The other day I was able to witness the interrogation of an Enemy of Peace (EOP), aka prisoner. He had been shot in the left leg taking a large chunk out of his thigh in the process. So, he was in the hospital on the ward in stable condition. A member of special forces(SF) appeared to do the interview. My role was to do a brief exam before and after the interrogation to document that no abuse occured. The SF guy was dressed in civilian clothes with a beard. He had on hiking shoes, jeans, and a button down short sleeve shirt. This is normal. Outside the wire (off base), the SF guys wear uniforms without name tags from what I understand. Inside the wire (on base), they dress casually. With the beards and all, it is actually not too difficult to pick them out of a crowd. I am told beards are worn to help garner respect with the locals. The EOP also had a beard and was probably in his twenties. He was actually one of the healthiest appearing EOP's that I have seen.
The interrogation was actually quite professional. There was no waterboarding! It was simply 45 minutes of questions about the EOP's background then specifics about the events leading up to his capture. Voices were never raised. Some of the conversation went something like this:
SF guy: Why were you shooting at us?
EOP: I was not shooting.
SF guy: But, we saw you shooting. Where did you get the weapon?
EOP: I did not have a weapon.
SF guy: But, we saw you shooting. Why did you try to run away?
EOP: I did not try to run away.
SF guy: But, we captured you when you were running away shooting at us with a weapon.
EOP: (silence)
The SF guy took extensive notes. No threats were made. It was simply information gathering. Today, the aforementioned EOP left the hospital for the detainment facility.
I have had several other interactions with SF all of which were curious. After a firefight in Kabul, a group of SF guys were helicoptered to our hospital. They all walked in under their own power. They did not want pain medicine. The first thing they asked is when they could leave and go back to the fight. I told one of them, "Dude, you just had a grenade blow up near your face!" He was taken for an eye exam and passed with flying colors. I would not be surprised if he ate a roast beef sandwich then immediately left the wire to meet up again with his SF brethren. Another had minor injuries from a blast. He also was able to leave the hospital that day. But, the thing that was the most remarkable about it all was that a large group from the SF community came to the hospital to check on the guys. It was kind of a circus outside the trauma hot box. SF has their own doctors apparently. I had to explain what was going to on to several of them to report up their chain of command. There was tremendous concern for the well being of their men. I have not seen any other unit, platoon, squad, brigade, task force, or whatever have such an impressive response. SF is clearly tight knit.
Not too long ago an SF guy was admitted to the ward for low back pain under the care of one of my colleagues. Low back pain is one of the most common complaints in primary care. It almost invariably will get better no matter what the medical provider does for the patient. So, I was exceedingly unimpressed to have a low back pain patient in the hospital. The patient received large amounts of pain medicine. As it turns out, I happen to be the only doctor on base that does back adjustments due to my background in osteopathic medicine. (On several occasions I have been paged to crack the backs of high ranking military officials. It's kind of annoying actually.) I did a minor back adjustment for the SF guy right there in his hospital bed. It did make him feel better temporarily, but his pain persisted. The next day the SF guy was flown to Germany for further testing. To me, this was ridiculous which I happened to mention to one of the SF doctors. Fast forward a month or so when I was approached in the emergency room by this same SF doctor. She ran up to me and yelled, "THE GUY HAD A TUMOR!" Excuse me. Yep, the SF guy's pain was caused by a tumor on his spinal cord. I felt like an idiot. I told her she had every right to get in my face and say "I told you so", but she did not. Instead she explained to me that SF guys do not complain and they do not lay in bed. When one of them does this, something very serious must be wrong. Fortunately, the tumor turned out to be benign (non-cancerous).
Without a doubt, SF is a unique subset of the military. I am told that we are not supposed to know what they really do out there. They are on the front lines here in Afghanistan. The commander of this war, General McCrystal, has a SF background. He has made many changes in our counterinsurgency strategy here. From what I understand, the military is relying more and more on SF in this increasingly complicated war. We will definitely continue to see SF guys within the walls of our trauma hospital. Perhaps my approach will be a little different the next time I encounter one of these characters.
Wednesday, April 28, 2010
Friday, April 23, 2010
Major Mid Life Crisis
At the ripe age of 34, I am noticing some disturbing trends and changes in me. Physically, things are going downhill. For example, I have been sick with the common cold twice since getting deployed. During my twenties, I hardly ever got sick. Now, I have to be very mindful of the limitations of my body when it is fighting a virus. Going out for a 5 mile run after a 10-12 hour work day is just not in the cards anymore. It frustrates me. This is normal I guess but it does not make it okay. During the month of March, I attempted to grow a mustache to celebrate the military tradition of "Mustache March". However, hair seems to be growing in all the wrong places now that I am thirtysomething. I wanted hair on my brow. Instead, ear hair is proliferating out of control! What is up with that? When I go to the barber, they offer me a trim of my ear hair and I actually really need it. Ridiculous! I won't even go into details on the hair growth in other areas other than to say that I am seriously considering investing in a device known as "The Manscaper" (patent pending). I saw this online at target.com. It costs $39.95.
