by John Nichol
It was a world she was increasingly anxious to return to. When she began her second tour, she found the experiences of the first weighing heavily on her. What she had already seen, far from making her blasé, had made her more alive to danger.
I was much more worried going on that second deployment. The threat levels were so high. But it was also that I had decided I was going to leave the RAF at the end of it, and I couldn’t stop wondering if I was tempting fate. Every time I got on board a helicopter, I was aware that this might be my last flight. On my way into a hot spot, in my mind I’d be going over the chat I’d just had with Mum on the phone. I’d think over everything we’d said, and I’d be glad I’d told her I loved her. And it would be going through my head that it might be the last conversation I’d have with her, ever. By then Mum knew the sort of thing I was getting up to. I’d won an award as Paramedic of the Year [given by the Ambulance Service Institute] for that operation at FOB Robinson, and it had made her the proudest mum in the world. But it also meant she found out precisely what had happened and how dangerous it had been. And that made things worse. I would worry about my mum worrying. Strange, you’re the one in the firing line; but it’s the people back at home you’re most anxious about.
Her feelings intensified after the Taliban brought down an American Chinook near the Kajaki Dam. ‘Thankfully, we didn’t have to fly into the area to assist, not that I didn’t want to. But I am left feeling really scared at the thought,’ she wrote in her diary. It brought home to her that one lucky shot for them – unlucky for her – was all it would take. ‘The bastards have found something that can get us.’ The thought nagged away at her. ‘It’s my last tour, but you always read stories of people getting killed within their final few months of being in the forces. I don’t want to be one of them. I’ve got a whole life ahead of me yet. Felt quite emotional. Mum and all the family must be having kittens at home. Thank God I’m leaving soon. I can’t put everyone through all this worry over and over again. Nor me, for that matter!’
Rachel did make it home, back to Swansea, where she could get those ‘killer heels’ out of the wardrobe, be happy-go-lucky again, the life and soul of every gathering. But she would never be the same girl who first went to war. ‘Young Rachel’, as she now thinks of herself when she joined up, had matured in a way that set her apart from others who had not seen what she saw. She didn’t talk a lot about her experiences, reasoning that her friends ‘probably wouldn’t want to hear about them and don’t need to know. Some of them still don’t really believe it. Well, they do, but they find it difficult to believe that it was me who’s been in a war zone, in combat, held a man’s head together. I’m proud of what I did, and I’d do it all again if I could turn back time. But I think I made the right decision to leave when I did.’
*
For paramedics such as Rachel McDonald, the principal job was to get casualties from the front line to the hospital alive. It fell to them to preserve a life to give the doctors a chance to save it. Lieutenant Colonel Paul Parker, a senior surgeon at Camp Bastion, was careful never to rush to his patients. He would be alerted that the emergency medical team was in the air but, rather than dash to the operating theatre to wait, he preferred to use the time to go to the mess tent for a bacon sandwich – because he knew the odds were that he and his team wouldn’t get another chance for many hours. ‘I waited until I heard the helicopters returning. I knew it took between seven and ten minutes to get the patients off the Chinooks, into the ambulance and across from the landing site. So you count five minutes, and then you put on your gloves and your apron. It was sensible given what lay ahead. People make the mistake of thinking emergency surgery is a sprint but, in reality, it’s a marathon, and that’s what you have to prepare for.’3
In the Second World War, it was established that there was a limit to how long surgeons could operate before they were so exhausted they needed days to recover. The precise number of hours varied with the individual, but that everyone had a ceiling – or a ‘wall’, in marathon terms – was indisputable. This was one thing – perhaps the only thing – that had not changed in military medicine since the 1940s. If the men wielding the scalpels didn’t pace themselves, they would make mistakes.
As it was, their work demanded extraordinary calmness and maturity. For Parker, this was why surgeons of his seniority had to be as close to the front line as possible. ‘The twenty-first-century battlefield moves very quickly, so we need surgical teams to move forward with the battle. And they have to be the most experienced surgeons.’ That had not been the case in the Falklands, where the bulk of the surgical team were young men who had yet to complete their formal training. There had been just one surgeon and one anaesthetist of consultant status; the rest were at various stages of experience and qualification.
