The most confronting thing for medical staff stationed at the NATO hospital at Kandahar airfield in Afghanistan was the stream of soldiers arriving with limbs missing. One, two or three limbs — and sometimes even four — torn from their bodies, above or below joints, leaving just a piece of jagged bone protruding from a burnt fleshy stump.

Perhaps the only thing more shocking to that toughened group of medicos was the bravado of some of the maimed soldiers, who would joke about their predicament while still in the trauma bay.

“Sometimes, they were able to make comments that were truly amazing,” says Commander Ian Young, 46, an orthopaedic surgeon with the Royal Australian Navy. “[When asked their weight] they would say things like ‘Oh, well, I used to weigh 200 pounds but now I weigh a little bit less’, because they knew they had lost one or two limbs. It was always a surprise to me and the staff around me that they would say things like that.”

Reflecting on his time on the frontline of Australia’s longest war, the Canadian-born surgeon, whose ‘day job’ puts him in Frankston Hospital amid the more mundane mending of bung hips, knees and shoulders, talks of the single-mindedness of deployment and the jarring transition between the theatre of war and the ordinariness of life back home.

“Often there’s no semblance of a limb left. It may be part-way through the leg below the knee where there is not much tissue left, just burnt bone. Or it can be all the way up to or above the knee or where the knee finishes.”

Daily, routine experiences would remind him that he’d been through something extraordinary. Most obviously, he no longer carried a weapon or found himself worrying about rocket attacks. But even something so trivial as a bunion could cast his mind back to Kandahar.

“One of my first operations back at Frankston was someone with bad bunions who needed bunion correction. Up until a month prior I had been managing people whose limbs had been amputated as a common injury.

“The people I used to work on, the really young men who had limbs off, would have given anything to have that foot still on their leg, even with the bunions.”

Commander Young speaks with a thick Canadian accent that he hasn’t been able to shake despite years of living in Australia. He jokingly refers to “this horrendous accent of mine”, but his demeanour is more that of an easy bedside manner than the sort of directness that might be expected from someone carrying the rank of Commander.

Young joined the Royal Canadian Navy in 1990 under a graduate training program while still in medical school and transferred to the Royal Australian Navy eight years later after marrying a Melburnian. Since, he has been deployed as an orthopaedic surgeon and health specialist across the Middle East, the Indian Ocean and in Penang and Indonesia. He is in clinical practice at Frankston Hospital several days a week.

His last Afghanistan deployment was from August to December in 2012, where he was part of a small contingent of eight Australian medical specialists serving at Kandahar Airfield. For more than a decade, the airfield housed tens of thousands of military personnel from 20 nations. Along with the obvious features of occupation it boasted a wide array of ‘home comforts’ — Internet cafes, coffee shops, gyms, restaurants and fast food outlets. If it wasn’t for the regular fear of rocket attacks and ubiquitous presence of military uniforms and weapons, those stationed there might have mistaken it for a desert pre-fab community.

Yet amid this relative comfort, the makeshift community would bear witness to the horrors of the frontline. In the trauma bays and operating rooms of the hospital Commander Young and his Australian and international colleagues toiled putting the bodies of broken soldiers back together.

In the wake of the 2009 ‘surge’, coalition casualties in Afghanistan rose sharply and although 2012 showed signs of improvement, the insurgency had barely abated by the time Commander Young took up his position at Kandahar. During his deployment, six diggers died and another 15 Australian defence personnel were wounded, with the International Security Assistance Force suffering more than 230 casualties.

Civilian surgeons in Australia are no strangers to horrific injuries and will often deal with victims of car crashes, industrial accidents, fires and even the occasional gunshot. Unlike most of the injuries a surgeon might see in Australia, those caused in combat are intentional and the weapons used to inflict them designed to maim and kill.

Combat casualties in Afghanistan were mainly caused by ballistics or blasts. When a bullet or piece of shrapnel enters a body it imparts an incredible force that causes massive damage through the projectile’s path and sends shockwaves through the surrounding tissue. If a bone is struck it can splinter, creating little pieces of human ‘shrapnel’ that can ricochet through tissue, causing even greater damage. On a grander scale, an improvised explosive device or rocket propelled grenade can easily tear through flesh and separate limbs from a body. The concussive force alone can cause terrible damage to a person without even needing to penetrate the skin. It was these blast injuries that would often cause the most harrowing injuries to soldiers and the greatest challenge to surgeons.

“It is quite extensive tissue damage, as you’d expect, and it’s outside what we’d normally see in Australia,” says Commander Young. “[We] would be dealing with people who had lost one, two or three limbs, sometimes damaging their fourth limb as well. And on top of those injuries that were mainly from improvised explosive devices there was potential for other injuries to the head, face and abdomen.

