The Longest Goodbye

31 August 2010


Camp Arifjan, Kuwait

Once the new crew was in place following the change of command, we old timers began to feel "old and in the way."  Perhaps I am projecting.  Our whole lives for the past six months have revolved around what goes on in the hospital.  I for one had a hard time staying away, which resulted in more than once observation "Oh...you're not gone yet."

Unfortunately we couldn't beam ourselves out of Kandahar.  The course of events leading to our C-17 flight out of theater was long and convoluted, in classic Navy style.  First we had to get our rooms into inspection-ready condition, and move into a large tent, with over 200 of our closest friends.  Many folks had already moved into the tent by the time I got there.  The first night they experienced a too-close-for-comfort rocket attack in which one person insisted he saw the contrail of the rocket cast light over the top of the tent.  The unexploded warhead was found wedged between two Texas barriers the next day.  Part of the rocket disabled a C-17 on the tarmac, piercing one of its tailfins.

Odd tent decorations

Moving in and out of any facility is not easy.  We are all carrying at least 80 lbs of combat equipment that we have never used - chemical-biological warfare gear, cold weather gear, various tools and garb that had been given to us in Fort Lewis.  I personally had two full seabags, a stuffed-to-the-brim rucksack, and a carry-on, plus my flack jacket and helmet.  I packed relatively light.

One Last Coffee on the Boardwalk

The tent was completely full.  I had a top rack that was not fit for sleeping, even if I could ignore the snoring, joking, bed creaking, and so on.  My bed listed at about 20 degrees.  I took another night of ICU call so I could sleep in the hospital.  The next two nights I crashed on an ICU bed in the corner, and a cot in a distant office, respectively.  Some relished the summer camp feel of the tents but I was more concerned at this point in getting some end of deployment sleep, well-deserved if I may say so myself.

On Friday night, we were feted by one of our friends who works with the special forces.  He got his hands on some local Afghani food - rice with raisins, a chick pea stew, and some dubious-looking goat meat.  After we feasted on the tasty local meal one of the special forces docs honored myself and two others with their unit coin, for taking great care of their fallen comrades.  It was touching.

Waiting in the terminal

That night I had an interesting conversation with a psychologist who was assigned to the special forces.  She had extensive experience with folks "redeploying home" (the unfortunate Army term for going home).  She told me that most folks get annoyed at little things they see on a day to day basis.  For example, one might be at a restaurant where a patron makes a big fuss that his hamburger is taking so long.  The redeployer will get disproportionately angry at this kind of scene - he or she will have seen so much truly worth getting irritated at (wounded soldiers, amputations, broken children) that this will just set the person off.  She strongly suggested that we get together with other folks with whom we had deployed, to reminisce with someone who "gets it."

Inside the C-17

After our final goodbyes with the comrades that had joined us halfway through our "roto," (the ones we remained close to, as the new guys continued to marvel that we were "still here?" more than a week after the change of command), we finally lugged our gear once more to the outgoing passenger terminal.  We boarded buses leading us to two enormous C-17s, the kind I watched take off nearly every day from the flightline.  They are gargantuan up close, and impossibly big from the inside.  We were allowed to take off our flak once seated, though many kept them on for the entire four hour flight.  No peanuts or ginger ale on this flight - it was all business.  Within minutes of being seated we were taking off much too steeply for FAA regulations.  I knew from many nights on the flightline over NA beers and cigars that our tail lights were extinguished as soon as wheels were off the deck - a tactical takeoff.

All grins

We arrived in Kuwait at Ali Asalem, a military terminal two hours by bus away from our Warrior Transition Program destination.  We were led, bleary eyed but happy, to our tents.  Our long route home had begun in earnest.

Last Call

25 August 2010


Kandahar, Afghanistan

I had my last overnight call in the ROLE-3 last night.  There have been a lot of bittersweet "lasts" lately.

We played our last hockey match on Monday.  Steve, our neurosurgeon, even played with broken ribs - from our hockey match the previous week. He said he just couldn't miss the occasion.  We showed up in particular for Tracy, our Canadian "mayor of Kandahar."  She is an ICU and trauma bay nurse who is pleasantly gregarious, seems to know everyone, and who has had a habit of getting us onto the hockey rink even when we might want to be sleeping after a night of call.  Unfortunately on this day Tracy learned she was going home a day early.  She was noticeably angry at the screw up: apparently someone had known about it for 3 weeks but hadn't bothered to tell her until the day before.

At Tracy's farewell lunch

Tracy couldn't play hockey on Monday as she had to pack and get ready to leave this place.  It's a common theme - as much as one wants to get the hell out of here and back to a normal bed, a reasonable temperature, green grass, a cold beer - I could go on - one feels the gravitational pull of a tight knit group of friends and colleagues that one really doesn't want to leave behind.  As Tracy told me, where else are you going to find a group that is so close, a group that shares tragedy in the horrible things we see, but also a group that gets together daily to break bread, play sports, drink yet another NA beer, or generally goof off (probably in an effort to forget the terrible things)?  Many of these events occur on the same day.  At home we have colleagues and may occasionally get together, but it takes effort, and it may take weeks of coordination to make a get-together happen.  Here at KAF we all have a shared set of intense experiences, see each other every day, live in the same dorm... and we have become like a family after six months together.  If you haven't been here it is difficult to relate.


