Taking a stroll around the ward at Craig Joint Theater Hospital here at Bagram Air Field can be kind of a surreal experience at times. If you stop to take notice of some things, it can reveal a lot about our world actually. In the area of the hospital where I work, there is one large room full of hospital beds known as the Afghan Bay. Right next to it is a similar room called the American Bay. The Afghans populate the Afghan Bay and likewise all Americans (and coaltion troops) go into the American Bay. One of the things I have noticed is the stark contrast in the nutritional status of the Afghans versus the Americans. In short, we are thick and they are thin!
The average Afghan is clearly malnourished. They are usually just skin and bones. It becomes very obvious when you pull back their hospital gowns to examine their wounds. There is absolutely no subcutaneous fat on the vast majority of Afghans. They are rail thin. We keep tabs on the "I and O's" of most of our patients. All fluid that goes into the body and all that comes out is recorded. It does not take long to see that the Afghans take in a significant amount less than the Americans. This is partly because the food we offer them is western and is not palatable in many ways for them. But, I think that the Afghans are simply used to taking in hardly anything. Their bodies have adapted. We are taught in medical school that in order to maintain your hydration status, you have to take in "maintenance fluids" based on your weight. The Afghans take in maybe half of this "maintenance fluids" day after day. Yet, they live on.
On the other hand, the average American is overweight. We know that. It's not that much different in the military population surprisingly. The American patients are pretty much always taking in their "maintenance fluids" and then some. We never have to worry about nutrition with these patients. They can have devastating injuries and we know that they will not have any problems healing as long as we in the medical field do our part. In a trauma hospital like we have here, nutrition is highly importaint. The Afghan patients are having lots of post surgical complications. Without a doubt I attribute it in large part due to their malnutrition. You cannot build healthy tissue without the necessary building blocks. It's a real problem. The other docs and I were brainstorming about this recently trying to figure out how we could get the Afghan patients to eat and drink more. We are trying to get them to drink high calorie shakes. And, we recently put out a "chai station" which has tea for them all day long. Chai tea is a big deal here. We'll see if these small changes help.
We have the exact opposite problem in our culture... we eat way too much. All you have to do is go into the staff lounges at the hospital to see this. We have boxes of candy, cookies, chocolate, granola bars, trail mix, hot chocolate, and many other foods with little nutritional value. Food is everywhere. You can't get away from it! At 2 in the morning I will find myself downing a giant peanut butter cookie to reward myself for admitting yet another trauma patient. There is no reaston to do this. But, it is like a reflex. I don't even think about it most of the time. I see food and I eat it. I have to consciously think to NOT eat. On the other hand, we have to practically beg the Afghans to eat more. One day not too long ago I got frustrated with this and launched into an eating pep talk in the middle of the Afghan Bay. It was like Knute Rockne's "win one for the gipper" speech except the message was to just please "eat one for the doctor"! They looked at me like I was nuts. Hilarious.
Alright, I better get off my soap box here. After all, I'm starting to get hungry!
Tuesday, February 23, 2010
Sunday, February 21, 2010
So, how's the war going?
Every so often a package will arrive with letters sent from school kids. The letters are intended for any of us over here. It can be quite comical to read these letters. Usually they will read something like, "Hello, this Johnny from Anywhere, USA. Thanks for being a soldier. How is the war going? Have a great day!" We have a little fun reading these and laughing about just how blunt kids can be. So, just how is the war going anyway? I'll give you what I know which is just a tiny slice. After all, my mission is simply to provide medical care. And, I am just a FOBBIT! (fobbit = someone who never leaves the forward operating base aka FOB)
Here at Bagram you can see easily many signs of the "The Afghan Surge". A giant new hangar is being built to store our C-17 cargo planes. Many of the C-17's here are from my home base in Charleston. I often wish I could just get on one of those and go home! Oh well, that's not going to happen anytime soon. New housing is going up each day. Some day soon deployed soldiers will be able to live in a new connex village just down the way from my B Hut Village. Connexes are those large containers you see on the back of an 18 wheeler or stacked on a giant ship. Over here they are stacked up and then snapped together like legos. Living in one is the lap of luxury on deployment. There are also warehouses being bulit and lots of activity in the industrial part of this base. Basically, this base is being built up tremendously. It's clear that we are here to stay for a long time. Just like Korea, Japan, and Germany we will probably have thousands of troops in Afghanistan for decades to come. This is the honest truth. Thinking otherwise would just be naive. We are here to stay!
