Dutch Queen's Day

Kandahar, Afghanistan

We've been waiting for this for weeks - Dutch Queen's Day, that is.  April 30th, yesterday.  There aren't too many milestones or events to put on your calendar, if you even kept a calendar, that is.  This one has been advertised all over KAF (Kandahar Air Force Base) for weeks.

My understanding is that the Dutch celebrate the birthday of their queen on this day.  I should have asked more questions - does the date change with the queen?  Or is it like Victoria's Day in Canada, same day every year regardless?  The Dutch still have a monarchy, so I presume it's the former.

The color orange is everywhere, the royal colors apparently.  I celebrated by getting an orange colored mango slushy.  Went well with my Dutch Stroopwafel ("Strope-vhaffel" - caramel filled waffle-like cookie).  Yes, this is a war zone.  I have to keep reminding myself.

Things that make you go "hmmm," part 1

Kandahar, Afghanistan


Me & Big Ben outside of Heroes, the British Recreation Center

My friends and I remark that this place is weird, and there are always weird sites, odd situations, things that make you scratch your chin and say to yourself, "hmmm..."

The Kandahar Hotel is one of those chin-scratchers.  It lies right behind the Cambridge (i.e. British - great curry) dining facility, and upon exiting Cambridge one always gets a glimpse of its big blue sign offering you a night away from your barracks or tent.  Why would someone want to spend good money to spend the night in a Conex box?  Hmmm.  The supposition is that this facility is used for, um, friendly relations.  That kind of thing is strictly prohibited here, at least it is for US forces.  I presume the same is true for the other NATO forces as well.

One can only imagine that attraction to the opposite gender grows exponentially with each passing day, month, or quarter here in Kandahar, or wherever you have hoards of young men and women away from their significant others, happy hours, or as the cartoonist Gary Larson would put it, places where the human courting/mating ritual is being performed (nightclubs, bars, Christmas parties, and so on).  I am just the scribe here by the way, commenting on what I think might be going on out there - no personal experience!

There is a funny Doonesbury cartoon which addresses this issue of attraction while on deployment - I found it hanging in one of our admin offices.  I'll insert below.

One of our Canadian colleagues told us that the last time he was deployed here, about a year ago, there was a small facility adjacent to the hospital staffed by Russian women who would give legitimate massages for a small fee.  It is now defunct, but I have noticed that the salon that cuts hair is filled with women named Svyetlana and other Russian-sounding names, and they are heavily accented.  I have to wonder if, once the massage parlor was shut down, they all defected...down the street to the salon.   And they don't give great haircuts either.  Hmmm.

I passed by the reception area for the Kandahar Hotel on my way home from the bazaar last Saturday.  My curiosity got the better of me.  The prices I had heard that they charge were true:  $180 for a single, $250 for a double, and $25 per night extra for cable.  Happy to note that the bomb shelter out in front was gratis.  The NATO barracks seem just fine to me.

Camp Hero

Kandahar, Afghanistan

As I write this the Beatles' "All You Need is Love" is playing in my earbuds.  Afghanistan needs a lot more than just love, no question.

Yesterday I had an opportunity to escape the first "wire" to see the Kandahar Regional Military Hospital, which we call "Camp Hero."  I was a strap-hanger as one of the surgeons had an actual mission helping out one of the local Afghani surgeons with a perplexing case.  We have also "adopted" a young 8 year old burned in a gasoline fire a while ago, and we visit him every time someone goes to Camp Hero.  My mission was to see their ICU and ward, as we transfer locals there after their acute issues are taken care of at our hospital.  I have heard some horror stories about the place - flies buzzing into tracheotomy tubes that we had surgically placed - that kind of thing.  I had to see if it was true, and whether we should be nursing our patients closer to health before sending them to the local docs.

Sign on the bathroom door at Camp Hero: Translates to "Don't Wipe With Sticks or Rocks.  Use Toilet Paper."


