Memorial Day at the Flightline

Kandahar, Afghanistan

This will likely be my most memorable Memorial Day.  There are no red and white checkered table cloths, no "it must be summer!" smell of charcoal burning, no bratwurst, hamburgers, or mom's German potato salad.  I am with my peers this morning, we are raising American flags one after the next.  Fifty today, many times more for July 4th.

Clip, clip, salute, hoist-hoist, lower, drop salute, repeat.

This tradition was started here last September 11th.  We take donations for American flags that are raised up the flag pole adjacent to the flightline.  It is more than a novelty to own an American flag that was flown in a war zone like Kandahar.  It reminds us of our brothers and sisters that have been here before us, and the ones who died here.  It is sobering.

We were pretty quiet as we raised and lowered the flags.  Every so often a jet would take off or fly by at low altitudes.  I could tell the jets were French Mirages.  I can tell now by their sound alone - I've been here long enough.  There was a huge New Jersey-like barrier between us and the flightline, but the flags were raised high enough to be seen by those on the other side.

I read today in our primary hard copy news source, the Stars and Stripes, that we have now had 1000 American deaths in Afghanistan.  While we folded the flags I pondered how many more would die here, how many more amputations, how many more broken and orphaned children.

I am unabashedly proud to be an American.  But I do look forward to a day when we can memorialize what happened many yesterdays ago.   I think it is only natural to question what exactly we are trying to accomplish out here.  And it is only natural to ponder whether the sacrifices being made here will be for a good and lasting cause.  We will remember, but what about the masses out there that seem to have less of an awareness of these sacrifices? Maybe I am too detached from 8000 miles away, but it seems that for some Memorial Day is not much more than the weekend you can get 4 tires for the price of 3, or half price shipping from Amazon.

We raise and lower the last flag, then put up the original flag that was flying this morning when we started.  We make sure to raise it all the way, then lower it to half mast.  Someone died yesterday.

The Princess of the ICU

Kandahar, Afghanistan


Jane with a family member of another patient, in her tiara

Perhaps it is because I have three young daughters, but I have become captivated by our latest star patient.  Of course her name is Jane Doe - it usually is, it seems.  Jane arrived a couple of nights ago on a ventilator after having survived an IED blast which took her left arm... and her family.  Tragic, no other words can describe it, and every other word would be just as inadequate.

Jane has not smiled yet and I don't expect her to.  I wonder if and when she will have the capacity to smile or be silly with her other 6 year old friends.  I wonder what she thinks at all.  I wonder if she knows what happened to her family.

Yesterday my wife sent me a care package with some toys for children.  There was a Disney princess tiara that I thought she might like.  She definitely does, as she wears it throughout the day.  After I showed her how to put it on I asked the translator if she wanted to take it off.  She looked confused and I didn't want her to think we were making fun of her or being mean in some way that foreigners behave.  She vehemently shook her head when the translation was made.  She wanted it on.

I want to adopt her and I am not alone.  I wonder to myself if this is even possible or legal.  I am told that it is against Afghan law to do international adoption.  What will happen to this poor girl?

Last night we received two more children in the ICU: one was bitten on the face by a viper - you don't see that every day in the US.  The other was another IED blast victim with shrapnel wounds to the belly, neck, and arm.  They should both do well I believe.  Viper-boy's father is here with him, and very thankful.  I don't know what happened to our latest IED victim's family.  As my wife said when she saw the photos above, war is evil.

Under Attack

Kandahar, Afghanistan

I guess it was our turn.  Our sister base to the north, Bagram, had been attacked a few days ago following a huge suicide bomb in Kabul which had killed 5 US soldiers.  I think the fight is on here in Kandahar province.

The night began innocuously enough.  Our Air Force colleagues who "rent space" behind our hospital, and who are responsible for air evacuating our ICU patients to Germany, were having their monthly BBQ.  It was a beautiful twilight and the hundred degree breezes almost seemed pleasant.  After a few burgers and NA beers the dreaded sirens began, followed by the Germanic-accented "Great Oz" voice pumped in over the base loudspeakers.  Known as the JDOC (no one seems to know what this stands for), Great Oz repeatedly informed us that "KAF IS UNDER ATTACK!  TAKE COVER!"

