An old war story and a tribute to a friend...

     I have not had anything too exciting recently, but I as looking back and realized I never posted anything about my time in Afghanistan. It's not like I was a "fobbit". For those non military people, a fobbit is someone who never goes out on mission. They basically never leave the FOB or forward operating base. At any rate, this particular story is dedicated to a friend of mine who is currently deployed to a less than desirable location and dealing with some of the worst trauma in the world. This one's for you. And now insert flash back visual affect. Yes, there are other ones besides "star wipe"!

     It was late May or even early June in Paktika Province of Afghanistan. It was actually pretty nice day out and we were gearing up for a humanitarian aid drop to the local orphanage when our Ops officer comes outside and asks where our PA is, a convoy hit an IED and there is an unknown number of casualties at this point. I tell him I'm not sure, but I am going. He says he would rather have the PA go as well. No offense to my friend the PA, but this is what I do. That was stated in a much more aggressive and verbose manner, but he wasn't relenting. Either way, I was going on this call. Especially since I was already completely geared up. So I double timed it over to the waiting convoy for a ride to the scene. I pass the PA and give him the heads up that we will be leaving in 10 mikes.
     As we close the doors to our Cougars and do a last radio and weapons check we get some traffic over the radio stating that we currently will be having approx. 8 patients in various levels of distress and they will be rendezvousing with us at a predetermined location.
     The ride out to the rendezvous point was bumpy to say the least. The funny thing is that in the several months I have spent over there, I have only been a passenger in one of these armored beasts two or three times. Apparently I wasn't missing a whole lot. Well, paved roads are a bit of a luxury over there and once we left the city, it was all dirt and country roads.
     Upon our arrival to the rally point, a perimeter was set up and the patients are brought into the center for care. Most of them are walking wounded. All of the wounded were Afghan National Army, or ANA. That makes my job much easier. However there were two that required a bit more attention. The first one, was possible closed head injury with epistaxis and altered mental status. One of the Navy corpsman assigned with the unit took care of that soldier. The patient I end up taking care of was also an ANA soldier. He was the TC or truck commander for an armored vehicle that had hit an IED. This poor gentleman's hips and lower extremities were covered in blood. Thankfully one of the ANA medics did a very good job of bandaging and even started an 18g IV on the guy. However, he was not out of the woods yet. Unfortunately over my many moons in that country I have had to undo a lot of bandaging that the ANA did to see exactly what I was dealing with and medivacing out. We quickly undid the bandages and got a quick look to find a tourniquet and an open tib/fib fracture. I have someone replace the bandages and spike an IV bag of NACL. I grab a quick set of vital signs and wouldn't you know it, the guy is a bit shocky. Who would have thought. He was tachcardic, hypotensive, and screaming in pain. Don't worry, brother. We will take good care of you and help you with you your pain. This is then spit back out through an interpreter.
      Now one thing that was not done prior to our arrival was a complete head to toe assessment. Mainly just an upper body and obvious injury assessment. So our pt's other leg is dowsed with blood so we cut off the clothing to find that his other leg also has an open tib/fib fracture which is bleeding profusely. Now I know in the US tourniquet use is almost taboo, however in combat situations they are the first line of treatment. This is because they are fast, effective, and recent data shows that they can be on for up to 6 hours before any permanent damage is done. Any way, I digress...
      This ANA soldier gets another tourniquet and bandage/splint job and a 16g IV with a 500 cc bolus of NACL right away. Supplies are limited and carrying liter bags of NACL is a bit much. The fluid challenge didn't do a whole lot for his vitals, so we hang a bag of Hextend. It is a wonderful plasma volume expander that helps treat hypotension second to exsanguinating injury very quickly. Blood is always the preferred resuscitative fluid, but it's very impractical in the field. However, after a 500 bolus he pinks up and his vitals are now with in a range I can treat his pain. This patient is what is referred to as an "urgent surgical" pt and requires immediate treatment at the receiving facility. Due to our location and current operational presence, the closest trauma center is Bagram. So we are waiting for "Dust off" to arrive on scene to transport our two critical patients.
     In the distance we can hear the rotor blades cutting through the air as our air ambulances approach and circle the scene for a safe landing zone. I give my patient a quick reassessment and some more pain meds. I also document what was done on the official war zone medical form, 2 inch tape. I place a 8 inch piece of tape across his chest and write what was done, what time the tourniquets were placed, what injuries were found, and what meds were given.
     As the flight team lands and clears us to approach we carry our pts over and give a very quick report to the flight medics. They probably didn't hear a word that was said between the rotor wash and their helmets. However, they get the patients loaded and take off for the worlds busiest trauma center, in Bagram.
     As the dust clears, and our hear returns, there is an eerie quiet that falls over the scene. It's amazing to think that with all that chaos of radio traffic, rotor wash, people shouting for extra hands to help, and the screams of the patients, that it was all over in 25 minutes. That was from the time we got on scene to the time the patients were in the air. That is one way to start the day. That is something coffee can never do.
     A few days later, I hear that our pt not only survived the trip, but is also complaining about the food at the hospital. Sounds like he is going to be just fine. The say with some effort on his part, he will also be able to walk again. It's nice to be able to be apart of something positive in such a chaotic and dangerous situation.

