Combat Doctor: Life and Death Stories from Kandahar's Military Hospital

The views and opinions expressed herein are the author’s and do not necessarily reflect those of the Canadian Forces or their Health Services Group.

To Christine

Thank you for waiting for me, and for sticking around after

For all the ones we couldn’t save

Foreword by Brigadier-General Jean-Robert Bernier

Introduction

Chapter 1 A Few Essential Concepts

Chapter 2 The Arm

Chapter 3 Lessons Learned

Chapter 4 Who Is This Dauphin Guy?

Chapter 5 Mr. Wiggly

Chapter 6 The Day the Australians Came

Chapter 7 Quiet Members of the Team

Chapter 8 What Happens to Our Soldiers After the Role 3?

Chapter 9 The Bicycle

Chapter 10 FOBs

Chapter 11 The Collector

Chapter 12 Mr. Rice Man

Chapter 13 Head Injury

Chapter 14 Darn Pilots

Chapter 15 Can We Try …?

Chapter 16 Mortuary Affairs

Chapter 17 Incidents

Chapter 18 September

Chapter 19 Cyprus

Chapter 20 Home

Chapter 21 Return to Normal

Chapter 22 PTSD

Appendix A Chain of Evacuation and Principles of Care

Appendix B The NATO 9-Liner

Appendix C TRAUMA 101: Trauma Care for the Uninitiated

Appendix D Ramstein

Acknowledgements

In early 2006, the Canadian Forces took possession of a ramshackle plywood medical facility in Kandahar with the task of turning it into NATO’s tertiary care (Role 3) hospital for Canadian and coalition forces. The Role 3 Multinational Medical Unit (R3MMU) was in the heart of Taliban country where much of the heaviest combat of the Afghanistan conflict would occur.

In delivering care to a vast number of casualties for almost four years, sometimes as the world’s busiest trauma centre, the R3MMU’s leaders and staff faced extraordinary challenges. They had to rapidly establish and operate at maximum capacity a full-service trauma centre in a desert environment halfway around the world with almost no supporting domestic infrastructure. They had to integrate and form into cohesive teams military and civilian staff from several countries with variably different medical scopes of practice, medico-legal frameworks, and medical cultures. The rudimentary infrastructure offered limited protection from an outside environment of extreme heat, ubiquitous fine dust, and wind that posed problems for ventilators, CT scanners, other equipment, surgery, critical care, and infection control. Almost daily, the staff treated horrific injuries among the victims of often indiscriminate violence inflicted by a barbaric enemy whose contempt for the laws of armed conflict, basic human rights, and the lives of Afghans knew no bounds. They had to live in very spartan conditions while on continuous call for months at time, contend with intercontinental medical supply and evacuation lines of communication, keep operating while under enemy rocket fire, and provide the same compassionate and professional care to Taliban casualties as to their mutilated child and adult victims. Above all, they had to provide a very high standard of clinical readiness and care in order to ensure that Canadian and allied combatants would retain their will to fight.

How, despite such incredibly difficult conditions, did the R3MMU achieve the highest war casualty survival rate in history, higher than the survival rates of major North American trauma centres, and become only the second recipient ever of NATO’s highest honour for medical support? Because of the professional skill, innovation, and dedication of the staff: from Canada, Britain, the United States, Holland, Denmark, New Zealand, and Australia. And it was also because of the courage, valour, and self-sacrifice of our medical technicians, eight of whom were killed in action, who provided immediate life-saving care on the battlefield. Because of the heroic efforts of so many other members of Canada’s armed forces and the support of the Canadian government, who gave us whatever we needed. And, just as critically, because of leaders like Marc Dauphin.