The offensive in southern Afghanistan is well under way now. Originally, the media was reporting that our marines were not encountering much resistance in Marjah. I knew better. One of my patients was in the thick of it down there just hours before being brought to our hospital. He described intense fire fights. This young guy was the expert marksmen for his company. He told stories of "taking out" lots of Taliban while constantly being a target himself. The stress level was incredibly high even for this experienced marine. Eventually, it all got to him and he suffered a stress induced seizure. Upon making it to his bed on our ward, he pulled the covers over his head and slept for probably a day. I've seen weary soldiers do this all too often. When that blanklet goes over those eyes and they don't talk for a day, well, you just know that a trip home is absolutely necessary.
The news has reported that the number 2 Taliban leader is now captured. Obviously, this is a good thing. On the other hand, civilian casualties continue. There is a report on the internet today that 27 civilians were killed yesterday in a NATO airstrike. Unfortunately, these casualties are inevitable. And, we know that at times the terrorists will use "human shields". It's insane, sick, and evil. Overall, we are now fighting a war based on COIN - counter insurgency. We are out there trying to win hearts and minds, so that the people of Afghanistan rise up and take control of their own country. Sounds simple, but it is extremely hard to do this. Each day when I interact with Afghans at our hospital I have to remember COIN. For me this means treating people right all the time no matter what. I am sure that I fail at this often. More importantly, our troops are out in Afghanistan interacting with the locals every single day doing their best to make a small dent in this complicated war.
So, that simple question "How's the war going" is not so simple after all. Every day I pray for peace and justice. Can those 2 things go together in this world in the year 2010? I hope so.
Here at Bagram you can see easily many signs of the "The Afghan Surge". A giant new hangar is being built to store our C-17 cargo planes. Many of the C-17's here are from my home base in Charleston. I often wish I could just get on one of those and go home! Oh well, that's not going to happen anytime soon. New housing is going up each day. Some day soon deployed soldiers will be able to live in a new connex village just down the way from my B Hut Village. Connexes are those large containers you see on the back of an 18 wheeler or stacked on a giant ship. Over here they are stacked up and then snapped together like legos. Living in one is the lap of luxury on deployment. There are also warehouses being bulit and lots of activity in the industrial part of this base. Basically, this base is being built up tremendously. It's clear that we are here to stay for a long time. Just like Korea, Japan, and Germany we will probably have thousands of troops in Afghanistan for decades to come. This is the honest truth. Thinking otherwise would just be naive. We are here to stay!
The offensive in southern Afghanistan is well under way now. Originally, the media was reporting that our marines were not encountering much resistance in Marjah. I knew better. One of my patients was in the thick of it down there just hours before being brought to our hospital. He described intense fire fights. This young guy was the expert marksmen for his company. He told stories of "taking out" lots of Taliban while constantly being a target himself. The stress level was incredibly high even for this experienced marine. Eventually, it all got to him and he suffered a stress induced seizure. Upon making it to his bed on our ward, he pulled the covers over his head and slept for probably a day. I've seen weary soldiers do this all too often. When that blanklet goes over those eyes and they don't talk for a day, well, you just know that a trip home is absolutely necessary.
The news has reported that the number 2 Taliban leader is now captured. Obviously, this is a good thing. On the other hand, civilian casualties continue. There is a report on the internet today that 27 civilians were killed yesterday in a NATO airstrike. Unfortunately, these casualties are inevitable. And, we know that at times the terrorists will use "human shields". It's insane, sick, and evil. Overall, we are now fighting a war based on COIN - counter insurgency. We are out there trying to win hearts and minds, so that the people of Afghanistan rise up and take control of their own country. Sounds simple, but it is extremely hard to do this. Each day when I interact with Afghans at our hospital I have to remember COIN. For me this means treating people right all the time no matter what. I am sure that I fail at this often. More importantly, our troops are out in Afghanistan interacting with the locals every single day doing their best to make a small dent in this complicated war.
