Bloody Sunday: Trauma # 4010 and 4011

Sunday was shaping up to be a pretty nice day. I taught an airway class in the morning to some of the medics and planned on taking it easy for the rest of the day. However, at almost exactly 12 noon we received the call - 2 Afghans shoot in a Taliban ambush. The initial reports were a bit sketchy, but it sounded like one patient was shot through the neck and critically injured and the other was shot in the back and was described as stable. 

Twenty minutes later the MEDEVAC helicopters arrive. I place myself at the "Triage Line" so I can get a good look at the patients after they are unloaded from the helicopter. Patient 1 was in fact shot through the upper right chest - not the neck. He has an intraosseous catheter in each leg - which is my first clue this guy is in trouble. His skin is gray. Clearly, he is in bad shape. The patient is directed to trauma bed 1.

Next off the helicopter is my casualty, patient 2, the gunshot wound to the back that was reported as being stable. He looks awful. His skin is an even more ominous color of gray than the previous patient. He is barely arousable. I ask the flight medic what medications the patient has received - hoping his altered level of consciousness is secondary to narcotics - the medic tells me no medications were administered. It's obvious to me at the point that this patient is in decompensated hypovolemic shock. He is dying. 

I help push patient 2 to trauma bed 2.  IVs are quickly established and he is placed on my monitors. I am pleasantly surprised to find a decent blood pressure. I intubate (put a breathing tube in) the patient after inducing anesthesia with Ketamine and Succinylcholine. I secure my breathing tube and look at the monitor. He doesn't have a blood pressure any more. He is now in Pulseless Electrical Activity (PEA) - which means that his heart is no longer pumping blood. We start CPR and do all of the things you do when someone's heart stops. After a few minutes of CPR and some drugs, we get a pulse.

Emergently, we take patient 2 to the OR in an effort to find whatever is bleeding in his abdomen. However, by the time we get him to the OR table his heart stops again. We start CPR and the surgeon decides to perform a resuscitate thoracotomy. His heart is empty and the only chance this patient has for survival is opening his chest and manually compressing the aorta while performing cardiac massage. This is the definition of a last ditch effort. His odds of survival are literally almost zero at this point. Fortunately, this "Hell Mary" intervention buys us some time. The surgeons now direct their attention to the abdomen, which is the most likely site of the internal hemorrhaging. His abdomen is opened in seconds. Copious amounts of blood, essentially his entire blood volume, pours out of the incision and on to the OR table and floor. The injuries to his internal organs are numerous and devastating.

There is a difficult decision that needs to be made. We have only a finite amount of PRBCs (transfusable blood) available. The other casualty, patient 1, has a serious chest injury and will require a massive amount of blood as well. However, statistically speaking, he has a much better chance of survival than my patient. Do we classify patient 2 as expectant and allocate all of the available blood products to patient 1, or do we make an effort to resuscitate both patients? Quickly, literally in a matter of moments, we decide to continue working on both patients. We notify the lab that we will start using whole blood obtained from soldiers on the FOB with compatible blood types. A call goes out to the entire FOB. Within moments we have 40 soldiers waiting to donate blood. Luckily, I and am able to place both an arterial line and a central line in the patient rather quickly. The transfusion of whole blood is given at such a pace, thanks to the expertise and skill of our medics, that I give up trying to keep track.

When it is all said and done, we transfuse over 20 units of blood products to my patient. We have to take him to the OR twice in order to control his bleeding. Remarkably, his blood pressure starts to normalize and the oozing of blood (from everywhere) begins to slow down. Everyone, including myself, is astonished that he made it out of surgery alive. By midnight patient 2 is on his way, along with patient 1, to Bagram in a helicopter. Somehow, against all odds, the guy makes it out of FOB Sharana alive.

Both of these patients have no business surviving those injuries. Their survival is a testament to the skill and expertise of the 691st FST - a unit that has been in Afghanistan for less than two weeks.

Approaching "Dust Off" carrying trauma # 4010 and 4011

Patient 2, my patient, shortly after emergency thoracotomy. Obviously, this photo has been heavily edited.

This is the nearly pristine 7.62mm projectile found in the abdominal cavity of my patient.

This is a large segment of Patient 2's liver.

The Reality of War

Warning: This blog update contains photographs that some may feel unsettling. This content is unsuitable for children.

Up until now, I've decided not to share photographs depicting injured patients. After quite a bit of reflection, I feel this was a mistake. This blog was created to share what it is like to provide combat causality care in Afghanistan as a CRNA. These photographs offer perhaps the most vivid illustration of what is happening in Afghanistan.  Below you will see some of the less graphic photographs that I have taken since I've been here. However, some of the readers may feel that these pictures are difficult to look at.

