by John Nichol
It was a philosophy that, to begin with, was at odds with prevailing military thinking. Military medicine was going through one of its all-too-frequent periods of retrenchment. With Saddam supposedly back in his box, this was seen as a time to adjust to the post-Cold War world that had emerged from the collapse of the Soviet empire, to cash in the so-called ‘peace dividend’. Defence needs were reviewed, spending slashed, regiments merged, redundancies demanded. Just as they had been in the aftermath of the First World War three quarters of a century earlier, and then again after the Second World War, the medical services took a major hit. Among the casualties were the specialist military hospitals, all of which were phased out, and hundreds of medics, who were made redundant or relegated to the reserve list. It was a short-sighted policy that would have a disastrous effect on the all-embracing nature of the military medical services for years to come.
The shortcomings of this policy of wholesale axing and downgrading of military medicine were soon exposed. Events in the Balkans revealed that ‘history’ had not ended – as some over-optimistic western political philosophers argued5 – and nor had war. War was not over but changing from being played out on a world stage to a localized one. Conflicts would be smaller but, given the historic enmities involved, more vicious and more bloody than ever, and laid-off medics were wanted again to deal with the suffering. Not only that but the nature of these conflicts demanded focussed medical services. The time was right for Hodgett’s radically reorganized casualty system.
It swung into action with the NATO military intervention in Kosovo in 1999, a peace and policing action to curb Serb-inspired ethnic cleansing. The countryside was mountainous, rugged and remote and, as a consequence, evacuation slow and unreliable. For the first time, armoured field ambulances going out to casualties, whether military or civilian, were tooled up to the same high standard as those on the streets of Britain. In the back, instead of just bare racks for stretchers and a few bandages, were defibrillators, suction equipment, splints, drugs, monitoring machines, plus the paramedics trained up to use them. The field hospital had its own casualty unit, with triage area and specialist resuscitation rooms. Its first patient was a local man with broken legs and a smashed chest who had been beaten up with an iron bar and left by the road to die. Friends brought him in, and he lived.
Over the next few months, more than a thousand cases were treated and two hundred and fifty operations performed, more than half of them on civilians. Military doctors and nurses found themselves dealing with injuries unseen by British medics for almost a generation – not since the Falklands, in fact. There were gunshot and stab wounds to deal with, as well as the horrendous consequences of mines, grenades and cluster bombs. A fourteen-year-old boy lost a hand and a leg after picking up a cluster bomb. A six-year-old threw a stone at a mine, which exploded and hurled shrapnel into his legs and abdomen. A farmer trod on a mine when crossing his own field. All these were the rotten fruits of war. But there was routine work to do as well, such as injuries from road accidents. Unusual for a military hospital was a servicewoman’s acute ectopic pregnancy.
The doctors learned to improvise. When a local teenager needed an emergency operation to amputate both his legs, it was discovered that one surgical saw had broken on the previous patient and the only other one the unit possessed was blunt. A carpenter’s hacksaw, suitably sterilized, did the job. Then, when a heavy weight was required to put a pelvic fracture in traction, a dumbbell was lifted from the soldiers’ gym.6
Decision-making was speedy because, as a matter of policy, the casualty department was manned by surgeons and anaesthetists of consultant status rather than by junior doctors. The result was that seriously injured patients could be on the operating table within fifteen minutes of coming through the hospital door, something that was almost unheard of in civilian hospitals, where the ranking consultant is generally at the end of the chain, not at its start. For Hodgetts, the lesson was clear and a new model established – ‘seniority saves lives.’
