4

The Medical Emergency Response Team (MERT)

AFTER SEVERE WOUNDING, whatever fluids the body has lost have to be restored, via tubes, directly, all as fast as possible. Breathing must be resumed either by or for the patient, and the death chill of hypothermia that prevents clotting beaten back, toxic cell death suspended. Now, in what remains of the hour from point of wounding, all hands on deck, not on solid ground in a cooled, bright trauma bay, with the patient on a comfortable waist-high gurney. Here, on a metal cabin floor, on a black plastic liner, inserting tubes into a badly damaged human, with everyone travelling at 180 m.p.h., under fire, under threat, on a rapidly moving, vibrating, noise-blasted platform inside a Chinook helicopter.

This is the work of the helicopter medical team, better known as MERT (Medical Emergency Response Team). What happens inside the helicopter is technically known as Pre-Hospital Medicine, but there is nothing pre-hospital about it. MERT fly an entire emergency department and operating theatre, with standard storage facilities, the same bank of monitors as a land-based facility, and a trauma team, all of whom specialise in emergency medicine in real life. It’s a four-person team. First out of the bay door are two paramedics (sometimes CMTs, sometimes civilian paramedics, there to experience what only war can give them) who will collect the casualties from the ground and somehow, under fire and a ginormous helicopter rotor, hear what has happened to them. On board, they hand over the same information to the flight nurse, who will administer the team’s work during the flight and manage communication between the team and the two pilots up front flying the aircraft. At the back of the cabin is the team leader, who has the final say.

It’s worth really understanding just why the role of team leader is so important – not just to the casualty who is being loaded and triaged but to the operation of MERT from the beginning and as a whole. The team leader – the person at the head of the casualty, reading upside down, calling the steps forward – is not what a hundred years of military medicine have led us to expect. For the first time ever, the person at this point – the very sharpest end of the military trauma system – is not a surgeon but an anaesthetist. Only anaesthetists have the collection of skills that can call back a life sent so far off course by casualty. When they use them in war, they are called ‘combat anaesthetists’. It’s not a very good name, and not remotely reflective of what they can do, because they don’t just save life, they sustain it under the most brutal conditions, readying the patient for the next stage of trauma care. Later, MERT team leaders would be emergency medicine and trauma specialists, intensivists, general practitioners, but they all train under a combat anaesthetist to learn their unique, remarkable skill set.

Here’s why and how that skill set evolved. As surgery developed, so did anaesthesia. Gas that induced sleeping meant breathing needed to be controlled, which meant putting tubes into the lungs, intubation. Anaesthetists learned to control blood pressure, mostly to depress it so that patients didn’t bleed to death as a result of surgical incisions. Polio outbreaks saw anaesthetists move full-time into Critical Care wards so they could manage the patients breathing inside the huge iron lungs. Control of breathing, control of bleeding, this became the job of the anaesthetist, rather than something the surgeon kept an eye on as they went along. By the 1950s anaesthetics had become an -ology, which meant it was studied, researched and improved. There was more practice, better drugs, better skills and, crucially for wartime, better kit. Better kit was efficient, computerised, reliable and, above all, smaller. Compact, powerful kit could eventually be put into helicopters, and with the arrival of portable monitors and ventilators anaesthetists could finally bring in their full range of life-saving skills, just like they did in the Critical Care units, airside.

MERT wasn’t just a new collection of skills and kit. It embodied a radical shift in dealing with military casualty, with military casualties. The anaesthetists who led MERT into Afghanistan were among the most experienced military medics at Camp Bastion. One had completed six tours in Afghanistan, and before that five tours in Iraq (which he never described without using the phrase ‘the furnace of Baghdad’). Although the worst of the Iraq casualties wouldn’t match the challenge to come of blast injury, the soldiers who came into the wards every moment of every day were damaged in ways not seen before: damaged but not dead, the unexpected survivors of their day. Close, intense, prolonged contact with a highly mobile enemy in chaotic urban settings produced bodies torn open by multiple gunshot wounds and multiple fragmentation injuries from rocket-propelled grenades. At hospital, within RPG range and so under fire for most of its time in Iraq, combat anaesthetists in the trauma teams understood that they had the skills to save these lives, but only if enough of them were brought to bear on the injuries all at once, everything that needed to be done at the same time. So a fundamental principle of military medicine changed. No longer one medic per casualty, as had been the case for a century. Instead, as many medics as were available and knew what should be done, with sometimes five medics per patient: all for one, all at once. A new fundamental principle, and what they say themselves says it best: surround and save.

