11

Critical Care Air Support Team (CCAST)

So here we are […] halfway home, somewhere in the sky.

Patient diary entry, 14 February 2011, 0130 Zulu time

GOING HOME. British casualties were moved as soon as the staff in Critical Care had made and held them strong enough for the journey. What they had at Bastion was damage limitation. What they needed from now on was definitive repair, and that could only be done at home. And besides, the next patient was bumping down at Nightingale, needing the bed and the medics waiting in the trauma bay.1 So those who could be moved were. Surgeries finished, transfusions holding, breathing steady, wounds packed tight, pain and infections managed. A different kind of movement of clinical capability – expertly managed transitions, skills designed not to waste any of the work that has gone before. For the time being.

The time being was a journey across a continent, three thousand miles, from Afghanistan to Britain.2 Along the time being, the patient was carried in huge aircraft, high above the planet, the C-17 Globemasters. Another world from Bastion, another life – going to another life. A critical care support team sustaining them in the air, like MERT, only much less bumpy. A medical team of six: one nurse per patient (and on CCAST the team leader was always one of these nurses), and one spare who went where they were needed, a Critical Care anaesthetic consultant, a trainee, an RAF medic and a medical technology specialist. Aircrew: a loadmaster who saw to what was carried whether it breathed or not, maintenance crew and three pilots, two flying, one spare resting, at the front. Sustaining life one pulse beat at a time as the miles flew past below. Surround and sustain.

When the 9-Liner was received at Bastion, the message about the wounding went out along the entire chain of care, from MERT quarters, through the resus bays in the hospital at Bastion, the hospital at Birmingham and the headquarters of the CCAST at Brize Norton – beepers going off thousands of miles apart within fifteen minutes of the blast of the IED. The aim for every critically ill patient was to get them home within forty-eight hours, but it was often much less than that. Severely injured patients could be ten hours in surgery and then less than a day on the ward. Scott Meenagh’s patient dairy covered only one day in what had become the first of the rest of his life: explosions, surgery, on to Critical Care at 1400 hrs on 25 January 2011, then off it by midnight to fly home.3

Even at maximum capacity during the hammering of the hospital in 2010 – five separate beds bearing five separate critically ill patients, five separate teams, one for each plus a stretcher case and walking wounded – this system (the air-bridge, they called it) worked properly throughout. It was once reorganised in 2010, because of the ash cloud from Iceland’s Eyjafjallajökull which seeded the sky with volcanic dust and fines and grounded all the planes over Europe, no matter who they carried.4 A CCAST flight was the last flight to land in the UK before the grounding, getting special permission to do so. And because no one knew how long the ban would last, a back-up was implemented that put a CCAST crew and aircraft in southern Spain because flights were possible across southern Europe. But it never came to that. Along the air-bridge, people were where they said they would be, when they were supposed to be, and they knew what to expect when they got there.

*

When CCAST landed at Bastion, they didn’t wait for their patient to be brought to them. From the moment the patient was prepared to leave his bed in Critical Care, he belonged to CCAST. Patient and machines. The patient they collected from the ward at Bastion was all lines, pumps, tubes, plastic bags, and none could be disconnected. CCAST arrived in the ward, and the consultant and the team leader nurse moved to the patient. They carried a heavy ventilator and monitors on thick black shoulder straps, and usually they had their own negative pressure wound therapy pumps (always in short supply at Bastion, and they didn’t want to let them go). A trolley with a stretcher slid into its side rails was lined up alongside the patient. On the stretcher was a vacuum mattress, like a flat square beanbag, where the air could be pumped in or out, moulding around the patient, especially helpful in the case of spinal injury, fractures and newly amputated limbs. Over that was an absorbent sheet for drawing up blood and fluids. At the top was a head-up backrest that kept the head raised at a 30-degree angle, helping to promote lung function, even if the patient was ventilated.

‘Transferring’ was called. All the lines and pumps were switched from the ward machines to their CCAST travel equivalent: ‘flick and click’ they used to call it, right first time on all of them. Then the patient was lifted over on to the stretcher. Another absorbent blanket was put on top of them and then a specially designed harness was strapped over everything, holding each limb in place like a black starfish, so nothing moved when it wasn’t supposed to. It was hard to see the human at all now, just quarters of body skin held together by nylon webbing and lines. A spoken handover, along with the paperwork that accompanied the patient all the way home: X-ray films, bloodwork, medical records (usually on a CD), the patient’s diary, the patient’s passport (theoretically there were immigration checks on arrival, although they never actually took place).

