Combat Doctor

by Marc Dauphin

  As I contemplated the boy’s situation, I marvelled at the resilience of the human body. But resilience, no matter how strong, is no match for death, the ultimate winner. Everybody — there were perhaps a dozen of us around the stretcher — was standing motionless, waiting for my decision: to accept treating the boy, or to send him on to an Afghan institution. Our hospital was full and, as an officer focused on caring for our soldiers, I was thinking that I should probably send the boy away. Our mission was to treat the sick and injured soldiers of the NATO coalition. We could also care for Afghan civilians injured as a direct result of the war. Then, only if we had the space and the resources, we could care for other civilians as a goodwill gesture. With our advanced technology and super-competent, can-do, resourceful specialists, we could perform what to the Afghan people looked like miracles.

  But saving this boy’s arm was beyond even the most advanced medicine in the world. Besides, we had to prepare for more wounded soldiers in the hours to come, as we had been made aware of a large operation that was to begin during the night. I knew I should just send the boy back to the Afghan civilian hospital. That much was obvious to everyone. But his father kept pleading with me. He thought we were still “negotiating” to save his son’s arm. In my mind, we were deciding — I was deciding — whether to try to save the boy’s life.

  That there was no pleading from my people to try to influence my decision was a tribute to how far we had come from being those well-meaning but unknowing do-gooders who had arrived in country only a few months earlier. My staff at the Kandahar Role 3 Multinational Medical Unit was by then a disciplined, tough, if somewhat ragtag bunch of professionals who were now among the best in the world. If anyone could save this kid, they could. We could.

  Pondering, I pursed my lips and looked at my people. Standing behind them, ensuring she was as unobtrusive as possible, my Commanding Officer (CO), Canadian Colonel Danielle Savard, was waiting for my decision. Avoiding my eyes in order not to influence me, she was studying the floor at her feet. I knew she would back me up, no matter how hard or how inhuman my decision might seem. But she could also tell, by my hesitation, that I was leaning toward taking him. When I turned a patient away, the decision usually came fast, loud, and clear.

  In my head, I was trying to figure out how much of a hill the boy had to climb to get back to health, and what the drain would be on our hospital. Were his kidneys shot from the dehydration and the massive amount of toxins generated by the dying muscle cells? If so, his care would be complex and our resources were finite. Did he have other injuries that we didn’t know about? That would complicate his care. What if a dozen injured soldiers arrived while we were immersed in trying to save the boy?

  This hesitation probably lasted less than two minutes, while the staff stood motionless at the stretcher’s side. If any one of us were to lay a hand on the boy, he would be in our care for keeps. While I was thinking, I tried to explain to the father that we were talking about saving his son’s life, not his arm, which was hopelessly too far gone. I tried to prepare the man for the possibility that we would turn him and his son away. But a father’s love does not lend itself to reasoning, especially through an interpreter, and I realized I was wasting my time.

  At that moment, my eyes met Colonel Savard’s and she immediately read my unspoken question. Her response was the very briefest, discreet nod. Which meant, “What the hell, Marc …? In for a penny!”

  Thanks for sharing that burden with me, ma’am. I owe you one. I don’t think I could ever have forgiven myself for not giving this kid his chance.

  Greatly relieved, I sighed and turned to the interpreter. “All right, tell the father that we are going to try and save his son’s life. But the arm has to come off right away. It’s killing him. We need his okay to do this.”

  The staff sprang to life, plugging in the monitor, putting up an IV, drawing blood, installing an oxygen mask, inserting a urinary catheter, asking for X-rays, calling the OR team in. I stepped back to give them room to work. That’s when the father grabbed my sleeve and said something.

  Colonel Danielle Savard, commander of all Canadian medical personnel in Afghanistan and the Arabian Peninsula. She was the last Canadian CO of the Role 3, my boss, and a great person who taught me a lot.

  “He says he’s willing to give his son his arm if you want to transplant it.”

