Angels Crying

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.

Simple Pleasures

There are a few things that I look at during a deployment that keep me somewhat contented with my present situation. I thought I would sit down and share a few of these little things.


We have relatively good showers here as compared to my last deployment. But even still there is something that is not very appealing about taking a shower with 10 other guys. But what few recognize is that if you break with conformity, there are some great benefits. Case in point, the first stall.

You see, the shower stalls are all very small. There is an A/C unit and ventilation system. This creates a flow of air from the back to the front of the walkway in front of the showers. Now the purpose of this is good, to prevent too much humidity from building up in the showers and cause a bad mold problem. However the byproduct of all this is creates a small physics problem. When the shower curtain is closed and the hot shower is running the cool air falls down and the hot air rises, the curtain is pushed into the stall. This means that everyone who takes a shower also ends up cuddling with the curtain. That’s OK if you like rubbing up against the same curtain with which about 100 other naked guys also cuddle. In addition to this when each person gets out of the shower, they leave the shower curtain open. This causes moisture to be trapped in the folds of the curtain. This moisture never dries out and thus little areas of mold start to grow in the folds, leaving the next guy to cuddle with the moldy curtain.

But the first stall is magical! No one ever uses the first stall because it is right by the front door. There is a perceived threat that if just at the point when you are about to step in the shower, the front door will open and you will be “hanging in the breeze”. But if you can get passed this unreasonable fear, you can find the secret of the first stall. At the very top of the wall of the first stall (and only the first stall) there is a 2 foot by 6 inch opening to the outside where the hot water pipes come into the shower building. This opening allows a gentle breeze from to inside of the stall and out to the hall that actually bellows the shower curtain outward, giving the showerer 6 more inches of valuable space. This breeze is very dry and thus dries the shower out very shortly after the shower is completed. In addition, no one uses this shower so there aren’t multiple people getting the stall wet and causing mold to grow; leaving me with practically my very own shower stall, clean and dry.

But there are more little things that make this deployment enjoyable. Time. I have more free time here than I ever have had in my entire life. It is great to be able to sit down and read a book for several hours per day. Having time at this period in my life is great for me. During medical school and residency, I was working inhumane hours. Now that I have finished that season of my life and now that my national boards are done, I can finally enrich my life with other things besides medical education. I am reading Joel Rosenberg’s Inside the Revolution and Augustine’s Confessions and Bill O’Reilly’s Pinheads and Patriots and Margaret Hogan’s My Dearest Friend – Letters of Abigail and John Adams. In addition to these, I am in a Bible Study and reading the Bible from cover to cover. This is a great time of personal, spiritual, and intellectual growth. The downside of this is it comes at a great cost to Kari and the kids. Of this deployment, my wife is far more the heroine than I a hero.

A few other simple things….the sunsets here are just as beautiful as home. The moon rise is magnificent. The stars are as clear as they are out in Proctor Colorado. We have encredible pecan pie and pralines and cream ice cream at the dining facility (DFAC). I have an actual bed. And I have a family that loves me.

Life is good. Thank you God.

We Will Never Forget

I take off my shoulder holster and hang it on a nail on my desk in my tent in the western Afghan town of Shindand to write these thoughts down. AFN is broadcasting the ten year anniversary memorial services at ground zero in New York. They raised the original ground zero World Trade Center flag as children that were merely infants at the time of 9/11 events, sang the national anthem. Moments of silence were observed at the exact times of the plane crashes and the collapses of the buildings. The President, our first black president, reads Psalms 46. The names of all the victims are announced.

I remember where I was 10 years ago. I had just finished one of the morning classes in Kirksville and headed into the lounge. About 10 other medical students were fixated on the TV as the news was replayed over and over again of the first plane hitting the first tower. Then we watched in horror as on live TV a second plane flew in from the right of the screen and plunged into the second tower. I knew on that day, as did the 20 or so other HPSP scholarship medical students, that our lives had suddenly taken a huge turn. I had a feeling at that time that I would be sitting in a place like this doing what I am doing.

All around the world people are commemorating today in their own various ways. In Kabul today they are having a large ceremony and raising the flags of over 30 different coalition countries that are militarily invested in this War On Terror. And they are doing this the very next morning after being hit with a car bomb that injured 77American troops. Here at Shindand, there is a 24 hour ruck march of remembrance during which soldiers from midnight of September 11th to midnight of September 12th will take shifts carrying the American flag around our flight line. Each person on the FOB remembers in his or her own way the events of 9/11. Some people seem calloused, while others are a very emotional. All of our lives collectively were changed on that September morning, resulting in all of us being here now.

I remember how angry I felt at the time. The thought that people would kill innocent people in the name of Allah seemed unthinkable. But now, the head of those responsible for the tragedy, Osama bin Laden, was killed by Navy SEALs, shot once in the head and twice in the chest. He has now faced the final judgment of God. And now the 3 other top Al Qaida leaders were captured. We are a strong nation.

But despite the patriotism, I cannot escape the chilling words of our Savior Jesus Christ, “When you hear of wars and rumors of wars, do not be alarmed. Such things must happen, but the end is still to come. Nation will rise against nation, and kingdom against kingdom. There will be earthquakes in various places, and famines. These are the beginning of birth pains. You must be on your guard….” When we say we will never forget, let’s never forget the important things, the things that are eternal.

Keep On Keeping On

Deployment has a way of sneaking up on my emotions when I least expect it. The other day I thought that I was doing well, when some news came my way rather unexpectedly. This particular piece of news, although I cannot share its contents, was not good. And from laughing and joking with my colleagues, we all sort of paused and looked at each other. After a weird collective insecure silence, we all quickly finished our conversations and scattered to reflect, each in our own way, the content of what we had been told. This left me missing home tremendously.

For about 3 hours I was in an official funk. I didn't want to talk to anyone. I didn't want to eat. I didn't want to do anything. I just wanted to sit and be miserable all alone. And, I don’t understand why when I am in a funk; I also want to listen to depressing music. But whatever the reason, I was definitely in bad shape.

Then, I went to dinner with my normal group that goes to dinner together. We all vented our frustrations. Before long I realized that I was here with other people that really know what I am going through, because they are going through the same thing too. I know this sounds obvious as I write this, but when you are wading through the bog of emotionality, the retrospectoscope is nowhere to be found, and practical reasoning is just out of reach.

Each one of us carries each other’s burdens as our own as we share a common experience. And it is surprising that this is all within a primarily secular environment. Why can’t we translate what we experience here as soldiers, back to our churches as soldiers for God? Personally, I think it is because back home we, deep down, don’t really believe we are in an all-out war for the souls of those we live around. And the Evangelical Church’s idea of community isn’t even close to the kind of community that is established here. In truth, life here is far closer to a commune.

But whatever the reasons were, after dinner we were feeling much better. That’s when I looked up and saw this huge flag in the hanger of the fire station near the hospital. I turned to the PA that works with me and suggested that that would make a perfect back drop for a picture. He agreed. And after asking the fire dept guys if we could climb on there truck, we laughed as we snapped a couple of pics each.

God Bless America, may we keep true to the Biblical values that founded our great nation.