Bastion’s Medics
AS THEY LEARNED THEIR WORK at the hospital, so the medics learned about each other. As in life, in books. So, meet the junior trauma surgeon. You might meet him anyway, in an NHS unit, if you need a surgeon to look at a hand or hip or leg that has been badly damaged. You’d never know that he’s been in Iraq, and that while he was there he counted the mortars that fell around him while he was in the operating theatre (forty-six), and that one night he lay flat on his belt buckle (military terminology for lying down as low as you can because people are firing at you) waiting to treat a casualty while a fire fight raged directly over his head. Or that he’s been in Afghanistan, and if there are more wars somewhere else, then he’ll go there. Which is why I can’t tell you his name, but I can tell you that when he does cardiac resuscitation he whispers the song ‘Nelly the Elephant’ to help him keep time, beating down hard and rhythmically, as the elephant SAID goodbye to the CIRCus, keeping a heart beating for the length of a song and several choruses until it could run on its own, picking up the rhythm, flipping back and forth to life. He does that today, and he did it in the trauma bays of Bastion, and that was how his colleagues got to know him.
The worst day the junior trauma surgeon ever had in Afghanistan started with a repatriation ceremony. He had woken up, put on his uniform and stood to attention in the open square at Camp Bastion as the coffin of a soldier who had been killed in the field was carried on to a Globemaster transport plane. Absolute silence, except for the voice of the chaplain and then the Last Post, and always, somewhere in the background, the Afghan wind in the desert. Then he had gone slowly and quietly to the hospital for his shift. No patients, just paperwork, left to his own devices and thoughts, never particularly welcome after a repat. But at 5 p.m. something worse happened. A 9-Liner: four serious casualties, two of them very bad indeed, and they’d waited for thirty minutes before it was safe for MERT to land and collect them.
Too long. With one already dead, MERT crew turned away to work on the other, still very bad when unloaded. Right turn at Bastion, everyone there pushing forward to surround where he lay, no heartbeat, so the junior surgeon opened his chest, and reached in for the heart itself, massaging it hand to heart, no ribs or chest in between, no muttered song for rhythm, just thin sterile gloves gleaming with blood on a pair of hands and the muscle itself, lying between them, not moving, not responding. Keep going. Blood and adrenalin in through the lines to help him, and finally, after four minutes the surgeon felt a flutter between his hands, and then a twist and then a rhythm, and then he could actually see it moving in the middle of all that blood, beating on, and then – not that he needed it – the monitor bipped a confirmation. No more time to listen, as there were many more injuries, but now the veins that held the lines were shutting down, so blood must be leaking out somewhere, blood pressure falling, patient falling back, so the team went back after him. His leg was gone, so an amputation to remove what remained just below the knee was being done. Lacerations to the lung, but not serious. Where else? Open up the stomach – blood so dark and deep – a huge haemorrhage, still bleeding, unstoppable, but they tried, more blood in the lines, back and forth, heart massage, but this time no fluttering, no movement, and the team leader called a halt.
Different work at the end of a life. Sewing up the wounds made by the blast and those others they had made fighting for survival. The work of an hour or more always, and dreaded, but he sewed slowly and carefully, the repat ceremony coming back to him with every suture and clip, because he knew that now there would be another. More remembering: the last time he had done this for a young dead soldier, a year earlier, another tour, Iraq. An open chest, blood pouring on to his shoes and the drapes around the trauma bay, litre after litre, and then the team leader said that he needed to think about stopping, and then that he should stop. And even now a year later, when he knew nothing could be done, it was the same despair, wishing with all his heart that something had been possible, that they had kept going out and kept hold of him somehow until they could see the way back.
