Afghanistan, “Casualties of The Nameless”
Stories written by Marco Di Lauro for Live Magazine/Mail on Sunday and publish on the Semptember 2, 2007 and February 7, 2010 issues.
A Chinook skims over the desert blowing up a sandstorm as it lands beside what looks like a huge marquee, in the most unlikely of settings. The back opens and a soldier is stretchered out to a waiting Land Rover and driven the few hundred metres to the entrance. He’s crying and screaming as the trauma team hurry him into the tent, telling him time and again he will be fine. But it is clear they are simply trying to keep him calm because they don’t really know if he will still be alive by the end of the day.
Outside the temperature is a sweltering 45 degrees and although the tent is air conditioned, it is still hot and humid inside. You can smell the blood mixed with the body odour of the soldier, who hasn’t been able to wash for days.
The red of the blood staining his khaki unform and the green of the hospital staff vests together with the blue of the surgeons’ gowns shines out against the tent’s white fabric walls.
The soldier looks pained but resigned. His face and torso are covered in blood and he has numbers written with marking pen on his forehead – his blood pressure and pulse readings, written there by the British Army Medical Emergency Reponse team that had flown out to pick him up from the front line.
After the trauma team have stabilised him he is wheeled through to the operating table for surgery to extract the shrapnel from his body.
This extraordinary tableau of war is played out in a series of tents in the middle of a desert, right on the edge of Camp Bastion, a 2,500 man Nato outpost in Helmand Province in southern Afghanistan.
This is a hospital like no other. There’s only ever one sort of car in the car park – Land Rovers. And the first thing you do when coming into the hospital as a patient, visitor or member of staff is unload and hand in your weapon at the reception counter.
As an outsider I was amazed by the commitment of the British military medical personnel in saving as many people as they could, no matter who they were, by the sheer number of patients admitted and surgical procedures carried out, and the by the personnel’s long hours – 24 hour or sometimes 48 hour shifts without giving in.
Inside the staff treat Brits, Danes, Estonians, Czechs and the occasional American and Dutch troops that make up the predominantly British Task Force Helmand. They also treat Afghan government troops, national police, as well as civilians and even their enemy, Taliban fighters.
They treat them all the same – in fact in a way they treat the Afghans better because while most British casualties are treated are flown back to the UK within 24 hours, Afghans stay for up to a month. The British are super-respectful of civilian casualties.
Of course there are many different levels of Taliban from hard-core Islamic fundamentalists to the so-called $10 Taliban – not real fighters, but maybe farmers, or growers of opium, who have perhaps shot a couple of rounds with a Kalashnikov. The British don’t actually hold anybody captive – the real hard-core Taliban fighters they treat and hand over to the Afghan authorities, while the lesser ones, the ‘small fish’ they tend to release quietly.
The field hospital is an air-conditioned complex of tents with a concrete floor running the length of its 150-metre spine. It has its own power, laundry, sewerage, plumbing and infection-control systems, and contains equipment that would leave most NHS hospitals green with envy.
Its five-bed accident and emergency department has two portable digital x-ray machines, a CT scanner and an operating theatre where two patients can undergo surgery simultaneously. There’s ward space for 25 casualties, including up to eight patients in intensive therapy beds, although the number has surged to 50 patients at one time. In addition to accident and emergency, surgical and ward care, the hospital also has physiotherapy, pathology, dental and welfare departments.
The medical staff include RAF and Royal Naval medical personnel but the main body consists of regular soldiers from 4 GS (General Support) Medical Regiment based in Aldershot and Territorial Army soldiers from 212 Field Hospital on a three-month stay, recruited primarily from Yorkshire and the Midlands.
The staff work punishing shifts. Back home Lieutenant Colonel Andy Bruce, pictured wearing a Union flag bandana, is a consultant orthopaedic surgeon at Doncaster Royal Infirmary. He had been at Camp Bastion for seven weeks and had performed about 130 surgeries. ’We are on call twenty four hours a day. If being on call is working, consultants are working one hundred day shifts.’
The hospital has three surgeons – an orthopaedic, a general and a neurosurgeon, but Andy Bruce is inevitably the busiest since most of the casualties have injuries to their limbs. Soldiers wear bulletproof jackets that protect their upper bodies but which leave limbs vulnerable. Plus many of the injuries suffered by both civilians and military are caused by shrapnel due to road side bombs, land mines and rocket propelled grenade attacks..
