Fatigue Sets In

30 July
Kandahar, Afghanistan


I think we have gone beyond the Groundhog Day effect, and now we are like cogs in a big machine, no lubricant, metal on metal, grinding out one day after another.  The machine moves inexorably forward, little torque forces adding up to comprise another 24 hour period.

It has been particularly busy this past 24 hours.  My pager barks at me incessantly.  I look, I am unimpressed by its proclamations.  "3 INBOUND ALPHAS.  DOUBLE AMPUTATIONS.  GSW TO THE HEAD."  And so forth.  We had 17 admissions, mostly from the trauma bay, and only 1 discharge in the last 24 hours.  Nowhere near our record of 29 trauma bay admissions in one day, but a handful of work.  And a lot of suffering.

I find myself wending my way to the trauma bay over and over, arriving now at the last possible minute, facemask on, bonnet on head, central line kits tucked under my arm.  This morning three dead on arrival, hopeless injuries from the get-go.  Dismounted IED blast victims with high traumatic amputations, one eviscerated, another with an non-survivable pelvic wound.  More carnage.

The ICU is filled with local nationals either caught in the crossfire or victims of unfortunate accidents.  We have one child of 4, a young girl hit by IED fragments.  Her mother died during the blast, and I have no idea where the father is.  She is attended to by her grandparents, a wizened old man and his wife who lovingly take care of their grandchild.  One is taken aback when one sees the old woman: she is of a sect here with whom none of us have come in contact.  She is covered in beaded cloth like a gypsy but her face has tattoos shaped like crosses, made of faded blue-black circles, in the four cardinal points of her face - north, south, east, and west.  She is like the witch from Snow White crossed with Mike Tyson.  She is a little scary, frankly, but the love she lavishes on her child when she sleeps next to her is story-book like.   Admittedly, an odd story.

 Across from the tattooed woman lies a child who either fell or was pushed into a cauldron of boiling water.  His little 5 year body is covered with burns, just less than 50% of his total body surface area.  The standard for comfort care in the case of burns, i.e. zero percent survival here in theater, is 50%.  He lies there like a mummy in his gauze bandages on his torso and extremities, a machine breathing for him.  I don't know where the rumor began that he was pushed - perhaps someone made it up.  But it would not surprise me, unfortunately.  Nothing is shocking here.  Not now, not after 6 months.

Odd Breed

Kandahar, Afghanistan

There is an odd breed of character who winds up in Kandahar.  He is called 'the contractor."  It stands to reason when you have thousands of soldiers on a large military base that all manner of support services are required - repair of vehicles, laundry services, food preparation, waste management, and so on.  These services are provided by civilian employees from around the globe (think Halliburton).  The U.S. undoubtedly provides the mother lode of these contractors, but there are South Africans, Filipinos, Indians, and the gamut of Western Europeans.  I'm sure I'm leaving out a few continents.

I don't know the screening process for one to gain access to a NATO base like Kandahar Airfield.  I imagine a security background check is required.  Allegedly these people are medically screened as well.  Hard to believe though.  Yesterday we admitted a U.S. contractor who easily weighed 270 lbs, had smoked for dozens of years and admitted to a cholesterol level greater than 300.  He stated that his blood pressure usually was above 170 systolic.  He said he didn't take any medications despite knowing that these numbers were grossly abnormal.  "That's a normal blood pressure for me," he insisted when we saw that he was 170/110.  He demanded to know why we insisted he stay in the hospital.  He was having a myocardial infarction at the time - a "heart attack."  Even after getting thrombolytics - clot busting drugs - he was being a true ass and trying to leave against medical advice.

There are a few commonalities among the contractors we see in the KAF ICU.  None of them wants to leave Kandahar - they must be making a king's ransom out here.  They will do anything to stay, or to avoid being sent uprange to see a cardiologist or other subspecialist.  We admitted a patient last May who also weighed nearly 300 lbs and was in florid congestive heart failure.  He was a 3 pack per day smoker and also had emphysema.  His body was so "used" to be oxygen deprived from his emphysema and heart failure that he had compensated by making a huge surplus of red blood cells.  A normal hematocrit (% of red blood cells in plasma) is in the 45% range: his was over 70%.  We had to phlebotomize several units of blood from him to ensure he wouldn't add "stroke" to his growing list of medical problems.  Despite all his problems he also threatened to go AMA - leave against medical advice.  He said he was making too much money here and couldn't "afford" to go home to South Africa.  I told him his money would be worthless when he dropped dead, which he probably would if he left AMA.  He stayed long enough to get medically evacuated.

