Falklands war 25TH anniversarY

Transcription

Vol. 153 Supplement 1
Fa l k l a n d s wa r
25 anniversarY
TH
JOURNAL OF THE RAMC
RAMC Journal Publications
HQ AMS, FASC, Slim Road, Camberley, Surrey GU15 4NP
Telephone 01276 412790
JOURNAL OF THE RAMC
VOLUME 153
SUPPLEMENT 1
FALKLANDS WAR 25th ANNIVERSARY
Editorial
Major General M von Bertele, Chief Executive DMETA
30 years ago when this author joined the RAMC he was told by
colleagues that it would be a short and dull career. Wars were a
thing of the past and a life stationed on the Inner German Plain
would soon pale. The Falklands war almost confirmed that. It was
a conflict fought by foot soldiers, in a hostile environment against
an enemy of unknown capability who nevertheless proved capable
of inflicting high casualties. Never again we were told. Future wars
would employ overwhelming force to minimise casualties. The
easy victory in the first Gulf war when a large complement of
hospital beds had been deployed, followed by relatively bloodless
peace-keeping missions in Africa and the Balkans, all conspired to
reassure political and military planners alike that risks could be
taken with their medical Services. Following the collapse of the
Soviet Union there was review after review, but the net effect, when
the logic was stripped away, was a reduction in capability,
culminating in the closure of military hospitals and a focussing of
attention on deployable capability. Yet now casualties have
returned in earnest and the capabilities of the Medical Services are
being stretched to the limit coping with them, so it is worth asking
in this anniversary edition of the Journal of the RAMC, what has
changed and what still needs to be done ?
The first point to be made is that the problems are largely
unchanged. The patient is the same, the environmental and
weapon threats vary from theatre to theatre, but disease and
wounding mechanisms are the same, despite the impact of body
armour and altered patterns of trauma, and the medical mission is
the same. Despite the controversy about military hospitals and care
of casualties in the UK, there are encouraging trends in almost all
areas of deployed capability and considerable successes in a few: but
fundamental problems remain in others. They will be considered
in turn; medical advances, resource challenges, and most
importantly perhaps, the people problem.
In 1982 we had a good understanding of war surgery. If the
patient got to a surgical facility we had surgeons who knew what to
do. Their daily practise was generalist, they had memories, if faint,
of service in small wars, and more recently in Northern Ireland,
and they worked in military hospitals with the colleagues with
whom they would deploy. They exercised together at least annually,
and they still reigned supreme in a Corps that was focussed in large
part on the doctrine of General War, where the best would be done
for the most, but where resources would be overwhelmed and
mortality was expected to be high. The challenge then, as now, was
in getting the casualty to the surgeon. Most would be expected to
die either in the immediate period following injury – they were
then, and are now, largely unsalvageable, or died from haemorrhage
over the next few hours, or died later from complications. With
fewer casualties, attention has focussed on providing better
resuscitation earlier for everyone, arresting non-compressible
haemorrhage, and getting the patient to surgery earlier. The
surgical team of general and orthopaedic surgeon. with consultant
anaesthetic support, introduced in the 1990’s, has delivered
outstanding success, and the provision of skilled aeromedical
evacuation for even the most critically injured patients has enabled
rapid return of casualties to the full spectrum of specialist services
that the NHS can offer. There has finally, been a recognition that
military casualties require more than just treatment on the NHS,
and the confirmation that a formal role 4 capability is required as
JR Army Med Corps 153(S1): 3-5
the final component of a comprehensive military medical
capability that will be able to deliver a seamless patient care
pathway.
Our medical assistants are better trained and better equipped.
Significant advances in development of haemostatic agents and
revision of doctrine on the use, and provision, of new tourniquets
has enabled haemorrhage to be better controlled. Better
understanding of fluid replacement means that resuscitation can be
tailored to give the patient the best chance of resuscitation and
surgery at the earliest opportunity. In the Falklands the focus was
on dressings, compression, and getting as much fluid as possible
into the patient. Tourniquets were almost a dirty word. Many
patients remained on the battlefield for hours, and by the time they
reached the surgical facility they were significantly hypothermic.
Coagulopathies were rare suggesting that the amount of blood lost
in survivors might have been small. Oxygen was not carried, and
was not even available during surgery. Now, the monitoring of
vital signs, including oximetry, is considered essential. Pain relief
was administered by morphine syrettes which were inadequate for
the task, and there was a problem of overdosing with subcutaneous
morphine, released later when a patient was being resuscitated.
Other agents were tried, sub-lingual buprenorphine was popular at
the time, and ketamine was used for the first time as both an
analgesic and short acting anaesthetic, but only now are we really
starting to address the problems and epidemiology of many
different types of pain. Battle injuries were not the only cause and
the management of pain from non-freezing cold injury (trench
foot) proved challenging even for the anaesthetist.
Evacuation in the Falklands was problematic Vehicles were
almost non-existent and helicopters were barely up to the task and
in short supply. But distances and therefore journey times, were
short. Escorts were not present on battlefield helicopters. Now we
agree that every casualty requires a comprehensive response, often
including a medical team to provide resuscitation and a helicopter
to ensure rapid evacuation. However, with finite resources we must
not lose sight of the need to reduce risk to the responders and the
aircraft, particularly as the more dispersed battlefield places
increasing demands to evacuate over greater distances. Better
decision making at the scene may reduce urgency and increase
flexibility, but we must now focus on training more paramedics to
perform this task and carry out research that will enable us to
understand the prognostic indicators in order to focus resources on
those who need them. The survival rates of those reaching surgery
in 1982 were high, but the question has never been satisfactorily
answered, were they the ones destined to survive? Current research
is aiming to answer some of these questions, so that medical
commanders can make more informed decisions and deploy the
right resources, in the right time scale, to give optimal care to the
casualty, and optimal support to the operational commander that
will increase his freedom to manouevre.
In the deployed surgical facility, a battery of tests is now possible;
then there was only a simple cross match, but the essence of surgery
is the same, and the challenge now is to train a surgeon to be
competent in trauma surgery when in peacetime practice the
emphasis is on ever greater specialisation. The competencies
expected of the war surgeon cannot be delivered in routine practise
in the NHS and we shall have to look either at taking a lead in the
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training of trauma surgeons within the NHS, or continue to rely
on additional training, much of which can only be obtained in
other countries. The loss of training places in South Africa has
been a significant loss to our ability to train trauma surgeons and
although simulation has been heralded for many years as the
answer to filling the skills gap, it is not yet sufficiently developed to
deliver this. In 1982 the first surgical teams deployed had only one
consultant ashore, a truly general and experienced surgeon, and he
had to oversee a number of senior registrars. That generation of
general surgeons is rapidly approaching retirement. Recently we
have been reluctant to deploy surgeons below consultant grade,
largely because of the impact on training programmes, but the
training opportunities available on current deployments under
consultant supervision may make us reconsider that stance.
We have been fortunate over the past few years, in that the rate
and complexity of casualties have increased slowly, giving us time
to learn from American experience, and develop our techniques.
Surgical facilities are well established, and our teams have an
opportunity to rehearse before deployment; in future they may
have to start again from scratch. As with our surgeons, the dash to
specialisation in the nursing cadre is in danger of distracting from
the training of generalist military nurses, but we have inadequate
data to prove whether the quality of care has suffered or benefited
from that trend. In the meantime we follow accepted wisdom but
risk over-qualifying some of our personnel at the expense of
delivering the right competencies to all of them.
Data collection in 1982 was largely based on the field medical
card and a retrospective interview survey of casualties was
conducted by medical officers in an attempt to inform work being
led by the Professor of Military Surgery. It was hardly systematic
but since then many advances have come about through
application of simple audit and the adoption of the principles of
clinical governance. For many years however we have struggled to
define and collect the comprehensive data sets that inform that
audit. The promise of information systems that would facilitate
and automate data collection and retrieval has distracted from
practise but the imminent roll out of DMICP will produce a step
change in capability, initially in the peacetime environment. The
momentum must be maintained into the deployed environment
and progress from being an electronic patient record to a functional
operational medical decision support tool. That will have to be
supported by a new organisation that will integrate data collection,
storage, retrieval and analysis, and that will inform epidemiological
analysis and decision making across Defence.
In considering equipment, logistic support, and sustainability,
we have probably turned the corner. In 1982 the scales were
adequate, but old; re-supply was geared towards General War, and
was woefully inadequate for light mobile forces. A RAP requiring
20 litres of Hartman’s would receive 2 or 3 large tri-wall boxes,
which collapsed in the rain and spewed their contents over the
mountainside. Now we have finally started to sort out scales in
modules, re-supply by single line item, rapid response to UORs
[urgent operational requirements], an understanding of the
acquisition process, and a supply chain that is responsive and
improving all the time. Further improvements will only be made,
however, if we start to place medical support officers into logistic
staff appointments at every level.
The debate about evacuation continues, but structures are still
geared to evacuation of the majority of land casualties by vehicle,
with the attendant escorts, and yet experience has shown that the
majority of serious casualties over the past 20 years have been
evacuated by helicopter. Coupled with strategic aeromedical
evacuation this has enabled progressive reductions in the deployed
medical footprint but without assurances on how helicopters will
be employed in future conflicts we risk moving out of step with
other acquisition strategies. We must fight, not for dedicated
helicopters which would restrict flexibility, but for better
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equipment in assigned aircraft, and better training for all medical
personnel who are likely to deploy. The debate about who should
be on the helicopter has been clouded again by inter-Service rivalry,
but articulation of clear doctrine and the delivery of the
competencies required to deliver the capability must be delivered
urgently.
Organisational change has been driven by many factors, but not
always by design. In 1982 control of the medical services was
dominated by secondary care clinicians, but they have now been
almost totally removed from the decision making process. The gap
has been filled by a small cadre of medically trained staff officers,
predominantly from the occupational and public health cadres,
and by a rapid increase in the number of direct entry medical
support officers. Despite improvements in staff training there is
still a long way to go, and there is an increasing need for clinicians
to return to the staff and policy forum. Promotion rules, changed
to introduce common terms of service for professional officers and
enable professional pay spines, now discriminate against the able in
favour of the eligible, and are an increasing source of irritation. We
serve and compete in an increasingly joint environment, alongside
and against officers of the other Services, who, while intellectually
and clinically gifted, are often operationally inexperienced and
untested in command.
As Yellowleas noted 30 years ago, the single greatest impediment
to progress and rationalisation is the influence of the single Service
medical directorates, and that remains true today. We must of
course retain the best of single Service identity but must accept that
cooperation and joint effort is essential if we are to overcome the
challenges of the future. Each Service is too small to sustain their
current posture, and this insularity has meant that too much time
has been wasted fighting internal battles. In each Service there is
still reluctance to allow able officers to compete against their
Service colleagues for staff appointments outside of the medical
services. Under intense media pressure there is also a danger that
attention will be focussed on today’s tactical issues and insufficient
attention given to the operational challenges of tomorrow.
A strategic vision is required for the next 20 years and that must
recognise the move from a tri-Service DMS to a truly joint DMS,
recruited through the single Services but delivered jointly. Where
a common standard can be applied to a capability, it should be
delivered jointly. We must train more officers and NCOs at every
level who will be able to sustain current levels of operational
capability, train the next generation, and provide the leadership to
deliver that vision. That training should be delivered through joint
structures where sensible, and when specific to the medical services
it should be designed and delivered to a joint audience,
supplemented by environmental differences only when essential.
We are moving in the right direction. Operations are
increasingly joint; clinicians from all 3 Services work together,
predominantly in a land environment; and there are moves to
manage them more strategically, optimising their training and
employment. . Paradoxically the only reason we are so strong today
is because of the operational challenges of the past 5 years. Should
conflict cease, because of our geographical dispersion, we risk being
fragmented, with too many clinicians focussing on their immediate
clinical practice in MDHUs, medically qualified staff officers
concentrating on clinical governance and policy in headquarters,
and medical support officers concentrating on the field medical
services. Much work is required to bring them together in new
peacetime organsiations.
Ultimately it is our people who deliver medical capability, and it
is hard to predict how we will fare over the next few years. In 1982
the NHS looked stable. You chose either a military career or a
civilian one; you could transfer one way but rarely the other; and
the routine practice of military medicine was satisfying, if not
always too demanding. Now we are fully embedded in the rapidly
changing training pathways of our NHS colleagues, and practice in
an increasingly specialised world. The requirement to receive knee
surgery from someone who only operates on knees may hold good
in peacetime specialist centres, but is not the environment in which
to train a generalist trauma surgeon. We must continue to work
together to agree on the competencies required by our staff, and
secure placements where they can be achieved.
Our people at every level tell us that they want to be trained to
do the military clinical task, but it is still hard to achieve that
training as we try to balance career needs, single Service demands,
and the wider service need. DMETA currently responds only to
customer demand, but in future should be placed to inform the
customer of the requirement, design it, and deliver. More needs to
be done to focus training on the military requirement, while
acknowledging the need to place and employ people in the NHS.
This can only be done if the 3 Services agree. Training overall must
improve, not just clinical, but importantly in command, leadership
and management, and focus on delivering a multi-disciplinary
command and staff cadre, open to clinical and non-clinical officers,
properly trained in medical planning.
The Royal Navy and the Royal Air Force should allow their
people to work more closely with their Army colleagues, and
develop early the right career profiles to allow better application of
common terms of service. The Army must offer up some
command appointments to the other Services, especially as
opportunities expand with implementation of Improved Medical
Support to the Brigade (IMSB). Single Service differences should
be retained either out of necessity, for example at role 1, or to meet
specific environmental needs, but as a source of strength, not
protectionism. This will only be achieved in an organisation that
has a clear purpose, is adequately resourced, and properly organised
and managed, with a focus on the fundamental output – the
delivery of a full range of military medical support to servicemen
and women of all 3 Services. That is the essence and purpose of a
Joint element in our medical Services. With greater acceptance
than for many years of the need for a comprehensive and capable
Defence Medical Service, now is the time to make the change.
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FROM THE EDITOR
In 1982, the editor wrote “The purpose of this editorial is to
stem the drift into oblivion of the object lessons adduced [from
the war]”. This remains, in a more general sense, one of the
aims of the RAMC Journal. Sadly, experience bears out the
suspicion that history is composed of lessons forgotten as often
as it is of lessons learnt.
I remember watching film on the news of Sir Galahad
burning whilst I was a medical student and realising that my
belief that wars had become something that didn’t happen
anymore was wrong. The Vietnam and Korean wars had been
years previously and World War II had been more than thirty
years earlier, talked about only by people of my parent’s and
grandparent’s generations. Times have changed again, and we
now live with a continuing backdrop of wars involving British
service personnel. Barely a week goes by without news of
another death in action, yet I still remember the emotional
shock to the Nation of the human cost of the conflict twenty
five years ago. What also marked out the conflict in the South
Atlantic was the almost universal support for what was judged
to be a “just war”. It is surely a matter of pride that the people
of the Falklands are as proud of and grateful to the Armed
Forces now as they were all those years ago and that the Islands
are more populated and more prosperous than ever before. And
still British as their inhabitants wish.
It is right, therefore, that we take this opportunity to mark
the anniversary of the Falklands War and to pay tribute to those
who served and to those who died. It is also important that we
draw on their experiences in any way we can to ensure that the
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“object lessons” are not forgotten. Anyone reading the articles
in this issue will readily realise that in many respects the
challenges facing the medic at war have changed little since, just
as they had changed relatively little in the years before.
Much of this special issue consists of articles originally
published in the Journal in the immediate aftermath of the
War. Where necessary, I have included commentaries placing
the articles in a modern context. Brief biographies of the
original authors are also included. I am most grateful to Surg
Capt Walker and Col Jim Ryan for their recollections of their
service during the War, one on board ship, the other in the Field
Hospital at Ajax Bay.
The Army Medical Services are extremely lucky to have
someone as enthusiastic and knowledgeable as Capt Peter
Starling as their museum curator and I am immensely grateful
to him for his patient responses to my many queries regarding
this issue.
In conclusion, the Royal Army Medical Corps lost four of its
members in the Falklands Conflict and it is to them in
particular that this issue is dedicated:
Major Roger Nutbeem
S. Sgt Phillip Currass QGM
L/Cpl IR Farrell
Pte K Preston
JR Army Med Corps 153(S1): 2
Fighting for the Falklands
Capt. Piers R. J. Page
"They landed approx 0930 GMT this morning in landing craft
and stormed the capital Port Stanley and have taken over the
government office - they landed with heavy armoured vehicles.
We're now under their control. They are broadcasting that all
local people will be treated as normal. Fairly peaceful in Stanley
at present time."
With these words, transmitted by Bob McLeod broadcasting
as VP8LP from Goose Green, the UK discovered at 1600 hrs
London time on 2nd April 1982 that the Falkland Islands had
been invaded by Argentine forces.
industrial base for the South Atlantic whaling industry. By the
mid 1960s, however, maritime engineering had produced the
factory ship and there was no use for the giant factories on the
shores of the island.
Background
The roots of the conflict (war never officially being declared by
either side) lay several hundred years previously, in the rapid
expansion of the empires of several European nations. In the
1690s the body of water between the islands was named after
5th Viscount Falkland, a future First Lord of the Admiralty, by
John Strong as he sailed between them. In 1765, the western
region was claimed for Britain by John Byron, on the grounds
of their prior discovery. Unfortunately, the eastern reaches had
been settled the year before by the French, who took exception
to the British claim before selling the settlement to Spain a year
later. Spain promptly took the British settlement in 1771,
returning it shortly after.
In 1774, the British left, assuring continued possession by
means of a brass plaque asserting the fact. Spanish government
continued from Buenos Aires until 1816, when Argentina
became independent and claimed inherited rights from Spain.
A brief but catastrophic period of Argentine rule, which
included a spat with the USA culminating in an armed visit
from the USS Lexington and a failed penal colony whose
soldiers mutinied and killed its governor prompted a British
return in 1833.
Over the following years, a British colony was established,
which thrived throughout the colonial era. Much later, at the
time of independence for many colonies, Lord Shackleton
(grandson of explorer Ernest) was commissioned to explore the
potential for viability and economic growth in the Falklands
(during which his ship was fired upon by the Argentine navy).
This inquiry found the islands to be net producers of wealth in
British public purse terms, and to be stable, settled and selfmanaging. This was not the answer the Argentine government
wanted to hear; when HMS Endurance, the naval exploration
vessel was listed for withdrawal by May 1982 and the “Kelpers”
of the Falklands were denied full British citizenship in 1981,
the junta saw its opportunity.
South Georgia
First landed on by Captain James Cook, the barren island of
South Georgia experienced an intense half century as an
Corresponding Author: Capt Piers RJ Page RAMC, Academic
Department of Emergency Medicine, James Cook University
Hospital, Marton Road, Middlesborough, Teeside, TS4 3BW
Queen Elizabeth Military Hospital, Woolwich
Email: [email protected]
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HMS Chatham off South Georgia
On 19th March 1982 an Argentine flag was seen flying at
Leith, the centre of the old whaling station. It had been run up
by Constantino Davidoff, a scrap merchant who had decided to
dismantle the station.
The flag was run down after immediate British diplomatic
action, but a further 7 days yielded no further co-operation;
Davidoff had been ordered to present himself and his permit for
the expedition to the British Antarctic Survey delegation on the
island. He continued to resist this and by the 27th this Steptoe
situation had escalated to the dispatch of a troop of British
marines aboard Endurance, countered by the Argentine
removal of nearly all the scrap men and replacement with their
own marines. On the 27th, the writing was on the wall when
two further missile boats arrived to support the Argentine
marines and aircraft from the mainland remained almost
constantly in the sky over Port Stanley.
What has never been clarified is the degree of orchestration of
this event by Buenos Aries. It seems quite possible that the
initial action was in fact spontaneous, but offered an ideal
opportunity for the junta to escalate its provocation of Britain.
Britain awakes
On Wednesday 31st March John Nott, Margaret Thatcher’s
defence minister, visited her to tell her that signals intelligence
confirmed preparations by the Argentine fleet for invasion of
the Falklands. This would be news to very few, as the entire fleet
were at sea and had deviated from the course of their normal
spring exercise.
By Thursday evening, the Navy had committed a task force
based around Hermes and Invincible, which it had vowed to
put to sea by the Monday morning. Land forces were put on
standby for immediate deployment and further ships set sail
from Gibraltar to meet the force on its way south.
Contact! – 2 April
At 0230 contact was called amongst the waiting marines; a fleet
could be seen assembling off Cape Pembroke, as intelligence
had predicted. What was not predicted, however, was the arrival
at 0430 of Argentine special forces by Puma helicopter at
Mullet Creek, south-west of their expected approach on Port
Stanley. They landed here unopposed and began their
infiltration. Within two hours their fierce assault on the
thankfully empty British marines’ accommodation at Moody
Brook demonstrated their will to win and destroyed any
credibility the argument that they had aimed to take the islands
without unnecessary losses might have had.
Simultaneously, a large force of Amtrack LVTP-7 armoured
personnel carriers was reported to be coming ashore by the OP
above Yorke Bay – already, 18 were rolling across the island.
Shortly after, assaults began on Government House, defended
by the marines who had not formed the initial OP parties. Rex
Hunt, Governor of the islands, called a meeting with Admiral
Busser (leader of the invasion) and requested immediate
Argentine withdrawal of forces. Busser replied that he felt with
nearly 3000 men on the island and 2000 more in reserve at sea,
he was unlikely to be made to leave.
At 0925, the miniscule force of marines surrendered to the
600 Argentine special forces who they had held at bay through
the early morning. Argentina had the Falklands.
Within a day, South Georgia fell after a similarly heroic
defence. Lt Mills of the Naval Party garrisoned at Stanley
previously and due for replacement had taken 12 marines to
the island after the escalation of the scrap metal affair. On 3rd
April, an Argentine icebreaker ship hove into view,
accompanied by one of the missile corvettes sent to reinforce
the landed marines. As he watched the jetty he had boobytrapped awaiting further incursions, a Puma brought Argentine
special forces to the island and discharged them in front of his
face, whilst the missile boat brought fire down on the position.
Mills immediately opened fire on the helicopter and one of his
marines scored a waterline hit on the missile corvette with a
Carl Gustav launcher. After ninety minutes of spirited defence,
the inevitable was accepted and surrender agreed.
As Operation Corporate began, careers were ending. Lord
Carrington had grossly underestimated Argentine will for the
invasion and as such his diplomatic efforts as Foreign Secretary
were far too little too late. He resigned, describing the invasion
as “a humiliating affront to this country.” John Nott also
tendered his resignation as Defence Secretary but Mrs.
Thatcher, concerned that the outbreak of war was no time to be
losing a cabinet, did not accept it.
become the less favoured of the two (the other being a
sundeck), due to its alarming tendency to move with a
helicopter in the hover above it.
Due South
As April wore on and the task force elements steamed south,
other elements of the plan continued. Ascension “Wideawake”
Island, over 1000 miles west of Africa, was to be used as a
staging post and therefore had to be reinforced. An RAF
deployable Marconi radar was quickly installed, giving a tactical
perimeter to the island, and a fuel farm established. Wideawake
had a vast runway for the American satellite station there, and
with extra logistic support was the ideal outpost to support the
operation.
Despite its excellent facilities, the British force still put great
pressure on the infrastructure and visits were strictly limited,
with several ships receiving their resupply by helicopter rather
than putting ashore.
The assembled land forces on their respective ships put the
cruising time to good use. Weapons were inspected, fired and
stripped daily, the decks of Canberra reverberated to the sound
of regimental PT and ceremonial bandsmen refreshed their
skills as combat medics. Despite wearing conditions and frayed
tempers, the British land forces were going to arrive ready to
fight.
Back in the UK, a diplomatic effort slowly gathered
momentum. Al Haig, the US ambassador to Britain, spotted
The assembly of the task force saw the initiation of a measure
last implemented in the second world war – “take up from
trade” of merchant ships. It was on this basis that that P&O’s
flagship cruise vessel the SS Canberra sailed its final leg from
Naples to Southampton for conversion to a giant troop ship.
As Canberra sailed home to its renaissance as the floating
home of the land force, the rest of the task force set sail on the
morning of Monday 5th April. Hermes and Invincible left
Portsmouth with Fearless, an amphibious assault vessel with 8
landing craft in its wake. Sir Galahad and Sir Geraint, both
logistics craft escorted by Antelope, steamed to join from
Plymouth sound and await the arrival of their partner ship Sir
Tristam from Canada. Arrow and Plymouth joined the carrier
group in the channel as their escorts. Another key vessel was
Glamorgan, a missile-destroyer carrying Admiral Woodward,
commanding the task force.
While the impressively rapidly assembled task force sailed on
towards the Falklands, Canberra metamorphosed from luxury
liner to high-capacity troop ship. Its living quarters were
chopped into tiny cabins and the swimming pool was drained
to be fitted with a helicopter deck. This helipad would in time
Total recall
Having found the floating contingent, land forces were now
needed. Brig Julian Thompson, commanding 3 Commando
Brigade had been warned off 5 hours before the invasion; his
brigade was now feverishly reassembling itself for war, just days
after many units had returned from NATO exercises. 42 Cdo
was based locally but on leave, so recall notices were issued and
policemen sent to relatives’ houses all over Britain to deliver the
news to relaxing marines. 40 Cdo in the North-West and 45
Cdo in Arbroath began their preparations as 42 personnel
streamed from all over Britain back to the South-West.
Further strength was needed, preferably at high readiness.
2nd and 3rd battalions of the Parachute Regiment fitted the
bill, but were also dispersed on leave (the later famous CO 2
PARA, Lt Col H Jones was skiing in the French Alps when he
heard of his unit’s deployment). 2 and 3 PARA were recalled in
a similar fashion – at one point, tannoy announcements could
even be heard on London stations informing all Parachute
Regiment personnel that they were to return to Aldershot
immediately.
“H” Jones VC, Commanding Officer 2 Para
Background noise
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the diplomatic difficulties in the USA’s twin interests of Britain
against the Eastern Bloc and hard-right South American states
(amongst whom Argentina was one of the foremost) against the
central American Marxists. He volunteered himself to conduct
negotiations personally, and consequently spent much of April
in the air. Unfortunately, his fellow ambassador to the UN was
not of a similar inclination and set a frosty backdrop to
negotiation by attending an Argentine banquet on the night of
the invasion and declaring that she could see no problem in
Argentina repossessing its own islands. To Galtieri and his
colleagues in power, a scantily opposed invasion of the islands
followed by a senior US diplomat apparently showing support
for their actions, suggested things were going very well indeed.
Over the first few days, though, some progress was made. The
EEC nations showed surprising solidarity; several put in place
immediate import sanctions (symbolically if not economically
significant), with an EEC-wide order being put in place on 9th
April. On 3rd April, the UN had passed resolution 502,
permitting use of force to regain the sovereignty of the islands.
The USSR had made objections but stopped short of using its
veto, sensing an ultimate battle it did not wish to be on the
losing side of.
Black Buck – 1 May
This was the name given to the nothing short of spectacular feat
of delivering bombs onto (around, in the event) Port Stanley
airfield by RAF Vulcan bomber. These behemoths of Cold War
airpower were due retirement within weeks; this, their
swansong, was a feat of logistics sadly unmatched by its tactical
impact.
Wideawake before reaching home.
When the bombs finally hit the airfield, some fell to the side
causing minimal damage to the dispersal and parked aircraft,
while some only cratered the runway. Just seconds after
appearing, XM607 was on its way home, payload delivered.
Although the tactical impact was short-lived with most damage
repaired within the day, the impact on morale of Britain’s
capability to strike the heart of the invasion force from such a
distance must have been significant. Withers won the DFC for
flying this mission, and Sqn Ldr Bob Tuxford, pilot of the
underfuelled Victor who had risked his life for the mission the
AFC.
Follow-up sorties were made by the Sea Harriers of the task
force, punching further holes in Argentine air capability and
morale.
The Belgrano goes down – 2 May
For more than a week, the crew of HMS Conqueror had been
tracking the movements of the General Belgrano after a warning
from Chilean intelligence that she had put to sea in the
direction of the task force. Conqueror’s initial task was to watch
and wait; as time wore on, however, it became obvious that the
vessel was likely to be forming part of a pincer attack on the
force. By the beginning of May, she was about to reach the
shallower waters of the Total Exclusion Zone, into which
Conqueror would not be able to follow her undetected.
It was unthinkable that the group should come under direct
threat, even with the inevitability of the global condemnation
that would follow an act of aggression such as this. Conqueror
was, therefore, ordered to engage Belgrano. Several Mk 8
torpedoes struck her as she turned, exposing a massive target.
The damage was catastrophic, and within the hour she was
sunk. Predictably, this caused outrage in many quarters – even
the British press quickly quelled their riotous headlines such as
“Gotcha!” as the extent of the disapproval became clear. One
more step had been taken down the path to war, with
consequences to be seen very quickly.
On the same day, the Sea Harriers took their first loss when
Flt Lt Paul Barton (on exchange to 801 NAS) engaged a Mirage
at close quarters whilst on Combat Air Patrol around the group.
Belgrano is avenged – 4 May
A Vulcan bomber
Staging out of Wideawake, the formation of 2 bombers and
supporting Victor air-air refuellers set out on 1st May. The first
Vulcan was obliged to turn back rapidly due to a technical fault,
leaving Flt Lt Martin Withers to make the lonely journey in
XM607 to the airfield. A complex system of sequential refuelling
by the Victors ensured viability of the mission – at each stage, one
tanker would give all its fuel bar return and reserve quantities
before turning for home. The final tankers gave more, in fact,
than was safe, relying on calling a Victor back out from
8
At 1400 hours 2 days later, a plume of white smoke snaked
towards HMS Sheffield as it protected Hermes and Invincible,
the only sign of the Exocet missile about to bury itself deep in
the ship. It had been fired by a low-flying Super Etendard, a
class of aircraft flown by the most able of Argentine pilots.
Although its warhead did not detonate, the ship was ablaze
within a minute and direct hits had been taken to both the
main engine and main generator. An unserviceable backup
generator curtailed all smoke extraction facilities and the
survivors struggled through acrid black smoke to reach safety.
20 were lost, as was the ship when it finally sank on tow 6 days
later.
A sombre mood prevailed back home when news of the loss
broke, and delight at early successes forgotten. Loved ones
would not be returning, and the fight had barely begun.
5 Brigade put to sea – 12 May
The Cunard liner QE2 left Southampton on 12th May,
carrying 5 Inf Bde, commanded by Brig Tony Wilson in
chipboard-lined splendour. The 3000 strong brigade consisted
chiefly of the Welsh and Scots Guards, in addition to a
Ghurkha battalion. Their routine was much the same as those
who had sailed before them – weapons handling, PT and
boredom.
Pebble Island – 14 May
Boat troop, D Sqn 22 SAS recreated the regiment’s North
African successes in this raid on the main Argentine air asset. It
had been adopted due to its proximity to the mainland and
distance from the hazards of constant bombardment which its
sister airfield at Stanley was suffering. The invaders had thus far
used this strip unopposed – resupplying at leisure and flying
frequent harassment sorties at the task force. A previously
placed OP instructed that numerous aircraft were seen at the
location, which they advised should be attacked overnight.
After the patrols were reinforced by Sea King, the attached
Naval Gunfire Officer called in support from Glamorgan which
enabled attachment of plastic explosive to equipment whilst the
garrison was pinned down.
The total Argentine losses numbered 11 aircraft, the fuel
dump and radar facilities. The cost of this was 2 minor injuries
to SAS raiders, all of whom were successfully exfiltrated by
helicopter. Events continued apace.
San Carlos – 21 May
The time at sea had been productive for the command element
of 3 Commando Brigade. The key question was where to come
ashore; Julian Thompson favoured a direct attack into Stanley,
various SF elements proposed disparate “softening” raids, but
one voice, and a relatively junior one at that, was heard above all
others. Major Ewen Southby-Tailyour had previously
commanded the marine party in the Falklands, and as a keen
sailor had spent a great deal of spare time exploring the
coastline. He had kept a sketch-book; this added a great deal of
weight to his opinion that San Carlos offered a sheltered,
navigable approach. The only problem was that it was on the
wrong side of the island.
There was no better fighting composition in the world for
long-distance terrain coverage, however, than the combination
of the Parachute Regiment and Commando Brigade. It was
decided at a meeting on 10th May that the landings would be
at San Carlos, with a 3 pronged move east to Port Stanley
supported by helicopter for troop movement where possible.
At around 0400, 2 PARA and 40 Cdo scrambled ashore at
San Carlos unopposed, with 45 Cdo reaching Ajax Bay at first
light. For several hours before the landings, there had been
diversionary raids at several other possible landing points; the
only possible resistance to the San Carlos landings had been at
Fanning Head. This had been signalled in by a special forces OP
just the day before, so the prelude to the landings had been a
helicopter-borne assault to neutralize the threat.
40 Cdo immediately secured the area to the east, into the
Verde mountains – in combination with 45 Cdo’s position at
Ajax Bay, the harbour was now well defended. 3 PARA cleared
Fanning Head definitively whilst 2 PARA dug in, having scaled
the ridge of the Sussex Mountains. Now, 42 Cdo could be
brought ashore from reserve.
As the light gathered, the inevitable attention from the air
began. Sorties of Argentine jets maintained constant pressure on
the group – Argonaut, Antrim, Broadsword and Ardent all took
repeated hits. Eventually Ardent, forming the southern screen as
well as keeping the pressure on Goose Green, took its 17th and
final hit. As its civilian NAAFI manager (a retired SASC
instructor) brought its machine guns to bear on the raiders,
Yarmouth took survivors on from alongside. Argonaut was
luckier – although hit repeatedly, it was crippled but not sunk.
By the end of the day, a huge defect had emerged in
Argentine tactics. Their zeal to destroy the defensive capability
of the group had blinded them to the fact that they had clear
shots on Canberra throughout. By the time Ardent was being
abandoned, Canberra had disgorged not only the fighting
troops, but their logistic support as well. The brigade was ashore
and ready to fight.
The Conveyor stops – 25 May
By 25th May Antelope was lost in a very similar fashion,
forming a perimeter well out into the Sound with no screening
mountains. The aerial assault was relentless and eventually
delivered a WWII design bomb which punched its way into the
ship, but like the Exocet which finished Sheffield, did not
detonate. Sgt Jim Prescott was tragically killed whilst trying to
defuse the rapidly overheating bomb – he managed, however, to
talk through the process to his team, ensuring that handling
knowledge was passed on in case of further incidents.
Atlantic Conveyor being refuelled by RFA Tidepool
A loss more pivotal to the assault was that of the Atlantic
Conveyor. She had been taken up from trade due to her massive
carriage capacity, and was bringing the Chinooks so critical to
the brigade’s overland assault in addition to tents, munitions
and Harrier mats. Ironically the Exocet that sank her may well
have been destined for Hermes; when the radar signature was
detected, chaff rockets successfully diverted the missile. When
it sought a second target, the giant, defenceless Conveyor was
in the frame.
As its oil-soaked plywood decking roared with flames, the
task force’s air assets went up in smoke as well. The only way to
Stanley was now by foot.
East to Stanley – 26 May
HMS Ardent on fire
Julian Thompson’s original plan had been a direct advance on
Stanley when the balance of the troops arrived. On 26 May
news arrived from London – an immediate advance should be
made, with a simultaneous attack on Goose Green. This
dilution of an already understrength force pleased nobody but,
9
orders being orders, 2 PARA dutifully turned south and set out
from the Sussex Mountains. Airlift was available for heavy
weapons, but boot leather would have to suffice for everyone
else.
Meanwhile, 45 Cdo and 3 PARA set off on the long tab
North and East, destination Stanley.
Sunray is down – 27 May
Goose Green was to result in one of the conflict’s highest profile
casualties – Lt Col Herbert “H” Jones VC. Naval gunfire began
to soften the target in the early hours of the morning, with
infantry fighting beginning at around 0600. The early phases of
the attack involved repeated contacts with entrenched machine
gun positions; well-dispersed, they bogged down the attack at
several points. It was to break such a bottleneck that H Jones led
his tactical HQ into the gully to the right of Darwin Hill,
which A Coy had so far failed to overpower. He was cut down
by an emplacement eventually neutralized by 66mm LAWs,
and with the words “Sunray is down” command of 2 PARA was
devolved to Maj Chris Keeble. It was time to test the alternate
command structure set out for just such an eventuality – Jones
had designated an entire alternate tactical HQ.
Thankfully, the strategy held good and the battle continued
apace. 3 were lost in one of the most distasteful episodes of the
war, when Lt Jim Barry sighted a white flag flying in the
trenches by the schoolhouse. He took 2 NCOs with him to take
the surrender of the position; once in plain ground, all were cut
down in a hail of machine gun fire.
That night, Darwin was taken and with it came the
information that the community hall at Goose Green held
civilians in large numbers. Keeble’s plan of softening the
settlement with an overnight bombardment was clearly now
unworkable; permission was sought from Brigade HQ to
negotiate. After a night of hasty field diplomacy Keeble went
forward to the Argentine position with 2 reporters to witness
talks, offering the options of surrender or release of hostages
followed by continued military action.
Air Vice Commodore Wilson Pedroza offered the surrender
of the garrison and shortly afterwards the men of 2 PARA
watched agape as the parade of 250 men were joined by another
three times as many. The British battalion had defeated a
defending force 3 times its size; the excrement smeared on walls
and destroyed furniture was testament to the brave new
Argentine world the islanders had been liberated from.
3 PARA now turned east to take Teal Inlet, a waypoint to
Stanley, while 45 Cdo had drawn the short straw (but long
walk) and were to head north to Douglas before following the
paras’ trail through Teal Inlet.
increasingly beleaguered Argentine garrison.
Closing in – June
After cross-decking from QE2 to Canberra and Norland, 5 Bde
were put ashore on 1 June. Their immediate task on 2 June was
to head east and form the southern prong of the attack,
potentially entailing a long, cold walk. A local civilian suggested
that telephone communications might still be working at
Fitzroy, so a heliborne party deployed to the nearest working
line at Swan Inlet. They managed to raise a farmer at Fitzroy
who confirmed that Argentine forces had been and gone,
leaving a golden opportunity. This was later confirmed by
Patrols Coy 2 PARA, now under brigade command.
Tony Wilson was keen to exploit this at the earliest
opportunity, and so commandeered the sole Chinook to move
the brigade to Fitzroy. A near blue-on-blue due to the
unannounced nature of the flight brought criticism from San
Carlos, but the brigade had, nonetheless leapt ahead.
By 3 June 3 PARA under Hew Pike were established at
Mount Estancia, staring up at Mount Longdon which stood
between them and the final objective of Stanley. As the days
passed, recce parties went forward to assess the strength and
disposition of Argentine defence and artillery was brought
forward to the battalion.
Farewell Sir Galahad – 8 June
Another blow was struck from the air with the bombing of Sir
Galahad as it lay in Port Pleasant near Fitzroy, with the Welsh
Guards aboard. After the Scots Guards were deposited by
Intrepid 3 days previously, it was decided that logistics ships
should be used to land the Welsh. In Fitzroy, 16 Field
Ambulance were due to disembark with a Rapier air defence
unit, but the Welsh were supposed to be at Bluff Cove, not
navigable by the ship. As the debate over safety at sea or a long
walk to Bluff Cove continued, 4 jets screamed over and
dropped a stick of bombs squarely on target.
As petrol, ammunition and equipment blazed, the embarked
troops triaged, treated and evacuated as best they could, many
working with horrific injuries themselves.
Stanley in sight – 31 May
42 Cdo’s move was less footsore but potentially far more lethal.
Key high ground to be secured in the battle for Stanley was
Mount Kent and the ground around it, which overlooked the
town. The only way to move the marines this far forward within
the required timeframe was helicopter – an unarmoured flight
in appalling weather, necessitating several hops for the required
numbers.
After being forced back by a whiteout on 30 May, 2 Sea Kings
deposited K Coy of 42 Cdo and Lt Col Mike Rose of 22 SAS
on Mount Kent, a Chinook following shortly behind with a
105mm gun and 300 rounds. After a day of isolation, the Sea
King force brought the rest of the battalion in a series of daring
low-level flights.
Once established the unit quickly secured Mount Challenger,
Estancia House and Bluff Cove Peak, tightening the grip on
Stanley and providing an LUP for 3 PARA and 45 Cdo. With
these units in place, a pincer was forming ready to close on the
10
RFA Sir Galahad
The final days – 10-14 Jun
The formation took shape, Stanley was encircled by
commandos, guardsmen and ships and the task force steeled
itself for the advance into Stanley. The plan was divided into 3
stages. Firstly, Mounts Longdon, Two Sisters and Harriet were
to be secured by 3 PARA, 45 Cdo and 42 Cdo (aided by the
Welsh Guards) respectively. This first phase was to take place in
the early hours of 12 Jun.
Phase two involved the capture of Wireless Ridge by 2 PARA,
who would be held in reserve during the first phase before
moving through and beyond 3 PARA. The Scots Guards were
to take Mount Tumbledown, the Gurkha rifle battalion Mount
William and the Welsh Guards Sapper Hill. This was scheduled
for the night of the 12th. The third and final phase would be a
move through 5 Brigade’s consolidated positions and into
Stanley, to defeat the occupiers in the street.
Longdon
Longdon proved a fearsome environment for the Paras; the two
months of occupation had allowed the Argentine forces to
develop two well defended positions with numerous bunkers and
machine gun emplacements. A combination of armament and
topography made Longdon a challenge for the toughest of
soldiers resulting in a hard fought engagement. The western
position, “Fly half” was taken rapidly, although the platoon
advancing from the west bypassed a position in the dark and
subsequently took rounds to their rear.
“Full back” lay to the east and was ferociously defended. The
advancing Paras began taking rounds from at least 2 GPMG
emplacements, joined by a .50 calibre heavy machine gun.
At the start of the attack on the position, the detonation of an
antipersonnel mine had triggered the beginning of a
bombardment, the grids having already been set. As the shells
rained in, the Paras tried sending a flank attack to the north of
the position. They sustained withering fire, and the flank was
recalled. The advance was finally made in true infantry style, on
their bellies from the west along the ridgeline, expending virtually
all grenades and finally resorting on 66mm weapons to clear
positions. The summit was finally taken at the closest of quarters,
with bayonet fighting in the trenches. The cost to the battalion
was 23 dead and 47 injured, but a decisive victory was had.
