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.

Thursday, March 20, 2008

To Kandahar Airfield

At Canada’s forward logistics base near Afghanistan, flags fly at half mast for Trooper Mike Hayakaze, killed by an IED Mar. 2, 2008 near Kandahdar, the 80th Canadian to lose his life in Afghanistan. The flags of Canada, New Zealand, Australia, NATO and the base’s Host Nation flutter in the late afternoon breeze beside a grey granite memorial to all of Canada’s fallen soldiers. One can not help noticing that there is a great deal of empty space on the memorial and it must give pause to every soldier who pays his or her respects at this site to think that their name may be the next on the wall. Behind the memorial are three, 6 by 8 foot patches of arguably the best manicured lawn in Islamdom. Signs invite visitors to walk on them but no one does because their lushness seems too miraculous in this arid country to trample under foot.

The base is a way-station for Canada’s war in Afghanistan. Everybody and everything that is travelling to or from Kandahar Airfield (KAF) passes through this place at some point. Its location is officially classified, although it is actually something of an open secret. Signs every where on the base remind visitors that photography is strictly verboten. In some ways the place has the feel of a summer camp. Each barrack has been given a distinctively Canadian name like Hell’s Gate Lodge (British Columbia) and Joe Batt’s Arm Lodge (Newfoundland). And although the base swarms with soldiers and supplies between troop rotations, it is otherwise an almost torpid, sparsely peopled place where time seems at a standstill. Guardhouses are staffed by two people even though, during my three visits thus far, I didn’t think there was enough work for one. The mess hall, which is open 24 hours a day, has two large screen TVs, one in English and the other in French blaring the day’s newsbytes and hockey highlights in an endless cycle. Mealtimes are easygoing affairs that begin with a large helping of mashed carbohydrate thrust abruptly on to your plate by an industrial-sized spoon attached to the beefy arm of a matronly Australian army cook. Assisting her are half-a-dozen fine-boned Indian men adorned in blue chef’s frocks and white paper serving hats who, thank Allah, add tastier items like tandoori chicken or vegetable curry to your meal.

Outside, behind the basketball court, is the ball hockey rink, behind which is a soccer pitch, where I watched barefooted members of the host nation’s army playing the beautiful game early one morning. It gets much too hot to play later in the day.

There is also a barber shop and a poorly stocked library and a little building that is used as a music studio. Peering in the window to investigate the sounds coming from within, I saw an off-duty soldier alone with his electric guitar in a reverie of the Blues.

The day I am to leave for KAF I pick up my PPE (army-speak for personal protective equipment) which consists of helmet and flack jacket and although I feel goofy wearing it I am grateful for the protection it offers. Last year I had to wear it during two rocket attacks on KAF. I spend awhile reluctantly reading about burns and hemorrhagic shock in children, which are the scenarios I am most afraid to encounter. I review and commit to memory the outward indicators of thermal airway injury and the approach to fluid resuscitation in children. Then it is time for a work-out. Entering the nearly empty gym I sally over to a machine that promises to bulk up my long neglected pectoral and trapezius muscles. Thank God no one is looking I think for most of the next hour. At lunch I find my work-out has done me no good when I am thrown forward and off balance while trying to slide open a refrigerator door to get at the chocolate milk inside. Perhaps if I lack the fitness to open the refrigerator I shouldn’t be eating what’s inside?

That night at about 10 pm, those of us heading to KAF don our PPE and stand out on the tarmac behind 40 soldiers who have just flown in from Canada and have had all of an hour to stretch their legs before getting on the next C17 Globemaster flight to Kandahar.

In stark contrast to the heat of the day the nights are still very cold at this time of year. The role is called.

“Civilian Sherk!?” cries the Lieutenant.

“Here Sir!” I croak from the back.

The last duty before climbing aboard is for the soldiers to clear their weapons. Each soldier must present his or her gun for inspection, open the bullet chamber showing it to be empty and then pull the trigger while pointing in to a barrel of sand. My travelling companion this night is a fascinating man who works for the Canadian Department of Foreign Affairs. He is returning to KAF from Sarajevo where he spent his two week leave visiting with his daughter and wife. He has spent the last 10 months or so living in Kandahar City with the Provincial Reconstruction Team.

