Rwanda to Afghanistan with Alexandra Douglas

Wing Commander Alexandra Douglas MG, reflects on her 3-decade career as a medical officer in the army and air force.

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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.

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Transcript:

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.

[Audience applause]

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 care plan was correct, I went home.

I was tired. In fact I was exhausted, but I had one more thing to do. You see it was Father’s Day, so I rang his father and I said to him ’I have delivered your son, he is safe and sound’, and just as I am now, we cried.

So, let me bring you back to the question. What makes the Australian Military Medical Services so effective on the frontline? Yes, we are well trained and equipped, but most importantly we care. We all care. Thank you all very much.

[Audience applause]

Leonne Pratt: I am crying too so thank you, thank you for that talk. On behalf of everyone here I actually want to say thanks for... It might have been horrific for you to actually relive some of those experiences, but I think it is also so quite tragic many of us have no knowledge, and no insights and this gave us a glimpse to probably just a fraction of the scale of the tragedy that you have experienced. So thank you for sharing, and thank for sharing your feelings.

Questions, would anyone like to ask Alex some questions?

Audience Member: Yeah, hi, my name is David. Thanks for such a powerful talk, it certainly brings to light that cliché that war is hell, it's just so horrific! In terms of the medics being prepared for that, because we are just so divorced from our modern first world, do army medical or defence medical people spend time in intensive care units and trauma centres in the public hospitals to get exposed to that?

Alexandra Douglas: Yes, absolutely David they are now. So medics, all the medical personnel, especially the full-time service personnel, are taken into or afforded positions in civilian hospitals where they get the requisite training and exposure. And this exposure is commenced here in Australia. You have your pre-deployment training here in Australia, and then at an interim destination you are prepared for the final journey where you get more briefings, more exposure, more training so that... you’re certainly not numb, but you are as prepared as you can be.

Audience Member: Thank you again, that was just fantastic. I am just interested in the reasoning behind the small team that you had in Rwanda? Why wasn’t it able to be larger?

Alexandra Douglas:  That's a fabulous question. So based on what our mandate—what our mission was in the country—our primary objective was support out of Kigali, and the original CCP construct was of, as described, the 5 personnel with the 2 SASR medics who essentially were our ambulance crew.

It had been augmented way more than normal by having infantry with us. So by the time the event occurred on Saturday, augmentees came later that day, but it was too late for the massacre itself.

I'm not sure in projecting back now how many more people would have been allowed in. It was a very, very difficult negotiation. I make light of it, but, you know, we had deputation of what we thought would be reasonably authoritarian, you know, we had a Major officer in charge of the infantry, myself and the Section Commander, and we stood there with a couple of others with us. But this RPA officer took a lot of negotiation and, you know, I am forever grateful he didn’t pull the trigger because he was furious that we were there... he was not having a bar of it. We were lucky to get in.

Audience Member: And civilian support?

Alexandra Douglas: So, there were some remnants. There was an ever decreasing presence of civilians. We... 2 or 3 Care Australia... I think they were Care Australia, I lose sight of that because they weren’t located with me. But on that day, we were unassisted by civilians and that’s not a comment on them, it’s just access.

Audience Member: Thank you very much ma’am for your talk, my name's Mark. I am interested in how you personally manage moral injury in the light of all you have experienced?

Alexandra Douglas: Mark that's a very good question. I have lived with a sense of personal disappointment on a moral level for a long, long, long time. It was the explanation of the starfish on the beach that made me come to at least some sense of comfort with it all and the story goes such as this. I don’t know if you are aware but:

There is a man walking along the beach with his son and his son notices that on the beach there are star fish that have been washed ashore, more than the eyes can see, and the son starts throwing them in. And the dad, being an adult like us, is very pragmatic and says ‘you can’t save them all.' And he goes, ‘but dad, I can save some. I must do what I can do and I can do this, I can’t save everyone.'