On the day Tracy left we took her out to Echoes, the Dutch cafe with the cartoonishly rude staff.  We ate together for one last time with our personal live wire, Tracy.  When it was time to say good bye she was crying.  We have made tentative reunion plans but we know it will never be the same.

We have been experiencing a region-wide dust storm the past couple of days.  It is more dangerous to fly missions in the dust, so many of our patients that would normally be transferred by helo are grounded at the various forward operating bases located close by, attended to by lower echelons of care.  At about midnight last night I received the page that 8 were inbound by Stryker or MRAP - vehicles used to carry troops around the countryside and armored to withstand IED blasts.  We assembled at just before 1am to meet the hoard.  After waiting an hour we were told that the patients wouldn't arrive for yet another hour, and that we would be paged again.

Our last cigar night?

I slept for that hour and dreamt about being a soldier in a ground war, being shot at over and over, with no place to take cover.  I awoke, troubled and a little nauseated.  I was thankful that I was only dreaming about being shot at, lying in a bed.  Our patients, who finally arrived at half past 3am, were in fact being shot at in some miserable landscape several hours away by vehicle.  When they finally arrived at ROLE-3, they had been traveling for hours in a hot and cramped vehicle.

Dropping off patients by vehicle, outside the trauma bay doors

They could have easily hit an IED on the way here.  One of the wounded had his foot blown off.  A young Afghan boy had somehow arrived with the group of soldiers, having fallen into a well (our third such victim in the past 3 months).  Amazingly, only the boy ended up in the ICU.  It was a strange way to end up my six months of call here.  Is there some metaphor concerning falling into a well I am missing?

By morning I was wondering if the nightmares of being shot at were something I should be concerned about.  Today I do not feel emotionally wounded after what I have seen.  We have been told that the medical professionals who rotate in a hospital like the ROLE-3, and who have seen horrible things, occasionally have PTSD or PTSD-like illnesses upon their return home.  From what I have been told, it is most often worst for the nurses, and most easily tolerated by the surgeons who operate and perhaps see the most carnage.  I know it has been hard on some.


The Commanding Officer being awarded the Boatswain's Pipe after the Change of Command ceremony

Today is the day of the Change of Command.  At today's morning report I witnessed some tears shed by those who are turning over the reigns to the new crew.  I think the tears were a combination of exhaustion, joy in surviving, and joy in knowing we made a difference to scores of people, both Coalition soldiers and Afghan citizens.  Our chief of trauma reviewed the numbers of people we had treated, the units of blood we transfused, the hundreds of orthopedic surgeries performed - many representing amputations, and other data.  When the numbers scrolled across the screen I think it sunk in for all of us present:  we put a lot of energy, effort, emotional toil... and on occasion, tears, into what we have accomplished and to what we have witnessed.  It is no surprise to me that tears were shed this morning.

Incidentally we have another evolution to complete before going home designed to deal with these issues that many will carry back with them.  It's called the Warrior Transition Program, which takes place in Kuwait.  I understand it must be done and it probably is useful for some.  I will be so preoccupied with thinking about getting home by that point I have to wonder if I can pay attention.

The Change of Command started at 10:30 this morning.  As we were still under a cloud of dust, it was mercifully cool by Kandahar standards.  After the benedictions, speeches, salutes and the final handing over of the flag, I got to shake the skipper's hand.  I am sure I saw a tear in his eye too.

Heart and Mind

22 Aug 2010


Kandahar, Afghanistan

We recently had a child in the ICU who had an IED fragment traverse through his frontal lobe of his brain. He had a pleasant, white bearded grandfather who spent hour after hour at the bedside of his grandson, coaxing him toward recovery.  Grandfather knew a bit of English, which is very atypical here.  At one point we proposed a plan for the child in which he would have a catheter placed in one of the ventricles of the brain, tunneled via subcutaneous tissue, and placed into the abdomen.  This life-saving procedure, called a ventriculo-peritoneal shunt, or "VP shunt,"would drain the excess spinal fluid that accumulated in the brain.  The only problem is that we could not do this procedure here as we did not have the shunts.  Because of our often suboptimal supply system, it could be weeks before we could get a shunt to Kandahar.  We proposed sending the child to Pakistan to have the procedure done there.  Grandfather stated bluntly to our neurosurgeon, "Why would I besmirch your name by sending my child there?"  He further explained that he felt our surgeon had saved his grandson's life up to this point, and he was confident the boy would ultimately get better based on interventions up to that point.  He felt the need to tell us that Americans are beloved by him, and throughout his village.  It would be a sad day indeed, when we leave.  We wryly noted later that we had won over one heart and one mind in the grandfather.  Incidentally, the boy did get better, and was determined not to need the VP shunt after all.

