"Little Kaenat"

Last night at 8:00PM I got a call from FOB Bostick.  The Colonel on the other end informed me there was a three year old Afghan girl who sustained a femur fracture and wanted to know if I would be interested in treating her; without hesitation I agreed.  The very moment I hung up the phone a middle ages man with a California surfer hair cut stood there staring at me.  He reached his hand out to me and introduced himself “How’s it going my name is Pete”; I offered my hand.  Pete is a name I have heard much about over the last weeks but this is the first time we actually met.  My base has a lot of soldiers on it but there are also a few other U.S. groups here including non-military.  One of these special groups is called the “OGA”, also known as “Other Government Agencies.” I can’t go into who they really are and what they specifically do but can tell you they are really important in the grand scheme of theater action.  Pete tells me he is really appreciative I have agreed to take care of this girl for specific reasons other than the fact I want to.  Pete tells me the child will be hear by 10:00PM shakes my hand again and disappears out of the door into the night. 

10:00PM finally comes and like clockwork Pete arrives in a helicopter with the 3 year old Afghan girl and her father. She is transferred into the FST for me to evaluate. “Rocky” our Afghan interpreter is present to help me gather information about the child from her father. I initiate communication with the father by introducing myself and shaking his hand. I learn my beautiful Afghan patients name is “Kaenat”. It’s obvious from the start that this child is from the higher sect of Afghan society based on her physical condition. Her dark naturally curly hair hides big brown scared eyes beneath.  I look her in the eyes and try to hold her hand but she wanted nothing of it; I have something to work toward with her other than medical care. I admitted her to our FST, made her comfortable, and made plans for reducing her femur fracture with application of a hip spica cast for 8:00AM tomorrow morning. After finishing her overnight orders I retreated to my shack for a night of sleep.

I was awoken this morning by our CRNA (anesthesia nurse) at 6:30AM; 30 minutes prior to my alarm. My anxiety was spiked initially but learned he thought I would be up and about planning early for the case; I guess he was a little excited.  Now I was awake so I started my day sooner than anticipated.  I made my way to the FST and found little Kaenat sleeping soundly with her father bedside.  Once the operating room was ready Kaenat was woken up; Afghan fury in her eyes.  Once her father soothed her we made our way to the OR.  Our CNRA aka “The Bear” gave her surgical sleeping juice and then we began.  Joe J assisted me and considering I have not put a hip spica on a child since my pediatric residency training at the Cleveland Clinic I was pleased; just like riding a bike Dr. GoodwinJ (one of my amazing CCF pediatric orthopedic attendings).  Kaenat was extubated and I carried her back to her waiting father in recovery. His eyes were impatient for my report of the surgery. “Rocky” informed him everything went well and for a second time during my short time here he hugged me; I don’t think that will ever get old.

Afterward “Pete” our new “OGA” friend thanked us and asked us over to their secret compound on our FOB for lunch; Joe J and I accepted. We had a great time and got to see a lot of really cool things but I can’t disclose any of it to you or I would have to ..; I like you better alive so I’ll just leave it at that.

Talk to you soon.

M

"RED SIX"

This morning I saw a patient for more than just orthopedic issues; much more for the both of us.  Sargent K was a scheduled consult for me by Charlie Company for his knees. He has had problems for years but has not complained about them because he was in a leadership position in his infantry unit; his soldiers were obviously put before his concerns. The issues this soldier has with his knees are significant and most soldiers I have worked with in the past would have used it as a ticket out of the military. He has served for 13 years, 4 deployments and at this point tells me in a defeated tone “I just can’t do it anymore.” I picked up there is more than just his knees bothering him and press further.  I find out this soldier of harden steal is cracking within from the recent loss of his platoon leader; tragically the same soldier we lost here in our FST. After hearing this I found myself suddenly re-experiencing the emotional turmoil from that fateful day. It was almost as if time stopped, I looked into his eyes with true understanding, put my hand on his shoulder and let him know he was not alone. I explained that all twenty people of our FST will remember his platoon leader indefinitely. Sargent K reached over to his right shoulder and lifted up his velcroed American flag on his uniform; a black name tape was underneath with big bright red letters across its surface “RED SIX”; the platoon leaders call sign.  He had these name tapes made for everyone in his platoon and they all wear them under their American flags; he was an exceptional leader and friend to all of them who put their safety and needs ahead of his own; just like Sargent K.  The day he died Sargent K’s platoon leader took the lead ahead of his platoon during a known dangerous route clearance mission; and played the ultimate price. After finishing up my consult Sargent K asked if we also wanted “RED SIX” name tapes to wear in remembrance of him. Without hesitation I said yes as did everyone else standing near me at the time. The name tapes are going to be made for everyone in our FST. “RED SIX” you are a hero and an inspiration to us all; I only wish I could have told you face to face. God bless you, your family, and all the lives you touched.

After a busy morning of consults our FST was notified that two U.S. soldiers were being medevac  to us after sustaining shrapnel wounds from a nearby exploding mortar; ETA 30 minutes. It sounded like they were stable from the initial reports but we take those with a grain of salt as we have already been burned.  Eventually we were warned the Blackhawk was near and when its pounding blades could be heard everyone took their place in this now well-rehearsed play.  The two soldiers were brought into the FST and the trauma resuscitation began.  Both soldiers were stable and the majority of their injuries were correctly identified as shrapnel wounds; a lot of them.  Joe J and I took the first soldier back to the operating room to remove some of the most superficial fragments and then we washed out his wounds and dressed them.  Mike M followed us with the second soldier.  Both of these soldiers did not need to be transferred to a higher level of care; we will keep them with us until tomorrow when we will reevaluate them and get them back to their unit soon. 

We received 2 more ANA trauma patients immediately following the U.S. soldiers; their injuries were from mortar shrapnel received from a different attack.  Both had additional spinal injuries that needed advanced imaging so we coordinated their flight to Baghram.

Tomorrow starts a new week and with it more unpredictable experiences; hopefully more good than bad. I’m ready.

P.S.  After a month my sons Turin and Talon finally got the video recording of me reading some books to them. My wife informed me they watched it 10 times throughout the day. Don’t worry boys daddy will do it again.

