Bad Day and Night
By LTC Jerold B. Campbell, CRNA, AN, USA
Chief, Department of Anesthesia
"Rocket City," Afghanistan
The last 36 hours have been....difficult. I am writing this in hopes of a catharsis. In the morning hours after yesterday and last night I am afraid that if I don't write this down it will be forgotten. It should not be. Perhaps the perspective might change over time but the facts, emotions and memories should be remembered.
It started at 0200 when I got called in for a head trauma. The American soldier had fallen approximately 20 feet off a cliff. He had a cervical collar ("C-collar") on and he was conscious. He was stable but complaining of back and neck pain. He could move everything and was going to need a CT scan. He would not be needing my services. I got back to my bunk at 0400, but could not sleep. My usual 0545 alarm sounded with me still awake. This day would continue with my usual morning shower and breakfast and then rounds at 0700.
After rounds we did our usual morning debridement and dressing change on our guy with 60 percent burns. He is entering his seventh week with us–an Afghan national who was driving a fuel truck for the American forces when hit by a rocket-propelled grenade (RPG). Everything went well. I then went walking around the base with my Certified Registered Nurse Anesthetist (CRNA) partner, Major "Scott." At 1030 the radio chatter started, and we knew something was up. We started for the hospital. Within five minutes we were hearing "Liberty Black"–our code for critical injuries and at least four patients. I say patients instead of soldiers because we take injured local nationals as well. We were told these were American soldiers. This was the end of my first two weeks in-country and the several dozen trauma patients we had seen had all been Local national, Afghan National Army, Afghan border patrol, Afghan defense force, Afghan police force, Khost provincial force. No Americans. We knew this was going to be bad.
We got to the emergency room (ER) and confirmed that we were prepared. The initial soldier had horribly displaced bilateral tibia-fibula (tib-fib) and right femur fractures. He was in shock. I was on call that day so I would take the most critical, and Scott would take the second most critical. This soldier went to Trauma Bay Two with Scott, so I immediately knew the next one would be bad. Eventually my patient arrived. Cardiopulmonary resuscitation (CPR) was in progress. It appeared his arms and legs were all fractured. We got him onto the stretcher and began our assessment. The medics had placed a tracheostomy
in the field and one line was going. I began ventilating with an ambu bag
with 100 percent O2
while we began Advanced Trauma Life Support (ATLS). Breath sounds were good. He was unresponsive. No blood pressure (BP). Stopped compressions, no pulse. Continued ATLS. We were unable to find a central line. The surgeon opened his chest. I checked the pupils and temperature and ears: fixed and dilated. Temperature was 85.6º F. The heart was empty of blood. My patient was gone. The medics had not wanted to give up so they did CPR all the way to the hospital. I gave a quiet salute. A hand on his forehead. I will never forget his brown eyes.
Time to focus. Had to get ready for the next one. While we reset, I went to help Scott. We set up the Belmont rapid infuser and began giving blood. They had gotten a Cordis (a large IV catheter) in the internal jugular vein and we started blood. I set up an A-line (arterial line) and someone stuck the femoral artery and we had our lines. After we determined that Scott's patient was the most critical, they moved to the OR and I stayed in the ER to help receive more incoming patients. We got four more but all were fairly stable with good airways and oxygen saturations. The respiratory therapists were doing a good job and had things under control.
We had no more immediate casualties coming in so I went to the OR to help Scott. Bilateral lower leg fasciotomies (fascia incisions made to relieve pressure) were done as well as a right thigh fasciotomy. Massive blood loss. The fractures were horribly displaced. We were giving blood and fresh frozen plasma (FFP) as fast as the blood bank could bring them. We got the bleeding under control and splinted his legs and moved to the ICU. The initial abdominal assessment was negative but he was not stable in the ICU. We moved to radiology for a CT scan. The ER was still busy but no surgical candidates so far. CT showed a cervical spinous process displaced fracture, some fluid in the belly, a humerus (upper arm) fracture and a pelvic fracture.
The surgeons decided they needed to explore his abdomen. Here we go again to the OR. Still transfusing. I took over and Scott went to help in the ER. Exploration of his abdomen revealed a rupture of the head of the pancreas, a small retroperitonal hematoma and some blood in the abdomen. We packed him open (packed some bandages in the wound and covered it) and began calling for a critical care air transport to get him to Bagram. By this time we had given him 13 units of blood, 11 units of FFP, 200cc 25 percent albumin, 3000cc of normal saline, and two six-packs of platelets. We rarely have platelets so we were fortunate to have them today. We got him back to the ICU but by this time his right leg dressing had saturated completely though. We re-explored his right leg in the ICU and ligated (tied off) some venous bleeders. He was starting to warm up and vasodilate. Bleeders began appearing where there had been none before.
