Week 20 and 21

I swear I have the worst luck. The other day I was
going to the ER to work a shift and as I was walking
down the hall I noticed everyone was running. That is
never a good sign in this business. I picked up the
pace and when I turned the corner there was absolute
chaos. The ER was right in the middle of a 20 patient
mass casualty from a suicide bomber. I put on my
scrub top and protective glasses and went to find some
work. I picked up a 16 y/o boy who had burns and
shrapnel injuries to the front of his body. He was
awake and moaning. His left chest and left thigh had
a puncture wounds and he had multiple small
lacerations all over him. His blood pressure was low
and his heart rate was high. We started giving him
oxygen and IV fluid. His left wrist had an arterial
injury and open fracture. When we rolled him over,
there was a piece of burnt, shattered human rib under
him. There was some difficulty controlling the
bleeding, but SRA Caldwell put on a great pressure
dressing and the bleeding was slowed. That is so
disturbing to pick up a piece of a murdering suicide
terrorist and then treat their victims. The next
patient I had was an adult male with an injury to his
eyeball. He had blood visible in the front part of
his eye (anterior chamber), but was otherwise stable.
Both patients went to CT scan and then the OR after
the more critical patients were operated on. The
third patient I had was an American soldier who had an
isolated ankle injury. When it was all over, no one
died although there were some very serious injuries so
overall a good day considering the situation.

When it was over we had a critical incident debriefing
and then we started seeing patients again like nothing
had happened. People were sitting around eating lunch
with their feet up talking about Brett Favre possibly
playing football again and stuff. Crazy isn’t it. Oh,
and here is some good news; The surgeon who has
turned me into a complaining blogger has finally left
the country, so the whole mass casualty ran smoothly
and no one fought over anything. Amazing.

The last trauma of the day was a 3 person vehicle roll
over. No one in Iraq wears seatbelts as far as I can
tell so of course these guys were terribly injured.
My patient had a severe head injury. He had somehow
rolled himself over on the stretcher during the
helicopter transport and was laying on his stomach
when he arrived. I listened to breath sounds while
the translator, God bless her, told him to roll his
ass over so we could help him which he did. When he
rolled over we were all shocked that he was alive let
alone conscious. His skull was obviously cracked wide
open with cerebral spinal fluid mixed with blood
running out of his partially amputated ears. He was
confused (no kidding) and uncooperative (go figure) so
I had to sedate him and intubate him. It was a bloody
mess from him swallowing all of the blood from his
facial injuries. Once that was done we got his
vitals, IV access, ultrasound and chest x-ray. It was
all very smooth. He then went to CT scan and WOW what
a terrible head injury. There was air in his brain,
blood in and around the brain which was swollen and
his skull was mush. His face also had numerous
fractures. I admitted him to the ICU for the
neurosurgeon to work on him, but his prognosis is not
good. I will check on him later this week and update
you.

The rest of the week I worked in my clinic. Not much
to report there and since it is an intelligence unit,
I couldn’t report much anyway. We get bi-weekly
briefings on the unit’s efforts and I get to see quite
a bit of what we do. Between the unmanned aerial
systems and the RC-12 aircraft, we provide a great
deal of very useful intelligence on the location and
activities of the enemy. We also directly support
ground operations with overhead surveillance. Again,
I wish I could tell you more. I am very proud of this
unit and they do an amazing and important job.
Working in the giant hanger that our battalion and our
aircraft are based in, you have a tendency to forget
about ground war going on. We see a lot of statistics
and pictures of captured bad guys, but the violence,
loss of life and the tragedies that are a part of war
are sometimes forgotten. That is why I have been
forcing myself to keep working at the hospital and to
continue the helicopter missions; to keep a
perspective and to try and help soldiers and the
innocent civilians and yes, even sometimes the enemy.

It would be very easy to ‘hide’ in the clinic and not
see what is going on. I could just go in, check
e-mail, see the patients that trickle in and the
occasional flight physicals, but is that really fair?
It seems selfish to not try and pull your weight as a
physician in this setting. There is a level one
trauma center a quarter mile away. Yes, they are
fully staffed and would probably never miss me, but I
try to lighten their load when I am there and maybe
just show them some support. I have had the
opportunity to use the training the Army has provided
me and I feel that I have made a difference in many
people’s lives and have been able to help people from
all backgrounds in this conflict. It has allowed me
to grow as a person, a physician and a soldier.

