Camp Salerno 2009

Homecoming

2009-06-02T23:30:00.000-07:00

By the skin of our noses, both Dr. R and I were able to get onto a plane late night June 1st. We travelled to Germany, Iceland, then Baltimore. Luckily, I arrived early enough at BWI that I was able to catch a flight to San Antonio through Atlanta. After almost 31 hours of straight travel I arrived home. I was greeted by the beautiful sight of my family. It was so great to be home.

Several weeks have passed and I am now busy being back at work; Afghanistan, and FOB Salerno seem so far away. However, I can truly say that there isn't a day that goes by that I don't thing about my time there, the people I met, the experiences we shared, and those that are still over there. I pray that they will remain safe in this very dangerous time. I hope that what I did over there, however small it may have been, will somehow contribute to the stability of such a wild and chaotic country. Take care.

Lost in Transportation

2009-05-31T02:36:00.001-07:00

(Which way?)

I was really hoping that this weeks blog would be of my homecoming, however, military transportation isn't exactly non-stop. Dr. R and I left FOB Salerno early Tuesday morning. We flew on a "puddle hopper," a small two propeller, 8 seat cargo plane. It had brought mail to Salerno. We actually helped empty the plane's contents, then got on board. What a ride. It went through the mountain passes and was rather bumpy. Some of the mountain sides were just a stone's throw away. Now I understand why some of our patient' couldn't be transferred to Bargram due to weather conditions. When we reached the hospital in Bagram, of course no one knew we were coming hadn't book us a flight out of Manas, as they had told us. I was a little ticked off. We hurried and did the required paperwork and left to find our own way home.

(Al Udeid AFB, Qatar)

At the PAX terminal (Airport) there happened to be a flight to Al Udeid AFB in Qatar (picture # 2) leaving within a few hours. We were able to catch this flight. It was on a C-130, a four propeller cargo plane. We rode with a country band that was touring Afghanistan, Matt Poss and Rolling Thunder. We were delayed and waited on the tarmac for about an hour and a half. During this time, the band sang some of their songs, pretty cool. They performed at Al Udeid the next day. Again, it was good to hear live music. They did a shout out for us while on stage and we took pictures with them after the show. I really appreciate their time and effort to come and entertain the troops stuck in the sand. The plane ride was just over 5 hours and we arrived around 11 PM, too late to catch the flight to Baltimore (BWI) leaving the next day. When we checked in, we were informed that we were booked for a flight to BWI on June 3rd. Huh?

(The Bra, the tent at the center of the base)

The last 5 days have been filled with excitement: sleep, eat, watch movies, eat, sleep, swim at the pool, eat, sleep, read, eat, surf the internet, sleep, walk around, eat...you get the picture. All in all, it's not a bad base to travel through. Notice I said travel through. As a surgeon, I wouldn't want to be deployed here. Among the many different missions of this base, one is to house and entertain troops to and from their area of responsibility (AOR). It is also a place for troops who are deployed for more than 6 months to come and enjoy some rest and relaxation (R&R). Therefore, there are more amenities here that help accomplish this mission. For example, picture # 3 shows what is referred to as "the Bra." It is a tarp in the middle of the coalition camp, where the majority of the troops stay. Wireless internet is available, and different activities occur here throughout the week. Additionally, 3 drinks containing alcohol can be purchased every 24 hours for those that want it (picture # 4).

(Indoor air conditioned mall)

Because so many of the troops here are "in transit," there are many rows of tents that serve as temporary barracks (picture #6). They contain 22 pairs of bunk beds. Much better than a cot, but after the last 4 months, it will be nice to have my own room! The base also contains multiple base exchanges (BX), one of which is indoors, like an indoor mall. It contains a food court, movie theater, wireless internet, barber shop, store, post office and large TV and game room (picture # 5). The best part is that it is air conditioned. This is greatly appreciated in 120 degree, 80% humidity weather. The base also contains a swimming pool (picture # 7). Part of my day has been spent laying by the pool , reading, and taking a dip to cool off. I will probably still come home without a tan. While walking through the base I came across picture # 1. I always loved the sign like this on the TV show MASH. Just a few more days and this adventure will be over. Take care.

(The pool)

I received this picture from Capt L. I was already gone, but the young man we took care of with the heart injury came back for follow-up in clinic. He is doing very well and posed for the camera to show off his scar (picture #8&9).

Parting...

2009-05-24T19:47:00.001-07:00

Today we discharged the patient with the heart injury. It’s amazing what the body is able to go through and recover from. He is doing very well. I took this picture with him this morning (picture # 1).

He was a friendly guy who would smile and wave to us on the ward. I couldn’t get him to smile for the camera. I’m not sure why he has such a horrifying look on his face. It turns out that he is the sole bread winner for his family. I’m glad that we were able to help him. My replacement arrived here yesterday. I will be leaving Afghanistan this week. The fact that as I get older time seems to accelerate continues to amaze me. Although over 4 months has passed since I left the United States, it has come and gone in a blink of an eye. I really believe that this has been a wonderful experience for me, both personally and professionally. Although being away from my family has been difficult, I feel closer to them now than I did before. They have been so strong and have flown through this like champs. I look forward to seeing them shortly.

I will miss the people I have met over here. I have worked with people from all of the services from all over the United States. I can truly say that they are a wonderful group of individuals that are sacrificing much in the service of their country. I couldn’t have asked for a better group. In this blog I have included pictures of many, but not all, of them. I’ve enjoyed their hard work and support in the trauma bay, their countless hours within the operating room, and their care of our patients in the ICU and ward. I commend them in the highest and would gladly have them take care of me if I were injured. I’m also grateful for the time we have spent together eating hundreds of meals, watching hundreds of movies, and also playing hundreds of games of Call of Duty. Thank you for all you have done. You as well as your family should be proud of your service. Keep up the good work. I will pray every day that God will watch over and protect you. Take care.

This is B, one of the army special forces guys out of Ohio.

This is a picture Dr. D and I took earlier with H, one of the “dustoff” flight medics.

This picture is of DP, a flight medic, and myself the day before I left.

This is a mix of nurses from the ward as well as the OR: F, R, M, L.

M is a CRNA. He is actually from Provo, UT. Funny enough, he deployed earlier to Iraq with one of my surgery attendings, John Sorenson, from the University of Utah. Small world.

L is a scrub tech from Florida and K is a scrub tech from Las Vegas. They did a great job.

W, me, B, and G in front of a Blackhawk.

Dr. R is an orthopedic surgeon in Maryland. She has also completed her deployment and will be leaving. Dr. G is an anesthesiologist who lives in England. He has just over a month to go.

This picture is of the surgeons and OR staff. We’ve worked together almost everyday for the last 4 months.

This picture is of the entire crew that works in the hospital. Most will complete their deployment in July.

Hearts and Minds

2009-05-16T01:00:00.000-07:00

(Khost)

***WARNING: This blog entry contains some graphic surgical images that may be inappropriate for some viewers. Please proceed at your own risk.***

(Mosque, Khost)

The pictures of areas off base were given to me by Jeff, a special forces medic. I don't get off the base, so I really have no clue as to what my surroundings look like. He graciously gave me these photos.

