Accessibility and affordability of extra-durable alloys conceived over the past several decades have change warfare, and the pattern of injuries we see in war. Flak jackets and Kevlar helmets are relatively impenetrable to small arms fire or small fragments from IEDs. High velocity rounds will go right through a Kevlar helmet, and we have seen a patient with an AK-47 round lodged in the middle of her brain - and it will likely stay there for the rest of her life. Likewise, direct hits from explosive devices of nearly any kind are mostly fatal from despite these protections.
In general, there are more survivors, or rather, survivors per servicemember attacked, then there were in conflicts as recent at Vietnam. This is largely due to improved protective devices (eg, armored vehicles, kevlar helmets, flak vests) quick access to medical care. Tactical superiority plays a role, but in Iraq and Afghanistan, the guerrilla warfare and use of suicide bombings have negated much of the conventional military advantage. Unfortunately, explosions which would have killed servicemen in the past now leave many with amputations, and many more with traumatic brain injury (TBI) and secondary, or coexistent post-traumatic stress disorder (PTSD). The DoD has made large investments in medical personnel and research in this area, but the treatment of TBI is still underdeveloped.
We have several patients in the hospital at any one time with TBI. Usually, this is from proximity to an explosion, but can be vehicular accidents, falls, or brawls. We are largely not equipped to handle these patients here, and they are sometimes the toughest patients to properly classify. For example, while it is quite clear that patients who have brain surgery for a concussive injury and subsequent brain swelling are to be stabilized, and then sent home, and patients with mild/distant exposure to explosives who do not suffer concussions and pass a TBI screening test should be able to stay in theater; it is difficult, however, to discern how to triage those in the middle. There are always soldiers who have a concussion and clear post-concussive anxiety who plead to stay here with their squad. And for each of these, there is another with no concussion who seems fine and pleads to leave (this includes malingerers, and there are some of those too). It is not an easy judgment call; determining who should be sent home for priority medical care, and who is fit to return to duty.
The other night, I think that we saw the results of one who slipped through the cracks. This gentleman was 40 feet from a rocket blast, and though he had no clear injuries (behind the wall), he was shaking like a leaf and had a massive headache. His CT was normal, and brain was not bruised, but it turns out that he has a history of PTSD, and related headaches, from exposure to another explosion in an earlier deployment. After years of behavioral therapy he somehow garnered approval to return to theater, and then he gets hit again. His nerves were fried, and one could see months and years of work unraveling.
He insisted on returning to his unit. He wasn't my patient, so it wasn't my decision - though it never really is the doctor's decision, as the commanding officer makes the final call - but I do wonder if something else is going to happen to him, or that he'll go unhinged if/when it does. We have to do better with this here, and when he returns to the US, and is expected to hold down an honest job, and get along with others in a world surreal to his own.
Friday, April 30, 2010
Thursday, April 29, 2010
MWR
Bob Hope don't come around much anymore.
No, there are traveling entertainers, of one variety or another, but haven't seen the big names around here. Since arriving, Bad Company, the Zac Brown Band, somebody-Whorley, 1/2 of the cast from a TBN show about motorcycle ganges, and "The World's Fastest Rapper" have made their appearances. This is a picture of the Hooters girls. [Note their variable reactions to the skull trauma on the scanner]. They were quite popular, as were the Dallas Cheerleaders.
The USO started off the morale campaign for soldiers, deployed, and otherwise, in 1941, and is probably most famous for the Camp Shows they sponsored to back defenses in the Pacific and Europe in WWII. Now their reach has grown to include access to communication back home, and ocassional sundries (ice cream, shaving kits, dog tags for kids, etc). They even sponsor a program at the hospital where they will record a DVD of the deployed parent reading a book for their children. I did this once, but I over-zealously attempted to read too much at a time (the final chapter of the Percy Jackson book we were reading together). My ambition left the kids with a video the top of my head as I tried to read the final 25 pages before my time in the video booth expired. Live and learn.