We made our way to the closest shelter and hung out for what seemed like a few hours.  These are small cement boxy enclosures giving off radiant heat like a brick pizza oven.  In the distance we could hear explosions and gun fire.  The first ambulances arrived probably within 30 minutes and we made our way to the trauma bay and ICU.  The rockets had exploded on the boardwalk and had injured a number of people, mostly with fragments and shrapnel from the rockets.  Several went immediately to the OR.  One patient had been partially eviscerated.

Great Oz continued to bellow in the distance every 30 minutes or so.  He informed us that we were under ground attack and to take cover.  The sirens went off a few more times and we hit the deck in the hospital.  I peered outside the hospital door and noted that all lights on base were out.

I noted that there was a huge variability in how people reacted to the situation.  Some folks were clearly rattled.  In the shelter I could here several people chambering rounds in their weapons.  That was more worrisome to me than a rocket hitting us or having an insurgent finding us.  I noted that some folks' eyes were wide open - they had the "fight or flight" stare.  Some people went a little nuts, began yelling at others and acting a bit irrationally.  The vast majority of us resorted to the default condition of being quietly professional, taking care of business and focusing on the patients.

After a few hours we had tucked in those patients who had either come back from the OR or who were in the on deck circle.  By 3am, roughly 7 hours after it had all began, I made it back to the barracks.  We all wanted to hear the Great Oz tell us "ALL CLEAR" but we heard nothing.  It is still "not clear" - we wear flak jackets and carry helmets wherever we go.

At 5am I woke up, as we had  to be at work by 6am.  Today was the day we moved into the new ROLE-3 and we had to get an early start.  You could not have scripted a more challenging scenario for that evolution.

Air Evacuation

Kandahar, Afghanistan

I could barely hear my cell phone when it rang.  I was sitting out on the edge of the flightline alternately watching loud jets take off and reading a travelogue about an insanely brilliant Scotsman who walked across Afghanistan right after 9/11.  I was distracted and it was loud.

"Get into the trauma bay - you have 5 minutes to be ready and on the flightline!"  The head of the newly-formed air evacuation team and my new ICU colleage, Jon, had taken a phone call from our Army helo squadron, Destiny.  We were needed to assist in picking up a critically ill child from a nearby base.  Not so nearby as I found out later - 30 minutes by helo when you are trying desperately to keep a child alive can seem like an eternity.

There are seven of us on the Enroute Care (ERC) team, all  with backgrounds in critical care or surgery.  Most of the time when a casualty is medevacced the medical care enroute is provided by the equivalent of an EMT, as in the folks that would be in the back of an ambulance stateside.  But on occasion - frequently as it turns out around here - the patient being cared for would benefit from having someone in the helo with a deeper breadth of understanding of critical illness.

Five minutes is not a long time when one needs to put on a flak jacket, ballistic eyewear, helmet, and gloves, get narcotics, paralytics, and the adrenaline-like drugs necessary to keep one's blood pressure acceptable when they are in shock.  We also carry extra magazines for our weapon, and lock and load.  This was my first day "on call" for the ERC and I was a caught a little off-guard.  We had actually known about this mission to get the 13 year old Afghan boy for a few days, but it kept getting cancelled for a variety of reasons.  It had again been cancelled yesterday morning.

Inside the helo with the flight medic, on our way to pick up the patient

I got to the flightline on time, but my head was spinning.  What was I missing?  How was this going to play out? My chin strap was all screwed up on my helmet and I felt like a real "nugget."

I boarded the helo from the side, as is necessary to avoid getting an unwanted "haircut."  Once inside I could hear almost nothing but the hydraulics and engine swatting the air.  It was hot yesterday - 116 degrees, and the helo was an oven.  We took off and I could see the flight tower fading behind our quarter.  I had finally escaped the wire!  First time in nearly three months.  Below me I could actually see ribbons of green, following the anemic appearing river-streams.  What was growing down there?  Poppies?  The green ribbons gave way to nobby-surfaced hills and gorges.  I was able to see a cerulean colored lake - really hard for me to believe.

We picked up our young boy and he was what we call "four-plus sick."  His breathing tube was filled with frothy blood-tinged sputum.  His blood oxygen levels were very low and his blood pressure was dropping.  My job was to help get him to Kandahar alive.

