The Culture and Politics of Health Care Work

Life and Death in a Field Hospital

Mark de Rond

• Publisher: ILR Press
• Year: 2017
• ISBN:
  9781501707933
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Doctors at War is a candid account of a trauma surgical team based, for a tour of duty, at a field hospital in Helmand, Afghanistan. Mark de Rond tells of the highs and lows of surgical life in hard-hitting detail, bringing to life a morally ambiguous world in which good people face impossible choices and in which routines designed to normalize experience have the unintended effect of highlighting war's absurdity. With stories that are at once comical and tragic, de Rond captures the surreal experience of being a doctor at war. He lifts the cover on a world rarely ever seen, let alone written about, and provides a poignant counterpoint to the archetypical, adrenaline-packed, macho tale of what it is like to go to war.Here the crude and visceral coexist with the tender and affectionate. The author tells of well-meaning soldiers at hospital reception, there to deliver a pair of legs in the belief that these can be reattached to their comrade, now in mid-surgery; of midsummer Christmas parties and pancake breakfasts and late-night sauna sessions; of interpersonal rivalries and banter; of caring too little or too much; of tenderness and compassion fatigue; of hell and redemption; of heroism and of playing God. While many good firsthand accounts of war by frontline soldiers exist, this is one of the first books ever to bring to life the experience of the surgical teams tasked with mending what war destroys.

1

Hawkeye

Hawkeye would occasionally play God.1 As a general surgeon with extensive experience in treating war casualties, he was expected to make difficult decisions. Every bit as vociferous, gifted, and contemptuous as the MASH character whose nickname had stuck, he showed up during a weeklong surgical training course at the Royal College of Surgeons, a block or so down from the London School of Economics and Political Science (LSE).

The college had been established by royal charter in 1800; the trade guild on which it is based was founded as early as 1540. The Company of Barber-Surgeons, as this curious amalgamation was first called, decided to divorce barbers from surgeons on the insistence of the latter. These surgeons went ahead and built themselves an anatomy shop near Newgate Gaol, at the corner of Newgate Street and the Old Bailey, to give them direct access to the bodies of executed criminals. In medieval times, its keepers were apparently allowed to exact payment directly from prisoners, which, perhaps unsurprisingly, incentivized keepers to be creative in supplementing their take-home pay: they charged for entering the jail, for taking irons off, and for putting them back on. The jail was to be fertile soil for the college’s cadaver labs, judiciously farmed to yield a steady flow of stiffs.

Today, the college stands in Lincoln’s Inn Fields, London’s largest public square and home to a tennis and netball court and a bandstand. Between it and the LSE stands George IV, a pub known colloquially as “the George,” popular with surgical trainees and social scientists alike. It is here that one rinses body and mind of the residue of days spent in the college’s clearly prosperous cadaver lab.

Pre-deployment training involved five days practicing on human cadavers made up to resemble recipients of the war’s signature wounds: ballistic injuries to the legs, amputations, abdominal bleeding, and injuries to the chest, neck, and head. The corollary of perfecting surgical practice is a tangle of saturated human tissue: the abdomen open and packed with gauze after an emergency laparotomy; the skull exposed and brain visible through a two-square-inch window cleanly cut and designed to relieve pressure; the neck mangled after multiple attempts at placing a tracheostomy tube; the chest propped open like a clamshell; a fasciotomy exposing the tibia and calf muscle; a long piece of linen wrapped around the pelvic girdle to hold in place a fractured pelvis; the bits that fell off during dissection carefully placed in a Tupperware container. They, together with the body, will in due course be disposed of. It is nearly impossible to rid oneself of the gummy pong of formaldehyde, and the purging of it is what the George is there to facilitate.

It is here that Hawkeye and I had our first chinwag.*

I didn’t know at the time, though it would soon become clear, that if I were to be allowed to deploy to Camp Bastion, Hawkeye would be my chaperone and guardian. He talked at length about previous deployments—to Bosnia, Iraq, Afghanistan, Ireland—and time spent at sea ministering to sailors in their reproductive prime but confined to the company of men except when, occasionally, the ship would dock in one or other colorful port and all bets were off. He spoke of the games lads play, many of which have strong sexual connotations, and the diseases they’d bring back on board the vessel, and of the horrors of war, and of the terrible suffering that humans wreak on one another, oftentimes with little reason other than having been given leave to, and of his inability to understand how it is that people inflict anguish on children, whether out of malice or ideology or neglect. He talked about himself, about how he would never be promoted beyond his rank, because he refused to take on significant managerial duties if it meant sacrificing frontline work, and of his inability to keep his forthright, and occasionally politically incorrect, tongue in check. He was firm in the view that no resources be spent on Afghan casualties who have a better chance of winning the lottery than surviving their injuries. To keep them alive just because we can is, he said, heartless, seeing that they would be offloaded onto a local hospital with fewer resources, inferior pain meds, and different standards of care. Better to let them go comfortably and be done with.