As we work day in and day out we realize that as medical care providers we are not on the front lines of this conflict. Our primary mission is to provide medical support and care to those troops that are, both US and US coalition. Our secondary mission is to provide medical care, as resources allow, to locals. As I mentioned before, we actually have a "local national" clinic that runs 5 days a week and allows us to see a variety of patients. In this blog I have already talked about several different disease processes that we have taken care of since my arrival in January. We are also very active in treating civilians who are injured in the conflict. We hope that in addition to other humanitarian efforts that are on going, this secondary mission will help win the "Hearts and Minds" of the people. This week it's meaning became a little more literal.

(Men in a field...I think it looks like a postcard)

This week began as any other. We were anticipating several elective cases during the week. However our plans were dramatically changed when armed men (Taliban) attacked the Governor's palace as well as stormed the municipal building in downtown Khost (picture # 5, see New York Times). There were about 30 men in all, several of which were suicide bombers wearing explosive vests. A firefight ensued between US special forces along side of Afghan commandos and the Taliban. Many were injured both military and civilian. We received and treated many of the wounded. It seemed to be a never ending stream of injured patients. In the blink of an eye our hospital was full, but more was to come.

The following day a Vehicle Based Explosive Device (VBED) went off at the gate of our base (picture # 6, see New York Times). It occurred in the morning when many of the locals who work on base line up for entry. 7 local people were killed. Minutes after the explosion, injured individuals drenched in blood began entering the EMT doors. We went into action. A triage area was established outside the hospital doors where several doctors initially evaluated the injured. Those that had expired were taken to the morgue. The more critical patients were brought to the EMT and treated by trauma teams. Patients with minimal injuries were treated in the clinic area, then released. We ended up treating 29 patients in all, 7 of which required an operation. Our hospital that only holds 8 patients was full with 5 ICU patients and 6 Ward patients. Amid the controlled chaos of the trauma bay, everyone present did an outstanding job in taking care of the injured. It was an amazing thing to witness and be a part of.

(Open wide)

One of the patients we treated was found by Jeff who went with his team to the gate to assist the wounded. There, he found a young man that was underneath several other bodies. At first they thought he was dead, but on further evaluation, he was alive. His only wound was a small penetrating wound to his right chest. He was rushed to the hospital and brought into the EMT. As we began to evaluate him, we could see that he was really sick. We quickly put him on a ventilator and placed a large IV and began giving him IV fluids and blood which seemed to help him come back to life. A tube was then placed in both sides of his chest with a fair amount of blood coming out of the right tube. An x-ray demonstrated a moderate amount of fluid still within his right chest and a piece of shrapnel in his heart. He was taken to the OR where we performed a right thoracotomy to evaluate his right chest. In addition to finding some injuries to his right lung, a small hole was seen in the sac around the heart that was draining blood. We opened the rest of his chest, called a clamshell thoracotomy, because it basically opens the chest like a clam (picture # 7). We then opened up the cover around his heart and found a hole in the atrium squirting out blood. A urinary catheter was placed in the hole to control the bleeding and the hole was closed with suture (picture # 8). As you can see it left a pretty big scar (picture # 9). He is stable and recovering well.

(All the way across)

Friday night, which is the equivalent of the Sabbath for Muslims, a suicide bomber entered a mosque just outside of Khost. I don't know if it was the mosque pictured above. Eight people were killed and eight others wounded. Because our hospital was already running over capacity, we did not see or treat any of the wounded. As I sit here and reflect on this past week I just can't help but feel overwhelmed by these events. Not because I feel that my life is in danger, but because of the precarious situation that Afghanistan is in. The US news is replete with the atrocities of Afghan civilians killed by US forces. I do not condone these occurrences at all. But after being here 4 months it is obvious that many more Afghan civilians are killed by their own countrymen, without regard for race, religion, tribe, sex, or age.

The US and US coalition forces should do everything in it's power to minimize civilian casualties, but the people we are at war against have no obvious regard for human life. With much planning and thought they go into towns and shoot their neighbors and blow up their municipal buildings. On sacred days they walk into their own mosques killing people of their own religion. They willingly drive a car loaded with ball-bearings and explosives to a gate surrounded by their own countrymen and then detonate it. How can we possibly win this war unless the people themselves want to change? I don't think it is the majority of Afghans themselves that are resistant. For the most part, they are a poor and humble people. Those with whom I have come in contact seem to be good natured and genuine. I'm not trying to stand on a soap box because I don't know what the answer is; the Roman empire, and the Russians (and now the US) both lacked it as well. I do think that providing proper education for these people as put by Greg Mortensen in his book "Three Cups of Tea" is the best solution I have heard. As long as these people have no real outlet and hope to better themselves I believe that their involvement in the drug trade and their pursuit of radical fundamentalism will continue. Take care.

Cinco de Mayo

2009-05-09T20:35:00.000-07:00

(Garcia and Danielson)

Another week has passed. First we need to say goodbye to Capt. Garcia, a CRNA, and Dr. Danielson, a Pediatric surgeon (picture # 1). They completed their deployment and flew out at the end of the week for home. I have heard that they are already stateside and should be home to their families later this week. They did a great job and were great to work with. We will miss them. Next, the little boy with beta-thalassemia that had his spleen removed and was treated for parasites returned to clinic this week with his father and sister. He looked great and was all smiles (picture # 2).

(First Seargent)

This week was Cinco de Mayo and we didn't want to miss out on it's celebration. Dr. D. put it best when he said, "it's funny that we are celebrating a Mexican holiday while on an American army base in Afghanistan." True, but let the celebrations begin. Because the 5th landed on a Tuesday, we actually celebrated this event on Saturday May 9th. The hospital had a picnic, complete with typical picnic games; pin the tail on the donkey (picture # 3), fill the urinal relay (picture # 4), wrap the mummy race (picture # 5), and a relay bag race (picture # 5). Please consider that all of these activities were done while completely sober as alcohol is strictly forbidden by General Order # 1.

(Mummy wrap)

(Bag race)

The picnic also included a wheelchair race (picture # 6) and the hitting of a pinata. At the end we had a bar-b-que with hamburgers, hot dogs, steak and all the trimmings. All in all it was a great time to relax and be with each other outside the hospital. I think everyone was grateful for this little diversion. The picnic concluded with the throwing of shaving cream pies. Everyone seemed to get a little shaving cream on them, some more than others (picture # 7). The middle of May is approaching, which means the end is even closer. Take care.

(First Seargent)

Toby Keith

2009-05-03T07:09:00.000-07:00

(Toby Keith)

Although my greater family (parents, brothers, and sisters) has always listened to country music, I haven't really been a big fan of it for many years. This week I gained a new respect for one of it's top singers. Toby Keith is currently on his seventh tour with the USO. During this tour he will visit both Iraq and Afghanistan. Last Sunday he came to little old FOB Salerno and put on a show with his band. It was held in the Fire Department tent (picture # 1). I didn't really know any of his songs, but it was fun to hear live music. The concert he provided was the 12th in 4 days. It was a whirlwind visit all over Afghanistan. He even went to many of the very small bases way out on the front called COBs (Combat Operation Bases). The music was great and the troops really appreciated his time and support. I now consider myself one of his fans and plan to buy his greatest hits album when I get back (the internet is too slow to download it here).