“So when you see these limbs, often there’s no semblance of a limb left. It may be part-way through the leg below the knee where there is not much tissue left, just burnt bone. Or it can be all the way up to or above the knee or where the knee finishes. And the hands or upper limbs, again it could be a finger or two that are damaged or missing, to a whole hand, to mid-forearm. It really depends on the proximity to the blast as to how much burn there was at the time to what you are looking at.”

As soon as casualties arrived at their medical unit at Kandahar the doctors, surgeons, anaesthetists and nurses would work to stabilise each man in the trauma bay. This meant an initial triage to determine the most pressing cases. The staff knew it was bad if a casualty arrived with an artificial airway already inserted, worse still if the patient was unconscious. The worst cases, though, were the casualties who had gone into cardiac arrest and were receiving CPR as they touched down. Only some could be saved. More often than not, however, the severity of their wounds meant they could not be revived.

A measured routine of treatment would kick in: medical staff would begin administering blood products, usually through through a catheter inserted directly into one of the body’s large veins. If the casualty couldn’t breath on their own, an anaesthetist would open definitive access to their airway if this hadn’t already been done in the field. Commander Young would then identify any injuries to the limbs, spine or pelvis that would need to be operated on. Then, once the casualty had been stabilised, he would replace any field tourniquets — typically, a rubber hose wrapped tightly around a limb to stem excessive bleeding — and replace them with pneumatic ones that would allow the casualty to better receive blood products.

AFGHANISTANThe coalition tollAustralia: 40 dead, 261 wounded

US: 2316 dead, 17,674 wounded

ISAF: 3430 dead Source: iCasualties.org

Those wounded that were conscious often could be confused or disoriented by painkillers or a blast, or they might be screaming in agony. Mostly, they were very focused. They would listen to the questions the nurses and medical staff asked and do their best to respond. Often the less severely injured were more worried about their wounded friends than themselves.

“Many of them had actually saved their mate’s life in the next bed,” says Commander Young. He recalls one young Australian solider who despite being wounded himself had applied tourniquets to his more gravely injured comrade. Because of his quick thinking, both men survived.

Ultimately, most casualties would require an operation of some kind. If they were stable enough they would be placed in a CT scanner to give surgeons a clearer picture of what they were dealing with. In the operating theatre anaesthetists would work across all casualties and general surgeons would “run the show”, identifying injuries. If there were no wounds to the chest or abdomen, the general surgeons could assist the specialists. At this stage Commander Young would begin operating on any injured limbs, working to stop the bleeding and cleaning the wound of contamination. He explains that despite the often extreme nature of the injuries, his training kept him focused. Surgery, he says, is like any trade in a way: you manage the task at hand instinctively through the skills and basic principles you know.

“So to manage that limb, no matter which limb it is, you take away debris, dead tissue, contaminated tissue from that area, clean it up, wash it out. That’s a very standard thing we do in any hospital in Australia,” he reflects now. “There will be a lot of contamination. Grass. Dirt, Bits of clothing. Bits of boot. And then things from the IED itself. So if it had projectiles inside of it, or shrapnel as I guess you’d call it, that potentially would be throughout the wound as well.

“Because of the contamination concerns we have learned from our previous wartime surgery that you don’t close wounds initially and you don’t tend to put metal in straight away because it becomes infected. So our standard is to put an external frame in with pins that go through the bone away from the area of injury which allows us to stabilise the bone, take the patient out of pain, but then also watch the wounds and be able to re-wash out the wounds every 24-to-48 hours as required or sometimes even sooner if they’re still quite contaminated.”

“We all just went on with our jobs. It was very reassuring that the resuscitation bay wasn’t loud, it wasn’t panicked. It was very quiet, it was very calm, everyone knew their role and did it very very well. And the same thing occurred as soon as we got them into the operating theatre. Everyone knew their role, everyone knew their job.”

The number of surgeons and medical personnel assisting at this time could vary significantly depending on the severity of wounds. For an isolated wound, a casualty might be operated on by one or two surgeons. Due to the nature of blast injuries, most casualties were generally worked on by three or four surgeons attending to different wounds. With more serious injuries came a greater number of medical personnel congregating at one time.  One US soldier, who had wounds to three limbs and across his stomach, chest, neck and head, had 13 surgeons, two anaesthetists and multiple nurses and medics attending him.

“It was what was required to do the most surgery in the shortest amount of time to get him to the intensive care unit,” says Commander Young.

The work was never easy but between the excellent facilities and the professionalism of the medical personnel, casualties had a good chance of survival once they made it to the hospital at Kandahar Airfield. Commander Young recalls that the hospital’s claim to fame during his deployment was a 99 per cent chance of survival for coalition soldiers who arrived with a pulse.

