- Rwanda (1994), Afghanistan (2001-)
- Army, Air Force
Wing Commander Alexandra Douglas MG, reflects on her 3-decade career as a medical officer in the army and air force.
Please note, this podcast includes depictions of violence, genocide, violence against children, pregnancy loss and issues regarding mental health that may be distressing to some listeners.
Leonne Pratt: And it’s a great honour to introduce today’s guest speaker Wing Commander Alexandra Douglas MG.
Alexandra is a specialist in Anaesthesia and intensive care medicine and has over 20 years’ experience in the Australian Defence Forces with both the Army and the Airforce.
Her service has taken her to both Rwanda and Afghanistan. Alexandra was awarded the Medal for Gallantry for her actions in Rwanda during the tragic Kibeho massacre in 1995.
Please all join me in welcoming Alexandra Douglas.
Alexandra Douglas: Thank you. Thank you all very much for coming today. I am somewhat surprised to see anyone and I am very honoured to see you, this audience today.
As you can see, I have been involved in the military for some time, 27 years to be exact.
I have served as a general duty army Medical Officer, and as an Anaesthetist and as an Intensivist. Some 10 years ago I transitioned to the Royal Australian Air Force. It was really a quite a natural transition for me. I realised I needed my creature comforts way more than the comforts of creatures, especially spiders.
But seriously... What makes the military medical services so effective on the frontline? Clearly training, resources and communication are pivotal to the basic success of any element. But in my experience it is more, much, much more than this and it’s neither issued nor learned—it is compassion.
So, today I am going to share my perspective, my personal experiences, my very human experiences. Hopefully, you too will then appreciate that anyone can ease suffering by choosing to care.
For those who have not experienced a military deployment and hopefully many of you have not. Let me set the scene for you. But before I do, please let me warn you many of the images are graphic and they include friends now past. I apologise in advance if this is confronting, it’s not my intent to offend nor distress but this is the reality of military medicine.
Today, as in the past, military medical missions are comprised of a collage of services, navy, army and air force. A collage of experience, we have full time, part-time, newbies and old hands. Gender: men and women. But we all stand, side-by-side striving to do the very best that we can, for all our patients.
The environment and the anticipated clinical load is vastly different to the non-deployed clinical experience so significant collective, medical and military training is usually conducted. In 1995 for example, before we deployed to Rwanda, a contingent comprising of infantry, logistic and medical company concentrated at Lavarack Barracks in Townsville.
We were co-located with Bravo Company 2/4 RAR. In hindsight now I understand the ruckus that erupted with our arrival. Trucks of echelon bags and trunks carrying our very necessary items. Essential items I should say, carrying our cosmetics, hair-dryer and civvies. We had to look our best to do our best well. Or so we thought.
Our medical company CSM Warrant Officer, Rod Scott MG, an SASR medic by trade, must have died of a million deaths when we formed up for the first time. There was lipstick, bobby pins and marching in step was nigh on impossible. And yet we did eventually [march in step] and this was despite our height disparities between 4 and 6-foot.
But our pre-deployment training focused on more than that, not just marching in step. We focused on safety and security, trauma and tropical medicine. We up-skilled in personal military skills including mine prodding. And whilst we were proficient, we were more than a little bit relieved that infantry had our backs, as we had their backs in medicine.
Still we all trained hard as it was clear from the media that we would need these extended skills and the knowledge to respond automatically to the clinical and the military threat that was there. But I note at the time in military medicine there was no new technology, there was no new specific treatments—nothing since Vietnam—and in fact we were issued Vietnam vintage dressings and bandages. They last particularly well I might add.
The ADF commitment to pre-deployment training continues to this day. In fact, it’s even more comprehensive. This pre-deployment training is mandatory now, it ensures that all personnel understand the context into which they will be inserted, so that they can operate safely within their environment. So, in addition to being updated on military skills and combat first aid, the broader operational health and strategic considerations, political and cultural sensitivities are all reviewed.
But let’s get back to Rwanda. In 1994 Australia’s offer to support the second United Nations assistance mission in Rwanda, known as UNAMIR 2, was accepted. I deployed as part of the second contingent in February '95. The people of Rwanda were still quite fragmented. The Hutu lead genocide of the Tutsis in 1994 was still fresh in the minds of the now Tutsi led government. We were located in the capital, known as Kigali, but as the officer in charge of the casualty clearing post or OICCCP—lots of acronyms there—we provided direct support or outreach to orphanages and into internally displaced people camps or IDP Camps. When my unit was back in Kigali, we integrated into the Australian-run UN Hospital. It was collocated with remains of the local general hospital. As a warden resuscitation doctor, I managed trauma, heaps and heaps of trauma.
