55 Field Surgical Team RAMC

Comment

The motivation and stimulus to establish this website was twofold.

Firstly my eldest daughter, Katie, has been pestering me for years to organise the various photographs and other documents that I retained from my time in 55FST. Clearly the material was not suitable assembling into any sort of ring-binder but would lend itself to a website or DVD.

It also came to my knowledge that much of the documentation about the FSTs had gone astray in the upsets to the RAMC that occurred in the middle to late 90's, when under the influence of Commander Harris, Millbank was closed and the move was made from London to Mytchett. It seemed important to make some of the other material accumulated at the time generally available.

The contribution made by medical services is rarely acknowledged. Detailed descriptions of battles are commonplace but the "butcher's bill" rarely has a mention other than in simple figures of so many killed or wounded. The opportunity was there to put that right.

Secondly, in the autumn or late summer of 2004 I saw a television programme about a Field Hospital in Iraq. One clip hit a  raw nerve. A surgeon was standing in front of a high tech anaesthetic machine which was festooned with variety of gas bottles and he was suggesting that the patient that he had just seen should now be dealt with by the unit neurosurgeon. The circumstances were different from my experience. A single FST in Oman in the 70's cannot be compared with the current large scale military intervention in Iraq. Both campaigns settled down into what one might now call "asymmetric warfare" with the opportunities to develope static medical servicesin relatively safe environments.

I had no issue with the surgeon. Modern surgeons generally have the appellation “Specialist” rather than “General”. The RAMC surgeons of the 70’s that I was used to were general surgeons and were by necessity versatile creatures who would turn their hand to any immediate problem.

Even though I had not touched an anaesthetic machine since soon after leaving Salalah I knew that, from my own experience, that the chances of an efficient supply of gases was probably “pie in the sky”. The supply of anything in a remote bit of desert was and probably still is, at best, uncertain.

There is a MOD website devoted to a current field hospital in Iraq. The provision of services and the degree of sophistication is of the highest order and great credit is due to those who set it up and manage the huge range of services that it offers. Unless there has been a huge change since the 70's I believe that reliance upon a long chain of supply and resupply would be a problem. The ordering and supply of surgical and medical materials electronically should in theory be very efficient. In practice there are many opportunities for links in the chain to fail and the more complex the databases of required materials the more opportunities for failure.

The Haloxaire was a simple robust bit of kit which, with the occasional use of  oxygen and a limited portfolio of drugs, did what it was meant to do. It was easy to use and did not require an anaesthetist of any great experience to operate it. Halothane has its disadvantages however and is not a strong analgesic. Following on from the Haloxaire the design and developement of the TriService Anaesthetic apparatus was another step forward. It did however sometimes require the provision of a mechanical ventilator and often used a combination of two inhalational anaesthetics from two vapourisers. Some of the simplicity of the Haloxaire was lost and it perhaps required a more skilled anaesthetist than the short service medical officer. It was a very versatile setup and could be used in a variety of ways giving it distinct advantages over the Haloxaire especially in the hands of an experienced anaesthetist.

I would suggest that whilst it is important to have highly trained experienced anaesthetists there is also a need to have "short service anaesthetists" who can cope with the less complex and demanding anaesthetics. The KISS principle applies and might very well both overcome any shortages and provide a service where resupply was a problem.

One could only ask whether the outcome for patients treated at the vastly more complex Gulf War Hospital with its highly trained and specialist staff was significantly better than that at 55FST back in 1972? We only saw a tiny number of patients. Were it possible it would be interesting to make comparisons. If outcomes were not statistically very different it makes a strong argument for KISS.

OFFICER'S MESS RCL

 On the 8^th of June 1972 an informal get-together and barbeque had been arranged in a well lit the officer’s mess. It was the eve of the fourth anniversary of the founding of PFLOAG. At 20:15 Joe and I left our seats on the patio and went to the FST to see someone who had sustained mortar wounds at White City. This was the anniversary of the founding of PFLOAG so one might have expected the adoo to be active.

