Back in theatre, in theatre

Captain Sush Ramakrishna writes about being catapulted back into Afghanistan, at Camp Bastion hospital.

Summer had not arrived in the UK, but getting off the plane with wind and rain in the face was a pleasant welcome after the last few months of unrelenting heat, scorching sun and dust. I was back in the UK hoping to find out where my future would take me. I have realised that nothing can be taken for granted however. I was offered a job in surgical training, but as the needs of the military take priority I suddenly found myself rescheduled to go back to Afghanistan. Straight away.

After initially being upset when I was told that I was not starting my hospital job, I was quietly glad because I knew that I would be back with the troops. My stay in the UK was short so I had little time to reflect on things which had happened over the previous months. Spending time with my parents and friends was good and gave me a chance to re-focus on the next few months ahead. I also found out that the new Dr Watson (in Sherlock on the BBC) had actually served on the current campaign in Afghanistan like his creator during the early Afghan wars.

ED team getting briefed regarding casualties

ED team getting briefed regarding casualties

When I got back to Afghanistan, I was told that I would be working in the hospital at Camp Bastion. Over the last two years, having spent majority of my time in primary care, I was looking forward to getting back into hospital surroundings and re-familiarising myself with the hectic working environment. Being the junior doctor in the hospital I have been given great opportunities to learn new skills. Dealing with battle casualties in the Emergency Department (ED) has certainly improved my clinical and procedural skills. Working under experienced and dedicated surgeons in the Operating Room (OR) I have gained invaluable insight to the specialty and under their supervision I have been able to reinforce my operating skills. On the whole, this experience has reinforced my ambition to train as a military surgeon. From a training perspective, following a patient from the ED to the OR and then finally to being discharged is something junior doctors are not often exposed to but I have managed to be involved in the patient’s care right from the time he arrives to the time of discharge.

The troops receive the best possible care with each expert providing the right input in the management. This is probably the least the troops can expect – expert medical care near to the frontline. Along with the doctors, the nursing staff, physiotherapists and other allied professionals work extremely hard to make sure that the best quality of care is given to the soldier presenting at the front door. The majority of the patients are NATO troops – US, UK, Georgians and Estonians.

The American and British surgeons operating on a complex trauma case

The American and British surgeons operating on a complex trauma case

Camp Bastion Role 3 hospital receives more trauma cases than most trauma centres in the world. The ED and OR work at a very fast tempo and the efficiency is down to the training we get prior to the deployment. American and British doctors work side by side and the expertise each one brings to the table is very beneficial to the team. I have been very lucky to have surgeons and ED doctors willing to teach me new skills and procedures. I have personally been in awe of the senior doctors in this place!

Going home…

Captain Sush Ramakrishna, a Medical Officer now returning to the UK, reflects on his experiences on the ground in Afghanistan.

As I am waiting in Camp Bastion for my flight to the UK, I reflect back on the previous weeks of desert operations and look forward to a nice shower and home comforts. We moved into Sangin as a Company group and everyone had a chance to share their ‘dits’ (stories) with their colleagues from different units. Sangin was completely different to our previous location – Kajaki. There was a busy and thriving bazaar. The local population lived in close proximity to us and it seemed that the Medical Centre in the main Sangin base treated more local nationals than we did in Kajaki. However, with the close proximity of the local populous came the close proximity of the insurgents. This meant that the troops here did not have much freedom of movement. From a professional point of view, it was interesting to speak to the Medical Officer based here. I realised how lucky I was to have been out on the ground with the troops while he had spent most of his time inside the medical centre.

With no shade in sight, it was challenging to keep cool in the scorching heat

With no shade in sight, it was challenging to keep cool in the scorching heat

Moving into the Sangin district, we were tasked to provide security for the local nearby villages. The operations saw us living out of our armoured vehicles – Jackals, Huskies and Coyotes. We had to be self sufficient with our food and water as we were in the desert for days at a time. We also had a specialist team from the Afghan National Army (ANA) who were embedded with us. They were very good at acquiring information from the locals and this helped us gauge the feelings of the population. We set up certain Check Points to deter any insurgents, and show that one of the aims of the campaign was to provide security, and assisted the ANA. As always, things did get interesting when we received small arms fire and we had to tactically move. We also had rocket-propelled grenades (RPGs) fired at us and one of the vehicles was involved in an explosion from an improvised explosive device (IED). Fortunately, there were no fatalities.