Here I think is a man who must know as much as anybody about Canada’s efforts in Afghanistan. He is very obliging with me but I sense he is more than a little weary of my sort of questions.

Progress is almost imperceptibly slow he agrees, while explaining that rebuilding Afghanistan is a task measured in decades or generations rather than months and Canadian election cycles. The security situation in Kandahar is very tenuous. And he knows whereof he speaks; he was a close acquaintance of Glyn Berry the Canadian diplomat killed by the Taliban in January 2006. He expresses, in the most restrained and diplomatic terms, the apoplectic frustration that Canada feels with other nations who will not make a commitment of troops to secure Kandahar province

“We’ll probably pull out if we don’t get some help” he predicts.

He has an unvarnished disdain for the Senlis Council who delivered an unflattering report on the efforts of the Canadian International Development Agency (CIDA) in Kandahar. He also disagrees with their assessment regarding conditions at the Mirwais hospital — the only civilian hospital in the province.

“CIDA had another consultant — I think a physician from Queen’s University -review the hospital and it’s nowhere near as bad as they [Senlis] say it is” he tells me, although he admits he has only been there once on a brief visit. He takes a pragmatic view of Senlis’ recommendation that Western nations should purchase the opium crop and turn it in to medical morphine.

“It will never happen. The Americans will never go for it” he says bluntly adding that Canadian soldiers are not actively involved in poppy eradication.

Finally I ask him to confirm a report I read in the Victoria Times-Colonist several days before I left Canada. It was stated that Kandahar city receives only 3 to 6 hours of electricity per day. I was astonished by this for two reasons. First, electricity flows in an almost obscene supply at KAF which is only kilometers from downtown Kandahar. And second, we’ve been trying to “stabilize and rebuild” Afghanistan since 2001 and after seven years one of the country’s main cities has only a few hours of electricity per day?! I was incredulous.

He explains that the Kajaki dam in neighbouring Helmand province was built to house three turbines. In three decades of war the dam has had next to no maintenance. Of late it has only had two turbines and one of them broke several months ago leaving just one to supply the region with power. There is a brand new turbine waiting to be moved to the dam, but repairs and renovations on the dam proceed at a glacial pace because of how badly the country’s infrastructure has been damaged by ceaseless war.

High above southern Afghanistan the lights along the cargo hold of the C17 change from green to red and we prepare for the plane’s descent. A tactical landing is a stomach churning manoeuvre in which the plane dives down sharply toward the landing strip rather than following the long slow descent more familiar to commercial aircraft. This is done to make the plane a more difficult target for anyone attempting to shoot it down. Trying to hold on to my supper as I feel my stomach rising to my throat, I watch in amazement as some of the soldiers throw their hands in the air the way riders on a roller coaster do. I guess you have to find entertainment wherever you can get it!

The muscular whine of the C17s engines recedes behind me as I cross the windblown tarmac, taking in the familiar surroundings without really watching where I’m going. I see they’ve finally condemned the old Soviet era hanger whose roof contained more mortar and bullet holes than actual metal and which always made quite an impression upon new visitors in case they had any doubts that they were in a war zone.

“Dr. Sherk?” says a man dressed in desert fatigues who I had not noticed standing beside me.

He looks a little like William Osler in battle dress. This is the Armed Forces’ Chief Internist, Col. Neil Gibson, a man who has a friendly, reassuring face, carries himself in an upright, capable manner and says what he’s thinking with an economy of words. Despite the late hour and an unpleasant cold brought on by being on-call continuously for two months, Col. Gibson is kind enough to carry some of my luggage to a borrowed Toyota 4X4 so choked with dust that the only way in is through the front passenger door. He helps me to my accommodations where feeling both excitement and apprehension after my travels, I crash in to a dreamless sleep.