So, that simple question "How's the war going" is not so simple after all. Every day I pray for peace and justice. Can those 2 things go together in this world in the year 2010? I hope so.
Tuesday, February 16, 2010
End of Life Care at Bagram
We spend years training to be doctors, and then we "practice" medicine for the rest of our careers. The nurses and technicians learn many skills, then perfect them over time. One of the most difficult things that we all have to deal with as healthcare professionals is end of life care. However, I am not sure it gets much easier with experience.
I will start with the good news. We do not see many Americans or coalition troops die within the four walls of the hospital here. Our medical evacuation system has become effective enough that 98% of the patients who make it to our hospital at Bagram will live. Often, our soldiers will have several surgeries and be back in the states 48-72 hours after being wounded. Just last night I had a patient who was on his way to Germany just 12 hours post injury after having 2 surgeries already! The patients who do not make it usually have devastating injuries and die close to the front lines at our forward surgical hospitals.
There is another population of patients here at Bagram, the Afghans. Our hospital is the end of the line for them. We do not send the Afghans on to Landstuhl Regional Medical Center in Germany. We do everything we can for them here before sending them to Afghan hospitals. This creates some very difficult situations. Let me explain.
In my 2 months here,I have seen a handful of Afghan patients with severe trauma that spend weeks at our facilities. Some were very close to death initially and received "massive transfusions" of blood. Their entire blood volume was lost and replaced several times over. This is bound to have some deleterious effects and it does. Usually these patients undergo multiple surgies to the arms, legs, and abdomen to "fix" their injuries. Unfortunately, the neurological status often declines rapidly in these patients. The bottom line is their brains are not working right and we cannot explain why. We are left with people on life support who have little hope of every being anything like what they used to be. They are essentially in a vegetative state. It's a difficult thing to see for everyone. And, there is a situation that is even more difficult. How about when the patient is one of our prisoners... wounded by coalition forces severely but is still alive and breathing? The soldiers who captured these prisoners are tasked with guarding them. I can only imagine what it is like to sit and look at someone for hours on end who has tried to kill you. The integrity that many of our young troops show in doing this is astounding.
End of Life Care is a controversial subject no matter where you are. I learned that first hand as a second year resident at the University of Nebraska Medical Center. We had a dying patient with essentially no hope. After watching this for entire month I eventually said to the family in a few words that they might consider comfort care only. It was not taken well. I was later chastised in an angry letter to the president of the hospital. I won't even bother to write what they called me in that letter. It had a profound impact on me. In the end, it made my resolve even greater to do the right thing at the end of life instead of the easy thing. Sometimes this is electing to not transfuse more blood or take a patient back to the operating room. After all, doctors never have been and never will be God.
Our problems with End of Life Care here at Bagram will continue in my remaining 4 months and then will persist indefinitely as long as we are at war. I do not pretend to have the answers. It is something that weighs heavily on each and every one of us. There are no easy answers.
I will start with the good news. We do not see many Americans or coalition troops die within the four walls of the hospital here. Our medical evacuation system has become effective enough that 98% of the patients who make it to our hospital at Bagram will live. Often, our soldiers will have several surgeries and be back in the states 48-72 hours after being wounded. Just last night I had a patient who was on his way to Germany just 12 hours post injury after having 2 surgeries already! The patients who do not make it usually have devastating injuries and die close to the front lines at our forward surgical hospitals.
There is another population of patients here at Bagram, the Afghans. Our hospital is the end of the line for them. We do not send the Afghans on to Landstuhl Regional Medical Center in Germany. We do everything we can for them here before sending them to Afghan hospitals. This creates some very difficult situations. Let me explain.
In my 2 months here,I have seen a handful of Afghan patients with severe trauma that spend weeks at our facilities. Some were very close to death initially and received "massive transfusions" of blood. Their entire blood volume was lost and replaced several times over. This is bound to have some deleterious effects and it does. Usually these patients undergo multiple surgies to the arms, legs, and abdomen to "fix" their injuries. Unfortunately, the neurological status often declines rapidly in these patients. The bottom line is their brains are not working right and we cannot explain why. We are left with people on life support who have little hope of every being anything like what they used to be. They are essentially in a vegetative state. It's a difficult thing to see for everyone. And, there is a situation that is even more difficult. How about when the patient is one of our prisoners... wounded by coalition forces severely but is still alive and breathing? The soldiers who captured these prisoners are tasked with guarding them. I can only imagine what it is like to sit and look at someone for hours on end who has tried to kill you. The integrity that many of our young troops show in doing this is astounding.