Grenades, mines, and guns still wreaked havoc on both sides of the conflict. As our spare capacity allowed, I would be sent to select patients to transfer out of the general hospital for treatment in our facility. This was very emotionally challenging job. The staff , or the remains of the clinical staff, from the local hospital were tired and not unreasonably so due to the continuing stream of causalities. We were all but certain that they could not provide the same standard of care that we could. But as emotionally challenging as this was, nothing was as comforting to as our rapid response mission to Kibeho.
Kibeho, a huge IDP Camp was forcibly closed, the borders were being contracted and in the stampeding 12 people had died. Our task was to deploy there and to provide medical assistance to those in need. We arrived at first light, it was a scene much as I would have expected in a concentration camp. The IDP’s were crushed up against razor wire, children’s hands reached out to our vehicle as we race on in to negotiate improved circumstances for them, including access to our care.
But we were not welcome, not welcome at all. The most senior officer of the Rwanda People’s Army (RPA), and the man most likely responsible for the chaos and the border retraction, almost spat he was so angry that we had trespassed into his domain. I suspect he wanted to exact revenge upon the IDP who had been members of the Interahamwe, the Hutu killing gangs responsible for the atrocities of the preceding years. Despite his anger and the fact that he punctuated each and every word with a pistol, finger on the trigger, pointed variably at members of our group, and despite this we negotiated the access we required. We were not going to be deterred.
The constraints were intentionally limiting. A remote location was allocated for our tiny clinic. We were prohibited from advertising our presence and under threat of eviction we were not to provide anything other than clinical care. No compassion donations of food or clothing would be tolerated.
Despite their constant and very watchful eye, we secretly fed and clothed all those we could. Even those who had not self-identified as requiring assistance were escorted into our makeshift clinic. We were going to help as many as we could, and we did. Then amongst ourselves we distracted our IPA soldier chaperons, we had a lot of things that we could do to distract them—trust me—we gave our patients everything that we could.
The work was hard, the work was sad, people with so little and coping with so much adversity. I was so affected by the human tragedy that we witnessed that I could neither eat nor drink by day. I had no desire to nourish myself when I could not provide for the IDP’s—some 500,000 IDPs. I certainly did not want to appear as heartless as the RPA guards who maintained the perimeter, and deny them basic sustenance. Instead, we worked endlessly and tirelessly and occasionally with sounds of very distancing firing, worse in the afternoon and evening. As the week progressed leaving the camp became increasingly difficult, a foreboding sense of doom was building like a tropical storm, oppressive and relentless.
On one occasion though, as we prepared to leave the camp for the night, the shooting had intensified and then became slight again. The same and uncomfortable silence of strangers stuck together for a moment in time. One of our soldiers has scooped up a child abandoned or recently orphaned, you could not tell the difference. She was unscathed, well not truly unscathed, her eyes told me a completely different story. There appeared to be psychological wounds that time may never heal. We were supposed to hand her over to the local government army forces, but there was no way we were going to do that. Our suspicions of horrific violence perpetrated against the IDP’s by these same people had been all but confirmed. And so instead we swept her into our 6-wheeler ambulance.
Initially the medic and I bandaged her. I thought that we could claim that she had an injury, but then my paranoia become a reality, an RPA soldier insisted on inspecting our vehicles as we transitioned the inner cordon.
Like a predator he eyed her. She started to cry, we attended to her imaginary wounds, more bandages applied to the previous bandages that still had no blood coming through. He slammed the door and we moved on. But I remained concerned that she would inadvertently reveal the real situation at the next gate, some 15 minutes away. So I gave her Valium and a biscuit—a diazepam, a sleeper. Fortunately, it worked quickly and she drifted off to sleep. We finished packing her into the ambulance blanket bin just meters from our final inspection point. She slept through this next inspection, together we had stolen freedom for her.
But sometimes it does not matter what you do, you cannot change the outcome. We had a man with the smallest, most inconspicuous wound on his belly. He was quiet, not a groan of pain nor did he make any effort to compress the gentle oozing of blood, blood welling into his belly button. We applied dressings and in response to my question ‘how are you?’ he replied, ‘I’m fine’, and with that he died. I’d done all that I could have at the time, we all have, but he died. But at least he died comforted by us.
