Sunday, February 22, 2009

Ho Hum

Because this base is smaller, everything is announced over a PA system (picture #1). Much like the movie and TV show MASH, all sorts of announcements occur. We are told about incoming traumas, at which point the trauma teams report to the EMT. Depending on how many casualties are expected will determine how many people show up. Additionally, we are given warnings about possible attacks, etc. Don’t worry, so far we have only had training exercises. No attacked since I have arrived. Additionally, the speaker announces when the demolition team will perform a “controlled detonation” (picture #2). This is usually followed by a rather large explosion. If you look close at this picture, you can see a smoke cloud in the background from the detonation.

This week didn't start out with quite the bang like the last. We started the week by performing a couple of elective surgeries on locals. Both were recurrent inguinal hernia repairs. Typically, I perform this type of operation laparoscopically. However, as mentioned, this is not possible, so I had to do it open. One man had a very large hernia that had previously been repaired 10 years ago in Pakistan. Both repairs went well and the patients left satisfied. The next several days were rather uneventful. I was able to go to the Haji-mart and pick up my custom tailored suits (picture #3). I think they look really nice and they fit very well. I’ll be shipping them home where hopefully the Afghan smell will be dry cleaned out of them.

On Friday night around 6 PM the speakers announced a MASSCAL was occurring. Over the course of the next hour, 6 wounded individuals arrived to the EMT. Two were critically injured enemy combatants. Both of these individuals required a fair amount of work over the next several days. One was taken emergently to the OR where the colon, liver, and kidney were repaired from a gunshot injury. Both of these patients survived, yet both also sustained spinal cord injuries and will never walk again. The other 4 men were Afghan Special Guard who had been involved in an IED blast. All four sustained non-life threatening injuries and are recovering well. In a blink of an eye, our hospital beds were full with plenty to do over the course of the next several days.

Finally, Dr. V's replacement arrived. Dr. V is a thoracic surgeon who practices in New York. He actually worked with Dr. Merrill Dayton, who practiced for many years as a colorectal surgeon at the University of Utah. Dr. Dayton then became the Chairman of the Department of Surgery at the State University of New York - Buffalo (SUNY-Buffalo), where Dr. V did his residency. Small world. Picture #4 is of where we usually can find Dr. V, surfing the internet about motorcycles, guns, random trivia, or news. He will be sorely missed, yet we’re excited for him to get back home after 90+ days in the sand. Safe travels. Take care.

Sunday, February 15, 2009

Crazy Week

(Hospital at night)
One of the wildest things about living on FOB Salerno is how dark it is at night (pictures #1 & 2). This base is a “no lights” base in that there are no outside lights at night, i.e. street lights, etc. We walk around with our own personal “non-white” lights to lead the way. The vehicles on base have their lights tinted orange or red. In addition, because there are no large lighted cities nearby, there is minimal light pollution. I have never seen a sky so filled with stars. It is really quite remarkable. Picture #1 was taken from the walkway right in front of my hooch directed west towards the hospital. Picture #2 shows the stain glass windows of the chapel at night.

(Chapel at night)

The week started out with a bang. I was called emergently to the ICU early Sunday morning. An American civilian contractor was in respiratory distress. His airway was almost completely closed off. The anesthesiologists were going to try and intubate him (put him on a ventilator); however, they wanted me present in case they were unsuccessful. They were. So, I performed a cricothyrotomy. This is the process of putting a breathing tube into the trachea through the neck just below the Adam’s apple. Gratefully, it went smoothly. He was subsequently transferred by Critical Care Air Transport (CCAT) to Germany. I haven’t heard what caused his airway to close although I suspect it was from an infection. Throughout the week we saw a fair amount of trauma. Up to this point, all of the injured patients I have cared for have been local Afghanis. This week that changed.

Three American soldiers were struck by a roadside IED. Two were killed instantly. The third was brought to the hospital in critical condition. We ended up in the operating room for the next several hours with him. He required extensive surgery on his arm (picture #3) including stabilization of a fracture, repair of the ulnar nerve and a brachial artery repair using a reversed saphenous vein graft (Many thanks to Drs. Kraiss, Sarfati, Wirthlin, and Feurer for my vascular surgery training). Additionally, we had to explore his abdomen and remove his spleen. Due to poor weather he stayed in the ICU overnight, and then was taken to Bagram, then Germany, and finally stateside by the CCAT team. I was told that he was doing well, that his arm wound looked good and that he had a strong radial pulse. As I was leaving the hospital after checking on him around midnight, I walked outside. It was dark, yet the sky was illuminated by a brilliant full moon and a million starts. I reflected on how sad it was that on the other side of the world, far away from where I stood, family members were finding out that their loved one was either killed or seriously wounded. After nearly 5 weeks, I finally realized that I was in a war zone.

