Life, Limb, or Eyesight

This past Saturday morning presented one of the most difficult situations that I have faced as a doctor. I was on call here in Afghanistan taking care of 4 patients with eyesight emergencies.
2 of my patients had already lost a left eye due to trauma, but both were having a very hard time excepting this fact. And, 2 of my patients had conditions that were seriously threatening eyesight in the left eye. Yes that's correct, I had 4 patients all with major trauma to their left eye. It's weird how in medicine you will see a cluster of similar conditions presenting at the same time. 2 of the patients had lost the left eye in blast injuries earlier in the week. Each day when I saw these patients they would ask me when the vision would come back in the left eye. I had to inform them that they no longer had a left eye. Saturday morning was no different. They asked about it, and I tried to be compassionate in my reply. Clearly, time is necessary for the reality of these devastating injuries to sink in and solidify.

The other two patients were even more challenging. One was a U.S. marine who had sustained facial trauma during an IED blast while he was riding in the turret as the gunner on a convoy. The butt of his machine gun slammed into his face. His check bone and eye socket were shattered into pieces. The soft structures of the eye were under enormous pressure. Our eye surgeon took him to surgery and repaired what he could. Now the issue was all the inflammation surrounding the eye. The decision was made to try the patient on high doses of steroids to calm this inflammation down. I wrote an order for whopping doses of solu-medrol (1 gram bolus then 250 mg every 6 hours for 3 days). Time would be needed for see if this would work. After about 36 hours at Bagram, the patient was flown to Landstuhl in Germany. I probably will never know if this marine will see out of that eye again. There are just too many patients to try to follow up on what happens to them. You have to move on to the next patient in crisis.

The 4th patient was the most difficult case. He was an Afghan who works an interpreter for the British Marines. Their camp came came under attack with mortars. The patient was peppered with shrapnel to his right side sustaining some relatively minor flesh wounds. However, somehow shrapnel also flew into his left eye. He was taken to surgery and a very improbable condition was diagnosed. He had a partial retinal detachment from the trauma. This is an absolute eye emergency. The retina is a very specialized structure. It is so specialized that very few eye doctors in the world operate on it. The condition needs a retina specialist. The U.S. Air Force does not currently have a retina specialist. There may not even be a retina specialist in the entire middle east trained to western standards. We were in a bind to say the least. Many phone calls were made. Because of a plethora of factors including world politics, we had no options other than to treat him here at Bagram.



The patient was beside himself. He understood fully that his eyesight was very much at risk and the clock was ticking. For several hours on Saturday morning, he approached me time and time again asking me questions that I could not answer. I was trying to provide care to all the patients on the ward, but really the situation with this one patient was absolutely killing me. It was tearing me up. I was actually nauseated for the entire morning. I knew that in the United States this patient would get surgery and retain his vision for sure. But, that would not happen here which to me was a very bitter pill to swallow. Our eye doctor looked into options. He did not have the proper equipment here to even attempt a retina surgery. The patient's vision was 20/300 at this point, legally blind in that eye. The decision was made to try a series of laser treatments in hopes that the retina would re-attach itself. It was a long shot. Our eye doctor lasered his retina approximately a thousand times I was told. At that point, it was a waiting game. The patient stayed in the hospital for the next 4 days while his flesh wounds healed up, but of course we were all focused on his left eye. 3 days ago he had a repeat eye exam. His vision was now 20/30 in his left eye with correction. Wow! Perhaps he would see again well with glasses. Yesterday he had another eye exam.... 20/20 without correction!!! Unbelievable. The eye doctor was amazed. I was so relieved. The patient was ecstatic. His gratitude was infectious. He had us all sign a T-shirt for him so that he could remember the names of everyone that cared for him here. It was corny but 100% sincere.

To me, the restoration of his vision during his 5 day stay here was a minor miracle. We often talk about the triad of life, limb and eyesight when triaging trauma patients. When any of these three are in danger, we go to heroic lengths and do everything humanly possible. However, in this case I think the most important intervention was divine.