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.