erected in the camp volleyball court. It was most appropriate. ‘Full metal jacket’ was US Marine slang for a 7.62 bullet, the very sort he had just dug out of the flesh of one of his patients. He laughed along with the film’s snappy dialogue, and the classic military profanities and ‘motherfucker’ insults of Gunnery Sergeant Hartman. ‘Excellent to hear all those lines again,’ he commented. One had particular poignancy in the circumstances: ‘The dead know only one thing – that it’s better to be alive.’
There was still no let-up. A few hours later, he was woken to be told that another batch of casualties was arriving in fifteen minutes. One dead, four minor injuries. They were US Special Forces, whose armoured Humvee had hit a mine. ‘Bizarre to have one killed outright with severe blast and lung injury and major burns while the others were almost unhurt.’ Sometimes the sheer arbitrariness of war was utterly bewildering.
If he ever doubted that, a suicide bomb at Gereshk the next day confirmed it. Six casualties were flown in. One was a small boy with ball-bearings in his scalp, another had ‘a penetrating wound to todger’. The film that night was A Bridge Too Far, about the abortive Arnhem operation in 1944. The relevance of its title and its subject matter – an under-prepared, over-ambitious military expedition in which raw courage was simply not enough to ensure success – could not have gone unnoticed.
Working alongside Rosell for a while was Territorial Army captain Ed Clitheroe, a junior doctor from Chester. He was trained in treating trauma, but he had never seen trauma like this. Back in England he had done four months of paediatric surgery as part of his training. His first patient on his new beat was a child, but there the similarities ended. The ten-year-old Afghan boy was brought into Casualty with a knife in his head, pushed in right up to the hilt. He had been in his father’s shop when there was a dispute with a customer. The customer pulled out a knife and lunged at the father, the boy got in the way and the blade went down with full force into his head. It was lodged in his brain. Amazingly, the boy was conscious, talking and on his feet – he had walked into the hospital with his father.
An X-ray showed the knife resting at an angle behind his eye and penetrating the frontal lobe. Simply to have pulled it out would have killed him or left him brain-dead. The most meticulous and intricate surgery was called for. The newly arrived (and shell-shocked) Clitheroe scrubbed up to assist, and watched in amazement as, over the next few hours, the surgeon in charge delicately probed inside the boy’s head until the knife could be removed, all the time aware that one slip could start a massive and fatal bleed. The lad recovered.
Not every outcome was so uplifting, however, and what came to haunt Clitheroe were the victims of suicide bombings, many lacerated by the ball-bearings packed inside the devices and suffering multiple wounds that required teams of surgeons working in tandem to deal with them. ‘They were very emotive injuries, especially among the children. The randomness just didn’t seem fair. I could never get used to that. And there were times when, no sooner had we cleared one lot and cleaned up than more were arriving.’7 But when he stood back from all those feelings after returning to the UK, he was proud of the people he had worked with, and proud of himself. ‘It was the finest medical job I have ever done. One of my frustrations was that the reporting in the media did not reflect what we were doing and how good the treatment was.’
Little of the work the Bastion surgeons did was ever routine. The removal of bullets and shrapnel from organs and limbs, the repairing of stomachs and bowels and broken bones, the deep scraping-out of wounds and skin-grafting of burns – all this demanded skills across many specialisms. Being a doc of all trades was what mattered.
