The role of the medic working on the ground in hostile environments has evolved enormously over the last 15 years.  For the purpose of this article, I will use my experiences in Iraq, as this is where I am at the time of writing.

In the early days of ‘private contractor’ work in Iraq following the end of the war in 2003, medics were generally unregulated and unregistered, most being ex-RMAs (now CMT1s) who had left the military and qualified as HSE Offshore Medics. Some had not done any ‘civilian’ courses but were hired on the strength of their military qualifications and experience; the guys would generally operate as firstly a PSD team member/operator, and secondly as a team medic. In those days the drugs and equipment carried by the medics was very limited; generally, FFDs, quick clot, blast bandages and if you were lucky some morphine auto injectors, Paracetamol and Ibuprofen.

Over the years, with the added involvement of oil and gas companies, alongside government contracts, the role of the medic has evolved from working as a ‘team medic’ into a ‘Tier 2’ medic who carries a comprehensive medical kit & medications and is able to function as a lone medic often in remote locations. These changes have caused multiple shifts in the industry standard and requirements to become a Tier 2. This should be a good thing, but it also comes with pitfalls.

As the industry grew and moved forward, ex-military medics who had no civilian qualifications no longer met the requirements set by the oil companies and so the HSE Offshore Medic became the standard. Ex-military medics were, and still are, preferred over civilians but only if they have completed the HSE OSM and are up to date with all their qualifications.

Since 2016 there has been another shift in the qualifications accepted within the industry to become a ‘Tier 2’. The oil companies operating in Iraq no longer acknowledge that having the HSE Offshore Medic is enough, and now will only accept guys who are either UK HCPC registered paramedics or HSE Offshore Medics who were previously military CMT1 medics with operational experience.

Outside of the oil and gas industry, namely the PSD or De-Mining industries, anyone who has completed a recognised paramedic, nurse or offshore medic course along with ACLS and Advanced Trauma management still meets the requirements to work as a ‘Tier 2’

Problems are starting to arise for companies who are rigid in the pre-requisites set down for their medics as this leaves a shortage of well-qualified medics in the industry and the salary is constantly diminishing leaving a huge issue with retention for these companies.

Ex-military CMT1s are finding it more and more difficult to reciprocate their qualifications across to the HCPC in the UK, and as of either March 2019 or 2020 (it is difficult to get a definitive date as it keeps moving) to become a UK paramedic you must have a bachelor’s degree. This means that unless companies are prepared to pay well, they will further continue to fill these positions.

At present I am working in Northern Iraq on a de-mining project, and have come across a few issues which may be worth noting for anyone interested in working in the hostile environment as a medic.

Firstly, on a positive note we carry comprehensive medical kits giving us the capability to deal with most situations; from blast injuries, gun shots through to anaphylactic reactions to name a few. We also carry around 20 medications; mostly analgesics (IV / IM), anti-inflammatories, anti-histamines, Broncho dilators and TXA for severe haemorrhages. We are in a fortunate position wherein we operate from a US military base and are on a state department contract giving us access to the medical facilities, plus the ‘dust-off’ should we need to Casevac a time critical patient.  Luckily in the 6 months I have been on the project I have only had to deal with one serious blast injury after a local shepherd stood on a land mine.

Although obviously not a good experience for the injured party, from my perspective it was an invaluable experience. Firstly, it gave me some ‘hands on’, as ‘skill fade’ is a very real issue on jobs like this, and secondly it gave me chance to work with and assess the skill level of the local ambulance crews whom we work with on the ground. I noted the local hospital we took the patient to was, in my humble opinion not fit for purpose, it was awash with doctors but nobody was prepared to take charge of the patient and the facilities available were, to say the least, minimal.

There were a few alarming points brought screaming to my attention as I watched the ambulance crew work. These crews are recruited from the local population and are quite obviously not to the same standard as any ex-pat medic, add to that the fact they have incredibly limited equipment and a culture which gets very emotional and animated upon seeing their ‘brethren’ injured. Once we got the patient into the ambulance and the crew saw the level of injuries and a not unnoticeable amount of blood, they fell apart leaving me to work alone. I attributed this to 2 things; a lack of training and a lack of frontline real-life experience. Ultimately the patient survived and walked away after a few days in hospital with the loss of an eye but otherwise intact. It may seem to some that losing an eye is quite dramatic and life changing but bearing in mind mechanism of injury I think he was very lucky indeed.

On a more positive note I was taught to use every incident as a learning experience, and I honestly think we all learned some valuable lessons that day; myself, the local ambulance crew, my ex-pat PSD team and the other ex-pat medics I spoke to afterwards all took something positive away from the incident.

Having spoken to the other medics on this contract, I have come up with a couple of pieces of advice I think are quite pertinent to anyone considering a career as a ‘Tier 2’

Firstly, speak to as many companies as possible and find out what each requires before spending hard-earned cash on courses.  There are qualifications which are essential obviously; Advanced trauma (PHTLS, ALS, ATT to name a few) and ACLS.  Secondly think about CPD and planning time on leave to go away and gain some clinical experience.

Secondly, a massive issue with these positions is ‘skill fade’ -you may do three or four eight-week rotations and treat nothing more serious than a cold. A lot of the guys will either do ‘bank’ work for an ambulance service, volunteer for St. John’s ambulance or pay to go abroad to places like South Africa to get some real time hands on and stay sharp.

There is still a good living to be made working in a hostile environment as a ‘Tier 2 medic’ but you must be prepared to spend time doing your research and getting yourself properly qualified. With all companies nowadays being put under more and more pressure to save money at every turn, some out there are offering peanuts, but if you are prepared to stand your ground and set yourself a limit as to what you will work for then there are positions out there, the days of the ‘pop star’ wages are over but it is possible to earn a good living.

We all must start somewhere, and I understand that having a job is better than sitting at home not earning, we all have responsibilities at home, but good medics are at a premium and the work is out there. The problems start to arise when overqualified medics take positions which pay well under the industry average as a means of paying the bills, the company soon cottons on to this and realise they can drop the daily rate to boost their profit margins knowing that ‘we all must work’. This has happened in the security contracting world and is starting to rear its ugly head in the medical industry too unfortunately.

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A Medics Experience on the ground in Iraq in 2018