M

"The White Cloud"

Today began with the excitement that our fellow surgeon Joey T (aka “The White Cloud”) returned from FOB Salerno; this FOB is located in the Khost region of Afghanistan; where Pat Tillman was killed. He left us temporarily to assist their FST during a busier than normal time; it’s nice to be back to full force especially because we expect our volume to increase in the near future.  Joey T and I are both surgical staff at Fort Knox and have a great friendship from working the past year together prior to deployment.  Being my first deployment into theater I have to admit my stress level was slightly subdued to the comfort of this relationship, and I think it would be apparent to most here that this translates into our working relationship as well.  

Following morning report the consults poured in with fury.  All were U.S. soldiers and one of them did need surgery for a fracture of his thumb; unfortunately after discussing the soldier’s situation with the command at Baghram the case quickly was stolen from me for infection concerns at our FST.  I understand the reasoning but felt depleted as another day of boredom would result.  I started the process of sending the soldier but he ended up not leaving today because of weather between us and Baghram.  Over the last 10 years a lot of studies have been done on patient outcome from surgery in theater. The consensus is there is an increase in the infection rate due to the nature of the severity of the injuries we treat and the fact that some real virulent strains of bacteria are present in this environment.  As such definitive surgical procedures on U.S. forces are restricted; only emergent cases can be done. Afghan National Army (ANA) and Afghan nationals are able to have definitive surgery by us if we don’t compromise our primary mission of emergent treatment of our troops. 

It has been 1 month since I entered this theater and days are starting to run together in a assortment of mental images; routines rule life and detours from them are rare. It’s easy to find yourself growing irritated with vices and quarks of others that originally were tolerable.  Social science has shown this to be the case on multiple occasions when people are isolated for long periods of time without physical access to the surrounding world in boring redundant daily conditions.  Hopefully our surgical volume will increase to bypass time faster.  Joe J and I are actually trying to form an alliance with the local Afghan surgeons so we can bring some of their more complex cases to our FST so we can mentor them. This really is a win-win scenario considering we get to perform more surgery, we improve these surgeons’ skills, and the Afghan population receives modern care from us and from their surgeons into the future.  There are many difficulties for this process including implants and other medical supplies but we are working on different possibilities to overcome these obstacles. We have included our friends on the Special Forces side to help form a conduit of communication with local Afghan providers; were moving at a slow pace but it’s something. 

Trauma did not rear its ugly head so far today; likely because our friend Mr. “White Cloud” returnedJ. The night is still young and we’re ready. Talk to you soon.

P.S. I love you Melissa, Turin, Talon and baby Myla.

M

"Taliban?"

Last night is still clouded in my mind and I’m not sure what the truth is; let me explain.  It was 6:00PM and we received notice that five Afghans were coming to our FST for significant injuries sustained after a probable attack on Taliban forces by an apache helicopter, aka “angel of death”.  No more information was given and we were told an ETA of 15 minutes.  When the two Blackhawks arrived 30 minutes later 2 of the 5 Afghans succumbed to their injuries leaving 3 to administer our surgical prowess.  Charlie Company met the bird and transferred them to us; it was immediately apparent 2 of the 3 patients were severely injured.  The worse one was brought into the FST immediately and evaluated. After about a minute he was taken to the operating room in a concerted effort by all three of us surgeons; the first time all three of us have worked together on a patient together.  Joe and Mike focused on his compromised airway which was significantly damaged by shrapnel, I focused on his right leg first followed by right arm which was mutilated; both had tourniquets stopping blood flow.  I dropped the tourniquet on the right leg and gained control of his bleeding.   It was obvious that this Afghan had a significant open fracture and was already displaying signs of “compartment syndrome” (excessive pressure in the leg from swelling) so I proceeded with a fasciotomy (release of compartment to decrease pressure) of his leg and externally fixation.  Once his leg was stabilized Joe and I focused on his mangled right arm.  Before we started we were informed that this patient and one of the others could be Taliban insurgents. I knew it was possible from the beginning that I might end up in this position but now that it’s before me I was shell shocked as well as everyone else in the OR.  We as physicians take a “Hippocratic Oath” when we graduate from medical school; that oath was being challenged at this moment.  I’m glad there was uncertainty about his insurgency status because it made it easier to follow the course of human compassion. There was really no time to dwell on the possibilities so we marched forward.  His whole right upper extremity was in bad shape.  Joe and I released the tourniquet with adrenaline flowing expecting to have to stop a life threatening outflow of blood.  I gave a count of 3 and then we released it; blood flowed rapidly but at a pace we could regain control in a relatively short amount of time. We worked through the night and in the end likely saved this “uncertain insurgents” arm. No further information could be gleamed through our command about their Taliban status. Would I treat them any different if they were determined to be definitively insurgents? I can’t answer that at this point but I’m sure in the near future my back will be against the wall to make that decision; I would like to think I’m a compassionate person. 

Once we finished it was well after midnight and our patients were transferred out to another medical facility. My well-deserved time of sleep approached and I collapsed into my bed; forgetting to set my alarm.  The result was waking up refreshed and ready for a new day of the unexpected at 9:45AM. Morning report was at 9:00AM, I hope they didn’t miss me too much. 

At 10:00AM my commander got a call there was an unknown Afghan that show up at the front gate of our FOB to see me, I guess my international fame has spread to Afghanistan; not exactly.  I learned this person was a disabled Afghan National Police officer who has been seen here at our FST multiple times in the past for significant injuries sustained from an IED blast 2 years ago.  I agree to see him so after a thorough search by U.S. army MP’s he is brought to the FST. He is here for a follow-up of a chronic bone infection of his left leg, and evaluation of his amputated right leg which is now replaced with a prosthesis.  I was expecting the worse based on past clinical noted but to my surprise he was doing well. I formulated a plan for him which was explained by our interpreter “Rocky”. I assumed he would just get up and walk to the door but I was surprised; he stood up came over to me, put his hand on my shoulder and proceeded to hug me; I was speechless and overwhelmed with emotion. I truly wish there was an “easy button” to push that would end war.  If people would look past government, religion, and conflicts they would realize we are all human; one in the same. I guess I found the answer to my question above.

Goodnight.

P.S.  I love you Melissa, Turin, Talon, and Myla.