My interests are definitely changing. I am reading for pleasure more than I ever have before. I now prefer a good book over a movie. I have seen 3 or 4 movies since getting to Afghanistan, but I have read at least 6-8 books. This is surely a sign that I am OLD. It seems that the older I get, the qwirkier I become. I actually got up at 0430 the other day and went for a run before work. And, I even enjoyed it! That's kind of sick. I used to think that this group of "old guys" here that goes out for a long run at 0500 on Sundays was absolutely nuts. Now, I am strongly considering joining them. Also, my moodiness is becoming legendary on the hospital ward. I can get cranky in a heartbeat. Don't even think about talking to me before I have had my morning cup of coffee because you just might get your head biten off. The nurses think I need an infusion of continuous intravenous lithium to combat the bipolar behavior. When I am in a good mood, I agree with them. But, catch me in a bad mood and you can kiss my #$%^!
Then, the other day it became readily apparent that I am truly in a mid life crisis. THERE I WAS, holding my right hand in the air uttering the words, "...I will defend the constitution against all enemies, both foreign and domestic." That is correct, the Department of the Air Force promoted me to the rank of MAJOR! There are now oak leaves on my collar instead of bars. I had gotten so used to those Captain's bars, but I am not sad to see them go. After the ceremony, I proudly walked down the street sporting my new rank. I saw a lowly Captain out of the corner of my eye. It felt good for him to render a salute to me. I thought to myself, "Heck yeah Captain, give me the respect." By the way, he was a chaplain but I did not care. I will probably get over this relative power high when Major responsibility is thrust upon me. Doing performance reports and scolding people does not sound all the appealing. But, it brings to light a much bigger issue. Am I ready to give up the military life? When I get home there will be one year left on my committment. I have now been in the Air Force for 10 years. There have been good days and bad days. Without a doubt, these 6 month vacations to Afghanistan have got to stop! But, am I ready to move on and be a civilian? I will be contemplating this question going forward. It is my Major Mid Life Crisis.
My interests are definitely changing. I am reading for pleasure more than I ever have before. I now prefer a good book over a movie. I have seen 3 or 4 movies since getting to Afghanistan, but I have read at least 6-8 books. This is surely a sign that I am OLD. It seems that the older I get, the qwirkier I become. I actually got up at 0430 the other day and went for a run before work. And, I even enjoyed it! That's kind of sick. I used to think that this group of "old guys" here that goes out for a long run at 0500 on Sundays was absolutely nuts. Now, I am strongly considering joining them. Also, my moodiness is becoming legendary on the hospital ward. I can get cranky in a heartbeat. Don't even think about talking to me before I have had my morning cup of coffee because you just might get your head biten off. The nurses think I need an infusion of continuous intravenous lithium to combat the bipolar behavior. When I am in a good mood, I agree with them. But, catch me in a bad mood and you can kiss my #$%^!
Then, the other day it became readily apparent that I am truly in a mid life crisis. THERE I WAS, holding my right hand in the air uttering the words, "...I will defend the constitution against all enemies, both foreign and domestic." That is correct, the Department of the Air Force promoted me to the rank of MAJOR! There are now oak leaves on my collar instead of bars. I had gotten so used to those Captain's bars, but I am not sad to see them go. After the ceremony, I proudly walked down the street sporting my new rank. I saw a lowly Captain out of the corner of my eye. It felt good for him to render a salute to me. I thought to myself, "Heck yeah Captain, give me the respect." By the way, he was a chaplain but I did not care. I will probably get over this relative power high when Major responsibility is thrust upon me. Doing performance reports and scolding people does not sound all the appealing. But, it brings to light a much bigger issue. Am I ready to give up the military life? When I get home there will be one year left on my committment. I have now been in the Air Force for 10 years. There have been good days and bad days. Without a doubt, these 6 month vacations to Afghanistan have got to stop! But, am I ready to move on and be a civilian? I will be contemplating this question going forward. It is my Major Mid Life Crisis.
Thursday, April 22, 2010
Aerovac
The name of the game in wartime medicine is air evacuation, otherwise known at aerovac. This is what allows us to keep people alive and to manage the constant flow of wounded warriors. In the year 2010, this is a rather elaborate process that has been perfected in many ways. Approximately 98% of soldiers injured in combat can be saved if they make it to a forward medical facility in a timely manner. We are a tertiary care facility at Bagram. The patients from all over Afghanistan are funneled here before leaving the country. If the patient has a surgical problem, chances are a surgery has been done at a forward surgical hospital to stabilize the injury. They come here and have more surgery. We have a lot of capabilities here, but also many limitations. For this reason, we must move our coaliton patients quickly out of our facility to Landstuhl Regional Medical Center in Germany.
A week ago the volcano in Iceland erupted and the aerovac system was thrown into chaos. Little did any of us know that mother nature above the arctic circle would affect us here in Afghanistan. Suddenly our well oiled machine was brought to grinding halt. No flights were allowed in or out of Germany. What on earth would we do with our coalition patients? The already high stress levels within the walls of our hospital soared to a new level. We were forced to set up cots in between the beds in order to make room for all the patients. There was literally about 3 feet from one patient to the next. Keeping them all straight in my mind was a challenge. I pride myself on knowing my patient's names and their stories. The numbers forced me to remember them simply as a diagnosis such as "right pneumothorax and axillary soft tissue injury" or "traumatic brain injury with L5 compression fracture". We have all been doing the best we can, but the tension has been rising. I have to admit that this does not bring out the best in me. Others are in the same boat.