Hawkeye is close to frontline troops, closer than many of his peers, and heir to the tales they bring back home. He is decisive and exceptionally skilled with the knife, happiest when elbow deep into a belly or chest where every vital organ and vessel—where life itself—resides. His patience with do-gooders wore thin long ago. He thinks they, like politicians, meddle in affairs of which they have little or no practical experience, foisting their armchair theorizing on a world they do not understand but feed on for piety or smugness or public opinion or political point scoring, and nothing would please Hawkeye more than to haul them by the hair of their neck into a busy operating theater to shove them face-first into that veritable war, the triumph of weapons designed, procured, and sanctioned on their watch.

His deportment is effective at hiding the benevolence inside. For while his peers fear or loathe him at times, or both, he cares deeply for those put in his care, and Royal Marines in particular. He would have been a marine himself were it not for a motorcycle accident that wrecked his wrist and left him unable to complete the monkey bars during a qualifying routine. At the time he was given the option of skipping the bars and taking a time penalty instead, but he refused. Everyone would forever know, he said, that he had been made an exception. Worse yet, he would know, so he opted for an ordinary Royal Navy career instead, qualified as a general surgeon, and made it his life’s work to look after the Royals. Hawkeye understood the Royals, and they him.

As the George loosens its faucets and gives generously, those due to deploy get a chance to socialize, and as the alcohol does the inevitable, stories begin to flow of deployments past, of things seen or only heard about, things fair and unfair, surreal but oh so real at the same time. They might hate war, but going to war reminds them of why it is they decided on a medical career in the first place. It shows them there is life beyond their mundane civilian medical practice. It is as Chris Hedges said it was—war is what gives life meaning. Those who choke up take a hike to return a little while later to more merriment, to tales of naked generals and toilet seats and illicit sex, all the while working the night into a bond more intoxicating and affecting than any drug could deliver. For in the end it is camaraderie that wins small wars.

In the little sleep I did manage the first night, I seemed to be doing ward rounds, checking in on injured soldiers, except that in my dream the building looked far less like a hospital and more like a dormitory wing with small rooms to each side, and I entered one of these but slowly and uncomfortably, finding myself caught in a sleeping bag barely able to move, and the room being packed full of amputees not so much in as on top of beds, and one of the doctors I hadn’t seen before taking me out of the room and roughly into the hallway I’d just come from, and angrily demanding of me what my business was, why I was here and with whose permission, and me trying to convince him that I was all right, that I had secured all the relevant permissions, and that he had no need to worry, but my riposte neither assertive nor effective and not helped by that ridiculous sleeping bag.

THE MOST COURSE was the first of four required pre-deployment courses and targeted specifically at surgeons and anesthetists. Next up was a Hospital Exercise (Hospex) staged in a near-perfect replica of the Role 3 hospital in Camp Bastion, but on a military base outside York, and designed to bring the entire hospital staff together. Cadavers had given way to real amputees. Even the sound of an approaching Chinook had been canned to be played while trauma teams awaited the arrival of casualties. The focus here was on process, inasmuch as MOST’s focus had been on surgical and anesthetic technique. Everything was designed to happen in real time, except of course that surgical procedures couldn’t, leading to a pointless scenario whereby surgeons would talk each other through whatever procedure they decided might save the day, only to be forced to stand by with little or nothing to do for as long as the procedure would ordinarily take. Little did I know then that the boredom experienced here would anticipate that in Camp Bastion, even if only on occasion, but when it hit it did so with a vengeance.

The third required pre-deployment module was also the longest in duration: a ten-day Operational Test and Evaluation Command (OPTEC) hosted at the Royal Navy base in Portsmouth and required for everyone about to deploy regardless of specialty or rank. Aside from a light-touch first-aid session, the emphasis was broadly on what to expect when dropped lock, stock, and barrel into a war zone. Practical sessions on what to do when taken hostage and how to identify land mines were a welcome diversion from lectures on Afghan language and culture.

“Why the fuck do we need to learn about Afghan culture?” Hawkeye had hissed during one of several PowerPoint presentations. A woman of Afghani origin had been keen for us to pick up some basic Pashto from an A4 crib sheet (actually she had said “crib shit,” which Hawkeye thought hysterical), along with things to do and refrain from doing when interacting with locals.

“Why spend an hour and a half telling us not to show these ragheads our feet if we’re going to shoot them anyway?” Hawkeye had said a little louder than I suspect he intended. And yet despite a gruff exterior Hawkeye was the only surgeon I would ever see hold the hand of Afghan boys and men worried sick about their plight, and delay procedures to make sure the interpreter was there to explain what the prognosis was and what would happen next. During one of our first ward rounds in Camp Bastion’s hospital, he got visibly upset when a sick old Afghan barfed all over, and through, his ragtag beard but without also being given a bit of attention, save to be handed a disposable cardboard bowl for the residual.

“Why doesn’t anyone give the poor sod some privacy?” he had asked. “Why not wheel the fucking curtain around?” Hawkeye had a knack for voicing what was on most people’s mind, however insensitive or inappropriate, and his tendency to run detailed commentaries on what everyone was or should be doing and what was wrong with whatever was going on would become the bane of his compatriots. Otherwise, his magnificent pair of hands might have made him the ideal surgical colleague.

