Ortho Crew

So here is a photograph of all the current Orthopaedic Surgeons stationed at Bastion.  From left to right are:  Me, Ed (US), Craig (British), Alo (Estonian), Kathryn (US), and Jon (British).  Ed trained at Balboa in San Diego and is currently stationed in Newport, RI.  Two days ago his wife had his third child - Brendan.  He is going to fellowship next year in Vail, CO.  Craig is originally from Glasgow - which means I can't understand a word he is saying.  He currently works for the NHS, specializes in joint replacement and lives in Peterbourough.  Alo is lives just outside Talinn and has three children.  Kathryn also trained at Balboa and is also stationed there.  She is married to a helicopter pilot in the Navy who is also on deployment - which means they only speak about once a month.  She is going to fellowship next year in Boston.  Jon also works for the NHS and specializes in Sports Medicine.  He works just outside London.  He is usually quite funny and charming, when he is not making fun of you.  Overall, its a great crew and we work well together.  Alo, Craig and Jon will all be leaving soon as the Estonians only stay for 3 months and the British for 10 weeks.  Wish we could say that.

They have a few different rules for the OR's at Bastion.  The most obvious one is that you can where whatever you want in the OR, thus my uniform.  They also don't make you where a mask.  One of the things that the anesthesiologists take advantage of is that they also let you eat and drink in the OR and sterility is somewhat of an afterthought.  There is nothing like walking up to an OR table with a cup of coffee in my hand, wearing my workout gear and staring at an open abdomen.  "I haven't seen a spleen like that since breakfast".   

Kandahar Redux

As a general rule, I try not to complain about my living situation on deployment.  I actually have it pretty good compared to 95% of the other troops here.  With one exception, and that was the flight to Kandahar.  I feel so strongly about it that I had to post a couple of pictures despite it happening almost a month ago now.  A recap of that day includes a middle of the afternoon bag load, a 4 mile drive that took about an hour and a half, a six hour wait at the airport, then a last minute change of aircraft from a C-17 to a C-130.  Below is the best representative picture as we are crammed 'nut to butt' in the plane.  The fact that the right side looks a little empty is because about 7 people are actually in the very back of the plane laying on the 12 foot high pile of luggage.  When we got aboard - in full battle gear - it was only about 140 degrees and I lost about 9 pounds.  Fortunately (I say this sarcastically), once we got up to altitude it was only 32 degrees.  It wasn't that long of a flight (again sarcastically) -  only 5 and a half hours.  I'm at the lower left hand side directly across from the Chaplain.

Never in my life did I ever think the words 'Thank God, I'm finally in Afghanistan' would ever come out of my mouth.  Yet it happened.  This is first thing everyone sees when they land at the passenger terminal in Kandahar.

The terminal was actually the national headquarters of the Taliban and has a very erie feel to it - almost as if it was straight out of a movie with thousands of bullet holes in every wall.  They haven't been back since.

Feels like i'm back in Residency

So after graduating medical school in 98, then internship in 99, followed up with residency ending in 2007 and finally a fellowship last year, I thought I would be finished with staying up all night, doing every bit of paper work and having nurses tell me what to do.  However, I have been proved wrong.

We have six Orthopaedic Surgeons currently stationed here (although we are going down to five in three weeks as the Estonian surgeon leaves and is not replaced).  And sorry to say there is plenty of work to go around.  Our call schedule runs in six day cycles.  We number ourselves 1-6.  Number 1 runs the show, takes all the trauma, sorts out the electives and goes on rounds and meetings.  Number 2 is number 1's assistant (we call them something else, but its not safe for web blogging).  Number 3 and 4 do the majority of elective surgery on the people that get full care here - most US and British are gone after only one surgery.  Number 3 and 4 also assist with trauma if shit really hits the fan - which seems to happen about every other day.  Number 5 is the free agent and helps out where they can.  And number 6 essentially has the day off.  We essentially go straight down the line from 6 to 1 and being 2 then 1 in a row can be quite a few hours awake.

Anyway, I was number 1 last night and we had a trauma call in at 1900.  Gunshot wound the knee.  I looked at the call and thought this might be a quick one - if no broken bones then wash out the wounds and pack.  If there was a fracture then an external fixation surgery and still done quickly.  They arrive at 1910, I evaluate the wound, place a tourniquet, write the consent, order the CT scan, and write the note.  This, is what a resident is usually for (the British bring trainees over here and I am seriously considering paying for my residents to come over - no joke).  Anyway, I follow the patient to CT scan and just like residency wait with all the other services to see what it shows.  Good news, no fracture.  Bad news, Arterial injury to the main blood supply to the leg.  Now he needs a vascular repair and fasciotomies (which is basically like releasing pressure in the legs to allow adequate blood flow).  Four surgeons scrub in - my team does the dissection to find the arterial injury, gets the vein graft and completes the fasciotomy.  Then, we wait.  After the arterial repair is done - I am the only one left on the Ortho team and I place a special vacuum dressing for medevac flight.  As if this weren't the end, now I have to write the orders and surgical op note.  I get home at 1:30 in the morning.  I say this a little in jest, and I'm happy to do it and we saved the patients leg - but man I'm getting too old for this.

Timeline

Sample only - not based on real events.

8:30 AM - IED detonates, three Marines wounded, one critically.  Within 30 seconds a US Navy Corpsman is on the scene and administers first aid, applies tourniquets and assesses for life threatening injuries.

8:32 - 9-Line Medevac reports sent from location 18 miles from Role 3 hospital.  Trauma page goes out to Bastion Hospital for Anesthesia, Trauma Surgery, Ortho, Emergency Medicine, Nurses, Radiology and the OR staff. 