Then as one, they moved. One nurse did nothing but check each line as they transferred, and it needed to be a nurse who didn’t mind shouting Stop!, being impolite about tangles, keeping things on track. Then into the back of a military ambulance, line by line, the stretcher slid out of the trolley rails on to a rack in the vehicle. A mile or so, at 15 m.p.h. – no faster, no matter what – to the runway where the transporter plane waits, then unloading, line by line, with eyes never leaving the points where machine meets human. Then slide out the stretcher again, up the ramp, on to the plane, sliding it into a bed frame clipped in on board, arranging the machines around it, line by line, no snagging on the stanchions and framework inside the aircraft. Stop. Check the lines, eyes on the patient, ready to go.

If the CCAST team ever had time to look up as they approached the aircraft, they would have seen a huge machine – the C-17 is not called the Globemaster for nothing – filling their vision waiting to take off. The first war artist who went to Bastion called the giant air transporter ‘resplendent’, like a cathedral, a huge vaulted space, lit to its roof, even though the inside looked like it was made of Meccano. The floor space is massive and square, wheels in blisters bulging along the rear sides out of the way. It isn’t just used to carry the casualties – one time the CCAST crew watched as a bulldozer bumbled its way out and down the ramp and set off along the runway to whoever had ordered it. Then straight away they went up and clipped in their cargo, in the same place, on the same modular system, forgetting what had been there moments before, ready for take-off. An entire Chinook can fit inside, if the rotors are folded up, or a single coffin, covered in a flag, clipped in safely all the way home.

The Globemaster doesn’t need a very long runway for take-off – up and off in less than 4,000 feet, ideal for the austere airfield. It goes when it’s told. Bastion runway was busy every minute of every hour of every day: transport aircraft, helicopters clattering up and down, and unmarked aircraft and unmanned air vehicles quietly going about their business. The air traffic controllers were the best in the world – no one passed their course unless they scored 80 per cent or higher. The Globemaster did whatever it could to help by making the most of the limited space it occupied.5 It turned on whatever the aircraft equivalent of a sixpence is, and it could reverse park. It flew stoically for 2,400 nautical miles at 40,000 feet, mountain ranges no problem, with two pilots, one in reserve and a loadmaster. Globemasters were never temperamental, so not much else was needed from ground crew when at rest.

Once the aircraft had cleared the ground and levelled out, beyond the range of enemy attacks, the seatbelt sign went off, the end of tactical darkness, and the lights went up. If there was no turbulence, they could unclip the starfish straps on the trolley, for easier access to the patient. Body armour and helmets off, and the sound of the world high in the sky suddenly bursting over them. Globemaster interiors were noisy, constant, unceasing rattle, clatter, droning hum. Too noisy to speak effectively for hours at a time, so they had their own comms system, headphones and mikes, separate from that of the pilots. This is what they used if they had to confer over their patient, so they left them on all the time and protected their hearing. CCAST crew don’t have the tinnitus legacy that many MERT crew have.

Some of the things that might have seemed complicated on board the Globemaster are not. The complex of lines and tubes and pumps swarming over the patient was not affected by the pressure changes of high-altitude flight. Bastion was 3,000 feet above sea level anyway, so patients have been treated at altitude before they ever took off. The cabin was pressurised to 5,000 feet and the difference didn’t matter enormously. It didn’t mean the medics could ignore the tubes and pumps and lines – they had to keep them clean and wiped, and level and stable, and the flesh around them moist – but they didn’t have to worry about the complicated equations about changing oxygen levels at altitude that are in the textbooks. But there are plenty of other things that were complicated enough.

They could move around the patient as necessary. There was plenty of room on the Globemaster, enough for a 360-degree approach, just like MERT, and plenty of light. They needed to take the straps off because their patient needed to be rolled every couple of hours. The vacuum mattress was excellent, but it didn’t stop pressure sores, which probably already started back at Bastion from the operating theatre and the ward. One nurse made particular efforts to remember extra gel pads, which she placed around her patients’ heads because otherwise they deplaned with blisters or sores and bald spots (occipital alopecia) – extra injuries that no one thanked you for once they got home. There were drugs to be monitored, and adjusted, keeping them down and steady, and dressings to be re-dressed.

