Arrival in Iraq

My arrival in Iraq was about two in the morning at Shaibah base in the middle of the desert outside Basra, and Dan Conner greeted me at eight o’clock in the morning. We had some breakfast, he gave me a tour for half an hour and an intensive ten minutes on the tri-service anaesthetic apparatus, which I had seen before but hadn’t really worked with, and there are definitely some quirks to it and some schoolboy errors that can catch you out.

I had Dan’s top tips for what not to do and how not to screw up, which was very helpful. Then we went and played volleyball and I broke three ribs… Dan was a very worried man for about six hours to see whether he was going to have to stay there and me be evacuated…

Field Hospitals & Equipment

The hospital in Iraq bore a very strong resemblance to my early time in Afghanistan because it was the same tented hospital with the same herringbone format, so there’s one long central corridor with an entrance one end and an exit at the other, and wards and departments coming off either side of the central spine, and that’s the traditional format for a field hospital, given sufficient space. That was the format in Iraq and in Afghanistan when I arrived there was exactly the same. It’s a very functional system, it works very well. After a month in Afghanistan we moved into the new prefabricated hospital, which is the one that’s standing now.

The major difference in clinical terms, and anaesthetic terms, was that we went from using the portable ventilator, Datex monitor and the tri-service to using a Draeger Primus machine in what resembled an ordinary operating theatre. It would be very difficult to have a standard anaesthetic machine in a tented environment, so it wasn’t until we moved into the new hospital that we brought things back up to date. We still did use the tri-service apparatus and we used TIVA quite a lot for secondary procedures.

Iraq & Afghanistan

The intensity for the majority of that tour was not as high as Afghanistan. It did surge at times, we had one major incident where a unit were basically mobbed by a crowd and there was lots of petrol bombs thrown and one or two rounds fired… and then a patrol was ambushed out in Alamara, which the Quick Reaction Force went in to relieve them and that was again another major incident.

When there was a surge like that, you would have casualties coming in the front door, you’d go and pick them up in ED resus, take them through to theatre, through to ITU and go to ED for the next one, and we’d be rotating fairly endlessly through that cycle for ten, twelve hours or however long it took to get through those guys. But that didn’t happen very often, so if you were on the go for 12-14 hours then, you would have time to recover, whereas in Afghanistan it could be like that for days in a row.

In Afghanistan we were manning the Medical Emergency Response Team (MERT), as well. During my tour we had one day on three on the MERT, because that could be very intensive, very draining. That was a 24 hour shift, and then you’d be back on the next day in theatres and ITU, and then on the MERT the following day. It waxed and waned but the intensity was generally a lot higher in early 2008 in Afghanistan than it was, certainly in 2004 in Iraq.

Medical Emergency Retrieval Teams

The MERT was at that time in the back of a Chinook. In the back of there you would have a loader and a gunner from the air crew and two pilots in the front. The medical team was a four-man team consisting of a senior RAF nurse who would be the operational commander of the medical unit, a post-fellowship registrar or consultant from ED or Anaesthesia, an RAF paramedic and then a fourth person who could be a doctor in training or a CMT or an ODP. And then you’d have a force protection unit of eight riflemen to provide protection on the ground for the MERT and we often had EOD bomb disposal on board as well, with or without a dog. So it was quite crowded in the back! But there was still room for, with the tailgate down, three stretchers end to end and walking wounded sitting on the seats on the side.

We had Piggott pouches, which are just a rollable series of pouches on the wall with equipment in them and medical Bergans, medical rucksacks open with kit on them as well, on the seats to the side. Generally speaking the worst two casualties would be loaded first and they would go feet first followed by head first, so that the two heads of the worst two casualties were together in the body of the aircraft, and as the consultant kneeled between the two. So you might do an RSI facing forwards and then turn round and do an RSI facing backwards, or equivalent, which was sometimes tricky but actually worked quite well.

MERT in Chinook, with doctor, specialist nurse and two paramedics. © IWM (12BDE-2007-006-072)

Balancing Risks

The major difference to civilian rescue helicopter work is that as a civilian practitioner, you’re trying very hard not to have to do anything in the aircraft, because civilian aircraft tend to be smaller, they don’t have a lot of space to work and actually you don’t want to have to do something en route, so you’re doing most of what you need to do before you get in the aircraft.

The big contrast with the MERT is that you’re a very big, very juicy target and the casualties that you’re going to retrieve may or may not have been deliberately injured in order to bring you there, which is what’s known as a come-on, so the Taliban would quite happily shoot an RPG at a bunch of children, knowing that half an hour later a Chinook would land somewhere nearby and they could have a pop at that.