And let’s not forget the most important member of the team. Chinooks are the best helicopters in the world (not a technical assessment, just a personal opinion), although they don’t look it at first glance.1 They are improbably huge and square, named after the largest species of North American salmon, grey-silver and fat-bodied, with small fin sets that look incapable of propelling the fish through the strong Alaskan river currents but which are in fact powerful enough to bring it from the ocean, up river runs and back, year after year. The helicopter equivalent is much the same. It has two rotor blades and three engines, none of which looks proportionate to the chunky grey body mass or capable of dragging it into the sky, and throwing it around, side to side, up and only just down, and then up high again. Yet they are, time after time, month after month, life after life. They land in the tightest of spaces, in an area no bigger than their propeller span or less – once in a very small compound with low walls on all four sides. The blades spun over the top of the walls and the back bay door hit a wall on its way down, so the medics had to jump down to the ground and squeeze round the outside of the helicopter to get their patient. Sometimes the Chinooks don’t land at all, just hover a few feet off the ground, and the paramedics have to really jump out and scramble back in after the stretcher and the patients are loaded, but it means the Chinook can get away really fast. Sometimes they stay only two minutes at the point of wounding, but two minutes is all the giant flying A&E department really needs. There is a Chinook display team that performs at air shows, where pilots demonstrate pedal turns, rollercoasters, nose-down quick-stops, spiral descents and running landings to hysterically appreciative audiences. While their crews wave at the public from the open ramp, they remember back to Afghanistan, where they learned all of it, as a matter of survival, so they could get to the point where Mark Ormrod and all those who came after lay, hearing in the distance the whump-whump of their rotors coming to fetch them back.

Chinooks are vital in this, because their passengers only have minutes. Any slower and there is no point, because the patient will either die on the way or more slowly as the effects of the deadly cascade become irreversible. This is what is often called the Golden Hour. An hour is the maximum time that the severely injured – those who are bleeding out their lives because of limb or torso damage – can survive and still be brought back. Much longer and, no matter what is done to them, they will either die soon after or several days later, but beyond the Golden Hour damage is done and sustained and can no longer be mitigated. The Golden Hour needs helicopters big enough to allow for surround and save, and not too far to travel, whether it’s Vietnam or Helmand Province or a pile-up on the M4 in the UK. The Golden Hour is more complicated than we imagined when we named it, for it is the time when the deal with death is done. But for the time being, life now, consequences later.2

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When MERT is called out, the crew run from their air-conditioned quarters through the sudden bright sun of Camp Bastion, crunching over the gravel, jumping into the dark of the helicopter. Briefings about what to expect on the ground start from the consultant as they lurch off the landing pad. Last-minute visual checks while they have the space of being the only people on board. The information has come in from the point of wounding, via a 9-Liner report on the unit’s radio. It’s called a 9-Liner because it contains nine lines of vital information, such as numbers of casualties, how badly they are injured, where the landing site is, how safe the landing site is. MERT helicopters can only surround and save two badly injured patients at a time, so knowing what to expect is crucial. (When Scott Meenagh was injured, the original call was for one seriously injured patient. But the next explosion happened while MERT was already in the air, so when they got there, things were problematic. But they’re MERT, so they managed.)

Two minutes out from the point of wounding, the team assembles in their place at the shoulder of the soldiers of the Force Protection Squad, who will go out and guard them (they pay particular attention to the safety of the landing-site section of the 9-Liner). On the ground, those waiting for them turn away from the downdraught from the huge rotors. Then back bay door down, heat, dust, chaos, blare, as they snatch up patients. Stretcher cases on the floor of the cabin, hands held out through the bay door to help up the walking wounded, as many seated as can be managed, some sent back and told to wait for another flight or vehicles to collect them. Up and away, back bay doors closing on the people still left on the ground, turning away from the updraught, already moving back to where they were before.

