National Defence Committee on April 29th, 2013

[The Chair, Conservative, James Bezan]

Good afternoon, everyone. We're going to call this meeting to order. We're at meeting number 77. We're going to continue with our study of the care of ill and injured Canadian Forces members.

Joining us for the first hour is Major Ray Wiss from the Canadian Forces Health Services. I think a lot of us are familiar with Major Wiss as an author, but he's also an emergency medicine specialist from Sudbury and a member of the Reserve Force.

In 2008, he was awarded the YMCA Peace Medal and the Ontario Medical Association Distinguished Service Award. In 2010 he received the Rotary Club's Paul Harris Award. He has been selected as the keynote speaker at the North York General Hospital Emergency Medicine Update. He's been one of our premier emergency medicine physicians and has been at a number of conferences speaking about his books, FOB DOC and A Line in the Sand, which I know a number of you have already read.

I want to welcome you, Major Wiss, to committee and extend to you our gratitude for your service to Canada. We also want to thank you for sharing the stories you have put in your books. One of the reasons we wanted to have you here today is to talk about your experience in Afghanistan and, more important, how we deal with a trauma at the front lines.

With that, I welcome you to bring your opening remarks.

[Major Ray Wiss, Canadian Forces Health Services, As an Individual]

Thank you very much.

Mr. Chair, members of the committee, thank you very much for having me. It is truly an honour to be here.

I'm going to talk to you about my time as a forward operating base doctor in Afghanistan. My time there, as you know, was very atypical medicine. I spent almost all my time in the combat area, a place where physicians almost never go.

I worked at the forward operating bases where living conditions could be fairly spartan and somewhat hazardous. Our FOBs were quite heavily attacked—including this one, which was the most heavily attacked in all of Afghanistan, setting a record one day with 19 rocket attacks in 24 hours.

This is the army's equivalent of an 18-wheeler. You get an idea of the size of blast that these rockets create when they hit. The shrapnel, the metal fragments thrown off from the blast, are lethal to a much greater distance.

Down in this corner, we had what's called a shower can. That's a sea container that has a hot water heater and some shower stalls inside. When that rocket hit, two of the shrapnel fragments tore through the multiple layers of metal around this shower and decapitated an Afghan soldier who'd been showering there, killing him pretty much instantly.

Because of that, a lot of Canadian soldiers who served at this FOB would refuse to shower in that stall. I made it a point to always shower there, because I figured that the odds of somebody else getting killed in exactly the same place had to be very low.

These are the people who did the shooting. These are Taliban soldiers with their favoured weapons. First there's the AK-47 rifle.

I should warn you, at this point, that I am showing you what it's like to be a doctor at war, so some of these images are fairly graphic.

This is an entry wound where an AK-47 bullet has gone into the body. These high-powered rounds create exit wounds that are much bigger, where the bullet comes out with a great amount of damage, probably lethal in the chest or abdomen.

This is an exit wound in an arm, an explosion of bone and tissue out the arm. If you look inside, you can see that the bones and probably the nerves and blood vessels are shattered. It would be very difficult to salvage this limb.

The other favoured weapon of the Taliban is the rocket-propelled grenade, or RPG. This is a small missile. It has a range of about 800 metres, with a little rocket motor there. It has pretty good punch, and will fill the air with small shrapnel fragments, like the ones that hit this Canadian soldier here. He was serving at this FOB right on the edge of the desert in this guard tower, standing pretty much exactly where I'm standing, manning the light machine gun that we all took turns manning to guard the approaches to the FOB. There used to be a beam here. The RPG round came in, detonated here, and showered him with fragments.

The first step to good patient care is not getting hurt. If you look at his chest, and especially here, in the death box—the heart and the great blood vessels where you will bleed out within a minute if you're hit—he has no marks, because he's wearing not just his kevlar vest, but also, right here, there's a metal bulletproof plate, front and back, that will stop an AK-47 round.

You also notice that he has no wounds from his eyes on up, because he's wearing not only his helmet but also his ballistic glasses. These are hardened plastic that will stop these shrapnel fragments from damaging the very vulnerable eye.