Four casualties came in. One dead on arrival, one dead in the trauma bay. And the day that was now a night went on. A morgue team arrived to collect his patient, and he pulled off his blood-soaked gown and gloves. The other two casualties were out of the trauma bays now, their lives secured in place, but they needed surgery on their injuries. So he had an hour to rescrub, put on fresh gown and gloves and then go back in – this time a hand to be saved. He remembered very little of the details. Sleep at 2 a.m. and then back into theatre first thing, and bed again the next 2 a.m., and theatre first thing for the next three days. As he operated, MERT landed and unloaded and went out again, and the procession of trolleys before him never stopped: gunshot wound to the stomach, fragmentation wounds to the face, blast injury to the lung, amputating one leg, amputating both legs, hand trauma, fragmentation to the upper arms, twenty of them, and then again the take-backs and the reworkings and the ward rounds. Exhaustion, drifting off during the moments of break – understanding what a thousand-yard stare was because he had one. Finally sleep. And then the next morning, beret on, stand upright, repatriation ceremony for the first death, in howling wind and then driving rain and constant flashbacks to the operating theatre and the moment the halt was called. The storm raged outside all night, but he slept through it, and the next morning the air was clear and the mountains to the north beautiful in the sunlight, and he could see all their features, rivers and ridges, where the sand of the desert met the warmth of the rocks at its edge. Closer, somewhere in the camp, small birds playing in the sand, two days of quiet to follow.1
Except that he’d adjusted his definition of quiet. Quiet could still mean days and days of ward rounds, and take-backs and trimming and re-trimming of stumps, because the blast wave still needed resisting days after it had exploded. Blast injury wasn’t new for him. He’d been in Iraq, when blast casualty from IEDs was an ‘emerging injury pattern’, something to be written about in short articles, rushed to medical journals, to let everyone who would come next know that this new weapon was causing significant injury patterns and casualty numbers, a complex of casualty ‘often resulting in traumatic amputation’.2 In 1914 surgeons had written home of the mutilating wounds of modern warfare, where ‘the amount to be done in a short time is large, and much increased by the multiplicity of wounds’, and that they already somehow understood ‘many surprises must be expected both in the direction of recovering and of final failure.’3 The same thing, across a century. The junior trauma surgeon thought about that when he did a last check on his patients before going off duty. In the low night light of the Bastion hospital ward he could see every bed used, but not full, every leg and some arms gone into a yellow bag. He stood at the door and felt connected to all the military surgeons who had gone before him, standing in dimly lit places and seeing in hospital the lives saved, blighted and failing there all at once, surgeons who had gone back to their tents and hurriedly written up a warning and sent it off, or a diary to seek sense in the madness. And then he turned and walked back to his tent.
Meet some more of the others. Meet the plastic surgeon. He was the first plastic surgeon to come to Bastion, and he came as part of the general trauma team, before anyone realised that it would be the plastics lot who stayed behind at the operating tables, hour after hour, even though this happens every time medics go to war. Even in 1914 a surgeon had written home warning those that were embarking for France that ‘skin-grafting and other plastic operations will have to be extensively practised’.4 When he looked back, the plastic surgeon didn’t remember any days in particular, just reckonings he’d made while standing at an operating theatre table, alongside unexpected survivors. Plastic surgeons learned to read the wreckage of the human beings brought to them like no one else. Orthopaedic surgeons focused on the bones that were their responsibility. Everything else, all the rags and sanded shreds, where veins and nerves end, what comes out from under the tourniquet when it’s finally safe to loosen, that was down to the plastic surgeon.5 If they weren’t careful, wreckage became war-like scrap – an official term, by the way, for military rubbish, to be disposed of. To stop that disintegration, bleep the plastic surgeon and watch him be careful at the operating table, for as long as the patient’s own physiology will let him, fingertip searching the debris for the material blasted deep into the body’s layers, debriding putrid flesh back to something pink and healthy, putting it back together wherever he can. Trimming tissue, muscles, nerves, refining the new edges of body at the stumps.6 Plastic surgeons: the men and women who can deal with soft tissues, the nerves, veins, arteries, bits and pieces, fingers, scalps, ears, lips, the really small things, reconstructing the human part of human beings.7
The plastic surgeon also learned that soldiers never listen, no matter how much he told them to keep their gloves on and not to cut the fingers off, because if they did that, the more likely it was that he would have to cut their fingers off – that little layer of scientifically designed fabric does do what it is supposed to do. But Spitfire and Hurricane pilots wouldn’t wear their gloves or goggles in the Battle of Britain for the same reasons: it was hot, and they worried that gloved hands were less sensitive or quick on their instruments and weapons. So sixty years apart both of them lost fingers and eyelids and flesh when it could have been saved, but who’s to argue with the young man with his finger on the trigger or the bomb detector as he goes forward into the fire.
