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Part 1 of Meta: John Watson's military service
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Published:
2012-01-13
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2012-01-13
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Dr John Watson, or, The strange case of the Army doctor's worn-out boots

Summary:

Meta: a detailed discussion of the various implicit and explicit references to John Watson's military service in BBC Sherlock.

Chapter 1: The RAMC mug

Notes:

(See the end of the chapter for notes.)

Chapter Text

Strictly speaking, the first reference to John’s military career is the dream sequence, but I’m going to set that aside for now because it’s hard to discuss without laying some groundwork, and the next reference is actually a good place to start doing that. So we’ll skip to the RAMC mug. I’m going to start with the basics – what the RAMC is, how it acquires medical personnel, and what's actually meant by 'medical personnel'.

The Royal Army Medical Corps is a distinct branch of the British army, responsible for providing specialist medical personnel and their services to the rest of the army, and in some situations to local populations in Afghanistan. Most RAMC personnel function in primarily RAMC-run settings like hospitals and clinics, and a smaller proportion in settings run by the army or local government. The rest of the medical care provided within the army and to the local populations the army is responsible for comes from non-RAMC medical personnel - I'll refer to them as regimental medical personnel.

There are two distinct classes of medical personnel relevant to this discussion:

Medical officers – these are RAMC personnel who have a medical or a higher nursing degree, and who function as doctors, senior nurses, or senior medical administrators.

Medics – these can be RAMC or regimental personnel, with or without a nursing degree or other qualification. Medics can function solely as medical personnel, or almost solely as combat personnel, or as anything in between those two extremes. A corporal with a nursing degree, who spends her days at a huge military hospital assisting a neurosurgeon in the operating room is considered a medic. A corporal with a nursing degree, who spends her days at a district center clinic dispensing care to women and children is considered a medic. A corporal without a nursing degree but with extensive training in emergency medicine, who spends her days at a forward operating base hopefully not being told to grab her gear and jump on the chopper because a section is stuck in a ditch under fire and one of them has been hit badly enough that he needs better help fast is considered a medic. A corporal without a nursing degree and with some very quick and dirty training in field first aid and a wash bag’s worth of gear over and above the regular first aid supplies for an infantryman, who spends her days making sorties against known Taliban positions, and who just did a very credible job of clamping an artery on a guy in a ditch under fire, is considered a medic*.

Okay. Now let’s talk a bit about how the British RAMC acquires its doctors, versus the American AMEDD. Remember, a British medical degree is an undergraduate degree: you go to medical school straight from the equivalent of high school. An American medical degree is a post-graduate degree: you finish four years of college before you go to medical school. .

Typically, an AMEDD medical officer is someone who joined the army before their last year of undergraduate education. Provided they are accepted to one of the medical schools the army has approved, the army will subsidize or completely fund their medical degree; in return, the officer will serve some number of years active duty and some additional reserve duty. The duration of service depends on the degree of support given. An RAMC medical officer, however, typically joins the army after completing their medical degree and at least a year or two’s additional medical training. A medical officer typically signs the same three to five year initial contract as any other kind of officer.

The differences in the two models have some interesting implications for the kind of people who become medical officers. A significant portion of the students I work with are AMEDD cadets. They have been, without exception, non-white, first generation Americans, from families who weren’t able to fund a medical degree by other means. With only one exception, they did not intend to stay in the army past their contractual obligation. The officer retention rate for the AMEDD is about five times higher than for other branches, but the RAMC officer retention rate is almost fifty times higher than the other branches because there’s very little reason to join the RAMC unless you specifically want to practice medicine in the army.

There’s also a difference in how the two bodies use medical officers. Because the AMEDD is paying for most of the medical degrees, it tends to confine medical officers to roles where their medical degree is directly applicable, so they’re more typically functioning as doctors. The RAMC is effectively getting its medical degrees for free, so its medical officers tend to sprawl into the same mix of medical and administrative roles that doctors in the civilian healthcare industry do.

And there's some difference between the RAMC and the AMEDD with respect to medics. An AMEDD medic is much, much more typically the corporal with the nursing degree and the job at a hospital, and relatively few AMEDD medics get close to the fighting. Those roles are filled by regimental medics. RAMC medics can be anything from the hospital nurse to the corporal grabbing her pack to go help the guy in the ditch.

But, at this point, the obvious interpretation is that is John finished his medical degree and a year or two of additional training, and then joined the RAMC as a medical officer.

 

Notes:

*Actually she’s considered a man, because women are not put in positions where there is an expectation of close, sustained contact with the enemy.

Chapter 2 will backtrack to deal with the issue of John’s dream sequence, aka “What’s a nice medical officer like you doing in a combat sortie like this?”