At least Mr. 70 percent had insurance and was able to get medevacced.  One fairly common occurrence is that the contractor has no insurance in spite of their inflated salaries.  A couple of months ago one contractor was dropped off at the trauma bay by some "friends" - on a mattress covered with the blood he had retched up.  He was in frank hepatic failure, supposedly from a chronic drinking habit.  We patched him up the best we could, transfusing unit after unit of blood.  We managed to get him uprange but I heard through the grapevine that getting a hospital to accept him in the states was problematic, as he had no insurance and was by anyone's estimate, a true "train wreck."  I don't know how that one turned out.

When a contractor winds up in our ICU we have to work with his or her employer to get them out of theater.  Whether they have insurance or not, it is the contracting agency's responsibility to get their employee out of theater.  Needless to say, none of them rush to the task: it would be far better for them financially to have us fix up their employee, ideally such that they didn't have to leave at all.  We see this play out over and over - the agency gives us a date they can get the patient out, then we add three to five days.  Mr. 70 percent's employers were bargaining with us to send him to South Africa via commercial airlines, sitting in a regular seat.  I could just imagine this behemoth in a middle seat with several bottles of oxygen and an iv in his arm.  We had another patient here recently who came in with a serum sodium level of 103 (normal is about 135).  This is potentially fatal and predisposes one to seizures.  Once we had him to 115 using hypertonic saline his superiors argued with us that he could make it to the Philippines on a commercial flight.  These guys are unbelievable.

Sometimes the patients are unbelievable.  We recently had an overweight female patient who was medevacced in a helicopter with a soldier who was critically wounded and was getting resuscitated actively in the flight over.  Apparently her gastric band that was placed to control her obesity had been failing and causing her to have nausea and vomiting.  She had the gall to complain that she was not getting expeditious medical attention.  My colleague who was resuscitating the soldier could barely restrain himself.

Rhetorical question: How do these patients get medically cleared to come downrange, to a place that is routinely hotter than 120 F, where rockets are landing all over the place, armored vehicles are speeding around the dusty roads, and everyone but them are carrying weapons?

"Guys, put me out."

Kandahar, Afghanistan

He was wheeled into the trauma bay in a hurry.  You can always tell when there is someone who is turbo-sick by the way the trauma team staff wheels in the patient, their heads down.

"Guys, put me out."  He was calm, almost too-knowing.  He wasn't looking down at the scene of the crime, his twisted and mangled legs.  He was not crying out, screaming, or moaning.  He was what we call a GCS 15 - a Glasgow Coma Score of 15, out of 15.  Completely with it.

"Guys, put me out."  It was a statement more than a request.

He wasn't at all like the soldier that had arrived a short while before.  That soldier "only" had half his foot blown off, once again prompting us to discuss after the fact: was he lucky or unlucky?  Certainly it's never "lucky" to have part of your body separated from the other good part.  But unlike his compadre now with us in the trauma bay, he was certainly lucky by some bizarre calculus.

"You're alright," someone coaxed.  "We'll put you to sleep in a few minutes.  We need to ask you some questions."  While the interlocuter attempted to engage our newest patient about what medications he was taking, prior medical history and such, the trauma crew descended. Quiet, orchestrated, busy hands.  IV's in.  Clothes cut off.  Cervical collar on.  Drugs drawn up.  Units of blood  and plasma were pulled out in a big box and hooked up to the Level One.  Pneumatic tourniquets were applied to his thighs and the now bloody nylon tourniquets - which had likely saved his life - were cut off.  The radiologist applied a probe to his belly and chest, looking for "free fluid" - a finding that would buy him an exploratory laparotomy to find out where he was bleeding.  Fortunately there was no fluid.

All this occurred in a matter of a few minutes, which certainly must have felt like hours to him.