In Iraq and Afghanistan, this changed, and with good reason. ‘The front line is not the place just for junior doctors,’ Parker said, ‘because sometimes you have to make a decision not to operate, sometimes you have to let people die.’ Stark choices were unavoidable. ‘If a casualty has a gunshot wound that goes in one side of the head and out of the other and he’s unconscious and totally unrousable, mortality is virtually 100 per cent. You could spend a lot of time on the operating table trying to suck out the dead brain and save him, but at the expense of someone with a spleen or a liver wound that is treatable. It’s a senior decision to say, right, move this chap to one side, under the care of a padre with some morphine.’
In the end, everything was rationed, even life itself. ‘If you’ve only got twenty or thirty units of blood and you have someone who’s been shot through his liver and is almost dead, then you could use up half your supply trying unsuccessfully to save him. That’s the decision you have to make sometimes: life or death.’
Playing God was never easy. At the very least, the stress of witnessing life at its rawest and death at its ugliest could become too much for the medics, and even the steadiest and most seasoned of hands was known to lose its grip from time to time. Parker’s colleague, Lieutenant Colonel Philip Rosell, an orthopaedic surgeon with a twenty-year career in military medicine, had what he called his ‘wobbly’ moments. He was making instant clinical judgements that, in civilian hospitals at home, would have involved lengthy discussions between whole teams of specialists – whether or not to amputate a man’s arm or leg, for example.
In the tented hospital at Camp Bastion, it was often his call alone whether a limb would be lost or not. ‘I was very aware that I was making life-changing decisions. But, yes, I did have to cut off quite a few legs, and I got fed up of doing it at one stage. Every time, you’re dealing with a broken body or a shattered life. That gets to you. I was pissed off at seeing young blokes coming in with limbs hanging on by bits of tissue. What was it all for? I just didn’t want to see another broken body. I was a long way from home and I’d had enough.’4 The feeling passed. With a good night’s sleep, a quieter shift, the stress of that responsibility – though not the responsibility itself – lifted, and he was back on track, mending those broken boys, doing, as he put it, ‘the best job any military surgeon could ever hope to do’.
On the table one day he had a young Special Forces soldier who’d been hit by three high-velocity rounds – one through his pelvis, one through his hip joint and one through each of his legs – and was going down fast. ‘By the time he reached us he was already almost clinically dead. We gave him more cardiac massage in the operating theatre, because his heart stopped again. We opened his belly and clamped the aorta to switch off the blood supply. Though that in itself was pretty dangerous, it allowed us to take a few moments to consider what to do next.’ Rosell quickly ran an expert eye over this body, with its mass of catastrophic wounds, each one of which could be fatal on its own. Where to start? The abdomen was open, the pelvic vein was punctured, and he reckoned it would take an hour of surgery at least, possibly two, just to stop the bleeding there. Both legs were tourniqueted. The clock was tick
ing, and a life was ebbing away. A decision had to be made. ‘I’m looking at his legs, and they are both perfectly salvageable injuries, but we’ve got a dying patient. We released the tourniquets, and one leg was bleeding so heavily I had to put the tourniquet back on straightaway. The other one was just oozing a bit, so we could leave that. I said: “That leg we’ll save; the other one we can’t.”’
It was a practical response based on a straightforward calculation of time. To have operated immediately on the heavily bleeding leg would have delayed the lifesaving surgery on the soldier’s abdomen, and the abdomen wound was the critical one and had to be dealt with first. But that meant it would be several hours before Rosell got to the tourniqueted leg, and the simple clinical fact was, after four hours with its blood supply blocked off, a leg was unlikely ever to work again. After six hours, it would be beyond any surgeon’s skills. This, as ever, was the downside of tourniquets, though such difficulties were far outweighed by the benefits. Binding a heavily bleeding limb as tightly as possible on the battlefield bought time, saved a life that might otherwise be lost there and then. The Toms swore by their tourniquets as a first aid, not just a last resort. Some went into action with them already in place, one on each arm and each leg. If they were hit, they needed only to tighten it themselves, without wasting time. The seconds saved could be vital. More to the point, knowing the tourniquets were already in place boosted their morale and encouraged their faith that, however hot the encounter, they had done all they could to up their chances of coming out alive.