(Apache Pilot?)

This week was much like the others; working in the hospital, taking care of patients. We had a busy week and had to postpone most of our elective surgeries on local nationals due to a significant amount of trauma care. On Saturday we found time to go to the flight line and get a closer look at some of the helicopters here on base. I tried on one of the helmets in a Blackhawk (picture # 2) that is used to transport patients to and from the hospital. I also was able to sit in the cockpit of an Apache helicopter (pictures # 3 & 4). Pretty cool. At one point, for a very brief time growing up, I thought about becoming a pilot, but eventually decided on medicine instead. The technology these things have is pretty amazing. I guess I'll just have to settle for a PS3 game. At least I won't have to worry about hard landings.

(Goiter)

This week we were able to squeeze in one elective case before it got too busy. As you can see, this lady had a very large thyroid goiter (picture # 5). It presented us with a nice challenge. The operation went fine and her neck looked almost as good as new, with a sizable scar at it's base (picture # 6). Life continues to go by at FOB Salerno. May is here. Take care.

Salerno Dynamite

2009-04-26T01:35:00.001-07:00

It continues to amaze me how fast the weeks pass. This week was much like the last. We spent much of it in the hospital taking care of our patients. Our free time was spent reading, watching, movies, working out, or napping. Dr. D’s office sent him a Napoleon Dynamite wig. We each took turns wearing it (picture # 1). Gosh…. As I have mentioned before, the base has several training facilities. We have used the “trauma” mannequins to help teach resuscitation to our medics. There is also a “combat” facility. There they have weapons that are connected to a computer. One shots at a different targets on a screen. The weapon feels and handles like a real one. Some of us from the hospital went and learned techniques to improve our 9mm skills (picture # 2). It’s within a nice air conditioned building. We are hoping to have a tournament within the next couple of weeks. Picture # 3 depicts one of the vehicles that are used off base. As you can see, it was involved in an IED blast. Luckily, no one on board was seriously injured.

(MRAP)

As I mentioned in my last blog, this was to be another “week of the spleen.” We originally had 5 patients scheduled for splenectomy, but only 4 kept their appointment. One of them was a 25 year-old male with the biggest spleen I have ever seen. He has had this for several years. It appears that he has beta-thalassemia intermedia. It’s not the most serious form of the disease, but has still resulted in splenomegally (enlargement of the spleen). He went to the OR (picture # 4) for splenectomy. As you can see, it was a pretty large specimen (picture # 5). Needless to say, his abdomen was a lot smaller after it was removed. He left the hospital 2 days later feeling much better.

(Monster Spleen)

The week ended busier than it began. We received multiple mass casualties with critically injured patients. This kept us busy in the OR (picture # 6). One patient was a local man who works here on base. He was shot with an AK-47 more than 5 times. He was brought to the hospital in critical condition on the verge of death. We began treating him in the ER and rushed him to surgery within minutes of his arrival. He was found to have injuries to his right arm, right lung, liver, more than 15 injuries to his small bowel, and a hole in the inferior vena cava (IVC, picture #7). This is a large vein that carries the blood from the lower half of the body to the heart. Gratefully, we were able to control the bleeding and repair it. He went back to the OR the next day where we put his bowel back together and repaired his broken arm. He remains critically ill, but is stable and is recovering. Because most of our patients arrive to the hospital cold, the OR temperature is usually turned up to the max. This day it was about 90 degrees. After the case, Dr. D. and I were drenched from our “work-out” (picture # 8).

(Sweat Hogs)

Finally, we say hello and goodbye to Dr I (picture #9). He is an orthopedic surgeon originally from Malad, Idaho. He came to help Dr. R with the orthopedic trauma that we receive. We anticipated him staying for a month before going to another FOB for the remainder of his deployment. We found out that he will leave this week. We’ve enjoyed having him around and wish him the best on the rest of his tour. Take care.

(Dr. I off to another FOB)

Spleen Brothers

2009-04-19T07:59:00.000-07:00

It seems that over the last two weeks we’ve had somewhat of a reprieve from the traumatic injuries that we have been treating. It has been somewhat of a welcome break to not have multiple people with severe wounds entering our EMT. At the end of last week we began treating a local man who drove a supply truck from town to one of the surrounding bases. His vehicle was involved in an IED blast (picture # 1). As you can imagine, the majority of his injuries occurred to his left side; a partial traumatic amputation of his left arm, a collapsed left lung, a ruptured spleen (it’s also on the left), perforated bowel, and a broken left femur. He was critically ill upon presentation. After resuscitation was initiated, that included the need for a massive blood transfusion, he was taken to the OR. There we finished removing his severely damaged arm, removed his injured spleen and bowel, and splinted his broken leg. He was taken back to the ICU in critical condition. Over the course of the next few days he would return to the OR several times. He slowly stabilized and began showing signs of improvement, except for his kidneys. Due to the seriousness of his injuries as well as requiring massive amounts of blood products he went into kidney failure. In the states this is treated by a phone call to a nephrologist (kidney doctor) who would initiate dialysis. This isn’t available here at FOB Salerno or in the cities and provinces around us. Miraculously, Dr. R, a hospital interpreter, found a doctor in Kabul who would accept the patient and initiate renal replacement therapy. The hospital commander was able to find a humanitarian flight for the patient and an escort to Kabul. He left this morning. My hope is that because he is young, with some time his kidney function will return and he will make a full recovery. We learned that he was married only a few months ago. This will be a real hardship on his young family.

We’ve started another week of the spleen. It was initiated on whom we affectionately refer to as the “spleen brothers” (picture # 2). These boys are 3 and 5 years of age, both with Beta-Thalassemia major. They require blood transfusions about every other week. They had their spleens removed on the same day. The following day, we found them recovering together in the same bed. In the upcoming week we will remove the largest spleen I have ever seen in an adult with the same blood disorder. There will be more to come on that case in the next blog. Take care.

April Showers

2009-04-12T01:36:00.000-07:00

(Notes to the troops)

The city of Khost sits on a kind of plateau surrounded by mountains. This forms what is known as the bowl. FOB Salerno is north of the city. Last night thunder clouds rolled into the bowl and gave somewhat of a fireworks show; lightening all around the bowl lighting up the sky. With it being so dark, it was quite the spectacle. Picture # 1 is the main hall of the hospital. My sister, Kim, works at my old elementary school. She helped a bunch of the students to write notes to the soldiers deployed over seas. We hung these notes up in this hall for all to read. It was nice to renew our perspective through the eyes of a child. Thanks Kim. Last week we spent several hours separating our living space into 6 separate hooches (Picture # 2). We first framed out the spaces with 2x4s, then created the walls with plywood. Eventually we will add doors.; for now, a shower curtain will do. It's not much, but even the little things help it fell more like home (Picture # 3).