In civilian life, surgeon David Rew specialized in operating on breast cancer, hernias, gall bladders and thyroids. But as Lieutenant Colonel Rew of the Territorial Army, and taking his tour of duty in Camp Bastion, the niceties of NHS practice had to be left behind. ‘In six weeks there I saw more major trauma than in the whole of the rest of my career. I was doing children’s neurosurgery, maxillo-facial surgery, abdominal surgery, chest surgery. I was a true old-fashioned general surgeon of a type we rarely see these days.’8 The expertise required was unparalleled in the history of military medicine. Once a field doctor’s job would be to cut off a leg, splint an arm and apply a bandage. Not these days. In the twenty-first century there are nearly forty extra procedures which a surgical trauma team needs to be skilled in, according to Paul Parker.9
With demands like these, it also helped if a doctor had an ability to ignore fatigue. Every member of the Bastion surgical teams was acutely conscious that there was no extra manpower to call in beyond those in the camp at any given time, no back-up. If a doctor went sick – and, in that climate, no one was immune – then everyone had to double up. As it was, the hospital was having to treat as many as twenty-four new casualties a day, and it was not unknown for surgeons to work sixteen hours at a stretch. Clitheroe was so exhausted during a marathon session of surgery that, in a lull, he kicked off his boots, climbed on to the temporarily vacated operating table and fell asleep. The job demanded physical fitness and mental toughness. ‘You’ve got to be able not just to withstand the onslaught, not just to survive, but to thrive on it,’ said Paul Parker.
Even when a doctor’s tour was over, his work wasn’t. Rosell was on the flight back home when the condition of a casualty on board, bound for Selly Oak, worsened. The poor man was unable to empty his bladder, and there, on the floor of the Tristar, Rosell inserted a catheter and rigged up a drainage bag. It was as near to a routine procedure as he had ever come, and even then it was at 35,000 feet in the air.
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At the end of the day, the real achievement of the medics in Afghanistan was measured by the number of men who – as with the Special Forces soldier Rosell had saved – were surviving wounds that, in previous conflicts, would have been fatal, offering no hope of recovery whatsoever.
This process began with the preparation the troops on the ground received before going into battle. They were drilled in what to do if their patrol took casualties, and carried with them into battle a compact pocket booklet that guided them through the correct procedures. The idea was not new – a similar card had been doled out to soldiers in the Second World War (though to what effect is unclear, since it was issued only to corporals and above). The twenty-first-century version was altogether slicker, easy to flip open and follow under the most extreme circumstances – and went to everyone. It was a no-nonsense, question-and-answer, do-this-don’t-do-that document to help troops do what was right if a comrade went down. It was printed, helpfully, on plasticized card so blood could be wiped off.
Common sense prevailed in its instructions. If they were under enemy fire, they were told to ‘win firefight’ first – the military priority always came first. But when they could turn their attention to their wounded, it instructed them on the recovery position (‘face down, head to one side’), on opening airways, and pressing fingers and knuckles hard into open wounds to stop the bleeding. ‘DO NOT remove embedded foreign objects,’ it declared. Give morphine for pain relief – jabbed into the thigh with an auto-injector – but not if the casualty had a head injury or difficulty in breathing.
Rew, who had been in Iraq, noticed a sea change in the skills and awareness of the front-line soldiers. The team medics in each section and platoon – now one for every four soldiers, a ratio previously the preserve of Special Forces – were better too, and not just in numbers. They were better trained than ever before and better equipped. Each wore a special belt with extra quick-action tourniquets, extra dressings, two Hemcon bandages which formed anti-bacterial seals over wounds, and a suction device to suck out vomit and blood. They had gloves, scissors and coloured priority labels – red for ‘action now’, yellow for ‘soon’ and green for ‘can wait’ – to attach to each casua
lty for the information of the next level of medic who took over from them.
The speed with which most casualties were picked up by the emergency medical teams of doctors and nurses, as well as paramedics, and ‘casevaced’ to hospital was another reason for greater survivability – though it was never fast enough. It was still taking an average of just over three hours to get the critically wounded to hospital and, as in the Kajaki Dam incident, sometimes significantly longer. Paul Parker took every opportunity to lobby for a dedicated fleet of small helicopters – lightweight Black Hawks rather than chunky Chinooks – for the exclusive 24/7, all-weather use of the medics, rather than always being on call for other purposes, such as ferrying troops or supplies.