And so, to refer across to a story might seem I’m deflecting, but it helps me deal with the fact that I couldn’t save everyone, and by attempting to do so the only way would have been engaging, and I have absolute confidence I would not be here today. And look... for many years I would have been completely comfortable with that. For many years I did not want to live with myself and what I saw as my failing to act. But that was not my decision to make for my entire group. By myself, yes that would have been my decision, absolutely. As the senior officer, I could not have made that for the group.

Audience Member: Thank you so much, Alex. Did you have much trouble with actual illness with your staff?

Alexandra Douglas: Being the mobile element, yes on occasion, because we were not in absolute control of the food that we were exposed to. And the sanitation, shall we say, in some of the different battalions that we would visit to check they were ok, was very substandard.

But in terms of preventative health, in terms of Malaria, we did particularly well. I don’t recall any of our personnel succumbing to Malaria or suffering from Malaria.

Now that might be that I was out of the area when it happened, but it was not brought back as being an issue. Certainly, different foods, we all had experiences unfortunately of not being at all well at either ends of our bodies, and no flushing water—it's a tragedy, let me tell you, it’s horrible.

So, does that answer what you were referring to?

Audience Member:  Yes, thank you. Could I ask a medical question?

Alexandra Douglas: Certainly. Sorry rest of the audience.

[Audience laughing]

Apologies...

Did you encounter very often cerebral arterial gas embolisms?

Alexandra Douglas: So, I wouldn’t say in Rwanda. So, now if we research across the more explosive environment, and someone who is better placed to recognise it. So, I didn’t, you know, as a baby doctor, I probably was not well placed to recognise it even if it was declaring loudly.

In Afghanistan... ah, I would have to say that I can't absolutely define a patient that I saw with it. I believe they either died at the scene or they were incubated so quickly afterwards that we didn’t recognise it as being the case, John. I can ask Annette, sitting in the audience. Sorry, I am going to defer to you there as well, there. Would you like to do that?

Annette Holian: I don’t have much to add to that. I do not recall seeing any case that we recognise as arterial embolism over there. We did... we were opening a chest and expecting gas to get into the circulation. We had the patient’s head down so the gas wouldn’t go that way or less likely, but... so there are techniques to try to avoid it, but I don’t recall seeing it...

Alexandra Douglas: Yeah. I think John's alluding to from point of wounding, aren’t you? You're talking about explosive injuries, correct?

Audience Member: Well blast injuries, and multiple central venous cannulations under very difficult circumstances...

Alexandra Douglas: So, certainly I know in Kibeho, I did commence resuscitation arterially. I hadn’t realised the patient had no circulation of note and the only vessel I could find ended up, I found out to be an artery in the end, once I’d established some volume. So, you did have the odd whoopsie. But I didn’t recognise embolism, no.

Audience Member:  It is a difficult thing to recognise, especially in those circumstances.

Alexandra Douglas: Yes, it is. Indeed.

Audience Member:  Thank you very much for your talk, very in-depth and humbling insight. I was just wondering about the logistics that you have supporting you. So, you've got your team on the ground, how do you go about the logistics of either moving patients out, or indeed getting more consumables in order to basically keep doing the work you are doing?

Alexandra Douglas: In what context are you talking about? Are you talking about historically what happened in Kibeho, or talking about what happens now?

Audience Member: Both there and in Timor-Leste?

Alexandra Douglas: Ok. So, in Kibeho what we had was all that we had... because of the firing, helicopters were being diverted away. It took a long time to actually get any helicopters in, and they came bare base—they didn’t come with any resource of note for us. So, I did end up having to do things I wouldn’t normally do, you know, I was reusing which I clinically would not normally do. But that’s what I chose to do at that time.

