Horn Of Plenty

In honor of the pilgrims we had an activity cornucopia to fill our holiday weekend which included:

the Dry-Tri row, bike, and treadmill run sponsored by a couple of our masochistic workout freaks,

Ironmen-in-the-mirror

Thanksgiving party favor-making courtesy of the Air Force (aka the fun service),

Chocolate, Oreo, Candy corn Turkey thing-a-jigs

the International Security Assistance Force Gravel Bowl,
 

Navy whups Army again, yawn.

debt settlement,

The high price of Dallas Cowboy fandom

And shopping, shopping, shopping.

Black Friday at the strip mall

UXO

It had been relatively quiet for the latter half of November.  There are several theories as to why.  It has been the Muslim holiday Eid-al-Adha which may have limited hostility.  Also, perhaps the "surge" which has been at it's peak this fall has had some effect on insurgent activity.  Finally, it has been the normal pattern for the Taliban to halt activity in the winter, reportedly to resupply and take refuge at home.  We had thought that this may have accounted for the slowness.  However, the weekend has proven that the war has not taken a seasonal hiatus yet as there have been daily cases.  One case was particularly grim.

Afghanistan is the most heavily mined country in the world.  Between the Soviet invasion and the current war, this country has been at war for 20 of the past 30 years and, as a result there is an enormity of unexploded ordnance (UXO in army lingo) throughout the country.  The United Nations puts the number of mines and UXOs in Afghanistan at 10 million, a number that is frankly hard to fathom.  Whatever the exact number, a Google search for "Afghanistan landmines" shows dozens of images that display the magnitude of the devastation from UXO.  It was only a matter of time before this fact collided with our reality.  That happened yesterday.

A 12 year old boy was brought to us.  He had been scavenging through a trash dumpster when he found a mortar round.  Mortar rounds, along with rocket propelled grenades, are often set so that they explode after completing a set number of revolutions.  This round must have been close to that number because it detonated in the boy's hand.  He lost his right hand, burned his left hand, and suffered abdominal and head injuries.  The good news is that he survived.  The bad new is that he faces a difficult future.

Giving Thanks

In spite of what some may call an austere environment, we have much for which to be thankful.  Among these: our deployment is over halfway complete, we have not lost any of our team members, we live in a prosperous society that values and dignifies its individual citizens, we enjoy many times in our lives free from fear, and we have plenty to eat, a warm place to sleep, the support of our families and friends, and our children are safe.  For these things, we are grateful.

The true need for sailors in the desert revealed.

To celebrate turkey day the DFAC is serving a great spread. Many troops from the small outlying posts are arriving to join in.  The lines will be long but they are a deserving group.  Here is a video link to the 2009 Thanksgiving spread made by a member of one of the preceding Foward Surgical Teams. 



Finally, we are thankful for the holiday cards supplied to us by the 3rd grade class at Holy Infant School in Ballwin, MO and the 5th grade class at Boyce Middle School in Pittsburgh, PA.  

Thanksgiving cards on display

Here are some select excerpts from our young friends:

"I was a skateboarding banana for Halloween.  I pray for your safety."  - Lucas, 3rd grade

    And we pray for your safety, Lucas.

"You are a big HERO to me.  A story I think is funny is my friend Emma tried to hug a chipmunk and it tried to get her. She named him Montgomery."  - Osa, 5th grade

   Sounds like Emma is the big HERO.

"If I could be any character in Modern Warfare 2, it would be you." - Mark, 5th grade

   Unfortunately, Mark, I suspect you would have to play Operation.

.

"Doctors are the best."   - Jack, 3rd grade

    Future president of the American Medical Association.

"Because of you I feel safe.  Do you have a dog?" - Don, 5th grade 

    Don, what's really on your mind?

"Fix them all up and get out of there!!!!" -Zach, 3rd grade, 

   Now that's a succinct summary of the mission.

"Did you know 32 miners were trapped in a mine for 71 days.  They all got out.  This story should inspire you to show most stories have happy endings.  And I know you will too!" - Olivia, 5th grade

   Olivia, thank you for the thought of the day.

We hope that you have a Happy Thanksgiving.

Life On The FOB: Part 6 - The 300

On the eve of Thanksgiving day and our annual American exercise in engorgement and gluttony (and giving thanks; I'm not trying to sound too cynical), I thought I would share something about the food.  Okay, the food isn't so bad here.  One of the myriad of contracting companies prepares, serves, and cleans up.  It could be a whole lot worse.  Sure we miss fresh milk and have sporadic fresh fruit and vegetables, but at least it's not MREs which is what the troops on the very small outposts subsist on.  When those guys come here for business, they always seem so very, very happy to be in our chow line.  So how can we complain?
 
As you might expect, it is definitely possible to put on weight on deployment.  Which leads me to my next point, but first a segue way.

A couple of years ago a movie called The 300 came out.  It purports to tell the story of the Battle of Thermopylae in which 300 defenders of Sparta took on a massive Persian army.