The knowledge gained from all this activity was invaluable. This hard disk of experience – the ‘institutional military medical memory’, to use Hodgett’s phrase – would be there to draw on in bloodier conflicts in other regions in the years ahead. What saved lives in the backstreets of Pristina, the Kosovo capital, would in the future be replicated in Iraqi villages and on the barren plains of Afghanistan. Hodgetts could see that, at the very end of the twentieth century, the nature of conflict was changing, and medics would have to adapt to these new realities. For one thing, their basic brief would be wider than ever before. In the Falklands, almost all the casualties the doctors dealt with were military personnel from either side; the same applied to the first Gulf war. But, in Kosovo, it was civilians, particularly children and old people, who were increasingly in the firing line, and not accidentally, as the result of being caught in crossfire, but as the deliberate targets of attacks and genocidal mass killings. Injuries were rarely minor. A common terror tactic was to throw a grenade into a house full of people, and the result of such unconscionable violence in a confined space was that the wounds of the few who survived were likely to be extreme.
The deaths of youngsters could be horrible to witness, even for the likes of Private Peter Keegan, a combat medical technician with a Territorial Army unit of the Royal Green Jackets. He was an experienced medic who’d served in a crash team in the Balkans before and had seen his share of horrors. Life’s hardships were second nature to him – he had decided to make a career in medicine when, aged thirteen, he had found his father nearly dead from a whisky and pills overdose. But what he now witnessed would shake him to the core.
Within hours of arriving in Pristina for a six-month tour, he and his ambulance crew were called to an area of waste ground where two children, a brother and sister, the boy nine, the girl twelve, had been killed by a mine. The details of the scene were disturbingly unforgettable. ‘Her hair was curly, his brown and in need of a trim. The mine had exploded between them, and each had one side of their body blown off, from head to foot. The curious thing was that the remaining half looked normal. The little girl was wearing jeans and a little summer top, the boy a T-shirt and trainers. It was a bizarre scene. I expected to see body parts scattered around, but there was nothing there.’7 As he bagged the remains of these two children, Keegan felt saddened by the sheer pointlessness of it all. ‘I tried not to let it affect me personally, but these are the realities you face as a medic.’ He took them to the overflowing mortuary in a local hospital. ‘There were so many bodies. The fridges weren’t working because there was no electricity, and the stench of rotting meat was beyond imagination. It was a real eye-opener for my first day in Kosovo, but worse was to follow.’
When he got back to his company headquarters, a fellow soldier took him down into the cellar. The building had previously been occupied by Serbian police and had an underground torture chamber. ‘There were shackles and chains on the walls, blood all over the floor and human heads stacked in a corner, half a dozen of them, all of young men. We found a sword and handed it over to the United Nations police.’
More than half a century earlier, British medics had had to confront the unspeakable horrors of the Belsen concentration camp in Nazi Germany when they were called in to nurse the survivors after its liberation. Now, one of their successors was facing sickening evidence of yet more genocidal atrocities in the very heart of a now supposedly civilized Europe.
*
A dozen years after his thrilling 1991 dash towards the Iraqi border, David Rew found himself back in the same place, suffering inside a suffocating NBC ‘Noddy’ protection suit. A second Gulf war was about to explode. Like the rest of the world, Rew had watched on television the terror attack on the Twin Towers in New York in 2001, and he had known then that there would be an accounting to come. In the civilian hospital where he worked, he expressed his instinctive view that another war was on the cards. ‘People looked at me very strangely,’ he
recalled.
The direction the American-led retaliation took did surprise him, however. Afghanistan, home to Al Qaeda and the Taliban, was an understandable first target. But then the Bush administration turned its big guns on the old enemy, Saddam Hussein, once more. The opinion Rew had formed of the Iraqi dictator back in 1991 was that he was a paper tiger whose only concern was personal survival. He was sceptical about claims that Saddam was about to unleash weapons of mass destruction. Nonetheless, in 2003, here he was back at a field hospital in northern Kuwait, hurriedly throwing on his IPE (Individual Protection Equipment) kit, pulling on the mask, checking the colour of the chemical-detection paper stitched to the outside – and hoping not to collapse from heatstroke. ‘We were in and out of the gear regularly, and had it on for a full five hours on one particular alert. I had to treat thirty-two people for heat exhaustion. In many ways, the equipment was worse than the threat!’
