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.

The Letter

10 Aug 2010

Kandahar, Afghanistan

 Another 30 hour call, another foggy-headed post-call day.  So much happens here in one typical day that it seems like several days strung together.  I look at photos from the previous day and realize we are about to break apart.  I notice people taking more photos of people they will likely never see again, giddy situational posing.  Addresses and e-mails are being jotted down.

Twister on the Boardwalk

Yesterday after rounds we trekked to the Dutch café for morning pancakes.  It was a completely spontaneous decision, the kind of thing you might do as a senior in high school on a warm May day.  In a way we are all about to “graduate,” and we won’t be seeing each other much longer.  It really didn’t matter that the café was closed on Monday mornings, it was the thought that mattered.  We settled for ice coffees while sitting on a bench on the Boardwalk.  Strangely, a medium sized dust twister appeared in the middle of the dusty, dry quad.  The moment was right for me to think to myself, There’s no place like home.

Yesterday after morning report we bade farewell first to our Dutch contingent and then to the latest group of Canadians.  Both had been special in my mind.  This group of Dutch folks had been here during the amazing Dutch run at the World’s Cup and had introduced us to orange wigs – heck, orange everything – as well as Dutch Queen’s day, stroopwafels, and other Dutch customs.  It seems the Role 3 is as much Dutch as it is American or Canadian.  This group of Canucks has likewise been special, causing us to develop a Jones for hockey, which we play every Monday, as well as Tim Horton’s doughnuts.  We’ve also quaffed enough NA beer with them to float a small boat.  They are all "graduating early."

The first group of Americans in our “Roto” will leave this coming Monday.  In college, due to an illness that put me out for 6 months as a sophomore, I graduated in December, the rest of my close friends having graduated the previous May.  I felt like a ghost in the ensuing fall semester.  I am wondering now if I will have that ghost-like sensation as, piece by piece, we are dismantled.

A few hours ago someone handed me a photocopy of a letter sent to us by a soldier.  It’s hard for me to read it as it conjures up a confusing gumbo of emotions – sadness and tears, joy, hope, and several more.  I had cared for this particular soldier as I remembered his name and knew the day of his injury from what he revealed in the letter.  I was on call that day, July 4^th.  This is part of what I read today:

My name is AJ and something I had never thought possible happened yesterday.  I was able to personally thank someone who worked on me at Role-3 in KAF.  A Dutch gentleman who was on vacation in D.C. stopped in my room at Walter Reed and told me he was my anesthesiologist.  It felt incredible to thank him and I hope to do the same thing for the rest of you with this letter.

I think you might remember me, if not by my wounds then by the date I was hit.  I was patrolling the Arghardab River Valley when I was hit by an IED on July 4^th, and came in with two other soldiers.  One was KIA… I received a shrapnel wound to my leg and face. 

From the stories I have been told I can do nothing more than marvel at the shear tenacity and skill you all portrayed in not only saving my life, but saving my leg.  I was informed about the marathon surgery and huge amounts of blood I was given and am so thankful to each and every one of you I can’t put it into words.

The best way I can thank you is to tell you I that I was discharged from Walter Reed today and am now an outpatient.  Everything is going great and I am expected to be able to walk and even run in small amounts…

There are many people who helped save my life but all of you at Role-3 played a major role and I am eternally grateful.  I plan on spending the rest of my life like it’s a second chance and I don’t intend on wasting it.  I have a wife and a 13 month old daughter that I am spending time with right now. 

Thank you for the hard work you are doing.  You are making a difference in people’s lives.  Continue saving lives and return home safely.

Now, I have to say that I feel a little guilty publishing this letter.  But I have a feeling that AJ wouldn’t mind if he knew that a fair number of spouses, parents, and siblings of folks who work at Role 3 follow this blog.  They can be proud knowing they might have played a part in saving this young man’s life.  Thank you AJ, for letting us all know.

When I leave, my biggest regret will be in leaving AJ and his peers behind.

"Peace Be With You"

07 Aug 2010

Kandahar, Afghanistan

That key moment in the Catholic mass when the priest passes on Jesus' blessing has always been my favorite.  One shakes the hand of his or her neighbor, wishing them peace.  As a child it was a break from the monotony of the vigils, the prayers, and the Latin, none of which I understood.  As an adult I appreciate the sentiment, and I do understand.

