Articles
MASCAL at Kandahar
Sean M. Maloney
Sean M. Maloney (CANADA)
MASCAL at Kandahar
It was a clear, warm day, the first after a cold early February. I had just come back to Kandahar Air Field after observing operations at the remote Canadian outpost in Spin Boldak, an Afghan border town to the south. My enforced espresso fast had ended and I was sipping a nice strong roast at the British NAAFI canteen around 1230 when I saw the bottom crawl on Sky News blandly announce in block letter, “Suicide attack in Kandahar City kills dozens.” Before I could down the dregs of my drink, the Big Voice public address system warbled the up and down tones alerting the base to a Mass Casualty event. I have worked out of KAF since 2003 and this was the first time I’d heard the MASCAL go off, so I hurriedly left the NAAFI and thumbed a ride towards the Multi-national Medical Unit, what everybody calls the “Role 3.”
Coincidentally I had just received a briefing from the hospital staff a week ago in the green Weaherhaven that was the MMU’s headquarters. I was greeted by Lieutenant Colonel Pierre Charpentier, Lieutenant Colonel Errol Villeneuve, and Lieutenant Commander Charls Gendron.
“Dr. Maloney? What specialty are you?” they asked quizzically.
“Military history. But my dad’s a gynecologist,” I hastily added. We had a good laugh.
In NATO’s world, medical facilities are designated Role 1 to Role 4, depending on capability. A Role 1 facility is essentially a Unit Medical Section, while a Role 2 can do everything short of surgery. A Role 3 has surgical capacity. In Afghanistan, a Role 2 (plus) type of hospital existed in some locations, which was a Role 2 with limited surgical capacity. The all-singing all-dancing full service Role 4 is located at Landstuhl, Germany. At Kandahar Air Field, the United States had been lead nation at the Role 3 until 2005, with Canada taking over the following year. In its 2008 iteration, the MMU had Canadians.Americans, Dutch, British, Danish and New Zealand personnel, plus a small number of Afghan staff.
The Kandahar Air Field Role 3 Multinational Medical Unit (R3 MMU) is organized into four components:
In-Patient Care; Clinical Support, and Primary Care, plus an administration section.
In-Patient Care is composed of the Operating Room, the Intensive Care Unit, the Trauma Bays (Resus) and the Acute Care Ward, while the pharmacy, (Forward Medical Equipment Depot, mental health services, X-Ray and the Lab fell under Clinical Support. Primary Care was responsible for Physio, dental services, preventive medicine, and the unit medical services. There was also an entire Canadian Role 1 that had medics deployed throughout Kandahar province with the Canadian units.
Normally, the Role 3 took referrals from British, Dutch, and American Role 2’s in adjacent provinces; the Mir Wais hospital run by the Red Cross in Kandahar City; and an Afghan National Army hospital located at Camp Hero, adjacent to the air field. Kandahar Air Field also had Role 1’s from Bulgaria; the Netherlands; the US; UK; Slovenia and the Kellog Brown and Root contractors.
While we were flipping through the power point slides during the briefing, the Regimental Sergeant Major, Chief Warrant Officer David Horlick, stopped in the middle and pointedly said, “These power point slides don’t really capture what we do. You have to see us in action.” I secured an invite from LCol Charpentier to do just that. And now, when I least expected it, it was time to see the moving parts in action.
The Sky News crawl quoted initial reports that there were fifty dead and fifty wounded in the attack. Mir Wais hospital in the city took the influx of wounded until they were full, then the Afghan army hospital near the air field filled up too. I arrived at the R3 MMU at 1240 hours and headed to the entrance to the trauma bays. The R3 MMU is a plywood one story building, almost a western frontier town hospital in external appearances. Its rudimentary exterior belies, however, its sophisticated interior. I could see the staff through the trauma bay doors and I knew from previous visits in 2006 (when my convoy was attacked with a suicide bomber) that after you went through the bays, there was an operating theatre to the right and an ICU to the left. Some of the staff were gowning up, but the entrance was starting to get crowded. There were US Air Force and Canadian medics, British doctors, Dutch nurses, a clutch of photographers, and even a whole platoon of Gurkhas. I asked the soldier beside me what she did. “Oh, I’m a physiotherapist,” she told me. “Almost all units have somebody assigned in the event of a MASCAL. Manpower is manpower, after all.”
A Canadian medic was stacking up fold-out stretchers next to the door six-deep when LCol Pierre Charpentier with his graying buzz cut emerged and held his hands up to quell the babble of voices.