These days, resupply is far more well organised. So there is on-demand. So, for any forward area there is on-demand, they can say what they need, but also based on their consumption there is a push system. So, you are noted to be using, ‘you have gone through X packs of bandages and your intravenous fluids are low’, it will be pushed forward to you based on the consumables you are using. If you find that there's a particular need that is not addressed by what you already have, you place a demand and say, ‘look, we’re starting seeing Malaria, or whatever, and that is then sent to you.

And that is delivered by the best means possible now in parts of Afghanistan, you know, at different times of the year it is impossible by road so it would be an aircraft if and when it can land, or an air-land drop. So, it just depends on the situation.

In Timor, Timor was probably not as elegant as the demand and the push system. That was still in the formative stages. So, really it was what you had you went with, and then you occasionally would raise your hand and say, ‘look I failed to appreciate this particular circumstance’ and more would be brought to you on occasion. Often times taking advantage of transport that was heading out for another reason. Okay?

Audience Member: Thank you so much for such a moving presentation. Really just the sort of question that rises in my mind, is all of your experiences there is, who cares for the carers? And do you feel the ADF provided adequate support for those who are doing your job and has that changed over time?

Alexandra Douglas: That is a fabulous question because I am thrilled to say the ADF does now. And in 1995 they did their very best.

But I was an unknown quantity and an unknown phenomenon. So, our group were rotated out of Kibeho. So, we went back in on Sunday and did more work there and then they rotated us out and sent in another group to tidy up what was left.

They then sent a Critical Response team to us. They had a hard job, we had never heard of a Critical Response Team and as far as we were concerned they were outsiders and they couldn’t possibly understand and we weren’t ready to bear our souls. And so, we were fine thank you very much, just fine. You know that argument when you are being told ‘fine’ can’t pursue it further but, you know it’s not the truth.

We got home and it was forgotten; it was an event a bit like grief we were given our period of time and I was expected to be over it. In fact, it wasn’t a consideration with me at all; I was welcomed back to the unit and the Matron there said, ‘Well, now you are back from your holiday you can do some real work.’ She had no understanding and I knew that at the time.

What really distressed me back then was our Mental Health Sociology Team had decided maybe there might be something to mental health and they sent out a survey on us. What they did was ask us to recollect the worse things that happened:

How did it make you feel?

Anything else terrible that you can think about, write that down and then put that piece of paperback in the nice brown envelope.

And it broke my nurse, I had a nurse that I absolutely loved and adored as a professional. He did that and that was the start of him breaking and he ended up in psych care. They had no understanding which I guess that was fair enough for the time, they’ve learnt their lesson.

These days now the psych teams are out there, we know to expect them. They start on psych before we go, it's about developing mental reliance. And they build that into us, and they tell us  ‘look after yourself, look after your buddy, anyone just raise your hand’. And the idea is you do not try and take these people of the environment—try and support them there—because the very moment you pluck them out you are saying, ‘you are abnormal’. And while this is a very reasonable response to a most unreasonable situation; combat war is not normal and it is quite reasonable for you to find it hard at times; and so, they help to keep you in location but for those that can’t we bring them home; and they get care at home and it is escalated up as they require but, the whole goal is to bring them back.

This is not about defence trying to be cheap saying ‘we will keep labourers as we like’ its proven that we keep people in the most normal environment that we possibly can. It is for their betterment and having been someone who I can put my hand on my heart in hindsight I now know I had PTSD. I thought it was normal to have nightmares every night, at least one or 2. I thought that was real, that was what living was about. It took me 20 years. I am not fussed, I can admit that now I am not a fast learner but, I got rid of them. I have faced my demons and I see well now. Kibeho and all the atrocities I have seen, they are not forgotten but, they are in their place.

Did that answer any of it?

I think I got distracted. I am so sorry.

Audience Member: We have a lot of gatherings here for veterans from past wars and I am just wondering if you feel whether there is any benefit to the groups you have been involved with, in having reunions or get-togethers when you are back in Australia?

Alexandra Douglas:  I actually quite like it. I think it is quite useful to be able to get back together and to work through it. We don’t all get on famously well all the time and it is the little niggly things that wear you down and tarnish memories.

