Back To "Normal"

The last few days have been a bit busier. Since my last post, we have seen a half dozen trauma patients and have done 4 cases. One patient was shot through the face, neck, and shoulder. He was a challenging intubation but Kevin did a nice job with him. We did a neck exploration (which was negative), washed out the wounds, and transferred him to Bagram intubated. One of the ER nurses from home, Carl Kusbit, came here with the medevac team to pick him up. It was nice to see a familiar face. Later that night, we got word that a patient was coming with "vomiting and abdominal pain". It was 23:00 when the call came in, and he was supposed to be here in 10 minutes. 3 of us waited about 45 minutes for him to show up. When he arrived, he indeed had emesis all over his face but he also had a left leg deformity, left chest crepitus, and a fractured pelvis. He had agonal respirations and no detectable blood pressure. We quickly ramped things up and awakened the rest of the team. He was intubated, lined, and had bilateral chest tubes inserted. He didn't improve, so I performed an ED thoracotomy. We worked on him for about 30 minutes but were not able to salvage him. I learned later that he was likely hit by a car, and a couple of his "buddies" dumped him off at an OCP near downtown Ghazni. This is the norm here; the reports are inaccurate and it takes a long time to get the patients to us. It's very frustrating. I assume he died from hemorrhagic shock but the source is not clear. I did a post-mortem FAST which was negative and shot a pelvis X-ray, which revealed the fracture. I assume he bled from both the pelvic and lower extremity fractures. I wish he could have gotten here faster; we might have been able to help him.

Two days later, we had 3 patients show up in rapid succession. One was a 10 year old boy who was caught in the crossfire between ANA soldiers and the Taliban. He was hit multiple times in the lower extremities. We washed his wounds out in the OR and sent him to the local hospital. He was very lucky because the bullet/shrapnel barely missed his superficial femoral artery, and he did not sustain a fracture. If his artery would have been injured, he surely would have died before he made it here. While we were finishing that case, we got word that 2 locals were coming in with multiple injuries after running into an IED. One patient sustained only a lumbar fracture and was very fortunate. The other patient had multiple soft tissue injuries, an open ankle with transection of the dorsalis pedis artery (he had a tourniquet in place when he arrived), and a positive FAST but was, surprisingly, hemodynamically stable on arrival. We washed out his wounds, ligated the DP artery, splinted his ankle, and I did a laparotomy and removed his spleen. It was a trivial splenic injury; one which we would have probably observed back home. Without a CT scanner, though, I was forced to explore him. I thought about repairing the spleen but I'm not convinced that follow-up is good at the local hospital, so I thought it was safest to remove it. We don't have post-splenectomy vaccines here, and neither do the locals. I think he'll be okay without them, though, because he actually had a small accessory spleen (purple tissue in the picture).

In the middle of all this, we heard about another patient coming with a GSW to the chest. There was some delay in getting to him because the LZ (landing zone) was still hot. By the time the Polish medics were able to reach him, he had already died. There was some question over how he died and whether or not the body was packed with explosives by the Taliban. This turned out to be a huge international incident because the Afghans were upset that the Polish didn't take the body away immediately and the Polish/Americans were obviously concerned with their safety in retrieving the body. I was asked to give my opinion on the mode of death, i.e., was he shot or was he cut open with the intent of packing the body with explosives. After the EOD (explosive ordnance disposal) guys cleared the body, I looked at it and took some X-rays. He sustained a GSW to the thoracic inlet, and the bullet traveled through the thorax and abdomen, ultimately coming to rest in the pelvis. From what I could see (we did not do a formal "autopsy"), it lacerated his left subclavian artery and who knows what other damage it did. It would have been a very challenging case had he been able to get here alive.

From a "non-trauma standpoint", things are going reasonably well. I've been blessed with tons of care packages the last couple weeks. Have received stuff from my wife and children, my in-laws and parents, aunts & uncles, co-workers, and my childhood church. I now have more food than I could possibly eat even if I were here for a year. The little Afghan boy with burns was sent back to us this week from Bagram. They decided not to graft him; I'm not sure why. The wound continues to heal nicely, however, and we enjoy having him around. We've been feeding him Rice Krispies treats after his dressing changes; he loves them. On a more somber note, one of the Polish soldiers from this FOB was killed yesterday in an RPG attack. It's the first soldier we have lost from here since my arrival. They had a "fallen soldier" ceremony for him today, which I'm told was very touching. Sadly, I couldn't attend because I was seeing another patient at the time.