Making it out of Afghanistan is a great feeling. Most people feel very relieved to be leaving a war zone. It does not matter that the military flights are always uncomfortable. We are packed in there like sardines. Wearing body armor makes it worse. Some people even have to fly back with caskets of fallen service members on the same plane. That's sobering to say the least. But, it is worth it to leave a war torn country. Our first stop out of Afghanistan is in another one of the "Stans"- Kygystan to be exact. This is a former soviet republic that is now an independent country. It has been in the news for several months due to civil unrest. It's unstable, but for now we have a base here that serves as the transit center to and from Afghanistan.
When the relief of leaving Bagram wears off, people generally have a lot of different emotions. For me, it is simply mental exhaustion. I just want to vegetate watching movies and doing other mindless things. There is a certain amount of hypervigilance about safety that goes along with being deployed. Even at a large base like Bagram, you have to be on guard. You learn to sleep with F-16's roaring through the sky and explosions off in the distance. Now, we understand the phrase that the "silence is deafening". It is strange to have pure silence although those moments are few here given that I am sleeping in a tent with 130 marines. We all need time to process everything that happened on our deployments. This will take weeks. For some it will take months. For others they may never reconcile what happened. My 130 marine roommates definitely had a very different experience than me. It all needs to be compartmentalized to a degree to return to normalcy.
Enough with the psycho babble... LET'S PARTY!!! That is exactly what is happening here in Kygystan. This base has all sorts of amenities to keep us occupied. The average stay here is about 72 hours. Having a little fun is important. There is a cool hangout here called "Pete's Place". It is located in the middle of the base. It has a large deck, pool tables, a stage for entertainment, and of course a bar. Everyone is allowed 2 alcoholic beverages a day. People let loose. The young nurses from Bagram have been severely tipsy on 2 beers. Nice. Karaoke was the center attraction one night. I thought about singing a Neil Diamond song, then thought the better of it. Last night there was music provided by the local Kygystans. It was really entertaining. They played some interesting instruments which rang out some American songs for everyone to sing along. The ladies had elaborate costumes for some exotic dancing which was quite a sight for many sore eyes. A good time was had by all.
In the next 48-72 hours I will be back in my close to the beach condo in Charleston. There will be a reunion with my dog Maddy. I cannot wait to jump in the ocean. Taking a nap on the sofa sounds fabulous. Lounging at the pool while catching some strong South Carolina sun is a must. Seeing friends and family again will be a lot of fun. When the dust settles, another deployment will be in the books. Then, the process will continue on with some serious decompression.
Wednesday, June 30, 2010
Sunday, June 27, 2010
The Best People
In the past week, a wave of new doctors, nurses, and medics arrived here at Bagram. These are our much anticipated "replacements". I am sure the group with is filled with plenty of talented people. There are not many things that I will miss about this deployment. But, I have met many outstanding people that I will always remember. Some of them set themselves apart in my mind.
Colonel Joe the dermatologist is well known in the Army medical world. You would never know this talking to him because he seems like a regular guy. But, he was instrumental in bringing a dermatologist to the Iraq War after soldiers started showing up by the dozen with nasty skin lesions from Leishmaniasis. This is a skin disease caused by camel spider bites. It can leave disfiguring scars. Colonel Joe has now deployed 3 times. He is a great dermatologist. The only requirement for a referral to him is that the patient has skin! He stays in fine shape by running almost every morning at dawn. When he was running one morning, a group of females yelled "NICE BUTT" as they drove by in their armored vehicle. Colonel Joe took it in stride. After all, he is the coolest colonel I know.
I have met so many good people here at Bagram that it would be difficult to mention them all. In my experience, it is the people that make or break a situation. I was able to get through this deployment because of the people here. And, the best people are the ones that made an impression on me that will last well beyond the confines of Bagram.
How about Airmen Chris? He is a physical therapy assistant who was assigned to the hospital ward and intensive care unit. His job involved working with very sick patients every day. He would help intubated patients move their arms and legs. He would walk patients with amputations and shattered bones. He would take patients outside who had not seen the light of day in weeks. He did this all with a smile, a great sense of humor, and an infectious laugh. Airmen Chris is planning to get a masters in physical therapy. I have no doubt he will be highly successful.
Then there is Sergeant Jen in the ER. She is a positive, upbeat person who embraced her job as a medic. She was clearly a valuable member of the emergency room team. She worked on countless trauma patients. Sergeant Jen would disconnect the patients from the myriad of medical equipment they are attached to upon arrival and then help resuscitate them. Doing this expeditiously is very important as many of these patients need blood transfusions and surgery not later but NOW. One day I found out that Sergeant Jen will be starting medical school this summer. It did not surprise me one bit. What did surprise me was learning that she is a ivy league graduate from the University of Pennsylvania... she is smarter than all of us!