The pilots would not want to stay on the ground, so you had a maximum of maybe 90 seconds on the ground, probably more like 60, you would land, the casualties would be thrown on board and you would take off again. You would get a very brief handover from whoever the medical person on the ground was, and you’d deal with whatever you found, and that was sometimes not what you were expecting.

The launch decisions were made in the Joint Operational Command. You would look at the information coming in over the radio and make a decision based on your estimate of what the medical urgency was, the operational risk to the aircraft, and whether there were troops in contact on the ground. If you had a casualty but there was still an active fire-fight going on, bringing the helicopter down in that would be that much more risky. That would have to be balanced against the clinical urgency. You might still go in, but that would have to be a balance of risks, as with any other decision in medicine.

Similarly landing where there’s an IED. You can wait for the area to be cleared, but then that might take an hour and if you’ve got someone who’s been hit by IED you can’t really afford to wait that long. So those sorts of balance of risks, launch decisions, would ideally be made early and then you’d launch. But because of the timeframe you might find that what landed in front of you in the aircraft was substantially different from what the nine liner said, and you could always be diverted in the air to something else and you might not have very much information about that casualty.

I remember having a six-week old baby with a burn land in my arms in the back of the MERT as a divert from another casualty that we were picking up, quite a flat baby, but fortunately was more or less managing its own airway and with an intraosseous cannula and 20 mls per kilo of fluid perked up quite nicely and was much more lively by the time we got into Bastion, which was nice. But you more or less had to work out what to do when the casualty landed in front of you.

Patterns of Injury in Iraq

The pattern of injury was certainly different, possibly more varied in Iraq because the tempo of operations was a little bit lower in 2004. Having been there nearly twelve months and the initial war-fighting phase was over, there was a lot of police action going on because there was infrastructure rebuilding, and where there’s money being put in there’s a lot of opportunity for people who are poor and desperate to make money, so we had a lot of non-conflict injury and a lot of police action injury.

We had ambushes where the British military supporting the Iraqi police were taking on armed criminals basically, so there were some generally armed criminals getting injured in those sort of contacts. There were certainly patrols getting ambushed and some of those were firearm injuries rather than blast injuries. There were some blast injuries and some IEDs but not nearly to the same extent as there were in Afghanistan later, or even later in Iraq, and we had a lot of non-conflict injury in both: where there’s a lack of infrastructure, a lack of electricity, people are cooking on kerosene stoves, they’re heating with kerosene and there’s a lot of burn injuries, and a lot of burn injuries with children.

Civilians

For the civilian casualties, where it’s a non-conflict injury they apply what’s known as an eligibility matrix, as to whether we can afford to use our medical resource to treat those casualties, and often it’s the ED consultant going to the front gate at the camp and assessing somebody as to whether it’s appropriate for us to take them, because people would just drive up to the front gate and climb out with a severely injured person and often the eligibility rules would be bent for hearts and minds reasons, particularly with children, and sometimes you could be put in difficult situations clinically because of the types of casualties you were taking in.

One that springs to mind was an eleven-year-old Afghan girl who we were called about in the middle of the night with an AK 47 round through her lower leg. Her father was a goat-herd, they lived on the side of a mountain under a tarpaulin and it had taken them three days to get to one of our forward operating bases. She was surprisingly well, she had an debridement, an ex fix and then a gastrocnemius flap by Mark Brinsden, who’s an excellent orthopod from Derriford, who did a fantastic job reconstructing her lower leg.

The decision-making there was swayed by the fact that if she had gone from us to the Red Cross hospital she would have had a below the knee amputation more or less on the spot with that injury, and the social implications for her, she would then have been unmarriageable, it would have immense implications for her later life, so Mark did a reconstructive procedure but also we then had to keep her long enough for some healing to go on for her to be able to be discharged. The Taliban put a lot of pressure on her father to bring her out of the British hospital and he had to be effectively bribed with in quotes ‘taxi fare’ to come and visit her every day, so a reasonable amount of cash changed hands to bribe him to leave her in the hospital so that she could heal. But those sorts of casualties can be challenging, not necessarily for clinical reasons.

In Iraq I have vivid memories of the fact that the chefs would always be aware if the surgical teams were working late and there would be trays of bacon butties arriving at one in the morning to keep you all going, which was very welcome. One of my memories of operational tours is that food is always very good unless you’re living out of ration packs, but in an established operation there’s always good food and that keeps you going.

IEDs

The IEDs were starting to be a little bit prevalent in 2004 but now by 2008 in Afghanistan they were more or less the standard pattern of injury and traumatic amputations were the norm. If you were far enough away you might have the multiple small-fragment pepperings but if you were anywhere close to the blast radius then the traumatic amputations were the rule rather than the exception, and multiple amputations became almost the norm as well.

