13

The Duty Critical Care Nurse

The main thing is not to get it wrong; if you get things wrong, it’s all lost.

Duty Critical Care Nurse, Birmingham, 2010

IN A SMALL PALE PINK ROOM on the fourth floor of the hospital the CCAST crew member met the families and did their best to explain the journey that had got them all to this point, from Afghanistan to here, to this room in Birmingham off a corridor that led to the Critical Care unit, where their loved one lay. It’s all in there, in the diary, there was a bit of a wobble three or four hours ago but we took care of it, of him, and we got here safely. And I’ll say goodbye now and wish you all good luck, the next few months won’t be easy but he’s a tough, brave lad, and I’ll hand you over to someone who can answer all your questions.

And then from the background came a nurse, with a white tunic on, and she thanked the CCAST member and introduced herself with her name and her title. She was the Duty Critical Care Nurse (DCCN), and from then on, she said, for the next few most difficult days while their loved one was still unconscious, they should come to her with whatever questions they might have: she was easy to spot (that’s why she’d got the white tunic, to make her stand out from all the other nurses who went past them in blue) and she was there for them.

By 2010 casualty numbers from Afghanistan pressed in on the staff at Birmingham. And even though they had moved into a bright, shiny, new hospital with more beds and a bigger lift, there were too many family groups arriving at once, too much to tell them, too many people to liaise with. So things went wrong, or went slowly, information muddled or late; it deepened suffering in a place where it lapped up the walls anyway.1 So a new nursing role was created – unique in the profession, unique to Birmingham: the Duty Critical Care Nurse, who did nothing else but care for the families and make sure she never got anything wrong. Her first day on the job was the first ever after the job was created, and saw the most ever casualties admitted at once to Birmingham, and the most ever families arriving to see them.

The first person on the job could and did cope. They had made a really good choice: just the right combination of strength, clear thinking and compassion. I can vouch for it because I interviewed her, and I felt better just walking into her office (although I had to explain to her that she didn’t have to keep her military hat on while she talked to me, because she hadn’t been sure of the protocol for historians).

She’d nursed in the field hospital in Iraq, where the wind blew sand into every nook as she worked, and the mortars rained down, crash crash crash every day, where she slept in a concrete pod known as a coffin for safety and where she reckoned there was a good chance that she would come home in an actual one, alone in the back of the aircraft. Then to Afghanistan. At Bastion there was no more fear, and an experience she cherished: being part of the team in the trauma bays and wards that provided the second and last lines of defence against death, and sent more men home alive than had ever been done before. She wrote patient diaries for the men she saw off to the CCAST team, to share how they had worked together for their survival. She wrote patient diaries for the families of men who died in her ward, so their families would know of their last hours.

Then to Birmingham, where her job was to care for the families she had written for in patient diaries, the people she had only imagined as she wrote, seeking to find ways to make the worst thing in the world a little bit easier. Watching the group, reading the room, face by face, to see who is the natural leader, who she should speak to – a mum, or a dad, or a sibling, or the patient’s other half, whoever has moved themselves most quickly to her side, is paying closest attention, not lost in crying. Sometimes – rarely, but sometimes – she could not read the room. The faces were tear-stained, shocked and hostile. A mum who repeated over and over that her son needed to go home now. A dad whose rage at his son’s wounding exploded from him over her and everyone there, and it took a good two or three days of clear speaking and careful silences before the situation turned and he came to trust her. Then the broken families, two families, learning the technique of getting them on either side of the patient’s bed, mothers of children, current partners, complicated, trust, clarity, getting it right.

She pushed open the door from the pale pink room to the grey-blue corridor and led them out, moving resolutely, making sure they were all coming with her, the questions starting now, the space changing as they moved – the pale pink room was utterly foreign, but in the ward was their family member, so the space they occupied was somehow theirs too. The first sight would be the hardest of all, she knew, because nothing could quite prepare them for that room, where all the patients – everyone someone’s child – were almost disappeared under their tubes and machines, broken into unidentifiable pieces, thin, bloodshot, eyes swollen into dark blue slits, skin ashen. Part of her job was guiding them up to the bedside, standing at one end, introducing them to the nurses in their blue tunics with the long plastic aprons and disposable gloves, who have momentarily stopped their work and who nod their greeting and then turn back to the patient. They may have been given aprons and gloves before they could move slowly closer and closer, daring to touch, softly speaking the patient’s name, checking that he really can’t hear them, murmuring, crying again. They saw the human, underneath the tubes, saw that he is still big enough to fill a bed, and then there are the parts of their human they don’t recognise – heavily bandaged stumps and limbs, swollen bigger than a boxing glove, that lay where hands should lie. And this is not a dream, they are not waking up; this is how it will be from now on.2

