Medics
After each patient who died I got this feeling […]
I think we all got it. I expect we all got it.
Paul Roach, Citizen Surgeon
AFTER SERVING AT THE SOMME from the first day (1 July 1916) until the last (19 November 1916) without so much as a scratch, a stretcher-bearer finally made it home to London for some leave. For a day he greeted his family and saw his home, and then found the pistol he had brought home in his pack, went up to his bedroom alone and shot himself. During the battle itself over 400 medical personnel were admitted to the front-line psychological units, although no other record remains of who they were, what their symptoms were or how long they stayed there.1 What we do know, now as then, is that military medical service is every bit as challenging physically and personally as military service itself. There are thoughtful researchers doing work to understand what the outcomes of these challenges are, but their findings aren’t likely to be in for a while, so in the meantime here are some of my observations, made between December 2014 and November 2016, as I talked to my medical friends and colleagues while I was writing this book.
Medics found many different ways to cope while they were actually in Afghanistan. One way they met the challenge was with time and space they claimed as their own: pizza night at the padre’s, and building a defiant garden, and walking the sniffer dogs, and games, and running around the camp roads until their lungs burned and all they could do was sleep. There were the Bastion Bakers: an emergency physician, two surgeons and two anaesthetists who went into the camp kitchens in the afternoons when they weren’t needed (the kitchens or the medics) and baked bread. They got really good at it – specialist ingredients sent from home, new recipes tried – Focaccia Fridays and a sourdough loaf, whose starter was taken back to the UK with its owner and was still breeding bread in 2014.2 Good for the bakers, good for the medics who stood and ate what they had baked, something very old and helpful to humans in breaking bread together.
All of it, side-by-side therapy, watching for each other. The American surgeon who treated the Afghan children at Bastion remembered this in particular:
Whenever the person I was entrusted to treat out there died from their wounds, I’ll admit it, it hurt, and as soon as I could I would need to step outside in order to catch my breath and have my space. I did not lose a single person who could have been saved, as busy as we sometimes got I never felt panicked, but after each patient who died I got this feeling […] I think we all got it. I expect we all got it.
Later, afterwards, we all would hang together and check on one another in the little ways that really mattered, eating together, talking, finding out if the other person was alright, finding things to laugh about, exercising. It was all we could do, but it mattered and it made the difference.3
Some things helped some medics more than others. The repatriation ceremonies, for instance. Standing out in the open, hearing the padre lead a service for the dead. Seeing the absolute precision of the ceremony, no matter how hard the wind was blowing or the rain soaking through their uniform, unflinching, seeing the coffin taken away to the aircraft they had flown in on surrounded by living soldiers, for a journey home alone. One of the surgeons written about in this book went to every single repatriation ceremony held at Bastion while he was there, and there were many. He considered it the least he could do, part of his work. Another, who certified the dead in the cool dark of the mortuary tent, went to only one; one was enough, no more. His time could be better spent.
The junior trauma surgeon went back to his tent and wrote the diaries that became such an important primary source for this book. He wrote, no matter how tired he was, whenever he had a break, once sitting in the sunshine outside the NAAFI canteen, with a huge mug of tea. He wrote quickly, and clearly and with no spelling mistakes or crossings out. It flowed out of him, page after page, filling volumes of red exercise books that he brought with him from home specially for the purpose. He’d begun diaries when he was in Iraq. They told of fear, and on the front page had little drawings of a mortar every time one landed close enough to him to be a near miss (forty-six in all). There was almost no fear at Bastion. The occasional rocket landed, but far away in the camp, and he never had to take cover under a hospital bed. He wrote of things that medical officers have so often written of, whatever or whenever the war. Of the weather, and of letters from home, and of nature somehow finding a way into their lives. Of his frustration with newly arrived officers who thought they could tinker with a system that already worked, of friends coming and going, but mostly of the work. No lists, just paragraphs of narrative of surgery, a conversation in his head:
Both operating tables stayed open pretty much constantly. GSW abdo, fragmentation to the face, blast to lung, unilateral traumatic amputations, bilateral lower limb amputations, GSW leg, GSW knee, fragmentation abdo, hand trauma, finger trauma, fragmentation buttock, fragmentation upper limb … these are the cases I can remember. There were more.
He remembered most of the individual procedures but very few of the individuals. It surprises him today when he meets someone who was one of his patients in the trauma bay or chilly operating theatre at Bastion, but it doesn’t bother him particularly. He had been very angry, for years after Iraq, but after Afghanistan he became trauma registrar at Birmingham and then came to Imperial to research heterotopic ossification, which is how I met him. He thinks that working to understand the science of the severe casualty he treated back at Bastion has helped him be less angry, to unpack the meaning of his own experiences, to decompress.