The plastic surgeon has deployed eight separate times to war zones and, as I write this, he’s training to deploy again, not to a war this time, but to what is left behind by civil war, to train surgeons how to rebuild humans in an ‘austere environment’, even when that austere environment is the place they call home. I can’t tell you his name either, or the name of the place he will be posted to when this book is published. But I’ll ask him to tell me about it when he comes back, whatever he can, because he’s got an eye for detail, like most plastic surgeons. He saw Bastion when it was just an air base, and right outside its relatively puny fences were the adversaries, looking back at him and sometimes firing rockets. Bastion had a tented hospital, like all field hospitals before it, but one that grew and grew, day by day, wings and wards added like a game of dominoes spreading out as the camp itself turned from an air base in 2003 into a fortified settlement into a city, secured by guard posts and blast walls, made of Bastion concrete: miles and miles of them, no more worrying what was beyond the wire. Camp Bastion, like all modern cities, turned into a giant car park as more and better military vehicles appeared in longer and longer rows, in their identical beige-grey desert camouflage paint coat. And in 2008 the plastic surgeon saw the hard-build hospital go up: huge pieces unloaded from the back of transport aircraft and bolted together. First one storey and then a second, and a whole spiral staircase clamped up the side from one to the other. A tarmac entry for ambulances, reinforced floors to take the weight of the new scanners, which he was happy to see because they in turn took some of the weight off him, telling him where the fragments were and where they were not, so he didn’t have to waste time and his patient’s blood searching for them.
Even when the hard-build was finished, they kept the old tented field hospital just in case the new one was overwhelmed. There’s a technical term for when that happens: Going Black. Going Black would have been catastrophic – military operations would have been suspended until the hospital could readmit casualties. Troops would have struggled to maintain morale, knowing the hospital was failing and there was nowhere for them to go when they fell.8 But there was always somewhere, and the need was never so great that every single medic in the camp was mobilised at once; throughout the war teams gathered on their shift and stayed away when they needed rest.9 The tented field hospital was also there in case the new hard-build came under attack. Anyone who had been in Iraq knew how it felt to operate with mortars falling all around, but at Bastion the blast walls held fast and the perimeter grew beyond the range of all but the occasional mortar or rocket going off somewhere in the distance.
But an attack was constantly in the mind of the Bastion Deployed Medical Director. Always a consultant, preferably in an acute specialty, the Deployed Medical Director had the last word on things like the boundaries of resuscitation (who was treated and for how long, and how many resources were used on them). They made sure that good ideas like Right Turn Resuscitation were implemented. They managed highly intense staff in a high-intensity environment. They thought about hard and difficult things all day, and this was particularly the case for the Deployed Medical Director in 2009, because he knew exactly what a hospital looked like when it was part of the aftermath of an attack.10 He had been in Belfast in 1991, when a bomb exploded in the fire exit tunnel serving the basement social club of the military wing of the Musgrave Park Hospital. The social club was full because the rugby World Cup final was on, and many of the medics were watching it on the big social club television. The explosion collapsed the two floors above into the basement, trapping the wounded and destroying the accident department, resuscitation room and operating theatre. Two medical staff were killed and nine others badly injured, including two child patients in the newly opened paediatric orthopaedics ward.
Preparations for an attack had been made which assumed that the accident department would be available, but it was not, and everything that would have been needed was destroyed along with it. Resus facilities were improvised in the road near the building by the anaesthetist, who scavenged drugs and equipment from Critical Care. There were no hi-vis jackets or protective clothing, no pre-planned system of radio communication and no triage labels of any kind, so patients went off in ambulances to other hospitals with staff having to remember what they had been told. No one knew if a second attack would happen at any minute. So in addition to a Major Accident Plan they needed special incident boxes, protective clothing and documentation prepared and ready for use in a pre-designated alternative treatment facility somewhere else on their grounds. After Musgrave Park he switched specialties to emergency medicine, and Musgrave Park was always somewhere at the back of the Deployed Medical Director’s mind, ticking over, causing him to refine and reshape the smallest detail so that a disrupted hospital could go on functioning. So the field hospital tent stayed, and got a name – Resilience – even though it was only used once, when the CT scanner was being installed in the hard-build and everyone had to be moved out back to the tents to let the technicians work.