Then inside, the medics gather in around the T1 (the code for the severely injured) patients deemed at the most risk. The stretcher is pulled away. The team leader is at the head end, the rest of the crew in their designated places, all looking for signs of life or death or blood. They check on the measures that have been taken on the ground, adjusting drips, checking chest seals, tightening tourniquets. In the case of a really bad high-traumatic avulsive amputation such as those of Mark Ormrod, they add more tourniquets, above the first. At the same time – and this is all at the same time, which is why the T in MERT stands for Team – they fit an oxygen mask if the face is intact, and the pads and sensors that hook the patient to the monitors around them in the cabin. They check for bleeds that may have been missed, that are easy to miss, that can kill just as quickly as the blasted limb – at the neck, the underarms, the groin – packing these as tight and fast as they can (‘aggressively’, their training manual instructs) with their own supplies of haemostatic dressings. Holding an empty hand behind them, palm up when they need more, knowing without looking that what they need will be slapped into it. Bleeding stopped, almost empty bath plugged, time to fill it up again, according to the team leader who saved Mark Ormrod, even though he had been certain at the time it couldn’t be done.3

Refilling is easier said than done on the cabin floor, with its plastic liner, which looks like the bottom of a black paddling pool. Veins shrunk flat in greying skin, hopeless to try to dig into them, not enough time or space to beat the cascade. So the team goes deeper, where they know a liquid flow of blood products can be released and sustained, into the patient’s bone marrow. The team leader has a drill, a smaller version of the domestic tool, with a switch on the handle that can drive a special needle through hard bone, preferably the shin bone. But shin bones are often gone in the back of the helicopter, so the hip bone or the chest bone or the long bone in the arm, all can be used in the absence of a shin. (In training they use Crunchie bars, because the texture of the honeycomb centre is much like that of human bone marrow.)

The team leader can feel when the drill hits marrow, zzzp, less than a second and in, and immediately starts the flow of clear bags of blood products, of fluids – water, salt, liquid analgesia for the pain. This is not just for the wound but because drilling is agony, the patient often bucking up and screaming as the metal hits bone, so it is better if they are knocked out. The next point along the pain pathway runs through MERT. Analgesia is delivered via IV lines for the patient on the floor – pain control for everyone they have taken on board, via injections or nasal sprays or soluble lozenges for those on the seats. Less pain now, hopefully less pain later, and it is easier for everyone on board doing the difficult things. Back to the drill. Bone marrow is spongey and readily soaks up and spreads whatever is put into it, so blue-gloved hands squeeze the bags to push the warmed liquids deep and fast into the patient watching for the normal human flesh tones to return and the grey to recede. (In the field, medics tuck the bags under their arms to get the contents warmed past blood temperature because those are absorbed more quickly than cool ones straight from the cold storage box – a matter of seconds, but this is the Golden Hour so every second counts.) It is tricky to do in the light of a blacked-out cabin, so the medics watch the monitors, which flash hard green around them, listen for the bips that beat life returning, and signal: bath filled – intraosseous transfusion works like a charm – plug holding, move on …

Blood comes first, but the crew must then move on immediately to breathing. Air from the outside is sucked in through wounds to the chest, abdomen, neck, wherever, and gets trapped in the space between the lungs and chest wall. Lungs are fine, delicate things, and it only takes something as light as air in the wrong place to collapse them, inch by inch, compressing and suffocating from within. Decompression can be quick, with a three-inch hollow needle slid under the fourth rib releasing trapped air – the best sound in the world, as any medic will tell you, because it means air is back in the right place again, provided it can be heard as it hisses out. Then the pressure should fall, restoring normal breathing motion – in out, in out, oxygen flowing again.

