I: It’s Monday 3rd November 2014. I’m Richard Barrett. I’m here today with Sarah Dixon-Smith to interview Commander Ben Siggers, RN Retired, now Consultant Anaesthetist in Salisbury, and we’re here as part of the World War I project to talk about developing anaesthesia and treatment in the field of conflict.
Ben, thank you very much coming along today.
P: Good morning.
I: Could we start by just asking you how you chose to go into the armed forces as part of your medical training?
P: I was a Royal Marines cadet at school and thoroughly enjoyed that, I liked soldiering, so I considered a career as a Royal Marine, and felt that that was probably a young man’s game and I might last longer if I went into a different branch of the armed forces, so initially was in contact with the Royal Navy, but then I was advised that the opportunities in the army might be broader because it’s a larger organisation, so I actually ended up joining Royal Army Medical Corps at medical school as a cadet, and went from there.
I: Tell me how your training in anaesthesia and training for the Marines, how it ran? Did it run parallel or did it diversify?
P: I started out with the Paras as a medical student, and did my [1:28]-camping and my jumps course on finishing medical school. Actually as part of my post-graduate medical officer training between house jobs and SHO jobs or my general duties time with the military, I realised that there was an opportunity to work with 3 Commander Brigade, Royal Marines, so I badgered and nagged the powers that be incessantly until they gave me the job and went down there for two years, which was where I did my commando training and enjoyed that thoroughly, and then came back into hospital practice, as is the usual pattern. I started out as an ED trainee, but I started that with a year of anaesthesia and ICU so at that point realised that I enjoyed critical care in the form of anaesthesia and ICU and cross-tracked to anaesthesia then.
I: And how was training for conflict, because at that time that was post-Falklands and pre-Iraq, pre-Bosnia.
P: So as an SHO, as an orthopaedic SHO in fact, as part of my ED training I had my first real experience of operational tours. I did a brief stint in Northern Ireland as an anaesthetic SHO, but then I got bounced to Bosnia at very short notice, in 2000 actually, and that was what you would call a mature conflict, in that we’d been there a while, we were fairly well established, the intensity of the operation or tour had died down somewhat. There was still plenty to do, plenty of trauma to manage, but a lot of it was non-conflict trauma by then, so it was at the multinational facility in Sipovo, which was jointly run by ourselves, the Dutch and the Canadians, so it was an experience of working with other nationalities which was actually very enjoyable and quite an eye-opener as to how other people do it. My first experience of being on operations, which was quite interesting, quite exciting, and gave me a taste for it, I think.
I: And when you came back, did you find that lessons learnt meant that guidelines for want of a better word had changed?
P: Our overarching doctrine is the clinical guidelines for operations, which covers everything, and within that specific topics are covered by Surgeon Generals, operational policy letters, and those are updated, CGOs [clinical guidelines for operations] are updated very regularly, as are SGOPLs, so there’s a continual process of updating which I think is much more evidence-based and much more refined these days than it perhaps once was, and probably happens on a faster turnaround than it used to because things are moving forward more quickly. Increasingly over recent years it’s become more and more difficult to keep up if you like, and that’s why I think we’ve had to enhance pre-deployment training in the way that we have. Even if you deploy every two years to the same field of operations then you can still be significantly out of date, so the need to update with what’s actually being done now and what the standard operating procedures now are is ever greater. When I came back from Afghanistan there was a realisation that we needed to significantly ramp up the pre-deployment medical training and critical care training, so the Educational Special Interest Group was formed and one of the first things we did was to develop the MOST course, which is the Military Operational Surgical Training course. That’s five days at the Royal College of Surgeons, it’s a surgical team multi-disciplinary course, so it involves surgeons, anaesthetists, now ED consultants as well, and theatre nurses, ODPs and ED nurses as well, and it’s a multifaceted course with parallel curricula for the different groups but joining together for the things where a multidisciplinary format is going to be more beneficial, and we put a lot of workshops on equipment in that, there’s a lot of … some lectures but a lot of workshops and seminars basically on different aspects. There’s a half-day on regional anaesthesia, which I’ve always found hugely useful to me, being part of teaching it has taught me a lot about regional anaesthesia, so that’s been immensely useful in my civilian practice as well, and we’ve done a lot of scenario-based training in that course. It’s never enough but it’s certainly a good start introducing the standard operating