Most patients were sedated, so their anaesthetic kept the pain away, but if they stirred or shifted under the blanket, the consultant checked the dosages and adjusted to take them back to comfortable stillness. The few that were awake (and asleep was much easier for the CCAST) got their pain management via epidurals or nerve block catheters or PCAs, which they might be administering themselves with a pump. Only certain models of pump were licensed for use on board military aircraft, in case they interfered with other systems or the other systems on board interfered with them. If there were no nerve blocks, CCAST staff could give analgesia themselves, but they preferred it if the patient came on board with what they needed. And they may very well have needed it. Waking pain could be affected by so many things in flight: the vibration of the aircraft, G-force, air sickness (which could be treated) and plain old-fashioned fear of the moments that were passing and the life to come (which could not).6 If the flight was long, the analgesia might have started to wear off as it neared the end, so extra medication could be given to help the patient with the manoeuvres of landing, deplaning and transfer. As along the entire length of the pain management pathway, and the CCAST was part of this, medics anticipated pain and its increase or change, and medicated accordingly to stop it happening in the first place, because under-treatment is damaging in the longer term, no matter who or where they are.

But some things were simply too complicated for CCAST. Feeding, for instance. The intravenous feeding tubes inserted in Bastion were removed for the duration of the flight. On CCAST the vibration of the aircraft and any sudden turbulence could cause the fine particles of the food to leak and then, rather than going into the stomach, they went where they shouldn’t, such as into the lung tissue, and got infected – micro-aspiration, to give it its proper name. Micro-aspiration causes ventilator-associated pneumonia, and ventilator-associated pneumonia causes death.7

On a CCAST flight, even the things they could rely on they were trained not to rely on. Stethoscopes weren’t a lot of use – difficult to use with ear protectors, so much background noise and so little human flesh to put them down flat on, since all the useful parts with something to listen to were covered in tape and tubes. The aircraft’s background clatter meant it was difficult to hear the bip of the alarm if a ventilator failed, so a light was added that flashed brightly and insistently. Temperature needed to be steady. Fluctuating body temperature indicated changing levels of metabolic disorder, that a body that had just managed to remember how to clot for itself had suddenly forgotten, and that a ravaged immune system was collapsing all over again. So they checked the monitor, constantly. The Globemaster had enough power for all the medical machines on board, and oxygen supplies, but the ventilators ran on batteries anyway, and the staff member responsible checked continually that they were not depleted, and that the store of spare batteries was as per regulations. In theory, the machines could be prone to electrical or magnetic emissions from the aircraft’s own power sources. They were tested for airworthiness, but CCAST monitored them, as well as everything else (that’s why the technician was there), all the way home.

CCAST had plenty of practice, so, as the rhythm set in amid the clatter of the flight, high above the planet, there was time to reach for the folder with the patient’s paperwork in it. The patient diary was there, with the entries from the nurses, and the surgeons and the MERT crew and the friends, so the CCAST added their piece.8 You were quiet and steady, or You’ve had a bit of a wobble, or We had to give you a little more anaesthetic because the strain had started to show on your face, shadows in the light cutting deeper in the frown. Not just the medics. One of the nurses went forward and squeezed into the pilots’ space with the diary and a pen, and the pilots made their entries. They pasted in a small map and marked out the route they were taking as the continent unfurled beneath their wings: landmass, rivers, mountain ranges, seas. That’s Armenia below us now (or Romania or Germany or Belgium) and We came this way because there were crosswinds or a storm that pushed us up higher up above the clouds.

And then back to the bedside. Emptying the negative pressure reservoir of the exudate, knowing that each cupful contained too much lost protein and that soon the body would begin to feed on itself again, so hurry pilots, find friendly tailwinds. Watching. Watching for eight hours, a quiet shift change to allow rest, but always someone watching, pulse beat by pulse beat. The CCAST weren’t asked to heal their patients but to hold them where they were when they were handed over, no worse when they landed, and sometimes, because it had been eight good hours without take-backs to surgery, even a little better.

*

But CCAST hadn’t always been there. Thirty years earlier another of Britain’s small wars was fought far away. The battle for the Falkland Islands, in the South Atlantic, lasted seventy-four days and was a military victory, despite shortcomings in every aspect of the operation. Supply lines were so strained that by the time the victorious British army arrived in the capital of Port Stanley, they were starving, and for the first time in nearly a century there was looting by troops for basic food and water.9 Medical provision for the 255 casualties was, despite the efforts of regimental medical officers and surgeons, basic. Everything was the opposite of Afghanistan, and nowhere could this be seen more clearly than in the case of a young Scots Guards-man, Robert Lawrence, who fought and fell on Tumbledown Mountain on the night of 13 June 1982.

