Ramadan Begins

Kandahar, Afghanistan

13 August 2010

The cultural sensitivity pamphlet on the Muslim holiday of Ramadan that was distributed to the command urges us to respect our Muslim guests by abstaining from eating, drinking, smoking, chewing gum, or using any tobacco products in front of them.  We should be mindful that they may be uncharacteristically curt, or appear tired or dehydrated.

Ramadan began three days ago.  The first three days are considered a holiday in which everything is closed, everyone rests during the day, and the local villages appear to be ghost towns.  During Ramadan Muslims are supposed to perform self-reflection and solidify their relationship with God.  Because Ramadan celebrates the month that Muhammed was bequeathed the first books of the Qu'ran, one is encouraged to read the holy book cover to cover.  Most fast from dawn to dusk in order to focus their energy away from worldly needs and toward reflection and prayer.

From previous Ramadans we can extrapolate that there will be fewer gunshot wounds, which requires a sniper or gunman to essentially violate the intention of Ramadan, but there will be the same number of IED blast victims because they have likely been in the ground long before Ramadan started.

                                                              Bochdalek hernia on CT scan

Yesterday while on call the trauma bay was quiet - I can only use the "Q" word in retrospect: one never states that it is quiet in the present tense.  Bad luck, kind of like sticking chopsticks straight up in a bowl of rice while in Asia - you let the evil genies out.  We did have some interesting non-trauma cases.  One case involved that of a contractor with left upper quadrant pain in his abdomen.  Turns out that his intestines had oozed through a congenital defect in his diaphragm, into his thoracic cage - a condition called a Bochdalek hernia, which is relatively rare.  The patient was taken to surgery and had his bowel returned to its rightful place in the peritoneum.

I also had a chance to review some films with our radiologist and his new, "Gucci," 64 slice CT scanner. Using his new toy he reconstructed some films so that one could see three dimensional images to include torturous vessels, broken bones, and even facial features.  Amazing was all I could think to myself.  Here we are in the middle of an unforgiving desert practicing 21st century medicine not far from pious Muslims Ramadan-praying in their mud huts, and herds of camels roaming right just outside the wire.  I could nearly forget that I was in a war zone and imagine I was in an academic hospital in the states, Canada or Europe.

By morning, Friday the 13th, we had come upon day four of Ramadan.   Our quietude was interrupted at 5:45 am with a screaming and hallucinating solder with a traumatic, below the knee amputation.  He had been given the drug ketamine in the field ("Special K").  Ketamine produces a state known as "dissociative anesthesia," which in addition to allowing the patient not experience pain, causes him to go into a sometimes agitated dream-like state.  Our patient was screaming maniacally.  In biblical times he would have been declared possessed by the devil.  "LOOK!  I can still move my good leg!" he shouted, showing us how he could kick his one intact lower limb.  "I can't feel a THING!  Give me some WATER! Some F*KG water!"  Fortunately he came in with a functional iv so we could properly put him out and intubate him, which took all of two minutes.  Off to the OR to complete the amputation the IED had started.

A few hours later we received our first big batch of trauma patients, five in all.  The first was rushed into trauma bay one, reserved for the sickest.  He was ashen and neurologically dim, barely conscious.  He was hemorrhaging from a bullet wound just below the left clavicle.  A thumb or finger placed in the wound staunched the bleeding, but if taken out, a low velocity garden hose stream of bright red effluent bubbled from that hole.  He clearly had severed the subclavian artery.  We worked together to intubate quickly, and place central lines and iv's.   A surgeon on the other side of the gurney placed a chest tube in his left side as I sutured a large bore central line under his good collar bone.  We all "hovered" the patient together to get an x-ray plate underneath him.  I counted several bloody gloves as we hovered him.  After the world's quickest chest x-ray he was rushed to the OR.  I followed, to assist in any way possible.  Within minutes I heard:
"We're losing him!" "He's exanguinating, I can't get control!"  Hands flew, trying to suppress the bleeding, trying to find the uncooperative severed artery.  His chest was cracked, emergency thoracotomy style.  "Get me the f*kg bone saw, now!"  "More laps!"  His sternum was brutally sawed open.  One surgeon managed to get his hand on the subclavian artery and pinch it against the chest wall.  Another bone saw cut the clavicle and first rib in two.  A clamp was placed on the culprit vessel and after about 45 minutes the bleeding was controlled.  The walking blood bank was again activated - how many times is that this month?   The patient is probably still in surgery but I am confident he will do well ultimately.

As I sit and write this, post-call, my pager has gone off four times, announcing at least five more casualties inbound.

So much for Ramadan.