6

Field Hospital Camp Bastion (Bastion)

WELCOME TO BASTION, the hospital. If the arrival is by helicopter, to Nightingale, then the journey has been minutes from the field, and the point of wounding and the shouting. Then there is a bump down on the landing strip and the shortest of journeys from there by ambulance to the receiving area, where trauma teams wait in the sunshine, and then more rushing into the trauma bay or operating theatre. But that’s not how most people arrived at the hospital at Camp Bastion.

Named after the high-strength concrete that was used in so much of its construction, Camp Bastion was the biggest British military installation since the Second World War. At its peak it was the size of Reading, an entire town that appeared in the desert, dense and sturdy, with ramparts and sentry posts and then desert again, and some mobile phone masts marking the world beyond. During 2008, after Mark Ormrod survived his triple amputation and changed everything the medics understood about severe but survivable casualty, they turned what had been a tented field hospital – brilliant but with limitations – into a new hard-build facility, with the same full range of life-saving infrastructure (scanning, communications, consultants) that could be found in twenty-first-century trauma units at home. Extraordinary, but at the same time never a good thing when a hospital at war moves from tents to solid structures. Bastion – throughout the rest of this book that name always means the field hospital at Camp Bastion.

Medics arrived at the camp in large military aircraft, C-17 Globemasters, long flights, uncomfortable, everyone in a middle seat in a bad economy class, but they long ago learned to sleep sitting up and where they could (most of them from being junior doctors in the UK during the 1980s). They sat, always just a few of them, scattered among hundreds of soldiers, some of whom would be their patients, but no one thought too much about that. Then, cabin lights suddenly went dark as the descent began and it all started to seem real. Darkness because higher altitudes were safe and the runway was safe, but the zone in between was not, and everyone, regardless of their experience, sensed the sudden vulnerability. When the lights went dim, and all that was left were the points of chemical green from luminous watch dials, body armour suddenly weighed heavy and no one recognised anyone else any more. All the same in tactical darkness, hiding the aircraft and hiding the hollow inside each of them, alone in the crowd, hemmed in by the stiff seat and the never-ending hum of the turbines. There were no other sounds from passengers, only from those charged with their safe delivery, who gave short orders about when to wait and when to move. Everyone felt every bump and jolt as the aircraft descended and their adrenalin spiked up and down.1 Sudden decompression, a thump as the giant wheels went down, then the final bump of the landing. Then the wide-mouth ramp lowered and the passengers prepared to disembark.

The Afghan air is hot – ‘like an oven’, many people wrote in their diary. The night was cool, but the smell of a desert camp was the same whichever time and whichever desert, and so was the instant salt-lick of dust on their lips. For some it was utterly strange; for the experienced it was once again a sign that they were back in the Middle East. One surgeon arriving at Bastion in 2010 joined the others in walking down the ramp directly off the aircraft on to the landing strip. Looking around under a full moon and clear skies showed a distant, empty horizon. Meanwhile, as they marched away, he saw a dusty, worn-out, carbon copy of the long thick queue quietly facing in the opposite direction and waiting to board.

Everyone, including medics, had a briefing on arrival (‘Why we are here’), and everyone, including medics, then went out to the range to test their weapons and their skills. But then they started to learn the standard things that new arrivals to war zones have always learned. What surrounds them, beyond the concrete of the camp, the landscape and beyond the air-conditioning and smell in the buildings, the weather. It was cold in the morning, and could be very beautiful: flat yellow desert bordered by dark brown mountains, sometimes hidden by dust clouds, sometimes lit orange by the sun, against the vivid blue of the sky. The cool clarity could be energising, making a first day at work something to relish. But by lunch-time it was very hot, especially under body armour, and they would be grateful the moment they pushed open the door of the hospital and walked into air-conditioning and stowed their protective shell. They learned to move at a clip across camp in daytime, to get back into the cool, except at night, which got cold quickly, a different shiver from that with air-conditioning. Evenings could be beautiful also, sitting back in a cheap folding deckchair outside their quarters, to look out on the geology, the eternity of space, night becoming dark, bounded by mountains that would be there long after the camp was taken down, sand blurring the traces until they were all gone.