A 9-Liner and then the sound of ‘Doe, a Deer, a Female Deer’ beeping from his pager called the hand surgeon to the trauma theatre at Bastion. (As part of the plastic surgery cadre, he was on call all the time, and he had the tune of ‘Do Re Mi’ from The Sound of Music as his bleep, not because he liked it but because he hated it, so he always took notice when it played, like hearing fingernails on a blackboard.) Like the others, he waited behind a yellow line until the anaesthetist called him forward, and although there may have been burns to the face or body that required his skills, the cases he most remembers, that he cannot quite yet live with, are those that involved hands.
Hands are about living, holding, doing the smallest thing, feeling the softest touches, fingertips. Hand surgeons work close up, their visual field no longer than the middle finger of their patient, turning the hand over and back, thinking, mending, saving. Hand surgeons are determined and clear in their mission: that they will never amputate hands that might be saved. The hand surgeon brought this certainty to Bastion, brought it every day he walked into theatre, and began to understand that military casualty only strengthened that resolve. As his colleagues worked on patients who had lost both legs, he knew how important it would be to their recovery that they had their hands. Every bit of function he could save, no matter how small, would enable their journey through their new lives. A new determination and resolve: they need their hands if they lose their legs.
‘Doe, a Deer’, a very bad day, called to theatre past a full set of trauma bays working on very severely injured casualties, and with five dead outside waiting for transport to the mortuary. His patient: both legs gone at thigh level, a mangled left hand and a right hand intact, although the elbow was smashed through with shrapnel. The hand surgeon was called forward to the left hand, cleaned up and lying waiting for him on the table. It was staying on, and he was going to fix it, on this very bad day, no matter what. The pieces he could see were pieces that could be mended and made back into something that worked and even looked like a hand. And so he did, disappearing into his own world as around him the surgeons and anaesthetists heaved stumps closed, and pumped in fluids and dragged life forward, one pulse beat at a time. He worked on, and the pieces came back together, more work to be done later, but good for now. Then the elbow – not much to be done there, so the right arm would never flex properly, but there were two hands still, to grip the equipment in the rehab unit, to offer in a handshake, to begin to feel a way forward in the new world he had come to inhabit. Throughout the very bad day those two hands at the end of two arms kept the hand surgeon going. No compromise, work done, as promised. Resolve strengthened.
A week later. Another patient, both legs removed above the knee, almost as bad as it got, and the blast wave had also blown open the right hand – both arteries in the wrist blown away and open fractures in the palm. He’d done the one the week before, and this one didn’t look much worse so he’d save this one too, and make rehab a little easier. The work: restoring the veins and arteries, making decisions about shunts or grafting, about how to tidy up the wrist that pumped in the blood, and sensation and function. Painstaking work, time-consuming work: at least half an hour to start with, bent in close, his own gloved fingers touching and testing those he could save, fifteen minutes gone. Tunnel vision, save the hand, I can save the hand. Then ‘Stop’, someone said firmly, at the borderline of saying and shouting. He looked up. The rest of the team had stopped, and they were all looking at him. There was more than a right hand on the table, there was an entire body, and it was still bleeding what little remained of the whole body’s blood out through the smashed arteries at the wrist. The voice again, the team leader, ordering him to amputate the hand immediately or the patient would die: not a risk but an absolute certainty of death. He performed the amputation quickly, neatly (though he always describes it as ‘chopping’). Technical term: fixation error – fixation on the hand and his ability to save it, hearing only his own resolution, losing the sense of the whole life.11 And then he stepped back from the table to allow another trauma surgeon his space.
