Saturday, October 14, 2006
Battlefield Medical Care
Trauma treatment of soldier
Letter From A Battlefield Hospital
Scott D. Barnes, LTC, MC, USA
To All, 08 DEC 2005
Well, as promised, with this letter I have kept my commitment to do better in keeping you informed of what I was doing over here in Iraq. Since I had only sent one letter previously, with this update I have doubled my correspondence. Again, if there is anyone else you think would want to get a copy of this letter, please feel free to pass it along.
I had every intention of trying to get this out just around Thanksgiving but very soon after that holiday, things seemed to pick up at work and I have just been trying to keep pace with the influx. November has been an interesting month. Certainly not as busy as October but patients would come more in waves than a steady stream. During the month of October, the 86th Combat Support Hospital (CSH) was the 3rd busiest trauma center in the world! You read that correctly, only the trauma centers in Miami and Los Angeles did more work than we did. Just think of all the trauma hospitals in New York, Chicago, Baltimore, Dallas, Philadelphia, Washington DC, and those in Europe, Asia, and Central/South America - most of which have 5-10 times the number of staff then we have here.
It's amazing what you can get done when you eliminate the burdensome task of JCAHO (hospital regulating organization) and the exponentially expanding administrative tasks that have grown like Kudzu (weed that has overtaken much of the highways in the southeastern US) as they choke off efficient patient care. That, and the fact that if you work 24 hours a day and live in the hospital while being locked down to about two square blocks, seems to help us see more patients.
This is medical and surgical care practiced the way that many doctors dream. You see problems, diagnose the condition, quickly plan the operation, and you just do it. Patients don't wait, doctors don't wait, OR staff doesn't wait. It is amazing! We all love it and if it weren't for missing our families or dealing with the occasional rocket and mortar attack, most of us would not want to leave.
I have had the privilege of being adopted by the neuro team. We have world class care here. COL Ecklund is the chief of the neurosurgery program at Walter Reed, COL Ling is the only neuro-intensivist in the entire department of defense (he actually works at Johns Hopkins neurosurgical ICU teaching most of the military's critical care and neurology residents as they rotate through), and COL Mork is the anesthesiologist dedicated to the neurosurgical cases. As a number of head injuries involve eye injuries, it is a somewhat natural pairing.
This has afforded me an incredible opportunity to be involved in quite a number of neurosurgical cases. COL Ecklund has shown me how to drill some burr holes in the skull and screw on plates to hold the bones after the case as well as closing up the scalp incisions over the craniotomy at the conclusion of the case. I can operate on the eyeball and use suture much finer than human hair, but to be a surgical assist to such a master as COL Ecklund has been inspiring.
These soldiers, civilians, and even prisoners have no idea how fortunate they are to have such skilled hands at work in their case. The integration of the whole team approach is one of the greatest factors in setting this experience apart. Within minutes of a patient hitting the doors of the emergency room you have a general surgeon, neurosurgeon, oral-maxilla-facial surgeon, urologist, orthopedic surgeon, and an eye surgeon all examining and conferring on the way to best care for a patient. The nursing staff, the OR staff, the radiology techs...everything...it all just appears. Sort of like magic, a couple of doctors get called, word starts to get out and the machine starts working. The medics start drawing blood, the radiology techs arrive and start shooting pictures, the administrative personnel (yes we do have some!) start preparing the necessary paperwork, the anesthesia providers coming around like all of the other doctors, blood products from the blood bank start to appear, and often the chaplain arrives.
It really is beautiful to watch if you have a chance to sit back and really see what is going on. Too often we don't see it because we are knee deep into the moment. We need to be reminded by those outside. Last month, the commander of one of the MP brigades asked to have a service for the OR/ER personnel that have meant so much to this unit over the duration of their deployment. This unit had been hit so hard week after week. Almost 40% of their members have been impacted by injuries. They had been such frequent fliers that we have become brothers in this struggle; the unit commander and sergeant major often join us in the operating room as we work on their men. This closeness and unity of purpose is not commonly seen between the medical corps (docs and the like) and the line units (real soldiers)...but in this setting we are brothers.