Yesterday I went with three other docs and our translator back to Camp Hero, likely my last visit there.  I had a sack of toys yet to give away to the kids that folks had sent me.  After visiting the children's ward and handing out the toys, I rejoined our surgeons in the OR.  Two patients had been prepped for surgery and our surgeons were essentially training their surgeons on some relatively complex procedures.  The first involved a patient whom we had cared for at the ROLE-3.  He had had his arm nearly blown off by an IED.  The hand was still viable but the flesh on the forearm and around the elbow had been largely been blown off.  In order to allow the remaining tissue to heal enough to take a skin graft, our surgeons had sewn his arm into his abdomen.  Our surgeons were cleaning up the now immobilized arm.  This is a fairly amazing procedure as far as I am concerned.

Sign at the entrance to the Camp Hero Operating Room - unnecessary in the US.

I looked over to the OR table 6 feet away with another patient being attended to by one of the Afghan anesthesiologists.  He was using his bare hands to start an IV, going to various sites on the patient's arm without using alcohol to clean the patient's dirty arms.  So in adjacent beds I was witnessing  third world medicine being practiced next to state-of-the-art medicine in the arm-to-abdomen patient.

Our surgeons scrubbed into three procedures yesterday before we were called back to the ROLE-3: an 18 month old child had a fragment from an IED penetrate her posterior skull, and as we would soon find out, was still lodged in her brain.  The mother had died in the IED blast.  Another heart and mind to be won in this 18 month old child.

Lines On My Face

19 August 2010


Kandahar, Afghanistan

I was up at 3am this morning getting numbers for ICU rounds, having just left the trauma bay after a quasi-mass casualty.  We had been paged a little earlier - 7 patients inbound from another helicopter crash. Again it was a CH-47 Chinook, a school bus with rotors.  It had crash landed and flipped over.    The text message gave us a 3 minute warning, which is virtually unheard of.  Seven inbound patients means you activate at least five trauma teams, each comprised of 5 or so people, most sleeping at the NATO barracks a half mile away.  No way they are going to make it in three minutes, so we cobbled together three teams and waited for the onslaught.

MRAP convoy with a device designed to defeat the IED at the front. 

As fortune would dictate we ended up treating 7 "walking wounded" - incredible.  I watched as the trauma team members sleep-walked into the trauma bay just before the victims.  No one was even remotely excited.  In my mind I compared this scene to the one in which we treated five or so soldiers who were in a V-22 Osprey crash, our first mass casualty, last March.  At that time you could smell the tension, and see it on everyone's face.  Even though this turned out to be more of a false alarm early this morning I knew that things will soon be different when the new crew takes over in a few days.

Not able to sleep after our faux-MASCAL, I now gather the numbers and data that begin to roll in on our patients in the unit at this early hour - dozens of labs, hourly urine output tallies, heart rates, blood pressures, intracranial pressures on our head gunshot victims, ventilator statistics, arterial blood gas measurements, and so on.  Each patient's data tells a story of what happened that shift, that day.  Are they trending toward the better or the worse?  Does anyone need blood or plasma this morning?  Can I pull the breathing tube out of their throats?  Must I put another invasive catheter into one of their veins or arteries to get even more information?

We have a theme going this past couple of weeks in terms of patient make-up: neonates and young children; the usual census of gunshot wounds to the head with swollen brains and parts of craniums surgically removed to allow the brain to swell even more; and Afghan and Coalition soldiers with gunshot wounds to the jaw, making their mandibles look like cracked eggshells.  The latter group generally gets their jaws wired shut and breathing tubes subsequently placed via their nares into their tracheas.  Getting these folks off the vent here has been problematic as a handful of them have aspirated or vomited, necessitating that we emergently take the wire cutters taped to the foot of the bed to snip those wires and quickly get a breathing tube through their oropharynxes into their tracheas.  That's not a pleasant situation.

Poster in the ICU made by my colleague Corey's wife reminding us that 'kids aren't just little adults.'

I grow frustrated at the seemingly never-ending stream of young boys and girls that wind up in our ICU.  I had no idea it was going to be like this when I came out here.  We pronounced another young boy dead in the trauma bay yesterday, a victim of an rocket propelled grenade (RPG) attack.  We presently have two young boys in the ICU with gunshot wounds to the backs of their heads.  They may do reasonably well in the long run, maybe only paralysis to part of their body, or difficulties comprehending what one says.  Even though they likely would have died if they hadn't been diverted our way, it is still such a tragedy.  Someone asked me recently, do people target these children?  It's a sickening thought.  We have always assumed that they are caught in the crossfire.  But why would a child be playing in an area where people are shooting RPGs at one another?  Wouldn't one run as fast as one could in the other direction?  Or perhaps that explains why our two boys have wounds to the backs of their heads.  We just never know.

In the past week we have had two infants, one 4 months old who had a bad pneumonia, and one 2 days old, who had been breech and delivered via C-section at one of our local FOBs.  They should both survive.  What kind of Afghanistan will they grow up in?

