Saturday, July 30, 2011

First 100 cases


Case number 100 - Only 47 days into deployment

To put this in perspective a little bit:
  -  This is an average of 2.12 cases a day.
  -  This would be 382 cases in a standard 180 day deployment.
  -  Combined this would be 764 cases in a year.
  -  In residency I averaged about 450 per year - and that was when I was 'trying' to operate as much as possible.
  -  In Naples I did 252 cases - in two years.
  -  In Philadelphia during fellowship I did 680 cases - and was so tired my hands ached at the end of the day.
 
It's difficult, but I wouldn't change it for the world.  I wish I could say that it was slowing down, but I'm now on day 65 and still on the same pace.

Monday, July 25, 2011

Sangin Valley

This following is a story from our daily email updates about the area we are in - Sangin Valley.  Last year at this time the British were the main forces here, but were taking very heavy casualties and decided to back out.  So, naturally, the Marines said they would take the ball.  Can you imagine going to work everyday knowing that someone in your platoon has a good chance of stepping on an IED?  And when they do find an unexploded IED,  a group of men called EOD springs to action to defuse and/or detonate each and every one.
One word - Courage!

Medevac Helo over Sangin Valley





Marine Corps Times
By Gina Cavallaro
July 25
SANGIN, Afghanistan -- Lance Cpl. John Farias parked himself in front of a video camera June 2 and fumbled his way through a seven-minute greeting to his family in Texas. A rifleman with 1st Battalion, 5th Marines, he discussed the austere living conditions at his patrol base, and his craving for sushi.
Farias, 20, talked about the way Sangin -- easily the nastiest place left for Marines in Afghanistan’s Helmand province -- was forcing him to “grow up.” “If you don’t take your responsibility to the fullest,” he told the camera, “one of our friends might die.”
Three-and-a-half weeks later, Farias was killed when his squad came under enemy fire during a patrol in the Upper Sangin Valley. His video appeared on YouTube several days later.
As of July 13, Farias is one of 12 men assigned or attached to the battalion lost here since it arrived in March from Camp Pendleton, Calif. Marines engage the enemy directly, but improvised explosive devices remain the biggest threat, officials said.
“We’re taking more casualties than anybody else, but this isn’t Tarawa -- I’m not taking 50 per cent casualties,” said Lt. Col. Tom Savage, 1/5’s commander, referring to Marines’ epic fight in the South Pacific during World War II. “The sky isn’t falling in Sangin,” he said. “We’re going to take casualties this summer, but it’s because this place is a minefield.”
The mission here is straightforward: Hold on to gains made over the fall and winter by Camp Pendleton’s 3rd Battalion, 5th Marines, which also took heavy casualties in Sangin. And although officials said things are better than they were last year at this time, when Marines replaced the British forces that had patrolled this area for years, the focus remains on security. So far, only fragile inroads have been made in allowing the local government to take hold.
The Helmand districts of Marjah and Garmser, once hotly contested areas that were cleared by Marines over the past 18 months, are close to making the transition to full Afghan government control, said Marine leaders operating in those areas. But Sangin is going to take time, effort, sacrifice and manpower.
Echo Company, 2nd Battalion, 8th Marines, and members of 2nd Combat Engineer Battalion, both out of Camp Lejeune, N.C., were sent to Sangin to supplement 1/5, inflating the battalion’s end strength to about 1,200. Another 40-plus replacement Marines were expected to arrive soon and help round out some of the squads hit hard by casualties.
There are thousands of IEDs within 1/5’s area of operations, which includes about 25 positions. And Savage’s Marines will never find them all, he said. Although they’ve unearthed nearly 400 unexploded bombs, more than 50 have been detonated by Marines on foot patrols, killing and wounding more than 100 troops.
Since the poppy and wheat harvests concluded, the Taliban have gone into high gear in their fight against Marines. The area, Savage said, is teeming with various enemy factions and is known as a commercial center for drug lords and other thugs who tax the population as a way of funding their activity. It’s profitable terrain that the Taliban want to keep at all costs.
June was a turning point. The Marines had been patrolling in relatively calm areas that seemed to light up overnight. More gunfights erupted, and dormant bombs began exploding underfoot, Savage said. It was as though the enemy had “unplugged IEDs” that were lying in wait while the harvests were finished, he said.
“This place is a sieve for the Taliban. There are literally thousands of IEDs here,” Savage said. “We find some but not all, and they keep putting in more. We just have to get through the summer fighting season.”
When Marine Corps Times arrived in Sangin in early July, Farias’ unit, 3rd Platoon, Bravo Company, had experienced the battalion’s toughest direct firefight to date, Savage said. He described the morale among those men as “not happy, but stoic.”
“Shooting back helps,” he added, referring to the frustration his troops feel when they’re targeted by IEDs, and unable to see or respond to their attackers.
Savage makes it a point to punch out often from the battalion headquarters at Forward Operating Base Jackson and visit his Marines when they’ve been in tough fights and taken losses.
“We talk a lot about the ‘hunter, not hunted’ mindset,” he said. “And it’s not just the Marines. A couple of platoon commanders have had a hard time with it. … The best thing is to get them right back out.”
Lance Cpl. Jack Woodworth, 22, was the only one left on his team in 3rd Platoon after the others were killed or wounded. He was put on the bench at FOB Jackson for almost a month before he was cleared to return to duty. Farias, whom he described as a close friend, was killed while Woodworth was still sidelined at Jackson. The two were looking forward to celebrating Farias’ 21st birthday when 1/5 returns home later this year.
“He was every average Marine: single, loved to party,” Woodworth said. “We were going to go out for his first legal drink when we got back.”
Capt. Ryan Hunt took command of Bravo Company on June 11 when the company’s commander was wounded by an IED. Hunt had been commander of Headquarters and Service Company, and, at the urging of Savage, had kept current on intelligence and activity throughout the AO.
“I knew it was more kinetic, morale was down. But we did a lot of talking about things, and they’re pulling together,” Hunt said of Bravo Company. “Some squads pulled together faster, but they’re all back in the fight and ready to close with and destroy the enemy.”
Bravo’s 1st Platoon is the hardest hit, Hunt said. But the experience has “bonded those guys.”
So far, Hunt has held a couple of “mini shuras” with local elders, but progress is slow. One held recently at Patrol Base Atoll, not far from Jackson, focused on security rather than deep government engagement. Nothing can happen here in earnest until the people feel safe to work with the district community council or the Americans.
Living conditions are rough at the company’s patrol bases, he said, and the Marines are often faced with drinking treated well water while on patrol because they can’t keep themselves supplied with enough bottled water at the base. The battalion pushes out supplies to the company as quickly as it can, he said, and they send help when it’s requested, whether it’s attack aircraft or intelligence, surveillance and reconnaissance assets.
“Higher headquarters understands we’re fighting in a minefield, pretty much,” Hunt said. “The company gets air support when it needs it: rotary, fixed-wing, even armed ISR.”
Half of his squads are led by corporals, but he expects to be able to get sergeants into those slots once replacements trickle in.
On July 2, Woodworth loaded up his gear in a mine-resistant, ambush-protected vehicle and headed back with his guys from Bravo to Patrol Base Faheem, north of Jackson. Officials described it as the northernmost company positions in 1/5’s AO. The Marines’ objective there is to siphon enemy activity away from Sangin’s district center.
It’s treacherous up there. Farias died not far from Faheem, named for a fallen Afghan soldier, and Woodworth said he expected he’ll soon see more firefights and more carnage from IEDs.
“I can’t just stay here at Jackson,” he said. “I’m a leader of Marines. I want to go do my job.”