procedures for massive trauma but also a lot of the non-technical skills, a lot of the CRM, the team work, the communication and those sides of things, which has meant that those teams hit the ground operationally running a lot smoother than they otherwise would, because a new unit arriving in Camp Bastion or whatever it is, historically they would take a few weeks to build up and get to know each other and start to run as a smooth, effective unit. In Camp Bastion the intensity was such in 2008-10 that there wasn’t time to build up gradually and get better, you had to be running smoothly from day 1 and that’s why the MOST course was intended to do some of that. HOSPEX which was the traditional Hospital Squadron training course, which is three days up in Strensall in Yorkshire, where there’s a whole hospital unit laid out in a hangar which can be exercised as a whole hospital. That had done some of the job but the MOST course was more intense and covered things in much greater detail clinically because HOSPEX had historically been to a certain extent largely a logistical exercise rather than a clinical one. And nowadays we have the MOST course, we have HOSPEX but with much enhanced clinical component, and then there are bolt-on courses for the different roles as well. So the Medical Emergency Response Team have a multidisciplinary course which trains just them, so they are the helicopter retrieval team and they train separately as a course as well. All of that has developed over the last five to ten years and is certainly making a difference to how effectively units function when they arrive in theatre.
I: It sounds like a very far cry from what happened in Bosnia.
P: Well I had virtually no pre-deployment training for Bosnia. I had probably had already done my mandatory annual training in lie detection and the various other, what we would call ticks in boxes for the military side, but I don’t think I had any clinical training. Fortunately I had reasonably recently been an operational RMO with a Commando Unit so my military and medical training was reasonably up to date, but I don’t think I got a lot before I went to Bosnia because I only had three days’ notice. For Iraq I think I had the standard pre-deployment military training, and I probably did HOSPEX but I can’t really remember much about it and certainly at that stage HOSPEX was largely a logistic exercise. So there wasn’t a lot of pre-deployment medical training as such. My arrival in Iraq was about two in the morning at Shaibah base in the middle of the desert outside Basra, and Dan Connor, [10:08] Commander who now works in Portsmouth, greeted me at 8 o’clock in the morning, we had some breakfast, he gave me a tour for half an hour, he gave me an intensive ten minutes on the Triservice anaesthetic apparatus, which I had seen before but hadn’t really worked with, and there are definitely some quirks to it and some schoolboy errors that can catch you out, so Dan ran me through those and I had Dan’s top tips for what not to do and how not to screw up, which was very helpful. Then we went and played volleyball and I broke three ribs landing on top of Dan, and he was a very worried man for about six hours to see whether he was going to have to stay there and me be evacuated, but fortunately it wasn’t too bad, so I stayed and he came home.
I: And was that you on your own then?
P: No, that was me as a post-fellowship registrar with two consultant anaesthetists and one intensivist at Shaibah at the time, and we ran things more or less on quite an informal basis in terms of who did what, but I was very keen to get stuck in so unless I was involved in something else, if there was a case going to theatre then I would go. The intensity for the majority of that tour was not as high as Afghanistan. It did surge at times, we had one major incident where a unit were basically mobbed by a crowd and there was lots of petrol bombs thrown and one or two rounds fired, so we had a few things like that, and then a patrol ambushed out in Alamara, which the Quick Reaction Force went in to relieve them and that was again another major incident. So when there was a surge like that, you would have casualties coming in the front door, you’d go and pick them up in ED resus and resus them, take them through to theatre, through to ITU, drop them off and go to ED for the next one, and we’d be rotating fairly endlessly through that cycle for ten, twelve hours or however long it took to get through those guys. But that didn’t happen very often, so if you were on the go for 12-14 hours then, you would have time to recover, whereas in Afghanistan it could be like that for days in a row. So that required more personnel. And the other aspect of Afghanistan in terms of intensity was that we were manning the MERT, the medical emergency response team, as well, during my tour we had one day in three on the MERT, because that could be very intensive, very draining, and then you’d have … that was an 11 am to 11 am shift, 24 hours, and you’d have the rest of that day off after you’d handed over at 11, and then you’d be back on the next day in theatres and ITU, and then on the MERT the following day, so there was a built-in rest period during the cycle. It waxed and waned but the intensity was generally a lot higher in early 2008 in Afghanistan than it was certainly in 2004 in Iraq.