8:35 - Wheels up for Medevac flight, one of three options.  Dust-off - usually in the air the quickest with medics who have some medical training.  PEDRO - Air Force PJ's (think similar training as special forces, but with medical to boot), or MERT (British Crew with Flight Nurse and Critical Care physician aboard).

8:43 - Medevac Flight lands and triages patient.  Packaged within 3 minutes and intubated and blood transfusions started on the flight to hospital.  Bastion Trauma Team assembled and waiting to receive.

8:53 - Medevac flight lands 300 meters from hosptial and ambulance ready to accept patient (has already been cleared of weapons). 

8:55 - Patient arrives in ED.  Vitals assessed, Blood drawn, Chest Xray, Pelvis Xray, tourniquets applied, full Physical Exam completed within 5 minutes. 

9:01 - Decision to proceed to CT scan made.  OR staff has OR ready.

9:07 - CT scan with contrast completed.  First patient needs surgery with Ortho and General and is taken Directly to OR.

9:15 - Patient prepped and draped and operation started - in 45 minutes!

11:05 - Operation complete patient stable and taken to ICU.  Plans have already been made for Medevac at 1:30 pm to next level of service, and will be back in the US (will a little luck and good weather) within 72 hours. 

And this is in the middle of nowhere Afghanistan.  I can't remember who said it, but there is a saying goes  that something like this - You judge a country by the amount they invest in treating their war wounded. 

I think we win!

South Helmand Institute of Trauma

I'm not going to take credit for the monikers we use here for ourselves, but I thought it was quite humorous and wanted to pass them along.  Apparently, someone before me named this hospital the South Helmand Institute of Trauma and it was staffed with the British and American Surgeons of Trauma And Research Department Society.  Spell it out people.  If you need help with it then email me on my personal account.

It was a tough day here and it was a tough day to be a Marine in the Helmand Province.  However, I would be remiss if I did not mention how incredible the people here are.  I've worked at over 10 different hospitals and several big time trauma centers and this is by far the best crew I've ever worked with.  We don't have to worry about helping out because someone is always asking if they can lend a hand.  We don't have to worry about asking people to stay late, because they volunteer.  When a severely injured serviceman or woman comes in there are 20 people just waiting in the wings to do what they can to help.  We have British treating Americans, Estonians treating British, and Americans treating the local populations - there are no uniforms here!  I would say that you could take this team and insert it into any trauma center in the world and they wouldn't miss a beat.  But Kaiser can't do what we do!!  It's hard for me to wrap my head around what is going on out here, but what I know for sure is that these guys on the battlefield are getting world class care and if any team in the world can get them back home alive its this one.

Finally Settling In

The last week has been a little bit of a blur.  The trip from Kuwait was as frustrating as most of the other travel.  The main source of this frustration is always the baggage, however, they added a little more excitement this time.  About 50% of our initial class from FT Jackson is still intact and travelled together to Khandahar.  The Navy Liason set up our flights and of course it began at 3 in the afternoon (It was 122 degrees).  We assembled for a 7 mile bus ride (it took an hour) with all our gear (four bags each weighing about 60 pounds) and travelled over to the Air Force transport terminal.  I was surprised by all the contractors I saw - someone is making a lot of money providing logistics and supplies to all of us.  The Air Force makes us show up three hours before the flight and they told us we would be in a C-17 (not a bad aircraft and usually configured similar to a commercial aircraft).  We were pleased because we could spread out and maybe sleep or break out our computers and watch a movie.  Surprise, instead it is a C-130 with only 52 seats (we had 51 people) made of cargo netting and you sit sideways and its cold and only goes about 280 miles an hour (making a two hour trip into 5) and we don't really have bathrooms, but we do have a can and shower curtain for privacy.  I thought I had won the lottery!  At least we arrived safe.

Khandahar was our next stop.  We landed at about 5 in the morning (due to the 1 and a half hour time change).  We were surpised and pleased that when we got out of the C-130 that is was actually only about 80 degrees with a nice breeze.  Now that our smaller team of 16 got to Khandahar we officially belong to the Medical component and they picked us up from the airport and transferred us over to another transient tent.  We met with the Commanding Officer (I actually met him when I was in Flight Surgery School and then he was my Medical CO while aboard the Roosevelt - small Navy) and got settled in.  It was busy base with about 30,000 people (however it was only supposed to hold about 15).  They had a nice area with several restaurants, including a sit down TGI Fridays - bizarre.  We ended us essentially staying for about 36 hours before doing the standard 'bag drag' and flying to our final destination - Camp Bastion in the southern Helmand Province.  This time we knew it was going to be a C-130, but the flight only took about 25 minutes - straight up and straight down.  Now our group of 122 from FT Jackson numbered only 11.  When we arrived we were met by the Medical Crew here and after some administrative things we got to our room at 2 AM and I finally laid down to rest.

The first couple of days here were for orientation to get used to the time change again and to get indoctrinated to how the British run a hospital, however out of the Orthopaedic Surgeons here three out of the five are US and one is Estonian.  I ended up doing surgery the second day I was here and haven't stopped since.  I have gotten a 'nice' room with two British Physicians as roomates - I affectionately call them Harry Potter and Benny Hill - not sure they like it.  The living conditions are sparse and its hot and windy, but hopefully I can get into some sort of routine - hasn't happened yet as |I have gotten 4, 2 and 1.5 hours of sleep the three nights I've been here.  I'm moving into another room shortly with only two beds and a desk soon and should have some limited use of WiFi to keep up a little better with email and the blog.  So far it hasn't been that bad, except for the British food and needing a tranlator to figure out what some of the Scottish people are saying (I usually just smile and nod my head when they talk to me).  Overall its shaping up to be a very busy summer, but at least I'm with a good crew.  All for now.