The other nurses or the consultants or the professors started to explain what was happening and what was going to happen. The DCCN listened as intently as the family because they wouldn’t remember everything that was said or understand it, and it was her job to remind them. They needed all the help they could get to become used to this new place in their lives, with the machines in it beeping and flashing, and they did so quite quickly: a bed is a bed, after all, sheets and blankets, even with all the tubes, head raised slightly on a pillow because that really helped them not to get ventilator-associated pneumonia.³ Sometimes the DCCN saw those at the end of the bed surreptitiously patting down the sheets to feel where the limbs ended, even peeping under the sheets to see where the tubes and lines went and if what was left was recognisable (‘Mum, you’re going to be taller than me again’, one amputee patient would say after waking to his mother).⁴

Then, after all of it, she guided them back down the corridors, into the lift and back to the car park for the drive home. In a way it was easier if the patient hadn’t been awake enough to see their reactions when they looked down at what was left of him. One patient understood this much later, when he saw the pain flicker back across the faces of his family several weeks after he came back home, and he was grateful he hadn’t been awake that day to see it for the very first time.

*

There is a scale for sedation – the Richmond scale – and the ideal is 0 (zero), for ‘Alert and Calm’.

The Richmond Scale

−1	Drowsy	Not fully alert; sustained awakening to a voice that says their name; some eye opening/eye contact for up to ten seconds
−2	Light sedation	Briefly awakens with eye contact to voice for less than ten seconds −3 Moderate Movement or eye opening to voice but no eye contact
−4	Deep sedation	No response to voice but movement or eye opening to physical stimulus, usually by gently shaking their shoulder or rubbing their chest
−5	Unarousable	No response to voice or physical stimulus

Waking is almost never as simple as feeling a touch and hearing a voice say your name. Sedatives are withdrawn slowly, a little every day, under careful supervision from the anaesthetist.5 Then as they go from a –4 to –3 up to –1, things can and usually do start to unravel. Almost everyone, soldiers and civilians alike, who wakes on a Critical Care ward finds the aftermath really difficult: altered agitated mental states, problematic memory, a very odd environment. Patients can’t understand why they are there, what is being done to them, and they lash out, yanking on tubes and lines, ripping them out: ‘the literature contains multiple reports of fatal self-extubations and removal of intravascular devices.’⁶ So there are usually restraints discreetly nearby, pharmacological or actual, hand mitts or soft straps for limbs on bed rails, and these are applied and monitored continually until the storm passes.

Waking soldier-casualties was worst of all, because they also had to contend with a collision of two worlds: Afghanistan and home. The storm began in Afghanistan, blinding sunlight, fighting, explosions, pain, those gathered around them shouting, shouting, then blackness. In the blackness they travelled thousands of miles, across continents, time passing pulse beat by pulse beat for the CCAST crew but stopped for them, and when they woke, it resumed, hearing first, slamming them back in the fire fight, still fighting, still on the ground in the dust, the enemy about them, and they scream for help, except the light in the blue-grey ward is dimmer, and the group gathered around them spoke softly, no more shouting.7 And no matter what anyone could tell them, their brain assumed capture, that the huge room with the inhuman light was a torture chamber, the lines in their arms and legs full of poison, the catheter in their bladder a bomb, and pain was rushing in so it must be true; the men and women around them were masked, covered in plastic, with unnatural hands in blue gloves, so torturers, interrogators – don’t listen to the words that come from behind the masks trying to soothe them.⁸ And their families were there, in Afghanistan, where there was nothing but danger, nothing, danger and pain, and whoever else was there they must get their families OUT of Afghanistan, OUT NOW. So the families were got away, just to the corridor, and the figures in blue swarmed over their patient and quietened him again, from the shouting and the wrenching.

So there is another component to the Richmond Scale: the Agitation Scale.