“As long as they survived the initial time in the field and transport to our facility they did quite well,” he says. “There were times when all of us struggled with an aspect of a procedure, but you always had your colleagues there and you could say ‘Could you just help me out here? Can you give me some assistance here while I’m doing this?’.

“We all just went on with our jobs. I found — and many people who observed it found — it was very reassuring that the resuscitation bay wasn’t loud, it wasn’t panicked. It was very quiet, it was very calm, everyone knew their role and did it very very well. And the same thing occurred as soon as we got them into the operating theatre. Everyone knew their role, everyone knew their job.

“We had the equipment that we needed and it just went seamlessly. There were never really any times of significant angst or anger and everyone just did their jobs. It was quite an experience from that perspective.”

Medical professionals are trained to cope with the trauma they see but the stresses of treating severe combat injuries coupled with being so far away from family and friends inevitably extract a toll.

“Once you’re done with that and have time for reflection, or in the unlikely event that a casualty did not survive their hospitalisation, those were the time when you go ‘Oh no’ and think about the ramifications of that,” says Commander Young. “And we often do think about these young soldiers going back to their home countries with these severe injuries and having such a challenging life ahead of them.”

Like soldiers in the field, however, the medical team had a camaraderie born of shared experience. What they went through they went through together, and if someone seemed to be going through a difficult phase of their deployment, as they all did sooner or later, those around them would rally to help them out. Being able to contact family and friends at home via email and Skype also boosted morale. For Commander Young, any chance to see his wife and four children, even just on a screen, helped ease the burden of his deployment.

“I’m very eternally grateful for that because as a family man I want to see my kids,” he says.

For the days when there was no word from home there were other ways to decompress. Hitting the gym. Watching a movie. Even getting a cup of coffee could help relieve some of the pressure of their environment. There was an effort to hold regular social events that would bring together the defence personnel from the many nations based at the airfield. The Australian contribution to these was regular barbecues held on their bit of turf inside the base.

“What Aussie doesn’t love a barbecue?” Commander Young chuckles. “We had a great area and people loved coming to our area because we actually had grass. That was very rare in Afghanistan.

“There were always social events and we would try to get together once a week along the flight lines to watch aircraft take off and look and have some cigars. That kind of thing. It’s just a way of having that camaraderie, having that support of people who know exactly what you’re going through because they’re going through it at the same time as you.”

“When the dust settles and you have to settle back into your previous life, your standard life, you’re like ‘Wow, how did I do it? I’ve got so many things to do now!’. You’ve got so many areas of your life pulling you in different directions, but when you’re on deployment life is simple.”

This social spirit worked in conjunction with the official support services available to defence personnel. All Australians deployed overseas are required to undergo a psychological screening at the end of their deployment and again three months after their return to Australia to assess how well they are reintegrating into society. In his previous deployment to the United Arab Emirates as Senior Health Officer for the Australian Defence Force, Commander Young instituted a policy of providing additional support to personnel carrying out roles that were considered potentially highly stressful, such as that of medical staff.

“There are certain groups that we think have an extremely stressful job and we might give them a mid-term assessment by a psychologist just to make absolutely certain that they aren’t being affected,” he says of the policy.

“So midway through their deployment [we] have a psychologist go and spend a little bit of time with every member. No ‘if’, ‘and’ or ‘but’ . . . and you just sit down and see how they’re going.

“That was another way to ensure that people were coping with their deployment, coping with what they were seeing and that they weren’t being significantly psychologically affected.”

By the end of Australia’s active role in a decade-long campaign, 40 Australians had died and another 261 had been wounded in Afghanistan. So when Commander Young’s deployment drew to an end in December 2012, and with it, months away from his friends, family and home, he felt a huge sense of relief.

“[There’s] nothing better than coming home, having the home-coming and giving your loved ones a hug and catching up with your friends,” he says. “There is certainly a honeymoon period when you come back where everything is great. [But] most of us, I think, do come back and experience ‘things are different’.

“When the dust settles and you have to settle back into your previous life, your standard life, you’re like ‘Wow, how did I do it? I’ve got so many things to do now!’. You’ve got so many areas of your life pulling you in different directions, but when you’re on deployment life is simple.”

Despite his first-hand experience of the cost of the campaign, Commander Young is glad to have been one of the more than 25,000 Australians who served in Afghanistan and is proud of the work he did there. For him, it was a validation of why he joined the military more than 20 years ago.

“I’m not Mr Macho,” he says. “I do get scared, but it’s a part of what I’ve trained for. I’ve always known that this is what I wanted to do: to help the injured in times of humanitarian need or in times of war.”