The remainder of the week continued to be busy. The highest ranking official in the region was killed by a roadside IED (see NYTimes article). He came to the hospital but was pronounced dead on arrival. We took care of his son, who suffered minor injuries. One of his security guards was not so lucky. He had an extensive blast injury to his head and face. I have pictures, but deemed them inappropriate for the blog. It was unlike anything I have ever seen; his face looked like hamburger. Anesthesia was able to intubate him. We scanned his head, face, and neck, and then took him to the OR. There we thoroughly washed out his wounds and made sure he wasn’t bleeding severely from them. We then dressed him and performed a tracheostomy. He was subsequently transferred to Bagram to be cared for by the neurosurgeon, ophthalmologist, and ENT surgeon. He will keep them busy for a while. Lastly, last night we had a transfer from the local hospital in Khost. A family wasn’t satisfied with the care their loved one was getting. We arranged for him to come to our hospital. The trauma team was assembled. We got the call that the medics could not feel a pulse, but that the patient was warm. Upon evaluation in the trauma bay, he was indeed pulseless. In fact, he was rigid from the rigor mortis. Only in Afghanistan!

(Pizza oven?)

Though the week was busy, we still found time for entertainment (picture #4). Pizza night is always a hit. Flatbread is topped with pizza sauce and any trimmings desired (pepperoni, black olives, ham, mushrooms, etc.), followed by a healthy portion of mozzarella cheese. They are then thrown into the sterilizers and cooked. My pizza was pretty good and was definitely a nice break from the DFAC. Movie nights continue (Picture #5), usually starting around 8 PM. Here we are in the OR watching “The Bourne Identity.” DVDs are always appreciated. On Valentine’s Day there was a special treat. After a wonderful prime rib dinner complete with horseradish sauce, the camp hosted a talent show (Picture #6). We went for a little bit. I give kudos to those brave souls who participated. Needless to say, it was like being in a bar with bad karaoke and no one drinking. I leave you with a picture (picture #7) of my new OR glasses, affectionately known as BCGs (Birth control glasses). Take care.


Saturday, February 7, 2009

Week of the Spleen

(The entrance to Haji-Mart)
Time to write again. This week was definitely more interesting than the last. Although the weather remains beautiful in Salerno, it is still winter in other parts of Afghanistan. I am reminded about this as I look upon the snowy mountains that surround us, especially to the north. Because of this the trauma work remains relatively slow. To pass time, I will sometimes visit the “Haji” mart (Picture #1). As I mentioned before, it is a market where local nationals (who have been screened) can come on base and sell their wares (picture #2). For the most part it is junk as seen in any market within the developing world. It does contain some things often seen in Afghanistan, such as rugs (picture #3) as well as items made out of marble (picture #4). There is a man who also makes custom tailored suits. As many of you know, in 2003 when I went to South Korea for a medical conference, I bought a tailored suit. It was very well done. I’m planning on getting one while here as well.

(Afghan rugs)

(Marble dishes)

Most of our activities of the week came from the Local National Clinic. This clinic is within the hospital itself. Local people pass through the two gates to get on base. Off base is referred to outside the “wire.” There are two perimeters of the base itself. An outside “wire” with a gate that is manned and guarded by the KPF (Khost Police Force). These are local Afghans who have been trained by Americans and provide the police force for the area. I have never been to the gate, but it apparently has a station with a metal detector that the locals need to pass through. They are then escorted to the American gate at the inside “wire” where they finally make it on base. The clinic is run by a local doctor, Dr. R who has been doing it since 2001 (picture #5). He is a great person and is a contact point for locals who need medical care. He also acts as a primary assistant on many of the procedures. This occurs at a great personal risk to his life. Therefore, he has to come on base Monday morning and stay until Friday evening, when he goes back to his family for the weekend. I’m grateful for his service and willingness to provide care for his countrymen.