I know very little about aviation or the operational air force. But, I am familiar with the phrase, "Flexibility is the key to Air Power." This has become rather apparent to us all in the last week. As people all over Europe were struggling to get from point A to point B, our aerovac system needed to find new routes as well. We had to think long and hard before putting certain patients on planes not knowing exactly how long it would be before they could have surgery again. Our most critical patients simply had to stay with us. Each day new ideas were coming forth on how we should handle this crisis. How about flights all the way to San Antonio? What about a stop over in Kuwait? Could the plane just stop to refuel in southern Europe before going all the way to DC? I am sure many hours were spent by higher headquarters wrestling with these questions.
To the relief of our entire medical staff, a workable solution has been found. There happens to be another theater of operations directly on the way back to the states. We still have many assets and a rather large foot print in Iraq. Why not utilize our medical facilities there? That is exactly what is happening. So, one of my patients caught wind of all this. He absolutely could not believe that after being blown up in Afghanistan, the next time he would see the light of day he would be back in Iraq! It is kind of insane, but for the time being it is the best that we can do. I'm just happy that we can all get a little more sleep now. More importanly, aerovac will be getting our patients home in 48-72 hours despite volcanic activity in Iceland.
A week ago the volcano in Iceland erupted and the aerovac system was thrown into chaos. Little did any of us know that mother nature above the arctic circle would affect us here in Afghanistan. Suddenly our well oiled machine was brought to grinding halt. No flights were allowed in or out of Germany. What on earth would we do with our coalition patients? The already high stress levels within the walls of our hospital soared to a new level. We were forced to set up cots in between the beds in order to make room for all the patients. There was literally about 3 feet from one patient to the next. Keeping them all straight in my mind was a challenge. I pride myself on knowing my patient's names and their stories. The numbers forced me to remember them simply as a diagnosis such as "right pneumothorax and axillary soft tissue injury" or "traumatic brain injury with L5 compression fracture". We have all been doing the best we can, but the tension has been rising. I have to admit that this does not bring out the best in me. Others are in the same boat.
I know very little about aviation or the operational air force. But, I am familiar with the phrase, "Flexibility is the key to Air Power." This has become rather apparent to us all in the last week. As people all over Europe were struggling to get from point A to point B, our aerovac system needed to find new routes as well. We had to think long and hard before putting certain patients on planes not knowing exactly how long it would be before they could have surgery again. Our most critical patients simply had to stay with us. Each day new ideas were coming forth on how we should handle this crisis. How about flights all the way to San Antonio? What about a stop over in Kuwait? Could the plane just stop to refuel in southern Europe before going all the way to DC? I am sure many hours were spent by higher headquarters wrestling with these questions.
To the relief of our entire medical staff, a workable solution has been found. There happens to be another theater of operations directly on the way back to the states. We still have many assets and a rather large foot print in Iraq. Why not utilize our medical facilities there? That is exactly what is happening. So, one of my patients caught wind of all this. He absolutely could not believe that after being blown up in Afghanistan, the next time he would see the light of day he would be back in Iraq! It is kind of insane, but for the time being it is the best that we can do. I'm just happy that we can all get a little more sleep now. More importanly, aerovac will be getting our patients home in 48-72 hours despite volcanic activity in Iceland.
Sunday, April 18, 2010
Special People
Morning rounds today started off with a little something special. Sundays are a day to sleep in of course. We start our rounds at 0730. (that's "sleeping in" for us medical folks!) This is when the inpatient doctors like myself get together with the surgeons, the pharmacist, the physical therapist, the lab manager, etc to see our patients one by one together as a team.
The military has a lot of quality people. We are a voluntary service. This attracts a certain kind of person. Over my ten years in the service, I have met countless military members. Most of them are at baseline solid citizens. Some of them are exceptional people. One such person is known as "Super Girl". She is a medic who works in the intensive care unit. Today she had something to say on her last day of work here. It was rather remarkable for her to stand up in front of our entire team and read the following:
A Special Kind of Person...
(A special dedication to all who served with me @ Bagram AF, Afghanistan Dec 2-Apr 21, 2010)
It takes a special kind of person... to think of someone else,
It takes a special kind of person... to put SERVICE before SELF.
It takes a special kind of person... to wear our blues and greens,
It takes a special kind of person... to work together as a team.
It takes a special kind of person... to handle all the stress,
It takes a special kind of person... to put forth their very BEST.
It takes a special kind of person... to look our enemy in the face,
It takes a special kind of person... to medically take care of them, especially at this place.
It takes a special kind of person... to makes the decision that we do,
It takes a special kind of person... to follow through and through.
It takes a special kind of person... to give medical attention and care,
It takes a special kind of person... even though life sometimes isn't fair.
It takes a special kind of person... to work long hours every day,
It takes a special kind of person... to accept the challenge, even without the pay.
It takes a special kind of person... to deal with the blood, guts, and tears,
It takes a special kind of person... to ease somebody's pain and take away their fears.
It takes a special kind of person... to help our soldiers, sailors, and airmen to get better,
It takes a special kind of person... one fight, one mission... we all work together.
I salute you fellow co-workers, for everything you've done...
