Before I get started, let me provide some follow-up and bring things full circle for the posting on Poppies and Parasites. The patient whose worm was featured had her "uncle" staying with her at the hospital as her guardian. Well, he apparently was going outside on a regular basis for smoking breaks - hashish smoking breaks.
So, I live in the Letterman Dorm, named after Jonathan Letterman, a surgeon during the Civil War who is credited as being the "Father of Battlefield Medicine." He was the medical director of the Army of the Potomac and in response to inefficient delivery of medical care, he established first aid stations at the regimental level with ambulance evacuation to mobile field hospitals at the division and corps headquarters.
This system is still the foundation of how battlefield medicine is still delivered today. Injured soldiers are triaged and treated at the facility closest to where they are injured, bearing in mind that the more forward the position, the more primitive the available medical resources. Once stabilized the injured are evacuated to the next echelon of care where additional treatment is provided. This process is repeated until the patients make it from here to Europe and on to the U.S. The level of care provided in flight is a function of the patient's acuity; some patients are transported in what are essentially flying Intensive Care Units. Depending on timing and injury severity, this whole process can be amazingly efficient.
Here at Bagram, we are the last stopping point for patients before leaving the country. So we see a mix of cases - some "fresh" trauma (patients who are being treated for the first time) and lots of "used" trauma (initially treated elsewhere). In my experience, we have seen a lot more "used" trauma, but I suspect as the weather improves and the tempo picks up, this balance will shift.
We take care of U.S. and coalition soldiers, contractors, Afghan soldiers, enemy combatants, injured civilians, and so on. In addition to trauma patients, we also treat surgical emergencies that come in through the Emergency Department. All of the U.S. and coalition troops end up leaving the country for further treatment or convalescence; the Afghan patients stay in our facilities until their care is complete and they can either be transferred to a local hospital or sent home.
In addition to being the last stopping point before leaving the country, we also have the best resources available in the country. This often leads to requests for us to take care of more complex cases as well as humanitarian cases. These requests need to be balanced against the mission of the hospital - ultimately we are here to take care of our soldiers.
Having said all of that, let me tell you, in Letterman style, about my Top Ten Cases here in Bagram (oops, wrong Letterman). Some of this is not for the faint of heart, and some of the pictures are pretty graphic, so proceed with caution. Also, this is a really long read, so you may want to divide it up into multiple sittings, or at least grab a cup of coffee to help you stay awake.
#10 - The Wound Washout - So this isn't really a specific case pertaining to one patient, but this is clearly the case that I performed most often on soldiers passing through our facility. Rockets, landmines, improvised explosive devices (IED), bullets, etc., make holes - dirty holes. Wounds are contaminated with dirt, rocks, metallic fragments, clothing - there are even reports of "biologic" fragments from other people - basically if you can think of it, it can contaminate a wound. Wounds like this are cleaned out - debrided - in the operating room and are left open meaning that the skin is not closed. These wounds can be packed with gauze dressings; they can also be dressed with a suction type of dressing in addition to a variety of other options. The patients are then taken back to the OR for wound washouts where the wound is re-inspected and further debrided as necessary. If the wound is determined to be sufficiently clean, it can be closed at that time. I have done this operation a lot in my time here.
#9 - Lower extremity revascularization - Fairly early on in my time here we had a local contractor come in after the circular saw he was using slipped and landed in is left leg, severing the main artery and vein to his leg. He was brought in with a tourniquet on his leg in an attempt to stop the bleeding. He was immediately taken to the operating room where we repaired his blood vessels using a piece of vein taken from his other leg. As those in the crowd who have done similar cases can attest to, these patients only seem to come in in the middle of the night. And, no matter how perfect the operation seems to go, there is usually some issue with the blood vessels - clot formation, vessel spasm, etc. - that requires additional time (sometime on the order of hours) spent in the OR. There have been a few other revascularization cases done by the other surgeons here as well. One patient, initially treated at a forward base, was too unstable to undergo an extensive vascular reconstruction, so the surgeons at the forward base inserted a shunt - simply a plastic tube - into his blood vessels to bridge the injured segments. This allowed time for him to be resuscitated. He was transported to us with the shunt in place and was deemed stable enough to go to the operating room where the team was able to repair his vessels and save his leg.