End of Life Care is a controversial subject no matter where you are. I learned that first hand as a second year resident at the University of Nebraska Medical Center. We had a dying patient with essentially no hope. After watching this for entire month I eventually said to the family in a few words that they might consider comfort care only. It was not taken well. I was later chastised in an angry letter to the president of the hospital. I won't even bother to write what they called me in that letter. It had a profound impact on me. In the end, it made my resolve even greater to do the right thing at the end of life instead of the easy thing. Sometimes this is electing to not transfuse more blood or take a patient back to the operating room. After all, doctors never have been and never will be God.
Our problems with End of Life Care here at Bagram will continue in my remaining 4 months and then will persist indefinitely as long as we are at war. I do not pretend to have the answers. It is something that weighs heavily on each and every one of us. There are no easy answers.
Sunday, February 14, 2010
Valentine's Day Off
Happy Valentine's Day everyone! It is an American made, commercialized holiday that is revered by many woman. This year I recieved an amazing Valentine's Day present... A DAY OFF WORK! It is not normal to work every day for weeks on end. Unfortunately, the previous rotation of doctors did just that. They had a schedule that allowed for zero days off for 6 months. Absolutely ridiculous! More importantly, it is completely unhealthy. 2 weeks ago I decided that this had to stop. There are 3 of us docs that work in the hospital ward. One of us has to be there at all times, 24 hours a day. We decided to cover for each other so that each person has at least most of one day off a week. So far it is working. Apparently, we have received some critical casualties in the last day. I would not know because I was NOT THERE! I was away from the hospital for a whole day.
So, for my 24 hours off I did what most Americans do on their days off, relax. I spent time reading a great book called "The Blind Side". It is a great story about an inner city kid who is totally neglected but gets rescued. If you have not seen the movie or read the book, I recommend it highly. This morning I slept in until 8 AM. After getting up at Oh Dark Thirty as we say in the military for the past 51 days in a row, it felt great to stay under the covers a few hours longer. I was able to get to church today which is always a good thing. Lent is coming up and I am planning to actually take it seriously this year. I'd like to learn more about my faith and there is no better time to do it then now. I was able to enjoy a smoothie and some pizza for lunch today. That hit the spot. I ended my day off with a run out to the incinerators and back. Oh what a site it is to see all the garbage that thousands of troops produce each day burned to ashes. Obviously, I am kidding. It's disgusting and a necessary evil I guess.
So, now I am back to the grind. I am back on nights this week. My batteries are recharged. I'm ready to work hard and do the best I can to take care of our wounded warriors. In the meantime, I will steal some valentine's day chocolate from someone and and endulge.
Cheers!
So, for my 24 hours off I did what most Americans do on their days off, relax. I spent time reading a great book called "The Blind Side". It is a great story about an inner city kid who is totally neglected but gets rescued. If you have not seen the movie or read the book, I recommend it highly. This morning I slept in until 8 AM. After getting up at Oh Dark Thirty as we say in the military for the past 51 days in a row, it felt great to stay under the covers a few hours longer. I was able to get to church today which is always a good thing. Lent is coming up and I am planning to actually take it seriously this year. I'd like to learn more about my faith and there is no better time to do it then now. I was able to enjoy a smoothie and some pizza for lunch today. That hit the spot. I ended my day off with a run out to the incinerators and back. Oh what a site it is to see all the garbage that thousands of troops produce each day burned to ashes. Obviously, I am kidding. It's disgusting and a necessary evil I guess.
So, now I am back to the grind. I am back on nights this week. My batteries are recharged. I'm ready to work hard and do the best I can to take care of our wounded warriors. In the meantime, I will steal some valentine's day chocolate from someone and and endulge.
Cheers!