"Peace be with you," urged our Canadian priest.  As the tail of a giant C-17 aircraft rolled from left to right in the windows behind him I thought to myself, This is the strangest place I have ever celebrated mass.

Through those windows, about 100 yards beyond, was the place where I examined the mangled bodies of the six suicide bombers a few days before.  A couple of dozen yards beyond that lies the runway where fighter jets, unmanned aerial vehicles, and Afghan Ariana airways jets take off.

While on call during the 30 hours preceding the mass, I had had in succession three very tragic admissions.  The first was a 24 year old woman who was 12 weeks pregnant.  She had been riding on a motorcycle with her husband and young child, shot from behind.  She was now paralyzed from the waist down, a bullet disrupting her spinal cord.  Her husband had survived but her young child was dead.  The child she carried had now survived the gunshot, the crash from the bike, and now two surgeries.  Peace be with you, baby.  Maybe God has a plan for you.

Early this morning in the trauma bay, not 50 yards from our makeshift chapel, a twelve year old child was brought in from the field, ashen grey.  An ultrasound probe placed on his chest confirmed what we already knew - he was dead on arrival.  Another IED blast victim, may he rest in peace.

Two hours before mass, just down the hall from where mass was being celebrated we admitted a young man from the OR who was dying in front of us.  He had been shot in the abdomen and had been down for awhile.  He was taken directly to the OR where he received a emergency thoracotomy, an aortic clamping, and a laparotomy which showed over 1.5 liters of blood.  Despite heroic efforts by the surgeons, the bleeding could not be stopped.  He was delivered to the ICU on three different vasopressors designed to maintain blood pressure, fluid and blood products running quickly into his veins.  His blood pressure was in the 50s despite all this.  More epinephrine boluses were given but it was clear that our efforts were futile, as blood continued to pour out of his chest tubes and various drains.  As is custom for Muslims, we had him face Mecca and called in an interpreter to read from the Koran.  

I thought of these events as I shook the hands of the small group that had assembled for mass.  Peace be with you, I told them.

Body Parts

05 Aug 2010

Kandahar, Afghanistan

The other day I was observing a splenectomy (removal of the spleen) in the OR.  The patient was a young child who had developed thrombocytopenia - low platelets - and by removing her spleen her platelet levels should begin to rise.  It was satisfying to see an elective procedure that had nothing to do with trauma for a change.  One of the OR techs standing next to me informed me that she had made the necessary arrangements for the soon-to-be-removed spleen.  What do you mean by that?, I inquired.  She explained that it was customary for Afghani Muslims to be buried with all of their parts, so we had to call Mortuary Affairs to come to the hospital to collect any body parts that are removed, whether it be a traumatically amputated limb, or a spleen.  My head began to spin when I tried to envision how this little girl's family would deal with a spleen in an urn or bag when they got back to their mud hut in whatever village they were from.

The girl has done well post-operatively.  No idea where her spleen is at this point.

This morning I was called to do a task that I would be happy to never do again.  The suicide bombers of yesterday were apparently sitting in body bags at Mortuary Affairs.  Someone had to fill out their death certificates.  A British medic drove me over to the refrigerated conex boxes sitting adjacent to the flightline, making small talk about the weather.  He was the one who had to pick up the body parts after their failed attack.  He was clearly disgusted and perhaps a bit traumatized, if I read him correctly.

With the help of another gent, I unzipped the six black bags one by one, biting my lip.  I really didn't want to see what was inside.  There certainly were recognizable human parts, admixed with brown scrub brush and dirt.  There is something obscene about seeing hair, skin, and flesh gathered together in no recognizable pattern.

I had problems filling out the death certificate.  What would I call the cause of death?  Occasionally we who work in the ICU have to be creative when filling out these forms: many of our patients expire with multiple organ systems in failure at the time of death.  But what about when someone blows himself to bits, what then?  I chose sudden cardiac death, which at least on some level seemed to fit.  I learned later that the correct phrase is total body disruption.  Grisly, in a semi-sterile sounding way.