Trauma team await the arrival of the next patient at the doors leading to the trauma bay

The helo took off and I had to take turns manually bagging the boy to keep his oxygen sats at acceptable levels.  It was loud and hot, especially with our long-sleeved fire retardant shirts, covered by a fire retardant blouse, covered by a 40 pound flak jacket.  Within minutes my ballistic glasses were filled with my sweat, which by now was pouring onto the patient as I bagged him.  I frequently lost my balance as the pilot banked to and fro between the valleys - I found out later this was a tactical way to get home safely - a "nape of the earth" flight designed to make it difficult for the bad guys to target us.  Unfortunately, the result from my end was that it felt like the amusement park ride from hell.  I thought for a moment that I was going to get ill on my young patient.

I managed to make it back to Kandahar without getting sick, and most importantly, our patient managed to survive the thirty minute flight unscathed.  I should point out the incongruity of seeing the patient's bearded father, in indigenous Afghan garb, strapped to the helo seat behind the patient, the entire flight urging us to bag harder and faster.

We got back to the ICU which by now was appearing like my favorite place on earth.  Our patient was safe.  He was descended upon by our nurses, doctors and respiratory techs.  I will now understand on a completely different level what is involved in getting our patients from dangerous areas in the rugged Afghan countryside to our little hamlet inside the wire.  I took off my kevlar vest and felt 10 pounds lighter.

Heating Up

Kandahar, Afghanistan


My colleague Jon and I sign a Quilt of Valor for one of our wounded Marines

Things seem to be heating up.  Yesterday the Taliban attacked one of our sister bases to the north, Bagram, an incident that has been widely reported in the news.  From what I understand, a contingent of Taliban insurgents attempted to get onto the main portion of the base.  Suicide bombers did manage to penetrate the outer perimeter, and there were small arms skirmishes leading to several enemy fatalities and a handful of coalition injuries.

Staff gather around the radiograph reading machine after the trauma victims have been scanned

You often run into old friends while downrange.   A few months ago, while calling the ICU in Bagram to inquire about a patient, I realized my medical school lab partner was on the other end of the line.  I hope to contact him today to fill me in on what really happened in Bagram with this attack.  The last time this kind of thing happened here in Kandahar was over a year ago.  During that three week period of increased threat, all hands had to wear full body armor.  I know it is the safe thing to do and the right thing to do, but I truly do not want to get into that situation.  My 0.6 mile walking commute to work will get much longer if that happens.

Is this the beginning of the Kandahar offensive?  Unlikely, given that Bagram is north of Kabul - which had its own devastating suicide bomb this past week, killing five US soldiers.  But business has been fairly steady of late.  We were greeted with three Alphas this morning - seriously wounded coalition forces.  They came in right at the time we typically do morning report and rounds, to discuss the overnight events and patient plans and dispositions.  More organized chaos, as patients went to and fro - CT scanner, OR, trauma bay.  It was ballroom dancing on stretcher-bearing rickshaws.

In the OR grafting a damaged artery

It is difficult to say much about the Kandahar offensive.  There are some that possess the "need to know," i.e. material not to be found in the news outlets, but I am not one of them.  Business around here always picks up in the summer months, so this could be just that.  Nonetheless, rarely does a day go by without one of the news outlets describing the "Kandahar offensive,"  which is "to start imminently."  For all I know, it has already started.

Fun Run?

Kandahar, Afghanistan

Flak jackets were clearly not necessary for this race!  Some went "all out"...

Yesterday I ran a 10K race - 6.2 miles in the Kandahar heat - in honor of a fallen soldier named Chance Phelps.  By my estimation there were over 200 of us who congregated at the Kandahar boardwalk.  It wasn't the most pictoresque of races, and there was the whole "Ghaacggk!" sensation of poo pond stink and dried particulate dust in the back of one's throat to deal with.  Still, it almost felt like being at home...  minus the beer truck at the end, as is so common with races at home.  The old cliche "we all won" didn't feel so cliche yesterday.  Chance Phelps, I trust you were smiling down on us yesterday.

Bloody Night

Kandahar, Afghanistan

Ebb and flow, ebb and flow.  We don't get business like ordinary, stateside hospitals, where one can expect an average number of admissions per day with a nice mean, median, and standard deviation.  Our days and nights are wholly unpredictable.

Last night we received yet another grouping of casualties.  The first set was gruesome, with the all-too-often seen bilateral lower extremity traumatic amputation patient.  Coalition forces this time, dismounted IED blast.  I presume this to be the case as it usually is.  This soldier had died enroute and was pronounced upon arrival, so on morning rounds the details were scant.  What we did hear is that this accident occurred in the dwindling days of his deployment.  There is something about that fact that leaves a gaping hole, an emptiness in one's stomach.

