Hearts and Minds

Providing medical care in a combat environment is challenging on multiple levels. The most difficult aspect, in my opinion, is having to turn away people that need care but do not meet the Medical Rules of Engagement (MROE). This is an incredibly complex issue. As many of you may know, we are technically in a draw down. That is to say, we are gradually going to decrease our military foot print in Afghanistan with the goal of eliminating all combat forces by the end of 2014. This smaller foot print will also lead to a decreased availability of US medical personnel and resources. As part of this process, we are insisting that than Afghans take a larger role in taking care of their wounded, both military/police and civilian. Therein lies the moral dilemmas we have to face here at FOB Sharana.
The 1980th FST is in the process of creating a mentoring program with local Afghan physicians. Just yesterday, we did two operative cases with an Afghan "Anesthesia Technician" and surgeons. The goal is to impart knowledge, to some degree, so that these medical professionals can better take care of their countrymen after we leave.

Afghans are more like us than not. They are a proud people that want nothing more than dignity, respect, and peace. Unfortunately, the Afghan society has been decimated by countless years of war, corruption, and systemic dysfunction. The country lacks a basic societal infrastructure, and over half of its "citizens" live in abject poverty. For decades the international community has vacillated between ignoring the plight of Afghans or exploiting them for the purpose of geopolitical point scoring. As with all wars, it is the innocent that suffer the most.

This series of photos was taken during an induction sequence with an Afghan anesthesia provider. I was serving as his mentor. The patient is a 11 year old boy that was shot through the upper arm with an exit wound through the axilla. His humerus was fractured mid-shaft. The photos uploaded a little goofy, but you get the point nonetheless.

I elected to use a supraglottic airway. The child was shot approximately 24 hours prior to our encounter and was NPO.

This was my counterparts first opportunity to use a LMA.

We did an extensive irrigation and debridement as well as a definitive closure of wounds. A drain was placed and the upper arm was placed in a cast.

Major Randall Moore, CRNA
1980th Forward Surgical Team
FOB Sharana, Afghanistan

A follow-up to my wounded handler and dog post

Just a quick follow-up to my previous post, "not all of our patients are human." I was made aware of the following article just recently published by the Wounded Warrior Project.

http://www.army.mil/article/87806/Working_dog_reunites_with_handler_during_bedside_hospital_visit/

I can't tell you how happy we are at the 1980th FST to see this. Amazing..no words.

From this...

To this..

Life in a Forward Surgical Team

Life in a FST (Foward Surgical Team) is often describe as hours and hours of boredom followed by moments of chaos and terror. The patients we receive are "fresh." In other words, they've been recently injured. It is not uncommon for the patients to arrive with IO (intraosseous) access because the medics were unable to obtain IV access. Sometimes we get a 30 minutes heads-up, sometimes it's 5 minutes. The injuries are often profound. More often than not, I intubate and anesthetize the patient within moments of arrival in order to ameliorate his pain and allow for a thorough examination of his wounds. As I alluded to in a previous post, IED injuries are complex and challenging to treat. Unlike a gunshot wound (GSW), IED injuries tend to have a "peppering" pattern with multiple areas of penetration. Also, many of these penetrating wounds can potentially be life-threatening. Our job, as a FST, is to resuscitate and stabilize the patient in the immediate aftermath of injury. Often this requires emergent surgical intervention. Most penetrating wounds to the abdomen, chest, and neck require surgical exploration. The orthopedic injuries caused by IEDs can be devastating and often require external fixation by our orthopedic surgeon. Our goal is to stabilize the patient for expeditious evacuation to a more definitive level of care.

On a personal note, I am in good spirits and doing well. I'm getting into the routine here. I try to run almost everyday and I am reading more than I have in years. I'm almost done with season two of Breaking Bad and I talk to my family almost every day. I've learned quickly that the key to staying sharp is being mentally and physically active.

Thank you for reading.

Most of the 1980th FST Health Care Providers. Steak and lobster night!

Me

My roommate: Major Campbell, MD. His hobbies include getting haircuts and receiving mail.