 At 20:30 an RCL round (75mm) hit one of the seats where we had been sitting and the edge of the concrete. Luckily most of the blast was thrown away from the assembled crowd.

 Nine people were injured.  The injuries were mainly from fragments of metal and concrete but also from being thrown about by the blast.

It can be seen from the graph below that two of the victims were very shocked and required over an hour’s surgery each. The first of these eventually lost his leg below the knee but was back to playing squash when I saw him several years later at RAF Honnington.

 The second required the same length of surgery but the rest of the victims required only short anaesthetics for their primary treatment. In the situation that we were in the physical movement of the injured on stretchers, rather than on smooth floored hospital corridors, was exhausting if not unnerving as the adoo continued to attack the camp and the FST was only just inside the wire.

The total duration of anaesthetics was                            6hrs and 50 mins

 The length of time taken to process casualties was          8hrs and 50 mins

MIRBAT

The injuries sustained at Mirbat were a different kettle of fish. High velocity bullet wounds, mortar and shell fragments predominated.

 The tactical situation was such that it took some time to casevac the injured by helicopter to the FST. The battle started at 05:00 but it was not until 12:40hrs that the first patient had been resuscitated to a state where he was fit enough to be anaesthetised.

Some 200 adoo from the Ho Chi Minh, Central and Eastern Units attacked Mirbat from the North and the East. The enemy was repulsed and withdrew taking their dead and wounded with them. Forty were left at Mirbat;  three unharmed, nine wounded and twenty nine dead. Intelligenge suggested that eighty nine had been killed and an unspecified number wounded. On our side seven were killed and twelve were wounded in action.

(These figures are from the SAF Journal - 23 people were treated at the FST five of whom were recorded as adoo in my anaesthetic records))

 The number of injured was greater (23 rather than 9) and the nature of their injuries was such that the priority for surgery had to be reassessed as they waited on the stretchers outside the FST. Not only did available members of the FST tend to them but also other soldiers and airmen on the camp pitched in as well.

 One of the main lessons to be relearned from this incident is how long it takes to process casualties from a battle. The 23 casualties took 28 hrs of FST operating time.

 This was not a battle where technically sophisticated weapons had been used; no fuel-air weapons, little phosphorus, no one burnt in vehicles, no chemical, biological or nuclear weapons that might be found on the European battlefield of the 70s.

Yet this low tech battle, fought between about 250 to 300 people, gave rise to casualties who very nearly exhausted a 12 man FST’s capabilities in the subsequent 28hrs.

Had the adoo attempted a co-ordinated attack along with the attack at Mirbat or in the immediately  succeeding days the FST would have been hard pressed to cope with a further influx of wounded.

It can be seen from the chart that many of the wounded, 16 out of 23, took less than 40 mins of the surgeons' time. It must be remembered though that even a short operative procedure needs the attention of the whole team.

In the event all the casualties that were presented to us were treated. Were more pressure put on the team it would have been hard to justify treating casualties 1 & 2 other than to make them comfortable.

Total length of time taken to process the casualties  was  28:00hrs

Total hours of anaesthesia  were                                     17hrs and 20 mins

Injuries were divided into those caused by guns, mines or mortars/shells

                     Gunshot wounds                                  54

                     Mine injuries                                       9

                     Mortar/shells/splinters                    41

                     TOTAL "War" Injuries                      104

• Anaesthesia for DPS is NOT included in these figures
• Total number of anaesthetics recorded on Nosworthy Cards by this FST was 275
• In the "war wounded" I have included those 10 civilians who whilst   not combatants, were wounded by mines, mortars or gunshot.

                      104 war wounded arrived at the FST alive.

                      100 survived (96%) and left the FST alive

Those who died soon after or during surgery

Case 162  -
Wounds to both sides of his chest. A large fragment from a mortar embedded in his spine causing quadriplegia.
He developed bilateral pneumonia and died two days after surgery

Case 203
Gunshot wound through right chest which resulted both in chest injury and a markedly dilated stomach.
Suddenly collapsed and died two hours after surgery

Case 204
Ricochet from an FN into his right temporal region causing significan cerebral damage with LOC, unequal pupils, irritable movements on the right side with flaccidity on the left.
Died four hours post op.