"Two 14 gauges, in!"
"GCS 15!"
"Tympanic membranes clear!"
The trauma team leader ordered for fentanyl to be given, a powerful morphine-like substance.  "Give 3 milligrams versed!"  The nurse repeated his order as she infused the relaxant into the iv in his arm.

"Etomidate 20 milligrams!  Sux [succynylcholine] 100 mg!"  The time had arrived for him to go to sleep, none too soon.  An anesthetic and a paralytic.  Sleepy-time.  A stainless steel curved, dull blade with a light on the end of it was carefully placed deep into his throat, but with deliberation, to reveal the vocal cords.  A clear plastic 8 millimeter diameter tube was slid through the cords.  An ambu bag was attached and the reassuring sign of vapor in the tube was seen.  We will breathe for you now.  Propofol, a milky-white anesthetic, was hung.  Nicknamed "milk of amnesia," this stuff is now famous as the agent that did Michael Jackson in as a drug of abuse.   Go to sleep, friend.

He would probably be awakened in two or three days, after several trips to the OR, when he got to Germany.  By then he would be a bilateral high amputee.  I think he already knew this by the time he got to the trauma bay.  He was unusually calm.  I would have bet he had thought through this scenario many times before in his mind - the stories are out there.  Some soldiers go out on patrol with tourniquets already applied, though not tightened, around their extremities.  Gruesome thought, gruesome war.

Numerology

Kandahar, Afghanistan

The Entire ROLE-3

39 days.  That's what someone told me on my last day of call this past Monday, so it's even less now until we depart this place.

39 has some sort of special quality to it.  Jesus wandered in the desert for 40 days and nights without food and water, tempted by Beelzebub.  It rained for 40 days and nights while Noah and his animals floated on the ark.  Heck, I'm down to 37 - I can make it!  We're sub-Biblical now, baby.

On the day I was told of 39 days I received notes from my daughters in the mail.  Zoe, the youngest, drew the picture above.  I believe it is a rendering of her but it she resembles Medusa in some vague way (of course she is a beautiful girl, especially to me).  She has written me several letters this deployment, many of which have included, "Dear Tim, I love you, love Zoe."  Via the cute little Medusa sketch by a charming five year old, I am reminded of how much I miss the girls and their mother, my wife.  37 days.  I am not alone in this department.

At the Northline Dining Facility, the "Troy" of DFACs

We have discussed among ourselves what we are going to do when we get back. Which food we crave most.  Steak on the grill.  A cold beer.  A fine glass of cabernet.  Thai food.  Pho (Vietnamese noodles - I may have been alone in that craving).

We discuss where we think we will go on vacation.  We talk about Kandahar reunions on the west coast, the east coast, Canada?

Some talk of the new cars they might buy, as many of us took the opportunity to sell our cars when we got our orders to come downrange.  I can't even imagine what driving will be like.  The other day I got to sit in a dusty, crappy old van which we commandeered to go to a distant DFAC.  It was so far that it had a Troy-like reputation: "yeah, I think there is supposed to be a wondrous DFAC on the other side of the runway over there... but I'm not sure.  I've only heard about it."  Sitting in the van was almost exciting.  Air conditioning, blowing on me in the 120 degree heat.  Odysseus on a trek to the far side of base. So weird.

Sushi.  That's what we are going to have.  In a little more than 37 days.

Luau!

Kandahar, Afghanistan

We are getting more creative with our diversions.  Last Friday one of our surgeons teamed up with the Morale, Welfare, and Recreation committee to throw a luau.  We were trying to get another use out of the large blow up pool, the first being the first annual pool party.  Also, I had received from my wife some blow up palm trees which really added to the ambiance - had to find a use for them.  No one was silly enough to propose tiki torches.  This whole base is one giant piece of tinder, waiting to go up in flames.

We "procured" goat meat, chicken, and vegetables from a local source.   Let's just say it was very fresh goat.  Someone also picked up some local na'an bread - actually 50 of them.  They look like giant hippopotamus tongues, but taste much better I am sure.

Nothing says "luau" quite like barbequed goat-kebobs, NA beer, and hippo-na'an.  We whiled away the evening until sunset, then retreated to the NATO barracks.  I think it's safe to say we pulled off the lone luau in all of southwest Asia last Friday.

