Motivation

Our group's t-shirt design says it all.

Well, I'm coming up toward the end of this deployment and although our group has had its share of frustrations dealing with the administrative side of the Navy, we have all grown as providers, gotten smarter and hopefully done some good.  I do have to admit, however, that it does become difficult every day for 6+ months to look down at your most recent trauma page and see that 4 more servicemen/women are coming in a after an IED and know that those four lives (and their families lives) will forever be changed.  I would be lying if I said I had a steady level of motivation to deal with this everyday.  As with most trying times, though, I had a defining moment earlier this week that will no doubt give me the motivation to continue to do what I do until my time is done.  It went something like this...

Jason and I were finishing a case early in the morning - around 9:30 -when both of our pagers went off alerting us of another casualty coming in.  'CAT A x 1 - IED - Bilateral Amputations'.  We get this page quite a bit, however, it can run the spectrum of mild soft tissue injures to 2, 3 and 4 extremity amputations, sometimes including the chest, abdomen, pelvis and eyes.  This particular one was bad.  They were already doing CPR when they came through the doors.  (As an aside, the chance of survival from blunt trauma where you lose vital signs prior entering the hospital is well less than 1%).  Despite this, we went to work.  Intubated, two large IV lines, blood, hemorrhage stopped, tourniquets applied, CPR continued - Chest thoracotomy in ED (Cracking the chest to do open massage of the heart).  Result - spontaneous cardiac activity returned.  His inital Ph of 7.0 was low, but not horrible.  We went straight to the OR.

For four fours the General surgeons explored his chest and abdomen.  The Ophthomologist and Neurosurgeon cleaned and sutured his face.  The anesthesiologist did a bronchoscopy to look at the airway.  The Ortho surgeons found all the arteries, veins and nerves and tied them off as well as cut away all dirty tissue.  During this whole time the soldier coded 4 times, but cardiac activity always returned.  No matter how hard we worked we could not stop the bleeding from his pelvis.  I performed a surgery I've only done once before and that time it wasn't during an emergency.  I took out the entire right side of his pelvis and was finally able to determine what was bleeding and stop it.  However, by then, it was too late.  The surgeon had been doing internal chest compressions for 45 straight minutes and we all finally knew the obvious.  Immediately after, a young Sailor came into the room along with the Chaplain and stood at attention.  The nurses cleaned the patient and draped him in an American Flag.  An announcement came over the hospital loudspeaker stating they would render honors to a fallen soldier.  Every single one of us - Doctors, Nurses, Corpsman, even the janitors - lined the wall exiting the hospital and gave this warrior one final salute.   

My motivation you ask?  Never to have to have this type of ceremony in my hospital again as long as I am here.

'From a distance we hear it

The sound of the helo's blades chopping the wind

And we run to it

Immobilize the spine, keep them warm, what are the injuries?

Airway, Breathing, Circulation

This one's bleeding out, that one's lost a limb

Together we work

Different nations coming together to save a life

Everyday we stare death in the face and say, no

We will prevail

Even with the lives of our adversaries in out hands

We prevail

We have no preference

We have no discriminations

We have no limits

We will walk through the fires of Hell with you

And bring you back alive

We will not be discouraged

We will not be disheartened

We will not give up

We are Role 3

And we are up to the challenge'

177 Days BOG, 204 away from home!

All for now.

Bastion vs Kandahar - Part 1

This sign says it all.

I don't even know what to say about this.  I'm never going here based on principle alone.

I've been in Kandahar now for about 3 weeks, so I've gotten a feel for the base, the hospital and the surroundings.  It's a lot different than Bastion/Leatherneck!  I thought I would do a head to head comparison, pointing out some of the main differences and see which one came out on top.  I'm going to try and not make anyone upset with this, as this is only my opinion - but then I decided, who cares if I piss anyone off - what are they gonna do - send me to Afghanistan?  

So, lets get ready to rrrrruuuummmbbbblllleeee...

