On this episode of The Naked Scientists, we’ll examine the evolution of the role of medicine in conflict, with contributions from a retired general, a war wound pioneer and a trauma expert.
In this episode
00:45 - The history of medics in warfare
The history of medics in warfare
Michael Brown, Lancaster University
A number of wars are currently raging around the world: most notably in Gaza, Ukraine and Yemen. As many people are forced to flee the fighting, teams of medics often run towards unimaginable horrors to help the injured. But what role can (and should) the medical profession play in conflict? Michael Brown is a lecturer in modern British history at Lancaster University and an expert on war and surgery.
Michael - Well, there had long been medical practitioners attached to military forces. You know, throughout human history, you know, the Romans, Greeks had physicians and surgeons in attendance. And throughout the mediaeval and early modern periods, we also see medical practitioners attending to the wounded and war. Most famously, in terms of the history of surgery, we had the French surgeon in the 16th century. He was a pioneer of surgical techniques, including things like tying off blood flow in cases of amputation. But in terms of the sustained provision of medical care to personnel in war, I think it's really the kind of revolutionary Napoleonic wars of the late 18th and early 19th centuries that mark a significant change. Prior to that, regimental surgeons had largely been appointed by the commanders on an individual basis. But in the latter part of the 18th century and going to the early 19th century, we see an increasing kind of provision of structured medical services. A Frenchman, Dominique Jean Larrey who served as Surgeon General of the Imperial Guard. He is responsible for a number of innovations in the medical care of wounded servicemen, including, for example, the introduction of ambulances or flying ambulances, modelled on the example of the horse artillery. As well as kind of a train core field litter bearers to kind of collect the wounded. And this is where we really start to see kind of innovation, I think in the field of medical care and war.
Chris - Back in history, the reason that surgeons pride themselves on calling themselves Mr. or Mrs, is because they were barbers back in the day and they had sharp knives, <laugh>. So is that sort of what started out as military medical intervention and then it became medicalized more professionally later, or was it different?
Michael - As a historian, really, of the early 19th century, I would argue that the level of professionalism among late the early 19th century section was actually exceptionally high, and in many ways actually war created opportunities for education. In a famous example, Charles Bell celebrated early 19th century Scottish surgeon, despite being a civilian, he actually travelled to the battlefield of Waterloo after the battle in 1815 to get experience of working with war wounds. And it was a formative experience for him, both intellectually and emotionally. So no, I mean, I think in many ways you could say that war was, you know, central to the professionalisation of surgical training in this period. And it's often been suggested that this kind of war is a driver of change. And I think there have been arguments made that actually, you know, this kind of structured provision of medical care for our first service personnel actually made a big impact on surgical training, more generally.
Chris - You mentioned the Napoleonic war. What happened then, the mark to step change, and what drove that step change?
Michael - Two things really. One is the scale of the conflicts. So, you know, this is a conflict involving much kinda larger forces than have been seen in previous conflicts. I mean, notably the French, for example, basically introduced universal male conscription, the so-called living on mass as part of their war effort. So there's a kind of growth of what we might now think of as a kind of total war, you know, as a phenomenon that civilian resources can be mobilised towards military and strategic ends. And I think that's what's really going on. But also I think the period is one in which the state is taking an increasingly structured approach to how it organises war, how it organises conflict, and a much sort of less decentralised approach to the fighting of wars. So I think, you know, by no means perfect medical military services, particularly Britain and other European countries, are subject to criticism. Throughout the 19th century, we were beginning to see a kind of increasing interest in the state in sort of providing these services for soldiers and sailors.
Chris - Would they have put their practitioners right up close to the front line so that you can get your people out urgently or did they just wait until everything was done and dusted and then they did what they could?
Michael - Larrey had kind of pioneered a concept of triage during the Napoleonic Wars, and that's really developed in the early 20th century. So you kind of, you know, you determine who needs treatment most immediately. It's really a kind of product of 20th century developments, the much more structured chain of treatment that one begins to see, particularly around the time of the first World War where, you know, you'd have kind of first aid posts, you've got, you know, kind of regimental aid posts, advanced dressing stations, casualty clearing stations, and finally kind of get to a hospital. So you can kind of basically treat people at various stages in that process. And that really is the kind of product of a much more structured intervention that you begin to see in the early 20th century.
Chris - Is it fair to say then that pretty much all facets of conflict these days are gonna have a massive medical component to them?