Chlorinated water at a high temperature tastes like one’s own urine and hence staying hydrated was hard! From a medical point of view, there were heat-related and scorpion bite casualties. Treatment was commenced on the ground and as casualty evacuation by road was not tactically possible, the casualties were cared for in situ. However, one of the casualties did have to be extracted by helicopter.

Keeping constant surveillance in the heat was tiring for the troops

Keeping constant surveillance in the heat was tiring for the troops

Working in temperatures of over 50°C was challenging and this arduous environment tested the troops, but the guys, being professional, got on with the job in hand. There was plenty of banter flying when the morale was dropping at times. On a very sad note, it was time I parted ways with my ‘Flashman-esque’ moustache as I was returning home.

Working in an austere environment and facing challenges, both professionally and personally, drove home the point of why doctors join the Army. Here, I was about to go back to the UK to start my job back in hospital as part of my training in August and I realised life was going to be very different from what I had grown used to.

Life in Kajaki

Captain Sush Ramakrishna is the 3 Medical Regiment (3 Med Regt) Medical Officer attached to D Company, 40 Commando, Royal Marines, in Kajaki. Here he writes about being a medical officer on the ground in Kajaki.

Captain Sush Ramakrishna

Captain Sush Ramakrishna

Being told to report to the Commanding Officer in the afternoon, I was nervous as to what was in store for me. I was positive that I hadn’t messed up on my exercise in Kenya. Had I not done enough time in the Medical Centre? Later, standing in front of the CO with three  other colleagues, I realised it probably wasn’t a dressing down. We were told that we were being penciled in for an operational tour in Afghanistan. This was great news for me. I had joined the Army as a doctor, but serving on operations was the carrot. We (the doctors from 1 Med Regiment in Münster) were then attached to 3 Med Regiment who were based in Catterick. The pre-deployment training involved us travelling between Germany and the UK for various courses and mandatory briefs. The New Year saw us in Catterick, embedded into our new unit, and the best part was the weekly training in the snow-covered hills of Yorkshire. You would be forgiven to think that we were training for a winter tour. Sending us to Jamaica or Barbados for acclimatisation for a summer tour of Afghanistan should be on the agenda for the new Cameron-Clegg government!

We were welcomed in Afghanistan by sandstorms and temperatures of over 40° C. The first week involved attending more briefs which consisted of useful tips and war stories of the guys who had spent the last few months out here. It did get a bit tedious – endless horror stories and sometimes reality was taken out of context. But, we were professionals and keen to go out on the ground. I was sent to Kajaki to be the Medical Officer for D Company 40 Commando, Royal Marines, along with two medics.

Flying over the Green Zone of Helmand Province, one could mistake this place for a holiday destination. Yes, I was finally here.  I arrived as the previous company of  3 RIFLES were moving out. The first few reminders of reality were the mortars being fired at random in the middle of the night – fortunately by us. One’s initial reaction when asleep was to reach for the body armour and slide underneath the bed, but later I got used to the loud explosions.  I managed to find a real bed with a mattress and acquire a fan for my room. This could be the Hilton of Kajaki?

The medical centre in the FOB is a concrete building able to accommodate a trauma bay, medical stores and the living quarters of the medical team. The whole company is involved in going out on patrol and can end up 5-6 km away from the base. It is therefore vital for their Medical Officer to go out on the ground to be near the troops in case there are any unfortunate incidents. I traveled initially in an ambulance, very much like an NHS ambulance. But, later it was decided they weren’t a good idea and we switched to quad bikes instead! I am always with the Company Sergeant Major. We deal with casualty extractions, treating the patient and calling in the helicopter.

It gives the troops on the ground the reassurance that there is good medical cover right behind them.

It is great to go on foot – or rather quad – patrols. It has greatly improved my soldiering skills and given me a better understanding of infantry tactics. I have also been able to meet the  locals working in the fields and the members of the Afghan National Police (ANP) who lead the patrols and work in the Observation posts, providing good intelligence and liaising with the local farmers. I was born and grew up in India and can speak Hindi, as well as understand Urdu. I can therefore communicate with some of the ANP personnel who also speak some Urdu. Many picked up Urdu during their time in exile in Pakistan when the Taliban regime had taken over their towns and schools.

