Mary Langcake, director of trauma at St. George Hospital in Sydney, discusses her experiences deploying to Afghanistan as part of AUSMTF2 from July to October 2008. She describes the high-intensity trauma experienced, including treating over 130 casualties and performing 158 surgical procedures. She struggled with the emotional challenges of treating many penetrating injuries and casualties, including children. After returning, she was diagnosed with major depression and PTSD. While the deployment had both positive and negative impacts, she believes more pre-deployment training and psychological support could help trauma teams be "ready" for such high-intensity missions.

1. WAS I READY FOR THAT?
Mary Langcake FRACS
SQNLDR RAAFSR
Director of Trauma
St George Hospital
Sydney NSW

2. NO!

3. READY FOR WHAT?
 The Mission
 The training
 The reality
 Coping?
 The aftermath
 Progress report
 Personal balance sheet
 How can one be ready?

4. THE MISSION
 AUSMTF2 – 22 July – 04 Oct 2008
 Deployed to Tarin Kowt in Uruzgan, Afghanistan
 Tasked to:
 augment the Dutch Role 2e hospital in TK
 provide Combat Health Support to NATO-led
International Security Force (ISAF) including Afghan
Security Forces (ANSF), and eye-, life- and limb-
saving health support to local nationals (LN)

5. THE MISSION
 AUSMTF2 – the team
 RAAF – PAF and SR
 Specialist MO's – General and Orthopaedic Surgeons,
Anaesthetists
 Nurses – Perioperative and Intensive Care
 Medical Assistants – OT and ICU
 OIC – Perioperative Nurse with subunit command
experience

6. THE TRAINING
 MRE
 Netherlands April 2008
 met and trained with 420
Hosp Cie
 reviewed equipment
 rehearsed casualty scenarios
 rehearsed MASCAL

7. THE TRAINING
 Force Prep – RAAF
 information re culture,
conditions, welfare, support
 classified information about
risks etc
 RSO&I – MEAO
 acclimatisation – 50o
C, dusty
 briefings
 weapons training
 TCCC

8. THE REALITY
One of the highest rates of battlefield trauma
experienced by a solitary ADF surgical and
intensive care capability in recent history

9. THE REALITY
CASELOAD
In 75 days
132 presentations to theatre – 78% emergency
158 surgical procedures – 81% emergency
26% ISAF – 50% AS
>29% - <16yo
Casemix
general – 43%
orthopaedic - 57%
41% penetrating trauma:
GSW, Blast, Knife


10. THE REALITY
 MASCAL
 Sept 2 2008 – SOTG came under sustained , heavy
enemy fire
 high velocity firearms, RPGs, mortars
 Fire fight lasted approx 4 hours
 11 casualties
 9 evacuated – 7 → Role 2e
2 → FST

11. THE REALITY
 Penetrating injuries from both GSW and blast
fragmentation
 One soldier critically injured with life-threatening
wounds
 Remainder – fragmentation injury +/- GSW
 Multiple procedures into the early hours of the
morning
 FST casualties admitted and required RTT
 Critically injured soldier underwent re-look
laparotomy then evacuated to Landstuhl

12. THE REALITY
CHILDREN

13. COPING – RSO&I
 Struggled with rapid fire exercise due to knee
 520 C on day of weapons training
heat exhaustion
 Threatened with RTA
 Confidence shaken

14. COPING – TARIN KOWT
• Casemix outside of
civilian experience

15. COPING - TARIN KOWT
High operational intensity 
no time to
“pick yourself up, dust yourself
off and start all over again”

16. COPING – TARIN KOWT
• No “personal space”
• Environment

17. CHILDREN
 8 yo boy
 GSW (L) thigh, exit ® flank
 Shocked
 DCL – stabilised
 Turned over for debridement
of flank wound
bradycardia, BP
 died on the operating table
– “missed” injury to IVC

18. CHILDREN
 13 yo boy
 Accidental shotgun
wound (L) thigh
 Shocked
 Leg pulseless, paralysed,
anaesthetic

19. ILDREN
morrhage control
Fix femur
mpt to revascularise
% of SFA missing
uccessful attempt to
scularise
AKA

21. MOTIONAL DISTRESS
ut of my depth
ot good enough
ividly reliving failure to save child
nsomnia
norexia

22. E AFTERMATH
old I was “a disappointment” as an officer
Confirmed my belief
“crashed and burned”
wo days later –
flight out delayed by dust storm
MASCAL – trauma team leader
Off duty after 0200

23. E AFTERMATH
mmunition removed from magazine
Weapon disabled without my knowledge

24. E AFTERMATH
fraid to go back to civilian practice in case I
made mistakes

25. E AFTERMATH
id not initially seek help
My fault for not being up to the challenge
lanned to resign from RAAF
elt humiliated
upported by RAAF to take leave of absence from
vilian employment

26. E AFTERMATH
rofessional help
Diagnosed major depression and PTSD
On-going management

27. OGRESS REPORT
till “relive” events on occasion

28. OGRESS REPORT
Poster girl for how we got it wrong”
ime heals all wounds
he positives outweigh the negatives
have gained more than I lost
Would like to “get back on the horse”

29. RSONAL BALANCE SHEET
ROS
Friendship
Teamwork
Afghanis
Experience in trauma
Acquiring new skills
Service
• CONS
– Demands of casemix
– Emotional challenges
– PTSD

30. OW CAN ONE BE “READY”?
RAIN FOR CASEMIX
mprove pre-deployment training
Simulations
Work as teams
Paediatric trauma experience
Visit trauma centres with high caseload of penetrating trauma
CSTARS
Senior visiting surgeons program to Landstuhl
Emergency War Surgery Course - Lackland Air Force Base, US

31. TTER PSYCHOLOGICAL SUPPORT
ORE DEPLOYMENT
 More opportunity to speak with those who have been before
“forewarned is forearmed”
 More time off before leaving – I was making calls about
patients at the airport
 Don’t deploy members with history of psychological illness?
 Would have precluded >50% of the team
 But be aware they may have greater need of
psychological support even if they continue to perform
“above and beyond the call”

32. TTER PSYCHOLOGICAL SUPPORT
DEPLOYMENT
 Only a Padre on base
 Phoning home not always an option due to OPSEC
 Individuals may take multiple hits with little if any
down time to “pick themselves up”
 Requires good team leadership but other deployment
issues often a higher priority particularly during high

33. OW CAN ONE BE “READY”?
ind some space even if it is under the covers!
ell people if you are struggling, don’t expect
hem to guess
ealise the “goalposts” are different and be
repared to accept it (tough in reality)
orgiveness – yourself, others

35. ARON COOPER, WGCMDR ANNETTE HOLIAN, SQNLDR MARY LANGCAKE,
GPCAPT GREGOR BRUCE
SQNLDR BRUCE ASHFORD
SQNLDR SANDY DONALD
AUSMTF2

36. “We have to do the best we can.
This is our sacred human responsibility.”
Albert Einstein

37. THANK YOU