One of the things I will remember the most from this
deployment happened just a few days ago. I admitted
an Iraqi soldier who suffered a massive stroke. While
I was on the ward giving the nursing staff and doctors
a verbal report, I noticed a medic holding an Iraqi
child. He was about 2 years old and had a scalp
incision that was stapled closed. I asked what
happened to him and the nurses told me that his father
was a terrorist and we attempted to kill him with air
attack. Unfortunately, he escaped and his family was
home. I am not sure if anyone else survived the
explosion, but no one has come to visit the child and
he is wounded, alone and scared. I watched the medic
hold him and comfort him. I had the strongest urge to
hold my own son again and when the medic stood up he
saw me looking and asked if I wanted to hold him. I
took him for a while and tried to hold him and make
him comfortable. I found that I had forgotten how to
do it. I had not held a child in 6 months.

I sat there holding this little boy, looking at his
head wound and looking into his eyes. He looked so
innocent. It was a confusing wave of emotions. Here
was an innocent child who was nearly killed and
seriously wounded by our forces in an attempt to kill
his father. Of course his father was trying to kill
our soldiers. Did our intelligence unit provide the
location of this child’s father? Had I worked his
father in the ER at some point or had I worked on one
of his victims from an IED or house bomb. Would this
child some day grow up to try and kill people or would
he grow up and participate peacefully in a democracy.
Or is he just a little boy who was wounded in a
strange and confusing war and needed to be held by
someone…….what a world.

Mass Casualty trauma bay, flight medic report

Another Mass Casualty treatment area

Mass Casualty, heard injury arrived prone

Head Injury patient, rolled over and collar placed

Head Injury patient intubated, CSF from ears

NERD!! Reading book on RC-12

Week 19 and 20

Well I figured the quiet couldn’t last for long. It
has been a busy couple of weeks.
I was under no illusions that the so called lull would
last. I have worked several ER shifts since the last
update and I have some cases to share with you as well
as some photos of some other lighter stuff.

One of the shifts last week, I was the supervising
physician on a trauma case. An Iraqi male wrecked his
motorcycle and had a pretty severe head injury. He
was not wearing his helmet and the only injury he has
was to his head and face. So before I begin, I would
like to remind you of last weeks update where I told
you about the surgeon who has single handedly removed
everything that we as emergency physicians enjoy about
our specialty. Please keep him in mind as I describe
this case and when I describe the next one. Luckily
when the patient arrived, most of the surgeons were
all tied up in a case and could not make the trauma
call. When the patient arrived, he was unresponsive
and had a plastic oral airway in. I immediately
intubated him, listened to his lungs while IV’s were
placed and a blood pressure was obtained. We then
examined him, rolled him, got a chest x-ray, a bedside
ultrasound, a foley catheter, and then took him to CT
and found a intracranial bleed from the head injury.
It took 8 minutes from when he arrived till CT and
then a total of 12 minutes till I called the
neurosurgeon for consultation. He had a bolt, (an
intracranial pressure monitor) and was in the ICU in
less than 30 minutes. This is the way a trauma should
be run. The “ER Doc” as we are called, receives a
patient, resuscitates them, stabilizes them and then
calls a specialist to disposition them. In a
collegiate setting, the surgeon works in tandem and
transits the patient to the OR and or ICU. But every
now and then you run into an “old school” surgeon who
does not respect emergency physicians or think he/she
needs them. These dinosaurs of medicine interrupt the
flow of the well trained and experienced ER staff and
cause havoc and chaos in some silly attempt to
demonstrate some sort of antiquated medicine pecking
order. Let’s discuss another case.