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Some of the most difficult decisions taken by the Deployed Medical Director related to local patients, Afghans civilians, their families and others. Locals made up the majority (probably as much as 80 per cent) of the patients cared for during the lifetime of the hospital. During the war there were no Afghan hospitals with the technology or capability to ventilate patients with severe chest wounds, therefore leaving Bastion meant death. So anyone intubated who could not be returned to Britain had to stay at Bastion until they could breathe unaided, which sometimes took days or weeks. They were discharged only when it was certain they could survive away from Bastion: probably in a local hospital that was under severe stress, and which could only provide medical care for two or three hours a day, where the rest of the time they would be looked after by their families. So beds remained occupied by those who were not badly injured British service personnel, and sometimes there were no spare beds. Meanwhile no one knew when the next 9-Liner would come in and everything the hospital had would be needed for some of their own. To paraphrase one of the earliest deployed medical directors, an extended field hospital stay provided a combination of quality assurance and professional insurance (surgeons could be sure their work had worked), yet it threatened to undermine the field hospital’s core objective: to support the military effort.12
On some days, though, that decision wasn’t very hard at all, such as the evening when five Afghan National Army soldiers came in, all in one go, packed into one Chinook. All T1s, the very worst, listed on the whiteboard in the trauma bay area:
Trauma Bay 1 |
Head trauma, bleeding from carotid. Airway obstruction. |
Trauma Bay 2 |
Sucking chest wound + cranial laceration. Shallow breathing. Weak pulse. |
Trauma Bay 3 |
Shrapnel left arm, chest, both eyes. Massive head laceration, brain exposed. |
Trauma Bay 4 |
Shrapnel wounds, concussion, in and out of consciousness. |
Trauma Bay 6 |
Shrapnel, arm + left eye gone, facial laceration.13 |
And so they were taken back and forth to theatre, over and over, because there was the time and the need to do really complex reconstructions that were all the patient was likely to get. So a huge workload for the plastic surgeons, rebuilding faces, eyelids, arms, hands, bodies. There was no surgical microscope at Bastion – microsurgery was done back in the UK, at Birmingham – so they couldn’t fix the really fine intricate structures that needed microscopes and precision instrumentation, as they would do at home. So they used the techniques demanded by the injuries of other, older wars, where equipment was less sophisticated but the damage the same. In 1940 the plastic surgeon Archibald McIndoe was confronted with another set of unexpected survivors: RAF aircrew, their faces and hands burned away in exploding Spitfires, Hurricanes and Lancasters. He needed to restore whole noses, chins, cheeks, not with small grafts but big, one-off reconstructions. So he used the technique of tube pedicles, a procedure in which whole sections of skin are raised on three sides but keeping their blood supply connected on the fourth. Their open end is moved up to where skin was damaged or gone, gradually, stage by stage – ‘waltzed’ up a limb – stitched in place, from a shoulder to the face for instance, or a thigh to an arm. Then, when the blood supply had reconnected, it was snipped away from their original site and sewn up to make a whole new cheek or chin or lip, all in one go. No need for microsurgery, but the patient mustn’t move their arm or shoulder where the graft came from until the surgeon said they could. No one does this now, because it takes so long and because they have microsurgery, but pedicles work and stay fixed, and at Bastion, with local patients, they had time. Military medics have to know a century’s worth of medical techniques, because they never know what they will be called on to do, under what circumstances. Something to think about for a new generation of surgeons who don’t do old-school procedures.
Perhaps the hardest part would have been explaining to a patient that they couldn’t move their arm for the next week if surgeons didn’t speak Dari or Pashtun or any one of ten other languages common in Helmand (there are thirty or more across the whole country). But fortunately they didn’t have to, because of what were always known as the Terps. Interpreters were crucial to the functioning of the wards at Bastion. Many of them had some medical experience, had been nurses or orderlies in Afghan city hospitals, and once they got used to the wounds and their treatment, medics only had to start off with a full sentence or two and the interpreters nodded and gave a full set of instructions to the patient. They came without fear to the bedside of children, and Afghan soldiers and CPERS (Captured Personnel on Operations). There was an interpreter there for every extubation of an Afghan – the opposite of intubation, the removal of breathing tubes – who explained what was happening and asked the patient to cough and then quickly translated as the situation was being explained by the various consultants and nurses, the eyes of the patient flicking anxiously back and forth from the speaker of the language they knew to the faces of the men and women who stood in authority. They advised the medics on religious and cultural issues, such as diet and when and how the beards of the unconscious devout might be shaved. They stayed in their Terp roles for years, and medics who deployed several times to Bastion were always pleased to see them again in their wards, as if they had been waiting for them to come back.
When you think of the hospital at Bastion, make sure you have room in your mind for the Terps, because they were always there, and the hospital couldn’t have functioned without them. They lived in their own tents, close to the hospital, and they often invited the medics back for talks and tea and a little light jewellery trading. Mining probably began in Afghanistan thousands of years ago, and there were still tourmaline, rubies, emerald and lapis lazuli to be bought and taken home for presents, although the plastic surgeon is equally proud of the cufflinks he had made in one of the engineering tents at Bastion out of used brass cartridge rounds.