Sign at the inner wire.

We are lucky to have my colleague, Jon, who is a Pediatric Intensivist.  He has taught me via the school of hard knocks how to treat critically ill babies and children.  I'm no expert, trust me.  But I am now PALS (Peds Advanced Life Support) qualified, have run a handful of codes on babies, and have put in numerous invasive catheters on young children.  I think I have at least a part of a pediatric internship under my belt at this point.  And I am sure I have seen the dark underbelly of what happens to some children in this particular world - babies scalded in milk, young children and babies run off the road and into canals by Taliban, spinal cords of young boys and girls transected by wayward bullets - or worse, intentionally directed ones.   I just want to get home to hug my girls and not think about this stuff for a long while.

Today I ran into two women I had trained with back in January at Fort Lewis.  I noticed that one of them looked markedly older.  I wonder about the lines on my face, the extra grey hair I have "earned," the ever-receding hair line.  I look in the mirror and only see the Afghan weathered red face, but I am sure I looked older to these women after only six months.

Giddy

Kandahar, Afghanistan

It must be graduation week, or at least it feels that way.  There is a giddy atmosphere that seems to permeate everything we do.  Morning rounds have become impromptu comedy routines.  If I am reading that last sentence and not writing it I would probably be put off somewhat.  When we round in the ICU for example, there are several people who may be in a "guarded" condition, others are trauma victims being being actively resuscitated or who have just come out of the OR with open abdomens or limbs missing.  Still others may have devastating head injuries, and we are waiting for them to "declare" themselves as there may be nothing we can actively do to save their lives or restore neurologic function.  How can one be silly or make jokes in this environment?  One can, trust me.  We don't poke fun of patients and they are not the objects of jokes.  But there are usually several situations each day that beg to be lampooned, and I feel that it is a defense mechanism to deal with what we see daily.

A few months ago I ordered a "travel gnome" to lighten up the mood every so often.  I have taken the gnome to various places around the base and have gotten dozens of people to pose with it.  It's an automatic mood-loosener.  Everyone needs a gnome or a gnome surrogate around here.

On Sunday we had our one and only sanctioned BBQ of the tour.  Back in the days before General McCrystal the various units on post, to include the Role-3, would have a monthly BBQ to get the command together, hand out awards, and generally promote good morale.  McCrystal nixed the monthly BBQ and allowed each unit one every six months.  Our other parties - the goat-kebob luau and the pool party were financed through various fund raisers - selling t-shirts, ball caps and such.  Our officially sanctioned BBQ had a theme - the 1980s.  Now it's pretty hard to go to the Thrift Store to buy costumes and such, but where there is a will, there's a way.  The best costume came from my ICU colleague, Corey, and his roommate, Joe.  They fashioned a Devo outfit out of parts from the ICU and OR.  The highlight of the evening was when Corey received his end-of-tour award - in his Devo outfit.  Classic.

Corey got his award a day early because he left today for Kuwait.  My numerical relief arrived four days ago, allowing one ICU watchstander to head home a couple of weeks early.  It is a bittersweet parting for me as Corey and I climbed aboard a plane on January 26th to begin this odyssey.  But I'm glad he will be home soon.

The International Security Assistance Force Medal that we all receive.  All are awarded 3 unit awards including the ISAF award, and many will receive a personal award such as a Navy and Marine Corps Commendation medal.  That's a lot of "chest candy" for one deployment...

Our flight schedule was posted yesterday.  We move into tents next week and then board planes for Kuwait between 27 and 29 August.  There are but two big events left: the mass arrival of our replacements and the Change of Command ceremony, where we officially hand the torch to our reliefs.  We are giddy.

Ramadan Begins

Kandahar, Afghanistan

13 August 2010

The cultural sensitivity pamphlet on the Muslim holiday of Ramadan that was distributed to the command urges us to respect our Muslim guests by abstaining from eating, drinking, smoking, chewing gum, or using any tobacco products in front of them.  We should be mindful that they may be uncharacteristically curt, or appear tired or dehydrated.

Ramadan began three days ago.  The first three days are considered a holiday in which everything is closed, everyone rests during the day, and the local villages appear to be ghost towns.  During Ramadan Muslims are supposed to perform self-reflection and solidify their relationship with God.  Because Ramadan celebrates the month that Muhammed was bequeathed the first books of the Qu'ran, one is encouraged to read the holy book cover to cover.  Most fast from dawn to dusk in order to focus their energy away from worldly needs and toward reflection and prayer.

From previous Ramadans we can extrapolate that there will be fewer gunshot wounds, which requires a sniper or gunman to essentially violate the intention of Ramadan, but there will be the same number of IED blast victims because they have likely been in the ground long before Ramadan started.