Wednesday, March 19, 2008

The Power of Audacity

My war begins in luxury. Those in Ottawa who decide such things have deemed that I shall fly to Afghanistan for my 5-week locum in business class. The rationale for this I am told, is that if I arrive well rested I will be all the more ready to assume my duties with a clear head, a stout heart and a steady hand. Though a year ago when I came, I travelled mostly on red-eye Canadian Forces cargo service flights and still managed to arrive feeling pretty good. What has changed I wonder in the last year? Has a civilian internist-intensivist become such an indispensible military asset that no expense should be spared in assuring him a pleasant trip? The logic that the doctor should fly business class so that the soldier won’t fly home in a coffin seems weak at best — to me anyway.
The full Colonel I am going to replace, a dedicated physician from Edmonton who began his career as a pipe-fitter, who has stayed with the Forces through good times and bad, and who has completed 3 tours in Afghanistan totaling many months, arrived here and will fly home in economy class.
I think I’m good at my job and that what I have to contribute is important. But in the grand scheme I don’t think it is more important than role of the brave medics who risk their necks “outside the wire” at forward operating bases and on battlefields across Kandahar province. In fact, 4 Canadian medics have been killed in the last 2 years here. Pictures of CplC Christian Duchesne (34) and Cpls Glen Arnold (32), Nicholas Beauchamp (28) and Andrew Eykelenboom (23) look down from a wall in the entrance to the hospital.
I have never flown anywhere in such style and I am befuddled by the array of buttons that controls my seat. Evidently I am too short for business class — a roller in the seatback, meant to gently massage my lumbar lordosis is instead crushing my mid-thoracic kyphosis and it is several panic stricken minutes before I find the button that brings this chiropractic manipulation to an end. Next to me on the flight sits a man whom I will resemble in 20 years, unless I am careful to eat properly and exercise regularly. Like a virtuoso pianist attacking the faster bits of a Rachmaninoff concerto he taps a Blackberry that matches the dark sheen of his expensive looking clothes. Interrupting his e-mail cadenza he smiles and asks in a friendly manner where I’m going.
“Afghanistan” I say. “I’m going to work on the Kandahdar Airfield for a few weeks.”
“What are you going to do there?” he says, looking a little puzzled after my unexpected response.
“I’m a doctor. I’m going to look after wounded people in the base’s hospital.”
“Are you a GP?”
People always ask that question, I’m never sure why.
“No, I specialize in intensive care. Right now, the military doesn’t have quite enough doctors who do my sort of work so they fill in the gaps with civilians like me.”
I have found that there are several common responses when people find out that I’m going on this trip. Some assume (wrongly) that it is quite exotic or dangerous on the Kandahar Airfield and that I must be a little crazy or very brave, or both. Others seem impressed at what they perceive (in part correctly) to be an act of patriotic or humanitarian commitment. Another kind of person wearily opines that the whole war is a quagmire, all the papers say so, and it may true that the Taliban are beastly, but nobody ever has, nor ever will bring “that country” under external control. Last are the people who, like my travelling companion really don’t know what to say next. Notions of war and wounded people seem thoroughly at odds with our immediate surroundings and the juxtaposition brings our conversation awkwardly to a halt until I venture to ask him what line of work he is in.
“Shopping Malls” he says brightening. “I plan them.”
“That must be very interesting,” I observe, thinking exactly the opposite.
“And where are you headed to plan these shopping malls?”
“Moscow and then India.”
I mention that my trip will take me through a city that is well known as a shopping destination.
“Yes, that place is really something, you’re going to love it,” he says with a hint of jealousy that he can’t go too. “I just attended a seminar last week about the Power of Audacity! That’s what that place is really all about.”
Adjusting my chair in to a reclining position, I feel tired but can’t sleep. I shift uncomfortably, filled with a sense of unease at being a person of privilege in this world of wars and audacious shopping malls. I think about the patients, mostly members of the Afghan security forces and wounded civilians, who within hours will be under my care, and about the global disparity between poor and rich, which is itself a form of violence.