You've helped me make a difference, in my deployment #1.
Written from the heart - SSgt Andrea' Mosca
The military has a lot of quality people. We are a voluntary service. This attracts a certain kind of person. Over my ten years in the service, I have met countless military members. Most of them are at baseline solid citizens. Some of them are exceptional people. One such person is known as "Super Girl". She is a medic who works in the intensive care unit. Today she had something to say on her last day of work here. It was rather remarkable for her to stand up in front of our entire team and read the following:
A Special Kind of Person...
(A special dedication to all who served with me @ Bagram AF, Afghanistan Dec 2-Apr 21, 2010)
It takes a special kind of person... to think of someone else,
It takes a special kind of person... to put SERVICE before SELF.
It takes a special kind of person... to wear our blues and greens,
It takes a special kind of person... to work together as a team.
It takes a special kind of person... to handle all the stress,
It takes a special kind of person... to put forth their very BEST.
It takes a special kind of person... to look our enemy in the face,
It takes a special kind of person... to medically take care of them, especially at this place.
It takes a special kind of person... to makes the decision that we do,
It takes a special kind of person... to follow through and through.
It takes a special kind of person... to give medical attention and care,
It takes a special kind of person... even though life sometimes isn't fair.
It takes a special kind of person... to work long hours every day,
It takes a special kind of person... to accept the challenge, even without the pay.
It takes a special kind of person... to deal with the blood, guts, and tears,
It takes a special kind of person... to ease somebody's pain and take away their fears.
It takes a special kind of person... to help our soldiers, sailors, and airmen to get better,
It takes a special kind of person... one fight, one mission... we all work together.
I salute you fellow co-workers, for everything you've done...
You've helped me make a difference, in my deployment #1.
Written from the heart - SSgt Andrea' Mosca
Wednesday, April 14, 2010
Return to Duty
During this deployment, I have witnessed countless Purple Heart ceremonies. Usually a general and his entourage come to the hospital to honor the wounded warrior. They will march into the hospital ward and spend a few minutes with each soldier or airman. It's a nice touch. A few nights ago we had 5 Purple Hearts awarded. I had admitted all 5 of these patients in the wee hours of the previous night. The group had been out and about in Afghanistan when their vehicle was hit with a rocket propelled grenade. I do not know much more than that. We try to respect the privacy of our patients here allowing them time to process what has happened. Sometimes they will talk openly about a firefight or an explosion. Most of the time they just want to sleep. This is rather obvious when the entire medical staff does hospital rounds together at 0630 every morning. The patients will often just pull the sheets over their heads and try to ignore us all. There is no need to bother them at this point. The thing they need the most is time away from the insanity of war.
But let's get back to my 5 patients from the other evening. The general entered the ward with a slew of support staff. He offered some words to each soldier before the following was read aloud, "This is to certify that the President of the United States awards the Purple Heart to Staff Sergeant ______ for wounds received in combat on 12 April 2010." The declaration goes on to say that the Purple Heart was first given out by General George Washington. These ceremonies are important moments for our troops. I have yet to get tired of seeing one of our wounded warriors be recognized. If I am present when a patient of mine receives the Purple Heart, the emotions are strong.
It is not uncommon for patients to come to our hospital after an IED attack (and they are definitely attacks when you consider the intent of the terrorist is to kill), get a full battery of tests, and then be deemed "Return to Duty". Essentially, the patient does not have any major injuries that require surgery. However, this is not to say that the effects of the attack are not profound. There is a term from years ago, shell shocked, which goes a long way in describing these patients. In the year 2010, we call it combat stress. Whatever you want to call it, the bottom line is that the mental strain of war has made its mark. After all, just being in a combat zone is beyond the normal human experience.
4 out of my 5 patients from earlier this week did not need surgery or long term therapy. They did not need to be hospitalized from a purely medical standpoint. But, we kept them there for a day anyway. The old adage of "three hots and a cot" still rings true. It is generally accepted in military medicine that getting these soldiers back to the fight is actually the best thing for them. I agree with this to a certain extent. I do not rush these patients back out to their forward operating bases. To me, being in a life threatening situation then being flown to a hospital for a full medical work up warrants some time off for pete's sake! This is where my training in Family Medicine comes in handy. We are trained to be advocates for our patients. So, my patients get a letter stating that they should be on convalesence for 72 hours and we make arrangements for them to stay near the hospital for that time. This seems like a reasonable compromise to me whether they are a special forces guy who is gung ho or an infantryman who is scared out of his mind.
But let's get back to my 5 patients from the other evening. The general entered the ward with a slew of support staff. He offered some words to each soldier before the following was read aloud, "This is to certify that the President of the United States awards the Purple Heart to Staff Sergeant ______ for wounds received in combat on 12 April 2010." The declaration goes on to say that the Purple Heart was first given out by General George Washington. These ceremonies are important moments for our troops. I have yet to get tired of seeing one of our wounded warriors be recognized. If I am present when a patient of mine receives the Purple Heart, the emotions are strong.