Wireless Ridge
The already battle hardened soldiers of 2 PARA readied
themselves once more for battle, their objective to take Wireless
Ridge in readiness to move into Stanley. In contrast to the austere
logistics supporting Goose Green, they had armour, artillery and
air support. At first light, the winning partnership of the 30mm
cannon of the Blues and Royals and GPMGs of the battalion had
cleared the bunkers and the assault on Tumbledown (in
conjunction with Scout-borne SS12 missiles) had neutralized the
Argentine guns which had hampered the final phase of the assault
from across Moody Brook. A and B companies, with the Blues
and Royals, finally got to look down to Stanley.
Tumbledown
The original plans for the Scots to assault Tumbledown directly
from the south up a fearsome slope were soon abandoned as a
result of the ferocity of resistance met by an initial recce party.
Given that 3 Cdo Bde were already dug in to the west, a
flanking attack from there seemed to offer (relative) safety.
The three companies assaulted from the west, moving
through each other in the line of march. With each wave, more
men were occupied by clearing and holding sangars as they
went, leaving a dangerously understrength force holding the
front line of attack.
The series of dogged and relentless attacks eventually took the
summit from, as it transpired, a very professional Argentine
marine company. The fighting had been every bit as bloody as
that on Tumbledown.
Harriet
In contrast to the heavy fighting from the outset on Longdon,
surprise minimized losses on Mount Harriet. After a delayed
start, the Welsh Guards and 42 Cdo got to the foot of the slope
undetected, and called in the spectacular firepower of the
assembled batteries of 29 Cdo Regt RA, a firm deterrent to even
the most committed occupier. As the rounds fell, the assault
continued forwards and cleared to the summit using small
arms, anti-tank weapons and grenades.
Milan, the latest hi-tech anti-tank weapon was used in anger
against the well established bunkers on the summit. When these
were overrun, a treasure trove of rations, ammunition, maps
and even a battlefield radar were taken.
Two Sisters
45 Cdo’s assault on Two Sisters was another triumph of
committed, brutally tough soldiering. The men had to fight up
the rocky outcrops under perpetual bombardment, eventually
ransacking the captured positions for shelters, warm kit and
food as they lay exhausted on the peaks of the mountain. Phase
one was complete, with all objectives taken.
Mount Tumbledown
Two more hills to go…
As the light gathered and battle raged on adjacent Tumbledown,
the Gurkha rifle battalion waited to start their assault on Mount
Williams. When Tony Wilson deemed the Scots close enough to
the finish line, the Gurkhas were waved off, again with all the
support that could be mustered. Artillery, Milan and .50 cal once
again entered the fray but equally potent was the dedication of
the Nepalese unit, which moved round Tumbledown under its
Scottish stewardship to assault Williams from the north. The
aggression worked up for the final attack proved unnecessary as
the Argentines fled in the face of the Gurkhas, who they had been
reliably informed were cannibals.
The composite of the hugely depleted Welsh Guards and 40
Cdo waited impatiently to take the final ground before Stanley,
Sapper Hill. White flags were already flying in the town, and
nobody wanted to miss the action.
For expediency, a company sized assault was launched by
helicopter and followed up by the rest of the composite on foot.
This made quick work of the few brave stay-behinds and by late
afternoon the Welsh and commandos watched the Paras move
into Stanley.
Going to town
Two Ssters
The move down from Wireless Ridge began at 1300, after
Julian Thompson surveyed the situation from the air. The
armour of the Blues and Royals, one vehicle proudly displaying
11
their regimental colour, ferried the Paras in as they swarmed
towards Stanley. The order was received to halt at the racecourse
– the occupiers wished to discuss terms.
Surrender – 14 Jun
For several days before the encirclement of Stanley, Col Reid
(listed as being 22 SAS) and Capt Rod Bell RM (who had been
raised in Latin America) had been transmitting on the medical
advice frequency of the King Edward Memorial Hospital,
known to be occupied. Although no reply was received, it
became clear early in negotiation that Gen Menendez’s staff had
been listening. They now wanted to talk.
In the afternoon of 14 Jun, Reid and Bell were carried
forwards by Gazelle to a bizarrely formal meeting with
Menendez. After quibbling over whether he could surrender the
geographically but not geopolitically separate islands in the
group, Menendez acquiesced to all terms except the use of
“unconditional” in describing the surrender.
After bad weather grounded him, Maj Gen Moore, task force
commander, eventually arrived for a final round of talks at
2300. At 2359 on 14 Jun 1982, Britain took the surrender of
12
the Argentine occupiers of Stanley – the Falklands were retaken.
As Britain celebrated its reassertion as a world power, the
units of both the task force and the occupation buried their
dead. To come was a massive effort in repatriating prisoners of
war and a long journey home. For now, though, it was enough
that the fighting was over.
Falkland Islands Memorial Chapel, Pangbourne, Berkshire
Chronology of events
The Falklands Conflict, 2 April to 14 June 1982, followed the invasion of the Falkland Islands by Argentina on 2 April 1982. It
was a unique period in the history of Britain and Argentina and, although war was never formally declared, the brief conflict saw
nearly 1,000 lives lost on both sides and many more wounded.
18 May
March 1982
Davidoff workers land on South Georgia
illegally. HMS Endurance sent to South
Georgia. Argentine naval vessels sent to
'protect' the workers.
April 1982
2 April
3 April
5 April
8 April
9 April
10 April
12 April
19 April
23 April
25 April
29 April
30 April
Argentine Forces occupy the Falkland islands.
Debate in House of Commons. UN
Resolution 502. Argentine forces take South
Georgia
Lord Carrington, Humphrey Atkins and
Richard Luce resign. Ships of the Royal Navy,
including the aircraft carriers HMS Hermes
and HMS Invincible, leave Portsmouth and
elsewhere.
US Ambassador Haig arrives in London to
begin his diplomatic 'shuttle' between the
nations.
Haig arrives in Buenos Aires.
EEC declares sanctions against Argentina.
Britain declares maritime exclusion zone 200
miles around Falklands.
EEC foreign ministers declare support for
Britain.
Britain warns Argentina that any warship or
military aircraft representing a threat to the
task force would be dealt with accordingly.
South Georgia recaptured, Argentine
submarine Santa Fe damaged.
Argentina rejects Haig's peace proposals.
Britain declares total exclusion zone. US
announces support for Britain.
May 1982
1 May
2 May
4 May
7 May
14/15 May
16 May
17 May
i
First British attacks.
Argentine cruiser General Belgrano sunk.
HMS Sheffield hit by Exocet missile.
British Government warns Argentina that any
warships or military aircraft more than 12
miles from Argentine coast could be regarded
as hostile. UN Secretary-General begins talks
with Britain and Argentina.
SAS raid on Pebble Island supported by naval
gunfire. Several Argentine Pucara aircraft
damaged or destroyed.
Final British proposals worked out.
Proposals sent to Argentina.
20 May
21 May
23 May
25 May
27 May
28 May
Argentine government rejects British
proposals.
UN Secretary-General admits failure of UN
talks.
Beachhead establishes at San Carlos. HMS
Ardent sunk, fifteen Argentine planes shot
down.
HMS Antelope damaged (explodes and sinks
next day). Seven more Argentine aircraft shot
down.
HMS Coventry sunk by air attack and
container ship Atlantic Conveyor destroyed by
Exocet missile.
British Forces move forwards to Teal Inlet and
Mount Kent.
British victory at Battle of Goose Green (2
Para).
June 1982
1 June
4 June
8 June
11/12 June
13/14 June
14 June
17 June
20 June
22 June
25 June
July 1982
26 July
5 Infantry Brigade arrive at San Carlos.
Britain and USA veto UN call for immediate
cease-fire.
Royal Fleet Auxiliaries Sir Galahad and Sir
Tristram bombed at Fitzroy.
Mount Harriet, Two Sisters and Mount
Longdon taken by British forces. HMS
Glamorgan hit by land-launched Exocet.
Tumbledown Mountain, Wireless Ridge and
Mount William taken by British forces.
General Menéndez surrenders to MajorGeneral Jeremy Moore
General Galtieri resigns.
Southern Thule retaken. EEC lifts economic
sanctions against Argentina.
General Bignone replaces General Galtieri.
Governor Rex Hunt returns to Port Stanley.
Ceremony of thanksgiving at St. Pauls in
London.
October 1982
12 October
Victory parade in London.
November 1982
4 November
A resolution calling for a peaceful solution to
the sovereignty dispute voted by UN General
Assembly.
JR Army Med Corps 153(S1): i
ROLL OF HONOUR
Royal Navy
HMS Coventry
MEM(M)1 F O ARMES
ACWEA J D L CADDY
MEM(M)l P B CALLUS
APOCA S R DAWSON
AWEM(R)1 J K DOBSON
PO(S) M G FOWLER
WEM(O)1 I P HALL
LT R R HEATH
AWEM(N)1 D J A
OZBIRN
LT CDR G S ROBINSONMOLTKE
LRO(W) B J STILL
MEA2 G L J
STOCKWELL
AWEAl D A
STRICKLAND
AAB(EW) A D
SUNDERLAND
MEM(M)2 S TONKIN
ACK I E TURNBULL
AWEA2 P P WHITE
WEA/APP I R WILLIAMS
LT CDR D I BALFOUR
POMEM(M) D R BRIGGS
CA D COPE
WEAl A C EGGINGTON
S/LT R C EMLY
POCK R FAGAN
CK N A GOODALL
HMS Fearless
MEA(P) A S JAMES
ALMEM(M) D MILLER
HMS Argonaut
AB(R) I M BOLDY
S(M) M J STUART
HMS Antelope
HMS Glamorgan
POAEM(L) M J ADCOCK
CK B EASTON
AEM(M) M
HENDERSON
AEM(R)1 B P HINGE
LACAEMN D LEE
AEA(M)2 K I McCALLUM
HMS Sheffield
CK B J MALCOLM
MEM(M)2 T W PERKINS
L/CK M SAMBLES
L/CK A E SILLENCE
STD J D STROUD
LT D H R TINKER
POACMN C P VICKERS
STD M R STEPHENS
Atlantic Conveyor
AEM(R)1 A U ANSLOW
CPOWTR E FLANAGAN
LAEM(L) D L PRYCE
Royal Marines
Royal Marines
HMS Ardent
AB(S) D D ARMSTRONG
LT CDR R W BANFIELD
AB(S) A R BARR
POAEM(M) P BROUARD
CK R J S DUNKERLEY
ALCK M P FOOTE
MEM(M)2 S H FORD
ASTD S HANSON
AB(S) S K HAYWARD
AB(EW) S HEYES
WEM(R)1 S J LAWSON
MEM(M)2 A R
LEIGHTON
AEMN(I) A McAULEY
ALS(R) M S MULLEN
LT B MURPHY
LPT G T NELSON
APOWEM(R) A K
PALMER
CK J R ROBERTS
LT CDR J M SEPHTON
ALMEM(M) S J WHITE
ALMEM(L) G
WHITFORD
MEM(M)1 G S
WILLIAMS
HMS Hermes
LT CDR G W J BATT
POACMN K S CASEY
LT N TAYLOR
HMS Invincible
LT W A CURTIS
LT CDR J E EYTONJR Army Med Corps 153(S1): 13-15
JONES
NA(AH)1 B MARSDEN
CPL J G BROWNING
MNE P D CALLAN
MNE C DAVISON
SGT R ENEFER
SGT A P EVANS
CPL K EVANS
CPL P R FITTON
LT K D FRANCIS
L/CPL B P GIFFIN
MNE R D GRIFFIN
A/SGT I N HUNT
C/SGT B R JOHNSTON
SGT R A LEEMING
CPL M D LOVE
MNE S G McANDREWS
MNE G C MacPHERSON
L/CPL P B McKAY
MNE M J NOWAK
LT R J NUNN
MNE K PHILLIPS
SGT R J ROTHERHAM
MNE A J RUNDLE
CPL J SMITH
CPL I F SPENCER
CPL A B UREN
CPL L G WATTS
MNE D WILSON
Army
Scots Guards
GDSM D J DENHOLM
GDSM D
MALCOLMSON
L/SGT C MITCHELL
GDSM J B C REYNOLDS
SGT J SIMEON
GDSM A G STIRLING
GDSM R TANBINI
WO11 D WIGHT
13
ROLL OF HONOUR
Welsh Guards
L/CPL A BURKE
L/SGT J R CARLYLE
GDSM I A DALE
GDSM M J DUNPHY
GDSM P EDWARDS
SGT C ELLEY
GDSM M GIBBY
GDSM G C GRACE
GDSM P GREEN
GDSM G M GRIFFITHS
GDSM D N HUGHES
GDSM G HUGHES
GDSM B JASPER
GDSM A KEEBLE
L/SGT K KEOGHANE
GDSM M J MARKS
GDSM C MORDECAI
L/CPL S J NEWBURY
GDSM G D
NICHOLSON
GDSM C C PARSONS
GDSM E J PHILLIPS
GDSM G W POOLE
GDSM N A ROWBERRY
L/CPL P A SWEET
GDSM C C THOMAS
GDSM G K THOMAS
L/CPL N D M THOMAS
GDSM R G THOMAS
GDSM A WALKER
L/CPL C F WARD
GDSM J F WEAVER
SGT M WIGLEY
GDSM D R WILLIAMS
Army Air Corps
L/CPL S J COCKTON
S/SGT C A GRIFFIN
Royal Signals
S/SGT J I BAKER
MAJOR M L FORGE
L/CPL J B PASHLEY
S/SGT J PRESCOTT
SPR W D TARBARD
CPL S WILSON
PTE M A JONES
PTE P W MIDDLEWICK
Royal Army Medical Corps
L/CPL I R FARRELL
MAJOR R NUTBEEM
3 Para
PTE R J ABSOLON
PTE G BULL
PTE J S BURT
PTE J D CROW
PTE M S DODSWORTH
PTE A D GREENWOOD
PTE N GROSE
PTE P J HEDICKER
L/CPL P D HIGGS
CPL S HOPE
PTE T R JENKINS
PTE C D JONES
PTE S I LAING
L/CPL C K LOVETT
CPL S P F McLAUGHLIN
CPL K J McCARTHY
C/SGT I J McKAY
L/CPL J H MURDOCH
L/CPL D E SCOTT
PTE I P SCRIVENS
PTE P A WEST
Royal Air Force & Others
Royal Air Force
Army Catering Corps
L/CPL B C BULLERS
PTE A M CONNETT
PTE S ILLINGSWORTH
LT COL H JONES
PTE T MECHAN
PTE D A PARR
CPL S R PRIOR
PTE F SLOUGH
L/CPL N R SMITH
CPL P S SULLIVAN
CAPTAIN D A WOOD
L/CPL A R STREATFIELD
Royal Engineers
SPR P K GHANDI
SPR C A JONES
CPL A G McIIVENNY
CPL M MELIA
LT J A BARRY
L/CPL G D BINGLEY
L/CPL A CORK
CAPTAIN C DENT
PTE S J DIXON
C/SGT G P M FINDLAY
PTE M W FLETCHER
CPL D HARDMAN
PTE M HOLMANSMITH
CPL D F McCORMACK
Royal Electrical and Mechanical Engineers
CFN M W ROLLINS
CFN A SHAW
2 Para
PTE K PRESTON
FLT LT G W HAWKINS
Falkland Civilians
DOREEN BONNER
MARY GOODWIN
SUE WHITLEY
Royal Fleet Auxiliary
RFA Sir Galahad
3RD ENG C HAILWOOD
2ND ENG P HENRY
3RD ENG A MORRIS
Atlantic Conveyor
1ST RADIO OFF R R HOOLE
Gurkha Rifles
L/CPL BUDHAPARSAD
LIMBU
14
ROLL OF HONOUR
Merchant Navy
Atlantic Conveyor
BOSUN J DOBSON
MECHANIC F FOULKES
STD D HAWKINS
MECHANIC J HUGHES
CAPT I NORTH
MECHANIC E VICKERS
Chinese
RFA Sir Tristram
RFA Sir Galahad
YU SIK CHEE
YEUNG SWI KAMI
LEUNG CHAU
SUNG YUK FAI
Atlantic Conveyor
HMS Sheffield
NG POR
CHAN CHI SING
Special Air Service
Special Air Service
A/CPL R E ARMSTRONG
A/SGT J L ARTHY
A/WO1 I M ATKINSON
A/CPL W J BEGLEY
A/SGT P A BUNKER
A/CPL R A BURNS
SGT P P CURRASS
A/SGT S A I DAVIDSON
WOll L GALLAGHER
CAPTAIN G J
HAMILTON
A/SGT W C HATTON
A/SGT W J HUGHES
A/SGT P JONES
L/CPL P N LIGHTFOOT
A/CPL M V McHUGH
A/CPL J NEWTON
A/WOll P O'CONNOR
CPL S J G SYKES
CPL E T WALPOLE
LAI CHI KEUNG
HMS Coventry
KYE BEN KWO
15
Introduction
These papers were published in the Journal of the Royal Army
Medical Corps in the months following the Falklands War. In
many respects they reflect medical practice at the time.
Unfortunately, they also draw attention to lessons we seem
compelled to relearn on a regular basis.
16
There are, essentially, two groups of papers. The first, personal
experiences provide a vivid description of life as a medical officer
in conflict twenty five years ago. The second are papers which
review particular areas of the practice of military medicine and
surgery. Where appropriate, these are accompanied by a modern
commentary.
THE FALKLANDS WAR
Original Contributors
AFG GROOM. Commissioned July 1974. Retired in the rank
of Lieutenant Colonel June 1993. Consultant Orthopaedic
Surgeon.
MD JOWITT. Commissioned 1972. Retired Lieutenant
Colonel 1989. Recalled April 1995. Retired as a Lieutenant
Colonel November 1995. Consultant Anaesthetist.
CG BATTY. MB ChB 1973. FRCS Glas 1984. SSC 2nd Lt 9
P ABRAHAM. National Service Commission August 1958.
Retired as a Brigadier February 1992. Director Army Psychiatry
1984-92. QHP.
Nov 1970
DS JACKSON Commissioned 1979. Retired as a Lieutenant
Colonel 1988. Consultant Surgeon
P CHAPMAN. Commissioned October 1972. Retired
Lieutenant Colonel July 1995. Consultant Surgeon 1988.
IP CRAWFORD. Commissioned October 1960.
Commandant and Post Graduate Dean RAM College 1989-93.
GM. QHP 1991.
RJ KNIGHT. Commissioned 1966. Retired as a Lieutenant
Colonel May 1982. Consultant Anaesthetist.
JB STEWART. Commissioned October 1958. Retired June
1983 in the rank of Colonel. Consultant Pathologist. Professor
of Army Pathology 1981-83.
R SCOTT. Commissioned October 1956. Retired August 1989
in the rank of Major General. Commandant and Post Graduate
Dean RAM College 1982. QHS.
JE BURGESS. Commissioned September 1975. Director
Primary Care – Health Alliance 1998.
RP CRAIG. Commissioned March 1963. Retired in the rank
of Major General September 1994. Director Army Surgery
1992-93. Commander Med UKLF 1993-94. QHS 1992.
JM RYAN. MB ChB 1970. FRCS 1978. SSC 2nd Lt (Cadet)
October 1967. DA Surg 1994-95.
JT COULL. Commissioned March 1960. Retired in the rank
of Major General December 1988. Consultant Orthopaedic
Surgeon. Director of Army Surgery 1988-92. CB 1992.
WSP MCGREGOR. MB ChB 1958. FRCS Ed 1967. SSC
Lt 29 Jan 1959. Cons Surgeon. Retired 1 Oct 1992. Died 4
March 2005.
M BROWN. National Service Commission January 1956.
Retired August 1980 as a Major General. Director of Army
Medicine , RAM College.
93
THE EVE OF THE SINKING OF THE ‘SIR GALAHAD’
Sir Galahad, Sir Galahad
My heart for you doth weep
You’re going to die tomorrow
So that fifty souls can sleep
But when you die Sir Galahad
The picture God will see
Mankind washing its conscience
In this cold and bitter sea
For on a cold June morning
Rained madness from the sky
Our soldiers, screamed and perished
You heard and knew not why
So Sir Galahad we will sink you
We will send you to the deep
Lay quiet in your watery grave
And guard our soldiers sleep
You burnt and writhed and twisted
And you knew all their pain
But you kept it all within you
Your memories and our slain
For your name will stand in history
As guardian of our slain
You will die with honour
While men will bare the shame
Your burning funeral pyre
Was there for all to see
A reminder of man’s inhumanity
And of how stupid we can be
(This poem was written by Jack Crummic, bosun on the
Tugboat “Typhoon” and handed to WO2 Viner.)
17
The Battle for Goose Green – The RMO’s view
Capt SJ Hughes
Abstract
Summary: By virtue of the Battalion I serve with, I was the first Task Force Doctor on to the Falklands. On Friday the
21st May, 2 Para made an assault beach landing, thankfully unopposed, on San Carlos beach, the RAP was with them
Introduction: As 2 Para occupied the Sussex Mountains for six days and on Wednesday 2 May, moved off at last light
to Camilla Creek House, 5 miles from Darwin. The Battalion laid up in the area of Camilla Creek during 27 May and early
the next morning moved out to create history….
Goose Green – Friday 28th May, 1982
We set off from Camilla Creek House at about 2 a.m. tired
before we started after the previous night’s TAB. On our backs
the RAP (Regimental Aid Post) Medics were all carrying in
excess of 80lbs of medical kit and the uneven ground ensured
that we all fell regularly.
We laid up near the mortar line just north of the Darwin
Peninsula whilst A and B Companies put in their first attacks.
There was a steady drizzle, and those of us who had worn our
waterproofs were glad of them – some of us even dozed.
About 2 hours after the initial H hour, Battalion Main HQ,
(including the RAP) moved off and down the narrow track onto
the Peninsula itself. To our left, a large area of gorse had been
ignited by white phosphorous grenades and the flames lit up the
night sky. The crackle of burning gorse could be heard above the
reassuring crump of the naval gunfire support. We had just come
level with the first cache of Argentinian prisoners, on the edge of
the track, when the first salvo of the Argentinian guns bracketed
the track.
We heard the distant crump and the incoming whistle and
barely hit the ground before the first rounds of “HE” hit the peat
either side of the track. We wormed our bodies in, face down to
the banks on either side of the track, so that our Bergens gave
our backs some protection. The reality of the war began to sink
in.
Again we were bracketed, but miraculously nothing landed on
the track, and the soft, wet peat, off the track, kept the shrapnel
to a minimum. We had no casualties.
A tracer round cracked 6 ins over my head from somewhere
off to the right – a stray round buried my head further into the
earth.
The first two attacks had had no casualties, but now D Coy
came up against stiffer opposition and Chris Keeble, the Bn
21C, asked me to move forward up the track to deal with the
first casualties. His parting words, as I led the RAP off were,
“Watch out for the sniper on the right flank.”
I then realised where that not so stray round had come from,
and was convinced that the collar of my waterproof jacket, white
on the reverse, would make me a perfect target. It may well have
but nothing happened.
We ran low and fast for about 400 metres, until we came
across the two D Coy wounded, both minor gunshot wounds. It
was about 6 a.m. still with a further 4 hours of darkness – so after
finishing our treatment regime, all we could do was reassure
them and keep them warm and sheltered from the rain until
dawn, when the first choppers would fly.
The CO, ‘H’ appeared, with his TAC HQ and came to find
18
out how the casualties were – “Alright Sir, we’ll try and get them
back to Camilla Creek in the captured Landrover.” He and the
Adjutant, one of my close friends, David Wood, were joking
about a shell that had landed between them, yet left them both
unscathed. “These Argies have got some shit ammunition.” It
was to be the last time I would see either of them alive again.
TAC 1 disappeared and Battalion Main moved in around us.
Time drifted by and the shelling periodically came our way. As
the sky started to brighten we lost the benefit of the naval gun
support and at dawn we found ourselves in a natural bowl of
land to the north of Coronation Point.
One or two more casualties were brought in, together with our
first dead. Two of my Medics had lost friends and I had lost some
of my own patients – we were all affected. We improvised shelter
for the wounded using a captured Argie tent until at first light
helicopters came in bringing ammunition resupply. We got the
casualties into the Choppers and I went back to my routine of
listening in to the Battalion Command net – Reading the Battle.
There was a big battle raging ahead of us, and nothing seemed
to be moving. We all began to dig into the peat because the
shelling was now more constant, our own guns becoming less
vociferous.
Shortly after 1300, I heard the message over the net “Sunray
has been hit.” The Battalion called for a helicopter to pick him
up and it became obvious that there were other casualties in
trouble. I rounded up my Medics and split them up into two
teams – one under my command and the other under Capt Rory
Wagon, the Doctor who had been attached to us from Ajax Bay
Field Hospital (Table 1).
Table I
2 Para Regimental Aid Post (2 & 9)
Team A
RMO (Doctor)
Radio Op
L/Cpl – RMA
Pte – RMA (3)
Team B
Attached Doctor
Radio Op
Cpl – RMA
Pte – RMA (2)
Table 1. Padre and his bodyguard moved with Team A. RAP Deployment
possibilities – 1. A & B Co-located. 2. A & B Deployed independently. 3. A &
B “Leapfrog” One moves, other deals with casualties.
Both forward companies had casualties in locations 1½ km
apart. Rory’s team went out to the right flank and I moved my
lads out to the left, to the hills around Darwin. As we moved
forward we had to dive for cover as two Pucara aircraft appeared
ahead. They roared over us and I turned in time to see them
spot two scout helicopters emerge from the direction of Camilla
Creek House. The Pucara swooped, like hawks, and the
choppers took desperate evasive action. One chopper
disappeared up the valley whence it had come and managed to
escape. The other chopper exploded in a ball of flame. The
Pucara disappeared.
We found ‘A’ Company on a hill 1 km to the west of Darwin,
their casualties collected together at the base of the hill,
amongst them the Company Medic. Again the shock of dealing
with people you knew in a far from clinical environment – but
we steeled ourselves and went to work.
We dealt with the casualties and I’d once more called for
helicopters. Ahead of us the battle carried on. There was no sign
of ‘H’ so I asked the Sgt Major. “H is dead, Sir, and Captain
Wood, and Captain Dent” – the CO and two good friends all
at once; - but there was nothing else but to continue the job.
The casualties had all had their wounds dressed and drips set
up. We’d given them pain killers and filled them full of
antibiotics. We tried to keep them dry and warm and kept up a
steady banter to reassure them, especially a lad with a head
injury, who I didn’t want to go into a coma.
By now we were beginning to run low on medical supplies –
there’s a limit to how much you can manpack. At least no more
casualties had come in, although there were some wounded
amongst the Argie prisoners for whom we did what we could.
Then over the hill came what for me will always be the
Seventh Cavalry – 4 scout helicopters, fitted with Casevac Pods
and bringing our medical resupply. We got all the wounded
away and even some of the more seriously wounded Argie
prisoners. Then the shelling started again and we moved up the
hill slightly, into a gully which gave natural cover against low
trajectory artillery fire.
It was here that we spent the rest of the day. The helicopters
coming in under cover of the hill.
We continued to treat casualties, our own, and in quiet
phases Argentinians, with the smoke of the battle field and the
burning gorse at times almost fogging us out. Fatigue was
setting in and we all wondered how much longer this could go
on. For most of the afternoon the battle had seemed to be going
against us, but, as dark set in, it swung back in our favour and
as darkness fell the artillery fell silent and gunfire became
sporadic. We were still holding three battle sick – twists and
sprains – and though we tried for a helicopter we knew they
would keep, if it didn’t arrive.
We were all expecting the battle to start afresh the next day,
so we set up a stag system to look after the casualties and laid
down in the gorse to sleep, after I’d first sat down with the RSM
and the Padre to work out who our dead were.
The day had been long and hard, tragic and frightening, the
night was bitterly cold, and we none of us had sleeping bags.
Some people lay down actually in burning gorse to keep warm.
I lay down in a clump of non-burning gorse and thanked my
stars for the space blanket I’d bought in the UK and shoved in
the back of my smock!
I managed to wrap my body in this totally non-tactical piece
of foil. The silvered surface caught the flicker of gorse flames
and I crinkled like a Sunday roast, but it made the temperature
bearable.
Although I was exhausted I wondered whether I would sleep
after the horrors of the day and as I lay in a twilight state every
rustle of my foil blanket was a machine gun and every gorse was
an artillery shell. I was aware of the tricks my mind was playing
on me – and I wondered if I was cracking up.
I slept.
I awoke in the half light of mid-morning and couldn’t feel my
feet. Then I could and they were painful. Around me the RAP
was stirring.
Chris Keeble happened by and told the Padre and I of his
plan. He would give them the opportunity of an honourable
surrender.
There followed a void; a lack of hostilities. Whilst the
Battalion took the time to fly in ammunition, we took the time
to fly out our casualties and do what we could for the remaining
injured amongst the prisoners.
It was as we were treating the prisoners that we heard the
news of the surrender. The battle was over. Although our work
was not quite finished yet, at least it would not get any worse.
All told we treated 33 of our own (Table 2) and over twice
that number of Argentinians.
Wounded
Killed in
Action
All Wounds
Fatal and
Non-Fatal
Gunshot
Wounds
*16
12
28 (56%)
Shrapnel/Frag
ments
*17
4
21 (42%)
Shot down –
Helicopter
Pilot (Massive
injuries)
0
1
1
33 (66%)
17 (34%)
50
Totals
Table 2. There were no burns, psychiatric or mine injuries. One case of a fatality
caused by close proximity explosion of a 30mm anti-aircraft shell has been
included as a fragment wound.
*All survived.
19
2 Para Memorial at Goose Green
20
My experiences in the Falkland Islands War (Operation
Corporate)
Captain J Burgess RAMC
It all began for us on the Second of April 1982, when we heard
that the Argentinians had invaded the Falkland Islands. Most
had never heard of these remote parts and had not been
following the events of the previous week when the
Argentinians had moved into the Island of South Georgia.
At the time of the Invasion 3 Para were on Spearhead, as well
as being part of the Parachute Contingency Force. All the
medical boxes had already been packed and were fully scaled for
a quick move. At 16.45 that Friday I asked the Intelligence
Officer whether we would be required that weekend and he said
there were no plans for the battalion to be deployed. I left for
London. Minutes later a call came through from UKLF putting
the unit on a greater stage of alert. A message was phoned to me
in London and I hastily returned to Tidworth.
Nothing happened until the following morning when the
CO spoke to his officers, though he knew few facts. Every
organisation in the battalion hastily obtained further war
stocks, and on the medical front this meant taking a trip to
Ludgershall to collect a large number of individual first aid
packs and extra dressings and drips.
These preparations went so smoothly that by the following
day they were nearly completed. Meanwhile, a small group of
the unit had flown to Gibraltar on the Friday night to
requisition the SS Canberra and arrange the accommodation.
There followed a few days of waiting; would we go or was it a
preparation for nothing? Eventually the date for leaving
Tidworth was agreed and on Wednesday, 7th we boarded the
coaches for Southampton,
This was a moving experience, large crowds turning up to
wave goodbye as the police-led convoy drove to the docks.
Once on board the Canberra it all shook into place, with the
Regimental Aid Posts of 3 Para, 40 and 42 Commando
occupying the crews’ hospital in the stern of the ship. This
arrangement worked extremely well with sufficient space for
each unit. The medics shared cabins while the doctors were in
the old First Class areas of the ship. Drugs and other medical
stores required for the journey were removed from the hold and
brought to the crew hospital. On Good Friday we sailed away
from Southampton to great cheers from a massive crowd that
lined the shores on either side of the water. Car hooters blew,
lights flashed and the cheers could be plainly heard coming over
the calm water. If this was going to war it was a great way of
setting about it.
Life soon became more of a routine with morning sick
parade, and then the rest of the day split into physical training
and lectures on various topics from interrogation to first aid.
Everyone received extra medical lectures and soldiers have never
been so keen to learn all about these important matters. An
extra team of stretcher bearers was found on the voyage and
these consisted of the cooks, mess staff and soldiers from the
Pay Corps. They were to do sterling work on the slopes of
Mount Longdon. A few medical problems were encountered on
the way: one soldier developed appendicitis and was operated
on by a Royal Navy Surgeon in the passenger hospital on SS
Canberra; he recovered in time to be fit enough to go ashore
with the rest of the force. The ship put into Freetown for the
day to refuel, and this necessitated the taking of anti-malarial
prophylaxis until the Falklands were reached, though there were
no cases of malaria encountered. The Canberra reached
Ascension Island after about ten days at sea, and there we stayed
for about two weeks until the other ships of the task force
caught up with the forward elements. The island provided a
much needed break ashore, but took its toll. Many went down
with foot problems; the combination of wearing light training
shoes on the ship, and the extreme dry heat of the tropical
island ripped the feet to shreds, and some of these problems
were only just cured by the time we reached our destination.
It would be wrong to think that life at this time was serious
quite the reverse. Most felt that while we were at Ascension
Island, the talking was taking place and we were only out on a
very pleasant cruise. There was much to do, whether it was
lying in the sun, watching films or improving the profits in the
bars. At one stage there was a threat of a submarine attack and
the ship sailed the ocean around the island. No one objected as
it improved the airflow in the ship. The ‘Canberra Medical
Society’ was formed from the doctors of the services and the P
and O staff, and this organisation arranged talks of various
degrees of seriousness.
Shortly, however, this fun was to stop. Notice was given that
the Canberra was due to set sail, and in a southerly direction.
This was the signal for life to become more serious. The lights
were dimmed properly and all became aware that war was
imminent. By day one could see 19 ships around the Canberra,
but it was also appreciated that there were plenty more beneath
the horizon and the surface. Most noticeable was the Elk, the
ferry that contained all of our larger cargo items and which had
been with us since the start of the voyage. The Norland was also
there carrying our sister battalion 2 Para. HMS Fearless, HMS
Intrepid and countless others protected us. A blood donor
session was arranged, taking 360 units from the battalion, and
about 1000 in all. The date of the session was so keyed as to
allow full recovery of the soldiers, yet the blood be suitable for
the expected date of the battle. On leaving Ascension Island
plans for the military operation came into the open. The
Commanding Officer, Lt. Col. Pike briefed us on the detailed
plan to land at Port San Carlos. The medical staffing was altered
as well as getting the team of stretcher bearers. We gained CSgt
Faulkner who had been in the RAP in Northern Ireland, and
who was currently out of a job, being on the air staff arranging
parachute manifests. This enabled us to double up on the
numbers in the rifle companies from one medical assistant to
two per company. The RAP was then going to consist of
Captain Burgess, Padre Heaver, CSgt Faulkner, Sgt Bradley and
Pete Kennedy.
At the earliest ‘O’ Groups we were told that we would be
going ashore in Landing Craft (LCU) from the sides of the
Canberra in the dark, and this procedure had been practised
while at Ascension, but two days from the planned landing it
was changed, the thought being that there were too many
troops on the one ship. Consequently 3 Para were transferred to
21
HMS Intrepid by means of LCU. Here we got our first
impressions of the conditions that the sailors had to endure
with a ship sailing with a far greater complement than it had
been built for. Even so the reception we received was superb in
view of the difficulties of having to house an extra Battalion
Group. It was while we were on this ship that a tragedy
happened. One of the Sea King helicopters flying with
members of the SAS on board came down at night after hitting
an albatross. The loss of these 21 experienced soldiers was a
hard blow especially as they were personally known to many on
board. It was a greater shock than the loss of HMS Sheffield.
Meanwhile the operation of the SAS to capture Fanning Head
still went ahead as planned. The night of D-1 was a long night
to remember. Since arriving on HMS Intrepid we had been
ready to go into action, and now was the period of attempting
to get some sleep while waiting for the time to go ashore and
face the unknown. We were sitting in the Wardroom, reading,
waiting, knowing that it was foggy outside, but that the fog
could lift at any moment and give our position away;
continually waiting for the bombs or torpedo to come at any
second as we slipped into the sound.
Eventually it was time to move and pick up one’s heavy
Bergen and proceed down to the Tank Deck and be loaded
aboard one of the LCUs. There was a slight hold up with 2 Para,
and their unloading of the Norland with her narrow gangways
and this resulted in 3 Para being further delayed. The company
medics went with their respective companies, and the RAP
followed up a few minutes later. By the time our boat floated
out of the stern of HMS Intrepid it was broad daylight. Apart
from the noise of the engine all was silent. It was a distinctly
eerie feeling as we sailed past other ships in the sound and made
our way up to the beach head about 3km from the settlement
of Port San Carlos. Birds hovered overhead, but there were no
aircraft.
Our landing craft reached the shore with no difficulty and the
RAP regrouped on the land just as the guns of a frigate opened
up on the enemy position on Fanning Head where there was
still resistance. A Pucara suddenly came from the East and
attempted to gun our positions but without damage. The Royal
Artillery and their Blowpipe returned the fire, but the effect at
that stage was more devastating on 3 Para than on the enemy.
Luckily no one was injured in the fighting. Our objective was
to move into the settlement and this was quickly achieved, the
40 enemy present in the village rapidly fleeing. However, they
brought down two Gazelle helicopters who were escorting a Sea
King with an underslung load; there was no explanation as to
why the helicopters were so far forward over enemy held
territory. After one pilot was brought down the enemy opened
fire on him in the water with a machine gun as he tried to swim
ashore. He was dragged out by the locals and taken to the bunk
house – the site designated to be the RAP but he died before
medical help could arrive. Meanwhile the mortars kept firing
on to the fleeing Argentinians. Later that day the battalion
established itself on the higher ground around the settlement,
and the RAP took up residence in the bunk houses with four
members of the press.
This building proved ideal in many respects, in that it
provided shelter and good clean facilities, but its main
disadvantage was that it was on the seafront and clearly visible
to any attacking Mirage and Etendard bombers. Air raids
continued that day, and for the next week, although no damage
was done.
On Sunday 23 May 3 Para sustained the first of its casualties
when there was an incident involving ‘A’ and ‘C’ Companies
and a map reading error. The end result was that 8 soldiers were
wounded, two receiving 7.62 rounds to the head, one serious
22
abdominal wound and the other limb injuries, some serious.
After it became clear that the enemy were not in the area, a Sea
King helicopter arrived in Port Sam Carlos and flew the CO
and half the RAP and stretcher team to the scene. The aircraft
was full, and the pilot presumably tired. To avoid Argentinian
detection he flew extremely low and as he approached the
casualties behind a slight rise the tail of the plane hit the
ground. This immediately caused the aircraft to lose control; it
took off again and began to spin before crashing to earth once
again. Luckily no one was injured in the crash and the
helicopter did not catch fire. The wounded were then given
further treatment and evacuated on other helicopters. They all
survived although the two with head injuries are left with severe
disability. The RMO and stretcher bearers were then flown back
to the bunk house in Port San Carlos where we were then
bombed, this time the bombs only just missing the house. It
was a day to remember!
The rest of the time in Port San Carlos went off really
without incident, apart from the bombing raids. The next move
for the battalion was to be a foot march across the island to the
East. The Company medics went with their companies and the
medical sergeant accompanied battalion headquarters; apart
from many foot problems encountered with the cold and wet
conditions there were few medical emergencies, the only
incident of note was an accidental discharge when the culprit
managed to shoot through his left shoulder with an SLR. As
soon as the battalion went firm in the settlement of Teale Inlet
the RMO flew in to treat some of the foot problems. He arrived
as the last of the enemy were fleeing to the East. Here the RAP
was set up in the bunk house and it was shared with a section
of the Special Boat Service who were mounting operations
throughout the time of our stay. The only problems were the
intense cold as it had started to snow hard that night, a number
of minor leg wounds caused by a sub machine gun and the local
population who had not seen a doctor for some weeks.
It initially seemed that we would be staying in the location for
a number of days to sort out the foot damage, but that evening
word came through from Brigade Headquarters that we were to
proceed onwards with all speed to Estancia House. The soldiers
marched onwards, often in agony. At Estancia House there was
a far smaller settlement consisting of one house and a large
barn. Part of the house became the RAP, and the barn an admin
shelter. It was here that we received news of the losses at Bluff
Cove which would mean inevitable delays. We were bombed at
night, but it was ineffective except in scaring the civilian
population, especially the children.
Estancia House brought changes to the medical organisation
of the battalion, and Captain Michael Von Bertele arrived with
two extra medics from 16 Field Ambulance. These were to
prove invaluable on Mount Longdon. Little happened in the
wait before the battle. There were visits by General Moore,
Brigadier Thompson, and the CO of the SAS; but this period
was used as a time to prepare the battalion for the rigours ahead.
There was a great delay, initially to await the arrival of two
Royal Marine units; and then to let 5 Infantry Brigade catch up
on their route from the South. The time was also used for
aggressive patrolling behind the enemy lines on the hill, and
attempting to find a way up the cliffs that buttressed the
mountain.
Eventually a medical plan was evolved which essentially made
two RAPs. Captain Burgess with his own staff would march on
the hill under the direction of Major Dennison the OC SP Coy.
As much medical equipment was to be taken as possible, and
personal items were excluded. The stretcher bearers would also
come with the first wave on foot, carrying some medical stores
and stretchers of the folding airborne type, and also a large
quantity of belt ammunition for the machine guns. No Red
Cross markers were used by anyone in 3 Para. The rearward
RAP would follow up behind in Volvo BV tracked vehicles with
further stores and would have the capability to move through
the first RAP and set up independently if the advance
proceeded down Wireless Ridge.
After extensive medical briefings the various sections were
moved up from Estancia House to an area occupied by ‘A’ Coy.
This move was by BV, and during the deployment news came
through of one minor injury as a result of a shrapnel wound.