Increasingly, too, the issue of whether doctors should expose themselves to the dangers of the front line was being settled in favour of the action men. The driving force came from the top, from RAMC colonel and A&E consultant Tim Hodgetts, who had no doubt that the welfare of his patients came before his. Serving in Afghanistan, Hodgetts felt doctors had no prior claim to survival. ‘The life of a consultant in emergency medicine like me is no more important or vital than the life of a private soldier.’ He led from the front, much to the surprise of soldiers in the field, who were not used to seeing a full colonel running off the back of a helicopter to treat them as they lay wounded and under fire. Hodgetts recalled dropping down into a poppy field as bullets rattled into the side of the Chinook. A wounded American soldier was carried fireman-style back inside the helicopter. As the Chinook rose into the air, Hodgetts went to work with procedures that would once have had to wait until the casualty was in hospital. ‘We can intubate and ventilate. They can have chest tubes and surgical airways put in. Some helicopters have cold boxes to store blood so we can give transfusions. We now have special needles that go directly into bones to get fluids quickly into the body.’
His rank gave him no more control than any other doctor had over the perilous conditions in the back cab of a Chinook hurtling at full tilt back to base. ‘It’s noisy, it’s cold. It’s vibrating, it can be pitch black, apart from a couple of torches. We are kneeling on the floor. We are not secured. It is like Alton Towers without the popcorn!’ But his calculation was that the benefits to his patients were worth all the extra risk to men and machines.
For all the speed and skills employed, the most crucial development increasing the survival prospects of the fighting men was the Osprey body armour they wore. This was often what saved the ‘unexpected survivors’, as Hodgetts called them – the men with three-limb amputations, a penetrating brain injury, 75 per cent burns or whose heart went into arrest in the back of the rescue helicopter and who would probably not have made it five years ago. Now, they could, and routinely did. The ‘golden hour’ that had once seemed the critical limit within which the life of a seriously wounded man could be saved was now reckoned to have shot up to four hours.
Such advances, while saving lives, did, however, pose uncomfortable issues about the quality of the lives being saved. Were men surviving who would have been better off dead, whose injuries and loss of limbs, organs and vitality meant they themselves would have preferred to be dead? These were questions the doctors did not feel qualified to answer. ‘When a casualty comes in,’ David Rew explained, ‘if he or she is alive and saveable, in the general sense of resuscitation and surgical treatment, you do what needs to be done. At that time, you don’t know whether they are going to live or die and what their quality of life is going to be. Your job is to save that life and to give them the very best chance of a high-quality life, accepting that it may be as an amputee. Should we keep this guy alive? It’s not our job to make that ethical judgement. You have to do your best for them at that moment. It’s the only thing you can do.’
Rew never ceased to be amazed by the courage of those he treated, their humour, their stoicism, their superb motivation. ‘They come in with multiple injuries, arms and legs missing, and they still crack jokes with the surgical team about being shot or stepping on mines. Some even ask for photos to be taken so they can show friends back home. That’s the sort of indomitable spirit they had – and when we saw it, we weren’t going to let them die, not if we could help it.’ Later, he would see men he had brought back from the brink of death not only surviving but thriving back home in the UK. ‘Some are doing extraordinarily well. OK, it’s not the life they had imagined for themselves, but a combination of inner drive, support and the fact that the army is trying to offer them ongoing careers means they’re not giving up. They still have an incredible lust for life.’ He was glad he had not let them die. And, in most cases, so were they.
18. Scars That Will Not Heal
Only Andy Stockton, the sergeant major who lost his right arm to a rocket-propelled grenade in Sangin, could get away with suggesting to his mate at Headley Court, the Defence Medical Rehabilitation Centre in the Surrey countryside, that they should sneak out of the Elizabethan mansion, with its neurological beds, physiotherapy gyms, hydrotherapy pool and prosthetic-limb department, nip down the lane to the pub and get ‘legless’. His companion, a bomb-disposal officer whose legs were sheared off when trying to deal with a suicide bomber at Camp Dogwood in Iraq, laughed at the use of the word which so neatly described his condition, drunk or sober. He might have glared at anyone else mouthing it, but not the one-armed Stockton, aka ‘Captain Hook’, a man who rose above the physical damage he suffered and did his best to help others in a similar situation to do the same.
