Statistics from Altmetric.com
The reality of emergency medicine in the war arena
I would not regard myself as superstitious, but 13 April 2003 was not what I would call a lucky day. It was the 22nd day of the ground war in Iraq and I was the officer in command of the emergency department of 34 Field Hospital. Seventeen days previously this had moved into Iraq in support of the 1st (UK) Armoured Division and had begun treating battle casualties on 27 March. Unusually the hospital was co-located far forward with the infantry and armour units on a disused military airfield close to the city of Al Basrah. By this time in the war the explosions around the perimeter had become less frequent, and the hostile incoming mortar and artillery fire had stopped. Challenger II tanks of the Scots Dragoon Guards and 2 Royal Tank Regiment could no longer be seen racing across the desert and engaging targets; and the nightly firework display of tracer from heavy artillery lobbing rounds across our accommodation tents had also ceased (an event that would wake even the heaviest sleeper, and cover the tent in gunpowder).
The day had started inspiringly at 0700 hours with a medley of marching music from the attached military band practising outside A&E, poignantly interspersed with the Last Post from a cornet player raised on a flat bed truck against a sky darkened by oil pit fires. An hour later the first routine of the day was the heads of department attending the Commanding Officer’s briefing (“Orders Group”). Serious business in hand, the Regimental Sergeant Major had stated that the stethescope was not an article of uniform, and was not to be worn around a doctor’s neck outside clinical areas. Predictably this was to precipitate a flurry of fluorescent and improvised striped tubes worn defiantly by the senior clinicians. In turn I briefed A&E clinical staff with the latest intelligence and assigned daily tasks, then flicked through the week old newspapers in the department. Later I reflected in my journal on the impact of the plethora of personal tributes in the tabloids to our soldiers killed in action. Dealing with death regularly in A&E, I considered, was often by dissociation and reliance on the fact that there is little opportunity to form any substantial relationship with a patient or their family. But I could not mentally dismiss those soldiers on whom I had pronounced death and placed in our temporary mortuary (a refrigerated ISO container, or “reefer”, known as the Grim Reefer) and whose images repeatedly appeared in print.
Since 2001 I had spent five months in the deserts of Oman, Afghanistan, and Kuwait where the weather could change in an instant, and today was to be a striking example. Imperceptibly to those working in the dim artificial light inside the green tented hospital complex a storm had rapidly closed in and was heralded by a “dust devil” (a euphemism for a small tornado). This proceeded with divine direction through the senior officers’ accommodation tents, most of which were unoccupied, miraculously sparing the near capacity 200 bed hospital. A young female soldier in the shower tent was witnessed to be lifted and transported spinning in canvas, Dorothy-like, some 50 metres sustaining serious chest injuries on landing. My own tent was forcibly moved, pulling free the securing bolts drilled in the runway, with the contents churned in an action akin to a giant washing machine. The same evening mother nature gave a second impressive demonstration, this time of sheet lightning: two soldiers on the airbase were struck, and one died of his wounds.
In the build up to war I had been deployed with the first medical elements to establish the A&E department in 22 Field Hospital in Kuwait. Attendance here had peaked at 80 per day, which although a fraction of a standard NHS department’s activity the manning was only one consultant and one SHO. Furthermore, the clinical routine was regularly interrupted by ballistic missile warnings for incoming SCUDs, or chemical attack alarms (one second on, one second off a vehicle horn). So reactive was the system that a reversing lorry could have the whole camp masked up in seconds (the same ripple effect was memorably produced by some chump running in his respirator to increase his cardiovascular workout). At two hours notice I had been transferred to 34 Field Hospital as it moved into Iraq to establish itself as the main medical effort to receive battle casualties. I had crossed the border at night in the back of a battlefield ambulance with one of my registrars, having been “sanitised” of all personal effects. We were to join the main body of personnel at the airbase. In satirical contrast with the convoys of armoured vehicles, they had moved forward on a blue coach bearing the inscription “Happy Journey”. A small department was established in 24 hours to support a 25 bed rapidly deployable hospital. Over the next week the 200 bed hospital was built alongside, using the necessary engineering expertise to supply running water, improved sanitation, and power. The department’s manning was then boosted to three consultants, four specialist registrars, and four SHOs, with two of the consultants resident at any time during peak activity. Attendance rose to 140 per day during war fighting, but with far fewer minor injury presentations.