These line units no longer see us as detached, primadonnas who sit in a luxury white hospital while they train in the mud and dirt. They see us in our environment and see the same faces when they come in on Monday morning as when they come in at midnight on Tuesday and again on Thursday night. They ask if we ever get any sleep and how we can keep going. My answer is always the same, "Sergeant, when you are on combat operations, when was the last time you slept and how do you keep going?" When the unit Sergeant Major told me that they do it because they don't want to let down their buddy next to them because he is depending on that help and they do it because they know that if they get hurt, they feel sure that the medical machine will not let them down.
I told him our answer was similar for how we can operate the way we do. I don't want to let down my neurosurgeon or my general surgeon who depend on me for helping with the eyes (a lot of the neurologic function in an unconscious patient comes from the eye exam and in a severely traumatized eye that can be difficult to assess even for an eye surgeon) and I don't want to let down that soldier who puts his life on the line in part because he put his faith in our ability to put him together if he gets broken. We work two sides of the same street but when we meet it is under the most difficult circumstances.
When those young MPs roll in after having been torn up by IEDs (improvised explosive devices) and their lives are in the balance, the family pulls together. The unit leaders come into the OR and the jobs are less defined, you just look for something that needs to be done and you do it. One young sergeant was badly broken and rushed to the OR. The IED had done its intended job and shredded this courageous American everywhere that wasn't covered by body armor. He was dying, but we weren't going to let him go without a fight. He had no immediate eye injury, so I just went to work getting the blood and hanging it on the infusers since those that usually do this were otherwise occupied. We kept pouring unit after unit into him but he was losing it as quickly as we were able to get it in. The trauma surgeon and the vascular surgeon cracked his chest and started going after his injuries to try to stop the hemorrhaging. His heart stopped a number of times. The trauma surgeon held his heart and kept squeezing to aid in circulation while the anesthesiologists were infusing the medications needed to restart the heart.
The two unit commanders were right there voicing their support and praying as they were watching the team. Two major injuries were found in the carotid and subclavian artery, but too much damage had been done, too much blood had been lost, and too much time had passed before his injuries could be repaired. We went through 45 units of blood. His heart stopped 7 times and we were able to restart it 6 times. When it became clear that we would not win this battle and that this young sergeant had gone into that good night, we turned off the machines and monitors, the chaplain stepped forward, and the unit commanders, nurses and doctors closed into a circle and we asked for the Lord's mercy on his soul and for God's peace with the family that will soon find out what we already know.
This hero paid the ultimate price while doing his country's bidding. I walked out onto the hospital roof, which has been my refuge after such cases. I usually stay closer to some cover because I don't want to give snipers any target practice but this time I went over to hang over the rail looking down into the parking lot/patient receiving area. This is where the men usually gather to wait for news on what happened to their buddies (we don't have a waiting room). I will never forget what I saw there. For the strength of the emotion, but also because I have seen it now too many times.
About 30 soldiers hanging out in various groups, some talking, some joking, some smoking, some tossing a football, some catching a few winks, but just doing what waiting soldiers do. LTC T (their commander) walked out to the group who immediately jumped up and gathered around the boss. I couldn't hear what was said from the roof, but I knew that commander had a difficult message to deliver. I didn't have to hear the words, these warriors' actions said it all. Some just stood there motionless, some grabbed their buddies and just let the tears run down their dirt-stained faces, others unable to contain their anger, went to find a wall and began hitting it. The commander and sergeant major moved through their guys, reaching out to each one with a hug or supportive arm.
Sometimes I can put all the damage and suffering behind me; my years in medicine have introduced me to death and in some ways I can detach myself. But to see this effect on his brothers in arms transformed my previously detached self and turned on my humanity. In the ER and the OR, I can be the professional doctor, but on the roof, I become a human again. Under the cover of darkness I feel the pain of what I've seen.
Once the sergeant's body was prepared, his fellow soldiers came through and paid their last respects. This will always be the hardest part of my time here, to see these rough men break down at the sight of their fallen comrade. These leaders and subordinates file past their brother, touching him and paying their respects, shedding their tears, hugging their surviving brothers. Then in a most amazing display of professionalism, they wipe their tears, put on their gear, and walk out of the hospital back to their unit and start their patrols all over again.
So the Sergeant Major asks how can we go without sleep and how can we operate for hours at a time. After seeing the heart of his soldiers, how can we not?
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