Last night I finally went to sleep at 1AM after a busy day of everything. 15 minutes into the enjoyment of my sleep there is a frantic knock on my door from our nurse anesthesia provider. “Special Forces just brought a patient in bad shape we need you now!” Thankfully I was not fully asleep at this point so it was relatively easy to pry myself out of my bunk. I get dressed and head to the FST to see what the excitement was all about. As I enter the reinforced steel door to the FST 10 sets of eyes are staring at me with intensity; 2 of them Special Forces medics. I quickly learn that the patient was a 25 year old Afghan woman who was shot in the thigh by an insurgent as they were trying to escaping from our elite commandos; oh and by the way she is 6 months pregnant. I go to see the patient and find her leg has a tourniquet placed and there is a significant amount of damage to her mid-thigh. We quickly get x-rays of the injured area and then the woman is taken back to the operating room. While she is being prepped I go back to radiology to view the films; wow, the middle third of her femur is gone. This must have been one hell of a GSW (gunshot wound) round that she was hit with. I quickly head back to the OR where our commander Mike M is ready with the patient to assist me. After scrubbing in we take down the tourniquet and find a significant amount of bleeding so we then place a controllable inflatable one in its place. The exit wound of the GSW on the front of the thigh was massive and it was fairly obvious a femoral artery injury was present based on the bleeding. I explored the wound to evaluate the femoral artery with Mike M and we found this patient was very fortunate the artery was mostly intact with just a small tear. I repair the artery and then let the tourniquet down; bleeding is now controlled and the patient now has good pulses. My next step was to externally fixate her femur. With a third of it missing and only a mini fluoroscopic machine it was a challenge to align it. After a little time it was finally fixated and stable. X-ray was brought in to confirm alignment and then we sterilely dressed the wounds. During the case our nurse used a Doppler ultrasound to listen for the baby’s heart beat to confirm fetal viability; 160 heart beats per minute confirmed the baby was still alive. She was brought out of anesthesia and then transferred to our recovery area. We called Baghram to medevac the patient for a higher echelon of care and were told she would be picked up by a Blackhawk in 2 hours. In reality I am only the first orthopedic surgeon of many that will be needed to reconstruct her leg. This was a significantly morbid injury and in this society I hope she will heal and recover but the negative weight of this environment is tipping the scale away from her favor. Once it was all said and done I ended up falling back into my bed at 6AM.