Tourniquets were not, however, ‘magic bullets’; they could not do the impossible – any more than Rosell with his scalpel could. Faced with this soldier with multiple injuries and time running out, he knew he had to cut his losses. ‘It was a really hard decision because, by leaving the leg for now, he would almost certainly lose it. But all we could do was save his life and then see what we were left with.’
Copious amounts of blood were needed for this patient if he was going to have any chance at all, and an emergency call went round the camp for donors. There were two hundred volunteers on permanent standby, already typed and cross-matched for emergencies like this. They stopped whatever they were doing and came at the double to the blood bank to be bled. In the end, the medics tranfused fifty pints into him – more than the total normally held in reserve in some hospitals back in the UK. His entire blood supply was renewed six times, which was an extraordinary achievement. Only in a war would such devastating wounds have to be dealt with, but only in a war were there the concentrations of fit, young and willing people whose plasma could be tapped at any time to provide the means of saving a life. And it worked. The soldier (minus his one leg) survived, thanks to emergency, selfless medicine of the highest order, involving not just doctors and nurses but the entire service community at Bastion.
Rosell knew how incredible this result was. ‘He was effectively dead on his second round of cardiac massage, but we used every facility on him and he eventually got through it. It just couldn’t have happened a few years ago.’ These were people playing at the very top of their game, using all the collective experience gathered in long-distance conflicts going back to the Falklands, to D-Day and Dunkirk, but refined most recently in Iraq.
The Gulf was where, for the first time, a fully fitted intensive care unit (as opposed to an aid post) had operated in the field. Bastion went even further. Rosell reckoned that the emergency care provided in that tented hospital in the middle of a desert, with lights hanging from the canvas roof, plastic sheeting on the wooden floor and barely enough room for the drip stands, was better than in many NHS hospitals. Technology was often5 the very latest – CT body-scanners and digital X-ray machines that could give an internal image of injuries in seconds. It was a whole world away from the grimy meat-packing warehouse in Ajax Bay, with stretchers on the floor and a tea urn that doubled up as a sterilizer for surgical instruments, where the Falklands casualties had been treated. And things were improving all the time. Paul Parker had needed to wield a hand-saw to amputate Sergeant Major Andy Stockton’s arm back in 2006. Now he was performing the same operation with a power tool. The medics boasted, with good reason, that you had a better chance of surviving a gunshot wound or a stabbing in Afghanistan than if you were attacked in the street directly outside a major London teaching hospital.
One reason for this high standard of care, of course, was that everyone, from platoon medic to surgical consultant, was getting a lot of practice. Medic Bob Steer, a veteran of Iraq and the early operations in Afghanistan, returned to Bastion as part of his Territorial Army rotation in 2007, and felt the change. ‘Things were far more intense than I’d seen in Iraq. We were really, really busy.’ Working with the trauma team, it felt to him as if the flow of casualties through A&E never stopped. It was like being on a production line, he recalled after one suicide bombing resulted in mass casualties. In the corner – at the end of the line, as it were – lay piles of amputated arms and legs. If it hadn’t been for the yellow clinical bags they were tied up in, he observed, this could have been a field hospital in any war in the past century. ‘In Iraq we went for days, if not weeks, without an incident, but in Afghanistan there was at least one virtually every day. And whereas in Basra the vast amount of casualties we dealt with were locals, here, increasingly, they were our guys, shot or blown up.’