M

"Specialist O and Abbas"

Yesterday was non-traumatic and rather boring especially considering the scorching sun weighed down on me crushing my motivation; 105 degrees and humid.  Today’s weather will be more of the same, but I’ll be busy indoors running an orthopedic clinic for U.S. soldiers to Afghan children.  Many of the Afghan kids are handoffs from the previous orthopedic surgeon I replaced; many had significant injuries that require multiple surgeries and I’m next in line.  Many of the surgeries I’ll perform while here in theater will be on the local Afghan population and a special emphasis will be on the pediatric population.  Most kids are not injured as the result of this war but rather the conditions they live in which predispose them to traumatic events.  After looking at my current population it is obvious that burns play a large role as most Afghan residences use a central fire pit in the middle of their homes for both cooking and heating. Kids not being taught the danger these flames present cause this scenario to capture them in serious accidental injury.  High degree burns are not quick fixes either, most require multiple surgeries which usually begin with skin grafting and end with surgically treating the many associated complications. 

My first patient is “Abbas” a pleasant 8 year old Afghan boy who 2 years ago fell into the flames of his family stove. He sustained significant 3^rd degree burns to both of his legs which have necessitated six surgeries to date; including multiple skin grafts, a partial amputation of his right foot and associated revision surgeries.  He is small for his age from my American perspective but I’m quickly learning this is the norm here in Afghanistan. He was not brought here by his mother or father as would be expected but instead by his 12 year old brother “Abfran”; he presents himself as a 25 year old man.  It is immediately apparent that young adolescents in the Afghan culture are part of the backbone of their society. They are given responsibilities beyond their years which instill maturity much earlier than their American counterpart.  Abfran watches my every move with scrutiny and uses out interpreter “Rocky” to decipher my intension.  It hard to interact with a boy of Abfran’s age on an adult level but I am quickly learning.  Abbas is doing well and I don’t foresee more surgery in his future. I pat Abbas’s shoulder, turn to Abfran and shake his hand; surprised by the testosterone in his grip, and say goodbye. They will return in 1 year for a follow-up. I also saw multiple U.S. Soldiers and another Afghan Child for routine orthopedic issues none of which needed operative intervention.  

Rubes is out for the majority of this week but Joe J and I have a new guest join us for our workout; Specialist O.  Specialist O is looking for direction for his desired “body transformation”. He’s young and never had sufficient athletic direction so Joe J and I are committed to bringing him on board our ship of fitness; it’s going to be a lot of work but what’s life without a challenge, especially here in Hell.  Today’s routine consists of weight training our backs, abdominal work, and interval cardio training at the end.  As Specialist O learned today “Intensity” is king in our routine; he never made it to the end and later informed us “I felt like I was going to puke”; we have a ways to go.  Afterwards Joe J accompanied him to the DFAC (cafeteria) for lessons on eating correctly.  It was Day 1 of his “body transformation” and although he did not finish were happy that he at least started; I hope he’s ready for tomorrow.

Trauma was non-existent until 6:00PM; Afghan ANA soldiers with significant injuries.  I’ll fill you in tomorrow as I’m getting ready for part 2 of "marathon limb saving orthopedic surgery".

Talk to you tomorrow.

M

"Last Night"

Last night turned eventful at 11:00PM when we were informed 3 U.S. soldiers were headed our way after an IED devastated their MRAP.  As usual our team assembled; preparing for whatever was thrown at us.  After 30 minutes 3 soldiers arrived as described and were transferred to our resuscitation area. There were no critical injuries but they were beat up.  I focused on a sergeant whose predominant injury was a bloodied left arm in a makeshift long arm splint.   After a thorough evaluation with x-rays he ended up having an open fracture to his elbow which I formally washed out and splinted.  The other two patients had the “typical” cervical spine pain that we see after IED blasts and were prophylactically protected with c-collars; one also had facial lacerations which were mended by our surgeons. After about 2 hours all were stabilized and transferred to Baghram airfield for further treatment and advanced imaging to rule out spinal injury. I finally fell into my bed at 2:00AM.

Sundays are supposed to be our free day with no morning report, a time to sleep in and let our bodies play alarm clock; at least that’s the plan.  8:30AM was upon me but I was oblivious as I was escaping my current reality in a vivid morning dream.  All of that changed when I was ripped from my temporary heaven to the harshness of my commander pounding on my door telling me I have another consult for Charlie Company.  Bewildered I crawl down from my perch, get dressed and head out the door; no time for a wakeup call from Jimi H or the wings of a red bull.  My patient this morning was a hard featured female U.S. soldier who injured her hand.  This soldier was involved in a recent Chinook helicopter crash and had a determined demeanor to survive. Her hand exuded work ethic from the many abrasions and calluses.  As I got more focused on examining her injury she was trying harder to hide her pain, especially with a master sergeant from her unit nearby. After a few attempts to gain information she finally described how she injured herself, but was adamant I give her a quick fix so she could continue her flight status.  This soldier was obsessed with performing her part within the unit she belonged; it was almost inspiring.  I wish I could have accommodated her fiery request but clinically I had to protect her for a likely injury that could worsen. Her stare after I informed her of my intensions cut through me in discontent.  She was placed in a cast and held from flight duty until I reevaluate her next week.

Here I am again, dusk at hand and wondering if this evening will be a replay of yesterday. Trauma isn’t a 9 to 5 job so predicting when it will strike is a waste of one’s energy. In the meantime we wait with readiness on our sleeves; good night. 

Talk to you soon.

P.S.  I love you my beautiful wife.

M

"Sammy"

This morning I was reminded of how much I miss my canine companion back in Kentucky (my retired racing greyhound Benzy) when I met “Sammy”; a Special Forces Belgian Malinois work dog.  Today we had training on emergency care of military work dogs from our vet Rubes, his tech and our base Special Forces master handler.  Sammy is 4 years old and the jack of all trades here in Afghanistan; he’s trained for both bomb detection and subduing unlucky insurgents.  When I first met him he wanted to lick everyone in the room with the playful spirit of a puppy, but once his SF handler gave the appropriate command he transformed into obedience immediately.  Sammy is a soldier just like all of us, he has the rank of Staff Sargent (E6), and he works his tail off. When not training and on a mission in the hot humid environment of Afghanistan he is responsible for keeping his human teammates safe by detecting  improvised explosive devices (IED), and when needed join close combat fighting. There are multiple other military dogs on our base each with different scripts to follow.  The four primary roles are bomb detection, drug detection, patrolling assistance and human submission.  Most military work dogs are either Belgian Malinois or German Shepard’s. Belgian Malinois are currently preferred because their more app to learn multiple roles; which increases the pups utility in a combat environment.  German Shepard’s may not have the versatility but there power in human submission is second to very few other breeds; they weigh 30+ pounds more than Belgian Malinois.  The training we received today was to become familiar with the basics of canine anatomy and how to perform lifesaving resuscitation for them.  Surgical veterinarians are not prevalent here in Afghanistan so when a work pup is compromised we “human surgeons” assume their care.  I was unaware of this prior to deploying but have no reservation about using my talents to assist them.  Interestingly enough Joe J saved a work dog on his last deployment when the canine needed emergent abdominal surgery for a “gastric torsion” (twisted stomach).  My priority will be the orthopedic aspects of their care with surgical stabilization of fractures being primary.  I look forward to treating my new furry friends and I’m sure two individuals are excited for me; my dad (who owns a Belgian Malinois), and my canine best friend Benzy. 