Patients are picked up from the field by a helicopter team made up of air paramedics, a trauma nurse, a doctor and a consultant, as well as a squad of infantrymen to provide protection on the ground.
‘We’re all experienced in trauma’’ says Surgeon Commander Adrian Mellor, a Royal Naval consultant anaesthetist, ‘however we are seeing kinds of things not seen since Korea. Not only do you have to cope with the stress of professionally dealing with a new scenario every time we go out, but there is the added stress of going into a battle environment to do it.’
Being in a combat zone the hospital is mainly aimed at catering for trauma cases. ‘I’ve seen more trauma cases here in five weeks than in four years back home,’’ says Lieutenant Phil Bond, whose civilian job is as an A & E nurse at Queen’s Medical Centre in Nottingham.
Once stabilized by the trauma team and after undergoing surgery in the operating theatre, British forces are then flown back to a military hospital in the UK. Those receiving longer term treatment are therefore Afghans.
Malalia, a five year-old Afghan girl, was run over by an Afghan National Army vehicle. Her right arm was crushed against a wall. Initially doctors at the field hospital thought amputation was the only possible solution. But in rural Afghan society this would have led to her being ostracized, so Andy Bruce promised her father that he would do everything possible to save her arm.
The dead and damaged muscle was cut out and the bone repaired with makeshift external scaffolds of wire, plastic tubing, aluminium bars and plastic ties because of the lack of specialist paediatric equipment. She needed further surgery every two days for sixteen days, and then skin grafting. Five weeks later, against all odds, the arm was healed and Malalia was able to move all her fingers.
Then there’s the story of Hassan, the hospital’s miracle boy. He was brought in with a shrapnel wound that had pierced his heart after being caught by a mine. He technically died on the operating table and would not have pulled through were it not for the efforts of Colonels Bruce and Andrew Hall. The shrapnel had penetrated his chest and pierced a hole in the right ventricle of his heart.. The wound in the heart bled, eventually forcing the heart to give up. The surgeons opened up his chest, drained it, stitched the wounded heart, sealed the child back up and left him in the lap of the gods. Had he been an adult he would have had a 2 to 16% chance of recovery. There is no documented occurrence of the operation being carried out on a child. Within five days Hassan was up and walking, two weeks later he was playing football.
It’s not just military personnel that work in the hospital. Michelle McLaughlin is a UK civilian working for the Defence Medical Welfare Service. The DMWS is the only hospital welfare service that provides emotional and practical welfare care for military patients, working in MoD hospitals in the UK and Uk medical facilities in Germany and Cyprus, as well as the operational theatres of Iraq and Afghanistan. She relishes the chance of being not just to help hospital cases but also any soldiers who need to talk to someone: ‘If I can help make just one person smile I feel I’ve done some good during the day.’
Next door to the massive tent a large new concrete hospital is being built, set to open in October. Were it not where it is, in the middle of nowhere, this could be thought to be part of a legacy that the British will leave the Afghans. Instead it’s a sign that this war is going to go on for a long, long time.
Twelve minutes past seven on a November morning in Camp Bastion, northwest of Lashkar Gah. I have only just woken up, but the four British medics with me have been on duty for 21 hours: Flt Lt Fiona McGlynn, an RAF emergency nurse since 2003 who has served in Kosovo and Iraq; Lt Col Simon Hunter, a Consultant in Emergency Medicine on his sixth deployment; Corporals Janice Mennie and Shaun Leach, both paramedics. The phone rings.
‘One casualty, category A,’ says Flt Lt McGlynn. That’s all they know as they race to the waiting car. Category A means the casualty can’t walk and is at immediate risk of dying – the precise reason why this MERT (medical emergency response team) was set up. It takes eight minutes to drive to the airstrip, start the Chinook helicopter’s two engines, put on body armour and weapons and do a final equipment-check.
The Chinook takes off. The MERT still don’t know where they’re going. In the deafening roar of the wind and engines, the signaller makes a hand-signal that means ‘Grid’ – the pilot has been given a grid reference, meaning that we’re essentially landing in the middle of nowhere. A different hand-signal means ‘FOB’ (forward operating base), which would have meant a certain amount of security at the landing zone. If they point to the Union Jack badge on their left shoulder, it means ‘British casualty’, and if they salute, it means ‘American casualty’. If they hold their hand down at their hip, that means child casualties. Because we haven’t been given any of these hand-signals, we know it’s probably a Danish or Estonian soldier, as they make up most of the other troops in Helmand.
