A Centre for Blast Injury Studies
I OCCASIONALLY GO DOWN to the Theoretical Physics department to ask them if the Time Machine is ready yet.1 When it is (because so far, nothing), I’m going to ask them to send me back, not very far geographically – so presumably a relatively easy trip – and hopefully return just along the corridor. I want to go to the lecture by the orthopaedic surgeon who had been at the Western Front when he came to speak at Imperial College in April 1919. I’d like to know who went to his demonstration, and then perhaps take him back with me to show him that, almost a century later, two rooms along, another meeting took place, just like his, with a lantern show and cinematographic film. He could meet the group of scientists and medics and casualties, the people I see every day, who want to make the way into the future easier for today’s wounded. One of the twenty-first-century speakers came up from Headley Court – Dave Henson’s prosthetist, who was reminded of just how far they’d come by the sight of double amputees standing and talking together during the fire alarm. The physio who had seen Mark Ormrod extubated and who built the garden and the test track and the greenhouse. And a scientist who’s done all the experiments to prove that their way works. That double amputees can walk, and walk well and that their step length and standing stance can be much more efficient than the literature and the out-of-date training and NHS standard indicate, and that the only limitations are prosthetic, not human.
Then I would give him the tour of the centre. He might already know about it because (and this is where having a historian in the department is handy) it turns out we’ve been doing blast injury research at Imperial for a century; scientists were working in laboratories even while he spoke in a lecture theatre. In 1914 one of the first volunteers for the war was Imperial’s Rector, Alfred Keogh. He became Director of the Army’s Medical Service and sent his closest colleague, Arthur Sloggett, out to France to observe the war and its casualties directly and to report back any particular problems.
In December 1915, after a year in which it had been made clear that artillery was going to be the main cause of casualty on the Western Front, Sloggett wrote to Keogh to ask him to initiate research into ‘the effects of bomb-wounds’.2 Imperial scientists were asked to design experiments that would produce ‘accurate data as to the average velocity, size and penetrating power of bomb fragments’. To achieve this, they could apply to the Trench War Department of the War Office for samples of German bombs. They could build a special metal walled space to facilitate the collection, enumeration and examination of the fragments obtained by blowing up the German bomb samples and seeing what marks they made on the copper wall sheets. (Copper is soft and therefore especially good at this sort of thing. We still use the panels today. They have one of those names where poetry and engineering unexpectedly intersect: ‘witness panels’.) Then they could use this data to design protective clothing for soldiers most likely to be in harm’s way (gun crews in particular). And while they were about it, could they give some thought to a design for overalls and gauntlets capable of protecting men against the barbs of ‘wire’ because these losses by men ‘getting hung up on wire were very serious and the moral effect was great in proportion’.
In Afghanistan throughout 2008 the physical and ‘moral’ effects of IEDs infesting the landscape were becoming increasingly serious for both British service personnel and their medics. As plans were made to convert the tented hospital to a hard-build, one orthopaedic surgeon had begun to think beyond the medical space and into the scientific. He had gone to Bastion as the only orthopaedic specialist in 2008, replacing one of the team who had saved Mark Ormrod. He’d asked for Bastion because he liked to find orthopaedic problems to solve, and he knew that Ormrod was an outlier, not an exception. Eventually there would be a permanent team of five orthopods at Bastion to deal with the hammering of blast injury. But for now there was just him. And a 9-Liner that told of five injured patients incoming, one of them very bad.
There had been six Afghan National Army soldiers in the vehicle that had driven over an IED, which had exploded directly beneath it. The driver had been killed outright, and four had minor injuries. Only one of the six was badly injured enough to become his patient. He was talking, so through a Terp he could tell the medical team that his vehicle had blown up, and yet it hadn’t. That the floor had not been smashed open, only that the metal under their feet had buckled up, right under where he was sitting, and that something slammed into them: no shrapnel, no bomb fragments in the cabin, nothing, but still his colleague was dead, torn apart, and all the others were able to walk away. A bomb and yet not a bomb. It didn’t make sense.