There are a few caveats I would like to share with the reader before you scroll down to read the rest of this blog update. First, none of these photographs depict American soldiers. I will not publish any pictures of injured Americans on this blog. I do not want to risk a family member or friend recognizing an identifiable feature. Second, I've taken steps to protect the identity of the causalities. Third, these photographs are intended solely for educational purposes. I have immense respect for the Afghans that we take care of here at FOB Sharana. These photos are used purely to illustrate both the realities of war and the challenges we face as a Forward Surgical Team (FST).
 

This is an IED blast to the lower extremities. The "peppering" pattern is the hallmark of an IED injury. The surgeons are attempting to ligate bleeding blood vessels.

 IED blast to the lower extremity. Note the placement of the tourniquet and the "peppering" pattern of the blast. That's me at the head of the table.

IED blast with injuries to the right upper extremity. The radius was essentially destroyed. The surgeons are placing an external fixation device to stabilize the injury.

IED blast with penetrating injury to neck. This was a tough one. The surgeon had to perform a hemi-thyroidectomy just to get to the tracheal and esophageal injuries.

IED blast with injuries to the face. Note the extensive swelling to the right side of the face. This patient suffered a devastating eye injury as well.

IED blast injury to the chest. The position of the surgeon's thumb indicates one of the two intra-thoracic injuries.

Same patient as above. Note the large entrance wound into the axilla which caused an injury to the right lung.

Gunshot wound to lower extremity. This patient sustained a peroneal artery transection that required repair.

Gunshot wound to left lateral chest.

Gunshot wound. The entrance was through lower back with the exit wound in left upper thigh area. The surgical instrument in the wound is used to illustrate track of projectile.

1980th Forward Surgical Team

This is a tough week for many of us. Soon, the 1980th FST will be going home after 9 long months of deployment to FOB Sharana, Afghanistan.

This is an exceptional unit that has accomplished many remarkable things in a challenging and stressful environment. Without reservation, I would put this unit up against any active duty or reserve FST out there. They have saved lives, and I am honored to have the privilege to work along side of them the last 7 weeks.

Goodbye..

The best group of enlisted and NCOs I have ever worked with.

1980th FST with previous provider group.

"Live to die another day."

Our goodbye bonfire/cigar party for the 1980th FST. The wood was "acquired" from numerous locations under dubious circumstances. Don't ask...

The new FST, the 691st from New York, is up and functioning. The 691st knows that they have big shoes to fill, and I am confidant that they are up to the task.

Meanwhile, there still is work to do.

691st and 1980th FST personnel waiting to take incoming patients off MEDEVAC helicopters.

MAJ Campbell and the 691st FST taking care of patient with a gunshot wound to the chest.

Blurry pre-trauma photo.

MAJ Campbell as "COL Awesome." Yes, he is allowed to carry a loaded weapon.

A Photo Essay

I'm not feeling particularly verbose this week. I thought I'd add a video and some pictures to the blog.

This video captures the arrival of an IDF (Indirect Fire) Casualty to the 1980 FST.

1980th FST personnel and MEDEVAC team uploading combat casualty for transport to Bagram

FOB Sharana "Town Square"

1980th FST at work taking care of IDF (Indirect Fire) Casualty 

Pre-Trauma preparation

 

Waiting for MEDEVAC Helicopter and talking things over.

Pizza on the grill night. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Playing practical jokes on the senior enlisted guys may seem like a good idea until you consider the consequences.

Case in point: Plastering the locks of the NCOs in Charlie Med so they need a cast saw to get into their offices. Bad idea...

Retribution....

"The Haircut."

Major Campbell has his sleeves sutured closed.

Not pictured: MAJ Campbell's favorite hat frozen in a 12 pound block of ice.

Incoming Patients: Trauma # 3314, 3315, 3316, 3317, 3318

We are awakened with a pounding on the door. We know, more or less, what that means.

The report we receive is 4 incoming ANA (Afghan National Army) soldiers that were injured after a suicide bomber exploded a VBED (Vehicle Born Explosive Device) outside a ANA-US military outpost.

BBC description of incident.


We have approximately 20 minutes to prepare for the patients’ arrival. The 1980th FST quickly swings into action with everyone preparing their stations for the incoming patients. IV bags are spiked, drugs prepared, supplies prepositioned, and roles/responsibilities are assigned.

For me it’s simple, I’m the anesthesia guy. Today, my CRNA colleague is in the number 1 position, which means I’m the number 2 anesthetist. CRNA number 1 gets the most critical patient with CRNA number 2 taking care of the second most critical patient. I check my monitors, oxygen, drugs, airway supplies, and suction to ensure that I am ready to go. My team (Team 2/Bed 2) does a “huddle” to make sure we are all on the same page. There can be no confusion about what is going to happen when the patients arrive.

Prepositioning of stretchers. We were told to expect 4 patients, we received 5.

Waiting for MEDEVAC.