I: How was your hospital set up in Iraq, just outside of Basra? Would it bear any resemblance to Camp Bastion?
P: Well it bore a very strong resemblance to my early time in Afghanistan because it was the same tented hospital with the same herringbone format, so there’s one long central corridor with an entrance one end and an exit at the other, and wards and departments coming off either side of the central spine, and that’s the traditional format for a field hospital, given sufficient space. That was the format in Iraq and in Afghanistan when I arrived there, it was exactly the same. It’s a very functional system, it works very well. After a month, six weeks in Afghanistan we actually moved into the new prefabricated hospital, which is the one that’s standing now. I think it’s been expanded since, but that was a purpose-built prefabricated hospital. The major difference in clinical terms, and anaesthetic terms, was that we went from using the portable ventilator and Datex monitor and the Triservice anaesthetic apparatus to using a Draeger Primus machine in what resembled an ordinary operating theatre. A big jump into the 21st century on moving into the new building, but it would be very difficult to have a standard anaesthetic machine in a tented environment, so it wasn’t until we moved into the new hospital that we brought things back up to date. We still did use the Triservice apparatus and we used TIVA quite a lot for secondary procedures, relook procedures, second look washouts and things like that. Latterly certainly a lot more use of regional anaesthesia for on-going pain control, so it might be sited if we’re generally dealing with a lot of limb wounds, so if the base of the proximal limb was clean enough then you could site it, nerve sheath catheter or something like that, and that would see that patient right through to Birmingham and their first few procedures in Birmingham. So there was increasing use of that and that was led to a certain extent by the Americans but worked out alongside the Americans. There’s a fantastic individual who you may have heard of called Trip Buckenmaier, who’s a US Army Colonel who managed to generate a large amount of funding from US government to develop acute pain control. That funded some very high-quality research under his guidance in regional anaesthesia and other forms of pain control. He essentially wrote the book on regional anaesthesia for traumatic injury and had some fantastic results, which we’ve adopted, and a lot of his techniques – the technique I use for super-clavicular blocks in my practice on a daily basis is his technique. So we’ve got a lot to thank him and his team for, but a lot of that was done with us as well. And Duncan Parkhouse and co. on the pain side with the academic department of defence anaesthesia here did a lot of that work as well.
I: Taking you back to Iraq when you arrived there, who would go out on one of the medical emergency retrieval teams?
P: The Medical Emergency Response Team was at that time in the back of a Chinook, occasionally a Wessex and latterly has been in a Merlin, so it was a Chinook when I was doing it, and in the back of there you would have the air crew, so you’d have a loader and a gunner from the air crew in the back and two pilots in the front; the medical team was a four-man team consisting of a senior RAF nurse who would be the operational commander of the medical unit, a post-fellowship registrar or consultant from ED or Anaesthesia, an RAF paramedic and then a fourth person who could be a doctor in training or sometimes a CMT or sometimes occasionally an ODP. And then you’d have a force protection unit of eight riflemen to provide protection on the ground for the MERT and we often had EOD, bomb disposal on board as well, with or without a dog. So it was quite crowded in the back! But there was still room for, with the tailgate down, three stretchers end to end and walking wounded sitting on the seats on the side. We had Piggott pouches, which are just unrollable series of pouches on the wall with equipment in them and medical Bergans, medical rucksacks open with kit on them as well, on the seats to the side. Generally speaking the worst two casualties would be loaded first and they would go feet first followed by head first, so that the two heads of the worst two casualties were together in the body of the aircraft, and as the consultant kneeled between the two, the head end of both casualties, and flip round and deal with either. So you might do an RSI facing forwards and then turn round and do an RSI facing backwards, or equivalent, which was sometimes tricky but actually worked quite well.
I: Would you be on the ground when this was happening or would this be airborne?
