Combat Doctor

by Marc Dauphin

  Personnel from Roto 6 (the one before us) and 7 unloading and triaging casualties, April 2009. The PAD clerk is about to “wand” the casualty.

  Major (now Lieutenant-Colonel) Bill Rideout (OC Role 3 Roto 6), triaging a casualty while the PAD clerk ensures he is clear. The other personnel fix the stretcher to the rickshaw. In spite of the enormous tension, hardly a word is spoken. April 2009.

  Meanwhile, the triage officer was at the patient’s head, also relying on his fingers, eyes, and ears.

  I rarely used my stethoscope, which was basically useless in that environment, what with the helo and the idling ambulance. I could usually tell at a glance who was in shock and who wasn’t yet. There are many clues: Is there active bleeding? And how abundant? What is the casualty’s alertness? What are his eyes like? What colour is he? How fast is he breathing? Tourniquets? Skin temperature? How deep is the orotracheal tube? And, of course, I could feel for the carotid pulse.

  In less than three seconds I would make my decision and direct the casualty to a trauma bay. And so on until the last one had been unloaded.

  Then, as the ward master closed the doors of the hospital to keep the cool inside, I would enter the trauma bays and the difficult part of my work would begin.

  So it was with those four Canadian casualties. As often happens, it had been an IED against a LAV (Light Armoured Vehicle — an eight-wheeled troop transporter with a 25-millimetre gun turret). The crew commander had taken shrapnel and fire in his face, but he was conscious, if a bit confused. The driver had been killed outright. The gunner had what I call “IED feet,” the kind of open, complex fractures of the calcaneuses that leaves those heel bones looking like plate glass after a car crash. That kind of injury left little hope of preventing an amputation, because every time you washed those wounds out you were forced to remove more and more dead little pieces of bone until, finally, there was nothing left to hold the foot up. Besides, those dead little pieces of bone secreted toxins. It was amazing to see how quickly the casualties improved once you amputated that limb: at once they were more alert. More alive.

  C’est comme ça.

  The two other casualties that day had the typical variety of IED fractures of the feet, legs, hips, sacrum, lumbar, and thoracic spine. They were in pain, but stable.

  Through it all was Annie, going from bay to bay. “You let the OC of the Role 1 have access to your trauma bays?” was the incredulous comment I got at the beginning of the roto. My answer was a shrug and a “Sure. Why not?”

  Annie is a family doc, the kind that had made a good living doing deliveries when she was a civilian. And with what docs were paid for a delivery back then, you had to do a lot of them to make any money. By the way, when my comrades from other provinces first meet me, they inevitably ask, “You actually gave up a lucrative practice in civvy street to accept a paltry army salary?” To which I answer: “You’ve got it all wrong; I’m from Quebec. When I signed up, my salary went up, not down.”

  Well, here’s to Annie, going from bay to bay, reassuring a soldier, translating for another, asking yet another about his mother, joking with a fourth: “Which one do you want to call first? Your wife or your girlfriend?” Just kidding.

  That day, one of the soldiers, the one in 2, I remember, was stoically putting up with the pain of his injuries, plus the added insult of whatever treatment we were providing. Then, suddenly, Annie became a mother (she has four kids). “Don’t you want something for your pain, soldier?” she asked him, as she delicately put her hand on his forehead. The soldier, just a kid really, bravely looked up at her and, putting all his trust into her motherly judgment, answered through clenched teeth, “I don’t know, ma’am. What do you think is best?” Just thinking about that moment still can shake me up. Funny, how some stuff sticks in your memory.

  After she’d finished with the casualties, Annie conferred with me to check on prognosis and expected dispositions. Then she went out to talk with the officers, coming back in every now and then to ask me about new developments, or when I was going to AE her guys out. Annie and me, we were a team.

  So, three of the guys needed an operation. I authorized opening the third OR because they were announcing more incoming.

  Then a U.S. Marine came in with a torn-off arm, accompanied by another slew of staff officers and first sergeants, this time Americans. Their senior med tech showed up to do the same liaison work with them as Annie did with ours. Same stuff. Slightly different uniforms is all. To the CT, then to the OR. More blood out. More blood in.