Nurse Laura volunteered to come to Afghanistan leaving behind a nice life in California. She is a member of the Air Force Reserves and was assigned to work in the Contingency Air Stage Facility (CASF). This is essentially a large tent behind the hospital that houses patients awaiting a medical flight to Germany. The CASF staff takes care of these patients, but they also serve as the staff to plan the flights to Germany. The CASF staff has moved up to 60 patients on one flight. That's amazing! Nurse Laura impressed me in many ways, but mostly because she helps the patients feel like human beings. The patients are often very affected by their war experience. They need someone to talk to about their lives. Nurse Laura gets to know them on a personal level. Often, she takes them to the coffee shop or to the dining facility. This helps them transition back to normalcy. She and the rest of the CASF staff help the troops to be regular people again.
Not all surgeons are created equal. Right away when I met Surgeon Todd he was different. He was soft spoken and friendly. He seemed to set everyone at ease in tense situations. As a vascular surgeon, he is a highly trained professional who repairs blood vessels for a living. He once helped reattach an amputated arm. That's intense! I enjoyed working with him because he was down to earth and humble. These are rare qualities in surgeons. But, Surgeon Todd also was assertive when he needed to be. At a meeting one of our commanders gave the doctors a lecture about how it was important to ALWAYS be nice to the nurses and medics. Surgeon Todd disagreed. He stated that sometimes people need to be told exactly what to do. When they make the same mistake repeatedly, then yelling at them is okay. After all, we are in the military and our mission is about saving lives.Colonel Joe the dermatologist is well known in the Army medical world. You would never know this talking to him because he seems like a regular guy. But, he was instrumental in bringing a dermatologist to the Iraq War after soldiers started showing up by the dozen with nasty skin lesions from Leishmaniasis. This is a skin disease caused by camel spider bites. It can leave disfiguring scars. Colonel Joe has now deployed 3 times. He is a great dermatologist. The only requirement for a referral to him is that the patient has skin! He stays in fine shape by running almost every morning at dawn. When he was running one morning, a group of females yelled "NICE BUTT" as they drove by in their armored vehicle. Colonel Joe took it in stride. After all, he is the coolest colonel I know.
I have met so many good people here at Bagram that it would be difficult to mention them all. In my experience, it is the people that make or break a situation. I was able to get through this deployment because of the people here. And, the best people are the ones that made an impression on me that will last well beyond the confines of Bagram.
Monday, June 21, 2010
Perspective
Last week a meeting was called at the hospital for all the soon to be departing personnel. We were told that we would all need to move out of our living quarters and that our replacements were due soon. For various reasons we would be housed in several different tents and temporary places near the hospital. In the event of a mass casualty event, we were all needed. Space has become a major problem here at Bagram with the Afghan Surge well underway. Some of us were asked to live in the hospital. I was mandated to live in the clinic. Tonight will be my sixth night sleeping on a procedure table. It is designed for minor procedures such as mole removals and toenail extractions. Instead, it is my bed for the foreseeable future. Toxic is the best way to describe me ever since this turn of events. I have been complaining constantly about this terrible situation. After all, how can the United States Air Force treat a doctor like this? This is a gross injustice of immense proportions, right? ABSOLUTELY NOT!
Recently, I learned that rank and titles do not matter when it comes to our space problem. Our head nurse who is a colonel is also living in her office. She is sleeping on a cot. The pharmacy supervisor who is a master sergeant is sleeping in the pharmacy. The head radiology technician is assigned to live in the radiology department. This is reality. There are definitely worse places to be. One morning not too long ago some soldiers were spotted sleeping on litters (aka stretchers) next to their armored vehicles. This was in an open space just a hundred meters from the hospital. That's rough. How about our soldiers who are in harm's way at this very moment in time? How about the Afghans who live in mud huts just outside the fence line of our base?
A few of my frieends and I recently watched the movie "The Pursuit of Happyness". It is a good movie about man who overcame incredible odds to make it big. It shows a little glimpse of what it is like to be homeless and to have almost nothing. The movie got me thinking about my situation and how pathetic it is for me to complain. Then, my friend Dr. Mike told me a little of his life story. You see, Dr. Mike was on food stamps for the first year of medical school. He has lived through some very tough times. He and his wife dropped out of high school after having their first child. Mike then graduated in his high school's vocational program. His wife earned a GED. The next decade was struggle. His wife worked the night shift at Wal Mart. Dr. Mike worked as a short order cook. They took college classes and slowly made their way through school. Mike had to donate plasma for money to help pay the bills. At one point, their apartment building burned down and they lost everything. They even lost their car. He rode the bus to school for 2 years at Syracuse University. It was never easy. They lived on $7,000 during Mike's first year of medical school. Then, Mike was awarded an Air Force scholarship. Life got better for his family. And, the Air Force gained an outstanding individual. The rest is history. It has been a pleasure to serve with Dr. Mike here in Afghanistan. He has inspired me to be a better person.