On 22 April, an overcast Saturday again, we rolled into the camp. We were met with an eerie silence and an immediate request to visit the decommissioned camp hospital. There were 50 people crammed into the courtyard each with injuries such as these. There was silence that even a heartbeat could have been heard. Violence had escalated overnight and now they were waiting, waiting for me. And there were more, many, many more waiting in the building. Now I could hear the softest of whimpers and the odd groan. Briefly I felt the despair of inadequacy, but I had my medical team of 5 augmented by 2 SAS petrol medics. I had fully stocked ambulance, and a re-supply truck, I also had a signaller and infantry soldiers—about 20 of us. I had a plan. My plan was simple and despite the odd argument with the RPA, who persisted in trying to eject us, we established our mass causality area. I gave strict triage criteria to my nurse and medic. It was tough job and I presume by this I may have condemned some to death, but I was focused on saving those that we could immediately. This was important because we were going to be locked out—I needed to save these people immediately. That said, my goal was to retrieve as many as we could.
So my immediate treatment area was on the ground in the vicinity of my ambulance, my notional ICU, and a UN truck, a ‘mog’, was my ward—whilst very convenient for rapid mobility, it was quite challenging when it came to placing patients on stretches one meter above the ground. That said the team worked, and worked tirelessly, through the most confronting circumstances. And so it went. We treated machete wounds to the body, neck, and faces, arms where people have tried to defend themselves... to shield themselves. That’s emotionally confronting, but more critical were the gunshot wounds to everywhere. I was busy, very busy, we all were.
Whilst I had noted increased tension within the camp as the week progressed, I thought that the violence of the preceding night would ease the tension, calm things down. But in synchrony with a massive tropical storm, the IDP’s decide to breach the boundary to escape what they must thought to appear to be a prison. They were breaking out of their imprisonment.
Tragically they had not anticipated the retaliation that would have ensue. A battalion of RPA soldiers opened up with automatic and semi-automatic rifles, 50-cals and rocket-propelled grenades. It was the most horrendous event to witness, and given our very strict rules of engagement, we could only fire when directly fired upon. All we could we do was remain in place in the way of incoming fire but well placed to protect and to treat those who needed it, and we did. However some 5,000 people—men, women and children—died. They were slaughtered in front of us.
It is so very tempting for me to stop here because these memories are very difficult to work through, but it is really important that we recognise the extremely arduous work that each and everyone did every day at Kibeho. Not just at the day of the massacre. Our days were over 12 to 14 hours long, and there was no respite from the elements or the hard labour that awaited us each day. The RPA took each and every opportunity to interfere, to stop the comfort that we brought.
I am truly proud of how compassionately each and every one treated the IDP’s. It would have been reasonable to stop, to leave that camp, but that never entered our minds. The Infantry not only provided our security in an environment in which they were continuously taunted and provoked by the RPA, they were also my stretcher-bearers. They forced through crowds of RPA soldiers to retrieve the wounded. They stepped through mud, excrement and death to save more souls.
The signaller was pivotal to the success of the plan, a plan reliant upon the coordination of casualty evacuation, and he continually appraised the headquarters of the situation. I would tell him, ‘tell them I have 2 priority one patients—patients who need to move within about an hour—about 4 to 6 priority 2 patients—these patients need to be moved within 6 hours—and countless others’. He would smile and say, ‘yes ma'am'. I would go away and attend back to my patients. I would imagine it wouldn’t have not been more than about half an hour I would go on back to him and say, ‘no, no, no... I’m sorry, I’m wrong’ and give him an update. Each and every time he smiled. He sent the updated massage.
But his support to me went beyond this. I had lost a child whose little body had been riddled with bullets. I’d struggled desperately hard to save this child, and as I was working on this child I looked up and within my field of vision was a gaggle of these RPA soldiers. They were laughing, laughing at my desperate efforts to save this child.
As he died I was overwhelmed. I stood up, I cocked my weapon—I was going to kill them. Fortunately, he ever so gently touched me and said, ‘ma’am... you are the doctor’. At that point the doctor in me had died and him reminding me helped me so very much. Whilst I was numb I moved to my next victim, and then the next, and so it went.
In reality, he saved more than me though. We were already taking effective fire into our position from a battalion that surrounded the camp. So, likely we were overwhelmed by guns 20 to one. I am sure my little pee-shooter would not have achieved much other than to get us killed, so I am enormously grateful to this man.
The cost was incalculable, estimated over 5,000 dead. But the magnitude of this blood lust, revenge killings whatever you want to call it, was never truly appreciated by the world. For me, the numbers did not matter, one, ten, a hundred, a thousand. I had been forced on occasion to shelter when it was just too dangerous to work on my patients, and in these moments, I have seen people killed, slaughtered, I saw death.