P: No, the major difference to civilian rescue helicopter work is that as a civilian [19:31] practitioner, a pre-hospital doctor, you’re trying very hard not to have to do anything in the aircraft, so you’re packaging the patient fairly comprehensively before you get in the back because civilian aircraft tend to be smaller, they don’t have a lot of space to work and actually you don’t want the patient to go off and have to do something en route, so you’re doing most of what you need to do before you get in the aircraft.
The big contrast with the MERT is that you’re a very big, very juicy target and the casualties that you’re going to retrieve may or may not have been deliberately injured in order to bring you there, which is what’s known as a come-on, so the Taliban would quite happily shoot an RPG at a bunch of children, knowing that half an hour later a Chinook would land somewhere nearby and they could have a pop at that, so a come-on was always a concern with launch decisions for the MERT, but the result of that is that the pilots would not want to stay on the ground, so you had a maximum of maybe 90 seconds on the ground, probably more like 60, you would land, the casualties would be thrown on board and you would take off again. You would get a very brief handover from whoever the medical person on the ground was, and then the casualties would land in front of you and you’d deal with whatever you found, and that was sometimes not what you were expecting.
The launch decisions were made in what’s known as the JOC, the Joint Operational Command, with the Joint Helicopter Force Commander and the Operational Commander and you as the medical MERT lead. You would basically look at the information that was coming in on the 9 liner over the radio, the call for help, and you’d make a decision based on your estimate of what the medical urgency was and the operational risk to the aircraft from it might be weather as much as other things. And whether there were troops in contact on the ground. If you had a casualty but there was still an active fire-fight going on, bringing the helicopter down in that would be that much more risky. That would have to be balanced against the clinical urgency. You might still go in, but that would have to be a balance of risks, as with any other decision in medicine.
Similarly landing where there’s an IED, if you’re landing in an un-cleared area then again that’s a balance of risks. You can wait for the area to be cleared, but then that might take an hour and if you’ve got someone who’s been hit by IED you can’t really afford to wait that long. So those sorts of balance of risks, launch decisions, would ideally be made early and then you’d launch. But because of the timeframe you might find that what landed in front of you in the aircraft was substantially different from what the 9 liner said, and you could always be diverted in the air to something else and you might not have very much information about that casualty.
I remember having a 6-week old baby with a burn land in my arms in the back of the MERT as a divert from another casualty that we were picking up, quite a flat baby, but fortunately was more or less managing its own airway and with an intraosseous cannula and 20 mls per kilo of fluid perked up quite nicely and was much more lively by the time we got into Bastion, which was nice. But more or less had to work out what to do when the casualty landed in front of you.
I: In Iraq there was a lot of injuries that were as a result of the lightly armoured vehicles, suggesting you might get through for more casualties at the time. How could you cope with that?
P: With the numbers or with the pattern of injury?
P: The pattern of injury was certainly different, possibly more varied in Iraq because the tempo of operations was a little bit lower in 2004 and having been there nearly 12 months and the initial war-fighting phase was over, there was a lot of police actions going on because there was infrastructure rebuilding and where there’s money being put in there’s a lot of opportunity for people who are poor and desperate to make money, so we had a lot of non-conflict injury and a lot of police action injury. So we had ambushes where the police were, the British military supporting the Iraqi police were taking on armed criminals basically, so there were some … generally armed criminals getting injured in those sort of contacts. There were certainly patrols getting ambushed and some of those were firearm injuries rather than firearm than blast injuries. There were some blast injuries and some IEDs but not nearly to the same extent at that stage in Iraq as there were in Afghanistan later, or even later in Iraq, and we had a lot of non-conflict injury in both, where there’s a lack of infrastructure, a lack of electricity, people are cooking on kerosene stoves, they’re heating with kerosene and there’s a lot of burn injuries, and a lot of burn injuries with children.
For the civilian casualties, where it’s a non-conflict injury they apply what’s known as an eligibility matrix, as to whether we can afford to use our medical resource to treat those casualties, and often it’s the ED consultant going to the front gate at the camp and assessing somebody as to whether it’s appropriate for us to take them, because people would just drive up to the front gate and climb out with a severely injured person and often the eligibility rules would be bent for hearts and minds reasons, particularly with children, and sometimes you could be put in difficult situations clinically … or clinical logistically, because of the types of casualties you were taking in. The two instances that come to mind of that would be the morbidly obese Iraqi woman with 50% burns who we resuscitated appropriately but then had nowhere to put her at all. Experience had taught us that taking her to Basra Hospital would be a death sentence for someone that unwell, at that stage anyway, although there were in theory some ring-fenced burns beds back in the UK, accessing those for a civilian was not an easy command exercise … but they did achieve it eventually.