Major Randall Moore, CRNA
1980th Forward Surgical Team
FOB Sharana, Afghanistan

Incoming Patient: Trauma #3296

Approaching MEDEVAC

ANA (Afghan National Army) Soldier with gunshot wound

Preparing to unload patient

Waiting to accept patient from MEDEVAC

 Patient is searched for weapons and unexploded ordnance prior to ATLS/Triage

Grant Campbell, MD

Major Randall Moore, CRNA
1980th Forward Surgical Team
FOB Sharana, Afghanistan

Not all of our patients are human

I will not discuss any specifics concerning the soldiers we are taking care of at Sharana. I feel that to do so would trivialize the sacrifices they are making here. As you can imagine, their injuries can be, and often are catastrophic. IED (improvised explosive device) injuries, account for approximately 70% of the causalities we see here in Afghanistan, and they are horrific. Our first two cases were a soldier and his working dog that fell victims to an IED attack. I took care of the soldier and my CRNA colleague assisted the veterinarian with the resuscitation of the dog. These pictures help illustrate what we are up against with these IEDS. After the initial resuscitation and surgery, both patients were medevaced to Bagram for more definitive care. It was heart warming to see the amount of care and resources that were dedicated to saving this dogs life. I'm told that both the soldier and the dog are doing well.

Vet and Orthopedic surgeon

Note the extent of the IED injuries

The dog underwent an exploratory laparotomy and chest tube placement

Post-surgery and extubated!

Major Randall Moore, CRNA
1980th Forward Surgical Team
FOB Sharana, Afghanistan

The Mission

My current place of employment

I’m assigned to a Forward Operating Base (FOB) Sharana in Eastern Afghanistan.  I’m serving in a Forward Surgical Team (FST). A FST is a small, mobile surgical unit. The FST typically includes 20 staff members: 4 surgeons, 3 RNs, 2 anesthetists (CRNAs), 1 administrative officer, 1 detachment sergeant, 3 licensed practical nurses (LPN)'s, 3 surgical techs and 3 medics. Our mission is to provide resuscitation, hemorrhage control, and surgical stabilization to combat casualties. The most typical kind of injuries we receive are from IEDs or gunshot wounds.

Each of us have clearly defined roles and responsibilities. During any given trauma these are my responsibilities as one of the two anesthetists:

* Secure the airway and perform tracheal intubation.
* Obtain central venous access
* Resuscitate the patient with IV fluids, blood, and vasopressors
* Provide sedation and pain control as needed.
* Provide anesthesia for patients selected for emergent surgery.
* Manage patients post-resuscitation and/or post-surgery until they are evacuated by air for more definitive treatment.

My Office. OR Bed 1

Advanced Trauma Life Support (ATLS) and triage

Entrance into trauma center from helicopter landing pads.

Major Randall Moore, CRNA
1980th Forward Surgical Team
FOB Sharana, Afghanistan

The Journey

I have had many family and friends inquire about my experiences here in Afghanistan. Therefore, I've decided to create this little journal as my way of keeping those interested updated about my experiences. This is not going to be a particularly profound or insightful blog, so lower your expectations. This is just my way of capturing a bit of what it is like to be deployed as a CRNA in Afghanistan.

My Journey to Afghanistan started at Fort Benning Georgia, the home of the Conus Replacement Center (CRC). This is where the in-processing and training occurs for soldiers deploying to a number of locations throughout the world. It's not a particularly fun or interesting experience, so I wont discuss it at great length here. We do lots of paperwork, get lots of shots, and sit in lots of lines. There are many classes and briefings (death by power-point) and your are issued an enormous amount of gear. We spend a morning qualifying with our M9 (9mm handgun) and receive some IED (improvised explosive device) training. Something like 60-70% of all causalities in Afghanistan are caused by IEDs, thus the emphasis on the training. Everyone's main goal at CRC is to leave on time and to avoid the dreaded "hold over" list.

The army has a strict policy about what can and cannot be photographed.  Therefore, some of the more interesting aspects of this deployment just cannot be shared.

Weapons Training and Qualification

Departure Day from CRC.

Small Pox inoculation 2 weeks post injection.  I tried my hardest, but I couldn't talk my way out of this one.

Waiting for our flight.

Logistical Staging Area (LSA) in undisclosed location in Middle East

Major Randall Moore, CRNA
1980th Forward Surgical Team
FOB Sharana, Afghanistan