+4	Combative	Overly combative, violent, immediate danger to staff
+3	Very agitated	Pulls or removes tubes or catheters, aggressive
+2	Agitated	Frequent non-purposeful movement, fights ventilator
+1	Restless	Anxious but movements not aggressive or vigorous

Gradually, moving back down the scale, patients had longer periods awake, and the fragments from the war that burst out – call signs, orders to get down, swearing – dissolved and were replaced by ordinary hallucinations from the medications – forklift trucks driving up and down the ward, strange creatures in the room with them, distortions of the faces of their visitors. They are awake enough by now to have the process explained to them, so somewhere in the very back of their mind there is enough understanding of their situation to keep them calm in the swirl. Families and the DCCN show them their patient diaries – going through the entries with them, hour by hour, showing them how they were carried by MERT, and CCAST, kept alive in the Bastion Critical Care unit and visited by their friends, who wrote messages for them, in their new future. Filling in the gaps. Every name, every entry, sparked a connection, memories, pulse beats, time evening itself out, two worlds becoming one new one. Days became days, and nights became nights. Eventually, the families didn’t need the diary any more and they could leave it at home (Scott Meenagh remembered his mother thought the diary was the most wonderful thing to have while she watched him before he woke), because everyone in or gathered around the bed understood where they were and was preparing for the next stage of the journey.

The next stage is breathing on their own. Most of the patients in Birmingham will have been intubated to help them breathe. Taking the breathing tube out – extubating – is the very last step in the process. A machine will keep them alive, but it cannot do enough to make them live. And the longer they are on the machine that breathes for them, the more dangerous it is. The muscles that inhale and exhale start to weaken, and the sort of gunk that is normally coughed away builds up; and gunk is an excellent breeding ground for infection, pneumonia, worsening respiratory failure – more machine, less person, less life. So eventually the tube for the ventilator that was so skilfully and carefully inserted back on the Chinook by the MERT had to be removed, and the breathing last done unassisted on the ground in Afghanistan had to resume.

Preparing for extubation takes a long time and is complicated. It can begin only when the patient is sufficiently clear of infection that they can be touched without the plastic gloves and aprons and masks in between, because touch – human to human, contact practice – is the only way it works. So meet the physiotherapist. Physiotherapists are primary contact practitioners; physiotherapy is defined as the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment and exercise rather than by drugs or surgery. Even though most of us think of bad backs or sports injury when we think of physios, we are just as likely to see them working on trauma patients, especially orthopaedic trauma, in Critical Care wards. Increasingly, whether military or civilian, physios are seen as an essential part of the multi-disciplinary team, preventing Critical Care patients getting worse by just lying there. The families on the military ward at Birmingham know all about this now as they’ve been watching physios work on the ward, in other bed spaces, since they came in.9

It is physios, they realise, who are carefully rolling or moving patients who are not yet awake. Rolling a patient on to their side increases the volume of the uppermost lung, and increased volume means a better-functioning lung. And while they are on their side, gently tilting the neck so that the head faces downward helps to clear gunk. Roll and tilt, return, roll and tilt: ventilated lungs work better and clearer, extra oxygen is absorbed more easily, everything closer to normal rather than further away. Roll and tilt and return. Gentle chest massage also keeps gunk production down, and improves circulation. Gentle joint massage, where there still are joints, does the same thing, stimulating circulation, slowing muscle wastage, all of which needs to begin to work properly when the patient can breathe again. Physios work quietly at the bedside, learning their patient, learning their sounds and the feel and temperature of their skin, moving them slowly across this part of the landscape, as softly as a palm placed in the small of a back to guide them up to a door.

Getting the patient ready to breathe on their own is called ‘weaning’. It can never come too quickly for the family, because fewer machines means recovery going the right way, but the patient is often not so sure. Anxious, used to the ventilator, dependent, worried what will happen when it stops, suffocating – maybe we should just leave it for the time being and see where we get to. In the end it is the physios who do respiratory work who are the experts on the use of ventilators. They will be mobilising their patients now, mobilising, like with troops, calling up their muscles, step by step, even if they are still a little sedated. They need to get their lungs working, their respiratory muscles, like all their other muscles, devastated by the injury and its aftermath, back to something near functional. They’ll need to learn to cough again, and to cough they need to sit up – and they can see in the eyes of the patient that they think that seems about as likely as asking them to fly across the room. But, even if it takes four physios together to raise the patient gently in the bed, saying don’t worry about the tubes and lines, we’ve got those, suddenly they are sitting up, swinging whatever legs the patient has over the side of the bed, head up, for the first time since going down, looking around at where they are.