After our canine training Joe J, Ruben and I went to the gym.  The intensity picked up today as we all realized there will be a PT test around October 1^st; that means I have to start running more, something I’m not real fond of.  I get excited about iron on a bar and the short bursts of intensity that follows; running unfortunately bores me.  Afterwards we head back to the FST and waited for events to occur.

Trauma did not solidify throughout the hours of daylight; evening is now settling in.  We remain prepared and alert.

Talk to you soon.

P.S. I miss my family and fuzzy friend Benzy.

M

"Easy Button"

My iPhone alarm carelessly blares at 7:00AM tearing me away from the comfort of my dreams. Last night was long and unsatisfying; I assisted Mike M in operating room with a urological emergency in an Afghan national army (ANA) soldier.  Fortunately, he was the only one and we weren’t overrun with false information.  We finished about 1:30AM; now I’m awake with my body thirsting for more R.E.M. (not the band) sleep.  Morning report went quickly but before I could escape to my bed Charlie Company reeled me in for 2 orthopedic consults.  Both were U.S. soldiers; one who needed a cast change for his forearm and the other a viscosupplementation injection into his knee for arthritis. Afterwards I determined sleep was futile at this point so I went back to my shack to read. 

With trauma held at bay the dynamic trio of Rubes, Joe J and I went to work out.  The gym was exceedingly hot today so we were exhausted when we finished.  On my way back to my shack I was caught off guard by the base Chaplin. He wanted my orthopedic advice for a problem he was having so I gladly saw him and got him squared away; I need God on my side out here. 

One interesting ritual I have after surgical cases is the utilization of the “Easy Button”. It’s Staples best contribution to mankind and part of my daily routine after a long hard day in the operating room. It doesn’t matter how tired I am or how good or bad my day went; I just hit that big red button and life is suddenly better.  Everyone needs one of these big red wonders; just hit its shiny red surface and experience the difference; life has never been so good. Think of all the problems that could be solved.  Addiction; hit an “Easy Button”. To play your part in world peace; hit an “Easy Button. Save our economy; hit an “Easy Button”. Sell a house in Cleveland that I’ve had on the market for 1 ½ years; hit the “Easy Button”; Oh, sorry the batteries where dead on that button. If I could just get these babies in the hands of insurgents they would see that pushing a button doesn’t have to blow shit up, but rather fill their lives with happiness and joyJ

Trauma was nonexistent today which was welcome after last night.  This night is just beginning and we have been informed that it could heat up; today is Afghanistan’s Independents Day.  A 7000 person march is set to occur this evening in downtown Jalalabad.  With insurgents integrated into the environment this planned peaceful gathering could take a violent turn and attacks on our base could occur just like in Kabul today; a suicide bomber killed 4 individuals.  Keep your finger crossed.

Talk to you tomorrow my friends.

P.S. Today was my wife Melissa’s birthday, yet another special day I’ll never be able to make up. Melissa you have the eternal bridge to my souls; my heart still skips to your touch. Our love forged three beautiful children and a partnership destine to forever.  You are with me no matter the distance; time is only a temporary nuisance. My heart is yours beyond the end of time; I love you.

M

"Supporting Cast"

Trauma has taken the slow road since the last event but it’s bound to pick up; and we all know it.  Our team prepares, checks all the lifesaving medical equipment and rehearses every morning.  During these slow times we have to stay mentally and physically prepared; it’s only the emotional part we can’t account for.  After the team’s daily routine I gave a lecture about how to orthopedically evaluate a trauma patient and the basics of reading x-rays.  Afterwards I saw two U.S. soldiers for orthopedic evaluations; one of which was sent back to the U.S. for further evaluation. 

Last night my wife sent me new pictures of my kids with our new live in guests; my mother-in-laws. Yes I said mother-in-laws. I belong to a “dysfunctional happy family” were my mother-in-law and step mother-in-law are best friends, and my father-in-law is the cool guy in the middle.  I have no words that can describe the confidence inspiring feelings I have knowing my extended family has stepped up in time of need; they are the “Supporting Cast” for my wife and children while I’m deployed.  I hope they realize this is not a short skit either; my active duty army wife (Melissa) is an emergency medicine doctor who will likely deploy a short time after my return.  This transition will be the most challenging of our relationship and family will play a pivotal role in our success.  We are the lucky ones.  Many families don’t have the luxury of support from their family and or the financial means to obtain this support. It’s going to be a long next 2 years with our military obligations but success comes to those who prepare and with our extraordinary family behind us we are positioned well to capture it. 

As trauma was slow today yet again Joe J and a new friend “Rubes” went to go work out. Rubes is the Veterinarian for our FOB and asked to join us; we are always at the gym the same time.  Rubes vet responsibilities are primarily for the work dog population of the Special Forces and Ranger Units on our FOB and within a large area in Afghanistan.  The treatment of these dogs is nothing less than amazing; the canines are treated as soldiers and have an actual army rank of Staff Sargent. The handlers of the pups are actually one rank less so they treat them with respect. I’ve met some of the dogs and they are trained extremely well; some are specialized in subduing individuals and others for IED and explosive detection.   I will likely commit a blog in the future to these amazing canines when I get a chance to talk with their handlers for more details.  It was nice to add Rubes to our daily workout routine, and I look forward to getting to know him better over the next 5 months here. 

