P – Pain/Environment/Evacuation
It differs from our civilian counterparts, as a massive haemorrhage will kill someone on the battlefield long before a blocked airway will. We use tourniquets far more freely in our line of work, and it would seem that the conflicts in Iraq, Somalia, and Afghanistan are helping the medical world adopt new protocols when dealing with traumatic injuries.
As CMTs, we carry battlefield trauma bags and small primary health-care packs. Extensive training, followed by intensive live tissue scenarios, best prepares medics for the types of injuries seen in war. Using ‘Amputees in Action’ was a major boost for our brigade; we were the first to trial the system. The guys were a mixture of military and civilians. I was amazed that some of them were literally reliving the trauma that they had already been through; battle-simulation noises and smoke contributed to the realism of the scenarios. Medics not suited to the front-line role were sifted out during these tests. Some medics are great in a clinical environment but not comfortable in the field, so this method of testing ensured that the soldier on the ground received the very best treatment that we could provide. When the make-up artist is done with guys already missing limbs, they look and feel exactly like the real thing. Add to that some realistic pyrotechnics, and you have some of the most-realistic training to date. Panic, shock, and awe equate to only a fraction of how you will feel when an incident proper occurs. Having said that, nothing prepares you for your own reaction. I have come to believe that every incident is different, and it’s always going to be the small things that get you flustered, or push you to 30,000 feet and rising. Mine is: ‘Where the fuck are my gloves? I am sure they were in my pocket!’
I have three junior medics in my charge, so the two remaining patrol packs will be used when members of the trauma team deploy outside the wire. As lead medic, I answer to the boss, Maj. Harry Clark, and advise him on all matters concerning his men and their well-being.
There is no room for error in my role, but I am prepared. I was waiting for this my whole life. Could I deliver under pressure, or would self-doubt cripple me? Ultimately, could I live with the prospect of letting these men down? Anyone who puts their head above the pulpit will open up to the chance of failure.
I learnt early on to leave my ego at home. An overactive ego has a tendency to get people killed. The state of the world today, not to mention a fair number of battles throughout history, will tell you that. The British insist that everyone has the ability to step up if required. One moment, you are carrying out orders from higher command; the next, you are stepping up to deal with situations that far exceed your pay scale or rank.
I covered the medical desk in brigade HQ, a job usually taken on by a senior captain or major. On my first day, a mass casualty call came in: over thirty Afghans, including children, were ambushed by Taliban fighters as they travelled by bus out of one of the district centres. I had to quickly evaluate and decide what major air assets were required, and then I had to make the necessary arrangements for evacuation. Further complicating the situation was the fact that the injured were local nationals; some would come to our own location at Lash, some would be seen at Camp Bastion, and those with less-severe injuries would go to the local hospital in the district centre of the provincial capital (Lash).
My moment of truth played out under the watchful eye of the brigade commander; this was when I could do with a bit of his ‘counselling’. The pressure I placed on myself was ridiculous, but I was determined to see it through. I did not falter. The assets required were multimillion-pound airframes carrying highly skilled teams. I wasn’t about to start playing my own version of war gaming or Risk. I briefed the chief of staff on what the medical situation required, and he, as a lieutenant colonel, gave the final order to move. Airframes were allocated to task, and, eventually, all casualties were retrieved and in the hands of medical personnel. It took several hours to complete, but the end state was welcome – not necessarily for our wounded, of course, but at least they were no longer at the mercy of the Taliban.
The buzzing activity of the PB brings me back to the moment. The hours have passed, increasing the heat; that, combined with my overzealous start to the day, has left me hungry. I tuck into more of my ration-pack pâté and biscuits before making my way into the ops room to help Kev tape up the windows, using black bin liner bags to drown out any light. Light from the smallest source travels far, and drawing attention to the room could have disastrous consequences.
Sangin Valley, 2006: Effect from a light source travelling at night initiated a 107 mm enemy rocket attack, killing two British soldiers.