Marc is the kind of military and medical leader who can motivate people to do more under difficult conditions than seems possible, while maintaining professional focus and calm in the midst of crisis and chaos. Since I was responsible for health service support to all Canadian operations during Marc’s leadership of the R3MMU, I knew him as a highly skilled emergency physician and superb officer who earned the profound respect and trust of those who served under his command. He had given up the comfort and safety of civilian practice to resume full-time service and risk his life overseas in order to help protect his military colleagues and relieve suffering among Afghans. I was not at all surprised to learn that Colonel Xavier Marks, the magnificent R3MMU commander in the TV series Combat Hospital, was based on Marc Dauphin. In saving the lives of so many Afghans and their allies during his rotation, he and his team helped earn Canada the gratitude of Afghanistan’s people and the tremendous international respect that we now enjoy as medical leaders. It is heartening to see how, when facing a dark threat, the noblest qualities of our civilization are manifested among so many Canadians, particularly the willingness to courageously sacrifice with stoic and disciplined determination and without regard for personal self-interest in order to protect others. As Montaigne recognized, the great joy of military service arises largely from working with people like Marc Dauphin to whom this quality is not only intrinsic, but occupationally essential.

The conflict has been tragic for Afghans, as well as for their allies who have sacrificed so much to help protect them. The Canadian leadership of the R3MMU and its unprecedented success were nevertheless historic achievements that earned Canada great esteem across NATO nations. This record of Marc Dauphin’s personal experiences and reflections presents details of the reality and the challenges that news reports could not convey. It is an important contribution to the history of our longest conflict, of the supporting role of health professionals from Canada and allied nations, and of the extraordinary accomplishments that we can achieve when united in a noble endeavour. Marc’s story is that of non-combatants, but their critical contribution to the higher purpose of Canada’s armed forces and mission in Afghanistan calls for reflection on Pericles’s advice that has lamentably proven so prophetic throughout history: Then take them as your example, like them remember that happiness can only be for the free, and that freedom is the sure possession of those alone who have the courage to fight for it.

Militi Succurrimus

Brigadier-General Jean-Robert Bernier,

OMM, CD, QHP, BA, MD, MPH, DEH

Surgeon General

It was a weather-beaten jumble of windowless plywood buildings. As an afterthought, shipping containers, tents, and pieces of a self-deployable hospital were adjoined here and there. On the dusty, sun-baked plain below some steep, ragged mountains, the hospital lay by the runway, behind ten-foot-high concrete blast walls, a few kilometres out from the ancient Taliban capital of Kandahar. Yet, in spite of its uninviting appearance, this was where thousands of lives were saved by the most advanced trauma technology known to man, technology that may be in Western hospitals in five, maybe ten years, once the lawyers and professors have finished debating the merits of each new intervention.

For nearly four years, under Canadian command, the Role 3 Multinational Medical Unit (R3MMU) had been getting bigger and bigger, until its first commanders would hardly have recognized it. From the inside, that is. From the outside, apart from the added sections, it was still dominated by that single-slant plywood roof that leaked like a sieve under the winter rains that followed the eight months of searing heat.

It was also my office and my home for the six months that I was the Role 3’s last Canadian Officer Commanding (OC). It was there that my team of professionals and I, from a dozen different countries, saved lives and saw ours changed forever. War does that to you. Even though we were forewarned, we are still amazed at how different we are now from the people who left their country to serve there.

Little did we know, in April 2009, that we were going to make history. That with that last Canadian six-month tour (or roto, as we called it) we would be treating an unprecedented number of severe casualties, a number not seen by Canadian health care professionals since perhaps the Korean War, and probably not since the Second World War. And that the casualties, because of quicker evacuation techniques and improved life-saving first aid, would be so severe that we — all the Role 3s in Iraq and Afghanistan — would be the first ever to receive people alive with such catastrophic injuries. In previous wars, most such casualties died before making it to advanced care. Now we had to save them.

The Health Services Group in Canada had been expecting a surge in the number of casualties for the summer of 2009. So in three weeks they had trained us on three months’ worth of simulated casualties. It turned out that they got it just about right. Except we just got hit a little harder, that’s all. Of the total number of casualties seen in the seven rotos during which Canada was responsible for the hospital, nearly 40 percent came in during the last one, Roto 7 — ours. And yet we maintained spectacular numbers: if you arrived at the R3 with vital signs, you had a 97 percent chance of leaving alive.