                                                              Bochdalek hernia on CT scan

Yesterday while on call the trauma bay was quiet - I can only use the "Q" word in retrospect: one never states that it is quiet in the present tense.  Bad luck, kind of like sticking chopsticks straight up in a bowl of rice while in Asia - you let the evil genies out.  We did have some interesting non-trauma cases.  One case involved that of a contractor with left upper quadrant pain in his abdomen.  Turns out that his intestines had oozed through a congenital defect in his diaphragm, into his thoracic cage - a condition called a Bochdalek hernia, which is relatively rare.  The patient was taken to surgery and had his bowel returned to its rightful place in the peritoneum.

I also had a chance to review some films with our radiologist and his new, "Gucci," 64 slice CT scanner. Using his new toy he reconstructed some films so that one could see three dimensional images to include torturous vessels, broken bones, and even facial features.  Amazing was all I could think to myself.  Here we are in the middle of an unforgiving desert practicing 21st century medicine not far from pious Muslims Ramadan-praying in their mud huts, and herds of camels roaming right just outside the wire.  I could nearly forget that I was in a war zone and imagine I was in an academic hospital in the states, Canada or Europe.

By morning, Friday the 13th, we had come upon day four of Ramadan.   Our quietude was interrupted at 5:45 am with a screaming and hallucinating solder with a traumatic, below the knee amputation.  He had been given the drug ketamine in the field ("Special K").  Ketamine produces a state known as "dissociative anesthesia," which in addition to allowing the patient not experience pain, causes him to go into a sometimes agitated dream-like state.  Our patient was screaming maniacally.  In biblical times he would have been declared possessed by the devil.  "LOOK!  I can still move my good leg!" he shouted, showing us how he could kick his one intact lower limb.  "I can't feel a THING!  Give me some WATER! Some F*KG water!"  Fortunately he came in with a functional iv so we could properly put him out and intubate him, which took all of two minutes.  Off to the OR to complete the amputation the IED had started.

A few hours later we received our first big batch of trauma patients, five in all.  The first was rushed into trauma bay one, reserved for the sickest.  He was ashen and neurologically dim, barely conscious.  He was hemorrhaging from a bullet wound just below the left clavicle.  A thumb or finger placed in the wound staunched the bleeding, but if taken out, a low velocity garden hose stream of bright red effluent bubbled from that hole.  He clearly had severed the subclavian artery.  We worked together to intubate quickly, and place central lines and iv's.   A surgeon on the other side of the gurney placed a chest tube in his left side as I sutured a large bore central line under his good collar bone.  We all "hovered" the patient together to get an x-ray plate underneath him.  I counted several bloody gloves as we hovered him.  After the world's quickest chest x-ray he was rushed to the OR.  I followed, to assist in any way possible.  Within minutes I heard:
"We're losing him!" "He's exanguinating, I can't get control!"  Hands flew, trying to suppress the bleeding, trying to find the uncooperative severed artery.  His chest was cracked, emergency thoracotomy style.  "Get me the f*kg bone saw, now!"  "More laps!"  His sternum was brutally sawed open.  One surgeon managed to get his hand on the subclavian artery and pinch it against the chest wall.  Another bone saw cut the clavicle and first rib in two.  A clamp was placed on the culprit vessel and after about 45 minutes the bleeding was controlled.  The walking blood bank was again activated - how many times is that this month?   The patient is probably still in surgery but I am confident he will do well ultimately.

As I sit and write this, post-call, my pager has gone off four times, announcing at least five more casualties inbound.

So much for Ramadan.

The Letter

10 Aug 2010

Kandahar, Afghanistan

 Another 30 hour call, another foggy-headed post-call day.  So much happens here in one typical day that it seems like several days strung together.  I look at photos from the previous day and realize we are about to break apart.  I notice people taking more photos of people they will likely never see again, giddy situational posing.  Addresses and e-mails are being jotted down.

Twister on the Boardwalk

Yesterday after rounds we trekked to the Dutch café for morning pancakes.  It was a completely spontaneous decision, the kind of thing you might do as a senior in high school on a warm May day.  In a way we are all about to “graduate,” and we won’t be seeing each other much longer.  It really didn’t matter that the café was closed on Monday mornings, it was the thought that mattered.  We settled for ice coffees while sitting on a bench on the Boardwalk.  Strangely, a medium sized dust twister appeared in the middle of the dusty, dry quad.  The moment was right for me to think to myself, There’s no place like home.

Yesterday after morning report we bade farewell first to our Dutch contingent and then to the latest group of Canadians.  Both had been special in my mind.  This group of Dutch folks had been here during the amazing Dutch run at the World’s Cup and had introduced us to orange wigs – heck, orange everything – as well as Dutch Queen’s day, stroopwafels, and other Dutch customs.  It seems the Role 3 is as much Dutch as it is American or Canadian.  This group of Canucks has likewise been special, causing us to develop a Jones for hockey, which we play every Monday, as well as Tim Horton’s doughnuts.  We’ve also quaffed enough NA beer with them to float a small boat.  They are all "graduating early."