It is not uncommon for patients to come to our hospital after an IED attack (and they are definitely attacks when you consider the intent of the terrorist is to kill), get a full battery of tests, and then be deemed "Return to Duty". Essentially, the patient does not have any major injuries that require surgery. However, this is not to say that the effects of the attack are not profound. There is a term from years ago, shell shocked, which goes a long way in describing these patients. In the year 2010, we call it combat stress. Whatever you want to call it, the bottom line is that the mental strain of war has made its mark. After all, just being in a combat zone is beyond the normal human experience.
4 out of my 5 patients from earlier this week did not need surgery or long term therapy. They did not need to be hospitalized from a purely medical standpoint. But, we kept them there for a day anyway. The old adage of "three hots and a cot" still rings true. It is generally accepted in military medicine that getting these soldiers back to the fight is actually the best thing for them. I agree with this to a certain extent. I do not rush these patients back out to their forward operating bases. To me, being in a life threatening situation then being flown to a hospital for a full medical work up warrants some time off for pete's sake! This is where my training in Family Medicine comes in handy. We are trained to be advocates for our patients. So, my patients get a letter stating that they should be on convalesence for 72 hours and we make arrangements for them to stay near the hospital for that time. This seems like a reasonable compromise to me whether they are a special forces guy who is gung ho or an infantryman who is scared out of his mind.
Saturday, April 10, 2010
Dollars and Sense?
Money makes the world go round, right? With that in mind, I think it is important to stop and think a little bit about the cost of war. Before even considering the human suffering and the tragic loss of life, the cash that it takes to wage war is staggering. As I ate my bagel this morning and thought about the day's plan for my patients, I realized that each bite and every spread of cream cheese cost the U.S. government several dollars. How do I know this you ask? Well, last week a friend who works in logistics informed me that every warm meal I eat here in Afghanistan costs $30. A company called Fluor runs the food service. They charge the U.S. government $30 every single time an ID card is scanned on the way into the dining facility. Last week I stopped to get a cup of coffee at the dining facility on my way home from picking up my laundry. My ID card was scanned, thus, our government paid $30 for my cup of coffee. I had no idea it was the most expensive coffee I have ever had. After all, not even a quadruple latte vanilla swirl expresso with whipped cream and a cherry on top at Starbucks costs that much!
There are many government vehicles here at Bagram. I only need to walk a hundred yards from my B-Hut to see a long line of MRAP's (Mine Resistant Ambush Protected). These are the hulking four wheelers that cost one million dollars to build. They are manufactured in my home of Charleston among other places. I often see them driven on the Air Force Base in Charleston before they are loaded on a C-17 and flown to the middle east. They are so big that only 2 of them fit on the world's best cargo plane. MRAP's carry about a dozen people. The whole point of the vehicle is to save lives. Are MRAP's truly "mine resistant"? Absolutely not. We see patients with devastating injuries every day here who are victims of IED blasts while in MRAP's. This is because the terrorists are always one step ahead of us. The main road at Bagram is often gridlocked with MRAP's trying to get to their destination or leave the base for a mission. They get maybe 5 miles to the gallon of gas. I am told that the price of gas here is quite high. When you figure the cost of shipping to this land locked country, a gallon of gas can cost as much as $30. It's right up there with my cup of coffee in the dining facility the other day! Can you imagine how much it costs just for fuel alone when a convoy of MRAP's goes out on a mission and is gone for hours to days?
Several weeks ago I was able to go on a tour of the F-15 fighter jets that we have here at Bagram. We were able to meet the pilots, learn a lot about their jobs, and then of course get to see the F-15 up close. These are $55 million dollar planes that were designed in the 1970's. According to "Biff" the pilot, these are the best planes on the globe. "Biff" gave us a run down on the capabilities of these birds. His enthusiasm was contagious. He showed us the missiles that are used in close air support strikes on suspected terrorists. These cost about $55,000 a piece and they pack quite a pop. If you think the fuel for MRAP's is expensive, well, it's nothing compared to the jet fuel used for th F-15. At any given time, two F-15 crews are "on alert" for emergency missions. Their goal is to provide an air strike anywhere in their region within 15 minutes of receiving the call. This correlates with approximately how long the average soldier's ammunition will last in an intense firefight. On any given day, F-15's can be heard taking off at all hours of the day. Their roar is deafening.
The cost of running the hospital here is also quite astounding. We have 2 Afghan patients that have been hospitalized for almost my entire deployment. Both have been in the intensive care unit for weeks at a time. Both have undergone many procedures and operations. They have wounds that may never heal. Even if they do miraculously get better and walk out the door, they will be subject to the limitations of the Afghan medical system. In short, I am not even sure you could call it a medical system. The main military hospital in Kabul does not have the most basic of medications. They do not have antibiotic ointment. They do not even provide food for their patients. There is no such thing as a nursing home in Afghanistan. The medical costs for the prolonged hospitalization of both of the aforementioned patients easily exceeds a million dollars. Actually, it is probably several million dollars. The argument could be made that neither of these patients should have received the care that they did given that they have very little chance of being okay once they leave our doors. These are the hard decisions that often are not made in the heat of the moment. We as health care providers want everyone to be okay. But, it does not work that way. Forging ahead with the care of these patients essentially is making the decision to spend thousands if not millions of dollars. I wish I could say that these are the only Afghan patients I have seen in this type of situation at our hospital. If I did say that, I would be flat out lying.