Full hospital, and a nightmare. What if ten wounded soldiers come in all at once? Where would we put them? The admission dates tell me this was probably taken July 14. The two last patients on the board are detainees, who cannot be sent to cells until they can take care of themselves. Thus, their long hospital stays.

A Few Essential Concepts

Before we begin, here are a few things to bear in mind.

The CF is the Canadian Forces, comprising the Royal Canadian Navy, the Canadian Army, and the Royal Canadian Air Force. To care for its members, the CF has the CFHS Group, or CF Health Services Group, which comprises physicians, also called medical officers or MOs (both specialists and family physicians); physician assistants (PAs); nurses (general duty nursing officers, or GDNOs); ICU nurses, or critical care nursing officers (CCNOs); nurse practitioners, operating room (OR) nurses, and mental health nurses; medical technicians (called med techs, or medics); social workers; medical administrators; pharmacists; preventive medicine techs (PMed techs); radiology technicians (or DI techs, for diagnostic imagery); biomedical equipment techs (or BE techs); lab techs; OR techs; dentists; dental assistants and hygienists; and physiotherapists. In addition, we are supported by supply techs, drivers, and clerks, who all have their own branches of service but serve with us. And let’s not forget our clergymen in uniform, the padres. All these people can be of any of the three services. The head of the CF HS is the surgeon general of the CF, presently an army officer, Brigadier-General J.R. Bernier.

The KAF Role 3, or simply the Role 3, is the Kandahar Air Field (KAF) Multinational Medical Unit (or Role 3 MMU). More about its capacities and why it’s called that will come later.

The CF deploys its members in Afghanistan on rotos, or tours of six to nine months. These tours are numbered, starting with Roto 0. During our combat mission in south Afghanistan, called Operation Athena, we went to Roto 11.

Master Corporal J.F. Vaillancourt, a diagnostic imaging tech (DI Tech) checks his work at the end of his tour, just before going back to Canada. In 2011, he returned to Kandahar for another roto in the now–U.S. Navy Role 3, where he distinguished himself as a hero (though he would tell you he isn’t). An Afghan would-be suicide bomber was brought in with her unexploded belt still on. Master Corporal Vaillancourt volunteered to do the CT scan while everyone else vacated the hospital.

Our U.S. Navy Augmentation Team had these T-shirts made. That last sentence wasn’t true. The U.S. Navy was very generous with us, staffing parties with incredible presents for all.

This book tells a few stories about what happened in the Role 3 during Roto 7, from April 2009 until October 15, 2009 — the day Canada formally handed over control of that hospital to the U.S. Navy.

I was the OC of the Role 3 during that period. My job was to see to the day-to-day operations of the hospital. Above me there was a CO, Colonel Danielle Savard, a Canadian pharmacist and administrator. We also had a task force surgeon, Lieutenant-Colonel Ron Wojtyk, a Canadian physician who was the senior medical authority (SMA) there. I also had a relationship with the NATO physician who was the adviser to the NATO commander of the region, Captain Bos of the Royal Netherlands Navy. Sound complicated? It is.

This is not the history of the Role 3. It is a collection of images that I remember from my time over there. I do not presume to tell the whole story, as I was not in a position to see everything. Although, as OC, I did see a lot.

I will also not speak of our Canadian wounded other than in general terms. The Canadian Forces takes the issue of patient confidentiality very seriously.

Emotion

In this book, there is a lot of emotion. Strange, I know, for an emergency room doctor to have emotions. Yes, I do admit that I am a strange bird. I wasn’t always, though. At first, I was just another ER doc. But then, in my late thirties, I got this weird notion: the notion that I could be a writer. So I started writing. Perhaps it was Stephen King who said, after someone told him that they’d like to write, Writing is a profession just like any other. You can’t wing it as a writer any more than I could wing it as a brain surgeon.