Case 216
He sustained a GSW fourteen hours previously. It impacted on to the vertex then passing down into the posterior cerebellar area. Deeply unconscious.
Died on the operating table.

Died later

Case 227
Sucessfully casevaced to the UK but died some weeks later possibly from chest complications.

The difference in the degree of sophistication in resuscitation and anaesthesia is very marked. Techniques had improved no end by 1975 and more regional anaesthesia and neuroleptics were used.

This is a little disturbing as it seems to suggest that huge leaps in technique does not actually greatly improve the outcome. Assuming of course that all other factors were equal.

WW II Tobruk

It is perhaps interesting to look at a much larger cohort of injured from WWII

The circumstances are different in one major respect and that is that the average time from surgery to wounding was 30 hours.

Ralph MARNHAM, later to become a Brigadier and be knighted, joined the RAMC as 2nd Lt in 1940 and by 1941 was a Lt Col attached to 62 General Hospital in Tobruk in 1941, He recorded that : -

" In the second period of 13 days  561 casualties were operated on...... average time from wounding was 30 hours "

 ...three surgeons, two specialist surgeons, two neurosurgeons and six general duties medical officers did  1167 operations in 20 days ...  

" on the 21st we started operating at 14:00 hrs and with half an hour off for breakfast, other meals were taken in theatre, continued for 24 hours, when (A) team went off for three hours returning at 18:00 hrs on the 22nd....

After the war he pursued a distinguished career as a surgeon at St George's Hospital in London

I do have a little bit of a "bee in my bonnet" when it comes to resupply. The "bee" attached itself securely to my scalp in Salalah simply because the supply line did not reliably reach the FST. We indented for both drugs and equipment and it either took an inordinately long time to appear or did not appear at all.

It was not only our RAMCsupply organisation. The RAF Regiment were told at one point just after some persistent attacks on the hedgehog line and the camp that they could not have any more ammunition for the time being as they had used their quota for the month.

I argue that it would be prudent to equip all medical units with the techniques and equipment that were effective when resupply failed. No exotic gases for anaesthetists, a limited range of medications, equipment that could be resterilised by cleaning it and dunking it in Cydex or the equivalent. Similarly with operating packs. Once they run out they run out. Cleaning and re-use will circumvent this problem.

Before anyone is tempted to shoot me down in flames, I am speaking from experience. I am not the only one to complain. Geoffrey Sharwood-Smith in the 1975 FST noted that : -

 "extended lines of supply and communication meant that the use of compressed gases had to be reserved for major or complicated cases"

PROVISION of MEDICAL HARDWARE.

55 FST was the only FST that was operating in 1972. One might have expected that, with only one FST to cater for the provision of equipment and materiel would have been of the highest order. This did not turn out to be the case.  It was an opportunity to get rid of old and battered equipment and write it off the books. We could see them rubbing their hands with glee in Ludgershall. The mentality of those who were meant to be supporting those of us at the sharp end beggars belief. If this was not the case then to those of us on the receiving end it did seem to be so.

There were three anaesthetic devices when I arrived.

• A portable Boyles machine complete with chipped paint and a few empty gas bottles. The prospect of any gas resupply was considered but realistically thought to be so unlikely that there was no point in trying to establish this as a main anaesthetic machine.

• An EMO inhaler covered in dust (what wasn't) tucked away at the back of the store. I did not have the experience to induce seriously ill patients with thiopentone/ether and was not prepared to try and learn in those circumstances.

• A Haloxaire. I was not familiar with this device but it was the answer to the maiden's prayer. It was ludicrously simple to use, robust and only required halothane to function. There was one oxygen cylinder with it which Airworks would fill for us.

The lessons to be learnt are obvious. How you overcome the hoarding mentality of the suppliers and the reluctance to send out the best kit is yet to be resolved.