The form up area was about 8 km from the objective, and at
this point most of the battalion gathered, and here were also
included a large number of civilians who had agreed to help the
operation by providing their own tractors to transport items
such as mortar ammunition. It was a glorious evening as the sun
slowly set, and all enjoyed a last hot meal in the comfort of a
dug in position. Major Dennison gave a short talk to those
under his command, and as he did so shells started falling close,
but soon all fell silent once again. The still air was disturbed by
the arrival of a helicopter with a secret signal stating that on the
latest intelligence the objective had now been occupied by a
battalion of the very best Argentinian Marines, instead of the
company strength that we had all been expecting. The outcome
of this was a resolute ‘No Change.’
At 2030 Zulu timing the RAP formed up and took its place
in the march towards Mount Longdon.
Shortly after leaving ‘A’ Coy position the RAP was in dead
ground from Two Sisters which provided some protection from
enemy OP and detection. The march moved on steadily until
the Murrell River was reached which was crossed with little
difficulty and then continued eastwards. The stretcher bearers
with their difficult loads suffered more than most on the march,
but at about 0100 on the 12 June the RAP reached the first of
the objectives about 1½ km from the western edge of the
mountain.
It had been a dark night up until then, but the moon slowly
rose above the eastern edge of the mountain silhouetting the
objective. Suddenly the peace was shattered as ‘B’ Coy
approached the mountain from the western edge, hit a
minefield and gave away their presence. The attack then began
to close in from the west, and as the support weapons were
unable to give effective fire from 1500m out, SP Coy and the
forward RAP then prepared to move up the slope to the rocks
at the western edge of the mountain.
The small arms fire by this time had begun to get intense,
with tracer and parachute illuminant lighting up the sky from
all directions. The RAP closed in to its position, a location
where it would remain until the end of the battle. It took some
time to regroup all the stretcher bearers, and they were required
at once to collect the wounded from the minefield to the north.
Very shortly after arriving the first two casualties were brought
in. The first was one of ‘B’ Company medics Private
Dodsworth. He had been going forward to help the wounded
when he was hit in the pelvis and legs by small arms fire. He
went into unconsciousness at the RAP and was soon placed on
the first BV to be transported back to the helipad for further
evacuation. He died shortly after leaving the RAP.
The BV borne RAP came up the hill after this incident and
provided extra necessary help with the second doctor. On their
arrival the casualties began to be brought down in a steady
stream. Many were seriously injured, having had limbs
amputated in the minefields, and these were dressed further and
then evacuated in the next vehicle for the six hour journey back
to surgery. Some of the injured had been trapped in the
minefields and due to the sniping at night they could not be
evacuated as the attempts were beaten back repeatedly. News
came through that another of the medics had been killed by a
shell. LCpl Lovett from ‘A’ Coy, and that another was trapped
in a minefield and was being mortared, and had possibly been
killed. The stretcher team leader approached me and asked if he
should make a further attempt to retrieve the injured from the
minefield, but I replied that as the injured had already been
treated by the medic it would be foolish to waste further lives in
repeated attempts. Having had two killed and one missing I had
to preserve my medical strength. The injured were soon
removed when the snipers had been cleared from the hill,
luckily none were too badly injured. The battle then took
another phase as we won control of the hill except for a few
small pockets of resistance dug into the rocks. A very heavy
mortar and artillery barrage then commenced, the rounds
landing amongst the vacated Argentinian positions. These
claimed many lives, and seriously put at risk the viability of the
RAP.
One Argentinian, in attempting to escape ran through the
RAP, indeed came between the area of the mortuary and where
the RMO was attempting to treat the injured. He was shot by
one of the sergeants who was standing by, and dropped dead in
the middle of the RAP. The following day prisoners were to
bury him in a makeshift grave, and while the Padre was saying
a few words over the grave he was fired upon by a sentry
escorting further prisoners down the hill. This led to a counter
attack, as we looked in the direction of the shots, there were
twenty of the enemy to be seen. Although a large quantity of
ammunition was expended, no further casualties were reported.
During the whole of the daylight casualties continued to
arrive and these were evacuated as soon as possible by
helicopter, although for some there was a very considerable
delay. Every time a large helicopter arrived the position was
immediately mortared again, so it meant that only the Scouts
and Gazelles could be used. That night the shelling of the
position continued with air-bursts lighting the sky and shower
shrapnel around the rocks. One shell blew a medical assistant
off a rock with slight injury, but an even closer burst knocked
out the CSgt and he could not be found for six hours. A radio
message asked that the medical team pick up a patient who had
been injured and who was lying on the southern slopes of the
hill about 500 metres from the RAP. It was decided that the
medical sergeant should go out in one of the BVs to retrieve
him. On the way out they struck an anti-personnel mine doing
slight damage to the vehicle. On trying to reverse out another
exploded. The vehicle returned without the casualty, but the
medical sergeant was so badly shaken by these events and the
shelling that he had to be evacuated as a battle casualty. The
medical staff was now critical with two dead, one other case
evacuated and two hurt by shell fire.
That night an armourer passed through the RAP going to the
top of the hill when he was hit by mortar fire, lacerating one
femoral artery and fracturing the opposite femur. Two others
went to his aid but these were also hit by mortar fire, resulting
in both sustaining bilateral fractured femora. They were in close
proximity to the RAP when they arrived, but the first died very
shortly afterwards, and another in a helicopter as he was being
evacuated. The third survived with one amputation, and the
other leg severely damaged.
The following morning saw advances by 2 Para who had
passed through our position the previous day, and this took the
pressure off 3 Para RAP. That morning an air raid passed over
the position to strike at Brigade Headquarters, and then it all
began to quieten, the shelling becoming less frequent and
certainly less accurate as the enemy OPs were destroyed. The
CO then began to brief his officers on the attack on Moody
Brook, and the advance into Stanley itself, at least as far as the
racecourse. During this ‘O’ Group on the side of the mountain
the snow continued to fall, and everyone wondered how the
23
attack on Stanley would result as regards casualties. As the RAP
was waiting, news came through from 2 Para that they were
pushing forward into Moody Brook and large numbers of the
enemy were to be seen fleeing in the direction of Stanley.
Minutes later came the order to advance with full speed to
Stanley.
The medical orbit of the move altered in that the RMO rode
in the BV with his usual team, while Captain Von Bertele
moved off before on foot. During the move it was learned that
there were white flags to be seen over Stanley, and all rushed
forward down the slope into Moody Brook. The snow had
melted by this time, the sun was shining, but clouds of smoke
were clearly visible coming from the western edge of the city,
and from Moody Brook itself. The RAP vehicle being the first
of the BVs to get into Stanley was stopped by a helicopter
carrying the 3 Para flat, and this was attached to a Bangalore
torpedo and carried high, victorious into the city.
The city was a mess, with no sewage, water or electricity; the
battalion was forced to live in squalor with no food provided
either. Looting Argentinian sources was the only way out until
further supplies could catch up with the advance. Luckily there
24
was no shortage of Argentinian food in Stanley itself, the frozen
steak being a favourite of 3 Para. Unfortunately with all the
inadequate sanitation most of the battalion went down with
diarrhoea and vomiting, and there was little that could be done
to prevent this without a proper water supply provided by the
Royal Engineers.
On the first evening in Stanley the RMO and Captain Von
Bertele along with two guards crossed the ‘White Line’ that
separated the opposing forces in the city, by showing their
Geneva ID cards, and then went up the road to King Edward
VII Hospital. They were the first British soldiers into that area,
and the welcome bestowed will always be remembered. It was
one of the proudest moments of being a member of 3 Para. It
is impossible to convey in words those embraces and messages
of thanks from the medical staff and other civilians sheltering in
the hospital.
The Third Battalion the Parachute Regiment lost 23 killed
and 48 wounded in the battle for Mount Longdon plus 12
wounded before the assault, and countless who suffered with
their feet and will continue to suffer; but to liberate those
islanders in the hospital did seem to make it all worthwhile.
My thoughts on the Falkland Campaign
WSP McGregor, OBE FRCS (Ed), Lt Colonel RAMC Consultant Surgeon
The regular soldier spends much of his time training for war. It
is curious that the more training he undergoes, the less he
savours the thought of going to war because the greater is his
knowledge of the terrible destructive capability of modern war
weapons.
My call came as a member of the Parachute Clearing Troop –
16 Field Ambulance, not unexpectedly because I had followed
the build up in the national press consequent on the invasion of
the Falkland Islands by the Argentinian Forces. I had just
finished a busy Outpatient Clinic and sat in my office
completely drained of all compassion for the wives of majors,
corporals and the rest of humanity when the ‘phone rang.
“Come and join us” was the call, so off I went to war. We all
knew that we were going to sail to war but we also knew that
this was going to be a limited cruise. We should meet in
Aldershot, parade, embark and sail and that somewhere around
Ascension Island, the politicians would sort it all out and we
would all turn around and sail back again. With a bit of luck I
thought I might miss out on about two weeks of outpatients
clinics.
We duly paraded in Aldershot and for the first time in my
long association with the Airborne forces, the unit P.C.T. was
up to strength and had been completely equipped with all the
paraphernalia of war that we had been trying to fight off for at
least 10 years. After several false starts, we actually set off in a
convoy of coaches and reached that most admirable port,
Portsmouth. Much more, we were actually allowed to board the
ship as part of the 2nd Para Brigade Troop. The ship itself had
been recently acquired and converted from a North Sea Ferry –
the Norland. Built for the holiday trade, with accommodation
for 1,000 passengers, it suddenly had to accommodate 1,500
fairly carefree Paras, with all, if not more, of their equipment.
Amid scenes reminiscent of the Hollywood films showing the
departure of Kitchener’s force for the Sudan portrayed so well
in the original film Four Feathers, the Norland sailed. I cannot
say that I was unaffected. It was an emotional occasion. The
crowds cheered, the band of 2 Para played such stirring music
as “Don’t cry for me Argentina” and the RSM of 2 Para
marched along the deck saying “If you lean on the rails, I’ll
break your arms – stand up”. The Navy were particularly good.
Ships in the dockyard sounded their sirens, Naval shore
establishments lined the banks and cheered and the dockyard
labourers showed a pride in the work they had put into these
ships over the past two or three days.
The journey south was accomplished with surprising ease.
The holiday air persisted and as the climatic conditions
improved, the holiday atmosphere became even more marked.
The 2 Para group entertained the ship’s officers; the ship’s
officers entertained 2 Para group and eventually we both
entertained one another, but suddenly we found ourselves at
Ascension Island. The war climate had not improved. The
politicians had not resolved the problem. Suddenly there was a
vast increase in traffic signals, cross decking of the supplies
between ships became more urgent. Essential supplies such as
ammunition were suddenly dug out from the bottom of the
hold where they had been buried under piles of arctic
equipment and rations. The holiday atmosphere evaporated
quickly and very impressively. It changed to one of sheer
professionalism. Training became more popular and more
universal. Personnel began board drills with a more serious and
interested attitude. The lifeboats of Norland were swung out
and lowered, much to the amazement of the Captain who in his
seven years in command, had never seen them move from the
chocks. Much to the gratification of the Medical Services
suddenly the big Army began to take us seriously. First Aid
lectures became very much better attended and certainly the
officers in the bar of an evening began to cultivate the company
of the medical officers with rather searching questions.
The Medical Services, to their great credit, carried on as
usual. Trained as they were to a superb level, they tried to pass
this knowledge on to the people whom before had been too
busy to take any notice. When it became obvious that due to
our combination of postings, circumstances and bad planning,
medical potential of the 2nd Battalion Parachute Regiment was
less than adequate - an intensive training programme was
instituted. Much of the emphasis of this was on the setting up
of intravenous infusions. We had provided, thanks to the preplanning of Major Malcolm Jowitt, RAMC, a plastic arm in
which the insertion of intravenous infusions could be practised.
It was after one such session when a member of 2 Para turned
to his Regimental Medical Officer and said, “For all the good
I’m doing Sir, I might well be sticking it up his ------”. This led
to a short time vogue for rectal intravenous infusions. I would
like here and now to condemn this practice, if only that in the
Falklands, it would have led to a spate of frost bitten bums,
comp saturated colons, unfixable drips, and dead soldiers.
With this and many other merry japes, we eventually made or
way south and suddenly the merriment went out of the
situation. Following a training lecture by the Royal Naval
personnel on the invincibility of the Royal Navy ships, came the
news of the sinking of HMS Coventry. If this put a damper on
the situation, it also concentrated the attitudes towards training
even more. The actual run into the Falklands was, to say the
least, sporting, with false sonar alarms about submarines which
turned out to be whales, sleeping in lifejackets, sailing through
minefields and making the arrival at the shore somewhat of a
relief. There is no doubt that by the time disembarkation from
Norland for the beachhead on rather flimsy landing craft, in
pitch darkness and under fairly adverse weather conditions took
place, the professionalism of 2 Para group had reached its peak.
I have nothing but admiration for the soldiers of the Parachute
Battalion, for the Royal Navy and for the Merchant Navy
personnel who risked much to get us there.
The arrival in San Carlos water of the M.V Norland
highlighted the lack of communication between the different
branches of the regular soldiers. While 2 Para disembarked and
landed without incident, the first task of the P.C.T. was to
establish aboard the Norland a mini-field hospital. This was
done with the alacrity and expertise which one would expect of
the unit. After a day spent in consistent air attack, it became
obvious that the big ships would have to be withdrawn from
San Carlos water during daylight and finally the message we
had been trying to give to the Navy for some time got through
– if there were troops ashore, the medical expertise should also
be ashore. Besides, ships were dangerous. So, with a little
difficulty, Parachute Clearing Troop arrived at Ajax Bay – the
25
first surgical teams ashore. Again it is a tribute to the Airborne
soldiers that within an hour of landing, a surgical facility had
been set up. This formed the basis of the field hospital which
was eventually established at the old Refrigeration Plant at Ajax
Bay of the Parachute Clearing Troop plus a marine medical
support troop plus two surgical teams from the Royal Navy.
This is the unit which bore the main bulk of the surgical load
in the Falkland Campaign.
The time spent at Ajax Bay had its moments. quite apart
from the large casualty load, there came a time when the
Argentinian Air Force decide to remove the field hospital from
the order. Had their bombs had the right fusing, they would
have done this most successfully. However, the unit survived.
As the fighting advanced towards Port Stanley, it became
obvious that surgical support was necessary nearer the front
line. The only surgical teams whose equipment scales and
general training fitted them for this task were 5 and 6 surgical
teams of P.C.T. 5 F.S.T. were despatched to Teale Inlet, 6 F.S.T.
were despatched to Fitzroy and in these locations, they carried
on the treatment of battle casualties for the rest of the
campaign. It fell upon 5 F.S.T to be the first to enter Stanley
26
where they set up in the local hospital. They were followed
quite shortly by 6 F.S.T. It is interesting that while at Ajax Bay
and in support of 2 Para elements of the P.C.T. were deployed
to reinforce 2 Para medical elements in the attack on Goose
Green. The attack went in against superior numbers and that
success has now entered the history of the British Army. Not
only were 2 Para outnumbered but they had to endure severe
mortar and artillery bombardment and the ever persistent
attention of the Argentinian Air Force. Towards the end of the
engagement, a party of airborne medics were carrying a
wounded man from 2 Para on a stretcher when they were
spotted by an Argentinian Pucara aircraft. As it prepared to
attack, the men carefully laid down the stretcher, cocked their
weapons and put up a very intense fire against the attacking
aircraft. It is perhaps one of the inconsequentialities of war that
the casualty on the stretcher is reported as saying “Don’t shoot
at it fellows, you might make him angry.” I cannot help feeling
that it was the anger of airborne forces which brought this
conflict to a quick and successful conclusion. I cannot also help
thinking that it was the expertise of the airborne medical service
which resulted in the remarkably low casualty figures.
War stores San Carlos settlement
Burn victims from Sir Galahad in Ajax Bay
27
Bill McGregor operating at Ajax
Sea King over Ajax Bay refrigeration plant
28
Medics treating wounded in the field Darwin Goose Green Battle
Bill McGregor & team operating at Fitzroy settlement
29
WO2 Les Viner treating a Galahad casualty on the ground at Fitzroy
Medics at the Battle for Darwin/Goose Green
30
Main entrance Red & Green Life Maching at Ajax Bay - Note fridge door
Charles Batty & FST at Ajax
31
Sea King over San Carlos Settlement
32
King Edward VII Memorial hospital Stanley - later burnt down
Bill McGregor operating in a KF shirt
33
Charles Batty operating
Post op Recovery area at Ajax
34
Galahad survivors coming ashore at Fitzroy
Sir Galahad burning
35
Sir Galahad abandoned
36
OPERATION CORPORATE – THE SIR GALAHAD BOMBINGS
Woolwich Burns Unit Experience
P Chapman
Summary
During Military Operations in the South Atlantic to recover the Falkland Islands in 1982, the troopship Sir Galahad was
bombed. Initial treatment of the injured in field medical units was followed by transfer to the hospital ship SS Uganda and
evacuation to the United Kingdom where 48 patients were treated in the Burns and Plastics Unit, Queen Elizabeth Military
Hospital, Woolwich. The treatment of these patients is described and the management of war burns discussed.
Introduction
On 8 June the Royal Fleet Auxiliary SIR GALAHAD was at
anchor in Fitzroy Bay. The 1st Battalion Welsh Guards, support
troops, their equipment and munitions were on board. They were
awaiting disembarkation from Bluff Cove as part of the force
involved in the coming assault on Port Stanley when, at
approximately 1700 hours local time, the ship was bombed by
Argentinian Sky Hawk jets. At least one bomb exploded at the
rear end of the tank deck which was the main assembly point for
troops and their equipment ready to leave ship. The blast caused
secondary detonation of a considerable amount of munitions,
including mortar ammunition stored directly below the ship’s
main hatch forward of the superstructure. Troops were killed or
injured by flash, blast and secondary missiles from multiple
explosions. A total of 78 soldiers were burnt. Within minutes of
the attack a massive evacuation of the ship was started, using
helicopters, lifeboats, landing craft and inflatable rafts. Many
wounded troops were successfully carried ashore, although all
their equipment was lost.
Medical facilities at Fitzroy were limited, as all the Field
Ambulance equipment had been lost on board the SIR
GALAHAD during the bombing. First aid was given and the
wounded evacuated as soon as possible by helicopter to Ajax Bay
where the main shore-based medical facilities were stationed in a
disused refrigeration plant. Some of the injured were transferred
directly to ships in San Carlos Water. All were ultimately
evacuated to the hospital ship SS UGANDA which itself was
under pressure to evacuate as many wounded as possible, to make
room for the large numbers of casualties expected from the
planned attack on Port Stanley1. Those fit enough were therefore
transferred from UGANDA to the smaller hospital transport
ships, HECLA, HERALD and HYDRA for passage to
Montevideo and onward flight in RAF VC 10 aircraft to the UK
via Ascension Island. On arrival in UK, wounded were held
overnight at the Princess Alexandra’s Hospital, Wroughton, and
then dispersed to other military hospitals in England.
Management
Of the burnt soldiers who reached the UK, 27 were considered
sufficiently healed to be sent home on sick leave, three were
transferred to the RAF Hospital, Halton, and 48 were transferred
to the Burns and Plastics Unit at the Queen Elizabeth Hospital,
Woolwich.
The field medical documentation and hospital case notes of
those patients treated at Woolwich were retrospectively analysed.
Each soldier was interviewed to make good any omissions in the
The Sir Galahad on fire in Fitzroy
necessarily brief field records and to provide background
information for construction of the historical picture.
In the South Atlantic
Immediate first aid at Fitzroy included hosing down of burnt areas
with cold water and application of basic field dressings2. As all
medical stores had been lost in the ship, the two field surgical
teams from 2 Field Hospital, supported by 16 Field Ambulance,
had an extremely limited capacity3. However, shore-based infantry
units, already established and equipped, were on hand to provide
intravenous fluids, drip-giving sets and further field dressings.
After receiving their basic first aid, casualties were transported
by helicopter as quickly as possible, many within half an hour, to
the medical unit at Ajax Bay. Space and resources at the
refrigeration plant in Ajax Bay were also limited, so about half the
patients were transferred to medical holding facilities prepared
aboard FEARLESS, INTREPID and ATLANTIC CAUSEWAY.
At Ajax Bay patients were routinely given intramuscular
penicillin and booster doses of tetanus toxoid4. Morphine was
available for pain relief. Hand burns were cleaned with cetrimide
solution and put into plastic bags containing silver sulphadiazine
cream until the supply of bags ran out. The remaining patients
were given saline-soaked field dressings until plastic bags were
again available on the Uganda. Other areas were treated with
saline soaks which were replaced with occlusive silver
sulphadiaxine dressings on UGANDA. Faces were left exposed
after cleansing. Other injuries such as shrapnel wounds were
debrided and treated as required.
Fourteen patients with greater than 10% burns were
resuscitated with intravenous fluid drips begun either at Fitzroy or
later at Ajax Bay. Eight of these were catheterised. Of a further 19
37
patients with 6-10% burns, nine required intravenous drips, and
two of these were also given a urinary catheter. A total of 10
patients required catheters, three of which were inserted at Ajax
Bay and the rest on board the hospital ship UGANDA. The main
fluids used at Fitzroy and Ajax were sodium lactate and Polygeline.
As most had been exposed to flash and smoke in the confines of
the ship, steroids were administered, before transfer to the
UGANDA, to 29 patients, roughly half of whom had one dose of
hydrocortisone 100mg intramuscularly, the rest having 1 gram of
Methylprednisolone intravenously six hourly.
Most patients were transferred by helicopter to the hospital ship
UGANDA within 24 hours. Here intravenous resuscitation was
continued using Dextran 70 in those still with high haematocrit
levels many hours after injury. The drip rate was controlled by
reference to hourly haematocrit levels measured on a hand-held
battery-powered centrifuge, using a regime now known as the
“Uganda Rule” (Table 1)1.
Hourly Haematocrit
>60
50-60
<50
Rate of infusion for
500 mls Dextran 70
2 hourly
4 hourly
6 hourly
Table 1 “The Uganda Rule”
Surgery on the UGANDA was necessarily kept to a minimum.
The most severe facial burns were treated with eyelid split-skin
grafts and tarsorraphies for corneal protection. A few escharotomies
were carried out, as well as emergency surgery for other injuries.
Parenteral prophylactic antibiotics, started at Fitzroy if available, or
otherwise at Ajax Bay, were continued orally for five days.
Two patients, one who developed a haemo-pneumothorax, and
the other who required revision of a traumatic below-knee
amputation, received blood transfusion at Ajax Bay. Blood was
given to two other patients on the UGANDA with 26% and 45%
burns respectively. In the relatively calm conditions of the SS
UGANDA, blood was cross matched before transfusion, although
at Ajax Bay group compatible blood was used without waiting for
the result of emergency cross match. No transfusion reactions have
been reported so far.
In the United Kingdom
The Queen Elizabeth Military Hospital Woolwich received 48
burns cases from the SIR GALAHAD, amongst other casualties
from the South Atlantic. The Burns and Plastics Unit at Woolwich
has 28 ordinary beds and six high care beds in a self-contained
burns ward. At the first indication of the expected casualties all
routine plastics patients were moved from the unit and booked
operations were postponed. Spare beds were made available on a
general surgical ward for overflow of the less severe cases, and extra
nursing staff were transferred from other parts of the hospital. The
day-to-day running of the unit was carried out by the army
consultant in burns and plastic surgery assisted by one junior
doctor. On days when large numbers of casualties arrived together,
junior doctors from other surgical departments were encouraged to
help in initial reception and clerking of patients.
A total of 48 male patients, aged between 18 and 41, all injured
on 8 June 1982, were admitted to the Queen Elizabeth Military
Hospital from 18 June to 2 July (Table 2). Twenty-five arrived on
the first day and 46 had arrived by the end of the first week.
All had burns of varying degrees to their hands. Forty-two
patients had burnt faces, 33 had burns on other parts of the
body and eight had associated non-thermal injuries (Table 3).
By the end of June de-slough and split skin grafting had been
carried out on 40 hands among 23 soldiers. Due either to
38
% body surface area burn
(Range 1-45%)
<5
6-10
11-15
16-20
>20
Total
No. of Patients
15
19
4
6
4
48
Table 2 Body Surface Area Burn of Sir Galahad victims
Hands
Faces
Scalps
Trunks
Limbs
Conservative
49
40
0
6
17
Surgical
44
2
6
1
3
Total
93
42
6
7
20
Table 3 Burn Wounding by Region and Treatment Method used
Conservative
Full employment
18
Limited employment 2
Hospital in patients 1*
Surgical
3
20
4
Total
21
22
5
Table 4 Employment Status related to Management (as at December 1982)
* Due to non thermal injury
incomplete de-slough or graft failure, 12 hands (seven patients)
required early re-grafting. Surgery was carried out to other areas as
shown in Table 3. Kirschner wires were used on five patients to
prevent finger joint contracture. Of the faces only two required
any grafting, the remaining superficial flash burns healing
conservatively with exposure. Twenty-five patients had superficial
hand burns which healed sufficiently with conservative
management to allow them to be sent home on sick leave within
three weeks of injury.
In early July the last two patients arrived, delayed in one case by
septicaemia in a 45% body surface area burn, and in the other by
revisionary surgery to a traumatic amputation of the leg. The
former underwent an extensive series of reconstructive operations
including bilateral tarsorraphy, bilateral split skin grafts to upper
and lower eyelids followed by Wolfe grafts to the same areas, and
split skin grafts to other parts including the hands, arms and scalp.
He required nine general anaesthetics before the end of
September.
Results
By the end of 1982, 21 soldiers had returned to normal
employment. Of these 18 had been treated conservatively. A
further 22 patients were employed in a limited capacity. They had
varying degrees of web space contracture, scar hypertrophy and
skin breakdown, and were being treated as out patients with
pressure garments, while three were admitted in December for
further grafts. Of this grouping in limited employment, only two
were treated conservatively. Five soldiers remained in hospital.
Two patients, after early repeated split skin grafting, required
full thickness cover to deep burns over the dorsum of finger
joints. Axial pattern groin flaps5 were successfully fashioned in
both cases, although thermal damage was so extensive that joint
implants and tendon transplants will be required.
Late breakdown of extensor skin over finger joints occurred in
two of the conservatively managed group and four of those
initially grafted. Apart from one who required a full thickness
cross arm flap, all underwent thick split skin grafts.
From the group in which Kirschner wires were used, two
remained hospital inpatients to allow their axial pattern flaps to
mature. The other three were transferred, after grafting was
complete, to the Joint Service Rehabilitation Unit at
Chessington, for active full-time physiotherapy. At the end of
1982 one of these was back at work as a heavy goods vehicle
driver and the other two were awaiting re-admission for further
corrective surgery.
None of the patients interviewed many months after the event
admitted to any respiratory trouble either at the time of smoke
inhalation or later, whether or not they had been treated with
steroids.
Continued use of pressure garments has been required to
counteract hypertrophic scarring and web space contractures in
24 hands (15 patients). In this group only one pair of hands was
treated conservatively. Hypertrophic scarring requiring similar
treatment occurred in three other burnt areas, all treated
conservatively.
By the end of 1982 64 operations on 27 patients under general
anaesthetic had been performed by the Unit.
Discussion
Distance: Casualty evacuation over a distance of 8,000 miles
presents enormous problems administratively, logistically and for
the patient. With many transfers from ship to ship, ship to
aeroplane and hospital to hospital in the UK, the journey from the
SS UGANDA to the Queen Elizabeth Military Hospital,
Woolwich, took an average of six days. The nearest usable air base
to the combat zone in the Falklands was 1,100 miles away at
Montevideo. Patients stabilised on UGANDA were transferred to
hospital transport vessels, which had been converted from survey
ships, for the journey to Montevideo. From there they were flown
to the United Kingdom via Ascension Island. This was a
substantial achievement; the American forces in Vietnam used
permanent air bases relatively close to the fighting and were able
to use large jets, taking 20½ hours for a journey similar to that
between the Falklands and the United Kingdom to evacuate
patients in large numbers direct to the United States6. In the early
stages of the Vietnam war most of the serious cases were evacuated
rapidly, sometimes within 24 hours of wounding, but as larger
more specialised medical facilities were established in the war
zone, transfer of these patients was delayed and definitive
treatment started immediately7. British soldiers arrived in England
tired, confused and some in great pain. The length of the casualty
evacuation chain precluded any reconstructive surgery in the
South Atlantic for burn cases. Emergency surgery included
amputations, escharotomies and tarsorrhaphies which were
carried out as indicated, but no definitive grafting was started until
arrival in the UK two weeks after injury.
Early Treatment: In order to cope with a large number of
casualties in a short period of time there needs to be an established
well rehearsed regime for burns treatment on the battle field.
Intravenous fluid replacement in the shock phase for large
numbers can be adequately controlled by following Sorenson’s
Dextran formula as adopted by the Army8,9. Experience on the
hospital ship has demonstrated that large numbers of patients in
the shock phase can be adequately monitored by hourly
haematocrit levels using the ‘Uganda Rule’. Despite this, some will
still be either under or over-resuscitated, but this is compensated
for by the fitness, age and morale of professional soldiers in a
regular army. Superficial burns of hands dressed conventionally
with bulky bandages make otherwise fit patients dependant on
others. However, plastic bag occlusion allows the patient a degree
of mobility and self help, relieving overworked nursing and
auxiliary staff for the more extensively injured10. The exposure
treatment of burns is well documented11 and this applies
particularly to superficial burns of the face which require virtually
no maintenance, a factor of importance when dealing with large
numbers.
Protective Clothing: To a limited degree clothing can give
protection from burn injuries. The SIR GALAHAD victims were
dressed for cold wet conditions with many layers of combat
clothing, although the hands and head were uncovered. Two
soldiers who were wearing gloves suffered only minor superficial
blistering to the hands. Some wore plastic waterproof outer
clothing with a hood, which was typically bunched up behind the
head. This caused deep burns where it ignited and fused to the
scalp. Others wore thick arctic parkas which gave a good degree of
protection, particularly when the face was protected with the
hood, as demonstrated by one quick-witted soldier who, although
losing a leg, had no facial burns. Except for those close to the blast,
multiple layers of clothing gave considerable protection. Analysis
of this incident shows that despite the large numbers of casualties
involved, many were of a relatively minor nature and might have
been prevented. Flash protective clothing, as worn by the Royal
Navy crews, could protect many hands and faces although both
availability and troop compliance are likely to cause difficulties.
Acknowledgements
I wish to thank Col BC McDermott CBE FRCS L/RAMC for
his encouragement and permission to report on his patients, and
Col R Scott FRCS L/RAMC for his advice on preparation of
this article.
References
1.
Chapman CW Burns and plastic surgery in the South Atlantic campaign.
JR Nav Med Ser 1983; 69: 71-79.
2. Jackson DS 1983; Personal communication.
3. Jackson DS et al. The Falkland War arm field surgical experience. Ann R
Coll Surg Engl 1983; 65: 281-285.
4. Williams JG, Riley TRD and Morley RA, Resuscitation experience in the
Falkland Islands campaign. Br Med J 1983; 286: 775-777
5. McGregor IA and Jackson IT. The groin flap. Br J Plast Surg, 1972; 25: 316.
6. Funsch HF Jet age evacuation of Vietnam casualties. Med Times 1966; 94:
1022-1029.
7. White MS et al. Results of early aeromedical evacuation of Vietnam
casualties. Aerospace Med 1971; 42(7): 780-784.
8. Sorensen B, Seirsen P and Thomsen M. Dextran solutions in the treatment
of burn shock. Scan J Plas Reconstr Surg 1967; 1: 68-73.
9. Kirby NG and Blackbury E. Field Surgery Pocket Book. London HMSO
1981.
10. Slater RM and Hughes NC. A simplified method of treating burns of the
hands. Br J Plas Surg 1971; 24: 296-300.
11. Wallace AB. The exposure treatment of burns. Lancet 1951; 501-504.
39
Commentary on
Operation Corporate – The Sir Galahad Bombings
Woolwich Burns Unit Experience
Lt Col Alan Kay FRCS FRCS(Plast) RAMC Consultant Adviser to DGAMS,
Burns & Plastic Surgery 16 Close Support Medical Regiment
The Falklands Conflict produced some iconic images of burn
injury in modern warfare; the skin hanging off the burnt sailors
getting off helicopters, the rescue attempts around the blazing Sir
Galahad, the smiling burnt faces of the casualties on SS
UGANDA lying on the floor in their makeshift ward with their
hands in plastic bags, the scarred Simon Weston. This paper
should be part of the iconography of medical planners as it is a
clear condensation of the issues around several key aspects of
military burn injury.
Much of the information presented in this paper confirms what
was already known. Ships engaged in war fighting are a significant
potential source of mass burn casualties, most casualties will have
small burns, some will have other non-burn injuries, burn
casualties (even small burns) place a huge strain on logistic
support, burn casualties can do well in extended evacuation chains
if moved early and initial management is good. These headline
messages are still valid. That said, some things would have been
done differently today.
There has been a shift in what is considered “best practice” in
burn care. Early excision (certainly within 48 hrs) of a burn
wound is now seen as a life saving measure in large burns. As in
1982, it is still considered impractical to perform such surgery
forward of Role 4. Only four burns greater than 20% entered the
evacuation chain after this incident and more recent conflicts have
also yielded very small numbers of large burns. It is, therefore,
difficult to test statistically whether our doctrine of not excising
large burns prior to evacuation is an unacceptable compromise of
care. Repeated anecdotal evidence from UK forces and
observation of the larger US figures has so far produced no
evidence to suggest we may be getting it wrong.
Aspects of the initial management highlighted in this paper
would be criticised now but we should not view matters outside
of the context of what was seen as best practice then. Most of burn
care has evolved through personal anecdote and prejudice rather
than being evidence based. There would have been no “National
standard” for a burn fluid resuscitation regime. The exposure
method of burn management would be deemed negligent by
many Burn Surgeons today. Here we must put ourselves in the
shoes of those who, adapting the knowledge of best practice at the
time, produced pragmatic solutions to a resource limited
environment. Adaptive thinking produces concepts such as “The
Uganda Rule”. Does this ‘making it up as you go along’ lead to
outcomes that are any worse than rigid pre-planned protocols?
The patients who are seen during the learning phase of adaptive
thinking may well be in receipt of sub-optimal treatment. Again,
though, we cannot answer the question “did they get it right?”. A
simple glance at the reported end-points does not inform the
debate about whether outcomes improved or worsened by what
was done or not done.
The liberal use of steroids for inhalation injury in the Falklands
Conflict is a clear example on non-scientific medicine; there being
then, as now, no evidence of benefit. The mechanism of injury on
40
the Sir Galahad should have produced casualties with inhalation
injury. The fact that none of the casualties required intubation nor
had long term respiratory sequelae was, particularly within Naval
circles, the evidence used to advocate prophylactic steroids as an
essential intervention for several years. I cannot help but feel that
one or two of the casualties would today have been intubated and
ventilated. One of the casualties with 48% burns arrived in the
Burn Unit a month after injury and this would now be regarded
at unacceptable. We should be asking ourselves the awkward
question that, did these casualties do so well because of the
omission of early aggressive treatment? For example, it is now well
recognised that the pulmonary insult of ventilation in inhalation
injury is in itself harmful.
The complexity of the evacuation chain from point of
wounding to definitive care is clearly highlighted. Without more
detail it is difficult to know, in retrospect, if any part of that chain
could have been improved on. In particular, the delayed arrival of
the most severely burnt casualty because of septicaemia is not
expanded on. Where in the chain was he held? Leading up to
1982, it was considered inconceivable that the UK would embark
on such a mission. There is nothing today that should allow our
strategists to be allowed to think that a similarly complex scenario
could not again be a reality. We must have in our system the ability
to evacuate severely injured casualties from all environments.
The four larger burns from this incident would in itself generate
a very heavy workload in any modern Burn Unit. Added to this
was the greater number of smaller but functionally significant
burns. Surgery to heal and reconstruct hand burns is demanding
and time consuming. The on-going rehabilitation and scar
management even more so. This total workload would today, I am
certain, have such an effect on any single unit that the patients
would be distributed to a number of burn services. This would
have been an excellent cohort to follow up and report on the long
term outcomes of hand function as they would represent about a
decades worth of experience for the average UK Burn Surgeon.
Personal protective equipment (PPE) issues are still with us. The
wearing of body armour to protect against chest penetration is
almost universal. Anti-primary blast wave technology is available
but, for conventional explosives, of uncertain value. Anti-burn
PPE has been around for decades but is not popular with
dismounted infantry. The time of maximum danger for burns is
when such troops use ships, aircraft and armoured vehicles for
mobility. Finding appropriate anti-burn protection for the
infantry is an area of on-going research.
This paper adds to our collective anecdote about military burn
injury. Its descriptive style makes it difficult to extract useful data
for analysis and it would certainly have been inappropriate to base
any doctrinal change in clinical practice on what it presents. It
does provide a good overview of the scale of the problem and gives
an insight into the pragmatic approaches adopted. It is a “must
read” for medical planners.
Army Amputees from the Falklands - a review
AFG Groom, JT Coull
Two years after the war in the South Atlantic the 23 major Army
amputees out of a total of 38 Service amputees resulting from
hostilities and their aftermath are reviewed. Of the total of 38
cases, 32 were major and six minor. It is noteworthy that, of the
major Army amputees, 11 (48%) occurred as a result of injury
sustained after the ceasefire. Minor amputations have not been
included. They do not, of themselves, pose the same problems of
management, nor was the eventual medical grading effected in
any of the four Army cases. The figures are not complete in that
they do not include amputations of digits secondary to burns. The
amputees present an opportunity to review the management of a
small group of severely injured treated under the most difficult of
circumstances.
Total casualties were 255 killed and 777 wounded. The 32
major Service amputees would, therefore, give an amputation rate
of 4% but if the 11 cases wounded after the ceasefire are excluded
the amputation rate falls to approximately 2.5%. Data on
amputation rate from other conflicts are not readily available.
Wiles1 reported an amputation rate of 3.5% among 29,000 battle
casualties admitted to Middle East hospitals in one year from April
1942 to March 1943 and similarly the amputation rate in the
European theatres in one US evacuation hospital for 12 months
from 1944-45 was 3.7%2. Incidentally, in this latter group,
clostridial myositis was the indication for amputation in 11% and
overall mortality was 6.4%. In the Falkland series no patient who
survived to reach primary surgical care subsequently died and in
no case was clostridial infection an indication for amputation.
Wounds of the extremities constituted 67.5% of injuries
operated on by the Army surgical teams3. This is similar to the
proportions encountered in a number of previous conflicts even
though the nature of warfare may have differed significantly.
The distribution of amputation levels is given in Table 1.
Above Knee
Through Knee
Below Knee
Above Elbow
Below Elbow
Totals
7 (2)
1
11 (7)
2
2 (2)
23 (11)
Table 1. Major Amputees – Army
The figures in brackets indicate those sustained after ceasefire.
Pattern of Wounding: Table 2 lists the relative importance of
wounding agents. It is sadly ironic that accidents during
garrison duties, even excluding those associated with mine-field
clearance, resulted in as many amputees as the bloodiest action
of the war, namely the battle for Mount Longdon. It is also
remarkable that anti-personnel mines were responsible for fewer
amputees during hostilities than after the ceasefire, especially so
since each battalion action involved direct assault against
prepared defences including extensive mine fields.
Anti-personnel Mine
Mortar/Artillery
Gun Shot
Bomb
Sidewinder
Booby Trap
High Explosives
9 (5)
3
3
2
- (4)
- (1)
- (1)
Table 2. Wounding Agent
The figures in brackets indicate those sustained after ceasefire.
Wound Management: First Aid. This was invariably given by
comrades on the spot. Such treatment in itself was hazardous and
indeed 2 cases were wounded while rendering first aid.
Wound Dressing: all cases had “shell” dressings applied. One
required seven such dressings. Tourniquets were used in only three
of 32 cases during hostilities. In none of those three did
inappropriate use of a tourniquet contribute to the indications for
amputation.
Evacuation: Methods were invariably improvised, often under
conditions of extreme difficulty and danger. Most cases were
manhandled to Regimental Aid Posts. One was dragged on a
ground-sheet more than 3 kilometres. Two cases were carried
similar distances on stretchers and three cases were carried by
stretcher but for shorter distances. Three were moved from their
site of wounding in a mine-field to a Field Surgical Unit by Volvo
BV202 (an articulated, rubber-tracked vehicle exerting extremely
low ground pressure) and one case was transferred by landing craft
direct to a surgical team. In all other cases rearward evacuation
from the Regimental Aid Post was by helicopter.
Analgesia: All cases were given “on the spot” intra-muscular
Omnopon (30mg syrette). Those in whom evacuation was
unavoidably delayed received two doses but two of the amputees
found the analgesia totally ineffective.
Resuscitation: Anti-tetanus – All 23 cases received a tetanus toxoid
booster 0.5 ml intramuscularly during the resuscitation phase.
Antibiotics: In the first 24 hours nine cases received Benzyl
Penicillin alone in accordance with normal policy whereas five
received Benzyl Penicillin in combination with other Penicillins
Benzyl Penicillin
Benzyl Penicillin with other Penicillins
Benzyl Penicillin with Metronidazole
Triplopen with Metronidazole
Other Penicillins alone
Ampicillin and Metronidazole
Tetracyclin/Erythomycine with Metronidazole
9
5
1
1
5
1
1
Table 3. Antibiotic Administration in First 24 Hours
41
Cases
Hartmann’s solution (litres)
Blood (units)
Polygeline (Haemaccel)
(500 ml)
23
15
13
Average
Range
Requirement
1.5
0.3-3
3.4
2-7
1.7
1-3
Table 4. Resuscitation – Intravenous Fluid Administration
(variously Triplopen, Ampicillin, Cloaxillin and Flucloxacillin).
Others received combinations including Metronidazole and one
case of a known Penicillin allergy was treated with Tetracycline and
later with a combination of Erythromycin and Metronidazole.
The antibiotic administration during this phase is summarised in
Table 3. No case had any other indication such as a penetrating
abdominal injury to dictate an alternative antibiotic choice.
Intravenous Fluids: Requirements varied with the severity of
wounding and the time to first surgery. There were clear differences
between the group wounded during hostilities and those wounded
after ceasefire and predictably the latter group require smaller
volumes of intravenous fluids for resuscitation. The fluid
administration is summarised in Table 4.