That might not be enough. Move up from the lungs in the chest to the throat and the neck. Stridor (Latin, not Elvish, for ‘grating’ or ‘squeaking’) is the high-pitched whistling sound that signals a blocked airway, impeded not by very much, perhaps: a scrap of debris from the explosive or the broken body, a minor wound on the chest or neck, all enough to restrict breathing. If the airway is blocked or broken, the medics have to make a new one: intubation. A tube is lowered carefully down the airway that leads into the lungs, the other end of which is connected to a ventilator to pump the missing air directly where it is needed. The team has practised and practised intubation back at Bastion because they all know you only ever get two goes to get it right (too long without breathing and failed intubation attempts can make existing damage worse), and they have to be quick. So it takes two pairs of expert hands, the team leader and the flight nurse. Some medics intubate lying down, some sitting up; the crew knows what kind of space to make for them, and they start to do it as soon as the team leader has indicated what is necessary. Give muscle relaxants, add analgesia to the lines to the veins as preparation and then insert the tube through the mouth, down the throat into the trachea or, as the training manual states, sometimes directly ‘through the large defect’ that is the face or neck wound or, as a last resort, through a surgical airway – a hole cut by the team leader directly somewhere, wherever they can, into the patient’s windpipe.4

Intubation can come to dominate in a process where priorities must be constantly assessed. The team leader at the top, bent over their patient’s head, at their throat, which suddenly becomes just an airway, the team leader losing sight of everything but the narrow tubes threading down into the lungs. Except that everything else is happening at the same time: get blood in, fill the tub (it won’t work without oxygenation anyway), be careful with the anaesthetic, look up not down, get it right or lose it. All at the same time. There are videos from MERT on YouTube, but they aren’t enough to explain what is going on at the heart of it, what extreme resuscitation really means. Blood, air, bone, life, pulse beat by pulse beat, unexpected survivors on the floor, unexpectedly surviving because of the skill surrounding them, the team working ceaselessly, not just chaos captured on a shaky phone camera.

Not all intubations are done on board MERT. Sometimes, not often, medics got off the Chinook to collect their patient and couldn’t get back on again. Chinooks were audible and visible from miles away, so there were times when, in between the 9-Liner and arrival, the landing site had stopped being a landing site and become a target. On a boiling August day in 2009 two medics with two soldiers from the Force Protection Squad jumped out of the back of the helicopter, knowing it would have to wheel away immediately, couldn’t even wait the two minutes or so that it would have taken them to fetch the casualty back in. As they ran across the ground, the rotors kicked up a blizzard of dust and rocks, so they moved as fast as they could to the stricken patrol group, paying no heed to what might lie in the soil beneath them. As the helicopter moved away, it felt as if they had been abandoned on another planet in the glare of the sun and insanity of the terrain – a full-blown fire fight around them and, all the while, the patrol group searching for devices, marking them, calling out to the medics – what is technically known as a semi-permissive environment for doing emergency medicine. The casualty was a T1, in a bad way, lying between two vehicles for protection. He needed a surgical airway, but kneeling at his head would create a too solid, non-moving target, so instead the team leader lay as flat as he could by his patient’s side on the hot, sandy ground and cut directly into his windpipe to create a space for a ventilation tube. Then he attached the tube to a portable manual resuscitator (not on MERT now, air from a plastic bag) and started to pump oxygen, squeezing the bag and finding enough quiet somehow amid the noise and haste to ensure a calm, regular rhythm, like a lung, in out, in out. And then twenty minutes that felt like twice that passed, and the rotors came back, thump thump, and the Chinook landed. Gathering the casualty up, running back, bagging him all the way, again not looking to see if the way was safe but this time getting back in and up and away.

Back on the helicopter, sometimes MERT had an audience in real time. There was room for those less badly injured, who’d walked up the ramp, shirtless and filthy, even if it meant they had to sit upright on an uncomfortable metal box full of medical supplies. Grey-faced from their own shock, they had nowhere else to look except at the sight of those others on the floor, hanging by threads, being fought for right in front of them.5 All around, hanging from the red webbing across the walls of the cabin, were more blood products, and blood-stained gloves reaching for them, squeezing the bags in, pints and pints for humans who have lost more blood than they should have, and are only alive because they are young and battle-fit, and used to fighting, whatever the time and place. Monitors. Bips. Listen, try not to listen. Tangles of lines going in and out, not to be tripped over, not to be disrupted. Keep your arms in. Drilling, intubation, screaming, lines, tubes, monitors, bips. Watching, while others surround and save their mate.