Some time in the near future we all will be home sleeping in our own beds. It will be a great feeling. When the euphoria of being home wears off, hopefully we will all appreciate the little things in life a little more. I can handle sleeping on a procedure table even if I know that someone had a large wart cut off on there the other day. At least I am not out in the cold or the heat for that matter. I guess a little persective goes a long way.
Recently, I learned that rank and titles do not matter when it comes to our space problem. Our head nurse who is a colonel is also living in her office. She is sleeping on a cot. The pharmacy supervisor who is a master sergeant is sleeping in the pharmacy. The head radiology technician is assigned to live in the radiology department. This is reality. There are definitely worse places to be. One morning not too long ago some soldiers were spotted sleeping on litters (aka stretchers) next to their armored vehicles. This was in an open space just a hundred meters from the hospital. That's rough. How about our soldiers who are in harm's way at this very moment in time? How about the Afghans who live in mud huts just outside the fence line of our base?
A few of my frieends and I recently watched the movie "The Pursuit of Happyness". It is a good movie about man who overcame incredible odds to make it big. It shows a little glimpse of what it is like to be homeless and to have almost nothing. The movie got me thinking about my situation and how pathetic it is for me to complain. Then, my friend Dr. Mike told me a little of his life story. You see, Dr. Mike was on food stamps for the first year of medical school. He has lived through some very tough times. He and his wife dropped out of high school after having their first child. Mike then graduated in his high school's vocational program. His wife earned a GED. The next decade was struggle. His wife worked the night shift at Wal Mart. Dr. Mike worked as a short order cook. They took college classes and slowly made their way through school. Mike had to donate plasma for money to help pay the bills. At one point, their apartment building burned down and they lost everything. They even lost their car. He rode the bus to school for 2 years at Syracuse University. It was never easy. They lived on $7,000 during Mike's first year of medical school. Then, Mike was awarded an Air Force scholarship. Life got better for his family. And, the Air Force gained an outstanding individual. The rest is history. It has been a pleasure to serve with Dr. Mike here in Afghanistan. He has inspired me to be a better person.
Some time in the near future we all will be home sleeping in our own beds. It will be a great feeling. When the euphoria of being home wears off, hopefully we will all appreciate the little things in life a little more. I can handle sleeping on a procedure table even if I know that someone had a large wart cut off on there the other day. At least I am not out in the cold or the heat for that matter. I guess a little persective goes a long way.
Tuesday, June 15, 2010
Too Hard or Too Easy
Several weeks ago I made the decision to move from working in the hospital to the clinic. For five months I was a "hospitalist". I only did inpatient care of our hospitalized patients. It was a great experience in many ways, one that I will never forget. But, there are no days off in the hospital here. I was going nuts. 157 days in a row of seeing blown up people has a tendency to do that! One of the family doctors working in the clinic wanted to get some hospital experience. There was a small window of opportunity to make a change, and we took it.
For the past several weeks I have been spending my days in the comfortable confines of the The Outpatient Clinic. They actually made me the boss as well. The hours are set. There are few surprises in the workload. The pace is very reasonable. And, I actually had a day off as well which was amazing. Nevertheless, there are still plenty of challenges even away from all the trauma patients. To be a good clinician in the outpatient world you must be efficient. Nobody likes a doctor who runs behind schedule constantly. It makes everyone irritable including the staff and the patients. Do you ever remember waiting a long time at a doctor's office? It is not the most pleasant of experiences. The bottom line is that as a doctor you have to do the best you can to get people in and out of there. It can make for a real grind especially in a high pressure clinic.
Our clinic here is far from high pressure. But, we do get patients referred to us from all over Afghanistan. It can be interesting at times. Recently, there was a patient I thought had a rare condition called occipital neuralgia. I injected some medication over a nerve on his scalp. It relieved the headaches he had been having for 3 weeks within a few hours. Several days later he is still headache free. Now the patient thinks I am REALLY smart which obviously is not the case. For every good case that we have like this, there are at least 3 bad cases. What I mean by this is that other doctors and physician assistants "dump" patients on us. When the patient becomes too difficult to figure out, they send them to us. When the patient has an alterior motive, they send them to us. When the patient is drug seeking (they want morphine), they send them to us. When it becomes TOO HARD to do the right thing, they send them to us!
It is easy to give someone a hundred morphine tablets when their back hurts. It is easy to make up a diagnosis when the patient demands an answer. It is easy to order a test instead of telling the patient that you do not think anything is wrong. It is easy to prescribe antidepressants instead of taking time to find out more about why the patient is crying. And... it is TOO EASY to send the patient to another doctor when they are too sick or too broken to serve in a war zone and their commander wants "boots on the ground". After all, the pentagon is very concerned about how many troops are here. Thus, commanders do not necessarily care if a soldier is healthy enough to do a job because the mission comes first.