#8 - Ruptured Ectopic - We recently had a woman come into the Emergency Room with sudden onset of abdominal pain who appeared to be quite ill. She was initially a bit of a diagnostic dilemma, but it turns out that she had a ruptured ectopic pregnancy. In this situation, a pregnancy develops in the fallopian tube instead of the uterus. The fallopian tube does not expand to accommodate the growing
pregnancy, so it ruptures leading to profound blood loss. I helped the Gynecologist in the OR with this case. We evacuated about 2.5 liters of blood from her abdomen (which would explain why she looked so ill; the average 70 kg male has a total blood volume of about 5 liters) and removed her fallopian tube. By the way, she was a bit of a diagnostic dilemma because General Order #1 says, among other things, no sex in the theater of operations, so it's a little curious how she ended up with this problem...
(Pictured: The Gynecologist and me in the OR; The ectopic pregnancy - the fallopian tube is being pulled up out of the pelvis, the purplish looking nubbin is the ectopic pregnancy. The white structure deep in the wound is the ovary.)
#7 - Urology cases - I have done 3 Urologic cases as the result of gun shot wounds to the pelvis, and because of proximity, all of these patients ended up with colostomies (where the colon is divided and brought out to the abdominal wall so that stool is diverted from the pelvis) for rectal injuries. The first patient was an Afghan soldier who had holes in the top and bottom of his bladder that required closure.
The second patient was a woman about my age who was in her third trimester of pregnancy at the time of her injury. She was initially treated at a local Afghan hospital where a C-section was performed - the baby did not survive, it is still not clear to me whether the baby was already in distress necessitating the C-section, or if the C-section was performed in an effort to save the mother and the baby died because of prematurity. She had a very complex injury at the neck of her bladder where it joins the urethra (the tube that urine passes through on its way out the body). The bladder was repaired and we left catheters in place to keep the bladder decompressed until all of our suture lines are well healed. It is unclear at this time whether she will ever be continent of urine again. I suspect she won't be, which will be a tremendous hardship in this country (not that it wouldn't be a tremendous hardship back home, it's just orders of magnitude worse here.)
The third patient was a recently married 16-year old girl. The bullet transected the lower portion of her ureter (the tube that connects the kidney to the bladder). We repaired this by bringing her bladder up to the lowest healthy portion of the ureter and sewing the two together. Her rectal injury was quite extensive - whoever tries to put her colon back together has their work cut out for them.
I've also done some scrotal and testicular work, but I'll spare you the details.
#6 - Land mine Injuries - This country is littered with land mines and no one is immune. The majority of land mine injuries we have seen have occurred in children. The first patient came in shortly after I got here. She was a 10ish-year old girl (by the way, no one in this country knows how old they are) who was out gather things in a field when she was injured by fragments from a presumed land mine explosion. She was taken to the operating room where some of her injuries were repaired. Unfortunately, she had a major bleeding episode on her 3rd day in the hospital (due to her injuries) that resulted in her needing CPR. We were able to get her to the operating and repair the bleeding blood vessel, however, because of a lack of blood flow to her brain during the episode, she died the following day.
We recently had two young brothers - 6ish-years old - who came in after
another land mine explosion. Both were quite ill when they first arrived and were emergently taken to the OR. One boy had injuries in both his abdomen and chest as well as all of his extremities. He is actually doing fairly well at this point. He is no longer in the ICU and will only need to go back to the operating room for
reconstructive procedures. (By the way, his intestines were chock full of worms.)
The other boy's major problem was significant facial trauma. The ENT and Plastic surgeons have reconstructed and closed his face. While his initial injury looks horrible, they have done a tremendous job putting all of the pieces back together.
(Pictured: One team exploring the abdomen, the other team in the chest; Significant facial trauma with soft tissue disruption and mandible (jaw bone) fracture.)
