A Line in the Sand Read online

  He had not gone far when the IED detonated—but far enough that his partner was shielded from the blast. The trooper supervising the team from the other side of the road was knocked off his feet and temporarily lost his hearing, but was otherwise unhurt.

  His buddies rushed to Private Peloquin’s side and started administering first aid. They were joined in less than a minute by the platoon medic, who did a superb job. But Private Peloquin’s injuries were devastating. Every part of his body that had not been covered by the fragmentation vest was torn apart. He was a big man, and very strong, but he lost consciousness almost immediately and died soon after.

  This is the first fatality for this FOB and this company, and everyone is taking it pretty hard. Nothing can prepare you for this, not even having gone through it several times before. Unfortunately, I am not in a position to help the troops very much. As I am the “new guy” on the FOB, it would be awkward to reach out to them. For their part, the soldiers are unlikely to seek me out for support unless they are severely affected.

  Our jobs as battlefield medical personnel did not end with the evacuation of the victim. We had one more important task to accomplish. Last December, Warrant Officer Gaëtan Roberge of Hanmer (a small village in Greater Sudbury) was killed by a roadside bomb. As with Private Peloquin, he suffered devastating injuries, including the loss of an arm. The soldiers with him that day, under enemy fire, had focused on trying to save their comrade and, failing that, extracting his body. We will never know for certain if the missing limb was vaporized, which seems likely, or thrown far away. Either way, the arm never made it home.

  Warrant Roberge’s parents found this very hard to accept, and complained bitterly about it in a front-page story in the Sudbury Star. This was noticed by the CF, which tries to do the best that can be done for casualties and their families. It is now standard operating procedure to ensure that all human remains are collected. The combat team commander and the medics made sure, personally, that this was done.

  Sounds grim, doesn’t it? It was. But by the time Private Peloquin gets on the Hercules, he will be whole.

  Through the ages and in all cultures, there are stories of soldiers taking insane risks and sometimes even losing their lives to retrieve the bodies of their comrades from the battlefield. “Everybody goes home” is part of the soldier’s code. We are taking it one step further.

  Every body goes home.

  JUNE 9 | Pashtunwali

  Some of the injuries I treated today were due to local societal norms, so this is a good time to delve into the subject of tribal society.

  Most of the population of southern Afghanistan belongs to the Pashtun tribe. This is the largest tribe in Afghanistan, comprising some 42 per cent of the country’s population. Because the Taliban are drawn almost exclusively from this tribe, some Canadians believe the tribe is opposed to us. This is incorrect: most Pashtuns oppose the Taliban to varying degrees, often with very good reason. The current president of Afghanistan, Hamid Karzai, is a Pashtun who fought the Taliban for years before 9/11. Like so many of his countrymen, he too had a family member murdered by the Taliban, in this case his father.

  The Pashtuns live by a strict tribal code of honour and behaviour called Pashtunwali. There are three key elements in Pashtunwali, the first two of which are closely related. Melmastia refers to the obligation to extend hospitality to anyone who arrives in one’s home. Pashtuns will deprive their own family of basic nutrition to be able to provide a meal to the visitor. Closely related to melmastia is nanawati, which mandates that hospitality can never be denied to any fugitive.

  Afghanistan’s geography has had a large role to play in this. Since the time of Alexander the Great, this area has been transited by invading armies. No one cared about Afghanistan per se. The country is mostly rocks and desert—only about 20 per cent of its land mass is arable. It is the topography of the region—the high mountain ranges of the Himalayas and the Karakoram and the deserts of what is now southern Afghanistan and southwestern Pakistan—that has funnelled invaders through here as they headed somewhere else. Depending on which way they were going, these invaders sought to reach the wealth of the Middle East, the markets of Central Asia or the ports of the Indian Ocean. Several empires were built on any one of these prizes, and those same empires often tried to conquer the other two. An area that spent most of its time dealing with foreign invaders developed a social code that supported anyone who was fleeing, since the chance that they were fleeing a common oppressor was high.

  But since good-news stories never have much traction, the existence of melmastia and nanawati are relatively unknown outside of Afghanistan. And since violence gets you on the evening news, a lot more people have heard about the third component of Pashtunwali: badal—the right of revenge.

  The tribe takes this so seriously that it is not an exaggeration to say that crossing a Pashtun is one of the unhealthiest things you can do on this planet. There is even an ancient Hindu incantation to the gods, asking to be saved from various natural disasters and one human one: “The revenge of the Afghan.”

  You might think that this cannot bode well for any kind of national reconciliation after so many years of civil war, but armed conflict between large groups doesn’t seem to trigger an intense need for badal.

  To really make a Pashtun crazy, you have to go after his zar (gold), zan (women) or zamin (land). Then you have a blood feud on your hands. In every reference I have read on the subject, the order of these three is always the same: zar, zan, zamin. First gold, then women, then land. You can infer from that what you will.

  On to today’s medical misadventures. Two young men arrived with stab wounds. One had a single wound to his upper arm which, though it was squirting arterial blood, was easy to control and to bandage. The other one had three small wounds in his upper back. One of these wounds was trivial, but the other two—one on each side of the chest a few centimetres below the shoulder blade—proved to be quite deep.