And the other one that springs to mind was an eleven-year-old Afghan girl who we were called about in the middle of the night with an AK47 round through her lower leg. Her father was a goat-herd, they lived on the side of a mountain under a tarpaulin and it had taken them three days to get to one of our forward operating bases. We went and got her. She was surprisingly well, she had an debridement, an ex fix and then a gastrocnemius flap by Mark Brinsden, who’s an excellent orthopod from Derriford, who did a fantastic job reconstructing her lower leg. The decision-making there was swayed by the fact that if she had gone from us to the Red Cross hospital she would have had a below-the-knee amputation more or less on the spot with that injury, and the social implications for her, she would then have been unmarriageable, it would have immense implications for her later life, so Mark did a reconstructive procedure but also we then had to keep her long enough for some healing to go on for her to be able to be discharged. And the Taliban put a lot of pressure on her father to bring her out of the British hospital and he had to be effectively bribed with in quotes ‘taxi fare’ to come and visit her every day, so a reasonable amount of cash changed hands to bribe him to leave her in the hospital so that she could heal. But those sorts of casualties can be challenging, not necessarily for clinical reasons.
In my experience the system always coped and off-duty teams would be called in if there was a major incident, and because everybody’s on site that’s easy to do. It’s actually easier than the hospital back here. It never seemed to be a major issue to escalate to the level required. Everybody would suffer a certain amount of fatigue, but generally things would calm down in time for that not to be a problem.
In Iraq I have vivid memories of the fact that the chefs would always be aware if the surgical teams were working late and there would be trays of bacon butties arriving at one in the morning to keep you all going, which was very welcome. One of my memories of operational tours is that food is always very good unless you’re living out of ration packs, but in an established operation there’s always good food and that keeps you going.
I: You must have seen a change in the pattern of injuries from Iraq to Afghanistan?
P: Yeah, very much so. The IEDs were starting to be a little bit prevalent in 2004 but now by 2008 in Afghanistan they were more or less the standard pattern of injury and traumatic amputations were the norm, with IEDs. If you were far enough away you might have the multiple small-fragment pepperings but if you were anywhere close to the blast radius then the traumatic amputations were the rule rather than the exception, and that … multiple amputations became almost the norm as well. I’m struggling to bring to mind the figures, but the number of multiple amputations is staggering, and fortunately the number of survivors is now very high from that, which had a bearing on our clinical management and that’s where we’d started to develop the damage-control resuscitation and damage control surgery principles to a much higher degree. We started to develop the massive transfusion protocols and we started to get a much greater understanding of coagulation matters in massive haemorrhage, particularly traumatic massive haemorrhage. That’s, I think, probably been the single most significant advance over the last six years in critical care in the military, and that’s filtered through to critical care in civilian practice as well. The number of survivors is a reflection of that really.
I: A platoon comes across an IED that blows somebody’s legs off and they’re now seriously injured. What happens next?