#5 - Craniotomy - We had another 6ish-year old patient who was injured by some sort of fragment to her head, most likely from an IED blast. The fragment penetrated her skull and had entered her brain. Our Neurosurgeon took her to the OR to perform a
decompressive craniectomy. I scrubbed in to help him with the case. The brain, encased by the skull, is contained within a protective, closed space. In most instances this is desirable, however, when there is bleeding or injury to the brain, there is no room for the brain to expand. This can lead to compromised blood flow to the brain, which worsens the injury, which causes more swelling which further compromises blood flow, worsening the injury, and the whole process spirals out of control. To break this cycle, a portion of the skull can be removed thereby releasing the pressure on the brain. The removed bone can be frozen and replaced at some point in the future, or a prosthetic plate can be inserted. This child's injury was so bad with such significant blood loss that we weren't sure we were going to get her out of the operating room. She lost at least the equivalent of her entire blood volume out of her skull during the operation. Amazingly she survived the injury, and while she will clearly have permanent "brain damage" each day she seemed to be a little better. Children have an amazing ability to recover from brain injuries.
(Pictured: My hand has the green under glove - the swollen brain is pictured between my thumb and index finger.)
(Ironically, during the time that I've spent writing this, I've helped the Neurosurgeon with another craniotomy. This case was a 5-month old who came in with an enormous head. He had a large cyst in his brain that was blocking the normal flow of cerebrospinal fluid causing a condition called hydrocephalus. We remarked during this case how life in this country is clearly survival of the fittest.)
#4 - Hirschsprung's Disease -
In the developing embryo, the nerve cells populate the colon from upstream to downstream. Hirschsprung's disease is a congenital anomaly where the nerves don't quite make it all the way to the end (occurs in about 1/5000 births). As a result, the downstream rectum is maintained in spasm and causes a relative bowel obstruction. Today in the US, this condition is usually discovered in newborns before they go home from the hospital. Thirty to forty years ago in the US this condition was not recognized in the neonatal period; rather children would have problems with chronic constipation, failure to thrive (poor weight gain and difficulty achieving developmental milestones), and potentially life threatening episodes of enterocolitis. Well, thirty to forty years ago at home is today here in Afghanistan, and in all honesty it's also survival of the fittest. This little boy showed up last year at 3 years of age with a lifelong history of
constipation, throwing up, and failure to thrive. At the age of 3 he weight roughly 8 kg and still wasn't walking. The surgeons here at the time took out a portion of the diseased colon and brought out a colostomy. By bringing the colon out to the abdominal wall, the fecal stream did not have to go past the spastic segment of rectum. This allowed the patient's abdomen to return to normal size, his weight doubled within the year and he was an active, healthy appearing child. We took him back to the operating room where we did a pull-thru procedure. We removed the remaining diseased rectum and brought the healthy colon down to his bottom, so he no longer has a colostomy. This was the first one of these cases I had done since finishing my fellowship. Needless to say I wasn't too thrilled about doing it in a Third World country.
Initially after the operation his abdomen was significantly distended - this gave me a few more gray hairs and caused a few sleepless night. In this operation 1-2 centimeters too high and you haven't gotten passed all of the diseased colon; 1-2 centimeters too low and you render the patient incontinent of stool. However, he got better and was ready to go home 1 week after his operation was completed. I've seen him back in the clinic twice now. His bowel function is relatively normal, his diet is improving, his weight has remained steady, and he is an active healthy looking little guy.
(Pictured: One of the other surgeons and me working on getting out the rest of the diseased colon; Me sewing the healthy colon down to his bottom; Patient in the clinic about 1 month after his operation.)
#3 Burn - About 7 weeks ago we had an 8ish-year old girl come in with a 40% total body surface area burn after a rocket hit her house. The circumstances of the rocket attack still aren't completely clear to me and sometimes I think it's probably better that way. While a 40% burn in a patient this age back home enjoys near universal survival, the same cannot be said for larger burns here in Afghanistan. This is because of poor baseline nutrition (not to mention the worms), higher risk for infection, and a general lack of resources. When she initially came into the hospital she was on a ventilator for several days and required
a tremendous amount of fluid and medication to support her blood pressure. In the last 7 weeks we have taken her back to the operating room no less than 12-15 times for wound debridements, escharotomies, and skin grafts. One of her trips back to to the OR was too put out a fire - when she initially came in, she had some sort of chemical substance on her face (presumably white phosphorus). We thought we had washed it all completely away, but about 3 weeks into her hospital stay, the Plastic Surgeon was looking at her face in the ICU and it spontaneously started sparking - nothing like re-burning a burn. The Plastic Surgeon and I did most of her operations together. Because burn patients are not able to regulate their temperature, it is necessary to keep the OR very hot during
these cases. For the majority of the cases we had the room temperature up around 100 degrees. Needless to say it gets very hot and sweaty under gowns and gloves during these cases - I think I probably lost a few pounds with each case. For all of the work related to this patient, our Ophthalmologist put us in for Army Achievement medals.