(Privacy)

This week was much like the others. It went by extremely fast and was filled with taking care of trauma patients as well as performing elective surgery on local nationals. Most of the weeks seem to have somewhat of a theme, meaning, patients with the same injuries tend to arrive in clusters. This week the primary injury occurred to the upper extremities. Locals involved in IED blasts arrived with devastating injuries to their hands. Unfortunately, they required amputations of these traumatic wounds. One of the cases we performed this week was a thyroidectomy. I have blogged before about the iodine deficiency that the Afghan people have due to living in a land locked country. The patient this week had the largest thyroid I have ever seen (picture # 4). After a couple of hours it was history (picture # 5). Time continues to pass here and the middle of April approaches. That means I have just about a month and a half to go. Take care.

Pediatric Care

2009-04-03T23:30:00.000-07:00

(Air Show of US Navy Intruder)

***WARNING: This blog entry contains some graphic surgical photos. Proceed at your own risk.***

During the week while walking to dinner we were treated to a mini-"Air Show." A US Navy Intruder flew over the base several times. It performed some aerial acrobatics much to the delight of those outside. It flew relatively low over the base. Picture # 1 is the best picture I could take given my resources.

One of the devastating things about war is the toll it takes on innocent people. A lot has been said recently in the news concerning civilian casualties caused be American operations. Of course, I am not in any way on the operational side of things, although what I have seen thus far makes me believe that American troops are only trying to act in the best interest of the Afghan people, and minimize any injury to them. What are not reported in the news are the devastating injuries that Afghan civilians are sustaining due to land mines, IED blasts, as well as attacks. The majority of the people that we treat here at FOB Salerno are local nationals or Afghan soldiers. In fact, we often joke that Khost hospital is on divert because local nationals come to our hospital after sustaining an injury instead of their own. But seeing the state of their health system helps me understand why they want to be treated by Americans.

Many of the injured civilians we treat are children. I am happy to do this as Pediatric Surgery is what I ultimately want to do. I also feel blessed to have Dr. D here, who is a pediatric surgeon. Picture # 2 is a 4 year old boy who suffered a shrapnel injury to his left cheek. His father drove 3 hours at night to bring him to our hospital to be treated. Now, a three hour drive in the states is one thing, in Afghanistan, it’s very dangerous, especially at night. We evaluated the child for any further injuries, and then took him to the OR to repair the injury (picture # 3). Later, as I walked out to check on the patients, I went to tell his father what we had found. I could see by the smile on his face that he felt his sacrifice had been worth it. He was pretty pleased with the results (picture # 4). I hate to think what this wound would have looked like if he had been treated locally.

Picture # 5 is the left hand of a 3 year old child. She accidentally stuck it in a generator. Electricity in Afghan cities is limited and highly regulated. Usually it is only available for specific hours during the day. In order to have electricity on a regular basis, many families rely on gas powered generators. Unfortunately, this little girl’s hand got too close to some moving parts. As you can see she lost several fingers. Dr. R, our orthopedic surgeon, took her to the operating room to evaluate and washout the wound. After several trips to the operating room, including placement of a skin graft over the back of her hand, the wounds were closed (picture # 6). It won’t be pretty, but it should be relatively functional.

Some of the most devastating injuries we take care of are burns. Picture # 7 shows the back and bottom of a 7 year old girl. She was found by American troops while visiting locals. They were horrified to see this little girl lying on the floor of her family’s home with such terrible wounds. They were told that this happened from a rocket attack. She was taken (along with her father) to the nearest FOB. She was subsequently transferred to our facility. Upon further evaluation, it was obvious that these wounds did not occur from a rocket attack. They fit the classic pattern of being placed in scolding water, mainly on the lower back and buttocks and feet (picture # 8). These wounds were also old, approximately 2 months. She was sickly appearing, due to a low blood count, and the fact that she wasn’t eating, because her bottom was scarring shut not allowing her to defecate.

Over the course of her hospitalization she would be taken to the OR on several occasions (picture # 9. First, she was taken to have her wounds cleaned and her bowels diverted. She underwent a loop sigmoid colostomy in order to allow exit of her excrement. Her back and bottom wounds were cleaned as was her foot. Dr. R. needed to remove some bone that was sticking out from her foot as she had been walking on this wound. Thankfully, she began eating again. Over the course of the next several days we allowed her nutrition to improve. She would then go back to the OR for removal of damaged tissue and placement of skin grafts (picture # 10). Upon changing her dressings afterwards, we were pleased to see that > 95% of her skin graft was healing nicely.

The bigger dilemma facing this child was long-term care. Both Dr. D and I have a limited period of time here at FOB Salerno, however, the wounds of this child will require extensive long-term care and follow-up. We didn’t believe that anyone in Khost would be able to do this, and with limited resources available at our hospital, we didn’t know if this was even possible after we left. Miraculously, through his network of pediatric surgeons, Dr. D was able to find the Afghan Reconstructive Surgery and Burn Center. It was established and is operated by Dr. Abdul Asat, an Afghan physician who has done some plastic surgery training in California. It is affiliated with the Grossman Burn Foundation out of California. After sending and receiving countless e-mails Dr. D was able to get in touch with the physicians at ARSBC, who expressed interest in assuming the care of this little girl. Additionally, he worked in conjunction with the US Embassy to help transport her from FOB Salerno to the ARSBC and pay for her care. What an impact this will have on her life. All are to be commended for working so hard to help this little girl (picture # 11). We’re grateful for the dedicated physicians at the ARSBC that give so much to the injured civilians they treat. Unfortunately, we have heard that they are having financial difficulties and hope that they can weather the storm.

Finally our Saturday was interrupted by another injured child. A 15 year old boy and his 7 year old friend were accidentally shot by the Afghan Border Patrol after an IED explosion. The 7 year old died in the helicopter on the way to our hospital. The 15 year old arrived in critical condition with a GSW to the right thigh. He was quickly evaluated in the trauma bay (picture # 12) then taken to the OR. Dr. R. put his right leg in traction due to a femur fracture. Dr. D and I spent the next couple hours restoring blood flow to his leg by repairing his femoral artery and vein that were injured by the bullet (picture # 13). He is doing well. Dr. R. will fix his femur fracture in the next couple of days. Just another day in paradise! Take care.

(Just another day at FOB Salerno)

Week of Amputations

2009-03-29T15:27:00.000-07:00

(C-130)

WARNING: This blog entry contains some graphic surgical photos. Proceed at your own risk. Picture # 1 is an Air Force C-130. These planes are the work horse of the military and provide troop and supply transportation all over both theatres of war.

Last week ended with a bang and this week began with one. On the receiving end were many of the local nationals that live nearby. After nearly 30 years of ongoing war, Afghanistan has become heavily populated with land mines. Anyone walking through this country is at risk of encountering one. Recently we treated 3 young men who were on vacation near Khost that happened upon a land mine. Picture # 2 demonstrates the devastating injury that occurs to limbs involved. You should also note how incredibly dirty the leg is. He was taken to the OR where the injured remnant was removed and the wound thoroughly washed (picture # 3). These types of wounds require multiple trips to the OR for washout of the wound before definitive completion of the amputation.