Michael - In more recent conflicts in the early 21st century, particularly in the West, you see this help for heroes phenomenon that soldiers deserve all possible medical care in return for their sacrifice. And I think there's been a great deal of both, you know, popular and charitable interest in wounded men coming back from Afghanistan and Iraq. And of course, you know, it's simply the fact that because of medical and surgical advances, wounds are far more survivable now than they were in the past as well. So, you know, that level of care has to be provided in the way they might not have done in the early 19th century or the 18th century, where the state had relatively little long-term commitment to the care of the wounded.
06:46 - How do military leaders plan for war casualties?
How do military leaders plan for war casualties?
Richard Shirreff
How exactly do the 21st century’s military leaders plan for war casualties? General Sir Richard Shirreff served as NATO’s Deputy Supreme Allied Commander Europe between 2011 and 2014.
Richard - War is a dangerous business. And you have to assume that if people are shooting at you or trying to blow you up, that you're gonna take casualties. As a commander, of course, you do everything you can to minimise the risk of casualties, but the reality is that almost invariably there will be people who are hurt, who are wounded, or people who are killed. So it's absolutely critical that the medical side is thought through and planned as an essential part of the operation. Every operation involves not only the movement of troops and vehicles and formations to get them into the right place at the right time to do the right thing, but they've gotta be properly supported with fuel, with food, with ammunition, and of course with medical support. And so medical support comes under the heading of logistics, which is everything there that allows an army or military force to operate.
Chris - And presumably the kind of medical support, you're gonna vary that according to what kind of conflict or what sorts of weapons, what sorts of engagement you anticipate seeing.
Richard - Every regiment or a battle group has a doctor who's a young captain, and at every level there'll be a medical specialist. So at a brigade level, you might have a field ambulance attached to it, commanded by a lieutenant colonel at a division, which is about 25,000 people. You'll have quite a senior colonel who is the Commander Medical who does the medical plan, who does the medical estimate. A whole range of factors are looked at in real detail, deductions are drawn, and out of that a range of courses of action are considered. One course of action is decided upon that best meets the needs of the plan and the commander's intent, and in which the disadvantages are outweighed by the advantages. And then once you know what course of action is, then you make a plan to put it in place. And that plan will bring together the assets that are particularly needed for a particular operation, which of course might change.
Chris - So presumably you are thinking about where to put things in relation to where you see the action going, how you see the action playing out so that you can, what evacuate people as rapidly as possible, anticipate what sorts of injuries you're gonna see, and therefore what sorts of care people are going to need in the short term before you can evacuate them once they've been stabilised to get them longer term help.
Richard - Yeah, I mean, the principle is that you try and treat as close to the point of wounding as possible. Every fighting soldier, tank crews, infantrymen, gunners. They're all trained with immediate battlefield first aid. And then within a section there might be one soldier who's a battlefield medic. It's a bit like being a sort of paramedic. And he can do a little bit more then of course, exactly that. Further back you've got the regimental aid post, and this is the whole point about trying to get people back as quickly as possible to stabilise them and then back through the system so they can be triaged into those who need the most urgent help as quickly as possible.
Chris - What about civilians, because they're potentially also in the geography in which you're operating, and they might become victims too. Is consideration given to them, and do you ever find that the military ends up treating civilians because they've become casualties?
Richard - Absolutely. Now clearly the priority must be to treat our military force because that's what they're there for. And it's all about treating the military force in order to ensure that not only are our soldiers treated as quickly as possible and return to battle as quickly as possible, but it's essential for morale. But yes, civilians are treated regularly and you've only gotta look at what happened in Afghanistan and indeed in Iraq, but Afghanistan, particularly where Afghan civilians were treated in military hospitals, and indeed of course it's not just civilians, but it's enemy soldiers as well will be treated in military hospitals.
Chris - They wanted to raise the Russia - Ukraine conflict. There were some people, including yourself, who said they were fearful that an invasion might be imminent because the Russian army had moved blood transfusion units and they'd also constructed field hospitals near the border with Ukraine. And people like yourself are arguing, you only do something like that if you're getting serious.
Richard - Absolutely. And it's an obvious combat indicator, the sort of level of logistic support being deployed in support of a military force. And when we saw the blood being brought forward and all the paraphernalia of military hospitals and the life, it was pretty clear that this was not just a demonstration or an exercise.
11:42 - Treating war wounds with fish skin
Treating war wounds with fish skin
Steve Jeffery, Birmingham City University
Steve Jeffery who is a burns surgeon and professor of wound studies at Birmingham City University. Steve spent two weeks in 2020 treating dozens of Armenian combat soldiers who were injured in a war with neighbouring Azerbaijan, and took a special piece of kit with him...
