Critical Care
The multiply injured soldier has multiple contaminated
wounds, is systemically unwell, immuno-compromised
following massive blood transfusion and requires multi-
system support in a Critical Care environment.1
MULTI-SYSTEM SUPPORT. Nursing, in other words. We know the name and the life story of Harold Gillies, pioneering plastic surgeon in Britain during the First World War, but we know almost nothing about the nurses who kept his soldier patients clean and uninfected and alive, who fed and watered them sip by sip through shredded mouths and noses, who watched over them in their pain – who made them strong enough for long anaesthetics and complex operations. We call this critical care nursing now and there was a Critical Care ward at Bastion, next to the pathology lab (good reason for that, see below).
Most of the patients who needed nursing at Bastion were locals, who went from short stays in Critical Care to the ordinary wards until they could be moved on. Nurses, like everyone else, relied on Terps for their daily communication with these patients, but usually, once the emergencies were passed, this was (mostly) straightforward. In some ways it could be easier than nursing at home. When I asked a senior nurse what she particularly remembered about this kind of work, she said Antibiotics. Her Afghan patients responded to antibiotics much more quickly than her patients back in the UK. No matter how serious their infections (and Afghanistan had myriad ways to infect the human body), a short course of antibiotics and they were usually all cleared up in forty-eight hours. No multiple courses and no allergies. So much easier than nursing in an antibiotic-resistant population. Just an observation, no control trial to test her hypothesis but something unexpected to appreciate.
So it wasn’t the long-stay patients who posed the greatest challenges to Bastion’s nursing staff; it was the short-stay ones. British military casualties who came in on MERT, who were revived in the trauma bays and had damage control surgery in the operating theatre only stayed in Critical Care until they could be moved back to the UK, usually twenty-four hours or less. Definitive surgery, the kind that needed microscopes and more kit than even Bastion could provide, could only be done at home, so in the meantime, critical care.
The meantime at Bastion was something more than holding the patient steady until the transport came for them. The meantime was when those watching most closely came to understand the exact terms of the deal for life that had just been done in MERT and the trauma bay and the operating theatre. Understanding really meant management of the consequences of the negotiation. The inflammatory storm – the tsunami in the body – receded, leaving behind its wreckage and poison throughout the body of the patient. Nurses worked in its wake, clearing a space so that later others could go on working. Starting with those multiple contaminated wounds.
Much of the nurses’ time, unsurprisingly, was taken up with wound care. By the end of 2009 most blast wounds were coming in avulsive, with the soft flesh and all its workings blasted high up the limb, away from the bone fracture. The surgeons did their best, and when they finished, the wound was swamped with hydrogen peroxide, a last sample was taken for lab tests and then what’s left came back to the ward at Bastion for management. Avulsive wounds bleed, and when they’ve been stopped from bleeding, they exude another liquid – exudate, as if they are sweating heavily under extreme stress (‘exudate’ comes from the Latin word exudare, meaning ‘to sweat’). Nurses see it in wards back home all the time from ordinary wounds and surgical repairs, just not as much of it. There was so much on the ward at Bastion.
Exudate can be clear, or opaque, amber or grey-green, odourless or foul. There needs to be just the right amount of it to indicate healing.2 Exudate keeps wounds moist and gently swills good stuff like proteins and growth factors and nutrients around a wound site, which encourages it to get on with healing. A good wound looks glossy, with small amounts of exudate visible and neat edges left behind by the surgeon. Too little exudate (scaly skin, dressing sticking to the wound) means that the body can no longer produce it and that something much more serious is going wrong, systemically, such as shock or severe dehydration. Too much, and the problem is local, at the wound face itself: disordered inflammatory mechanisms make the actual wound eat into previously undamaged tissue, and there’s little enough of that to spare on an avulsive wound. Too much was usually the problem at Bastion.
Too much exudate, like sweat stains on a shirt, soaks through ordinary dressings. When exudate gets to the outside layer (with the uncharacteristically dramatic medical name of strikethrough), then any antimicrobial properties of the dressing, the barrier between air germs and vulnerable wound sites, is lost. It’s the same principle for when the blood or gunk from a scrape on your knee soaks through your plaster: it means the plaster (dressing) is useless. It should be taken off, till the bleeding or seeping has stopped, and then a new one put on. But in military wounds, especially avulsive blast wounds, the exudate keeps coming, and if it isn’t kept clean, it starts to smell like the nastiest sweat imaginable, and you can’t keep taking off the plasters and putting on new ones because it means more chance of infection, less chance of healing, and it hurts. It really hurts.
