wellingtongoose (wellingtongoose) wrote,
wellingtongoose
wellingtongoose

Explaining John Watson's Medical Discharge

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(art credit: punkypeggy)



I explore the reasons why John Watson was discharge from the army. I also explain the discharge process and calculate John Watson’s army pension from his CV.


I have written before that doctors are very valuable to the armed forces – they would not be discharged for a shoulder injury or a psychosomatic limp. Both of these things do not prevent John from being an army GP.


Something more must have happened for an experience doctor like John to be discharged.




A Canon Tie-In


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Thecutteralicia has recently pointed out in ACD!Holmes John Watson states that enteric fever emaciated him and forced him to leave the army.








I was struck down by enteric fever, that curse of our Indian possessions…For months my life was despaired of, and when at last I came to myself and became convalescent, I was so weak and emaciated that a medical board determined that not a day should be lost in sending me back to England







She puts forward the theory that in the modern adaption John Watson was not discharged on account of his shoulder injury but rather a tropical infection that followed.


Whilst this theory agrees with the original ACD canon - it does not seem a likely scenario in the modern era:


As thecutteralicia writes:








However there are still plenty of other infections and diseases our modern soldiers have been suffering from in Afghanistan: MRSA, gastroenteritis, malaria, Q fever, leishmaniasis,


John expected to recover totally without any permanent disability and to return to his duties with nothing more than a nasty scar. However, in the middle of his recovery he contracted an infection. Perhaps it was complicated by another concurrent infection, like malaria or dysentery, but either way John became critically ill and almost died.








I do like this infection theory, its very intriguing. However the main problem I have with this theory is that we are now talking about 2010 and not the 19th century.


Disease can spread like wildfire through military bases - we have many accounts of British troops being decimated in the 19th century due to cholera, plague, dysentery etc. However healthcare and sanitation has vastly improved, so has our understanding of what causes disease.


Food poisoning (gastroenteritis) still happens on a frequent basis everywhere but it is no longer life threatening - antibiotics and fluid replacement are sufficient for severe cases. Besides, food hygiene standards in the military should ensure that outbreaks are isolated, and very uncommon.


There are vaccines, treatment and/or prophylaxis for malaria, leishmaniasis, tetanus, typhoid, hepatitis, cholera etc.


British troops are provided with a very high standard of healthcare that is incomparable to what ACD!Watson would have received. The NHS also contributes some of its best civilian doctors to fill expertise gaps if needs be. There is a huge thriving specialty for Infectious Disease and Tropical Medicine in the UK and plenty of well qualified experts to deal with disease like malaria.


Generally as a population we are in much better health compared to even the comfortably well off Victorian doctor. Therefore John Watson is also much less likely to suffer long last ill effects from the diseases mentioned compared to his Victorian counterpart.



More importantly John would have lived almost exclusively inside military bases. The vast majority of British RAMC doctors are based in Camp Bastion - their patients mostly come to them and not the other way around. For battlefield emergencies there are paramedics.


Although military life may sound harsh - John is not an ordinary soldier - he's an officer. He also spends most of his time in highly sophisticated, well equipped large military bases. He would be able to enjoy creature comforts that are available, including TV, internet, better-than-hospital-canteen food, particularly in Camp Bastion (actual combat officers in more remote military camps would endure a much more basic existence). Even if he wasn't an officer - all military bases have a good standard of sanitation and healthcare. Much, much better than the general population in Afghanistan.


John as any army doctor would not be out mingling with the local populations on a frequent basis. Incidences of tropical disease among British troops in Afghanistan are small and isolated. Tropical disease when faced with good sanitation and correct precautions do not spread. The isolated incidents inevitably come from contact with locals or expeditions to remote regions outside of the main base. John would be doing neither.



Side Note - Meet MRSA


MRSA stands for Methicillin resistant Staph. aureus. Staph. aureus is a bacteria that lives harmoniously on our skin, in our noses, on our eyelids. It will also cause disease - it just depends on the situation.


There is no such thing as good and bad bacteria. It's not like MRSA is sentient, though if it was, it should be suing the British Press for libel.


The media have conducted what amounts to a witch hunt against MRSA. It's nothing more extraordinary than a strain of Staph. aureus that is resistant to one particularly antibiotic, Methicillin - a type of penicillin. It's not going to cause a pandemic, it does kill people but far less people than Influenza. It's just slightly harder to deal with when it causes disease than non-resistant strains.