(Washout)

We also dealt with several IED extremity wounds this week. Early this week the Taliban detonated an IED that hit a passenger bus (See New York Times). We received many patients who were seriously injured. As a recurrent theme, someof the injuries involved the lower extremities (picture # 4). These individuals were also taken to the operating room for removal of the destroyed tissue and washout of the wounds. Over the course of the next several days they would be taken back to the OR for additional cleaning. Once the wound were considered clean and no further tissue loss is noted, they are finally closed (pictures # 5 & 6). I know that much has been written about the incredible work with prosthetics that is happening for soldiers in the United States who have these same types of injuries. Unfortunately, a prosthetic limb is a luxury only few of those injured in Afghanistan will obtain.

(Dressings)

(Completed amputations)

We ended the week on a bright note. Because time is really all we have while deployed, many people spend it on academic endeavors. In fact, there are multiple classrooms here on base, and some soldiers can take offered college credit courses while here. Others participate in web-based courses, for example, Dr. R, the orthopedic surgeon is completing an MBA. On Saturday and Sunday I took a Pediatric Advanced Life Support (PALS) class. It was taught by 3 certified instructors and included both didactic and hands-on training, complete with a “megacode” scenario performed on a computerized mannequin (picture #7). I am now PALS certified. Not a bad way to pass the time. Sunday evening, we were invited to one of the Special Forces (SF) compounds on base for a bar-b-que. Some of the local Afghans that they work with cooked up some local dishes. It was delicious and included, fresh fruit, batter fried vegetables, flat bread, beef kabobs, fried chicken, rice, and a variety of dipping sauces. It reminded me of Indian food. Jeff, one of the SF medics celebrated his birthday (picture # 8). Take care.

(Happy Birthday Jeff)

M5

2009-03-22T06:04:00.000-07:00

(Does the 'stach make us look tough?)

This month was officially identified as “Mega Medical Mustache Madness March,” or M5 for short. Any male (or female) in the hospital who wanted to participate simply stopped saving their mustache. This is permitted as part of the uniform in the military. Picture # 1 includes all of those who participated. We had to take a picture at the half way point, as several were going on leave and would not be present for a final picture. Many decided to shave after the picture, I have decided to keep mine until 1 April. Since everyone wears a uniform, it’s the only way to be a little different.

This week the people of

Afghanistan

celebrate Nowruz, which is the beginning of the New Year. The whole week was considered a holiday. The base was put on heightened security to be prepared for the worst. We did experience an increase in injured civilians. The Taliban detonated several bombs in the area, one of which was in Khost (See article in New York Times). The two survivors we took care of were gravely injured civilians that required the amputation of booth lower legs (picture # 2, to be uploaded tomorrow). They are recovering and will survive. I spoke with one of the Afghanistan physicians that works at the hospital about the current situation. He told me that the people who are from Afghanistan love the Americans and want peace. It’s the “others,” mainly Taliban and those from Pakistan that continue to wage this war. This has been my experience. The local national people we treat are really a delightful people who live in the poorest conditions. A great majority of the “bad guys” we have cared for are not original to Afghanistan. It’s unfortunate that the fate of this country is being determined by radicals who don’t even live here. We decided to celebrate Nowruz by having (virgin) Pina Coladas. Picture # 3 shows Capt G serving us this treat during movie night.

(Capt G. serving Pina Coladas during the movie)

The week was pretty busy. We mainly took care of local nationals. In addition to the elective cases, there were several emergencies we treated, mainly; gun shot wounds, burns, and blast injuries. The New Year didn’t start out so well for many of the locals. In clinic, the father of one of my patients brought in a parasite that the little child expelled after receiving some medication (picture # 4). Ascaris lumbricoides, also known as roundworm, occurs in humans when an ingested egg releases a worm that penetrates the wall of the small intestine and enters the bloodstream. It is then carried through the liver and heart to enter the pulmonary circulation where it grows and molts. In 3 weeks, the larvae are then coughed up respiratory system and swallowed returning it to the small intestine. Here they mature into adult male and female worms. Fertilization can now occur and the female produces as many as 200,000 eggs per day for a year. These fertilized eggs become infectious after 2 weeks in soil and can persist in soil for 10 years or more. It’s life cycle can be seen in picture # 5 which was taken from http://www.dpc.cdc.gov/cdc.gov. We tend to feel a lot of these parasites within the bowel of the patients that we treat. I decided to try one for a treat (picture # 6).

(I got worms)

Each week we participate in a conference call that includes medical teams all over Iraq and Afghanistan, Germany, and the United States (Walter Reid Medical Center, Brook Army Medical Center, Wilford Hall Medical Center, as well as Cincinnati and San Diego). We discuss American soldiers that have been treated during the previous weeks. It allows us to get feed back on their current condition, as well as discuss possible areas where care could improve. It’s a great way to learn from other surgeons treating the same types of injuries. The trauma director in charge of keeping track of these patients as well as the overall trauma care in both theatres of war paid us a visit over the weekend. It was a pleasure having Dr. B around and to get to know him better (picture #7). Take care.

(Back row: Me, Dr. P, Dr B, Front row: Dr R, Col O)

Same old

2009-03-15T02:14:00.000-07:00

(SSgt P, Me, Dr. G, SSgt B dressed up to go to the range)

It’s hard to believe another week has gone by. Gratefully, the weeks seem to be passing rather quickly. This base is equipped with both a “large” and “small” arms range. They are in constant use by different units for training purposes. On one Saturday we had the opportunity to go to the “small” arms range for target practice. Picture # 1 myself with 3 other Air Force hospital staff all dressed up to go. The range is a very controlled placed with safety at a priority. All of us had the opportunity to fire the M16 (picture #2). Once I sighted in the scope, I was a rather deadly shot, hitting the kill zone at 300 meters. I guess if the surgeon thing doesn’t work out, I could become a sniper! Picture # 3 is the obligatory “tough guy” photo opportunity. I don’t think it’s really all that frightening.

(This picture scares me!)

The week was filled with the same activities that had been previously described. Each morning started with team rounds (picture # 4), where the condition and plan for every patient is discussed. We did have several elective cases planned this week, including the removal of a spleen from a small child with Beta-Thal

assemia (picture # 5). We also dealt with traumatic injuries that can come at any hour. Early one morning at 0230 the loud speakers throughout the base announced the arrival of an injured patient. We ran to the hospital to find an American soldier who had been shot in the leg. His injuries were primarily musculoskeletal, and required a trip to the OR to washout his wounds and stabilize the fracture. Within several hours he was on a helicopter to Bagram and subsequently transferred stateside. This early morning call was just the beginning as members of the Khost Police Force were involved in an IED blast. Several were killed at the scene and we only received two injured, one of which was critical. We spent the next several

hours attempting to save the police officers life (picture # 6), unfortunately, his injuries were too severe and he passed away.

