September Ending

It feels like Indian summer here in Qalat.  The mornings are cool, even chilly, while the days are warm and sunny.  Unfortunately, unlike home, there are no leaves turning color to get the true feeling but oh well.

We have seen 69 patients in the month of September.  I was frankly surprised that it was that many as the pace has been very uneven.  There have been long stretches of quiet with little to do except train and clean interrupted by bursts of extraordinary effort.  Perhaps this reflects the pace of the war itself in this region.  Few engagements but many casualties when they occur.  We seem to be busier on the weekends which coincides with the beginning of the Muslim work week.  Go figure.

We have certainly seen our share of tragedy but I believe that have had our successes as well.  Every patient who has arrived with a pulse has left our care with a pulse.  That is something in which our team takes pride.  Knock on wood.

Here is an update on one of those successes.  Awhile back I wrote about 10 year old boy who was critically injured with a sucking chest wound.  He survived and came back to us for followup.  He is doing well and everyone agreed that he was one tough kid. 



Life On The FOB: Part III - If Dust Were Water, We'd Be All Wet

We've been here a month and there hasn't been a hint of rain or, for that matter, hardly a dang cloud in the sky.  This has lead to some interesting observations.

When you refer to tours to Iraq or Afghanistan, you call it a "trip to the sandbox". This makes sense because sand connotates tropical beach vacations and sandbox connotates carefree backyard childhood play which, of course, is exactly how we think of our tours here.  (It also, ahem, makes for brilliant puns in blog titles.) 

The problem is that it really isn't sandy here.  It is, well, dirt with a little rock thrown in for landscaping.  In fact, the FOB is the El Dorado of dirt.  You swim in an ocean of dust.  That is until it rains, when you supposedly swim in an ocean of mud. But then there is no worry of that since we've come to the conclusion that rain is just a myth.

Anyhow, having become experts on all things dirty, we have discovered some fantastic new uses for the stuff.

Tabletop Covers

Drywall and Siding

  

Advanced Vehicle Detection System

Contemporary Sculpture

All of this leads to the point of this post which is to show the reader the covert war in Afghanistan.  That which you won't find out anywhere else so that you know what is really going on.  Here is the evidence of that hidden agenda.

War's Dirtiest Secret.  America Hoarding Afghanistan's Most Abundant Resource.

 
Screw WikiLeaks, you read it here first.

Helicopter Crash

More news.  The crash victims came to us.  There were three survivors.

Some news about the victims here, here, and here.

As one of the few navy units in this area, we have frequently worked with the SEAL units involved.

One of the SEALs was from northeast Missouri near my home town, St. Louis.

Election Day

Saturday was Afghan Election Day.  You might not have noticed it on the news but the elections definitely made their mark here. 

It had been weirdly quiet for the preceeding week.  We have been told repeatedly to be ready for more business but after the Labor Day chaos it had really not materialized.  I would call the casualty rate a slow dribble until the elections.

The pages went out at breakfast.  "3 casualties.  ETA unknown."  3 turned into 8 ANA regulars all from one IED blast.  Several were taken to surgery for stabilization.  This lasted until early afternoon.  Remarkably most of the patients had already flown out and clean up was underway.  The flight system for MEDEVACs is always in motion and we often only treat patients for a few hours. 

Then came the call that Americans were inbound.  This round included an American sergeant with a missing foot and badly injured leg that could not be salvaged.  Another limb claimed by IEDs and another amputee with a long rehabilitation ahead but fortunately still alive.

In the late afternoon came the day's final call.  This was an Army soldier who committed suicide with a gunshot to the head.  It was a tough gut check after so much expended effort to save other lives.  It was also the team's first experience of the "ramp" ceremony.  The body is bagged and draped in the American flag.  The body is then borne by a guard on a litter, feet first, to a waiting ambulance.  Its path is marked by parallel lines of service members facing inward and standing at attention.  The body passes the ranks and a final salute is rendered before the door to the ambulance (or helo) is closed.  It is the first step in the final journey home of the deceased soldier and a grave end to a difficult day.

Life On The FOB: Part II - Hooch Sweet Hooch

MAKE YOUR DREAM OF RUSTIC MOUNTAIN LIVING COME TRUE!

CUSTOM TOWNHOMES IN A GATED COMMUNITY.



EXQUISITE VISTAS.

WELCOMING FOYER.

COZY SUNDECK.

MANY UPGRADES.

WALKING DISTANCE TO COMMUNITY AMENITIES.

  4 BEDROOM UNITS FROM THE $1.40s

The IED Threat.

Improvised Explosive Devices have been a weapon of choice for the insurgency in both Iraq and Afghanistan.  We were given a (very, very) long brief about IEDs during our training at Ft. Dix.  Since it is germane to our work here, I thought that I would write about it.  

The design of an IED is more complex than you might guess.  They can be command-operated by a remote "trigger puller" or victim-operated through use of a switch.  The switches can be simple pressure switches attached to say, a garden hose, that activates when stepped on or rolled over or the switches can be sophisticated infrared sensors with heat-seeking capability.  They can be connected to a cell phones internal circuitry such that when that cell phone number is dialed, the IED activates.