1)  Hospital - This may seem simple at first.  Kandahar's hospital is a newly built facility with a brick structure (rocket proof), brand new OR's and all the accoutrement.  It's almost as if you are stepping inside any community hospital in the US.  We even have our own office, complete with a coffee maker, a computer and a bed.  The OR's are state of the art and have little 'Star Trek' doors that whisk open with a push of a button.  But, we are on deployment in the middle of the desert, so it seems a little surreal.  Bastion was a simple structure, basically a tent with metal beams, a huge open room OR, with the ER just 2 steps away.  We could also wear our uniforms anywhere we wanted and I didn't have to change into scrubs 5 times a day.  The biggest factor, though, is the distance from our rooms to the hospital.  I took it for granted at Bastion, but I could get between my room and the hospital in 3 minutes (527 steps - yes, I counted many times), but here it takes about 12 minutes - which is a long time when responding to a trauma (no I haven't counted the steps yet - too busy dodging cars to concentrate).  Winner - Bastion.

Bastion - 1, Kandahar - 0.

2)  Gym - I've been able to spend some time in the gym, both here and at Bastion.  The gym at Bastion (see the GTL post from a couple of months ago) was no frills.  Get in and get out.  The up side was that it was only 10 feet from my room and I found that during lunch there were only about 5 people there.  The downside was that is was hot and most of the equipment was falling apart.  Kandahar has a brand new Gym, with brand new equipment and is open 24 hours a day.  There are a couple of downsides though as they have a two shoe policy (they don't want you to track dirt in, go figure), it's always busy and it's not uncommon to find yourself working out next to a hairy Slovak who hasn't showered in days.  Despite this, I have to give the nod to Kandahar.

Kandahar - 1, Bastion - 1

3)  Housing - This one is easy.  The rooms here at Kandahar are twice as big, the showers have these huge rainforest-like shower heads, they are rocket proof and my roommate doesn't snore.  Winner - Kandahar.

Kandahar - 2, Bastion - 1.

4)  NATO partners - At Bastion we had the Brits and Estonians, here we have the Canadians and Dutch (although the Cannucks and Dutch are leaving in about a week for good).  The Brits had a great sense of humor, but could be abrasive.  The Estonians had no sense of humor and were always abrasive.  The Canadians say 'Ey' a lot and have a maple leaf on every piece of clothing they have.  And the Dutch have Amsterdam - enough said.  All of them, though, are great to work with and are excellent in their field.  I'm going to have to hedge my bets here and say its a draw.

Kandahar - 2.5, Bastion - 1.5.

5)  Boardwalk/Shops/Bazaar - This thing just blows my mind.  The Boardwalk is about 200 yards by 100 yards and has:  TGI Fridays, KFC, Mamma Mia's Pizzaria, Nathans Hotdog's, Cold Mountain Creamery, a German PX, a French PX (you can actually buy crepes), Dutch PX, Canadian PX, a bike store, barber shop, three or four carpet shops, two places to buy pirated DVD's and knock off electronics and five or six other random stores where you can buy anything from Nikes to Abercrombie and Fitch clothing.  And the coup de grace - a Hockey Rink - courtesy of our friends up north.  Winner - Bastion, I'm actually taking away points due to the sheer absurdness of the whole thing.

Bastion - 2.5, Kandahar - 0.

Yes, this is a Hockey Rink in Afghanistan.  No, it makes no sense at all.

(Sing along if you know the tune)  'America, f@%$ yeah, coming to the save
the mother (blanking) day, yeah'.  Heartburn and food poisoning 24 hours a day!  

Stay tuned, on the next episode when I will take on - Traffic, efficiency, leadership, free time and cafeterias.  

172 days BOG, 199 away from home.

All for now.

Veteran's Day

My Grandfather, WWII Veteran Georgia B. Morrison

Tomorrow is Veteran's Day, so take at least a short moment out of your 'busy' day (off) to think about the 1% of the population, and their families, who did and still do the things that others won't.  They may not agree with the leaders that send them to God awful places, but they still do it so we can enjoy our freedoms and lifestyles.  (Oh, on a personal note to the Occupy Whatever movement - quit whining, get over yourselves, and get back to work.)