Now, you have to understand that these are direct-fire weapons. You have to see the person you're trying to kill to use them. So it's a gunfight, and Canadians do not die in gunfights. We're much better soldiers than the Taliban. If you look at the months of heavy fighting in Afghanistan, in Kandahar, with over 120 combat deaths, only eight of them were from direct fire by the Taliban.

So what killed us? Well, this killed us: this is what's left of a motorcycle after a suicide bomber blew himself up beside an Afghan army vehicle. You can see the shrapnel fragments that went through the vehicle like a hail of lethal bullets.

Even scarier is the suicide vehicle packed with explosives. This is on a testing range here in Canada. You can see on this test vehicle the mannequin representing the crew commander and the sentry. When something like this happens—this explosion—as you can imagine, anybody with their chest and head outside the vehicle is not going to do well.

This is the scariest thing you could do in Afghanistan—not getting shot at but going down the roads of Kandahar province. This is what killed us, the IED or roadside bomb—low-tech warfare at its best.

Sometimes we got lucky, but sometimes we didn't. This is, again, on a testing range in Canada. As you can imagine, if the breach into our armour is complete, as you can see here, nobody would survive this kind of an explosion. Even if the breach is only partial, our soldiers are in big trouble.

Paradoxically, the armour that protected them so well a second before now works against them by containing the force of the explosion inside the vehicle. This causes an overpressure to build up, which can be lethal all by itself. That can lead to some unsettling situations, because soldiers killed by overpressure have no marks on them.

It can be very hard to explain to young soldiers that their friend is really gone, that behind the faces that look so peaceful, the internal organs have been turned to mush.

Even if the armour is not breached but only buckles, we're still going to have serious injuries. The floor of the armoured vehicle comes up into the crew compartment so fast; it's as if the soldier had jumped off a third- or fourth-storey balcony. So even though the wounds on the surface won't look that bad, you look inside with X-rays and the bones are just shattered; the nerves and blood vessels are ripped up. It's very hard to salvage this limb. Often, amputation is the only option we have.

Limb wounds are bad to look at, but easily the most horrifying wounds are facial wounds, because even for well-trained medical personnel, these are very hard to take. They're not all that lethal, actually. All mortality from head and neck trauma is only about 5% if the patient is still breathing. If the windpipe is disrupted, that mortality goes up sevenfold.

The reason this guy is still alive is that he has benefited from a procedure where we actually cut into the neck and put a tube directly into the lungs, to push air into the lungs, bypassing the damaged face.

In 20 years of emergency medicine in Canada I've done this procedure three times. One of my medics on my first tour did this three times in six months, and did them so well that Colonel Tien, whom you heard from a few weeks ago, actually wrote an article about him in The Journal of Trauma, and about the quality of training that our medics receive.

Some people have expressed surprise and even criticism that as a doctor I'm heavily armed, but in the combat area I am a soldier first. Our job, for my medics and for me, is that once the shooting starts, we help win the fight. It makes no sense to take our weapons offline and open up a gap in our defences.

Once we're pushing the enemy back, we're in a good position to cover, and then we can attend to the wounded, especially at the base of one of these mud brick walls. They're like concrete and can stop a bullet. It can be difficult to do when something like this is going on right above your head. I would encourage you to focus on the top right-hand corner here.

[Video Presentation]

[Maj Ray Wiss]

So yes, that bright red light is what it looks like when an RPG goes flying right over your head.

[Major Ray Wiss, Canadian Forces Health Services, As an Individual]

It's difficult to deliver medical care here. It's dusty, it's noisy, it's dirty, and it's scary. It's also a little disconcerting, because once you finish patching up the wounded man, the young medic with you immediately turns and wants to videotape the firefight to post on his Facebook page. That's a generational thing that I could never really understand.

I would much prefer it if I could deliver care in my armoured ambulance, the Bison, which has everything I have in my level one ambulance here in Canada. Even better was delivering care at the FOB, where I have everything I need for that first half hour of trauma care. That's all I need to do, because in half an hour my ambulance comes to take them back to the Role 3 Hospital and outstanding care.

Just to give you an idea, this is not a helicopter crashing. This is a helicopter landing under fire to bring our wounded back directly from the battlefield. That's how good these pilots and machines are these days.