As I walked out of Mortuary Affairs I wondered about their families.  Were they proud of their sons, their brothers?  Was it worth it?  Where do these bodies go from here?, I asked. The International Red Cross mediates the exchange of bodies apparently.  Or what's left of them.

Bombshelter Blues/Bloodbath

04 August 2010

Kandahar, Afghanistan

Heard in the bombshelter yesterday morning: "This makes 51 rocket attacks and two ground attacks!"  There was a tone of excitement in his voice.  He didn't give a time range over which this occurred, but it seems like I've lived through more than 51 of these things.  I am weary of them.  I returned to my book, awaiting instructions from the Great Oz.

I had gotten to the bomb shelter early, having been out on the flightline again, a few yards away.   I had had a few spare hours on my hands before I taking over the ICU for another 24 hour shift.  I was daydreaming about Alexander's initial seige on the Persians a couple millenia ago when the sirens went off.  The cousins of the Persians now attacking us, I thought to myself as I lay on the ground, dust filling my nostrils.  I heard two Shoomp-Shoomps of rockets landing somewhere nearby, and then scurried my ass over to the shelter.

The day had started inauspiciously.  Earlier that morning I had noted that we hadn't had a rocket attack in at least 10 days.  The rumor is that the security forces are finally trying to smoke out the area from which the rockets are launched - brilliant tactic.  Maybe they were finally making a difference, I thought to myself as I headed towards the Kandahar International Airport.  As I finished the last 100 yards of my 30 minute run the sirens had gone off.  I sprinted much faster than I thought I could to the nearest bomb shelter.

The ne'er do wells were out in force yesterday.  Their ground attack was as brazen as it was ludicrous.  From the details that are emerging it seems that at the time of the flightline rocket attack, two of them simultaneously detonated explosives (and themselves) at one of the perimeter gates, paving the way for a tractor which attempted to breech the fence.  Ten other insurgents bum-rushed the gate and were promptly gunned down by a .50 caliber machine gun.  It was a short attack but created the usual mayhem on post.  We were confined to a hardened shelter - the hospital for me.   Great Oz kept barking out non-information updates, most incomprehensible, but we did finally figure that we now could go about our business on base only if dressed in flak and helmets.

I was happy to be on call yesterday.  Going anywhere in flak is so onerous I would rather just stay put.  We had a steady stream of patients throughout the day - only a few injured from the rocket attack, fortunately.  After an eventful night in the ICU which included the small 50% burned child "coding," and being subsequently resuscitated at about 4am.  He had stopped breathing after being overmedicated with narcotics for his burns.   Shortly after wrapping up the code and feeling assured the child was safe, I was paged with word that a patient with traumatic amputations was inbound.

He arrived at 6:15, crazed and yelling that he couldn't breath.  This is odd because if you can yell that you can't breath, you probably don't have an intrinsic lung problem.  It didn't matter, he would soon be sedated and have a breathing tube inserted into his trachea.

He was thrashing around and it was difficult to gain iv access.  I could feel his blood dripping off his macerated right arm onto my shoes.  I looked down, blood was everywhere.  His arm clumsily fell off the gurney by accident, the damaged bones evident by the limp and awkward way it dangled.  I lifted the arm gently back onto the gurney.  More blood.  He was cold, having been in the field a long time and his cold blood was acidic, resulting in problems with coagulation.   Another doc and I attempted to place large bore central lines below his clavicle.  Neither of us were successful.  I finally managed to get one of these lines into his femoral vein, in his groin.  We had been in the trauma bay all of 5 minutes and it looked like a slaughterhouse, blood everywhere.

I spent the next six hours with him, resuscitating him, putting in more lines through which blood, plasma, and platelets could be poured with our Level One, our life-saving blood pump.  We frenetically gave calcium, bicarbonate, vasopressors to increase his blood pressure, warmed saline, and other life-supporting fluids and medications.  We were going backwards, blood dripping onto the diaper-like "chucks" under the patient, and ultimately spilling on the floor.  I eventually made the decision to activate the "walking blood bank" - legions of volunteers of various blood types that could be summoned to donate "whole blood" of the appropriate type which would be pumped into the patient ("whole blood" as opposed to component therapy - packed red blood cells, plasma, and platelets, which occurs 99.9% of the time).  After over 120 units of blood component therapy and over 12 units of fresh whole blood we finally turned the tide, and the parameters of coagulation began to right themselves.  We had transfused many human being's worth of blood to save his life - a veritable bath of blood.