The USO started things in partnership with the DoD, and now the DoD has it's own section called the MWR which stands for Morale, Welfare and Recreation. So, there is an entire DoD mini-budget for gyms, movies, concerts, computer access to augment that which was the backbone of the USO. As I connect to the internet daily from this MWR computer to write my blog, check email or connect with family on Skype, I am definitely benefiting from the resource. And again, I am humbled by the set of tools, psychological distractions, as they are, which those before me had to suffer this (and worse) same warish banality.
The USO started off the morale campaign for soldiers, deployed, and otherwise, in 1941, and is probably most famous for the Camp Shows they sponsored to back defenses in the Pacific and Europe in WWII. Now their reach has grown to include access to communication back home, and ocassional sundries (ice cream, shaving kits, dog tags for kids, etc). They even sponsor a program at the hospital where they will record a DVD of the deployed parent reading a book for their children. I did this once, but I over-zealously attempted to read too much at a time (the final chapter of the Percy Jackson book we were reading together). My ambition left the kids with a video the top of my head as I tried to read the final 25 pages before my time in the video booth expired. Live and learn.
The USO started things in partnership with the DoD, and now the DoD has it's own section called the MWR which stands for Morale, Welfare and Recreation. So, there is an entire DoD mini-budget for gyms, movies, concerts, computer access to augment that which was the backbone of the USO. As I connect to the internet daily from this MWR computer to write my blog, check email or connect with family on Skype, I am definitely benefiting from the resource. And again, I am humbled by the set of tools, psychological distractions, as they are, which those before me had to suffer this (and worse) same warish banality.
Wednesday, April 28, 2010
Me myself and I
Young people are spoiled. Spoiled by the lack of responsibility, boundless energy, and the naivete to venture boldly down any given path. The aged are spoiled with wisdom, avoiding futile forays, and handling responsibility efficiently, which is necessary given the lack of energy. Its too bad you cannot get these life advantages in tandem.
Starting a family and then working to support them is sacrificing selfishness. It is well worth what is given up, but it is easy to forget defining characteristics, habits, and interests of the man alone.
I communcate with my family daily; usually by email, often by telephone, and sometimes by videoconferencing (Skype). This still leaves, what seems to me, anyway, an enormous amount of time to spend by myself. Reading comic books, writing poetry, mastering Kung Fu, collecting scorpions, whathaveyou. Some people make new friends, and spend their waking moments drinking coffee in the company of their new D-BFF (deployed-BFF). In these 4 decades though, I have made plenty of friends, and right now, I prefer to spend time with myself - the me that I haven't seen much of since the 10 years of medical training and kids started. And in between private attempts to impersonate Dave Matthews on the Persian guitar I have (so far) commondeered, or mastering the eagle pose during my late night physical fitness, there is (perhaps, dangerously) sufficient introspection time, during which I have drawn through 2 or 3 steno pads a complex soup of matrices, lists, ideas and doodles.
That is the way deployment to this place is, at least if you can keep your head square. You work like mad. To exhaustion. You see things that will destroy your faith in humanity, if you let them. But you don't because you cannot. So, you compartmentalize the horror. Leave that when you go home to your trailer. Take the time you have with yourself and capitilze on the beauty of life. Buff and polish your body and soul, you must. Use the terrible suffering you witness to give the relative ease of your life perspective and lead you to greatness. That, or kick back with your D-BFF.
Starting a family and then working to support them is sacrificing selfishness. It is well worth what is given up, but it is easy to forget defining characteristics, habits, and interests of the man alone.
I communcate with my family daily; usually by email, often by telephone, and sometimes by videoconferencing (Skype). This still leaves, what seems to me, anyway, an enormous amount of time to spend by myself. Reading comic books, writing poetry, mastering Kung Fu, collecting scorpions, whathaveyou. Some people make new friends, and spend their waking moments drinking coffee in the company of their new D-BFF (deployed-BFF). In these 4 decades though, I have made plenty of friends, and right now, I prefer to spend time with myself - the me that I haven't seen much of since the 10 years of medical training and kids started. And in between private attempts to impersonate Dave Matthews on the Persian guitar I have (so far) commondeered, or mastering the eagle pose during my late night physical fitness, there is (perhaps, dangerously) sufficient introspection time, during which I have drawn through 2 or 3 steno pads a complex soup of matrices, lists, ideas and doodles.