You heard a bit about the role I played in delivering ultrasound to Canadian emergency medicine. I did bring my machine along with me for my first tour. On my second tour, I actually convinced an ultrasound company to lend, for free, ultrasound machines to all of our FOBs for use on that tour.

I have to disagree a little bit with Colonel Tien here. I did teach this to my front-line medics, and I became convinced that with some brief and focused but intensive training, they could develop quite a facility with this technique.

That's the key message I want to leave with you from this oral presentation. These young medics, 28, 26, 24, and 22 years old, are extraordinarily competent. The training delivered to Canadian Forces combat medics these days is superlative.

I want to show you something here. This is what happens when three badly wounded Canadians land in the FOB all at once. Even if you don't have a medical eye and you don't speak French, I think you will all agree that this is a doctor and a half a dozen medics going about their work in a calm and professional manner.

[Video Presentation]

[Maj Ray Wiss]

For the trauma indications we dealt with, I felt as well surrounded by these young medics as I do by my vastly more experienced trauma nurses here in Canada in my level-one trauma centre.

[Major Ray Wiss, Canadian Forces Health Services, As an Individual]

The only thing more impressive than their competence was their courage.

This is an incident I described in my second book, where a medic ran forward under fire to reach a wounded soldier, got there and realized the solider had lost his helmet, and immediately removed his own to protect the casualty's head. That kind of courage came at a price. We lost eight combat medics in Afghanistan, and we were a small group to start with. Compared to the size of our group, we had the highest casualties of any of the elements in the battle group.

This individual and the one just before him were medics who served at my FOBs and on my tours. They were more than just my colleagues and comrades-in-arms; they were my friends. Two more of these individuals were from my hometown of Sudbury, in northern Ontario, including this young man, who was the last medic to die. He was the son of a very good friend of mine. I was having dinner with the father when the son was killed.

So when you tell the story of the Canadian Forces Health Services in Afghanistan, you tell them that the medics got to their patients or they died trying. For that, we will remember them. I hope Canada does as well.

Thank you.

[Applause]

[The Chair, Conservative, James Bezan]

Thank you so much, Major. That type of reality is what we sometimes need to hear about to really form our attitudes when we are dealing with such a serious topic.

In the interest of time, since we only have an hour with Major Wiss, I would suggest we stick to five-minute questions and answers. With that, Mr. Harris, you have the floor.

[Jack Harris, NDP, St. John's East, NL]

Thank you, Chair.

Thank you, Major Doctor Wiss—we have to call you both. That was a very moving presentation. Some of us have been there and recognize the terrain; however, we didn't experience the kind of trauma you did. It's news to me, I think, and it surprises me to hear the number of medics who actually lost their lives. I don't think that's well known. We think of medical personnel as being there when the trauma patients come in, not as those who actually suffer and die themselves. Thank you for letting us know that. It's certainly well worth remembering that those who served as medics also risked and lost their lives in the service of their country. And thank you for your service.

Most of our information, of course, about wartime trauma service comes from watching M*A*S*H* on TV in the seventies or thereabouts, so it's good to see the realities of that in a different context.

I have to admire the presence of mind you showed with the group dealing with three trauma patients at once. As you say, it was a very professional attitude. Thank you again for showing us all of that.

I want to compliment you and your group, of course, for having received the very special NATO award for the Role 3 Multinational Medical Unit at Kandahar. I've looked at your book, and thank you for writing it and for informing Canadians in a very special way what it was really like.

I think most committee members are satisfied—we haven't heard any evidence to the contrary—that the kind of trauma service that was provided in combat or in theatre in Afghanistan was second to none, and the awards, of course, speak for that.

We're looking at the care of ill and injured soldiers. Obviously, the first response was very good. Unfortunately, we're hearing stories about post-trauma, whether it be post-traumatic stress injury or other details. We had one individual talking about something else come to see us. He told us he was diagnosed at Kandahar air force base with post-traumatic stress disorder. Incomprehensibly, he was told he had two months' leave and was given a ticket home. He came home on a civilian aircraft, without support or decompression or anything like that, which was surprising.

We have also heard, of course, as everyone has, about the concern around what's happening afterwards with post-traumatic stress disorder and the level of treatment we offer. We sometimes also hear concerns about the level of financial support under the new Veterans Charter and such issues.

