Combat Doctor

by Marc Dauphin

  Back to our soldier.

  At this point the combat medic will take over from the TCCC, unless there are multiple casualties. If that is the case, the medic will coach the different TCCCs and direct the operations. Now we have to get Jim out of here, the faster the better. NATO, which runs most of the combat operations in Afghanistan, has imposed a ninety-minute rule from injury to damage control surgery. If a casualty takes more than ninety minutes to reach a surgical team from the moment of his injury, I have to write a report about it. So the quicker Jim’s patrol sends out a call, the quicker the MEDEVAC helicopter, or “dust-off,” will come and get him.

  They don’t just call on the radio and scream for help. They have to send out a message with all the important info so that the helo team knows everything there is to know about the evacuation. Details such as how many wounded, how bad (laceration to the thumb, or bullet in the head?), where they are, what does it look like at the point of injury (POI), where they are to pick up the casualties (weather, suitability for landing a chopper, wind, and, oh! yes, are the bad guys still shooting at you?). These facts have been boiled down to nine in total, and a special message matrix has been adopted by all. This we call the 9-Liner.2 If you want a chopper to come and get your wounded guys, you have to send out a 9-Liner. As soon as you send out a 9-Liner, everybody involved gets it, including us at the Role 3.

  Once the medic gets a hold on the situation, he or she will also send out a MIST for us at the hospital. This is a slightly more detailed report stating the Mechanism of injury, the Injury itself (a description), the Signs (as in “vital”), and the Treatments already administered. A good MIST gives us a perfect picture of what to expect. So, five wounded, five MISTs. No wonder the medic is so busy that the TCCCs are the ones providing the care for the injured. The TCCCs were the medic’s hands and eyes.

  Afghanistan was divided into four regions, each with its own command. They were Regional Command North, RC(N); East, RC(E); West, RC(W); and South, RC(S). That last one was us. The Role 3 hospital at the time I was there was Canadian-run, but was under the direct control (called OPCON) of RC(S). And RC(S) ran the battle. So they allocated the helicopters and distributed the casualties to the different hospitals. Usually, though, you didn’t have to be a rocket scientist to figure out that most of the severely wounded soldiers would come to us. Unless they were so unstable as to be sent to a closer Role 2 hospital.

  All right, what’s with all these “Roles”?

  A Role 1 is your basic medical clinic, plus. One or a few physicians or PAs, med techs, or nurses (Canadian Role 1s don’t have nurses). They can see any number of sick or lightly wounded, but have no retention capacity. They can stabilize a serious casualty, but they can’t admit. They have no operating room (OR) and no surgical capacity except for minor surgery, done under local anaesthesia (dealing with ingrown toenails, suturing a laceration, removing a superficial foreign body, taking care of minor sprains and fractures). Usually they are open from morning till late afternoon, unless they are on a Forward Operations Base (FOB), in which case they run 24-7. On Kandahar Air Field (KAF) we have counted in excess of thirty-five Role 1s. Canada had its own Role 1, distinct from the Role 3. The Canadian Role 1 was responsible for treating all Canadian personnel on KAF, even the ones who worked in the Role 3. Canada’s Role 1 was OPCON to the Canadian commanding general. Not so the Role 3, remember? More on the Canadian Role 1 later.

  A Role 2 is the equivalent of a community hospital back home, but equipped for a war zone. It has a small admitting capacity, but technically is much evolved. Role 2s have one or more ORs, surgeons (trauma surgeons), anaesthesiologists, ER docs, a blood bank, and a small lab, and some have radiological capacities; i.e., they can take some simple X-ray films. There were a number of Role 2s in RC(S). Qalat and Tarin Kowt come to mind because they were very busy. And also Bastion, the very large British Role 2 in Helmand Province. It was as big as us, capacity-wise. So much so that it was declared a Role 3 in 2009. A Role 2 is always under national command. So, in Tarin Kowt, there were two Role 2s — a U.S. one and a Dutch one. Depending on whether they have any troops operating in an area, a nation may want to deploy some medical assets in another nation’s Role 2. In Bastion, the British Role 2 that became a 3, the U.S. Navy had some surgeons, nurses, and various techs. Sometimes a Role 2 has more than one anaesthesiologist, more than one surgeon, and some basic specialists in fields like ENT, orthopaedics, and internal medicine.