This is what we deal with every day in the clinic. It is not glamorous. It is not exciting. Actually, it is frustrating as heck. But, it is a job that has to be done. Nobody will ever give me a medal for filing the most paperwork to send sick and broken troops home. The exact opposite of that is true. Nevertheless, I was taught in my training to be an advocate for the patient no matter what. In the end it is very difficult to do what is the right thing instead of avoiding what is TOO HARD or doing what is TOO EASY.
For the past several weeks I have been spending my days in the comfortable confines of the The Outpatient Clinic. They actually made me the boss as well. The hours are set. There are few surprises in the workload. The pace is very reasonable. And, I actually had a day off as well which was amazing. Nevertheless, there are still plenty of challenges even away from all the trauma patients. To be a good clinician in the outpatient world you must be efficient. Nobody likes a doctor who runs behind schedule constantly. It makes everyone irritable including the staff and the patients. Do you ever remember waiting a long time at a doctor's office? It is not the most pleasant of experiences. The bottom line is that as a doctor you have to do the best you can to get people in and out of there. It can make for a real grind especially in a high pressure clinic.
Our clinic here is far from high pressure. But, we do get patients referred to us from all over Afghanistan. It can be interesting at times. Recently, there was a patient I thought had a rare condition called occipital neuralgia. I injected some medication over a nerve on his scalp. It relieved the headaches he had been having for 3 weeks within a few hours. Several days later he is still headache free. Now the patient thinks I am REALLY smart which obviously is not the case. For every good case that we have like this, there are at least 3 bad cases. What I mean by this is that other doctors and physician assistants "dump" patients on us. When the patient becomes too difficult to figure out, they send them to us. When the patient has an alterior motive, they send them to us. When the patient is drug seeking (they want morphine), they send them to us. When it becomes TOO HARD to do the right thing, they send them to us!
It is easy to give someone a hundred morphine tablets when their back hurts. It is easy to make up a diagnosis when the patient demands an answer. It is easy to order a test instead of telling the patient that you do not think anything is wrong. It is easy to prescribe antidepressants instead of taking time to find out more about why the patient is crying. And... it is TOO EASY to send the patient to another doctor when they are too sick or too broken to serve in a war zone and their commander wants "boots on the ground". After all, the pentagon is very concerned about how many troops are here. Thus, commanders do not necessarily care if a soldier is healthy enough to do a job because the mission comes first.
This is what we deal with every day in the clinic. It is not glamorous. It is not exciting. Actually, it is frustrating as heck. But, it is a job that has to be done. Nobody will ever give me a medal for filing the most paperwork to send sick and broken troops home. The exact opposite of that is true. Nevertheless, I was taught in my training to be an advocate for the patient no matter what. In the end it is very difficult to do what is the right thing instead of avoiding what is TOO HARD or doing what is TOO EASY.
Sunday, June 13, 2010
GO BIG RED!!!
One of the ways that people cope on deployments is to compartmentalize. You simply stop thinking about certain aspects of your life. Your life back home is so far away that you will drive yourself nuts if you do not put it on the shelf for a while. For me this has meant forgetting about laying on the beach in Charleston, walking my dog around the community pond, or taking a road trip down to Kiawah Island. But, now I am getting close to leaving Afghanistan. Life back home does not seem so far away. I can start thinking about better days ahead.
For as long as I can remember, sports have been an important part of my life. My earliest memory is getting my picture taken as a 3 year old with a baseball cap on and a wiffle ball bat in my hands. I can recall clearly watching sports practically non stop as a kid. New Year's Day 1984 was a marathon of college football for me. I sat in our TV room and watched 3 football games in a row. The last game was one of the greatest games in college football history. It was the 1984 Orange Bowl between the Nebraska Cornhuskers and the Miami Hurricanes. The game ended just before midnight when Nebraska went for a game winning 2 point conversion and were denied. Miami won the game 31 to 30. They were crowned national champions. Bernie Kozar was Miami's quarterback. He was only a freshman at the time. Of course, he would later become a hero in my hometown as the quarterback of the Cleveland Browns.