  Then we got the two from the shootout at the OK Corral. It seems two Afghan soldiers had developed a dislike for each other, and decided to settle it the Wild West way. One shot in the head, the other in the chest. C’est comme ça. More blood. Chest tubes. CT. OR. It’s a good thing I had three ORs going.

  Then I had to handle some other stuff. Air Evacs to organize. Others to sign off. The blood bank was running short of type O, and I tried to get some off of Tarin Kowt. I had to arrange transport for that blood, and then start arranging for AEing our guys and that U.S. Marine out.

  When I sat down for a minute in my office to slosh down a Pepsi, one of Annie’s med techs stopped by to tell me what he said was the most hilarious joke he had heard in a long time.

  It seems that a bunch of Afghan guys had come up to the front gate of one of the FOBs asking for a shovel. They almost got arrested then and there. You use a shovel for one main thing in Afghanistan, and that’s to put in IEDs. No, no, they said. It’s to bury a woman. So, curious, the guards at the gate called up the medic to the bed of the Afghans’ pickup truck. “Hey, she’s not dead!” exclaimed the medic. “You can’t bury her! Bring her up to my aid station. I can do something for her.” But, to the intense surprise of the medic, the Afghans refused his help and left.

  I couldn’t see what was funny in that story. Then the med tech delivered his punchline as if it was the funniest thing in ages: “Those idiots probably buried her alive!” And he laughed so hard that tears ran from his eyes.

  When he left, I just sat there, staring after him, my Pepsi growing warm in my hand. I was stunned that he could find that funny. My God, what has this country turned us into? Callous, black-humoured, and, undoubtedly, people who were hurting inside. We were going to have some fixing up to do on our souls when we came back home.

  Then the Dutch medic popped his head around the corner. Geez! I’d forgotten all about him. Before I could say anything, he smiled at me and handed me my keys back. I didn’t remember having given them to him.

  “We’ve got something to show you, doc,” he said as he motioned for me to follow him. Outside, the sun was a lot lower, but it was still blindingly hot. There sat my bike, but it was changed. The seat had been replaced with a new one. The chain had been oiled. It had two new tires, and brakes on the back wheel.

  “We wouldn’t want you to get hurt riding that thing, doc.”

  At that moment, the contrast was so great between that simple act of kindness and the harsh reality of that country that it brought tears to my eyes. It still does today.

  C’est comme ça.

  Like I said, you never know what’ll stick in your mind.

  FOBs

  In the past rotos, Forward Operating Bases (FOBs) had played an important role in the medical chain of evacuation. They still do, but not for our soldiers anymore. FOBs are those rather large bases that we built “forward” of KAF. These FOBs permitted us to operate from them rather than from KAF, saving time and fuel and adding efficiency. Forward of the FOBs we built patrol bases, which are smaller. Forward of those, you had the foot patrols, and still more forward, the mounted patrols. There’s always someone forward of you. So it’s no use bragging that you were forward of someone else. If someone brags to you that he was “forward,” just remember that somebody else was even more “forward” of him.

  On a FOB there were hundreds of troops and so, to serve them, we had medical units. These small units — a physician
or a PA plus a bunch of medics — had to deal with all health matters, from the quality of water and food to dealing with wild cats or vipers, caring for cuts and colds, and handling multiple trauma victims who arrive all at once. It could be a harrowing job.

  In past rotos, medical people on the FOBs would handle Canadian wounded because many of our casualties were evac’d by road. In 2009, with an extensive dust-off system in place, allied casualties were evac’d directly from Point of Injury (POI) to the Role 3 via Black Hawk helicopters. It followed, logically, that the workload on the FOBs decreased, right? Not so. That’s when they started bringing carloads of wounded civilians and police to the FOBs. These guys were busy.