Decompression is a technical term used by the military for a scheduled period immediately after deployment where personnel are given time to unwind physically and mentally. Everyone coming back from Afghanistan, including most of the medics, stopped over in Cyprus for around thirty-six hours,
in a friendly environment that allows you time to start ‘winding down’ prior to rejoining friends and family in the UK. It provides time to talk through your memories with friends and colleagues who have shared similar experiences to your own.4
Decompression works for soldiers, who travelled and decompressed together as a formed unit – on the beach, at the show in the evening, on the deckchairs by the pool. But medics travelled singly, alone in the crowd. And once the crowd discovered who they were, they wanted to ask them hard questions about their mates who didn’t make it home, or who went home in CCAST weeks ago, and what happened to them in detail, what they’d done – how many amputations, how did they go, why did he die? So no decompression for them, just being forced to relive over and over in detail what they had been doing: no jokes, back to their surgeon voices, dragging it all back up again in the queue for food, on the beach, in the shared camp bathrooms. Often not decompression, only more compression.
The hand surgeon remembers not only every individual procedure he did but every individual he did them to, and it was a lot because with his beep, ‘Doe, a Deer’, he went to every single trauma call, and many considered him the hardest-working man in Bastion. For him, ‘you are always linked once you’ve removed someone’s limb’. Every single trauma call, one day after another, and he knew he had to develop some kind of coping strategy, some kind of resilience. So he told me that each day he put all the memories he accumulated at Bastion in a box in his head, and closed the lid on them tightly and didn’t think about them until he got home, and by the time he had finished his second tour, the box was pretty full. At the same time, looking back, for him and for most of the surgeons there was a sense of satisfaction, of a job mostly well done, of being lucky to have seen it all and been part of something so extraordinary and not been found wanting, and a sense that they might never be quite as important, as necessary, as this again, at least professionally.5 That sense helped them then and helps them now.
Back home and back to work. The hand surgeon works at a London hospital with a huge trauma unit, and every time, every single time, he hears a helicopter there’s the same knot in his stomach that he had at Bastion, hearing MERT arrive at Nightingale, ‘Doe, a Deer’, waiting behind the yellow line for the call. He too was angry for a long time after he came back from his second tour, and when he discussed a third with his family, they said no, absolutely not. And so, knowing he would not return, he started to unpack the box in his memory, starting with the difficult cases, the failures. Unpack the deaths. The time when he had to call a halt and stop the team who were sure life would somehow come back from where it had been lost with only a few minutes’ more work. The moment he examined a child burned all over except for a patch of undamaged skin under one of her arms and who died because there was nothing at all that he or anyone else could do for her except relieve her pain.
He considers it part of his responsibility to seek out the patients whose hands he amputated, to see how they are recovering, to ‘make an apology’ (his own words). He went to the military ward at Birmingham one day to meet the soldier whose hand he had really tried to save, fixation error, but could not. He started by introducing himself: ‘I was part of your operating team at Bastion. Is there anything you want to know?’ The soldier was pleased to see him, sat up in bed and smiled, but kept the stump of his arm covered with a sheet. His girlfriend and parents were in the room with them, and so somehow the hand surgeon never got to say what he wanted: ‘I’m sorry I had to take your hand off.’ He still hasn’t, even though he knows the patient well now because their paths cross professionally, and the patient knows who he is and what he did. He’s waiting for his chance to ask about it, and that’s when he’ll be able to make his apology (and the patient will probably be puzzled that he needs to do so at all because, after all, as a result of his surgery he didn’t die). At the medical school where we both work he teaches the two hand cases he described for me in this book, with a PowerPoint presentation and photographs, and he shows each new generation of surgical residents what success and failure really mean.
Packing and unpacking boxes of memories, trying to make sense, reordering. That’s what the American surgeon calls it.
It’s not PTSD – it’s different […] I’ve looked it up and it doesn’t quite fit […] whatever version of PTS that I might have right now it does not feel like a ‘Disorder’ I don’t think. Even though I get to have my issues, it feels like there is still some kind of ‘Order’ to them, ‘PTSO’, perhaps, like something necessary is going on, and my soul or psyche is busy achieving its new balance […] This process, this PTS re-ordering, I think it’s the process for how I will get back to what I was. It wouldn’t make sense otherwise.
Back at work, back at home. Yet how to get back home, really, knowing something has been left behind? (I would have rewritten this, but the surgeon has put it so beautifully and when I read it to other surgeons they said that is it exactly.) So, in his words:
They say war is intoxicating, but it wasn’t intoxicating for me. It’s like the intensity and the sharpness of the experience carved deep channels in my mind, and my thoughts as they flow about their daily business easily find themselves rolling downstream into those channels […]
Since I’ve been back, I’ve been moulting, I suppose. I’m impacted but not injured. I’ve had up days and some down ones too […] It’s like there are these pockets of soap bubbles of overpowering emotion floating about in my life’s arena, and when I’m not bopping into them and they’re not bopping into me everything is fine, perfectly fine. But there you can be, marching along, doing your thing, and one of those little bubbles find you and ‘pop’ it bursts and for a little bit you’re under its spell and you’re right back in Afghanistan or more likely you’re just getting emotional and tearing up for no reason. ‘It’s my allergies’ I say as I excuse myself if there’s someone around.6
Almost everyone I have met in writing this book has gone back to their post in the NHS or the Defence Medical Service, to medical schools or to their practices. They research, treat and teach. The anaesthetist team leader from MERT goes out regularly with the air ambulance service in their helicopter, and when he is on board, everyone learns. They remember. The DCCN was posted overseas in 2016, but her personal diary went with her, along with the annual quietness on the anniversary of the deaths of her Bastion patients.