The signal for an incoming Scud missile was the rhythmic sounding of a car horn, and the camp was so nervy that, more than once, the warning beep from a reversing lorry sent everyone into a panic. ‘Gas! Gas! Gas!’ went up the cry, and they would all rush to mask up. Bob Steer, one of the many Territorial Army medics called up, was told in pre-deployment training that twenty minutes was the maximum period a body could stand being in a full NBC kit. ‘But on our very first day I sat in a trench with mine on for something like six or seven hours. Scuds were supposed to be on their way. We were told one had hit another camp and a yellow mist had exploded out of it.’
But there were lighter moments too. At Camp Coyote in Kuwait, where a two-hundred-bed tented hospital was set up, Philip Rosell, an army surgeon, was out jogging, wearing ski goggles to keep the dust out of his eyes. From a billet he passed came the wonderful jazz strains of a Blue Brothers number, but it was not a record that was washing out and over him but the real thing – live music. Military bandsmen had arrived to take up their fighting role as stretcher-bearers and medical orderlies but were keeping their hand in with a jamming session. The insane incongruity of it all tickled him. ‘I was getting my very own blues concert while running in ski goggles in a war zone – such a strange sensation.’ He felt as if he had dropped into a scene of madness and mayhem from M*A*S*H.
The medical set-up for this second bite at Saddam Hussein embodied all the advances and alterations in approach that had been proposed and debated over the past decade. The consensus was that the vast majority of soldiers who died in combat would do so within ten minutes or so of being injured, their wounds so severe they were unsaveable. For the rest, there was generally a window of two to three hours in which they could be treated – for the bullet to be removed or the haemorrhaging lesion to be stitched. So surgeons from a wide array of disciplines were ordered into forward positions, and the first field intensive care units were set up under canvas so that even complex cases could be handled close to the battlefield and not only at some remote hospital far behind the lines. Each forward surgery team had a dozen light lorries and could pack up and move on to a new location at great speed. The first Gulf war had shown that it was perfectly feasible for the battlefront to advance sixty miles or more in a day, and the medics had to keep up. They also had to be flexible in their approach. If casualties could easily be evacuated, then their job might simply be to clamp an artery or bandage an abdominal wound and leave it to the surgeons at the main field hospital to do the complex work. But if they were in remote areas and sandstorms grounded the casevac helicopters, they had to be prepared to handle difficult cases, for days on end if necessary.
For David Rew, the developments were historic. ‘We were taking a quantum leap. The old-style field hospitals were designed for quick and dirty surgery. Now we had forward positioning of very high levels of skill and equipment to give the guys with major wounds the best chance of survival.’ It was the proper response to a new type of warfare. Until the late nineteenth century, wars had usually been fought out like board games between opposing sets of combatants on a small battlefield. The twentieth century saw total war between nations, with the full engagement of large armies and civilian populations. Post-Cold War modern warfare, however, tended towards small, geographically precise engagements and policing actions, complex in structure, often with more than two opposing sides and including irregular militias and small groups of insurgents.
For medical planners, this was a new world. ‘You no longer get a whole battalion wiped out from an artillery strike, as you did in the First World War, or twenty thousand casualties in a day on the Somme. Or even a mass attack such as D-Day. Today’s battlefields are widely dispersed, with relatively few individuals in any one place and generally taking injuries in small numbers.’ But the greatly enhanced power of modern weapons, particularly in deliberately targeted anti-personnel explosives such as mines, IEDs and suicide bombs, meant the wounds were likely to be serious. ‘So, whereas, before, we as medics had to do the minimum for the most,’ Rew explained, ‘now it was a case of doing the maximum for the few. If a vehicle is blown up, there are three or four bad casualties, who need instant, intensive treatment. We’re taking incredible expertise into the field now, and the expertise is not any one individual surgeon but multiple surgeons with different skills, A & E specialists and anaesthetists.’