In this stunning sunset over the mountains that shield us from Kandahar city, one is reminded that in a country filled with ugly activities, there are moments of quiet beauty

Looking for Lazarus

Kandahar, Afghanistan

I walked my colleague Jon out to the flight line.  I wanted to get a photo of him in his garb.  I think we look slightly bad-ass in our helmet and flak waiting for the SH-60 helo to come pick us up.  Some people wait for trains or buses.  We wait for a 20 ton, gunsmoke grey chopper.

We had gotten another call right at our change of shift - the calls seem to always come right at noon.  Someone was very sick at a FOB 45 chopper minutes away and they needed medical assistance that couldn't be provided by the EMT level care which is assigned to the helo detachment.  Today's patient is a closed head injury who has already blown a pupil - that means his brain is swelling and pushing on the cranial nerves which regulate pupil size.  It's dire.  It's the 21st call our Enroute Care team has gotten in the past 40 or so days.  We getting fully utilized these days after a slow start.

My last trip was over a week ago.  I was called to pick up an adolescent local Afghani who had been bitten by a bee near his mouth.  His throat had become swollen and he got intubated at the distant FOB, i.e. had a breathing tube placed.  His lungs started to bleed and he was in shock.

This day I was picked up by our Air Force brethren - we ride with either Army or Air Force helos.  Air Force likes to keep the helo doors open until we get our patient aboard.  I hadn't had a ride like this.  I was sitting about two feet away from a gaping hole in the helo, a 6 ft by 8 ft hole.  I was strapped in around the waist.  We flew low and fast across the countryside.  I could see villages filled with mud huts below me. I imagined I was Jesus walking through the countryside two thousand years ago.  Did Lazarus' house look like the ones I was seeing below me?  Could this really be the 21st century?  Dirt roads, no cars, little vegetation.  Desolate.

I was wearing our new helmet which allowed me to hear the banter of the pilots and gunners.  Each side of the helo was equipped with what looked to me like a 50 cal machine gun.  Every so often I'd hear "Suspicious contact, 11 o'clock!"  The gunner would swing his machine gun to the azimuth of interest.  It was usually a shepherd or something completely benign.

We landed and picked up our patient.  He seemed stable at the time, but as Murphy's Law dictates, he would crump before the trip was over.  About 10 minutes before landing his blood pressure tanked and his oxygen saturation dipped.  I gave life supporting medications, one dose after another.  Blood began to pour out his endotracheal tube, frothy, like strawberry soda.  My blood pressure rose commensurately.  We successfully bagged him by hand and finally got his vital signs to normalize, but not without 10 minutes of hair-ball maneuvers.  I almost forgot how queasy I get on the ride back, with the helo racing, dipping and diving.  Almost.  I think I lost 5 pounds of sweat on that particular ride.  I felt very mortal.  I was exhausted and wrung dry.

The Dog Days of Summer

Kandahar, Afghanistan

I may have been the only one who noticed, but I knew she was crying.  She hid it well.  One of the trauma teams had been called in yet again, and her team was assembling outside the NATO barracks to catch the duty van.   We have five trauma teams now and each team is supposed to have at least a day off between trauma call.  But it rarely works out that way.  Whenever more than one Alpha (the sickest of our trauma victims - life is in the balance, usually) shows up in a nine-line message, a second trauma team gets called in, then a third, and so on.  A day without being called in these days is a rarity.

Her team had just gotten off their call a few hours before.  Clearly she was being stretched to the limit.  Many of us are.  This week has been particularly bloody.  In the past two days alone we have had several casualties of coalition forces, folks either dead upon arrival or with a grim prognosis for survival. I just read in the news headlines that the coalition has had 12 dead in 48 hours.

We go through blood products like water here.  One of our key pieces of equipment is the "Level One," which pumps units of blood into a trauma victim in minutes.  We had a trauma victim here this week who had survived the traumatic amputation of both lower extremities and part of one upper extremity, and had a trauma bay thoracotomy and resultant cross-clamped aorta.  It was a huge save.  He had over 80 units of blood transfused before he got medevacc'd up-range.