All in all, we have been nearly successful in getting all of her burn wounds covered with skin grafts and healed. The cosmetic
result is far from perfect and if she were in the US she would be looking toward a long series of scar revisions and reconstructive operations, probably over the next few years. It is still unclear what resources will be available for this girl's long-term care. And, while it sounds very shallow, in a country where this her main purpose in life is to get married and have children, it will be very difficult for her family to be able to marry her off with her altered appearance. Her father expressed this concern to a news agency during a recent interview.
(Pictured: Appearance of the burns roughly 48 hours after the initial injury; The Plastic Surgeon and me working in the OR - probably doing a skin graft; Getting my medal; The current state of wound healing (she has a feeding tube dangling from her nose to provide adequate nutrition to support her wound healing) - it doesn't necessarily show up very well, but she is sporting a brightly colored sequined purse and had on matching shoes.)
#2 - Hydatid Cyst - So, more parasites... Echinococcus granulosus. So, I'll spare you the all the details on this one, but this is a parasite that uses the human as an intermediate host. The ingested parasite invades through the intestines and gets trapped in either the liver or the lung. When caught in either of these places very large cysts can form. If these cysts get large enough and are refractory to medical treatment, surgical excision is needed. This patient is about 13-years old. She had cysts in both of her lungs as well as her liver. She went to the operating room on 2 separate occasions - the first time to take the cyst out of her left lung and the second time to take the cyst out of her right lung and liver. The way the division of labor fell between the surgeons, I was involved in the liver portion of the case. This was the first time I had done a case like this and as you can tell from the commentaries of the people in the OR, this is clearly something we don't do everyday.
#1 - Omphalocele - An omphalocele is a congenital anomaly where the abdominal wall does not fully form. As a result, the intestines and potentially
other organs protrude from the abdomen with a sort of gelatinous covering.
This patient was brought to one of the forward bases by his "uncle" on day of life #1. (I say "uncle" because it seems like every male relative is the uncle.) We transferred him to our hospital and took him to the OR to return the intestines to the abdomen and close the defect. (Also the first case of this type since fellowship - again would have preferred not doing my first in a Third World country.) Caring for a neonate in a combat support hospital was a bit of a challenge - it can be difficult to scale things back from a 100 kg healthy young troop to a 2.5 kg newborn. But, he went home yesterday eating well with his abdomen closed. He was with us for about a week and his
"uncle" was the only relative here with him the whole time. When I asked where the mother was or if she would be coming, I was informed that in this culture women don't travel.
(Pictured: The baby before the operation with his intestines herniated into the sac above his abdomen; Me before the operation; Baby on the day prior to discharge from the hospital with things back where they should be.)
Well, it's down to the final countdown for me. My replacement has arrived. Now I'm just waiting for the infamous "they", be it he, she, it, or they to figure out when "then" is going to be. So, in the meantime I'm just waiting for "then"... Waiting for Godot...
I've been back home now for 5 days. The trip home was a bit of an adventure - an earlier than expected departure, a missed flight, worries of deportation (that sounds a bit more dramatic than it actually was, but trust me, I'm not creative enough to make that up), a side trip to Iraq - the bottom line is I made it safe and sound. I can now add several new countries to the list of places I've been in the world - Kuwait, Iraq, Qatar, Cyprus, Italy, and Germany. The picture was the view from my accommodations in Kuwait (I stayed in the trailer just at the left edge of the picture, not the tents in the foreground). The picture was taken in the middle of the afternoon while the winds were howling and the dust was flying - you can barely make out the sun. 
e, so "fresh" air usually includes a mix of burning aviation fuel, and on this occasion, cigar smoke as well.