Steve - In my suitcase with me, I brought a number of items. Amongst that was some fish skin, which I knew from previous experience would be particularly handy in a setting where you have probably more patients than you know how to deal with and when there would be some challenging wounds.
Chris - When you say fish skin, do you literally mean the skin of fish?
Steve - Yes, it has been processed a bit, but not a lot, which is the beauty of the fish skin. It's a byproduct of the fishing industry. There's a fish factory in northwest Iceland where they used to throw the fish skin away, and then somebody had a light bulb moment of saying, well what could we do with this? It's descaled and then it is pasteurised and then it's freeze dried. From that moment on, you can keep it at room temperature on the shelf.
Chris - And what do you do with it? How is it used?
Steve - You rehydrate it with water or saline or whatever you've got for about a minute, and then that makes it nice and pliable. Then, you put it onto your wound that you will have debrided. Combat wounds particularly are often very dirty and contaminated with lots of horrible bits and pieces from the battlefield. When you debride a wound, what we mean is that we take away all the dead and the dying tissue and leave a nice healthy bed. Then, we have to put something on as a temporary cover, and the fish skin works very well in that role.
Chris - Do you have to change that rather like a wound dressing or do you put that down in there and then leave it for the duration of the healing?
Steve - It'll start to degrade, the body doesn't like having anything next to it, but also at the same time it encourages blood vessels to grow through it. It's very good at encouraging the growth of granulation tissue as well as being an antimicrobial there. If you think about the life of a fish, the ocean is full of bacteria and they're constantly swimming through bacteria. So there are proteins in the structure of the skin which are innately antimicrobial.
Chris - And a person doesn't become sensitised, like develop an allergy to it, because they're in close contact with it? Could you keep on using this for a person?
Steve - The only people that can't use this are people who are allergic to fish, as you can imagine. But even those people, when you are actually truly allergic to fish, it's actually a protein within the muscle of the fish that you are usually allergic to, not the skin. So the vast majority of people will not develop an allergy to this, so it's used subsequently.
Chris - And what sort of a difference does this make? Have you done head-to-head trials? I know it's very hard to take an equivalent injury and do a direct comparison, but have you got data before and after doing this to show that this really makes a difference?
Steve - Data in combat injuries is hard to get off, so you have to extrapolate. It's been used in burns head to head against allograft, which is where you take skin from a dead human. So it's the same species, but the problem with taking skin from another human is it has to be very highly processed in order to make sure there's zero risk that there's any viruses or prions or anything that we might not yet understand can be transmitted. Now it turns out that fishes, they also get viruses, etc., like all animals do, but we are so distantly related to fish that there's no viruses that affect fish that can also affect humans. So you don't have to do all that mega processing of the skin that you would if you're taking an allograft from another human or the alternative if you're taking another type of xenograft. So xeno means foreign species, from a pig, for example, but then it would also have to be highly processed because there's obviously risk of viral transmission from pigs to humans.
Chris - And just going back to my point which was, have you evidenced this is actually better to do this? Obviously it's one thing to do it, but if you don't know it's better, we don't know we're improving outcomes with this. So what's the evidence this works?
Steve - In the burns world, which is similar, you do a burn excision, so you do an excision and then you will often put allograft on. It's been shown to be as good if not better than cadaveric allograft in that situation. And also, in other wounds, not combat related wounds but say, for example, leg wounds, leg ulcers, etc., it's been shown to be very efficacious and the company that makes it are selling an awful lot of it around the world.
17:34 - How do we treat soldiers' mental health problems?
How do we treat soldiers' mental health problems?
Theresa Mitchell, Help for Heroes
While many people are left with physical scars or killed in conflict others have less visible wounds - such as trauma or mental health conditions. Theresa Mitchell is the head of the hidden wounds service at the Help for Heroes charity.
Theresa - I think a lot of people will resonate with the idea of shell shock from the First World War, probably since Afghanistan and Iraq and those more recent wars. This idea of a hidden wound and PTSD have become more in the public domain but, unfortunately, pretty much as a depiction in movies and literature as people being mad, bad and sad, which is very untrue.
Chris - In essence, then, it's always been there, but we haven't always talked about it?
Theresa - Exactly that. It's always been. Mainly men were coming home and were either uncommunicative or had physical sensations, because PTSD presents itself not just in the mind but also in the body, but they didn't have a name for it. They just knew that people were changed by the experiences that they had undergone.