But I’m a natural storyteller. So, I figured that, with a little work, I could … yeah. A little work.

Anyway, after some years of practice, I got down to writing my first novel. A few years later, I handed it to an editor. It’s a damn good story, Marc, but it’s not a novel, he said. It’s a movie script. Go back and write me a novel.

I must have looked really dumbfounded because he proceeded to explain (he’s a very patient man), "You’re telling me the story from the outside, as a camera would. In a novel, you have to get inside your characters’ heads."

Okay. Sounded easy. But it wasn’t. I just couldn’t get the hang of it. Frustrated, I turned to my wife.

Marc, you’re cold, analytical. You describe without emotion. You’re distancing yourself from the people in your story. As if you were an ER physician.

"But I am an ER physician."

Not when you’re trying to be a novelist.

She let that one sink in, then asked, "How do your characters feel?"

Still I didn’t understand. Again she helped. "You have to feel what your characters feel. Then, only then, can you tell the story in such a way that your readers will feel it, too."

I tried. Then one day, that switch in my brain flicked on, the one that lets you get inside your characters. Eureka! I had discovered how to dig inside my head, grab my emotions, and tear them out to put them on paper. It was like acting, only with the written word. I was starting to get somewhere.

So I rewrote my novel, starting with a blank page.

That took care of a couple more years.

Not bad … said the editor.

I took the manuscript back. I don’t like it either, I said. And I rewrote it from scratch — again.

Another few years passed. Maybe Mr. King did have something.

But then a funny thing happened. My ER medical practice became harder and harder. I even found myself getting upset about a patient one night.

Once you’ve opened that floodgate, Marc, you can never close it again, said my wife.

Fortunately, that was about the time I decided to get out of the ER.

So that’s the reason my writing is so emotional, rather than cold, factual, and analytical. Now you know why. And now my comrades will understand why I was such a weird fellow on tour.

The Arm

When you get back home, make sure you tell everybody what you did here.

— Lieutenant-General Lessard, Commander of

Canadian Expeditionary Force Command, Summer 2009

It was a balmy 35°C evening; the boy was one breath away from death. We gazed down at his tortured little body. He couldn’t have been more than eleven. How he had managed to survive up to now, we couldn’t understand. He had already been operated on in Mirwaïs, Kandahar’s main civilian hospital. While there, the surgeons had tried to reattach his left arm, which had been almost severed just below the shoulder. The wounds had been badly closed, and now the raw, dried, rotting flesh under the skin was exposed. The external fixator had been clumsily installed. I didn’t need to check the pulse in the arm: there wouldn’t be one. The swollen, blackened flesh below the wound was just a jumble of dead cells. That the surgeons had failed to save the arm was obvious. Except to the boy’s father, who kept pleading with us to save it.

In more than thirty years’ experience with maimed and torn bodies, I had never seen a totally black limb. Frostbitten, dead toes, yes. But a whole arm? I was surprised that there was no smell, other than the usual stink of rotting flesh. This was not gaseous gangrene, the infection that kills in a few hours. This was dry gangrene, the black, drying, mummifying transformation of cells into parchment. The boy didn’t have an IV. He was dehydrated and unconscious, and he was dying fast. His father had driven untold kilometres on dangerous roads, talked his way onto the base, carried his son in, and placed him on a stretcher in the resuscitation area, the trauma bays.

As I contemplated the boy’s situation, I marvelled at the resilience of the human body. But resilience, no matter how strong, is no match for death, the ultimate winner. Everybody — there were perhaps a dozen of us around the stretcher — was standing motionless, waiting for my decision: to accept treating the boy, or to send him on to an Afghan institution. Our hospital was full and, as an officer focused on caring for our soldiers, I was thinking that I should probably send the boy away. Our mission was to treat the sick and injured soldiers of the NATO coalition. We could also care for Afghan civilians injured as a direct result of the war. Then, only if we had the space and the resources, we could care for other civilians as a goodwill gesture. With our advanced technology and super-competent, can-do, resourceful specialists, we could perform what to the Afghan people looked like miracles.

