Dr Charley Johnston grew up in Kenya and the Seychelles, and attended medical school in Belfast. He joined the Navy as a medical student and has been heavily involved in military anaesthesia throughout his career. He served in many war zones, including Bosnia, Iraq and Afghanistan and was instrumental in setting up the field hospital at Camp Bastion, fighting to ensure that the medical teams there were properly equipped. In addition to his work as a ‘jobbing gas-man’, he was appointed Defence Consultant Advisor for the military on the 7th of September 2001 (‘four days before all the rules changed’), served on the AAGBI Council for a number of years and in 2007 became a Queen’s Honorary Physician. In this section of his interview, Dr Johnston discusses his career in the Navy, both Gulf wars and his work in Afghanistan.
I joined the Navy as a medical student. I joined the Navy Reserves at 16 as what the Navy calls a stoker and what the rest of the world would call a diesel mechanic, with a view to spend as much time with the Navy as I could to find out what the Navy was like before I sold myself for thirty pieces of silver.
I did my house jobs with the Navy in Plymouth. I had debated on doing them in the Ulster Hospital, but I got some threats from the IRA, because of the naval connection. How real it was, I’m not certain, but that made my mind up that I would go and do my house jobs with the Navy. I did both medicine and surgery and orthopaedics house jobs. After that I had to go to Dartmouth for what we call the short knife and fork course: how to behave as an officer and a gentleman, and there was a couple of months gap between end of house jobs and Dartmouth, and I did three months anaesthetics just as a gap filler. To my enormous surprise, enjoyed it hugely.
Then I disappeared off into the submarine world for a couple of years. The Navy also trained me as a diver and I got involved in some of the diving research things and submarines where the doctor is responsible for atmosphere monitoring. A submarine is the biggest closed circuit breathing apparatus in the world, so there’s parts of this that were purely coincidentally very useful and the diving world.
The next step after the submarines was heading down to Haslar and starting anaesthetics there. I was in Haslar until ’82, whenever, I then got something that would be totally unacceptable now, where I was sent out as the only anaesthetist in Gibraltar, as still SHO/Registrar.
Some memories sit fairly vividly. There was a horrible incident. Meningitis was very common, or seemed to me to be very common. Having a wee girl come in with fulminant meningitis, such that she had a respiratory arrest coming into hospital and incubating her and keeping her alive until she was flown back. She subsequently died. Not helped by the fact that my son was at her birthday party five or six days before.
“Some memories sit fairly vividly”
We provided the anaesthetic service for the obstetrics and it really was being able to provide the anaesthetic service that I’m sure that obstetric anaesthetist would love to be able to provide, where you saw every mum at the antenatal classes, so you could talk to them, you weren’t dependent on midwives’ prejudices and things like that. It was military personnel rather than Naval, included MOD, civilians as well, hence it was 300 deliveries a year. It meant you were on call the whole time, 24 hours a day, 7 days a week.
Gulf War I
After that, I went to my ASCAB, Armed Service Consultant Advisory Appointments Board, I was asked, ‘Where do you think you will go?’ This was Gulf War I was just starting and I said, ‘I will be joining Argus on her way out to the Gulf next week.’ And that was true!
“I will be joining Argos on her way out to the Gulf next week”
I was in the Gulf for six months, Gulf War I was total idleness, I did absolutely nothing or as near nothing as made no difference at all. We expected quite a lot of casualties, the casualty estimates weren’t good, the casualties that happened were non-existent.
I went to assorted war zones- not as peaceful as the first one. Bosnia, which wasn’t great, but the major cause of deaths was road traffic accidents. We should not have provided care for the local population was the theory, because you don’t want to set up a medical system that isn’t part of the local infrastructure. The snag is with where Šipovo was, what should have been the local hospital was on the other side of what, in NATO speak, the inter-ethnic boundary line, which meant that in practical terms, the locals around Šipovo did not wish to go to the hospital that they should have done, so we did whatever was needed, which stopped us getting bored, provided a service that they wouldn’t otherwise have had.
“After Bosnia: Kosovo, Afghanistan a couple of times, Iraq for the next Gulf War”
After that, again, in all cases it was back to Haslar, I was on an aircraft carrier, Kosovo, Afghanistan a couple of times, Iraq for the next Gulf War…
I was involved in setting up Camp Bastion, but I never served there, I visited it as part of the checks and balances thing. It had a fantastic reputation and justifiably so.
We got it set up well, largely because of Andrew Gilligan. I was able to get anaesthetics completely re-equipped for Gulf War II, and that made a massive difference. I never actually spoke to Gilligan, but he tried to contact me and had spoken to my secretary just as I was about to go out to Afghanistan, which would have been Spring 2002. He then did a piece on The World at One and it was very cleverly done. Everybody had the impression that he’d been talking to me and that I’d been speaking out of turn, but actually when you analysed the transcript he didn’t say that at any point, but he was making the point that the anaesthetic equipment that we had in Afghanistan was third-rate. Inadequate.
“The anaesthetic equipment we had in Afghanistan was third-rate. Inadequate”
The tri-service apparatus that Ivan Houghton had sorted out was outstanding equipment for the Falklands, but monitoring in particular hadn’t moved on and it was woefully inadequate. Because it was a small scale unit and because we said there might be Russian chemical weapons, we’d brought the monitoring equipment for the chemical defence pack, which was a decent Datex monitor, everything you’d want for monitoring. What we had in that small field hospital was as good as anybody could ask.
Equipping Bastion & Andrew Gilligan
I was given the job on the 7th of September 2001 and four days later all the rules changed, or 9/11 to use the American terminology that we tend to refer to those days. It was fairly obvious in military planning that Gulf War II was going to happen. Blair and Bush were clearly determined that it would happen, so the military was planning for it, although there was no political, ‘This is going to happen,’. It was contingency planning and the military does a lot of contingency planning.