The first group of Americans in our “Roto” will leave this coming Monday.  In college, due to an illness that put me out for 6 months as a sophomore, I graduated in December, the rest of my close friends having graduated the previous May.  I felt like a ghost in the ensuing fall semester.  I am wondering now if I will have that ghost-like sensation as, piece by piece, we are dismantled.

A few hours ago someone handed me a photocopy of a letter sent to us by a soldier.  It’s hard for me to read it as it conjures up a confusing gumbo of emotions – sadness and tears, joy, hope, and several more.  I had cared for this particular soldier as I remembered his name and knew the day of his injury from what he revealed in the letter.  I was on call that day, July 4^th.  This is part of what I read today:

My name is AJ and something I had never thought possible happened yesterday.  I was able to personally thank someone who worked on me at Role-3 in KAF.  A Dutch gentleman who was on vacation in D.C. stopped in my room at Walter Reed and told me he was my anesthesiologist.  It felt incredible to thank him and I hope to do the same thing for the rest of you with this letter.

I think you might remember me, if not by my wounds then by the date I was hit.  I was patrolling the Arghardab River Valley when I was hit by an IED on July 4^th, and came in with two other soldiers.  One was KIA… I received a shrapnel wound to my leg and face. 

From the stories I have been told I can do nothing more than marvel at the shear tenacity and skill you all portrayed in not only saving my life, but saving my leg.  I was informed about the marathon surgery and huge amounts of blood I was given and am so thankful to each and every one of you I can’t put it into words.

The best way I can thank you is to tell you I that I was discharged from Walter Reed today and am now an outpatient.  Everything is going great and I am expected to be able to walk and even run in small amounts…

There are many people who helped save my life but all of you at Role-3 played a major role and I am eternally grateful.  I plan on spending the rest of my life like it’s a second chance and I don’t intend on wasting it.  I have a wife and a 13 month old daughter that I am spending time with right now. 

Thank you for the hard work you are doing.  You are making a difference in people’s lives.  Continue saving lives and return home safely.

Now, I have to say that I feel a little guilty publishing this letter.  But I have a feeling that AJ wouldn’t mind if he knew that a fair number of spouses, parents, and siblings of folks who work at Role 3 follow this blog.  They can be proud knowing they might have played a part in saving this young man’s life.  Thank you AJ, for letting us all know.

When I leave, my biggest regret will be in leaving AJ and his peers behind.

"Peace Be With You"

07 Aug 2010

Kandahar, Afghanistan

That key moment in the Catholic mass when the priest passes on Jesus' blessing has always been my favorite.  One shakes the hand of his or her neighbor, wishing them peace.  As a child it was a break from the monotony of the vigils, the prayers, and the Latin, none of which I understood.  As an adult I appreciate the sentiment, and I do understand.

"Peace be with you," urged our Canadian priest.  As the tail of a giant C-17 aircraft rolled from left to right in the windows behind him I thought to myself, This is the strangest place I have ever celebrated mass.

Through those windows, about 100 yards beyond, was the place where I examined the mangled bodies of the six suicide bombers a few days before.  A couple of dozen yards beyond that lies the runway where fighter jets, unmanned aerial vehicles, and Afghan Ariana airways jets take off.

While on call during the 30 hours preceding the mass, I had had in succession three very tragic admissions.  The first was a 24 year old woman who was 12 weeks pregnant.  She had been riding on a motorcycle with her husband and young child, shot from behind.  She was now paralyzed from the waist down, a bullet disrupting her spinal cord.  Her husband had survived but her young child was dead.  The child she carried had now survived the gunshot, the crash from the bike, and now two surgeries.  Peace be with you, baby.  Maybe God has a plan for you.

Early this morning in the trauma bay, not 50 yards from our makeshift chapel, a twelve year old child was brought in from the field, ashen grey.  An ultrasound probe placed on his chest confirmed what we already knew - he was dead on arrival.  Another IED blast victim, may he rest in peace.

Two hours before mass, just down the hall from where mass was being celebrated we admitted a young man from the OR who was dying in front of us.  He had been shot in the abdomen and had been down for awhile.  He was taken directly to the OR where he received a emergency thoracotomy, an aortic clamping, and a laparotomy which showed over 1.5 liters of blood.  Despite heroic efforts by the surgeons, the bleeding could not be stopped.  He was delivered to the ICU on three different vasopressors designed to maintain blood pressure, fluid and blood products running quickly into his veins.  His blood pressure was in the 50s despite all this.  More epinephrine boluses were given but it was clear that our efforts were futile, as blood continued to pour out of his chest tubes and various drains.  As is custom for Muslims, we had him face Mecca and called in an interpreter to read from the Koran.  

I thought of these events as I shook the hands of the small group that had assembled for mass.  Peace be with you, I told them.