The Afghan soldiers do not have the same type of protection as the Americans. For example, they don’t have protective body armor covering their chest and abdomen. They also drive around in the back of pick-up trucks, not in heavily reinforced vehicles. Therefore, when involved in an IED blast, they can sustain extremely severe injuries as was the case in our patient. The rest of the week was rather uneventful; however, there is a buzz in the air that things will really start to get busy. I leave you with a picture of the exercise facility in the early evening with a rising full moon (picture # 7). Take care.

(Moon over Salerno)

Warming up

2009-03-08T07:56:00.000-07:00

(Landing at the scene)

There has been an increase in activity around FOB Salerno. I don’t know if it is due to the transition of troops moving in and out of theatre or improved weather conditions, however, this week was busier than last. Picture # 1 is an amazing picture of a black hawk helicopter landing at an injury scene. I didn’t take it, as I am not allowed to, nor do I particularly want to, go off base or as we call it “outside the wire.” This was actually an incident between American troops and enemy combatants. This stockpile of weapons (picture # 2) demonstrates what our troops are up against. Unfortunately, due to experience and many casualties, most troops that travel outside the wire do so in heavily armored trucks (picture #3). This has greatly helped to reduce injuries sustained from IEDs, etc. Unfortunately again, not ALL troops ride in these vehicles. Some still travel in HUMVEEs which have been reinforced with armor; however, they still don’t offer the same degree of protection.

We spent most of the day taking care of a soldier that was riding in a HUMVEE when it was attacked (picture #4). The body armor usually protects the chest and abdomen from severe injury, however, the head, face, and extremities are often exposed. This soldier suffered terrible burns to his extremities and face. After a quick evaluation in the EMT he was taken immediately to the OR. There treatment continued by warming the patient and starting fluid resuscitation. When the skin is burned, the body loses its ability to regulate temperature control and maintain its fluids. Therefore, these types of injuries usually result in the patient being very cold and dehydrated. Deep burns that go all the way around a limb can cause constriction of the extremity due to swelling. When this occurs an escharotomy is required to restore blood flow (picture #5). Once stabilized he was transferred by helicopter to Bagram; within 24 – 28 hours he will be stateside at the BAMC burn center where they will continue his treatment. Unfortunately, one of the soldiers in his company was killed. As he was transported from the morgue to the helicopter, everyone available on base lined up by the flight line to pay their last respects and give him a “heroes'” goodbye (picture #6)

.(Escharotomy)

(Heroes' goodbye)

The rest of the week remained busy with both elective and emergent cases. The thyroid gland is an organ that regulates the metabolism of the body. It utilizes dietary iodine to make the thyroid hormones. In Afghanistan there is a deficiency of iodine. Because of this some individuals develop markedly enlarged thyroids that cause breathing and swallowing problems. Almost every week we see someone in clinic who is symptomatic from a thyroid goiter. We were able to take out two rather large thyroids this week, one of which was on the mother of an interpreter here at the hospital. I’m glad to say, everyone did very well. Picture # 7 shows just one side of the thyroid we removed. The young man I spoke about last week also recovered to the point of being discharged from the hospital. Dr. D and I posed with him before he left while he showed off his wounds (picture # 8). As the weather warms and as more troops move into the area, life is guaranteed to be busier. Although I enjoy the challenge, I continue to hope that the injuries we treat will be minor and non-life threatening. I leave you with a bumper sticker on one of the Special Forces vehicles (picture # 9). Take care.

Life continues

2009-03-01T01:28:00.000-08:00

(Tow Truck?)

As an army base, the flight line is filled will all sorts of helicopters that fly missions around the clock. You never know what you will see up in the air. Picture # 1 was taken as I was walking back to the hospital after lunch. The HUMVEE must have broken down, so it caught a ride back from a "Chinook". Helicopters are also instrumental in transporting wounded from the scene to our hospital. There are always two helicopters, one being the “chase” helicopter that provides air support. The medics that provide care to the patients are incredibly brave (Picture # 2). These guys are part of the “cowboy dustoff.” They fly out to the scene, pick up the patients, and provide medical support back to the hospital. They are just two of a great group of nurses and medics providing care to the wounded soldiers that we treat. The landing pad is right across the street from the hospital. After the helicopters land, “litter” teams go out and pick up the patients and transport them to the EMT for evaluation (picture # 3).

(Litter team)

One of the best things about deployment is meeting people from all over the country. I have had the privilege of meeting so many great people, who are making tremendous acrifices to serve their country in this capacity. For example, picture # 4 is of me with two of the primary care physicians here at FOB Salerno. Dr. M (left) is a family practice physician charged with taking care of the aviation unit. She just graduated from her residency last July. She will be here for 12 months and will have the joy of celebrating her 1^st year wedding anniversary here. Dr. W (right) is a dermatologist by training, but is the primary care physician for the rest of the base. She works tirelessly to make sure her patients are well cared for. She has 3 beautiful children at home and a husband who is in the last year of his surgical training! And I thought training was hard on my family! Only 1 ½ more months to go and she’ll get back home to them.

This was also a week of turnover. After 14 days of travel, Dr. V’s replacement finally arrived. Dr. D (picture #5) is a pediatric surgeon from Florida. He is in the army reserves and has previously been deployed to Iraq. How lucky am I. I actually love pediatric surgery and am planning on further training after my Air Force commitment. I’m glad Dr. D is here and I look forward to working with him. Capt G is pulling a face in the background. He just arrived and will be working here as a CRNA. Welcome!

(Dr. D, Capt G, Me)

The week was definitely interesting. An American contractor came to the clinic from another base complaining of a piece of steak being stuck in his esophagus. It had been there for about 2 days. He wasn't able to swallow and was choking on his own saliva. The weather did not permit him to be transferred to another facility for another 24 – 48 hours. Because it had already been in there 2 days, we didn’t feel like this could wait any longer to be removed. Usually, in the states this would be a rather easy problem to deal with using an endoscope. Here in the middle of Afghanistan, it proved to be a little more challenging because we really don’t have any advanced endoscopic equipment. We were however, able to find a single eye piece colonoscope (picture #5). I know this sounds gross, but we're somewhat limited in the middle of Afghanistan! Anyway, after it was cleaned and sterilized it was just another endoscope. We were then able to use it to push the piece of steak into the stomach (picture #6), thus clearing the obstruction. After a period of observation, he was able to eat and was subsequently discharged. Our week ended by treating a 15 year old Afghani boy who had been shot in the chest. We took him to the OR where we stopped his internal bleeding, repaired his broken sternum, and closed his chest wound. Picture # 6 is a picture of his open chest. Straight in is the sac containing the heart. The pink thing at the bottom is his lung. I’m glad to report that he is doing well and will make a full recovery. Take care.

Ho Hum

2009-02-22T01:58:00.000-08:00

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.

Crazy Week

2009-02-15T00:08:00.000-08:00

(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.

(BCGs)

Week of the Spleen

2009-02-07T06:00:00.000-08:00

(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.

Another Week...

2009-02-01T01:18:00.000-08:00

(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.

Downtime...