That is the way deployment to this place is, at least if you can keep your head square. You work like mad. To exhaustion. You see things that will destroy your faith in humanity, if you let them. But you don't because you cannot. So, you compartmentalize the horror. Leave that when you go home to your trailer. Take the time you have with yourself and capitilze on the beauty of life. Buff and polish your body and soul, you must. Use the terrible suffering you witness to give the relative ease of your life perspective and lead you to greatness. That, or kick back with your D-BFF.
Tuesday, April 27, 2010
Watch your 6
The sign seems stupid. If it were in your neighborhood, it would be guilded and a little overbearing. It has amazing power here. Very simple, it states, alone on the side of the road: "Complacency Kills."
Unfortunately/fortunately, there is no conventionality to this war. The evil hajis just launch rockets into the air and run--for they certainly cannot maintain any position and have hopes to continue breathing--hoping they land on someone's head. Most of the time, they miss the heads and just make a bang. Once in a while they reach the statistically inevitability, as that room of chimpanzees typing Shakespeare, and someone walks under a falling ordinance. The bastards do this to the good hajis, and they do this to us. There are well-fortified, usually permanent structure bases, like here. And there are easy targets; isolated, undermanned FOBs (forward operating bases). This is entirely a guess, as I have no official knowledge of this either way, but I gather these are lower-yield, easier targets lacking much of the high-tech capacity to quickly hunt down the would-be murderer(s).
We get trauma triplets flown in here at a steady, but random pace. Always 3. Your guess is as good as mine as to the consistency of this phenomenon. One patient either dead, or near dead with fatal injuries, the next with completely recoverable soft tissue shrapnel injuries, and a third, perhaps with a concussion, otherwise, esssentially, untouched, but suffering from PTSD, regret and denial, and most poignantly, a sense of responsibility failed. What do you say to the 19 yo kid who in the midst of a chuckle, took a bite out of his burrito, while, in great non sequitur, the exploding fragment ripped through the neck of his dining companion; and who then, futilely, but determinedly, held this young carotid together with his hands, as he became soaked with the fleeting life of the other? We had another RPG meal-time attack come in the other night. The surgeons spent all night repairing the mascerated young sargeant as his 2 comrades waited in angst. And after expending the reserves of the blood bank, and satisfied with establishing normal blood pressure and heart rate, they then declared him stable enough to have a CT scan of his brain. Unfortunately, the talking and purposeful movements the patient made prior to the surgery belied the nonrecoverable fatal brain injury which only now became evident on film.
This is the only way the terrorists can operate, as we whip them on every "conventional" level, but it is cowardly nonetheless. Cowardice and desperation go hand-in-hand and lead to these essentially unpredictable, and unpreventable actions. We have safeguards to prevent all that we can: mortar shields, communication systems, air defense and surveillance. All of this is what limits the effectiveness of their cowardly cunning. Any target cannot prevent all that is viciously random in this nature, however, so we must remain vigilant. Analagously, in the US: wear your seatbelt, and watch where go at night. Complacency kills, so watching my 6, best as I can.
Unfortunately/fortunately, there is no conventionality to this war. The evil hajis just launch rockets into the air and run--for they certainly cannot maintain any position and have hopes to continue breathing--hoping they land on someone's head. Most of the time, they miss the heads and just make a bang. Once in a while they reach the statistically inevitability, as that room of chimpanzees typing Shakespeare, and someone walks under a falling ordinance. The bastards do this to the good hajis, and they do this to us. There are well-fortified, usually permanent structure bases, like here. And there are easy targets; isolated, undermanned FOBs (forward operating bases). This is entirely a guess, as I have no official knowledge of this either way, but I gather these are lower-yield, easier targets lacking much of the high-tech capacity to quickly hunt down the would-be murderer(s).
