Thursday, March 27, 2008

The Boy from Bastion

One of my patients is a 3 year old boy from Helmand, the next province over, who was taken by his father to the British Bastion Air Field Hospital after he inhaled a small bead. It was decided to send the child to the Kandahar Air Field Hospital to have the bead removed.

The little boy arrived by helicopter already intubated. Xrays showed the jelly-bean sized bead nestled menacingly in a bronchus on the right. The child was difficult to ventilate and needed to be bagged by hand for several hours by the ICU nurses. Details of events prior to his arrival were sketchy but it is clear that his airway was very threatened.

I have heard from various sources the agonizing story of how the bead was extracted . There being no pediatric trachs available, the child was tracheotomised with a pediatric endotracheal tube (ETT). The bead could not be coaxed from its position in the airway however, and they returned to the operating theatre the next day to replace the ETT with the smallest adult trach available, whittled down to fit the child. Brief, tense moments of optimism as the bead was manipulated ever closer to the tracheal orifice were repeatedly erased as each extraction attempt failed to hold it for those crucial final seconds needed to deliver it out in to the open.

Again and again it would slide away and with it, the hopes of those in the room. The team of doctors improvised as best they could with the available tools. One surgeon even cut a tiny piece of mesh from the lining of his jacket, forming it in to a little net with which to trap the nefarious round bit of glass.

According to one who was present, the difficulty of the situation was added to by having more people than necessary in the operating theatre — all offering well intentioned advice. This is actually one of the challenges of working together in a multinational medical partnership. Moreover, the surgeons and anesthetists did not know each other well making it harder to offer advice without seeming off-putting. At one point it became virtually impossible to oxygentate and ventilate the child. Several frantic minutes passed before bilateral pneumothoraces were discovered and relieved with needle decompression and chest tube insertion. An orthopedic surgeon proposed passing a suction catheter down under fluoroscopy. To this someone else added the suggestion of placing a needle through the trachea to prevent the bead from tumbling down once it had been lifted close enough to the proximal end of the airway.

And after several hours the bead was finally captured.

Now 10 days later on the ward, the boy often jerks rigidly into an opisthotonic posture, crying out as his muscles from his neck to his toes stiffen painfully beyond his control. And though his eyes are open he does not interact. He seems unaware of the string of bright red, star shaped Christmas lights that the nurses have strung along his bedrails. Gathered into his father’s arms this man and his little son regard each other uncomprehendingly.

Yesterday the American medical team held a barbeque for every one behind the hospital, outside a tent called “The Stand Easy” that opens out on to the airstrip. One of the nurses carried the little boy out to the party, holding him in his muscular arms allowing him to feel the warmth of the afternoon sun. Only a few hundred yards away war planes land thunderously and take off, screaming through a haze of dust and I watch this scene in which frailty exists next to unimaginable power and it leaves me not knowing what to think.

Epilogue to this story:
We started to make plans to discharge the child. I called an Afghan physician at Bost Hospital Lashkar Gah . He was willing to receive the child but he told me to be honest with the boy’s father about the prognosis. The doctor was concerned that the boy’s father not be disappointed with the civilian hospital if the outcome was not going to be good.

It was difficult to explain all this to the boy’s father. He was crushed to learn that his son might never be the same again. Through an interpreter he pleaded with me not to send him to a local hospital and vowed that if he ever had enough money, he would take the boy to Pakistan or India for treatment. The family lived a 5 hour car trip to the west of Kandahar. I asked him if he had been able to let the boy’s mother know what had become of their youngest child. He told me the Taliban had destroyed the cell phone tower in their town and the mother was not fully aware of the child’s situation.

This was a difficult moment for me. Knowing that in Canada extracting the bead would have taken just a few minutes in the hands of a pediatric surgeon with the right tools. Knowing that after an anoxic injury, improvements would be very slow and disappointingly incomplete. Everybody worried that without a supply of enteral nutrition to drip down the NG tube it might be nearly impossible to feed the child enough. And we knew that there was no where else to send him but to the Afghan hospital closer to his home.

Several days later I called the physician at Bost Hospital to find out how the boy was doing. He told me that predictably, after 2 days the father had become impatient with the evidently stagnant neurological recovery and the hospital’s insufficient resources and taken the child home against the doctor’s advice.

If bleak reality is your cup of tea, I refer you to the website of the Senlis Council. Take a look at a report entitled War Zone Hospitals in Afghanistan: A Symbol of Wilful Neglect. The report contains photographs and clinical vignettes from the Bost Hospital where we sent the boy.


Elizabeth Erb said...

Dr. Sherk

This week we have been listening to Alberto Manguel's 2007 Massey Lectures on CBC Ideas.
They are entitled "The City of Words". Stories, he summed up in his final lecture at Convocation Hall, Toronto, help us in several ways:
--help us phrase better questions
--console us
--warn us of the folly of our greed and our willingness "to kill the Philistine"
--help us name our experience
--teach us to be vigilant about the power of our technologies
--help us imagine ways of remaining alive together on this much abused earth.

The stories you are writing on this blog are part of this "City of Words". There is also a "City of God" that helps us in similar ways.

sullip said...

Nice writing Dr. Sherk, and congratulations to CMAJ for publishing your blog. It's nice to read about a side of life in Afghanistan where the emphasis is on saving lives, not taking them.

Unknown said...

I can't say it's great to read stories like this one, but it certainly helps me appreciate the situation in Afghanistan.

There's so much frustration in the NATO world about whether or not we should even be in Afghanistan, and in my opinion the large-scale media misses tragedies like this one which highlight exactly why and when a Western presence is wanted by locals.

I appreciate knowing Canada is wanted in Afghanistan.

Elizabeth Erb said...

I heard President Bush speak to day as he got off the plane in Rumania where he has gone to attend a NATO summit. "We must win in Afghanistan. We can't afford to lose. If we do not defeat Osama bin Ladan in Afghanistan, we will be fighting him in our own lands."

My question is "What does winning against the Taliban look like?" "What is it in the Taliban's world view that permits them to label western democracies as "Shaitan"? "What can we human beings do to stop labelling each other in ways that
give us permission to kill each other?"

Gopher MPH said...

I am struck by a problem often overlooked in dealing with an emergency. Especially when the 'excess' people are all highly trained to deal with the problem but who aren't the ones with their hands immediately on the situation.

In our efforts to 'help', to 'do something', we fear that inaction is worse than anything else. Even when our actions might not really be beneficial. I've had to deal with this - admittedly not in an immediately life-critical situation like this - at work. I do not envy you.

I hope your stay in Afghanistan is beneficial to you and the others there.