Wednesday, July 20, 2011

Living in Style


This is the first room that I was assigned.  An 8 x 18 foot cargo trailer stacked on top of each other and held together by who knows what.  I shared this with two British Residents - Matt (Internal Medicine) and Adam (Emergency Medicine).  They were great, but we all had different schedules so sleep was often hard to get.  I can't complain, though, as all the rest of our group are in tents - more room, but even less privacy.



'Little America' - Go Phillies!
This is my new room, which I share with a US Anesthesiologist - Matt from Balboa Naval Hospital.  We get along well, and have similar hours.  He is doing a Pain fellowship next year at UC Davis.


That is Matt and this illustrates the width of our room.  Not much space, but we get by.


This is the outside of our barracks.  100 people live in this building and there are ten of these.  Each floor has two male bathrooms and one female - it is a coed Barracks, but only about 10% women.  These were put in place about a year ago and I can only imagine what the government paid for these.  I would guess based on the wear and tear already noticeable inside that they might last five years.  The only good point is the 'yard sale' that occurs every time somebody leaves.  Essentially anything they don't want they put in the hallway - thinking about hoarding all of it and starting an online store on ebay.

All for now.

Friday, July 15, 2011

GTL - Afghanistan Style

For those unfamiliar with the popular show 'Jersey Shore', it is an MTV program that features 6 Italian American, 20 something, ne'er do wells that spend their days lounging around their furnished beach house,  drinking, fighting and partying.  One of the personalities, Pauly D, has come up with the term GTL - which stands for the most important things to do during the day.  Gym, Tan, Laundry.  Much to the horror of my wife (she may be filing divorce papers as she reads this), I actually like the show.  I like it so much that I've tried to incorporate GTL into the day to day living here at Camp Bastion.  It goes something like this:

   1)  Gym - I actually like to call this the 'sauna'.  Granted, it feels cool when you first step in, but that is because you are going from 114 degrees to around 90.  I don't usually like to work out in an 90 degree gym, but, hey, you have to take what you can get.  They do have 12 treadmills, 12 stationary bikes, 6 rowing machines, a couple of stair climbers, a few free weights and a bunch of nautilus equipment - all of them from the early 90's.  They also have 3 or 4 TV's (showing only British TV) - so I can enjoy Cricket or Benny Hill while I slowly run myself into cardiac arrest.  Also, as you may well know, the Brits and Americans dress differently, especially when it comes to work out attire.  Apparently, according to the Brits, I dress like a German Pedophile (I've been told this by several of them).  I will defer to my sister to answer this, but I'm not sure I want to know the answer.  Anyway, about an hour of this and I'm ready for an IV - so this leads me to...

