Today was an exhausting day. I woke up to after staying up way too late to go over to the clinic and see some follow-up patients. These patients were Afghan army soldiers that we had taken care of after they were shot by the Taliban in the legs and abdomen two months ago. They were doing well. After fixing their intra-abdominal wounds, we had put external fixators on to stabilize the fractures and sent them for definitive surgery at a local afghan hospital. We found out later that they don’t have any capability at that hospital to do the definitive surgery that they need. Instead that hospital took them in, collected the money from the government to take care of them and after they were “stable” they got discharged from the hospital. The problem is that the hospital does nothing for the external fixators. They just leave them on! And then we see them back at 2-3 months after the accident and our eyes were like saucers to see the ex-fixes still on. The fractures don’t heal very well. But they are slowly healing. The ex-fix is not supposed to be the definitive surgery for these types of fractures.
Anyway, we were seeing these follow-up patients when the radio started blasting that there had been an IED explosion and 4 afghan locals were wounded. About twenty minutes later, they were coming out of the back of the Field Litter Ambulance… two kids, two adults. The first one out the door is an older female…she’s dead. The next one out is a stretcher with two kids on it. The kids were so small that they were laying with one head at one end of the stretcher and the other kids head at the other end of the stretcher and their feet didn’t even meet in the middle. There was a boy and a girl. The girl was about 5 and barely over 20kg. She was trying to roll over to one side but not crying or moaning. She had huge black eyes and abrasions over her face and head. Her left arm and leg are bent in ways that God did not intend. The little boy…a little smaller than the girl was crying (thank God for crying…it means that the airway and lungs are intact). I was almost as happy to hear that little boy cry as I was to hear my own boy first cry when they pulled him through the c-section incision when he was born.
I went busily to work on the little girl. ABC. A…airway; she was unconscious and could not protect her own airway if she were to vomit. She needed to be intubated (a breathing tube placed in her mouth and down into her trachea to prevent her from suffocating). The anesthesia providers went to work and easily intubated her. Next…. B ….breathing; they squeezed the ambu bag and her little chest didn’t rise, but we could hear breath sounds on both sides. Her O2 saturation was low but had come up slightly. We got a chest x-ray that revealed the problem ….she had air outside her lung that was collapsing her lung on the left. I placed a chest tube to release that air and that helped things a little bit. But still she had low O2 saturation…..think, think, think, what could be doing this. The x-ray showed that the tube was in good position and the repeat x-ray after we had put the chest tube in showed that the air was evacuated but what was I missing…..why was her O2 saturation so low……well her stomach was full of air, so we put a tube through her mouth into her stomach to relieve that air which helped, but she still had low O2.
I looked at the chest x ray one more time and thought about the mechanism of injury, then it hit me….pulmonary contusion! She had sustained a huge blast from the IED. That blast basically slammed her lungs into her chest wall causing huge bruising on the inside of her lungs. The only way to get more oxygen to the lungs was to increase the pressure of O2 in the airways. This can’t be accomplished with a non-cuffed endotracheal tube. We needed a cuffed endotracheal tube so that we could make a seal around the inside of the air way and thereby increase the pressure of the O2 in the airways. We did this and BINGO she started to get better…at least in regard to the breathing part.
A….dealt with. B….dealing with but improving. C…circulation. It is amazing how God makes little kids. During this whole event, her blood pressure was pretty steady and even appropriately high to help perfuse blood to her badly injured brain. Still I add a central line to the left subclavian vein to the mix to give us a fighting chance to be able to resuscitate this little girl.
Now how about the brain… What was I to do with the head injury? Clearly she had a horrible head injury evidenced by her “raccoon eyes” and non-reactive right pupil. I gave her a dose of mannitol that helps lower pressure on the brain but she needs more than that. She basically needs a neurosurgeon RIGHT NOW. In the US she would already be in the OR….not here. So we call the nearest neurosurgeon.