And that is why I carry that in my shirt pocket...

                Recently I was working my preferred rescue station when we got a call for pedestrian accident. It was early enough in the morning where I figured it would be a fender bender that was the result of two soccer moms that wanted the same parking space. As we are coding along to the call, dispatch had information that was very much the opposite of what our original hypothesis had to say.

                As it turns out, it was a pedestrian vs vehicle call. Depending on what had happened, it could be a serious call or it could be nothing and we sign off the pt. This call was very much not the case. As it turns out, our pt was backed over. Yes, backed over by a rather large vehicle that most rednecks in the area would be proud to call their own. So needless to say, this poor pt was not exactly happy or feeling all that well. Btw, both axils passed over this pt at a fairly slow rate of speed. Thankfully the driver of the “Cletus-mobile” got out to see what he monster jammed into the ground and didn't flea the scene.

                Upon our arrival we find our pt on the ground in front of the vehicle in what looked like a yoga position. If I had to give it a name, it would be the dead cockroach since the pts legs were folded in such a way. Looked like the pt was sitting Indian style and fell back with their legs stuck in that position. It was a bit of challenge securing this one to the back board, but we got it done.

                On further inspection, questioning, and assessment, we come to find the pt was struck by the truck while it was backing up and it then proceeded to roll over this poor person twice. So in the back of our toasty warm ambulance we did our “eyes and scissors” assessment. The revealed a couple of small abrasions and lacerations, and an open tib/fib fracture but not real bleeding. And although the laying of hands may be therapeutic, it is also a good diagnostic tool. Our pt had crepetus to the left anterior chest wall and pain upon palpation to the pelvis. Our findings with our super duper ALS equipment showed relatively normal vitals and a good cardiac rhythm. Auscultation of the lungs did however show absent breath sounds to the left chest.  The pt was tachypniec, orthopniec, and dyspniec. So I reach into my front shirt pocket and pull out a 14 gauge IV catheter that will be placed into the second intercostal space, mid clavicular line with a flutter valve in just a moment. The pt tolerated well and respiratory effort was no longer as exaggerated. That is why I always carry one there. You never know when you might need it for a decompression or a needle cric. Just saying…

                Anyways, as soon as we get our basics down, we tell the FD to drive to the local trauma center and we take off priority 1. Enroute we do two large bore lines, get a bit of a better history, and what not. Pt has a GCS of 15 the entire time, btw. So we get some pain meds on board and continue to monitor and continue treatment as best that we can. The lungs of this pt are now diminished on the affected side, but they are actually there now. Score!

                Upon arrival to the ER, the trauma surgeon meets us at the door and is given a basic report. Upon arrival to the trauma bay, my partner and I are asked 1,000,000 questions, much of which was multiples or obvious (Is the pt intubated? Really?). We get our pt over to the bed and try to make it out of the room alive.