   2)  Tan -  Most of the UK has dreary, rainy, cloudy weather, with little sunlight and few beaches, so when the Brits get around the sun they love to try and get a tan.  When I first arrived on day one, in the middle of the night, I read a posted notice on the front door of our 'dorm'.  It laid out the appropriate attire for sunbathing outside.  What!  They do realize that we are in the middle of a desert.  I was confused the first time I was outside my room around noon and saw countless people laying out - some even drug out there mattresses so they could adequately expose both the front and the back, making sure to have an even tan.  After perseverating on this for days I decided that if you can't beat them, join them.  Much to my good fortune, the two doctors that moved out of our room left two camping chairs - perfect for the sport (sorry, I'm not dragging my mattress outside, its much too dirty as it is).  I soon found that sunbathing in Afghanistan is not for the faint of heart, so after 7 minutes and 16 seconds I packed it in - burnt to a crisp, although about 5 pounds lighter - which leads me to...

   3)  Laundry - I'm actually cheating on this one.  The extent of my laundry doing amounts to carrying a bag of dirty clothes to the contractors just behind the hospital (more on this later - contractors that is).  Every 6 or 7 days I drop my laundry off at 7 am and by 9 that night I have a wet pile of wrinkled, faded, and sometimes not even my own clothes.  Sweet!

And there you have it, this is the extent of the stuff to do in your free time at Camp Bastion, brought to you by a sunburnt, dehydrated, wrinkled clothes wearing American who looks like a German Pedophile.  All for now!

Friday, July 8, 2011

All in a weeks work

Operating Room at Camp Bastion - 4 Room Open Bay
(We are not supposed to take pictures in there - so don't tell)

    Life around this deployment is set around the hospital.  I usually spent about 12-15 hours there a day.  The day begins with rounds starting at 7:45 with a team of surgeons - General, Plastics, Ortho, Anesthesia, and Nursing in the ICU (called ITU in the UK).  90% of the inpatients are local nationals (many of them kids), ANA/ANP - with UK/US/Etc making up only a small portion - if they are injured they usually fly (medevac) home immediately.  At 8:45 the Ortho surgeons on call go to morning board rounds with about 40 people from every department.  We attempt to make a plan for all the patients.  Unfortunately the plan sometimes includes sending them to the local Afghanistan hospitals when we are finished with their initial care.  They have a medical establishment that is about 100 years behind us and so, sadly, this sometimes can be a death sentence for those that still have significant medical needs (more on this in a later post).  After the board rounds, the OR starts - anywhere from 2-8 'elective' cases a day.  I have been averaging about 2 cases a day for myself - some of which take 30 minutes and others that take 2-3 hours.  At any point in the day -  and usually often - we have medevac calls where every team reports to the ER and awaits the arrival of new Trauma patients.  At that time the elective schedule comes to a halt and we take care of the newly injured - these cases take quite some time.  After the schedule for the day is done we have another set of meetings at 7:45 and then rounds after that.  I usually have time to grab a quick bite to eat at some point, but otherwise go back to my room and relax for a couple of hours.  Not much else to do at old Camp Bastion.

    The OR is one giant room - all open bay - 4 rooms total and no dividers so we can see the other teams operating at the same time.  I have even gone straight from one case to another table and started helping without rescrubbing.  It's really quite a trip and sterile technique is more of a suggestion than a rule here.  

     We get a report every week outlining what we did as a team.  Last week the Ortho team cases were:
2 Triple Amputations
7 Double Amputations
6 Single Amputations
50 Irrigation/Debridements/Wound Vacuum/DPC's (Cleaning and closing wounds)
4 Arterial Reconstructions (Two popliteal, One Femoral, one Brachial - 3 legs and an arm)
2 Femoral External fixators (Applying a device with pins and bars to hold broken bones in place)
3 Tibial External fixators
1 Pelvic External fixator
4 Fasciotomies - 1 arm and 3 legs (releasing tight tissue to allow blood flow to damaged extremities)
5 Skin grafts
I also did 3 chest tubes (for blood or air in lungs) and a tracheostomy (making a hole in the neck to breath out of) - and, no, I am not really qualified to do this.
     Hell of a week for any department - much less one in the middle of a desert in a mobile hospital.  


Three out of 4 OR's at once - One Thoracotomy, One Laparotomy,
and another with a double amputation

As a final note, my good friend and former partner in Naples started his deployment this week and also has started a blog.  I invite you to follow him as well and keep him and his beautiful family (April and Jackson) in your thoughts.  Zook in Kandahar.

All for now!