I reset the OR and moved to the ER. Another wave of casualties were on their way. We were starting to get Afghans now. The next wave were from an improvised explosive device (IED) blast and fire. This time it was burns as well as trauma. This continued from 1100 until 1600. We took a total of 13 casualties, brought five to the OR. One burn was third degree and 60 percent. We could not help him. We moved him to the expectant area and provided comfort care. He died that evening. I got the last patient to the ICU at 1830. Constant movement for the last 7.5 hours. We reset the OR and ER to prepare for more arrivals.
Over the loudspeaker we heard "Attention, all available personnel report to the flight line for Hero Flight." Hero Flight is the base's sendoff for all American soldiers who have been mortally wounded. This would be the sendoff for my brown-eyed soldier. As we had a lull, Scott and I began moving toward the flight line (airport runway). As we came out of the hospital, an ambulance pulled up to transport our brown-eyed soldier. We asked if we could help. Scott and I helped two other soldiers carry the stretcher on which his flag-draped body lay. We carefully loaded him in the ambulance and then walked to the airport runway. This would be my first Hero Flight.
This is a chance for soldiers to pay homage to their fallen. In a single line, soldiers silently made their way onto the runway and lined up on either side of the rear of a C-130 cargo plane. The engines were off and the rear of the plane was open. Standing there on the gravel runway behind the C-130, surrounded by more than 500 soldiers, the only thing you could hear was the occasional breeze. The ambulance made its way to the end of the line and the brown-eyed soldier was moved into the C-130 through the gauntlet of his fellow soldiers. Utter silence and calm broken only by slow movements as each soldier in turn raised his hand in salute as their fellow soldier passed. The base chaplain said a few words and led us in prayer. Then, a smart RIGHT FACE, and the line silently marched off into the darkness. This fallen soldier was on his way back to his family.
I made my way to the dining facility (DFAC) after realizing I was suddenly very hungry. As I sat down to eat, my radio started to chatter "incoming" about a minute before the "Big Voice" loudspeaker throughout the base started announcing, "Incoming, incoming, incoming!" The DFAC has three eating areas: left, right and center. The center is not reinforced to withstand incoming rocket and mortar fire, so everyone in the center started moving to the left and right. We heard the impact maybe 100-200 yards away. After about 15 minutes, the all clear sounded and I moved my way back to the hospital for possible casualties and to sign the roster. After incoming have cleared, all hospital personnel sign in for accountability.
A few minor injuries trickled in but nothing major. A couple of soldiers who were near the explosion were taken to be evaluated for traumatic brain injury (TBI) but they were ambulatory and would not need anesthesia. About this time, one of the Afghan soldiers who was initially cleared began having worsening abdominal pain. We brought him to the OR and found a ruptured spleen and minor liver laceration. We did a spleenectomy and repaired his liver laceration. The surgeons actually decided to close his belly. This would be the first time in two weeks that I actually awakened a patient and extubated them in the OR. We all thought that was funny. Strange what things make you laugh after a day like this. He woke up okay, and we took him to the ICU.
After resetting the OR I moved toward my bunk. I needed a shower and sleep. I had been up for 20 hours with only four hours sleep the previous day. As I was walking to the shower, my radio chirped: "Anesthesia to the ER." It turned out there was an Afghan soldier who had been driving when an IED went off and he had hit the windshield, causing lacerations to his lip and some fractured teeth. The base's dentist was requesting some conscious sedation for the repair and extraction.
After an hour and a half, I finally got my shower. Feeling half human again, I returned to my bunk. Sleep would be elusive and intermittent. Another day and 0700 rounds would be starting in just a few hours. I just prayed that we would not get any "Liberties" before sunrise. I needed to let my family know I was okay. I email daily and I know they will be worried about me. I have missed my usual times for Skyping. Checking my computer, I realize I have no connection. It is because standard operating procedure here is to curtail all communications until a deceased soldier's family is notified.
It's often repeated, but very true. War is hell. Or what you imagine hell could be like for those who suffer through it. I am fortunate in that I have the consolation of knowing that last night everyone who could have been saved was. So far, everyone who had a pulse when they came in the door has survived. I can only hope that remains true for the rest of my tour.
Next entry: Busy Day at Rocket City