                After the report is done, I inquire to the condition of our pt and find out there was a displaced femur, which explains the odd leg positioning, broken ribs, a chest tube, and a tib/fib fracture. This pt was very lucky because this could have been so much worse.  Now that is one way to start a 24 hour shift.

I hate getting waved down...

                My partner and I had just dropped off “the dude” at the cath lab and finally were cleared to head back to our coverage area. We make a few strategic turns here and there to get us out of this particular city ASAP. Unfortunately that did us no good. As we are driving up one of the larger avenues, we are waved down by a portly woman standing next to someone that I can only describe as Dave Chapelle's crack head character he played on his show. You know the one he had before he went crazy with fame and fell off the face of the earth only to land in Ohio. Anyway, I digress…

                My partner, who feels it’s a good idea to pull over and save the world in the middle of what I would refer to as “not the safest place on earth” flips on the lights and pulls us over to take  a look. My first thoughts are “Three things are probably going to happen. We either going to get robbed, shot, or stabbed”.  Thankfully none of which happened, but judging from the location, anything could have happened.

                So we find a moderately old (relative term) man lying on the ground with his pants and boxers halfway between his knees and hips. Thanks for that buddy. Gross. So I ask him “Hey man, what’s going on?”, you know the typical national registry type test questions.  He responds with a grunt an odd waving of his arms. My partner is calling him “sir” and really playing the part of the good cop really well. We stand him up, pull his pants up and he says “take me…hospital” with a smile on his face. He then proceeds to point in the direction of a particular hospital that is about 6 miles away. If he pointed to the east, it would have been half a mile away. Then he starts to get mad. I still do not know the reason for the change in attitude…whatever.

                We get the pt on the gurney and secure him down. Since he is angry and we are “in da hood”, I point out to my partner that it is probably not a good idea to for him to have control of the cane he was walking with. He immediately tries to take it away. Not a good idea. The pt gets very upset and spews a long list of derogatory terms in our general direction. He also won’t let go of the cane.  So in his altered state, we just loop the leg straps around it a few times to prevent any “sword play” with his walking stick.

                Oh by the way, our initial assessment raveled pin point pupils and altered mental status. Guess what buddy, we are going to the closest facility since you are currently a/o x “wtf”. That didn’t make him happy, and I just let my partner try and cure this guy with “the power of positive thinking”. Better him than me. I was running low on patience. It dropped to a critical low when the this guy said he wasn’t going to tell us his name. And I’m done. Let’s just go to the hospital that shares the same name as the city we are currently in.  Ugh! I had to turn the radio up so I couldn’t hear the “conversation” in the back.

                Upon arrival to the ER, the staff look at the guy on our gurney and instantly know him. Apparently he is a regular here and has since lightened up. I think he was just happy to be out of the cold and into the much warmer ER. The total time we were with the pt was about 25 minutes, but it was just so frustrating. “Just keep swimming”…

The Dude and his cath

                Recently the phone rang at the station without the fire radio toning out. That is usually not a good sign. I pick it up and dispatch tells us that we have a emergent cath call out of the local hospital that needs to go priority one downtown to the waiting cardio team. We are so totally on this one! My partner groans and mumbles something about where is the MICU right now. Whatever.

                So we roll priority 1 up to pick up our pt. This guy was not at all what I thought he would be. I thought we were taking “The Dude” from “The Big Labowski” to the cath lab. Long hair, mannerisms, probably a thirst for white russians, and what not. The only thing he was missing was a white Russian. However, el dude-a-rino had a bumped troponin and was looking pretty ill. NSTEMI ill. So I tell the guy we are going to get him packed up and have a safe and fairly comfortable ride down to the city from the country. The roads around here are not the greatest.