The response I get is chilling…no neurosurgical intervention for Afghan locals that come in to the ER with a GCS of 8 or less. That is the Clinical Practice Guideline (CPG) in theater.
The words hit me like a ton of bricks. The neurosurgeon on the other end is actually someone I know from back home in the states. He says he will take her if I think that the head injury is the only thing that’s wrong. He wants to help, but it has to be an isolated head trauma.
I wish she only had an isolated head trauma. I put the phone down and take another look at her. For the first time in the hour that we have had her, her vital signs look stable. I look at the repeated Chest x-ray. She has one of the worst pulmonary contusions that I have ever seen. She has blood coming out of her lungs and into the ET tube from the bad contusions. She has a broken arm and a broken leg. This is the opposite of isolated head trauma. I grab the phone again and with a frog in my throat I tell him thanks, but she is not an isolated head trauma. He again says sorry. I say, “I know”. And we hang up.
So now I have stabilized her but her brain will continue to build up pressure until it no longer functions, and I can’t do anything about that.
So now I check on the other two patients that are alive. The little boy is doing fine. He is crying and the nurses are taking care of him like he is their child. There is something remarkable about seeing an American nurse holding and caring for a child like that. It is as if they temporarily adopt the child as their own. But he is doing fine. He is just a bit bruised and cut up but he will be fine. The last patient is a 35yo woman who is 9 months pregnant. The baby seems to be doing fine, although all we can check is fetal heart tones which are appropriate for gestational age. But the lady has a bad contusion on her head and had lost consciousness at the time of the blast. She has a closed head injury and needs a CT scan to make sure she doesn’t also have a intracranial bleed like the little girl.
The people in charge of arranging medivac flights get the next call. We let them know that we have two category alpha patients that need medivac to the local Afghani military hospital. I am not going to let the little girl die in this hospital. I feel strongly that the Afghan people need to see and treat the consequences of the IEDs that their own people are making. Despite some push back from the transportation arrangers, my friend that oversees them arranges that both the pregnant woman and the girl get sent to the Afghan military hospital. I know full well that the woman will be OK, but the little girl will die in about 12 hours. I just hope that the parents, if they are still alive, will be able to be there before she dies.
After a few minutes, the flight medics show up and the sound of blackhawks preparing for takeoff fills the trauma bay. We package up the patients, securing all the lines and take them out the door on stretchers and load them on the blackhawks. A few minutes later, they are out of site on their way up north.
I sit outside behind the ER exhausted. I sit for a while and reflect on the situation that just presented itself to me, while picking up little stones and throwing them at a coke can that had missed the trash can. I was a confused mixture of tired, angry, sad, and relieved. I was proud of what the team accomplished. We had stabilized 3 very sick patients and got them transported. We fulfilled our mission. But ultimately we can’t do what the little girl needed. I reason with myself that even in the US this girl with her head injury and her pulmonary contusion (not to mention the broken arm and leg) would have been “touch and go” for a while. She might not have made it even in the US, let alone out here in 2nd century Afghanistan. My stomach starts to growl and I head over to my tent to meet my buddies for dinner.
After dinner, I went walking through the hospital when the commander walked up to me and said that the Special Forces guys have a detainee that they need to have medically cleared before they send him for interrogation. So we lock off the back of the ER (the same room those hours before we fought to keep the little girl alive) and in walks a young man in a blindfold with a security escort. I look this 22 year old over and get a complete history and physical examination. He is perfectly healthy. He even smiles at me while I check his cranial nerves.
Just then the Special Forces SSG says, “I heard you guys were busy today.” “How’d you hear that?” I asked. “This is the guy that planted the IED” He coldly responded. Just then my blood boiled. This arrogant 22 y.o. punk that smiled at me just killed 16 of his own people including that little girl. The story that the Special Forces gave me was that the bomb had been planted for an Afghan army convoy that was supposed to go over that route today. Instead the convoy delayed a day and four cars packed with local Afghanis, headed to an engagement party for a couple that was getting married in a few weeks chose that route. That explains the little dress that the girl was wearing that kept raining sparkly sequence onto the stretcher as we cut her clothes off.