The physio helps with the movements to start with, but eventually leaves the patient to do it on their own. And just sitting up helps with core, and balance, even without really trying. Every moment spent upright is medical pure gold – no drugs, no machines – just one human being expertly guiding another into a new space. Even ventilated oxygen distributes itself better as the patient moves, and that will mean better circulation, better digestion, the body getting going again. It helps with the hallucinations too, and the space between sedations gets longer and calmer and more work can be done.10

More physio over the next day and week. The cough is vital, so the muscles that do the coughing must be continually worked and strengthened. Stand up, sit up, raise their arms up and down, breathe in and out to increasingly longer counts – hold their breath for a few counts, relaxed breath out, huffing (almost as important as coughing). The physio tries to get the patient to be able to do things on their own – cough, huff, sit, lift themselves, roll to the side. For patients with multiple amputations this is sometimes too demanding, so the physio is there at their side, at their joints, gently massaging to restore circulation and prevent contraction by the new scars, which cover their bodies like paint splatters. For those patients without a knee joint, the best exercise is to get them to roll over completely, on their front, and then carefully lift the stump a little backwards, and then a little more, making what muscles are left remember what work is like. Strong and long hip flexor muscles, in particular, really help when the time comes for a new leg. So everyone came to welcome the work of the physio, because when they said so, up came the prosthetists for a look and the promise of a first prosthetic.

Physios, talking about new legs going in where the space in the bed is, meant more to the patients than any other conversation they had since they arrived in Birmingham. It meant they could see where they were, orientation, interacting with other humans, following instructions, achieving a result, taking back a little control, no longer just someone to whom things were done. A partnership began that would last well beyond Birmingham – and a different kind of conversation, with someone who didn’t know what they were like before the deal was done. And beyond the military ward these relationships prove the case for the presence of physios beside all Critical Care beds, part of the early assessment process for civilians of whatever age and diagnosis. There’s no magic drug or surgery that gets Critical Care patients moving better than one-to-one physiotherapy. A study across the whole hospital at Birmingham found that physios reduced the stay in Critical Care wards by eight days, with better outcomes both physically and psychologically.11

*

One of the physios who courteously but firmly drove this system forward had also been to Afghanistan. He’s still in the military, so I still can’t tell you his name, but from now on whenever I talk about ‘the physio’, it’s him. He deployed to Camp Bastion twice: the second time between April and September, the hottest time of all, 54 degrees outside. But he wasn’t outside much, just moving between the physio tent and the hospital. His presence was part of the principle of the movement of clinical capability forward in war zones, as far forward as it will go, and physio skills, as we have seen, are essential in the Critical Care wards, wherever they may be and whoever the patients are. Most of his patients left in the beds at Bastion were locals, and he worked with them as he worked at Birmingham, slowly, carefully, rolling and tilting, reminding them how to breathe and how to cough. Sitting up, huffing, slowly mobilising their muscles. He worked with an interpreter at his side to explain what he was saying, and he took the patients who could manage it out for short walks in the early-morning sunshine cool of Bastion, and then back to bed, three weeks, four weeks and finally strong enough to go back to whatever waited for them at home.

He did the same for the CPERS, the Captured PERsons, who also spent weeks in the ward, but surrounded by white wheeled screens and heavily armed guards. The guards watched his every move, every roll and tilt and turn, watched as he and other physios lifted their patients to a seated position, then to a bedside chair and then a short walk. Terps did the talking for him, but from behind one of the screens so as not to be identified later, and occasionally one of the guards would call him over to remind him that if he was going to be lifting a patient into a seated position, it would be a good idea for everyone if he remembered to remove his side-arm. When the CPER patients were ready for a longer walk, there was an elaborate manoeuvre where the screens were rolled into a long white corridor so the CPERS could move outside without seeing or being seen by the locals in the camp. His CPER patients had different injury patterns from everyone else he treated at Bastion. Not much blast injury or amputation. On the battlefield they attacked standing up, facing their target, firing semi-automatic weapons and rockets. They had no body armour, and the middle of their bodies made an easy target, so instead they were usually suffering from wounds to the abdomen. These were always full of infection, and bellies could be swelled to bursting with the gas released by the bacteria, so physiotherapy was crucial to restore circulation, mobilisation and intestinal function – getting their bowels going. So the physio worked and rolled and got used to waiting for the interpreter behind the screen to call out whatever it was he called out. Then one day, when they were recovered enough, the guards would come out from behind the screen and take his patients away, he never knew where.

