"He who wishes to be a surgeon should go to war"

Canadian MDs risk life and limb in Afghanistan

By Graham Lanktree

Captain Ray Wiss, an emergency physician from Sudbury, Ontario, spent most of his three months in Afghanistan working on the front lines Photos: Courtesy of Capt Ray Wiss

Major Sandra West stepped out of the plane onto the dusty tarmac. This was Kandahar air base. Mere moments later word came down: 11 casualties, all of them Afghan National Army soldiers who had just been caught in a firefight, were headed her way.

Welcome to Afghanistan.

That was Maj West's brusque introduction to the country when she arrived last August. A senior military physician from Ottawa, she had been put in charge of all medical cases that were brought into the NATO air base hospital.

She found herself remembering Hippocrates' millennia-old aphorism: "He who wishes to be a surgeon should go to war."

"I knew more about gunshot wounds in my first week working in Kandahar than my entire career," says Maj West. "If you ever want to do trauma, after going through something like this nothing is going to faze you."

PREPARING FOR WAR
Maj West had little time to prepare for Afghanistan after being added on short notice to a rotation that would last from August through to the end of February this year. Just days before flying to Kandahar from Canada she finished a 12-week trauma course given by the military at Montreal General Hospital. "At the hospital, though, they get trauma cases in ones and twos — not eight or ten like we do in Kandahar," she says.

Or even more, sometimes. The worst situation she saw there brought 21 new Afghan patients into the hospital when 15 of the unit's 16 primary care beds were already occupied. For situations like that, military trauma physicians have developed their own triage shorthand: Alpha, for life threatening cases; Bravo, for serious wounds; and Charlie, for broken bones, cuts and bruises.

"You need lots of flexibility as a leader," observes Maj West. Not only to manage the number of staff working around you, but also to deal with whatever event is just around the corner. "Often we would get a call from a medic where they're under fire or they've been in a situation where there's an explosion," she reports. "They're trying to make an assessment and casualties could change in transit, or they don't know how bad the wounds are." She would have to prepare herself and the trauma team of at least nine other doctors for anything.

OUTSIDE THE WIRE
What the medics do on the front lines, however, is what really saves lives, says Maj West. There's a saying on the Kandahar airbase: "If you arrive alive, you will survive."

Captain Ray Wiss, an emergency physician from Sudbury, Ontario, treated soldiers in the critical moments after their injuries as the lead medic of an armoured ambulance crew. "One day when I was out there, one of our vehicles hit a mine," he recalls. "Trying to go from one injured guy to the other, to the other one, and making sure my team was doing this task, that task and managing everything — it was unforgettable. I was working at the most intense level I ever have. Your goal is to stabilize those people immediately. You're intubating them and starting multiple IVs and knowing that the chopper is 30 minutes away. It's stressful. You want to make all the right decisions."

AN UNUSUAL PATH
Capt Wiss's experience is unique; physicians rarely travel outside the wire, beyond the limits of the Kandahar base. But some paramedics had been killed, he says, and the military needed help out in the field. "When these gaps appeared people on the ground knew I had combat training as an infantry officer. So they asked me to take a front line position. I had to have a long conversation about it with my wife."

After only a couple of weeks in Kandahar working with Maj West as a trauma team leader, Capt Wiss set off for an outpost along the border of Pakistan on the edge of the Red Desert. It wasn't the first time he'd done something like this. He had trained in the Canadian infantry, working as a medic in South Africa in 1994 during the run-up to elections marking the end of apartheid, and Nicaragua in the mid-80s. He still carries a souvenir from Nicaragua: shards of an AK-47 bullet, lodged in his left knee.

When he responded to calls from Canadians, Capt Wiss would steel himself to treat severe injuries. "When Canadians come in it's always IEDs," he says. "The explosion comes from underneath so you're dealing with lots of leg wounds and other things from the waist on up. You can survive getting your legs ripped off. But if something happens to your chest and abdomen then the chances aren't as good." Luckily, in a pinch his skilled hands can perform needle thoracocentesis on collapsed lungs under some of the most extreme conditions.

CARING FOR THE TALIBAN
But Capt Wiss didn't only treat Canadians; many Taliban fighters who had just seen combat against Canada's forces would be brought in with gunshot wounds.

Captured Taliban fighters are terrified that at some point they're going to be tortured, he says. They're surprised when their wounds receive the same attention that a Canadian soldier's would.

Over at the Kandahar airbase the same prisoners treated outside the wire by Capt Wiss would be brought to see Maj West's team wearing blacked-out goggles and earmuffs to block any defining sights or sounds. They're then taken to a closed-off area where an interpreter, who translates between the medical staff and their patient, stands behind a screen hiding their identity. Maj West would also remove her nametag and rank. Just to be safe.

Some of her soldier colleagues learned to protect their identities the hard way. A number of soldiers purchased Afghan cell phones and used them to call back home. Resourceful Taliban fighters tapped into the calls and would later call those numbers back, terrorizing their families back in Canada by identifying themselves and saying "We've got your relative and you're never going to see them again."

Yet Maj West also felt for many of the Taliban fighters she treated. "Often they were young kids, 16 to 18 years old, who had been recruited to plant roadside bombs with the promise of money, or threats to their family's safety."

GAINING EXPERIENCE
Just a few weeks ago a Taliban rocket landed so close to the airbase medical building that it shook. Even on the heavily fortified NATO base rocket attacks aren't infrequent. So why would physicians — especially civilian physicians — put themselves in danger's way?

Dr Steven Wheeler, who finished his second tour in Afghanistan as a civilian at the end of February, says that he's a much better anesthetist for having gone. "I learned tons. In Canada I don't regularly take care of that many patients all at once. We would see four, seven patients arrive all together. If we ever had a mass casualty event in Calgary, now I'd be prepared."

Living with the military surgical staff taught him a lot. "My roommate was a surgeon from Vancouver. Over dinner we'd talk about abdominal compartment syndrome. I'd ask, 'What can I do to reduce this?' That constant sharing of ideas was excellent for my practice."

He learned to prioritize cases by their urgency as they arrived and was awed by the innovations that came from staff on all sides. (For more on the military's advances in emergency medicine, read our article in next month's issue).

FIGHTING SHORTAGES
About this time last year the Canadian military put out a desperate call for physicians to work in Afghanistan. They only had half the number of doctors they needed and military officials predicted it could be three to four years for the number to rise, staunching the gaps.

However, the response was quick. One year later, the military has the physicians it needs. Generous cash incentives for enlisting may have played a part. Physicians receive a signing bonus of $225,000 plus an annual salary of up to $165,000 for a four-year enlistment in the Canadian Forces, and medical students close to graduation get a signing bonus of $180,000 — enough to pay off looming debt. And civilian physicians are compensated handsomely; they make $3,000 to $5,000 per day for one-month tours. That totals up to $155,000 for just a month in Kandahar.

"For many, the money enables them to go to Afghanistan," Maj West says. "You're asking people to put their lives at risk. There's no guarantee you're going home alive or able to continue practising medicine." But she believes many of those who go aren't in it for the money.

Despite the risks, Dr. Wheeler says it was worth it to work with the Canadian medical team in Kandahar. "I would be very happy to go back to a situation like Afghanistan. It would be very difficult to find people doing that level of medicine anywhere. They truly are the best of the best."