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.