  The Role 3, for which I was responsible during six months in 2009, is a NATO hospital. Staff from many countries is assigned to serve there, under NATO command. From late 2006 to October 15, 2009, the KAF Role 3 was Canadian-run; that is, its command, staffing, and stuffing (the material stuff) was Canadian, but it was a NATO establishment. My boss, through Colonel Savard, was a Dutch general, the CO of RC(S). His medical adviser was a Dutch Navy captain, Captain Bos. In addition, I also had a Canadian physician, Lieutenant-Colonel Ron Wojtyk, as a medical boss. Lieutenant-Colonel Wojtyk was the SMA, or senior medical authority, the person responsible to Canada and to NATO for whatever was medical in the hospital. Yes, we had to work out an agreement as to who was responsible for what. I’m not sure I completely understood, so I probably ended up stepping on his toes a few times. He was good enough, and cool enough to overlook all my un-political bumbling. (Thank you, Ron, for your patience and support.)

  A Role 3 has a larger capacity than a Role 2. In addition, it has some super-specialties, like vascular surgery, neurosurgery, oral and maxillofacial surgery, radiology, and psychiatry. It also has better support, such as a more elaborate radiology and lab facilities, including CT scans, angiography, and ultrasound.

  Now you start to see the picture. Everything is built around the Role 3. Other hospitals or clinics (in NATO parlance we speak of medical treatment facilities — MTFs) transfer to us. We’re the hub. But whatever cases can be completely treated at other MTFs don’t need to come to us. We take on only the worst cases. And, since we don’t have a large holding capacity, we like to evacuate our wounded to other, more elaborate, MTFs. And yes, we evacuate to a Role 4. It’s in Landstuhl, Germany. That’s where I worked in 2007–08. A Role 4 has everything. You name it, it’s got it. From open-heart surgery to neonatal intensive care, dialysis, and reconstructive surgery.

  So, back out in our dusty Afghan village, Jim is being treated by the TCCCs, the medic has radioed in the 9-Liner and the MIST, and RC(S) has assigned a flight to go and get Jim and ordered that helo to take him to the Role 3.

  At the helo flight, a bell rings to indicate that, somewhere, a casualty needs evacuation. The helicopter crew, who were watching a Charlie Chan film, immediately spring to life, grabbing their gear, dropping their Cokes, and running out into the blistering heat to their machine. The pre-flight walk-around of the Black Hawk helicopter had been done when they started their forty-eight-hour shift the evening before. They don’t know where they’re going yet, only that somebody, somewhere, needs their help. And they’ll give it, even at the price of their lives.

  The pilot swings into his seat as he is putting his helmet on and plugging himself into the headset. The co-pilot, who is doing a quick walk-around, gives him the turning index finger sign to start the engine. As the first turbine starts its whine and the heavy blades start spinning, the two medics are putting on their body armour, their tac vests, and their helmets. They check their weapons, chamber a round, and put them on safe. Then they start readying their medical equipment: they pull out a couple of IV bags, attach tubing, and get rid of the air bubbles. At the same time, the flight engineer checks out the chopper and loads the Gatling gun if their machine has one (the U.S. Air Force ones, do; some, like the U.S. Army ones, don’t). Meanwhile, the pilot has put on his body armour and his tac vest and has started to receive the 9-Liner. He finds out from this where they’re going, and what the situation is (how many wounded and their condition, et cetera). The 9-Liner is repeated a few times on the air, and now the medics h
ear it, too.

  “Line 3, Alpha, one … Line 6, Echo … Line 8, Alpha, one CDN …”

  The whole crew now knows they are going to pick up a severely wounded Canadian soldier, and that the landing zone (LZ) might be hot by the time they get there.

  The chopper takes off. “KAF tower, this is Dust-off Six-Four requesting clearance for flight to the western end of the runway and a northbound departure.”