We get trauma triplets flown in here at a steady, but random pace. Always 3. Your guess is as good as mine as to the consistency of this phenomenon. One patient either dead, or near dead with fatal injuries, the next with completely recoverable soft tissue shrapnel injuries, and a third, perhaps with a concussion, otherwise, esssentially, untouched, but suffering from PTSD, regret and denial, and most poignantly, a sense of responsibility failed. What do you say to the 19 yo kid who in the midst of a chuckle, took a bite out of his burrito, while, in great non sequitur, the exploding fragment ripped through the neck of his dining companion; and who then, futilely, but determinedly, held this young carotid together with his hands, as he became soaked with the fleeting life of the other? We had another RPG meal-time attack come in the other night. The surgeons spent all night repairing the mascerated young sargeant as his 2 comrades waited in angst. And after expending the reserves of the blood bank, and satisfied with establishing normal blood pressure and heart rate, they then declared him stable enough to have a CT scan of his brain. Unfortunately, the talking and purposeful movements the patient made prior to the surgery belied the nonrecoverable fatal brain injury which only now became evident on film.
This is the only way the terrorists can operate, as we whip them on every "conventional" level, but it is cowardly nonetheless. Cowardice and desperation go hand-in-hand and lead to these essentially unpredictable, and unpreventable actions. We have safeguards to prevent all that we can: mortar shields, communication systems, air defense and surveillance. All of this is what limits the effectiveness of their cowardly cunning. Any target cannot prevent all that is viciously random in this nature, however, so we must remain vigilant. Analagously, in the US: wear your seatbelt, and watch where go at night. Complacency kills, so watching my 6, best as I can.
Sunday, April 25, 2010
Near but so far beer
I like my beer. At some point, likely during gustatory nerve-washing in college, I developed a taste for the stuff, and now, I do enjoy a cold one as much as anybody. Beers of all kinds have their place, but I favor the ice-cold-pilsner-served-up-with-pizza-beer, and, most preciously, the rich-snack-in-itself-porter/stout (preferably imbibed in a tall, walnut booth within a dim bar accompanied by one who has an equal appreciation of that moment). So, I guess I miss beer, and I miss the beer-experience.
We do a fair assortment of non-alcoholic beverage here. The hospital DFAC even offers something from Germany called Astra, which is completely detestable, and gold-labeled Coors, which is tolerable when taken immediately from the freezer where it must reside for at least 20-30 minutes. These "beers" are free. The BX about 1 mile from where I work and sleep has the finest selection to include Lowenbrau and Becks. If you are going to drink near-beer here, those are undeniably the best, and can be had for $1 a piece. [I usually buy no more than a six pack at a time as I have to walk with it for a mile, and access to a refrigerator only at work].
There is a pizza trailer/restaurant called Ciano's, which serves mediocre pizza, and unsavory Italian food (though I have a high standard), and if you coordinate things properly, you can enjoy a cool pauci-Lowenbrau with some passable pizza. If you close your eyes, you can imagine that you are back in the US, but the hordes of M-16 toting soldiers eating their own personal 8 slices decked out in full battle gear belies this mirage quickly. Plus, there is no warm-fuzzys after this near beer. That is the near beer-experience
I am a scientist but unfamiliar with the chemistry involved in making beer without alcohol. It likely is not very difficult, but there is just something wrong about removing the fermentation of dextrose from the final product. More is lost than just the alcohol content. The taste suffers, but powerfully (and strangely) the experience is diminished. And maybe this is psychological, and I still drink it. That is what we have.
We do a fair assortment of non-alcoholic beverage here. The hospital DFAC even offers something from Germany called Astra, which is completely detestable, and gold-labeled Coors, which is tolerable when taken immediately from the freezer where it must reside for at least 20-30 minutes. These "beers" are free. The BX about 1 mile from where I work and sleep has the finest selection to include Lowenbrau and Becks. If you are going to drink near-beer here, those are undeniably the best, and can be had for $1 a piece. [I usually buy no more than a six pack at a time as I have to walk with it for a mile, and access to a refrigerator only at work].
There is a pizza trailer/restaurant called Ciano's, which serves mediocre pizza, and unsavory Italian food (though I have a high standard), and if you coordinate things properly, you can enjoy a cool pauci-Lowenbrau with some passable pizza. If you close your eyes, you can imagine that you are back in the US, but the hordes of M-16 toting soldiers eating their own personal 8 slices decked out in full battle gear belies this mirage quickly. Plus, there is no warm-fuzzys after this near beer. That is the near beer-experience
I am a scientist but unfamiliar with the chemistry involved in making beer without alcohol. It likely is not very difficult, but there is just something wrong about removing the fermentation of dextrose from the final product. More is lost than just the alcohol content. The taste suffers, but powerfully (and strangely) the experience is diminished. And maybe this is psychological, and I still drink it. That is what we have.