But saving this boy’s arm was beyond even the most advanced medicine in the world. Besides, we had to prepare for more wounded soldiers in the hours to come, as we had been made aware of a large operation that was to begin during the night. I knew I should just send the boy back to the Afghan civilian hospital. That much was obvious to everyone. But his father kept pleading with me. He thought we were still negotiating to save his son’s arm. In my mind, we were deciding — I was deciding — whether to try to save the boy’s life.

That there was no pleading from my people to try to influence my decision was a tribute to how far we had come from being those well-meaning but unknowing do-gooders who had arrived in country only a few months earlier. My staff at the Kandahar Role 3 Multinational Medical Unit was by then a disciplined, tough, if somewhat ragtag bunch of professionals who were now among the best in the world. If anyone could save this kid, they could. We could.

Pondering, I pursed my lips and looked at my people. Standing behind them, ensuring she was as unobtrusive as possible, my Commanding Officer (CO), Canadian Colonel Danielle Savard, was waiting for my decision. Avoiding my eyes in order not to influence me, she was studying the floor at her feet. I knew she would back me up, no matter how hard or how inhuman my decision might seem. But she could also tell, by my hesitation, that I was leaning toward taking him. When I turned a patient away, the decision usually came fast, loud, and clear.

In my head, I was trying to figure out how much of a hill the boy had to climb to get back to health, and what the drain would be on our hospital. Were his kidneys shot from the dehydration and the massive amount of toxins generated by the dying muscle cells? If so, his care would be complex and our resources were finite. Did he have other injuries that we didn’t know about? That would complicate his care. What if a dozen injured soldiers arrived while we were immersed in trying to save the boy?

This hesitation probably lasted less than two minutes, while the staff stood motionless at the stretcher’s side. If any one of us were to lay a hand on the boy, he would be in our care for keeps. While I was thinking, I tried to explain to the father that we were talking about saving his son’s life, not his arm, which was hopelessly too far gone. I tried to prepare the man for the possibility that we would turn him and his son away. But a father’s love does not lend itself to reasoning, especially through an interpreter, and I realized I was wasting my time.

At that moment, my eyes met Colonel Savard’s and she immediately read my unspoken question. Her response was the very briefest, discreet nod. Which meant, What the hell, Marc …? In for a penny!

Thanks for sharing that burden with me, ma’am. I owe you one. I don’t think I could ever have forgiven myself for not giving this kid his chance.

Greatly relieved, I sighed and turned to the interpreter. All right, tell the father that we are going to try and save his son’s life. But the arm has to come off right away. It’s killing him. We need his okay to do this.

The staff sprang to life, plugging in the monitor, putting up an IV, drawing blood, installing an oxygen mask, inserting a urinary catheter, asking for X-rays, calling the OR team in. I stepped back to give them room to work. That’s when the father grabbed my sleeve and said something.

Colonel Danielle Savard, commander of all Canadian medical personnel in Afghanistan and the Arabian Peninsula. She was the last Canadian CO of the Role 3, my boss, and a great person who taught me a lot.

He says he’s willing to give his son his arm if you want to transplant it.

That just about did me in. Speechless, I could only bite my lip and pat the father on the shoulder as I shook my head.

I turned to the interpreter.

Please tell him that we’re not that good.

Lessons Learned

We did a lot of things well on our roto — very well, in fact. And I’m very proud of our team. But I don’t want people to get the idea that we invented our method of doing things. No, it was the intensive training we received beforehand that was the key — training based on lessons learned during previous rotos. In addition to a bunch of really good and pitiless teachers.