Lawrence was part of a mission to take a high ground position, from where the capital would be encircled and the enemy defeated. Initially it was successful, then everything went wrong. The enemy was waiting for them, and there was heavy shelling, snipers and hand-to-hand fighting across impossible terrain in terrible weather – 40 knot winds and blizzards, freezing temperatures. There was no protection against the weather, let alone the weapons of the enemy – a woollen beret instead of a helmet, and no body armour. Lawrence had been on the mountain for several hours and his battalion were beginning to make progress when he was shot in the head by a high-velocity bullet that blew away half his brain, bringing him crashing to the ground. He could feel the wound it left behind, hot and searingly painful, so he thought he would pack it with the snow that lay on the ground around him, which was when he found he couldn’t move. And in the meantime, blood – not enough to kill him there and then but bad enough.

There were helicopters to evacuate casualties off the mountain, but not enough of them, and they were only a means of transport, nothing else. Broken radios and general chaos meant it took two and a half hours for one to get there, and when they loaded him up, there wasn’t really enough room in the cabin so ‘his head ended up hanging out of the door as they flew along.’10 At the field hospital no one thought he would make it, so he went to the back of the queue for surgery. But he did survive, and after four hours his head was operated on to clear away the dead brain tissue and bullet fragments. Then he was taken to a hospital ship moored in the bay. No pain relief because it was thought to mask symptoms. He had a nine-inch-long wound that began above his right eye and disappeared over the top of his head, constant, thrumming pain and nightmares – dreadful nightmares, for which the answer was a coffee or a beer and a cigarette with whoever had the night shift. Then to Uruguay for an excruciatingly painful brain scan that made the ever-present pain even worse. But the scan confirmed he could fly home for treatment safely, on a VC10, which could hold sixty-eight stretchers in three tiers up and down its metal sides, with aircrew – stewards not medics – who walked up and down a central aisle to mind their passengers (they were never really patients) during the seventeen-hour flight.

Lawrence’s injuries had left him partially paralysed on his left side, with a flailing arm that hung down the side of his body. He had some initial physio on the hospital ship and was coming to understand somehow that this would probably be permanent, but the pain was all that filled his head now, so he took a bottom bunk, because he could get into it and picked his own arm up when it dropped out of the cot on to the floor. He could only tell it had fallen out by looking over to see, and the steward walking by kept treading on the arm without him realising. At one point he was brought a meal, a proper old-school aircraft meal, with portions of stuff in separate little plastic compartments. He was handed it as he lay in his place and then left alone. He was incapable of eating it where he was, but he worked out that he could manage it if he got out and sat on the floor, leaning up against the cot. Hunched over the meal, he scooped out the food with a plastic fork in his one good hand.11 One of the plastic compartments had some black goo-like sauce in it, and he was about to try it to see what it was when he realised that it had come from him – blood and cerebral fluid oozing out of the wound on his head, pooling on the tray. There had been air trapped in his head wound, enough to be affected by the change in cabin pressure, and it had caused the leak. And the pressurisation had made his pain worse, but it was so bad by now that worse meant nothing very much overall. Around him the others on the aircraft assumed he would die at some point during the journey or at least soon afterwards, but Lawrence held on, alone and untended, and willed himself home.

Lawrence survived more brain surgery and sub-standard rehabilitation and today lives with the paralysis and the pain from his injury thirty years before (he calls his useless arm ‘Elliot the watchholder’). His memoir of his wounding and of the deficient military response to it, When the Fighting Is Over: Tumbledown, A Personal Story, was considered hugely controversial when it was written in 1988, but he was right, and it only got worse. Deficiency in the Defence Medical Service became outright degradation after years of spending cuts. In 1997 the House of Commons Defence Committee questioned whether the Defence Medical Service could actually survive, given that they were ‘not sufficient to provide proper support to the front line […] and show little prospect of being able to do so in the future’.12 If there is no available military medical service, then a nation cannot go to war. An entire service, not just a hospital, Gone Black.