Complete traumatic amputation
Gross disruption
Primary vascular damage
Secondary vascular insufficiency
13
7
2
1
Table 5. Indications
Indication for amputation
This is summarised in Table 5. The commonest indication (13/23)
was completion of a de facto traumatic amputation.
In 12 cases the final level was the same as the level of traumatic
amputation. In one case the traumatic below-knee amputation
initially completed at that level was revised to through-knee. In
seven cases the indication was gross disruption of bone and soft
tissue and in only two cases was the indication primary vascular
damage. They both involved the upper limb and although they
were theoretically salvageable there was also a complete loss of the
brachial plexus rendering attempts at salvage inappropriate. In only
one case was secondary vascular insufficiency the indication for
amputation where a gun-shot wound to the knee causing a severe
compound upper tibial fracture raised the question of vascular
damage. Two days later a below-knee amputation was performed,
revised five days subsequently to an above-knee.
It is noteworthy that, in spite of the conditions of combat, and
occasionally long delays before surgery, in no case was the
indication for amputation due to the presence of clostridial or any
other infection.
Operative treatment
The optimal surgical treatment is two procedures, one to
perform or complete the primary amputation with wound
excision and a second for delayed primary closure, either by
suture or graft. This was achieved in three out of nine cases of
those wounded during hostilities requiring primary amputation
and in six of 11 such cases wounded after ceasefire.
Of the remaining six occurring during hostilities, five
required an early revision prior to closure and two required
dressing changes with general anaesthesia. Of the remaining
five occurring after ceasefire, four required early revisions.
Three cases required secondary amputation after initial
justifiable efforts at conservation.
Late stump revision was undertaken in only four cases and in
42
two of these this amounted merely to trimming a bony spur.
One case underwent formal stump shortening in an attempt to
alleviate prosthetic discomfort but unfortunately healing was
delayed and discomfort not ultimately relieved. One case
elected to undergo forearm shortening to permit fitting of a
functional prosthesis. Apart from these two cases the remaining
21 have opted to retain their emergency amputation stumps
although prosthetic advice was sought in every case at the first
consultation regarding the need for and the advisability of early
refashioning.
Rehabilitation
On return to the UK all amputees were referred at the earliest
possible opportunity to the Limb Fitting Centre. The service
offered was exceptionally good and temporary prostheses were
supplied with great speed, many within 24 hours. Only one of
12 below-knee amputees and five of eight above-knee amputees
had stumps resembling the accepted standard length.
Rehabilitation has, in some instances, been spectacular. Three
of 12 below-knee amputees have passed the basic fitness test
and a further three are likely to achieve this standard. One is
still employed as a physical training instructor. Four of the BK
group (including the double amputee) have been medically
discharged. Predictably those discharged have been the younger,
more junior soldiers for whom Army life depends almost
entirely on physical skills and who have least to offer in
technical or managerial roles. Among the eight above-knee
amputees rehabilitation has been less dramatic and none, of
course, can truly run. Six have been medically discharged. The
two that have opted to continue are both exceptionally
motivated and fit. Both were due for promotion at the time of
wounding and it appears that this may still be possible.
Of the upper limb amputees one has been discharged. While
the fitness test is the challenge for the lower limb amputee the
annual personal weapon test is the problem for the upper limb
amputee. Of the three still serving two have passed and the
third is likely to do so.
Amputation is a mutilating operation following devastating
injury. Many authors have stressed the importance of early and
continued attention to psychological factors in the treatment of
amputees. This falls largely into the responsibility of the doctors
treating the wounds and of the voluntary and welfare
organisations. The families also require considerable support.
It is easier to identify where external psychological factors
have delayed rehabilitation than where they have contributed to
it. This series contains two distinct groups, namely those
injured in battle or in dangerous but essential tasks (eg minefield clearance) and those injured by other instances, such as the
Sidewinder missile and booby trap after the ceasefire.
The latter group was injured accidentally in circumstances
they could not regard as worthwhile. They were therefore at a
psychological disadvantage and it was reflected in subsequent
performance.
The need for understanding, support and information to
both amputee and family cannot be over stressed. Motivation
must be fostered and energy channelled away from resentment
and into rehabilitation.
References
1
2
3
Wiles P. Analysis of Battle Casualties admitted to Middle East Hospitals
April 1 1942 to March 31 1943. Lancet April 1944; 523-525.
Odom B reported in Coates J B. Surgery in World War II: Orthopaedic
Surgery in the European theatre of Operations.
Jackson D S et al. The Falklands War: Army Field Surgical Experience. Ann
Roy Coll Surg Engl 1983; 65: 281.
THE FALKLANDS WAR
Commentary on
Army Amputees from the Falklands - a review
JR Army Med Corps 1984; 130: 114-6
LT Col John Etherington
Consultant in Rehabilitation, DMRC Headley Court
It was both timely and fascinating to read the paper that LtCol
Groom and Maj Gen Coull wrote on the management and
subsequent rehabilitation of amputees from the Falklands War.
Some of us can recall some of the legacy patients from that war
in the military hospitals of the 80’s and 90’s. The paper reminds
us of the constant of modern warfare, but also serves to
highlight the differences in service provision since the Falklands
conflict.
In 1982, service amputees would have been referred to the
local NHS Limb Fitting Centres. Since June 2006, the Armed
Forces have had its own Limb Fitting Centre located at the
Defence Medical Rehabilitation Centre (DMRC) at Headley
Court. The service was developed in response to the inconsistent
provision of limb fitting for the serving personnel. This paper
states that the service provided was exceptionally good with
rapid provision in prosthesis. With notable exceptions, such as
the West Midlands Limb Fitting Centre, over subsequent years
prosthetic provision was inconsistent, often slow and inevitably
limited by local NHS financial pressures. This often led to
frustratingly long periods waiting for limb refitting, with delays
in rehabilitation. After prolonged staff-work at all levels in the
DMS, money was made available to provide a service-wide
Limb Fitting Centre. A private company is now contracted to
provide prosthetic sevices, which are manufactured at DMRC
and fitted to the individual there. This new service provides
rapid prescription and adjustment of the prosthesis whilst at the
same time allowing continued rehabilitation of the patient.
This month will complete one year of prosthetic provision at
Headley Court. We are subsequently auditing our throughput
and early outcomes, which we hope will be a subject of a
publication in this journal shortly.
The current data indicates that there are currently 62
amputees serving in the Armed Forces, many of whom have
been in the Services for some years. There have been 42 cases
treated at DMRC since June 2006 and we have records of 25
aeromedically evacuated cases during the same time. The figures
are comparable to those reported by Groom and Coull, with an
almost identical distribution of amputation levels.
From a rehabilitation perspective the authors make two very
interesting points. Firstly, that the potential occupational
outcome for soldiers with below knee amputations is very good.
Higher amputation levels are associated with longer
rehabilitation times and lower functional outcomes. The longterm vocational outcomes of these servicemen remains
unknown but with the technical improvement in prosthetic
provision functional capability is likely to be higher than 1982.
Consequently, I believe, we may need to review our concept of
medical grading for these patients, considering both functional
potential and the aspirations of the individual.
Secondly, the authors raise our attention to the psychological
factors, which influence the rehabilitation outcome of
amputees. Interestingly, they state that management of this is
the responsibility of the doctors treating the wounds and of
voluntary and welfare organisations. The necessity of support to
families of injured service personnel is also stressed. Fortunately,
I believe our provision in this area has improved considerably.
There is widespread recognition of the influence of
psychological factors on the outcome of recovery and every
effort is made by the acute services and rehabilitation team to
identify and ameliorate these issues, even from the point of
wounding. All members of the rehabilitation team contribute to
this, but particularly those from the mental health, occupational
therapy and social work teams. I believe that group-therapy, led
by a military remedial instructor within a rehabilitation unit
with a Service ethos, together with similarly injured wounded
service personnel, contributes to their psychological support and
hopefully their long-term outcome.
This paper illustrates that whereas the types of injuries
sustained then and now are very similar, there has been
significant progress in rehabilitation provision in the Defence
Medical Services with the aim of returning the injured back to
the maximum possible psychological and physical health.
43
THE FALKLANDS WAR
Army Field Surgical Experience
DS Jackson, CG Batty, JM Ryan, WSP McGregor
Keywords: Field Surgical Team, Advance Surgical Centre, High Velocity Missiles, Wound Excision
Summary: In the recent Falklands campaign four Army Field Surgical Teams were deployed in the two phases of the war.
They functioned as Advanced Surgical Centres and operated on 233 casualties. There were 3 deaths. The patterns of
wounding and the methods of casualty management are discussed and compared with other recent campaigns.
Introduction
During the recent conflict a Naval task force which included a
land forces element, consisting of 3 Commando Brigade and 5
Infantry Brigade was dispatched to the South Atlantic. The
initial landing of these units on East Falkland took place on
21st May 1982. Support for the land forces provided by the
Army Medical Services consisted of:
1. A Regimental Officer (RMO) assigned to each major unit.
At a later stage some units were assigned a second Medical
Officer.
2. 16 Field Ambulance RAMC providing second line medical
support for the land force.
3. Surgical teams drawn from 16 Field Ambulance (Parachute
Clearing Troop) and 2 Field Hospital RAMC.
Additional support was given by a Royal Navy Ship’s Surgical
Team of the Marine Commando Medical Squadron whose
experience will be reported separately.
A Task Force of this magnitude has not been deployed since
World War II. The conflict took place at a distance from base
of 8,000 miles, and with such long lines of communication and
a relative lack of surface transport, obvious difficulties with resupply of medical stores and rearward evacuation of casualties
to base hospitals was envisaged. The medical support, therefore,
had to be self sufficient to a degree not previously experienced.
Four Army surgical teams were deployed during this period.
They had to work under hostile conditions, often very close to
the battlefield, and were bombed by the Argentinian Airforce
on a number of occasions.
The lack of suitable buildings, the virtual absence of roads,
the often impassable terrain, and the appaling weather
conditions, all influenced the collection, treatment and
evacuation of casualties. These features also influence the
surgical management of the wounded.
The Campaign
From the surgical point of view the campaign can be regarded as
having occurred in two phases.
Phase One
On the morning of 21st May 1982 a number of beach-heads
were established on East Falkland in the area of Port San Carlos,
San Carlos and Ajax Bay (Fig 1).
Marine Commandos and Paratroopers were landed, largely
unopposed. Field Surgical support for these units was provided
by the two Field Surgical Teams of the Parachute Clearing
This article first appeared in the Annals of the Royal College
Surgeons of England and is reproduced by kind permission of
the editor
44
Troop of 16 Field Ambulance, and a Royal Navy Ship’s Surgical
Team (SST) drawn from the Commando Medical Squadron.
An Advanced Surgical Centre was established in a disused
refrigeration plant in Ajax Bay, and dealt with casualties
resulting from the landings and the subsequent bombings of
ships in the Falkland Sound and San Carlos Water. In addition,
the wounded, following the celebrated battle for Darwin and
Goose Green by the 2nd Battalion the Parachute Regiment,
were treated at this Centre during 28th and 29th May.
Phase Two
With the arrival and deployment of 5 Infantry Brigade over
the period 31st May – 2nd June, preparations were made for
the next major land battles and the final assault on Port Stanley.
Two Army Field Surgical Teams designated FST 1 and 2, and a
Holding Section – vide infra – drawn from their parent unit 2
Field Hospital in Great Britain, in company with 16 Field
Ambulance, provided the Brigade medical support and were to
reinforce the Parachute Field Surgical Teams designated FST 5
and 6, and the Royal Navy Surgical Support Team on land.
As plans were drawn up for battles to take the horse-shoe
shaped perimeter of mountains surrounding Port Stanley, Field
Surgical Teams 1 and 2, their Holding Sections and 16 Field
Ambulance less their advance party, were embarked on Royal
Fleet Auxillary Sir Galahad in company with the Welsh Guards.
The object was to set-up a more proximal Advanced Surgical
Centre (ASC) at Fitzroy Settlement from which the enemy had
withdrawn (Fig. 2). In addition, FST 5 was moved to Teal Inlet
and FST 6 remained at Ajax Bay. However, events altered the
planning. With only elements of FST 1 ashore, Royal Fleet
Auxillary Sir Galahad was bombed with the loss of all surgical
equipment. Both teams were re-supplied with a variety of
medical equipment gathered from the supporting fleet. FST 1
was then sent back to Fitzroy with FST 6 forming a two table
A.S.C. as originally planned. FST 2 having survived the
bombing was established in the refrigeration plant at Ajax Bay,
alongside the Royal Navy Surgical Team which remained static.
The final deployment of the Field Surgical Teams is
illustrated in Fig 2.
Field Surgical Teams
Field Surgical Teams (FSTs) are essentially highly mobile units
capable of working independently in small groups. They can be
rapidly deployed and become operational within 15 minutes of
arriving at a location, subject to basic facilities being available,
e.g. buildings, tentage, water, heat and light.
Each team consists of a surgeon, anaesthetist, resuscitation
officer, four operating theatre technicians, a blood transfusion
technician and a clerk(1).
The four Army Surgical Teams were organised as shown in
Table 1.
From PCT
of 16 Field
Ambulance
From 2
Field
Ambulance
Fig 1 Map of East Falkland
FST 5
Surgical registrar (CGB)
Consultant anaesthestist
General duties medical officer
FST 6
Consultant surgeon (WSP McG)
Anaesthetic registrar
General duties medical officer
FST 1
Senior surgical registrar (DSJ)
Dentist with resuscitation training
FST 2
Senior surgical registrar (JR)
Dentist with resuscitation training
Table 1. Organisation of Army Surgical Teams
Region
Head and Neck
Chest
Abdomen and pelvis
Upper limb
Lower limb
Number of Cases Percentage
36
14
18
7
30
11.5
68
26.5
106
41
Table 2. Analysis of injuries treated by operation
Missile
Bullet
Fragment
Mine
*Unclassified
Fig 2 Deployment of Field Surgical Teams on East Falkland
Holding Section
Nursing and postoperative care were provided by holding
sections consisting of trained male nurses and medical assistants,
either from 16 Field Ambulance or 2 Field Hospital.
Pattern of wounding
We comment only on patients operated on on land by Army
surgical teams. Two hundred and ten cases underwent surgery by
the four teams during the campaign. In addition FST 2 and FST
5 both utilised the civilian hospital in Port Stanley after the
ceasefire, and operated on a further 23 cases. These included
neglected war wounds, mainly Argentinian, and sadly a
considerable number of patients, Service and Civilian, injured by
unstable ordnance, unchartered mines and booby-traps.
Several casualties were injured by the accidental discharge of
weapons which included the misfiring of a sidewinder air-to-air
missile onto a group of soldiers on the airfield at Port Stanley on
13th July 1982. Table 2 gives a breakdown by region of the
surgical operations performed by the four teams. The figures do
not include the many patients who passed through the units with
a variety of conditions requiring treatment but no immediate
surgery. These also included several types of cold injury
(immersion foot, trench foot, and frost bite), a variety of medical
problems and more significantly numerous burns cases,
resuscitated before evacuation to the Burns Unit on SS Uganda.
FST 1 and 2 and 16 Field Ambulance, as has already been
mentioned, were involved with the immediate resuscitation of
more than fifty burns cases resulting from the bombing at Bluff
Cove.
Table 3 provides an analysis of the wounding agents and the
breakdown is as expected and correlates well with the results from
more recent conventional wars (2-6). This analysis is quite unlike
those reported from Northern Ireland where bullets cause a
higher percentage of the wounds (7).
Number of Cases Percentage
74
31.8
105
45
25
10.8
29
12.4
Table 3. Wounding agents
*Unclassified: includes secondary missiles, road traffic accidents, sidewinder missile.
Priority One
Priority Two
Priority Three
Require immediate Require resuscitation
Require no
resuscitation and/or
and early surgery resuscitation and
immediate surgery
delayed surgery
Table 4. Priority of treatment
Casualty Management
The vast majority of casualties were received by helicopters as the
only effective method of transport(5-8). It is worth noting,
however, that particularly after the Bluff Cove bombing, many
casualties walked considerable distances.
The mobility of Advanced Surgical Centres precludes a large
holding capacity. Thus to avoid being overwhelmed with cases
the ASC’s in the Falklands dealt mainly with the most severely
injured. These priority One and Two Cases (Table 4) were
immediately resuscitated, operated upon and quickly evacuated
rearward, often within hours of surgery, by air onto the hospital
ship SS Uganda which functioned in this case as a general
hospital.
The majority of wounds were caused by high velocity missiles.
All wounds, therefore, were presumed to be heavily contaminated
as a result of the cavitation effect of the wounding agent(9).
Treatment was by accepted surgical techniques(1).
On arrival at a centre patients were resuscitated using a variety
of intravenous fluids, Hartmann’s, plasma expanders and whole
blood. The airway was secured, endotracheal intubation being
carried out if necessary. Tetanus toxoid booster and benzyl
penicillin were given to all except cases of known hypersensitivity
to the penicillin group of drugs. In addition, head wounds
received sulphadimidine, and patients with abdominal and pelvic
wounds were given metronidazole and either ampicillin or a
cephalosporin.
45
An operating list was compiled by the resuscitating officer,
anaesthetist and surgeon working together, though each of the
casualties was continuously reassessed in accordance with the
dynamic nature of the triage system, leading to frequent
alterations of the list, depending on their changing clinical
conditions(1). The response of each casualty to resuscitation was
carefully monitored, and on occasions, in cases of severe multiple
injury, immediate surgery was used as part of the resuscitative
procedure.
In cases of limb injuries, entry and exit wounds were incised
along the axis of the limb. Wide fasciotomy was practised, often
including muscle compartments not seen to be involved. Skin
was preserved as far as possible but subcutaneous tissues and dead
muscle were widely excised, until the latter demonstrated healthy
bleeding and contractility. Comminuted fractures were treated by
lavage, removal of detached small fragments, approximate
reduction and maintenance of bone length, and external POP
splinting over well padded loose dressings.
Damaged tendons and nerves were marked wherever possible
by silk sutures for secondary repair. Only important arteries and
veins were repaired or vein patched (femoral, popliteal, brachial).
Limbs beyond salvage were immediately amputated at the lowest
possible level through healthy and uninjured tissues. Skin flaps
were left long and bone ends covered by myoplastic flaps loosely
approximated. A guillotine method was used when time was
short. All wounds were loosely dressed and left open for delayed
primary closure on the hospital ship (3,9).
Abdominal and pelvic penetrating wounds were all explored
and presented major clinical problems; however, a number of
abdominal wounds were tangential and did not enter the
abdominal cavity. These patients did not have laparotomies at the
advanced surgical centres, but were evacuated rearward with the
knowledge that some might well come to laparotomy by virtue of
the indirect injury to abdominal contents which may be caused
by high velocity missiles (4).
At laparotomy a long mid-line incision was employed for wide
access and arrest of haemorrhage was the immediate priority.
With injuries to the small bowel it was common to find multiple
perforations and lacerations caused by a single missile, in addition
to severe mesenteric haemorrhage (4,9). Small bowel perforations
were dealt with by marginal excision and closure or by segmental
resection and end to end anastomosis. Colonic injuries which
reached the Advanced Surgical Centres were few in number.
Those of the right colon were treated either by marginal excision
with simple closure or hemicolectomy and anastomosis. Wounds
of the left colon usually involved bowel resection and a colostomy
with mucus fistula, or repair with proximal colostomy, combined
with generous drainage, or exteriorization of the injured segment.
Liver wounds were inevitably low velocity (3,9). One case of
hepatic injury was treated by wound excision, laparotomy,
marginal liver resection and haemostatic repair with drainage.
The biliary tree was repaired and ducts splinted with drainage.
Chest injuries presented few problems. Patients with chest
wounds were largely self selecting (4). No patients with
mediastinal involvement reached surgical help alive in this series.
Most of the wounds were peripheral or tangential, and because of
the lungs’ peculiar resistance to the cavitational effect of high
velocity missiles did not require formal thoracotomy (3,9).
Excision of the wounds along conventional lines, followed by
tube drainage, was the standard treatment. Only 6 thoracotomies
were carried out and these in cases of persistent haemorrhage and
massive pulmonary injury. Also 1 of our chest wounds had a large
defect posteriorly resulting in a sucking wound. Here
thoracotomy was followed by swinging a large muscle flap to
cover the defect.
Casualties with serious wounds of the head and neck were few
among the survivors. Almost all high velocity penetrating
46
wounds are immediately fatal (9).
Our cases on the whole suffered from low velocity injuries. the
small number of survivors from high velocity missiles had
tangential wounds resulting in compound skull fractures, severe
soft tissue loss and brain destruction. Unlike other wounds, head
wounds were closed, dural defects in particular being covered,
and in one case a rotation flap was used.
Maxillo-facial wounds were only dealt with by the Advanced
Surgical centre when they presented an airway problem.
Tracheostomy was carried out with minimal further attempts to
deal definitively with the wound in 3 cases. No attempts were
made to remove the wounding fragments if they were not
obvious or easily accessible.
It should be emphazied that only life and limb saving surgery
was carried out at this level, and thus our work in a way was
greatly simplified. The extensive problems that will follow, such
as those of reconstructive surgery were not considered and are
beyond the scope of this report. Post operatively casualties were
held for as short a time as possible compatible with the nature of
the surgical procedure and the availability of helicopter transport.
Rearward evacuation took place from 1 to 36 hours after
treatment and was to the hospital ship SS Uganda. The
maximum flight time from the most forward surgery centre
(Fitzroy) was approximately 40 minutes, and our casualties
tolerated this extremely well.
Agent
Bomb blast
fragments
Gunshot
wound
Anti-tank
mine
Site of
Cause of
Time of
injury
death
death
Small intestine Haemorrhagic 14 Day post -op
Inferior vena
pancreatitis on SS Uganda
cava
Pancreas
Gross brain
24 hours
Head
damage
postoperative
on SS Uganda
Pelvis Perineum Uncontrollable
Died on
both legs
bleeding
operating table
Massive tissue
table at
loss
Fitzroy
Table 5. Details of 3 deaths
Results
There were 3 deaths and details of the cases are given in Table 5.
The figures only reflect the immediate mortality. It is beyond our
scope to deal with the long term results though it is hoped to
present there is a later study. We are, however, happy to record
that no further deaths have occurred (to this date) following
evacuation and repatriation.
Discussion
Sited as they were on East Falkland, the four army teams
functioned as Advanced surgical centres. This was necessary
because of the manner in which the battle was conducted and
the difficult terrain. Surgical facilities further to the rear would
have posed insurmountable problems in casualty evacuation as
helicopters were in short supply, had a limited load carrying
capacity and many had no night flying capability.
Conventionally, casualties having been initially treated by
their Regimental Medical Officer at the Regimental Aid Post, are
evacuated rearward by road or air to a Field Ambulance. Here
resuscitative measures are checked and continued and casualties
sorted, such that the most seriously injured are preferentially
further evacuated by air, road or rail to a well equipped Field
Hospital. Advanced Surgical Centres short circuit the chain but
are less than ideal in many respects. The equipment is basic,
though adequate, and is geared only to life or limb saving
surgery.
It is tempting to draw comparisons with reports from other
Campaigns (2,5,7,10-14). However, there were aspects of this
was which makes direct comparison difficult. In Vietnam the
American Surgical Services were all permanent installations, on
a grander scale with sophisticated laboratory and diagnostic
equipment available. Specialist teams were on hand to deal with
regional injuries. Thus head wounds were dealt with by
neurosurgeons and chest wounds by thoracic surgeons (3).
The reports from the Yom-Kippur War show that the Israeli
Armed Forces are provided with echelons of medical care similar
to those planned by the British Army Medical Services, with
surgical facilities usually well back at the 3rd echelon (15).
However, their lines of communication were short with some
civil base hospitals close to the fighting. This is also true of
Northern Ireland. In the Falklands War the difficulties of
logistics, transport, communications, terrain and bad weather
necessitated the tactical advancement of the surgical facilities
available, in order to provide adequate surgical treatment for the
casualty as close to the point of wounding in both time and
distance.
Not since Anzio in 1944 have surgical teams worked in
isolated groups on a beach-head with small advanced surgical
centres close to the fighting, with only the basic equipment and
the ships functioning as base hospitals (16). The concept of the
ASC is not new (13). It worked well. It provides surgical care,
basic at best, at a forward level and is aimed at those patients
who would have otherwise died if the conventional approach to
surgical support had been adopted. It is worth commenting that
no insurmountable clinical problems were encounted by the
surgeons, most of whom were of junior hospital doctor status.
Only one consultant worked at an Advanced Surgical Centre
(WSP McG). The training of surgeons in the British Army
includes time spent in all major surgical specialities in addition
to the normal training in general surgery. Most of us approached
the conflict with a certain amount of apprehension concerning
our ability to deal with the widespread range of clinical problems
we would encounter, though previous service in Northern
Ireland undoubtedly provided a framework of experience. In the
event there were no particular difficulties. The thoracic problems
we encountered should all be within the competence if a general
surgeon, though neurosurgical injuries posed difficulties.
However, we feel that a neurosurgeon, whilst needed in a field or
Base Hospital has no place with a Field Surgical Team in an
Advanced Surgical Centre.
The extremely low mortality experienced by us deserves
comment. With very few exceptions our patients were evacuated
from close to the point of wounding by helicopter and taken
directly to resuscitation and subsequently surgery, either at an
Advanced Surgical Centre or to the Dressing Station of 16 Field
Ambulance which had an advanced surgical centre co-located
with it (FST 1 and 6). The Dressing Station provided a useful
filter, treating the minor wounded and passing on Priority 1
Casualties to the Surgical facilities. Evacuation times, however,
from wounding to surgical care varied considerably from several
minutes to several hours, and though most patients reached
surgery quickly, there are many reported instances of
considerable delays particularly following night battles because,
as has already been mentioned, not all helicopters could fly at
night. On several occasions casualties were brought to us who
had been wounded at the start of the night battle, and had
waited all night on the mountains for evacuation at first light. It
is likely, therefore, that some of the more seriously injured died
before evacuation was possible thus paradoxically improving our
survival figures at the surgical centres. However, in contradistinction, a very short evacuation time presented us with a live
patient who had received wounds which inevitably would and
did prove fatal (Table 5, patient 3).
Argentinian casualties presented a significant group and it is
sad that we have no information on their fate. Most were
transferred to Argentinian Hospital Ships from SS Uganda.
The final common pathway for all our cases was to the
hospital ship SS Uganda. We are very grateful to our colleagues
of the Royal Navy who ran this floating hospital, and who
absorbed casualties directly when the advanced surgical centres
were overwhelmed, particularly for example with the burns cases
after the Bluff Cove bombing. Without them the Advanced
Centres would have been flooded and thus rendered relatively
ineffective.
The authors would like to thank Colonel R. Scott M Ch FRCS
Professor of Military Surgery and Major General W. Pryn OBE
FRCS Director of Army Surgery for their help in the preparation
of this article and Mrs D Brockley for the preparation of the
manuscript.
References
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3.
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Kirby NG, Blackburn G. Field Surgery pocket book. London; HMSO,
1981.
Rich NM. Vietnam missile wounds evaluated in 750 patients. Milit med
1968;133:9-22.
Whelan TJ, Burkhalter WE, Gomez A. Management of war wounds;
Advances in surgery; Vol 3, 227-350.
Joshi HC. Abdominal injuries in the forward areas. Indian Journal of Surgery
1974;36:350-5.
Watts JC. Military surgery. Ann R Coll Engl 1960; 27:125-43.
Hampton OP. Wounds of the extremities in military surgery. St Louis VC
Mosby Company 1951.
Boyd NA. A military surgical team in Belfast. Ann R Coll Surg Engl 1975;
56:15-25.
Dudley HAF. Some aspects of modern battle surgery. JR Coll Surg Edinb
1973;18:67-75.
Owen-Smith MS. High velocity missile injuries. In: Hadfield J Hobsley ed.
Current surgical practice Vol 2 London. Edward Arnold 1978;204-9.
Melsom MA, Farrar MD, Volkers KC. Battle casualties. Ann R Coll Surg
Engl 1975; 56:289-303.
Brown RF, Binns JH. Missile injuries in Aden. 1964-1967 Injury
1970;1:293-302.
Soul JO. War Casualties in Oman. JR Nav Med Serv 1977:63:85-91.
Bruce J. Surgery in far eastern theatres of war. JR Army Med Corp
1949;93:57-67.
McDermott BC. A field surgical team in Borneo. JR Army Med Corp 1968;
14:97-101.
Michael D. Medicine on the battlefield. A review. JR Soc Med 1979;72:37073.
Estcourt HG, Clarke SHC, Ross JA et al. Abdominal wounds at a beachhead. A clinical review of 65 cases. Lancet 1944;12:38-41.
47
THE FALKLANDS WAR
Commentary on
The Falklands War - Army Field Surgical Experence
Ann R Coll Surg Engl 1983; 65: 281-5
Professor JM Ryan
Reviewing this paper, published nearly a quarter of century ago,
the writer is immediately struck by how much has changed.
Although those deploying did not realise, the war was to be a
watershed, at least in medical terms. The Army (land based)
surgical support elements were lightly equipped, lean and
austere and would have been easily recognised by an earlier
generation of surgeons deployed in support of troops fighting in
the Boer War and World War 1. Even the field clothing worn
by the surgical teams were a throw back to an earlier century –
Long sleeved vests and KF pattern shirts worn with aprons.
Never again would field surgical teams deploy in such manner.
It was of course not meant to be this way. Carl Von
Clausewitz’s observation that ‘the plan would not survive the
first contact with the enemy’ proved prophetic. The initial plan
envisioned that surgical support for the wounded would be
afloat on the hospital ship SS Uganda and the liner SS
Canberra. Field Surgical teams (FSTs) were to be held in reserve
and few thought they would be needed. The Argentine air force
put paid to that plan, necessitating the early deployment of
Royal Navy, Royal Marine and Army personel ashore and into
a disused refrigeration plant at Ajax Bay.
Turning now to the paper – it is immediately obvious that
only part of the story is told here. The paper relates the
experience of the Army FSTS only and barely a mention is
given to the considerable experience of the Royal Navy teams
both ashore and alongside the Army FSTs, and those deployed
on the hospital ship SS Uganda and on ships and liners
throughout the fleet. Memories fade with time and it is difficult
to recall why this was so. There was certainly no malice or
jealousy, more likely a desire to be first in the race to publish.
What a pity, as a paper describing the total experience would
have left a more complete and better record. How invaluable
the retrospectoscope!
Jackson et al’s paper gives a vivid and raw account of surgery
ashore under the most primitive and sometimes dangerous
conditions. It will shock many reading it for the first time in the
light of early 21st century advances. So many features are
striking. The majority of the surgeons and anaesthetists were
trainees with only one consultant surgeon and one consultant
anaesthetist. Towards the end of the campaign a lone trainee
surgeon was deployed forward to work single handed in Teal
Inlet – something unthinkable in the modern climate of clinical
governance. Yet there were no fatalities at Teal Inlet. The
equipment scales were basic and limited. This was the age
before field ventilators and oxygen generators. Paper towels
were used due to the absence of any linen. Surgeons and their
assistants worked in shirt sleeve order and with the bare
minimum of instruments. Table lighting was appalling,
sometimes with bare light bulbs in use. There was no imaging
and laboratory support was confined to blood group typing.
Another striking aspect of the campaign was the scarcity of
helicopters for both evacuation of the wounded to the FSTs at
Ajax and for evacuation to the Hospital Ship and other
48
receiving ships. Most of the helicopters earmarked for casualty
evacuation went down with SS Atlantic Conveyor destroyed by
an Exocet missile early in the campaign. Another example of
Von Clausewitz’s dictum on planning. Further difficulty was
caused by Argentine air attacks over San Carlos Water. Such was
the danger that the Hospital Ship could only anchor close to
Ajax at night and then only for short periods. This further
altered planning as the original intention was for the FSTs
ashore to confine their operations to life and limb salvage.
Evacuation delays now dictated that as much surgery as possible
was to be performed to avoid potentially lethal wound infection
in the majority of wounds.
The paper provides an analysis of wounding agents and
injuries by region. The preponderance of limb wounds is
striking but not surprising. Lengthy delays in evacuation
occurred due fighting at night and the lack of helicopters.
Jackson et al report in the paper that some of the most seriously
injured died before evacuation was possible which paradoxically
lowered hospital mortality. It is sad to recall a note of bitterness
here and it concerns the numbers operated upon by Army FSTs.
Following the publication of the paper some senior Royal Navy
colleagues questioned the numbers cited and felt that the Royal
Navy teams had not been given credit for their contribution.
Such disagreements are all too common, even in reports from
civilian hospitals. Fortunately this has caused no lasting ill
feeling.
The war was to provide a sharp reminder of the danger of
providing close in surgical support. The redeployment forward
of two FSTs with a role 2 dressing station in support of 5
Brigade’s daring assault at Fitzroy/Bluff Cove put surgical and
medical teams at hazard in a most unexpected way. The FSTs
and role 2 elements were boarded on the troop ship Sir Galahad
alongside the Welsh Guards and other support personnel. With
just elements of the dressing station and one FST ashore the
ship was bombed with considerable loss of life. The author was
aboard with his FST and saw at first hand the effects of the
bombing and the chaos that followed. It is fair to say that for a
considerable time few expected to get off the ship alive and
uninjured.
In the months and early years following the war individuals
and some national organisations, notably the British Limbless
Ex-servicemen’s Association (BLESMA), began to question the
decision to send such junior surgeons to work under such
adverse conditions. BLESMA questioned the apparently high
amputation rate and the surgical techniques used. In fact the
teams were better trained that might appear. All had been
exposed to the surgery of war in Oman or Northern Ireland and
all trainees were older and vastly more experienced than their
counterparts today. A careful analysis of the available data
supports early decisions to amputate and to carry that out at the
lowest possible level to allow a ‘site of election’ amputation later.
Further analysis of those who died of wounds (only three)
suggests the injuries sustained were non-survivable even under
optimal conditions.
In conclusion this writer hopes that the current generation of
military surgeons might find some valuable lessons in the paper
under commentary. It might also cause them to reflect on the
advances that have occurred in the last 25 years. What a joy it
would have been to have had the field surgical facilities of today
transported back through time to Ajax. One final comment –
at least in Ajax Bay at the end of a long operating session the
unit Commander – Surgeon Captain Rick Jolly produced
copious quantities of best Navy rum before bed time.
49
First and second line treatment - A Retrospective View
DS Jackson1, MD Jowitt2, RJ Knight3
Senior Specialist in Surgery, CMH, Aldershot, 2Specialist in Anaesthesia, Parachute Field Surgery Team, 16 Field Ambulance,
Aldershot, 3Consultant Anaesthetist, BMH, Dharan
1
Summary
The case history of a single casualty is recorded. A critique of aspects of his treatment is presented. Some suggestions for
modifying aspects of his treatment are considered.
A factual account of the wounds received by a soldier during one of the land battles in the Falklands Campaign is presented
together with an account of his initial (first and second line) and subsequent (third and fourth line) treatment.
Comments and suggestions are offered on aspects of treatment given in the first and second line medical facilities as they
existed during the Falklands Campaign.
Case History
During the battle for Mount Longdon, a 23 year old man
sustained extensive injuries of the legs from a mortar blast. His
left leg had been almost completely amputated at mid-thigh level
and there were numerous injuries of the right. The incident
occurred at about 20.00 hours and field dressings were applied to
the wounds almost immediately, papaveretum 20mg, being given
intramuscularly shortly afterwards. Although he was bleeding
freely from his amputation site, no tourniquet was applied and
no intravenous infusion commenced at that time. He was
evacuated to the Fitzroy Field Surgical Facilities by helicopter, a
flight of about 20 minutes.
On his arrival in the resuscitation area, only 45 minutes after
injury, his pulse was 100 and his systolic blood pressure less than
60 mm Hg.
He was semi-conscious and quite incoherent. An intravenous
infusion was immediately set up and in spite of the rapid infusion
of 1,000ml Compound Sodium Lactate Solution followed by
two units of O Positive blood, his condition deteriorated. To
control bleeding, an Esmarch Bandage was applied as a
tourniquet to the left thigh.
During the initial infusion, a full clinical examination was
made which revealed multiple deep shrapnel wounds of the right
leg. An Esmarch Bandage was then applied to the right thigh as
a tourniquet and a second intravenous line was established.
He was taken to theatre at about 21.15, i.e. about 75 minutes
after injury. Anaesthesia was induced with ketamine and
relaxation for intubation with suxamethonium bromide.
Relaxation was maintained with alcuronium and the casualty was
ventilated by hand using the Laerdal bag. However, his blood
pressure remained unrecordable for the first 20 minutes of
anaesthesia in spite of manually pumping the drip chambers and
infusing a further two units of blood, 500mls of Polygeline and
1,000mls of Compound Sodium Lactate and dropping the head
of the table about 15 degrees.
Slowly, his blood pressure and pulse returned to relatively
normal values.
Wide excision and debridement of his various wounds and
completion of the amputation lasted about 90 minutes. Postoperatively his blood pressure and pulse remained stable at 110
(systolic) and 85 respectively. The initial intravenous line was
discontinued and he was given one litre of Dextrose Saline 12
hourly by the second line.
50
He was evacuated to our hospital ship, the M.V. Uganda, about
12 hours after his initial surgery, where his haemoglobin was
found to be 9.2 g/dl and a further two units of blood and 500
mls of Polygeline were given.
Once aboard the M.V. Uganda, he underwent a further eleven
general anaesthetics employing a variety of techniques. An
epidural cannula was also placed to provide post-operative
analgesia. Most of his later anaesthetics were given to facilitate
inspection and redressing of his wounds. Other procedures
included fasciotomy of the right leg (two days post-injury),
delayed primary suture and refashioning of his amputation
stump (five days post-injury) and split skin grafting of the right
leg (at three weeks). Evacuation to the United Kingdom, by ship
and air, took place one month after injury. In the United
Kingdom, he received two further general anaesthetics, both for
manipulation of the right knee.
Comment
The Falklands Campaign is generally held to have been unusual
in a number of ways and not altogether relevant to a N.W.
European war, this latter being the contingency for which the
principal training objectives of the RAMC are currently aimed.
However, it is not disputed that the South Atlantic Campaign
was the first occasion in recent years in which the RAMC, in any
number, have provided first and second line medical support on
the battlefield. It was undoubtedly the first occasion in which the
RAMC had been involved in a large-scale battle utilising
advanced electronic weapons systems similar to those which
would be used in a European conflict.
In the case described, the injuries were substantial though by
no means unusual as mortar wounds have been a feature of
military surgery for many years. These important points arise
from the management of this patient, all of which relate to the
severity of the wounds and the delay likely to ensue between
injury and evacuation in the less favourable conditions which are
likely to exist in a conflict in Europe. These points, blood loss,
pain and infection will each be considered in this paper.
The Buddy/Buddy system of primary care appears to have
worked in this instance; field dressings were applied and analgesia
given shortly after injury by his comrades. However, direct
questioning by the authors of the casualty described and of others
injured in the campaign revealed that self-help was often the only
help available. When one considers the nature of the conflict, the
terrain, the weather and, above all, the intensive fire which was so
often a feature of the campaign, this is not so surprising. Perhaps
this need for self-help would benefit from greater emphasis
during training, which still tends to stress the mutual-aid aspects
of primary care.
Blood Loss
Because of the extent of this casualty’s injuries, blood loss was
enormous with the patient presenting almost exsanguinated. It is
well-recognised that fit young men can withstand very severe
injuries providing that blood loss is halted, or fluid replacement
commenced quickly. With the conditions that existed on the
battlefields of the Falklands and which are likely to apply to
future conflicts, the placement and maintenance of intravenous
infusions in hypothermic, hypovolaemic patients is almost
impossible. The reception at the Field Surgical Team locations of
a casualty who had received intravenous fluids was consequently
the exception rather than the rule. In such circumstances and in
view of the probable absence of immediate intravenous fluid
replacement, attention must be drawn to the staunching of blood
loss. Because of the usual inadequacy of field dressings applied to
this type of injury, perhaps consideration should be given to the
re-introduction of the tourniquet for selected cases such as this.
Selected indications for the application of a tourniquet are
traumatic amputations and limbs injured to such an extent as to
make them unsalvageable1. Extending the use of the tourniquet
to lesser limb injuries would expose the casualty to the many
disadvantages and dangers of the tourniquet. However, most of
the complications are the result of faulty application or
management of the tourniquet rather than the tourniquet itself.
It must be remembered that the particularly disastrous
consequences of misuse of a tourniquet are likely to outweigh the
benefits in unskilled or even semi-skilled hands.
Current teaching in the RAMC to unit first aid instructors is
that a tourniquet should only be used as a last resort and the
reality is that this means never. In a peacetime situation, in a
country where skilled medical attention is readily available, the
use of a tourniquet is probably not as vital as in a battle situation.
However, with the conditions which existed in the Falklands and
which are likely to apply to an even greater extent in a conflict in
Western Europe, it is likely to be a matter of several hours before
a casualty receives any form of skilled medical aid, particularly if
injured at the start of a night battle2. It is the experience of the
authors that all casualties received in the surgical centres who had
sustained a traumatic amputation or a wound that rendered a
limb unsalvageable arrived in a state of considerable
haemorrhagic shock and probably would not have survived
extension of the evacuation line. From this, it must be concluded
that casualties with similar injuries may have just simply bled to
death in the absence of immediate evacuation and it is these losses
which a tourniquet may well prevent. That this hypothesis is
likely to be accurate is confirmed by several Regimental Medical
Officers and Medical Officers of 16 Field Ambulance who took
part in the first line management of the injured 3. Certainly it is
their opinion that serious consideration be given to the reintroduction of training in the use of the tourniquet at all levels
of First Aid instruction.
Pain
Analgesia was given to casualties by the injection of 20 or 30 mg
Papaveretum ‘intramuscularly’ from a syrette. Given the length
of a needle atop a syrette, the extent of many of the injuries and
the rapid onset of hypovolaemic shock, it is almost certain that
insufficient quantities of the drug were absorbed to provide a
serum concentration adequate to provide any measure of pain
relief.