  This is immediately granted. KAF at the time was the busiest single-runway airfield in the world, having passed Gatwick, near London, sometime in May 2009, with more than five thousand takeoffs and landings per week. Dust-off flights have absolute priority over every one of those except in the case of an in-flight emergency (a plane on fire, or a plane with engines malfunctioning).

  “What did you do in the war, Dad?”

  “I was an air traffic controller, son.”

  “Cool job, Dad. Sort of like back home, right?”

  “Yes, son. Sort of.”

  All traffic in the landing or takeoff pattern is temporarily diverted, but it doesn’t take long for a Black Hawk helicopter to clear the runway.

  A note about weapons. On KAF we all had to be armed at all times. There were some exceptions: people in the OR, nurses caring for patients, personnel directly caring for Taliban (for obvious reasons), those out jogging or at the gym, or if you were in your tent or in your room. Now, even if you didn’t wear your weapon at work, you still had to carry it to and from your job. When you were not wearing your weapon at work, you had to lock it up. Me, I’d wear my weapon (that 9 mm) at all times. Not because I felt threatened, but because I’m absent-minded. When I’m doing anything medical, I forget everything else. Therefore, I’d be liable to leave my weapon lying somewhere. Losing your weapon is the worst no-no, the biggest boo-boo in the military. There are apocryphal tales of a soldier dropping his or her weapon in the potty (we don’t call it that — more like, “The Blue Rockets”), and having to … well, you get the image, I’m sure.

  Now, in KAF, when we were at a low or medium state of alert, we’d carry our weapon in its holster, and the magazines with the bullets in another part of the holster. When the threat level rose, we were ordered to insert a magazine into our weapon. This is more dangerous, but all the bullets are still in the magazine. When the threat was immediate (like the time those bad guys succeeded in getting on-base and were running all over), we would cock the weapon, and that inserts a round into the chamber. Your weapon is now “live.” Just pull the trigger, and ka-pow!

  So chambering a round is not something you take lightly. Bullets in a magazine are one on top of the other, but slightly staggered, one to the left, one to the right, one to the left, and so on, in a repeating WW pattern. So, before you chamber a round, you look at your magazine: let’s say the top bullet is to the right. You insert the magazine, cock the lever, then take out the magazine. The top bullet is now to the left. Now you know for sure that there is a round in the chamber and that the weapon is ready to be fired.

  That’s how the flight medics prepare for takeoff: they never know if they’re going to have to defend their helicopter when they get to the casualty. And for a wounded person, whether a comrade or a civilian, they’ll take any risk. They pride themselves on their altruism. The U.S. Army flight medics’ motto is, “When I have your wounded.” During the Vietnam War, upon arriving in the area where they were to pick up some casualties, a dust-off team was warned to leave instead of landing because the LZ was too hot (“hot,” as in full of flying bullets), and the major in charge (a Major Charles Kelly) replied, “When I have your wounded.”

  No landing zone (LZ) is too “hot” for those medics. By the way, Major Kelly was shot through the heart and died minutes after saying those immortal words. I guess the guy on the ground was right. The U.S. Air Force dust-off crews are called Parachute Jumpers, or PJs, because they are trained to get to and evacuate air crew downed behind enemy lines. Their choppers are always armed, and their motto is, “So that others may live.” The U.S. National Geographic Society has recently produced a six-part documentary on the U.S. Air Force dust-off teams. It is called Inside Combat Rescue and it will give you an idea of the work these guys do.

  I’m proud to have served with these unassuming heroes, and to have flown a half-dozen missions with the U.S. Army dust-off crews at the end of my tour. For them it was just another day at the office. For me it was a lifetime experience I will cherish till the day I die.

  Back to our soldier.

  Now the chopper flies as fast as it can toward the pickup location. You can imagine the tenseness of the crew. They are risking their lives for their brother-in-arms. In addition to this, they will have to treat him on the way back. So, to the stress of the danger they add the pressure of having to perform flawlessly medically.