The Level One

Last night during my call we received a full trauma bay of victims who had been ambushed.  The Taliban had somehow gotten a handful of grenades and other explosives into their living spaces.  The victims arrived in their gym shorts and shirts, when we typically see them in their cammies and flak.

As usual, the trauma teams, surgeons, doctors and nurses all performed admirably and throughout the night, stretching the limit of our operating rooms, ICU and ward staff.




As the summer reaches its apogee, the heat climbs along with it.  Last week it was 51 degrees Celsius, which translates to 'f*ing hot' in Fahrenheit.  123 to be exact.  You know it's hot if you can be shirtless in Celsius degrees if you transposed it into Fahrenheit (51 F, as in).  We have had numerous heat stress and heat stroke casualties here over the past two weeks.  One team was trapped in a fire fight without water.   Scary - fighting the enemy and 120 degree heat, without water.  Could hell be worse?

One-man Afghan tank, near Camp Hero

As we approach summer's apogee, the news is not all bad.  We are on our last lap here.  Our reliefs have just arrived at their training sites this week.  I am told we have just over 20% of our tour left (some folks have elaborate pie charts and countdown websites that calculate these things down to the second or tenth of a percentage).  Phineas Gage, whom I wrote about recently, walked out of here.  We save many.  It's not all bad, but through the thermocline layer comprised of the dust,  the heat, the blood, and the dead it is occasionally difficult to focus on the good.

World Cup Mania

Kandahar, Afghanistan

Olé! Olé-Olé-Olayy!!  

This morning at 2am I could here some football fans who had rooted for Spain celebrating their team's victory about a quarter mile up the dusty road.  We wearily made our way from the Canada House back to our barracks, stumbling a bit in the dark like some non-drunk drunks.  We had been cheering for our adopted World Cup team, the Dutch Oranje.

We have a moderately sized Dutch contingency at the Role-3.  They are a lovable bunch and we quickly adopted their team after the US got ousted a couple of weeks back.  Last weekend we got rowdy at the Dutch cafe Echoes, where the Oranje surprised the Brazilian team which was heavily favored.  I secretly think we are looking for any excuse to get festive out here, but this seemed like as good a reason as any.

The hype for the World Cup had been building for a few months before it even started.  The dining facilities (DFACs) had life-sized cutouts of famous players, none of whom I could recognize.  I'm not even sure I could pick Beckham out of a crowd.   The DFACs also had all the World Cup countries' flags hanging from them.

The best place to watch the games is where each country's inhabitants "hang out" here on base.  So if you are going to watch England play, you must go to Heroes, the UK recreation center and ice cream store.  To watch the Yanks, go to Niagra DFAC (we have an inexcusably small recreation tent that is really subpar as compared to the Canadians, Brits, or Dutch, but a new USO is on the way).  To watch the Dutch, you must go to Echoes or Dutch corner.

I'm not much of a soccer fan but the World Cup is exciting.  One thing that occurred to me as we watched a 90 minute match with only a 15 or so minute halftime, is that there are no Superbowl-style, over-the-top commercials.  In fact, there are very few commercials at all.  The play is more of an ebb-and-flow of tides moving in and out,  as opposed to American football where there is usually a lightening-strike long-bomb pass or kick-off return for a touchdown.  It's an acquired taste, and one that does not easily translate to the American palate which is used to short bursts of intense, sound bite-length, exciting plays.

Last night we watched the 90 minute game, then two 15 minute overtimes.  One goal.  That's what several months of excitement and hype came down to.  Now the life sized soccer cutouts can be taken down, the orange flag banners can be put away, and my shock orange Dutch fan wig can be sent to my daughters to play Little Orphan Annie with.

Olé! 

"My Head Broke My Fall"

Kandahar, Afghanistan

Old Russian armored vehicles on our run route

"I was lucky because my head broke my fall."  This was the quote my running buddy, Franche, remembered from one of her many traumatic brain injury (TBI) patients.  We ran this morning and got sidetracked on the subject of TBI.  TBI will be remembered for generations to come as one of the hallmark injuries of this war, a result most often from victims of IED blasts.  We see many TBI patients, or more specifically mild TBI (mTBI), which can be likened to a concussion.