Wednesday, February 10, 2010
Afghan Avalanche
We have been preparing for several weeks mentally for a huge influx of patients. The well publicized offensive on the horizon along with the "Afghan Surge" will likely bring many more casualties our way. But, much to everyone's surprise our first mass casualty event had nothing to do with war.
We had a small snow storm in northeastern Afghanistan over the weekend. The mountains surrounding us are now covered in snow. Apparently there is a mountain pass that is highly traversed between Kabul and Mazar-e-Sharif up north. 2 days ago an avalanche occured onto this mountain pass. It was approximately 2 miles wide apparently. Hundreds of Afghans were trapped. The temperatures were in the teens and twenties.
A "mascal" was called yesterday afternoon. The entire hospital staff was ready. We waited for several hours with all of our equipment at the ready. We had about 20 doctors including myself in the trauma bay prepared for the worst. Thankfully, it was not so bad. Most of the people were walking wounded, or not really even patients at all. Many were basically refugees. They had nowhere else to go, so coming to an American base was their best option. As with any calamity, there were a lot of rumors flying and a ton of misinformation. Several hours after the entire staff was called in, patients started coming my way to be admitted to the ward.
Frostbite was the number one diagnosis. We admitted a slew of patients with hand and foot frostbite mostly to monitor them. Their extremities needed to be re-warmed and time given for the tissue to be re-perfused. One patient of mine arrived with a body temperature of 84! He received warm IV fluids at 104 degrees. He had special blankets put on and a continuous temperature probe inserted. Amazingly, he was alert and talking a little bit even when he was severely hypothermic. It took 2-3 hours for his temperature to return to normal. His feet were swollen and blue. By morning the color in his feet was returning. He was moving his toes. Most of his feet had sensation. Our orthopedic surgeon held off on amputation. It would take weeks for the extent of the injury to declare itself.
When all was said and done, we had a ward full of patients and a tent full of refugees. One patient did die here. Heroic measures were taken, but he was too far gone. Most of our Afghan patients were seen, treated, and transported off the base within 24 hours. We have to be ready for the next wave of patients, so there is not time to delay. Sadly, I was told by someone that hundreds of people were left at the avalanche site. Our choppers could only transport a fraction of the victims. The news today is reporting 150 dead in the avalanche. It's a stark reminder that we are in a third world country and that mother nature is so very powerful.
We had a small snow storm in northeastern Afghanistan over the weekend. The mountains surrounding us are now covered in snow. Apparently there is a mountain pass that is highly traversed between Kabul and Mazar-e-Sharif up north. 2 days ago an avalanche occured onto this mountain pass. It was approximately 2 miles wide apparently. Hundreds of Afghans were trapped. The temperatures were in the teens and twenties.
A "mascal" was called yesterday afternoon. The entire hospital staff was ready. We waited for several hours with all of our equipment at the ready. We had about 20 doctors including myself in the trauma bay prepared for the worst. Thankfully, it was not so bad. Most of the people were walking wounded, or not really even patients at all. Many were basically refugees. They had nowhere else to go, so coming to an American base was their best option. As with any calamity, there were a lot of rumors flying and a ton of misinformation. Several hours after the entire staff was called in, patients started coming my way to be admitted to the ward.
Frostbite was the number one diagnosis. We admitted a slew of patients with hand and foot frostbite mostly to monitor them. Their extremities needed to be re-warmed and time given for the tissue to be re-perfused. One patient of mine arrived with a body temperature of 84! He received warm IV fluids at 104 degrees. He had special blankets put on and a continuous temperature probe inserted. Amazingly, he was alert and talking a little bit even when he was severely hypothermic. It took 2-3 hours for his temperature to return to normal. His feet were swollen and blue. By morning the color in his feet was returning. He was moving his toes. Most of his feet had sensation. Our orthopedic surgeon held off on amputation. It would take weeks for the extent of the injury to declare itself.
When all was said and done, we had a ward full of patients and a tent full of refugees. One patient did die here. Heroic measures were taken, but he was too far gone. Most of our Afghan patients were seen, treated, and transported off the base within 24 hours. We have to be ready for the next wave of patients, so there is not time to delay. Sadly, I was told by someone that hundreds of people were left at the avalanche site. Our choppers could only transport a fraction of the victims. The news today is reporting 150 dead in the avalanche. It's a stark reminder that we are in a third world country and that mother nature is so very powerful.