Monday, March 17, 2008

Welcome to my blog from Kandahar

Hello and welcome to my blog. I am presently on the Kandahar Airfield (KAF), which is a 40 minute drive outside of Kandahar City in Afghanistan. Some time before I left Canada, I was contacted by an editor at the CMAJ (Canadian Medical Association Journal) who requested that I keep a web diary of the things I was seeing, doing and feeling as a physician in this war zone. I am not a journalist and I am not a member of the Canadian Forces. I am not being paid to write this. However, I am a proud Canadian, grateful for my political freedom and economic advantages, and as a physician, I am especially grateful for my medical education, which was subsidized by Canadian taxpayers.

I am proud of what I think Canada stands for among the world’s nations. We strive for the ideals of democracy, human rights, tolerance, pluralism, the separation of church and state, and perhaps most importantly, hockey. These ideals are the underpinning of modernity — that conceptualization of political, economic and social order that is very much at the heart of this multinational, United Nation’s sanctioned Afghan campaign. There is some pretty good hockey here too! In a couple of weeks a team of ex-NHLers is coming to KAF for a ball hockey friendly with a team of army guys.

But I digress... and before I get much further, a few words about my biases, intentions and limitations. The opinions I express are entirely my own. I do not represent in any official capacity the Health Services Branch of the Canadian Forces, the CMAJ, or its publisher, the Canadian Medical Association. I tend to believe that armed conflict destabilizes rather than strengthens societies; that violence is generally a very ill-advised method of solving conflicts because it usually results in only further violence. I believe that modern warfare is a public health catastrophe and far more dangerous for innocent civilians — especially children — than it is for the combatants. I think that war is perpetuated in part because it is a very profitable endeavour for some morally bankrupt individuals and companies.

However, I also believe, because I have personally seen the evidence, that the Taliban represent the very worst in human thought and action.

I will never forget St. Patrick’s Day 2007 when I and my colleagues at the Mutinational Medical Unit were unable to save the life of an 8-year-old girl who bled to death from shrapnel injuries inflicted by a Taliban car bomb. Any of my esteemed colleagues here could tell you similar stories.

I believe that security is the sine qua non of civil society and that the attainment of security in Afghanistan is an essential goal that Canada can proudly help to accomplish. But I am not an apologist for this war and I have 1 or 2 criticisms to voice that you will read in due course. One of my grandfathers was a Mennonite conscientious objector. The other was briefly a member of the Army Medical Corps stationed in Canada at the end of the Second World War. My wife’s grandfather was a decorated Royal Canadian Air Force squadron Commander who, barely in to his twenties, piloted bombing missions over northern Europe. Therefore, currents of pacifist protest and martial action blend within me and I think of myself (perhaps a little grandiosely) as a loyal civilian critic of the Canadian Forces.

I have been and continue to be unspeakably impressed by the bravery, decency and professionalism of many men and women who wear Canada’s uniform in Afghanistan. It is an honour to work with them and, where I can, I hope to tell you about them and the good work they do.

Every word you will read has been screened by ranking members of the military and the CMAJ to make sure that there is no violation of patient confidentiality or operational security. The CMAJ editor understood it rather nicely I thought: “It’s not censorship in the usual sense, it’s just a question of not saying anything that can help the enemy,” she said. By reading this blog, you will not necessarily know more about reconstruction efforts in this impoverished, war-ravaged central Asian nation of 32 million people. You will not likely learn anything that you can productively apply to your own medical practice. But through my eyes and words you may be by turns enlightened, enraged, or entertained. Thanks for reading.

Friday, March 7, 2008

Introducing the CMAJ Blog

The CMAJ Blog provides immediate impressions from the front lines of medicine. We begin with blogger Dr. Peter Sherk, a critical care physician from Victoria, British Columbia, who is on his second deployment at the Kandahar, Afghanistan, Multinational Medical Unit. Dr. Sherk will be blogging about 3 times per week beginning March 17, 2008 and ending around April 10, 2008. The opinions he expresses are entirely his own, and not necessarily those of the CMAJ or its publisher, the Canadian Medical Association. Please note that Dr. Sherk’s postings have been screened by ranking members of the Canadian Forces to ensure there is no violation of operational security. We welcome your comments on both Dr. Sherk’s postings, and on the CMAJ Blog in general. Enjoy!