  A quick look with ultrasound determined that the patient had a pneumothorax, popularly called a “collapsed lung,” on the left. In this situation, air has escaped from the lung and gone into the chest cavity. This air does not move in and out of the body with respiration, and as it accumulates it can exert so much pressure that the lung can no longer expand—hence “collapsed lung.” This is a Bad Thing: the patient’s oxygen saturation (a test that allows us to determine how well the lungs are functioning) was worrisomely low.

  The treatment for this condition is to make a small hole above the fifth rib, in line with the middle of the armpit, and to insert a plastic tube into the chest cavity to allow the trapped air to escape. I punched through the chest wall and was rewarded with a satisfying “hiss” of pressurized air escaping. The patient’s oxygen saturation improved.

  I then switched the probes on the ultrasound machine to look for bleeding in the chest and in the abdomen. The abdomen was fine. There was bleeding in the left chest, but I already knew that—it was coming out of the chest tube on that side. I discovered that there was also bleeding on the right, caused by the stab wound on that side of the chest. Blood can do the same thing as air: if too much of it accumulates in the chest cavity, it can also collapse the lung and provoke the same kind of breathing problems. So I zipped a second chest tube into him and managed to secure it as the medevac helicopter landed.

  Lots of blood, lots of life-saving procedures, everybody alive at the end. The perfect emergency medicine interaction!

  The unique aspect of the case was the “mechanism of injury.” It turns out that the two patients are cousins. They live in one of the ubiquitous mud brick dwellings that house most of the population here in the hinterland. These structures, called “compounds,” are designed with Afghan history in mind: a country constantly at war prepares for defence in even the most mundane of circumstances. Each compound resembles a small fort. The walls are thick enough to stop even a modern rifle bullet, and there is often a well in the centre of
the compound. Add some food and ammunition, and you are ready for a siege.

  Back to our story about the cousins. The compound they live in has two doors, one on the front and one on the side. Persons exiting from the side door are in a position to look into the neighbour’s backyard for a few seconds before they turn a corner. As said neighbour is unable to afford a high enough wall around his yard, there is the possibility that his women will be seen by someone exiting from the side door. These women would be in full burka, but would be unaccompanied by a male relative.

  This was unacceptable to the owner of the house in question. He had warned the cousins that exiting through their side door was intolerable to him. This intervention failed to achieve the desired result: the cousins kept exiting via their side door. Their neighbour then took things to what was, for him, the next logical step: physical violence, with at least the possibility of killing the target.

  View of several Afghan family compounds

  (Photo courtesy Master Corporal Julien Ricard)

  Close-up of corner of compound (the well is visible)

  Graduation day

  This kind of behaviour will have to be moderated if Afghanistan is to evolve. While a functioning government and legal system, backed up by a professional police force, will help, the lasting solution is education. Far more than any legal means or coercive system, it is education that rids humans of their baser instincts.

  More precisely, we must focus on the education of women. Those of us involved in developing-world work have known for decades that the highest return on investment comes from educating women. It is much more likely that the skills acquired will remain close to the family and village of the person receiving the training.

  Addendum, October 15: Under the Taliban, there were 600,000 students and 1,500 schools in Afghanistan. In 2007, those numbers were 6 million students and 9,000 schools. Despite the Taliban’s out-and-out war on the educational system, that system has grown by leaps and bounds: in 2009, there were 8 million Afghan children in school.

  JUNE 10 | The Contractor

  There is a man here who could be said to be performing both the oldest and the newest function in warfare. Let’s call him “the contractor.” In reality, the contractor is a composite of a few different people who are doing the same job. I have commingled them to protect their anonymity.

  The contractor is a Canadian who has had extensive military experience in the CF, both in Canada and on various deployments. He was approached by a fellow veteran and asked to return to Afghanistan to work for a private security company. He agreed. For all intents and purposes, he is a mercenary, a soldier for hire.

  The Iraq war saw the advent of companies that, for a hefty fee, would take over functions that previously had been the sole purview of the military. These included perimeter defence of bases, escorting supply convoys and even limited, but nonetheless aggressive, patrolling. The rationale was that these companies could provide additional manpower right away. No need for the military’s recruitment and training cycle, no benefits or pensions to pay during and after the individual’s employment.

  The behaviour of these companies has been controversial. Thanks to a statute rammed through by Paul Bremmer when he was the “administrator” of Iraq,* employees of these organizations are not subject to Iraqi law. The problems caused by granting this immunity came to the fore on September 16, 2007, when employees of the Black-water company (now re-incorporated under the name of Xe) who were escorting a convoy through Nisoor Square in downtown Baghdad shot and killed seventeen Iraqi civilians. The Blackwater men claimed they thought they were under attack. They were mistaken. The incident was investigated by the FBI, which found that at least fourteen of the dead were innocent Iraqi bystanders. Despite this, none of the Blackwater employees have faced criminal charges for this incident (though a civil suit is ongoing).