  That just about did me in. Speechless, I could only bite my lip and pat the father on the shoulder as I shook my head.

  I turned to the interpreter.

  “Please tell him that we’re not that good.”

  Lessons Learned

  We did a lot of things well on our roto — very well, in fact. And I’m very proud of our team. But I don’t want people to get the idea that we invented our method of doing things. No, it was the intensive training we received beforehand that was the key — training based on lessons learned during previous rotos. In addition to a bunch of really good and pitiless teachers.

  In the following pages, I will complain about the way the Canadian Forces did things during the dark years. And I’ll be justified. But when the CF started to do things right, they caught up fast. So it was with the KAF Role 3 hospital: Roto 7 was better than the earlier rotos, and Roto 8 was even better than we were. The people from Roto 8 will probably read this and cringe at the way we did some things. And they’ll be justified, too, for there is always room for improvement. Every roto does the best they can with what’s at hand. Just as every roto does better than its predecessors, both qualitatively and quantitatively.

  What is really remarkable about our story, Canada’s story, is how everything came together to improve the system from roto to roto. And it all started in Wainwright, Alberta.

  In Wainwright, the Canadian Forces deployed the 1st Canadian Field Hospital to head up our training. The personnel for the Role 3 in Afghanistan assembled there from all over Canada, months in advance of deploying, for an intensive three-week exercise designed to build us up into a solid team. That exercise was the best; it was realistic, very difficult, and designed to expose our inadequacies. It revealed how bad we were, but it also showed us how we could improve. And it was done far enough in advance of the tour that we had time to make the necessary adjustments.

  A Canadian Bell 412 Griffon flies into a violent sandstorm. Those guys have all my respect.

  The instructors gave us the desire to better ourselves, showed us why we should, and gave us the time and money to do it. We were also lucky that a good percentage of the personnel on our roto had previous deployment experience.

  And as I said, everything we saw in Wainwright was the sum of all the lessons that had been learned by others on previous rotos. Each time the CF deployed 1 Canadian Field Hospital in Wainwright, they altered the training routine to reflect the changing conditions in Kandahar. When we started training in October 2008, it was at the start of Roto 6, so the CF flew in the CO of the last roto, Roto 5, who’d just-returned, along with his sergeant-major, to meet and coach us.

  In addition to being an outstanding speaker, that CO, Lieutenant-Colonel (then) McLeod, had the very latest intelligence and lessons learned from Kandahar. He had interrupted his post-deployment leave to brief us, and when he spoke to us that night, you could have heard a fly in the tent. One part of his speech that stuck in my mind, that I constantly played back throughout my time in country, was how, in the difficult times during his roto, he had always been reassured by the tall silhouette of his OC of the Role 3, Major Will Patton, calmly moving from trauma bay to trauma bay, helping with a tricky manoeuvre here, giving counsel there, always in charge, always ahead of things. That night, I vowed to try to emulate Will, an ER medicine teacher, a good friend, and a good comrade from Edmonton.

  That’s how it was. We, as a group, had the wisdom to accept everything they taught us during the exercise, and added just a little of ourselves. And we were wise enough not to change the way they had been doing things — except to tweak the mac
hine just a bit, to improve any little shortcomings they told us about. The processes of unloading, triaging, damage-control surgery, Air Evac’ing, all the discipline in the trauma bays, that was all taught to us. We invented nothing. And we applied it exactly as it had been taught to us. Therein lies our wisdom: in accepting the system, and not modifying it. (Well, maybe we did a little.) We had the smarts to understand that the system was the product of many brains who had actually been there, and of many lessons learned. And that’s what I’m proud of: in the first few weeks as OC of the Role 3, I changed exactly nothing of what my predecessor on Roto 6, Major (then) Bill Rideout had been doing. Nothing. I did tinker with some details because I had more personnel available than he did (another good call for the CF: they reacted quickly to our needs). Other than that, if Bill or Will had returned to Kandahar halfway through our roto, they would have recognized the hospital and fallen easily back into their own routines. Because, basically, the process hadn’t changed.