A young American soldier arrived to the ER on a
Blackhawk from an IED injury. He had been initially
seen at the 86th CSH in Baghdad and was already
intubated, partially sedated and stable. This should
have been an easy case of confirming the endotracheal
tube placement, breath sounds, oxygenation and then IV
access, blood pressure, nature if injuries,
medications administered, imaging studies performed
and then treatment if necessary and then admission.
However when this patient arrived, the surgeon whom I
have mentioned decided this stable patient was going
to be his pet project and his opportunity to torture
the emergency physician of the day. I looked at his
tube, the depth of it, then listened to breath sounds
and then looked at his vitals. We began to unpackage
him from his flight and then this surgeon decided that
it was time to interrupt. He wasn’t happy about the
order we removed stuff, the lines we hooked up,
basically anything we did. I kept going and so did
the staff but you could tell he had messed up the
routine flow and we had already lost time. I began to
ultrasound his abdomen and chest and he yelled that
the probe was in the wrong spot, (which it wasn’t) and
the reached over and cranked up the gain on the
ultrasound to the point where the image was washed out
and worthless and then went on to tell me where to
look. He basically untaught everything that I learned
in 4 years of training. The location was wrong, the
image was wrong and the sequence was wrong. I turned
down the gain, took my own images and had to ignore
him to complete the ultrasound. Then he wanted us to
turn off his sedation to do a neurological exam before
he was even rolled to look at his back and take a
chest x-ray. He then wanted to extubate (remove the
endotracheal tube) before he even had a CT scan for
his obvious head injury. Maj Delforio, who is the OIC
of the ER was able to distract him long enough to get
him to CT. He ended up with a skull fracture and a
small intracranial bleed. He should have remained
intubated and then had his numerous shrapnel injuries
washed out in the OR and then weaned off his sedation
and extubated in a controlled fashion in the ICU. But
this surgeon, poo-pooed his injuries, forced us to
extubate him in the ER (which is crazy) and then when
the radiologist looked at his CT, found the bleed,
yelled at the staff for removing his tube before he
could go to the OR. Total time in the ER (2 hours).

I know that in my previous post “perspectives” that I
remind people to put things in perspective so that
they wouldn’t complain about trivial things, but this
situation needs some complaining. This guy is
literally hurting people. You are probably asking why
somebody doesn’t do something about it and so am I.

I am actually assigned to this base as a flight
surgeon in a clinic with a military intelligence unit.
I happened to be a residency trained emergency
physician and when I arrived here I volunteered to
work in the ER to help patients and to decrease the
work load on the staff in the ER. This one person had
become such a hindrance to treatment and to the flow
of the patient care that the other volunteers in the
ER have stopped showing up and the ER staff has become
very unsatisfied with their job. This is a real shame
because there is real opportunity to grow as a
physician and to help wounded soldiers and innocent
civilians.

Whew. OK, now that I have that out of my system I
would like to talk about another case and then about
some fun things I did the last 2 weeks.

A young American soldier was injured when his vehicle
was struck by an explosive device. He was seat belted
in his vehicle, wearing his body armor and helmet and
his Oakley brand ballistic sunglasses. The shrapnel
fragments penetrated the glass and it struck this
young man. Because he wore all of his gear and was
wearing a seat belt, the only injuries he sustained
were to his face. He has some minor burns, abrasions
and shrapnel punctures to his face. Amazingly his
eyes were uninjured thanks to his Oakley sunglasses.
I am not trying to sell this product, just that I am
amazed at how effective they are. Included in the
photos is an image of the 3-dimensional reconstruction
of his facial CT scan showing the hundreds of tiny
glass and metal fragments embedded in his face. If
you look closely you can see how his eye sockets are
completely unaffected. Also I included a photo of him
in the ICU to show his facial injuries. This is a
classic case of why you wear your protective gear. He
was a very nice kid and even injured he was very
professional and tough. I love helping people like
this.

The outdoor pool opened up last week and a group of us
have gone a few times for some sun and for barbecuing.
This is usually the group I hang around from the
hospital and from the flight line. I also have sat on
the roof of a building near the flight line a few
times drinking some iced tea and watching the planes
come and go. Overall, things are good and I having
nothing to complain about. I hope this post wasn’t
boring or uninteresting, but since a lot of traffic I
have been getting is from health care professionals and
people interested in the field, I thought they might
understand the situation and want to hear about it.
Thank you to all the people who have posted comments
and linked this site to theirs. I will keep an eye
out for interesting cases the next few weeks and don’t
worry I won’t quit it’s not my style

See you soon.

3-D CT scan of shrapnel wounds

Wear your eye protection!!

Paul and I looking tough. . .

Sitting on the roof