During 20 years of operation in Afghanistan, battlefield medicine and treatment have advanced in ways which would have been thought impossible in peacetime.
Requirements for new or more sophisticated equipment were fulfilled within days. Doctors and medics on the ground were changing how they treated people within hours, based on their experiences.
In such a fast-paced environment, these changes and continuous improvements made a difference instantly – saving lives and improving the outcomes for those wounded in action.
The Defence Consultant Advisor in emergency medicine at the time, now Major General Tim Hodgetts and the Surgeon General, recalls one instance where such improvement came about.
You cannot imagine a more difficult environment to treat a patient." Maj Gen Tim Hodgetts
“On the helicopter in 2007 in Afghan as the Doctor on the back of Medical Emergency Response Team – you cannot imagine a more difficult environment to treat a patient. You’re on the back of a moving platform on your hands and knees, with the heli flying 50 feet above the ground with the doors open.
“At night you can’t show any light. It’s difficult to find a vein, where to put a drip in. Having been through that on one night, I thought ‘we’ve got to be able to do better,’ we need adult intraosseous – a metal needle into the bone marrow cavity, to inject fluids and drugs directly into the marrow.
“For many years we’ve been told it’s only suitable for small children. American industry had come up with adult solution through a battery-powered drill. It looked like what we needed. I put the case in from theatre, and we had it within four days.”
Many of the medical advances made in Afghanistan have gone on to help civilian patients, including in the NHS. Key to this was evaluating the results, and recording and sending back the data.
The first 1,000 uses of the bone marrow technique were evaluated and published, and it’s now gone on to be regularly used for adults, in both ambulances and emergency departments.
This was also the case with emergency procedures. Previously, ‘ABC’ (airway, breathing, circulation) was routinely used by paramedics and doctors. The lessons learned from Op Herrick [the Afghanistan operational name] meant that it was changed to ‘CABC’ to prioritise Catastrophic external bleeding.
“We started using blood products on the helicopters from 2007, initially red blood cells, then plasma. We demonstrated the drop in mortality rates through this. We believe it had a profound effect for some of our outcomes.
“When we develop something it almost certainly has civilian application, but we have the casualty imperative to test it and find solutions. We can then pass that understanding into civilian practice.”
Major General Hodgetts recalls the experience of running an emergency department in Camp Bastion, the main base in Afghanistan during Op Herrick.
Initially it was a tented area, although one which was equipped like a regular hospital, and in some respects, better than a standard civilian emergency department. There was a blood bank close to the front of the hospital storing blood flown in from the UK, although fresh blood donation could be taken if necessary. Platelets are required for clotting, but when these are taken from a donor in UK they will only last 5 days. At the time, these platelets could be delivered from Birmingham to Bastion in just two days, which is a remarkable feat of logistics.
“We were configured as a trauma facility – better than most civilian A&Es, with two CT scanners just for trauma. The operating theatre was right next to the emergency department. All the critical care capability was together at the front end of the hospital.
Recalling the multinational makeup of the medical teams, Major General Hodgetts said:
It is the most challenging clinical environment I’ve ever worked in, but equally the most rewarding." Maj Gen Tim Hodgetts
“There was a unique unity of purpose. The whole hospital can turn on a dime when a patient comes in, you can feel that concerted effort.
“Working in a multinational setting was extremely stimulating. That was the pinnacle of my clinical career. What I’ve lived through and believe, is that when you get different nations together, you can take the very best from each one to create a fabulous hybrid which continues to evolve. We kept learning from each other.”
Major General Hodgetts set up an emergency department in the civilian hospital in Kosovo in 1999 immediately after the aerial bombardment ceased. The department is still in existence today; but in Afghanistan, the focus was on supporting the Afghan National Army to develop their own hospital capability.
Civilians did arrive at Camp Bastion for treatment, and Major General Hodgetts found that was another challenge.
“It might not be in the mission, but when you put a red cross on top of a tent, the local population will come. And remember, all of our hospital doctors and nurses work in the NHS where they treat the most needy first. So if you’re a local national, soldier or enemy, the most serious patient gets treated first in a field hospital, irrespective of their background.
“Are you going to turn away a critically ill child because they don’t neatly fit the medical rules of eligibility? We trod that tightrope every single day.”
As well as procedures and equipment to treat those injured, the experiences of medical professionals led to evolution in personal protection. A pattern of increased groin injuries was spotted, due to a large number of Improvised Explosive Device attacks.
This led directly to better protection for the groin, dubbed ‘ballistic boxers.’ Better neck and side protection of body armour followed, as did changes to vehicle protection.
In something Major General Hodgetts terms ‘innovation translation,’ lessons from the frontline were brought back to the NHS through both formal and informal channels. Through a combination of handbooks, clinical guidelines and personal experience, the NHS has mirrored the military approach.
Now, during the current pandemic, the lessons learned in Afghanistan – particularly those about innovating fast in response to a crisis - are again being brought to the fore; demonstrating the enduring importance of collaboration between Army and civilian medical professionals.