Basic battle discipline was the only way to survive here. The atmosphere around the base is one of trepidation. A structure opposite us and identical to our own houses the Afghan army; they look on inquisitively as we continue to turn the ramshackle base into a workable fortress in minimal time. My peripheral vision witnesses a flash of movement – a group of Afghan soldiers diving for cover – as I hear the initial crack of incoming rounds.
Taliban rounds slam into the base, punching small holes into the walls and sandbags. Kev sends the initial contact report, and already the heavy machine guns on the roof are letting rip, pounding the enemy positions. The sound is deafening, making it hard to tell the difference between outgoing and incoming fire. Monty and Scotty are directing our fire. Bursts from the .50-cal. guns stop only to allow the distinctive crack of the 7.62 mm GPMG or 240.
Amid the noise and chaos, the boss, Maj. Clark, tries hard to control his men, issuing direct orders for the link man Elder to carry to the roof. Under heavy fire, Elder sprints off into the clouds of sand and broken brick thrown up by the rounds pumping into the buildings. He returns with news of what and who is being engaged from the roof. It appears that the fighting-age males noted earlier have returned, and they are now just south of their original position. It’s hard to tell if they are the exact group; however, the grid and descriptions logged all point to that conclusion. This time they are armed, which now make them fair game.
Scotty Pew has eyes on ten or more enemy fighters: they are using the canal and compounds as cover, moving freely between tree lines and overgrown fields. His gun group engages them with several bursts from the .50 calibre. The rounds from this weapon system are the same size as a thick felt-tip pen or a large Sharpie – you don’t want to be on the receiving end of 50-calibre fire.
Within ten minutes, five enemy fighters are confirmed dead. An Apache has arrived on station and is now stalking Taliban targets from the sky. This strange looking hi-tech helicopter has the profile of a mantis. The Apache is the biggest success story in Helmand. In military terms, it is a ‘force multiplier’, meaning that it can deliver the firepower of a support weapons company and more, with two air crew, a chain gun, and a pile of missiles. It’s not long before the engagement starts to appear one sided. With no reports of friendly casualties, the balance has been tipped in our favour: nine Taliban are confirmed dead.
I take a sip of water during the lull in gunfire, and it would seem that all is well. Relaxing too soon, a blast pierces my ears, rattling every bone in my body. First, I see a flash, and soon I feel the shock wave from the explosion. It’s close, far closer than I would like. Something has been hit. As I wait for more explosions, someone shouts, ‘Incoming!’
Kev quickly follows this with, ‘No fuckin’ shit, Sherlock.’ He looks across at me and gives the nod of approval that our taped-up window job has achieved its goal. No inward blast, luckily for Kev – it would have cut him in two in the spot where he sits relaying updates to brigade HQ.
A voice screams, ‘Medic! Medic!’ Whenever the dreaded call comes, it always sounds desperate. I instantly think, Gloves? A quick check confirms that they are in the pocket where I left them, so it’s all good.
The base is in silence. Jen and I sprint out from our cover, almost colliding with the boss. He directs us to the outer wall where Cpl Tony McParland was firing from. The sweet smell of burnt
carbon against the metal from the big guns on the roof forms a thick wall of smoke impairing each step. When multiple rounds are fired, you’d be forgiven for believing that you’re just present at a fireworks display. The distinct smell is one that never leaves you.
It’s a short distance to Tony, so we get there quickly. Stomach churning, I dread what we will find. As I said, no incident is ever the same, so our systematic approach to treatment must happen without delay. Tony’s body is abnormally twisted, and I initially spot a mangled hand with fingers missing. Relieved that it is only fingers and not limbs, I take a deep breath. Like clockwork, our treatment begins. Already in enough cover so no movement is required, I talk through each section of MARCH-P in my head, making sure not to miss a single thing. My assessment takes less than sixty seconds, getting the all-important tourniquet applied to a heavy bleed on his left arm. It’s care under fire, so the initial survey is super quick – we are just lucky enough to carry out any medical interventions at all. As the gunfire resumes, we drag Tony into the cover of the CAP.