A Cesspool of Possibilities


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(art credit: sheWolf294)



However, as I said: I still like the theory that John did become critically ill because of how it reflect the canon ACD!Watson’s discharge.


If John were to fall critically ill - I would say it would be due to his bullet wound rather than a mixture of tropical infections.


The shrapnel would have produced an entry wound that would allow all the normally docile bacteria on his skin to enter the bloodstream in huge quantities (and the bullet probably added a few new bacteria of its own).


Several things can happen:



1. Osteomyelitis - infection of the bone. This doesn't have to occur in the shoulder. The surgeons will have a done a thorough washout and paid special attention to making sure the procedure is as a sterile as possible. What they can't control is where the bloodstream seeds the bacteria. He could have osteomyelitis in any bone but it is more common in the long bones of the leg.


Osteomyelitis is treated with months of very potent, very poisonous antibiotics given through a line that goes straight into the heart (which gives you an idea of how serious this is).  John would be unfit for duty for a much longer period if he had side effects from the antibiotics which could easily have given him acute renal failure, temporary deafness to name but a few common effects.


I think John really did have a very painful leg for a very long time. This most likely contributed to his psychosomatic limp in one particularly leg as in times of stress the brain can fall back into a pattern of reliving old wounds. For example: the myriads of patients who state that their leg has hurt on and off for decades after a fall even though physically the leg is fine.


However despite frail health during treatment - most people recover from osteomyelitis or have permanent joint/bone damage. John appears to have recovered fully and as he's not hooked to a dialysis machine, or hard of hearing, I don't think he suffered long term sequelae from the treatment. In fact he does appear to be in robust health.


There is no reason to discharge John from the army during his treatment period. There is every chance and indeed expectation that he should be able to recover as a fit young man with the correct treatment.


ACD!Watson was discharged because enteric fever had bought him to the verge of death and given the state of Victorian medicine it was quite possible he would never recover his health. On this basis the army was right to discharge him.



2. Infective endocarditis: bacteria might also seed to the heart valves.


Staph. aureus (of MRSA fame) is particularly good at completely destroying perfectly healthy heart valves in under a week. John would need major valve replacement surgery and potentially be on warfarin (if he has metallic valves) for life. This alone is good enough reason for him to be referred for assessment to see whether he is fit to carry on active duty in a combat zone in the modern era.



3. Brain Abscess  – a collection of pus inside the brain from infection



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This is thankfully rare but cannot be ruled out. Although the brain has a “filter” in its blood vessels to keep out bacteria – brain infections nevertheless occur from blood-borne bacteria.  Again, our old friend Staph. aureus is often a prime culprit. Brain abscesses can cause functional brain damage but more often they cause seizures. Even after the abscess has been drained and resolved – the damaged brain tissue may still be a focus for seizures and a significant number of patients do go onto the develop epilepsy.


The fact is once John had one seizure from his brain abscess it would be impossible to say whether it would be the last, if or when he will have another one, or if he would eventually go onto develop epilepsy.


Patients with epilepsy (and all other seizure conditions) who have had one or more seizures in the past 10 years are not able to join the army. In terms of medical discharge – a seizure disorder like this may very well have caused John to be discharged due to the implications of having a fit whilst on active duty (even in the relative safety of a military base).


The other thing I want to mention is that we never see John Watson driving (this is because Martin Freeman does not have a license) but being banned from driving by the DVLA due to his seizure(s) could be a fitting in universe explanation.




The Mental Options - PTSD and Depression


I have already dedicated a meta to John's PTSD (or lack of PTSD). From a medical point of view - it is very unlikely that John actually has PTSD.


John, himself and his Post Traumatic Stress Disorder.


As a doctor John would not be fighting on the front lines or out on patrol. He would be working in the hospital back at the military base. They are technically in an active combat zone but would not be in combat. Therefore combat situations are not a routine part of his job. The firefight in which he got shot was most likely the first and the last combat he ever experienced. The most plausible way for John to be injured Taliban insurgents attacked the army base (which they did in 2012 to Camp Bastion) and John was injured in the ensuing fight.


The other reason why I now err more towards a physical explanation for his discharge is that PTSD is very common particularly in combat soldiers on the front line. If everyone with PTSD was discharged the army would have a troop shortage.


The conditions is treatable and most people do make a good recovery given time and appropriate therapy. As I said before discharge is done an individual basis - the severity of the symptoms, coupled by response to therapy, functional status etc are influential in the decision.