Some of what the medics do looks really strange. Every single piece of information gathered during the Golden Hour is, well, golden. So in order not to forget it or waste time taking it repeatedly, MERT crew use Sharpies to write important data on whatever flesh remains undamaged on their patient – respiratory rates, heart rates – it’s the best place of all for the next set of medics to find it, written on the body indelibly, in thick dark letters, signs of life. Writing on flesh, letters and numbers, where previously there had only been tattoos. Writing records was important, and not just those Sharpied on to patients. MERT crew tried to remember all their difficult cases, so they could learn from them. One team leader took his black plastic knee pads out just before each shift began and wrapped them in green sniper tape. Sniper tape is the military equivalent of duct tape – used for everything, and always a couple of rolls of it knocking about. It’s fabric adhesive tape that tears off very easily and is flexible around odd shapes, and you can write on it. Inside the helicopter as the patient was stabilised or no longer needed his attention, the team leader straightened out his own leg and wrote on the knee pad, just the basics, to prod his memory when he was back in his quarters: time of treatment, levels of responsiveness (E for Eyes, V for Verbal, M for motor), respiratory rate, heart rate, oxygen levels.6 If the patient died, he crossed through the first line of information. When he got back, he entered the data in his own personal diary, with simple illustrations of stick men, showing where the wounds were and any other details he thought were important. Then he ripped the sniper tape off his knee pads and, because the adhesive is really good, stuck it on the diary page as well. It was an effective system, and it was adopted by the colleagues that came after him. When he got home, the diary was the basis for his research. Not a randomised control trial or anything formal: sniper tape from his knee pad. Research can take many forms. And taken together, all their tapes showed the statistical contours tightening – because of extreme resuscitation techniques the chances of surviving severe injury between 2006 and 2014 went from 83 per cent to 92 per cent and holding.⁷

Ninety-two per cent: so still the 8 per cent chance, even if all the other odds are in their favour. The seated wounded learn in an instant that the hurly-burly of the cabin is better than the moment when the team leader sits back on their heels and reaches out to hold back the others with a gloved hand and speaks firmly but more quietly than before to call a halt. And they see suddenly that the pile of folded black plastic in the corner is in fact a pile of black body bags, and the crew moves as fast as possible to cover the dead. And then they watch as they go to whoever needs them next, past their failure, shifted a little way over. Later, one team leader remembered the sudden, intense loneliness he felt at the moment he called a death, as if he had been first to that point, after the casualty, and was waiting for everyone else to catch up, and that the seconds in which they did so, medic or comrade, were infinitely long. If life is difficult to measure in the back of a Chinook, then death can be even harder. Over the noise of the rotors medics can’t hear breathing, can’t feel a pulse, even though they check anyway. Sometimes the dust and debris covering a body are so thick, or the flesh is so burned, they can’t get lines in, can’t get monitors on. They can’t do the tests they are supposed to do before calling a halt. Then sometimes they know, as soon as they look, that what is left on the floor cannot possibly be alive, even though it was loaded by the team medics as such, and they don’t even begin, and instead one of them straight away reaches for the pile of black plastic.

And on they would fly, and then finally the helicopter would turn and bank to land at Bastion. Two landing pads. One, just outside the hospital, was named Nightingale (for what I hope is an obvious reason). And then, a short hop and the always impressive 180-degree turn to land at the dedicated helicopter landing strip, where the Chinooks lived all in a row, with MERT quarters just nearby. Even if it was due to go out again, which it often was, the pilots sat quietly for a few seconds while the giant rotors slowed down, and the engines ticked as they cooled and then finally apply a brake. They walk around the craft and check it for bullet holes and then finally sign it over to its ground crew engineers, who had waited, one ear permanently cocked since the arrival of the 9-Liner, which they also saw, until it returned safely (and they did all return safely). As the engineers refuelled it, MERT nurses cleaned the cabin clean of the blood on the thick rubberised lining on the floor. The Chinook’s original fit had no blood mat, so fluids seeped into every crack and screw thread, and it was impossible to get clean or rust-free. The mat made everything easy, a big fluid spill kit wiped all manner of matter away, and while the nurses did that, they made a list of what supplies needed replenishing (everything usually) or what flew off during flight and needed re-fixing to the cabin walls. Bullet holes, nothing could be done about those, but they emptied the sharps bin and cleaned the windows and gathered up the blood-soaked dressings and never quite managed, no matter how hard they scrubbed, or how long the ramp was left open, to get rid of the smell of a ripped-open human being. There was not just blood to be cleaned away. Dust is more permanent than blood in Afghanistan. It has its own particular quality, very fine, and gets in everywhere, into the delicate electrics of monitors, engine parts, window frames. So afterwards ground crew cleaned as diligently as the nurses, a constant battle with blood and dust, while they waited for the next call, when they would all do it all again.