We Don't Need No Stinkin' Patches

02 Aug 2010

Kandahar, Afghanistan

We don't need patches, but we seem to like them.  There has been a proliferation of unit patches representing the various departments and sub-departments, thanks to some creative minds and a willing embroidery shop here on the Boardwalk.

Every patch tells a story.  The one above is the trauma bay patch showing the silhouette of the UH-60 helo that brings us our wounded, and the one in which we on the Enroute Care team fly when picking up casualties.  Their motto is curious: "Actually, We Don't Have Any Days Off."  It's true that the trauma teams never seem to have a day to themselves, which distinguishes them from their nurse counterparts in the ICU or ward who work two days on and two days off.  Apparently this assertion has created a rift in the nursing community - I am finding this out via my roommate, who is a nurse.

To be frank, I preferred their other motto they were considering: "Will Work For Hot Meals."  The story behind this is as follows:  because we tend to spend large tracts of time in the hospital when casualties come in, need to go to the OR, need resuscitation in the ICU, etc, we often would miss dining facility meals and have to eat the meals brought in from these DFACs.  The patients have first dibs on the food, of course, but there was usually plenty of food - hot food - to feed the hospital staff as well.  We would eat these meals when we were in the old ROLE 3 in a place called the "Standeasy."  The Standeasy was a tent that was "tricked out" with a wooden deck, Christmas lights, and an old dimming TV on the inside.  There were several fly strips hanging from the ceiling, filled with decaying black flies.  It was gross and quaint at the same time.  It was comforting because one could sit on a frat-worthy couch and eat some warm food, away from the trauma bay or ICU - you could forget them for 30 minutes or so, which was good for the soul.


One of the trauma team members applying the logo to a helicopter door, which was brought to us as a makeshift litter during one of our mass casualites.

Apparently we ate too much food and some was being wasted.  So instead of titrating the right amount of food through trial and error, the command decided to nix hot food for the staff.  We now eat day or two old sandwiches, cold and very unappetizing.  This has been a nagging sore which hasn't quite healed since the policy was instituted.  In the Navy when deployed, one has few things to look forward to:  mail and hot food comprising most of those things.  When the food gets screwed with, folks get angry, and they have been for awhile.  As one nurse told me recently, "It chaps my hide that I have to serve a hot meal to a Taliban, then go to the break room to get my nasty cold sandwich."  I couldn't disagree with him.  So, "Will Work For Warm Meals" struck the right cord with me, but I think the patch-makers were a bit spooked knowing the command would eventually (quickly probably) find out about the motto.

I designed the ICU patch, "Like a Cobra Bite to the Face."  If you've been following along you may recall that we had a child who was bitten by a viper on the face, a story the ended up on the front page of the NY Times.  The child had initially been billed as a cobra bite, and the legend has endured.  The phrase "like a cobra bite..." has become part of our vernacular here in the ICU.  If you've had a bad day, it's "Like a Cobra Bite to the Face."  OK, we're admittedly a bit stir crazy after 6 months.

My favorite patch is the lime green CCAT Anesthesiologist patch - "Passing Gas in the O.R. or at Altitude."  The CCAT team is the crew that takes our sickest patients from our ICU eventually to Germany.  They are manned primarily by anesthesiologists who typically work in OR's in military hospitals in the states.  They work hard and under challenging conditions, usually with several patients "trying to die," riding in a C-17 which happens to be very crowded and extremely loud.  As far as I know, there has never been a death while on a CCAT mission.  Incredible.  Oh, passing gas refers to the gas of sedation used in the O.R. - we call anesthesiologists "gas passers."  Every subspecialist has his or her own monniker:  ENT docs are "booger pickers."  Orthopedic surgeons are "knuckle draggers."  Internists are "fleas" - the last thing to leave a dying subject.  A stethoscope is a "flea collar."  We're a weird bunch, but keeping things light keeps one's sanity intact.

