In 2008, Lance Corporal Hangam Rai was patrolling in Helmand province in Afghanistan – a Taliban stronghold that saw some of the fiercest fighting of the war – on a routine mission to resupply a nearby checkpoint. Since the beginning of the conflict in 2001, improvised explosive devices (IEDs) – munitions converted for use as road-side bombs – had become the weapon of choice for the Taliban-led insurgency, and were responsible for 66 per cent of all coalition deaths in the war.
The patrol was on edge, progressing slowly and scanning the ground ahead. At one point, having seen something suspicious, the commander – riding in the first of four armoured Land Rovers – ordered the patrol to stop and Hangam and his colleagues to dismount and search for hidden IEDs.
Cello Gauze: If you’re on patrol and one of your unit is shot, you don’t rush straight to them – you don’t want to get yourself or someone else injured. Once we have assessed the situation, and it is safe to approach, we follow a procedure called CACBD, which stands for catastrophic bleeding, airways, circulation, breathing and disability. Every soldier carries a personal first aid kit containing two tourniquets that they are trained to use on themselves or another soldier, but they are only suitable for injuries or amputations where some of the arm or leg remains. If you have a wound to your neck or torso we have to use Celox. This is a gauze that has been impregnated with chitosan, a clotting agent derived from crustacean cells, that we pack into the wound and that can stop severe bleeding in as little as three minutes. Before this we used the American QuikClot powder, but if you ripped open a packet with your teeth and inhaled it, or it went in your eyes, you could be seriously injured yourself.
Hangam was 10 metres away from the commander’s Land Rover when it slowly edged forward, detonating an IED. It was a massive explosion, ripping the first vehicle in half and throwing the gunner 50 metres away. Hangam, miraculously, was unhurt, but the driver of the vehicle suffered the loss of two limbs and the commander, who was stripped completely naked by the blast, sustained serious internal injuries.
Forceps: We use these for areas that are hard to reach, such as down the windpipe. In a battlefield situation, however, I would use my hands because it would be quicker.
As the combat medical technician for the company, this was the multiple-casualty, mass-trauma event that Hangam had been training for. His quick actions that day – triaging his patients, directing the other medics in his team and coordinating the evacuation – saved the lives of both soldiers. But it was close – the emergency evacuation helicopter arrived in less than half an hour. “If it had been delayed by five minutes,” Hangam says, “the commander would not have survived.”
Nasopharyngeal Airway: Once we’ve controlled the bleeding we move to the airway. If the casualty’s mouth is blocked, we use a nasopharyngeal airway to open the passage from your nose to the trachea. I carry two sizes – to work out which one to use I measure the tube against the casualty’s little finger, as it’s normally a similar size to your nostril. We also carry an oropharyngeal airway, for the mouth, though it is better to go through the nose as this doesn’t run the risk of making the casualty gag and vomit.
As the war in Afghanistan continued, the modified Land Rovers were replaced by more robustly armoured vehicles, and the kit carried by Hangam, who received a commendation for his actions, evolved to reflect the realities of modern insurgent conflict. And yet, although fatality rates have fallen for British soldiers – in 2015 a study found that around 265 casualties survived injuries that would have been fatal at the beginning of the war – these indifferent, utilitarian objects poignantly convey the brutal trauma of war.
Russell Chest Seal: The next step is breathing. Generally, there’s not much we can do for this other than record breathing rate for the doctors on the evacuation helicopters. If the casualty has a punctured lung through a penetrating chest wound, however, we can use the Russell Chest Seal. With a puncture wound to the lung, when you inhale, 50 per cent of the air comes from the mouth and 50 per cent from the wound. If left untreated, the injured lung can inflate and compress the healthy lung, making it impossible to breathe. The chest seal – a bandage with one large valve surrounded by four smaller valves – allows air out but not in, returning the pressure in the lung to normal and allowing the casualty to breathe.
Intravenous Needle: After breathing comes circulation. We need to replace any blood the casualty has lost with fluid to ensure their blood volume is sufficient to continue to pump oxygen around their body. Many soldiers train as team medics and, along with other basic medical tasks, they are trained to insert an intravenous needle. I carry two sacks of saline fluid, which should be sufficient until the medivac arrives.
Intraosseous Needle and Drill: If you are unable to give fluid through the veins – often because blood flow is restricted to extremities when the body is in shock, or if the casualty has lost both their arms and legs – we have to give fluid through bone marrow. If there are still some flat bones, like the tibia, this involves using a small electric drill to insert specially developed intraosseous needles into the bone. Alternatively, if they have no limbs, we have to use a sternal intraosseous infusion – a small cylindrical device that has a ring of six needles around one large one that is forced into the sternum: an incredibly painful procedure.
Naloxone: All soldiers also carry a small auto-injector of morphine in their medical kits that they are trained to use. Sometimes, however, a casualty can receive many doses from different soldiers, so I always carry naloxone, which blocks the effect of the opiate in the case of an overdose.