  But then, some FOBs were extremely quiet, while others were constant pandemonium. This could vary from one roto to the next. It was the “Roto Lotto” I guess. On Roto 7, it was Wilson and Ma’sum Ghar that were the busiest, and by far. These two FOBs by themselves sent me hundreds of cases. In Wilson, a Canadian physician, Linda Rodger, was the head of the team. And on Ma’sum Ghar, Martin Bédard was the PA. Ray Wiss, who has written books about medical care on the FOBs, is a Canadian ER physician who came to Afghanistan twice for a few weeks to replace the docs or PAs during their R&R. These physicians and PAs were the senior medical authority on the FOB, responsible for all the health care delivery. A lot of times, their medics were out on patrol with the troops, so it could get very hectic very fast when a bunch of badly injured people arrived all at once on the doorstep, what with the medics all gone. Plus, you were constantly under attack there, and the base was much smaller than KAF. So the odds of the bad guys hitting something with a rocket were much higher on a FOB, although the only two medics injured on base on Roto 7 were hit on KAF.

  C’est comme ça.

  To be able to treat multiple simultaneous casualties with reduced medical personnel on a FOB, most team leaders had devised ways to train non-medical personnel to help them. Some of these people were naturals and caught on very quickly.

  “What did you do in the war, Dad?”

  “I was a cook on a FOB.”

  “So, not very different from here, eh?”

  “Hardly, son, hardly.” (Apart, that is, from putting up IVs on patients, putting tourniquets on others, and supporting the airways of still a few more.)

  And all injuries seemed so much worse in the isolation of a FOB. I mean, here I was, in my nice (plywood) Role 3 with a gazillion specialists at my side to give me advice and help when I was in over my head. But out there, you were it: the SMA, the senior medical authority. It could get very lonely when the buck stopped with you. It’s a hell of a lot scarier dealing with two badly wounded people in a small community hospital than dealing with six in a large urban teaching hospital.

  One day, physician John Cockburn went over to FOB Wilson to give Linda a break. While they were handing over, six casualties came in. Or maybe there were more and only six needed to be intubated. Linda will tell you her story one of these days. Anyway, John is a veteran. In fact, he is even older than me. He spent his civilian career practising anaesthesia as a GP. So he’d seen it all, right? But while you’re practising anaesthesia, you’re dealing with one patient at a time. In a crisis, maybe two. Well, that day, Linda had time to intubate four patients, and John two. After that, shaking his head, John had a greatly increased respect for the FOB docs. Not that he hadn’t respected them before, but doing that kind of rock ‘n’ roll gives you a different perspective on medicine. Maybe I’m wrong about the details described her, but it was something like that.

  Now, these folks on the FOBs sure learned how to be handy with an ultrasound machine. Our comrade Ray Wiss (he of the books FOB Doc, and A Line in the Sand) trained us all before we left; and, what’s more, Ray arranged for a company to lend us three ultrasound machines to use on the FOBs for the whole duration of the roto. It was the first time, to our knowledge, that ultrasound had been used so far forward. Lieutenant-Colonel Wojtyk arranged that, so he’d be the person to consult if you want to know more.

  It was a team effort: one person minded the net, another backed up the goalkeeper, yet another scored goals, while a fourth neutralized the other team’s best players. After the game, each player had his or her version of what happened. These versions were all accurate, but they were all different.

  So Linda and Martin were often on the phone with me, sometimes several times a day. Technically, as members of the Role 1 organization, they should have called Annie. But I was the trauma guy, and I was also where their patients would end up, so it made sense that they’d call me to give me a heads-up about what was coming. Or to seek support after the fact. Remember the “lonely” part?

  One night, I got a half-hour-long call from Martin, and a play-by-play description of what he was doing after he received a dozen kids who had eaten some artillery product or other that they had found lying around. Kids over there are always hungry. Well, here’s Martin, saying, “I think I’d better intubate number seven. Hang on a minute, I’ll be right back …” and then I could hear him doing his thing, including telling a tank mechanic at what frequency to bag the kid once Martin had intubated him. Then he’d be back on the phone. I couldn’t help him, because I didn’t know what he was dealing with, even though my people at my end were frantically hunting for information in the medical literature. I guess there aren’t many cases of kids eating artillery stuff back home. So I just gave Martin what support I could while I heard his drama unfolding. Seldom have I felt so helpless. By the way, all of those kids survived. I hope they’re making the best of the lives that Martin gave them back.