Maybe it's not your field, but you're still working in a civilian hospital. You still come across veterans and people who have served. Would you have any comment, suggestions, or offerings on what happened after Afghanistan for our soldiers?

[Maj Ray Wiss]

Yes, I sure do.

As you say, I'm still quite intimately involved with our wounded afterwards. For any one of them who comes into my area, I tend to become their personal physician, including Bill Kerr, who is our only triple amputee of the mission, and a number of other severely emotionally and physically wounded.

There are two important messages I want to pass on to your committee. The first is that every other nation in NATO, and I think by extension on earth, recognizes that the work we do with mental health is the best in the world. You have to be very careful when you talk about the disasters that happen in any system. There's a real danger when you are talking about people with PTSD who have fallen through the cracks—and there's no question some people have, that's inevitable in any large system. But there has to be some balance there, because the danger is that other people with the same problem will not seek the care. There are a tremendous number of resources out there and some very competent and caring people working in that field, but these people have to declare that they're having difficulty. That's a really important message we need to pass along. There has to be the balance in the reporting of how we manage PTSD that reflects that, and it can't just be the horror stories that are out there that, yes, we must address. There has to be the balance. Every other nation, including the United States, with vastly more resources, is looking at us to try to copy what we do in mental health.

As for the charter itself, I have offered a written submission about that, and I imagine the government feels quite bruised about this issue, with some fair justification. The charter was implemented to deal with a great number of veterans' concerns, and it did so pretty admirably. But the people working on the charter had been looking to the past, as they had been for 50 years. They had the great mass of aging veterans in mind and they served them well.

As I believe the committee is aware, my life has been somewhat chaotic recently, so it was only in the last few days that I was able to pull this presentation together. I realize now, as I hand out my written submission to you, that I've left out the key point I wanted to make. When the legislation was enacted, as I stated, it did a good job of addressing the needs of most veterans. But when the charter was written, no one could have anticipated how effective the Canadian Forces Health Services would be. Had the war in Afghanistan been fought 10 years earlier, we would have had three times as many fatalities and not nearly as many severely wounded individuals. But precisely because of the exceptional training our medics received, many soldiers who would have died in earlier conflicts are being dragged through the valley of the shadow. They survived, but they are horribly mangled, and there are more of them than anyone expected. For this small group, the charter's benefit restrictions can adversely affect their long-term health and welfare.

In my written submission I outlined why additional benefits might be considered for these individuals, but I omitted to mention that this compensation will lead to a great benefit for the government.

As a medical officer, I am a force multiplier. That means our soldiers fight harder when I'm around because they know they'll be well cared for when they get hit. All the combat team commanders I served with told me I had a great impact on morale. The reality is that you too can be force multipliers. To quote Napoleon, the morale of the troops is three times more important than their equipment. What you want from your armed forces is operational effectiveness. Back them up when they get hurt and you'll get a tenfold return on your investment.

[The Chair, Conservative, James Bezan]

Thank you.

Mr. Strahl, you have the floor.

[Mark Strahl, Conservative, Chilliwack—Fraser Canyon, BC]

Thank you, Doctor, for your presentation, as well as for writing your book. I've read both of your books, and they did the best job, from anything I've seen, in explaining not only what you did, but why we were there and why each of the individuals who went over there played an important role, much like in the other, perhaps more famous wars. Canadians know a lot more about what we did in World War I and World War II, and I appreciated even your bringing people up to speed on things that happened in Bosnia, for instance. And thank you also for going there when you didn't have to. It reminds me of the greatest generation who felt called to go. We all thank you for that.

I want to talk about a specific incident you mentioned in your book, and I'm not sure if it's been resolved yet. You mentioned that some of the medics were paying up to $600 out of their own pockets to get better backpacks so they could better serve the fallen on the field. What was provided for free to them was inadequate, so they were spending their own after-tax dollars to supplement their kit.

Was that ever resolved, to your knowledge, or is that an ongoing concern?

[Maj Ray Wiss]

There was a huge step taken forward on that, because after that book came out, actually, it came to the attention of General Natynczyk. He actually put a lot of those guys together and said, “Okay, that's fine, guys, but you have to agree, we can't buy a different one for each one of you because then the next guy is going to come in and want something else.” But they did come up with something that was much closer to what they all wanted. These guys are all individualists. They probably want a little tweak here, a little tweak there. But what's operational now is much closer to what we need.