Spartan warrior.  All cape, no clothes

Now I have no idea about the historical accuracy of the film.  But in the finest tradition of Hollywood portrayals of Ancient Greece ala Brad Pitt's Troy, it seemed to me chiefly notable for the chiseled physiques of the loin-cloth laden actors.  In fact, I would summarize the plot as: chop off a head, flex your pecs; militant speech, bulge the biceps; primordial screaming, flash the abs; super slow-mo sword shot, tighten those gluts.  Have I missed anything here?

Not to be outdone, we have our own version of the 300 on the FOB.  Namely 300 pounds.  As in, are you going to return home bench pressing 300 pounds or weighing 300 pounds?


So what's it gonna be?


The marathon man

Perimeter Road Running Diehards

 or the ice cream man.

Dessert Line Diehards

In the end, you may look like a stunt double for The 300 or like you chowed 300 tubs of hot buttery popcorn on movie night.  But then Brad Pitt never had to resist the pie tray.

Rolando, one of our corpsman, embraces hard core training.

Organized Chaos

Our team was assembled from across Navy units worldwide.  Many of the members had little or no trauma experience since even the largest navy medical centers often defer local trauma to civilian hospitals in the area.  Most of the experience native to the team resulted from the residency training of the physicians and prior combat zone tours by some of the members.  The training effort to get every one up to speed has been considerable and ongoing.  This is because the resuscitation bays are nothing if not "organized chaos" especially during a mass casualty.  It is critical for people to know their role and stay in their lane in order to develop a pit crew type of coordination.

During one of the codes, the base public affairs officer was present to photograph the proceedings.  Here are some samples that demonstrate the process.

Outside triage performed.

Litters are carried in.

The crew converges.

 
Multiple procedures may occur at once.

 Patient must be lifted by hand for survey and xrays.

 

Once evaluations are completed, patients are moved for surgery or MEDEVAC.

Comic Relief

I feel like I use the words "tragic" and "sad" a lot when referring to the cases we see.  Maybe they are overused, but other times they don't seem to do justice to the situation.

This past week there was one in particular that sticks in the gut because the children are always harder emotionally.  A four year-old girl came to us with a serious head injury that resulted from a motor vehicle accident.  When she arrived she was still moving but she deteriorated quickly.  Although our sense was that her wound was fatal, no one felt comfortable making that call here given our limited resources.  We stablized her sufficiently for transport in order allow her to see the neurosurgeon at KAF.  Unfortunately she died the next day.

Duke, my hero

 
Normally I have to manufacture something amusing or uplifting but not this week thanks to the USO.  Several nationally syndicated cartoonists visited the FOB last week.  The group included Garry Trudeau of Doonesbury, Mike Luckovich of the Atlanta-Journal Constitution, and Rick Kirkman of Baby Blues.  There was a separate group that included Jeff Keane of Family Circus, Tom Richmond of Mad Magazine, and Stephan Pastis of Pearls Before Swine.



This was pretty remarkable because very few celebrities that come for visits to combat zones venture this far forward.  We were all impressed that they did so.

Natalie, our anesthesia tech chats with Rick Kirkman

They each spent time chatting with the troops and drawing personal cartoons and characteratures.  They also handed out collectibles.   Here are more samples of their work.

Mike Luckovich

 

Rick Kirkman

Doonesbury Swag

The Miranda Trauma Center

We held a ceremony dedicating the FST to SO3 (SEAL) Denis C. Miranda.  Attending the ceremony was the Commodore of Naval Special Warfare Group 2.

Miranda Trauma Center

Denis was one of the SEALS who died in the helicopter crash on September 21, 2010.  He arrived to us pulseless but with some electrical activity, a testament to a commando's conditioning.  We put blood directly into his heart but it was readily apparent that his wounds were not survivable and he was pronounced here.  He was honored with a ramp ceremony on the FOB flight line before his body was taken home.

Denis was from New Jersey.  He enlisted in the navy and was initially a navy corpsman before beginning Basic Underwater Demolition School, the first step in SEAL training.  He was a medic and a sniper with SEAL Team 4 based in Little Creek, VA and deployed with them.  His biography is here.  His obituary is here.  A tribute to him can be found here.

SEALs at the ceremony

The commodore remarked during the dedication that he had attended all of the memorial services and funerals for the four members of his command killed that day.  He described the scene at Denis' funeral in which all of the students at his high school lined the streets to honor their fallen alumna.  He wished to emphasize that, based on his experiences, there was no question that Americans still support the troops.

Plaque honoring SO3 Miranda

Because he was a fellow sailor, a former corpsman and our patient, we felt that it was a fitting tribute to name the FST after him.  May he rest in peace.

Life On The FOB: Part V - The Memorials

Today is Veteran's Day in the United States.  In honor of those who have given so much I wanted to look at how they are remembered here.  But first a thought about war memorials.