*

The plastic surgeon who had built the garden at Bastion also worked at Birmingham. He never minded seeing the physio at the bedside of his patients on the military ward because physios had tended to his back and neck after long hours at the operating table. In Afghanistan he got used to reading about the wreckage of blast injury, how it hid death deep inside a human being. So he favoured ‘meticulous repeated marginal debridements’ to preserve as much tissue and functional potential as possible.12 He saw most patients in theatre every forty-eight to seventy-two hours until the last scrap of dead or infected tissue was gone, going after the smallest fragments driven high and away from the original wound that were difficult to get at, difficult to dig out, keeping the patient sick from infection. The patients couldn’t eat solid food six hours before an operation, so a patient who may have been awake, breathing and only just back eating properly, digestion remembering how to do its job, physiologically restoring, was suddenly hungry again, and the lines were back, and the sedation. That was just the start.

Next came the actual reconstruction. Blast injuries are avulsive – they blow skin off high up the limbs away from the bone end, leaving little for surgeons to work with, so they couldn’t simply fold over spare skin and muscle and make an end (this is called primary closure). They needed to take skin and ideally muscle with good healthy blood supply from somewhere else altogether and move it to the wound. This is a flap, a much deeper, more complex slice of tissue than a graft, one with all the mechanisms it needs to survive, vessels, arteries, its own little world. This is where they need the microscopes (which they didn’t have in Bastion), to connect up the smallest workings, one by one, sometimes taking a whole day in theatre for just a single movement of whole flesh to wound.

Before they could start, they needed to plan these surgeries. More complicated than it sounds. The trick was to find somewhere with enough viable tissue (the ‘donor area’), cut it out and work out where it should go. Not just that. These were flaps for young humans; they needed to stick because they’d be making demands on them for a good long while to come, so the soft tissue they moved from one part to the other had to be robust. They didn’t take any muscles for free flaps that were used for core stability and which would be essential to rehab when their patients eventually got there. There are some expendable muscles, like those of the inner thigh, or from along the chest, that might not have been damaged in the explosion, so they used those, preferably in a way that meant they didn’t have to turn the patient over and then back during the actual surgery. Lines, tubes, touching, trying not to make something almost infinitely complicated any more difficult.13 And they didn’t do anything at all but plan until the patient was stable – no fevers from infection (still called pyrexias, as they were in the First World War), getting proper nutrition and off any strong meds that control things like blood pressure. If they weren’t stable, the flaps failed, the donor area was wasted and the patient went four steps back, not forward at all.

So they didn’t rush, although a Critical Care ward that was full of young men waiting to be reconstructed sometimes made that impossible. One patient spent forty-five hours in surgery over two months – not unusual – another seventy-five hours, another thirty-three. Keep going back, no matter how slow the healing, or the infection, keep the family informed. Multiple visits to theatre mean the best possible care.14 And it’s why surgeons and patients who had both been at Birmingham during the war are usually pleased to meet and, when they do, ask each other odd questions like ‘I can’t remember if I operated on you’ or ‘Do you think you operated on me?’ And it’s rare that either of them can ever remember, but for a moment there’s a bond, a space in time, with no one else in the room, and they chat about how it was, and they both feel a little better afterwards.