I was my own greatest disappointment. My actions, whilst correct according to our mandate, conflicted with my humanitarian values. But to define our mission to Rwanda as the Kibeho massacre would be to lose sight of the comfort and relief that we brought to so many men, women, and children. Rwanda is now an Africa success story, a nation that has emerged out of adversity. And we helped them on this journey.
So, in 1999 East Timor was making a very difficult transition to an independent state to be later known as Timor-Leste. As the medical officer to the Special Air Service Regiment I’d deployed with 3 Squadron to the newly established response element within INTERFET known as Response Force or RES-FOR. We had the very best equipment but, still there was very little in terms of changes with respect to military medicine in the treatment of severe trauma. Our well establish resuscitation drills combined with the superior ability of helicopters was the foundation to our superior outcomes in acute trauma.
This ultra-mobility also allowed us to penetrate deep into the heartlands of East Timor. When not required in the capital of Dili I would patrol on foot with a small element into villages and then set up a clinic for the day. As a uniformed female doctor, I was quite a novelty—woman in uniform, a doctor no less, and carrying a gun. Regardless, I was always welcomed on each and every occasion. The villages would manifest out of nowhere and within in moment we would be surrounded by patients. What impressed me the most was their patients and overwhelming gratitude for everything, anything, offered to them—always gratitude.
I remember being summoned by a local nurse. I was needed atop of a hill, and by hill I mean mountain. So my security and I bounced over the country roads the highest speed our rather tired Land Rover could muster. We were under the gun, and we were under pressure, and we stormed up that hill as best as we could. The extended family had gathered for the birth of the first child to this lady now struggling with a very difficult labour.
I stepped into the depths of their very modest home. She looked terrible, she looked like she was going to die. Too tired, she opened her eyelids briefly and then closed them again. I am no midwife, but I was devastated to learn that she’d laboured for over 24 hours, and she had nothing left. I told her that I was there to help, but to be honest I was unsure what she’d heard or understood. And saying I was there to help, I had only the most meagre of medical kits. What I did have in abundance was fear. I looked at her and my heart broke immediately.
She had crowned many hours before, but the crown had lassoed around his little neck. He was now dead. Cold and dead. I delivered him, the placenta and I tidied her up. I was not sure how much she had heard or if she even cared. But I gave her as much compassion—love if you will—as I could.
However, her eventual realisation was going to be extremely traumatic, I knew that. But still this was proving very difficult for me to do. But it wasn’t about me and I knew that, so I went to talk with the family to tell them all there wasn’t going to be a grandson, there wasn’t going to be a son or going to be a nephew. And despite delivering this rather shocking news to them, they thanked me, and I apologised and again they thanked me. And just as I am now, I get very sad when I think about this. I was sad then and I cried all the way down that hill. But, I was so relieved that I could bring compassionate care to their sides, even if it wasn’t a great outcome.
Let me bring you to the Middle East. The Australian commitment to the conflict in the Middle East has been pivotal for the improvement of combat-related trauma care, and advancements in weaponry such as IEDs or improvised explosive devices have been countered by military tactics, trainings, armored vehicles, and body armour. But despite this there is still the potential for catastrophic wounding such as traumatic amputations. Despite this we had a 99% survival rate at my medical unit Kandahar, Afghanistan.
Why? This amazing statistic is a consequence of the Joint Theatre Trauma System. The JTTS, as it is now known, is a coalition, and when I say coalition I should really just say the US. The coalition initiative that's all the implantation of a comprehensive approach to the management of trauma. This was achieved through the establishment of evidence-based treatment guidelines, trauma care training and medical resources including equipment and consumables, and a newly conceived continuum of care that commenced at the point of injury. This cohesive combat care package culminated in timely clinical case follow up, and the collection of data for overall system evaluation and improvement. Some of you have glazed over... so, what does that really mean?
Well the frontline medical kit was supplemented with a tourniquet. Old becomes new, doesn’t it? This is known as the Combat Applied Tourniquet, or CAT; and NPA, or a Nasopharyngeal Airway were pivotal to saving lives. In combat the majority of injuries causing death are irreversible brain and torso injury, but some 50% of KIA, or killed-in-action, are caused by reversable states including airway loss, tension pneumothorax and extremity haemorrhage.
Knowing this, our troops now have the equipment and training to potentially address this. You may be surprised to realise there is no role for CPR in combat. The clinical outcome in trauma resulting in cardiac arrest under the best of management circumstances is still abysmal. Doing CPR on civilian trauma has terrible outcome, so imagine during combat where there is fire going 2 ways, up and down, the focus is unit and individual safety first.