Fast forward to 2004. I was a first year resident (intern) at the University of Nebraska Medical Center. I was living among countless diehard fans of the aforementioned Nebraska Cornhuskers. They call it Husker Nation. Late in the fall that year, I obtained 2 tickets to a Nebraska football game. I invited my good friend Allen. He was nine years old at the time. I was serving as his "big brother". We made our way to Lincoln and found our seats high up in the 72nd row. The wind was howling. Allen became uncomfortable and scared. He was quite upset. We left our seats and went down to ground level. Allen asked me, "Why don't we just get another seat?" My reply was something like, "Buddy, this stadium has been sold out since 1962! There are no other seats." We were standing there and Allen began to cry. I did not know what to do. Out of nowhere an usher approached me and asked me what the problem was. I explained the situation. He said that perhaps he could find a solution to our dilemma. He lead us through the crowd, talked to a few people, and the next thing I know we were sitting at field level right behind the end zone! It was incredible. At halftime this same usher found us and led us through the stadium. He took us on a tour of the locker room and weight room. He then showed us the trophy cases including the National Championship and Heisman Trophies. Our day was complete. I became a Husker fan for life.
On Friday it was announced that the University of Nebraska would be joining the Big Ten Conference. Are you kidding me? I am so fired up!!! It will be fabulous to see the Huskers play the Ohio State Buckeyes in Columbus some day soon. I cannot wait for the Huskers to dominate Michigan in the big house. It will be a blast when Nebraska plays Iowa. My nephew Joe is a die hard OSU fan. Let the trash talking begin! My good friends Brad Meyer and Drew Porter are big supporters of their alma mater, the University of Iowa. They both met their wives in Iowa City. We will have fun tailgating in Lincoln together. Geoff Cooper loves his Penn State Nittany Lions. A trip to see a football game in State College, Pennsylvania is a must now. I get excited just thinking about all this. Good times are ahead. Afghanistan will be in the rear view mirror soon. I will come home a changed man for sure. This was a life changing experience. But, very little can change the core of one's personality. After all, I came out of the womb a sports fanatic. So, the news of Nebraska joining the Big Ten is music to my ears.
GO BIG RED!!! (By the way, the N on the Husker football helmet stands for Knowledge)
For as long as I can remember, sports have been an important part of my life. My earliest memory is getting my picture taken as a 3 year old with a baseball cap on and a wiffle ball bat in my hands. I can recall clearly watching sports practically non stop as a kid. New Year's Day 1984 was a marathon of college football for me. I sat in our TV room and watched 3 football games in a row. The last game was one of the greatest games in college football history. It was the 1984 Orange Bowl between the Nebraska Cornhuskers and the Miami Hurricanes. The game ended just before midnight when Nebraska went for a game winning 2 point conversion and were denied. Miami won the game 31 to 30. They were crowned national champions. Bernie Kozar was Miami's quarterback. He was only a freshman at the time. Of course, he would later become a hero in my hometown as the quarterback of the Cleveland Browns.
Fast forward to 2004. I was a first year resident (intern) at the University of Nebraska Medical Center. I was living among countless diehard fans of the aforementioned Nebraska Cornhuskers. They call it Husker Nation. Late in the fall that year, I obtained 2 tickets to a Nebraska football game. I invited my good friend Allen. He was nine years old at the time. I was serving as his "big brother". We made our way to Lincoln and found our seats high up in the 72nd row. The wind was howling. Allen became uncomfortable and scared. He was quite upset. We left our seats and went down to ground level. Allen asked me, "Why don't we just get another seat?" My reply was something like, "Buddy, this stadium has been sold out since 1962! There are no other seats." We were standing there and Allen began to cry. I did not know what to do. Out of nowhere an usher approached me and asked me what the problem was. I explained the situation. He said that perhaps he could find a solution to our dilemma. He lead us through the crowd, talked to a few people, and the next thing I know we were sitting at field level right behind the end zone! It was incredible. At halftime this same usher found us and led us through the stadium. He took us on a tour of the locker room and weight room. He then showed us the trophy cases including the National Championship and Heisman Trophies. Our day was complete. I became a Husker fan for life.
On Friday it was announced that the University of Nebraska would be joining the Big Ten Conference. Are you kidding me? I am so fired up!!! It will be fabulous to see the Huskers play the Ohio State Buckeyes in Columbus some day soon. I cannot wait for the Huskers to dominate Michigan in the big house. It will be a blast when Nebraska plays Iowa. My nephew Joe is a die hard OSU fan. Let the trash talking begin! My good friends Brad Meyer and Drew Porter are big supporters of their alma mater, the University of Iowa. They both met their wives in Iowa City. We will have fun tailgating in Lincoln together. Geoff Cooper loves his Penn State Nittany Lions. A trip to see a football game in State College, Pennsylvania is a must now. I get excited just thinking about all this. Good times are ahead. Afghanistan will be in the rear view mirror soon. I will come home a changed man for sure. This was a life changing experience. But, very little can change the core of one's personality. After all, I came out of the womb a sports fanatic. So, the news of Nebraska joining the Big Ten is music to my ears.