For the plastic surgeon, the longest and the hardest case of all was a patient he had first seen at Bastion, one of the worst cases of blast injury, most of one leg simply pulverised. The damage was so extensive that he had had to perform a hind-quarter amputation – a hemipelvectomy – where all of the leg and half the pelvis is removed – like wrenching out the leg on a plastic doll, except there is nothing wrenching about it; it takes hours to repair the nerves and veins and soft tissue around such a huge wound. Hind-quarter amputations are very rarely done in normal medical practice – usually only for cancers where large tumours have grown in the upper thigh.¹⁵ At Bastion it had been worth the decision to operate – life saved, stabilised, future possible. CCAST kept him stable, and got him back to Birmingham, where he spent a year on the ward, back and forth to theatre. The plastic surgeon came to know him well, and was pleased to see that he was managing a wheelchair, becoming more independent, and on one particularly good day they played ping-pong in one of the recreation rooms. And then suddenly the patient developed complications: stability failing, infection, sepsis, bleeding, oxygenated blood not getting where it should, the cascade unstoppable, no future any more, death. For the surgeon who had fought alongside him it was very hard. But there was that afternoon’s clinic and the next day’s patients, so on he went. Even after the war was over, and the ward cleared, suddenly there was a new MIST report for patients being transported home by CCAST from the attack on holiday-makers in Tunisia, one of them with fifty separate trauma wounds. Days after their discharge he joined military colleagues at a meeting of international civilian trauma experts to advise them how best to organise their units in the aftermath of the Paris attacks of November 2015.

*

Pain, always pain. The consultant who co-ordinated the treatment of pain from point of wounding onwards summed up the challenge they faced at Birmingham in Critical Care and beyond:

The population we are dealing with often have complex pain issues. We are also dealing with mechanisms of injury that are not routinely seen except in a few centres around the world. To what extent these various injuries created their own patterns of pain is impossible to quantify.16

Unexpected survivors at Birmingham were patients in a great deal of pain. Beyond the military ward consultants thought about post-operative pain, post-amputation pain, inflammation pain, all the other kinds of pain, as separate things, affecting separate patients. But for the military cohort all the kinds of pain that can be imagined, all at once, all in one person, all the time. Every stage of treatment, every different procedure had its own challenges of pain (especially dressing changes), different and yet the same. Pain is a continuum.

Back to fundamental principles, because fundamental principles were almost all they had. Pain is not acceptable. Alleviation of pain is a human right. The first stage in the treatment of pain is asking about pain, asking an individual about pain, not looking at the chart that says what should be happening, what they should be feeling. The pain service at Birmingham was entirely individualised because they had no choice, no chart for what was happening, because that’s the way it is with unexpected survivors.

Away from the bedside, an infrastructure had to be created to deal with patterns of pain that were impossible to quantify. It was based on a pain team, unimaginatively named the Military Pain Team. The consultant who led it ensured that, whenever members of the team spoke to each other, or the patient, which they did every day, sometimes more, they spoke the same language. Not easy. Pain resists language – not just because the experience of pain can render the sufferer speechless, whimpering, but because it’s an innate human problem that our brains are limited in their ability to describe pain objectively.17 So pain treatment, of any kind, is based on hard (not very good and not very consistent) questions. We’ve all been there: how does the pain feel? Is it distracting? What is it on a scale of one to ten? Or ten to one, if one or ten is very painful? What colour is it? If your pain was an animal, what animal would it be? Instead the language the pain team spoke was deliberately simple and clear because they used the system the pain consultant and the team thought was the best: the World Health Organisation’s pain ‘ladder’. The WHO pain ladder is designed to be used for cancer patients, as part of their global initiative to improve treatment and palliative care for non-communicable diseases, but it is based on the same fundamental principles as the pain pathway that started at point of wounding in Afghanistan: wherever and however possible, there should be freedom from pain. Pain should not prompt pain treatment; pain treatment should block pain before it starts or gets worse. So using the WHO pain ladder system, analgesia is given every three to six hours, not on demand. According to the WHO, this is cheaper and much more effective than waiting for the patient to ask or call or cry out.¹⁸ The ladder has three simple steps which determine how much and what kind of analgesia is given:

First step – no pain at rest, mild on movement

Second step – mild pain at rest, moderate on movement

Third step – continuous pain at rest, severe on movement.

And it is a dynamic ladder: pain is assessed in relation to what has gone before. (How is pain now? Is it better than before or worse that before?) Patients can travel up and down the ladder as their pain gets worse or better, and it is much easier for everyone if pain can be described comparatively along the way. Quickly the pain team discovered that, although the WHO ladder was the right system for them, it wasn’t quite long enough, so at Birmingham it had a fourth step: severe, uncontrolled pain.