So there’s a twenty-first-century solution: negative pressure wound therapy. It sounds like a physics solution, and it is. Dressings are applied over the wound site, packing down right to the wound bed. The dressings are gauzy material, and impregnated with antimicrobials. If it’s a deep wound, thick pads of the gauze are used, pushed down inch by inch – not too tight, not compacted, just enough to fill, with the tail end left outside the wound, so nurses never forget there are rolls deep in there, and eventually all of them will be taken out. But it’s wonderful stuff, so if they get it right they can leave it in for as long as necessary (sometimes two weeks even). The gauze is absorbent, permeable, but very gently so, like lung tissue, so you’d hardly notice as the liquid passes through it safely. And then a drain tube, with a round transparent pad at one end, is settled on the dressing, with all the edges sealed around the wound. At the other end of the tube is a fat plastic box that contains the compression pump. Turn it on, and the negative pressure created by the gentle force of the dressing absorption meets the positive pressure from the pump and the exudate is drawn away up the tube, into a collection canister, almost silently – just a slight, constant hum from the compression unit, one of those excellent sounds medics like to notice on a trauma ward. And for the patient, no ripped dressings, no more smell, no more lying in bed knowing almost nothing for certain except that the smell of rot comes from themselves.
Turn on the pumps, let them manage the wound and then step back to see more of the consequences of the deal. Beyond the wounds, a systemically unwell patient. Life now, but of very poor quality in the meantime. A hungry, degraded body that had started to lose muscle mass almost the moment it was injured, because it had almost no other reserves. Soldiers were usually super-fit, with almost no body fat, as a result of exercising compulsively and competitively as a way to pass the time. Many of them had been out in forward positions for months living off rations, with not much fresh fruit – plenty of tinned, but not a great diet considering the physical demands and the stress. And even though now they are stable, lying in one spot, not moving and mostly asleep, they use up energy just by being, by staying alive, by surviving on the spot, no movement forward. So nourishment is as necessary as the oxygen in the ventilator, the negative pressure pump on the dressing and the antibiotics in the intravenous lines.3
Not just hungry. Something much worse than just hungry. The body in the bed might be still and sleeping, but inside it has begun to turn on itself, feeding off whatever it can find, because it needs the energy to make it to the next pulse beat. And although the inflammatory storm has passed, inflammatory responses are still there, now chronic and dangerous. There are no more dead cells to eat, so now they start on live ones because they can’t tell the difference any more. Exudate is full of protein, and if the little collection vessel attached to the tube is filling up and emptying regularly, it’s good in one way but it means that the patient is loosing fluid and protein.
Here are the technical terms for what happens when a traumatised body starts to feed on itself. They all begin with ‘hyper’ – and that’s never a good thing. Hypermetabolic: galloping energy consumption where muscle tissue is broken down directly and feeds into the bloodstream for energy for the cells. Hyperglycaemia: traumatic diabetes, where insulin levels are out of control every which way, damaging liver and kidneys. Hyperlactatemia: acid levels soaring because there is less oxygen because of bleeding, more energy needed from everywhere else, stress hormones, flooding in because this is extreme trauma, and poison from infections. Here’s a non-technical term to describe what is happening: a cannibal chemical soup that is gradually eating the human from within to survive and killing them at the same time.
So in Critical Care new intravenous lines, preferably directly into the stomach or, if there were complications, straight into one of the large veins in the chest or the arm. And before inserting the new line, nurses make complicated calculations and measurements (or ‘defined algorithms, tables and equations’) – how much of muscles that lifted rifles or dug out mines has now wasted away – to work out what exactly needs to be put back in. Essentially proteins, glucose, fats, amino acids, immune supplements, even fibre, to prevent constipation, which everyone can do without. The jury’s still out on fish oils, but fatty acids might be a way to help and they don’t seem to do any harm. And perhaps, when the lines are in and the calculations are done, nurses can watch and see some improvement, life a little better.
The easiest and most immediate way for nurses to make their patients’ lives better was to treat their pain. They had general anaesthesia to start with, on the way into surgery. Then, if they were awake, normally or post-operatively, questions about pain (pain treatment always starts with questions) and then drugs and plenty of them: synthetic opioids (opiates only if the compound derives actually from the natural source of opium, the poppy, grown all over the world throughout human history, quite a bit of it in Afghanistan, oh the irony). Opioids work best on acute pain, particularly post-surgical pain. Lots of that at Bastion. So opioids are the best response overall. They bind to specific receptors in the nervous system and quieten them down. The pain itself is reduced, and the sensations of pain in body and mind are also lessened. The downside of opioids it that they knock the patient out, or make them very woozy. And they aren’t site-specific. Opioids are a whole-body response, when something that targets more carefully would really help too.