For them all, small things can trigger big memories. One MERT medic had stains all along the edge of his canvas watch-strap where blood had seeped over his disposable gloves during a long and complicated resuscitation in the back of the helicopter. There was no cleaning the strap, and he didn’t have a spare, so last thing at night and first thing every morning the bloodstains were what he saw when he put his watch on or took it off. Khaki canvas watchstraps always start him remembering. Recently I went to hear a lecture from a surgeon who had been at Bastion in all the worst years, and I put a pile of papers down in front of me that had a 9-Liner set on the top. These are visually quite distinct: laminated plastic cards, pale pink, pre-printed with a list of the information that will be needed to call down MERT, all held together on a steel ring. While the surgeon waited to start, he caught a glimpse of the 9-Liner lying in front of me and he stopped stock still, for that extra second that doesn’t have much to do with time. And then he laughed, a little, and said. ‘Oops, bit of a flashback there.’ And I put it away, out of sight, and was sorry not to have known better.
In many cases, diaries have been replaced with photographs, endless scrolling of photographs from their mobile phones and now on their computers. Some of them look at them too much, know the images too well and should probably put them away at some point. Perhaps there should be some research on the impact of personal photo archives, a brain scan to see what happens when they look back. Many of them continue to deploy, or go and train medics in countries they once deployed in, where things have really not got any better since they left, and I worry about them, which they think is funny, but it’s hard not to worry when you work in a blast injury studies centre.
When I look back through the notes I took during my interviews, it strikes me that everyone I spoke to could fit into one of two categories. Some (most) spoke from memory – well-organised narrative memory, tour by tour, case by case, giving meaning to their actions, or still seeking it, and using their time talking to advance that process. Even if they needed diaries or their photographs to remind them of details, even if it was the first time they had spoken about their experiences at length, their thoughts were ordered and their retelling was calm, reflective, self-aware. Sometimes they looked out of the window and took a few slow breaths, and then continued. Several pushed up the sleeves on their scrubs and showed me where the cutis ansorina (medical term for goosebumps) had appeared as they remembered and talked, or laughed about the sweat on the palms of their hands and from their foreheads, as their bodies still kept the score of their experiences.
Then there was a second group that I spoke to (not many), who switched into what seemed to be another personality when they talked about Afghanistan and their work there. They suddenly switched to the present tense. Short bursts of words. Pauses. Clenched fists hidden under the table. And they were unable to guide me through a linear, chronological narrative, no matter how much prompting from diaries, or journal articles or photographs. They flashed up fragments, phrases, moments – sometimes it felt like a bombardment from their past and I didn’t know where to look or what to write down. Despite our friendship, their support for the work, they moved into a space where suddenly they were mystified by my attempts to order the technical experiences of combat medicine – it can’t be done, you don’t understand, everything happened at once, it can’t be explained, not if you weren’t there, aren’t there now. Emily, I don’t want to be in Helmand any more. My questions had taken them somewhere where they were not masters of their memories, and so, once I had come to understand what the difference between the two groups meant, I stopped asking them to speak about it at all, even in a roundabout way. And I took out all the material I got from them because it did not belong in a history book.
From both groups, many have made the same casual remark: I’ll deal with all of this when I retire, and something in me hopes (if that is the right word) that this will be the case. Recently another American surgeon who served in Vietnam, working on so many injured children that he became a paediatrician on his return home, wrote of just how this happens. How, no matter how long after the event, he and his colleagues from all the wars since will always have hard questions to ask of themselves.
Older folks like me are always surprised when they become symptomatic long after the trauma has occurred. Ageing veterans are more vulnerable physically, psychologically and financially, and they have more time for reflection. When I told a Veterans Affairs psychologist that I did not think my late-in-life symptoms were related to my Vietnam experience, he smiled. ‘If you really believe that you were not affected by running into a minefield, disarming a disturbed soldier while he was threatening to shoot you, and watching your patients die while you treated them in the mud and under fire – you are an idiot.’
[…] I did not realise that the intimacy of just being present when a patient died would create an existential bond that would always be remembered […] It was likely that some decisions made using an in-the-moment survival mentality would breach our own deeply held moral beliefs. And when we revisit them, absent the drama and without the support of like-minded individuals, we know there can be no do-overs – only the do-laters that will become our challenges for the future.
If we allow ourselves to carefully examine the events and decisions that injured our moral selves and ask, ‘What kind of person am I?’ the answer will be very complicated.7