This is a link to a story of a young woman and her family she left behind after being killed in Afghanistan.  I started residency with her husband and I think of them often.

Moving on when mom is killed at war

By Wayne Drash, CNN

November 8, 2011 -- Updated 1325 GMT (2125 HKT)

Kristen Choe's mother, U.S. Navy Lt. Florence Bacong Choe,
was killed in Afghanistan two years ago.
http://edition.cnn.com/2011/11/08/us/cnnheroes-war-widower/index.html

All for now.

     

MERT

 

MERT team activated - they will be on scene in less than 15 minutes.

MERT stands for Medical Emergency Response Team and is probably one of the most intense jobs that one can have as medical professional.  They are a team of highly trained British Soldiers that are tasked with flying into dangerous areas, picking up severely injured patients and essentially keeping them alive until they arrive here.  In addition to the perils and dangers of flying anyway, they often take fire while swooping in to get patients and often times have to fight there way out.  The carry a cadre of people, including an Anesthiologist, Paramedic and a Nurse.  I can say without a doubt that they have saved many a life during my time here and my hat goes off to them.

About a month ago, while on a call to pick up a casualty, the MERT team came under heavy fire.  They were able to take off, but they took significant damage and had to make an emergency landing only minutes later.  One of the force protection crew was injured, but the rest were just shaken up.  They were all back out doing the job again in less than 24 hours. 

 

Working in a loud, small space, flying nearly 200 MPH

Another successful transport.  Door to door in less than 30 minutes.

Naples Reunion (Sort Of)

I've been in the Navy for a while now (13 years active duty) and have served at six different commands and moved 8 different times.  Along the way I've met a lot of great people (and some not so great).  Some of my greatest friends are from my Navy time (and greatest enemies).  If you spend long enough in the Navy you begin to learn what it means when someone says 'It's a small Navy' (in fact its the largest in the world by an order of magnitude).  It's not uncommon to know several people at a new command or meet old friends when deployed.  Well, it's been a long deployment, with many ups and downs, but by far the highlight is being reunited with one of my great friends (saving the lives of our servicemen not withstanding).

Jason and I have known each other for nearly five years now.  We first met when we were stationed together in Naples.  Since then we have made a lot of people different with our Laurel and Hardy approach to surgery, taken and passed our board exams,  gone off to fellowship, and one of us got married while the other had a child.  We have kept in contact often while back at home, which is rare as one grows older.  Jason has been at Kandahar now for about three months and before each of us left (actually even while we were at Naples) we talked about how nice it would be to be deployed together (well, nice is relative here).  Despite the odds it has come to fruition and we were reunited when I got transferred here about two weeks ago.  It's been tough being at a new command so late in the deployment (you know how they say you can't teach an old dog new tricks), but Jason has kept me sane and has been a great friend.  Despite being away from his young son and wife, he constantly keeps a positive outlook and works his butt off (mainly in the gym, but thats work too).  Here's to Jason and hoping he gets home soon.  

The dumbest thing I've seen

I might get in trouble for this one.

There have been a lot of 'weird' things that happen here.  Things that surprise me and make me scratch my head in wonder.  Weird things like a young child who had a terrible wound to the head, whom we all wrote off as another tragic result of war - only to have him walk out of the hospital with his father 4 days later.  Weird things like doing CPR on a labrador after they were medevaced on an Osprey (Marine transport helo, capable of fixed wing flight as well),  Sadly, he didn't make it.  Weird things like ICU physician trying to grow a garden in the middle of Afghanistan - it didn't take.  But there have only been a couple of moments where I thought - 'that is just dumb'.  Here is dumbest.