The "bait" for a victim-operated IED can be anything that will get someone's attention.  Dead animals, traffic cones, trash piles, and abandoned vehicles have been used.  Stuff animals have also been used which as you might surmise would get a child's attention.  MRE pouches given away to locals have turned up wired to IEDs.  Anything out-of-place or unusual has to be viewed with suspicion.  One of our colleagues at Kandahar told me the story of insurgents wiring an IED to the dismembered leg of a US soldier that resulted in more casualties by members of that soldier's unit.  He had treated them at Walter Reed.

The explosives are surprisingly simple made from easily obtained ingredients.  ANFO is a combination of ammonium nitrate found in fertilizer and diesel fuel oil.  A dense biomass booster agent such as flour or sugar or powdered drink mix can be added to increase the energy release and the destructive potential.  The powdery result can then be combed into dirt to hide its content.  This makes it hard to find.  The homemade explosive (HME) labs are important insurgent resources and a critical target for coalition forces.  They are usually chemistry lab-in-a-kitchen or -garage setups.

The penetrating power of the IED can be increased using a shaped charged known as an EFP, or energy formed projectile.  These are curved copper plates with explosive behind it.  The energy of the explosion bends the copper into a torpedo-shaped projectile that can penetrate armored vehicles.  These types of devices are believed to be made in Iran and imported into the theater.

EFP's in cement

The US military has made a concerted effort to counter the IED threat by creating a whole new generation of armored vehicles.  Known as MRAPs, mine-resistant, ambush protected, these have helped reduce the loss of life by US service members.  Still the game of one-upmanship continues.  Some of the IED explosives are in the 500-1000 lb range, capable of tossing these vehicles into the air.

MRAP

Our brief at Dix consisted of six hours of Powerpoint which, as I mentioned was anything but "brief." However, there were some videos shown that kept your attention by the truly disturbing content.  Insurgents, it seems, like to post video on the web of their handicraft in action.  Jihadist soundtrack included.  War-trophys for the internet age, I suppose.

One video showed an explosion that launched the Humvee gunner about 25 feet into the air and about 50 feet forward.  Another video, made by a French film crew, showed the stages of construction of an IED.  The construction site was a busy street corner in broad daylight where hundreds of cars and onlookers passed by.  Guess nobody, including the film crew, was moved to report it because the video finished with footage of it hitting a convoy.  (With friends like the French....)  Finally, one showed an IED blast hitting a convoy followed by the rescue effort at the rear of the destroyed vehicle.  About a dozen soldiers gather trying to pull the wounded from the wreck.  This turns out to be a second "kill zone" and the insurgent/video taker detonates a second device that hits all of the dismounted troops including the wounded.

It makes you realize what we are up against.

Colbert Report

A group from FOB Lagman appeared via satellite feed on Colbert's Been There, Won That episode from Wednesday night.

I don't think that any of us actually are in the group.  You had to get up at 0200 and the group was on for oh, about 2 seconds.

Don't know why we missed it.  Must have been all the Near Beer in our evening blow out.  But we were there in spirit.

The base held a 9/11 commemoration that was fortunately short on mosque location protests or debates on Quran burning.  But it did include the unveiling of a mural.

New mural in dining facility

I'll try to post again soon.

Life On The FOB. Part I - Overview

Coalition forces are spread out throughout the country of Afghanistan by a network of Forward Operating Bases, or FOBs.  They have varying levels of services, amenities and capabilities.  Some are quite primitive.  Ours is mid level so I'm told.  Nevertheless, FOB life is definitely a shared experience for deployed service members.

Forward Operating Base Lagman is named after Staff Sergeant Anthony Lagman who was killed in 2004 while conducting operations with the 10th Mountain Division in Afghanistan.  He is memorialized at the base entrance.
 

FOB entrance

Here and here are links to online memorials.

Bird's eye view

Here is Global Security's blurb on FOB Lagman.  Some of the information is dated but for reasons of operational security I won't be expounding much on the discrepancies.  The US army has the largest presence but the Romanian army presence is still significant here.  As for the US navy, we are a small school of fish in this pond.

As far as amenities, FOB Lagman has a good DFAC, a decent gym, and a Green Beans Coffee.  What else could you ask for?  Other than clean latrines.  But then I'm soft.

Uh, "Deployment First, Coffee Second"

Apparently, The Taliban Don't Celebrate Labor Day. Who Knew?

We were going to have holiday routine on Labor Day.  The team has been working hard.  Between trauma codes, OR cases, training, watching standing, restocking supplies, and cleaning, there is a lot to do.

Ted, our Officer-in-Charge, at first scheduled a work day but I requested that he consider giving the team some down time.  He agreed that this was a good idea.  Nevertheless, the group being admirably motivated, requested more training so he did schedule a quick drill for the afternoon.  The day was not to go as planned.  (And I turned from hero into goat as it became apparent the day was jinxed.)

At 0730 there was a call for a gunshot wound.  The patient was taken to OR where his leg had to be amputated.  We were about to wrap up when a call came in that there were multiple casualties inbound from an IED blast.  We took 10 patients over the next few hours.