These guys are keen to work for the right reward, even when they don’t actually receive it. Some haven’t been paid by the government for two months but they rarely complain. Their ambition is to see their country better run. That is the real motivation which  keeps them here doing their job. They do not lack courage for sure, nor hospitality. The cups of Chaai (sweet green tea) and Dudey (local bread) are always offered to the ISAF guys even when they have not eaten anything themselves. They are a proud bunch of guys and the future of the country might well lie in providing the right training and incentives for them.

On a lighter note, they are as vain as many men and always demand moisturizers to improve their skin and thicken their wild hair!

Being on the front line is exciting as it gives you the feeling of being in the midst of things. But, when someone is injured, the reality is very different to what you would imagine. My first casualty was a man with a gunshot wound to the leg. Everything went so fast. I thought the treatment and extraction only lasted a few minutes but actually it was more than an hour.

We learned some things from that incident and tightened our procedures. I felt it was very important that we had had a medical officer on the ground.

There is nothing like a routine day on operations, especially working in the Med Centre. Teaching and training my medics is one of the highlights of my week – it gives an opportunity to re-learn things and assess their level of expertise and knowledge. I go through various scenarios with them. We were unfortunate to have to deal with fatalities following an ANP vehicle involved in an IED explosion. This happened in the middle of the night. The med team was stood to and we received two casualties. Unfortunately, both were dead on arrival. They had suffered horrific injuries. The third casualty which followed had been in the back seat and had facial injuries and lower limb injuries. We moved quickly to get him to hospital. We realised that communications between the ANP and us had to be improved for future incidents.

The moustache is coming along well

The moustache is coming along well

During my time at Kajaki, I have managed to pick some new things – a hairy pet which could be mistaken for a slug growing as a moustache!

The CSM (Curator of Shifty Moustaches or Company Sergeant Major) seems to have okayed it. I might be fine as long as I stay away from the wrath of the RSM (Regulator of Shifty Moustaches or Regimental Sergeant Major)! As the gym is a stone’s throw from the med centre I train about 4-5 times a week. I am now the proud owner of a smoking pipe with cherry-flavoured tobacco. With more practice, I might have the panache to keep up my moustache. On a finishing note, I just found out that Arthur Conan Doyle, an Army surgeon when based in Kandahar (during the early Afghan wars), found his inspiration for Sherlock Holmes (was he knighted for that or his service to his profession?) while he was in Afghanistan. I am still staring at the beautiful starlit sky waiting for my inspiration!

The life of a Nurse in FOB Inkerman

Sergeant Mal Dick is a Combat Nurse from the Queen Alexandra’s Royal Army Nursing Corps, based in FOB Inkerman in Sangin for the duration of Operation HERRICK 12.

Bergen packed and goodbyes said, I trundled off towards the airhead and a much trained for trip into the southern part of the green zone of Afghanistan. Having completed the training package the previous day I mulled over all that I had learned and hoped would not have to put to use, such as the soldiering skills of weapons handling, ie using a general purpose machine gun, or the grenade machine gun,  and compound clearing (could you imagine!) I had a little chuckle to myself whilst sat in the “departure lounge” waiting to be called forward for the flight out on a Chinook helicopter. To be honest it was more of a nervous laugh as I had watched a program called “Chicks at war” (I think that’s what it was called) along with my wife, the Thursday prior to deploying.  The program followed the trials and tribulations of a female Corporal Gunner who was serving at Forward operating base (FOB) Inkerman, which she nicknamed FOB Incoming because of the amount of contacts it was having. I remember my wife looking at me rather wide eyed stating: “You won’t be going there will you?”

“Of course not” I had replied. At that point I believed I was working in Bastion. You can imagine her face when I came home the next day and said: “You’ll never guess where I’m going!”

With reality looming I checked I had all my kit, Bergen and day sack, body armour on, weapon attached, helmet and goggles. Check complete I couldn’t help wonder that despite shedding all the extra kit  why I was feeling too heavy.  Nothing I could do about it now as I was heading up the ramp of the helicopter. I’ve flown on a Chinook before but this flight made me a little nervous, not because I was flying out to a Forward Operating Base but because there were no seats left and I would be perched on the boxes of cargo which to my mind were too near the open end of the drop doors. I gave a nervous glance to the cargo master and his positive thumbs up did not quell the thought that this journey would be a bit like a roller coaster ride with no safety harness.