It’s now 5:30PM and I’ve been informed a soldier is going to be medevac to our FST for me to evaluate a blast injury to his arm; ETA 30 minutes.  The whole team will mobilize for this type of scenario because meanings get lost in translation and we could be dealing with something completely different; it’s better to be over prepared than under prepared.  35 minutes later two Blackhawks showed up with 6 injured U.S. soldiers; case in point.  One of the soldiers was a female with a gunshot wound (GSW) to the abdomen so Mike M took her directly to the operating room.  Joe J and I triaged and evaluated the rest of the soldiers; 1 broken forearm, 3 head and neck injuries, and 1 eye injury, but all stable.  I stabilized the broken forearm and sent him to the barracks for the night as he had no other injuries. We called Baghram for transfer of the others for advanced imaging.  The soldier in the operating room had an exploration of her abdomen which showed no major internal injuries; she was very lucky and so were we.  Once all of the soldiers were stabilized and packaged up for the flight they left on two “Steel Angels”.

Five minutes after our patients left we got another notification one soldier was going to be medevac to us; here we go all over again.  This discussion will be continued.

P.S. I miss my boys and girls.

M

Rusty Cage

The clock strikes 7:00AM and I'm awake.  A unique day awaits and if all goes as planned the rusty cage that holds me here will be broken; at least for a short time. I'm slated to leave the FOB on a Blackhawk for a training mission. I could just play it safe and be bored another day on the FOB, but the adrenaline inside me is calling; just like every time I throw my wingsuit on and jump out of a plane.  I'll be informed of the mission when I meet up with the "Dust Off" team (Blackhawk rescue team) at 1:30PM, but there’s no guarantee I can make it. If a trauma comes in or something else pulls me I’ll have to reschedule; my fingers are crossed.

The day started off with morning report just like every other.  Once done I was hit with three orthopedic consults from Charlie Company; most post IED evaluation. If we could figure out a way to rid the theater of IED’s the amount of injuries and death would decrease exponentially.  Once finished we were put on notice a trauma might be coming to our FST but after 45 minutes of inpatient waiting the trauma was transferred directly to Baghram.  Joe J and I quickly worked out and then I started to prepare for my temporary ticket out of here.

I showed up at the “Dust Off” team building decked out in body armor, Kevlar, and my M9 with 45 rounds.  I met the chief pilot who took me out to the bird to give me a safety briefing and show me where I will be sitting during the duration of the 90 minute training exercise.  The exercise is part of the RIP/TOA; a transition from the current aviation unit to the 82^nd Airborne’s unit.  There will be multiple exercises which mostly involve familiarizing the new pilots to the terrain and higher elevations of Afghanistan.  After about 20 minutes we were ready to go so I strapped in my 4 point harness next to the other two flight medics who were going along.  The engines of the “Steel Angel” began to scream followed by its blades of fury; then we were off. The pilot took the bird up to about 1000 feet and we began cruising over Jalalabad City.  An airborne perspective showed just how lush and green this area really was; this did not flow with the third world nature of the local hard structures.  Many of the building were deteriorating back to the sand that created them, while new buildings were being created; an equilibrium of sorts.  We headed out over the wetlands and rivers at the base of a nearby mountain. Children were swimming and adults were cleaning their cloths in its depths.  With as hot as it was, and given the chance, I would be right there with them.  We started to climb the elevation of the mountain until we cleared their lower tops; about 8000 feet.  Then we proximity flew on its rocky side until we were upon a small flat area near one of the peaks.  It was then that multiple high altitude approaches to landing were made by the incoming pilot under the watchful eye of the chief.  The views from this peak were spectacular. The landscape was melted in colors of brown to red on a blue sky canvas; multiple rivers carved at the mountain bases. It was not the lush beauty of my personal liking but beautiful none the less.  The next stop was a deteriorating sandy city about 15 miles away; at its center a coliseum with stadium seating surrounding a lush lawn.  I was told this was a stadium for their national sport “Cricket”. No one was playing in the midday scorching “Ramadan” sun and won’t until the religious holidays end.  One interesting sight on the way back to the base was a large ornate swimming pool in the middle of a desert compound miles from Jalalabad City; I wonder who lives there?  This trek across the Afghan terrain was a breath of fresh air for me.  I’ve never been secluded like this and the chance to get out of my rusty cage was welcome; now I’m back and refreshed for my next challenge; the cage is closed for now. 

Keep pushing forward to your dreams; their waiting.

P.S. I love you Melissa, Turin, Talon, and Myla

M

"Believe"

I woke up today thirsting for motivation. My body felt drained and attempts to leave the comfort of my fleece blanket were defeated.  Today I had to deal with the emotional aftermath from yesterday. If I try to hide it will find me; so I’m going to confront this demon face to face.  I know this is not the place to sit on the sidelines with my emotions because this scenario is likely to be on replay throughout my time here.  As I laid in bed I turned to the left, a large American flag on my wall was staring at me; I was inspired.  This flag is not just a representation of my country; it represents a diverse population with tolerance, strong will, compassion, and a focus which is led by a moral compass.  We believe in freedom for all and realize the decisions we make may not always be righteous but freedom is the destination we desire; so we drive on. We are not perfect but at the end of the day we are a good people who ”believe” in what could be; I believe.  I finally muster the strength to leave my bed and prepare for the day.

Morning report was as expected, a check on how everyone was doing. Most kept their emotions in check as shown in the stoic faces. Afterwards, I was hit hard with orthopedic consults from Charlie Company and via teleconference from FOB Bostik (a base about 100 miles away).  There is no orthopedic surgeon at FOB Bostik so the word that I exist here at FOB Fenty has spread like wildfire.   Today could have been labeled “National Pediatric Orthopedic Day” as everywhere I turned there was an injured Afghan child.  I wish I could fix every child myself but logistics are what hamper that especially at FOB Bostik.  Unlike the U.S. patients can’t just jump in a taxi or personal car and drive a long distance for medical care; IED’s, financial resources, and parental ignorance at part of it.  In these cases I end up being an orthopedic medical broker making deals with local Afghan hospitals to secure care in their local area or somewhere close.  When the patients are from my local area I can take care of a lot of them. Some cases can push the limits of my surgical abilities but I’m often the end of the road for this population; health care is scarce.  In addition I have to manage these patients within the need of our soldiers and trauma load and not compromise the readiness of our FST.  It’s a fine line that needs to be walked and there are many more details involved than just doing surgery.  There is the surgical aftercare, follow-up and nutritional deficiencies of this population.  In the end I will help anyway I can; I wouldn’t be able to sleep at night if I didn’t. 