“Attention please. We have a MASCAL event. There has been a suicide attack in Kandahar City. We will be taking the overflow from Camp Hero. The bulk will be coming by ground, not by air. There are numerous head and neck injuries.”
The crowd continued to mill about the J-shaped road. It looked like there were too many people preparing to do too many different things. RSM Horlick sensed the emergent confusion and took control, his voice booming.
“Ok, we have the first ambulance coming in. Everybody not involved, back up.” The assembled augmentees parted to either side of the road as a US Army ambulance arrived.
“Litter and Gurney!”
The civilian victim had a black beard and was about thirty. He had a serious neck wound and one of the medics was holding his head so it couldn’t move. I could see bandages circling his chest and he’d been hit there too. He didn’t make a sound. The orderlies carefully removed him from the vehicle and whisked him inside.
Without a pause, a white civilian ambulance with Pakistani markings wheeled around the drive and screeched to a halt, going the wrong way. Two Canadian medics emerged from the back with another casualty. He had a head injury, his skull muffled with an Israeli-type combat bandage. And then a tan-coloured Afghan National Army truck pulled up in front of the Pakistani ambulance. A US Army medic and two Afghan Army medics kicked open the back to reveal two victims-one had a gut wound and the other was missing his right arm. A tourniquet had been applied and the stump covered up. A third victim was assisted from the truck tailgate by a pair of Gurkhas-he was a man with a long, grey beard, an elder. He was mobile but looked shocked.
As the RSM untangled the ambulance ‘Mexican stand off,’ a camouflaged Afghan Army Land Cruiser pulled up and the Afghan medics assisted by Canadian medics unloaded more shattered bodies. The blood dripped and pooled into the dust on the road as the staff unfolded and stacked more stretchers and deployed a number of gurneys-these weren’t the regular hospital gurneys. These came equipped with two large black wheels to facilitate ease of movement in crowded spaces.
I noticed a bloated guy in shorts and a loud t-shirt avidly taking pictures with a professional camera. “Who are you with?” I asked, figuring he was media. He blushed red. “Oh, I, uh, take pictures.”
“For who?”
“Um, myself. These’ll be worth something on the net.”
When he saw that RSM Horelick was taking notice, he backed up to run away and narrowly was missed by two more incoming ambulances. Fortunately the staff had stacked enough kit-there were six casualties jammed into them along with the medics who were keeping them alive. More blood. People were walking through the blood mud now and I could see the imprint of a desert combat boot-except it was red. A young guy with head trauma, assisted by an Afghan civilian medic, walked around the corner, seemingly out of nowhere. Two medics rushed forward and gently laid him on a blanket, which was then transferred to a gurney.
A green Canadian ambulance, with its callsign 83H visible on the door, rounded the bend. A Captain Michael leapt out.
“One lower body and hands, one lower body and upper extremities, plus a penetrating chest wound,” he called out.
“We have only one bay left,” a voice rose above the noise.
The next in the procession of carnage was a US Army ambulance with its siren needlessly on.
“One head, severe neck, extremities, gut possibly spleen. Number two neck, head, jaw.”
“Okay, start moving new patients to the headquarters building.” Orders went out to clear away the briefing tables and projectors and use the Weatherhaven as overflow. Another Afghan ambulance, then another US Army ambulance.
“Head, face, priority”
“Head, upper arms”
This went on for some time. At no time did any of the patients cry out or display any emotion. Was it Pashtun stoicism or was it really good drugs? I couldn’t tell. Then four French soldiers armed with MAS assault rifles and with their full protective gear ran around the corner and reported to the RSM. They conversed off to the side. There was a force protection issue. It is easy to assume the R 3 MMU, being in the middle of Kandahar Air Field, was secure. With the influx of civilian and non-ISAF vehicles and personnel coupled with the sense of urgency, there was a possibility that the enemy might infiltrate a suicide bomber disguised as a casualty or even a vehicle-borne IED into the Role 3 and blow it up. The results of such an attack would be catastrophic. All civilian vehicles, already searched once on entry to the base, were searched again by the troops and then the patients were all re-checked by the medical staff, just in case. There is no ‘rear area’ in Afghanistan.
Two men wearing beards, Oakley sun glasses, tan civilian clothes, non-standard side-arms, unmarked ball caps and carrying non-descript pouches walked up to me.
“Are you here from [insert super-secret organization code name here]?”
“Uh, no. I’m a military historian. I think you want to talk to him.” I gestured towards the RSM. They nodded slowly and went inside to join the fray.