On the operating table the orthopaedic surgeon stood still for a second or two as he looked down at what were possibly the worst injuries he had ever seen where there was still a recognisable leg. The skin was somehow still attached, although the muscles underneath were dead and mostly turned to mush. The bone was so badly fractured it was possible to concertina the limb from its full length up into a squashed flesh cube a quarter of the original size. If the bone had been whole, he could have saved the leg, patched up the soft tissue on the ward and then a slow rebuild of grafts and flaps. But the bone was gone, so there was nothing to build on and so the leg was amputated.
Strangest of all, he had seen it before: the bone at least. He’d seen it in four patients, none of whom got near a war zone except inside their own heads. They had all been ‘jumpers’ who had tried to kill themselves by jumping off a high building, jumpers rather than fallers because jumpers land on their feet and fallers twist and struggle in the air to escape their fate. Jumpers take all the impact of their fall on their feet and legs, and that was where he had seen bones concertina up into themselves like that. He’d done a fellowship in Baltimore, at the world’s leading shock trauma unit – where the concept of the Golden Hour had been formulated – where the trauma unit was close by the psych building and where patients jumped off one roof (which wasn’t high enough to kill) and (not directly) ended up in the operating theatre of the other.3 He’d had two patients there, where their jump had ended with smashed heels, broken femurs and thighs, open fractures, shattered pelvises. They had ended up having trauma care and orthopaedic surgery at the same time, life and limb one and the same, just like he would do at Bastion. And he’d had a third and fourth patient when he returned to the UK – one off a 110-foot roof and one who’d jumped off an iron railway bridge: smashed heels, all the rest and damage to the lower spine. So all of them, like the Afghan patient who now lay on the operating table before him, with the same kinds of injuries: they had been hit very hard, very intense, very localised from below, with most of the impact going on their feet and legs. So it didn’t matter where the hit came from, it had the same effect. Invisible energy, transmitted up limbs, destroying everything in its path. Do something about it. There was the problem he had come to find: the last of five patients, in the desert, destroyed by the heartbeat under the soil. Blast injury.
The orthopaedic surgeon began by writing a journal article that was read by others in the field who were also becoming interested, who were all coming at it from a slightly different angle, including someone who was taking time out from a medical degree to study bioengineering. And he introduced the orthopaedic surgeon to his supervisor. Bioengineering was exactly the right place for the orthopaedic surgeon to go because bioengineers also see the human body as a locomotor system. Bioengineering is where engineering solutions are brought to bear on medical conundrums, where a joint is seen as a hinge and a bone as a girder, and they can mathematise physical destruction. He found a home, then he found funding for it, and by the end of 2008, less than a year after the patient with the concertina-ed leg was brought to him at Bastion, the Blast Lab was born.4
It has a much grander name, and much better funding now: The Royal British Legion Centre for Blast Injury Studies (we call it ‘CBIS’). But the questions it seeks to answer are the same as they were in 1915 when a military medic asked the scientists of Imperial: what are the effects of bomb wounds? What are the effects of blast injury? The answers, as they find out every day, are everywhere they look, however they go looking for them, from the twisted metal of the blasted vehicle flooring to the smallest micro-cell in the human body. Feature films that have huge explosions as part of their plot explain this really well. When the massive bomb has gone off, and the debris has settled and the hero has crawled out from wherever he or she has taken shelter, the first thing on the soundtrack is car alarms, hundreds of them, all going off at the same time, even if the car has no other visible damage apart from settling dust and a few scratches. It’s the blast wave that does that, to a vehicle’s electronics, invisibly, just like what it can do to all the human bodies in its impact zone. When you hear a car alarm set off by a blast on the news or in a film, you are hearing the alarm in the human body – damage, deep and long-lasting, already done.5
Blast injury was known and feared before 2008, but studying it was a matter of gathering statistics and working from them, whether hospital admission figures from Iraq or the early phase of Afghanistan, which came with increasingly desperate pleas to understand and brace for the new forms of casualty.6 Or data sets that turned up unexpectedly: such as a whole archive of material from the Zimbabwean War of Independence in the 1972–80 phase that described cheap and effective vehicle modifications to deflect the impact of blast from fields of Russian mines, whose siblings still litter Angola, Cambodia and Afghanistan.7 But it was still only statistics: useful for building models and hypotheses, but limited.8 To begin to answer the questions about blast injury, first it needed to be understood, and to be understood it needed to be simulated – recreate the injuries in an environment where they could be measured, quantified, studied. Slow them down, see what they do microsecond by microsecond, cell by cell, intervene.