I filmed the arrival of MEDEVAC. The video stops at 3:06 because it dawned on me that I needed to go inside and take care of patients.

The suicide bomber, for whatever reason, detonated the VBED prior to arriving at the gate. His mistake likely saved numerous lives. After the VBED explosion, the insurgents peppered the outpost with IDF (Indirect Fire). 




Major Randall Moore, CRNA
1980th Forward Surgical Team
FOB Sharana, Afghanistan

Incoming Patient: Trauma #3309

It's a running joke here that the report you receive concerning an incoming patient rarely resembles what comes rolling in the door. It's like a game of telephone-so any information we receive is taken with a grain of salt. The report for trauma patient #3309 was surprisingly accurate. We were told it was going to be an AUP (Afghan Uniformed Police) with a gunshot wound (GSW) to the pelvis. The patient did in fact have a gunshot to his pelvis. The one major inconsistency with the report was the fact that the patient was not an AUP-he was a 12 year old boy.

Waiting for the MEDAVAC helicopter. The gentlemen with the flashlights will inspect the patient for weapons and unexploded ordnance.

From the beginning, the story we received from the patient (via our translator) didn't add up. The child claims to have been shot while watching a firefight from the roof of his home. He was found to have a cell phone (unusual for a 12 year old in Afghanistan) and a live 7.62 mm round in his possession. The trajectory of the projectile is inconsistent with the explanation of events. Clearly there is more to the story.

ATLS Station. Initial evaluation and resuscitation. Our medics are establishing IV access while the surgeon and CRNA assess the patient.

A GSW to the pelvis is an extraordinarily dangerous injury. There are a number of rather large blood vessels that are located in this area, and damage to any one of them can be life threatening. We were prepared for the worst but hoping for the best.

If you look closely, you can see the entrance wound by the surgeon's left hand. The exit wound is posterior-lateral right buttock area.

Believe it or not, this kid was lucky. If the bullet had traveled one inch in either direction, he would likely not have made it to us alive.

This is typical of Afghanistan. You rarely get the whole story. I still don't know the circumstances of why or how this child was shot. Likely, the child was obfuscating to protect either himself or someone else. What I do know is that this is the second child we've taken care of in less than two weeks that suffered a gunshot wound. Sadly, this is not an anomaly in Afghanistan. In the US, a child getting shot is a tragedy. In Afghanistan, it's just another day.


Major Randall Moore, CRNA
1980th Forward Surgical Team
FOB Sharana, Afghanistan

Life on the FOB

Living on a FOB (Forward Operating Base) is an interesting experience. A FOB is a secured forward military position, commonly a military base, that is used to support tactical operations. My current location, FOB Sharana, is located in eastern Afghanistan near the Pakistan border. Our location is strategically important for a number of reasons. Unfortunately, I really can't tell you any of those reasons. Suffice it to say, Pakistan is very close, and that is not a coincidence.

FOB Sharana is an incredibly active military base. There is a constant hum of activity with all kinds of military vehicles and aircraft (both manned and unmanned aircraft) operating 24 hours a day. There are a variety of military units at FOB Sharana. Some I can talk about, and others that shall remain nameless. The following is a small collection of random photos for your viewing pleasure.

Believe it or not, the Soviet Union used this exact piece of real estate during their failed invasion of Afghanistan. The guard tower and walls you see here were constructed by the Russians. Thanks fellas...

The quality of this gym is amazing considering our remote location. The food is terrible, but the gym is nice.

Speaking of the gym. There is a contingent of Polish special forces here. They like to hang out at the gym and all of them look like this. This is the look I get when I get too close to them.

"I will crush you"

Coca-Cola Zero: Canned in Kabul! I drank it anyway.

This is one of the two "poop ponds." Admittedly I'm not an environmental scientist, but I've yet to comprehend why we have two ponds of "you know what" just festering in the middle of the FOB. I've asked a number of people about this and I just get a shrug of the shoulders and comments like "who knows, it's the army." Apparently, there is a sign by each of the ponds that states "No Fishing!" 

La poop pond. The smell is glorious.

Joe Alderete, our orthopedic surgeon, climbing on the tail of a Blackhawk for no apparent reason. You just have to know Joe. Joe will be leaving us in a few days and he will be greatly missed.

(Photo Credit: Grant Campbell) "Dust Off"departing (minus Joe) after patient delivery.

I would like to conclude this post on a more serious note. Pictured below is an Apache attack helicopter. If you are a bad guy, this is the last thing you want hunting you down. This week, within a 24 hour period, our Apache helicopters from FOB Sharana killed 57 Taliban insurgents. I realize that the news in the US rarely covers it anymore, but there still is a war on. Almost everyday an American loses his or her life here in Afghanistan.

Death from above.

Major Randall Moore, CRNA
1980th Forward Surgical Team
FOB Sharana, Afghanistan