Spoken from the Front (7 page)

The ODP and I started working on the guy with the serious
head injury and at the back we left the paramedic to assess
the two who were conscious. He very quickly did an assessment
and he basically gave me the thumbs-up, which meant
their injuries were nothing too serious – and we could
concentrate on dealing with the casualty in front of us, as he
was the most seriously hurt. He was there on a stretcher. At
the same time, we told the flight nurse, who was in comms
with the pilots, that, as soon as we could, we'd get the pilots
to send a message back to the hospital confirming how
serious it was. We were also letting them know how serious
it was. We can categorize our injuries in various ways. At that
stage, we were using the T1, T2, T3 system. T1 was critical, T2
was serious, T3 was minor, walking wounded. This guy was
T1 – and the other two were T2s. If someone is requiring a
stretcher to move, they are a T2. The flight time from Musa
Qa'leh to Bastion is approximately twenty-five minutes. As
soon as the pilots have done their stuff and got us up there to
fifteen hundred feet – which is usually within twenty seconds
– we get some basic light on.

During the flight back, this guy was unconscious, or had a
significantly reduced level of consciousness. I was concerned
that he had a major head injury. You can't do anything about
the original injury: if there is any brain damage it has been
done by the bang on the head. But what you want to do in
serious head injuries is to prevent further damage. And the
best way of doing that is to be sure the patient has enough
oxygen, enough blood flowing around his system. And the
best way to ensure that is to anaesthetize him and ventilate
him in the back of the cab. These are techniques that normally
take place in hospital but we're finding that they help an
awful lot to reduce morbidity and disability at the end of
the day.

A ventilator is essentially a life-support system. You
have to give the patient drugs to render him completely
unconscious and 'paralyse' him. This patient had a drip in
already [when the MERT took him over] so we gave him his
drugs through the drip. The paralysing agent worked: it takes
about thirty seconds. All the time we were giving him oxygen
and 'bagging' him by hand. The ODP did a manoeuvre to
stop him regurgitating while he was unconscious. Then we
tried to intubate. This is quite a delicate procedure, even in a
hospital with good light and with a patient not moving
around. Although the patient was paralysed, we had a whole
helicopter moving around and juddering. And you have
actually got to put a tube the diameter of your finger, and
about a foot long, through the vocal cords of the patient. So
my target was probably about 10mm and the tube diameter
was about 8 mm: you have got to be accurate and it's a
relatively skilled procedure. But it's a potentially life-saving
procedure – the guys who need it wouldn't survive the
twenty-five minutes back [to Bastion] without it.

Then the ODP assessed the patient for further bleeding,
external bleeding. He couldn't find much but the patient had
a broken right leg – it was pointing in the wrong direction.
There was no bone sticking out but the leg had an extra
'joint', which it shouldn't have had. The patient was covered
in crap – mud, stuff like that. Everything was happening
simultaneously. Once we had secured the airway, we didn't
want to lose it. Then we used blades to slit his clothes off to
expose his chest, making sure there were no injuries to it. We
use blades with a curved bottom so you can't stab the patient
by accident: they're childproof, basically. I was concerned
because there was no obvious injury to his chest but we were
not ventilating very well. One side of his chest was not
moving and I thought, because he had been in a blast
situation, that he might have blast lung, caused by the
pressure wave of an explosion. An explosion can burst a lung.
His abdomen had no obvious injury. It was soft, it was not
expanding and there was no bleeding into it. It was just his
leg.

You can lose a lot of blood from a broken femur and he was
quite shocked so I was assuming he was losing blood from
his leg internally. And once we had checked there was no
reason why the ventilation was not working – i.e. the tube
was in the right place – I decided, technically, to operate.
Basically, that meant making two holes in the side of his
chest.