Wednesday, February 3, 2010
Groundhog Day
The news made it here that the good old Pennsylvania groundhog saw his shadow yesterday. Thus, winter will rage on for ya'll back home. I understand it has been a rough winter for most of the USA. Even back in good old Charleston, South Carolina it has been chilly. But, groundhog day has another meaning for us here on deployment.
The movie "Groundhog Day" with Bill Murray is a mediocre flick in which the same day occurs over and over and over. It actually gets annoying watching it. In many ways, that is what deployment is like. Each day runs into the next. You get into a routine and things just feel the same every day. Routine is good in many ways because we know what to expect. It allows us to relax. But, we also need some excitement in our days. The major events of my days here are working, eating, and exercising. A warm shower often is a highlight as well. I guess this is not all that much different than home on a typical weekday. However, there is one main difference which is the lack of freedom that we have here on a military post in a combat zone. You can't just get in the car and cruise over to the ocean. You can't just go for a run through a scenic area of town. You can't just take your dog for a long walk. It's the lack of freedom that can be really drive you nuts!
So, my own little groundhog day has been playing out since I got comfortable with my routine here in early January. It has been testing my ability to keep a positive attitude. With 5 months left to go, the light at the end of the tunnel is stll way out there. However, today I received a big piece of humble pie to put it all into perspective.
We have a 23 year old Army soldier in the hospital right now for a relatively minor condition. He had surgery and will recover just fine barring some unforeseen event. I got to talking with him today about his job. He provides security for colonels and sergeant majors when they are out and about meeting with Afghan village elders. He is in harm's way often. It's a tough job I am sure. I will not be rushing him out of the hospital because I know he needs a break. But, here is the kicker. This fine young soldier was deployed to Iraq previously. Okay. so have tons of other people. But, how many people had an 18 month deployment to Iraq, then just 4 months at home, followed by a 15 month deployment to Aghanistant? That's right, when all is said and done (god willing of course), this solider will have served 33 of 37 months in a combat zone. That's insane!!! I cannot imagine that. It seems like a prison sentence to me. And, he has 3 kids back home. Holy cow! What a major sacrifice for him and his family.
So, my little Groundhog Day will be just fine. I have nothing to complain about today.
The movie "Groundhog Day" with Bill Murray is a mediocre flick in which the same day occurs over and over and over. It actually gets annoying watching it. In many ways, that is what deployment is like. Each day runs into the next. You get into a routine and things just feel the same every day. Routine is good in many ways because we know what to expect. It allows us to relax. But, we also need some excitement in our days. The major events of my days here are working, eating, and exercising. A warm shower often is a highlight as well. I guess this is not all that much different than home on a typical weekday. However, there is one main difference which is the lack of freedom that we have here on a military post in a combat zone. You can't just get in the car and cruise over to the ocean. You can't just go for a run through a scenic area of town. You can't just take your dog for a long walk. It's the lack of freedom that can be really drive you nuts!
So, my own little groundhog day has been playing out since I got comfortable with my routine here in early January. It has been testing my ability to keep a positive attitude. With 5 months left to go, the light at the end of the tunnel is stll way out there. However, today I received a big piece of humble pie to put it all into perspective.
We have a 23 year old Army soldier in the hospital right now for a relatively minor condition. He had surgery and will recover just fine barring some unforeseen event. I got to talking with him today about his job. He provides security for colonels and sergeant majors when they are out and about meeting with Afghan village elders. He is in harm's way often. It's a tough job I am sure. I will not be rushing him out of the hospital because I know he needs a break. But, here is the kicker. This fine young soldier was deployed to Iraq previously. Okay. so have tons of other people. But, how many people had an 18 month deployment to Iraq, then just 4 months at home, followed by a 15 month deployment to Aghanistant? That's right, when all is said and done (god willing of course), this solider will have served 33 of 37 months in a combat zone. That's insane!!! I cannot imagine that. It seems like a prison sentence to me. And, he has 3 kids back home. Holy cow! What a major sacrifice for him and his family.
So, my little Groundhog Day will be just fine. I have nothing to complain about today.
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