Saturday, April 24, 2010
Screwed
This picture from a radiograph of one of our patients shows a bolt lodged adjacent his R maxilla (upper jaw/face). I am sure if there were a little more force, it would have traveled through the maxilla, and likely into the brain. This is a recent wound, and he was transported quickly to the US after stabilization, so it is tough to tell if this was a septic explosive device or
not - his infections, and he likely has them brewing, are yet to come.
This reminds me: the surgical paradigms here are thus altered to account for this kind of nonsense. Trauma patients from auto wrecks in the US, for example, have entirely different injury patterns and are not taken back to the OR for the large number of repeat washings as they need to be here. This took me some getting used to. Just imagine the ballistics. With a projectile, meant to explode and inflict damage hits the ground, the wall, the roof of a structure, there are various perimeters, roughly circular, which define the injuries to be expected. In a car wreck, the force is pretty well vectored one direction - thus, people looking at a car driving away from them into something are much less likely to become injured than people watching a car driving toward them into something. Follows the laws of physics, but not something you typically think about in daily care of patients in a civil society. I quickly assimilated into the habit of counting bullet holes and matching wounds. When I take care of leukemia patients, I rarely think of these types of things.
Friday, April 23, 2010
Grand central horror
The battle injuries in Iraq come less frequently, thankfully, than they used to come. There are still plenty of IEDs, snipers, and injuries from accidents (see Thursday's blog); more than any of us would like to see. Nonetheless, there is no denying that the bulk of the battle injuries come from Afghanistan, just as CNN reports. During Volcanogate 2010, we have been the epicenter for all patient traffic to the United States from both Iraq and Afghanistan. Everyone going out has been through this facility, and now that the volcano dust is diminished, we are shipping out the backlog of folks from throughout the AOR to LRMC (Landstuhl Army Regional Medical Center).
We had a medic who was shot in the head while tending to a soldier who sustained a minor injury. When he arrived, he looked as though his brain would herniate, and he would die. He had a revision craniectomy, and his CT improved, while he showed complete normal function of both hands and feet, and normal speech. Another young man fell prey to an IED and lost both of his legs and most of his fingers. His inhalation injury, incurred from inhaling the burning of his own flesh and surroundings, bought him intubation, but he answered my questions appropriately, blinking and nodding his head, and giving a thumb up. These were the more severe, but we had dozens come through, most of them giving a thumb up, if they had one to give.
We have launched several missions with planes filled with patients bound for the states. All CCAT teams based in Germany were here to assist with evacuation, and we were able to move patients smoothly back to the States. Now with the shorter flight to Germany now back open again, the CCATTs have scaled back and the mission frequency has diminished. We are, however, still full of patients. Sick ones. I am anxious for the pending mission to get these boys home, or one step closer to it, and out of limbo, where resources are rationed, manpower is relatively fixed, and it is starting to get hot.
We had a medic who was shot in the head while tending to a soldier who sustained a minor injury. When he arrived, he looked as though his brain would herniate, and he would die. He had a revision craniectomy, and his CT improved, while he showed complete normal function of both hands and feet, and normal speech. Another young man fell prey to an IED and lost both of his legs and most of his fingers. His inhalation injury, incurred from inhaling the burning of his own flesh and surroundings, bought him intubation, but he answered my questions appropriately, blinking and nodding his head, and giving a thumb up. These were the more severe, but we had dozens come through, most of them giving a thumb up, if they had one to give.
We have launched several missions with planes filled with patients bound for the states. All CCAT teams based in Germany were here to assist with evacuation, and we were able to move patients smoothly back to the States. Now with the shorter flight to Germany now back open again, the CCATTs have scaled back and the mission frequency has diminished. We are, however, still full of patients. Sick ones. I am anxious for the pending mission to get these boys home, or one step closer to it, and out of limbo, where resources are rationed, manpower is relatively fixed, and it is starting to get hot.
Subscribe to:
Posts (Atom)