And they are the only group that I have not been able to reach for this book. Most interpreters have tried to slip back into their lives in Afghanistan without anyone noticing at the end of the war. Only those working in front-line posts between 2012 and 2014 have been allowed entry into the UK, and, as far as any of us can tell, that category did not include those working at the hospital. Afghanistan’s own hospitals need them to work there, but it would mean exposing the kinds of expertise they could only have gained at Bastion, and that is a death sentence. The medics who came home worry about them constantly, try to find them, to make contact, to bring them here, but none of them has so far been successful. They all had the same expression when I mentioned Terps – regret, worry, fondness, resolution – and as soon as they’d finished talking to me went back on email, pressing the cause of the men they left behind. It’s perhaps worth saying again: most of the patients in Bastion were Afghans, needing weeks and weeks of work, and this would have been impossible without the Terps.
Among the Afghan patients were not just army, police and civilians but also CPERS, although most just called them ‘enemy combatants’ (and in other parts of the camp they called them ‘detainees’, but never ever ‘PoWs’). They all had a call on the medical facilities at Bastion, and the principles used to treat them were the same no matter what. Save, maintain survival, strengthen, reconstruct. Keep alive, no matter who or what. Then, when they could survive, they were collected and taken somewhere else, to another hospital or to an internment facility.14 So there was a double pressure to move these particular patients out of the wards, to free up beds and to begin interrogation for intelligence that might include information that would prevent future casualties being created that would need those beds. Meetings ran long over schedule and past politeness as surgeons and clinicians argued about who could and should be moved out of the hospital wards. Daily reckonings, never getting any easier as the war went on.
Like the time a Chinook pilot who flew his MERT team out to casualties every day was called out to take an Afghan baby, dangerously ill with meningitis, from a local town to a civilian Afghan hospital. He had a new baby at home and, like all new parents, was suddenly super-sensitive about the infection. The Afghan child would almost certainly die without access to the antibiotic therapies only held at Bastion. So he ignored the MERT team leader, ignored the watchmaster, ignored the air traffic control tower at the Bastion airfield who tried to make him turn round and bumped down at Nightingale to deliver the child there. He’d flown mission after mission, in the heaviest of fire – had walked round his Chinook night after night to check it for bullet holes – but the child was suddenly his patient, the only one he would ever have, so worth the consequences, worth the loss of the bed. He never found out what happened to her, but he knew for certain that, if the decision fell to him again, it would go the same way.15
One day in January 2010 four beds were in use in the Bastion operating theatre at the same time, drawing on all the available skills in the place. It was a ‘Mass Cas’ – a mass casualty event – not of the same vehicle or unit, but of the same family. An entire Afghan family, injured by an IED, treated at an American unit in the field and then sent to Bastion once they were stable. The youngest, a baby, had died of head injuries soon after wounding, and a ten-year-old had suffered dreadful abdominal injuries. An American surgeon, posted to Bastion to support an ongoing offensive, found himself leading the teams treating the family, and in particular the badly injured child. There was a reason he had not gone into paediatrics, he remembered: because the pain of losing children despite his work and expertise was unbearable. And children die so easily, so quickly, when he thought he’d saved them, maintaining their blood pressure until the very last moment, and then they race their pulse up high and simultaneously lose their blood pressure down low – they crash hard – and then they die.
After five days of treatment most of the family had recovered and were ready for discharge. Only the ten-year-old in ITU ward bed number 7 remained. She had survived four separate surgeries to repair her intestines and abdominal wall, but her first tentative steps on the path to survival were dogged by sepsis. Sometimes her kidneys worked, sometimes not. Sometimes her white blood cell count was almost zero, other times almost normal. Hour by hour surgeons and nurses sat by her bed, wondering what else they could do, with interpreters coming and going, no one far from despair. Like the adults usually in the beds, she struggled in the nightmare world of sedation and pain, twisting in the bed, pulling at her lines. The surgeon decided to lighten her sedation very carefully, moment by moment, so that she could hear her father leaning over her and repeating low and gently, in Pashtun, that she should try not to pull at the tube in her throat, or the so many lines connecting her little body to the machines and fluid bags that kept her alive. She was just conscious enough to hear him, to understand and to nod her head obediently to her father.