Let’s face it we want to make the memories as good as possible; so, to be able to catch up and to work through these issues out of the pressure of war, out of the pressure of the sleep deprivation and everything else that wore away at your resilience is a good thing.

In fact, one of the hardest things that came with returning from Rwanda was that we arrived back on one day and the very next day our whole contingent was separated. We had no one. I went back to a very lonely experience. My parents, I love my mum and dad to death they are here in the audience and thank you for coming, they wanted to welcome me back and I said ‘no’ and I thought that was a good idea. I came back to a lonely airport and I had an officer who was the colonel of Nursing Corp at the time and she came on over and she grabbed me like a mother duck does. So, I had someone and it is important to keep these someones that make us feel it's ok.

Does that answer your question?  

Audience Member: Yes, it does. I feel the same I think it is really important to be able to get back to people that we are deployed with; and here at the Shrine I think that we need to do more of that for deployments post-World War Two.

Alexandra Douglas: I think the fear is that people think we are trying to glamorous conflict. But I think it's about allowing us to reintegrate back into society. That’s my opinion.

Audience Member: I think it is that and I think it is being together, not necessarily being able to talk about what you endured but, knowing you are with people that went through it too.

Audience Member: Thank you so much. I work in the education area here at the Shrine. We have the beautiful painting that George Gittoes did of you on display at the moment. I thought I might ask you what you think will be useful, from your perspective; for us to say in particular to teenage school students that are coming through the Shrine about that paintings?

Alexandra Douglas: Can you say that again? I am not sure, can you say that again, please?

Audience Member: So, we bring school students through the Shrine and as they are in groups we can prompt them to think about it in a particular way. So, if there is something in particular that you think that could be useful for them? I am thinking about maybe what they can take and apply in their own lives. Because they are not going to be in a situation like that, one hopes, but there might be things that you feel that they can do in their own lives. Thank you

Alexandra Douglas: So if you look at that painting it is very penetrating look, it’s a look of trying to see what exactly I can do and I didn’t have a lot of recourses and I think it is useful to share with people that you don’t need a lot. You just need a commitment to try, not to be scared of trying, and if you commit and you care whatever you do is going to be wonderful. That would be my suggestion.

Audience Member: Alexandra I hope you don’t mind me asking this; several times you highlighted how you felt guilt about not having recourses or whatever it might have been. And I wonder how you have overcome that and if you have?

Alexandra Douglas: For the most part I do not consider guilt.

If I truly sit down and think about it I feel trouble that I could not do more. And there was a reporter… help me, who was the reporter?... Well they said it is like a tower on your soul. You cannot shake it and my sense of guilt sits there.

But what I have done is I have just limited it to just that one spot. Because I was losing my life to this guilt. Most people would go out and walk along the road and they would go, ‘What a beautiful day’, and I would go along and, ‘oh, that’s so sad, that person is dying or going to die I can tell’. That was my overall gloom of life. And I was losing everything that makes it wonderful to be human. I did not want to care about patients, it took me a long time and I tried so hard not to like patients and that is, I choose anaesthesia, I did not want to care, you put those people to sleep, you do not have to talk, and I love people and that’s the thing I have now and that is humanity.

And being human is making errors, being human is not being able to do everything you want, we do not have that capacity. So, I think what it is, is that I have accepted it. It is there. I don’t focus on it, it’s just there.

Leonne Pratt: Thank you Alexandra, thank you for all your compassion and your care for humanity, it was very much on display today. Please everyone warmly thank Alexandra for sharing her experience.

[Audience clapping]

Voiceover: Thank you for listing to the Shrines podcast series. Please share this podcast with your friends and family to help raise awareness of the extraordinary work undertaken by our current serving men and women.

Alexandra has also written an article featured in the Shrine Remembrance Magazine; links are available in the episode show notes.

Thank you.