Spoken from the Front Page 6
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.
July 2006
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.'<
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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.
And the rest of the day went just as badly. We were trying to assess the western side of Garmsir. Every time we stopped, we'd get mortared. They had us pinpointed every time. A nightmare. That's why it took so long. The colonel said: 'Stay there and we will get you some more resupplies.' And the Chinooks came down and dropped stuff, water and food, and we carried on. The mortar positions were dug in. They [the Taliban] would just appear and disappear and that was when we started to learn about the tunnel complex that they had. They were hiding vehicles because we were getting reports of vehicles one minute – we could see brand new Toyota 4x4s – and they would just disappear. In daytime. They weren't scared. Some of them had black turbans and red bands around their turbans. Anything with a black turban and you knew you were against more of a trained force – rather than something just thrown together. Anyway, we concluded there were large pockets of enemy down there. Nowhere near a thousand. But they were fast and well trained: very movable from one day to the next.
10 July 2006
McNab: The government announced that 900 extra troops would be sent to fight the Taliban. The move came at the request of military commanders because fighting had intensified in Helmand. The first of the reinforcements were due to arrive within two days, and the number of British troops would then be bolstered from 3,600 to 4,500. Senior defence sources denied, however, that the move was the direct result of the death of six British troops in a month. The announcement of more troops was made by Des Browne, who had taken over from John Reid as defence secretary. He denied that British forces had underestimated the Taliban threat and said it had been expected that insurgents would put up a 'violent resistance'.
14 July 2006
Flight Lieutenant Christopher 'Has' Hasler, DFC, RAF
It was at night and we were making a five-ship [Chinook helicopters] assault on two compounds in Sangin. We thought we had the element of surprise but somehow they knew we were coming. We were low on fuel too but we had support: three or four Apaches, Harriers, B1Bs [US B1 bombers], F15s or F18s, a Predator and more [all aircraft or unmanned aircraft]. We had aircraft stacked up from ground level to space supporting this one op. But we were holding so long – the commander was an Apache guy. I was the third Chinook in to land. But the two aircraft behind me had to peel off because of [a lack of] fuel. This made the troops very vulnerable – they did not have quite enough men on the ground to defend themselves.
So I was tail-end Charlie going in. By the time the heli in front of me was about fifteen feet off the ground, I was still at about a hundred feet and maybe a half K or a K behind him. The landing site was a dry riverbed. And then suddenly it opened up. There were three or four firing positions on each side [of the riverbed]. I saw an RPG go under and over the heli in front of me. He had landed now so I knew I had to go on. It was a long approach knowing you had to fly through this shit. You can't manoeuvre at all otherwise you'll fuck the landing. So it was just a question of 'slow, straight, steady'. The amount of fire was such that it backed down our nightvision goggles. I couldn't see much at all. It was so bright that the goggles weren't giving much [assistance]. I was mostly flying in on instruments. The aircraft flares were popping up as well and they really backed down the goggles too. There was a second of clearness where my goggles came back in and I saw we were about to land in some water. I managed to pitch up and over that but then I got into the dust cloud. I couldn't see anything. It was a bit of a rough landing and the guys were knocked off balance. We said before that the max we wanted to be on the ground was thirty seconds but we ended up being there for a few minutes while getting engaged. I was sitting there thinking, Oh, fuck, without much to do except look at the view. There were other places I wanted to be at that time. But we got the boys off.
We wer
e on the deck and tensions were running high. Then I started to take off but there were two troops still on who hadn't had time to get off. So we lifted off, but then someone shouted we still had two guys on so I held it there. But the guys had already decided they were going to go for it – leave, jump. I was going to put it back down but they just jumped, not knowing how high we were. We were probably twenty feet off the deck but we could have been 200 and they were going to go for it anyway. They just jumped – that was real balls. The radio-ops guy broke his foot landing. It was a communications problem [in the back of the helicopter], but these things happen.