2009-01-26T03:36:00.000-08:00

(Winter rain)

Not much to write home about today. It’s been raining (picture #1). Khost, Afghanistan is on a plateau of sorts surrounded by multiple mountain ranges. Just north of it is Tora Bora which stands 14,200 ft tall. Therefore, it has its own eco-system. This is very nice for us, as in most of Northern Afghanistan the weather is cold and snowy, for us it is much milder. It’s 50 – 60 degrees during the day, thirties at night. Instead of snow, we see rain. When it rains, the Taliban and other radicals don’t like to work, so we have a lot of downtime. I guess I should consider this a blessing, except for the fact that it makes the time go by a lot slower. It did give me time for a haircut (picture #2). Hopefully, the clinic will begin to get busier as well. I did perform an inguinal hernia repair on a small 6 year old boy last week. It went well and I will see him in clinic next week for follow-up. I have spoken to many of the local doctors and have told them to start bringing me patients. They state that there are several who are undergoing a work-up and will come to clinic soon.

Otherwise, I’ve tried to fill my time with books, movies, and TV shows. There all over the place here. I brought an external hard-drive and already have multiple seasons of shows as well as hundreds of videos. In regards to books, I finished “Deep Survival” by Laurence Gonzales. This was recommended to my by Dr. McGreevy last spring. It’s a wonderful book about the psychology behind people who survive harrowing situations. I’m currently reading “Ghost Wars” by Steve Coll. It is a book about “the secret history of the CIA, Afghanistan, and Bin Laden, from the Soviet invasion to September 10, 2001.” I’ll let you know what I think. I’m also trying to refresh my memory and learn different aspects of trauma surgery. I’ll never know what will come into the trauma bay, so I’m trying to prepare myself as much as I can.

(Boot leg copies)

There is a “Haji” mart on base where locals come and peddle their goods. I will write more about this and include pictures in a future post. It was raining when I went today, so it wasn’t out in it’s full glory. You can get anything there; from Afghan rugs, to knockl-off Rolex watches, to recently released movies (picture #3). I picked up “Slumdog Millionaire” for 3 dollars. I’m not sure on the quality of the film yet. The other day I watched “Step-Brothers” with Will Ferrell. It was an obvious boot leg copy made by someone in a movie theatre as I could hear the audience laughing, eating popcorn, and at one point someone stood up. Nice. Life remains good here in Camp Salerno. I’m just enjoying the lull before the storm. When the weather warms up, I’ll wish for days like today. Take care.

(Medevac Helicopter)

A day in the life...

2009-01-22T18:07:00.000-08:00

(The original clinic above, and the new hospital below)

It has been a busy last several days. My typical day begins around 0530. I wake up, shower, and usually try to call my family. I will then go and round on my patients. The hospital is a fixed building that has been there about a year. Originally it was a tent (picture #1), then a tent hospital. It is now a “state of the art” facility (pictures #2). It has a trauma bay that contains four beds for evaluation and resuscitation. We have a new CT scanner that is smoking fast and provides great images when needed. It also has an OR with 2 beds (picture #3) that is attached to the ED. We are capable of running both OR’s simultaneously, and already have done so since I have been here. There is also a ward/ICU. There are four total beds, with the capabilities of caring for critically ill or routine patients (pictures #6). Since most of the patients we are dealing with are local nationals, we take care of them until they can leave the hospital. Anytime a specialist is needed, such as ophthalmology, neurosurgery, or ENT, we can transfer them to Bagram, a much larger facility. Otherwise we care for them. This makes it necessary for everyone to be on the same page and keep people moving through the system, so we can accept new patients.

(The OR Suite)

Once I have seen my patients, the whole team meets around 0715 for rounds. This includes; hospital commander, all surgeons (me as well as a thoracic surgeon and orthopedic surgeon), medicine doctors (there is an internist that works in the ED, as well as primary care providers), nursing staff, and anesthesia (we have an anesthesiologist and two CRNAs). We talk about the patients and make sure everything is happening to make them well and free up beds. After rounds we will begin the cases for the day. There is a local national’s clinic. People come from miles around to be seen. Once they are appropriately evaluated and prepared they will go to the operating room. Clinic will also be seen at this time.

(Our 8 bed ward; ICU capable)

Since the Taliban and other radical Muslims want to inflict the most possible damage, most of the trauma occurs during the day. This is exactly opposite what happens in the states, where trauma usually occurs at night. Around 1030 or so, we usually start receiving trauma patients. Most suffer from blast injuries from IEDs, or have been shot. Injuries range from mangled extremities to burns, to penetrating injuries of the extremities or torso. One never knows what we are going to see during the day. So we usually evaluate the trauma patients and treat them as needed. This usually means making the clinic patients and or the locals that will be operated on wait. Luckily, we have nothing better to do, so everyone puts in there best effort and we are usually able to finish around 1700 (picture #7). I will usually walk around and see my patients again and make sure they are doing well. After wards, it’s to the hooch or gym, followed by a scrumptious meal at the DFAC. So far, we’ve been watching movies at night in the surgeon lounge of the hospital. By then, I’m usually tired and ready for bed, so it’s lights out, only to repeat it again in the morning. Take care.

(Sunset on the flightline)

First day...

2009-01-21T05:28:00.000-08:00

I arrived at FOB Salerno early the morning of Jan 20th. I walked to the hospital and introduced myself. They were all surprised to see me, as no one told them when I would arrive. Dr. S was also happy to see me, as I was his replacement. After showing me the ropes, I assisted him in performing a subtotal thyroidectomy on a local national for a large multinodular thyroid. I then walked around the base and became familiar with it. Dr. S packed and caught an early morning flight for Bagram. I'm happy that he can get on his way, since his wife gave birth to there second child while he was here!

Today, was another fun packed day. I operated on a young man who was shot in the chest and abdomen 2 days ago. He was initially evaluated and treated in a hospital in town. Because he was so sick, they sent him to us. During the operation we found a hole in the stomach. Since repairing it, he has stabilized and greatly improved. I also experienced my first mass casualty (masscal). 6 injured Aghanistan National Army (ANA) were injured by an improvised explosive device (IED), as well as shot at. I had to take one to the OR to explore his left thigh as he had a gunshot wound and large hematoma. I was worried that his artery had been damaged. Upon exploration, I found a hole in the large vein of the leg that I repaired.

Once, things settled down, I was able to move into my "hooch." We have it nice here at FOB Salerno. We have fixed structures to live in (Picture #1,2,3). The walls and roof are over a foot thick of reinforced concrete. They can withstand a 110 mm shell. Six individuals live in each section. We pretty much divide the place into six small areas. I have included some pictures. All in all, things are going well. On my next post, I will write more about the base. Take care.

(There are endless rows of housing)

(My new home for the next few months)

In the air again....