P: The immediate care will be done there and then by … sometimes the casualty themselves, the CAT tourniquets are designed to be applied by the casualty with … as long as they have one functional hand they can apply one to their own limbs, and then by their buddies obviously. That single piece of kit and its use has certainly saved countless lives in recent conflict. The compression bandages, certainly within my memory, the standard first field dressing was a big, fluffy, absorbent thing with a strap on it, and it was very good at soaking up blood but not very good at stopping bleeding, so we have the Israelis to thank for developing elastic compression bandages which are very good at compressing bleeding. So direct compression with or without novel haemostatics, HemCon and Quikclot being the obvious ones, and Celox latterly. So direct compression and novel haemostatics, indirect compression with CAT tourniquets, all of that would be applied by the troops on the ground and then they would be simultaneously putting out a 9 liner back to Bastion for the MERT and the MERT typically launch times … you know you have the launch decision to make, but you’d be launching within 10 minutes generally and flight times around Helmand would be … the longest flight was to Kajaki Dam, which was 35 minutes, but typically 10-20 minutes was an average flight time to get there, so you might be there as little as 20-30 minutes after the injury, and if effective external haemorrhage control had been achieved you would have a live casualty to then work on. You, in the back of the MERT, could enhance the haemorrhage control and you could treat chest injuries up to and including thoracostomies and you could RSI and manage airway and breathing to that extent. You could give analgesia and in certain instances with regional anaesthesia, but more often with intravenous ketamine or morphine and you could achieve splintage and you could start to transfuse blood and FFP so you could do a lot to start the process of damage control resuscitation. If you were giving blood, you would call ahead to Bastion to let them know you were doing that. Then they would activate the massive transfusion protocol and blood would be up in the rapid transfusers by the time you arrived in ED resus. So that could be continued fairly seamlessly and part of the effect of the enhanced pre-deployment training was to make the process through ED resus much quicker, so that you could be in and out of resus in … I’ve got some pictures showing it in about 13 minutes, which might be average – you could certainly do it quicker than that in certain instances. And during that time you would have had a primary survey and you’d have a rapid infusion catheter put into a subclavian and you’d have RSI form that was required and hadn’t been done and you’d certainly have some volumes of blood and FFP on board. Your CAT tourniquets would have been probably replaced with pneumatic tourniquets during that time and [34:31] would be started, so all of that could happen in a very quick time and you’d be off, usually to CT, with on-going resuscitation through CT to theatre. The damage control surgery side of things would be trying to get away from the old model of the surgical teams coming and treating the casualty in series, where the orthopods would come and do their bit, the general surgeons would come and do a bit of laparotomy and explore the pelvis and whatever in practice, and the whole thing taking a long time, the casualty getting colder and colder and more and more cardiopathic, more and more acidemic and starting to go into very much a downward spiral, which even if they survived the first 12 hours would then put them in line for multiple organ failure over the next few days and sepsis. So the idea was to get surgical teams working simultaneously and have on-going resuscitation during that surgical event and have the whole thing wrapped up very quickly and the patient into ICU quickly to be physiologically stabilised, even if that required the surgery to be very much curtailed to the extent of achieving haemostasis, then putting the patient into ICU, getting them warm, dealing with their coagulopathy and then bringing them back to theatre once they were physiologically back on track. That process, that ethos of damage control resuscitation and damage control surgery I think made an enormous difference and dealing with everything in parallel, the transfusion, the coagulopathy, the warming, the electrolytes, everything being done simultaneously to the surgery, I think has made an enormous difference to the survivability of some of those injury patterns.
The first triple amputee to survive was a Royal Marine called Mark Ormrod who actually flew back to Birmingham on the flight that I flew out on, on the same aircraft. He survived to an excellent quality of life, so I think that was the point at which the question, ‘Is it worth resuscitating, or is it worth causing these guys to survive with that severity of injury, I think he answered that question very firmly by getting back on his feet and walking his fiancé down the aisle with him within a year, on two prostheses, and that answered that question.
I: What analgesia do they have?
P: Morphine. It’s very traditional on the ground, and that may change over time, but I think for the moment morphine is the tried and tested – it’s titratable, as we all know. I think there’s a case perhaps for ketamine, but ketamine is not necessarily as forgiving, certainly paramedics using ketamine under licence in this country now, particularly critical care paramedics, I think it’s probably a little way off for combat med techs on the ground to be using ketamine. Perhaps the way things might go in future. Morphine for those first few minutes is probably all they have, and you can start to use more advanced things on the aircraft.
I: Could you try and describe what it’s like when you land in one of these helicopters at a site?