  So this book is about us. Not only is it about us as a team during Roto 7, but also us as in all the rotos that came before Roto 7. The CF Medical Service certainly deserves all the accolades it gets for the job in Afghanistan.

  Throughout the seven rotos that Canada was responsible for as part of the Role 3, its staff kept up a record of 97 percent survival for all casualties who arrived there with a heartbeat. That is the best record in all of Iraq and Afghanistan. It is the best record for a hospital in a war zone, ever. And we saw nearly 40 percent of those patients during Roto 7.

  The trauma board on a typical day. The Roman numerals in the first column indicate which trauma bay the casualty is in. These are all very seriously injured people.

  A typical evening, with six U.S. casualties coming in two waves, all of them with serious, life-threatening injuries.

  Who Is This Dauphin Guy?

  I had been trying to write this book for over a year. I had most of it written down, many chapters with a lot of action and a lot of emotion, but somehow the tone just wasn’t right. “It isn’t you,” my friends and family would say, with very concerned looks. Then, by chance, I met one of our ICU nurses at one of my clinics. She had been in Kandahar at the same time I was. It hadn’t been her first time over there, though. She had experience, and knew what it was like to come home — twice. When she inquired about my writing, I confessed to her my inability to get the proper tone.

  She smiled comprehendingly. “You’re probably too bitter, too cynical,” she told me. “Those missions do that to all of us.” Only then could I see the hurt in her soul, the hurt she had managed to hide so well. She never stopped smiling, and her beautiful eyes still crinkled when she did. But the hurt was there, unmistakeable.

  It wasn’t a call for help, just an observation on how war changes all of us, on how no one ever comes back the same. And I have learned to say, C’est comme ça. “So it goes,” to paraphrase Mr. Vonnegut. This expresses my inability to change what’s happened to us, the desperate yearning for a coping mechanism, and also my profound, irresistible desire for others to understand. If it had only been me, I wouldn’t talk about my time in Afghanistan, except with my comrades. And even then, only through the obvious running gags about the heat and the sand or the need to brush your teeth before you eat. Me, I’d just bury all these stories deep inside, and try to get on with what’s left of my life. But as the leader of that extraordinary team who, for a brief few weeks in the summer of 2009, coped with an avalanche of casualties, numbers never seen in our time by the Canadian Forces Medical Service, I felt the need to tell the stories, their stories, stories of extraordinary resilience in the face of constant death and untold suffering.

  But these are also stories of fantastic medical advances, and their consequences on the soldiers who live, fight, are wounded, and, sadly, those who still die. We must never forget these men and women who go out and perform incredibly difficult missions in your name.

  This may sound corny to some, but remember this: among all that background noise in different shades of grey that you hear from all those analysts about what’s happening over there (Are we winning? Are we making a difference? Is it all worth it?), I just remember the simple facts: in the 1990s, the Taliban took over in Afghanistan. They imposed a brutal and incredibly repressive regime that demanded, among other things, the stoning of women (ugly); the impaling of men (very ugly); and, worse, the keeping of their population illiterate (that way, they could make them believe anything). We, in Canada, like the rest of the world, didn’t do a thing to stop them, except the occasional, brief (and rare) public wringing of hands between the latest hockey scores and the automobile commercials. Then the Taliban began to shelter a bunch of even more regressive people in their land; people who wanted to impose their way of life on the whole planet. That’s where I got off the bus. Mr. Clinton did try to catch them with air strikes, and promptly lost a bunch of public opinion points for his efforts.

  Then the Taliban’s protégés struck. Everybody remembers where they were and what they were doing when 9/11 happened. A lot of Canadians died there. If 9/11 had happened in, say, Toronto, and that many Canadians had been killed, we would still remember it as a very deadly day in Canadian history.