                After talking with the nurse and pt, I learn that he is an ER doc. I was kind of surprised, but if the Dude was going to be a doc, he would totally work in the ER. Just sayin’. He said the whole episode stared a few hours earlier in the day and that he was still at about a 7/10 in pain. He had the whole shebang, diaphoresis, an elephant on his chest, dyspnea, and nausea. His vitals were pretty good though. Slightly brady with a touch of hypertension. Oh and this is on 20mcg of IV NTG. The RN bumps him up to 30mcg before we leave and the guy is still in pain after that and 2 of Dilaudid. Our orders were to increase the NTG as needed for pain and to keep his BP above 100 mmHg. Got it.

                Now I treat all pts as though I am loading them into a helicopter/airplane. No bubbles, pumps set, IVs check, etc, etc. You need to make sense of the chaos that is the tubing and wires of multiple pumps, the monitor with 12 lead, bp cuff, spo2, and so on. If he was intubated, it would have been even more of a challenge. At any rate, we get him all dialed in and secured we make our way out to the truck.

                Our pt is currently nauseous and diaphoretic. And the ER has already discharged him, so it is our med box to the rescue. I really didn’t want him to vomit in the truck. Not that there was a rug on the floor that tied the room together or anything, but no vomiting = a good trip.  He gets a normal dose of the amazing antiemetic, Zofran. I am speaking from personal experience that this med is wonderful. It doesn’t get you high, it just takes away nausea like the big kid took your lunch money. Great stuff.

                At this point we are starting our decent from green country side to grey urban waste land. While we are enroute, the pt states his chest still hurts. He just bought 5 more mcg/min of nitro and a reassessment. A short time later he states that it didn’t help with his pain and so I get him up to 40mcg/min with no relief. His pressure was still good, but I wanted to help him with his pain and the drug box is already cracked. Since he was on a moderate dose of nitro, I decided to go with Fentanyl for pain management. He tolerated two separate doses of the med well. He received two because he was still in pain. It brought his pain down some, but not completely. Now I’m no cardiologist, but I’m pretty sure the only way to get rid of his pain was the cath.

                So we get to the facility and The Dude is doing pretty well. Well enough to make comments about how hot the nursing staff to me and to say hello or more accurately “What’s up” to everyone passing us on the way to the lab. I have to say he was a lot of fun to take care of. And when we finally transferred him to the bed in cardiac holding he shook our hands and said things like “Great job, man” and “Thanks a lot, bro”. It made you feel good inside to know that you helped get your patient to definitive care in a fast, safe, and laid back kind of way.

New Year and whatnot...

So the new year showed up with nothing too exciting. We only did two transports the the entire 24 hour shift. So this very stagnant shift gave me a lot of time to twiddle my thumbs and actually pay attention to the dumb, funny, and more often than not abstract things that I have either thought, uttered, or had the pleasure of being within ear shot. Here is just a list of the gems that were cranked out in the not so distant past.

"That meth is not going to smoke itself" - A less than enthusiastic medic's comment about a citizen of the "D".

"Hey...here's a dead body. Sorry" - A fellow medic describing a call that involved transport of a pt with active DNR orders and the conflicting family request. 

"We turn drama in to trauma" - Well this was actually posted on facebook my one of the junior medics I served with in the USAF. Not sure if it is original, but it's all the more funny coming from him. You know who you are.

"Transporting an old person in full arrest to the ER without ever achieving ROSC is like saying, here you do the paperwork" -  one of my many strokes of genus after a full arrest. I was probably cleaning up the truck with no one around to enjoy my brilliance.

"Come on! Hurry up! Walk the line!" - An accurate description of someone trying to finish up a call so they could get back to the football game.
      <Note> You can't rush diabetes. Just FYI.

"We all want to be heroes, but more often than not we have to be the bearer of bad news" - A profound little nugget that fell out of my head while I was talking to a student about pronouncing patients and breaking the news to family.

"SOD!" - Sitting post and reading the side of passing trucks. This is the result of being bored and cooped up in the truck for way too long with an already goofy partner.

"Don't thank me, thank Zoll" - A some what cocky response to an accolade my partner and I received after a CPR safe.

I am sure last year, even last week was full of sarcastic one liners, profanity, and verbal beat downs sprinkled with a fine dust of profound insight into the human condition.