P: Generally the pilots will hover overhead if there’s still rounds flying around, they’ll just circle overhead until they get the word that things are starting to calm down a bit and then they can come in safely. The MERT has taken a few hits over the last few years, small rounds, small arms generally, but it’s had a couple of close calls with rocket-propelled grenades, it’s again balance of risks, how quickly you go in. As a medic, I don’t want to overstate the risk to you as an individual. Certainly you lead a very cushy life compared to the guys on the ground, and you don’t usually get off the aircraft. The aircraft has armour plating up to about the 2’ height around you and underneath you, so you’re very well off compared to most of the guys. Generally speaking if you’re landing at a hot landing site then the force protection will pile off the back and secure a perimeter of sorts, the RAF paramedic generally will run off and get a handover and triage the patients to come on board and what order and what way round, the casualties will pile on and you, as the doctor, are just sat there waiting for something to land in front of you, because it’s actually slows the whole process down if you start getting off and taking a hand. Generally you will sit there and the paramedic will triage things to come in and make sure that the worst injured will land next to you. As I say, you’re only there for 60 seconds or so. You do have occasional close calls. You’ve got [39:46] call signs which are the Apaches generally escorting you, so you’ve got some top cover with some fairly beefy hardware, and so that tends to suppress any local threat. The pilots will do very much evasive flying, so they will fly at low altitude, throwing the thing around the sky to make it a hard target, and then they’ll bounce straight up to 3,000 feet above small-arms and RPG range, and they will use local cover a lot as well. So they’ll weave in and out of gorges and canyons and fly next to cliffs and things like that, which make you … it means that anyone who’s trying to hit you, you’re just a difficult target to get an angle on, basically. So they’re very good at that. And the pilots love it, they love throwing the thing around in the sky in a way that they’re not allowed to back here. It’s not for the weak of stomach but it makes you feel safer.
Part of the difficulty is more the environment than the flying. It’s the fact that they have to have all the doors open to point the weapon systems out of, so you’ve got the airstream rushing through the cabin and if you’re doing 120 knots you’ve got a 120 knot wind coming through the cabin. I was there in winter, and it was a particularly cold winter so there was a lot of chill to contend with. You had to try and keep your casualties warm but expose them enough to treat them. The light could be an issue. If you were flying at night you’d have pilots on night vision, so you couldn’t have a lot of light ‘cause it made you an easier target and it potentially compromised the pilot’s sight so you were using blue light in the back of the cabin and the one thing that doesn’t show up in blue light is veins, so a lot of interosseous cannulae at night and the height of the casualty off the floor could definitely be an issue with intubation. If they were on a standard US or UK army stretcher, they’re very close to the ground and they’re very flat so you’d be kneeling on the floor next to them and you’d have to get low enough for your laryngoscopy, which could be quite a challenge if there wasn’t a lot of space, ‘cause you couldn’t like out. You’re kneeling but you’re trying to get your head next to your knees to get a decent angle on the laryngoscope. We did have AIRTRAQ, generally wasn’t required but that could be almost the most difficult aspect of an RSI, that and communicating with your ATP and making sure that the RSI went smoothly and safely. The RSI pillow, which was a little wipe-clean fairly sold pillow, was almost our most precious piece of kit because that was the thing that would put the airway a little bit higher and give you the better laryngoscopy that you needed to do RSI in those circumstances. You would always factor in the difficulty and the potential risk of an RSI and the potential for a can’t intubate, can’t ventilate, that would factor into your decision-making of am I going to do the RSI on board, or am I actually just going to manage with a [42:55 Bagwell] mask, because there’s not too much bleeding in the airway, and we’ll do the RSI in the resus, which is going to be safer? Pre-hospital physicians are on a spectrum from the very interventionist to the not-so-interventionist. I’m probably at the not-so-interventionist end of the spectrum. I would rather that things were done in the safest possible environment if possible, and if I can manage the airway simply en route to resus then let’s do the RSI in resus, and it’s always the potential for a cardiovascular decompensation in flight, which is a difficult thing to pick up and diagnose and treat in flight, or certainly harder than when you’ve got that much noise around. Clinical examination and diagnostics are very hard with aircraft noise. The other end of that is diagnosing death can be very difficult and I think there were certainly instances where you would have stopped resuscitation and CPR sooner if you were on the ground, but because it’s very difficult to hear heart sounds and hear breath sounds anyway, to diagnose death you’re continuing till you’re on the ground and away from the aircraft noise before you actually diagnose death and stop. And I’ve certainly stopped resuscitation in the back of the ambulance from the landing site to resus, as well as diagnosing in the air where I felt confident in that decision. But bizarrely that can be one of the stranger challenges of that environment.
