Ok, so it’s 0100 in Afghanistan in the beginning of the spring. It’s a cool night with a waning moon with little cloud cover, so it’s clear but still pretty dark. So where do you think I am? You’re damn right, I’m sound asleep in bed. Well, I was until the lights get flipped on and my door is basically kicked down by one of the runners that was sent to get me. “Doc, you got patient!” is the first thing I remember. So as I am going from zombie to paramedic as I am putting my uniform on and getting my medic bag or aid bag as we called it, I am told that we have 4 patients and that they look pretty bad. Thanks new guy.
So we get over to the ANA or Afghan National Army TMC to find four pts ranging in severity. All four of them were victims of either shrapnel or small arms fire. Three out of the 4 are talking and basically complaining. The one that isn’t complaining is wrapped up like a mummy with ace wraps and kerlex bandages. This wasn’t just “blast concussion” weirdness, but something else was going on. As much as I hate to undo another medic’s bandage (ANA or US medic) we had to see what we were dealing with. So we start untangling this poor guy. It did take much to tell he was in bad shape. He was unresponsive to verbal stimuli, was breathing fast and irregular and then slow and irregular, and he had unequal pupils. I bet his blood pressure is all jacked too. Just a professional guess/opinion here. As we are getting the bandages off I check for a radial pulse and don’t find one. Great, he says sarcastically. So we move up to the brachial and its very weak and slow. Well, I guess this guy is very late down the shock time line.
So the bandages are off and we find a very neat linear and open gsw to the head. The bullet that hit this guy literally separated the two ventricles of the brain and was bleeding pretty badly. Oh and you could see the grey matter swelling. Well, that helped us to know what we are dealing with. The rest of the physical exam was pretty benign. He was “only” suffering from a GSW to the head with increased ICP even with his ballistically created vent.
Treatment and resus was going on while we were getting a good look at the entire picture of our sickest patient. However, since he was profoundly hypotensive (60/30), the other medics were unable to get in any peripheral access. I asked one of the corpsmen to pop in an IO. He attempted to get the FAST1 in place but he didn’t have any luck. I was standing at the head of the bed and gave it a shot and it popped right in. Now we were able to get his pressure up with some plasma volume expanders and hopefully able to reperfuse the squash a bit.
Mean while, the ANA PA was standing next to us and I tell him that this patient is loosing his respiratory drive. So what is his solution, you ask? He proceeds to the supply room and returns with a suture kit and 2-0 silk. What are you doing with that? I ask. He then proceeds to suture this poor guy’s tongue to his lower lip to prevent it from occluding the airway. 10 points for creativity, but I think a PVC challenge is in order here. I say thank you for your help and tell our interpreter to tell him to get out of the way. This guy needs an airway and he needs soon.
As this was all going down, our PA (US kind) asks me “Want me to go grab the RSI kit”? Please, sir. So he takes off in a full run. Mean while we start prepping this guy for the RSI. We get what meds we had on hand, and reassessed. Vitals were better than 60/30 but nothing super amazing. Our PA returns with the little black box that contained our RSI meds. I have to say I am not the biggest fan of Veccuronium, but it does the job. The 2 minute onset time seems like forever. Oh and don’t forget about that whole sutured tongue thing. You would think that it would have made for an easier intubation, but it actually did the exact opposite. It was a pain in the ass to say the least. So we get the drugs on board, our paralytic, the sedative, atropine, and some lidocaine for the ICP. As the drugs are taking effect, we assign jobs. You listen to lung sounds, you check BP continuously (doing that manually sucks, btw), and I’ll place the tube. I actually had to attempt the intubation twice thanks to Dr. Frankenstein’s suture job on the tongue. Ugh, that still makes me mad. Thankfully, the tube was placed on the second pass and we were able to get his sats up.
Now we reassess our situation, our patients, and our supplies. We are currently bagging an adult ANA soldier who has been sedated and paralyzed for transport due to airway control, we have 3 other patients, one who is an urgent surgical due to a GSW to his foot with loss of sensation and pulses to the extremity, and two other very minor patients that require nothing more than a bandage and some Motrin. Oh and “Dust Off” will be here in 45 minutes. Great. We just turned this little mud hut into an ICU. Hope we don’t get mortared tonight.
Thankfully no rockets or small arms fire bothered us that night. Unfortunately, our priority 1 patient wasn’t doing so well. His BP continued to fall and he was still bradying down even with fluids and pressor infusions. We kept him sedated and hopefully as pain free as possible before be died. But he didn’t make for the helos to take him to BAF for more definitive care. The other patient did and I am sure he was fine.
When we brought the other pt out to the HLZ to load our pts up into the helos, one of the medics asked me where the GSW to the head was. Sorry man, he didn’t make it. He just looked at me for a minute then he understood and took report on the other. The interesting thing about this portion of the event was that it was all done in almost complete darkness with just NVGs and good direction from the flight crew. As the birds take off and we could no longer hear them, I take off my NVGs and just look around. I was standing in the middle of the huge HLZ in the middle of the night with almost no sound. It was like being on the moon. A bit surreal to say the least.
We found out some interesting information from one of our “terps”. He said he was talking with the ANA medic who initially took care of the GSW to the head. Apparently he ran out under fire to grab the guy and pulled him to safety. He also made a second trip out there to pick up a rather large chunk of this guy’s brain that was on the ground and proceeded to stuff it back into the cranial vault. I know what you’re thinking. WTF? We were told he had to appreciate the small victories over there. I was just happy that he was serious about being a medic. After all, he did risk his life to pull him to safety.
The positive that came out of this experience was that it was my second successful intubation in country and more importantly that we worked well as a team to get the job done. Additionally, I was complemented by everyone on for my “trauma skills”. It made me feel good to hear that. No one likes to lose a patient, but you have to do the best you can for everyone and learn from your experiences. I think this was the situation at solidified my title as “Doc”. And the “Doc” vs rank is another story…
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