Talk to Me Like My Father: Frontline Medicine in Afghanistan
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Another sergeant with an obviously broken femur insists his comrades be attended first. When an X-ray shows his right chest to be half full of blood, an American Special Forces surgeon appears from nowhere—I thought we were the only doctors in the camp—and puts a chest tube into the man's thorax. The sergeant begins coughing blood and a Special Forces nurse anesthetist also appears; I ask him to intubate as I put in a second chest tube. The sergeant's blood pressure still falls, so I start large central lines into his femoral veins to pump blood into him. His blood pressure drops further. I put a large needle into one side of his chest and then the other. Great plumes of blood-tinged air spurt from the needles: bilateral tension pneumothoraces—air building up around the heart until it can't pump. The Special Forces surgeon and I look at one another quizzically. That shouldn't happen with chest tubes in place.
The management of battle trauma has been changing quickly, the Special Forces surgeon tells me as we work on the man. He's just spent a year in Iraq, doing trauma resuscitation full time. "We're going away from crystalloid"—saline-based resuscitation fluids commonly used in civilian practice—"and we're using larger volumes of blood products up front"—plasma, packed red blood cells, platelets, frozen concentrated fibrinogen, and recombinant Factor VII, an important clotting protein costing $5,000 a dose. "We're also very aggressive about warming them, and we're using fresh whole blood more and more often." The practice of taking blood straight from on-site donors and running it into the wounded ended in civilian contexts in the 1950s—it was felt to be more efficient to separate blood into constituent parts and administer as required. But the lesson of Iraq, he says, suggests that fresh whole blood retains its ability to clot—crucial to trauma patients—far better than frozen, stored blood.
It's not so surprising when put like that: Not many tissues work better after a month in the fridge. More striking, I think, working alongside him, is the way military medicine is not quickly or broadly generalized to civilian practice. The experts, it is generally felt, work at places like Harvard or the Cleveland Clinic. But who would know better how to take care of young people with blunt trauma or gunshot wounds than doctors in Iraq and Afghanistan?
We work the rest of the day resuscitating the crash victims. The man with the head injury deteriorates, his right pupil grows very large and unreactive, his pulse slows to 35. Four of us convene at the foot of his bed. Hours earlier, we discussed a decompressive craniotomy, a desperate measure with little data to suggest that it works. But now he is near death and no one can think of anything else. The oral surgeon takes him to the OR and begins drilling holes in his skull. As the skull flap comes off, the sergeant's pulse rises and his eye begins to constrict again.
We've run out of frozen concentrated clotting proteins, so the Americans activate their walking blood bank—soldiers prescreened for hepatitis and hiv—and within an hour 40 men and women donate blood. We run this whole blood into two more terribly wounded patients and finally they both begin to stabilize. The Special Forces surgeon returns from the operating room, removes his gown and gloves, and nods approvingly. "I love whole blood," he says.
Meanwhile, we suspect the sergeant with the broken femur might also have fat embolism syndrome, in which the violence done to the bone pushes the marrow fat into the bloodstream, where it becomes lodged in the brain, lungs, kidneys. We have to stabilize his fracture before evacuating him. In the OR, Sanjay Acharya gives him anesthesia. Moments later, the oxygen content in his blood drops to 38 percent (normal is 95 to 98 percent) and the sergeant turns the color of an eggplant. This is an anesthetist's worst nightmare—and still Acharya speaks levelly, moves quickly but unhurriedly. We bag the patient hard, adjust his ventilator settings, and slowly his saturations pick up. Orthopedic surgeon Steve Masseours lifts his eyebrows and we all breathe in on the sergeant's behalf. Finally, his saturations rise to 90 percent and Acharya nods for Steve to begin. I step out of the operating room to look around.
The hospital is carnage; puddles of blood under the stretchers; Dutch, American, Canadian, Australian, and British nurses and doctors all working madly, calling for more blood, more hot blankets, more IVs, another ct scan, more blood, more blood, more blood. From the emergency entrance closest to the airstrip, breathing in the now-evening air, I can see the tents housing the primary-care clinics. Out of them stretches a long line of American blood donors, sleeves rolled up. In one tent, among the phlebotomies and flying paperwork, is a boy—Abdullah, maybe 11 years old—who was badly burned when he failed to notice that the brush he gathered for a fire contained an illumination grenade. When his father arrived at the hospital a week after the accident, Abdullah was still sedated and on a ventilator. Abdullah's father visited for a few hours and then began the long journey home to the rest of his family in the Panjwei District. Now Abdullah is awake and free of the ventilator, and every night he weeps for his father. Another boy, whose family lives closer to Kandahar, lost a leg after stepping on a land mine; his father remains by his side. Later that night, Abdullah rolls over and calls to the old man, "Please, come talk to me like my father."
the helicopter crash heralds an upswing in fighting. Every time the weather warms noticeably, the commanding officer tells us to expect more work—by which he seems to mean coalition personnel. There has already been a steadily increasing flow of ana soldiers, anp officers, and men who describe themselves as contractors—South Africans, American ex-military, British ex-military with unit tattoos and the characteristic mustache. Their injuries are suffered far outside the wire and consist of rifle fire, for the most part. No one will say anything explicit. All we are told is that when they are fit to travel, they will be evacuated along with the soldiers.
Photographs By: Kevin Patterson
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