I’m struggling to bring to mind the figures, but the number of multiple amputations is staggering, and fortunately the number of survivors is now very high from that, which had a bearing on our clinical management and that’s where we’d started to develop the damage-control resuscitation and damage control surgery principles to a much higher degree.

We started to develop the massive transfusion protocols and we started to get a much greater understanding of coagulation matters in massive haemorrhage, particularly traumatic massive haemorrhage. That’s, I think, probably been the single most significant advance over the last six years in critical care in the military, and that’s filtered through to critical care in civilian practice as well. The number of survivors is a reflection of that really.

Resus & Recovery Process

The immediate care will be done there and then… sometimes by the casualty themselves, the CAT tourniquets are designed to be applied by the casualty. As long as they have one functional hand they can apply one to their own limbs, and then by their buddies obviously. That single piece of kit and its use has certainly saved countless lives in recent conflict.

You’d be launching [the MERT] within 10 minutes generally. The longest flight was to Kajaki Dam, which was 35 minutes, but typically 10-20 minutes was an average flight time to get there, so you might be there as little as 20-30 minutes after the injury, and if effective external haemorrhage control had had been achieved you would have a live casualty to then work on. You, in the back of the MERT, could enhance the haemorrhage control and you could treat chest injuries up to and including thoracostomies and you could RSI and manage airway and breathing to that extent. You could give analgesia and in certain instances with regional anaesthesia, but more often with intravenous ketamine or morphine and you could achieve splintage and you could start to transfuse blood and FFP so you could do a lot to start the process of damage control resuscitation.

The analgesia is morphine. It’s very traditional on the ground, and that may change over time, but I think for the moment morphine is the tried and tested. I think there’s a case perhaps for ketamine, but ketamine is not necessarily as forgiving, certainly paramedics using ketamine under licence in this country now, particularly critical care paramedics, I think it’s probably a little way off for combat med techs on the ground to be using ketamine. Perhaps the way things might go in future. Morphine for those first few minutes is probably all they have, and you can start to use more advanced things on the aircraft.

If you were giving blood, you would call ahead to Bastion to let them know. Then they would activate the massive transfusion protocol and blood would be up in the rapid transfusers by the time you arrived in ED resus. So that could be continued fairly seamlessly and part of the effect of the enhanced pre-deployment training was to make the process through ED resus much quicker. I’ve got some pictures showing it in about 13 minutes, which might be average – you could certainly do it quicker than that in certain instances.

The idea was to get surgical teams working simultaneously and have ongoing resuscitation during that surgical event and have the whole thing wrapped up very quickly and the patient into ICU quickly to be physiologically stabilised, even if that required the surgery to be very much curtailed to the extent of achieving haemostasis, then putting the patient into ICU, getting them warm, dealing with their coagulopathy and then bringing them back to theatre once they were physiologically back on track. That process, that ethos of damage control resuscitation and damage control surgery I think made an enormous difference and dealing with everything in parallel simultaneously to the surgery, I think has made an enormous difference to the survivability of some of those injury patterns.

The first triple amputee to survive was a Royal Marine called Mark Ormrod who actually flew back to Birmingham on the flight that I flew out on, on the same aircraft. He survived to an excellent quality of life, so I think that was the point at which the question, ‘Is it worth resuscitating, or is it worth causing these guys to survive with that severity of injury, I think he answered that question very firmly by getting back on his feet and walking his fiancé down the aisle within a year, on two prostheses, and that answered that question.

The Medical Treatment Facility at Camp Bastion. It included two operating tables and an ITU

The emergency department at Camp Bastion, © IWM (12BDE-2007-006-099)

Evasive Flying

Generally the pilots will hover overhead if there’s still rounds flying around, they’ll just circle overhead until they get the word that things are starting to calm down a bit and then they can come in safely. The MERT has taken a few hits over the last few years, small rounds, small arms generally, but it’s had a couple of close calls with rocket-propelled grenades, it’s again a balance of risks, how quickly you go in.

As a medic, I don’t want to overstate the risk. Certainly you lead a very cushy life compared to the guys on the ground, and you don’t usually get off the aircraft. The aircraft has armour plating up to about the 2’ height around you and underneath you, so you’re very well off compared to most of the guys.

Generally speaking if you’re landing at a hot landing site then the force protection will pile off the back and secure a perimeter of sorts, the RAF paramedic generally will run off and get a handover and triage the patients to come on board and what order and what way round, the casualties will pile on and you, as the doctor, are just sat there waiting for something to land in front of you, because it’s actually slows the whole process down if you start getting off and taking a hand. Generally you will sit there and the paramedic will triage things to come in and make sure that the worst injured will land next to you. As I say, you’re only there for 60 seconds or so.