---

* British term meaning “chat.”

2

Reporting for Duty

The journey to Helmand was less challenging than I had been led to expect it would be. After a bit of shut-eye in a darkened waiting room at RAF Brize Norton—the UK’s largest Royal Air Force station—Hawkeye and I were flushed out for our 0400 (4 a.m. in twenty-four-hour military time) flight to Helmand, wrung through security, and in characteristic hurry-up-and-wait fashion directed toward a further two linoleum antechambers, each crowded but lackluster for the late hour and the onset of memories of home.

I was just about to make my second bed of the night when we were called to board a plane from which any and every identifying mark had been removed or painted over. None of it mattered, of course, as we’d be on the inside looking out during our first leg en route to Central Asia. Officers were seated in business, foot soldiers in economy, which is where I would have ended up had it not been for Hawkeye’s insistence that I needed a chaperone, and as he wasn’t about to sit in cattle class, neither would I. Sleep came quickly, and before long we found ourselves on a desert landing strip. Rumor in the cabin was that we had landed in Bahrain, though this was never confirmed. After another hurry-up-and-wait four-hour layover in an improvised canteen (a “one in one out” fridge with a tall stack of water bottles beside it, a toilet block, sandy courtyard, and games room), we were fed bite-size into an army green TriStar for transport to Helmand, where we arrived just after 2100.

Hawkeye and I stepped out into the black fog, drifting with the tide toward a makeshift registration desk and, beyond that, our litter of worldly belongings now covered in fine desert sand. My two bags were lightweights in comparison with the camouflaged carryalls of Hawkeye: jeans and tees, a flack jacket and helmet, a couple of Moleskines and ballpoints, a Nikon D700 with three prime lenses, a sleeping bag, a box of breakfast bars in case we were caught out without dinner, toiletries, and a small photo album. Unlike everyone else here I carried no weapon—not allowed to—and my standard civilian-issue protective gear looked scrawny compared with Hawkeye’s beefier military kinfolk.

There is nothing that quite compares to losing one’s virginity in a militarized zone. Everything here followed a function-before-form mantra. Yet even the functionalism of Frank Lloyd Wright always had a certain beauty about it, whereas here the lot was metal or rubber or canvas, grubby when used, camp when clean, the overriding scent a pomander of kerosene and exhaust fumes. Febland awaited our arrival. We had met several times prior to deployment and, I thought, had always hit it off. Still, my well-intentioned but tactless “How’s the tour been so far?” met with a snappy “Well, what do you think?” followed by a painful silence. Escorted into a dusty four-by-four, him at the wheel, we made our way from the flight lines to the small hospital, trading the scent of kerosene for a medley altogether more familiar: of iodine, chlorine, ethanol, and isopropyl alcohol. There was little to see on the way of the four-by-two-mile poorly lit camp. What began as a tactical landing zone in Helmand in 2005 had grown into a garrisoned unit with the arrival, in 2006, of Thirty-Nine Engineer Regiment Royal Engineers, to become the largest British overseas base since the Second World War. It was named after the Hesco Bastions, the collapsible wire-mesh, heavy-duty-fabric-lined, stackable, sand-filled sacks designed to provide protection against bullets and bombs, and now caught in our headlights. They, and a series of large concrete slabs, also made for useful partitions, separating the British camp from the adjacent US Marine base Fort Leatherneck, Denmark’s Camp Viking, and a small enclave for the Estonian contingent.

We pulled up into the ambulance bay—a concrete slab that separated the hospital’s two clapboard divisions, admin and the mortuary on the left, trauma and the wards on the right, and used daily to hose down bloodied gurneys—heaved our gear from the back of the truck onto the floor, and wandered past reception into the hospital.

It had been a limbs-in-bins sort of day was the word upon entry. One Gurkha was still being worked on, his upper legs and buttocks ripped to sloppy twine by a large metal nut stuffed in with a homemade explosive. One of the orthopedic surgeons grabbed hold of his femur to assess extensive damage to his right bum cheek, bits of skin, flesh, and muscle left dangling spaghetti-like as he did so, the inside of the Gurkha’s netherworld an angry red. Blood oozed out as fast as it was being pumped in, and yet staff seemed unruffled. A treatment plan was quickly put together and circulated. Scrub nurses dispensed and collected sterile cotton swabs, right hand for new, left for old, qu...

Table of contents

• Foreword
• By Way of Introduction
• 1 Hawkeye
• 2 Reporting for Duty
• 3 Camp Bastion
• 4 A Reason to Live
• 5 Legs
• 6 Apocalypse Now and Again
• 7 Boredom
• 8 Christmas in Summer
• 9 A Record-Breaking Month
• 10 Kandahar
• 11 War Is Nasty
• 12 Way to Start Your Day
• 13 Back Home
• Epilogue
• By Way of Acknowledgment
• Notes