Once I was caught up Joe J and I went to the gym to recharge.  It’s obvious to me deployments forge long lasting friendships. Not only are we having the same experiences but there is an underlining sense of understanding.  We talk about our feeling and deal with them partially together.  Many of these friendships will be formed; the more the better. 

Fortunately today was uneventful and we all had time take a big breath, reflect, and compose ourselves.   After a day of reflection I came to the conclusion that one soldier may have past but five other survived.  It could have been much worse but we dug deep, performed well and now five families will be reunited with their loved ones. I’m going to focus on the positive just like I do with everything else in my life.  If my emotions didn’t get involved then I guess that would be a hint that I’m in the wrong profession.  Every physician and medical personnel here is compassionate about being here, saving lives and making a difference.  We all “believe”.

P.S. Melissa, Turin, Talon, and Myla you give me more strength than you will ever know.

M

HERO LOST

 I wish I could wipe my mind of today. It was black and a void was torn open within me. A US soldier who was a son, husband, and father was lost. We did everything possible to save him; everything. Our hearts and soul weren't enough; now a family cries from an irreplaceable loss. I hope "I'm sorry we did all we could" helps the families pain even a millionth of a percent; likely it won't.

I woke up to a day that was just like any other so far; hot, humid and sunny. There was no morning report and we were all going to sleep in, but life never goes as planned. My commander knocked on my door at 8AM to let me know an Afghan soldier was being medevac to us after rolling his Humvee over. I got up, got ready and headed to the FST. After about 20 minutes the soldier arrived withering in pain. An x-ray showed a pelvic fracture which accounted for his discomfort and plans were made to send him to one of the national Afghan hospital to be fixed after I stabilized his pelvis. Nothing else was on the docket for the day so Joe J and I hit the gym as usual. Afterward we went back to our shacks to get ready for lunch, but lunch was going to have to wait. Our XO ran into my shack and informed me that 6 US soldiers were hit by a massive IED and were being medevac to us; ETA 30 minutes. I ran to inform our Commander and Joe J. Initial information suggested multiple orthopedic injuries so initially I was amped up.  Just as Joe J and I entered the room we were told the bird just went wheels up and to get ready. After about 5 minutes a report from the flight medic on the bird said one of the soldiers was starting to crash; seriousness suddenly descended on the FST. This was not going to be our typical IED blast after all. Ten minutes past and finally the Blackhawk could be heard in the distance; the tension was high and adrenaline was flowing. Charlie Company went to get the soldiers off the bird and returned faster than normal. Medics were yelling as they ran next to the vehicle. We all knew this was definitely not going to be good. Two flight medics jumped out of the vehicle screaming to get the two soldiers out. As we all lent a hand to help we could see a medic performing chest compressions on one of the soldiers. Three others and I brought this soldier immediately to the operating room.  The second soldier was brought to the trauma resuscitation area. Initially I focused on the orthopedic injuries of the soldier in the OR. His left arm had a significant orthopedic injury which was bloodless from a tourniquet.  I released the tourniquet, gained control of his bleeding and then reduced and stabilized his fracture.  I felt a good radial pulse in his wrist; each beat was his heart trying to survive.  He had multiple other injuries that I needed to address but he was decompensating.  Mike M and Joe J went into heroic surgery mode. I left at this point to go evaluate the other patient and four more that arrived by this time.  All of the patients were stable except for the soldier that arrived on the initial flight with the soldier in the operating room; I focused my attention on him.  Anesthesia was able to intubate him after much effort from facial injuries, and then I began my trauma and orthopedic evaluation.  I stabilized the soldier’s injuries, sequentially screened the rest and went back in the OR. Initially, everything was going well and then the soldier took a turn for the worse. I was trying so hard to keep my emotions in check; I was losing.  I knew after reviewing the soldier vital signs and seeing what our two general surgeons were struggling with, the light at the end of the tunnel was diminishing fast.  Heroics weren’t enough, and after 1 ½ hour of insane effort he was gone.  Tears flowed down every face in that room, our hearts were torn and our spirits ripped out of us all.

 I was not ready for this. When I trained in the civilian medical world I learned to shut my emotions down when someone died, but here at this moment I could not.  I was crushed and bleeding, something I’ve never experienced before.  I guess my love for the brothers and sisters of our armed forces is more than skin deep. We are all one in spirit but separate as individuals.  God this was hard. 

All of the other 5 soldiers survived and were subsequently transferred to Baghram via Blackhawks. We were informed the deceased soldier would be leaving on a “Hero Flight” at 10:00PM and we were invited to participate with the rest of the active duty population on the base. I have never been a part of one; it’s not going to be easy. 

It was now 10:00PM and our FST members and at least one hundred other soldiers were present for the “Hero Flight”.  We lined a walkway from the mortuary to a spot where a Blackhawk would arrive to take the body. The moon was partially obscured by wisps of clouds but its light covered all of our faces; tears ran free for all.  After about 10 minutes a Blackhawk slowly approached from the distance bathed in moonlight; its blade pounding just like our hearts. Once it was in position we were all called to attention, and slowly the soldier was wheeled down the walkway; covered by an American flag immersed in the celestial rays. Soldiers were audibly heard sobbing as emotions erupted.  The hero was moved into the arms of the “Steel Angel”, and then it disappeared into the moonlight. “Goodbye my friend” I said out loud and then turned to walk with Joe J back to the FST; tears running down our faces.

Goodnight. Please say a prayer for our fallen hero.

M

"SHOW IN TELL"

Another wakeup call at 2:00AM, this time an orthopedic consult from Charlie Company.  I try to awaken and head over to evaluate the soldier.  The U.S. soldier in question rolled over a John Deere Gator and injured his foot. As the only orthopedic surgeon I somehow have also been elected to be the base radiologist; the feeling I never left my residency is abundant at this moment.  To my chagrin the soldiers X-ray is negative and I quickly picked up my dream where I left off. 

I reawaken at 7:00AM, rehash my morning routine and head to morning report.  The second I walk in the FST I’m hit with two consults; its official everyone on this base knows I’m here.  The first consult was for a U.S. soldier who was shot in the hand during an armed conflict north of our location. Fortunately the injury was minimal with the exception of a small GSW (gunshot wound) fragment. No surgery was indicated so he will recover in theater and be back in the fight soon.  The second consult was for an Afghan ANA soldier who sustained a severe blast injury to the hand.  The original injury was 4 months ago but due to the severity the reconstruction and rehabilitation periods have been extensive.  I removed a previously placed wire and discussed with the patient that one of his wounds needed to be skin grafted.  Using our interpreter “Rocky” to communicate with the ANA soldier we determined the best time was after “Ramadan”.  Ramadan is a tough time with the nutrition and fluid restriction. Skin grafts require excellent nutrition and attention so the plan will be to keep him for 5 days at the FST following the procedure for monitoring. 