You do have occasional close calls. You’ve got the Apaches generally escorting you, so you’ve got some top cover with some fairly beefy hardware, and so that tends to suppress any local threat. The pilots will do very much evasive flying, so they will fly at low altitude, throwing the thing around the sky to make it a hard target, and then they’ll bounce straight up to 3,000 feet above small-arms and RPG range, and they will use local cover a lot as well. So they’ll weave in and out of gorges and canyons and fly next to cliffs and things like that, which make you a difficult target to get an angle on. So they’re very good at that. And the pilots love it, they love throwing the thing around in the sky in a way that they’re not allowed to back here. It’s not for the weak of stomach but it makes you feel safer.

Part of the difficulty is more the environment than the flying. It’s the fact that they have to have all the doors open to point the weapon systems out of, so you’ve got the airstream rushing through the cabin and if you’re doing 120 knots you’ve got a 120 knot wind coming through the cabin. I was there in winter, and it was a particularly cold winter so there was a lot of chill to contend with. You had to try and keep your casualties warm but expose them enough to treat them.

The light could be an issue. If you were flying at night you’d have pilots on night vision, so you couldn’t have a lot of light ‘cause it made you an easier target and it potentially compromised the pilots’ sight so you were using blue light in the back of the cabin and the one thing that doesn’t show up in blue light is veins, so a lot of intraosseous cannulae at night.

The height of the casualty off the floor could definitely be an issue with intubation. If they were on a standard US or UK army stretcher, they’re very close to the ground and they’re very flat so you’d be kneeling on the floor next to them and you’d have to get low enough for your laryngoscopy, which could be quite a challenge if there wasn’t a lot of space. You’re kneeling, but you’re trying to get your head next to your knees to get a decent angle on the laryngoscope. The RSI pillow, which was a little wipe-clean fairly sold pillow, was almost our most precious piece of kit because that was the thing that would put the airway a little bit higher and give you the better laryngoscopy that you needed to do RSI in those circumstances.

Clinical examination and diagnostics are very hard with aircraft noise. The other end of that is diagnosing death can be very difficult and I think there were certainly instances where you would have stopped resuscitation and CPR sooner if you were on the ground, but because it’s very difficult to hear heart sounds and hear breath sounds anyway, you’re continuing till you’re on the ground and away from the aircraft noise before you actually diagnose death and stop. And I’ve certainly stopped resuscitation in the back of the ambulance from the landing site to resus, as well as diagnosing in the air where I felt confident in that decision. But bizarrely that can be one of the stranger challenges of that environment.

Special Forces

Special Forces have been obviously immensely active in southern Afghanistan. Those sorts of operations can have quite extended timelines to get back to Bastion so you sometimes need a medical resource closer to where they’re operating. That can be very small, it can be just a MERT that travels along with them in effect, or it can be something more substantial, and they have their own medical support unit in-house.

With the recent expansion of Special Forces, there has more recently been a need for an enhanced medical capability. 16 Air Assault Brigade developed an additional medical support unit which could provide an enhanced medical capability… [that] involved the Light Surgical Group who were a group of surgeons, anaesthetists, ODPs and others who were able to provide a medical facility which was whatever that operation required. So the heavy-weight option would be a single operating table, two critical care beds and up to eight ward beds, to support a larger operation, or to support a longer extended timeline away from other medical facilities. And that certainly has allowed them to operate more flexibility and further away from Bastion, in a way that they would otherwise only have done at risk.

Transferring an injured child to the hospital in Camp Bastion, © IWM (12BDE-2007-015-046)

After Afghanistan

As medics, if you’re part of the hospital squadron you might be there for six months, but generally as a consultant you’re an individual augmentee to that organisation, so you’re there for two to three months and you haven’t had as long away from home, although it can seem like a lifetime if it’s a very intense operation. You have a certain number of days of Post Tour Leave (POTL) for the number of days you’re away, and that’s very welcome to spend time with family and just decompress a little bit.

There have been attempts to provide some sort of decompression facility for the troops coming back and Cyprus and Croatia are the two that I’ve visited. Fortunately I’ve not had to spend a long time there, but I think the intention was for the troops coming back from experiencing that level of intensity and that level of violence and no alcohol for six months, that they would rather that they had their first few beers and their first bar fight in a contained environment, rather than back on the street and being picked up by the police and all the bad PR that might ensue. Fortunately with an  elevated rank and a shorter tour, you hopefully manage to bypass most of that and don’t spend more than 12 hours in those facilities before moving on… The last thing anybody wants when they’re half-way home is to stop!