Once there, our next move is to identify the need for early surgery. More often than not, injuries sustained on the battlefield require minimal first aid and super-quick evacuation to the hands of the highly skilled surgeons in Camp Bastion, the world’s busiest trauma centre. No fingers are found on initial assessment and no lives are ever risked hunting for those fingers. Jen starts to dress his wounds before Tony can get eyes on them.
Noise from the guns engaging the enemy from above make it hard to concentrate, and the failing light offers up its own set of problems. I relay to Kev that we have at least one cat-B, which signifies that he is an urgent surgical case and has life-/limb-threatening injuries. The UK military have an established system to prioritise injuries into three groups, which indicate to everyone involved the urgency of the sustained injuries:
Cat-A – Life-threatening injuries, and the casualty requires urgent medical treatment.
Cat-B – Life-threatening injuries, and the casualty requires urgent surgical treatment.
Cat-C – Non-life-threatening injuries, and the casualty can be held for up to four hours.
Kev initiates a ‘nine-liner’ to HQ. This set of nine questions is answered by call signs on the ground and then sent up via the radio net to brigade HQ. These answers are then assessed at the medical desk, resulting in a decision which will see an instant response if relevant or a timely extraction, depending on the injury. This was the same call I received when I covered the desk; but now I am the one on the ground making the desperate call for support, a completely different perspective.
The nine-liner provides vital information to the chain of command, and all UK medical teams use it on operations:
Line 1: Location of the pick-up site.
Line 2: Radio frequency, call sign, and suffix.
Line 3: Number of patients, by precedence (cat-A, cat-B, or cat-C).
Line 4: Special equipment required.
Line 5: Number of patients by type (stretcher/walking wounded).
Line 6: Security at pick-up site.
Line 7: Method of marking pick-up site.
Line 8: Patient nationality and status.
Line 9: Contamination.
While I have assessed that Tony is stable, I do not have the luxury of a CT scan, and I would never assume that something far more sinister isn’t going on. An X-ray computed tomography, or CT scan, is a medical imaging method employing tomography to create a three-dimensional image of the inside of an object; in medical usage, images of internal organs. In simpler terms, the CT is a body scanner that looks for abnormalities or potential bleeds that aren’t showing on the outside.
The trouble with treating physically fit soldiers is that they can often disguise severe injuries until it’s too late. Their fit bodies will sometimes mislead medics into thinking that all is well. The human body is an amazing piece of engineering: it’s designed to shut down and protect itself. It will fool an untrained eye before free-falling at a rapid rate. I remember my time in Sierra Leone, when a British army officer walked away from a helicopter that had crash-landed. She died minutes later from a massive internal bleed. On the ground, we treat for the worst and hope for the best.
A close encounter with an RPG does not leave a healthy outcome in anyone, so with an air of caution, I administer Tony 10 mg of morphine. Because it’s intramuscular (IM), it could take up to thirty minutes to take effect.
An IM medication is given by needle into the muscle. This is as opposed to a medication that is given by a needle, for example, into the skin (intradermal [ID]), just below the skin (subcutaneous [SC]), or into a vein (intravenous [IV]). Medics are issued morphine auto jets, each holding a one-hit IM dose of 10 mg. The method works when time is limited. I have never been a fan of this system; it’s easier to monitor a patient’s progress if the morphine is given intravenously. It can be titrated (diluted), and, therefore, faster acting and with less likelihood of overdose. In my view, this process can be very helpful. For example, in 2006, surgeons in Camp Bastion had to deal with an opiate overdose before getting stuck into the actual wounds. My theory on the administration of morphine is that a tiny amount of pain lets a casualty know that he is still alive; better still, it lets me know that he is alive.
I can manage a casualty easily if he is still with it. If the security situation deteriorates, his treatment will stop until our safety is re-established. Titration of morphine is the way forward, and most forward-operating medics like this system, along with the use of other pain-relieving drugs. Many of the grunts (infantry soldiers) on the ground often refuse morphine. No one wants to lie helplessly in such a hostile environment.