In this case, no further analgesia was given until the patient
was well into the post-anaesthetic phase of surgery; no more than
six hours after injury and at a time when his intramuscular
volume had been replaced. Other patients had received multiple
doses of Papaveretum in a relatively short duration of time
without any analgesia but achieving a large depot of opiate which
was later absorbed during resuscitation, rewarming and
anaesthesia, to provide profound respiratory depression at the
end of surgery, often requiring massive doses of Naloxone to
reverse. In these cases, poor peripheral perfusion was possibly,
and paradoxically, life-saving.
The authors suggest that the administration of an opiate by the
‘intramuscular’ route to the severely injured on the battlefield is
questionable and the dubious value of ‘intramuscular’ opiates in
this context has been discussed at great length in the past 4. The
problem was identified by the F.S.T.s in Salalah in 1971 and very
effectively controlled by the withdrawal of all syrettes from the
troops 5. This was discussed in a well-received paper in
Edinburgh the following year. In addition, it is also the personal
experience of one of the authors that the intramuscular
administration of opiates gave no relief whatsoever to the pain of
the injured after the bombing of R.F.A. Sir Galahad.
Having made the case for withdrawing intramuscular opiates
as first line analgesia, consideration must be given to a
replacement. Recent work has shown that those shocked patients
who require analgesia should receive it intravenously and
incrementally. However, we must accept that the intravenous
route, however desirable, is almost completely impractical in the
field.
Ideally to fulfil the role of a first line analgesic, a drug must
have the following characteristics:
1. It must be well absorbed in the shocked casualty.
2. Overdosage must be unlikely
3. It must be strong enough to provide pain relief in the severely
multiply injured.
4. In the self-help context discussed earlier, self administration
should be simple and rapid.
5. It should be relatively stable and retain its potency in extremes
of climate
It is suggested by the authors that Buprenorphine administered
sublingually may well satisfy the criteria mentioned above.
Sublingual absorption is reasonably rapid 6 and the possibility
of overdosage by this route is remote. In the one reported case 7
of overdosage where suicide was attempted by the sublingual
dissolution of 35 to 40 400mcg tablets, no clinical effects were
observed apart from slight drowsiness. One case of acute urinary
retention in association with sublingual Buprenorphine has been
observed 8 but this was in a 66 year old man.
That it is potent enough is well-documented, comparing
favourably with intramuscular morphine or intravenous
pethidine 9 and the duration of pain relief from buprenorphine is
substantially longer than with other analgesics 10. though the
incidence of sedation and nausea are slightly greater with
buprenorphine, this should not present a clinical problem 11.
Buprenorphine has little effect on the direct endocrine and
metabolic response to surgical insult 12.
It may be that reduced absorption will occur sublingually in
the shocked casualty with the accompanying dry mouth.
However, in the Falklands Campaign, wounded soldiers were
anaesthetised by crash induction techniques 13 and therefore sips
of liquid to aid dissolution of the tablet would make little
difference to their subsequent management.
To our knowledge, Buprenorphine has not been used as a
front-line analgesic and therefore there are no reports of its safety
in this context. However, it is our contention that there is now
51
sufficient favourable evidence for this drug to be legitimately
considered as a replacement for intramuscular opiates in the
front-line and that it should be fully evaluated with this specific
purpose in mind.
14 Dhalgreen B et al. Local Effects of Antibiotic Therapy (Benyl-penicillin)
on missile wound infection rate and tissue devitalisation when
debridement is delayed for twelve hours. Acta Chir Scand Suppl 1982;
508: 271-279.
15 Jackson D S. Soft tissue limb injuries in the Falklands (awaiting
publication).
Infection
Recent experimental work14 has shown that if antibiotics,
particularly a penicillin derivative, are given immediately on
receipt of a missile wound, then the extent of wound excision
required is significantly reduced when delayed debridement is
anticipated. Also, the infective complications are reduced 15. it is
the contention of the authors that consideration should be given
to the issue, to each soldier, of an injectable antibiotic which may
be administered by himself or his buddy at the time of wounding.
The wounded soldier would not suffer if absorption were
inadequate but would have everything to gain if adequate serum
levels were achieved, either prior to peripheral shut-down or if the
injury were not sufficient to evoke a full shock response.
The drug should have a similar spectrum of activity to that of
Benzylpenicillin and should be stable in liquid form in extremes
of temperature – Gentamicin and Septrin are two possibilities.
Perhaps the use of an auto-inject system, as used for the
administration of Atropine to soldiers who are the victims of
chemical attack, should be investigated.
The patient in this case history was extremely fortunate in that
he was evacuated by helicopter direct to the F.S.T. at Fitzroy, and
it is not an exaggeration to state that his life was saved by the
speed of his evacuation, as were the lives of many others.
Undoubtedly, he would not have been saved had the terrain and
weather not mitigated against the conventional use of wheeled
and tracked vehicles as envisaged in a European was. If the
advanced surgical centres are deployed to save the substantially
injured with immediate resuscitation and surgery, then, in the
light of the Falklands experience, perhaps the whole format of
medical evacuation should be restructured to take into account
the unquestioned excellence of helicopter transport with
squadrons dedicated to the Medical Services as in other armies.
Conclusion
We feel that in the light of the Falklands experience, there are
areas in the Medical Services which need to be improved or reevaluated, particularly in relation to the use of tourniquets,
control of pain and the use of antibiotics. The solutions suggested
in this paper are based on current views.
It is only by raising questions and suggesting alternatives that
the RAMC can continue to provide the teeth arms with the best
medical support at all times and this has been the object of this
paper.
References
1
2
3
4
5
6
7
8
9
10
11
12
13
52
Hamilton Bailey’s Emergency Surgery, 10th Edition, Dudley HAF ed,
Bristol, John Wright and Sons Ltd. 1977
Jackson D S et al. The Falklands War: Army Field Surgical Experience. Ann
R Coll Eng 1983: 65: 281-5
Willis M and Wagon R. Personal Communication.
Beecher H K. 1945
Mayes F B. Personal Communication.
Crossland J. Lewis Pharmacaology, 5th Ed. Churchill Livingstone; 1980: P
34
New Zealand Med J 1979; 89: 633: 255-256.
Br Med J March 1983; 286: 763-764
Ellis R et al. Pain Relief After Abdominal Surgery – A Comparison of i.m.
Morphine, Sublingual Buprenorphine and Self-Administered i.v.
Pethidine. Br J Anaes 1982:54: 421-428
Kay B. A Double Blind Comparison of Morphine and Buprenorphine in
the Prevention of Pain After Operation. Br J Anaes 1978; 50: 605-609
McQuay H J et al. Clinical Effects of Buprenorphine During and After
Operation. Br J Anaes 1980; 1013-1019
Fry E N S et al. Relief of Pain After Surgery. Anaesthesia 34: 549-551
Jowitt M D and Knight R J. Anaesthesia During The Falklands Campaign
– The Land Battles. Anaesthesia 1983; 38: 776-783
First and second line treatment in the
Falklands Campaign
From Col R Scott, L/RAMC, Professor of Military
Surgery
1. The case history presented in this issue of the Journal by Major
Jackson, Major Jowitt and Lieutenant Colonel Knight, raises a
number of issues for discussion.
2. As the authors point out there are injuries, particularly
traumatic amputations of the limbs, for which pressure dressing
alone is insufficient to control bleeding. In such cases a
tourniquet applied, as distally as possible, may be a necessary life
saving measure. However, I believe that more limbs and more
lives will be lost by the unskilled application of tourniquets,
than by neglect of their use, and that our first aid training
should continue to stress the value of direct pressure for the
control of haemorrhage. Since we now have records of almost
4,000 army casualties from the Falklands and from Northern
Ireland held in the Department of Military Surgery, we will
attempt to clothe the bare bones of this statement with some
data.
3. I entirely support the authors’ view of the dangers of
intramuscular morphine in shocked patients, but I cannot
accept that the intravenous route is almost completely
impractical in the field. When the evacuation time is long and
the need for analgesic greatest the patient will usually come into
contact with a doctor soon after injury. When the evacuation
time is short, as in this patient, control of haemorrhage and
splintage of injured limbs may obviate the need for an analgesic.
An oral analgesic which is absorbed and which is rapidly
effective, would have obvious advantages especially if it were
universally available. However, it has yet to be shown that
Buprenorphine fulfils all the criteria necessary for an analgesic
that is universally available to the soldier in action. Detailed
study of its possible use in this situation is required.
4. The prevention of infection in missile wounds has long been a
subject of study in the Department of Military Surgery and
some experimental work by my predecessor suggested that fatal
gas gangrene from contaminated penetrating missile wounds
could be prevented by intramuscular penicillin 1. During the
Borneo confrontation we set up a trial of oral tetracycline to be
taken by soldiers immediately after wounding and found that it
was not absorbed. There is, therefore, a good case for antibiotics
given intramuscularly but a vast amount of clinical and
experimental work has shown that wound contamination
develops into wound infection after a lag period of some hours,
and we would hope that in the usual military circumstances the
casualty would receive treatment from medical personnel.
5. The authors raise many questions of importance in the
management of the injured. Their views underline the need for
further research in this important field and a continuous
revaluation of our own experience.
R Scott
Reference
1. Owen-Smith, M S Antibiotics and anti-toxin therapy in the
prophylaxis of experimental gas gangrene. Br J Surg 1968;
55: 43-45
THE FALKLANDS WAR
Commentary on
First and second line treatment - A Retrospective View
PAF Hunt
SpR in Emergency Medicine and Critical Care Medicine. Department of Academic Emergency Medicine, The James Cook
University Hospital, Middlesbrough, TS4 3BW
The original article by Jackson, Jowitt and Knight was first
published in 1982 with a commentary by Col. Scott L/RAMC,
Professor of Military Surgery at the time. The case report they
describe involves significant lower limb traumatic injuries with
a partial amputation secondary to blast. They present some
interesting points worth reflecting upon again, particularly with
the benefit of the subsequent 25 years of further experience in
dealing with this group of casualties. Both the original authors,
and Col. Scott in his later commentary, discuss a number of
issues all of which are worthy of further consideration from a
modern perspective. These points: haemorrhage control,
analgesia and prevention of infection, will be discussed
separately.
Haemorrhage control
The authors state that the casualty received effective ‘buddybuddy’ immediate care at the time of wounding, consisting of
first field dressings and analgesia. Environmental and tactical
considerations at the time inhibited the effective provision of
‘buddy-buddy’ immediate care and the authors stressed the
importance of ‘self-help’ systems of immediate care in such
circumstances. Recently, modern training and equipment has
been designed to better meet these aims, including self- and
buddy-aid Battlefield Casualty Drills, Team Medic, BATLS
knowledge and core skills training and the provision of the
Combat Aid Tourniquet which can be applied by casualties
themselves. The evacuation of the casualty is interesting in so
far as a support helicopter was used as transport - an infrequent
opportunity during the conflict. The time taken from the point
of wounding to reach an appropriate resuscitation area was less
than one hour, which is quite impressive even by modern
standards.
The authors specifically make note of the fact that no
tourniquets were in place at the time of arrival in the
resuscitation area, despite the presence of significant ongoing
external haemorrhage, although they reflect on the fact that first
aid teaching at the time of the conflict advised against the use
of tourniquets other than as a last resort. They reiterate the
contrast between peacetime and battle situations in cases where
haemorrhage control is vital and recommend the reintroduction of tourniquets for cases of severe external
haemorrhage, especially from traumatic amputations where the
chance of limb salvage is slim. In his commentary, Col. Scott
rightly re-emphasises the risks of injudicious use of tourniquets
Correspondence to: Maj Paul Hunt RAMC
Research Fellow, Department Academic Emergency Medicine,
James Cook University Hospital, Middlesborough
and discusses the importance of direct pressure for the control
of external limb haemorrhage.
The authors also stress the fact that no intravenous infusion
had been commenced until the casualty arrived in the
resuscitation area. This may have been due to inability to
successfully site an intravenous line due to hypothermia and
shock. The introduction of more effective and practical
intraosseous devices provides the ability to administer
resuscitative fluids to the casualty where previously unfeasible.
The emphasis placed in the original article on the need to
replace fluids aggressively in cases of severe or uncontrolled
haemorrhage can now be considered inappropriate. Modern
pre-hospital teaching recommends that the use of intravenous
fluid in such cases should be limited to sustaining essential
organ perfusion, especially cerebral, whilst permitting some
degree of hypotension to reduce the risk of disrupting vital
blood clot and exacerbating haemorrhage. The authors note
that the casualty was “semi-conscious and quite incoherent”
with a pulse rate of 100 and a systolic blood pressure less than
60mmHg. This may have been due to the opioid analgesia
given at the scene although it was arguably more likely to be
due to hypovolaemic shock. A rapid infusion of 1000ml of
crystalloid was initially administered in the resuscitation room
followed by two units of whole blood. The authors note that the
casualty’s condition deteriorated following this, requiring the
application of tourniquets to both thighs in an effort to stem
the continuing haemorrhage. They describe the use of the
Esmarch Bandage (also known as an Esmarch Tourniquet), a
narrow hard rubber band with a chain link that can allow the
band to be tightened around the limb. It could be argued that
the use of such a large volume of fluid before first ensuring
adequate control of haemorrhage may have aggravated the
clinical situation, although it is difficult to clarify this from the
account given. The use of large volumes of fluid for
resuscitation was routine practice at the time of the conflict
although even current practice may have required the use of
large volumes of fluid for resuscitation in the face of massive
haemorrhage and critical hypoperfusion. While not stated
explicitly in this case report, whole blood was generally used for
emergency transfusion during the conflict and this may have
had some advantages over the packed red cell units used today,
especially in terms of providing some clotting factors as well as
oxygen carrying capacity.
From the description given, the total volume of fluid
administered in the first 24 hours amounted to around 3000ml
of crystalloid, 1000ml of colloid and 6 units of whole blood.
There was no mention of the estimated volume of blood loss
throughout the casualty’s initial resuscitation or surgery. Once
53
evacuated to the hospital ship, the authors state that the patient
was transfused a further 2 units of blood due to his
haemoglobin level being 9.2 g/dl. It could be argued that a 23year-old soldier would not require further blood transfusion
with this level of haemoglobin and that the risks of a
transfusion reaction or transmission of a blood-borne infection
would outweigh the potential benefits, although no such
complications were acknowledged in the case report. However
it is fair to say that modern practise is to be far more cautious
with blood transfusion than was the case twenty five years ago.
Initial haemorrhage control may have benefited in this case
from one modern-day intervention, namely the use of novel
haemostatic agents such as QuikClot or HemCon, the use of
improved pressure dressings and possibly from the earlier use of
tourniquets. Avoiding the lethal triad of coagulopathy,
hypothermia and acidosis requires significant attention to detail
for cases such as these. Vital measures include ensuring the
maintenance of core temperature as much as possible with
warming devices, warmed fluids where needed and protection
from the elements in the pre-hospital setting. Resuscitation
efforts must be concentrated on the providing adequate tissue
oxygenation and perfusion in order to minimise acidosis,
although the balance must be set against the need to reduce
exacerbation of haemorrhage by overzealous fluid
administration. The use of fresh frozen plasma in conjunction
with packed red cell transfusion is recommended to maintain
adequate coagulation in the face of increased clotting factor
consumption and continued blood loss. Finally, there may be a
role for the more swift use of recombinant Factor VIIa in severe
trauma cases where coagulation disorders are expected although
its effectiveness is markedly reduced in circumstances where
hypothermia and acidosis have already taken hold.
Analgesia
In the case report the casualty was given intramuscular
papaveretum 20mg at the scene. Paraveretum (Omnopom), a
mixture of hydrochloride salts of opium alkaloids, was a
commonly used drug for pre-operative sedation and relief of
moderate to severe pain until the early 1990’s. The authors offer
the opinion that the design of the drug delivery device and
presence of hypovolaemic shock would have resulted in
inadequate tissue absorption and an ineffective serum
concentration of the drug. Multiple doses of the drug were
often given over a relatively short duration of time despite, or
perhaps because of, the limited analgesic effect. Once the
hypovolaemic state was being corrected there was a significant
risk of the rapid redistribution of a large concentration of
opioid into the systemic circulation leading to potential
complications from cardiorespiratory depression.
The original authors and Col. Scott both comment on the
dangers of administering intramuscular opiates in shocked
patients. The administration of analgesia by the intramuscular
route in the pre-hospital setting has advantages and
disadvantages. The equipment and training required is limited
and the method is amenable to self-treatment. However,
absorption from this route does not occur at a constant rate, is
highly dependent on local tissue perfusion and is therefore
particularly unreliable in shocked patients.
In this article, sublingual buprenorphine was proposed as
satisfying all the criteria for an ideal pre-hospital analgesic.
Buprenorphine is a partial agonist with a long duration of
action. Although the side effects are rare, such as nausea and
respiratory depression, when they do occur they can be
persistent and difficult to reverse. The search for a reliable, safe,
54
effective, rapid, well-absorbed and stable alternative to
intramuscular morphine continues and there is a lack of highquality evidence, such as randomised control trials, regarding
pre-hospital analgesia. Considerable research is ongoing in this
area and several options have been suggested including oral
(transmucosal) fentanyl citrate, intranasal diamorphine and
methoxyflurane.
In his commentary, Col. Scott correctly emphasises the need
for appropriate splintage of injured limbs for pain relief and
disagrees that the intravenous route of drug administration is
completely impractical in the field. However, with the recent
advances in intraosseous access devices it is possible that these
will replace the intravenous route in the field as a method for
the administration of enhanced pain relief and other important
drugs required in the pre-hospital setting.
Prevention of infection
The authors comment that early administration of antibiotics
may be beneficial to outcome in circumstances where there is a
significant delay to primary debridement of wounds caused by
penetrating trauma. However, there is no firm evidence to
support the use of empirical antibiotic therapy in penetrating
trauma where casualty evacuation times are short. The potential
risks of serious complications from empirical penicillin therapy
are infrequent but significant, with an overall risk of
anaphylaxis estimated to be around 1 in 5000 cases with a
subsequent mortality rate of around 1 in 10 of these. However,
evidence does suggest that there is a lag phase of a few hours
between initial wound contamination and the onset of wound
infection. In this case, it is not unreasonable to accept the delay
until casualties reach a facility that can provide definitive care
and ultimately wound debridement. In cases where this care is
substantially delayed there may be a role for empirical antibiotic
therapy, either by the intramuscular or perhaps intraosseous or
intravenous route. The choice of which antibiotic to use, and
one that would remain stable in the pre-hospital setting, is still
the subject of further investigation and research. Current
clinical guidelines should be consulted and reflect the best
presently available evidence.
Conclusion
The authors present a case report describing a mechanism and
pattern of injury all too familiar to UK military medical
personnel with experience of current operational commitments.
It serves to highlight a number of issues that are still as valid
now as they were 25 years ago. A better understanding of the
pathophysiology of severe trauma has provided potential
therapeutic opportunities that were unavailable at the time the
article was written. However, the problem of how essential
clinical interventions for such casualties can be provided
effectively in the field remains as much an issue now as it was
then.
The main issues continue to be the control of external
haemorrhage, appropriate resuscitation to restore adequate
tissue oxygenation, analgesia and secondary prevention
measures. The most important of these measures include
cerebral protection and the prevention of hypothermia.
Finally, Col. Scott’s comments on the importance of further
research and continuous revaluation of experience and practice
(now considered central components of effective clinical
governance) ring ever true with the increasing complexity of
medical equipment, greater expectations and the ongoing
challenges of modern warfare and operational environments.
Soldiers Injured During the Falklands Campaign 1982
Sepsis in Soft tissue Limb Wounds
DS Jackson
Summary
The factors related to the development of sepsis in the soft tissue limb injuries sustained by soldiers during the Falkland
Campaign have been assessed. Delay in surgery and delay in antibiotic administration are the most important factors, and
where delay in surgery is inevitable, delay in antibiotic administration assumes an even greater importance.
Introduction
The principles of the management of battle casualties and the
role of surgery in the treatment of missile injuries are well
established 1,3. Avoidance of septic complications with their
associated increase in morbidity and mortality in the wounded
has always been of paramount importance. This is achieved
mainly by immediate antibiotic therapy, early debridement
(within six hours) and delayed primary suture (DPS).
Hours
Wounding to
Surgery
Septic cases
Wounding to
Antibiotics
Septic cases
0-3
4-6
7-9
10-11 13-15 >15
11
1
9
1
8
2
10
1
2
1
9
3
17
0
11
2
7
4
5
1
2
0
7
2
Table 2. Intervals: Wounding to Surgery and Antibiotics
Method
Two hundred and thirty three soldiers were injured in the
Falklands Campaign. Data were obtained from the field
medical cards, case notes and Hostile Action Casualty System
coding sheets, and the records of all soldiers who received soft
tissue limb wounds were analysed. Burn injuries were excluded.
There were 174 injuries to the limbs and of these 49 involved
the soft tissues only, ie 28% did not damage bone. Twenty eight
lower limb and 21 upper limb injuries were studied.
Results
The wounding agents covered the whole spectrum of weaponry
(Table 1) and the range of tissue trauma varied from extensive,
with tissue and skin loss and neurovascular injury, to minimal.
9 mm
Mine
Shrapnel
7.62 mm
Grenade
Mortar
4
5
4 (2)
8 (2)
4
12 (3)
Shell
HV. Unspec
Helo Crash
Sidewinder
Bomb Fragments
TOTAL:
5 (2)
2
1
1
3
49
Table 1 Wounding Agents
The figures in brackets indicate the number of cases in which sepsis developed.
The time intervals from wounding to first surgery and
wounding to antibiotic administration are given in Table 2.
Only 20 patients, 40%, underwent surgery before six hours had
elapsed and nine patients, 18%, were delayed over 15 hours. A
higher number of patients however, 28 (57%), received
antibiotics before the six hour point.
Table 3 gives the intervals at which delayed primary suture
was carried out and most operations took place between five
and seven days after initial surgery. Delay beyond this point was
usually because of a dirty wound which required further
dressings or further excision before safe closure. In this event
skin grafts were used as a method of delayed closure. This
technique was used for three legs and two arms.
All the wounded in this series were given antibiotic cover
(Table 4) and this was mostly one of the penicillins. In only one
case was a combination used, Triplopen and Metronidazole, the
Days
Number
0-4
4 (3)
5-7
40 (6)
8-10
3 (0)
11-13
2 (0)
Table 3. Intervals: Surgery to DPS
Magnapen
Crystapen
Triplopen
Penicillin (unspec)
Tetracycline
Metronidazole
Erythromycin
2
8
26
10
2
1
1
Table 4. Antibiotics used in limb wounds
latter being employed to cover possible concomitant bowel
injury.
Of the 49 cases reviewed, three patients had septic wounds at
delayed primary suture, ie frank pus in the wound, an incidence
of only 6%: but subsequent infection after delayed primary
suture developed in a further six cases making a total of nine or
18%. Erythematous or moist wounds and very minor degrees
of infection, have been excluded, as have those wounds which
had primary closure delayed because of separating sloughs and
were not overtly clinically infected.
Examination of the time intervals between injury and first
surgery in those casualties who developed sepsis (Table 2)
reveals that seven of the nine cases occurred when wound
excision was delayed beyond six hours. Twenty-one of the 49
casualties were given antibiotics after six hours.
Septic wounds also resulted in seven of the nine cases in
whom the giving of antibiotics was delayed beyond six hours.
Unfortunately there was insufficient time to prepare a fifth
table showing the delay to surgery in those cases in which
antibiotics were administered within three and six hours
respectively.
Table 1 also gives details of the wounding agents in the septic
cases and does not suggest any link between the nature of the
agent and the development of infection as the cases are evenly
distributed.
55
Delayed primary suture was used as a method of closure in all
casualties in this series and Table 3 illustrates the intervals
between initial surgery and closure in the septic cases. It is
striking that no infection occurred after DPS when that interval
was greater than seven days.
Discussion
The prevailing conditions in the Campaign led to erratic and
often very delayed casualty evacuation, particularly as most of
the battles commenced at night, and helicopter transport was in
short supply 2.
Current military surgical teaching dictates that all operations
should be performed within six hours of injury to reduce
infective complications 1. Twenty nine of the 49 casualties were
treated after six hours had elapsed and this can readily be
explained by the nature of the terrain and the consequent
evacuation difficulties, coupled with the application of the
triage system relegating these injuries to a lower priority when
force of circumstances dictated it 1,3. The infection rate in this
group approached 25% and this high infection rate can be
related to delay in the primary wound excision.
There were no septic complications when antibiotics were
administered within three hours of wounding and this confirms
recent experimental work showing that early antibiotic therapy
(benzyl penicillin) totally inhibits the usual growth of bacteria
in missile wounds when excision is delayed for twelve hours 4.
It would appear that the antibiotic prevents the growth of the
initial sparse mixed flora of contaminants derived from clothes
and skin which, were they allowed to thrive, would have
prevented the recovery of reversibly damaged tissue and led to
super-infection with more pathogenic organisms. In addition,
the recovery of tissue damaged on the periphery of the wound
leads to a more limited primary excision. In another
experimental study by the same authors with no antibiotic
therapy, the conclusion is reached that infection can be
overcome by wound excision within six hours but would be out
of control by 12 hours 5.
Owen-Smith and Matheson demonstrated that
benzylpenicillin totally protected clostridial-contaminated
sheep thigh wounds from gas gangrene provided that antibiotics
56
were given within nine hours of wounding 6. No cases of gas
gangrene were encountered in the limb injuries reviewed, but
the infection rate in this series in that group of wounded who
received antibiotics beyond six hours after injury was 33%.
The extent of initial wound excision is an unknown quantity
in this series, the patients having been operated upon by several
different surgeons of varying experience in the management of
these types of wounds 2. However, inadequate or insufficient
wound excision will substantially contribute to the
development of sepsis if at delayed primary suture devitalised
tissue is not recognised and closure is undertaken. It should be
appreciated that the second operation in the treatment of a
battle wound provides an opportunity to inspect it and re-excise
it where necessary and not just to close it. Indeed, altering the
emphasis of the second operation from closure to inspection
may permit a more conservative initial excision. In this series six
cases of sepsis developed after delayed primary suture suggesting
that the wounds were closed inappropriately. Five cases were
closed well beyond the seven day point because of wounds
which were of doubtful cleanliness. None became septic.
Acknowledgements
I would like to thank Col R Scott L/RAMC, Professor of
Military Surgery, for his help in the preparation of this paper
and Mrs. Vera Crawford for the typing of the manuscript.
References
1
2
3
4
5
6
Field Surgical Pocket Book, Kirby N G, Blackburn G. London HMSO
1981.
Jackson D S. et al. Falklands War: Army Field Surgical Experience. Ann R
Coll Surg 1983; 65: 281-285.
Owen-Smith, M S. High Velocity Missile Injuries in Hadfield J, J. Hobsley
M. Ed Current Surgical Practice. Vol 2 London. Edward Arnold . 1978;
204-229.
Dahlgren B, et al. local Effects of Antibacterial Therapy (Benzylpenicillin)
on Missile Wound Infection Rate and Tissue Devitalisation when
Debridement is Delayed for Twelve Hours. Acta chir Scand Suppl
1982;508: 271-279
Dahlgren B, et al. Findings in the First Twelve Hours Following
Experimental Missile Trauma. Acta Chir Scand. 1981; 147: 513-518
Owen-Smith M S, Matheson J M. Successful Prophylaxis of Gas Gangrene
of the high velocity missile Wound in Sheep. Br J Surg 1968; 55; I: 36-39.
THE FALKLANDS WAR
Commentary on
Soldiers injured during the Falklands Campaign 1982sepsis in soft tissue limb wounds
Lt Col Paul Parker
The major cause of preventable death in war-time has always
been infection (1). One of the greatest medical lessons learnt in
WW II was the prophylactic use of penicillin in the surgical
units closest to the front (2). In the jungles of Burma, soldiers
carried their own antibiotic tablets. Medical corpsmen gave
antibiotics at point of wounding in Korea (3). In this small but
significant series, there were no septic limb complications when
antibiotics were administered within 3 hours of wounding.
Septic wounds resulted in 7 of 9 cases where antibiotic
administration was delayed beyond 6 hours(4).
These simple yet important clinical observations were borne
out by later experimental work at Porton Down: Intramuscular
administration of Benzylpenicillin, begun within 1 hour of
wounding, was effective in preventing streptococcal infections
in a pig model of fragment wounds. When this administration
was delayed until 6 hours after wounding, the medication was
not effective (5).
Two thirds of all war wounds are in the extremities and most
are not immediately fatal(6). Yet we repeatedly forget the
lessons of history and thus the eminently preventable morbidity
and mortality associated with these complex open limb wounds
still occurs. The US Military have recently (re)introduced a
combat pill pack containing oral Moxifloxacin for pre-hospital
self-administration in the field by the wounded soldier (7).
Current UK military practice mandates iv Benzylpenicillin and
Flucloxacillin on arrival at Role 2 for extremity wounds and iv
Cefuroxime and Metronidazole for cavity wounds (8). These
guidelines should still be followed pending a review of the
available evidence.
References
1.
2.
3.
4.
5.
6.
7.
8.
Feltis JM. Surgical experience in a combat zone. Am J Surg 1970 119:2758
Poole LT. Army progress with penicillin. Br J Surg 1944 32:110-1.
Scott R. Care of the battle casualty in advance of the aid station.
Presentation at Walter Reed Army Medical Center Conference on 'Recent
advances in Medicine and Surgery' based on professional medical
experiences in Japan and Korea. April 19 1954.
Jackson DS. Sepsis in soft tissue limb wounds in soldiers injured during the
Falklands Campaign 1982. J R Army Med Corps 1984 130(2):97-9.
Mellor SG, Cooper GJ, Bowyer GW. Effect of delayed administration of
Benzylpenicillin in the control of infection in penetrating soft tissue
injuries in war. J Trauma 1996 S128-34.
Parker PJ. Bullet and Blast Injuries: Initial Medical and Surgical
Management. 2006 Curr Orth 20:333-45.
Tactical Combat Casualty Care: Tactics, Techniques and Procedure. Center
for Army Lessons Learned. 2006 6-18.
The British Military Surgery Pocket Book. 2004 UK: British Army
Publication AC 12552.
57
Rate of British Psychiatric Combat Casualties Compared to
Recent American Wars
HH Price
Division Psychiatrist, Headquarters, 8th Infantry Division (Mechanised), US Army, Europe
Summary
This paper examines factors leading to the low rate of combat psychiatric casualties in the British recapture of the
Falklands compared to the American experience in North Africa, Italy, Europe and South Pacific theatres during World
War II, the Korean Conflict and Vietnam. The factors compared are those thought to affect rates seen in these past wars.
The factors highlighted are psychiatric screening of evacuees, presence of psychiatric personnel in line units, intensity of
combat and use of elite units. Factors also mentioned are presence of possible occult psychiatric casualties such as frostbite
and malaria, amount of indirect fire and the offensive or defensive nature of the combat. A unique aspect of the Falklands
War examined is the exclusive use of hospital ships to treat psychiatric casualties and the impact of the Geneva Convention
rules regarding hospital ships on the classic treatment principles of proximity and expectancy. The types and numbers of
various diagnoses are also presented.
The British Campaign in the Falklands produced a remarkably low rate of psychiatric casualties. When viewed in light of
American experience in recent wars, this low rate represents a concentration of optimal factors leading to healthy function
in combat. The results of this war should not be used to predict a similar outcome in future combat as this particular
constellation of factors may not recur.
Introduction
The Falklands war is described by Surgeon Commander ScottBrown, as one of the Navy psychiatrists involved, as a 20th
century reincarnation of the Afghan Wars or the 1896 Sudan
Expedition1. Despite the technological advances of naval and air
warfare in this conflict such as Exocet missiles and Harrier jets,
the land war was fought without many of the weapons used in
recent wars. There was little use of heavy armour or helicopter
gun ships. General Thompson, the land force commander, said
“The only difference between Hannibal and us is that he went
by elephant and we are going to walk” 2. And walk they did,
carrying most of their supplies, due to the poor road system on
East Falkland.
During the course of the war which lasted a total of 74 days
with a 25 day land campaign from the landing at San Carlos
Water to the capture of Stanley, the British lost 237 men killed,
777 wounded with 446 receiving significant hospital treatment.
The rate of evacuated psychiatric casualties was 2% of all
wounded with 16 declared cases evacuated from the hospital
ship, Uganda. This rate compares favourably to the American
experience in recent wars i.e., 23% of medical evacuees were
psychiatric casualties in WWII, 6% in Korea and 5% in the
early stages of the Vietnam War, reaching a high of 60% during
the drug epidemic of 1972 3,4. The Falklands produced a low
rate of psychiatric casualties. This paper will examine the factors
which the American experience suggests affects psychiatric
casualty rates, two of which were not present in the Falklands
and six factors which were.
Factors not Present
The low psychiatric casualty rate in the Falklands is significant
in that two factors believed to have decreased psychiatric
casualties in American experiences were not present in this
campaign, i.e. the presence of psychiatric personnel in line units
58
and psychiatric screening of all evacuees.
Due to the psychiatric disaster in the American Army during
the Tunisian Campaign in 1943, psychiatrists were sent to corps
level, then further forward to evacuation hospital level during
the Sicily invasion. On 9 November 1943 the War Department
re-established the position of division psychiatrist with the first
division psychiatrist reaching a division at Anzio in March
1944. The increasing forward assignment of psychiatrists
during World War II coincided with, and perhaps led to, a
decrease in psychiatric casualties. However, even as late as
August 1945, only seven out of 17 divisions in the Southwest
Pacific had division psychiatrists5. During Korea, within 6-8
weeks of the onset of fighting, division psychiatry became
operational6. By the time of Vietnam, there were more
psychiatrists in the theatre per Army troop strength than in any
previous war. 3 Though Abraham has written extensively on the
treatment of battleshock (the British term for psychiatric
combat casualties) and has proposed the development of
Battleshock Rehabilitation Units at division level supported by
Field Psychiatrist Teams, these have not yet been fully
organised6. There are no behavioural science teams attached to
British line units corresponding to the division psychiatrist,
psychologist, social worker, and enlisted behavioural science
technician (91G) in the U.S. Army. No Royal Army Medical
Corps psychiatrists were invited to the Falklands.
Psychiatric screening of medical evacuees has also been found
to decrease rates of psychiatric casualties in the American Army.
During the New Georgia Campaign in the Pacific during July
and August 1943 no screening of evacuees occurred in the 43rd
Infantry Division. This division had large numbers of
psychiatric casualties as well as medical evacuees subsequently
found to have psychiatric disorders at base hospitals7. This
division lost 10% of its strength during one month to N-P
casualties. It is reported that men actually “tagged” and
medically evacuated themselves to rear bases. In another
division, the 37th Infantry Division, also on New Georgia and
taking the same amount of physical casualties, all psychiatric
cases were screened by the division psychiatrist producing a
negligible N-P evacuation rate7. During the Korean War and
the Vietnam War all psychiatric evacuees were screened by
psychiatrists except for drug abuse cases evacuated from
Vietnam through Drug Rehabilitation Centers run for the most
part by internists or general medical officers4. No psychiatric
screening occurred in the Falklands because the two Royal Navy
psychiatrists present were aboard ship for the duration of the
conflict, one aboard the hospital ship Uganda and one aboard
the Canberra, a troopship with a 50-bed hospital8,9.
One was to have been placed in a mobile field hospital, but
as all tents were lost in the sinking of the Atlantic Conveyor, the
hospital was set up in a refrigeration plant at Ajax Bay primarily
for surgical cases. All psychiatric casualties were evacuated to
the Uganda. Though the British have a similar understanding
of combat psychiatric casualties and their treatment10 as
American psychiatrists, the location of the psychiatrists was not
optimal for the rapid return to duty of cases. The Geneva
Convention prohibits return of troops to combat from a neutral
territory and permits wounded to be taken prisoner from a
hospital ship. Therefore casualties were sent by ambulance ship
to the neutral port of Montevideo and then to Britain by
aircraft. Once aboard the Uganda at San Carlos Water the
evacuee was as good as home in Britain despite the 8,000 mile
distance.
The Canberra, on the other hand, was legally a troopship and
thus a legitimate military target, by Geneva Convention rules.
Consequently after offloading troops and equipment during the
landings on 21st May and taking on some casualties it was sent
the next day to the east of the Total Exclusion Zone out of range
of land based Argentine aircraft. If the British had been able to
obtain complete air superiority, the Canberra could have been
kept closer to the land battle medical evacuation chain and used
for the treatment of psychiatric casualties and their return
directly to combat.
Of the 16 psychiatric cases evacuated to the Uganda, ScottBrown reported that four were battleshock cases, four had
formal psychiatric illnesses, precipitated by combat all of whom
were depressed, four were survivor reactions with bereavement
and fear of minor trauma and four were cases of
hyperventilation and depression without exposure to land
combat1. The battleshock cases were treated with rest, warmth,
food and small group therapy. The psychiatrist aboard took
charge of a 250 bed low dependency ward and performed many
consultation-liaison activities such as pain control consults and
amputation counselling.
Morgan O’Connell, the psychiatrist on the Canberra,
consulted on eight cases. One was a case of bereavement, one
had psychosomatic chest pain with family stresses, two were
cases of alcohol abuse, one a case of acute paranoid
schizophrenia with a previous history of hospitalisation, two
homosexual civilian ship’s crew members with depression and a
Senior NCO with disseminated sclerosis. He was also involved
in preventative psychiatric group work with survivors of the
Ardent after section, as well as the Special Air Service Squadron
which lost 19 men in a helicopter crash. Only the bereavement
case had been involved in the land combat; his helicopter
crashed and the pilot died in his arms under heavy fire from
Argentines8.
Despite absence of psychiatrists ashore or in line units and
the lack of psychiatric screening of evacuees all of which were
removed from combat and sent to Britain, the Falklands
Campaign still produced the remarkably low rate of 2%
psychiatric cases of all medical cases. When viewed in the light
of the American experience in the past three wars, this low rate
represents a concentration of optimal factors leading to healthy
functioning in combat.
There are five optimal factors which appear important but
first a look at an important factor which, while decreasing the
rate of diagnosed psychiatric casualties, leads to their evacuation
under other diagnoses.
Occult Psychiatric Casualties
Marlow (1979) pointed out that during World War II “severe
combat that produced few people who were labelled by the
Medical Department as combat psychiatric casualties, also
produced compensatorily large numbers of personnel
withdrawn from battle for frostbite, illness or light injury, as
well as AWOL and self-inflicted wounds”11. The low number of
psychiatric casualties in the British campaign may have been
offset by the fact that 20% of all land casualties were due to
immersion foot12. A number of exposure cases however,
occurred when the landing ship Sir Galahad was bombed at
Bluff Cove with no voluntary component to their condition.
Therefore the number of occult psychiatric casualties may have
been negligible.
In a climate very similar to the Falklands, when the 7th
Infantry Division invaded Attu in the Aleutians in May 1943,
large numbers of cold casualties occurred in a campaign lasting
21 days. This division, desert trained with neither proper
training nor clothing for the cold wet weather, suffered 553
KIA, 1,154 wounded, 2,205 diseased, of which 1,518 were
frostbite and trenchfoot. The North Pacific theatre had the
lowest overall psychiatric casualty rate of the war13. In the
European theatre during World War II and again in Korea,
frostbite was also noted to be an evacuation syndrome.
Evacuation of psychiatric casualties has occurred under
organic diagnosis such as “blast concussion”, and diarrhoea. In
Italy after the invasion at Salerno in September 1943, the
incidence of diarrhoea increased by one third in the 5th Army.
“Most patients recovered promptly after three to five days
regardless of whether sulfonamides, or bismuth or Paregoric
were used”14. During this same period many patients who had
bypassed evacuation hospitals and were evacuated to North
Africa with diagnoses of “concussion” or other somatic disease
were subsequently discovered to be neuropsychiatric
casualties14. The ratio of diagnosed psychiatric casualties to
battle casualties was one to eight. Later in the Italian campaign
with more thorough evaluation the ratio rose to one out of four
to five battle casualties14. At times command pressure
influenced diagnosing of psychiatric casualties. On Guadalcanal
in 1942 General Patch, commanding the American Division,
insisted on court-martialing officers with neuropsychiatric
diagnosis. The division psychiatrist, serving also as the division
surgeon, circumvented this by labelling these cases as “blast
concussion”15. During the Iwo Jima campaign a high incidence
of “blast concussion” evacuees occurred in Marine units. It was
suspected that this was an attempt to decrease incidence of
“combat fatigue”9.
Malaria during World War II was another example of an
evacuation syndrome, preventable by taking Atabrine. On
Guadalcanal in November 1942 so many men were lost due to
malaria that all men with temperatures up to 103º were ordered
to remain in combat. This caused much resentment towards
“healthy” N-P casualties5. Again in the battle for Buna, New
Guinea in 1942 the 32nd and 41st Infantry Divisions, both
without psychiatrists, overwhelmed forward treatment centers
with malaria and diarrhoea cases5. By December 1942 the
Southwest Pacific theatre psychiatry consultant reported that
59
42.7% of cases evacuated to the United States were psychiatric.
In the past, when no possibility of evacuation existed, rates of
psychiatric casualties and other evacuations syndromes were
low. On Bataan in 1942 little psychiatric disease occurred
despite heavy fighting, lack of food and inevitable defeat18.
During the Vietnam War most psychiatric evacuees were
screened by the “K-O” teams. “Drug abuse became a kind of
evacuation syndrome with most of these patients becoming
casualties only on the basis of the positive urine screening”4.
This paper will now examine five optimal factors in the
American experience which were present in the Falklands War.
Elite Units
The British troops involved were from elite units such as the
Marine Battalions, Special Air Service Regiment, Parachute
Regiment, Special Boat Service, Guards and Gurkhas. These
units have been serving together for years, the majority having
seen service in North Ireland. The men knew their leaders and
vice versa; strong group cohesion existed. The units were not
dispersed and they fought together. Similarly, low rates of
psychiatric casualties have occurred in American elite units.