Site-specific pain relief is called regional (as opposed to general) anaesthesia. Regional implies a bigger area to be treated than local anaesthesia, which is for smaller things such as single teeth. The anaesthetist who kept the patient under for their surgery comes back to the ward. They have ultrasound machines which help them locate the exact nerve that needs blocking, and once they’ve done that, they insert a needle, with a small plastic catheter (about the size of angel hair spaghetti) threaded through it. Needle in, needle out, catheter inserted. Dressing on, please, nurse. And then the catheter is connected to a pump full of medication and slowly starts to dispense it directly where it is needed. It blocks the nerve sending the screaming signals from the injury to the brain. Simple. Put the drugs where the pain is, where it starts, stop it going all the way to the point where the chemical soup is started – the hormones, the stress, the fear. There are lots of advantages to nerve blocks, and fewer side-effects. Opioids cause drowsiness, and they usually cause constipation, itchiness and they can make the patient feel sick. The lack of drowsiness means the patient can move more, maybe even have a little physiotherapy to get their systems going.
And just like negative pressure wound dressings, medics can use as many nerve blocks as necessary to prevent pain. Multiple injuries, multiple nerve blocks, multiple ways and means. Nerve blocks, lined up somewhere clean and convenient, not anywhere where the bones are fractured, so they can be managed without causing more pain and damage. And not too high on the body, or too low: in fact, just right. An amputation of the leg or legs, they get an epidural (catheter in the spine, a nerve block too, one of the first to be used frequently). Abdominal or pelvic injury, along with upper limb injury, and they get a nerve block catheter just above the collarbone. Sometimes it was the shredding of blast injury that made nerve block use too difficult, so then it was back to general analgesia, usually via patient-controlled analgesia (PCA) pumps – patient feels pain, patient depresses button on pump, patient gets more painkiller. The first jokes soldiers made after they found themselves in Critical Care were usually about the PCA pumps – threatening to take more if their mates came in and bored them or cried, miming multiple pumps of the drugs and lolling dramatically.
So more pumps and machines round the bed and catheters to monitor for the nerve blocks for the patients who stayed awake. All those instructions in journal articles about keeping the catheter site clean – those are for nurses, who have to go in and look closely at every entry point for signs of redness, swelling, with the patient inhaling sharply when nurses gently touch it with their very gloved hands. Unmonitored, infection can bite deep and quick; in epidurals a dirty catheter is a fast lane to neurological infections such as meningitis. Epidural catheters warrant their own chart, filled out hourly, with things like drug levels in the block, and a pain score; if there’s a severe, unexpected infection, this is where it will be seen. If the pain starts to come back, then get the anaesthetist to come and up the dose. And nurses know their way around the pumps the patients use themselves, how to turn them on and off and up or down, and how to change the batteries. It’s a lot to remember, but remember how much easier it is now the patients aren’t battered into submission by strong IV medications, usually opioids, and anything that helps keep them off ventilators is most welcome. And there’s science to back all of this up.4 Wherever the nurse is, whatever they are watching, if in doubt, labs – skin, blood, catheter tips, anything, test it all, again, even if they’ve tested the regulation amount of times already. That’s why the pathology lab, where the testing could be done, was so close by at Bastion.
Even though nerve blocks and epidurals have been common for years in civilian hospitals, the tented military hospital just couldn’t provide a sufficiently sterile environment for their use. But the hard-build made of hermetically sealed Portakabin units could. Throw in portable ultrasound machines and really good catheters, and experience in their use, and nerve blocks came to Bastion in time for 2009, when they would be really needed. Here’s that underlying principle of military medicine again – move clinical capability as far forward as it will go, even if sometimes it means waiting for a hard-build. Because it means that next time they will have worked out how to use nerve blocks in a more austere environment, as well as even smaller ultrasound, different bacteria-resistant catheter tips, cold storage to keep them all in, all ready to go. Clinical capability forward: bring the hospital to the patient, in a hard-build or a helicopter, bring as much of the hospital at home to the patient in the war zone. Do it quickly, do it well and (hopefully) everything is easier the other end.