So it changed. Proper funding, a new strategic plan and the intention of providing something close to NHS-standard care delivered, ten years later, the system described in this book. The men and women who made it happen are still in the service (so still no names), still making improvements to the system – marginal gains now – refining well past their original targets and one day, hopefully, preparing to write their own books telling of their work. How self-aid, buddy aid, team medics, combat medical technicians, MERT, Bastion and the flight home on CCAST became the best system for managing severe casualty from the point of wounding in military medical history. In 2009 another committee could report that care of the wounded serviceman was exemplary, with much to teach the NHS in terms of trauma provision.13

*

Two patient memoirs – Lawrence’s When the Fighting Is Over and Ormrod’s Man Down – thirty years and an entire world of casualty provision apart. As I wrote about the best, I wanted to remember the worst. And no matter how good the system gets, being wounded is the same. Across the years, a human falls, in paralysis and pain, a new life from that moment on, high-velocity rifle bullet or IED. Mark Ormrod was the first triple amputee to be brought home with his own medical team, on a Tristar aircraft that made multiple stops for refuelling and wasn’t quite yet the expert space of the Globemaster. He lay in one of three medical beds in what would otherwise be the first-class cabin. There were actual passengers (officers) returning from deployment just feet away, and no privacy curtains. For hour after hour they could do nothing but watch as the medical team tended the patient and their lifelines, as the injury bit deep, muscles wasting, skin tone fading, all straps and flesh ending where it shouldn’t. And sometimes these passengers knew that there were coffins being transported to the rear as well and that, no matter how their tour had gone, it had come down to this journey, across the continents, the barely living alongside them, the dead at the back.14

*

Back to the clatter and watchfulness of the Globemaster, flying all the way home, without stopping. There was a hard thump as the wheels dropped ready for landing. One nurse always remembered two things from her CCAST service: dragging the vacuum mattress out of the plane to wash it after the patient was gone, and the impact of that sound. On leave she avoided her local post office because it had an old-fashioned franking machine, and its heavy chunk down on the envelopes reminded her of the punch-thump of the wheels and the work she did high above the earth, securing her leg of the journey back, and what it asked of her in the unceasing rattle and hum.15

Landing, deplaning, transferring lines and tubes and batteries, one ambulance per patient non-negotiable, paperwork. Then a new, different, demanding responsibility after every carry, even those where they had been on duty for forty hours straight, including the immersive intensity of the flight. The nurse team leader went all the way to the ward with the patient to see their families. A short conversation, holding themselves straight, even breaths, a last effort to keep the strain off their faces as they quietly explained what they had already written in the patient diary, that the flight was smooth, that maybe there was a bit of a wobble, but they were always watching. And they gave them the actual diary: Here, you can read it yourself, later or when you have time, please do, it will help you understand that your loved one was never alone, not for a minute. There’s a map that shows where we were flying when you were getting to Birmingham, resolving to be brave no matter what or at least to stop crying, waiting for us to land, hearing the blue-light police escort for our ambulance, fearing the meaning of the sound of sirens. A handover to the Critical Care staff at Birmingham and then over.

The medical handover to the Critical Care staff in Birmingham wasn’t quite the end of their mission. The last thing was the journey back to wherever their aircraft was homed. Before Globemasters this was Lynham, a two-hour drive from Birmingham that felt like four when every last one of their resources was gone (easier once they moved to Brize Norton, which was only an hour away). The aircraft would be waiting, so they went back up inside to clean up. They threw away the absorbent sheets, washed the mattress, stowed the equipment and set it recharging, so it would be ready for the next team. Then, whatever lay ahead, a twenty-four-hour break, and in the meantime another team came on duty at Brize, ready in two hours, and waited for the Globemaster to collect them, where they wait now, today, as you are reading this, in case they are needed, as they were in Tunisia, in June 2015, bringing the wounded back home from the attacks on the beaches.

For the Afghan cohort, CCAST did it all in one day, came home, short break, and the next day went out again, back across the continent, high in the sky to collect another patient. Freight clipped in where the stretcher would go, and unofficially a bit of light smuggling: after all, it was a very large aircraft, and what else were nooks and crannies for if not for fresh food, always at a premium at Bastion. Fruit – one anaesthetic consultant brought a pineapple with him so regularly that anyone seeing it knew that he was on the CCAST that shift. Fruit and milk. Especially milk – fresh milk for brews was currency in the desert, where one could dream of bowls of cereal in good cold milk. Cornflakes in UHT weren’t wonderful, so they were mostly used with chocolate melted in the microwave for crispie birthday cakes.

On one flight a nurse decided to borrow the night-vision goggles and look out of the windows at the darkness they moved through. As she remembered what she saw, she suddenly looked past me, back into a different distance. She told of how the Globemaster doesn’t have a lot of windows, and after a few minutes she decided that was a good thing, because actually she didn’t really need to be reminded that there was so much sky, so many stars, that’s really all there was out there, for hours and hours, and suddenly, against the infinity, the aircraft didn’t seem master of anything, just a small, grey shape, holding itself, holding everyone in it, ploughing through the darkness and clouds, bringing them home.