To be a Role III hospital you have to have certain capabilites, including multiple surgical specialties, a CT scan and an ICU.  We are able to take care of about 99.9% of the things that come though the door.  I can't even imagine what it costs to run this place with all the supplies and manpower, but its a lot.  There was a recent article in the New York Times that estimated that for every troop the US deploys here it costs the taxpayers about 600K to 1 Million dollars.  One would think, then, that anything that could save money would be a welcomed addition.  This seems not to be the case and in fact it seems we are spending more than ever.  Enter an absolutely non-essential, useless piece of expensive equipment.  Actually three of them - MRI scanners!  Some of you may think, wait, MRI's are good, they can diagnose a lot of things that xrays and CT scanners can't, and to some extent you would be correct.  However, there are a couple of major problems with these.  First, when we order MRI's we usually have a specific question we want answered that will change how we manage the patients.  In the time I've been here I could honestly say that I have contemplated needing an MRI once - on a patient with a spinal fracture, I wanted to see if there was an injury to the cord.  Other than that, even if we do know the answer then we can't do anything about it anyway - so whats the use.  Second, the MRI should be very patient friendly, meaning we should be able to get the patient in and out easily.  Well, the MRI is in the back of an 18 wheeler parked out in back of the hospital on a sloped foundation near the medical waste and laundry.  Sweet.  It also has no ramp, just stairs.  I suspect we will have as many injuries while transporting the patients on a gurney up those damn stairs.  Thirdly, MRI scanners are generally in use in areas that aren't prone to sand storms.  I can see the first time they leave one of the doors ajar and a sand storm comes through and ruins a 1 million dollar (conservative estimate) piece of equipment.  Not only that but MRI's attract metal and according to geological analysis Afghanistan sand has one of the highest ferric (iron) contents in the world.  So the first time we turn it on we may create an attraction similar to Disney's Space Mountain - it will be called 'Indoor Sand Storm Carosel'.  I'll be the first in line.
     According to NGO statistics Afghanistan only has one functioning MRI in the entire country - and its in Kabul, a long way away.  So one could look at this as something that could be useful for them.  But, alas, they are not authorized to use it - so strike four.  Overall, with the work to build the concrete foundation, the transportation of the machine and the set up, I think we are probably in for around 3-4 milsky - each.  Pretty good use of taxpayers money.
    Now, should I choose Admirals Mast or just a straight Courtmarital?

For sale - MRI - used only once.

All for now.

4608 - On the Move

Fleet Surgical Team, Noble Eagle 4608 (retired)

On May 2nd, 2011 I met half of the 15 people that would make up 4608 in Norfolk, VA.  At that time we had all heard rumors that we were going to Camp Bastion, but some of us would be stashed elsewhere to make up for shortages.  On May 8th at FT Jackson we met the other half - 1 ER Doc, 1 General Surgeon, 2 Anesthesiologists, 5 Nurses, 4 corpsman, a Master Chief and myself. Since then we have become good friends, worked our butts off and seen things that we will probably never want to talk about again.   

Our Noble Eagle number has now been retired and will no longer be filled - which can be seen as a good sign as we are no longer needed in certain parts of the country.  We have all been reassigned to Kandahar for the duration of our tour (3 stayed there to begin with and 3 are coming from an outlying FOB (Forward Operating Base).  It can also be seen as bad sign as the footprint of Navy Medicine is getting smaller here.  As you read this we will be settling into our new assignment and with any luck will be finishing out our final 6 weeks of deployment continuing to do what we've been trained to do.  

If you get a chance you can watch the video from the BBC and British Forces Broadcasting Service in which you will see me starting at about the 2:53 mark in the light blue scrub cap with a Union Jack on it - it was a gift from one of the British surgeons.  Unfortunately for the censors (and the Brits) the big '1776' and 'Don't Tread on Me' that I drew made it on the video.  One last jab!  Brilliant!

http://www.bfbs.com/news/afghanistan/behind-scenes-camp-bastion-hospital-52608.html

147 Days BOG, 174 Away from Home

All for now.