Camp Hero was built about 2 years ago by the US.  It's a humble place, but pretty serviceable by Third World standards.  The humility of the physical plant is not the rate limiting step in health care, of course.  We prove that daily in our shack of a hospital here in Kandahar Air Field (KAF) - it's the people that matter, and we happen to have some of the best.  The Afghans are seriously limited in this department.  To become a doctor in Afghanistan one must attend school for four years, and then enter an apprenticeship which very roughly approximates our residency programs.  The Taliban didn't help matters in recent years: As Greg Mortensen pointed out in Three Cups of Tea, the large medical school in Kabul where most are trained was prohibited from showing photos or actual cadavers during anatomy class in medical school - too scandalous apparently.  Hard to know how to heal someone if you don't even know the body parts.  It is fair to say that these doctors, few in number, would be more akin to physician or surgical assistants in our country.  Nothing wrong with PA's, and they do need lots of them.  But they also need trauma surgeons, internists, burn specialists, and more, to get through this war and beyond.

We met up with some US Air Force health care providers who passed along some of their frustrations.  I respect these guys immensely.  They spend the better part of a calendar year attached to this hospital, trying to get the Afghanis to become self-sufficient.  These guys have few opportunities to share a joke or conversation with their peers.  The work can sometimes be thankless.  One of the biggest challenges they face is to give enough assistance (supplies, specialists, medevacs) to help out those truly in need, while at the same time holding back assistance when that may be the best strategy to get the locals to learn how to develop their skills, their supply lines, and so on.  Too many handouts creates a welfare-like system which will never allow them to become self-sufficient.

In spite of these limitations, the doctors and nurses at Camp Hero are making a difference.  We realized this a few weeks back when, after a bomb blast in downtown Kandahar which wounded and killed dozens, we only received a small handful of casualties at ROLE-3.  The rest went to Hero.  Their spartan ICU was full of sick folks.  This doesn't mean the outcomes were all good - I am sure they weren't - but the willingness to take on such a large group of wounded spoke volumes.

Just getting to Camp Hero was eye opening.  First of all, my impression of living on KAF is that we have a huge buffer between us and the rest of humanity out here.  Not true.  A few minutes outside the Entry Control Point (ECP - imagine towers with guys carrying big weapons, huge NJ barriers, lots of concertina wire and you'd be close) we saw huge bombed out "projects" surrounded by litter and mudhuts.   Our interpreter, who grew up mere minutes away and now lives somewhere near DC after he escaped the Soviets as a boy, explained that these were the Soviet barracks which were abandoned, then taken over by the Taliban.  We dropped some 500 pounders onto the roofs, but there are still enough livable apartments for perhaps hundreds of families.  We toured the area in our Land Rover, got out, and were surrounded by dirty little kids, all cute and wanting to 'high five' us.  They knew enough English to ask for a dollar.  The area was filthy, filled with water melon rinds, American food and candy trash, and other 'occupier detritus.' The kids, many barefooted, could care less as they tromped through it.  We saw their new school, all new bricks and paint, contrasting the rubble-filled projects a few blocks away.  Who were these people and how did they get inside the outer wire?

We passed markets manned by kids - where were the adults? - and a field filled with old Soviet tanks and trucks.  Our interpreter told us that there were mines inside that weird used car lot filled with gun muzzles and treaded vehicles.

The half-day I spent outside the inner wire expanded my world.  I returned to KAF, noticing no children trying to 'fist punch' me, no detritus, no 'used tank lot,' only camouflaged NATO members walking to dining facilities filled with food flown in from thousands of miles away.  I saw our humble woodshed of a hospital filled with educated doctors, nurses and corpsmen and realized it was a lot less impressive from the outside than Camp Hero.

Horse Latitudes

Kandahar, Afghanistan

Contrary to what you may imagine, there are periods of down time here in this war zone.  We have had one of these periods this last week.

I think of these periods as the horse latitudes.   The horse latitudes is a nautical term describing the part of the ocean in which sailable wind is absent - in fact, there is absolutely no wind at all.  I spent several days in the horse latitudes when I sailed from Hawaii to California as a 15-year-old, on a 30-foot boat.  It is spooky and disquieting. If you were on a Spanish galleon you might be at sea for days, perhaps weeks, without wind, waiting for the next gust, gale, or squall.  The unusual name comes from the fact that the Spanish sailors would jettison their horses overboard in these seas, because of water shortages.  Sick thought.