Mild is a true misnomer, and the implications of the word concussion come nowhere close to the injuries seen at our hospital.  Concussion is getting a fair amount of press coverage these days because of what retired NFL football players are experiencing after their careers are over.  I'm sure these injuries are terrible as well, but they cannot be comparable to what we see.  When one is exposed to an IED blast his or her head suffers acceleration-deceleration injury the likes of which one doesn't see that often in the "real world."  The shear forces may cause damage on a micro scale such that our best imaging techniques can't pick up where the damage lies.

The man who felt lucky that his head broke his fall was blown out of a second story building.  His buddy had tripped off an IED and died in the resulting explosion.  He was blown out of a window or wall and fell on his head when he hit the ground.  Franche told me that he had the typical severe headache and memory problems that she sees in dozens of patients each week.

The memory problems are strange and can be severe.  She recently had a patient who was in an IED blast who could not remember anything beyond a date more than one year prior to the blast.  Each morning she would see him he would forget that they had met the previous day and had established a medical relationship.  He would get rebooted to sometime in 2009 each morning as he awoke.  She finally wrote him a letter detailing the blast, what had transpired since the blast and what therapy was ongoing for him.  He kept the letter with him and read it every day before seeing her.  It was like a scene from the movie Memento, except he had a letter, not tattoos which served as his memory.  When he got to the States he wrote her a letter thanking her, and telling her he still carries the letter around.

Other side effects of mTBI are headaches of migraine proportions.  They are difficult to impossible to treat.  No one knows yet what the natural history of these headaches or the other mTBI symptoms will be.  Nine years into this IED driven, TBI-resulting war, and we still do not know if these are lifelong symptoms, or ones that will resolve in time.  I truly hope for the latter as these headaches are debilitating for many.

Mental anguish can accompany these headaches.  Even though they are debilitating, there is no scar or amputation that earmarks one as a war-injured.  Their peers or superiors may label them as malingerers (unfortunately, there are malingerers out there, which feeds this perception).  PTSD often accompanies TBI as well, for a wicked one-two punch.  The patient ends up feeling helpless and sometimes persecuted.  Guilt feelings may accompany these other two emotions.

Many soldiers and Marines do their best to mask the symptoms of mTBI so they can get back to their units.  The loyalty bond is strong.  They memorize the answers to the MACE exam (the military acute concussion exam) - a 30 point memory quiz which identifies them as mTBI victims.  We have good intel that this is being done;  there are three versions of the MACE so often they get foiled that way - they only know the answers to the first MACE.

Many patients have suffered multiple TBI events.  Franche's "winners" in this category are in the double digits - one with 11 and one with 12 prior events.  Unbelievable.

Many mTBI patients can resemble young Alzheimer's patients, their symptoms are so severe.  I remember being at Walter Reed or Bethesda Naval Hospital during my training and having some of these patients show up for pulmonary appointments: they would have no idea why they were there, they just had a sheet of paper telling them to be at my clinic at a certain time.  Many ultimately ended up with guides who would be responsible for getting them to their various appointments on the medical campus.

I fear that we will have a cohort - a large cohort - of young folks from this generation who will be wandering around our streets as homeless people, confused and cognitively disabled, victims of war without visible scars.  Please remember them in your thoughts, prayers, and deeds as I am certain you will see these unfortunate victims of war as time goes by.

Note: While waiting for photos to upload for this post I note a National Public Radio post sent to me via Facebook: "Please help us find veterans who experienced concussions while serving in Iraq or Afghanistan."  At npr.org.  Weird.

Camp Hero, Revisited

Kandahar, Afghanistan

I have received several boxes of toys for children recently, I believe inspired by the Princess of the ICU, our little Jane Doe.  We have a large cache of toys in the ICU but we were starting to encroach on storage space for our equipment and medical supplies.  So one of our senior nurses loaded up the boxes of toys in a hospital crib, and stowed it in the morgue.  Yes, the morgue.  So I felt compelled to get these toys out to the community, pronto.