Just as I was turning to leave the FST one of the Charlie Company soldiers calls my name out. I turn toward her and expect to hear about another consult, but instead she says “You have a package that needs to be signed for”. Finally, the family package I’ve been waiting for since I touched down on the FOB.  I wondered what my wife could have stuff in there. I gave her hints but I wanted to be surprised and told her not to tell me.  It’s really sad but there is a small amount of jealousy when others on our team get boxes every other day. You can see it on most of our team members faces when someone is excitedly opening it in front of the room like “show-in-tell”.  Were in kindergarten all over again with the exceptions of age and the fact were in Hell.  I took the higher road; I grabbed my box, raced out the door to my shack and stared at it like a “New York Strip” cooked just the way I like it. After 5 minutes of intense staring I realized getting a knife and opening it was much more productive.  It was Christmas in August here in Afghanistan when the box was finally opened. Cookies, pop tarts, protein bars, pictures, magazines, and a custom pillow with my kid’s pictures printed on it; I was in heaven.  It’s the “little things” that mean the world to me now, unlike the life I temporarily left behind in the U.S. 

I spent a moment of the day talking to my family on Skype at the MWR and then headed back to my shack. Along the way I decided to go on top of our FST to take pictures of the distant mountains since there was little dust in the air and the visibility was better than normal. While on the roof I noticed a Blackhawk approaching the FOB so I took pictures of it.  The ironic thing was that the Blackhawk was slowly moving toward the FST and then the doors burst open and patients were transferred out of the bird to an ambulance. Shocked, I ran down the stairs and entered the FST to find the whole team ready for a trauma.  I was quickly informed that five U.S. soldiers were being medevac to us from an IED incident about 15 miles from us.  I quickly changed into my scrubs, grabbed my “game face”, and headed back to meet the trauma.  3 soldiers were gurney bound and 2 ambulatory. They were traveling in an MRAP when hit by a large IED.  Most had mild facial injuries, two had broken jaws, all had back injuries, and 1 had an open lower leg wound which needed my attention.  After the trauma resuscitation was complete and all patients were stabilized, I took the patient with the lower leg injury to the operating room to wash out his wound and fixate his leg. Once I finished the patients were medevac to Baghram for further treatment and advanced imaging.  All were lucky today and will likely to return to the fight for freedom soon. 

Live as vivid as a dream. Talk to you soon my friends.

P.S. Honey I already ate a box of blueberry fig bars, please send moreJ

M

Brothers and Sisters

It’s 11 P.M. and I’m lying in bed half asleep when my commander busts through my door and informs me 4 U.S. soldiers involved in an IED blast were being medevac to our FST; ETA 20 minutes.  I wake myself up, throw my scrubs on and bolt out the door to the FST. We prepare for the worst as no other information is available.  15 minutes later the pounding beat of a Blackhawk can be heard in the distance so Charlie Co. heads out to meet the bird and transfer the soldiers to us.  We waited impatiently with our adrenaline pumping; 5 minutes seemed like 30.  The atmosphere is always more tense when U.S. soldiers are involved.  There’s an intangible bond with them you real can’t explain. Each soldier becomes your temporary brother or sister rather than a fellow soldier; we all bleed red, white, and blue over here. The transfer ambulance pulls up and the doors swing open; two soldiers are on gurneys and the others ambulatory.  This team was doing route clearance in our local area when the incident occurred. Initial estimates put the IED at 150lbs of explosives based on the damage to their armored MRAP.  It appears insurgent activity is heating up all around Jalalabad (JBAD); where we are located. There have been two IED’s locally in 3 days and multiple others that were found by our forces and destroyed. I should also add that another suicide bomber made a run at our FOB last night, but fortunately he was “neutralized” by our forces prior to inflicting harm and or damage.  The soldiers were rushed into the FST and the trauma triage process started.  The two ambulatory soldiers were just beat up but stable and sustained mild injuries.  Our gurney bound patients were stable but had probable spine injuries which will have to be evaluated at Baghram.  There were no acute orthopedics surgical issues in any of the soldiers.  After our resuscitation was complete the “Steal Angel” arrived to transfer two of the patients and the other two were sent to our recovery area for evaluation by our primary care physicians and traumatic brain injury team (TBI). I finally made it back to bed by 1:30A.M. and crashed into my awaiting dreams. 

My evil alarm clock rang at 7:00AM waking me to a new day.  I stepped down from my bunk slightly tired but ready for another day.  As such I kicked the tunes on, dressed, grabbed a red bull, and headed out the door for morning report. Today we recapped the trauma our team has seen so far and ways we can improve. Afterwards I helped out with two orthopedic consults at Charlie Company, then relaxed and waited for trauma. 

I was sitting at the desk in my shack when one of the Special Forces medics came in to talk to me. He was interested in getting a copy of the lecture I gave Wednesday so he could use it to help train other SF medics in the future.  I copied it for him without any reservation.  I said “Go saves some lives” and handed it to him.  Like I said in the past the relationship between the surgeons and SF community is important.  When these commandos are preparing for or executing a mission there is confidence in knowing us surgeons have “game faces” on ready to save and rebuild them; we pride ourselves on it. I can’t even begin to tell you the respect I have for this community. If the mission sounds impossible be prepared to be amazed. The current trend of this war is more toward small special operation missions so the chance of us dancing in the operating room with them is increasing; we’re always ready for heroes.

Night is rapidly approaching, sleep well friends.

P.S. Kids give your mother a big kiss for me.