[Mark Strahl, Conservative, Chilliwack—Fraser Canyon, BC]

Congratulations on that real-world improvement that you helped bring.

You also brought your ultrasound expertise. When we travelled to Downsview last year we saw the goal of bringing the ultrasound technology to the battlefield.

I've asked this question before, and you mentioned it briefly. How close should we be to getting that tool to our medics on the ground, without someone like yourself, who is obviously an international expert on it? You said you felt this could be a battlefield tool. Can you maybe just expand on that a little bit?

[Maj Ray Wiss]

Yes, absolutely.

The thing I'm an international expert on is teaching ultrasound to rank beginners. I've taught 8,000 Canadian physicians how to use ultrasound; they had never picked up an ultrasound probe, ever, in their lives. At this point in Canadian emergency medicine, I would say if you're not using ultrasound daily, you're a dinosaur looking for a tar pit to fall into.

So yes, it can be done. Among those 8,000 doctors, I guarantee you there were some who were pretty slow and much less sharp than my medics. Yes, we can be using it.

The other thing I would tell you is that I went to see the operation at Downsview. To be honest with you, what we need is off the shelf right now. There is an ultrasound unit on the market right now that's half the size of a pitcher of water, and it will tell me if the lung has dropped, if there's bleeding in the chest, bleeding in the abdomen, around the heart, very effectively, within seconds. And I can teach a medic how to do that in about 10 hours. So that's out there.

[Mark Strahl, Conservative, Chilliwack—Fraser Canyon, BC]

What do you think is holding back the military from adopting that?

[Maj Ray Wiss]

They're not being held back that much. I've taught all the special forces medics how to use ultrasound, and I know that CANSOFCOM bought 16 or 17 units just recently. It's getting out there, definitely. Emergency medicine is still evolving in this area, and I think the army is following that quite closely.

[Mark Strahl, Conservative, Chilliwack—Fraser Canyon, BC]

You deployed twice to Afghanistan. Can you speak to the lessons learned that were applied right away? Were there marked improvements between your two deployments in terms of the front-line medical care?

[Maj Ray Wiss]

It was huge. When I got there on my first tour, the FOB I was at was really oriented to a non-physician, so there weren't very many other options for me, other than what was available to the medics. I made a number of recommendations at the end of my first tour, all of which were implemented. When I got there on my second tour, I might as well have been working in my level-one trauma centre. There was nothing I couldn't do on that second tour that I do at home.

[Mark Strahl, Conservative, Chilliwack—Fraser Canyon, BC]

That's great. Thank you.

[The Chair, Conservative, James Bezan]

Thank you.

Mr. McKay, it's your turn.

[John McKay, Liberal, Scarborough—Guildwood, ON]

Thank you, Chair.

Thank you, Dr. Wiss, for your service.

You mentioned in your presentation that there are not that many doctors who go to the forward operating base. Why is that?

[Maj Ray Wiss]

The fact that I did will I think explain the question a bit better. It was really an accident of circumstance. I got there on a francophone rotation. I'm French Canadian. I'm an ex-infantry officer. For the five years immediately prior to my deployment, I had been the doctor for our SWAT team, or tactical unit, of our police department. A lot of my infantry reflexes had come back. I could shoot straight, I could move tactically—I was an unusual mix as a doctor. When there was a gap in the coverage at one of the FOBs that is normally covered by a senior medic, what's called a physician assistant, they asked me to take that place. Again, a big part of the reason for that was precisely because I was francophone. A lot of francophone senior medics will serve on anglophone rotations because they speak English; the converse is not true. It was harder for the francophone rotations to fill all those spots.

[John McKay, Liberal, Scarborough—Guildwood, ON]

Is it therefore because the doctors are not soldiers, in the sense of fighting soldiers?

[Maj Ray Wiss]

Well, I could shoot straight, yes, and they asked me if I would do this job and I said that I would.

[John McKay, Liberal, Scarborough—Guildwood, ON]

Do you feel that the presence of a physician at a forward operating base—and I'm assuming the answer is yes—is a significant upgrade to the outcomes of the casualties?