LCol Charpentier emerged again and addressed the crowd. He stepped around the blood drying in the dust.
“All ambulance crews are back. No more patients are coming. We are standing down the MASCAL status. You can return to your parent units.” The crowd started to disperse.
“Come with me,” he said. “You get to see how we do business. This one is going to be a challenge. It’s the biggest so far.”
The activity in the trauma bay nearly blew my mind. I counted a large number of trauma bays, each marked by a red roman numeral. Each bay was a pod, a microcosm of frantic, purposeful activity, yet all were connected as if it was one large organism. It wasn’t as mechanical as I thought it would be -it was organic.
I counted no less than four different nationalities at work in each bay. There were Canadian doctors and nurses; Dutch nurses; US Air Force para-rescue jumper medics; US Special Forces; British and Australian surgeons and nurses; French orderlies; a bearded Dane. Then a Slovak doctor arrived, asking if he could assist. What struck me was how there was no arguing, no debate, no national histrionics: it was all interoperable, so to speak. If only NATO politicians could perform as well together. Major Sandra West handled ‘traffic control’ with a specially-marked white board that listed severity of wounds, bay location, and potential priority for triage purposes. A red line was on the floor to keep people back so the board was unobstructed.
“We have 14 confirmed so far, with two more possibles,” she indicated. “One of our problems is interpretation. We put the word out to Task Force Kandahar for more terps, but we’ve had to press some of our cleaning staff into service.” One of the Afghans was getting gowned and masked by an orderly who sported elaborate Maori arm ink.
Imagine the situation if it was reversed. You, an English or French-speaking Canadian, have been wounded in Afghanistan and been taken in the dark back of a vehicle to an Afghan hospital where nobody speaks English or French. How would you communicate how or where you were wounded? What would your mental state be if you didn’t understand what was being done to you-let alone having to deal with the pain of wounds? It was imperative that the patients’ anxiety level be lowered as quickly as possible.
It was now 1330 hours. Only one hour had passed since I left the NAAFI.
I saw a sign over the OR door: “Kandahar Institute of Surgical Science.”
“Valium! IV!”
“Are there more casualties?” A man with a red ball cap and a clip board pushed by and headed to a groaning man lying on his side on a gurney. Another man was wheeled to the X-Ray, suspected of having head trauma. A cluster of imagery techs were crowded around the computer screen looking at the interior of a casualty. One of the tech shook his head. “The C-6 and C-7 are severed. There’s nothing we can do. He’s 19 years old….”
Three staff members were working on the guy with the jaw wound.
“Terp!”
“What does he need?”
“He needs to pee.”
“Catheter!”
I conferred with the Task Force surgeon, LCol Heather Coombs and made a list of the casualties and wound types to get a sense of the nature of the attack. Of the fourteen, there were three chest injuries, ten head injuries, and one patient who had an emergency tracheotomy. It looked to me at the time like all of the casualties had been looking down at something or sitting in a stadium or amphitheatre when the device was detonated.
A nurse in greens wearing a shoulder holster reported to LCol Heather Coombs: Camp Hero delivered another casualty-he had a penetrating skull wound that the Afghan hospital couldn’t handle. The man’s skin was dark with dried blood and he was unconscious. Without space in the bays, he was taken to the headquarters lecture room and a team went to work on him there. Two F-16’s thundered down the KAF runway, temporarily blotting out any form of verbal communication. Around 1405, Camp Hero sent another casualty over. This person had a severed femoral artery and they didn’t have the resources to repair it.
The staff in the R3 MMU Tactical Operations Centre collected as much info as they could and relayed it to the Provincial Operations Centre. Unlike a civilian hospital, R3 MMU is a tactical unit and like any military unit it relays tactical data to decisionmakers who will use that information for subsequent operations. This is important for a number of reasons. First, the type of device and its effects could help lead us to the perpetrators who conducted the attack. Second, the location of the attack and the tribal affiliation of the casualties could be indicators as to future enemy action-or it might give warning of a larger attack that was underway either in the city or elsewhere. Third, the willingness of the victims to publicly condemn the enemy could be used for information operations purposes-and that was time sensitive. Information operations are critical to counter enemy attempts to influence the population especially in a environment where the will of the people is the critical element for success in the conflict.