A diagnosis of PTSD is not sufficient for automatic medical discharge, even if John had PTSD


Military psychiatrists are probably the best people to deal with PTSD, and therefore it is in the  military's interest's retain these soldiers for treatment rather than hand them over to the civilian NHS as soon as they are diagnosed.


As for depression - again John does not display symptoms consistent with clinical depression at the beginning of the series. His general low mood is much more likely to be due to having to adjust to civilian life.


Depression is common in soldiers (if only because depression is terribly common in the general population). As a GP, a significant proportion of John's job may have been to manage depression in soldiers.


Again, discharge depends on the severity of depression. Mild depression, appropriately treated and controlled does not necessitate a discharge. If John really did have severe clinical depression when he was discharged, the army has a duty to provide him with appropriate rehabilitation and mental health services.


The therapy sessions we have seen are not how the NHS would treat severe depression, nor is it how the army would treat PTSD.


The therapy session looks every much like a civilian counselling session, that John himself has a organised on his own initiative.



The intermittent tremor in his hand is not enough for John to go before the medical board.



Firstly, John is an army GP, he has to be a qualified GP in order to take a locum GP position when he is in civilian world. As a GP an intermittent tremor does not affect John's ability to do his job, practical procedures can be and often are delegated to nurses. John's main job is to interview, diagnose and prescribe medication (which is now done on computers). My GP worked through two broken arms (at the same time) and had no problems - she just got another doctor to sign the prescriptions.



Secondly, Mycroft has proved that John's tremor only occurs when he is relaxed. It goes away when he is stressed. Therefore it would not affect John's work even if he was a surgeon (which he is not). Not matter how many times a doctor has done a procedure there is always an element of underlying stress. Trust me, I know as I have the opposite to problem to John but even so I've yet to be labelled unfit to work as a doctor.



Procedure for Medical Discharge


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Veterans UK has a very good webpage on the process of a military medical discharge.


http://www.veterans-uk.info/medical_discharge_pathway/index.html


Soldiers who have sustained injuries that affect their function and ability to remain on active duty will be referred to a regional occupational health team. Occupational health specialists aim to help patients adapt to their injuries and adapt their jobs to suit their current functional status. For example: during John’s recovery from his soldier wound – he would may be taught how to perform daily tasks one handed such as making tea and dressing (it’s not as easy as it sounds).


For many soldiers, after a period of recovery and amended duties they can return to their normal jobs. Occupational health thought John evidently couldn’t.


The next step is going before a Two Member Medical Board (TMMB). It’s akin to an interview/health check up. The two members are usually military doctors who scrutinize the occupational health reports, medical reports and take into the account the views of the soldier in question. The board issues Joint Medical Employment Standard grade. These grades may qualify the soldier for full active duty or a certain set of amended duties or restrict soldiers to duties outside of active combat zones.


Alternatively, the board may recommend a medical discharge. This is influenced mostly by the nature of the medical condition and occupational health reports.


The medical discharge request then goes through the Army personnel center – and if the recommendation is accepted a date for discharge is set.  It is only after this that the soldier in questions gets to hear about the decision. I imagine that John might have mistakenly thought he would not be discharged and was then faced with the horrifying reality that he would be out of the army in X amount of days.


Once discharge is approved – rehabilitation and support services will engage with the soldier. I have heard mixed views about the effectiveness of these services and I think it depends on the soldier’s personality whether he/she finds them helpful.


John would have access to therapists after his medical discharge but his therapist might not be a military therapist. She certainly doesn’t look or act like any military psychologist I’ve ever met.


As a civilian, John is a supposed to be cared for by the NHS, but unfortunately mental health provision for veterans is not as good as it should be. There are few psychologists who can specialize in therapy for ex-servicemen because as a proportion of the population ex-servicemen are a very small percentage. If John doesn’t want to travel far for expert help, he’s only available option may be the local civilian therapist.




Army Pension



Through the Army pension calculator online: https://www.gov.uk/armed-forces-pension-calculator


With a few estimated dates:


John’s CV faithfully reproduced from screenshot in TBB by Trishkafibble (http://archiveofourown.org/works/503732) it says that John graduated medical school in 2004. This means he would have served in the army for a maximum of 6 years.


According to the calculator his pension would have been:  £11436 lump sum plus £3812/year.



It is quite true that he cannot survive in London on an Army pension though the lump sum would have tide him over until he managed to get the locum’s position.



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Tags: character: john watson, fandom: sherlock bbc, meta: john watson
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