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MERT service can come at a cost for those who work in the crews. Tinnitus is common – the ringing in the ears an unending echo of the shouting, chaotic soundscape of the Chinook cabin. Spines, backs, necks, shoulders, knees, all are affected by the weight bearing down on them shift after shift, and the constant vibration, leaving behind chronic pain and in some cases real, physical, career-ending disability. And these are just the things we know about now, only a few years after their final flight in Afghanistan in September 2014.

And there are other costs, yet to be quantified, of finding themselves in a place where they battled for survival every step of an uncharted way, and remember only those competitions where they were not the master, and, where the handover was about failure, how they failed, where they went too far or not far enough and had to turn back alone, and where the pile of black body bags went down rather than gathering the dust circulating in the points of light shooting through the cabin where they worked. The anaesthetist who had intubated the patient on the ground between two vehicles under fire never knew what happened to him after he handed him over. A couple of months later he saw the man’s parents on the television talking about their son who had died in Afghanistan, and he knew that his patient hadn’t made it after all and he cried alone as he watched, as he cried when he told me about it, years afterwards. Six thousand five hundred cases transferred to Bastion by MERT, and most of their crew’s personnel remember just one patient, usually one who ended the journey wrapped in one of the black plastic body bags.

But they know that if anyone can keep a life saved along the way, it is them, and the knowledge and the skill to do it never leave them. Almost everyone who served on MERT that I have ever met keeps a tourniquet in the glove compartment of their car, just in case. When it seems a lot to take in, all this business with blood and breath and extreme resuscitation, start there, in a glove compartment that probably looks like the one in most cars, with the car manual and the round tin of car sweets and the tourniquet, black strap and Velcro, that can stop a bleed, and save a life, wherever. Just in case.

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And what of the soldiers on the ground who turn away in the grit sprayed by the Chinook’s downdraught and then go back to their base, their vehicle, the war?8 Pay attention to what MERT leaves behind, someone said to me in the course of my interviews. It was an excellent point. What happens to the people who saw their comrade fall, and to the medics who kept them alive until MERT thundered over? One CMT oversaw the loading of three very severely injured casualties after a day-long fire fight that had felt to him as if it had lasted ten minutes. They had driven to the landing zone, and he had been forced to put a line for fluids into a patient with half his head blown away, working in the back of the vehicle as it bumped along to meet the Chinook. He had been pretty chuffed by that, feeling like a real doctor, in gloves and stethoscope. It was night, pitch black, and the only light came from the unit’s head torches until the back of the helicopter opened up and paramedics wearing night vision goggles moved forward to receive his patients. Not a second wasted, as was their way. The only contact he had with anyone outside the unit for weeks, and not a spare word spoken.9 As the ramp closed up, a hand threw the yellow resupply bag out at him, as was also the way: swap a treated patient for the supplies used up, dressings, oxygen, fluids, IV lines. But he was distracted; now the patients had gone, he realised he had not had body armour on, had none on now and was at risk from enemy fire in the flashes of torchlight. He turned to begin thinking about where his armour was and, as he did so, a soldier from the unit, mistaking the yellow resupply bag for rubbish, picked it up and threw it skilfully back into the helicopter through the almost closed ramp gap.

Fury. The patients had needed almost all his supplies, and it meant he would be scrounging around for replacements until a new drop or a return to Bastion. The thought got him back to his vehicle, inside the door, too angry to sit down, standing at the back, holding on to the seat in front. Then, as they drove, he had time to gather his thoughts, to – as he put it – square himself away, and then for what he later thought was probably twenty minutes he did nothing, as the adrenaline of the day drained from him. Then he began to shake, horrendously, unstoppably, before noticing his clothes were soaked in blood. Back at base he jumped out of the vehicle and stripped off his kit, to burn it until it was gone. Then he put on clean clothes. He remembered smoking ten cigarettes in a row, while drinking four cups of tea, without stopping.10