Some information about the attack came from the patients that were lucid. The bomb was detonated around 1130 outside of Kandahar City, but it wasn’t clear whether it was in Zharey, Daman or Arghandab district. Later on it turned out that the Taliban bombed a sporting event in Arghandab district. Abdul Hakim Jan, a senior police figure in that district, was killed which produced a level of instability in that district that the enemy could exploit. By deploying more police and replacement leadership in a timely fashion, it was possible that the Taliban were deterred from making another move on Argahndab (the enemy tried to take over that district in November 2007-and failed in the face of combined Afghan-Canadian action).
A counter IED team arrived and asked that the shrapnel be collected from the wounds so they could assess what type of device it was. The bits and pieces didn’t appear to have a pattern-no nuts and bolts or washers, just jagged metal. At this time it wasn’t clear how the bomb was infiltrated into the event, but later on it was determined that a suicide bomber using a vest device conducted the attack. The casualty numbers were adjusted upwards as the afternoon progressed-80 killed and 100 wounded. Mir Wais hospital was dealing with 48 wounded and estimated that they had 55 dead.
Back at R3 MMU, two of the more severely wounded died by 1455 hours. I saw a masked surgeon and four staff in the Kandahar Institute of Surgical Science working quickly and deliberately on a man with a severe head wound. Unlike the trauma bay’s white and wood look, the OR had a bluish-green hue to it, most likely from the lights reflecting from the bevy of surgical greens bent over or moving around the table. It was like a different work in there through those doors, quiet and comparatively serene but no less purposeful.
LCol Charpentier moved throughout the facility, keeping a quiet watch in the background. R3 MMU staff were now confronted with a number of dilemmas. The possibility existed that they would have to take more casualties from Mir Wais or Camp Hero but things were getting crowded. Could some patients be moved to the Role 2 in Camp Bastion, the British base in Helmand province? Or to Bagram Air Field north of Kabul? How would they get there? Who would provide the aircraft? Helicopters to Bastion, C-130 Hercules to Bagram? What about triage-who would go where? The crowd around the white board brain-stormed solutions. The issue revolved around sending people with the patients-were they qualified for aero-medical evacuation care? And then how would these people- both medics and civilians- get back to Kandahar?
The interpreters moved back and forth between the bays as the nurses and medics bantered about hooking up a bloody mary and vodka to the IV stand. The information operations team then arrived. They secured permission from the CO to interview patients about the attack, as long as the patients consented to the interviews and understood how they would be used. Working through one of the terps, the team asked one man who I’ll call Zia if he would allow himself to be interviewed for Kandahar radio. Zia was propped up-he had an injury to his skull and one of his shoulders: he had a few tubes in him. He periodically spat blood from an injury inside his mouth into a bowl. Zia explained that he was watching a dog-fighting match, a common sports event in the region. He was engrossed in the event (he had some Afghanis down on the prime contender) when the bomb detonated. He blacked out and didn’t remember a thing until he woke up in the Role 3.
“Does this attack contravene Islam?”
Zia agreed vehemently and spat out more blood. “Yes. Those who did this are un-Islamic bastards.”
“Mr. Zia, we pray for the return of you health, God willing. Thank you very much.”
The sun was starting to get low and the mountains were casting indigo shadows. I stepped outside for some air and to get a coffee as two CH-47 Chinook helicopters thundered by. The R3 MMU smoking area was full to capacity with people in OR greens and Crocs-I’d forgotten how many medical people actually smoke. I took out a Romeo-y Julietta, circumcised it, lit it and puffed away with the rest of them. Things were winding down and plateauing as the patients stabilized, the tension and drama ebbing away, replaced with fatigue. The CO and I walked in the direction of the dining facility. “That is what we do,” he simply said and quietly regarded the route as we walked on.
It was the end on one bloody day and another was about to begin. The next morning Taliban terrorists mounted a suicide attack down in Spin Boldak, the latest in a series of futile attacks designed to kill Colonel Rezziq, the local militia commander. It wounded 3 Canadians and 27 Afghans. Thirty more Afghans were killed by the bomb. The Role 3 MMU once again prepared to receive the carnage….
Sean M. Maloney, PhD
Dr. Sean M. Maloney PhD,
Historical Advisor to the Chief of the Land Staff, Canada
born 1967 in Kingston Ontario Canada
-Military History
- served as the Canadian Army's historian for 4 Canadian Mechanized Brigade Group in Germany at the end of the Cold War and as the historian for Operation KINETIC, the Canadian contribution to KFOR in Kosovo.
He now serves as the historian for Canadian Afghanistan operations and has travelled to Afghanistan annually since 2003 to observe both the OEF and ISAF missions.
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