Reflections on FSTs – Past, present and future.

Major Joe Johnston             – Senior Specialist in Surgery
Major Bill de Bass                – Specialist in Anaesthesia
Capt Nick Cetti                     – Trainee in Surgery

Sgt Gerry Farrell                  – Senior OTT
Cpl Bud Holder                     – OTT
L/Cpl Pete Starling              – OTT
Pte Pete Canning                – OTT

Sgt Mick Pargin                    – Senior Nurse (SRN)
Sgt Roger Lynn                    – Nurse (SRN)
Cpl “Mac”                               – Nurse (SEN)

Sgt Dave Barrow                  – Laboratory Technician
Sgt Roger Hicks                   – Radiographer

Pte Tony Powell                   – Clerk

The RAMC did not have an established Field Surgical Team that could be deployed at a moments notice. The nearest to that was the one which formed part of the PFA (Parachute Field Ambulance) based in Aldershot.

The PFA had deployed to Dhofar in the middle of 1971 in response  to a request from BATT for medical support. It was not the first FST in Dhofar. There had been both RAF and Army FSTs before it. The subsequent FSTs after the PFA were composed of a rag-bag of members from various UK and BAOR hospitals. Some of the members of the FSTs knew of each other whilst others had actually worked together. Obviously the members did not know each others idiosyncrasies. The group that assembled at 2 Field Hospital in March 1972 to form the Johnston FST were not yet to be a team. We drew OGs, were jabbed, spent time on Ash Ranges before becoming “live cargo” in the hands of the RAF and being  whisked off to RAF Salalah via Cyprus and Masirah where we had a day’s wait as they did not fly on Sundays.

The team, whose core was made up of OTTs, was heavily represented in the Sgts Mess. The constituent members of the team were both highly trained and experienced. Hence their rank. Their deployment to Dhofar had a significant effect on their parent hospitals. Practically, when the webmaster was detached to Dhofar an OTT at Rinteln, Pete Canning, was also detached. After all without his anaesthetist to fuss over he would have been underemployed. It did exert pressure on the OTTs left behind as their finely tuned duty rotas were disrupted.

Perhaps the most significant pressure on the system was the detachment of the anaesthetist. The Army had about fourteen hospitals or outposts which required an anaesthetist and had thirty anaesthetists to fill those posts. Ten or so were too junior and inexperienced to go to Dhofar; the Trainees in Anaesthesia. Ten were so senior that their absence as consultant anaesthetists at a major hospital was out of the question. The ten in the middle of the sandwich, those graded “Specialists in Anaesthesia”, had the good fortune to be in that part of the army anaesthetic family who could be posted to Dhofar. The webmaster was one of those more junior “Specialists in Anaesthesia”.

It was unsustainable of course. Reducing the number of anaesthetists in the busiest specialist referral hospital in BAOR, BMH Rinteln, to a Trainee and a Consultant was not practical. The consultant could work on his own but the trainee needed supervision which doubled the consultant’s workload. The Advisor in Anaesthetics at Millbank, Col John Voller, had a difficult juggling act.  Eventually the army had to eat humble pie and involve both Crab Air and the Matelots to man 55FST in Salalah.

The webmaster has no knowledge of the pressures on the surgical side but imagine that they also were considerable.

The cohesion of the “Johnston” FST was quickly established on account of searching for solutions to the difficulties that had presented themselves. The wholly inadequate arrangements were a challenge which pulled the team together. The  FST that had been there in late ’71 had experienced a fire which had destroyed part of the tentage at 01:30 one morning. The FST that had preceded us had so little work to do that they had little incentive improve their local circumstances and left us with a very basic FST environment. The RAF OC RAF Salalah recorded in the ORB 540 that they had suffered from “morale problems due to their light work load.” Improvement and development of the FST was a challenge that helped focus the team and eliminate boredom. The adoo of course made their contribution, which was often considerable.

Station Medical Centre consisted of an office, a six-bedded ward, an ablution block, and a store.  A Twynham hut named “The Rainford Ward” nearby held beds for about a dozen patients. A standard marquee  sheltered the Mobilex  X-Ray apparatus and sheltered waiting patients from the sun. A dark green “F” assembly  was used as an operating theatre. The “F” assembly was unlined,  ventilated with an aircraft blower but having no airconditioning was unbearably hot.

I had looked after the medical centre in Kirkee McMunn barracks in Colchester in the late 60s with the help of a bombardier and a driver. The gunner regiment and the other units carefully molly-coddled artillery, helicopters of two sorts, Land-Rovers and three tonners not to mention all sorts of other associated kit. I could not help but muse that relatively little investment was made in the physical and mental well being of the soldiers compared with the care lavished on the hardware.  The days of every fourth soldier having extra first aid training and  there being Combat Medical Technicians were far off.