I could go on and on with examples of costs that will make your head spin. Maybe this is information that the American people really should not know about it. You can go about your life blistfully unaware of all this. But for me, it really begs the question of whether or not all these dollars make any sense???
There are many government vehicles here at Bagram. I only need to walk a hundred yards from my B-Hut to see a long line of MRAP's (Mine Resistant Ambush Protected). These are the hulking four wheelers that cost one million dollars to build. They are manufactured in my home of Charleston among other places. I often see them driven on the Air Force Base in Charleston before they are loaded on a C-17 and flown to the middle east. They are so big that only 2 of them fit on the world's best cargo plane. MRAP's carry about a dozen people. The whole point of the vehicle is to save lives. Are MRAP's truly "mine resistant"? Absolutely not. We see patients with devastating injuries every day here who are victims of IED blasts while in MRAP's. This is because the terrorists are always one step ahead of us. The main road at Bagram is often gridlocked with MRAP's trying to get to their destination or leave the base for a mission. They get maybe 5 miles to the gallon of gas. I am told that the price of gas here is quite high. When you figure the cost of shipping to this land locked country, a gallon of gas can cost as much as $30. It's right up there with my cup of coffee in the dining facility the other day! Can you imagine how much it costs just for fuel alone when a convoy of MRAP's goes out on a mission and is gone for hours to days?
Several weeks ago I was able to go on a tour of the F-15 fighter jets that we have here at Bagram. We were able to meet the pilots, learn a lot about their jobs, and then of course get to see the F-15 up close. These are $55 million dollar planes that were designed in the 1970's. According to "Biff" the pilot, these are the best planes on the globe. "Biff" gave us a run down on the capabilities of these birds. His enthusiasm was contagious. He showed us the missiles that are used in close air support strikes on suspected terrorists. These cost about $55,000 a piece and they pack quite a pop. If you think the fuel for MRAP's is expensive, well, it's nothing compared to the jet fuel used for th F-15. At any given time, two F-15 crews are "on alert" for emergency missions. Their goal is to provide an air strike anywhere in their region within 15 minutes of receiving the call. This correlates with approximately how long the average soldier's ammunition will last in an intense firefight. On any given day, F-15's can be heard taking off at all hours of the day. Their roar is deafening.
The cost of running the hospital here is also quite astounding. We have 2 Afghan patients that have been hospitalized for almost my entire deployment. Both have been in the intensive care unit for weeks at a time. Both have undergone many procedures and operations. They have wounds that may never heal. Even if they do miraculously get better and walk out the door, they will be subject to the limitations of the Afghan medical system. In short, I am not even sure you could call it a medical system. The main military hospital in Kabul does not have the most basic of medications. They do not have antibiotic ointment. They do not even provide food for their patients. There is no such thing as a nursing home in Afghanistan. The medical costs for the prolonged hospitalization of both of the aforementioned patients easily exceeds a million dollars. Actually, it is probably several million dollars. The argument could be made that neither of these patients should have received the care that they did given that they have very little chance of being okay once they leave our doors. These are the hard decisions that often are not made in the heat of the moment. We as health care providers want everyone to be okay. But, it does not work that way. Forging ahead with the care of these patients essentially is making the decision to spend thousands if not millions of dollars. I wish I could say that these are the only Afghan patients I have seen in this type of situation at our hospital. If I did say that, I would be flat out lying.
I could go on and on with examples of costs that will make your head spin. Maybe this is information that the American people really should not know about it. You can go about your life blistfully unaware of all this. But for me, it really begs the question of whether or not all these dollars make any sense???
Tuesday, April 6, 2010
The Trauma Hot Box
There is a very important room at Craig Joint Theater Hospital here at Bagram. It's called The Trauma Hot Box. It's located in the ER. It is equipped with 6 patient beds, 4 ventilators, racks of supplies for procedures, 2 crash carts for cardiac/respiratory arrest, and anything else you can think of that might be needed for critical patients. The most unique thing about this room is its temperture... it is kept at a toasty 95 degrees. Why you ask? Well, there is a well known fact in medicine that warm trauma patients do better than cold ones. So, here at Bagram we do eveything we can to help our patients even if it makes the staff all hot and bothered. Of course, we have rules about that too. Clearly posted on the the door of The Trauma Hot Box is a sign that says:
1. You do not speak about The Trauma Hot Box.
2. No complaining.
3. No gawking outside the window.
4. No passing of gas.
The Trauma Hot Box was used to its full capacity on Easter Sunday. As I slept off my night shift, waves of new trauma patients arrived throughout the day. We were only getting warmed up on what was dubbed "Sunday Bloody Sunday". I arrived at work at 1900 hours and at 1905 a "Level 2 Trauma" was called over the loud speaker. This is when a large bolus of patients is due to arrive which will exceed the capabilities of the in hospital staff. Most of the doctors and nurses are paged to come to the hospital. What happened next can best be described as controlled chaos. The medical evacuation teams brought in severely injured Americans one by one. Each bed in The Trauma Hot Box was manned by 2 doctors, a nurse, and 2 technicians. I happened to be teamed with our vascular surgeon on this night. We first unhooked our patient from the vast amount of equipment attached to the stretcher. Then, we moved him over to our bed. Next, we began a systematic examination of him from head to toe. I started at the head and our vascular surgeon began at his feet. We called out our findings as we progessed. The same scenario was playing out in the other 5 beds in The Trauma Hot Box. "The pupils are equal and reactive bilaterally"... "The pedal pulses are strong on the right"... "Lungs are clear. Heart is regular"... "No wounds noted on the head"... you get the picture. Simultaneously, the technicians drew blood, obtained vital signs, and placed the proper monitors onto the patient. In the corner of the room, the pharmacist was dolling out medications and the lab was busy running tests on the blood samples.