As mentioned in the title, this was the week of the spleen. Beta-Thalassemia is a disorder of the oxygen carrying component (hemoglobin) of the red blood cells. Individuals who have this disease have not only abnormal production of the blood cells themselves, but early destruction of these cells as well. The clinical manifestations of this disease are determined by its severity: mild, intermedia, major. This can be seen as a mild anemia that is asymptomatic to severe anemia requiring frequent transfusions beginning in infancy. The severe form is often accompanied by iron overload of the body and it's associated complications, which are many. I, myself, have Beta-Thalassemia minor. Other than my girlish figure and pale appearance, I suffer no real complications. Children with the major form of the disease have a characteristic look (picture #6).

One of the functions of the spleen is to remove old and damaged blood cells. Therefore, in children with a more severe form of Beta-Thalassemia, their spleen enlarges known as splenomegaly (picture #7, spleen indicated by blue crosshatch marks). Normally it should be roughly the size of a clenched fist. In addition to relieving abdominal discomfort, removing the enlarged spleen in these kids theoretically prolongs the period of time between needed blood transfusions. Unfortunately, this procedure only treats a symptom of the disease, and does not cure it. Therefore, we limit this procedure to those children who are truly symptomatic from their splenomegaly and require frequent transfusions. This week we removed very large spleens from two pretty small children (picture #8). We don’t have laparoscopic capabilities here at Salerno, so everything is done open. Having been doing primarily laparoscopic surgery at Wilford Hall, it has reminded me how much fun open surgery is as well. It is still quite challenging to get the enlarged organ out of a “relatively” small hole. (Thank you Dr. Nelson for all the spleen experience, as well as to those mentioned before for the pediatric experience). Having children in the hospital has also reminded me how much I truly love pediatric surgery (picture #9). I really can’t see me doing anything else long-term. Take care.

Sunday, February 1, 2009

Another Week...

(Drs. G and R, MSgt W catching some rays)

Another week has gone by. Time continues to pass. The days are much shorter when we are busy; however, the weeks seem to pass rather quickly regardless. Everyday is similar to the previous; rounds, OR, clinic, await traumas (picture #1), 3 square meals, reading, movies. Saturday mornings we have “formation.” We meet at 0730 dressed in our uniforms. Announcements are made and then we usually have a training session. Sunday’s are nice in that we don’t meet for rounds at 0700, so we are able to sleep in and have a leisurely morning. Clinic runs Monday through Friday, so there is usually a lot of free time on the weekends. This will most likely change once spring and summer arrive, so we’ll enjoy it while we can. Picture #2 contains the physicians assigned here. We have a great group and enjoy working with each other.

{From left to right; Dr. R.(Orthopedics), Dr. G (Anesthesia), Me (General Surgery), Dr. V (Thoracic Surgery), Dr. B (Internal Medicine)}

The base is an Army base, with over 3000 soldiers and government contractors. Construction is ongoing. They are even paving some of the roads and modernizing them with street signs (picture #3). Artillery cannons (120 mm) are on either end of the base and are heard throughout the day. Helicopters are constantly coming and going at all hours of the night. The dining facility also runs both day and night to accommodate all shifts. Last Friday we were privileged to have steak and lobster (picture #4). I was nervous at first, but the lobster was actually really good! I had better start working out, or I will end up gaining weight.

(Surf and Turf)

The clinical aspect is the best part of the deployment. I’m grateful when were not treating injured soldiers, however, the experience of doing so is great. At times, being in a “developing country” makes the treatment decisions much more difficult. For example, we took care of a local citizen who was shot twice, once in the abdomen and once in the chest. Unfortunately, one of the bullets severed his spinal cord resulting in paralysis of his legs. He was initially “under” treated at a local hospital and arrived to us gravely ill. After operating on him and nursing him back to health over a 2 week period of time, we discharged him home to his family. Unfortunately, this may be a death sentence for him. He really should have gone to a skilled nursing facility or rehabilitation unit. These institutions just aren’t available here, and we don’t have the resources to provide them. It’s hard to know that after all we did for him he may not end up living very much longer.

For me, the local national’s clinic is slowly picking up pace. Last week I saw a 7 year old boy in clinic with a right inguinal hernia. We took him to the OR and repaired it (Thank you Drs. Meyers, Scaife, Black, Matlak, and Downey for the pediatric surgery experience). This is the boy and his father at his follow-up visit (picture #5). We are also currently taking care of a 9 month old girl who was burned by her father. She is extremely cute and much adored by the hospital staff. I don’t think I’ve ever seen her on the bed, as she is always being held by someone. Picture #6 shows her with her mother. She arrived to us from an outside area 3 weeks after the burn with terrible scarring of her feet and ankles. We excised these areas and skin grafted her. She is recovering well and will most likely go back home this week. She will be missed. Take care.