They learned that the wind could get up strength in minutes, enough to gather up a desert full of sand and swirl it over the camp, blocking out the sun, covering everything, driving them into the nearest tent, provided it hadn’t blown away. They would blink to clear the sand from their eyes until it stopped just as suddenly as it had started, and then they continued where they were going. Even when there wasn’t a sandstorm, they learned that there was a technical term for the dust that settles on everything in their whole lives that wasn’t in a hermetically sealed structure: dust and fines. Dust is dust wherever you go, but fines are particles smaller than dust that move in a mass like water and were dedicated to destroying their kit and were especially serious for MERT crews. Dust and fines are like nothing else, and everyone showed me film they had taken of them on their phones. Dust and fines, inches deep, like standing in shallow waves on a beach (or cocoa, said a practical one), washing over their desert boots, sinking them, centuries of it from a landscape worn fine by fighting and killing.

As they changed from military tunics to scrubs, they learned where there was a hospital laundry that turned around washing within a day, from the beds of casualties or backs of medics, and if they paid a little extra, the laundry ironed it for them. So they would really only need two sets of combats: one on clean, one in the wash. And if they didn’t realise how MERT worked, they would once they understood about laundry. MERT always needed more, because in the very worst of times MERT was called out ten times a day, and they didn’t change between flights, so the blood that went over the disposable aprons and gloves on to their combats stayed there for the whole shift.

*

For all the medics their first real day came when the watch-master sent through the 9-Liner that also went out to MERT in their quarters. They learned a different kind of waiting in between signal and landing. The pulse quickened but not the pace, said one of the poets among them, and that readiness was all, both for themselves and for the place.2 Drugs had to be stocked, in rows, trauma bays cleaned, sight lines straight and clear. There was an informal briefing, outlining what was expected, then everyone split into their teams. Trauma packs were taken out – pre-numbered, pre-printed labels for each patient, each T1, ready for them immediately, so there would be no waiting, no muddle with scans and labs when they were needed. Interpreters were called, if the 9-Liner indicated foreign nationals. The resuscitation trolleys were moved to one side of each bay so that the gurney carrying the casualty could fit in easily. The portable X-ray was positioned wherever the radiologist thought it should go, and the CT scanner was checked. (In the early days the vibrations of a helicopter landing nearby could set it off, so it had to be recalibrated carefully each time.) On the ward beds, heated mattresses were turned on because the rest of the place was cold from the air-conditioning. A runner arrived from the lab with shock packs for each bay expected to be in use. They contained red blood cells and fresh frozen plasma, and their boxes had a timer alarm that would ring if the contents were left for longer than thirty minutes. It was rare to hear the shock pack alarm because, no matter how much blood went in on MERT, more was always, always needed: at least one shock pack per amputation, so plenty were to hand.

But for now, there’s time. Time for a brew, and a smoke outside the hospital, usually leaning against the same sunny outside wall where they took their breaks, listening out.3 Then no more time. Dust swirled, and the helicopter approached the landing pad. Joggers from other parts of the camp, keeping fit by pounding the track of the Bastion boundary, stopped to watch, shielding their faces from the glare of the sun. Back inside, medics putting down their mugs, putting on their gloves and visors and bright green plastic disposable aprons.⁴ Listening hard, and if they heard the helicopter bump down on the landing pad, they knew that life was not yet the master inside their cabin, and that their struggle would be at the limits of desperation.

Then the ambulances dashed forward the short distance. A look from the MERT crew inside told them if they needed to switch on their blue lights, to race to the hospital. Or that only a slower journey was necessary. Across a century, medics and nurses knew that look, that strain, dreading the work to come yet praying they needed to do it; anything the ambulance could unload alive was better than it creeping past them to the mortuary tent. Blue lights, speeding tyres through gravel, these things were at that moment, in the minds of the medics, who waited as medics have always waited, somehow a good thing.5

