Innocence Lost

"We owe our children, the most vulnerable citizens in our society, a life free of violence and fear."
 Nelson Mandela



When we have long stretches of quiet, three or maybe four days, I begin to develop a sense of foreboding. It's difficult to describe, but I feel as if we are going to be punished for the lack of casualties in the preceding days. I become tense from both inactivity and this sense that something, something very bad, is going to come through the door. 

Yesterday, November 21st, was a bad day. The call came from the local Afghan hospital in Sharana. They have 3 civilians injured by a land mine. Their ages are 6, 8, and 20. As usual, the story behind the injuries is suspect, but that really doesn't matter at this point. We agree to accept the two most critically injured of the patients - the 6 and the 20 year old.

I knew it was going to be a bad night as soon as I saw the faces of the medics when the ambulance doors opened. They were obviously distressed by what they saw. The back of the ambulance was dark, but I could see one of our medics doing CPR. I say out loud, to no one in particular, "I hope that is not the child they are doing CPR on." It was the child.

The child comes off the ambulance first. His face is terribly mangled by the blast. The injuries are beyond description. We direct him to Trauma bed number 2. I decide that patient 1, the 20 year old, will have to wait for an anesthetist until we figure out how to intubate (put a breathing tube) the 6 year old. We quickly determine that the child has a pulse and the two of us discuss how to go about intubating him. We conclude, despite the extent of his injuries, that we can get him intubated without doing a cricothyroidotomy (making an incision in his neck to access his trachea). After 2 attempts, my colleague intubates him successfully with a Glidescope.

I immediately leave the child to attend to the 20 year old. His injuries are serious as well. He has a severe blast injury to his right forearm. His hand is almost black from the lack of blood supply. He will need surgery to revascularize his hand.

Meanwhile, the resuscitation of the child continues. The resuscitation team learns that he has a badly fractured skull - which means he likely sustained a serious brain injury. The difficult decision is made to do a frontal craniotomy in an effort to give this child a chance for survival. We have no neurosurgeon. The general surgeons and the dentist will have to do it. During the surgery it becomes obvious that the damage done to his brain is severe. The surgeons struggle to relieve the pressure on his brain. They do everything they can, but his vital signs remain unstable.

After surgery, the child is taken to the ICU. Everyone works feverishly to stabilize his vital signs and curtail the swelling of his brain. However, it becomes obvious that there is nothing else to be done. At 1:10 am, on Thanksgiving Day, the child dies. I take some solace in the fact that he did not die alone. He was surrounded by the servicemen and women of the 691st FST. We never even learned his name.

Trauma # 4028 and 4029

MAJ Randall D. Moore, CRNA
691st Forward Surgical Team
FOB Sharana, Afghanistan