He was unconscious, he was sedated, he couldn't feel anything.
So I put two holes with a big scalpel blade mid-way
down both sides [of his chest]. Then I could stick my finger
into his chest, making sure there was no obstruction and
making sure that the lung was up. And the lung was down on
one side because I couldn't feel it. As soon as I stuck my
finger in, the next thing I could feel was a 'sponge' and that
was the lung. The right lung had collapsed. I was releasing
any trapped air that had caused the lung to collapse. And
gradually it came up and the ventilation became easier. He
was obviously responding to that treatment. Only a senior
clinician could have done that. And that is the sort of intervention
that putting a senior clinician on the MERT can
achieve. Probably only five per cent of all casualties require
that intervention so the argument [from critics of the MERTs]
is: why are we endangering the life of a senior clinician, a
valuable asset, to help such a small number of people?

I would say a valuable asset is only valuable if it is used
appropriately. Otherwise it becomes an expensive ornament.
So unless you're going to put them out there, they can't
help. And each patient saved is a British soldier who is now
back with his family at home. His injuries may be severe,
but he's back with his family. Anyway, we did all this
[treatment] in twenty-five minutes because, after that, we
landed in Bastion.

The hospital HLS in Camp Bastion is approximately five
hundred metres from the front door. When the Chinook
arrives, bringing in casualties, military ambulances are
already waiting to ferry the injured to the emergency department.
Everyone knows how many casualties are on board
because of the number of ambulances waiting: one per
casualty. The next few minutes can be the most dangerous for
the casualties, moving them quickly from the back of the
Chinook into the ambulances without causing them further
harm. Usually there's no time for the Chinook to shut down,
which means the rotors are still turning and the engines are
still pushing out the super-heated exhaust fumes. Add to this
mixture the darkness and the adrenalin that's running high,
and it's easy for mistakes to happen: intravenous lines can be
pulled out, airway tubes become dislodged, even stretchers
dropped.

In most cases, the casualties are loaded into the ambulances
without too much delay. The ambulance crews are well
practised by now. On the first few occasions, when the crews
sometimes drove up too close to the Chinook, the hot exhaust
would melt the blue lights on top of the vehicles! I accompanied
the most seriously injured casualty in the back of the
ambulance with the ODP; the other members of the MERT
escorted the remaining casualties. Within a few seconds, we
were at the emergency department. The trauma teams were
awaiting our arrival. They had been waiting a while, and
were already aware of the number of casualties and their
injuries. The last link in the chain for the MERT is to hand
over the casualties to the awaiting trauma teams, one team
for each casualty. Clinical information is handed over quickly
and succinctly. We use a recognized system, which takes
thirty seconds, and as soon as it's complete, the trauma team
descends on the casualty simultaneously assessing and treating
the injuries. This is a well-practised drill.

The role of the MERT is now complete; it has provided
that link from the medic on the ground to the emergency
department in the field hospital. It has handed over live
casualties.

The trauma teams quickly confirmed the serious nature of
the casualty we had handed over. The head injury was the
most serious, and required emergency neurosurgery. At
this time, in 2006, there was no neurosurgery in Afghanistan.
This casualty needed to be evacuated to Oman. The transfer
was the responsibility of the embedded RAF critical-care
transfer team. These teams are constantly on standby at
Camp Bastion to transfer the critically injured from the
hospital to other locations around the globe, if required.

The transfer went according to plan and the casualty
arrived in Oman within three hours. He underwent neurosurgery
within six hours of wounding. Six hours may sound
like a long time, but even back in the UK this time line is often
not possible. The fact that this is achievable in Afghanistan, in
the middle of a war zone, is a testament to the medical system
and the people who run it. No one part is more important
than another: from the medic on the ground to the MERT, the
hospital at Bastion and finally the transfer team of the RAF,
it's a chain. And any chain is only as strong as its weakest
link.

In this instance, the casualty survived, despite very severe
injuries, and he is now back with his family. The two other
soldiers injured with him underwent immediate surgery at
Bastion and were evacuated back to the UK, where
eventually they made a full recovery.

Colour Sergeant Richie Whitehead, Royal Marines

I had to take a last-minute visit to Garmsir, down south. They
needed a forward air controller – JTAC [joint terminal air
controller], as they call it. And there was none available
because 3 Para, in their wisdom, had taken everything and
everyone with them for their ops. I was in the Ops Room and
they were short [of an air controller]. I said: 'Everyone should
be able to do this. We've all had basic training of being able to
call in air if needed.'