Chris - When did we realise that we needed to do something about it and when did we transition away from the stiff upper lip mindset?
Theresa - I think they took it seriously even in the First World War because I think what they needed was people back at the front. They needed people to be battle worthy and battle ready. It was the way in which it was treated. It was quite brutal. To begin with, it was about rest and relaxation and bringing people back, but then they decided that probably it had an organic origin, and they used barbiturates or they used medication or they put people into comas or really brutal treatment like brain surgery. People have heard of lobotomies, those sorts of things. You talked about the stiff upper lip; that still exists. That motto of soldier on and get on with it and be the best soldier you can be.
Chris - Are there different gradations of exposure? If someone sees something awful and it causes PTSD, does someone get twice as bad PTSD if they see something twice as awful? Or is it very much down to the individual?
Theresa - I think both, which isn't the straightforward answer, is it? You expect somebody to have an acute stress response when they witness something, whether that's a car accident or if they're in combat. But people recover from that. What happens with PTSD is it becomes enduring. It is imminently treatable, I want people to hear that, but I think that maybe what you are talking about is something that we call moral injury whereby, if there's something that we would call an act of omission or commission, if there was something I did do or I should have done and I didn't, that can make the PTSD more difficult to treat. PTSD is very much fear-based. It's not the event that causes the difficulty, it's your belief about the event, what you thought was going to happen. It isn't a coherent timeline with PTSD.
Theresa - It's not like a memory, it's fragmented. If your belief is that you did something awful or you didn't prevent something awful happening, that makes it difficult to treat. If I give you an example, a young man who held a child who'd been mortally wounded in an attack. He held that child for a period of time and what happened was that he had a child himself of the same age at home and the reason he struggled so much was he felt that it was his duty to protect that child and he had failed in that duty. So therefore, whilst the event itself was really, really awful to witness, there was a deeper sense around it. There was a belief he had about it and it was the belief that created the difficulty for him.
Chris - Are we getting better at treating it? Because I've seen over the years a number of people with different viewpoints about how we should or shouldn't go about talking people down from the aftermath of particularly harrowing events and experiences and so on, and what's good to do, what's not good to do. This seems to sometimes be at odds with previous guidance. So do we know the best way of managing this now?
Theresa - I feel that this idea that I don't want to talk about it, events were so traumatic and so dreadful at the time and so chaotic that you didn't actually manage to process what was happening in a coherent way. Therefore, by revisiting those events, in a way that means you can tolerate it. I think that the gold standard treatments, which are EMDR, which is eye movement desensitisation and reprocessing, and trauma focused CBT which is the model I practise in, I think those models, they're evidence-based and actually have been proved to be really effective in allowing people to process the trauma that they live with. It's perfectly normal when you've been through an event that's left you with a wound like this to want to avoid thinking about it, wanting to avoid things that remind you of it, but what they do is they maintain and perpetuate the difficulty. Having the courage to look at the difficulty that you have will be the best thing that will help you through it.
22:36 - How do doctors operate in warzones?
How do doctors operate in warzones?
Natalie Roberts, Médecins Sans Frontières UK
What are some of the operational challenges faced by doctors working in some of the world’s most dangerous active warzones? Natalie Roberts is the executive director of Médecins Sans Frontières UK, which is also known as Doctors Without Borders...
Natalie - The first stage of emergency response is really trying to get into somewhere and try and work out what's going on. So we do that through a sort of specially trained group of people. We send them in to try and first of all, just spend a day or two really understanding what's going on, talk to the people who are there and try and work out the first steps of what we should start doing and how we could be most helpful. So it can be a little bit chaotic because you go into places where maybe you don't already have any team members, maybe never been there before, you might not speak the language. You have to, first of all, start by finding translators, finding somewhere to stay, finding some cars to drive around in, and then working out who you need to talk to to understand what's going on. So those first stages of emergency response are really about trying to understand the situation as best as you can.
Chris - There must be some things which are commonalities. It doesn't matter where you go to, a conflict or a war zone, you are always going to expect the same sort of things. Generally, what are they?
Natalie - The first worry you have wherever you go anywhere is - this is a war zone. It's very dangerous. You're going into a dangerous place. You're usually going into a place where people are leaving or trying to leave. First of all, you have to start thinking about, well, how can I make sure that I'm as safe as possible? Maybe I need to not go straight into the heart of the conflict. Maybe I need to start off a little bit further away. But you're trying to balance that with the fact you know that there's a conflict, there's a war going on, that people need you to be there and you don't want to take too long getting there to help them, because every day that you're delayed in choosing where to go and what to do, that's a day that maybe you could have spent saving people's lives or at least trying to to help them in some way. So really it is about balancing those considerations about, this is uncomfortable and this is dangerous, and what risks am I taking, versus how can I do this as quickly as possible to be useful on the ground?