“I was given the job on the 7th of September 2001. Four days later all the rules changed”
So I got the transcript of Gilligan’s World at One piece and went round to all of the force commanders and the people rather further up the line than I was and said, ‘Look, Gilligan was wrong whenever he said that we had inadequate kit in Afghanistan, but that was because we’d done a fudge, a fudge that we couldn’t do on a large scale operation. The anaesthetists, led by Ivan Houghton and many others, sorted out the equipment we needed. And I said, ‘If we do not go with this new list, the press are already aware that the existing kit is inadequate and what is more, I am warning you that they know and if you decide that this is not to be funded, then I am recording that you have been warned.’ And so Gilligan meant that Datex, for example, got the biggest single order for AS3 monitors that they’d ever had prior to Gulf War I. I think it was 160 of them or something like that. They had to drag them in from all over the world, but it meant that we went well equipped.
“The press are already aware that the existing kit is inadequate… I am recording that you have been warned”
This is into Gulf War II and on to Afghanistan. We were already in Afghanistan, but in a small scale, then Helmand and setting up Camp Bastion, with CT scanner and everything built into it. And I can recall being asked by the Secretary of State for Defence, what did we need to make sure that we were running to Health Service standards? And I was able to say, ‘A significant deterioration of what we’re running at the present!’
For some time before they went bad, we had an extra anaesthetist in the hospital, so that we could put an anaesthetist in the helicopter to go out to retrieval and so if there was seriously injured people, you had either an anaesthetist or an A&E consultant. We did have senior trainees with us as an extra, but it was somebody experienced there, as soon after an incident as it was safe to land a helo without it being too major a part of the target system. And the results coming back from that were very, very impressive.
It starts with the first aid training, every serviceman is given first aid training, starting with the buddy care, so you’re dealing with people who’ve been taught how to do the basic stuff. Then you’ve got the troop medics, not full-time medics but they’ve been given rather more stuff. Then you’ve got the people you send out in the helicopter and a team being back at the hospital. You know what’s coming back, you’ve often heard not from the ambulance rumour service, (what the ambulance has been told to expect to get and what actually pulls up at the door have almost no relationship) because the anaesthetists or the consultant in the hospital would have a talking hat and could get onto the radio system. You would have a team waiting in A&E for them to come, because everybody was only a couple of minutes away and you’d a team that was working very closely together, so that everyone could get on with things.
“It was ATLS working exactly as it should do”
It was ATLS working exactly as it should do. We’d two consultants and a senior specialist registrar out there, so it was a consultant-provided service to an extent that you couldn’t do that in the UK. You couldn’t provide that in the NHS, it would be far too expensive… it would be nice to provide a Rolls Royce service, but unaffordable. Are you going to put your consultants and anaesthetists into the ambulance going down the motorway? No you’re not, you can’t afford to.
NHS vs. Military
The bit that I think the Health Service could do with integrated teams, people who work together. The nature of the structure is that it’s difficult- you have a disciplined structure in the military which contrary to the usual view is not a, ‘I am telling you what to do.’ The captain on the ship may take the final decisions, but he’s taking advice from everybody and if he’s only doing what he wants to do the system will break down very fast. There is nowhere in the system in the Health Service that allows everybody to feel that their input has been taken care of.
On an aircraft carrier, the air crew want to do their flying to make sure they’re totally up to speed, which means that ideally the carrier spends its whole time with a 30 knot wind going across the deck for take-off and landing, but the engines need maintenance, the seamen need to do their exercise: just like the Health Service, it’s a complex organisation with lots of conflicting priorities. The medics don’t come into it too often, but any time I came in, it was more or less on the top of the list immediately. If we could get something similar in the Health Service, I think the system would work a lot better, but you see, a chief executive is not seen in the same manner as the captain of a ship is, he’s not recognised as that, and what’s more he doesn’t have the working advice structures, that head of department and things. It’s a very different culture and there are bits that the Health Service is trying to absorb from the military.
I would say my proudest achievement from the military side was getting the re-equipping, and then Camp Bastion was that taken on a stage further. My involvement in the planning for Bastion was limited to the anaesthetic world, but because of what we’d done with Argos on Gulf War II where we’d CT scanners and so on, we were moving things on and demonstrating that you could have decent kit fairly close to the front line.
“When I took over running anaesthetics… we were running at 19% manning”
What was I proud of in the military was integrating the reservists totally into military anaesthesia. That worked and I was really proud of the way that worked. October 2001 the ordering council mobilising the reserves was put in, but the military were very, very short of anaesthetists. Whenever I took over running anaesthetics, in terms of fulfilling the number of posts that we should have had, we were running at 19% manning. It meant that we could do the Gulf War, but what we couldn’t do was the long-term follow-up with the continuing supply.
I went to check whether the Ordering Council, which had been done to mobilise TA service people, and we could mobilise any reserves we needed. The TA were saying, ‘To get one person we will mobilise six.’ And I said, ‘If you do that it’s a one shot weapon, because if somebody ends up going who’s unhappy with it, they leave and if somebody ends up getting mobilised and not being sent, they’ll leave.’ So I then said, ‘I will talk to people and we will get names.’ And just by phoning up people and running a plot which within two months of the reservists being mobilised, I had a plot running out 18 months ahead.
We were able to keep the steady supply going and not lose our reservists, because they had demonstrated that they were an integrated part of the military anaesthetics and it worked very well in anaesthesia; the other specialities it didn’t work as well is the impression that I have, but then I would say that, wouldn’t I?