Ten years ago, I walked into the Armed Forces Careers Office in Swansea, Wales, and announced blithely to the Corporal sitting at the desk that I wanted to join the Royal Air Force as a doctor. Being eighteen, I was at once entirely sure that I knew what I was getting into, and at the same time, utterly clueless about military life. I had no close relations who had served in the Armed Forces (my grandparents having missed World War 2 due to their youth), and I had no school Air Training Corps or Combined Cadet Force to enthuse me. In July 2002, after undergoing four days of rigorous aptitude testing, interviews, fitness tests, medicals, and leadership exercises, I received a letter telling me I had been granted a Medical Bursary from the RAF, conditional on getting my place at Bristol University to read Medicine. It was the start of a great adventure, and a career that has kept me enthralled from the outset.
Flying Doctors
The concept of “Flying Doctors” came swiftly on the heels of the use of aeroplanes in combat. Early aircraft had patients fitted beneath their wings, in a “side car”, before later developing airframes with enough room to fit the unfortunate patient inside. Flight and medicine are intimately linked; just as the battlefield required developments in Trauma Surgery and Emergency Medicine, flying forced doctors to concern themselves with the abnormal physiological environment faced by pilots, aircrew and passengers. Such “Air-mindedness” is key to all branches of the RAF Medical Service: from the widely publicised Medical Evacuation Retrieval Team (MERT) and Critical Care Air Support Teams (CCAST) – the flying Intensive Care Unit; to the station General Practitioners, Occupational Health Physicians and Secondary Care Physicians based throughout the United Kingdom and overseas.
Training in the RAF will largely depend upon the stage at which a doctor joins, from undergraduate medical students to fully qualified Consultants. All, however, will go through Initial Officer Training at RAF College Cranwell, a course normally lasting 12 weeks. They will also complete a course of speciality training, including Aviation Medicine, Occupational Medicine and Medical & Military Ethics and Law, although some trainees may delay parts of this training for operational purposes. Thereafter, junior doctors will apply for their Speciality Training in Primary and Secondary Care, and senior doctors will prepare for deployment.
Centre for Aviation Medicine
In caring for a population of approximately 35,000 personnel, it is unsurprising that the RAF has a wide variety of specialist doctors, including Physicians, General Surgeons, Trauma specialists, Psychiatrists, General Practitioners and Ophthalmologists. Perhaps less well known are the research doctors working at the Centre for Aviation Medicine (RAF Henlow) and at Farnborough, the site of the RAF’s centrifuge. This is used by RAF Aviation Physicians to study the effects of G-forces and abnormal physiological environments on pilots. RAF Henlow also boasts the Air Equipment Investigation Group (AEIG), a research facility for testing military equipment (including subjecting it to pressure, G-forces and extremes of temperature), as well as being home to the Accident Investigation and Human Factors (AIHF). AIHF analyse the root cause of all RAF and Royal Navy aircraft accidents, can advise on Army and civilian aircraft accidents, and even have an RAF pathologist.
In bases at home and overseas, an awareness of flight remains prominent in the minds of RAF General Practitioners. Pilots and aircrew are subject to rigorous medical examinations, and have their own separate medical category of fitness that they must reach before they may even start flying training. RAF GPs need to be aware that even the common cold may have implications for flight safety. As new developments in pharmaceutical and surgical practice come forward, these are subject to evidence based review by military subject matter experts, who decide whether new treatments are suitable for the aircrew cadre. However, preventative medicine is equally important at the Primary Care level. For example, an exciting and pioneering physiotherapy programme is being developed to condition fast jet pilots – and their cervical spines – against the extremes of acceleration they face with new high performance aircraft.
My own fascination with Aviation Medicine grew slowly but steadily after joining the RAF. However, it was the combination of a Special Studies Module at university, and a ‘taster week’ spent as an FY2 at the RAF Tactical Medical Wing, that cemented my interest in Air-minded Medicine. Imagine taking a trauma call. Imagine assembling the team, allocating roles, preparing equipment. Imagine receiving the casualty, controlling the bleeding, a rapid sequence induction and intubation, stabilising, transfusing, giving analgesia and antibiotics. Now imagine doing it at night in the back of a helicopter. MERT teams may be forced to work with low light levels, in freezing conditions and subject to the insidious roar of the twin propellers of a Chinook helicopter, speeding at low level through the night. Ordinary medical procedures become challenging in flight; typically, cabin pressure will range from 5-8000ft on more multi-engine aircraft such as those used by CCAST’s flying intensive care unit. On a commercial aeroplane, passengers notice their ears “popping” as the cabin pressure decreases and the aircraft ascends. The CCAST team must manage physiology and physics in a military aircraft, kitted out with delicate medical equipment, and transporting high risk patients. Devices normally secured with air cuffs, such as laryngeal masks, must be filled with water. Medications normally stored in glass bottles are required in plastic, pliable containers to avoid bursting on ascent. The condition of the patients, too, must be carefully monitored. A pneumothorax on the ground may easily become a tension pneumothorax at a lower cabin pressure. The relative hypoxia, so easily tolerated by fit, healthy passengers on a commercial flight, may be catastrophic for a patient medically evacuated with cardiac or pulmonary conditions.
The Future
In August, I will start CT1 training in Wessex to become an Acute Medical Physician. Aviation remains a source of fascination, and adds further challenges to the relatively new discipline of Acute Medicine. The future holds further training in Aviation Medicine, deployments to foreign climes, and the opportunity to work and research with informed and engaging people. Even after ten years of medical, officer and aviation medicine training, one cannot know it all. But, perhaps, I’ve started to scratch the surface.