Chris - What sorts of medical problems do you end up trying to solve?
Natalie - They can really vary from place to place. So for example, I went into Ukraine with this idea that really I needed to be setting up surgical units to treat people with war injuries. And what you always find anywhere is that you're never alone. You're not alone with just a bunch of people around you. There are always other doctors, or there are always other healthcare workers who are already working there. And in Ukraine, it actually wasn't the war injuries that were most important. It was actually the elderly people. It was cold, it was winter, suddenly their electricity had been cut off, they couldn't move around anymore because of the war going on around them. A lot of the people that would normally look after them had fled and so they were left behind. And so in some place you have to change your opinion immediately of who you're trying to help. The other, you know, extreme is somewhere like northeast Nigeria. which is also an active war zone where again, it's not necessarily about treating wounded people, it's more about the children that are in that space who maybe are struggling to access the right type of food and the right type of healthcare. And you have to immediately start thinking, who are the people I'm here to try and help? It is very challenging to even understand that in the first place.
Chris - Do you find yourself worrying about yourself when you're there, or do you put all that to one side or do you continuously think, how am I going to get out of this? How do I get home? Am I going to get stuck here?
Natalie - Anyone going through that situation needs to worry about themselves. If you're not worrying about yourself, nobody will be worrying about you and something we have to learn is we're not there to sacrifice ourselves. We are there to try and be useful, but you can't be useful if you can't work, and you can't be useful if you get injured, if you fall sick. So you need to look after yourself and you need to worry about yourself. There's a moment when you're in that situation, you start thinking, 'oh, I feel fine now. I'm used to this, this is normal.' That's the moment you should start thinking about taking a break and seeing if somebody else should come in and replace you.
Chris - How do you prepare for all that kind of thing though? Is that something that MSF trains you for, or is it literally a case of being mentored by someone on the ground and really finding out the hard way. How to do this, do this safely, protect yourself, look out for your own interest, but also look after the people that are there the best way you can.
Natalie - You don't always know how you're going to react in that situation, but MSF and other organisations do prepare you to start thinking about where you're going to be, how you're going to cope with that. They also do quite a careful selection procedure, recruitment procedure to decide who will work with the organisation. You go on a special training, I did mine for about 10 days in the German forest, which is a scenario where you're supposed to kind of think what this is like in reality. So they do test you a little bit so you're aware of the realities, but there's only so much they can test you before you go. What I found quite useful actually was working in the National Health Service in the UK because if you think about working in the emergency department, if anyone's ever been to A&E, you get all these different patients coming in all the time. You're constantly having to, to think about what you're doing and what's going on. And while you can't equate that to a war zone, if you've learned to deal with that and the stress that comes with that, that gives you this idea that you probably can cope with some elements of stress. Then I think that idea of mentoring, of going with somebody who's maybe experienced something similar before when you're going for the first time to somewhere like that so that you can just talk to them and just cross check, not necessarily what you're doing in terms of your work, but more about how you're feeling and how to cope with the situation that's around you.
Chris - Do you find though that it's tricky sometimes because there are things that you think, if I were in my, well-funded, relatively speaking, NHS job, I could solve this in the blink of an eye and I don't have access to this piece of equipment, this drug, this course of therapy, which could rescue this person and I'm going to have to give them less good care. Do you end up with that conflict?
Natalie - Absolutely. It can be at times really frustrating, really tricky. You have to think on your feet the whole time. You know, you go somewhere and you're maybe seeing diseases you've never seen before. I'd never seen Diphtheria or Ebola in the National Health Service. And so not only are you trying to think, I don't even know what I'm doing here, I've never seen these types of diseases or injuries before, but I'm also not sure I'm well equipped to deal with them. You've got those two uncertainties of seeing something you're not familiar with and not having all the equipment that you would have normally at home, and it can be really uncomfortable. In some ways the way to deal with that is to think of everything as a challenge. Think about how you can be creative, think about how you can maybe innovate, you know, try different things out. And particularly if you're working with local staff, with doctors and nurses and other healthcare workers who are from there who have to work in that situation all the time, they've often got really good ideas about things you could do when you are kind of more used to having your laboratory tests or your X-ray machines and they're kind of saying, well there's this trick and I can teach you this, and you actually learn an awful lot that way.
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