The trauma bay, awaiting a mass casualty

Our horse latitudes period was bookended by two mass casualties - the first being the V-22 Osprey crash, which I have described.  The second was two nights ago when a bomb went off outside the governor's mansion in Kandahar City.  Four died and many were wounded (again, this is in open press).  We received a handful of contractors, whose nationalities were ambiguous when they first arrived.  This created a bit of comedy in the trauma bay the other night when one of our surgeons was placing a central venous catheter into one of our patients, who happened to be enormous.  Clearly he was not Spanish-speaking (South African as it turned out), but the surgeon kept offering quite loudly "Poquito dolor!  Poquito dolor!," which means "This is going to hurt a little" - in Spanish.  Hey, you do what you must.

We hear rumors of what is going on outside the wire.  Mostly these are news reports that someone has happened to read online.  Even though most of us have Secret clearances, only rarely does someone throw us a nugget of information about what we might be seeing as the summer goes on.  We treat what comes through the trauma bay doors, that's all.  But the latest rumor is that President Karzai is trying to squelch the upcoming Kandahar offensive.  Some wonder if the recent quietude is somehow related to the rumors.  I doubt it.

Mass casualty night, around midnight, in the ICU

Between our mass casualties it has been calm and quiet.  But you just never know around here.  Generally you don't get a breeze, you get a squall.  "Alpha's" tend to come in groups, for example, when an IED blows up under an MRAP.  We have all had guilt feelings now and again: we don't truly want to be busy - that means our men and women are being hurt, come in broken, and sometimes die.  We clearly do not want that.  At the same time, we like to practice our craft, and being idle tends to work against the psyche.  It's a pickle.

Today, during an idle moment, I walked into the ICU and found one of our surgeons helping a young girl  "stay between the lines" as he helped her color some Disney scene.  This little 8 year old had been hit by a stray bullet and is now paralyzed below the waist.  We have all taken turns nursing her back to health - some say we have "adopted" her.  But this scene was different.  It was precious, and I don't often use that word.

Creepy-Crawlies

Kandahar, Afghanistan

Warning: If you are eating or about to eat, wave off on this post.

This morning as I arrived at the ICU I was greeted with the unsavory revelation that our Afghani two year old had worms.  Not too startling, except for the fact that it came out of his chest tube.  I know this to be true because in our digital age one can see the evidence in a photo, which a nurse gleefully provided.  Gross.  It was in in a toomie - a large syringe that some had used to suck it right up.

The two year old had come to us from some local forward operating base with known effusions, i.e. fluid, in his chest cavity between the lung and chest wall.  It was nearly coffee colored.  We figured it was most likely tuberculosis, although we had a few other theories.  Round worms didn't make our top ten list.

Prior to rounds, one of our infectious disease colleagues brought over his collection of worms that had come from various orifices of patients over the past few months.  I had seen one photo of a young child who was intubated - i.e. had a breathing tube down her trachea - and in whom a large white round worm was found crawling out her right nostril.  That sucker was included in this morning's show-and-tell.  I hadn't eaten breakfast up to that point, fortunately.

We have other interesting specimens crawling around here in Kandahar.  Apparently it is locust season as now I see them all over the place.  This place conjures up the Old Testament in more ways than one.  I had to escort a juicy locust out of the ICU a few days ago.  He wasn't so bad after all, probably fairly clean, which is more than you can say about the fly tape that hangs from the ceilings everywhere around here.  Filled with black flies.  They are above hospital beds, in front of the OR doors, and most disgustingly, in the Stand Easy where we eat food when on call.  Gross.

My friend Joe revealed to me that he was really tired today because he had call last night.  Lots of cases? I asked.  Not really, he said.  In the tent where the on-call guys sleep the amorous (or just plain loud) rats that were bouncing on the tent ceiling kept him awake all night.  Gross.

Mass Casualty

Kandahar, Afghanistan


One of the ROLE 3 Operating Rooms

"Mass Casualty," or "MASCAL" in our lexicon, is a term most of us would rather not hear.  Something truly bad has happened, to a lot of people.  Our trauma bays fill up all at once and a mass page goes out to all hands involved in handling trauma.  This was what we were supposed to be training for in Fort Lewis, Washington during the month leading up our arrival in Kandahar.