Military nurses moved quietly around their ward at Bastion, men and women dressed the same in combats but most of the women with the neat bun of hair tucked at the back of their head. It looks like a world away from any other world or any other time, but especially from that of their predecessors in the First World War, who wore the uncomfortable starched dresses and white veils and remonstrations from Sister if the laundry hadn’t been done well or frequently enough. But whatever the uniform, nursing military trauma across a century is in essence the same: watching the wound, watching the wounded, feeling strongly about those whom they will never actually meet in person.5 Hearing without listening the change in breath sounds, seeing mates gathered at the doorway, knowing when to call a surgeon, when to change the negative pressure pump. Better scent receptors than the finest perfumer, and knowing how to keep a smile even for those who might not yet be able to see it. Seeing problems no one else can see, and finding solutions. Not solutions that involve algorithms, tables and equations – so no research trial or journal article, or points on the promotion scale – but still solutions that make things easier, better, not just for their patient but also for the patient’s kin, who wait along the road for their loved one to be strong enough to reach them.
Patient diaries are just such a solution to a range of problems for nurses across Critical Care, whether civilian or military. And they are the answer to a hard question, the one about what happened while their patient was asleep. In 2008 a nurse arrived at Bastion. The long wait in the aircraft hangar, then the tactical landing in Afghanistan, bumping down on the runway in total darkness, the dust and fines, then the drive to the hospital. But the hospital was like nothing that he had experienced on his tours in Iraq. The ITU (Critical Care) looked like it did at home: the same artificial light, the same air-conditioning, a world within a world, quiet, safety. A ward round, wounds and the wounded explained to the staff caring for them (patients rarely sufficiently awake) and then swiftly patients gone, flying back home, someone new, sedated and ventilated, in their bed. Most unconscious until Birmingham, and he knew this was going to be a problem. He’d watched patients wake on an ITU ward, saw their panic at where they were, not knowing why they were as they were, and the deep stress inflicted on them by the process. ITU staff tried to explain, but shifts and bleeps got in the way. As ITUs became more advanced, so did a condition known as ITU-PTSD – the stress induced, post-traumatically, by not knowing what has happened to the patient during the hours and days that are missing from their memory.
How much worse, he thought, would this be for the soldier who fell in the desert, was swooped away by MERT, saved and nursed at Bastion, flown half a continent away and then woken, not with their unit around them dusty and shouting, but their family, strained and weeping. At home ITU-PTSD was being mitigated by something very simple: a diary. In it nurses wrote down the things they would say if their unconscious patient could hear them.6 Not a medical record – that was something separate – a diary. Of pain, of sleep, of dreams, of weather outside the window, of visitors, of watching, of time passing. They should have patient diaries at Bastion, where the moments in between the explosions and echoes could be recorded, sorted and retold.
The nurse had been working in a health service in one form or another for long enough to know that this sort of thing was better done himself, improvised rather than waiting for clearance. So when he went home on leave he designed a notebook that could be a diary, and took it to a printer, and paid £180 to have several hundred copies made. Very simple, A5 size. On the cardboard cover were basic details such as name and date of admittance, and inside three columns: Date & Time, Narrative and Signature. And then, when the boxes of diaries arrived back from the printer, he went round all his colleagues and handed them out and explained how they worked. Some of them already knew because they’d seen them in Critical Care at home, but everyone said what a brilliant idea, right from the outset. A civilian innovation adapted and improved in their little ward in a hospital in the desert. Watching their wounded became something different, something better. They pulled up a chair and dug out a pen (often from where some of them had stuck it in the bun at the back of their head) and remembered what they’d just done, how they might have told the patient quietly about it even though he was unconscious, but now they could tell him in a way that he might eventually know and understand. How much blood he’d been given, that they had donated their own blood to the hospital’s supply and now it flowed through his veins. That, even though they were supposed to have gone off duty, they had stayed on at his side. That someone had been watching him, never a moment alone, until they handed him over to the next watcher, and they to the next, until he was awake.