Beyond copper walls and German shell samples available from the War Office, Imperial got equipment that could simulate the worst effects of blast on whatever material they chose. It consists of really big bits of kit, very heavy, very blasty (according to the medic who introduced the surgeon to the bioengineers in the first place), and initially they put them on the sixth floor of our building in South Kensington and no one entirely remembers how they got them up the stairs. But when the Lab became a Centre, everything was formalised and given a proper home, Level minus one on the lift buttons. Today meetings in Bioengineering are punctuated by distinct thuds coming from the basement labs under our offices. We don’t tend to notice them any more, but we try to remember to explain them to visitors. The lead engineer, who works with the orthopaedic surgeon who started it all off, even has a personal tagline: ‘I know how to hit things really hard and measure them.’9 And they can talk to each other – engineers and medics in the same place. They can go next door and ask one another what is happening, and get an explanation, using whichever is most necessary, an equation or a CT scan.
One of the CBIS bioengineers was doing a public engagement with schoolchildren, who asked him if he had always wanted to work with explosives. He said he had, that if his eight-year-old self could see him when he started his job, he’d be really impressed that he could get paid to blow things up. And for a year or so, blowing things up, and filming them, slowing the film down so he could see every single thing that happened on the B of the Blast – at the very beginning – then measuring the physical effects, was enough. He was getting good hard data but also useful life lessons, such as that the novelty of blowing up a raw egg soon wore off. Egg bits went everywhere and were really difficult to clean up, and after a couple of days the shock lab equipment started to smell of rotten blasted-egg debris. So he stuck to tomatoes and oranges. And then something else happened that surprised him. He stopped being obsessed with blowing things up, and started being obsessed with protecting humans from what happens when things blow up.
He’s the bioengineer who works on blast lung, and he has become every bit as preoccupied with breathing as MERT medics in their Chinooks. He wants to know why the architecture of lung tissue works the way it does, why long after the echo of the original blast has died away in the air it is still present in the lungs, still deadly, why lungs tear so easily and keep tearing. Lungs are the only tissue in humans to tear in this way (there’s a biblical word for it, which is also the medical word – to be ‘rent’). They are so very fine, and they are never at rest, and perhaps it has to do with fatigued areas, or local defects that are exacerbated by the blast wave and just go on and on collapsing. But in the meantime, until he has figured this out, blast lung is assumed in all patients close to an explosion, and treated immediately, and he is using his knowledge to design a material that can be added to body armour so that both the blast wave and the blast fragments can be resisted. He has colleagues who are working on the linings of heavy soldier boots so that a blast wave from below can be mitigated, and others who are making materials that can go on the floor of vehicles for the same purpose.10
It isn’t just Imperial. There are sites all over the country and all over the world where research into the effects of the nightmare that is blast injury is ongoing, which all began at around the same time, 2008 or 2009, when the scourge of the IED began to be felt, urgently, bloodily. But the war in Afghanistan is now over, has been for several years, and history shows us how, beyond this initial emergency, this kind of progress can be stopped in its tracks, by factors more complicated to understand than war or blast – institutional resistance and inertia.
Take something that happens to 70 per cent of military amputees that causes them chronic pain and disrupts prosthetic use. It’s becoming the most significant obstacle to a return to an active lifestyle, so they know a lot about it at Headley. This is heterotopic ossification (HO), where soft tissue that isn’t bone turns to bone. Not bone growing oddly, but something that had never been a bone – like a nerve or a blood vessel or a muscle – ossifying, becoming a bone. Within months or years (HO is like that) it grows inside the amputation stump, following the line of whatever its original form was – long, winding spires following nerves, or webbing where it was blood vessels. It changes stump volumes completely and presses on other nerves and joints, causing pain, which is usually when a CT scan is ordered, and there it is, like coral: HO. It happens to civilians – just a few of them, who have hip replacements or spinal surgery, and it’s relatively easy to treat, with medication and radiation. But it happens so often to military amputees that it is now officially classified as a wound-specific condition, and with complex casualty medication and radiation aren’t always a match for ravaged inflammatory mechanisms and immune systems, so the only solution is more surgery. Sometimes the spire of HO can be removed on its own, but often it means more, higher amputation, an above-the-knee turning into a hemipelvectomy. No more chance of a prosthetic. Back in the chair, never out again.