A true MASCAL can be gruesome in many ways.  There will undoubtedly be casualties who are dead on arrival, likely several mangled or severely wounded persons, and a triage bay will need to be set up to prioritize care.  We get the word triage from the French verb trier, meaning to sort.  A sad reality of a true MASCAL is that some casualties that arrive alive will be quickly sorted into the expectant category, meaning that they will be expected to die.  These patients are given medications to make them comfortable - morphine for example - but generally they will not be placed in one of the other categories once committed to this one. The other categories are delayed (care can be delayed), immediate (life, limb or eyesight is at risk), and minor.  Obviously, patients can be upgraded or downgraded as the MASCAL plays out.  Traditionally the unit dentist or oral surgeon is the Triage Officer, the person who has to play God on this bloody stage.  I believe I may be tasked to be the next Triage Officer when we move into the new hospital.  I do not look forward to this task, however necessary it may be.

Yesterday at 1:30 am I got the mass page, the one everyone else got too.  "12 casualties inbound.  Plane crash.  Report to the trauma bay."  It didn't explicitly say "MASCAL" but you got the message.  This was the real deal.  My roommate and I stumbled quickly into the inky black night.  It was surrealistically quiet as we rushed toward the ROLE 3.  Helicopters could be heard spanking the air in the distance.

I arrived to see the beehive of activity in the trauma bay.  The staff were remarkably quiet and workmanlike.  I was happy to see that.   There were no truly mangled bodies or people "actively trying to die," as we say.  Four had already been pronounced dead on arrival.

This is in the newspapers by the way, I am not divulging state secrets.  A V-22 Osprey had crashed for reasons as yet unclear.  You may have heard of the Osprey:  it is a twin rotor, half-plane/half-helicopter which rotates its rotors forward like a plane once it is airborne.  It looks like something out of Avatar.  I was actually surprised to see 5 of them flying in formation a few days ago here on post.  The last I had heard of the Osprey, Congress was thinking of canceling the program because of its terrible track record during the operational testing phase.  A few years back 19 Marines were killed in an Osprey crash.  There were numerous other close calls and crashes that I recall reading about.  No doubt this latest accident will call the platform into question again.

The casualties were prioritized but there was no need for a Triage Officer.  Patients were prioritized based on their clinical picture and what their CT scans looked like.  Excellent care was rendered.  We busted our asses for the next 15 or so hours, and the medevac assets were mobilized.  The most severely wounded should be at a higher echelon of care as I write this.  I made it back home to my cave yesterday afternoon and passed out.

Kandahar Post Office.  Flag at half mast, again.

Diversions, With a Twist

Kandahar, Afghanistan

The ROLE-3 Hockey Team

One of the biggest challenges for the downrange crew is keeping oneself occupied between the incoming traumas, call days, and various other work-related duties.  One really needs a mental or physical diversion to stay sane out here.  And you have to be creative.  It's not as though there is an abundance of options in which to occupy one's free time. Yes, it is nice to have time to read a book, but human interaction is a key ingredient for a successful diversion.  Books don't always cut it.

I joined the Morale, Welfare, and Recreation (MWR) committee.  Our mission is to come up with interesting ways to keep folks entertained, keep their minds off of work and the things we experience there.  At our MWR meeting we found that we have many restrictions in what we can do.  Can't collect dues for some arcane reason, for example.  It's hard to have a pizza party for 100 people without a budget.  Every distinct unit, like our medical detachment, used to be able to have one BBQ every month, with food, drinks and charcoal provided.  Apparently we were all having too much fun as now we can only have one every six months.  We'll have our BBQ right before this deployment is done, in August.

The MWR folks have come up with some fairly simple diversions.  Stacy, one of our trauma team nurses has organized team hockey, cricket with the Aussies, and ultimate frisbee on the dusty boardwalk pitch.  We played hockey for the first time yesterday - brutal.  No one had to go to the ER but blood did flow.  It was fun.  Great relief for all the pent up stress.

Cervezas at Sunset

I organized an event called "Cervezas at Sunset" - not real beer of course (more Cheerio flavored NA beer).  We meet on Friday evenings and try not to talk about work - mostly successful.  Our inaugural event was last Friday.

A small handful of us run together on Sunday mornings.  Last Sunday we circumnavigated the runway - 9 miles and change.  When we reached the northernmost side of the runway a UAV (unmanned aerial vehicle) flew 100 feet overhead, on its landing approach.