  A number of these companies are now active in Afghanistan, including the Canadian entry into the market, the company that employs the contractor. He has sixty-three men under his command, most of them ANA veterans who have been attracted to this job by the higher pay.

  The contractor’s men take care of the “perimeter defence” of the FOB. This means they have the relatively easy job of protecting the base from attack. They staff various observation posts along the FOB walls twenty-four hours a day. These are strong defensive structures, with excellent fields of fire that are constantly illuminated. Thus the tedious guard post duty is removed from the list of chores our soldiers have to perform while on the FOB. If we ever face more than harassing fire on our walls, the Canadians will join the contractor’s men in repelling the attackers.

  I asked the contractor the obvious question: if the Canadian Army is willing to pay these individuals more than Afghan soldiers receive, why not give the same amount of money to the Afghan government to fund the training of more soldiers? This would enhance the links between the population and the government by providing more government jobs while giving us closer control over these individuals.

  The answer I got was quite reasonable. The contractor maintained that many of these individuals do not want to join the army, even for better pay, for any number of reasons. The private security company therefore gives us access to men who would otherwise be unavailable. The presence of these men on the gates of the FOB frees up far better trained and equipped Canadian soldiers to go outside the FOB and take the fight to the Taliban.

  There is no question this is useful. We do not have enough soldiers to patrol all of Zhari-Panjwayi while defending our FOBs and outposts. Either we hire this company or we sit in our FOBs and let the Taliban run riot.

  So it makes sense. Nonetheless, there is something disquieting about the concept of privatizing war. Although I can’t quite articulate why, I think that nations need to take responsibility for everything that happens when they decide to participate in an armed conflict. Putting some of the people armed by the state in a legal environment that is removed from military discipline doesn’t seem right. I am sure these companies would claim they are not “armed by the state,” but that would be a meaningless splitting of philosophical hairs. The state allows them to be armed and is their only employer.

  The first Baron de Rothschild said, “When there is blood in the streets, buy property.” Cynical, yes, but he was stating an eternal truth: there is money to be made during wars. In its purest expression, that money is made by men who are willing to soldier for a fee. Until their most recent incarnation as organized, for-profit companies, mercenaries always joined a national army. They fought, albeit for cash rather than for ideals, under the command of an existing military structure. What we are doing now separates the mercenary from the army he is serving.

  JUNE 11 | The Things I Miss, the Things I Enjoy

  Today is Michelle’s fourth birthday. Although we celebrated it a few days before I left, it is still the first important family event I will miss on this rotation.

  I can’t help but wonder what the long-term effect of this absence will be on my daughter. I plan to cut back on my professional activities for several months after I return from this mission, to try to make up for my time away. I worry that that will not be enough.

  As much as Michelle’s future emotional well-being concerns me, I didn’t have much time to think about it today. FOB Wilson sits astride Ring Road South, the main highway that runs the length of the northern edge of Zhari district. This road links Kandahar City with the district of Maywand (farthest west in Kandahar province) and Helmand province even farther to the west.

  Supply convoys travel down this road to get to the Coalition outposts in the western part of the district and in Helmand province. These convoys are run by private Afghan companies that hire armed guards to ride shotgun on their vehicles. These guards, and the drivers they are meant to protect, provide the FOB Wilson UMS with a large proportion of its patients. The Taliban attack these convoys almost daily.

  Today there were attacks on two separate co
nvoys. Two critically injured men were sent in from the first attack. One of them had received a large piece of shrapnel in his lower left abdomen and arrived with very low blood pressure. A part of his bowel was hanging out of his body. He was barely responsive. A quick physical exam assisted by ultrasound confirmed that he had no other injuries and that there was serious bleeding in his abdomen. It is impossible to control this bleeding in the field, so it was urgent to get him evacuated to a surgical facility. My priorities were to get IV lines started to bring his blood pressure up with fluids, but only a little. If a bleeding site cannot be controlled by direct pressure, as is the case in the chest and abdomen, it is unwise to bring the blood pressure up higher than is needed for a safe transfer. We achieved this quickly; the medics here are slick at starting IVs.

  Although this man was now stable in the cardiovascular sense (his blood pressure was okay), his diminished level of consciousness made it essential that I protect his airway before the medevac took place. The danger was that he would choke on his tongue or vomit into his lungs during the helicopter ride.

  His intubation was delayed, however, by the arrival of the second patient. This man was alert and oriented and had normal vital signs, but he had been shot in the middle of his throat. The bullet had travelled down and to the right, exiting to the right side of his right shoulder blade. Ultrasound examination showed that there was bleeding into his chest cavity, so we prepared to place a chest tube. But it was the neck injury that needed attention first.

  The danger was that one of the arteries in that part of the body had been partially cut. If this artery ruptures, a hematoma (large blood collection) can accumulate so quickly that the patient’s airway is crushed. When this occurs, it is no longer possible to pass a tube from the mouth into the lungs. As much as I wanted to secure the airway of the other patient expeditiously, I intubated this man first. Once he was under general anaesthesia, I was able to put the chest tube in very easily. This drained off the blood that had been accumulating in his chest cavity, preventing it from collapsing his lung.