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.