Outside the comfort zone

A Maxillofacial Surgeon at War

Michael (Mike) Williams graduated BDS from Manchester in 1982 having been an Army Cadet. After taking his FDS in Glasgow the army sent him to Sheffield to study medicine and he subsequently passed his FRCS in both London and Edinburgh. He was appointed a consultant maxillo-facial surgeon with the rank of colonel and also holds a post in the NHS in Southampton. The following article is an account of a typical tour of duty in a field hospital as part of OPERATION HERRICK, the current British operation in Afghanistan.

The hospital’s mission is in support of Coalition troops but patients can also be local civilians and enemy combatants. The vast majority of casualties arrive by helicopter and we are usually given sufficient notice of the number and nature of casualties to allow rapid organisation of the reception and resuscitation bays.

On arrival casualties are quickly checked for weapons and munitions before entering the resuscitation bay. One of the great challenges in this situation is the rapid triage of casualties since it is often the case that there are multiple casualties from the same incident. It is interesting and reassuring to observe that despite several different surgical specialties from multiple nations, our protocols are identical. Ballistic trauma in a military setting leads to very high energy transfer wounds often with a complex pattern of injury; these injuries are very different to those I encounter in my civilian hospital practice.

Management follows the ATLS protocol but in the military setting, hypovolemia secondary to catastrophic blood loss is often the primary risk to life, such casualties are often unconscious with multiple injuries and consequently the almost instant availability of CT scanning within the hospital is invaluable (figure 1). Despite the high number of casualties combined with the small cadre of surgeons and only 2 operating theatres it is surprising how treatment progresses seamlessly with minimal delays or fuss.

The operating theatres are very similar to those found in a modern NHS hospital but are slightly more cramped particularly with regard to head room, however levels of equipment and asepsis are excellent. Operating can, on occasions, continue all through the day and night and it is this together with the need to rapidly assess the injury, formulate a management and treatment plan before starting treatment that I find so rewarding.

Coalition casualties receive surgical stabilization in our hospital prior to being rapidly evacuated either back to the United Kingdom or in the case of American or Canadian casualties back to Germany prior to transfer to home soil. Each week we have trauma tele-conferencing between both Birmingham and the United States which allows us to follow the progress of these patients.

Afghan casualties receive more definitive care within our facility prior to transferring to a local Afghan hospital. Away from the hospital, life on the camp is quite simple and the standard of catering excellent. As a consequence it is perhaps fortunate that the camp has fantastic sporting facilities. There is friendly rivalry between the different nations including the prestigious and hotly contested “Hospital Triathlon League” using Rowing, Cycling and Running machines (Swimming in Kandahar is, not surprisingly, impossible!).

Life however is not without it hazards with the camp regularly receiving rocket attacks, protection being provided with air raid shelters and blast wall protection around all buildings. It is impossible to forget that this is a very dangerous war zone, and is reinforced by “ramp ceremonies”, very dignified and somber occasions whereupon the entire camp parades to pay respects to a fallen comrade of any nation as their coffin is escorted onto an aircraft prior to repatriation.

A 6 week tour rapidly passes and again wearing helmet and body armour as I await takeoff for home, I have to readjust to my very different NHS practice, while realising how very much has been achieved in that short time.

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