Among those who found themselves moving further to the front than they had ever expected was RAF Flight Sergeant Frank Mincher, a trained casualty nurse. He took his place on a rescue helicopter with a new-fangled Immediate Response Team. It meant completely rethinking how he did his job. Procedures usually carried out in the calm sanctuary of a hospital ward would have to be done in the cabin of a fast-moving Puma. In the air, he put a drain into the chest of a badly hurt Iraqi. He, like most other medics in the second Gulf war, cut his teeth on injured and sick civilians, because there were so few military casualties. The American advance was rapid, the resistance slight. Baghdad fell in little more than a fortnight.
The British contingent’s role was to secure the southern section of the country around the city of Basra, and Tim Hodgetts, now an RAMC colonel, was in the back of a blacked-out ambulance following the troops across the border into Iraq. They were better equipped for the job than any medics before them had ever been, but he still felt exposed. Though he had access to a mobile X-ray machine and an ultrasound scanner, the nearest CT scanner capable of giving the best picture of internal injuries was hundreds of miles away, and he had no neurosurgeon or burns specialist. As for his two surgical teams, they could easily be swamped by a run of casualties. He remembered feelings of frustration and apprehension. Just staying alive was an effort in the desert, with the heat, the restriction on water, and food out of army-issue packets, but he and his men had to be able to perform to the highest standard, however austere the conditions.
In the event, just as with the first Gulf war twelve years earlier, the fighting never reached the intensity that had been feared. There were notable acts of bravery, however. Trooper Chris Finney of the Blues and Royals, just eighteen and a soldier for less than a year, was driving a Scimitar armoured car in action against enemy armour when it was mistakenly attacked by coalition fighter planes. He escaped, but then turned to see that his gunner was trapped in the turret. Finney went back through flames, smoke and exploding ammunition to rescue his wounded friend and to get him away, as the planes roared in, spraying cannon shot at him for a second time. He also tried to save the driver of another armoured car, despite now being wounded himself. Another soldier was saved by his Kevlar helmet. His Land Rover turned over and fell in such a way that only his helmet stopped it crushing him. Incredibly, it took the weight of the vehicle as he lay underneath for nearly an hour waiting to be rescued.
And there were deaths. Kosovo veteran Peter Keegan, with experience of handling the dead, was given the job of mortuary technician and received his first body shortly after the invasion began. ‘I unzipped the bag, and the whole of his body was burned beyond recognition. But then I saw a tat
too on his leg and I recognized him as a mate I served with in Kosovo. It was a shock, but this is what you see when you are a medic.’ Andy Poole, who had served in the Falklands, was another mortuary worker, and recalled the sight of burnt and headless bodies from the fighting. Amputated legs and arms were also brought to him to be tagged and bagged.
The conquest of Basra and the surrounding region was relatively trouble-free, though not without moments of dread. One ambulance driver remembered approaching Basra airport, where serious opposition was expected, in the dead of night. In the back of his mind was the thought that his ‘wagon’ wouldn’t stand a chance if it was hit by a rocket, and nor would he. Certainly, the red crosses painted prominently on the sides and roof were going to offer no protection. Frank Mincher was helicoptered into the scene of a ‘friendly fire’ incident and, though an experienced A & E nurse, shuddered at the awfulness of the injuries he saw that day. ‘I’d seen nothing on that scale before.’
Generally, the most harrowing task for the medics was dealing with the terrible injuries sustained by children. Keegan transferred to hospital work and was moved by the plight of a little Iraqi girl, with lovely dark skin and beautiful big brown eyes, who had stood on a mine. ‘She had lost her left leg below the knee and was in a lot of pain. I talked to her as I changed her dressing, and a little smile of gratitude came on to her face. I found that very rewarding. It made my work as a medic worthwhile.’ A corporal driving back to the hospital found his way blocked by a group of distressed local people around a car. He got out and saw the limp figure of an eight-year-old boy on the bonnet, with gunshot wounds in his stomach. His father called frantically to the medic: ‘Help my son, please help him.’ It took half an hour to reach the hospital but, to the soldier, sitting with the boy in the back of the blisteringly hot ambulance, and watching as this little life slipped away, time was achingly slow. ‘His father kept asking me, “Is he dead? Is he dead?” ’8 But there was nothing more the soldier could do.