M

The General

Today we will have a special guest visit our FST:  Major General Patricia D. Horoho; the soon to be 43rd Surgeon General of the United States Army.  She also happens to be the first female ever to be nominated to this high position and in December she will be promoted to Lieutenant General when she replaces the current Surgeon General.   It’s not every day someone of this caliber visits an FST in the middle of a war zone, and we are honored. It is interesting to note she was a patient of mine at Fort Knox in the past so I was happy to see her on a personal note.  Her motivation for visiting our FST to gather information on how to improve the medical care of U.S. soldiers in the theater and what better way than to experience it yourself.  We will be performing a mock MASCAL for her to show the trauma evaluation we use so she and her team can critique the process and improve it. It would be even more interesting if we had an actual trauma for a real life experience but that’s a shot in the dark.  We all met early this morning to hammer out the details and to pick one of us to be the mock patient; Sergeant Marvin won. He was dressed up as a wounded soldier with fake blood, wounds and all.  Once we finished preparing our FST we were informed the General was 10 minutes away.  Sergeant Marvin was placed on a gurney, strapped in, and put into an ambulance which waited nearby for the call.  Poor Sergeant Marvin; it was hot, he was strapped to gurney and there was no General Horoho. Finally, after 30 minutes she made her way to the FST with at least ten staff members; we made the call and “Injured” Sergeant Marvin rolled in.  We quickly grabbed the gurney from the ambulance and brought him into to trauma bay; sweat rolling down his cheeks.  We went through our trauma evaluation, and of course I made sure there were orthopedic injuries; what else is important.  During the evaluation we were watched closely and asked many questions about the process we use, the training prior to deployment, and our opinion on a multitude of issues from improving patient care too how to improve physician retention.  I gave my honest opinions and moved on. I never got a chance to talk to the General other than “Hi, it’s nice to see you again”, but we had a lunch planned with her and the base providers so I planned on talking to her then.  Once we concluded the MASCAL we took a team photo with General Horoho and then disbanded until lunch.

It’s been two days since I hit the gym so Joe J and I planned on working out two times today to ease our egos.  I’m considering entering a bench press competition that the FOB is putting on in the next week so I need to keep the intensity up. Today I’ll test my strength to get an idea if I’m ready.  My workout went well and was able to bench press 275 lbs. 8 times; I only weight 180 lbs. so I’ll easily be 300+ for a competition.  My biggest worry is injuring myself, but that’s slowly falling by the wayside.  I’m still deciding.

After my workout I hurried back to my shack to get my ACU’s on for the lunch with the General.  I met the other providers then headed to the DFAC (cafeteria).  We got our lunch went to the “reserved” private room set up for the luncheon and waited for her to arrive. I was looking forward to talking with the General; at least until one of our sergeants ran in to tell me a trauma just arrived and they needed me.  I took a big breath, tried hard to smile, and headed for the FST.  Once I entered all eyes were on me; just like every other time an orthopedic issue is at hand, a blank stare of cluelessness.  This patient was a young DOD civilian contractor who fell 15 feet off a scaffold.  I evaluated him, reviewed his x-rays and diagnosed him with an acute hip fracture. I contacted Bagham for medevac and a Blackhawk was sent urgently for the transfer.  This is a great example where my role on an FST is frustrating.  I have all the knowledge and skill to definitively treat this patient but I’m limited to mostly emergent stabilization.  After the patient was stabilized the bird flew in and transferred the patient to Baghram.  Oh by the way, during my call to Baghram I learned the three ANA soldiers we sent them were stable and doing well; our team was inspired and confidence elevated.

The rest of the day was relaxed and I spent the time talking to my wife and children.  It’s remarkable, no matter what kind of mood you’re in hearing the voices of people you love can brighten your spirit. It get emotionally overwhelming as well, especially when my two and four year old sons tell me “I love you”. They never really said that prior to my deployment, but I’m kind of glad because it fuels me more than I ever thought here in Hell; I love you guys too.

Until tomorrow my friends.

M

Daddy Time

Its 3:56 A.M. and my Afghan cell phone sings. In a stupor I climb down from my bird nest and answer the phone.  On the other end my son Turin is sobbing asking me to come home. My wife informs me he has been crying for a period of time prior to his bedtime; upset he did not have his “daddy time” on Skype today.  I try to soothe him but it is in vein.  It seems these episodes are increasing, but with no way to alleviate the situation my heart remains torn with no healing in sight.  Times like this makes me feel this adventure is for soldiers without connections back home.  The stress of a father being separated from his kids is great, sometimes overwhelming; this wound will only grows with time.  I hang up the phone, pray for strength, and try hopelessly to regain sleep. I love you Turin, you’re always on Daddy’s mind.

Sleepless hours roll by and it’s now 7 A.M., my iPhone alarm sounds out like a drill sergeant; I don’t want to wake up.  I just want to lay here drowning in my emotions from the night.  I eventually find the strength and prepare for another day. 

Today at morning report I lectured about “Splinting and Casting”, to the medical personnel on the base. I feel confident my lecture will be useful to their daily skills here, and if just one soldier benefits I’ve succeeded. There will be many more in the future. We also learned our VIP guest will be visiting us tomorrow and not today.

The clock struck 11 A.M. and all hell broke loose; two traumas at once. We were given a 30 minute ETA and told the first was an MVA and the second an IED.  ETA’s are worthless in theater trauma as they both showed up in 15 minutes; it’s “go time”. All were Afghan national soldiers (ANA), and the IED victims faired the worse.  The Special Forces showed up with the IED soldiers and were immediately on me to assist. The relationship between the ANA and our Special Forces (SF) is more than skin deep.  They navigate them through thick and thin and facilitate SF missions. Their relationship is mutualistic, close and absolutely necessary.  My adrenaline took off once I examined them and all three ANA soldiers had fractures, two of them surgical.  There were a lot of associated injuries which took priority, including significant head injuries.  Once they were stable enough I took them back to the operating room one at a time.  With the help of the SF medics I fixated their unstable fractures, washed out lacerations and sutured them.  After my surgeries were complete and they were stable we packaged the soldiers up and called Baghram to schedule a “Steel Angle” for medevac.  This was our true first trauma challenge and I can say with honesty three people’s lives were saved today; hopefully tomorrow too.  The fourth soldier who was involved in the MVA was stable from the start. At the end of all the resuscitation efforts we learned his name was “Saddam Hussain”; we laughed. It’s not every day you can say “Saddam” was your patient.

Our team is coalescing much faster than I anticipated. It’s real gratifying to see individuals work as a team. We are all pieces in the larger puzzle, each as important as the other.  A lot more challenges will come but I feel confident we can overcome them. 

I’m going to bed. Talk to you tomorrow.

P.S. Turin got his “Daddy Time” via Skype and was very happy.

M