GO BIG RED!!! (By the way, the N on the Husker football helmet stands for Knowledge)
Tuesday, June 8, 2010
The W
For the first five months of my deployment I worked exclusively in the hospital on the Intensive Care Ward. (I recently moved to the clinic which I will explain later) It's commonly referred to as the ICW or simply The W. I am not sure if there is a place quite like it anywhere else. I have never heard of a section of the hospital being called an intensive care ward. But, here at Bagram it makes sense. The patients on The W are very sick. Essentially, when patients in the Intensive Care Unit come off a ventilator (breathing machine) they are sent to The W. They arrive with jaws wired shut, tracheostomies in place, bowels in discontinuity, limbs amputated, wound vacuums in place, chest tubes on suction, drains in the belly, and external fixators holding bones together. Simply stated, these are complicated, sick patients who are recovering from horrific injuries.
The work done every day on The W is outstanding. It is always busy. There is a constant flow of injured Afghans. And, almost every day a group of American and coalition patients are loaded onto litters and transported out of the hospital onto planes to leave Afghanistan. The hospital beds fill up again in a matter of hours and the entire process begins again. There is rarely a reprive from this. The staff has to be ready to work hard at all times. This can be a real grind to say the least. All of us have felt it. And, each of us has needed to lean on others to survive and stay sane.
The staff I worked with on The W was diverse. There was a large group from Nellis Air Force Base (AFB) in Las Vegas. Travis AFB in northern California is the home station for many others. The nurse manager is from Shaw AFB just up the road from my home station of Charleston AFB in South Carolina. One of our doctors was an Army internist from Heidelburg, Germany. Another doctor is stationed in Japan. Other places represented include Seymour-Johnson AFB in North Carolina, Andrews AFB in Maryland, and Lackland AFB in Texas. We cannot forget our medic from the Idaho Air National Guard as well. I am sure that I have forgotten someone.
On the whole, the staff is quite young with ages mostly in the twenties and some in the thirties. I bet there were a few fortysomethings as well! Some were quite experienced while others are just beginning their careers. Several nurses work on maternity wards back home. Others work in post anesthesia care units and emergency rooms. A few come from clinics much like the one I work at in Charleston. The bottom line is that almost none of us had seen anything like what we have here at Bagram. It was certainly a shock for many of us. The learning curve was steep. Yet, everyone stepped up to the challenge. We did things that we never expected to do and acquired knowledge in areas that will only help us in the long run.
Without a doubt, The W has made its mark. We shined when both the President of the United States and the President of Afghanistan visited us this year. More importantly, we impacted the lives of a heck of a lot of patients. The work is definitely something to remember. But, work is merely one aspect of life. In the end, it is the people that made up The W that really matter.
The work done every day on The W is outstanding. It is always busy. There is a constant flow of injured Afghans. And, almost every day a group of American and coalition patients are loaded onto litters and transported out of the hospital onto planes to leave Afghanistan. The hospital beds fill up again in a matter of hours and the entire process begins again. There is rarely a reprive from this. The staff has to be ready to work hard at all times. This can be a real grind to say the least. All of us have felt it. And, each of us has needed to lean on others to survive and stay sane.
The staff I worked with on The W was diverse. There was a large group from Nellis Air Force Base (AFB) in Las Vegas. Travis AFB in northern California is the home station for many others. The nurse manager is from Shaw AFB just up the road from my home station of Charleston AFB in South Carolina. One of our doctors was an Army internist from Heidelburg, Germany. Another doctor is stationed in Japan. Other places represented include Seymour-Johnson AFB in North Carolina, Andrews AFB in Maryland, and Lackland AFB in Texas. We cannot forget our medic from the Idaho Air National Guard as well. I am sure that I have forgotten someone.
On the whole, the staff is quite young with ages mostly in the twenties and some in the thirties. I bet there were a few fortysomethings as well! Some were quite experienced while others are just beginning their careers. Several nurses work on maternity wards back home. Others work in post anesthesia care units and emergency rooms. A few come from clinics much like the one I work at in Charleston. The bottom line is that almost none of us had seen anything like what we have here at Bagram. It was certainly a shock for many of us. The learning curve was steep. Yet, everyone stepped up to the challenge. We did things that we never expected to do and acquired knowledge in areas that will only help us in the long run.
Without a doubt, The W has made its mark. We shined when both the President of the United States and the President of Afghanistan visited us this year. More importantly, we impacted the lives of a heck of a lot of patients. The work is definitely something to remember. But, work is merely one aspect of life. In the end, it is the people that made up The W that really matter.