Our particular soldier had a large bandage on his right leg. We tested the blood pressure in his ankle versus his arm. It was normal. Thus, he was unlikely to have any major bleeding in the leg. He also had gaping wounds of his scrotum and his left leg. This made sense given the mechanism of the injury. The floor of his vehicle was blown upward which smashed his legs when an Improvised Explosive Device (IED) went off as they drove down the street. Luckily, our patient was completely awake and aware of the situation. His brain was spared any trauma. Next, we rolled the patient onto his side to look at his back. The spine was palpated and a finger (gloved of course) was inserted into his rectum much to his dismay. Welcome to Bagram!
Having done our head to toe exam, he was now ready for x rays. The radiology technicians rolled in their portable machine. Multiple x rays were taken of all the possible problem areas. This took several minutes as the patient needed proper positioning and such. We are able to view the X rays right then and there on the portable machine looking for obvious problems. As soon as all the X rays were done, our patient was ready for the CT Scanner. We "packaged" him up by unhooking the monitors, connecting the oxygen to a tank, replacing the bandages on his legs, and covering him with blankets. He was now ready for transport. We wheeled him down to the radiology suite, moved him onto the scanner, then sat back as the radiology technicians programmed the machine to obtain images of the patient from his skull to his pelvis. This is called a "Pan Scan" which pretty much everyone gets who is involved in an explosion. We use technology to the extreme here.
My patient that night was taken to the operating room shortly after finishing his scans. This is also pretty much a standard procedure at Bagram. Within several hours he was admitted to the hospital in stable condition. He had a full on trauma assessment, was surgerized, and now was ready to move on to his next stop in Germany. There was a happy ending for this patient. Barring any unforeseen complications, he would keep both legs and walk again someday in the not too distant future. As for the other 5 patients who came through The Trauma Hot Box that night, some did well and some not well. On this Easter Sunday, we did our best and I guess that is all you can ask. In the end, The Trauma Hot Box was in disarray with bloody bandages all over the floor and medical equipment scattered around the room. The cleaning crew quickly entered to get The Trauma Hot Box ready for the inevitable next round of casualties.
1. You do not speak about The Trauma Hot Box.
2. No complaining.
3. No gawking outside the window.
4. No passing of gas.
The Trauma Hot Box was used to its full capacity on Easter Sunday. As I slept off my night shift, waves of new trauma patients arrived throughout the day. We were only getting warmed up on what was dubbed "Sunday Bloody Sunday". I arrived at work at 1900 hours and at 1905 a "Level 2 Trauma" was called over the loud speaker. This is when a large bolus of patients is due to arrive which will exceed the capabilities of the in hospital staff. Most of the doctors and nurses are paged to come to the hospital. What happened next can best be described as controlled chaos. The medical evacuation teams brought in severely injured Americans one by one. Each bed in The Trauma Hot Box was manned by 2 doctors, a nurse, and 2 technicians. I happened to be teamed with our vascular surgeon on this night. We first unhooked our patient from the vast amount of equipment attached to the stretcher. Then, we moved him over to our bed. Next, we began a systematic examination of him from head to toe. I started at the head and our vascular surgeon began at his feet. We called out our findings as we progessed. The same scenario was playing out in the other 5 beds in The Trauma Hot Box. "The pupils are equal and reactive bilaterally"... "The pedal pulses are strong on the right"... "Lungs are clear. Heart is regular"... "No wounds noted on the head"... you get the picture. Simultaneously, the technicians drew blood, obtained vital signs, and placed the proper monitors onto the patient. In the corner of the room, the pharmacist was dolling out medications and the lab was busy running tests on the blood samples.
Our particular soldier had a large bandage on his right leg. We tested the blood pressure in his ankle versus his arm. It was normal. Thus, he was unlikely to have any major bleeding in the leg. He also had gaping wounds of his scrotum and his left leg. This made sense given the mechanism of the injury. The floor of his vehicle was blown upward which smashed his legs when an Improvised Explosive Device (IED) went off as they drove down the street. Luckily, our patient was completely awake and aware of the situation. His brain was spared any trauma. Next, we rolled the patient onto his side to look at his back. The spine was palpated and a finger (gloved of course) was inserted into his rectum much to his dismay. Welcome to Bagram!
Having done our head to toe exam, he was now ready for x rays. The radiology technicians rolled in their portable machine. Multiple x rays were taken of all the possible problem areas. This took several minutes as the patient needed proper positioning and such. We are able to view the X rays right then and there on the portable machine looking for obvious problems. As soon as all the X rays were done, our patient was ready for the CT Scanner. We "packaged" him up by unhooking the monitors, connecting the oxygen to a tank, replacing the bandages on his legs, and covering him with blankets. He was now ready for transport. We wheeled him down to the radiology suite, moved him onto the scanner, then sat back as the radiology technicians programmed the machine to obtain images of the patient from his skull to his pelvis. This is called a "Pan Scan" which pretty much everyone gets who is involved in an explosion. We use technology to the extreme here.