  So that’s why we went: to stop those people, and to give back control of Afghanistan to the Afghans. It’s that simple, as the little guy used to say. Plus, the Afghans are the ones who helped to topple the Soviet regime, that totalitarian, evil monster that blackened out half of Europe and threatened the world with Armageddon for nearly half a century.

  That our allies and friends got sidetracked and went off to fight another war in Iraq at the same time, leaving us to hold the fort in southern Afghanistan, is for history to judge. All I know is that things kept getting worse in Kandahar and Helmand province where the Canadians and the British were trying to regain control. And the casualties kept piling up.

  That’s where my personal story intersects history.

  I was born in 1953, in the second wave of baby boomers. I had a great education in a private school, in the old part of Quebec City, and went to med school with most of my friends. That was during the second part of the Vietnam War. In those days, contrary to today, the war was all over the TV screen. Every night, you had snippets of the action caught live by embedded or free-roaming TV crews. Although we were numbed by the numbers of wounded and dead, we were all increasingly aware of the unpopularity of the war. (Again, history will judge if that was an “appropriate” war — for now, we are much too close to it in time to stand back and be objective. I was against it then; but now, I’m not so sure.) The important fact here is that, in those days, the Canadian population had not evolved enough to distinguish between an unpopular war and the conscripts who were forced to fight it. Nor even between them and the soldiers in our army, the Canadian Army, who weren’t directly involved in Vietnam. For the civilians, it was just simpler to condemn everybody — all the soldiers, that is — and get on with the partying. By the way, unlike many of the people who lived through them, I can remember the sixties and early seventies.

  When I ran out of money in the fall of 1972, my classmates told me about the solution to survival: just enlist in the Canadian Forces, and they’ll not only pay your tuition, they’ll give you a salary. It was too good to resist. I jumped in. At first, they let you keep your beard and your long hair like all the other kids (and were we ever hairy!). But then that fateful first summer of service came, and I had to get the famous haircut and wear my uniform. I was sent out of the country for the summer, had a great time, had some very eye-opening, intense moments with the military and military medicine, and came back for the fall semester.

  And that’s when I learned how hostile the population back home was toward the military. Even in civilian garb, because of my short hair, people figured out immediately that I was in the army (even the cops then had long hair and were allowed sideburns). I got insulted, jeered, jostled, and even spat upon on the street for being in the mili
tary. Plus, most young Quebecers’ mood was decidedly separatist in those days, and the CF represented Canada, the “oppressor.” This did not make for a very active love life.

  Did it hurt? You bet. I could have tried to get out of the contract I had signed, like some of my buddies tried to. But I needed the money, and I was angry: nobody was going to push me around and tell me what to think, or how to live. I did try to explain to people that there was a difference between those who were forced to fight a war, and the war’s appropriateness; that Canada was not even involved in Vietnam; and that the CF was there to protect them. Nobody would listen, and the jeering only got worse. So I did what most young men in the military in those days probably did: I clammed up. I ignored the ignorant people (not always feasible “Hey, hey milita-ray, how many kids did you kill today?” or its variant “… how many girls did you rape today?” — definitely not easy to take, when you’re a lovesick twenty-year-old).

  So, I got on with my life, concentrated on my studies, graduated, and started to serve in the Forces. Although I don’t take easily to authority (just ask my dad), I thrived in the military. I was like a fish in water. My bosses thought so, too. Although they (correctly) judged me as immature — I am a late bloomer — they (especially then Lieutenant-Colonel Pierre Morisset, later a major-general and surgeon general of the CF, and still a good comrade) set out a nice career plan for me. The only problem with that plan was that it involved being away from home even more than I was already. That didn’t go over well with my family. So, forced to choose between a great job and a great family, I chose the latter. In those days, the military’s attitude toward family life was, “If we had wanted you to have a family, we would have issued you one.” So, at the end of my contract in 1980, I got out.