So, as they hoped it had at point of wounding, pain treatment at Birmingham began with a clear question that the military pain team’s patients could answer because it was about their own pain and its history, and that was less of a hard question because they designed it to be easier. From that they built individualised, multi-modal treatment. Another fundamental principle. For the kind of pain that requires a fourth step on the ladder nothing is ever going to work on its own. Mild drugs, not opioids, starting with paracetamol and ibuprofen. Nerve blocks and lots of epidurals. Drugs to treat anxiety about future pain and futures in general. If the pain ‘is not amenable to a regional technique’, use drugs to treat pain at the nerve site. A double hit is best: opioids that treat pain at the place of pain and where it registers in the brain, modified release or immediate effect, as strong as necessary, even if that meant the hallucinations came back. Hallucinations are better than pain: intense and unpleasant but better than pain.19 Whatever the maximum dosage for all the medications was, you can be sure the pain team used it for their patients who found themselves trapped and terrified on step four of the pain ladder until they came back down.

Eventually, most of them did come down, one step at a time, sometimes backwards then forwards again, and mostly never quite off the ladder, staying on the first step – mild pain, but better than yesterday. It was pain treatment as conversation, where each listened carefully to the questions of the other because they understood the language being used and it was a good place to start; but also, the pain team hoped, it gave their patients some sense of control or at least participation in their own treatment, because the pain team knew they would need it. Pain would follow them out of Birmingham, into rehab and everything would be easier if they understood their pain, and could express it clearly.

Other conversations too, other hard questions, such as why could a patient feel a limb that was clearly no longer there. It was nurses from the pain team who answered that what they were feeling was called a phantom limb, and it was quite normal that they should feel it because phantom limbs have been known about for centuries. Almost everyone who has an amputation, for whatever reason, gets them. Phantom limbs, as they say in the textbooks, are caused by aberrant inputs from the peripheral nervous system travelling to the brain and back again. They are not about memory of injury; psychological factors do not affect who gets a phantom limb, although eventually the suffering degrades the sufferer at all levels. Phantom limbs hurt: pain just like in the rest of the body that the patient can see, but somehow different. Throbbing, knife-like sensations, burning, pricking, cramping. Or just generally very weird. Phantom limbs feel heat, or cold, or moisture or itching, phantom toes crossing, or pins and needles, or flickering like electric shocks, or cramping, lasting for minutes or hours, unpredictable.

At Birmingham they tried to help. In the case of phantom limbs they put a thick stocking end over the stump, if it was healed enough, so the patient could feel its sides and their brains could adjust. The physio came back and gave them exercises that worked with the phantom sensations rather than fighting them: things like bending down to scratch itching invisible feet. Everyone, patient, pain team and physio, at least felt they were doing something, although there is, thus far, not much evidence that it worked.

Nurses waited at bedsides to answer hard questions as they had always waited. In the First World War it was nurses who sat until their post-operative patients were awake enough to hear the news that their legs were gone or that the darkness was never-ending because they had been made blind. At Birmingham genital injury was one of the worst things to prepare a patient for. It was the first thing they asked on waking, only ever semi-joking. One of Scott Meenagh’s unit mates wrote in his diary: ‘You alright mate? Your balls are okay and I look forward to seeing you soon.’20 Unexpected survivors meant more and more of it, harder and harder conversations. Blast injury takes a particularly horrifying form on the pelvis. If the pelvis is fractured, or even if the ligaments that hold it in place are snapped, then the ends lose their rounded shape and destroy everything that they used to neatly encircle. Too high for a tourniquet. Blood vessels run across all joints of a pelvis and the ends of the bones rip them open, arterial bleeds. If the blood vessels aren’t torn, then other things are, disastrously. Prostate injury, urethral and bladder injuries, colon and bowel perforation. Avulsive injury means loss of penis and testicles. In the trauma bay surgeons applied a pelvic binder to put back some of the shaping and control around the delicate organs. Then complex repairs, fast, direct suturing, an absolute need for speed because poison was leaking into a system that had no ability left to combat it. But practice meant lives were still saved, triple amputees bundled up in their binders and sent on to CCAST for home. Life now, life undignified and painful thereafter, new terms of the deal. So even if surgeons worked for hours repairing, reconstructing, doing what they could, gone is gone. Hardest of all was to explain to a girlfriend or partner that the plans they didn’t even know they had for a family, and the means to make one, were now gone too.