‘Twelve of us would go for a drink,’ the sergeant major recalled, ‘and we’d joke that we had only eight legs and six arms between us. I believe the banter and black humour were part of the recovery process. You have to keep your mates’ spirits up, and they keep up yours in return.’ It worked. Another amputee wore a T-shirt with a slogan on the front proclaiming, ‘I went to Afghanistan and all I got was this crappy false leg.’ Others were planning to go sky-diving and sailing. One had a simpler ambition – ‘to be able to stand in a pub with my dad, in a pair of trousers, not leaning on the bar and nobody knowing’.1
Stockton was an amazing role model. Within hours of coming round from the operation to amputate his arm at Camp Bastion hospital, he was up on his feet and outside the ward dragging on a cigarette and chatting away as if he’d just had his nails clipped. Within a year, he was skiing, white-water rafting and taking an instructors’ diving course. He was driving a specially adapted motorbike, which he bought from his £57,000 compensation payment, a paltry figure compared with the small fortunes often paid out in damages to ‘victims’ in civilian cases with far less serious injuries, but it did enable him to pay off the mortgage on his house and get on with his life. He has eight different attachments for his prosthetic arm, including a snooker-cue holder, a ski-pole holder and a hook to amuse his children – hence his nickname. Like Admiral Nelson, he was an action man before an enemy shot away his arm, and he was determined to be an action man afterwards. But, unlike Nelson, his injury meant that he left the service. He would not have been returned to the front line, and he couldn’t face that. ‘I’m a soldier. I want to run around with a gun,’ he said. ‘I didn’t join the army to be stuck behind a desk.’2
He quit, as have a significant number of the seriously wounded returning from Iraq and Afghanistan since 2003. A few – the wise ones, perhaps – stayed in the down-graded jobs they were offered, realizing that this was the moment they most needed the comradeship, the protection and the mutual support of service life. Shannon, the wife of paratrooper Stu Hale, disabled in the Kajaki minefield, saw this clearly from the start, and the first thing she impressed on him after he lost his leg was not to leave the army. It was something to belong to and to hold on to, she reminded him. Her husband agreed. ‘What’s the point in me having a desk job in civvy street when I could just as well have one here with the guys?’ he said. He retrained as an intelligence officer and, in that role, ironically, was posted back to Afghanistan. ‘It’ll be different. I won�
��t be out on the ground and back behind my sniper rifle. But I can still count for something out there, do some good, make a contribution.’
For a lot of other casualties of the front line, the idea of working in the welfare office or the regimental museum – of being, as they saw it, second-class soldiers and an object of pity – was too great an indignity. Sadly, they did what they had never done on the battlefield and crept away to lick their wounds in private, the psychological effects of their condition, their sense of loss, even harder to come to terms with than their physical impairment.
To overcome these feelings takes almost superhuman reserves of guts and determination. Gunner Adam Nixon lost his left leg to a pipe bomb in Basra and, from being a marathon runner, was wheelchair-bound, constantly in pain and haunted by the fear that he might yet lose the badly damaged other leg as well. His life became a never-ending series of flashbacks, panic attacks and insomnia, punctuated by painkillers and anti-depressants. Until, that is, he was persuaded to go on a skiing trip to Colorado with similarly ‘wounded warriors’ from the US forces. Strapped into a spring-mounted bucket seat on a mono-ski, he hurtled down through the snow with a smile of happiness and achievement on his face. ‘This is the most fun I’ve had in years,’ he told an observer. ‘Until now I’ve just stayed at home and festered, but I’ve had enough of dwelling in the past. I want to get going.’3 Moving on means somehow becoming philosophical about what has happened to you.