Likewise the inadequate facilities provided for the FST were scandalous. Not only was the accommodation still substandard, when one considers that there had been opportunity to develop it over several years, but the logistics chain to support it had all but collapsed. Supplies of oxygen were requested but they never appeared. Medication such as Neostigmine, the reversal agent for neuromuscular blockers, widely used in anaesthesia, likewise was omitted from re-supply packs.

The circumstances might have been different had some genuine interest been expressed in the FST by senior RAMC officers.  A perusal of the RAF ORBs 540 reveal that no senior officer appeared until Col Cameron Moffat in February 1973 and the NEARELF ADMS in 1975 towards the end of the deployment.

We were not just whingeing and being disagreeable for the sake of it. The provision of an adequate surgical environment, properly supplied, was a duty of care owed to the soldiers from the very first time they were put at risk. If a date were to be selected it might be the middle 60s.  The first mention of an FST was when  ”the RAF FST went home for Christmas” on 18th Dec 1970. How, over the years, had the needs of servicemen at RAF Salalah been so neglected by the failure to develop the FST buildings and facilities ?

Our “new best friends” from the Royal Engineers assembled and fitted out a Twynham hut for us which then became an semi air-conditioned operating theatre. They laid concrete bases for the X-Ray machine and the Path Lab. They joined our various buildings with concrete paths which alleviated the difficulties of humping stretchers over stony ground.

We were deeply in debt to them.

Somewhat direct and curt requisitions were made to Ludgershall for vital medical equipment. We made no friends but two of us were very near the ends of our commissions anyway so we were perhaps a little disinhibited. We obtained some of the equipment we indented for and some we did not. Frustratingly, for example,  we were supplied with a diathermy machine but it was lacking in the leads that were required for it to be of any use.

We were probably going to be censured when we returned to civilisation but we had coped well with the RCL on the officers’ mess and the aftermath of Mirbat. All of those who were brought to the FST alive had left it alive. We had some credit in the bank. Accordingly discretion went out of the window.

The reasons for having 55FST in Dhofar are obvious. Many lessons were learned and many of those lessons have probably been lost. There may be something to be gained by comparing the Johnston 55FST of 1972 with the  Camp Bastion in later years in Afghanistan.

The purpose of both of these surgical facilities was to limit damage and make the patients fit for onward repatriation to medical facilities in the UK.

The obvious difference was the degree to which each was resourced.

Data that the Israelis obtained in the Israeli-Lebanese war suggested that of those wounded who died 85% did so within very few minutes. A good number who did not die within that time frame were treated in the time frame of “The Golden Hour”.

There were some seriously injured in the 85% cohort who survived in Afghanistan. They came to be known as the “unexpected survivors”. Their survival depended upon immediate front line help from very well trained first aiders. Sophisticated treatment, close to their point of wounding, by a very skilled and experienced team in a large helicopter of which there were few; both helicopters and teams. Formal damage control surgery undertaken at Camp Bastion Hospital often by several surgical teams who had the benefit of many of the facilities of a UK District hospital; MRI and CT scanners, blood banks, modern operating facilities and well staffed post-operative intensive care.

The unexpected survivors survived. The quality of that survival is most carefully examined in Emily Mayhew’s book  “The Heavy Reckoning”. It gives a penetrating insight into the post-traumatic world of the injured serviceman.

Those who were severely injured but did not die also received superb treatment as well whether or not it was within or without the Golden Hour. Outcomes were variable but the long term was not as devastating as that experienced by the “unexpected survivors”

The really seriously injured in Dhofar in 1972 from the 85% cohort did not survive. None were plucked out and saved. Those injured who survived the first five minutes usually did live and left the FST alive following damage control surgery. How long they lived is another matter. The Americann trauma surgeon from Maryland University, Dr R Adams Cowley, made the following observation :  -“There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later — but something has happened in your body that is irreparable.” He did not know it but was referring to the inflammatory storm initiated at the moment of injury which may be ameliorated in that first hour.

In Dhofar the UH-1 helicopter pilots bravely extracted the living injured from the place of injury where often they simply had lots of first field dressings applied in an attempt to staunch the bleeding. As Sgt Willams says the night before Agincourt to Henry V, his king, “Blood is the argument”. It was then. It is now.  In reality very few of these injured were delivered to the FST within the “Golden Hour”. The survivors of Mirbat certainly were not. What they did do was get to the FST alive because they were fit young males who had massive reserves which helped them adapt physiologically to their injuries.

Triage lined them up in order for surgery based on the relative need for urgent damage limitation surgery. The fragment a mortar shell in a calf was at the end of the list whilst the exsanguinating abdominal bleed had priority.

The triaged patients lying in the marquee needed managing both to stop them deteriorating and to alleviate their pain. The first patient following Mirbat I put on the table at midday. The last patient from that affray I took off the table thirty hours later. All of those in the triage queue had intravenous cannulas inserted and had drips running. Its an awful lot of managing.