Body Parts

05 Aug 2010

Kandahar, Afghanistan

The other day I was observing a splenectomy (removal of the spleen) in the OR.  The patient was a young child who had developed thrombocytopenia - low platelets - and by removing her spleen her platelet levels should begin to rise.  It was satisfying to see an elective procedure that had nothing to do with trauma for a change.  One of the OR techs standing next to me informed me that she had made the necessary arrangements for the soon-to-be-removed spleen.  What do you mean by that?, I inquired.  She explained that it was customary for Afghani Muslims to be buried with all of their parts, so we had to call Mortuary Affairs to come to the hospital to collect any body parts that are removed, whether it be a traumatically amputated limb, or a spleen.  My head began to spin when I tried to envision how this little girl's family would deal with a spleen in an urn or bag when they got back to their mud hut in whatever village they were from.

The girl has done well post-operatively.  No idea where her spleen is at this point.

This morning I was called to do a task that I would be happy to never do again.  The suicide bombers of yesterday were apparently sitting in body bags at Mortuary Affairs.  Someone had to fill out their death certificates.  A British medic drove me over to the refrigerated conex boxes sitting adjacent to the flightline, making small talk about the weather.  He was the one who had to pick up the body parts after their failed attack.  He was clearly disgusted and perhaps a bit traumatized, if I read him correctly.

With the help of another gent, I unzipped the six black bags one by one, biting my lip.  I really didn't want to see what was inside.  There certainly were recognizable human parts, admixed with brown scrub brush and dirt.  There is something obscene about seeing hair, skin, and flesh gathered together in no recognizable pattern.

I had problems filling out the death certificate.  What would I call the cause of death?  Occasionally we who work in the ICU have to be creative when filling out these forms: many of our patients expire with multiple organ systems in failure at the time of death.  But what about when someone blows himself to bits, what then?  I chose sudden cardiac death, which at least on some level seemed to fit.  I learned later that the correct phrase is total body disruption.  Grisly, in a semi-sterile sounding way.

As I walked out of Mortuary Affairs I wondered about their families.  Were they proud of their sons, their brothers?  Was it worth it?  Where do these bodies go from here?, I asked. The International Red Cross mediates the exchange of bodies apparently.  Or what's left of them.

Bombshelter Blues/Bloodbath

04 August 2010

Kandahar, Afghanistan

Heard in the bombshelter yesterday morning: "This makes 51 rocket attacks and two ground attacks!"  There was a tone of excitement in his voice.  He didn't give a time range over which this occurred, but it seems like I've lived through more than 51 of these things.  I am weary of them.  I returned to my book, awaiting instructions from the Great Oz.

I had gotten to the bomb shelter early, having been out on the flightline again, a few yards away.   I had had a few spare hours on my hands before I taking over the ICU for another 24 hour shift.  I was daydreaming about Alexander's initial seige on the Persians a couple millenia ago when the sirens went off.  The cousins of the Persians now attacking us, I thought to myself as I lay on the ground, dust filling my nostrils.  I heard two Shoomp-Shoomps of rockets landing somewhere nearby, and then scurried my ass over to the shelter.

The day had started inauspiciously.  Earlier that morning I had noted that we hadn't had a rocket attack in at least 10 days.  The rumor is that the security forces are finally trying to smoke out the area from which the rockets are launched - brilliant tactic.  Maybe they were finally making a difference, I thought to myself as I headed towards the Kandahar International Airport.  As I finished the last 100 yards of my 30 minute run the sirens had gone off.  I sprinted much faster than I thought I could to the nearest bomb shelter.

The ne'er do wells were out in force yesterday.  Their ground attack was as brazen as it was ludicrous.  From the details that are emerging it seems that at the time of the flightline rocket attack, two of them simultaneously detonated explosives (and themselves) at one of the perimeter gates, paving the way for a tractor which attempted to breech the fence.  Ten other insurgents bum-rushed the gate and were promptly gunned down by a .50 caliber machine gun.  It was a short attack but created the usual mayhem on post.  We were confined to a hardened shelter - the hospital for me.   Great Oz kept barking out non-information updates, most incomprehensible, but we did finally figure that we now could go about our business on base only if dressed in flak and helmets.

I was happy to be on call yesterday.  Going anywhere in flak is so onerous I would rather just stay put.  We had a steady stream of patients throughout the day - only a few injured from the rocket attack, fortunately.  After an eventful night in the ICU which included the small 50% burned child "coding," and being subsequently resuscitated at about 4am.  He had stopped breathing after being overmedicated with narcotics for his burns.   Shortly after wrapping up the code and feeling assured the child was safe, I was paged with word that a patient with traumatic amputations was inbound.

He arrived at 6:15, crazed and yelling that he couldn't breath.  This is odd because if you can yell that you can't breath, you probably don't have an intrinsic lung problem.  It didn't matter, he would soon be sedated and have a breathing tube inserted into his trachea.

He was thrashing around and it was difficult to gain iv access.  I could feel his blood dripping off his macerated right arm onto my shoes.  I looked down, blood was everywhere.  His arm clumsily fell off the gurney by accident, the damaged bones evident by the limp and awkward way it dangled.  I lifted the arm gently back onto the gurney.  More blood.  He was cold, having been in the field a long time and his cold blood was acidic, resulting in problems with coagulation.   Another doc and I attempted to place large bore central lines below his clavicle.  Neither of us were successful.  I finally managed to get one of these lines into his femoral vein, in his groin.  We had been in the trauma bay all of 5 minutes and it looked like a slaughterhouse, blood everywhere.

