What are the rules in hell?

Blood and Dust is a 30 minute video made in 2010 by former soldier and now independent video journalist (and sustainable farmer), Vaughan Smith, about the work of a US Army air ambulance medivac team in Afghanistan.

Paramedics scramble out of a helicopter into a cloud of dust, clutching a stretcher. They re-emerge bearing a desperately injured marine. As the chopper swings into the air the paramedics have already started the life-saving protocol. In military medicine before ABC comes another C – control of the principal killer, catastrophic bleeding. The marine’s body is a ‘container’ and they have to make good the fluid lost when an IED blew off the ‘container’s’ legs. In the shuddering helicopter, shouting instructions and information over the din, the team members, bulky with the clobber all soldiers wear under fire, insert lines into flat blood vessels. And I, as a new house officer, worried whether I could get a Venflon into a patient I was escorting on the night train from Truro to London!

The technical skills of the army paramedics are impressive. So is the fact that they never forget that the ‘container’ is a fellow human being. They communicate with him gently, letting him know that they are with him also in spirit.

Despite the high-tech equipment the tourniquet remains a vital tool. It was invented by a Frenchman and first employed in 1674. Its use is still debated, but the consensus is that, though it may threaten some limbs, it saves more lives. Soldiers can see that and some go into battle with tourniquets in place on each limb so they can tighten them without help if they are hit.

Vaughan Smith was ‘embedded’ with a US Army aviation regiment. ‘Embedding’ enables journalists to get near the front line, though under circumstances which restrict what they can report. It’s a trade-off, but Smith was able to convey the reality of what the medics are doing. Not just for the injured soldiers - they evacuate civilians, even enemy Taliban, if they need it. There is no escaping the human cost of war .

Military medicine has become more effective over the centuries, often despite those in command of armies. Wellington may have beaten the French on the battlefield, but it was Napoleon who thought injured solders’ lives were worth saving. Stretchers were introduced to remove the French wounded promptly from the battlefield. Fifty years later the British generals in the Crimea didn’t think stretchers worth unloading from the troopships. And though most armies are now committed to care of wounded combatants, medicine has struggled to keep up with the technology of killing.

One thing that has never changed is the courage of the medics. They used to work behind the lines, which was dangerous enough. In twenty-first century conflicts everywhere is a front line and, as Vaughan Smith’s video shows, the medics pick up the wounded from the heart of the fighting. The nearer the medics are to the battle, the more wounded soldiers survive, but the greater the risk to highly trained personnel whose skills are literally vital.

Not many soldiers go to war to save lives. Army medics do. Increasingly successfully, as the survival statistics show. One in four soldiers seriously injured in combat in Vietnam died; in Afghanistan it is around one in fourteen. This has raised the question of whether the medivac units should be considered a ‘force multiplier’. Under the Geneva Convention, vehicles bearing a red cross enjoy safe passage. But if they make the force significantly more effective, they could be regarded as increasing the strength of the army. It isn’t that those extra ten lives saved mean ten soldiers return to combat; most are too seriously injured ever to go to war again. But because the soldiers know they are going to be looked after, the effect on morale is substantial. Would the Taliban be justified in shooting at the medivac helicopters? Should the tourniquet be considered an offensive weapon? War is hell, but we are still working out the rules for civilised behaviour in hell.

Medic: Saving Lives - From Dunkirk to Afghanistan describes vividly the development of battlefield medicine. By journalists John Nichol (who as an RAF officer was shot down over Iraq in 1991) and Tony Rennell, first published in 2009 by Penguin ISBN-13: 978-0141024202

This article was first published in the NASGP Newsletter April/May 2011

Judith Harvey

Judith Harvey was a research scientist, ran the VSO programme in Papua New Guinea and taught in a Liverpool comprehensive school before going to medical school. She has been a partner, a salaried GP and a locum, an LMC chair and a long-time supporter NASGP. Her charity, Cuba Medical Link, enables medical students to go to Cuba for their electives.

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