Chapter 2: John's dream sequence

Chapter Text

In Chapter 1, I talked about the difference between a medical officer and a medic in terms of training and the amount of time they spend actually dispensing medical care. The take-home message was: medical officers belong to the RAMC, have medical or nursing degrees, and spend their time either practicing medicine or managing people who practice medicine. Medics may or may not belong to the RAMC, and their role can be anything from solely medical to almost solely combat. Medics with solely or primarily medical roles may be RAMC or regimental medics, but the more combat-flavored medics are always regimental medics. The RAMC has obligations under the 'protected medical personnel' provisions of the Geneva conventions that mean RAMC personnel cannot have solely, primarily, or even substantially combat oriented functions. We know John is an MD, and he’s got an RAMC mug, so the obvious conclusion at the end of Chapter 1 was that he had finished his medical degree and a year or two of additional training, and then joined the RAMC as a medical officer.

However, I did make a point of setting aside the dream sequence for that discussion. Now, we’re going to backtrack and tackle that. I will try to do this as clearly, fairly, and calmly as I can, but you have to realize, the first ten seconds of BBC Sherlock made me scream with delight, because of the implications of this footage for the character of John Watson.

We’re going to talk about risk exposure and how it relates to medical personnel. I’m going to divide the risk exposure into two types - let’s use the terms ‘chronic’ and ‘acute’, since we’re talking medicine, and I’m going to relate those two kinds of risk exposure to the two different classes of medical personnel that we’re interested in, medical officers and medics.

Chronic risk exposure – I’m using this to mean being somewhere there is a constant significant chance of close, sustained fighting breaking out.
Acute risk exposure – I’m using this to mean being somewhere there is little to no chance of sustained fighting, but there is a significant chance of sporadic events like IEDs, car bombs, etc.

As far as is faintly possible given the nature of the conflict in Afghanistan, medical officers do not have chronic risk exposure. They do not go on combat sorties or on security patrols, they do not frequent isolated fire stations or forward bases in hotly contested areas. They might make visits to operating bases or district centers that are at some risk of attack, but that would be the exception rather the rule, and at the first sign of trouble they'll be moved out of possible harm's way. So, medical officers generally only have acute risk exposure: the possibility of something like a car bomb attack at an otherwise reasonably secure base, or of an RPG or IED attack while travelling between bases.

Medics, because they cover the whole range of roles from ‘practically a medical officer’ to ‘infantryman who can tie a proper tourniquet’, can have wildly different chronic and acute risk exposure depending on their particular role.
 
Okay, now let’s talk specifically about the very first reference to John’s military career, his dream. This footage comes from the Ben Anderson documentary “Inside Afghanistan”. Personally, I sort of use the entire documentary as extra-canonical material, but for other people’s use I’m confining myself to only the frames we see in the episode. What are we looking at?

We’re clearly not in a city or town or on a military base of any kind
We could, conceivably, be near a road but there’s no evidence of vehicles
There are British and Afghan infantrymen (you can tell the British by their pale brushstroke style camouflage, and the Afghans by the mix of dark brushstroke camouflage and civilian clothing)
There’s a lot of small arms fire, both from behind the cover of a low wall and on open ground
There’s firing an RPG on open ground
There’s an aerial bomb strike in the near distance
There’s a soldier kicking a door or gate in

What are the circumstances under which an RAMC medical officer could see this firsthand? I suppose if I really stretch the limits of reality, I could come up with something like “he was travelling between bases in a convoy that was attacked by the Taliban”. This doesn’t really work, though, because in that situation the convoy commander would be interested in getting the hell out of there, not in having everyone including the flipping medical officer he’s transporting pile out of the vehicles and start a knockdown drag-out fight that included advancing over open ground under sustained small arms and RPG fire. The idea that he would pursue the attackers to the point where he’s kicking in doors and calling in close quarter airstrikes with a medical officer in tow is just outrageous.

So. The only faintly plausible alternative is that despite his medical degree, John isn’t a medical officer, he’s a medic. The genius of this (I felt, as I screamed and shimmied on the couch) is that it makes John’s experience much more analogous to that of ACD canon Watson. Back in 1880, many British army surgeons were willing to wade into the thick of battle to tend to the wounded even as the fighting raged around them; nowadays medical officers are kept as far from the action as possible, and that role belongs to the medics.

But John isn't a medic like the corporal in Chapter 1, grabbing her pack and heading for the guys in the ditch – the fact that the guys in the ditch are calling for a medic to be choppered in means they have stopped trying to advance and engage, and are actually looking for a chance to pull back from the rest of the action to avoid putting the chopper crew and medic in the middle of an active firefight. John is the kind of medic who moves with an advancing line of infantrymen across open ground while they exchange sustained small arms and RPG fire with the enemy, and then pursue the enemy to the point of kicking in doors and calling in close quarter air strikes to drive them out of their defensive positions and into an open engagement.

We’ve talked about how medics can have primarily medical or combat roles; RAMC medics are by definition on the medical side of the spectrum, and the regimental medics can be on either side. John is at best at the very rag-end of the RAMC food chain: an RAMC medic who has somehow ended up running with the infantry on combat sorties, and presumably reverts to his medical personnel function when someone needs him. But this is stretching reality really, really a lot, because RAMC personnel cannot have substantially combat oriented roles. John's presence in an infantry advance over open ground under sustained fire is much more consistent with him being a regmental medic, whose primary role is to fight or lead men who fight, but who can provide medical assistance in an emergency, and who for reasons we can conjecture about later drinks his tea out of an RAMC mug.

 

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