During the breakout from the Anzio beachhead in Italy in 1944
the 1st Special Service Force, a brigade of American and
Canadian volunteers suffered a minimum of psychiatric
casualties while taking heavy physical casualties17. Also in Italy,
the 100th Infantry Battalion composed of Japanese-Americans
from Hawaii suffered 109 battle casualties in a two week period
with only one psychiatric casualty17. The 442nd Regimental
Combat Team also made up of Japanese-Americans had a
similar low rate17. The three Airborne Divisions fighting in
Europe during World War II never had a neuropsychiatric
casualty rate higher than 5.6% of battle casualties18. It should
be noted, however, that in the Vietnam War the rate of
psychiatric casualties did not increase when regular Army
volunteer troops were replaced by draftees in 19674.
Duration of Combat
The Falkland land campaign lasted only 25 days. Brief duration
of combat exposure has, in American wars, been associated with
low N-P casualty rates. During the invasion of Saipan, in a
campaign of short duration from 19 June to 12 July 1944, the
27th Infantry Division had relatively few cases of psychiatric
illness consisting of 5.6% of all admissions despite intense
combat and heavy physical casualties19. The low incidence of
“combat exhaustion” type cases of World War II during the
Korean conflict has been attributed to the rotation policy for 12
months in the combat zone.
This factor alone cannot always be relied upon to produce
low rates. 24 hours after the newly arrived American Division
went on the offensive at Guadalcanal, one third of the 350
casualties at the clearing station were psychiatric7. Later during
the New Georgia campaign 70% of the total N-P casualties
occurred during the first month, 26% in the second and 4% in
the third and final month20. This decreasing incidence was due
to improved screening of casualties but also to the changing
character of the combat as the island was cleared. On Okinawa,
in April 1945, after an initial period of light combat and
relatively unopposed landings the psychiatric casualty rate rose
on the third day of intense combat18. Of 100 psychiatric cases
evacuated to Saipan a large sub-group consisted of men with
over 140 days combat in the theatre18. Psychiatric casualties can
occur early in a campaign in men with previous combat.
Indirect Fire
In American wars the presence of indirect fire is associated with
increased N-P rates. The British force experienced limited
heavy bombardments, no intense counter-attacks, and
60
intermittent air attack. Few psychiatric casualties occurred
while the Task Force was at sea despite the threat from Exocets
and Argentine fighters. Similarly, during the voyage to Okinawa
no psychiatric problems arose in troops due to the heavy
Kamikaze attacks18. However, once landed at Okinawa 13.3%
of all admissions were psychiatric cases. This was attributed to
concentrated heavy artillery fire18. At Anzio the rate of N-P
casualties rose in support troops for the first time due to heavy
continuous bombardment of the surrounded beachhead.17.
Later in Italy, the 88th Infantry Division in 22 days of combat
in the Voltera area was under severe artillery fire and the N-P
casualty rate was 24% with an incidence of diarrhoea as well17.
Lack of exposure to artillery barrages has been suggested as one
factor in the low psychiatric casualty rate in American troops in
Vietnam3.
Unopposed Landing
The most vulnerable moment for the British was the initial
landing at San Carlos Water. The Argentines who had the
opportunity to move in units to oppose the landing did not
take the initiative. Heavy fighting at the beachhead as at Anzio
and Salerno leads to heavy physical casualties and psychiatric
casualties. When the 31st Infantry Division invaded Mindanao
at the Parang beachhead in the Philippines, 25% of the initial
400 casualties were psychiatric.
Offensive vs Defensive Posture
The British were constantly on the offensive in a mobile fluid
advance primarily fighting with light infantry weapons. After
the improvised battle at Goose Green in which the 600 men of
2 Para Battalion captured 1,400 Argentines while losing their
Commanding Officer, it was decided by the British command
to fully prepare for the final assault on the defensive perimeter
around Stanley where the Argentines had withdrawn.
Rapidly advancing troops experience low psychiatric casualty
rates. During 3rd Army’s sweep across France in August 1944,
the rate of psychiatric casualties was 7.4% of non-fatal
casualties21. In Italy during the pursuit to the Gothic line, the
advancing 34th Infantry Division troops had low rates of
psychiatric breakdown despite severe physical fatigue in four
days of marked fighting alternating with periods of no fighting
during which it took heavy physical casualties. Under
favourable tactical circumstances, even in the presence of severe
fatigue and wounded rates, low N-P rates tend to occur.
In Vietnam as the posture changed from offensive operations
to more defensive withdrawal the rate of psychiatric casualties
increased despite the overall decrease in combat participation.
Summary
The low rate of British psychiatric casualties in the Falklands
was due to a number of positive factors: the use of elite units,
short duration of combat, little exposure to indirect fire, an
unopposed landing and a consistently successful offensive
posture, all of which influenced the rate of psychiatric casualties
in past American wars. This low rate occurred despite the
absence of any psychiatrists on land during the campaign and
the absence of psychiatric screening of evacuees. The
combination of favourable factors occurring in this conflict is
not likely to occur in the most predictable future American
conflict, a high intensity European war. The low rate of
psychiatric casualties experienced by the British should not
decrease planning and training for dealing with these casualties
in any future conflict involving either the British or U.S. Army.
References
1
Scott-Brown A. Presentation, Symposium on Military Psychiatry. Royal Army
Medical College, Millbank, Sept. 30, 1982
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Sunday Times of London Insight Team. War in the Falklands: The Full Story.
Harper and Row, New York, 1982
Tiffany, W J and Allerton, W S. Army Psychiatry in the mid-60’s. Amer J
Psychiat 1967; 123: 812-813.
Jones, F D and Johnson, A W. Medical and Psychiatric Treatment Policy and
Practice in Vietnam. J Soc Issues 1975; 31 (4): 49-65.
Challman, S A and Davidson, H A. Southwest Pacific Area, in Glass, A J AND
Mullins, M S (eds). Neuropsychiatry in World War II, Vol II, Overseas
Theatres. Washington DC, U.S. Government Printing Office 1973; 513-577.
Glass, A J. Psychotherapy in the Combat Zone. Amer J. Psychiat April 1954;
725-731.
Billings, E G. South Pacific Base Command, in Glass, A J and Mullins, M S
(eds), Neuropsychiatry in World War II, Vol II, Overseas Theatres. Washington
DC, U.S. Government Printing Office 1973; 473-512.
O’Connell, M. Psychiatrists at War. Paper presented at Symposium on Military
Psychiatry, Royal Army Medical College, Millbank Sept 30, 1982.
Rottersman, W and Peltz, W. Western Pacific Base Command in Glass, A J and
Mullins, M S (eds), Neuropsychiatry in World War II, Vol II, Overseas
Abraham, P. Training for Battleshock. J R Army Med Corps 1982; 128: 18-27.
Marlow, D. Cohesion, Anticipated Breakdown, and Endurance in Battle.
Considerations for Severe and High Intensity Combat. Unpublished, Dept. of
Military Psychiatry, Walter Reed Army Institute of Research 1979; p14.
Lessons of Falklands: Prepare for Surprises. U.S. Medicine Feb, 1, 1983; p3.
Frank, R L. Alaska and the Aleutians (North Pacific Area), in Glass, A J and
Drayer, C S and Glass, A J. Italian Campaign (9 September 1943 – 1 March
1944), Psychiatry Established at Army Level, in Glass, A J and Mullins, M S
(eds), Neuropsychiatry in World War II, Vol II, Overseas Theatres. Washington
Kaufman, M R and Beaton, L E. South Pacific Area in Glass, A J and Mullins,
M S (eds), Neuropsychiatry in World War II, Vol II, Overseas Theatres.
Washington DC, U.S. Government Printing Office 1973; 429-471.
Beaton, L E and Kaufman, M R. As We Remember It, in Glass, A J and
Glass, A J and Drayer, C S. Italian Campaign (1 March 1944 – 2 March 1945),
Psychiatry Established at Division Level, in Glass, A J and Mullins, M S (eds),
Neuropsychiatry in World War II, Vol II, Overseas Theatres. Washington DC,
U.S. Government Printing Office 1973; 47-108.
18 Markey, O B. Tenth U.S. Army, in GGlass, A J and Mullins, M S (eds),
Neuropsychiatry in World War II, Vol II, Overseas Theatres. Washington
19 Kaufman, M R. Central Pacific Area, in Glass, A J and Mullins, M S (eds),
20 Hallam, F T. War Neurosis-Report by XIV Corps Surgeon, in Glass, A J
and Mullins, M S (eds), Neuropsychiatry in World War II, Vol II, Overseas
Theatres. Washington DC, U.S. Government Printing Office 1973; 10631069.
21 Thompson, L J, Talkington, P L and Ludwig, A O. Neuropsychiatry at
Army and Division Levels, in Glass, A J and Mullins, M S (eds),
Footnote by:
Col P Abraham L/RAMC FRCPsych
Professor of Military Psychiatry
Captain Price was obliged to refer to “the rate of evacuated
psychiatric casualties” as “2% of all wounded” since these were
the only data available to him. The true figure for incapacity for
psychological reasons was approximately four times that
number.
The principal reason for this was that many were evacuated
with a physical label, a case of hysterical deafness diagnosed
subsequently in UK being fairly typical.
Others avoided going through the evacuation chain by virtue
of recovery before being caught up in it, or because the sudden
armistice forestalled the need for transportation as a casualty.
Concerning the possibility of occult psychiatric casualties
occurring amongst those with cold injury, this was indeed not
unknown, but the number may well have remained small
because responses to cold stresses of one sort or another were
managed within the unit wherever possible, which happens to
be the correct procedure for overt psychiatric casualties as well.
61
THE FALKLANDS WAR
Commentary on
Rate of British Psychiatric Combat Casualties compared to
recent American Wars
Morgan O Connell
After twenty five years, in general this paper reads correctly,
however it needs to be emphasised that there were psychiatric
assets ashore in the form of two dual qualified nurses embedded
in the Surgical Support Team in Ajax Bay. They had been
extracted from the psychiatric departments in the Royal Naval
Hospital Haslar and the Royal Naval Hospital Plymouth, not
because of their psychiatric qualifications but because of their
SRN qualifications. Nevertheless they did function in this dual
capacity within the Surgical Support Team and provided
support for the surgeons and physicians on the ground in their
triage.
It is not entirely correct to say that no Royal Army Medical
Corps Psychiatrists were invited to the Falklands. I initiated the
signal in the aftermath of the Battle at Goose Green when it
became apparent that we were already beginning to experience
psychiatric casualties amongst 2 Para. This signal requested the
deployment of an Army Mental Health Team. My
understanding is that this was over-ridden by more senior Staff
Medical Officers who quite clearly failed to understand the
importance of having mental health assets on the ground, and
in particular Mental Health assets identified with the Units in
question, i.e. with the Army as opposed to the Navy/Royal
Marines. I believe this had a long term effect on the subsequent
failure/unwillingness/difficulty in recognising psychiatric
casualties amongst the returned combatants.
Whilst the Paper is entitled Rate of British Psychiatric
Combat Casualties Compared to recent American Wars and by
implication is addressing psychiatric casualties during combat,
it needs to be emphasised that just because the shooting has
finished, it does not mean that psychiatric casualties do not
continue to present. This is amply born out by the number of
Veterans on the Books of Combat Stress, the Ex-Services
Mental Welfare Society (some 400) whose traumatic experience
is identified as being the Falklands. It was certainly my
experience before I left the Navy in 1996 that we continued to
see casualties presenting from that conflict on a regular basis
and indeed it was because of this that we set up the first PTSD
62
treatment programme in the country in the Royal Naval
Hospital Haslar in 1987, to which Army casualties were
referred who were suffering as a consequence of 1982.
It has been suggested that amongst the occult psychiatric
casualties were a number of non freezing cold injury/trench foot
cases. I have discussed this with Rick Jolly who was the MOIC
in Ajax Bay, in addition to which I saw some of these cases
myself on board Canberra and there was no doubt in my mind
that whilst they may well have had some form of psychological
symptomathology, their primary disorder was that of trench
foot and to have retained them on the ground with the
inadequate facilities experienced by the fighting units, would
have added to the burden of those units.
Why were the figures so low? (and I believe the figures are
valid). Well first and foremost of course, we won. Secondly the
country was behind us as a whole as was witnessed by the send
off which was exceeded only by the welcome on our return.
Thirdly it was a relatively short conflict and there was virtually
no record of atrocities. This was confirmed by the International
Committee of the Red Cross who visited Canberra when it was
hosting the 4,500 Argentinean prisoners of war who were
returned to the Argentine. In addition there was virtually no
night fighting other than in the final stages of the conflict and
so the issue of combat exhaustion was a relatively minor
problem.
The breakdown of the psychiatric casualties currently on the
Books of Combat Stress by unit, reflects what we have come to
expect. i.e. where there are significant numbers of physical
casualties including fatalities, then there are psychiatric
casualties in proportion.
Finally all are in agreement that the three week journey to the
site of the conflict was a wonderful opportunity to complete
preparation, if that can ever be completed, for going to war and
by the same token the return journey, particularly for the
sailors in their ships, even those which had sustained damage,
gave all the opportunity for recovery.
Military Cold Injury During the War in The Falkland Islands
1982: An Evaluation of Possible Risk Factors
Lt Col RP Craig
Abstract
Throughout the history of war, there have been many instances when the cold has ravaged armies more effectively than
their enemies. Delineated risk factors are restricted to negro origins, previous cold injury, moderate but not heavy smoking
and the possession of blood group O. No attention has been directed to the possibility that abnormal blood constituents
could feasibly predispose to the development of local cold injury. This study considers this possibility and investigates the
potential contribution of certain components of the circulating blood which might do so.
Three groups of soldiers from two of the battalions who served during the war in the Falklands Islands in 1982 were
investigated. The risk factors which were sought included the presence or absence of asymptomatic cryoglobulinaemia,
abnormal total protein, albumin, individual gamma globulin or complement C3 or C4 levels, plasma hyperviscosity or
evidence of chronic alcoholism manifesting as high haemoglobin, PCV, RBC, MCV or gamma glutamyl transpeptidase
(GGT).
No cases of cryoglobulinaemia were isolated and there was no haematological evidence to suggest that any of those men
who had developed cold injury, one year before this study was performed, had abnormal circulating proteins, plasma
hyperviscosity or indicators of alcohol abuse. Individual blood groups were not incriminated as a predisposing factor
although the small numbers of negroes in this series fared badly.
Although this investigation has excluded a range of potential risk factors which could contribute to the development of
cold injury, the problem persists.
Two areas of further study are needed: the first involves research into the production of better protective clothing in the
form of effective cold weather boots and gloves and the second requires the delineation of those dietary and ethnic factors
which allow certain communities to adapt successfully to the cold. A review of the literature in this latter area is presented.
Introduction
Local cold injury may greatly reduce effective combatant troops
in war and can result in considerable morbidity during exercises
in peacetime. Its significance and occurrence is underestimated
and frequently under-diagnosed. Until the Falklands War of
1982 the last occasion in which British servicemen fought in a
cold climate was in Korea and the remaining medically
qualified veterans of that conflict have nearly all retired.
There are historical instances in which the cold has inflicted
more battle casualties than the enemy. Larrey 1 reported the loss
of 11650 out of 12000 men of the 12th division of Napoleon’s
Grand Army during the Russian Campaign and Hitler’s
advance into, and subsequent retreat from, the USS during
World War II resulted in both sides losing catastrophic numbers
of men from the cold 2. The British Army documented 115,361
cases of frostbite and trench foot in the official records of World
War I but the majority of these occurred early in the conflict.
With the introduction of duckboards, the issue of dry socks and
strictly imposed foot and hygiene discipline the incidence
dropped during the later years of the campaign 3. The influence
of these measures in combating cold injury was again manifest
during World War II in North West Europe where British
casualties were much lower than the 91000 suffered by the
United States Army of whom some 87% were infanteers. There
were times during the winter of 1944-1945 when the cold
resulted in up to one-third of American battle casualties 4,5.
No accurate figures for the number of British and
Argentinian troops who fought in the Falklands and sustained
cold injury are available although symptoms were recorded in
28.5% of 3 Para and 20-30% of 2 Scots Guards 6.
Non-freezing and freezing cold injury not only reduces
fighting capability but also occurs sporadically in the United
Kingdom and in North West Europe amongst soldiers either on
exercises or as a result of sleeping rough whilst intoxicated.
Any blood constituent which would impair flow at reduced
temperature is likely to predispose to damage in a cold
environment. Cryproteins are known to do so 7.
The digital necrosis seen in patients with cryoglobulinaemia
is clinically indistinguishable from that produced by freezing
and this appearance raised the possibility that there might be a
group of otherwise asymptomatic individuals who had small
quantities of cryoglobulins circulating in their blood which
might predispose them to developing cold injury. The further
possibility that there could be a number of Servicemen who
were polycythaemic and hyperviscid due to the effects of
chronic alcohol ingestion could explain why some but not all
personnel who served in the Falklands campaign sustained cold
injury whilst others subjected to similar conditions did not do
so.
This study examines these possibilities by comparing venous
blood obtained from British Servicemen who had clinical cold
injury during the campaign with a similar group who
experienced the same environmental conditions but did not do
so and a further group who did not participate.
63
Subjects and Methods
Six groups of soldiers, three from 3rd Battalion, The Parachute
Regiment and three from 2nd Battalion, Scots Guards were
studied. The first two groups (A) consisted of men from these
battalions who were diagnosed as having sustained cold injury in
the Falklands. Confirmation of this diagnosis has been
substantiated in most cases by objective measurement of
impaired nerve conduction and by abnormal vasomotor
response to a cold stimulus observed by strain-gauge
plethysmography8,9. The second two groups (B) consisted of
men of similar age who had gone to the Falklands but who did
not sustain injury despite being subjected to an identical
environment. Selection of these subjects was made by the subunit commanders who had led them during the war. The third
group (C) consisted of a similar number of soldiers who did not
go to the Falklands and who had not previously suffered the
effects of cold elsewhere in the world.
All personnel gave informed written consent for venipuncture,
which was performed two to three hours after a midday meal.
Consent forms were numbered serially and allocated randomly.
Thus the sampling and analysis was performed blind and the
groupings constructed after the results were obtained from the
lists provided by the units.
Samples of 20ml venous blood were withdrawn from the
antecubital fossa using a venous tourniquet into syringes and
needles warmed to 37ºC. 10ml of this blood was immediately
transferred to EDTA lined bottles previously warmed to 37ºC
and replaced in a warmer at the same temperature. The warmed
specimens were centrifuged at 37ºC for 10 minutes at 1000 rpm
followed by 15 minutes at 200 rpm. Thereafter, the supernatant
plasma was collected into plain bottles at room temperature and
transferred for cryoglobulin, total protein, albumin, IgC, IgA,
IgM, complement C3 and C4 estimation. These plasma samples
were divided into three aliquots, one placed at 4ºC, one at 37ºC
and the third retained at room temperature. Regular inspection
was carried out for 72 hours but no cryoproteins were observed.
Immunoglobulin (IgG, IgA, IgM, C3 and C4) levels were
estimated by immuno-nephalometry on a Disc 120 laser
nephalometer (Hyland Laboratories, USA) using goat antisera to
IgG, C3 & C4 (Atlantic Antibodies, USA), IgA, IgM, (ICL,
Scientific, USA). Total protein and albumin levels were obtained
by standard laboratory techniques.
The other specimens were analysed by routine methods on a
Coulter S Senior, (Coulter Electronics, Linton, Beds.) for
haemoglobin, packed cell volume, red cell count and MCV.
Plasma viscosity was determined on a Harkness Coulter
Viscometer9 and gamma glutamyl transpeptidase levels were
estimated by an automated method using the technique of
Szasz10 on a Coulter Kem-o-mat autoanalyser.
Reference ranges were: total protein, (55-79g/1), albumin,
(30-42g/1), IgG, (5.4-16.1g/1), IgA, (0.9-3.4g/1), IgM (0.52g/1), C3, (0.7-1.7g/1), C4, (0.1-0.7g/1), plasma viscosity (1.51.72cp) and GGT (6-28iu/1).
Quantitative data were compared between groups using an
unpaired test and blood group data were analysed using a Chi
Squared test with Yates correction where applicable.
Results
Although the mean ages of the groups in 2 SG were higher
than those in 3 PARA, no statistical differences were evident.
They are shown on Table 1.
Table 1
Subjects Studied
Number
Age (Yrs)
3 Para
Group A
14
Group B
15
22.2
2.33*
Group C
16
20.3
2.55
Group A
16
24.4
3.10
Group B
16
23.8
4.02
Group C
16
25.8
4.74
2SG
* 1 SD
Information was obtained from the RMO’s of the two battalions6
on the distribution of blood groups as was data on those soldiers
who were studied. Tables 2(a) and 2(b) show these distributions.
The variation in the proportions of blood group genotypes
between the two battalions reflects regional differences in the
distributions of blood groups. In this small series no protection due
to the carriage of blood group A was found nor were there any
statistical indicators suggesting an increased tendency to suffer cold
injury in holders of blood group O.
Blood
Groups
A
B
O
AB
Rh Pos.
178
41
183
25
Rh Neg.
30
0
51
0
208
(40.9%)
41
(8.1%)
234
(46.0%)
25
(4.9%)
Rh Pos.
165
52
263
18
Rh Neg.
17
182
(33.3%)
9
61
(11.2%)
19
282
(51.7%)
2
20
(3.64%)
3 Para
Totals
2 SG
Totals
Table 2(a)
ABO and Rhesus Distribution between the Study Groups
A
B
O
AB
Rh+
Rh-
Group A
8
1
4
1
10
4
Group B
6
1
8
0
13
2
Group C
7
0
8
1
12
4
Group A
5
0
9
2
15
1
Group B
4
2
10
0
16
0
Group C
5
2
9
0
14
2
3 Para
2 SG
Table 2(b)
64
Hb g/l
PCV
Red Cell Count
(10–12/1)
MCV
(f1)
3 Para
Group A (n=14)
Group B (n=15)
Group C (n=16)
15.02±0.92
15.47±1.16
14.91±1.04
45.5±2.34
46.09±3.17
45.38±3.00
4.885±0.357
49.89±0.357
4.912±0.351
89.14±3.11
88.50±3.34
88.56±2.52
S Scots Guards
Group A (n=16)
Group B (n=16)
Group C (n=16)
16.10±0.88
15.50±0.71
16.18±1.02
47.54±2.72
45.83±0.47
47.774±3.02
5.033±0.241
4.893±0.201
4.998±0.290
92.13±4.00
91.30±2.55
93.25±4.16
Table 3 Haematolog y Results ±ISD
P<.05
The results of haemoglobin, packed cell volume, red cell count
and mean corpuscular volume are delineated in Table 3.
Haemoglobin levels were found to be higher in Group C of 2 SG
when compared to Group C of 3 Para (P<.05) but MCV levels were
comparable between all groups despite being numerically higher in
2 SG.
Table 4 gives the results of plasma viscosity and gamma glutamyl
transpeptidase (GGT) levels. Once again these figures were similar,
the GGT levels in 2 SG being higher than those in 3 PARA. The
levels in Group B of 3 PARA were higher than Group C (P<.05).
Viscosity
(cp)
Gamma GT
(IU/1)
3 Para
Group A (n=14)
Group B (n=15)
Group C (n=16
1.688±0.121
1.682±0.079
1.655±0.057
16.93±8.84
23.00±10.78
12.75±4.88
2 Scots Guards
Group A (n=16)
Group B (n=16)
Group C (n=16)
1.663±0.067
1.644±0.087
1.691±0.092
31.19±35.73
27.19±23.75
26.5±11.55
and C3>1.70g/1 in three. There were eight men with raised MCV
in whom only one had an elevated GGT but four had raised plasma
viscosity and C3. Plasma viscosities higher than 1.72cp were
measured in 20 individuals. In this group two had an elevated
MCV, four a raise GGT and five a raised C3.
It can be concluded that the incidence of alcohol abuse based
upon haematological and biochemical markers in this series of 93
soldiers was very low one year after 61 of them had served in the
South Atlantic. In only one individual were all markers positive and
although he was in the affected group of 2 SG there is no evidence
on these results to suggest that alcohol abuse played any significant
part in the development of cold injury in the Falklands.
There were no negroes in 2 SG but all four of those in 3 PARA
suffered cold injury.
Discussion
Table 4 Plasma Viscosity (c p) and Gamma Glutamyl
Tranpeptidase GGT (IU/1) Results ± ISD
Finally, Table 5 shows the results of total protein, albumin, IgG,
IgA, complement C3 and C4. No statistical differences were
evident.
Both total protein and albumin levels were at or above the upper
limit of normal for the laboratory reference range which is thought
to reflect the excellent state of nutrition and fitness seen in these
soldiers.
Cryoglobulins were not found in any of the soldiers who were
studied.
Six soldiers had GGT levels in excess of 50iu/1. in four of these
the plasma viscosity was raised but MCV was above 95fl in only one
There are several factors which may cause an individual to be more
susceptible to local cold injury. Caucasians fare better in a cold
environment than negroes who have a 2.8 to six fold increased
likelihood of developing symptoms, although the reasons for this
difference have yet to be defined 11, 12, 13. Animals or man either adapt
to their environment or perish. There are numerous recorded
examples of man’s ability to avoid cold induced injury despite
exposure, which in non-adapted individuals would cause damage.
This capacity would appear to be related to maintenance of higher
skin temperatures and has been reported in Arctic Indians 14,
Alakaluf Indians 15, and in Arctic Eskimos 16. It remains unclear as
to what the aetiology of this adaptive response can be ascribed
although an Eskimo’s basal metabolic rate is higher than a Caucasian
of comparable surface area and lean body mass 17. By inference, this
excess energy expenditure could be taking place in the vasodilated
extremities of these peoples. Little et al 18 (1971) tested skin
temperature responses in groups of young and adult Peruvian
Indians. One group was compared with adult American and British
Caucasians. The adult Indians, regardless of their place of dwelling,
maintained higher skin temperatures after cold exposure than the
Total Protein
(g/l)
Albumin
(g/l)
IgG (g/l)
IgA (g/l)
Igm (g/l)
C3 (g/l)
C4 (g/l)
3 Para
Group A (n=14)
Group B (n=15)
Group C (n=16)
84.57±3.78
84.2±4.39
81.19±4.12
44.86±3.25
44.0±1.89
42.25±3.11
11.71±0.01
12.08±1.81
11.25±1.47
2.40±0.96
2.30±0.83
2.55±0.56
1.49±0.52
1.55±0.69
1.35±0.63
1.25±0.24
1.33±0.23
1.38±0.29
0.45±0.24
0.49±0.41
0.39±0.15
S Scots Guards
Group A (n=16)
Group B (n=16)
Group C (n=16)
86.88±4.22
84.31±4.96
86.75±3.82
44.06±3.43
44.00±3.18
42.44±1.86
12.51±1.85
11.84±2.00
13.09±1.63
1.98±0.58
1.63±0.51
1.92±0.79
1.72±0.54
1.76±0.63
1.74±0.54
1.43 0.30
1.34 0.21
1.42±0.18
0.59±0.42
0.61±0.41
0.52±0.19
Table 5 Protein Results (g/1±ISD )
65
whites implying a strong genetic effect, but they also maintained
higher temperatures than the Indian children which would suggest
a degree of adaptation during life. The influence of genetic mixing
between Indians and Caucasians was studied by measuring the rate
at which cold induced vaso-dilation (CIVD) occurred after hand
immersion at 5ºC in two groups of Canadian Algonkian Indians
from two villages19. They concluded that the onset of CIVD
occurred later in the Indians with greater Caucasian admixture.
In addition to these genetic factors there is a real possibility that
diet may contribute to adaptation to environmental cold. Laursen17
(1983) has noted that the capacity of Alaskan Eskimos to cope with
freezing conditions appears to be lost if they transfer their diet to
that of Westerners and stop consuming seal blubber and fish.
Sinclair20 (1953) failed to find any cholesterol deposition in the
corneas of Eskimos on a traditional diet which contains the highest
known proportion of dietary fat. Coronary heart disease is not
observed in these people 21. Fish and blubber fat is rich in linolenic
acid as is the dietary fat consumed by the Japanese in whom
atherosclerosis is also rare. He extended his experiments by joining
a community of long living Eskimos in Greenland in 1976 and
subsequently consumed seal and fish as his sole nourishment for
100 days 22. This resulted in extension of his bleeding time from four
minutes to in excess of 50 minutes and greatly decreased his platelet
aggregation. He postulated that this effect was caused by the high
intake of linolenic acids resulting in the production of prostacyclin,
(PG13) and thromboxane (TXA3) rather than PG12 or TXA2
which are derived from linoleic acid. Whereas PG12 and PG13
both de-aggregate platelets, TXA2 promotes thrombosis whilst
TXA3 has little or no effect upon platelets. These interesting
findings do suggest that diet may be an important contributor to the
circulation of blood in the extremities of Eskimos who consume
traditional food and may reduce the likliehood of intravascular
thrombosis during periods of impaired flow and hyperviscosity in a
cold environment 20,22.
Rather more difficult to explain on either genetic or dietary
grounds is the capacity to adapt to occupations involving the
handling of cold objects or immersion of feet in cold water.
Examples include Gaspe fishermen23, fish filleters24, and Canadian
lumberjacks25 whose feet remain immersed and cold for long
periods without deleterious effect. A fish diet in the first instances
and active movement and exercise in all examples may result in
improved circulation in these cases along with an acquired capacity
to vasodilate.
Raynaud’s phenomenon whether it be idiopathic or secondary to
peripheral vascular disease, thromboangiitis obliterans, vibration
injury, previous cold injury or to mixed connective tissue disease
greatly increase predisposition to the effects of the cold26.
Other factors which have been delineated include moderate but
not heavy cigarette smoking, fatigue, ethanol consumption,
hyperhidrosis, reduced lean body mass, blood group O individuals,
inadequate clothing and footwear, hygiene, rank and
motivation3,11,25.
With the exception of ABO blood groupings no attention has
been paid in the literature to the possibility that the physical
properties or composition of the blood itself could predispose to the
development of cold injury. Nor is it clear whether the pathological
effects of the cold upon the extremities is the direct result of
intravascular thrombosis alone or due to an inflammatory response
with endothelial damage and vascular destruction in addition. Eady
et al 27, (1981) in a study of cold induced urticaria and vasculitis,
demonstrated the appearance of complement C3 in dermal blood
vessels following a cold stimulus which preceded deposition of fibrin
and immunoglobulin within the vessel wall and was associated with
mast cell degranulation. There was later perivascular infiltration by
inflammatory cells and later still vascular endothelial disruption.
Controls showed no such response.
Cryoglobulinaemia has been recognised since 1933 28, and the
66
conditions in which it has been observed include myelomatosis,
lymphoma, mixed connective tissue disorders including rheumatoid
arthritis, systemic lupus erythematosis, Sjogren’s disease, cirrhosis,
Crohn’s disease and disseminated malignancy29-33. there were a
number of cases reported above in whom the aetiology of
cryoglobulinaemia was unknown and they were described as being
essential or idiopathic. McGrath and Penny7 (1978) demonstrated
greatly increased blood and plasma viscosity in cases of
cryoglobulinaemia with an associated increased red cell aggregation
on cooling at low shear rates. They suggested that this finding
explained at least in part the localisation of damage to the skin in
those peripheral tissues of the extremities most exposed to cold.
Dehydration due to the combined effects of excessive sweating
within the clothing required in a cold environment along with a
reduced intake of water also results in hyperviscosity34. Chronic
alcolhol abuse is associated with a raised MCV and gamma glutamyl
transpeptidase, (GGT)35-38.
This study has investigated several components of the circulating
blood in soldiers who served in the Falklands Campaign of 1982
and has effectively excluded many of them as being aetiological
factors in the development of non-freezing cold injury. Thus the
reasons why some and not all individuals who are subjected to
similar adverse environmental circumstances develop symptoms
remains unanswered.
The study was performed one year after the event. As no cases of
cryoglobulinaemia were found in any of the soldiers in any of the
three groups who were studied, it would seem most unlikely that
small groups of individuals with asymptomatic cryoglobulinaemia
exist. Whereas it is recognised that epinephrine release produces
distal vasoconstriction in association with fear, the concomitant
production of cryoglobulins in these circumstances has not been
investigated. Perhaps venous sampling of parachutists prior to their
first jump might confirm or refute this possibility. It is known that
the circulation in the fingers can be reduced to 3% of control levels
following immersion in water at 13ºC for two hours39 or to zero at
temperatures between 0ºC and 8ºC 40. Associated with this
diminution of flow is a tendency to sludging and microvascular
occlusion. Thus, polycythaemia or hyperviscosity would tend to
accentuate this phenomenon41. Although high haemoglobin levels
have been recorded in chronic alcoholics42 it is still disputed whether
this is entirely due to the alcohol or whether it derives from the
stimulus provided by consistently high levels of carbon monoxide
found in heavy smokers who also drink. The possibility that certain
soldiers might be found to have biochemical or haematological
evidence of chronic alcohol abuse was explored bearing in mind that
one year had elapsed between the exposure to cold and also that the
alcohol intake was restricted to two cans of beer per day during the
sea voyage between Ascension Island and the Falklands. This
restriction, however, would not necessarily prevent a considerably
greater intake by alcohol abusers who could have increased their
consumption by certain forms of barter.
The concept of hyperviscosity and an increased tendency to
sludging associated with a high haematocrit and polycythaemia may
contribute to the high proportions of chronic alcoholics who form
the bulk of most of the civilian series of frostbite43-45. More likely is
that these cases occur due to acute inebriation causing them to sleep
rough in cold weather. It is nonetheless worthwhile to consider
chronic alcoholism particularly in troops who are to be exposed to
the extremes of cold either on exercise in peacetime or in war.
The tendency for negroes to be more susceptible to the cold than
Caucasians was confirmed in this study albeit with small numbers.
The proportion of the population with Group A blood is higher
in Scandinavia than in the rest of Europe and it has been postulated
that this is associated with an evolutional capacity to withstand
cold46. Group B blood becomes increasingly common through
Eastern Europe and into Asia46. Group O American soldiers have
been found to have 1.8 times increased chance of cold injury during
training in Alaska. Whereas 3 Para have a pattern of blood groups
which is in close parallel with England despite drawing from all
areas of the nation, the 2 SG who recruit 60% of their troops from
north of the border had a pattern of distribution which is identical
to that found in SW Scotland with a Group A proportion of only
33% and with 52% Group O. This would appear to reflect a Celtic
rather than Scandinavian ancestry. There is no indication, however,
to restrict soldiers’ employment because of their blood genotypes.
Complement C3 and IgM deposition in the walls of dermal
blood vessels has been shown to be an early finding in the
development of vasculitis associated with cold urticaria27. In this
series, immunoglobulins, complement C3 and C4 levels were all
indistinguishable between groups and none of these proteins have
been shown to be of aetiological importance in the development of
non-freezing cold injury.
It was not possible to obtain information on the smoking habits
of the men from these two battalions who served in the Falklands.
Information from the 93 who were investigated as regards smoking
was not sought. Previous work carried out in Alaska11,12,25 has
revealed that light smokers (less than 20 per day) had a higher risk
of sustaining frostbite than non-smokers or heavy smokers (more
than 20 per day).
Conclusions
The cold produced considerable morbidity and loss of fighting
strength during the Falklands Campaign as it has on numerable
occasions throughout the history of war. This study has excluded
some of the possible factors within the circulating blood which
might have predisposed to its development.
The following areas of research warrant further evaluation.
Improvements in cold weather clothing and particularly foot and
hand wear is a major priority. Further data on the microscopic,
electron microscopic and biochemical nature of the effects of cold
upon blood vessel walls, nerves and dermal cells is required. The
possible contribution of diet and specifically those rich in omega 3
polyunsaturated fatty acids similar to that consumed by Eskimos
who have successfully adapted to their environment needs
investigation. Ways in which the prolonged bleeding time
produced by this diet could be rapidly corrected in the event of
wounding should be sought. Evaluation of vasodilator drugs as
prophylactics might prove a worthwhile avenue for study.
Finally, standardisation and quantification of the effects of
previous cold injury is required in order to assess prognosis, future
employment standards and the possibility of improving late vasospastic symptoms of sympathectomy the value of which in the
acute phases of frostbite remains questionable45,45.
Acknowledgements
6
7
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9
10
11
12
13
14
15
16
17
18
19
20
21
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23
24
25
26
27
28
29
30
31
32
The efficiency and co-operation of 2 SG and 3 PARA in providing
soldiers for this study is greatly appreciated. Both the ABSD and
John Boyd Laboratory gave inestimable help with venous sampling
and analyses. Particular thanks are due to Dr. Pamela Riches and the
Protein Reference Library at the Westminster Hospital for advice
and for the cryoglobulin, protein and complement estimations.
This study was approved by AMS Research Executive Committee
as Project No. 277.
34
References
37
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2
3
4
5
Larrey, D J. Memoirs of Baron Larrey, Surgeon in Chief to the Grand
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Vaughn, P B. Local Cold Injury – Menace to Military Operations: A
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Whayne, T F. Cold Injury in World War II: A Study in the Epidemiology
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Whayne, T F. and Debakey, M E. Cold Injury Ground Type. US
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Hands, P and Warsap, J. RMO/s 3 Para, 2 SG. Personal Communications,
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McGrath, M A and Penny, R. Blood Hyperviscosity in Cryoglobulinaemia:
Temperature Sensitivity and Correlation with Skin Blood Flow. AJEBAK
1978; 56: 127-137.
McCaig, R. Personal Communication. 1983
Harkness, The Viscosity of Human Blood Plasma: Its Measurement in Health
and Disease. Biorheology 1971; 8: 171-193.
Szasz, G. A Kinetic Photometric Method for Serum Gamma-Glutamyl
transpeptidase. Clin Chem 1969; 5: 124-136.
Sumner, D S, Criblez, TL and Doolittle, W H. Host Factors in Human
Frostbite. Milit Med 1974; 139: 454-461.
Miller, D and Bjornson, D R. An Investigation of Cold Injured Soldiers in
Alaska. Milit Med 1962; 127: 247-252.
Orr, K D and Fainer, D C. Cold Injuries in Korea during 1950-1951.
Medicine 1052; 31: 171-220.
Elsner, RW, Nelms, JD and Irving, L. Circulation of Heat to the Hands of
Arctic Indians. J Appl Physiol 1960; 15: 662-666.
Hammel, H T. Thermal and Metabolic Response of the Alakaluf Indians to
Moderate Cold Exposure. Wadd Tech Report No. 60-633; Wright Patterson
AFB: Ohio 1960.
Brown, G M and Page, J. The Effect of Chronic Exposure to Cold on
Temperature and Blood Flow in the Hand. J Appl Physiol. 1952; 5: 211-227.
Laursen, G A. Whole Body Effects of Cold and Hypothermia. At Workshop
on “Medical Operational Problems in a Cold Environment”. Alverstoke, 1983.
Little, M A et al. Population Differences and Developmental Changes in
Extremity Temperature Responses to Cold Among Andean Indians. Hum Biol
1971; 43: 70-91.
Hurlich, M G and Steegmann, A T. Hand Immersion in Cold Water at 5ºC
in Sub-Arctic Algonkian Indian Males from Two Villages: A European
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Sinclair, H M. The Diet of Canadian Indians and Eskimos. Proc Nutr Soc
1953; 12: 69-80.
Dyerberg, J and Bang, H O. Haemostatic Function and Platelet
Polyunsaturated Fatty Acids in Eskimos. Lancet 1979; ii: 433-435.
Sinclair, H M. Prevention of Coronary Heart Disease: The Role of Essential
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Leblanc, J. Hildes, JA and Heroux, O. Tolerance of Gaspe Fishermen to Cold
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Nelms, J D and Soper, D J G. Cold Vasodilation and Cold Acclimatization in
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and discussion of its Prediction. Milit Med 1969; 134: 1307-1316.
Porter, J M et al. Evaluation and Management of Patients with Raynaud’s
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Eady, R A J et al. Cold Urticaria with Vasculitis: Report of a Case with Light
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Med 1966; 40: 837-856.
Aizawa, Y et al. Vasculitis and Sjogren’s Syndrome with IgA-IgG
Cryoglobulinaemia Terminating in Immunoblastic Sarcoma. AM J Med 1979;
67: 160-166.
Lerner, A R, Barnum, C P and Watson, C J. Studies of Cryoglobulins: 11. The
Spontaneous Precipitation of Protein from Serum at 5ºC in Various Disease
States. Am J Med Sci 1947; 214: 416-421.
Mayer, L, Meyers, S and Janowitz, H D. Cryoproteinaemia in the Cutaneous
Gangrene of Crohn’s Disease: A Report of two Cases. J Clin Gastro-enterol
1981; 3 (Suppl 1): 17-21.
Beeley, J M. Fluid Balance during Exercise in a Cold Environment. At
Workshop on “Medical Operational Problems in a Cold Environment”.
Alverstoke, 1983.
Baxter, S et al. Laboratory Tests for Excessive Alcohol Consumption Evaluated
in General Practice. Br J Alcohol and Alcoholism 1980; 15: 164-166.
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Peripheral Markers for Diagnosing Alcoholism and Monitoring for Continued
Abuse. Br J Alcohol and Alcoholism 1981; 16: 167-177.
Clark, P M S and Kricka L J. Biochemical Tests for Alcohol Abuse. Br J Alcohol
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Glutamyl-Transpeptidase as markers of Drinking in Working Men. Lancet
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Barcroft, H and Edholm, O G. The Effect of Temperature on Blood Flow
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Lapp, N L and Juergens, J L. Subject Review: Frostbite. Mayo Clin Proc
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1965; 40: 932-948.
42 Gravett, P J. 1984 (In Preparation).
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68
44 Isaacson, N H and Harrell, J B. The Role of Sympathectomy in the
Treatment of Frostbite. Surgery 1953; 33: 810-816.
45 Golding, M R et al. The Role of Sympathectomy in the Treatment of
Frostbite, with a Review. Surgery 1965; 57: 774-777.
46 Mourant, A E. The Distribution of the Human Blood Groups. Oxford:
Blackwell, 1954.