Saturday, June 5, 2010
Living and Dying with Dignity
In the summer of 2009, an Afghan local national (civilian) was shot in the abdomen. He was transported to Bagram for life saving treatment. He likely would have died had he not been brought here. His abdomen was opened, the bowel injuries were sutured together, and he was given an ostomy (bag for collecting stool). His intestines were left in discontinuity. The plan was for him to return months later for his bowels to be sewn back together. Similar patients present to our hospital nearly every day. However, this particular patient was destined to become one that most of us will never forget. He would get many nicknames during his stay. I will simply refer to him as Mr. G. He was a middle aged man with a large family, nine children and a wife to be exact. He maintained a long black beard. He was quite thin and short like many Afghans. Mr. G was pleasant, easy going, and likeable.
This past January, Mr. G was admitted to the hospital to have his ostomy bag removed, a hernia repaired, and his bowels to definitively repaired. My good friend Dr. Mike Greene was his attending physician. The operation went as planned. Mr. G spent the next few days recovering. All seemed well. Dr. Greene prepared his discharge papers. Mr G was set to leave, but then we noticed a foul smelling discharge coming from his incision. It was feces. Mr G had developed a dreaded enterocutaneous fistula. What the heck is that you ask? Well, essentially it was a tract from his bowel to his skin. Fistulas are a rare complication of any surgery. It is the body's response to the trauma of surgery. I do not claim to be a fistula expert. In fact, Mr G's fistula was the first I had ever seen. I hope I do not ever see another one.
It is difficult to summarize what happened in the next 140 days of Mr G's hospitalization. I'll do my best. The irony of a fistula is that it was caused by surgery and by doing more surgery you can actually cause more fistulas. One fistula is bad enough. You do not want more! So, we had to calmly wait to see if Mr G's fistula would heal. The output of feces needed to be controlled to avoid infections. Mr G was not allowed to eat. We started him on Total Parenteral Nutrition (TPN). This is basically an entire day of nutrition in one bag that is given intravenously. His bowels needed to rest in order to have any chance of the fistula closing. TPN is labor intenstive for the pharmacy and it is very expensive. The cost would make the hair on the back of your neck stand on end. At any rate, the fistula was given time to heal. Weeks turned into months. The darn fistula just would not heal. The surgeons were chomping at the bit to do something about it. After all, a chance to cut is a chance to cure... except in the case of fistulas!
Mr. G eventually did go back to surgery. In fact, he had over 50 trips to the operating room. Our team of excellent surgeons did everything they could to find a solution. His abdominal musculature was removed and thrown into the bucket. This left him with the grand canyon of all abdominal wounds. It was not pretty. In addition to his fistula, Mr G had numerous complications. One of the main risks of giving TPN is infection because it has to be given through a large IV inserted in the chest or neck. Mr G developed overwhelming blood infections that made him critically ill not once but actually 6 TIMES! I am not exaggerating. He was put on a ventilator (breathing machine) for prolonged periods of time. We treated him with the best medications known to man. He always pulled through. Simply stated, Mr. G is a survivor. One night I was on call and we had a power outage in the hospital at 3 in the morning. The patients in the intensive care unit were prioritized because their ventilators had no power. Mr G was considered a low priority. I walked into the ICU and Mr. G was breathing on his own despite the fact that his endotracheal tube (breathing tube) was still in place. It was like breathing through a straw and he was doing it no problem. We took out the breathing tube because he obviously did not need any help breathing. He left the ICU later than day and was back to his normal self. The legend of Mr. G grew larger.
As the weeks passed, the surgeons kept trying all sorts of different ideas. Unfortunately, nothing worked. He had 5 skin grafts done to close his abdomen all of which failed. After over 4 months taking care of Mr G, my colleague Dr. Greene needed a break. I became the attending physician for Mr. G. It was clear to me that we were reaching a crossroads. An incredible amount of resources has been used in his care. Mr. G had been on an emotional roller coaster. So, Mr. G and I had a frank discussion through the interpreter. I told him that he was in charge of his health care, not the doctors. I told him that he needed to do what was best for him and his family. It was important to say this to him because in Afghanistan people will do whatever doctors say. They do not question us. I let Mr G think about this for several days. Then, one morning with his father by his side Mr. G informed me that he wanted to leave the hospital. Enough was enough. We began to make arrangements for this to happen. However, there was not agreement among the doctors about what was best for Mr. G. In the meantime, Mr G became critically ill once again. I was called to his bedside during the night because he had a fever of 105. He once again has bacteria in his blood. He went back to the ICU. Those of us that had taken care of Mr G for over 4 months were disgusted. It was difficult to see him so sick once again. But, Mr. G survived this trip to the ICU yet again. He was back to his normal self in 3 days. After all, Mr G is the ultimate survivor.
Several days later, Mr G was lead out of the hospital in a wheelchair. It was early in the morning on a clear day. I pulled a wagon full of medical supplies for him. We loaded him onto the ambulance for the short ride to the base entry control point for his release. The ambulance doors were closed. Mr. G waved good bye. Some tears were shed as they drove away. His fate was now out of our hands. He was scheduled for a follow up appointment at our hospital. I doubt he will be back. In fact, he may not even be alive today as I write this. One thing I know for sure is that Mr. G is either living or dying with dignity.