The randomness of the violence - when it occurs in ones' deployment, how it occurs (a nameless, faceless enemy - if you can call an IED an "enemy") - is a topic I have shared with my colleagues.  This is an odd war.  As one of my colleagues likes to note, these young men often come into the trauma bay with various amputations and injuries,  likely not having even seen the enemy.  The enemy probably didn't see the explosion that caused the trauma.  It seems so pointless from this perspective.  The flip side is the fact that seeing the enemy wouldn't make the tragedy of death or the morbidity of the trauma easier to live with.

Later on in the night we had another handful of trauma victims that came in from a helicopter crash.  I don't yet know the specifics but fortunately the injuries weren't extreme, and there were no deaths.

Operating Theater

Kandahar, Afghanistan

The British call the OR the "operating theater," which not only sounds cooler, but it truly is more accurate. I have not spent a lot of time in the operating room since I did my third year of medical school rotations, pre-9/11.  If one isn't  accustomed to the ebb, flow,  and etiquette of the OR one feels uncomfortable.  I had that sensation up until very recently.  

My recent experience in the OR prior to coming to Afghanistan was limited to challenging bronchoscopy cases in which the patient had to be placed on a mechanical ventilator in order to get biopsies to evaluate for lung cancer, for example.  It was always made clear that we were guests of the OR staff in these cases - we weren't part of the "club," we just had visitor's passes to go backstage.

I routinely go into the OR these days, for a multitude of reasons.  Yesterday my services were needed emergently when we admitted a gun shot victim via the trauma bay who decompensated rather abruptly, was intubated and placed on a breathing machine, and then had copious blood return from his breathing tube.  A bronchoscopy was needed to determine the location of the bleeding: the bullet had traversed from his right shoulder and was now resting below his left first rib.  It likely traveled through part of the lung, but exactly where, we couldn't figure out from CT scan.  I was now part of the OR-based trauma team, which felt good.  We found the bleeding and within an hour the patient was taken from the OR to the ICU.

I frequently go into the OR - which is located no more than 50 feet from the ICU - to find out how trauma patients are doing during their damage control surgery.  I need to be prepared for whatever messes have cropped up during surgery.  Occasionally I am able to perform procedures in the OR which help out the anesthesiologist.  I have good rapport with all the OR staff, which is clearly a new paradigm for me.  It doesn't hurt that I trained with most of these people in the US during our ramp-up phase, or that I eat lunch and dinner with most of them.  We are a small team, and game day is every day.

The theater part of the OR is at times fascinating to observe.  If a patient comes to our facility with "polytrauma" - a fancy way of saying the patient is mangled, likely from an IED blast - there is usually a team of orthopedic surgeons dealing with amputations involving the lower extremities.  There may be vascular injuries being repaired on other parts of the body by either a vascular or general surgeon.  The abdomen is frequently opened up to evaluate for damaged bowel.  Many of these procedures are simultaneously occurring, while the critical support staff - anesthesiologists, OR nurses, scrub techs and so forth, are quietly going about their business a few feet from the table.  These are small rooms literally stuffed with people.  They are hot, with a goal temperature of 105 degrees.  This is because the trauma victims are generally hypothermic from blood loss, and when that happens their blood doesn't clot well.  People are sweating through their sterile gowns and when the surgery is completed, they look like they have run a marathon in the Kandahar sun.

We are preparing to move to our new ROLE-3.  It is much more sterile and has state-of-the-art operating rooms, clean floors, no fly tape hanging in front of the OR doors, and no plywood signs declaring "Kandahar Institute of Surgery."  No character there, albeit it's probably where I would want to have my trauma surgery performed.  And though it is contiguous with the new and shiny ICU, it's a bit farther and one has to traverse through heavy stainless steel doors.  This relationship I have with the OR and the beehive of activity that goes on inside will soon be changed.  I will miss that.

Little Romania

Kandahar, Afghanistan

Icon inside the Romanian Eastern Orthodox chapel

My friend Joe and I decided to tour the Eastern Bloc portion of the base this afternoon.  The NATO folks gather in various encampments throughout the base here on KAF.  The Romanians and Bulgarians have one of the more interesting compounds, as they have erected an Eastern Orthodox church on its periphery.  Made of simple plywood, it nonetheless is inspired and is clearly the most elegant structure on post.