THE FALKLANDS WAR
Commentary on
Military Cold Injury
Surg Commander Jason Smith
This paper, written a year following the Falklands War and
published in the JRAMC in 1984, explores some of the reasons
why some soldiers succumbed to cold injury during the
campaign. It asks the question why some were affected while
their comrades-in-arms, who were exposed to the same
conditions, were not.
In this day of publication bias (of positive studies) it is
refreshingly negative in its results, as all the suggested
haematological abnormalities the paper set to explore were not
in fact present in the subjects. Although the modern day soldier
is better equipped and less likely to sustain cold injury than 25
years ago, it is still a very real risk in austere environments
particularly when other hostile factors are present.
There are parallels to be drawn with other forms of
environmental illness, in particular heat-related illness. It is still
not fully understood why one soldier is more likely to suffer one
of these environmental medical problems than those around
him. However, there have been advances in knowledge of how
hypothermia affects other conditions, in particular the
detrimental effects in multiple trauma patients with ongoing
haemorrhage, and potentially beneficial effects following
cardiac arrest.
The disastrous effect of cold in trauma patients where there is
ongoing haemorrhage contributes to the lethal triad of
hypothermia, acidosis and coagulopathy. Mortality in patients
who fall into this group is high.
There is now reasonable evidence to suggest that whole body
cooling following cardiac arrest improves survival, due to a
reduction in cellular oxygen demand and metabolism. The
same could be surmised from the anecdotes from the same
period as this paper, of penetrating trauma victims during the
Falklands conflict, where a self-selected group of patients
survived in the cold of the South Atlantic winter for hours
without formal resuscitation or critical care treatment. This
group had presumably stopped bleeding through tamponade
(or other mechanisms) and therefore the effects of the
hypothermia were of benefit in slowing metabolism and tissue
metabolism without causing continuing haemorrhage due to
adverse effects on the coagulation cascade.
However, we are now into the realms of conjecture.
Returning to the topic of this paper, in 1984 we were no nearer
to the truth about why some are affected by cold while others
are not. I wonder if modern science has brought us any further
to an answer.
For an up to date summary of the topics of cold injury and
hypothermia, I would recommend the special edition of this
journal dedicated to Medicine in Hostile Environments
(December 2005). As the title of one of these papers says, cold
still kills.
Jason Smith
Surgeon Commander Royal Navy
Consultant in Emergency Medicine
Derrifield Hospital, Plymouth
69
Resuscitation experience in the Falkland Islands campaign
JG Williams, TRD Riley, RA Moody
The recent campaign to retake the Falkland Islands was a novel
military exercise from many points of view. This was
particularly so for the medical support, which required much
improvisation at all levels. Several surgical teams from the Royal
Naval and the Royal Army Medical Corps were deployed in
support of both the fleet and the troops on land. Two Royal
Naval teams embarked in SS Canberra, and the journey south
on board provided an opportunity to discuss and decide on a
specific resuscitation policy for the casualties that might be
encountered. We discuss the details of this policy and the results
of using it.
Resuscitation policy
The essence of the resuscitation policy was that it should be
simple and straightforward, using a minimum of procedures,
drugs, and fluids. This would aid the speed at which large
numbers of casualties could be resuscitated. Once formulated,
it was taught to all personnel likely to be concerned in
resuscitation.
Airway – The airway was to be managed in the usual manner
with clearance of all foreign material from the mouth and
pharynx, support for the jaw, and insertion of a Guedel airway
if necessary. Facilities for endotracheal intubation and assisted
ventilation would be available in the resuscitation area. Patients
with maxillofacial injuries would probably be nursed prone, but
patients with other injuries would probably be supine when
attended. Any penetrating injury of the chest or any clinical
evidence of pneumothorax would require the insertion of an
intercostal chest drain in the mid-axillary line between the
fourth and fifth and six ribs and directed apically on the side of
the injury. These patients would be nursed sitting up, if not
contraindicated by shock.
Analgesia – Intravenous morphine was to be used, diluted 15
mg in 5 ml of water, and given in small doses (3 mg) often,
titrated according to pain. The importance of checking the dose
and time of any analgesia given previously was emphasised. For
chest injuries it was planned to given buprenorphine
hydrochloride 0.3-0.6 mg or, if unavailable, pentazocine 30-60
mg intravenously. Inhalational Entonox (50% nitrous
oxide/50% oxygen) would also be available.
Antibiotics – All patients with open wounds were to be given
benzyl-penicillin intravenously, one megaunit immediately and
repeated every six hours for 24 hours. Patients with penetrating
head wounds were to be given sulphadimidine 1 g four times a
day intramuscularly in addition. Those with abdominal wounds
were to be given immediately gentamicin 80 mg intravenously
and metronidazole 500 mg intravenously. With these more
complicated injuries postoperative antibiotic treatment was to
be defined by the operating surgeon. It was decided not to
attempt to exclude penicillin hypersensitivity in view of the
difficulties in obtaining an accurate history.
Antitetanus – It was decided not to attempt to administer
This paper first appeared in the British Medical Journal and is
reproduced by kind permission of the editor
70
tetanus toxoid vaccine to all troops before the expected battles
as their basic level of immunity would have been high due to
normal service vaccination programmes, and the wide
distribution of troops among the ships of the Task Force would
have made it impossible to cover all the combatants with this
policy. Thus postinjury boosters would still need to be given
and in some areas would have resulted in three antitetanus
injections over only a few months. It was therefore decided to
limit active antitetanus immunisation to booster injections
given during the resuscitation of all casualties with penetrating
injuries or burns. Human antitetanus immunoglobulin was
available for use at the discretion of the surgeon.
Other drugs – Diazepam 10 mg in 2 ml was to be given for
excess anxiety persisting when pain had been controlled by
morphine. Naloxone 0.4 mg diluted to 2 ml was available to
reverse opiate overdosage. Methylprednisolone 1 g immediately
followed by 0.5 g every six hours was to be given for any lung
injury whether caused by trauma, blast, smoke inhalation, or
drowning. It was not planned to give steroids routinely for
shocked patients except for irreversible shock. Adrenaline 1 mg
in 500 ml 5% dextrose was set up in the resuscitation area daily
for the treatment of anaphylactic shock.
Oxygen was to be given to all shocked patients through a
moderate concentration Venturi mask.
Fluid replacement – Intravenous infusions were to start after
a blood sample had been taken for cross match through a large
bore intravenous cannula sited in a forearm vein as soon as
possible after admission. If vasoconstriction precluded
peripheral venepuncture a cut down or central line was to be
inserted. Initial infusion would be with one litre of compound
sodium lactate solution followed by 500 ml of polygeline.
Polygeline was chosen in preference to other colloids because of
its unbreakable bottle, light weight, temperature stability, and
because it would not interfere with blood cross match. The
speed of infusion was to depend on clinical judgment. The
sequence of compound sodium lactate followed by polygeline
would be repeated if clinically indicated. Cross matched blood
would be given, if indicated, when available. Cross match times
would be half an hour for an urgent cross match and two hours
for a routine cross match, though a small stock of O-negative
blood was to be held in the resuscitation area for lifesaving
urgent transfusion.
Burns – Burns cases were to be treated with attention to the
airway, analgesia, penicillin, and tetanus toxoid as already
described. Intravenous fluids would be given at 120 ml per 1%
of burn over the 24 hours after the time of the burn, using
crystalloid (compound sodium lactate) and colloid (polygeline)
in equal proportions plus additional crystalloid for normal daily
requirements. It was not planned to give intravenous treatment
unless the burnt area was 15% of the total body surface area, or
greater. Silver suphadiazine cream was to be used topically with
polyethylene bag occlusion for hands and feet. Any evidence of
blast or smoke inhalation injury to the lung would be an
indication for methylprednisolone 1 g immediately followed by
0.5 g every six hours.
Monitoring – The usual measurements of pulse, blood
pressure respiratory rate, and level of consciousness would be
used. It was not planned to use central venous lines for
measuring venous pressure.
Clinical results
The main reception areas for treating casualties from time to
time of the landings on 21 May to the surrender were first SS
Canberra and then a disused refrigeration plant at Ajax Bay,
which was later supplemented by forward surgical stations at
Teal Inlet and Fitzroy. We were present and responsible for the
resuscitation at all of these sites except Fitzroy, and the policy as
described was used in these areas where over 500 battle
casualties were treated. Overall, the simplicity of the policy and
the planning and rehearsal that went into it paid dividends.
Resuscitation proved to be rapid, efficient, and effective. Only
three patients died at this stage of their management. One
reached Ajax Bay irreversibly shocked, having lost both legs
when an ammunition dump exploded at Goose Green, and
could not be resuscitated, and two were admitted to Teal Inlet
moribund from severe penetrating high velocity gunshot
wounds to the head.
Specific aspects of resuscitation deserve the following
comments:
Airway – No upper airway problems were encountered, and
no patients required endotracheal intubation before surgery.
This included several admissions with wounds to the head, face
or neck who were nursed prone to maintain their airway, but
even these patients appeared to have travelled well in a variety
of positions without problems. All penetrating wounds of the
chest were treated with intercostal drainage with, in many cases,
relief of respiratory embarrassment by the drainage of
substantial volumes of blood. Heimlich valves were used to
provide a one way seal to these drains and these often became
blocked if blood was draining. The only solution was to change
the valves frequently but a non-blocking seal would have been
an advantage. Several patients who had been exposed to blast
had pneumothoraces without external evidence of injury and
these also received intercostal drains. Sucking chest wounds
were occluded with airtight dressings. With these measures,
nursing in the sitting position, and giving oxygen to those who
were clinically cyanosed or in whom restlessness suggested
hypoxia, all chest wounds were managed in slow time, and no
patient required immediate emergency surgery.
Analgesia – Morphine given in small doses intravenously at
frequent intervals was very effective in controlling pain and
relieving anxiety. No problems were encountered with
respiratory depression and in the event non-opiates were not
used as an alternative to morphine for chest injuries.
Antibiotics – No specific figures can be given, but infection
did not prove to be a problem provided that the surgical
principles of extensive wound debridement and delayed
primary suture were followed. Antibiotic policy as planned was
followed with the exception of penetrating head wounds when
metronidazole was given in addition to penicillin and
sulphadimidine when it was learnt that some patients with head
injuries evacuated to the hospital ship SS Uganda had improved
when metronidazole was added to their treatment. No cases of
tetanus, gas gangrene, or hypersensitivity to penicillin were
seen.
Other drugs – Diazepam was use in small doses in a few
patients who remained agitated, noisy, and disruptive to other
patients despite adequate pain relief with morphine. These were
all patients who had suffered painful superficial facial and hand
burns. Diazepam 5 mg with most effective in controlling this
agitated behaviour without harmful synergism with morphine.
No patients required inotropic cardiac support in the
resuscitation areas.
Steroids – Methylprenisolone was given to all cases of near
drowning, blast lung, or smoke inhalation. Treatment was
started as soon as possible and continued for 24 hours. Three
cases of severe blast lung were seen: in all these clinical evidence
for pulmonary oedema was apparent at admission and before
treatment with methylprednisolone had been started.
Nevertheless, all were managed with high doses of
methylprednisolone (1 g immediately followed by 1 g every six
hours) plus frusemide as necessary and oxygen. Despite severe
pulmonary oedema and profound hypoxia these patients all
survived. One required intubation and mechanical ventilation,
though this could not be started until 24 hours after injury
when he was transferred to SS Uganda. Methylprenisolone (1 g
immediately, 0.5 g every six hours for 24 hours) was given to 57
patients with burns from the Sir Galahad who were treated at
Ajax Bay. None of these patients developed respiratory
complications despite exposure to blast and smoke.
Methylprednisolone was not given to patients with gunshot
wounds to the chest, and no problems were encountered.
Intravenous cannulation – In most patients it was possible to
site a large bore cannula into a forearm on arrival. Central lines
through the internal jugular or subclavian approach were used
in several patients who were severely shocked on arrival but
these seemed to confer no specific advantage over finding and
cannulating a forearm vein. Several patients had received initial
fluid replacement in the field from a forward regimental aid
post, but cold and movement in transit almost invariably meant
that these venous lines had ceased to function by the time the
patients reached the surgical stations.
Fluid replacement – Many patients were severely peripherally
vaso-constricted when admitted to the surgical stations but this
was related to cold as much as to blood loss. In a fit young
population circulatory resuscitation proved very effective, with
only one patient, already described, in irreversible shock. Most
patients with simple gunshot wounds required only a litre of
compound sodium lactate followed by 500 ml of polygeline
before surgery. In those in whom blood loss had been serious
blood was given as soon as available. On board the Canberra
cross matched blood was used but ashore cross match was
impractical for lack of both time and facilities and group
compatible blood was given. No transfusion reactions were seen
in either location.
Burns – After the bombing of the Sir Galahad 130 patients
were admitted to Ajax Bay in one hour. Seventy three of these
casualties were suffering from relatively minor trauma or burns
and were transferred immediately to ships in San Carlos Water.
Most of the remaining 57 were suffering from burns to the face
and hands. Sheer weight of numbers meant that a standard
intravenous replacement regimen had to be adopted, and all
patients with greater than 10% burns received intravenous
fluids – about three litres compound sodium lactate and one
and a half litres polygeline – over the next 20 hours, before
transfer to the Uganda. This resuscitation proved necessary but
satisfactory for all except a few patients with more extensive
burns (20-30%) who were underinfused as judged by
haematocrit estimation performed the next day. Pain relief was
good with morphine, though several agitated patients required
a small dose of diazepam (5 mg) in addition. Burns were treated
with silver sulphadiazine cream and exposure, except for the
hands which were enclosed in polyethylene bags.
Discussion
The resuscitation policy as described was simple and
conventional,1 and no new lessons were learnt when using it in
the resuscitation of over 500 patients. Although the injuries
71
were often severe and multiple, the injured on the British side
were highly trained, fit men with a strong will to survive. About
20% of the casualties treated were Argentines and the fitness of
these cannot be gauged nor their will to survive, though many
of them were clearly profoundly relieved to be out of the battle
and out of the cold. Language difficulties and fear made pain
relief and sedation more difficult to achieve but there were no
other specific problems.
The high success rate achieved in the resuscitation of a large
number of casualties, some with severe injuries and many who
had remained in the field for some hours before evacuation, is
a testament to this fitness and morale, and also to the skill and
training of the personnel concerned. The results may also reflect
some degree of selection in that those patients with the most
severe injuries or obstructed airways may have died before
evacuation. Intensive rehearsal before the invasion enabled
paramedical personnel to help with resuscitation so that no
delays occurred once patients were admitted, even at time of
mass casualty reception. The 57 patients admitted after the
bombing of the Sir Galahad were all received at Ajax Bay within
one hour, and none had to wait a considerable or dangerous
length of time for treatment. The standardisation of
resuscitation procedure and the elimination of choice in the use
of fluids and drugs contributed greatly to the speed of this
treatment.
The availability of blood also contributed greatly to the
effective resuscitation of the more severely wounded. Ashore,
72
blood was given without cross match but with confirmation of
the patient’s group by serology, and the time gained outweighed
the dangers of possible mismatch. In the event no transfusion
reactions were seen, though the possibility of sensitisation to
future transfusion remains.
The only other fluids used for intravenous infusion for
resuscitation were compound sodium lactate and polygeline.
Other crystalloid solutions such as saline, dextrosesaline, or
dextrose, and colloid such as dextran or plasma were not used
and not missed. Similarly, only penicillin was used to treat
wounds, apart from the special conditions described, and this
was effective and safe. the possibility of anaphylactic reactions
was considered, but it was thought impractical and too time
consuming to try to elicit a history of this, particularly when
such a history would probably be unreliable. Adrenaline was
available for the treatment of any anaphylactic reaction but
there was none, justifying the selection of this policy.
We acknowledge with thanks the many medical staff, RN,
RAMC, and P and O, in SS Canberra and ashore who
contributed to the formulation and to the execution of this
resuscitation policy. We also thank Mrs Janice Saul for typing
the manuscript. We are grateful to the Medical Director
General (Navy) for permission to publish this article.
Reference
1. Kirby NG, Blackburn G, Field surgery pocket book. London: HMSO
1981. (Accepted 18 January 1983).
THE FALKLANDS WAR
Commentary on
Resuscitation experience in the Falklands Islands
Campaign
Br Med J 1983; 286: 775-7
Keith Porter
Each major military campaign leaves a legacy and in the case of
medicine this may be clinical, policy or operational. Perhaps
the most famous quotation in relation to trauma is that by
Cannon, an American Surgeon practicing during the first
world war, who reported in 1918 “shock may hinder bleeding”.
The Falkland Islands campaign was no exception.
In a pre ATLS era Williams et al reported devising a
resuscitation policy very similar to an ABCD primary survey.
Their desire was to create a system which was “simple and
straightforward using a minimum of procedures, drugs and
fluids” – principles similar to those used at the Birmingham
Accident Hospital (“simple things should be done well always”
Peter London, Senior Surgeon).
Contemporary care remains similar albeit with some
advances in assessment and resuscitation techniques. In
relation to airway care there has been the addition of naso
pharangeal airways and rapid sequence induction of
anaesthesia frequently delivered in a forward position as part of
the MERT teams. Oxygen can now be delivered in higher
concentrations with the use of the trauma mask. Non
operative management of penetrating chest trauma, where
indicated, remains unchanged as does the use (at the moment)
of titrated opiates. Early blood transfusion led to more
effective resuscitation in the severely injured, a lesson
reinforced by the current conflict.
In relation to major incidents the successful management of
the multiple burn victims from the Sir Galahad was an
illustration of “doing the most for the most” with the adoption
of a generic fluid replacement policy for all patients with burns
>10% - applying principles ahead of the creation of the
MIMMS course.
Lessons from the Falkland Islands campaign have advanced
medical education but so often history repeats itself. How will
the current campaigns in Afghanistan and Iraq may be
remembered? - for the use of hypotensive resuscitation
strategies (remember Cannon), tourniquets, haemostatic
dressings and damage limitation surgery with early blood
transfusion (remember the Falklands), FFP and platelets.
Correspondence to: Keith Porter
Professor of Clinical Traumatology, Royal Centre for Defence
Medicine, Selly Oak Hospital Birmingham
R Army Med Corps 153(S1): 73
73
Lessons from the Falklands Campaign
“The tumult and the shouting dies;
The Captains and the Kings depart:
…Lest we forget – lest we forget!”
Rudyard Kipling
Although he wrote in another context, Kipling’s words from his
renowned Recessional hold a prophetic warning for the Army
Medical Services and, more important for their masters, lest they
forget the hard-learned lessons of the land battle for the Falklands.
On many occasions in the history of warfare the lessons of earlier
campaigns have had to be relearned anew and it is sad but salutary
to confirm the validity of the truism that history teaches that we do
not learn from history. The purpose of this editorial is to stem the
drift to oblivion of the object lessons adduced. As the drama and
activity of the brief land campaign start to recede into the mists of
memory it is important to collect and collate the medical
information, to identify shortcomings as well as successes, and to
define the doctrines on which future teaching policy may be based.
To this end the five professors of the Royal Army Medical College,
none of whom was a member of the Task Force, have been asked
to write a brief and preliminary appraisal of the medical problems
encountered in the areas of their particular specialism.
In such operations as the recapture of the Falklands the public
gaze not unnaturally concentrates on the work of the surgeons, and
certainly the rapid and effective treatment of surgical casualties is of
paramount importance not only for the saving and conservation of
manpower but also for the maintenance of morale among troops
in the field. However, no one should doubt the significant
contribution made by all the component parts of the Army
Medical Services and amongst those perhaps the most relevant is
preventative medicine. The effective mental and physical
preparation of troops committed to battle in one of the most
hostile environments known to man is clearly a key factor in
determining a successful outcome.
The series of reviews that follow must be regarded as provisional
and preliminary in terms of the opinions expressed. It may be that
some of what is said now by the professors will turn out to be
wrong when analysed by the more scientific and critical appraisals
that will follow, but that does not mean that these things should
not be said. It is right that they should be said and discussed so that
ultimately, truth will emerge.
Preventative Medicine
Col I P Crawford, GM, FFCM
It is without question that our troops involved in the Falkland
Islands campaign suffered from medical conditions which might be
considered preventable. What we need now is to look at the
conduct of the campaign and consider how well we anticipated
problems and how successful we were in overcoming them. It is of
particular importance to identify those areas where execution fell
short of intention and to seek reasons for the discrepancies.
In any campaign there are two types of casualty, those that are
the direct result of enemy action and those resulting from a hostile
environment, the latter encompassing not only the physical
environment but also the prevailing health circumstances.
It behoves us therefore to consider the environment of the
Falkland Islands and review the health risks pertaining. We had
available at the outset a reasonable amount of information upon
which to base our appreciation. The presence in the United
Kingdom of senior medical and other islanders helped in this task.
From the purely “medical” point of view it appeared that the
only conditions of note causing problems in the local population
were upper respiratory tract infections, bronchitis and a small
amount of tuberculosis; no exotica that one could ascertain. Such
complaints did not pose a direct threat to our troops but pointed
to problems we were likely to encounter.
The physical environment on the other hand did pose problems.
The South Atlantic in winter is no place to be by choice and a long
sea voyage with worsening weather is not a happy prospect.
Presuming that motion sickness had not taken too great a toll of
the Force, and there is not much that can be done to reduce the
incidence, we needed to know what conditions of weather and
74
terrain would confront our troops on arrival at the Islands.
The answer, extremes of heat and cold apart was the worst
possible environment in which to survive irrespective of carrying
out military activities. The climate wet, cold and extremely windy,
the terrain wet, boggy in places, rocky elsewhere, some small
mountains, minimal roads or tracks and generally ground
impassable to vehicular movement. Outside the main settlement
no shelter to be found and no protection from the weather. In short
hostile in the extreme. The one essential of which there was no
shortage, indeed an excess, was water in its natural state.
With a population of the order of eighteen hundred and
sanitation appropriate to local circumstances it was clear that the
addition of the Task Force would overload the local system apart
from any disruption caused by the presence of the enemy or by
military action. The nature of the terrain in part dictating the style
of warfare indicated that the troops would have to be self sufficient
with regard to food and that individual ration packs would be the
order of the day.
With these thoughts in mind what could be done to reduce the
toll the ‘environment’ would exact upon the Task Force? For once,
time, in a curious way, was on our side. The long journey to the
South Atlantic made possible adequate preparation and training in
terms of further education and practice in first aid, primary
medical care, basic hygiene and instruction in the use of protective
clothing. Time was also well spent in building upon the ‘Fit to
Fight’ programme so that on arrival in the war zone the troops
would be able to accomplish the extremely demanding operation
required of them. Was the appreciation of the situation accurate,
did the preventative measures taken succeed in their aim and was
there any oversight?
In general terms the measures outlined above, together with the
enhanced state of fitness and training of the troops, helped to
ensure the successful outcome. However, not all went well and in
particular the climate took a more fearsome toll than was
anticipated. The incidence of non-freezing cold injury to the feet,
trench foot, was high and presented a continuous drain on
manpower. Factors contributing to this incidence: firstly the
unavoidable immersion during landing, continuous wet weather,
boggy ground, river crossings and lack of shelter; secondly those
possible avoidable, inappropriate footwear (no marching boot was
equal to the conditions), poor foot hygiene, no facilities for drying
gear, and in some cases previous cold injury. In short, conditions
were optimal for this debilitating condition and the incidence
reflected it. In the event only a proportion of those affected came
into medical care, many pressed on regardless. How much longer
they could have continued is an open question which fortunately
was not put to the test. Probably associated with good preparation
on the voyage was a very low incidence of hypothermia; those
concerned recovered quickly and did not require evacuation. In a
campaign where if it was needed it had to be carried on the man,
shortcomings in the equipment for load carriage rapidly came to
the fore and in particular the excessive loads carried by many
accelerated the onset of fatigue to an unacceptable degree.
During hostilities the main food supply was either the Arctic or
the General Service 24 hour ration pack; a significant number of
troops did not eat all their rations with a consequent loss of weight
and possible loss of efficiency. Reasons given for this failure ranged
from “unappetising” foods, shortage of time, nature of operations
to lack of potable water with which to prepare the meal –
particularly the Arctic ration.
Supplies of appropriate clothing, always a problem in cold/wet
conditions, were somewhat limited and drying of clothes was
usually difficult if not impossible.
Such were the problems of the hostile environment; encounters
with the enemy added two further stresses apart from direct
weapon casualties. The first, noise induced hearing loss, was a
hazard to which all were exposed both during preparatory training
and during operations. We shall not know the magnitude of this
injury for some time to come. The other condition of note was
gastro-enteritis. During the campaign the incidence of enteritis was
of insignificant proportions but the disease began to make its
presence felt with the cessation of hostilities and the liberation of
Port Stanley. This development, surprising to some, was probably
due to the more widespread adoption of communal cooking, the
gross contamination of all accommodation and surrounding areas
by enemy troops, and damage sustained by the water supply plant,
mains and sewage disposal system such as it was. Here as elsewhere
the sterling efforts of the environmental health personnel saved the
day.
In summary it can be said that provisional comment from the
preventative medicine aspect is that there is room for improvement
but that much of the effort directed by the Army Medical Services
into improving the fitness of the soldier, his awareness of hostile
environments, his training in first aid, and attempts to improve his
equipment paid off in this campaign.
As a last word it must be added that it was fortunate that there
was time on the voyage south to make good some of the
deficiencies in unit preparedness.
Field Psychiatry
Col P Abraham, FRCPsych
It is difficult for those who, like the writer, did not take part in the
land battle to recover the Falklands to realize how ferociously each
engagement was fought. These encounters, and the battle of
which they formed part, were mercifully curtailed.
Had they lasted longer the number of those whose inability to
fight was not attributable to injury or sickness would have
escalated alarmingly. The chief reason for this assertion is that the
number of such battleshock cases is inexorably linked to the
number of wounded, and as the fabric of the unit is eroded by
casualties, both physical and psychological, so does it become
harder for the remainder to sustain themselves and each other in
the face of bombardment and bereavement. Fortunately the same
arithmetic applied with even more force to the enemy.
In order to support this claim that the number of battleshock
cases was about to achieve significant proportions it is necessary to
show that the law linking the incidence of battleshock to the
incidence of wounding did in fact hold in this particular force and
that the number of stress reactions was rising.
The battalions under study are three of the finest fighting units
to be found anywhere. Training is tough, cohesion tight,
leadership strong. Motivation and morale were acknowledged to
be good. Commanders held the initiative and understood well the
need to ensure respite for their own troops while denying it to the
enemy. It is chastening to record that the ratio of battleshock to
wounded still amounted to between five and ten per cent.
It may be argued that with single figure numbers it matters not
militarily and little from the humanitarian point of view whether
the cases were managed successfully or not. This overlooks the fact
that changing any one of the favourable factors mentioned,
including the shortness of the war and the limited number of
wounded, would have dramatically altered the picture. With
perhaps a third of the battalion out of action, whether or not a
section or two of physically fit men get back to effective duty
begins to matter. Furthermore, some of the casualties were key
men, the successful return to their original role of any one of
whom would have justified the precious place in the land force of
a man whose skills were devoted to this task.
There were no such specialized medical personnel ashore. In
addition communications were difficult, a situation compounded
by the peculiar arrangements of the Geneva Convention whereby
once a casualty reached a Hospital Ship he was forbidden to return
to the war. These circumstances negated the fundamental
principles of early forward intervention and rapid return to duty.
In the Falklands, battleshock casualties who left their units did not
return to active duty. It is probably also fair to say that some of
those occurring within the battalions could have been better
managed, even though some previous knowledge of the subject
was hurriedly amplified on the journey South. (One CO, to his
credit, even read carefully an article on the subject published in
this Journal!)
Would there always be time to do this? It is contended that the
management of psychological problems in battle should be an
integral part of First Aid Training of all medical personnel and all
junior leaders, officers and NCOs. It is further contended that
there should be a specialised presence forward with a field medical
unit. The Israelis have recently proved yet again the efficiency of
this policy in Lebanon, but only because they had organized and
trained for it in peacetime.
If we do not adopt these twin measures we might not be so
lucky next time.
75
Medicine
Brig M Brown, FRCP
In his general preface to the History of the Second World War, Sir
Arthur MacNulty 1 emphasises the value of medical histories of war
to record discoveries and progress in medicine and surgery under
the stimulus of warfare, to relate how problems of medical
administration in theatres of war were met and solved, and to detail
mistakes and errors for the profit of those who come after.
In the short Falklands Islands campaign the main problems were
those of logistics, and medically, apart from cold injuries, there
were no new or old diseases to diagnose and treat. The small
healthy civilian population meant there were no serious demands
on the physician, and the rapid repatriation of the Argentinean
prisoners of war prevented a potential serious epidemic situation.
The emphasis lay on fitness, selection of personnel and the
elimination of the unfit. The correct application of the Pulheems
system and its Employment Standards was again highlighted in
those cases requiring evacuation for medical reasons. These
included peptic ulcer, asthma, recurrent bronchitis and one case of
hypertension. Too often in peacetime the officer with well
controlled hypertension on treatment is not downgraded. Selection
of recruits with recent asthma or even intermittent therapy without
proper screening tests still occurs.
In the Falkland Islands campaign the supply of drugs was
limited, there was no return to duty if case-evacuated to a hospital
ship, and therefore there was no “line of communication” medical
category. Since the Second World War there has been a new trend
in therapy – the use of drugs to prevent long term effects or relapses
on such conditions as hypertension, peptic ulcer, asthma and gout.
In the Services, these people are otherwise fit, pass their BFT, are
often employed in highly specialised jobs, and have considerable
service and experience. But as in the present campaign, medical
drugs are not a first priority, and so regular therapy cannot be
guaranteed. A review of this problem, the numbers involved, the
effect on careers and the cost from wastage is needed in the light of
these experiences. Certainly in the selection of recruits, or at their
final medical, there is no place for any doubtful cases. Continued
research into better selection methods and functional testing as in
the Exercise Liability Test 2 for asthma is essential.
In this short campaign there were no epidemics, no exotic
diseases, and no major civilian problems as seen in the Second
World War. The potential risk situation of the large number of
prisoners of war, in a poor state of hygiene, with little
accommodation was prevented by early repatriation. Should an
epidemic have occurred, there were grave doubts expressed by the
Consultant Physician, who arrived after the ceasefire, as to whether
the required medical supplies would have been available. The
medical drugs are limited in the Field ambulance and Field
Hospital equipment for War. Research is required into the newer
drugs, their shelf life, modular packing, and use in the field so that
in the future, these are quickly available to meet specific
circumstances and changing situations. Contrast the requirements,
for example, of Camp Foxtrot in Zimbabwe, with a Field
Ambulance in Jordan helping a United Nations force, and the
Falklands Islands campaign.
To quote Major General Sir Henry Tidy 3 – “The traditional and
essential function of military medical services is the maintenance of
manpower in a state of fighting efficiency. Such function involves
two separate factors, first the selection of the fit and suitable and
elimination of the unfit, and secondly the prevention and
treatment of disease. As physicians we have an important role in all
three.”
Pathology
Col J B Stewart FRCPath
The Army Medical Services played a distinguished part in the
Falklands Islands campaign and the courage and self-sacrifice of
the Field Ambulances and Field Surgical Teams have been
rightfully recognised and honoured. Less glamorous but
nonetheless valiant contributions were made by other medical
units. These contributed significantly to the success of the
medical operation and added lustre to the reputation of the
Corps. Army Pathology notably played its part throughout the
hostilities and continues to provide an essential laboratory
service to the Islands in the aftermath of the fighting. The
operational readiness of the pathology services was well
illustrated by the specialist sub-units, particularly Army Blood
Supply Depot (ABSD) and The David Bruce Laboratories
(DBL) – units established during the Second World War for
just such contingencies. On mobilisation of the Task Force
DBL were able to issue large stocks of vaccine and smoothly
gear their increased vaccine production to provide adequate
emergency stocks. ABSD was heavily committed throughout
the campaign and 1600 units of fresh blood were urgently
collected and in four separate lots, each accompanied by a
courier, delivered by air to Ascension Island. From Ascension
individual deliveries were made by helicopter to passing
hospital ships of the Task Force.
The blood was issued in new CPD-adenine preservative
giving extended shelf life of 42 days (previously 28 days). The
blood packs were transported in Ordnance Cardboard
76
Polystyrene boxes. The latter containers and the increased blood
preservation had both been the successful outcome of research
and trials carried out at ABSD during the previous two years
and both developments proved highly successful under field
conditions. The entire blood supply operation demanded and
received great co-operation from UKLF, local military units and
the staff of ABSD. Signal traffic and the various logistic
exercises worked smoothly throughout and reflected realistic
training in the past. The Commanding Officer ABSD records
with pride the outstandingly loyal support of his civilian staff
who worked long hours collecting and processing blood; one all
day session was completed the following morning at 0500
hours. Before the Hercules transport aircraft could land at Port
Stanley blood was dropped by parachute on the disused end of
the runway – and delivery successfully completed without the
loss of a single unit of blood! ABSD continues to supply the
Falkland Islands from Aldershot with a regular monthly
delivery of fresh blood by air.
In addition to the smooth blood supply organisation
members of the Parachute Field Ambulance, who had
undergone previous training at ABSD, instructed other
personnel on the ships travelling down to the South Atlantic in
blood collection and resuscitation. These men demonstrated
splendid improvisation in blood storage on the ground and also
supervised the bleeding of Argentine prisoners at the height of
the fighting. This valuable contribution highlighted the
additional role of ABSD, namely its commitment to regular
training in resuscitation procedures.
A Laboratory Technician Class 1 accompanied 2 Field
Hospital and at the end of hostilities was responsible for setting
up a laboratory service in the small civilian hospital in Port
Stanley in liaison with the local civilian general technician. A
basic diagnostic service was quickly established using the fully
serviceable field laboratory equipment. Many of the early
problems involved basic field hygiene and public health checks,
including control of water and milk supplies and highlighted
the need for experienced Army technicians with broad general
training in all laboratory disciplines – versatile all rounders. A
senior laboratory technician is now posted to the Falklands on
a five months rotation. The reference laboratories at Royal
Army Medical College are the regular destination for specimens
from outstations abroad and it was not long before interesting
material, including surgical biopsies, cytological specimens and
specimens for clinical chemistry and serological tests were
arriving at Millbank. A steady stream of interesting case
material arrives regularly from the Falklands. Consultant
Pathologists have made the long journey to Port Stanley to
conduct autopsies and review the laboratory facilities.
There are still many lessons to be learned from the Falklands
conflict. The Army Pathology Service clearly demonstrated an
excellent state of preparedness for its war role. The need for
continuing energetic research and development in areas such as
blood supply in war were underscored. In these days of ever
threatening financial and staff cuts it is important that such
vital tasks are fully recognised and given maximum support in
terms of resources and skilled manpower in order that we
remain prepared for any future conflict. The need for
experienced all round technicians also vindicates the Army’s
policy of a broad general training at RAM College. It is hoped
that in the final analysis of all medical aspects of the Falklands
campaign the contribution of Army Pathology will be fully
realised and supported.
Surgery
Col R Scott FRCS
Although surgeons and anaesthetists of the Army Medical Services
have been continuously deployed with field surgical teams in
support of military operations worldwide since the end of World
War II, there has been no experience since then of the problems of
surgical support of a Naval Task Force. Although surgical teams
have often been situated some thousands of miles from a main
base, the daily rate of casualties has seldom exceeded the capacity
of the teams and casualty evacuation by air from the point of
wounding to the field surgical team, and then rearward to a main
hospital at base, has always been possible. The experience of the
surgical teams in the Falklands has emphasised the lessons learnt
from previous experience but has also raised possibilities for
improvement in the future.
Although the Task Force contained elements from all three
armed services, initial planning was the responsibility of the Royal
Navy. With the necessity for tri-service co-operation, it is essential
that the Medical Officers of all three services understand fully the
responsibilities and capabilities of the other two. Experience in the
South Atlantic strengthened the case for tri-service co-operation in
the education of surgeons and anaesthetists and in the training
exercises of forward surgical units. Difficult though they may be
to achieve, the value of realistic training exercises has been
repeatedly stressed by those involved in the South Atlantic
operations, who emphasise the importance of familiarity with the
equipment, the value of team training, the necessity of training
with their host medical units, and the importance of simple
military fieldcraft which can become as important for the survival
of surgeons and anaesthetists as it is for combatants.
Forward anaesthetists must be completely familiar with field
equipment and its potential. Anaesthetic experience based on the
district general hospital is insufficient to equip an Anaesthetist to
function effectively in an advanced surgical centre. He must be
fully prepared to utilise his robust equipment to its full potential
and be prepared to improvise as a changing military situation may
demand. The simplest method of anaesthesia is often the safest
and best in these circumstances. He must be supported by
competent, well-trained operating theatre technicians who have
trained with the team.
The Surgeon also needs the support of a well-trained team of
operating theatre technicians who know their equipment, know
their fieldcraft and have trained with other members of the team.
Whereas at present the scales of equipment meet the need for
going to war, they are capable of improvement and individual
items must be repeatedly subjected to detailed scrutiny to effect
these improvements.
The surgeons and anaesthetists must be physically fit and
psychologically capable of continuing to function under extreme
physical and emotional stress. The surgeon must be capable of
rapid decision and rapid surgery. He must be trained and capable
of operating on the head, chest and abdomen, as well as the limbs.
Although limb injuries constitute the majority, injuries of the head
and trunk provide the most taxing surgical problems. If lives are
to be saved by forward surgery, the military surgeon must be a
truly general surgeon.
Rapid evacuation from point of wounding to surgery is the
most important factor in the saving of lives. Lives are also saved by
effective first-aid and resuscitation, but in this campaign it is
difficult in a retrospective study to assess their value. The
appointment of a consultant surgeon to the force, with a specific
duty to monitor treatment and assess its value at each point in the
evacuation chain, could have provided much information that is
unfortunately now lost. Regrettably, also lost is the opportunity to
assess the impact of new weapon systems on personnel and the
exact cause of a large number of superficial burns sustained by
some soldiers in one notable incident.
The value of a specialised team for the treatment of burns in the
base hospital, in this case a hospital ship, was proven. The maxillo
facial Team was also usefully employed at base but it was
interesting to note that other injured soldiers survived the long
journey back to the United Kingdom for specialist treatment,
without apparent ill-effect. The speed of evacuation by air
undoubtedly contributes to the successful management of
specialised surgical problems.
The last, and possibly most important lesson, is that a
professional army needs its own professional surgical teams as part
of its medical support for operations worldwide.
References
1
2
3
MacNulty A S History of the Second World War - Medicine and Pathology
HMSO London 1952
Carson J and Winfield C Exercise testing in servicemen with asthma. J R
Army Med Corps 1982
Tidy H History of the Second World War - Medicine and Pathology
HSMO London 1952
77
Port Stanley Airport after being bombed by RAF Vulcan
bombers as part of the Black Buck missions in May 1982
Argentine marines outside Government House, Port Stanley
on 2nd April 1982
RAF Sea Harriers over the south Atlantic
Vulcans, Victors and Nimrods at Wideawake airfield,
Ascension Island
Royal Marine Commandos march towards Port Stanley
78
Maintenance men working on a Sea Harrier aboard HMS
Invincible
One of the Vulcan bombers responsible for operation Black
Buck, then the longest bombing mission ever attempted
A casualty from HMS Sheffield being carried to the sick bay
on HMS Hermes
HMS Sheffield on fire after being struck by an Exocet missile
An Argentine soldier cooking in a sheep shearing shed at
Goose Green
HMS Ardent sinks on May 21st 1982
HMS Ardent sinks on 23rd May 1982 after being hit by
Argentinian 500lb bombs
79
A British military funeral on the Falklands
Argentine rifles piled beside the road to Port Stanley Airport
Teniente de Naviro (Lieutenant) Alfredo Astiz signs the
instrument of surrender of South Georgia on board HMS
Plymouth
Argentinian prisoners of war
Royal Marines escorting Argentine prisoners
80
Argentine prisoners under guard outside Port Stanley
Naval Party 8901, the Royal Marine Garrison evicted by the Argentines, outside Government House Port Stanley after the
surrender
HMS Exeter, the only Falklands ship still in commission
The task force returns home
The Parachute Regiment remembers the fallen
81
Port Stanley cathedral. The whalebone arch is a reminder of a
long dead industry
25 years on……. cruise ship visitors are welcomed to Port
Stanley
Falklands wildlife
82
JOURNAL OF THE
R OYAL ARMY
MEDICAL CORPS
FALKLANDS CONFLICT
C O M M E M OR AT I V E I S S U E
Volume 153, Supplement 1
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Map of Falkland Islands (Frontispiece)
Chronology of Events
From the Editor
Editorial M von Bertele
Fighting for the Falklands P R J Page
Roll of Honour
Introduction to original papers
The Eve of the Sinking of the Sir Galahad J Crummic
The Battle for Goose Green SJ Hughes
2 Para Memorial, Goose Green
My Experiences in the Falkland Islands War J Burgess
My Thoughts on the Falklands Campaign WSP McGregor
Photographs Section 1
Operation Corporate - the Sir Galahad Bombings P Chapman
Commentary A Kay
Army Amputees in the Falklands - a review AFG Groom JT Coull
Commentary J Etherington
Army Field Surgical Experience DS Jackson CG BattyJM Ryan WSP McGregor
Commentary JM Ryan
First and Second Line Treatment – a retrospective view DS Jackson MD Jowitt RJ Knight
Commentary PAF Hunt
Soldiers Injured During The Falklands Campaign 1982 DS Jackson
Commentary P Parker
Rate of British Psychiatric Combat Casualties Compared to Recent American Wars HH Price
Commentary M O’Connell
Military Cold Injury During the War in the Falkland Islands 1982:
an evaluation of possible risk factors RP Craig
Commentary J Smith
Resuscitation Experience in the Falkland Islands Campaign
JG Williams TRD Riley RA Moody
Commentary K Porter
Lessons from the Falklands Campaign
IP Crawford P Abraham M Brown JB Stewart R Scott
Photographs Section 2
Retention Positive? What I can remember 25 years on. M von Bertele
Looking Back 25 years: a naval perspective AJ Walker
A Personal Reflection on the Falkland Islands War of 1982 JM Ryan
Campaign Medals: The South Atlantic Medal
Original Contributors
The 1982 War Memorial
Views and opinions expressed in this Journal are those of the authors
and imply no relationship to MOD or AMS policy, present or future.
