Captain Ray Wiss, an emergency
physician from Sudbury, Ontario, spent most of his
three months in Afghanistan working on the front
Photos: Courtesy of Capt
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."
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.
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
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."
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.
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."
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
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).
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."
Captain Ray Wiss, a Canadian
Forces physician, kept a diary of his experiences
in and around Kandahar from November 2007 to January
2008. The following two entries describe part
of his time "outside the wire," working
on the front lines.
Captain Ray Wiss travelling
between bases on the most dangerous road in Afghanistan
On the road
December 18, 2007 -- This was my last day at Forward
Operating Base (FOB) "Lynx."* Yesterday
I was asked to cover the base at "Leopard"
for the next month to give the senior medic there
a break -- he'd been there since August.
The distance between the two
FOBs is less than 10km, so helicopter transport
wasn't going to happen. That meant I would have
to join a convoy and go by road. This is a lot
worse than it sounds.
We would have to take the road
known to be the second most dangerous road in
the world (only one road in Iraq is worse).
Since it had been some time
since anyone had driven it, the likelihood of
encountering roadside bombs (aka IEDs) was extremely
high. Our convoy would have to detect and destroy
any IEDs that had been placed along the road.
The troops do this regularly
and are either used to it or very brave. I slept
poorly till about 0400 and then not at all. I
don't think anyone could tell how I was feeling
- I still have a lot of pride, maybe too much.
The seriously wounded soldiers
I've treated here were all injured by IED strikes.
While waiting to board one of the light armored
vehicles I kept seeing their severe leg wounds,
some of which had led to amputations. My awareness
of my lower limbs, which had gone back to normal
a couple of days after treating the wounded from
the last IED strike, became exquisite again.
We left FOB "Lynx"
right after breakfast and I took my position in
one of the rear hatches. For most of the trip
we were in flat, open terrain. Potential ambush
sites were at least 200 metres away. At other
times, there was good cover all the way up to
You feel extremely vulnerable
on the roads of the Panjwayi district, west of
Kandahar. As I stood in the vehicle's hatch, I
found myself wiggling my feet around, almost unconsciously.
It probably looked like I was working out a cramp.
What I was really doing was enjoying how good
it felt to have my feet working properly. I was
hoping intensely they would feel the same at the
end of the day.
Rockets at FOB "Leopard"
December 21, 2007 -- FOB "Leopard" has
the dubious distinction of being the most heavily
rocketed FOB in all Afghanistan. Next to IEDs,
rockets carry the largest warhead of anything
in the Taliban's arsenal. Unnervingly, their arrival
is announced by a hissing noise that you learn
to recognize very quickly. Fortunately, though,
it gives you a chance to hit the dirt.
main danger is from the shrapnel. The two pictures
on the right show the effect of a rocket on a
shower stall. The shrapnel came in here:
It then crossed the room after
cutting clean through the thick steel of the shower
bunker and shattered the mirror on the opposite
If you're observant you will
notice two pieces of shrapnel entered the shower,
but only one crossed the room to the mirror. The
other piece struck and killed an Afghan interpreter.
Some of the men avoid showering
in that stall. I, however, make it a point to.
The odds that another rocket will kill someone
in exactly the same spot have got to be pretty
*FOB names have been changed.