Chilling on the Flightline

01 Aug 2010

Kandahar, Afghanistan

I am post-call now, 30-odd hours of start-and-stop, hiccup, run-and-go.   I try to recall what happened over the last 30 or so hours - my mind's eye is distorted right now, as if on some of the hypnotic drugs I have prescribed during this time.  And an odd 30 hours they were, but not atypical for what has gone on around here lately.

I began the day sitting on the flightline, watching the to and fro of Davids and Goliaths taking off every five minutes or so.  I am on Enroute Care Call which means I am tied to the hospital, donned in my FRACUs (fire retardant army camouflage uniforms), awaiting a mission to be spun up.  I have the reputation of always getting a mission when I am on call.

I am reading a biography of Alexander, who died not far from here, and who also had an outpost that I can make out in the craggy mountains across the flightline - if you believe that rumor.  I look up from my book and see a true Goliath landing about 200 meters away - a Russian IL-76, which has hunched-up shoulder-like wings which makes it look like a hawk descending on its prey.  It is clearly the loudest plane ever built.  I make a mental note that the Russians might have been landing IL-76s here 30 years ago, for supply runs to their soldiers who were then fighting the mujahedin.  The more things change...


Kandahar Int'l Airport

I see another Goliath, a C-17, flat grey, taking off steeply.  It might be my ticket out of here in a few weeks.  A David takes off - a small unmanned aerial vehicle (UAV), being driven by some guy either here or God knows where, remotely.  I have heard these UAV video game players get hazardous duty pay.  It must be a joke, but one can never be sure what to believe around here.  We see UAVs buzzing around here all the time, like annoying flies.  But I am sure they are invaluable to our protection so we welcome them.  In the next 15 minutes I see pairs of jets taking off and landing - A-10s, F-18s, French Mirages, Belgian F-16s.  Always in pairs, like Noah's Ark.  Where are they going?  There is no air threat here.  Are they dropping bombs on Taliban out there?  I can only speculate.

I take over my ICU watch at noon.  It is moderately busy with several patients coming out of the OR from a recent busy spell we have been having.  I have managed to read through charts of at least 8 patients, listen to lungs, palpate abdomens, and examine wounds when I get the call for an enroute care mission.  I now languidly throw on my flak, get two additional magazines for my M-9, and pick up my bag of tricks - medications, syringes, saline flushes and so on, which may be needed to keep someone alive for 45 minutes or so.  Back to the flightline.

I see a white 747 at the end of this busy runway as I wait for our two helos.  This is the busiest one runway airport in the world if you believe that particular rumor.  I believe it.

I am in the chase helo now for some reason.  I see the actual medical helo, with its red on white cross, out the open window to my left as we travel close to the earth.  To my right I see a herd of camels running somewhere pretty fast.  I curse because I can't get my camera out quickly enough.  We are traveling low because of poor visibility due to a sand-fog that has enveloped us for a couple of days.  I remember something that allegedly came out from the Wikileaks scandal recently - that the Taliban have gotten their hands on surface to air missiles.  I wonder to myself if our traveling at low altitudes puts us at a higher risk for these missiles.  I urge myself to think about camels instead.

We pick up our patient who is remarkably stable for one who has an open abdomen: he took some fragments from an IED in the hip, nicked some of his small bowel and then landed adjacent to his navel, his umbilicus.  The flight home is notable only for the eery sunset through the sand mist sky.

When I arrive back at the ICU I am now four hours behind in my work - getting labs and data from the patients in the ICU.  I had barely gotten to know them before I left on my mission.  While I was gone my colleague, Jon, had to re-intubate a small boy who had been shot through his frontal lobe.  He was back on the breathing machine and Jon and I performed a bronchoscopy, me still sweaty from the hot helo ride back.

I play catch-up all night and manage to hold the fort down until about 7:30 am, thirty minutes before morning report.  Feeling smug that I might have salvaged an otherwise challenging evening, I then get a page that 5 Alphas are inbound, many children.  One of the nurses I had worked closely with all night asked, "Dr. Q, when is this going to end?"  It was a rhetorical question with no good answer.  When we get on that C-17, I thought to myself.