Ten days later the child was recovering. One by one her problems were fixed, and her throat tube was removed and the lines replaced by food and drink. She sat up in bed, she could walk as far as her father in the chair, and was strong enough to climb into his lap. And one day her father came and she got up, and together they went home. The surgeon remembered all his patients, but he remembered the children the best. Afghan families were huge – a family of nine after the family of five – even though he never knew their names or enough of their language to talk to them. So many children, always at Bastion. One British medic sent home for an acute paediatric textbook because he simply didn’t have the experience demanded by their casualty. He brought it home, battered and stained, pages falling out because he had used it every single day of his deployment.
*
But somehow they learned, just as surgeons had learned in other wars. They learned that, no matter how good the kitchen food was, it got boring (and it was better if they didn’t think too hard about the roasting tins, which were sometimes borrowed by the trauma teams to catch the blood from patients as it poured off the operating table), so food parcels, the great staple of morale in the British Army, found their way to Bastion in the twenty-first century just as they had to the Western Front a hundred years before. The plastic surgeon liked cheese in his, preferably cheddar because it lasted longer, but anything with really strong flavours worked, such as smoked and tinned fish. If you’ve ever wondered who actually eats smoked oysters in a tin, the plastic surgeon is one of them, but only when he is on deployment.
If they wanted a walk that felt a little like a walk did at home, they could go and ask to borrow the sniffer dogs and take them out, on leads. The creatures seemed to enjoy Camp Bastion more than anyone, but then dogs enjoy almost anywhere. An emergency physician, Bastion’s own Kipling, who wrote poems as well as diaries, wrote about them and the group of volunteers who gathered outside the working dogs pound every evening:
There are two types of dog and they differ –
There is one type you don’t want to stroke –
The Labs and the Spaniels are sniffers,
The Alsatians will go for your throat.16
There were dogs in the pound that the doctors recognised because they had also been flown into Bastion injured. The vet had to be called to treat them, and sometimes this took a little time (no room on the 9-Liner for non-humans). One of the busiest MERT flights ever involved nine casualties, most walking, and a sniffer dog who had spent too much time searching for explosives and collapsed from heatstroke. Back in the trauma bay at Bastion they badly wanted to run lines into him to restore his fluids, but they resisted and waited for the vet.
On his first tour the plastic surgeon made a volleyball court, scrounging gravel to mark out the lines and sewing a net for games in the late evening in the last of the light, when the hospital was quiet. He was really pleased when he went back for his last tour to see that it was still there, and people still found it useful at the ends of their Bastion day to split into teams and remember who was looking after the ball, and laugh and run their way into sundown. On the last tour he noticed that the blast walls now completely encircled the camp, even the long runway, and that the flags were almost permanently flying at half-mast. They hardly ever used the tannoys, because there were simply too many times when the news was too bad; instead, messages about deaths were carried to the various parts of the camp in person, and everyone obeyed the protocols quickly because they’d had a lot of practice. And he decided to make something at Bastion that wouldn’t die or fly away or turn into a scar or stump, just for himself, so he built a garden.
He marked the garden out with wooden fencing scrounged from somewhere, and wedged terracotta pots into the dust and filled them with strong little plants and arranged them all in a neat, elegant scheme. Salads, herbs and plants whose names he never discovered but which grew and grew despite the heat and desert. There’s even a technical term for them now because there have been hundreds of these defiant gardens – built in worlds surrounded by war and violence, offering sustenance, refuge, testimony, relief. He thinks of it now as just a little patch, but scale isn’t important. With defiant gardens, even a micro-restorative environment is restorative, in an unexpected multiplicity of ways.17 There were many gardens built at Bastion, but they could only really be appreciated from a helicopter in daylight, and usually people in helicopters in daylight had other things to think about apart from astonishing patches of green popping up in the desert camp. The plastic surgeon sat out in his garden not in the cool of the evening but in between the long bouts of surgery, when the sun was at its brightest and hottest. The surgical theatres at Bastion were air-conditioned, sometimes a little too efficiently, and they got chilly after hours of operating. Patients had to be warmed up once they came back to the wards. Everyone shivered under their cotton scrubs by the time they had finished, and it was worst of all for the plastic surgeon. Back at home the theatres where he stood for hours and mended burns injury were kept really warm – 28 degrees minimum – all the time, because the cold is bad for burns patients. So he was used to working in the warmth, flourished in it. When he went out into the garden in the glare of the sun, it was to warm himself up properly and to see how his plants were doing, the bright hope of green in a leaf, not the dull khaki of uniform T-shirts or the laundry-bleached blue of theatre scrubs or the base yellow of the limb disposal bags lined up against a wall.18
Some things were beyond the power of a garden, though. A MERT team leader walked into the hospital at Bastion to do the paperwork for a job they had done earlier that day. It had been extremely tough – both legs lost, lines inserted wherever there was room, the casualty as far gone as humanly possible – but they had brought him some of the way back, and all the way to the operating theatre, so really a job gone quite well. She moved from the heat of the open ground into the immediate cool of the hospital, the ringing in her ears from the noise and vibration of the helicopter cabin diminishing with each step. As she pushed open the trauma unit door, file tucked under her arm, the silence halted her in her tracks. No noise in the trauma bay, no doctors bent over her patient, calling to each other, giving updates, no clattering instruments, monitors, machines. Instead they were stood back, stopped, and the team leader was quietly explaining that they should put down whatever they were holding, and that care was to cease.19 The rest was silence. And in the trauma bay next door a team still worked, desperate to ignore the silence that had descended just behind the curtain a few feet from their own efforts to battle back.