The path lab sergeant, Roger, was multi-tasking. If he was not bleeding someone for transfusion he was given a fairly free hand with analgesic pethidine for those who indicated that they were in pain. He felt slightly guilty that he might have given some patients too much but I had given him the instruction “if he appears to be in pain give him a shot of this and keep a record”. He felt vindicated. There were, to begin with, twenty two patients in his queue.

Managing a set of patients like than absorbs a huge amount of resources not in the least because, unlike pre-planned hospital cases, their conditions may be changing all the time and variation in their state needs assessing and decisions must be taken based on that assessment. Their iv drips need attending to, careful records need to be kept of pulse and blood pressure, pain has to be managed, toilet needs have to be addressed, the blood and the dust has to be cleared up. Just consider that it might take five minutes to check blood pressure, pulse and iv drip, make the appropriate record, make a decision depending on the evidence gathered. Multiply that by twenty two. Constant review is required  that may adjust their place in the queue  dependent upon altered need.

They often have to be picked up and moved around – thank God for the concrete pathways that the RE laid. Can the nurses do most of this porterage ? Not really. They are dealing with the patients who have come out of the operating theatre and administering post operative care. The sheer volume of work can be overwhelming. The three remaining FST members, an RAF Chief Technician, some BATT and many willing volunteers from the RAF stepped up to the plate and helped to save the day. The attached description of a 1947 PFA gives an indication of the manning scales of such a unit assessed following wartime experience.

Triage is very very labour intensive.

Those who reached the FST within the Golden Hour and those who took a little longer generally made something of a full recovery. Some obviously did not and they were left with visible life changing damage. For those who had lost a leg there would also perhaps be the long term effects of blast. which are so well described in the book by Emily Maitlis ” The Heavy Reckoning”. In truth we lost sight of the long term outcome for Omani nationals and had very little feedback about the outcome for those from Britain.

One lesson to be learned was that with prompt and relatively unsophisticated medevac 99% of those who had survived the first five minutes after wounding might just survive even though they did not have damage control surgery close to their place of injury. They had to wait until they arrived at the FST some time later.

Where does this position the MERT teams who did such splendid work in Afgahistan. What is their place in future or present wars – Ukraine for example.

The Chinooks and Pumas are primarily designated for trooping and supply. They have secondary roles as casualty evacuation platforms. Totally medically dedicated heavy lift helicopters are only likely to be found in conflicts where not only is there air superiority but also lack of threat from shoulder launched anti-aircraft missiles such as a SAM-7.  $15k to damage a $25 million Chinook and so break up the evacuation chain is surely good value for the enemy’s money ? There has to be the ability to establish an extremely sophisticated damage control medical facility nearby manned by several surgical teams with MRI, pathology, ICU etc etc. Think Camp Bastion in Afghanistan.

This was just the sort of medical facility that the Russians now target in Aleppo in Syria and in the Ukraine again and again.

That sort of casevac chain which is tuned to succour the “unexpected survivors” is unlikely to last long in a European battle field where the enemy is uncivilised.   It is probably  a provision that does not reward the huge investment in men and material that would need to be made in it.  Even in our sophisticated society there is a limit to our resources; how many unemployed anaesthetists are there at the local labour exchange ? How many Chinooks are there advertised  for sale in the back of “Aviation News” ?

There is a strong argument, in my mind, to set the sights lower, to attempt to salvage more of those injured, who with relatively much less sophisticated care, can be saved.

It is perhaps a question of how do we identify these injured with whom it is a practical proposition to achieve a satisfactory outcome.

A sensible dividing line might very well be those who reach, by whatever means,  the FST alive.

I arrive at this opinion from the very small number of war wounded who arrived at 55FST in the spring and summer of 1972. They had the strength and resilience to survive their initial wounding and once there, hopefully, their condition could only get better. In fact, of that group of 100 who arrived at the FST alive, all left it alive. Admittedly sometimes short of an arm or a leg. I suppose we might call them the “Golden Hour Group” even though it was mostly over an hour since their wounding. Perhaps the Golden Hour should not be an expression of time but more a description of condition ? Perhaps we should view the Golden Hour like the Atomic Clock ? It can, in some cases be stopped. If we take up that concept then casevac teams may not be under such pressure to risk entry into “hot” pickup zone but may delay their arrival until that zone is secured.

The trick is to get them to the FST alive without the potential vulnerability of the MERT evacuation system. Perhaps pain relief, tourniquets and packing the wounds with haemostatic dressings is adequate to achieve this end ?

It should reasonable to expect that trained soldiers in the British Army have this degree of knowledge of first aid and be able to apply it.  Some, the Combat Medical Technicians, especially so. Training at regimental level is a regimental responsibility which requires more than a three man medical team to implement  to keep the unit current as men are both posted in and leave. It becomes more difficult to implement as the component units of a field force become smaller.

It is probably wrong to expect a jebali member of a fifty man Firqa to have these skills.

If we are going to aim for  maximum benefit it may, surprisingly,  very well be that the 1972 arrangement is still valid; simple first aid and prompt evacuation to a collection of modestly equipped experts.

Full circle.

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