Another group of us are doing an intense work-out program called Crossfit.  Last night, in the middle of our insanely difficult workout we were mercifully interrupted by an incoming rocket, announced by what sounds like a Sci-Fi movie siren.  We hit the deck for 2 minutes, then took shelter in a bunker close by.  Before our workout was done we were hitting the deck and bunker again - our second of the night.  Thanks Taliban!

This morning I ran by myself to the southernmost tip of the runway.  As I approached my turnaround point two Marine Corps Harriet jets zorched a couple of hundred feet overhead.  Yes, we have diversions here, but everything is slightly off-axis and weird.

V-Fib Arrest

Kandahar, Afghanistan


Part of the ICU Staff here at ROLE-3 - Good Friday

                                                                                                           We do other things at our hospital besides trauma.  That's a good thing for all parties.

Two days ago, during a relatively quiet morning, one of our ISAF (International Security Assistance Force) allies rolled into the trauma bay, pale and death-like, with a breathing tube in his mouth and a medic forcing air into his lungs with a bag-valve mask.  He was witnessed to have passed out, CPR was begun, and a defibrillator was hooked up - this all at his barracks, thanks to some quick-witted mates of his.  He was in ventricular fibrillation, "V-fib" in medical parlance, which means his heart was quivering as opposed to pumping blood.  Seconds are precious in this situation - you need to pump the heart using chest compressions, then shock the heart out of V-fib as soon as it is seen on the defibrillator monitor.  A brain deprived of oxygenated blood produces an "anoxic" injury which can lead to brain death, vegetative states, or other unpleasant outcomes.  We think he was lucky as chest compressions were begun immediately and he was shocked within a few short minutes.

We attacked the patient with urgency.  Central lines and arterial lines were placed within minutes while we had a runner get the necessary medications.  His ECG showed what we anticipated - a myocardial infarction - a "heart attack."  Within a few minutes we had fibrinolytic drugs coursing through his system - what we call "clot busters."  His blood pressure returned to a more normal level but we kept him on the breathing machine as we began cooling his body, as is indicated in these situations.  Patients tend to have better neurologic outcomes if you cool them to hypothermic levels for at least 24 hours.

A medical save, as opposed to a trauma save.  It was very satisfying to be a part of this one.  Our patient was flown by our ISAF colleagues to a higher echelon of care the next morning.  It would be nice to run into him one day.

Suffer the Children

Kandahar, Afghanistan

Eastern Orthodox Chapel in the Romanian Camp

I did not expect to see 3 children in the ICU this morning when I arrived.  I soon learned there had been four.  One had passed away shortly after arriving.  He had likely been caught in the crossfire somewhere out there beyond "the wire."  I am not even sure where he came from.

There is an alarming number of children who are wounded or killed whom we see, and countless others whom we don't.  This isn't news.  Children have been the innocent bystanders in this country for decades, since the Soviet invasion.  The emphasis here is on innocent.

The other three children, all young boys, were hurt or maimed while goat herding.  An IED went off, same old story.  Of course it could have been a mine from the Soviet times too, who knows?  It doesn't matter to the young boy who now only has one intact limb, and if lucky, one eye.  We do our best with these young patients, but sometimes our best isn't good enough.

The 'wire' is out there somewhere, but this isn't it


I had just finished reading the magnificent book Three Cups of Tea last night, which is the true story of Greg Mortensen and his efforts to build schools for children in Pakistan and Afghanistan.   The subtitle of his book is One Man's Mission to Promote Peace...One School at a Time.  Mortensen and his co-author told the painful truth of how much the children in this region have suffered, from the Soviet times, the Taliban scourge, and now the post-9/11 reality.  This was heavy on my mind when I walked in this morning.

The base's mosque, which I am sure, pre-dates our arrival

When I sat down to tell the young amputee's father that his son's life was forever altered - as if that weren't already obvious - the bearded, weathered-faced man told me that as long as he and his wife lived, they would care for the boy.  He thanked us profusely for our assistance.  I had learned earlier he was the one who carried his near-dead son's body to one of the FOBs in southern Afghanistan.  He was happy now that his son's broken body was at least alive.