My misgivings had been unfounded and I realised that I probably had the best seat, as I watched the desert swiftly pass by a couple of hundred metres below. The vastness of the landscape was remarkable with the contrast of the view of the Green Zone even more so as we circled and landed at the helicopter landing site outside FOB Inkerman.  I stumbled down the ramp with bags on back,  met by a barrage of shouts instructing me in that age-old squaddy language of profanity to get in behind the wall ASAP! Once through the gates the pace was a lot calmer as I was met by Lance Corporal  Jodie Hill who cheerfully stated “Welcome to stinky Inky”. I have to admit being met by this bubbly Welsh blonde was far removed from what I had imagined would greet me in the middle of the desert.

The Medical Centre after the tidy up!

The Medical Centre after the tidy up!

Having booked in at the Ops room I headed off with Jodie to the Medical Centre and met up with the Medical Officer, Major Demontes. As we approached the Medical Centre  ‘the Doc’ was outside to greet  me with a warning that the medical centre needed ‘a little work ‘as it had been recently moved from its original ‘building’ into a more central location. Probably just needs a little squaring away I thought, as I pushed through the vinyl curtain door into the Hesco building. To say I was off the mark would be a bit of an understatement. I don’t mind telling you I had a bit of a moment, with more than a hint of Obsessive Compulsive Disorder, seeing boxes of medication, team medic packs, etc etc etc, strewn around. The container being used as the med store didn’t look any better and I am sure I wailed that it would take me weeks to sort it all out. In the end it took a couple of days of concerted effort and it is, I am pleased to say, a fully functioning medical centre complete with a reception area, a primary health care bay and 2 bedded trauma bay with all the kit and equipment laid out neatly.

Drama out of the way it was time settle into camp routine. The day starts at 0700-ish when I get up from my mosquito net covered cot bed and try not to bump into anything in my 1 metre x 3 metre ‘room’. I don my shorts and t-shirt and head off around camp on my morning run, 10 laps is about 7 kilometres so this tells you how big it is. Despite its size the camp holds a fair amount of buildings, equipment and soldiers, including contingents of marines, engineers, gunners and various other attached personnel. Run finished, I head to the showers, or should I say to a cold hosing, for my early morning wake-up call (ablution containers are not plumbed in yet). There’s nothing like cold water to make you have a ship (read fast) shower and conserve water, whether you want to or not. Off to breakfast in the cookhouse and as with all meals thus far they have been generally excellent. We’ve not had ration packs too often and have a pudding of some sort most evenings (of course I save these for Sundays as a treat).

Work day then starts at 0800 when we have sick parade and start all the administration for the day (equipment care checks, mopping to keep the dust down etc). Sick parade is meant to finish at 1000 however it tends to run all day as people come in off the ground. As with any medical centre we see a range of common ailments, ie athletes foot, dodgy tummies, aches and pains, however we have had the out-of-the-ordinary that have required treatment at the field hospital in Bastion. I hadn’t given this a moment’s thought that these wouldn’t always be for battlefield injuries. All of this may sound almost mundane. However the environment (sandstorms, high temperature) the austere conditions (Hesco buildings, temperamental electricity supply) and of course the occasional incoming small arms fire and the odd explosion (a war story for another day) ensures that it is anything but.

My role as front line nurse does not see me confined to FOB Inkerman alone. It also includes other duties such as trips down the 611 Highway to provide medical cover and to  touch base with the patrol bases (the Mastiff really is a great piece of kit); a 3 day stint at the most forward PB in the Inkerman area of operations, providing medical cover whilst other assets were re-assigned. A taste of PB life  put into perspective the relative luxury of FOB life:  no electricity, no fresh food, and Sanger (watchtower) guards 3 times daily (thank goodness for the weapon familiarisation). This is where I learned what ground signs are really like and eyeballed copious ‘murder holes’ from which the insurgents operated.

As you can see the role of the nurse within a FOB is a multi-faceted one that daily provides challenges on many different levels. It gives an opportunity to see a side of military life not often visited by the ‘Grey Mafia’ and a chance to utilise the skills learned. It is a rewarding role that despite some of the perceived hardships I continue to look forward to fulfilling and developing for the remainder of this tour.