What a backward country. “We all, like sheep, have gone astray, each of us had turned to his own way; and the Lord has laid on him the iniquity of us all.” Isaiah 53:6. We all need a shepherd. Look what we are doing to each other.
Anyway, we were seeing these follow-up patients when the radio started blasting that there had been an IED explosion and 4 afghan locals were wounded. About twenty minutes later, they were coming out of the back of the Field Litter Ambulance… two kids, two adults. The first one out the door is an older female…she’s dead. The next one out is a stretcher with two kids on it. The kids were so small that they were laying with one head at one end of the stretcher and the other kids head at the other end of the stretcher and their feet didn’t even meet in the middle. There was a boy and a girl. The girl was about 5 and barely over 20kg. She was trying to roll over to one side but not crying or moaning. She had huge black eyes and abrasions over her face and head. Her left arm and leg are bent in ways that God did not intend. The little boy…a little smaller than the girl was crying (thank God for crying…it means that the airway and lungs are intact). I was almost as happy to hear that little boy cry as I was to hear my own boy first cry when they pulled him through the c-section incision when he was born.
I went busily to work on the little girl. ABC. A…airway; she was unconscious and could not protect her own airway if she were to vomit. She needed to be intubated (a breathing tube placed in her mouth and down into her trachea to prevent her from suffocating). The anesthesia providers went to work and easily intubated her. Next…. B ….breathing; they squeezed the ambu bag and her little chest didn’t rise, but we could hear breath sounds on both sides. Her O2 saturation was low but had come up slightly. We got a chest x-ray that revealed the problem ….she had air outside her lung that was collapsing her lung on the left. I placed a chest tube to release that air and that helped things a little bit. But still she had low O2 saturation…..think, think, think, what could be doing this. The x-ray showed that the tube was in good position and the repeat x-ray after we had put the chest tube in showed that the air was evacuated but what was I missing…..why was her O2 saturation so low……well her stomach was full of air, so we put a tube through her mouth into her stomach to relieve that air which helped, but she still had low O2.
I looked at the chest x ray one more time and thought about the mechanism of injury, then it hit me….pulmonary contusion! She had sustained a huge blast from the IED. That blast basically slammed her lungs into her chest wall causing huge bruising on the inside of her lungs. The only way to get more oxygen to the lungs was to increase the pressure of O2 in the airways. This can’t be accomplished with a non-cuffed endotracheal tube. We needed a cuffed endotracheal tube so that we could make a seal around the inside of the air way and thereby increase the pressure of the O2 in the airways. We did this and BINGO she started to get better…at least in regard to the breathing part.
A….dealt with. B….dealing with but improving. C…circulation. It is amazing how God makes little kids. During this whole event, her blood pressure was pretty steady and even appropriately high to help perfuse blood to her badly injured brain. Still I add a central line to the left subclavian vein to the mix to give us a fighting chance to be able to resuscitate this little girl.
Now how about the brain… What was I to do with the head injury? Clearly she had a horrible head injury evidenced by her “raccoon eyes” and non-reactive right pupil. I gave her a dose of mannitol that helps lower pressure on the brain but she needs more than that. She basically needs a neurosurgeon RIGHT NOW. In the US she would already be in the OR….not here. So we call the nearest neurosurgeon.
The response I get is chilling…no neurosurgical intervention for Afghan locals that come in to the ER with a GCS of 8 or less. That is the Clinical Practice Guideline (CPG) in theater.
The words hit me like a ton of bricks. The neurosurgeon on the other end is actually someone I know from back home in the states. He says he will take her if I think that the head injury is the only thing that’s wrong. He wants to help, but it has to be an isolated head trauma.
