Tuesday, November 27, 2012

A Photo Essay

My last few blog updates have covered topics of both a serious and dark nature. I'm going to lighten things up a bit with another photo essay. Plus, I'm not really feeling particularly verbose this week.

On a personal note, things are going well. Our surgical volume has decreased over the last week - which of course is a good development. Another important milestone occurred this week - our replacements are in-processing at Fort Benning. The end of this deployment is near.

The is TESS. She is awesome.

This is Tess with her handler. The handler was injured during an night operation and was brought to use for evaluation. Tess was clearly concerned about him and eventually made her way on to the bed. The bond between a military working dog and handler is strong.

This is a 5 y.o. boy with an inguinal hernia that we fixed.

The MRAP (Mine Resistant Ambush Protected) vehicle. These things have saved countless American lives.

This is Hashish. We found this in the pockets of one of our Afghan patients. Apparently he likes to party.

This is a photo of the 1980th FST shortly after our arrival. The gentlemen that look a bit out of place are Polish special forces.

These are rocks that the insurgents place inside IEDs. It is said that they often coat the rocks in human feces in an effort to cause a secondary infection.

This is one of the handful of working dogs that we have taken care of here. My colleague is starting an IV.

MAJ Randall D. Moore, CRNA
691st Forward Surgical Team
FOB Sharana, Afghanistan

Thursday, November 22, 2012

Innocence Lost

"We owe our children, the most vulnerable citizens in our society, a life free of violence and fear."
 Nelson Mandela

When we have long stretches of quiet, three or maybe four days, I begin to develop a sense of foreboding. It's difficult to describe, but I feel as if we are going to be punished for the lack of casualties in the preceding days. I become tense from both inactivity and this sense that something, something very bad, is going to come through the door. 

Yesterday, November 21st, was a bad day. The call came from the local Afghan hospital in Sharana. They have 3 civilians injured by a land mine. Their ages are 6, 8, and 20. As usual, the story behind the injuries is suspect, but that really doesn't matter at this point. We agree to accept the two most critically injured of the patients - the 6 and the 20 year old.

I knew it was going to be a bad night as soon as I saw the faces of the medics when the ambulance doors opened. They were obviously distressed by what they saw. The back of the ambulance was dark, but I could see one of our medics doing CPR. I say out loud, to no one in particular, "I hope that is not the child they are doing CPR on." It was the child.

The child comes off the ambulance first. His face is terribly mangled by the blast. The injuries are beyond description. We direct him to Trauma bed number 2. I decide that patient 1, the 20 year old, will have to wait for an anesthetist until we figure out how to intubate (put a breathing tube) the 6 year old. We quickly determine that the child has a pulse and the two of us discuss how to go about intubating him. We conclude, despite the extent of his injuries, that we can get him intubated without doing a cricothyroidotomy (making an incision in his neck to access his trachea). After 2 attempts, my colleague intubates him successfully with a Glidescope.

I immediately leave the child to attend to the 20 year old. His injuries are serious as well. He has a severe blast injury to his right forearm. His hand is almost black from the lack of blood supply. He will need surgery to revascularize his hand.

Meanwhile, the resuscitation of the child continues. The resuscitation team learns that he has a badly fractured skull - which means he likely sustained a serious brain injury. The difficult decision is made to do a frontal craniotomy in an effort to give this child a chance for survival. We have no neurosurgeon. The general surgeons and the dentist will have to do it. During the surgery it becomes obvious that the damage done to his brain is severe. The surgeons struggle to relieve the pressure on his brain. They do everything they can, but his vital signs remain unstable.

After surgery, the child is taken to the ICU. Everyone works feverishly to stabilize his vital signs and curtail the swelling of his brain. However, it becomes obvious that there is nothing else to be done. At 1:10 am, on Thanksgiving Day, the child dies. I take some solace in the fact that he did not die alone. He was surrounded by the servicemen and women of the 691st FST. We never even learned his name.

Trauma # 4028 and 4029

MAJ Randall D. Moore, CRNA
691st Forward Surgical Team
FOB Sharana, Afghanistan


Saturday, November 17, 2012

Trauma # 4027: The 13 Year Old Sheep Herder

Trauma patient 4027 was a 13 year old boy that was simply in the wrong place at the wrong time. He was with his uncle herding sheep when he was caught in the middle of a combat engagement. Initially, he was taken to the local Afghan hospital by his uncle. His injuries were so severe that it became obvious that he would die without the intervention of the 691st FST. We agreed to accept him, and he arrived by ambulance to our facility at about 5:00pm - almost 5 hours after his injury. 

When he arrived it was clear to us that he was in bad shape. His color was terrible and he was essentially unresponsive. I put him to sleep and placed a breathing tube within five minutes of his arrival. We placed a central line and arterial line and began infusing blood in as fast as we could. Within 30 minutes of his arrival, he was in the operating room.