The priority order of casualty care management is life before limb or sight-threatening injuries. So life before limb before sight. And we no longer consider the ABC. We think CABC, for catastrophic haemorrhage, airway, breathing and circulation. But catastrophic life-threatening haemorrhage is a priority and it’s so easily fixed. General torso injury has priority over a limb injury, a pulseless limb has priority over a limb with a pulse, and finally, open fractures have priority over closed fractures.
But all of this is managed very rapidly prior to evacuation within 10 to 15 minutes by helicopter, or the most appropriate means to the closest facility. As hospital base clinicians we had have clear guidelines as to what is the standard of care is. We have visibility to the results of our management through the patient’s subsequent care journey. And we had clinical peer-review—powerful forces for the maintenance of high standards of care. Our clinical guidelines directed focus to that of damage control resuscitation and damage control surgery. Navy folk understand this term very well. The term ‘damage control’ is a maritime concept meaning the crew run vital repairs on a stricken vessel. Similarly, in the clinical context these temporising measures are for the preservation of life, not absolute restoration. So, not what we would consider definitive surgery. Gone are the days where we spend 6, 8, 10 hours correcting fractures, everything so the person looks terrific but still dies at the end of their surgery. The surgeon concentrates on stopping the source of bleeding and removes any contaminants within about 45 minutes. The anaesthetist focuses on normalising the physiological parameters such as the patient can clot normally and fight infection. Assisting us now are novel drugs like Tranexamic Acid or Factor 7A. We also have techniques that have proven so successful that civilian trauma services employ them as well.
But not all injuries need to be catastrophic to have a great impact on those involved in their care. I have on several occasions been moved to tears. In Tarin Kowt, for example, we had some young men involved in an IED detonation. Fortunately, the protection afforded by the vehicle was in this case life—and mostly limb—saving. And one young man, very lucid, was worried how his wife would be told the news. I asked if he wished to call home... to be honest I wasn’t sure if I could make this happen, but I was certainly going to try. He said yes.
A minor miracle occurred and I handed him the phone. I gave him line of sight privacy, but I needed to remained close just in case he deteriorated. It was because of this that I had the privilege to hear the most tender of conversations, a conversation in which he was consoling her. Despite his pain he had compassion, his need was now to care for her. We had met his need.
The advent of our ultra-long-haul AME aircraft—pictured up the top there is the C-17 Globemaster—this has been pivotal to the Australian continuum of care of the combat casualty. This extraordinarily, versatile aircraft allows a mass evacuation of casualties, and when augmented by the military Critical Care Transport Team, the ability to evacuate critically ill patients on life support.
One of my most memorable missions was in response to a green on blue shooting incident. An Afghani soldier had fired upon our troops. Through fate I was fortunate enough to be able to respond rapidly and to greet them upon arrival at an interim facility. They were thrilled to be met by an Aussie uniform or 2, but, the pleasure was all truly all mine. Whilst I didn’t recognise the face, I knew the voice—‘ma’am great to see you’ said one of my medics. This same medic had handed one of his tourniquets over to his nearest casualty. He was too badly wounded at the time to move, and since he thought he was going to die he no longer needed his.
But not all our retrievals are conducted on military aircraft. We adapt and utilise the most expeditious means possible. Sadly, we have to occasionally use Emirates, it is a difficult situation but someone has to do it! [Audience laughing] But in one case I was Indeed privileged to assist a fellow who had newly been rendered an amputee multiple times over. I was amazed at his motivation to rehabilitate. He was not going to be defined by his injuries. He even asked me to buy some fitness magazines. I went to the newsagency and it is remarkably difficult to find magazines that don’t focus on the entire body and I didn’t want to remind him of his loses so I would have spent close to... it felt like my lifetime looking. I settled on what I thought was the best of a bad bunch. And I reluctantly handed them over, and he immediately thanked me and gave me this cheeky little grin, as he does, and he said ’thank you ma’am’. He even joked about the modifications he would need to do to the routine they had on offer for the limbs he had missing.
I spent many times by this man’s side. He shared the recollection of the event: the red dirt, the cloud of dust, the sense of flying through the air... and then nothing, just his immediate concerns for harm he may have caused to his mates. Not the mangled remains of his limbs.
Eventually we could affect the return trip home for him. A very long 30-plus hours for me, but with him in a medicated sleep it was much reduced. As we arrived at the Australian airport his concern was that his partner should see him as the able-bodied man who still loved her very much, and so, we sourced him flowers and a card; so, he could greet her as he needed to.
I delivered him the Australian Force Hospital, I even made a pest of myself. I insisted on him receiving the immediate surgery he needed and had been planned, and then, when I was certain that his