I wish she only had an isolated head trauma. I put the phone down and take another look at her. For the first time in the hour that we have had her, her vital signs look stable. I look at the repeated Chest x-ray. She has one of the worst pulmonary contusions that I have ever seen. She has blood coming out of her lungs and into the ET tube from the bad contusions. She has a broken arm and a broken leg. This is the opposite of isolated head trauma. I grab the phone again and with a frog in my throat I tell him thanks, but she is not an isolated head trauma. He again says sorry. I say, “I know”. And we hang up.
So now I have stabilized her but her brain will continue to build up pressure until it no longer functions, and I can’t do anything about that.
So now I check on the other two patients that are alive. The little boy is doing fine. He is crying and the nurses are taking care of him like he is their child. There is something remarkable about seeing an American nurse holding and caring for a child like that. It is as if they temporarily adopt the child as their own. But he is doing fine. He is just a bit bruised and cut up but he will be fine. The last patient is a 35yo woman who is 9 months pregnant. The baby seems to be doing fine, although all we can check is fetal heart tones which are appropriate for gestational age. But the lady has a bad contusion on her head and had lost consciousness at the time of the blast. She has a closed head injury and needs a CT scan to make sure she doesn’t also have a intracranial bleed like the little girl.
The people in charge of arranging medivac flights get the next call. We let them know that we have two category alpha patients that need medivac to the local Afghani military hospital. I am not going to let the little girl die in this hospital. I feel strongly that the Afghan people need to see and treat the consequences of the IEDs that their own people are making. Despite some push back from the transportation arrangers, my friend that oversees them arranges that both the pregnant woman and the girl get sent to the Afghan military hospital. I know full well that the woman will be OK, but the little girl will die in about 12 hours. I just hope that the parents, if they are still alive, will be able to be there before she dies.
After a few minutes, the flight medics show up and the sound of blackhawks preparing for takeoff fills the trauma bay. We package up the patients, securing all the lines and take them out the door on stretchers and load them on the blackhawks. A few minutes later, they are out of site on their way up north.
I sit outside behind the ER exhausted. I sit for a while and reflect on the situation that just presented itself to me, while picking up little stones and throwing them at a coke can that had missed the trash can. I was a confused mixture of tired, angry, sad, and relieved. I was proud of what the team accomplished. We had stabilized 3 very sick patients and got them transported. We fulfilled our mission. But ultimately we can’t do what the little girl needed. I reason with myself that even in the US this girl with her head injury and her pulmonary contusion (not to mention the broken arm and leg) would have been “touch and go” for a while. She might not have made it even in the US, let alone out here in 2nd century Afghanistan. My stomach starts to growl and I head over to my tent to meet my buddies for dinner.
After dinner, I went walking through the hospital when the commander walked up to me and said that the Special Forces guys have a detainee that they need to have medically cleared before they send him for interrogation. So we lock off the back of the ER (the same room those hours before we fought to keep the little girl alive) and in walks a young man in a blindfold with a security escort. I look this 22 year old over and get a complete history and physical examination. He is perfectly healthy. He even smiles at me while I check his cranial nerves.
Just then the Special Forces SSG says, “I heard you guys were busy today.” “How’d you hear that?” I asked. “This is the guy that planted the IED” He coldly responded. Just then my blood boiled. This arrogant 22 y.o. punk that smiled at me just killed 16 of his own people including that little girl. The story that the Special Forces gave me was that the bomb had been planted for an Afghan army convoy that was supposed to go over that route today. Instead the convoy delayed a day and four cars packed with local Afghanis, headed to an engagement party for a couple that was getting married in a few weeks chose that route. That explains the little dress that the girl was wearing that kept raining sparkly sequence onto the stretcher as we cut her clothes off.
What a backward country. “We all, like sheep, have gone astray, each of us had turned to his own way; and the Lord has laid on him the iniquity of us all.” Isaiah 53:6. We all need a shepherd. Look what we are doing to each other.
Heartbreaking story. I have tears streaming from just reading it, but I needed to hear it. These are the stories that keep it real. This is a real war, may I, here in the comfort of my home, never become numb to it.
ReplyDelete