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In search of courage. Well, that is how it all started. I was fairly advanced in surgical training not to mention age, when I decided to join the Territorial Army (TA). My peers, on hearing this couldn’t decide whether I had attained early senility or was simply in a middle age crisis. As for me, I still search the rationale of the irrational action that has moulded me into who I am now. But then, this is what Army does best.

I will put that to rest by a frank admission of being a man who never grew up. (The lure of handling a gun.) So, there I was at the TA centre exploring whether I could go to Iraq as a trauma surgeon! It took me some time to realise that the Army didn’t need me as much as I needed it. My physical fitness was in question but somewhere along the line I convinced myself that I would improve, and anyway how bad could it be? After all I was joining the medical corp, not the marines, not the infantry…. We don’t run around? Or do we? It was in Sandhurst when training Colour Sergeant brought my hubris down with the words “Sir, in the Army you are first a soldier and then anything else, so I suggest you better run and catch up with the pack”. It was hard to go through the course, what with the obstacle course, freezing nights in the field under a basher and miles and miles of keeping up with my peers who were probably half my age.

Slowly, very slowly, I learned to be a member of a team, who cannot and will not fail simply because my failure reflects on all of us. They were me and I was them in a primeval sense. I came to know why soldiers, young lads, who could out drink me any day, would throw themselves on a live grenade to save mates in their platoon. Somehow in the freezing November nights of Brecon Beacons I discovered myself, probably found who I really was.

They told me, and I never believed, until I was at the passing out parade, that I would feel six feet tall. I did, despite my wife taking pictures of a different man in the parade, mistaking him for me! She has since had her eyes tested.

Back at my Field Hospital, I still wanted to go to Iraq. After all, what better experience, what better opportunity, what better feather in the proverbial cap, exists in a surgeon’s life! But they found me too new, too raw in military terms to take me along. So, here I was with my unit deploying and me staying behind!

Next came Afghanistan, well, I wasn’t going to miss this one. Push ups and press ups, combat fitness test, weapons training, military knowledge, you name it … I was going!


My comfort zone was the abdomen, chest was manageable, no clue of head and even lesser clue of ENT and junctional trauma. My Advanced Trauma Life Support (ATLS) became <C>ATLS – where C stood for catastrophic bleed. My refined surgical skills (or so I thought) became ‘Damage Control Surgery’.

Prior to deployment, training consisted of simulated exercises in a mock hospital in York, which was an exact replica of the Camp Bastion Military hospital. Insertion of realistic looking casualties with constant training of the deploying personnel both in terms of decision making and team work happened on multiple seemingly endless weekends. It gelled the group, and more importantly rehearsed roles that would lead to one of the best trauma care.

The Army takes you through a course stretched over five days that effectively equips one to handle most if not all surgical trauma cases in military settings. From basic amputation to evisceration of eyes, tracheostomies and vascular repair are practised in the Military Operational Surgical Training (MOST) course.

Despite the near one-year pre deployment training, the level of trauma presented to the Field hospital in Camp Bastion is an experience that cannot be replicated in civilian settings.

By far the commonest injuries faced by soldiers are those sustained from improvised explosive device (IED) blasts. These lead to severe contaminated wounds to lower extremities and pelvis. The predominant action of surgical care is aimed at preserving life and limb. This is the classical Damage Control Surgery that goes along with Damage Control Resuscitation concept leaving reconstructive surgery to a later date. These reconstructive procedures are undertaken at Royal College of Defence Medicine (RCDM) in Birmingham after casualty stabilisation and CASEVAC from Afghanistan.

By far the most difficult areas of human anatomy are the junctional injuries incurred by sniper attack. Neck, armpits and groins that have encountered high velocity missiles injuries with the inherent cavitatory effect in those vital areas are difficult to explore and control.

Camp Bastion hospital, however, is probably the only place where speed of transfer of casualty from point of wounding, combined with immediate access to theatre and CT imaging makes the outcome of intervention fruitful. The teams are geared for the sole purpose of patient management. This is achieved by constant rehearsal of individual roles to a point that every member is geared to his or her assigned duties. It appeared to me that there was no expense spared to provide the most up-to-date medical equipment.

The advancement of surgery in trauma, gained through experience in Iraq and Afghanistan has led to many a change in trauma care that is now percolating to the civilian NHS trauma centres. The protocol of one unit of blood with one unit of Fresh Frozen Plasma (FFP) with one-pooled platelets; so called 1:1:1 transfusion protocol is now widely accepted in NHS practice. Another example is the use of Tranexamic acid within 30 minutes of severe trauma has more or less been accepted by most civilian trauma centres. Similarly, use of thromboelastography (ROTEM) is now being employed in multiple NHS trauma centres.

By the end of this year the British troops in combat role would have withdrawn. Was it all worth it, what was gained? As a soldier it is not for us to ask, but I am sure somewhere a young Afghani girl now going to school, would someday express her gratitude for the foreign blood spilt on her Afghan soil.


Declaration of Competing Interests: None declared.

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Shlok Balupuri

MB BS, FRCS MD, Sunderland Royal Hospital, Kayll Rd, Sunderland, Tyne and Wear, SR4 7TP, UK.

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