The patient diary system started small but soon spread, and the medical officer in charge recognised how well they worked, so they became part of the official system, part of the standard paperwork, part of a training course even. That sort of thing usually took years and committees and meetings – in Bastion, double-quick smart, something that works, use it. They were one of those things that, as soon as they were told about them, everyone just knew were a good thing. Word spread out of the hospital and up the runway to where the MERT crew lived. Just like everyone who handed over a patient they had kept alive, MERT crew wanted to know what happened to the soldier rushed into a trauma bay. So nurses on the ward let them in to see their patients, to read the diaries and to understand what had happened afterwards, and then they asked if they too could make entries, so the soldier would know he had not just been slung in and out, but that many people had looked after him in flight, that he had been fought for, every second, every pulse beat, all the resources and effort they had to offer.7 And somehow filling out the diaries helped the MERT crew too, although one RAF nurse remembered always walking away quickly from the ward, tears on her face, which she wiped away as she found her way back to her quarters to make ready to go out again.
Friends too. Diaries gave them something to do when they came to see their friend, who couldn’t hear them or reply, so they didn’t just have to stand there and worry whether they were allowed to touch him nervously on his shoulder or if they would mess up the lines running in and out of him, or bother a nurse to ask. They could just pick up the diary and find a pen and sit down and write, including the time and the date. This could sometimes go wrong. The plastic surgeon was on the ward checking on a patient and watched as a group of soldiers sat by their unconscious, heavily sedated, battered comrade and started to write in the diary. After a while they realised it wasn’t who they thought it was, so one of them quickly wrote ‘Sorry mate, we thought it was someone else. Get well soon anyway.’ (This was told as a joke by the Bastion medics but is testimony to something more sobering. Soldiers could be living at a patrol base cheek by jowl with each other for months, sharing immediately every detail of each other’s lives, but blast injury could render them unrecognisable one to the other, swollen, battered, anonymous, a remnant.) Diaries went home in the paperwork folder on the Critical Care Air Support Team flights between Afghanistan and Birmingham, where nurses and flight crew added their thoughts and messages. Entry by entry the diaries grew as a record, beyond the medical, of the human beneath the lines.
Pen to paper, important for everyone, making a record. When patients made it out of the trauma bays and the operating theatre, patients who by rights shouldn’t have, nurses took a red marker pen and drew a small red heart next to their names on the admissions board. These were the first visible notations given to unexpected survivors by anyone at Bastion – the journal articles describing the condition in technical medical detail hadn’t really got going – and they made for a good, easily read answer to the hard question of what happened to the patient next.
*
On 2 January 2011 nurses in the Critical Care ward at Bastion began a patient diary for Scott Meenagh. Scott had no memory of what had happened to him after the first forty seconds of the MERT flight in the Chinook, so the diary pages (four of them, double-sided, even though he was at Bastion for less than twenty-four hours) told him what had happened there, words from medics, MERT crew and his comrades who had held it together and got him on board the helicopter.
One of the paramedics visited him in Critical Care:
Scott, Get well Soon! I came to get you and load you on the RAF MERT Chinook. You are in great hands now and will be in the future as you get back in it!
One of the nurses who had attended him and the other casualties from his unit in the trauma bay came through to the ward:
I was in ED [Emergency Department] this morning co-ordinating the help you and your colleagues needed. This was a real privilege to do. You may have dark days ahead but I am sure your friends and family will get you through the months to come.
After them came his nurses, pulling up a chair next to his bed, finding a pen, starting to write to the patient whom they would never actually meet:
Hi Scott; I looked after you when you first came to the Critical Care unit from the operating theatre. We kept you asleep and gave you lots of pain killers. Keeping you asleep was difficult at first because you are such a big bloke. Anyway, all the best and stay strong.
The hospital padre, who had waited in the ward all day, as he did whenever casualties were admitted, wrote:
Scott, from the time of this incident itself you’ve received all the care it was possible to give. As people have visited you today, I’ve prayed for you and those involved. My prayers for your recovery and return to full health as you face the future.
No matter that he couldn’t hear them, a steady stream of visitors had sat down at his bedside to write in the diary, from his CO (‘The thoughts and prayers of all at 2 Para are with you’) to his mates. ‘That’s airborne’ was one response to the news of how he had applied his own tourniquets. And from a particularly close friend in his unit who badly wanted him to know that he had been there, as long as he could, although he too was on his way home:
Scotty, it’s […]. How’s it going brother. Am just going on R&R and I’ll come to Brummy [Birmingham] to visit you. We’re […] still going on that holiday we always planned on a beach somewhere.
Am gonna sit here now till they kick me out and mumble crap in your ear. I’ll probably bore you but your just going to have to listen. See you in Birmingham Meenagee, love your brother […].
And from a MERT crewman, the first real statement that Scott’s life would now be something very different from what it had been that morning:
We brought you back from Bastion and now the best we have is for you. Good luck for your onward journey and beyond.