2009-01-20T06:30:00.000-08:00

All geared up in the C130

I was able to fly out of Manas AFB for Bagram AFB (BAF) late Sunday night. We flew in a C130. It is a 4 prop jet cargo plane. It is smaller than the C17 which is the plane that can also carry tanks etc. (Picture #1) You can see me in my full battle gear; including helmet, weapon, and individual body armor (IBA). We were crammed up near the front of the plane, with our baggage on pallets in the back. All in all it was a pretty smooth ride. Gratefully, despite the combat maneuvers and no windows I was able to make it without throwing up. When I arrived at the base, we underwent the ritualistic in-processing. There was a flight scheduled for Camp Salerno at 0130, so I waited around the airport for about 2 ½ hours hoping to catch it. I was told that I was number 151 on the standby list. As the flight time approached, the waiting room became packed and it was obvious that I wouldn’t get on, so I went to the “In Transit” tent. (Picture #2&3) There I slept on a cot with 120 other guys. The next morning I went back to the terminal to catch a flight only to be told that there were no flights for the next couple of days. What!

Me and 120 other guys

So, I walked around the base. This is the real deal. A real Army/Air Force base in a war zone. There are bunkers (Picture #4) outside most living quarters and along major roadways. During the day it is busy. A lot of people and a lot of cars. There is also a fair amount of construction going on all around. The flight line (where the planes and helicopters are located) is really big. During the day and night planes and helicopters are coming and going. It’s amazing how loud those things are when you are this close. The hospital (Picture #5) is right on the flight line, with a large helipad containing multiple black hawk helicopters.

Bunker along the side of the road

Balgram Military Hospital

Using the advice of Dr. W, I went to the command section of the 455th EOG (my unit). They were able to find me a flight to Camp Salerno on Jan 20, at 0530. It was not a passenger flight, but a cargo flight to the camp. They were kind enough to accommodate me and even better is that I was able to sit in the "jump" seat, which is basically the back seat in the COCKPIT! It was an amazing ride and well worth the extra wait. I kick myself because I didn't take a picture. Take Care.

Waiting...

2009-01-18T04:46:00.000-08:00

I was bumped from my flight yesterday, so more waiting. It was nice, because I ran into Dr. S at the DFAC. She is a trauma surgeon at WHMC who left for Afghanistan shortly after I got there. She is on her way home. We were able to catch up, which was nice. It sounds like she did a great job. I'm on a flight for later today. I will then have to do it all over again in Balgram. I will probably be there for 1-3 days until I can get a flight to Salerno. More to come then. Take care.

Still moving...kind of

2009-01-17T18:15:00.000-08:00

Overall, the trip to Afghanistan has gone well. It has been somewhat of a tour de force. We (me and a DC-10 full of military members, dependents, government contractors) left BWI at around midnight on 15 Jan 09. We flew to Ramstein AFB where we had a 2 hour layover for refueling the jet. While there I ran into Dr. C. He is a Trauma Surgeon at Wilford Hall. He left almost a week before me to check out the way the trauma system runs at Landstuhl Regional Medical Center, since many of our patients (US soldiers) will eventually be transferred here on their way back to the states. The way the military trauma system has been set up during these conflicts is really amazing; simplified, soldiers are cared for in the field by medics and brought to a Forward Operating Base (where I will be). We stabilize them and then ship them to the next level of care, in my case Bagram AFB. They are then re-assessed, stabilized, and transported by flying ICU's to Landstuhl, where the process is repeated, and they are then sent back to the states. All in all, most of the US injured are within the continental US in about 72 hours. This has greatly reduced the mortality rate to around 1/15 injured.

After our break at Ramstein, we travelled to Adanas, Turkey, again for refueling. We were there another 2 hours. I was able to call and talk to Kristen, which was nice. It was then off to Manas AFB, another 4 ½ hour flight. During the flights I have had the privilege to talk to many different people. "Rog" was a bearded member of the special forces. Let me tell you, the moment I saw him I knew that he was a real life "Jack Bauer" and could probably snap my neck with his little pinky finger. Another, 1^st Lt Miles is from Georgia, is in the military police. He is also on his way to Camp Salerno. Hopefully, our paths will only cross at the work-out facility or in the dining facility (DFAC). We finally arrived at 6:30 AM after a total of 5 hot meals and 5 – 6 movies. We were briefed on the rules and what we needed to accomplish while there. It was then pretty much "hurry up and wait." (The AF is really good at that). We are basically in a way station to Afghanistan. Manas AFB is located in Bishkek, Kyrgyzstan. It is really cold, 1 degree today! The accommodations aren't bad. I share a room with 2 other Gentlemen. One is a young man who use to be in the military, but now works as a DOD civilian in military intelligence (T). The other is a retired commander from the British Royal Navy. He also works as a civilian contractor in military intelligence (J). Mainly, all I have been doing is waiting. I have had many meals at the DFAC, some are better than others.

lovely accomodations

At one of my meals I ran into two additional surgeons going to Balram, Dr. M is a general surgeon. He has about a year left, and believe it or not will be taking a job at the new Riverton Hospital. He lives in Dayton, Ohio, and has family ties to SLC, Utah. Small world. The other, Dr. B, is an orthopedic surgeon from Eglin AFB, Florida. I met him while teaching an EMEDS course in December. Again, small world. It's nice to know who will be taking care of folks I send to Balgram. Anyway, today is full of more dragging my bags around (now a total of 5 bulging, heavy bags, mostly full of things I hope I never have to use), waiting in line, then off to Bagram. We'll fly in on a C17. It's supposed to be a pretty fun ride as they basically dive down to the landing gear performing combat maneuvers. Then, I'm sure I'll be briefed, wait, most likely acquire more gear, then wait some more for a ride to Camp Salerno. Take care.

Me, Dr. B, Dr. M, and Dr. W

Manas at night: that's pretty much it!

T, J and Dr. S enjoying a Baltika #9

Off I go...

2009-01-14T09:26:00.001-08:00

Well, after a whirl wind of a preparation due to the short notice, the day came to depart. My family accompanied me to the airport and were able to see me off to the gate. It really hasn’t hit any of us yet that I am leaving. So far, it feels just like another conference or business trip. The kids are so use to me being gone, i.e. on call or home late, that I don’t know if they will fully grasp it for a couple of weeks. I probably won’t until I get there.

The base is an Army Forward Operating Base (FOB) near Khost, Afghanistan which is near the Afghanistan/Pakistan border. It has been there for several years and actually has a structured hospital with a CT scanner. In addition to taking care of injured soldiers, I will have the opportunity to participate in the local national clinic that provides humanitarian surgery. Apparently people come from hundreds of miles around to be seen in this clinic. I will have to refresh my memory on diseases within developing countries!

Although it will be difficult to be separated from my family, I feel privileged to be able to do this. It truly is a once in a lifetime experience. I will be faced with situations that I never dreamed of. It will really be a growing experience both personally and professionally. My anxiety isn’t over my safety (I’ll be protected by big, buff, automatic weapon toting, security forces, I’m not nervous about Kris and the kids (they are in a great neighborhood with a lot of support), I’m primarily worried about whether or not I will be up to the task.

I will use this blog to document and share my experiences while I am here. I hope it will allow my friends and family to see and better understand a world that is so greatly separated from the luxuries and safety we so easily take for granted. As I will be travelling for the next several days, I will post again once I reach Manas AFB. Take care.