I: Can I just ask you about some of the other activities that go on in Afghanistan. Everybody’s enthralled as to what happens to the little groups of Special Forces that go out. How are they managed, who looks after them, ‘cause they may be beyond the bounds of a Chinook or nobody really knows where they are.
P: Sure. Special Forces have been obviously immensely active in southern Afghanistan for the British Special Forces primarily the southern area, south of Helmand for example, but also carrying out a lot of operations to find the key figures who require arresting and arrest them. Those sorts of operations can have quite extended timelines to get back to Bastion so you sometimes need a medical resource closer to where they’re operating. That can be very small, it can be just a MERT that travels along with them in effect, or it can be something more substantial, and they have their own medical support unit in-house within those units who do a lot of that, but with the recent expansion of Special Forces because their role has been expanded, their numbers have been expanded as well, there has more recently been a need for an enhanced medical capability. 16 Air Assault Brigade developed an additional medical support unit which could provide an enhanced medical capability to Special Forces, and that’s, from an anaesthetic point of view, involved the Light Surgical Group who were a group of surgeons, anaesthetists, ODPs and others who were able to provide a medical facility which was whatever that operation required from just a MERT type level of response up to a full surgical and critical care facility. So the heavy-weight option would be a single operating table, two critical care beds and up to eight ward beds, to support a larger operation, or to support a longer extended timeline away from other medical facilities. And that certainly has allowed them to operate more flexibility and further away from Bastion, in a way that they would otherwise only have done at risk.
I: What happens when your time in Afghanistan or in any conflict, what happens to you then, when –
P: As medics, if you’re part of the hospital squadron you might be there for six months, but generally as a consultant you’re an individual augmentee to that organisation, so you’re there for two to three months and you haven’t had as long away from home, although it can seem like a lifetime if it’s a very intense operation. POTL, which is post-tour leave, you have a certain number of days of POTL for the number of days you’re away, and that’s very welcome to spend time with family and just decompress a little bit. There have been attempts to provide some sort of decompression facility for the troops coming back and Cyprus and Croatia are the two that I’ve visited. Fortunately I’ve not had to spend a long time there, but I think the intention was for the troops coming back from experiencing that level of intensity and that level of violence and no alcohol for six months, that they would rather that they had their first few beers and their first bar fight in a contained environment, rather than back on the street and being picked up by the police and all the bad PR that might ensue. So I think there was an element of that to it, but given fortunately elevated rank and a shorter tour, you hopefully manage to bypass most of that and don’t spend more than 12 hours in those facilities before moving on. But I think they have a value to the guys coming home, although … the last thing anybody wants when they’re half-way home is to stop! They want to carry on and get home, but you can see the good intentions behind it.
I: And I gather you’ve kind of sublimated all this by working with the Air Ambulance since?
P: Yes, Simon Hughes, who’s the anaesthetic lead for trauma in Southampton, the major trauma centre there, is ex-RAF. He and I met on the MOST course, the Hampshire and Isle of Wight Air Ambulance were recruiting, this was two years ago, Simon asked me if I’d like to be involved, and having just the military and left my pre-hospital practice behind, I was very keen, so I’ve now started flying with them. I think civilian pre-hospital practice has had a lot of work to do in recent years. It’s traditionally been a mixed bag, has always carried the stigma of being the preserve of the enthusiastic amateur, with a mixed quality involved, and I think that there’s, over the last several years been a strong initiative to try and tighten up the clinical governance, very successfully from what I’ve seen, and make it a much more professional sub-speciality into the life in this country. Certainly the Hampshire and Isle of Wight Air Ambulance, together with the Thames Valley and Chiltern Air Ambulance, have been very active in that, despite having done a year of helicopter rescue working in Australia and my MERT working elsewhere, I had to go through a two-phase competency-based training to work with the Air Ambulance, and I begrudged that not at all because I think it’s been very useful for me but it’s also very nice to be working in an organisation that you know can put its hand on its heart and say, ‘This is a highly professional organisation, which provides good quality of care’. And we recently had a CQC visit, which was able to put the rubber stamp on that, which was very nice.
I: What a fantastic story. Commander Siggers, thank you very much indeed for your time.
P: Thank you for having me.