With no sign of a let-up in the violence, roadside and suicide bombs took an ever greater toll of coalition soldiers, and posed new problems for the Bastion surgeons. Bullet wounds were relatively easy to deal with – they were usually a straight, clean line through tissue. But IEDs would cause thirty to forty penetrating injuries, legs blown off, arms blown off, skin, flesh and bone ripped apart and flayed open. Nor were the injuries just plain blood and gore. Because these bombs were usually laid in the open, in ditches and beside roads, lots of dirt immediately got into the wounds. ‘These were incredibly complex cases, and they took an awful lot of time and effort to clean and to sort out,’ one surgeon recalled.6
If they could be sorted at all, that is. In Philip Rosell’s diary for the second half of 2007, the ominous initials ‘KIA’ (Killed In Action) cropped up with depressing regularity. At a Sunday church parade, he and his comrades gave vent to a defiant rendering of ‘I Vow to Thee, My Country’, knowing that, just forty-eight hours earlier, two British soldiers had been caught in an ambush and made ‘the final sacrifice’. The second verse of that hymn, normally omitted in a Britain where congregations are wary of patriotism, seemed particularly relevant:
I heard my country calling, away across the sea,
Across the waste of waters she calls and calls to me.
Her sword is girded at her side, her helmet on her head,
And round her feet are lying the dying and the dead.
Rosell, his mind filled with thoughts of home and friends, had not long returned to his quarters when he was called back to the hospital to treat three men seriously wounded in a rocket attack. ‘Interpreter with head injury came back in full arrest – unsuccessful resusc. The second was a soldier with high traumatic amputation hip level, loss of large amounts of buttock tissue. The third had bilateral severe leg injury, traumatic below knee amputation one side, high thigh wound with mush to mid-tibial level on the other side.’ The surgeon worked through the night, cutting away the man’s left leg at the knee and the right at the upper thigh. One death and a double amputation – these were grim times. On another day he noted, ‘three lower-limb amputations and two hand partial amputations before tea time!’ Outside, the coming and going of the MERT helicopters bringing in each new crop of broken bodies seemed endless. The rescue teams were now flying as many as ten missions a day.
Some conditions were beyond even the collective expertise at Bastion. The lungs of a soldier caught in a blast up at Kajaki – still as much of a flashpoint as ever – were so badly burned that the only remedy was to fly him back to England to hook him up to a heart-lung machine. It was touch
and go. There was every chance that, scarcely able to breathe, he would die before he got there, but it was a risk the doctors had to accept. It was the right call. The man survived. ‘Good news to end the day on,’ Rosell noted when he heard. He celebrated the saving of a life with a vigorous work-out in the gym. But it was small compensation for the loss of three of the soldier’s comrades who had died in the same incident.
A day later, the doctor watched as a large patrol of armoured vehicles assembled inside Bastion to go out on a night mission, and he called out his best wishes to the troops as they headed into the setting sun. ‘Hope I don’t meet them again in the next few days as casualties,’ he thought to himself, full of foreboding. He had the same reaction to a pleasant young Grenadier Guards subaltern he shared a joke with. ‘Seriously do not want to see him as a punter,’ he wrote.
In the early hours of one Saturday morning, he was in his accommodation ‘pod’ and just about to get into bed, when the padre collared him. A major incident was going down at the village of Garmsir: two soldiers were dead and four Priority One casualties were on their way in. The action on the ground had been so intense that the helicopter had been held at bay for several hours before it could land to evacuate the wounded. These men were going to be in a desperate condition. They finally arrived at 4 a.m. One had taken a bullet through the head – ‘v. poor prognosis’ – one had an eviscerated bowel, another a shoulder wound, and a fourth had a two-inch bullet from an old-fashioned Soviet rifle embedded in the soft tissue of his lower leg. Their patrol had been caught from behind by Taliban forces, and the fighting had been very close and extremely nasty.
The next helicopter brought a fifth casualty, a medic, who had been advancing under fire to care for the man with the head injury when a 500lb bomb collapsed the compound wall on top of him. Like so many others in this situation, he was tormenting himself that he could and should have done more to help his wounded comrades, when in fact he had done all any man could be expected to do. ‘Very impressive bloke’ was Rosell’s verdict. For the next six hours, until, outside, the sun was high in the sky, he fought to save them, cleaning the wounds, removing loose dead bone, repairing and pinning what he could. All five pulled through and, twelve hours later, they were splinted up and on the ambulance-plane heading back to England.