Experience in Oman in 2001, Afghanistan in 2002, and again in Iraq in 2003 has confirmed that a substantial proportion of a field hospital’s work will be soldiers incapacitated by an enteric virus. Particularly important lessons were learned by 34 Field Hospital at Bagram airbase in Afghanistan when an outbreak of Norwalk-like virus manifested in a novel and severe form among the hospital’s 76 staff. Forty per cent of the staff were ill and a further 20% quarantined, with five cases of meningitis (two requiring ventilation, and one with DIC). This was particularly clear in my own mind as I had been the emergency physician and had required to take the additional roles of consultant ITU, consultant general medicine, and junior doctor for the whole hospital because of staff shortages. It is convenient to point the finger at “poor hygiene” in both instances, but this group of viruses is notorious for its high attack rate among institutions, including NHS hospitals. Traditional cases of dysentery (salmonellosis, shigellosis, amoebiasis) were very rare compared with historical precedents in war because of improvements in field hygiene and perhaps, as the Professor of Military Medicine observed, this was simply nature expanding to fill a vacuum. This experience was translated into a process of assessing infectious disease patients separately from conventional patients. A 14 bay assessment tent was placed adjacent to A&E and infectious patients streamed to this area for assessment by staff with appropriate protective equipment. The broader concern was for recognising and separating those patients showing the first symptoms of biological warfare (particularly those highly contagious conditions such as smallpox and pneumonic plague). Distant from us our NHS colleagues had the real and present threat of controlling the global SARS crisis, no doubt working through similar thought processes.
With domestic normality at 34 Field Hospital rapidly restored after the morning’s storm, focus was drawn to the clinical activity. It was lunchtime when we had an influx of critical patients over 90 minutes. A soldier with an acute onset dilated cardiomyopathy and fast atrial fibrillation. Two escaping prisoners of war with gunshot wounds, one with damage to a popliteal artery and a shattered tibia, the other with multiple limb wounds. A 15 year old Iraqi boy unconscious with a closed head injury after a road accident. An 18 month old Iraqi girl who had fallen into a burning pit of oil sustaining facial and limb burns. A 7 year old Iraqi girl with an amputation of the hand and abdominal fragments from playing with a landmine. A 14 year old Iraqi girl with 60% burns. A 3 year old Iraqi boy with a compound tibia fracture after a road accident. A 12 year old Iraqi girl with 20% burns from two weeks ago and septic shock. And a prisoner of war with appendicitis.
So what? Nothing you could not cope with in your own practice. But what if the nearest CT scanner and neurosurgeon is in another country? Would your general surgeons perform burr holes or a craniotomy on clinical grounds alone? What if your burns services are also in another country: can you really spare an anaesthetist for the inter-hospital transfer, as it may take a day for them to return? How will you manage the patients in A&E when your two surgical teams are occupied; there are no surgical reinforcements? How will you improvise if your paediatric resuscitation equipment is “limited”? And what if your intensive care unit is full? These were a day’s worth of challenges.
So few words cannot do justice to the intensity of this experience, of frustrations balanced with fulfillment and spiced with a little anxiety. Nothing has yet been said of the effort required to simply sustain yourself in a desert environment, without climate control, washing out of a mess tin, and eating packet meals (termed Meals Ready to Eat, or less charitably Meals Rejected by Everyone). The personal challenge to anticipate and manage the requirements of equipment, people, and procedures to provide the emergency medicine service across three field hospitals and within the medical regiment was enormous, is not one I would have missed, and was only achievable with the quality and resourcefulness of my staff. It is quite amazing, I thought as I lay on my sleeping bag under the mosquito net that night of 13 April listening to the tanks trundling behind the protective berm (a wall of sand), the wind and rain, and the indiscernible crackle of the tannoy, how quickly you can adapt to the most bizarre circumstances. And almost regard them as normal.