1
Retention positive? What I can remember 25 years on
Major General M von Bertele, Chief Executive Medical Education and Training
Agency (DMETA)
Was the Falklands War a good war? Not in the sense of a just
war, but for those involved? Certainly for me it was. The seeds
were sown a year earlier. The Parachute Clearing Troop of 16
Field Ambulance, was on Exercise POND JUMP in Canada
with the 3rd battalion The Parachute Regiment, 3 Para. We
rounded off 3 weeks of training with a live firing attack on a
small hill, and suffered a single casualty, a soldier injured by a
grenade fragment thrown too close to the advancing line of
troops. It was daylight. At the wash up, the CO Lt Col Hew
Pike, noted the accident and that it shouldn’t have happened,
and then made a fateful comment. He referred to soldiering,
and what we had achieved over the past 3 weeks, and hoped we
had enjoyed the final assault, for it would never again happen
for real. Warfare had changed. That evening Sphinx Battery 26
Regt RA took on the battalion in a post exercise brawl,
hospitalizing about 30 paras and gunners. All agreed it was a
good fight, reinforcing the rivalry and camaraderie of the green
and blue. It was a busy night for the RAP, and the RMO,
Captain John Burgess.
I left Canada via Vancouver and Seattle, joined my unit for a
more traditional exercise in Denmark fighting the red forces on
the northern flank, spent 5 months including Christmas, on
Op BANNER, Musgrave Park and Armagh, and then joined
the PWO in Norway for my second winter with the AMF(L).
It was what the field ambulance doctors did; a round of
exercises and live medical support.
On my return in late March I prepared for a skiing
expedition. We were due to leave on the 3rd of April, and
despite the belligerent tone of diplomacy in the South Atlantic,
and the fact that we were the Spearhead surgical team, my CO
said we could go if we left a phone number – good news to me
since we planned to be out of contact for 10 days. By Monday
morning, after a great day’s skiing, and having ignored several
calls, I was ordered back to Aldershot, and, in hot water with
WO2 Fritz Sterber, the Warrant Officer on my surgical team. I
paraded the following day, Bergen packed.
A full 2 weeks later I found myself in Southampton Water,
hastily assigned to the Townsend Thoresen Europic Ferry as
ship’s doctor, to accompany the light guns and scout helicopters
for the Task Force, and about 60 soldiers. The 4 officers on
board shared the bridal suite of this curious vessel, a throwback
to the 1950s. The hold carried 1,000 tons of ammunition, and
three 105mm light guns and on the deck, 3 scout helicopters.
The bursar was busy filling all available space with fresh
victuals, steak, potatoes, and beer.
What did I know? I had qualified 3 years earlier, completed 2
house jobs in the NHS and then I had attended the PGMO
course, discovered that I quite liked running and tabbing, hated
marching, learned about general war in Germany and linear
flows of casualties, NBC and re-supply by boxes 1-4. Within
weeks of joining my first unit I was in Norway, running a sick
parade each morning before skiing and learning about arctic
warfare and the problems of providing medical support in
hostile climates. I knew then that the MOs boxes contained
hardly anything of any use for managing routine illness, but
that the MO down in Voss had a well stocked dispensary and
that it was always worth a visit with a patient, and the prospect
of a day on the slopes. I was soon adept at knocking up hot
meals, could manage on menu D for several days, recognise and
treat scrot rot and frostbite, plus a host of minor breaks and
sprains. A year followed of P company, parachute training,
medical centre duties, exercises and detached duty. I saw my
first gunshot wounds, blast injuries and the first use of the
RPG7 against troops in a landrover. Life was reasonably
predictable, it was fun, and while not clinically demanding,
being a spare doctor offered enormous variety. I even persuaded
a dental colleague to show me how to extract teeth and
administer an inferior dental block. The PFA exercises were
always instructive, we had solid and experienced NCOs, and
although we rarely saw our surgical teams we could always pop
in to the Cambridge and assist on a list, since that is where our
clinicians worked.
By the time we reached the Southern Hemisphere it was still
not clear that we would go the whole way. We had done lots of
weapons training, flown multiple sorties over water in our
single engine scouts, visited the Canberra several times, and I
had sorted out the rather good sick bay kit provided by the
Navy, including my dental satchel. I even felt confident enough
to extract a molar with a pea sized abscess on it, which had
failed to respond to antibiotics. We had settled in to a satisfying
routine, exercise, sick parade, reading, pre-dinner drinks,
dinner, and a game of cards in the evening. The peace was
briefly shattered when a soldier, on fire picket duty at night in
the hold, decided to prime a couple of grenades to see how they
fitted together. He appeared in our cabin at about one in the
morning, hands cupped round his mouth with blood pouring
on to the floor, and looking up from my cards I assumed he had
a nose bleed, so I laid the cards down, picked up the sick bay
key, and told him to follow me. My cabin mates were
impressed, for they had all spotted that he was missing 2 fingers
but it was only when we reached the sick bay that I saw the full
extent of the damage. My reputation was made, cool under fire,
and 2 weeks later when the helicopter brought back a comatose
platoon commander from Goose Green, a bullet in his liver, 18
hours after injury, the pilot, my cabin mate, wept with relief
when he saw me. He had been flying non stop for 18 hours.
We went ashore at Ajax Bay on the evening of the first day of
the landings. The plan to provide surgical support from afloat
failed at first contact with the enemy, and we hastily repacked
our kit and huddled in the bottom of a landing craft. Within an
hour of landing we had knocked a hole in the wall of the old
refrigeration plant for the generator exhaust, and set up our first
table. This was familiar territory. Soon we were receiving
casualties from the sea, flown or shipped ashore. At first light we
trooped outside to watch the Skyhawks resume their attack, and
were informed that we were now part of the Red and Green Life
Machine, in a stirring address delivered by Surgeon
Commander Rick Jolly. We dug shell scrapes as a precaution,
but found warmer drier sleeping spaces in the old cold store,
and continued operating. The casualties were seamen, and
Chinese laundrymen in bri-nylon shirts that had melted into
their skin. We watched the planes being shot down, the
83
beachhead building all the time, and saw the Ardent towed, on
fire, into the sound. We listened to the commentary on the ops
room radio, and watched open mouthed when the bomb
exploded in a forward compartment. Thirty minutes later the
bomb disposal warrant officer was brought ashore, his arm
hanging on by a thread, his colleague lost in the detonation.
The first serious land casualties we saw were blue on blue, paras
who had successfully engaged their colleagues in the confusion
of patrolling the opposite shore. We were still operating when a
Skyhawk dropped two 500lb Matra bombs on the building.
One exploded in the mess hall next door killing and injuring
several marines. It set fire to the ammunition dump, and for the
next 6 hours our shell scrapes were ablaze with white
phosphorus as mortars and shells detonated in the blaze. We
carried on operating. The other one landed 10 feet away in our
sleeping accommodation. It did not detonate. We finished our
list and went outside while the bomb disposal team took stock.
A RAF sergeant was scratching his head when I went in to
recover my Bergen with the spare anaesthetic kit. We were
going to set up an alternate FST. He explained that these bombs
could be set to delay detonation, but the plans were in French
and he could not read them. Armed with an O level and a long
summer holiday in St Raphael 2 years earlier I sat down to
search for that elusive phrase that might mean time delay.
Ninety minutes later it has not gone off so we re-entered the
building and just got used to our French lodger.
For the next few days we settled into a sort of routine. Food
and fresh water were in short supply, field sanitation was poor,
but the hospital was working. Post operative casualties built up,
but when we could, we flew them out to SS Uganda, the
hospital ship. It was a good trip to go on as the medical escort.
There were no flight nurses ashore. The prospect of a meal on
board made up for the risk of being shot down. Once we flew
out to sea for two hours in low fog before admitting defeat and
turning for shore, low on fuel, until we landed on Hermes and
had to unload all of our stretchers as we came under threat of
attack again. Food supplies were running low and we were on
half rations for a while, and were starting to get tired. The
surgical teams often operated through the night, and the strain
was showing in the faces of some of the team. It was hitting the
older married men harder. Our first Argentinean casualty was
Ossie Ardilles, named after the footballer, who had dislocated
his knee ejecting from his Skyhawk over the sound. He was
shocked when he saw the impact of their bombs on the
hospital.
The battle for Goose Green came as a surprise, the passage of
information being a bit thin, but we heard it on the World
Service just before the casualties started arriving. The shock of
the RSM turning up to announce that “H” was dead, the
adjutant too, hit us all. We knew these people. The casualties
kept coming and our triage was tested to the full. Colonel Bill
Macgregor continually reassessed priorities, appearing
throughout the night in his green apron to take stock. He was
furious to discover that a patient with a head wound and open
brain injury had been left in a corner labelled “expectant”. He
operated, and the soldier, properly treated made a reasonable
recovery, although when I saw him 6 months later in Woolwich
he had considerable functional impairment. My opposite
number on the other team, Captain Rory Wagon, had gone
forward with 2 Para’s RAP, and I alternated between
resuscitation officer and surgical assistant, with the medics
putting up drips, administering analgesia, and antibiotics. We
ran low on penicillin as the numbers of Argentinean casualties
rose, and on one memorable occasion a casualty was given IM
penicillin, IV, by mistake. He had a short fit, but recovered
quickly with diazepam, convinced that he had been given truth
84
serum. Then we ran low on induction agents and started to use
ketamine for the minor debridements. This was left to us
juniors, and caused some interesting recovery phenomena. One
SF soldier entertained us to half an hour of bawdy songs before
sinking into deep sleep. We were bleeding troops to provide
fresh blood, and we had all given a pint. Then the Argentinean
casualties exhausted our supply so I was dispatched to the PW
holding cage to ask for volunteers. They were very reluctant
until we showed the senior officer how many casualties we had
inside, and then the blood supply problem was resolved,
although it was not used on our casualties – hepatitis screening
was not possible.
For several days we continued to receive Argentinean
casualties from the battlefield, the last one some 4 days after the
battle. Left for dead in a trench, he survived despite a serious
wound to his buttock and the loss of one eye. The first funeral
was a sombre affair. A mass grave dug by an engineer tractor,
and the bodies laid one by one, wrapped up in body bags. I can
still hear the voice of Padre David Cooper, and every time the
footage is shown on the television I am transported back to that
moment. One month earlier it had been beyond the
imagination of us all.
We followed the progress of the force as they tabbed and
yomped across the island. Rivalry was always present, but the
teams by then were well integrated and clinically they deferred
to Colonel Bill, by far the most experienced clinician. Rick Jolly
was a dynamo, charging around everywhere, but every other
evening he would appear with a bottle of whisky or rum that he
had razzed from some ship, and give us a small tot to bolster
morale. We fell out once or twice over re-supply and rosters,
and it was with some relief that I found myself despatched one
night to embark on the Sir Tristram for a night trip to Teal Inlet
to join the RAP of 3 Para, before they moved up to Estancia
House. The RMO, Captain John Burgess, had already been
blooded at San Carlos Sound, and was glad to see me and my
two medics, Cpl Parkin and Private Davey Wilson, although we
doubted that it constituted a doctrinally pure collecting section.
We spent the next few days looking after the troops who were
suffering badly from the wet and cold. The march over the
island had left many with cold and painful soggy feet, and
although the CO rotated them back to the barn attached to the
Estancia farmhouse to dry out and get a decent meal, many
were still dug in under ponchos in forward positions. We went
out with medical supplies and spent a few nights with the 2
forward companies and the artillery battery up on a hill above
Estancia House. Water was being flown up by helicopter in
jerry cans. It was a laborious process, and the battery was
camped 50 yards from a peaty pond. I was intrigued to see a
small stone sump near the outlet of this pond, with a pipe
leading down the hill, so we walked down beside it for 2 miles
to find the other end attached to the side of Estancia House,
where the patient water-duties man was filling jerry cans from
the tap.
John Burgess described the battle on Mount Longdon in the
Corps Journal 25 years ago, but my recollection is still vivid.
The moment when Cpl Mills trod on a landmine and the sky
gradually filled with flares and tracer, and the artillery and
mortars started, was dramatic, but the noise was barely different
from our exercise in Canada 9 months earlier. This time we had
to go through it to reach the RAP, by now set up between the
rocks on the reverse side of the hill. There was not much we
could do. Casualties were brought down to us or made their
own way, and we revised dressings, gave morphine and
antibiotics as best we could. The use of lights was out of the
question with constant sniping for most of the night, and only
when dawn started to break could we refine treatment and start
to put up drips. It was raining slushy snow and everyone was
cold. Evacuation by vehicle was no longer possible, enemy
artillery was still falling on the slopes below us, and it was
several hours before the first helicopter reached us. By then we
had about 40 casualties in the RAP, and more arriving every
hour. The first helicopters to arrive were Scouts and evacuation
was painfully slow, but eventually a Sea King arrived and they
started to go more quickly. A burial party was arranged and
many of the Argentinean dead were interred that day. For two
and a half days we stayed there on the hill, harassing fire
whizzing overhead, first 105mm and then big guns, 155mm air
burst, which sent shrapnel pinging around the rocks. The roar
of the shell overhead and the rush of air following was
misleading because the shell had by then already exploded a
hundred yards down the hill. The odd round fell above us,
extracting a steady toll on people moving around, most
devastatingly in the incident described by John Burgess, when
my memory is of a single round falling between 3 men, killing
2 of them and amputating the legs of the third. They were only
about 50 yards from us and still alive when we reached them,
exsanguinating within seconds. I can’t remember applying a
tourniquet to the survivor, but we tried to apply pressure to his
wound, and failed to get a drip into him. By the time we had
carried him to the safety of the rocks it was too late.
The following night, artillery changed to mortars, and rounds
started to fall around us. We could not dig in as the soil was 4
inches deep on solid rock, and so we huddled under a large
boulder and prayed, until the cry went up “Medic”. A soldier
had been blown through the air by the blast from an exploding
round and was unconscious. John and I debated whose turn it
was to go. I lost, and ran terrified across the open ground to pull
the casualty under cover. By now it was safe to use a torch but
a detailed examination revealed no injury, and we concluded
that the blast had literally knocked the breath out of him. Sure
enough he slowly came round, deaf, but otherwise unhurt apart
from a very sore back where he had landed on a rock. Within
minutes the mortars had been silenced, but it was hard to get
any sleep while adrenaline was running high. The following
morning, clear and cold, saw us moving up for the final assault
on Port Stanley, but as everyone will now know, the fighting
was over. My section and I took off our helmets, put our berets
on, and walked with the lead company into Stanley. We left
them at the racecourse and on a whim, and because the
islanders had been told to congregate at the hospital, walked
through the Argentinean military police roadblock, and made
our way to the King Edward VII Hospital. We were given a
rapturous welcome. The islanders had been listening to the
radio, and knew that a ceasefire had been called. The hospital
had been commandeered by Argentinean doctors and there
were several hundred patients in it. I went to talk to their CO,
a youngish surgeon who had trained in Germany, and who
spoke good English. I explained that the war was over and asked
him to hand over all weapons and evacuate the hospital.
Without argument he produced a brand new and un-fired
Browning 9mm pistol and handed it to me. The others did the
same, and then for half an hour we discussed the war, his
patients, and how to move them. They were remarkably open,
and expressed sadness that the British had felt it was necessary
to fight for the islands. They told us that from the moment the
Belgrano was sunk they knew that they would lose, as we were,
after all, still a significant military power, but they, like us were
caught up in events. We discussed the casualties we had treated,
and they expressed gratitude for the care we had given to their
people, word had somehow got back to them, and then they set
about moving their patients to a ship in the harbour. Within 3
hours the hospital was empty, and in the lull we decided to have
a bath. As darkness fell there were scattered disturbances, a few
shots were fired and buildings set on fire, but no-one came near
the hospital. Judging it too dangerous to venture outside we
accepted a can of beer from the staff, and settled down to talk
about their experience of occupation. Our uniforms had been
taken to be cleaned, by then we stank, and so we were clad in
theatre greens. Thus it was that General Jeremy Moore found
us, the collecting section of the PFA, slightly drunk, at
midnight, when he came to tell the hospital that the war was
over.
85
Looking back 25 years - a naval perspective
Surg Capt A J Walker
ex Surg Lt HMS Plymouth 1982
As a young Surgeon Lieutenant, being sent to sea as Squadron
MO and deploying to the West Indies in HMS Plymouth was
to be the highlight of GDMO time. However, all was not to
turn out quite as expected. Nobody anticipated sailing to war as
we left Rosyth in mid March 1982. In fact we were to
participate in major fleet exercises off Gibraltar, replenish and
head off across the Atlantic to a five-month tour of Caribbean
islands, Florida and Belize.
How quickly life can change! We were not to see Gibraltar
again for some months and by 1 April were heading south with
a Task Group. Rumours abounded: would we be the Acension
Island guard ship or the fleet mail ship – after all we were a 21
year old frigate – a fine old lady, but somewhat dated compared
with those shiny Type 21, 22 and 42 ships. Life on board
changed quickly, although we all had a secret hope that a
diplomatic solution to the crisis (and invasion by 2 April)
would result and allow us to proceed on our Caribbean tour.
Firstly, food was rationed to allow a 70-day reserve (in effect the
choices reduced and the quantity was more portioned), and
then we began to train hard with fire, NBCD, damage control
and first aid exercises. Little did we know how important all of
these were going to be.
The balmy tropical weather at Ascension saw us in shorts
rapidly loading war levels of stores and ammunition, before
detaching south in the van of the Force heading for S Georgia.
We embarked D Sqn 22 SAS and a Naval Gunnery Spotter
(NGS), the wardroom lost anything precious and was now full
of medical stores and F Ident 107’s and 106’s were issued to the
medical staff. One of the senior rates said that he knew we were
really going to war when the medical staff began issuing
individual morphine autojets – items normally kept very
securely under lock and key and mustered regularly!
On 14 April, we rendezvoused with the red-hulled HMS
Endurance who had been hiding around S Georgia. The task
group ships lined the side to cheer her in quite an emotional
meeting, and I think her ship’s company were quite glad to be
once again in company with grey warships. As the weather
cooled, we neared the danger area and the MO’s from HMS
Antrim, Plymouth, Endurance, 45 Cdo and RFA Tidespring
met to discuss the medical plan for action. Tidespring with a
surgical team on board was to be the Role 2 facility and Antrim
with her larger sickbay to be the main receiving facility. Blood
donors were identified and bled to produce a small pool for the
group as we assessed that we were far enough away from action
to allow them to recuperate.
By the 19 April we were at action stations, concerned about
the submarine threat, and beginning to see icebergs and getting
used to the southern ocean long swell and high winds. Two days
later we were off S Georgia. SAS insertions to the Fortuna
Glacier were hampered by weather and helicopter crashes, but
Surgeon Capt A J Walker, Defence Consultant Advisor in
Surgery, Derriford Hospital, Plymouth, PL6 8DH
86
suddenly on 25 April we were in action with helicopters firing
on a surfaced Argentinean submarine. At 14:15 we opened fire
on S Georgia – the long-awaited war had begun in earnest.
S Georgia capitulated with only one casualty – a submariner
who lost a leg when his boat was hit. Lt Cdr Astiz surrendered
the garrison at Leith in Plymouth’s wardroom and the Union
Jack and White Ensign were once again flying on sovereign
British territory.
The next period was taken up by joining the main Task Force,
hearing of Vulcan raids on Stanley airfield, being elated that the
threat from the General Belgrano was neutralised yet devastated
that HMS Sheffield was hit, burned out and abandoned to sink.
Finally there were preparations for the landings. Life at sea had
settled into a pattern and having been blooded at S Georgia, the
ship was fully prepared and ready. When the mist allowed, the
sight of the Task Force in convoy – warships, RFA’s and civilian
Ships Taken Up From Trade (STUFT) was impressive.
D Day was 21 May. We crept in poor visibility towards the N
Falkland coast. HMS Antrim opened fire on Fanning Head
about 01:00 and in what was now a clear, starry night we could
see the flashes of the fall of her shot. By dawn the first waves of
Commandos and Paras were ashore and we were in San Carlos
protecting the huge white liner Canberra, while offering NGS
support to the landings. The first Argentinian planes appeared
about 08:45, but it was during the afternoon that the ships in
the sound came under most intense attack. Having circled
Canberra with all guns blazing, as her protection, we were sent
to tow the immobilised HMS Argonaut into the relative safety
of San Carlos, bringing their battle-weary crew some
sustenance, support and power (we were later to bury their dead
at sea in the solemn, highly emotional but very traditional naval
manner). Later that night, once again on patrol in the Sound,
we watched HMS Ardent blaze like a large Guy Fawkes beacon
as ammunition exploded. This was true war – unpleasant and
hard, but we were steeled to it.
San Carlos Water was to be our daytime anchorage and we
came to be comfortable there – we knew the direction of air
attack and besides out at sea there was the worrying potential
for Exocet attack! Night-time sorties to land Special Forces
combined with gunnery serials on Argentinean positions and
convoy duties for STUFT entering and leaving San Carlos. We
were able to follow the battle for Goose Green and the land
advance to ring Stanley closely. Air raids had become routine
and all was going well. However, on 8 June we were ordered to
fire on an Argentinian lookout post on Mt Rosalie overlooking
San Carlos from W Falkland. A raid attacked us just before
17:00 causing damage to the funnel, turret, after PO’s mess and
mortar handling room. A fire broke out when a depth charge
exploded and fires raged in the after portion of the ship
engulfing the junior rates’ dining hall and the PO’s mess. The
sickbay had to be evacuated forwards to the wardroom, and
there we dealt with 5 casualties, including severe smoke
inhalation and a major penetrating injury to the temporal lobe.
All the casualties were evacuated to the Red & Green Life
Machine at Ajax Bay, where I was later to see the host of burns
casualties from the attack on RFA’s Sir Galahad and Sir Tristam
the same day.
Contemporaneous photographs, seen subsequently, make our
plight look worse than it seemed aboard. We had survived battle
damage, including a major fire aboard, but power, weapons and
propulsion were all intact. Superficially we looked very battered
and required patching up at anchor before sailing for repairs at
Stena Seaspread where we met with HMS Glamorgan licking
her more serious wounds from an Exocet hit. Suffice to say, we
were sufficiently patched up to be back on the gun line by 14
June and to hear of the surrender in Stanley. The next 48 hours
were stormy at sea and we rode this uncomfortably –
accommodation and messing being limited by our internal
damage. We were honoured to be the first frigate to enter the
inner Stanley harbour from Berkeley Sound and to be able to
see Stanley itself for the first time.
Our return via Ascension Island and Gibraltar was
uneventful, but allowed a period of de-stressing, tidying of the
ship as far as possible and a return to more relaxed cruising. Our
welcome back at Rosyth was overwhelming, arriving under the
Forth Bridges to the stains of a piper and the Band of the Royal
Marines, and of course to the masses of families and friends. It
had been an unexpected, short and intense war from which
many lessons were learnt, and from which we were lucky to
return relatively unscathed.
…and yes I did return to the Caribbean later that year with
another ship of the Squadron!
HMS Plymouth following Argentine air strikes
87
A personal reflection on the Falklands Islands War of 1982
JM Ryan OStJ, FRCS, MCh, DMCC, Hon FCEM, Col L/RAMC(V)
Emeritus Professor of Conflict Recovery, UCL, UK & International Professor of Surgery, USUHS, Bethesda, MD, USA
Introduction
On April 2nd 1982 Argentine troops invaded the Falkland
Islands by sea and air. By April 5th the first ships of the British
task force had put to sea. Civilian liners and ferries were
requisitioned as troop ships, and a 200 mile exclusion zone was
declared on April 12th. In seven weeks a task force of 28,000
men and over 100 ships was assembled and sailed 8,000 miles.
The invasion to re-take the islands took place on the 21st May
– war was joined. 10,000 men were landed on a barren shore
and within three and a half weeks the Islands were re-taken and
the war was over.
The war would create novel problems for the Defence
Medical Services. Lines of communication and re-supply lines
were over 8,000 miles. The war would take place in winter with
virtually no usable buildings or other infrastructure in which to
locate medical assets, including field surgical teams.
Personal Background
In 1982 the author was a 37 year old Senior Specialist in
Surgery (in modern parlance – a Specialist Registrar) in the
sixth and final year of higher professional training programme
and seconded to St Peter’s Hospital in Chertsey. It is worth
pausing for a moment to reflect on this old and discarded
training programme. Three years of general professional
training, followed by six years of higher training had resulted in
exposure to the generality of surgery. It included postings to
nine separate hospitals including three NHS secondments to St
Bartholomew’s, Hackney and St Peters Hospitals with training
in general, orthopaedic, plastic, neurosurgical, thoracic and
vascular surgery – an unimaginable variety today. All military
surgeons in training at that time had very similar training
programmes. The aim was to produce a surgeon trained in the
generality of surgery ready to work alone or in small groups in
field surgical facilities. This system of training probably gave the
surgeons who would deploy a training edge not available to
civilian trainees of the period
This was also the age before war surgery workshops,
Definitive Surgical Trauma Skills (DSTS) courses and the
myriad of other training opportunities, including overseas
secondments, available to today’s military surgeons and their
teams. Training in the art and science of war surgery prior to
1982 was not easy. Military surgeons ‘cut their teeth’ during
secondments to the Military Wing, Musgrave Park hospital in
Northern Ireland. The ‘Troubles’ were in full swing and a
generation of surgical trainees worked with an earlier generation
of military surgery consultants such as Bill McGregor, Bill
Thompson and Brian Mayes who had learnt their trade during
a myriad of post colonial conflicts in far flung places like
Cyprus, Aden, Malaya and Borneo. There was, in short, an
institutional memory for the surgery of war which would
become evident as the Falkland Islands war progressed. The
military surgeon’s bible and almanac at that time was the latest
edition of the Field Surgery Pocket book edited by Kirby and
88
Blackburn and which became essential reading for all deployed
military surgeons, irrespective of previous experience or colour
of cloth.
Medical Support
Before turning to the main body of this paper – a reflection on
events - it is worth giving an overview of the medical support
for the task force which includes the Fleet at sea and the ground
invasion force. The Medical Branch of the Royal Navy was
doubly tasked and had the greatest impact on medical
operations. They had to provide medical support, not only for
the Fleet, but had the additional responsibility of providing
comprehensive care ashore for the Marines of 3 Commando
Brigade, 2 Battalions of the Parachute Regiment and the
Brigade support elements including special forces and air assets.
At sea the Royal Navy Medical branch provided what would
now be described as 1st Role and enhanced 2nd Role assets
throughout the Fleet and had the additional tasking of
manning the only hospital ship – the SS Uganda and its
support ambulance ships tasked with medical evacuation by sea.
On land each Commando Battalion was provided with 2
Commando Medical Officers RN and supporting medical
elements. On the beach head at Ajax bay they deployed the
Marine Commando Medical Squadron with two Royal Navy
Surgical Support Teams (SSTs) with their supporting elements
acting as an Advanced Surgical Centre (ASC).
The Royal Army Medical Corps provided Regimental
Medical Officers (Army) to each major field unit (2 to the
Parachute Battalions) and manning for Regimental Aid Posts
(RAPs). Surgical support was also provided. Initially this
consisted of 2 FSTs from the Parachute Clearing Troop of 16
Field Ambulance RAMC to reinforce the ASC. Later 16 Field
Ambulance deployed 2 independent surgical teams designated
55 FST. Shortly afterwards the main body of 16 Field
Ambulance deployed to provide definitive 2nd Role medical
support for the forces ashore.
The Royal Air Force Medical Branch was tasked with aero
medical evacuation from the theatre of operations – initially
from the air head at Montevideo and later from the islands.
While not deploying FSTs the RAF provided comprehensive
medical support in the air, particularly critical and intensive
care en route. Their achievements were outstanding – all
evacuated wounded service personnel survived to reach the
home base and were received into UK based military hospitals
– now, sadly, consigned to history.
A Personal Reflection
It is strange to look back over a quarter of a century to a war
that we never anticipated. In 1982 the Cold War still occupied
our thoughts – and planning. The RAMC were exercised for a
major conventional, and possibly a nuclear and chemical war, in
Europe. All worked to a strict military doctrine, which defined
how medical support would unfold and was based around mass
casualties and numerous huge Field and General Hospitals.
There was little flexibility in our thinking. Principles of War
Courses, run annually, were run by the book. Directors and
Professors of Military Medicine and Surgery would tolerate no
discussions. These courses were exercises in Doctrine and
debate was not encouraged. This author remembers discussion
concerning Field Hospital with upwards of 600 beds – unheard
of today. Doctrine defined what would be attempted at each
Role – then called echelons. Mortality would have been
appalling and the approach would have been ‘the most for the
most’, hoping to get as many as possible home to UK based
hospitals using all means including cross channel ferries.
What was faced in 1982 was unexpected and appeared to be
outside planning. This was the first campaign of what would
become the norm – expeditionary warfare with new doctrines
and new methods of working – and new expectations. Mrs
Thatcher’s statement in the House of Commons some years
later that wounded soldiers in war would get the same
treatment as the injured in NHS hospitals had not yet been
voiced. The first Gulf war was undreamt of and later
expeditionary wars in the Balkans, Iraq and Afghanistan beyond
our wildest imagination.
To War on the QE2
Mobilisation was fast and frenetic, however it was characterised
by what many medics would still recognise today – an ‘off the
truck, on the truck’ mentality, shrouded in a fog of uncertainty
and chaos. The author was assigned to table 2 of 55 FST,
mobilised in Aldershot. The first named anaesthetist was one
Major H Hannah. That is until it was realised that this was
Helen Hannah – a woman. Not just any woman, but the widely
admired and redoubtable Major Helen Hannah RAMC. This
caused consternation. The British Armed Forces were not yet
ready for a woman on their battlefields and she was quickly
replaced by the equally well known and redoubtable Lt Col Jim
Anderson RAMC who would soon be appointed OC 55 FST
with two surgical teams – FST 1 commanded by Major David
Jackson and FST 2 commanded by the author. 55 FST had its
origins in the Western Desert and it was a privilege to be part
of it. The author is sure that other mobilising medical teams
will have encountered similar headaches. His diary reveals that
55FST departed Aldershot on the 12th May at 0430 under
command of Jim Anderson and two hours later embarked on
the QE2 in Southampton. Work was still under way on the
helipad and elsewhere. At our first O Group we were told
without humour that the ship had been re-designated LPLL –
Landing Platform – Luxury Liner. She put to sea at 1600 hrs
with no one believing that the team would get much past the
English Channel.
The author kept a diary throughout the campaign and it
helps to illustrate the surreal atmosphere on board. It seemed
bizarre to go to war on the world’s finest luxury liner. A few
diary entries reflect the mood on board. 12 May …retired to
the 1st class bar for large gins at 2100 hrs – retired to bed at
2330 hrs! 13 May….Lifeboat drill ad nauseum. 15 may ….
Superb lunches – fresh salmon yesterday – fresh crab today and wonderful wines. 15 May…My first operation at sea – an
appendicectomy on a young combat engineer – in the QE2’s
operating theatre. 17 May ….Captain’s cocktail party! It
became increasingly easy to imagine that all were on a holiday
cruise, at least for the officers.
Reality checked in on the when active service conditions were
declared. The QE2, initially bound for the Falkland Islands,
now turned away and headed for South Georgia. Why? The
given explanation was a threat from submarines. This would
lead later to a spectacular insult by the crew of the P&O vessel
SS Canberra which went directly to the Falkland Islands to off
load her troops – some time later her crew hung a sheet over the
side with the ditty – P&O cruises where Cunard refuses!
Whether Cunnard’s QE2 was not to be risked or whether
there was a genuine submarine threat is for historians to decide.
All who cruised on the QE2 retain an enormous affection for
her (in 1985 while on tour in Hong King the author had a
chance to reboard the ship and explore familiar surroundings)
ASC at Ajax Bay
As one who never left the safety of the ASC (apart from an illfated sea journey on Sir Galahad and discussed later) the author
will confine remarks to the surgical support for the wounded at
the ASC at Ajax Bay. A Time traveller from the Boer War or the
First World War would have recognised the ASC at Ajax Bay. It
was situated in a meat refrigeration factory facing the San
Carlos Water near San Carlos settlement. It was ideal in many
respects – vast and open and lending itself to
compartmentalisation into operating theatres, wards, primitive
laboratory and living accommodation for staff and supplies. A
nearby area of open ground facilitated landing by helicopters
delivering wounded from the battlefields. On the down side the
ASC was filthy and dusty rendering efforts at cleanliness nigh
impossible. There were no windows and no air conditioning.
The building was heated by air pumps delivering hot air. The
author was still at sea during the initial landings and the
subsequent battle for Darwin – Goose Green. However, Rick
Jolly has left a memorable account in the Red and Green Life
Machine of the outstanding work performed by the Marine
Commando SSTs and the Parachute Clearing Troop’s FSTs.
Sir Galahad and The Bombings at Fitzroy/Bluff
Cove
A personal reflection from this author must include the
bombing of the RFA logistic ships RFA Sir Tristram and Sir
Galahad which took place on the morning of the 8th of June.
Sir Galahad, carrying Welsh Guards rifle companies and
elements of 16 Field Ambulance including the two surgical
teams of 55 FST, arrived off Fitzroy settlement. The ship
should have anchored in Bluff cove some 5 miles away but
could not get up the narrow channel to the planned
disembarkation beach. For reasons beyond this review
disembarkation at Fitzroy was delayed. Some elements of 16
Field Ambulance including No 1 team of 55 FST (Major
Jackson’s team) had got ashore but the remaining troops
including the author’s team (No 2 team 55 FST) stayed
aboard. It seems surreal now with the passage of 25 years. With
the departure of 16 Field Ambulance and David Jackson’s team
the author and a group of other Officers retired to the
Wardroom. Lunch was taken and the group stayed in the ward
room comforted by tots of whiskey, hot coffee and a dubious
movie on the ward room TV monitor. Sometime later and
without warning (and the author is still uncertain about
timings) Sir Galahad and Sir Tristram were bombed by a flight
of Argentinean fighter bombers. Chaos ensued – those of us in
the ward room were thrown from our seats by the explosions,
we were uninjured but were now trapped in a blacked out and
smoked filled room. We were quickly rescued by a young
unnamed 2nd Lieutenant in the Welsh Guards who found a
hatch behind the bar which led out to a passageway going
forward and out onto the open deck which resembled a melee.
We quickly realised that a very large number of our comrades
had been killed and a greater number wounded – most of them
on the tank deck which had taken a direct hit. Others taking
the air out in the open were also killed. Among the dead was
89
Major Roger Nutbeam, second in command of 16 Field
Ambulance. Lt Col Jim Anderson, officer commanding 55
FST and anaesthetist with no 2 team had also been outside and
was badly injured. All the FST equipment, along with much of
16 Field Ambulance’s stores was destroyed. The ship was
abandoned, many, including the author, clambered into
dinghies and life boats. Others were winched directly off the
ship by helicopters hovering over the deck. These pilots and
crews displayed extreme gallantry – the ship was on fire and
exploding ammunition was propelled skywards towards the
rescuing helicopters. The survivors came ashore at Fitzroy and
were cared for by those already ashore. The author well
remembers being sheltered by WO2 Les Viner RAMC under a
mound of peat smoking his cigarettes and drinking whiskey
from his water bottle. For a time at least, the author while safe
and well was incapable of direct assistance to the on-going
rescue effort.
In concluding this episode it is interesting to reflect on the
accuracy of books reporting historical events even those
written during or shortly after the event. The author has a
book entitled “The Scars of War” by Hugh McManners, a
friend from the conflict. In describing the Sir Galahad episode
(which was related to him by someone who was in the USA at
the time of the attack!) Hugh switches David Jackson’s team
and the author’s – placing the author ashore during the attack
and with Jackson still on board at the time – the reverse of
what actually happened. It makes one cautious about veracity
and accuracy when perusing historical works.
Return to Ajax Bay
16 Field Ambulance would stay at Fitzroy settlement with two
co-located FSTs. One commanded by Bill McGregor who had
moved forward from Ajax Bay, the other was David Jackson’s
team from 55 FST. The other 55 FST team (the author’s) were
on Sir Galahad and lost all their personal and unit equipment.
They survived and were returned to San Carlos to be reequipped and re-positioned in Ajax alongside Royal Marine
Medical Squadron’s SSTs. The other PCT FST, commanded by
Charles Batty, was deployed forward to Teal Inlet to support
operations in that area. Six FST/SST units were now in position
on land to support the land battles - three at Ajax (two RN, one
Army), two at Army FSTs at Fitzroy and one at Teal inlet. At sea
surgical support was in place on the Hospital ship SS Uganda,
SS Canberra, HMS Fearless and Intrepid. Further surgical
support was in place on both aircraft carriers. In addition every
major RN unit at sea had comprehensive on board medical
support including further SSTs. Thus the scene was set
medically for the forthcoming land battles.
Medical Support for the Final Land Battles
The author’s diary recalls that the final land battles to take Port
Stanley and force an Argentine general surrender commenced at
0200 on Saturday 12 June - the entry states tersely “The attacks
start at 0200hrs – we will be busy by morning.” It would indeed
be a busy day – the author’s team operated on 16 cases
commencing at 1030 hrs and ending at 2200. Overall the diary
records that the three teams (2 RN and 1 Army) carried out in
excess of 30 procedures without fatality. 12 June was the
Queen’s official birthday but also the day that HMS Glamorgan
was struck by a shore based exocet missile – the first time such
an attack had taken place. The ship survived the attack – an
evening briefing reported that she was ‘steaming and fighting
but had sustained serious damage and casualties were heavy’.
The pattern was now set for the next 4 days – battles for the
mountains were fought by night with casualties arriving by
helicopter at the surgical centres at first light. The consequence
for the wounded was very long delays before evacuation – all
90
were hypothermic to a greater or lesser degree on arrival at the
surgical centres. Anecdotally few were bleeding heavily on
arrival but warming and fluid resuscitation produced dramatic
and unexpected recurrence of bleeding. Each day was
characterised by lengthy lists followed by early to bed with a
mug of rum and tobacco supplied by Surg Capt Rick Jolly.
By Wednesday 16 June the land battles were over and Port
Stanley liberated although it would be a further day before an
islands wide surrender was signed. Thus began a long wait for
medical teams – the usual outcome and an example of the
“hurry up and wait” mentality that will be familiar to readers.
It was not until Saturday 19 June that personnel were briefed
leading to low morale and disgust – the army FST personnel at
Ajax were all Galahad survivors and had been living and
working in the same clothes for nearly 2 weeks and were now
stinking. To compound matters the FST was moved from Ajax
Bay onto the hold of a ship – the Elk – and told to wait in the
hold. A move to Port Stanley after 24 hours probably prevented
violence – the FST still held their weapons and ammunition. It
is curious to reflect on such careless and thoughtless behaviour
by movements staff – a briefing, even when there are no hard
facts, still inspires trust and goodwill. It is interesting to hear
similar reports by medical teams deployed on later missions in
the Balkans, Middle East and Afghanistan – Plus ce change!
The Aftermath
Most medical personnel were quickly back loaded to UK by
Ship to UK as indeed were most of the fighting troops. This
cleared the way for fresh units, arriving daily to embark and
begin garrison duties. The author’s FST drew the short straw
and stayed pending the arrival of 22 Field Hospital. It was a
busy period – the FST was the only surgical resource ashore,
and after the departure of SS Uganda – the only surgical
resource for the population and garrison on land and at sea. It
was a busy period - the local population had been virtually
without hospital medicine since the invasion. In addition a
number of incidents with mines and missiles kept the casualties
coming.
As elements of 22 Field Hospital arrived in small packets – so
the FST slowly disintegrated. It was quite sad not to have been
stood down as a unit and to have returned to UK together. On
a positive note the slow draw down did allow the group time to
readjust to peace, to travel a little and to see the beauty of our
surroundings – something not possible during the conflict.
Conclusion
The war in the Falklands was a watershed. It had more in
common with the past than with wars and conflict of the 1990s
and the 21st century. It harked back to the Great War and even
the Boer war. Medical support was austere and minimalist.
Never again would surgical teams operate in disused factories
dressed in KF shirts with no gowns or theatre linen. Ashore
there were no imaging, ITU, and less laboratory support than
was available during World War 2. Yet it worked. Rick Jolly
reported that only two people who arrived alive at surgical
centres subsequently died. It is worth considering how different
things might have been if the support ship Atlantic Conveyer
had not been lost with a tented field hospital, support vehicles,
heavy medical equipment and dedicated medical helicopters.
Casualties would have been lifted off the battlefield much
earlier and many, with very severe injury, would probably have
survived to reach surgery. The effect might have been to reduce
the killed in action (KIA) rate but it is sobering to reflect that
this would likely have driven up to died of wounds (DOW) rate
in the forward hospitals.
References
Jackson DS, Batty CG, Ryan JM, McGregor WSP. The Falklands war:Army
Field Surgical experience. Ann R Coll Surg Engl 1983;65:281-285
Marsh AR. A short but distant war- the Falklands Campaign. J R Soc Med
1983;76:972
Shouler PJ, Leicester RF, Mellor S. Management of infections and
complications during the Falkland Islands campaign. In: Gruber D et al, Eds.
The pathophysiology of Combined Injury and Trauma. London: Academic
press Inc(London) Ltd, 1987:43-51.
91
CAMPAIGN MEDALS
South Atlantic Medal
Obverse
The crowned head of the Queen facing right surrounded by
Elizabeth II DEI GRATIA REGINA FID. DEF
Reverse
Armorial bearings of the Crown Colony of the Falkland Islands
and its dependencies, encompassed by the legend, SOUTH
ATLANTIC MEDAL and sprigs of laurel.
Size
36mm diameter
Metal
Cupro-nickel
Ribbon
32mm wide, shaded and watered bands of blue, white, green,
white Blue.
The small white metal rosette signifies that personnel served ashore or afloat below
35 degrees south or who flew operationally below Ascension Island.
92
The 1982 War Memorial
94

Falklands war 25TH anniversarY

Transcription

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