Today I went with one of our translators on a mission back to Camp Hero to see if we could distribute the morgue-toys.  We loaded up one of their Land Rovers with many of these boxes, as well as some clothes that some others had collected.  We drove through the entry control point, past a line of semi's and trucks, perhaps a hundred deep.  They wait, sometime for days, to get clearance to come through the inner wire and onto post.

We stopped first at a forward operating base about 2 miles outside the inner wire where we dropped off the clothes and half of the toys.  They are now bound for a homeless shelter in Kandahar City.  Our translator has "adopted" a few homeless shelters and supplies them with food and clothes - and now toys - every month or so.  He says the kids will be thrilled - most of them have never seen a toy.

We then meandered through a few more entry control points on our way to Camp Hero.  Once at Hero we found several waiting children who are now the proud owners of matchbox car sets and Dora the Explorer dolls.  The boxes we had brought also had Hannah Montana paraphernalia, various cartoon character masks and dolls, and so forth.  It was a bit incongruous, the realization that they have no idea who Raggedy Anne is, much less Hannah Montana.  It just didn't seem to matter.

We visited a young boy, whom I had met on my previous visit.  He was burned in a horrible accident involving auto fuel.  When I saw him a few months back his chin was fused to his chest from the burns.  One of our surgeons has been slowly debriding his wounds and grafting skin onto the wound in multiple stages.  His chin is now off his chest and he has fairly good range of motion, but he has a ways to go.  I had taught him the "exploding fist punch" on my first visit and was glad to see he still remembered it.  He's such a sweet child, smiling and throwing out whatever English phrases he has learned in his 5 months as a patient at Camp Hero.  His face beamed when we gave him a soccer ball and a matchbox car set.  As I look at his photo now I am reluctant to include it here as it occurs to me that it may be shocking to some.  But it's not gratuitous.  It's a piece of the 'real life' Afghanistan we encounter out here.  Please know that the large wound you see does not seem to cause him pain: he pulled the dressing off himself to show us, and the tissue we see appears healthy - it will heal on its own.

We ate lunch at a dining facility for the local Afghanis.  It was an honor to be invited, and it was clearly the best meal I have had since arriving here in early March:  rice with lamb, chick peas, fresh tomatoes, onions and mint leaves.  There was also freshly baked na'an bread.  We used our hands to eat - right hand only!  It was sublime.

Phineas Gage pays a visit

Kandahar, Afghanistan

Actually, Phineas Gage died 150 years ago.  Gage was a young railroad worker who, while pounding on a tamping rod which had explosives packed below it,  had the rod blown through his cheek, traverse his brain and travel out other side of his head to land 80 feet away.  Gage was able to walk away from the accident, and despite becoming a bit of an eccentric relative to his pre-accident state, lived a normal life.

Last night, in the middle of an exceptionally busy day in which we admitted 29 trauma patients, we were paid a visit by an Afghani Gage.  This fellow somehow had an explosion detonated in front of his face which resulted in a 4 inch long bolt blown through the his right cheek, across his nasal cavity, resting adjacent to his second vertebral body.  Amazingly it missed the most vital vessels and nerves.  By report the patient presented to a local forward operating base with a chief complaint of "headache."  (You can't make this up.)  He allegedly walked into the clinic.  He was billed to us as another "IED blast victim."

He arrived at our hospital on an enroute care mission, already intubated and on a breathing machine.  This morning he was taken to the operating room.  Our neurosurgeon teamed up with our oral maxillofacial surgeon (OMFS) to extract the menacing object in a staged procedure.  Once it was determined that the dura - the cover of the spinal cord - was intact, and that no major vessels had truly been damaged, Steve, our neurosurgeon, methodically approached from the back at the base of the neck.

Sandra, our OMFS, was staged at his front side and debrided likewise, until she could feel the object.  Despite its size, she had a hard time locating the bolt which was located deep within his cheek or nasopharynx.

At one point I heard her say to Steve - who could easily see the end of the bolt from the back side, "Wiggle it a little so I can see it."  Like I said, you can't make this up.  Finally, Steve, who could better visualize where the bolt should be came to the patient's front side, inserted a plyers-like tool deeply into the gaping cheek-hole and plucked out the near pristine looking bolt, like a cork from a wine bottle.  We were amazed.

