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?