Two had serious burn and blast injuries to the face.  Three others were taken to the OR to stabilize fractures (Dave was definitely cool today) and prevent dangerous swelling of the leg compartments.  Others had various degrees of shrapnel or projectile injuries.  Fortunately there were no KIAs.  The unit's colonel came by to give out Purple Hearts, which, while deserved, is not my idea of a great Labor Day gift.

Aric, our CRNA, gives report to the MEDEVAC flight nurse

Just as we got the last patient out by helo in late afternoon, word came of another gunshot wound.  A security contractor had accidently shot himself while cleaning his weapon.  Our collective response to this one was "@#$%."

Then there was a stab wound to the chest that turned out to not be much.  (Lots of knife stabbing and rock throwing around here.)

The base chow hall (or DFAC, i.e. dining facility, in army lingo) did serve up a Labor Day dinner with BBQ ribs and decorations.  The phone center had free phone calls home.  So the day wasn't a complete wash.  Besides the team did good work today.

Anyhow, I'm a little tired to write anything amusing so I'll wish you a good holiday.

Labor Day's final casualty

Orthopedists: Cool or Not Cool?

Dave is our orthopedic surgeon.  He continues to insist that he is as cool as the PJs, heck even cooler than those commando types.  This in spite of being resoundingly overruled by the voice of reason (i.e. all the rest of us).  This is not surprising for orthopedists.  They generally think that everyone in medicine should be in awe of the hammer, saw and screw specialists.

So I leave it up to you, the informed public, the gentle readers to decide for yourselves.  Is Dave cool or not cool?  Let us examine the evidence:

Dave is cool when he performs patient care.  Here he is in surgery.





Dave and Paul, our transplant surgeon, in surgery.

On the other hand, Dave is not cool when he does pretty much anything else.

Dave chillin'

Based on what you have seen so far, you might believe that the weight of evidence is fairly evenly balanced, that it is difficult to decide the issue.

However, here is the smoking gun.

These are Dave's boots.  He insists that he has scribbled his blood type on them.  After all, we are in a combat zone.

Dave's blood type or something else?

Dave, cool dudes like PJs don't write their GPAs on their boots.  This is not cool.

I rest my case.

Echelons of Combat Care

There are five levels or "roles" of combat medical care.

Role I is the aid rendered by the army medics and navy corpsman in the field or that given by the battalion aid station that follows the combat units into the field.  This is the tourniquet placed on the bleeding extremity.  Evacuation is as soon as possible, usually within minutes or hours.

Role II is immediate lifesaving surgical care intended to provide immediate resuscitation and hemorrhage control in the "golden hour" after injury.  Evacuation is intended to be within 72 hours. An FST is a Role II facility.  We have added capacity by virtue of the air force nursing complement that staffs the medical holding tent and the army medical company that provides primary care.

Role III is a complete field hospital with all surgical specialties, ICU capability and full ancillary services.  This is the highest level of care in a combat zone.  Kandahar is our Role III facility.

Role IV is definitive medical care outside of combat zone but within a theater of operation.  The army hospital at Landstuhl, Germany is Role IV for Middle East operations.

Role V is the medical care available in the continental US or CONUS.

Two bed OR at the FST

These levels of care apply to US or NATO troops.  It is a different story for the Afghan nationals.  If they are lucky they might get as high as Role III, provided that they are not bumped by coalition casualties.  Otherwise they are transferred to a local facility such as the civilian hospital at Kandahar.  The care provided is what you might expect of a barely functional healthcare system.  Reportedly, the staff goes home at night leaving the patients to themselves, there is minimal janitorial service, the patients eat what their families bring them, and one gets exactly the care for which one pays.

The situation in Qalat is even worse.  The staff at the local hospital is essentially a few Jordanian doctors who are expected to pull out soon.  Where that will leave the locals is hard to ponder.

Embrace The Suck

Ramadan is ending and the Afghan elections are upcoming.  We were warned by higher authority to expect to get busier.  It didn't take long.  We had nine trauma codes over a span of 20 hours.

Two separate IED blasts plus two MVA's (motor vehicle accidents).  The saddest case was a 10 year-old boy with a sucking chest wound from some type of fragmentation round.  The story was sketchy but it may have been a mortar.  He went to the OR for chest tubes and exploration of the abdomen.  The surgeons had to repair damage to his stomach and diaphragm.  Word from the next level of care was that he was doing okay.

IED shrapnel taken from patient

On a lighter note, some Air Force PJ's showed up to escort the patients for one of the MEDEVACs.  PJ's, or Pararescue Jumpers, are the Air Force's version of special forces.  Their primary mission is pilot rescue but they are also well-trained medics. The thing is, they are at least 3 rungs higher on the cool ladder than any of us.  We wear army green, regulation hats, boots, and have regulation haircuts.  They have their own camouflage color, t-shirts, ballcaps, sneakers, and have cool sideburns.  They also have subdued Velco patches attached to their equipment vests that say cool things like "Pedro", "Lambchops", and "Embrace the Suck".  Words to live by in this environment.  We have been wondering if 40-something guys can ever be that cool.  Doubtful.