My patient that night was taken to the operating room shortly after finishing his scans. This is also pretty much a standard procedure at Bagram. Within several hours he was admitted to the hospital in stable condition. He had a full on trauma assessment, was surgerized, and now was ready to move on to his next stop in Germany. There was a happy ending for this patient. Barring any unforeseen complications, he would keep both legs and walk again someday in the not too distant future. As for the other 5 patients who came through The Trauma Hot Box that night, some did well and some not well. On this Easter Sunday, we did our best and I guess that is all you can ask. In the end, The Trauma Hot Box was in disarray with bloody bandages all over the floor and medical equipment scattered around the room. The cleaning crew quickly entered to get The Trauma Hot Box ready for the inevitable next round of casualties.
Saturday, April 3, 2010
Combat Dining In
Deployments do not have to be only work and misery. Just like anything else in life, it is what you make of it. There is some fun going on here at Bagram. During the month of March, all the doctors grew mustaches. The other day we had the final judging. I am NOT proud to say that I finished third in the "Nice Try" category. One of our orthopedic surgeons took the prize for the sleaziest while an emergency room doctor won the most majestic mustache. A good time was had by all especially at the final judging when several people showed up in outrageous costumes.
Last week we had another fun event called "Combat Dining In". It was based on a traditional military event that military organizations will have back home about once a year. I had only gone to one of these "Dining In" events in my whole career and that was 10 years ago during my officer training. Of course, this involves a dinner but that is just a small part of it. The main entertainment of the night revolves around "The Grog". This is a disgusting, horrifying, putrid concoction of juices, solids, and other toxic substances. Various people are called to drink "The Grog" in front of the crowd to punish them all in good fun. So after months of planning, the medical personnel gathered for the first ever "Combat Dining In" here at Bagram.
The event started with the traditional brewing of the grog. A large pale with a reddish broth was front and center. Several duty sections from the hospital were called forward to make their contribution. From the ward where I work, we poured in a foley bag full of "urine" and a pleura vac filled with "serosanginous discharge". The folks from the dietary division added "feces" from a colostomy bag along with some "vomit". The intensive care ward contributed a suction container full of "pus". The gynecology clinic did some stirring of the grog with a well used speculum of course. Alas, the grog was ready for consumption.
The first people to drink the grog were our commanders. In order to have the privelege of dowing a glass of this foul substance, the victim had to make his or her way through a combat obstacle course as the entire crowd pummeled him or her with water balloons and super soakers. After low crawling under a barrier and then coming to attention, a salute was made to the head table. Then, a glass of grog was held high for a toast "To the Grog". Drinking commenced often resulting in rhythmic wretching as the particpant tried to ingest the "The Grog". Finally, the cup was placed on the head before one final salute was given. After our commanders were tortured several times over with this process, a whole slew of people were called to "The Grog". I was spared. By the end, the dining hall was an absolute mess. The floor was soaked, uniformes were covered in grog, and water balloons were everywhere.
We military folk are strange I know. In the end, "Combat Dining In" was a huge success. We were all able to have some laughs and for a short time forget about the insanity surrounding us. That's a good night on deployment in my book.
Last week we had another fun event called "Combat Dining In". It was based on a traditional military event that military organizations will have back home about once a year. I had only gone to one of these "Dining In" events in my whole career and that was 10 years ago during my officer training. Of course, this involves a dinner but that is just a small part of it. The main entertainment of the night revolves around "The Grog". This is a disgusting, horrifying, putrid concoction of juices, solids, and other toxic substances. Various people are called to drink "The Grog" in front of the crowd to punish them all in good fun. So after months of planning, the medical personnel gathered for the first ever "Combat Dining In" here at Bagram.
The event started with the traditional brewing of the grog. A large pale with a reddish broth was front and center. Several duty sections from the hospital were called forward to make their contribution. From the ward where I work, we poured in a foley bag full of "urine" and a pleura vac filled with "serosanginous discharge". The folks from the dietary division added "feces" from a colostomy bag along with some "vomit". The intensive care ward contributed a suction container full of "pus". The gynecology clinic did some stirring of the grog with a well used speculum of course. Alas, the grog was ready for consumption.
The first people to drink the grog were our commanders. In order to have the privelege of dowing a glass of this foul substance, the victim had to make his or her way through a combat obstacle course as the entire crowd pummeled him or her with water balloons and super soakers. After low crawling under a barrier and then coming to attention, a salute was made to the head table. Then, a glass of grog was held high for a toast "To the Grog". Drinking commenced often resulting in rhythmic wretching as the particpant tried to ingest the "The Grog". Finally, the cup was placed on the head before one final salute was given. After our commanders were tortured several times over with this process, a whole slew of people were called to "The Grog". I was spared. By the end, the dining hall was an absolute mess. The floor was soaked, uniformes were covered in grog, and water balloons were everywhere.
We military folk are strange I know. In the end, "Combat Dining In" was a huge success. We were all able to have some laughs and for a short time forget about the insanity surrounding us. That's a good night on deployment in my book.
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