Silence. When, no matter what they did, the cascade could not be stopped and the poison was everywhere, when no matter how much blood had been pumped back in it simply flowed back out, when nothing anyone was doing seemed to make any difference. Skin cooling, colour fading, eyes losing light, for the last time. Then the moment, the single moment, when the team leader looked at his watch and asked his team to stop, diagnosing and pronouncing death as quietly as any priest at a committal. Heads shaking, pleading for another two minutes, perhaps something else, something different, but there was never another two minutes, and at the back of the collective mind there was relief that it was over, and that someone else had had the calm and courage to make the call. Eventually knowing that there was nothing more. A moment of reflection, a shift into stillness, for everyone’s sake. Silence. Much quieter voices began the paper trail that followed the dead, as dressings were applied to wounds stitched up as a courtesy, lines left in, gloves and aprons ripped off and binned for burning. Many of the staff were emergency specialists from home, so they had seen death before and knew what was expected from them. Waiting until the other bays are empty so the body could be discreetly wheeled away, the blood mopped off the floor, the supply cabinets restocked for next time.
Those waiting outside pacing the corridors – some of them friends, often from the same unit – were told, and sometimes the surgeon could not help but notice as he told them that their desperate faces were red and abraded from the same blast that had blown away their comrade.20 A Minimise protocol was announced. Minimise meant a death at the hospital, so no internet, no mobile phone use, total communication blackout to prevent the information getting out before the next of kin had been told. It could last a few hours or days, until everyone was properly accounted for. Across the desert in the American military camps it was called the River City protocol (from the musical The Music Man: ‘Ya got trouble, right here in River City …’). At Bastion everyone knew when someone had died at the hospital: one word, Minimise, and silence fell across the huge camp.
Bastion always had its own mortuary. It was not particularly large and in the early years, before the hard-build, had been a tent with limited lighting, the shadowy canvas folds absorbing all other sounds, cloaking itself around the black plastic body bag on the table at its centre. As Bastion modernised, so did its mortuary, becoming a refrigerated hard-built unit, with its own staff. Access was always tightly controlled as the administration and preparation of death and its consequences were undertaken. Because the deaths of British nationals meant a long journey halfway around the world, across the continents, an international death certificate was required. Certification was done by the most senior doctor, usually the medical director, at the hospital – the one who had been at Musgrave Park and Kosovo, and had deployed to Iraq and had signed a hundred certificates there, and then many more at Bastion.
It was a task he undertook alone. Just him, and the dead, in the tent and then in the hard-build mortuary. Sometimes there was so very little left of the body that all he could write on the death certificate was ‘Total body disruption’. He knew that there was nothing about his experience that was worth the learning, so no junior surgeons or doctors came in with him; he never whispered a short lecture about certification in the mortuary but instead covered it in other training sessions, in other places. There was usually something to send home and bury but sometimes not much. When Richard Hillary was burned to death training to fly night fighters in 1944, there was nothing left that distinguished his body from the wreckage of the aircraft, and so, like all the other aircrew whose remains were nothing but ash, the coffin carried into church for his funeral was full of sand. Something was better than nothing. Sand is still used today to make up for the weight of a remnant body in a coffin. Death at Bastion. Dust and fines and sand.