This past January, Mr. G was admitted to the hospital to have his ostomy bag removed, a hernia repaired, and his bowels to definitively repaired. My good friend Dr. Mike Greene was his attending physician. The operation went as planned. Mr. G spent the next few days recovering. All seemed well. Dr. Greene prepared his discharge papers. Mr G was set to leave, but then we noticed a foul smelling discharge coming from his incision. It was feces. Mr G had developed a dreaded enterocutaneous fistula. What the heck is that you ask? Well, essentially it was a tract from his bowel to his skin. Fistulas are a rare complication of any surgery. It is the body's response to the trauma of surgery. I do not claim to be a fistula expert. In fact, Mr G's fistula was the first I had ever seen. I hope I do not ever see another one.
It is difficult to summarize what happened in the next 140 days of Mr G's hospitalization. I'll do my best. The irony of a fistula is that it was caused by surgery and by doing more surgery you can actually cause more fistulas. One fistula is bad enough. You do not want more! So, we had to calmly wait to see if Mr G's fistula would heal. The output of feces needed to be controlled to avoid infections. Mr G was not allowed to eat. We started him on Total Parenteral Nutrition (TPN). This is basically an entire day of nutrition in one bag that is given intravenously. His bowels needed to rest in order to have any chance of the fistula closing. TPN is labor intenstive for the pharmacy and it is very expensive. The cost would make the hair on the back of your neck stand on end. At any rate, the fistula was given time to heal. Weeks turned into months. The darn fistula just would not heal. The surgeons were chomping at the bit to do something about it. After all, a chance to cut is a chance to cure... except in the case of fistulas!
Mr. G eventually did go back to surgery. In fact, he had over 50 trips to the operating room. Our team of excellent surgeons did everything they could to find a solution. His abdominal musculature was removed and thrown into the bucket. This left him with the grand canyon of all abdominal wounds. It was not pretty. In addition to his fistula, Mr G had numerous complications. One of the main risks of giving TPN is infection because it has to be given through a large IV inserted in the chest or neck. Mr G developed overwhelming blood infections that made him critically ill not once but actually 6 TIMES! I am not exaggerating. He was put on a ventilator (breathing machine) for prolonged periods of time. We treated him with the best medications known to man. He always pulled through. Simply stated, Mr. G is a survivor. One night I was on call and we had a power outage in the hospital at 3 in the morning. The patients in the intensive care unit were prioritized because their ventilators had no power. Mr G was considered a low priority. I walked into the ICU and Mr. G was breathing on his own despite the fact that his endotracheal tube (breathing tube) was still in place. It was like breathing through a straw and he was doing it no problem. We took out the breathing tube because he obviously did not need any help breathing. He left the ICU later than day and was back to his normal self. The legend of Mr. G grew larger.
As the weeks passed, the surgeons kept trying all sorts of different ideas. Unfortunately, nothing worked. He had 5 skin grafts done to close his abdomen all of which failed. After over 4 months taking care of Mr G, my colleague Dr. Greene needed a break. I became the attending physician for Mr. G. It was clear to me that we were reaching a crossroads. An incredible amount of resources has been used in his care. Mr. G had been on an emotional roller coaster. So, Mr. G and I had a frank discussion through the interpreter. I told him that he was in charge of his health care, not the doctors. I told him that he needed to do what was best for him and his family. It was important to say this to him because in Afghanistan people will do whatever doctors say. They do not question us. I let Mr G think about this for several days. Then, one morning with his father by his side Mr. G informed me that he wanted to leave the hospital. Enough was enough. We began to make arrangements for this to happen. However, there was not agreement among the doctors about what was best for Mr. G. In the meantime, Mr G became critically ill once again. I was called to his bedside during the night because he had a fever of 105. He once again has bacteria in his blood. He went back to the ICU. Those of us that had taken care of Mr G for over 4 months were disgusted. It was difficult to see him so sick once again. But, Mr. G survived this trip to the ICU yet again. He was back to his normal self in 3 days. After all, Mr G is the ultimate survivor.
Several days later, Mr G was lead out of the hospital in a wheelchair. It was early in the morning on a clear day. I pulled a wagon full of medical supplies for him. We loaded him onto the ambulance for the short ride to the base entry control point for his release. The ambulance doors were closed. Mr. G waved good bye. Some tears were shed as they drove away. His fate was now out of our hands. He was scheduled for a follow up appointment at our hospital. I doubt he will be back. In fact, he may not even be alive today as I write this. One thing I know for sure is that Mr. G is either living or dying with dignity.
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