  The U.S. Army dust-off choppers fly at low to medium altitudes. There is always another helicopter following the dust-off to protect it, almost as if daring the bad guys to take a shot. That second helicopter is heavily armed. It can also carry some casualties if there are too many for the first helicopter. In that case, while the second helo is picking up their casualties, the first one flies guard over it, using a sickening manoeuvre of tight, sudden turns called a figure-eight. If you’re moving around inside the chopper, caring for casualties while it’s doing protection, you better have a good hold on your breakfast. And if you’re not monkey-tailed (tied to the aircraft through a harness akin to a tail), you hope that the doors are well shut.

  When a dust-off lands at the POI to collect the wounded, especially in summer, after months without any rain, it kicks up an enormous amount of dust. This dust is the result of the unforgiving sun baking the clay over and over. It gets to the consistency of fine talcum powder. We called it moon dust. There is often so much of it that the dust-off crew, as they land, will lose sight of the ground for the last twenty or thirty feet. This is called brown-out. It takes nerves of steel to land in those conditions. Yes, helos have crashed because of this.

  Once on the ground, one member of the crew, usually a medic, will jump out and hang on to the chopper with one hand until the dust has dissipated enough so that the medic can see. This may take up to five minutes. If that crewmember takes that hand off the chopper before the dust is clear, he or she may lose contact with the machine. The dust in the air is that thick.

  Once sight has been re-established and if there is no shooting going on, the flight medic will disconnect from the chopper and walk toward where the casualty is waiting. A quick exchange of words (probably screamed — those Black Hawks are noisy) is the transfer of info. At the same time the patient is being loaded by someone else aboard the helo. While the first flight medic is getting the report, the other medic will begin care, giving medication or performing any life-saving procedure that needs to be done. Everything is communicated by hand signal now. Voice and stethoscope are useless. The other medic hops onto the chopper and the helo leaves the scene. On board, there is little verbal exchange between the medics so as not to clutter the intercom, and not to distract the pilots, who are in contact with RC(S).

  During our roto, we had the privilege of placing two of our flight medics with the U.S. 82nd Airborne Division’s dust-off crews. I believe these two medics are the only two Canadians ever to have served a full tour in that position. I lift my hat to those two very brave medics, whom I have the privilege to call comrades, Pierre Desrosiers and Eric Mantha. Those two are part of the richness that the CF possesses. I hope they make good use of their experience and expertise.

  Picking up casualties at a POI is very different from doing Air Evacs; I know, because I have done both. While all this is going on, at the Role 3 preparations are being made to receive the casualty. A trauma team is either assembled or called in.

  And now, to fully appreciate what is about to happen, you need TRAUMA 101 (Appendix C).

  * * *

  1 At the moment of this writing, Quebec has produced more specialists th
an its hospitals can absorb. Therefore, more than a dozen graduating Ob-Gyn specialists have no place to work, while at the same time thousands of pregnant women can’t find an obstetrician.

  2 See Appendix B for the NATO-format 9-Liner.

  The NATO “9-Liner”

  TRAUMA 101:

  Trauma Care for the Uninitiated

  What happens when someone is injured?

  Think of the human body as a bunch of cells. Everything is made out of cells: your heart, your bones, your brain, your muscles. And these cells need sugar and oxygen to live. Here, in trauma, the sugar part is not as important as the oxygen, so we’ll ignore it. For the oxygen, an analogy is a city of zillions of houses, each one of which needs constant delivery of oxygen to survive. The houses consume oxygen and spit out carbon dioxide (CO2). CO2 is toxic, so it must be taken away immediately. The streets of the town are our veins and arteries. The red blood cells (RBCs) are trucks that carry oxygen to the houses — the cells — and take away the garbage, the waste product of the cells’ oxygen consumption, CO2. If you don’t have enough trucks to carry the oxygen, the cells that don’t receive any die, then YOU die because the cells are what you are made of. Not enough trucks can be caused by loss of RBCs, such as in blood loss. There can also not be enough oxygen (because you stop breathing, for example, or something blocks your windpipe, or something keeps your lungs from expanding), so that, even if you have enough trucks to carry the oxygen, there is no oxygen available. In trauma, you get the worst-case scenario: you lose the trucks and the oxygen supply at the same time. So we have to move fast to ensure that we give you enough oxygen and enough blood to transport it to the cells.

  Principles of Resuscitation Before and In the Trauma Bay