This is moments after his arrival. The patient arrived in the prone position. It was clear from the beginning that he was seriously injured.

Dr. Yoder

The picture below is a good illustration of what a typical ATLS resuscitation looks like. The surgeon (Dr. Yoder) is positioned on the patient's left with the CRNA (me) at the head of the bed. There is a medic on each side of the bed. A recorder, seen at the foot of the bed, documents everything for posterity. It looks chaotic, but it is in fact highly orchestrated.

Trauma resuscitation: Controlled chaos.

The patient post surgery. If you look closely you can see blood coming out of the patient's breathing tube. He sustained a serious lung injury. Both sides of his chest cavity were filled with blood.


This is the deceptively small entrance wound. The projectile that entered this child's chest cavity did a significant amount of damage.

Without a doubt, the vast majority of children in Afghanistan live an incredibly difficult life. Most live in a constant state of malnutrition. The illiteracy rate for boys is somewhere in the 85% range. The illiteracy rate for girls is an even more appalling 94%. Child labor is almost ubiquitous. Unlike the United Sates, violence inflicted upon children is not an anomaly in Afghanistan. The sad truth is that generation after generation of Afghans have lived this harsh existence. It's an almost inconceivable reality, but sadly, it is their reality.

MAJ Randall D. Moore, CRNA
691st Forward Surgical Team
FOB Sharana, Afghanistan

Tuesday, November 13, 2012

SGT. Kyle Osborn

"Never think that war, no matter how necessary, nor how justified, is not a crime. Ask the infantry and ask the dead."  Ernest Hemingway

I've started and stopped writing this particular blog entry several times in the last two months. However, the events of recent days have compelled me to resume writing this post. My previous attempts were aborted because I felt that I did not possess the words to properly articulate my feelings on this matter. I still feel woefully inadequate in that regard, but I'm ready to at least follow through with it this time.

I did not know Kyle Osborn. Our paths crossed briefly on September 14 - the day after I arrived at FOB Sharana. Kyle was killed in action the day before. His remains were brought to our FOB in order to prepare him for his flight to Bagram Air Field - and ultimately home to Indiana. As with all American servicemen killed in combat, Kyle was to receive a "Hero Flight." Standing along the walkway to the helicopter were several hundred fellow soldiers. I vividly remember standing there, completely silent, as Kyle's flag draped remains were taken to the helicopter for the first leg of his journey home. There really are no words to describe the solemnity and gravity of that moment. It's an experience that makes an indelible impression. I think of Kyle often. I know it may sound strange, considering the fact that we didn't even know each other, but it is the truth. I wonder how his family is handling the crushing tragedy of this loss. I wonder about his wife and how she is coping with being a widow in her 20's.

In the first twelve days of November, we have already lost eleven soldiers here in Afghanistan. The statistics of this war are quite sobering. Since I've been on active duty (late August), we've lost 83 coalition soldiers in Afghanistan - the vast majority of which were American.

Yesterday was a difficult day here at FOB Sharana. We had another "Hero Flight." Another life ended far too early. Another unspeakable tragedy for a family back in the United States.

SGT. Kyle Osborn

Here is a short video of SGT Osborn's funeral procession.

Wednesday, November 7, 2012

Bloody Sunday: Trauma # 4010 and 4011

Sunday was shaping up to be a pretty nice day. I taught an airway class in the morning to some of the medics and planned on taking it easy for the rest of the day. However, at almost exactly 12 noon we received the call - 2 Afghans shoot in a Taliban ambush. The initial reports were a bit sketchy, but it sounded like one patient was shot through the neck and critically injured and the other was shot in the back and was described as stable. 

Twenty minutes later the MEDEVAC helicopters arrive. I place myself at the "Triage Line" so I can get a good look at the patients after they are unloaded from the helicopter. Patient 1 was in fact shot through the upper right chest - not the neck. He has an intraosseous catheter in each leg - which is my first clue this guy is in trouble. His skin is gray. Clearly, he is in bad shape. The patient is directed to trauma bed 1.

Next off the helicopter is my casualty, patient 2, the gunshot wound to the back that was reported as being stable. He looks awful. His skin is an even more ominous color of gray than the previous patient. He is barely arousable. I ask the flight medic what medications the patient has received - hoping his altered level of consciousness is secondary to narcotics - the medic tells me no medications were administered. It's obvious to me at the point that this patient is in decompensated hypovolemic shock. He is dying. 

I help push patient 2 to trauma bed 2.  IVs are quickly established and he is placed on my monitors. I am pleasantly surprised to find a decent blood pressure. I intubate (put a breathing tube in) the patient after inducing anesthesia with Ketamine and Succinylcholine. I secure my breathing tube and look at the monitor. He doesn't have a blood pressure any more. He is now in Pulseless Electrical Activity (PEA) - which means that his heart is no longer pumping blood. We start CPR and do all of the things you do when someone's heart stops. After a few minutes of CPR and some drugs, we get a pulse.