Tonight Steve examined the patient, after his breathing tube was removed.  He is moving all four extremities and speaking coherently.  Steve wants to get his picture with Afghan Phineas, standing side by side, and mount it in a photo next to the X-ray with that thing inside his head.  They'll have to flip a coin for the bolt I'd imagine.

Trauma Bay

Kandahar, Afghanistan

The city of Cusco in Peru was the center of Incan culture many centuries ago.  I spent a month there during medical school and was amused to find out that in Quechua, the Incan language, Cusco means umbilicus: Cusco was the navel of the Incan world, its figurative epicenter.

The trauma bay is our umbilicus.   Although we provide outpatient medical care for thousands, our raison d'etre is the trauma bay and our ability to quickly resuscitate trauma victims and get them to the operating room or ICU in an expeditious fashion.

                                                    The Wait

Many subplots play out in each trauma bay, every day.  It might as well be called the drama bay.  First there is the wait:  we learn about incoming trauma victims through cryptic "9-lines" -- terse messages with slivers of information about what is heading your way in usually 30 minutes or less.  We joke about how inaccurate they often are.  We may assemble dozens of people who anxiously wait for a truckload of people actively "trying to die," and then a handful of patients who barely rate medical attention get wheeled in.  Or, we may get virtually no notice and a victim gets dropped off without a pulse, or exsanguinating before your eyes.  So the wait has a true angle of suspense - what really is coming our way?

Once the patients get situated into the bay there is the frenzy.  First the patient must get "trauma naked."  He is descended upon by at least two people with trauma shears, getting the patient completely naked so that an accurate primary survey can be conducted.  While this is happening each person on the team is rushing to do his or her bit part - starting an iv, securing the airway, getting a blood pressure.  If it wasn't so serious it would be cartoon-worthy, like when a cartoon cat and dog get in a fight and all you see is a dust ball with cat or dog paws coming out of that ball.

When the blood begins to pool on the floor a new phase of care is reached: this person is really sick and could die.  Although every trauma victim deserves this kind of respect, it does get kicked into a higher gear if there is a lot of blood, some bowels hanging out, or other body parts mangled into unnatural positions.  I just left the trauma bay not 2 hours ago during a mass casualty in which a patient was given a surgical airway in the field - his neck was cut below the Adam's apple and a breathing tube was inserted into the airway.  But it wasn't really in his airway - it had been put in the wrong tissue plane and instead of air going into the lungs, blood was coming out of the tube.  The collective pucker factor in that bay that I was in grew and grew.  His oxygen saturations dropped even after that tube was removed and another was put into the same position.  The decision was made: we had to re-attempt to get the tube in from above, from the mouth.  This is can be difficult in a non-challenging situation, like when one is taken to the OR for an appendectomy.  But if you are trying to see the vocal cords in the oral cavity of a patient who now has several tablespoons of blood in his throat, well, that is what one calls a shit sandwich.  Fortunately for this patient, an airway was secured from above.

While the now-unconscious patient had an anesthesiologist placing a tube into his bloody orifice, he had one physician on his right side cutting into his thorax to place a chest tube, another one sliding a needle about two inches long below his left collar bone in order to place a straw-sized iv there, and a third poking another needle into his groin for even better access.  He already had a nurse or two attempting iv's on his arms.  Hieronymous Bosch could not have painted a more gruesome visage, but it was all being done with the intention of saving his life.  We save many lives in the trauma bay, and it's not always pretty.

Funny things happen in the trauma bay sometimes.  This morning before the mass casualty, one of my colleagues was able to pluck a bullet out of back of a lucky Afghani.  The pristine bullet had settled near his his shoulder blade.  What a souvenir for him, if he is allowed to keep it.

In the old Role-3 I remember a word painted on the ceiling over where a trauma victim would have been lying supine:  Breathe.  As if he had a choice, but I understood.  Help us help you.

The red line is painted on the floor outside the trauma bays.  One is not supposed to cross that line unless she is actively involved in the resuscitation or trauma bay activities.  It is commonly violated by well wishers hoping to lend a hand.  The problem with that is that it spoils the choreography.  Even if you are just trying to yank a boot off, it's not your place.  Honor the red line.