In the following pages, I will complain about the way the Canadian Forces did things during the dark years. And I’ll be justified. But when the CF started to do things right, they caught up fast. So it was with the KAF Role 3 hospital: Roto 7 was better than the earlier rotos, and Roto 8 was even better than we were. The people from Roto 8 will probably read this and cringe at the way we did some things. And they’ll be justified, too, for there is always room for improvement. Every roto does the best they can with what’s at hand. Just as every roto does better than its predecessors, both qualitatively and quantitatively.

What is really remarkable about our story, Canada’s story, is how everything came together to improve the system from roto to roto. And it all started in Wainwright, Alberta.

In Wainwright, the Canadian Forces deployed the 1st Canadian Field Hospital to head up our training. The personnel for the Role 3 in Afghanistan assembled there from all over Canada, months in advance of deploying, for an intensive three-week exercise designed to build us up into a solid team. That exercise was the best; it was realistic, very difficult, and designed to expose our inadequacies. It revealed how bad we were, but it also showed us how we could improve. And it was done far enough in advance of the tour that we had time to make the necessary adjustments.

A Canadian Bell 412 Griffon flies into a violent sandstorm. Those guys have all my respect.

The instructors gave us the desire to better ourselves, showed us why we should, and gave us the time and money to do it. We were also lucky that a good percentage of the personnel on our roto had previous deployment experience.

And as I said, everything we saw in Wainwright was the sum of all the lessons that had been learned by others on previous rotos. Each time the CF deployed 1 Canadian Field Hospital in Wainwright, they altered the training routine to reflect the changing conditions in Kandahar. When we started training in October 2008, it was at the start of Roto 6, so the CF flew in the CO of the last roto, Roto 5, who’d just-returned, along with his sergeant-major, to meet and coach us.

In addition to being an outstanding speaker, that CO, Lieutenant-Colonel (then) McLeod, had the very latest intelligence and lessons learned from Kandahar. He had interrupted his post-deployment leave to brief us, and when he spoke to us that night, you could have heard a fly in the tent. One part of his speech that stuck in my mind, that I constantly played back throughout my time in country, was how, in the difficult times during his roto, he had always been reassured by the tall silhouette of his OC of the Role 3, Major Will Patton, calmly moving from trauma bay to trauma bay, helping with a tricky manoeuvre here, giving counsel there, always in charge, always ahead of things. That night, I vowed to try to emulate Will, an ER medicine teacher, a good friend, and a good comrade from Edmonton.

That’s how it was. We, as a group, had the wisdom to accept everything they taught us during the exercise, and added just a little of ourselves. And we were wise enough not to change the way they had been doing things — except to tweak the machine just a bit, to improve any little shortcomings they told us about. The processes of unloading, triaging, damage-control surgery, Air Evac’ing, all the discipline in the trauma bays, that was all taught to us. We invented nothing. And we applied it exactly as it had been taught to us. Therein lies our wisdom: in accepting the system, and not modifying it. (Well, maybe we did a little.) We had the smarts to understand that the system was the product of many brains who had actually been there, and of many lessons learned. And that’s what I’m proud of: in the first few weeks as OC of the Role 3, I changed exactly nothing of what my predecessor on Roto 6, Major (then) Bill Rideout had been doing. Nothing. I did tinker with some details because I had more personnel available than he did (another good call for the CF: they reacted quickly to our needs). Other than that, if Bill or Will had returned to Kandahar halfway through our roto, they would have recognized the hospital and fallen easily back into their own routines. Because, basically, the process hadn’t changed.

So this book is about us. Not only is it about us as a team during Roto 7, but also us as in all the rotos that came before Roto 7. The CF Medical Service certainly deserves all the accolades it gets for the job in Afghanistan.

Throughout the seven rotos that Canada was responsible for as part of the Role 3, its staff kept up a record of 97 percent survival for all casualties who arrived there with a heartbeat. That is the best record in all of Iraq and Afghanistan. It is the best record for a hospital in a war zone, ever. And we saw nearly 40 percent of those patients