And someone said: 'Can you do it?'

I said: 'Of course, I can.'

He said: 'You've got half an hour.'

I went and packed my kit. We drove down through Nad Ali
and via western desert in WMIKs [armed Land Rovers]. It
was a big patrol and it was with an OMLT [operational
mentor liaison team]. The chief of police [Afghan National
Police] from Garmsir had rung up the colonel, the head of the
provincial reconstruction team and said: 'Look, there are a
thousand Taliban down here about to attack us.' We knew
early on that whatever number you were given, you divide it
by three at least, because the Afghans do exaggerate just a
touch. The colonel wanted to know the true picture – the lie
of the land – so he sent some people down to see what was
actually going on. This was at the peak [of the 2006 Taliban
resistance] because the summer was a lot busier than the
winter months. It was hot, 60°C plus on some days. It was
horrendous. There was a captain in charge of us. Fourteen
headed down in four wagons, all WMIKs. Off we went for
what was supposed to be twenty-four to forty-eight hours.

But we came back ten days later because of different things
that were happening. We had to have resupplies down there.
We got mortared, shot at. We called in Apaches on different
targets that we had. We were literally one of the first patrols
to Garmsir. We were the 'Dirty Dozen', as we called ourselves.
We were there to sneak about and have a look and see
what was going on.

We were all senior men. There were a few warrant officers,
one colour sergeant, a couple of sergeants, two corporals, and
there were a couple of officers and we were just like: 'We're
too old for this. What are we doing?' We were just thrown
together.

During the drive down across the desert, we were trying to
keep out of the way of different villages. The drive took six
to eight hours. We took four vehicles from the Afghan
National Army with us. We were mentoring these people as
well, so we said we'd take them with us. So at night I would
put them in a harbour position, a good old-fashioned triangle
harbour position. We would be in a small triangle in the
middle and then we would stick them on the outside. One,
for protection, and two, to mentor them on what a harbour
position was all about. We slept in the wagons, or next to the
wagons in sleeping-bags.

On one of the very first nights, these lads came running up
to us with the interpreters, saying they'd seen someone in the
dead ground. And they wanted to go and investigate. We
used to take turns to stay up just for questions like this. So,
me and my mate said: 'Take five of you and don't go out any
further than you can still see us, and then come back.' And
this one bloke was notorious for being quite a switched-on
kiddie. He was younger. Whereas the others used to group in
the evenings and smoke, just like a Cub Scout evening, this
bloke actually did want to learn and he wanted to go places.
He disappeared and went a little bit further, then he went out
of sight. We were watching him through our night goggles
and he just disappeared. And I looked at my mate, Tommy,
and I was like: 'This is a mistake.' He'd gone. We'd lost him.
Then half an hour later he appeared about a K to the left –
we'd got our thermal imagery out – and walked back in. A
perfect patrol. I said: 'Where have you been?'

He said: 'I saw them [the Taliban]. I just wanted to follow
them: they scattered off this way. There were eight of them.
They were watching us.'

I said: 'You only went with five men.' So we gave him a bit
of a telling-off, and we said: 'Where was your map? Where's
your compass?'

He replied: 'I haven't used it.' And he had just walked out
a good two K in the desert, turned left, done a big box around
with no compass. His local knowledge and his whole background
of tribal warfare were amazing. So he came back in
and that was that.

Because we knew we were being probed and looked at, we
called in air. He [one of the pilots] said there were about eight
Taliban and we could see vehicles out on the horizon. There
was a B1 bomber in our area. We decided, for a show of force,
to ask him to drop a few flares. A show of force, that's all
we wanted. We gave them our grid so that they didn't
accidentally drop anything on it. But he dropped the flares all
over our harbour position. So now we were lit up at three in
the morning, like a circus. He'd got the grids back to front. So
we had to get up and move quickly because we had
completely given our position away.