Busy Day at Rocket City
By LTC Jerold B. Campbell, CRNA, AN, USA
Chief, Department of Anesthesia
"Rocket City," Afghanistan
Yesterday was another busy day. It began at 0330 with a "Liberty Black" (four or more patients). You may have heard about this one in the States.
There was an attack at one of the contractor bases. There were no American troops. This was a base for contractors who were doing road construction. They shot the guard and then ran a dump truck full of explosives onto the base and detonated it. The last count we heard was 26 killed and 47 injured. The patients we were getting were the overflow from that attack. This base was a long way from us but they were trying to evacuate the wounded to Bagram AFB. The helicopters could not make it that far and could not get through the mountains. So the plan was to evacuate some of the overflow to us and then load them onto a C130 from here to Bagram. I am sure all the forward operating bases in our sector got wounded also.
It amazes me that people who are trying to improve Afghanistan and are not soldiers would be attacked. Apparently the Taliban does not want Afghanistan to improve in any way. From my conversations with the local Afghan people, the Taliban wishes to keep the country weak and unable to mount any resistance. Building roads does not further their agenda. Nor does supplying healthcare, education or humanitarian aid. That is one reason why our hospital is a frequent target for rocket attacks from the surrounding mountains. It also is not in Pakistan's interest to have a strong neighbor to its west. They already have a hostile relationship with India on their east so they do not wish to have a strong country that could oppose them on their west. This is one reason they only give lip service to the fight against the Taliban in the border region between Pakistan and Afghanistan. On some level the Taliban is serving Pakistan's interest in Afghanistan even though the Taliban is causing some trouble in Pakistan also. It is a very delicate game that is going on over here and the Afghan civilians are caught in the middle of a chess match between the U.S., Pakistan, the Taliban and Al Qaeda. No wonder we have been here for 10 years.
Getting back to our patients. The initial treatment they received was very good. We got two waves with a total of 10 or 11 patients. Most had already had some type of surgery. Our task was to triage and evaluate them after such a long flight and to make sure they were stable and did not have any injuries that were missed and needed treatment. I was first call that 24 hours and my first patient was on a ventilator. He had received a neck injury from shrapnel. He had already had his neck explored and was stable. We still treated everyone as if they were freshly wounded and had just arrived. We did not want to miss anything even though they had already been seen. So the mantra is: make them naked, roll them side to side and shoot a chest x-ray. The purpose is to put a hand on every piece of skin front and back and to not miss any possible injury. A tiny puncture wound can cause massive damage. The neck patient and the others were stable for the most part, and were moved to the ICU. They only required minor treatment while waiting for the C130 to get here.
At 0700 we got three more patients who had been involved in an unrelated IED blast. One patient had a depressed skull fracture with an epidural hematoma and an open globe injury to his left eye. My patient had a basilar skull fracture with a cerebral spinal fluid (CSF) leak from his nose and ears. He was combative, so we anesthetized and intubated him. The third had multiple puncture wounds from shattered glass as well as fractures of his arms and hand. The first two got a CT scan and were evacuated, and the third we took to surgery. We finished up about 1500.
Today we did debridements and dressing changes on our guy with the 60 percent burns. Then did an abdominal washout and colostomy on our guy on ECMO* (see sidebar, below). He was too unstable to move to the OR, so we did his surgery at the bedside in ICU. We have worked so hard on this guy but I am having doubts whether he will make it. He is the one I did a case report on earlier that initially came in after a piece of IED passed though his abdomen. His injuries were just so massive that it is a miracle he is still alive.
The base has been locked down for the past five days due to intelligence received about a possible attack. This was the first day we reopened the gate to locals who needed medical treatment. The local national clinic was overflowing. There was a brother and sister who were three and four years old. They were here to be evaluated for Thalassemia, an inherited blood disorder which causes formation of defective hemoglobin and leads to anemia. It is common in this area. It can cause enlargement of the spleen and spleenectomies have been done for children at this hospital in the past. The three year old boy has been receiving blood transfusions every 20 days. They were both small and thin. I was asked to start IVs on them, draw blood, and sedate them for CT scans. That took most of the afternoon. I really felt for them and their family. This can be a death sentence for these kids if they don't get proper treatment to prevent complications. A difficult thing to accomplish in this hostile environment. The four year old girl was a bit dazed from the anesthetic I gave her for the CT scan. She was terrified and would not hold still for the scan.
Rarely a dull moment here.
*ECMO = Extracorporeal Membrane Oxygenation.
LTC Campbell: "This is a device that takes unoxygenated venous blood, circulates it through a pump and filter, adds oxygen, takes away carbon dioxide and returns it to a patient. In this case, we took a very large cannula (tube) and inserted it into the patient's right internal jugular vein and threaded it down past the heart into his inferior vena cava. The machine then, via a hole in the end of the cannula, pumped the unoxygenated blood that was returning to the heart into the oxygenator on the pump, and added oygen to the blood and also removed carbon dioxide before returning it to the patient via an upper opening in the cannula near the heart. Its purpose is to help get oxygenated blood into a patient who has severe lung damage which prevents it from funcitoning normally. The lungs' function is to remove carbon dioxide and take in oxygen.
"This was a very unorthodox thing to do out here in the middle of nowhere. One of our surgeons had worked with this device back home, and had brought a portable unit with him. This was the first time any of us are aware of that this technology was used in a combat environment. It bought the patient time.
"You can see the controller underneath the table. The centrifuge pump is the circular device clamped to the table leg. The oxygenator is the white box taped to the other leg of the table. You can see one limb of the cannula extracing darker blood, entering the centrifuge, exiting the centrifuge, entering the oxygenator and then exiting the oxygenator back into the internal jugular. You can also see that the return limb has brighter oxygenated blood."