I can’t see anything, because I’m sitting in the only corner of the helicopter that isn’t taken up with equipment, MERT members or the Quick Reaction Force (four soldiers to protect the MERT) and their guns. I’m not close to a window, so I have no idea what’s going on outside or where we are. It’s about 20 degrees, incredibly noisy and very bumpy. I see one of the soldiers from the QRF vomiting.
The landing is rough and sudden – as they always are. I am very nervous: although the MERT don’t intentionally land during firefights, it would be very easy for a hidden enemy to shoot an RPG and take out the helicopter as it lands. The first thing I see is dust. The helicopter becomes full of it as it approaches the ground, blinding the crew. As it touches the ground, the same currents suck all the dust out of the cabin, to a perimeter about a hundred meters away.
As soon as our wheels touch down, the wounded man’s unit are already bringing him towards us on the stretcher. It’s a young Danish soldier, gravely wounded in an IED attack while on patrol near Patrol Base Barakzai in Southern Helmand. Two of the Quick Reaction Force run out to secure the ground. A Loadmaster mans the machine gun at the ramp. Another is on the side-mounted machine gun.
In my time embedded with coalition forces I have seen every horrible thing you can imagine. In Iraq in 2004, I saw a guy blow himself up about a hundred meters in front of me, killing sixty people and wounding me, sending legs, hands, heads all over the street. I’m afraid I can no longer be shocked, but I can be horrified.
The Danish soldier has some of the worst injuries imaginable. His entire abdominal area is gone. He has no more genitals. Both legs are gone below the knee. He is not conscious. He is basically already dead, but it is not the MERT’s job to decide that. I try not to react. If the MERT have an emotional response, they are very good at hiding it. It is easier to see emotions on the faces of the Quick Reaction Force, who as young soldiers aren’t used to this. They are clearly shocked.
The MERT begin cardio-pulmonary resuscitation. Flt Lt McGlynn checks the airways and gives oxygen. Lt Col Hunter checks for haemorrhages and gives blood. The signaller is ordered to give heart-massage: it takes so much energy to do this that they each only do two minutes at a time. There is no smell on the helicopter. There is so much wind from the gun ports and open ramp, you can smell and hear nothing but the engine. Mostly the MERTs do not need to communicate with each other. Each member knows exactly what to do.
The flight takes about ten minutes, during which the MERT concentrate on keeping the patient’s heart beating, respirating him and stopping him from bleeding out using tourniquets. They get back to the field hospital at Bastion, transfer him to the operating room, and the base medics put a screen around his body. That’s when they call his time of death. I do not see the MERT again until the debriefing, half an hour later. They look tense and exhausted and even though it is not that hot, they are pouring with sweat. They look like people who have run a marathon. The colour of their faces is not right, and they are panting.
“It’s extremely stressful managing patients in cardiac arrest in an environment which is extremely noisy and very rough,” says Lt. Col Hunter. “The stress begins from the moment we are alerted for a possible casualty as we race to the helicopter, with often no information of what or where we are going. Not surprisingly, the information that may be relayed to us as we travel towards the incident can be sketchy and it is not until the casualties are on board that we really know what we are dealing with. The ability to take a pulse, assess breathing and even communicate easily with the injured is often impossible in the back of the helicopter and this can be made worse by language difficulties as we treat patients of many nationalities.”
“But when you see the guys regaining consciousness on the back of the cab, or looking better with good pain relief,” says medical officer Maj. Clare Hayes-Bradley, specialist in anaesthesis and intensive care with the second MERT team, “you really feel that you’ve done a good job. We don’t always win. It’s crushing when a young lad that you’ve tried so hard to save is ultimately found to have unsurvivable injuries.”
At 10am, the MERT attend the daily regimental briefing then hand over to the second four-strong MERT team. Between them, these eight medics – plus their Quick Reaction Force – cover the whole of Helmand province, responding to Category A and B emergencies whether involving coalition forces, Afghan National Security Forces, civilians or Taliban fighters. They are the only medevac service that has doctors on board able to transfuse blood on the helicopter, and they use some of the most innovative techniques in the field.
“The MERT exists to bring the Emergency Department to the point of wounding,” says Flt Lt McGlynn. “The work done on the ground prior to our arrival is without doubt saving lives – application of tourniquets, dressings to cover the wounds, painkillers and IV lines with fluids – but we provide more advanced medical skills and techniques, administer stronger medication, transfuse blood products, and anaesthetize patients. But the best service we provide is morale. The troops on the ground know that no matter where they are, we will fly in and do everything we can to ensure they get home in the best possible condition to their families.”