Emergently, we take patient 2 to the OR in an effort to find whatever is bleeding in his abdomen. However, by the time we get him to the OR table his heart stops again. We start CPR and the surgeon decides to perform a resuscitate thoracotomy. His heart is empty and the only chance this patient has for survival is opening his chest and manually compressing the aorta while performing cardiac massage. This is the definition of a last ditch effort. His odds of survival are literally almost zero at this point. Fortunately, this "Hell Mary" intervention buys us some time. The surgeons now direct their attention to the abdomen, which is the most likely site of the internal hemorrhaging. His abdomen is opened in seconds. Copious amounts of blood, essentially his entire blood volume, pours out of the incision and on to the OR table and floor. The injuries to his internal organs are numerous and devastating.

There is a difficult decision that needs to be made. We have only a finite amount of PRBCs (transfusable blood) available. The other casualty, patient 1, has a serious chest injury and will require a massive amount of blood as well. However, statistically speaking, he has a much better chance of survival than my patient. Do we classify patient 2 as expectant and allocate all of the available blood products to patient 1, or do we make an effort to resuscitate both patients? Quickly, literally in a matter of moments, we decide to continue working on both patients. We notify the lab that we will start using whole blood obtained from soldiers on the FOB with compatible blood types. A call goes out to the entire FOB. Within moments we have 40 soldiers waiting to donate blood. Luckily, I and am able to place both an arterial line and a central line in the patient rather quickly. The transfusion of whole blood is given at such a pace, thanks to the expertise and skill of our medics, that I give up trying to keep track.

When it is all said and done, we transfuse over 20 units of blood products to my patient. We have to take him to the OR twice in order to control his bleeding. Remarkably, his blood pressure starts to normalize and the oozing of blood (from everywhere) begins to slow down. Everyone, including myself, is astonished that he made it out of surgery alive. By midnight patient 2 is on his way, along with patient 1, to Bagram in a helicopter. Somehow, against all odds, the guy makes it out of FOB Sharana alive.

Both of these patients have no business surviving those injuries. Their survival is a testament to the skill and expertise of the 691st FST - a unit that has been in Afghanistan for less than two weeks.

Approaching "Dust Off" carrying trauma # 4010 and 4011

Patient 2, my patient, shortly after emergency thoracotomy. Obviously, this photo has been heavily edited.

This is the nearly pristine 7.62mm projectile found in the abdominal cavity of my patient.

This is a large segment of Patient 2's liver.

Friday, November 2, 2012

The Reality of War

Warning: This blog update contains photographs that some may feel unsettling. This content is unsuitable for children.

Up until now, I've decided not to share photographs depicting injured patients. After quite a bit of reflection, I feel this was a mistake. This blog was created to share what it is like to provide combat causality care in Afghanistan as a CRNA. These photographs offer perhaps the most vivid illustration of what is happening in Afghanistan.  Below you will see some of the less graphic photographs that I have taken since I've been here. However, some of the readers may feel that these pictures are difficult to look at.

There are a few caveats I would like to share with the reader before you scroll down to read the rest of this blog update. First, none of these photographs depict American soldiers. I will not publish any pictures of injured Americans on this blog. I do not want to risk a family member or friend recognizing an identifiable feature. Second, I've taken steps to protect the identity of the causalities. Third, these photographs are intended solely for educational purposes. I have immense respect for the Afghans that we take care of here at FOB Sharana. These photos are used purely to illustrate both the realities of war and the challenges we face as a Forward Surgical Team (FST).

This is an IED blast to the lower extremities. The "peppering" pattern is the hallmark of an IED injury. The surgeons are attempting to ligate bleeding blood vessels.

 IED blast to the lower extremity. Note the placement of the tourniquet and the "peppering" pattern of the blast. That's me at the head of the table.

IED blast with injuries to the right upper extremity. The radius was essentially destroyed. The surgeons are placing an external fixation device to stabilize the injury.

IED blast with penetrating injury to neck. This was a tough one. The surgeon had to perform a hemi-thyroidectomy just to get to the tracheal and esophageal injuries.

IED blast with injuries to the face. Note the extensive swelling to the right side of the face. This patient suffered a devastating eye injury as well.

IED blast injury to the chest. The position of the surgeon's thumb indicates one of the two intra-thoracic injuries.

Same patient as above. Note the large entrance wound into the axilla which caused an injury to the right lung.
Gunshot wound to lower extremity. This patient sustained a peroneal artery transection that required repair.

Gunshot wound to left lateral chest.

Gunshot wound. The entrance was through lower back with the exit wound in left upper thigh area. The surgical instrument in the wound is used to illustrate track of projectile.