For some unknown reason, the Romanian/Bulgarian camp has been the target of a disproportionate number of rocket attacks and have suffered several casualties.  Are the bad guys shooting at this stately church?  Just a thought - I doubt they are that good, frankly.  But it makes one wonder why.

The Eastern Bloc encampment is situated on a corner that abuts the legendary Poo-pond.  Maybe when the NATO reps were sitting around a table divvying up territory someone said "Last in NATO gets the Poo-pond plot."  There is an urban legend that is widely circulated here:  one of the Romanian special forces soldiers lost a bet.  He had to swim in the Poo-pond.  Adding some credibility to the myth is that he was found out and promptly sent home.  Last one is is a rotten egg!

Poo-pond at the intersection leading to the Eastern Bloc camp

Detritus of War

Kandahar, Afghanistan         




If this truck could talk...

I don't think we are much different than other countries who have fought their battles on others' lands - we leave a trail of junk, anthropologic droppings which point to our existence during the warring period.

Many of us comment to ourselves as we see new barracks being built, "what will this place be like twenty years from now when we have left Afghanistan?"  (God willing.)  "Will the Taliban or their successors be sleeping in my barracks room?"  "Who will be using the brand new hospital which we will be moving into imminently?"  I suppose if this is the legacy we leave, it's a lot more than a "trail of junk."  But will it remain that way? - that is the question.  Or will it someday become a source of revenue for some enterprising Afghan who figures out how to dig up the copper piping and wire to sell on the black market.

Russian tanks on the way to Camp Hero - lots of them

There is war detritus all around us.  Across the flightline there is a nipple-shaped object that rises  out of the natural contour of the mountain range - clearly a man-made structure comprised of mud and stone.  The rumor is that it is one of Alexander's fortresses left here centuries ago.  Hard to prove, but it's a great story.

A few weeks ago I ran around the flightline, a nine mile jaunt, during which we saw a half rainbow rising out of the Taliban-infested mountain range.  Ironic and incongruous, I thought.  We also spotted the wreck of an old Russian jet plane, presumably a MiG.  More appropriate, I thought.


Wreck of a Russian MiG

This past week I noticed more junk at the other end of the runway - old police cars and troop carriers.  There was also an old combi-van that looked like a surfer hippie mobile.  If only that hulk could talk, I thought to myself.  What stories would it tell?

Post-Apocalyptic

Kandahar, Afghanistan

My new Dutch friend, Oskar, remarked that "it is post-Apocalyptic."  He was referring to how the base looked as we were doing our early morning run.  A fine mist of orange dust has settled in over Kandahar.  There is no wind, so you can't call it a dust storm.  Ambient light is dim and orange.  It is quiet, like when the snow falls, but not as soothing.  There are no jets taking off, as they typically do at this time of day - I am sure they are grounded for safety reasons.  You can't even see a city block's distance.  If I were a ship I would drop anchor.  Smart people are wearing bandanas.  Guess I am not so smart today.  After our run I wipe the fine particulate dust off my face.  I look like a ghost.

Rocket Attack

Kandahar, Afghanistan

If you can't make much out of this photo, I'm not surprised.  I couldn't see much either when I was lying on my belly a few hours ago.  We were enjoying lunch at the dining facility (the "DFAC") when the foreboding alarms went off, alerting us of an incoming rocket.  As we have been instructed, we all hit the deck, covering our heads.  One does this for several minutes and then seeks out a bomb shelter or "hardened" building.  I didn't hear the rocket hit but when you are able to hear the impact, the noise is a "shoomp-SHOOMP."  This is the second time I have had to do this at the DFAC - for some reason it's a little more alarming to see everyone hit the deck in the chow hall.

The attacks rarely have hurt anyone in the past several years, although there have been a couple of casualties and a handful of serious injuries.  They are scare tactics, used with varying degrees of success.  My lunch buddy actually filmed the scene today, putting his camera above the tables to see what he could see.  When we reviewed the video later we saw that about 10% of the dining hall was still sitting, eating.  My buddy joked that this was probably a good time to go up for dessert.  Clearly the attacks don't scare everybody.  Why test fate though?

On the way to the DFAC we noticed it seemed hotter than usual...  Last year the highest temperature reached was 128.  Only 114 today.