A few years ago, my sister was married in a church in the famous Italian neighborhood in St. Louis called The Hill.  This church had been built amongst the square grid of streets in a crowded neighborhood that was populated during the great wave of immigration a century ago in America.  It was ethnic community in every sense and this church was part of its fabric.  But with time and the march to the suburbs, that ethnic identity had gradually waned.

Before the ceremony I was wandering the back of the church where I stumbled on a seemingly forgotten photo album.  The album contained pictures of the young men from that neighborhood who had been killed in America's wars.  The majority of the pictures were of World War II veterans but also some were from Korea and Vietnam.  There were no pictures from the current conflicts.  As I flipped through the pages, I wondered about the young men, the lives they lived and those they didn't live, and how much their legacy depended on that neglected photo album.

And so it is on the FOB.  The tragedy of the life lost too young is immense.  Yet, even here, where that tragedy is experienced most immediately, the memorials tend to recede from constant thought amidst the inevitability of daily routine.  Furthermore, the war in Afghanistan is now America's longest war and one of the small consequences is that the memories of these men are receding even here.  Some of them were killed three, four, five, even six years ago which is an eternity in the tempo of unit deployment.  Therefore I  wanted to display the ways they are remembered even if their personal histories are vague to us.

Structures are named for them,

The FOB Gym

SPC Scott Andrews

the Romanians have erected memorials,

Cross at the Romanian Chapel

Memorial Garden nestled between tents

barriers and walls are painted,

Jersey Barrier

and the dining facility has reserved them a place.

The Empty Chair

The Walking Blood Bank

Blood is a precious resource.

One of the unique aspects of trauma care in a combat zone relative to that in the US is the administration of blood.  It is an element of care that is greatly complicated by logistics and available equipment and trained personnel.

In the US, blood is taken from a donor and immediately divided into its components which include red blood cells, plasma, and platelets.  These components are refrigerated and stored until used.   They are ordered individually for patients depending on that person's needs.  One of the reasons for the division of blood into its parts is that blood supplies are scarcer than demand.  Component therapy, thus, increases efficient use of the resource.

In cases of massive transfusion, all of the components are usually given in rough proportion to their ratios in blood.  In effect, blood is reconstituted to its original form.  Unfortunately one of the drawbacks to this system is that the processing and storage of blood products lessens their effectiveness.  Old red cells, plasma, and platelets are not as good as the "fresh" blood that circulates in our arteries and veins.

Here at the FST "blood banking" presents certain challenges.  We keep a store of red blood cells and plasma.  However, we are limited as to the blood types that we have on hand because our storage capacity is smaller than that of a hospital in America.  When our supply gets low, we require a resupply by helicopter to maintain our mission capability.  Additionally, we do not carry platelets, in spite of their crucial role in forming clot, due to their very short shelf life.  

The Blood Cooler.  (No diet Cokes please.)

One of the solutions to these problems is the maintenance of a "walking blood bank."  Specifically, American service members willing to give blood are screened so that we can take blood in its whole form directly from the donor and transfuse it into a patient.  This fresh whole blood is in many ways superior to the components used at home because it is not processed, frozen, and stored to the same extent.  It seems to have better oxygen-carrying capability and better ability to restore proper clotting function.  The main limitation is that tests that we use to screen for viruses and infection are not quite as accurate as those used in American blood banks such as the Red Cross.  Fortunately all service members are prescreened for most of these agents as part of routine military health care.

When a patient is brought for care and it is apparent that their transfusion needs will exceed our supply, the walking blood bank is activated.  The loudspeaker on the FOB calls for volunteers who share the patient's blood type to report to the tent maintained by the tenant army regiment's medical company.   The volunteers are processed, poked, and prodded just like at the bloodmobile back home.  Their donated units are then walked up the hill to the FST and brought into the OR where they are transfused immediately into the patient.  We have already had numerous patients that have required up to ten units of fresh whole blood in surgery.  That is in addition to the other blood components that we administer.

As the FST's anesthesiologist and, therefore, the prime user of blood, I wanted to recognize this unique contribution that our service members on the base make to each other.  What better way to do that than a T-shirt.  Here is that T-shirt, which I ordered and am happy to report is being handed out on the FOB.

Linda, one of our OR techs, crosstrained as a model.

Don't worry, they get a juice box too.

November Rain

Can you believe it?  It finally rained here.  Drizzle.  For about 30 minutes.  But now that it has happened, we're expecting lush lawns and gardens.

Work continues to be steady.  Our most recent trauma included six Americans in an IED blast.  Fortunately most were not seriously injured.  Our surgeons did make a great save on an Afghani with a gunshot wound to the chest that penetrated his diaphragm and lacerated his spleen.  He required nearly 30 units of blood including blood from the walking blood bank but word from the next level of care was that he has survived and is off the ventilator.

The biggest news, however, is that hump day is rapidly approaching.  For those of us who left in July, we are within days of the halfway point in this deployment.  It will feel quite good to start the downhill portion.

Oh by the way, here are those lush landscapes:

Lush Lawn

Lush Garden