As a photographer, I first came to Camp Bastion in 2007, reporting for Live magazine. I saw a lot of terrible things, but was impressed by the MERT teams who were on 24-hour call – at that time there were three in each team. That’s why I have returned two years later to spend eight days with the MERT. As soon as I arrived at Bastion on the morning of November 22nd, I saw a MERT Chinook landing, four hospital ambulances rushing toward the landing strip nearby and then quickly coming back to the hospital front door and unloading four Afghan security force casualties and several body bags. The MERT personnel were running around holding the stretchers and a blonde nurse was treating one of the casualties. That was Flt Lt McGlynn.
“In my eight weeks here, the MERT has treated over 150 casualties which has included British, American, Danish and Afghan soldiers, Afghan police, civilians and suspected Taliban fighters,” she says. “The saddest cases are the children. Afghan children are smaller than their western counterparts and like all children they go out to play. They see something shiny and pick it up but out here it is likely to explode in their hands. I was involved in a mission to collect two seven year old girls who were caught in a blast. One of the girls had a deep wound to her head and her brain was exposed and the second had deep wounds where the hot metal had cut her abdomen and legs. Both girls were conscious and terrified in a big, noisy dark helicopter. I speak pidgin Arabic and tried to reassure them. The first girl needed neurosurgery at Kandahar to survive her brain injury, but three weeks later they were discharged from hospital.”
A few days later I am with the MERT when they receive a similar call: two local children, one seven and one fifteen, have been caught in an IED explosion. The flight out takes less than ten minutes. I have no idea what to expect, and neither do the MERT. As soon as we land, British soldiers bring the first wounded child on board. Then a second stretcher appears. The child’s face is covered by a sheet, but I can see one of his feet hanging off the side of the stretcher. It is only attached by a small piece of skin. I do my best to cover that up, because I don’t want to see it. The second child is conscious but not reacting – he is in shock. Nobody tries to comfort him – they don’t have the time as they concentrate on keeping him alive. There is also an adult with them, I assume a father or uncle. He is silent.
The Chinook lands at Lashkar Gah and the children are transferred to a civilian hospital. The fifteen-year old is stabilised, but the seven-year old is already dead. Within twenty minutes of returning to Bastion, the MERT are on call again, this time to evacuate a British soldier injured in a grenade attack. I do not accompany them, but emergency nurse FS Tony Kyle later tells me what happened.
“Fighting continued whilst we received the casualty, but we continued to work on him knowing that we could be hit at any time,” says Kyle. “This is my first tour to Afghanistan and MERT and to be honest I didn’t know what to expect. I usually work in an Emergency Department back home and although I have experienced the rigours of looking after patients at the roadside, nothing can prepare you for this. My first day consisted of four shouts to various parts of Afghanistan. Three of the patients had multiple amputations.”
“My family is concerned for my safety,” admits Maj. Hayes-Bradley. “I can’t deny we’ve come under fire, but it’s nothing compared to the threat the guys on the ground are under.”
“When the phone rings, you wonder, what will this job be?” says cpl Leach. “A British soldier stepped on an IED, lost both his legs? A child shot in a friendly fire incident? A Danish soldier involved in a road traffic incident? An enemy fighter with a gunshot wound to the chest? Whatever it is, the team will take the Emergency Department to the battlefield. To me it’s the best job in the world.”
On my eighth day at Bastion, preparing to leave, I witness one last trauma. A British soldier is brought in by Chinook and transferred to the operating room, his lower right leg blown off by an IED. It is even more disturbing than the Danish soldier, I think, because I can see his face. I can still picture it now. It is quite hot in the operating room, but very quiet. Flt Lt McGlynn – or Fiona, as I now think of her – has brought this man all the way from the battlefield to this operating table: this is the end of her responsibility. After that, the surgeons with the green aprons take over – British, American and other nationalities, way more surgeons than I’ve ever seen in any other hospital. They close around the casualty, and I leave with Fiona.
“It’s always emotive treating British casualties,” she says. “They look so young, I try to hold each one’s hand and tell them we will get them home. One soldier looked into my eyes, down at his injured body, looked back at me, squeezed my hand and tears started streaming down his face. I will never forget the look in his eyes. I am passionate that these brave men and women who face the unknown everyday receive the very best medical care that we can provide. This job can be emotional, tiring and frustrating. I’m not afraid to display my emotions. But I am the boss.”