  I did visit both Ma’sum Ghar (Martin’s FOB) and Wilson (Linda’s), but it was at the end of the roto and they’d already left. Ma’sum Ghar was by far the nicest, with its mountain inside the FOB (no kidding). I suppose the folks who spent six months there should tell you about it. What I really liked about Ma’sum Ghar was that, at night, it was really lit up as if it was broad daylight. You could set your route by those lights. The dust-off helos would fly right between the double peaks in that Ma’sum Ghar mountain when doing evacs. Something about no tracer bullets coming up from the ground there. As opposed to other mountains, where a pretty stream of coloured lights would follow you when you flew past in the darkness …

  Those were my comrades in the FOBs during Roto 7. I wish I could tell you more about them. About how the medics got to be good at intubating wounded people. Or how cooks and mechanics learned how to know if a casualty was going bad. But I wasn’t there. I’m sure Linda will one day tell you how it was.

  I spoke about Wilson and Ma’sum Ghar, but on other rotos, Nathan Smith was bad. Arthur, a physician with the PPCLI then, showed me a photograph of him and his team taken on Nathan Smith. When I looked at it, I recognized the face of a medic who had lost his life over there. Arthur’s response was, “Yeah, that picture was taken early in the roto … when we were all alive.”

  C’est comme ça.

  The Collector

  I remember the night he arrived, because I had just spent the afternoon with the new USAF Mentor for the ANA hospital. They had changed over the physicians occupying that position and, as is the case after all turnovers, you had to get used to the new person and his or her way of working, while at the same time making sure he or she knew the limits of what you can and will do for them. I had a good feeling about the new guy, who did have large shoes to fill, because Josh, the last doc, was a real Mother Theresa (in the good sense) and one heck of a physician. Yes, he had spoiled us, and yes, we had grown accustomed to being spoiled.

  The new doc, Hermann, was an ER specialist, just like Josh — and me. ER physicians are used to thinking outside the box because they constantly deal with situations and conditions not “written up in the books.” Hermann was no exception.

  “Sir, I have a local national here,” he began, on the temperamental phone that was our sole means of communications. He always called me “sir,” even though we were the same rank. I
guess it’s all that white hair of mine. Come to think of it, John, whose hair is even whiter than mine, never called me “sir,” even though I outranked him. Yeah, it was definitely the hair colour.

  “He’s about ten, maybe twelve years old, and he’s been shot in the jaw,” he continued. The bullet had actually entered through the front teeth, before taking out the right half of the kid’s tongue, then exiting through the right jaw, pulverizing that bone and the teeth on that side. The boy had been brought to the ANA hospital, where he had arrived choking because he had no jaw to pull his chin away from his airway and the blood from his wounds was filling his mouth and throat. Those are the most difficult cases to intubate. Yet Hermann had done it, and related as much to me without any fanfare. Had it been me, I would have been ecstatic at my skill (luck?), and would still have been on the adrenalin high as I phoned the Role 3. I know, because it had happened to me before. But Hermann, he was just as calm as if he were talking about the weather.

  “Yeah, send him on, Hermann. We’ll see what we can do for your kid,” I answered as noncommittally as I could, thinking that you never know what you’ll find, so never promise much. And I’d called him “your kid” to subconsciously prepare Hermann to take him back once we had done our thing. Hermann told me that, as far as he could tell, the boy had no injuries other than the bullet wound to his face.

  Well, it was a case of the casualty being exactly as announced. How Hermann had intubated him sure beat the heck out of me. “Hey, doc, this is really weird!” exclaimed Troy. He was bagging the little fellow through what was left of his cheek, as if Hermann had inserted the tube right in front of the boy’s ear. I couldn’t help glancing at the monitor above Troy to reassure myself that the sats were 100 percent.