I spent the next six hours with him, resuscitating him, putting in more lines through which blood, plasma, and platelets could be poured with our Level One, our life-saving blood pump.  We frenetically gave calcium, bicarbonate, vasopressors to increase his blood pressure, warmed saline, and other life-supporting fluids and medications.  We were going backwards, blood dripping onto the diaper-like "chucks" under the patient, and ultimately spilling on the floor.  I eventually made the decision to activate the "walking blood bank" - legions of volunteers of various blood types that could be summoned to donate "whole blood" of the appropriate type which would be pumped into the patient ("whole blood" as opposed to component therapy - packed red blood cells, plasma, and platelets, which occurs 99.9% of the time).  After over 120 units of blood component therapy and over 12 units of fresh whole blood we finally turned the tide, and the parameters of coagulation began to right themselves.  We had transfused many human being's worth of blood to save his life - a veritable bath of blood.

We Don't Need No Stinkin' Patches

02 Aug 2010

Kandahar, Afghanistan

We don't need patches, but we seem to like them.  There has been a proliferation of unit patches representing the various departments and sub-departments, thanks to some creative minds and a willing embroidery shop here on the Boardwalk.

Every patch tells a story.  The one above is the trauma bay patch showing the silhouette of the UH-60 helo that brings us our wounded, and the one in which we on the Enroute Care team fly when picking up casualties.  Their motto is curious: "Actually, We Don't Have Any Days Off."  It's true that the trauma teams never seem to have a day to themselves, which distinguishes them from their nurse counterparts in the ICU or ward who work two days on and two days off.  Apparently this assertion has created a rift in the nursing community - I am finding this out via my roommate, who is a nurse.

To be frank, I preferred their other motto they were considering: "Will Work For Hot Meals."  The story behind this is as follows:  because we tend to spend large tracts of time in the hospital when casualties come in, need to go to the OR, need resuscitation in the ICU, etc, we often would miss dining facility meals and have to eat the meals brought in from these DFACs.  The patients have first dibs on the food, of course, but there was usually plenty of food - hot food - to feed the hospital staff as well.  We would eat these meals when we were in the old ROLE 3 in a place called the "Standeasy."  The Standeasy was a tent that was "tricked out" with a wooden deck, Christmas lights, and an old dimming TV on the inside.  There were several fly strips hanging from the ceiling, filled with decaying black flies.  It was gross and quaint at the same time.  It was comforting because one could sit on a frat-worthy couch and eat some warm food, away from the trauma bay or ICU - you could forget them for 30 minutes or so, which was good for the soul.


One of the trauma team members applying the logo to a helicopter door, which was brought to us as a makeshift litter during one of our mass casualites.

Apparently we ate too much food and some was being wasted.  So instead of titrating the right amount of food through trial and error, the command decided to nix hot food for the staff.  We now eat day or two old sandwiches, cold and very unappetizing.  This has been a nagging sore which hasn't quite healed since the policy was instituted.  In the Navy when deployed, one has few things to look forward to:  mail and hot food comprising most of those things.  When the food gets screwed with, folks get angry, and they have been for awhile.  As one nurse told me recently, "It chaps my hide that I have to serve a hot meal to a Taliban, then go to the break room to get my nasty cold sandwich."  I couldn't disagree with him.  So, "Will Work For Warm Meals" struck the right cord with me, but I think the patch-makers were a bit spooked knowing the command would eventually (quickly probably) find out about the motto.

I designed the ICU patch, "Like a Cobra Bite to the Face."  If you've been following along you may recall that we had a child who was bitten by a viper on the face, a story the ended up on the front page of the NY Times.  The child had initially been billed as a cobra bite, and the legend has endured.  The phrase "like a cobra bite..." has become part of our vernacular here in the ICU.  If you've had a bad day, it's "Like a Cobra Bite to the Face."  OK, we're admittedly a bit stir crazy after 6 months.

My favorite patch is the lime green CCAT Anesthesiologist patch - "Passing Gas in the O.R. or at Altitude."  The CCAT team is the crew that takes our sickest patients from our ICU eventually to Germany.  They are manned primarily by anesthesiologists who typically work in OR's in military hospitals in the states.  They work hard and under challenging conditions, usually with several patients "trying to die," riding in a C-17 which happens to be very crowded and extremely loud.  As far as I know, there has never been a death while on a CCAT mission.  Incredible.  Oh, passing gas refers to the gas of sedation used in the O.R. - we call anesthesiologists "gas passers."  Every subspecialist has his or her own monniker:  ENT docs are "booger pickers."  Orthopedic surgeons are "knuckle draggers."  Internists are "fleas" - the last thing to leave a dying subject.  A stethoscope is a "flea collar."  We're a weird bunch, but keeping things light keeps one's sanity intact.