Without warning, Tony now starts to act erratically. Did I misjudge the severity of his head injury? For a second, I question myself. My own pulse increases, and my palms are suddenly sweaty. Shining my torch, I look deep into Tony’s eyes, and then I reassess the wound. I check behind his ears and look up his nose, searching for anything that I may have missed. Any abnormal posture or seizures?
My panic is short-lived as Scotty McFadden comes in, telling Tony, ‘Man up, ya fucker, and stop acting like a fuckin’ lunatic.’
Tony starts to laugh. Using the buddy system to identify any type of traumatic brain injury is a great tool. Guys know their own soldiers, and Tony’s behaviour wasn’t at all out of character. Relief for me, and a morale boost for the troops watching the theatrics unfold.
Adding to all this, Abbie and Sean come bounding into the CAP with three additional casualties. All have multiple shrapnel wounds; one in particular requires urgent surgery to a wound penetrating his abdomen. We have a potential mass-casualty scenario, and Kev quickly updates the nine-liner.
Within twenty minutes, all casualties are stabilised. As my team finish off preparing our injured for evacuation, I disappear into the ops room to update the boss and get a ‘wheels up’ time from Kev. Wheels up is the time that the helo (or rescue bird) will leave Camp Bastion. This allows me, together with my team, the time we need to manoeuvre our injured out to the HLZ.
The attack came at last light, an age-old tactic adopted by every fighting force since the very barbaric yet successful days of both Genghis Khan in the East and the Romans in the West. The Taliban are creatures of habit, and generally attack from positions that have been successfully used before; this was employed time and time again to systematically slaughter the Russian occupiers during the late 1970s early ’80s. It ensures that the attack is on the Taliban’s terms and at a time of their choosing. They also know the area and all potential escape routes, including ours. In military terms, it’s all about controlling the battle space – another piece of information I picked up during my time on the medical desk.
In 2006, our government believed that we could control Helmand with fewer than 4,000 troops. We sent 40,000 to Iraq, and by 2008, we had around 8,000 soldiers in southern Afghanistan – the most dangerous place on the planet. I didn’t need a PhD to underst
and that our politicians may have underestimated just how many jihadists we were taking on.
News from Camp Bastion says that wheels are up; we have what is known as the ‘golden hour’ – a window of time in which to get casualties off the ground and into surgery as quickly as possible. Including our own treatment, the evacuation will be complete in just under an hour, including flight time. This is reassuring, and it offers our casualties the best possible chance of survival; hearing that the medical emergency response team (MERT) helicopter is airborne is welcome news. The MERT offers our casualties a secondary lifeline should they deteriorate on the rescue bird. The MERT are the unsung heroes of the battle to secure Helmand. The team is made up of highly qualified medical personnel who are capable of giving in-flight lifesaving treatment if and when required.
Sgt Maj. Davey Robertson leads a patrol from our base to secure the route to and from the HLZ. The chosen site is an old football pitch opposite our base on the other side of the canal. All of this is happening under the cover of darkness, and the young Jocks rely heavily on the basic low-level soldiering skills, which cover movement at night. With technology ever moving forward, it is sometimes easy to forget the basics. My team and I are on foot and carrying four extremely heavy casualties. Davey relays via a runner, confirming that the landing site is secure. My extraction group is ready, and we prepare to move.
The evacuation must be measured at all times with clear command and control. My role ends only when our casualties are airborne; until that time, I must keep a grip on the situation. Hearing the sound of the Chinook in the distance, my mind is buzzing with questions as I mentally check that I have covered everything. Which way is it going to land? Are we at the right end of the football pitch? Are my casualties stable enough? Who am I going to hand over to? My list is endless, and no one can answer the questions. My heart races again, and my palms are still sweaty.
The Chinook comes in low and fast, touching down amidst a huge cloud of debris. On the ground, the cool night air on my face is quickly warmed by the downdraught of the powerful double engines to the rear of the aircraft.
Battleworn: The Memoir of a Combat Medic in Afghanistan Page 5