There are several research projects into the causes and possible treatment of HO going on now, one of them at Imperial, and the consensus is that it’s blast, complicated by genes and inflammation. For me as a historian the most important factor is that none of this is new. HO was identified a century ago, by a medical scientist working for the military in First World War France, who was handed over a ward full of soldier amputees whose stumps were persistently painful and couldn’t take a prosthetic. The scientist used X-rays (one of the first to do so for medical research purposes) and found that there was bone where there shouldn’t be bone. Then she looked at the records of their injury. All of the patients had received serious musculo-skeletal damage as a result of an exploding shell – blast injury – damage from the fragments and damage from the invisible wave of energy that passed through them at the same time. The blast wave, she concluded, was causing HO.11 And then nothing. The scientist, Augusta Déjerine-Klumpke, died in 1927, and her work was lost. Not just her work, even the memory of her, despite her importance to medical history as a pioneering medical scientist who made significant contributions to the study of the structure and repair of human neuroanatomy. Then, in the twenty-first century, a whole new cohort of military amputee patients presented with persistent pain and difficulty with their prosthetics, and X-rays revealed bone growth where none should be, some of which can be removed surgically but not all. So they go on suffering while the scientists pick up threads laid down a century before and start to follow them again. Like with pain, what a terrible waste of time.
Not just military amputees. Nearly everyone who survived the 7/7 bombings in London and needed an amputation has developed the same thing: HO.12 And I may be just a historian, but from where I sit the evidence looks persuasive that 70 per cent of anyone who loses a limb to a blast injury, be it bomb or mine or IED anywhere in the world, where the invisible wave passes through what’s left of their body, that body will get the extra bone where bone should not be: HO. And pain and prosthetic malfunction will follow.
Everyone, in all the minefields or civil wars or battlegrounds, man, woman or child, will see some if not all of the complications of blast injury. I wrote this section on 22 March 2016, ten hours after the bombs in the airport and tube station in Brussels killed thirty-five and injured hundreds more. Many were in a railway carriage, just like in London, where the metal walls contain and concentrate the blast wave, magnifying its effects, meaning more energy absorbed by humans, blast lung and all the rest. Survivors were interviewed on television, covered in dust and minor lacerations, saying they were fine, even though they had been in the carriage where the bomb went off, and everyone who studies blast lung shouts at their television – ‘Go to A&E, get a scan, you are not all right.’ Five days later, another blast, in Lahore, killed seventy and injured almost three hundred. The Lahore blast was so large it could be heard several kilometres away, firing up car alarms all over that part of the city, just like in the films.
And then there’s Afghanistan today, after the foreign armies have gone and taken Field Hospital Camp Bastion and all those other extraordinary medical facilities with them, leaving only ordinary ones behind. On 19 April 2016 a huge truck bomb went off in Kabul, obliterating an entire car park, its blast wave smashing every window for a wide radius, including those of the city’s largest mosque. Kabul’s ambulance service faced the very worst day since its founding in 2003. All fifteen of its vehicles were immediately rushed to the scene, removing victims to the city’s hospitals. It looked like something from the Somme – some ambulances carried as many as twelve victims inside one vehicle, the seated packed in and over and around the stretchers. The doors of two vehicles broke off at the hinges because of the multiple heavy loads carried over eighty-three separate trips between the bomb site and the medical facilities.13 It was the worst attack in the country’s capital in fifteen years of war, remarkable even by Afghan standards. The next day it was reported that sixty-four people had been killed and 347 wounded, but that figure was likely to be on the low side for both categories.
All these survivors across the world will all get some variations of all the other things we are coming to understand at the cellular level at Imperial. Not just a known military cohort but an entire global population of blast casualty on every continent, living out the pain of the echo of the blast and its invisible armoury one difficult step and day at a time. For most of them there is no one watching, no one going back to the lab with what they’ve learned to try to make it better. So what happens at places like Imperial can only ever be a start.