Stretchers were lifted out of the ambulance, and one of the MERT medics who had come in with the helicopter ran alongside with the stretcher crew, straight into the Emergency Department. At Bastion this was made up of six emergency trauma bays, marked by yellow lines, taped on the floor, and divider screens between each. As the casualty was wheeled into the bay, they gave a report and ‘it is important that all receiving team members remain silent and listen’, according to the textbook, so that everyone knew precisely what was required of them in what was left of the Golden Hour.⁶ MERT had worked to keep the patient alive until this point, and now it was up to them to surround and save for the short journey between the trauma bays and the operating theatre. So more of what was done on MERT, done all over again (fresh dressings, fresh tourniquets), doing more of it (blood, fluids, analgesia). A bigger team than MERT. Here on the ground a trauma team leader, two nurses, two doctors, someone who did nothing but start and keep the records (with the biblical designation of ‘scribe’) for the patient, two airway specialists and a radiographer, who provided a detailed assessment of the casualty with images and scans (X-ray, ultrasound and CT). And there were other things to do, like rolling the patient carefully over to check their back (difficult to do on MERT, not enough room). And off they went, all at once. If all the bays were full, medics swarmed around their patients, filling the department; one of the deployed medical directors took to wearing a whistle on his lanyard in case control was lost in the room, but he never had to blow it.

It was not that different from what they would find in the trauma bay of a large NHS hospital, except the Bastion bays ran hot, with more patients in a week than most NHS trauma departments see in a year. Despite being a field hospital, in a desert, in the middle of a war, the Bastion Emergency Department ran better than most if not all NHS equivalents because, although it was small, it was perfectly formed and perfectly located. When the hard-build went up, they could make sure that the Emergency Department was within easy wheel of the ambulance bay, and that the imaging suite was directly next door, and the operating theatre also next door. And all of it actually next door, not down a corridor or round a tight corner that it was difficult to get stretchers down smoothly. This could be done in a hospital that was built from scratch and carefully planned, and really only does one thing (trauma), but not in the patchwork of nineteenth- and twentieth-century components that make up most of our current NHS provision.

And because Bastion medics didn’t have to cope with long journeys to radiology and back, or wait for bloods, they could refine their system even further, by the smallest degrees. A small degree, a second gained in the Golden Hour, is part of the science of marginal gains. What had been two steps (resuscitation, then surgery) became one at Bastion because it could – resuscitation AND surgery AND imaging AND blood transfusions. Everything happening at once, every pulse beat fought for carefully planned and practised, full of expertise.7 Be ready before they get into the bay. Move the patient once, from the stretcher to the operating trolley and use the move to check for injuries. Start at the top AND bottom of the patient. Get portable X-ray and ultrasound machines so they can work on the move, and get quickly out of the way, so the next person waiting can step into the space. At Bastion it was called Right Turn Resuscitation because it was a right turn into the Emergency Department, where the entire team was waiting. From a 360-degree battlefield to a 360-degree hospital, flying or on the ground, someone everywhere, working, surround and save.⁸ Right Turn Resuscitation is fast and necessary for unexpected survivors, but it needs a whole team, and if it’s instigated for patients who won’t make it past the operating theatre door, then the team has been tied up when they could have been more use elsewhere. There’s such a thing as ‘over-triage’, where things are imaged or intubated or done unnecessarily. And Right Turn Resuscitation is exciting and urgent, and teams can get carried away, which is why an experienced scribe is necessary so that, as each of them call out their activities for the record, control and pace are maintained. It needs a firm and experienced team leader for the same reason, and plenty of training in realistic rehearsal scenarios. But when it works, it works. Without it there would be far fewer unexpected survivors and no opportunity to learn the challenge of the scourge of Bastion, blast injury.

*

Surround and save and learn. This is what happens after the heartbeat under the soil has thumped and blown a human being up into the air with its force. Learning the consequences of an invisible wave, a ‘blast wave’, pulsing through a body, as damaging as the fragments that they can see and actually feel. It is difficult to overstate the power and consequences of the blast wave, so here is testimony from the first day of the battle of the Somme, 1 July 1916, as a young pilot from the Royal Flying Corps headed out over the La Boisselle salient. One of the huge shells that flew across the lines all day landed nearby:

Suddenly the whole earth heaved, and up from the ground came what looked like two enormous cypress trees. It was the silhouettes of great, dark cone-shaped lifts of earth, up to three, four, five thousand feet. And we watched this, and then a moment later, we struck the repercussion wave of the blast and it flung us right the way backwards, over on one side.9

Or, as a scientist put it half a century ago: ‘the Blast Wave is a shot without a bullet, a slash without a sword. It is present everywhere in its range.’

