WOW!! What a week!

First, I must apologize for not writing in 7 days. In my defense, though, it has been a bit crazy at times this week. Will try to summarize the high points.

Generally, we don't do a whole lot here late at night (unlike back home). I'm not sure what the reason(s) for that are, but I assume that most military operations are happening during the day. This week was a bit different, though. Sunday night, I was asked by the Polish to see a soldier with abdominal pain. His history and exam were classic for appendicitis, so I did an appendectomy. Caught it early enough; he hadn't perforated yet. It was a fun case because we don't have any laparoscopic equipment here, so I did it the "old-fashioned" way. Hadn't done an open appy for 3 or 4 years. Since it was a Polish soldier, I had their orthopod scrub in with me. I think he enjoyed the case as well. The patient has done well and is back with his unit. The Polish nurses were happy with his scar, too. One of them showed me her scar (which was huge) and said she wished I had done her operation. Guess that was a compliment. After the case, I wandered up to the D-Fac and caught the last 6 minutes of the Steelers-Bengals game (it was about 01:00 here); that was a real bummer.

The next day, we had a couple more patients. One sustained 2 GSW's; one to the forearm and one to the thigh. No vascular injuries; we placed an ex-fix and evac'd him to Bagram. When I called them to give report, I spoke with COL Warren Dorlac. He's the trauma director for both theatres (OEF & OIF) and he wanted to come visit us since we were all "new", so he flew down here on the Medevac. He's a really nice guy and very well-known in the trauma community (that's him in the center of the picture at the back). He gave us a run-down of the current data/outcomes coming out of both theatres as well as reviewed the military CPG's (Clinical Practice Guidelines). He only intended to spend a night with us, but he got "stuck" here for 2 days since there were no flights. It actually worked out well, however. We were invited to eat traditional Afghan food with several of the Polish and Afghan medical folks, so COL Dorlac joined us.

Shortly after the meal, we had another casualty. The patient was an ANA soldier who was involved in a car accident and sustained a horrible pelvic fracture. On the initial X-rays, it looked like the left hemipelvis was essentially free-floating. He was nearly dead when he arrived here, and we worked very hard to salvage him. Initial base deficit was -17, hemoglobin was 4, and INR was 3.4 (those are all REALLY BAD numbers). I've been looking for a chance to do preperitoneal packing, and I thought this guy might benefit. Neither I nor COL Dorlac had ever done it, but he had at least seen it done once before. We made a lower midline incision to access the preperitoneal space and, after being met with a lot of blood, packed it with combat gauze. I then lap'd him, which was negative. We activated the walking blood bank for him, which is where pre-screened donors give a unit of type-specific blood and then we give it directly to the patient. We only have packed red cells and FFP here (no platelets), so the fresh whole blood is awesome (and it works well). I forget how much we gave him, but it was a lot. We also gave him factor VIIa. We then placed an ex-fix and, after tightening it, realized he also had SI disruption on the right! He had stabilized somewhat after all this (INR 1.5) but was still on some vasopressin. I talked with COL Dorlac about going back in to ligate the hypogastric vessels, but we decided not to. Well, somehow he made it to Bagram alive (although he did arrest once on the helicopter) and they took him straight to the OR. COL Dorlac was with him (he used the Medevac flight to return to Bagram) and the first thing they did was ligate his hypogastrics. They also found, however, that his left external iliac artery and vein were completely transected at the level of the inguinal ligament and they shunted both of those. I had only ever seen this type of injury once before, but it was in the setting of an open pelvic fracture and was much more obvious. I've been beating myself up all week for not ligating the hypogastrics here and for not exploring his groin (I actually thought about doing it once during the case when he wasn't getting better after packing). He had an impressive hematoma around both groins while he was here and we couldn't feel pulses in either extremity but we attributed it to hypotension. I wish I had a doppler; maybe it would have made a difference? That being said, he woke up at Bagram and followed commands. They ultimately did a left above-knee amputation and repaired an extraperitoneal bladder injury. The other day, they attempted to repair his pelvis but the orthopod said it was unreconstructable and he would require a hemipelvectomy. This is a death sentence in Afghanistan, and the ethics committee is discussing what to do next. Sadly, I don't expect him to survive.

Two days after that patient, we had another ANA soldier come in with extensive injuries from an IED blast. He was wearing a Kevlar helmet and body armor, which saved his life. In the picture, you can see tourniquets on both thighs. These are a life-saver here. He was not bleeding at all from his legs. However, he also was near-death when he arrived and had lab values similar to the guy above (in fact, our machine said his hemoglobin was "too low to detect"). In a span of 4 days, we activated the walking blood bank twice! He required a right above-knee amputation and we washed out extensive wounds to his left leg and left buttocks. The wounds here are VERY DIRTY and are filled with rocks, bolts, screws, and whatever else they can pack into an IED. I did a proctoscopy on him as well, but the rectum was uninjured. For as sick as he was when he arrived, he left here with a normal pH, an INR of 1.2, a hemoglobin of 11, and he was not on pressors. He received 13 units of fresh whole blood, 4 packed cells, 4 FFP, and 4 cryoprecipitate as well as factor VIIa. Again, a testament to the utility of fresh whole blood. In Bagram, they diagnosed a small epidural hematoma and a mandible fracture as well, but he is awake and following commands! I have to say, if you've never seen the walking blood bank in action, it is AMAZING. These last 2 patients really exemplify the strength of the team that we have here. All 14 members of this FST were integral to the survival of these patients, as were the soldiers who graciously donated their blood.

On a lighter note, the little Afghan boy with burns is doing well. We have been seeing him every day and doing his dressing changes. He actually smiled at us for the first time today, which was cool. The wound is nice and clean. I'm waiting to hear back from the folks at Bagram about whether or not they will take him for a skin graft. Unfortunately, he is Med-ROE (Medical Rules Of Engagement) negative, so if they are busy with coalition cases, they won't take him. We don't have the tools to do it here or I would at least attempt to graft it. It will be a tough area, though, due to its proximity to stool and urine and the graft may fail. Any advice from my burn experts back home?

I also recieved my first mail shipment this week. Got packages from my wife, my dad and stepmother, my colleagues at work, and Lou Epstein even sent me the Pittsburgh Sunday paper. It's like Christmas here when you get mail, so thanks to everyone who sent stuff. I really appreciate it and it means a lot to me! Also, got to mix it up with some of the "brass" earlier today. The Afghans once again invited some of the medical team over for lunch. Did I say before how good the Afghan food is? Lamb is awesome! Anyways, I walked into the room and there were 2 full-bird American colonels, the Polish general, and some other very important people. I felt a bit like a fish out of water, but it was kinda neat. It's nice to be included in that crowd, I guess. They really appreciate the medical support that we give to the FOB. As an aside, my friend CPT Kevin Creel (our CRNA here) is also blogging. Feel free to check his site out at http://kevin-ghazni.blogspot.com/. Talk to everyone again later!