A blast wave is a pressure wave, and this scientist, Theodore Benzinger, had a decade that included the entire Second World War to study the effects of extreme pressure waves on human physiology. He became a leading expert, his insights and experiments so valuable that the American Air Force was prepared to overlook the fact that he was a Nazi, had worked with colleagues who used prisoners in their experiments, and had been one of the doctors on trial at Nuremberg. Benzinger’s name had mysteriously disappeared off the list of defendants and he went back to work in his lab, before finally leaving Germany for good to work in the United States, where his eulogies noted not his Nazi past but the fact that he was the inventor of the ear thermometer.10

Blast is present – blast impacts – everywhere in its range. And from 2009 it was present in almost all the casualties who presented at Bastion. So learning blast was essential. Learning from every single blast injury casualty who passed through their hands, whether on the floor of the MERT helicopter or in one of the six trauma bays or the operating theatre at the hospital, where the surgeons and anaesthetists had a long time to get acquainted with the utter wreckage that was a human being, still smoking from the blast that brought them there. They learned not to be surprised when the body on the trolley was shorter than normal, because the feet, shins, thighs and sometimes pelvis were simply blown away and all that was left was in tatters, hanging limply over exposed bone, gaping holes through into the stomach, groin gone, yet somehow with oxygen circulating, life gripping on, a heart rate still fluttering in all the mess. Then they learned to find and accept the rest of it, everything blasted into their patient, in exchange for what was gone – pebbles and rocks, dust and debris, pieces of everyone else injured in the same blast, bones and flesh and skin suddenly mixed and indistinguishable. A piece of boot, a tough leather heel wedged between ribs. And the shrapnel of the bomb itself, whatever was to the bomb-maker’s hand – nuts, bolts, ball-bearings, bicycle gear pieces, or grenade or mine fragments, twenty years in the rusting – dissolving in their sudden saturation of fresh, living blood.11

Not just bones and ligaments. The blast wave is especially dangerous to soft, air-filled organs. It bursts eardrums (‘tympanic membranes’ as they are known in the labs) – we used to think that it was the sound of the blast that did it, but now we know it’s the pressure wave. Or the blast wave can perforate the gut, spreading infection from within, no help needed from external fragments. Only the human eye seems adapted to cope with the blast wave, because there is no air between its multiple fine layers. It helps if the eye is protected, which it usually was in Afghanistan by sunglasses, and if the eye’s owner isn’t looking at the blast when it goes off. So nothing much has changed since the Second World War here, although sometimes the place between the sinus and the eye socket, which does have air in it, can be affected and blown out through blast.¹² Lungs are also soft, air-filled organs. The lungs, with their finest of fine membranes, are the least dense organ in the entire body, made almost entirely of air.¹³ Blast lung occurs when the force of the wave ruptures these finest of fine membranes, bleeding begins again, damage begins and by now you should know where this will end. Bad blast lung kills quickly, takes out the central mechanism to get oxygen in the blood, with blood coming back up the intubation tube as the lungs dissolve; there is nothing to be done. But blast lung can happen slowly, sneakily, and it’s much worse in civilian victims of explosions, because they are usually injured in enclosed spaces (such as tube carriages), so the pressure on the fine lung membrane is more concentrated.¹⁴ There are obvious things that can be spotted on a chest X-ray in the trauma unit and treated, but there are more subtle effects. A patient may present as ‘not too bad’ respiratory-wise, but within days their breathing has become laboured, they’ve got chest pain and their now permanent cough has blood or foam in it.¹⁵ If caught in time, blast lung can be treated with oxygen therapy, via a face mask or a ventilator, and slowly the membrane recovers and strengthens and can begin to work again.