Tuesday, April 29, 2008

Thank you, Dr. Sherk

Thus concludes the first CMAJ blog. Dr. Peter Sherk, a civilian internist and critical care specialist in Victoria, British Columbia, recently returned from a deployment to Kandahar, Afghanistan at the Multinational Medical Unit. We thank Dr. Sherk for his thoughtful submissions and hope that you enjoyed reading them. If you’re thirsting for more, we recommend reading similar accounts of life in Afghanistan by Dr. Sherk and others, in Outside the Wire: The War in Afghanistan in the Words of its Participants (Random House Canada; 2007).

Stay tuned for more CMAJ blogs.

Barbara Sibbald
Deputy Editor, News and Humanities
CMAJ

Wednesday, April 16, 2008

“Muhibullah”

There are few things on earth faster moving than 4 stretcher bearers with a badly injured patient. First you hear the helicopter approaching, and then you feel the whirling and thumping in your chest. The Blackhawks whump down nimbly 200 yards from the back of the hospital whose plywood walls resonate in time with the rotor blades. A minute or 2 later the doors of the emergency room burst apart as a blur of medics stream in carrying the wounded, slowing only at the last second to carefully set down their precious cargo in the resuscitation bays.

You can kind of tell how sick the patient might be by first looking at the face of the medic. Sergeant Lopez (a pseudonym) had sprinted in to deliver a 5-year-old boy lying half-naked and crying under a pile of woollen army blankets. Lopez’ face was smeared with dust, sweat and worry. He watched intently as the trauma team assumed the next phase of the child’s care, knowing he had done everything possible and hoping it would be enough. Two hours ago this corpulent straight-talking US Army medic was riding south in a convoy through the Shahjoy district of Zabul province after many weeks “out in Taliban country huntin’ for bad guys.” He and his unit of 10 men were returning to KAF to resupply and were looking forward to a shower, a hot meal and a place to sleep softer than the floor of a Humvee.

As they entered a village, curious children approached the convoy thinking they might receive a piece of candy tossed from a vehicle’s turret. Lopez emphatically denies that his unit gives candy to children in this way. “The kids sometimes get way too close to the vehicles,” he tells me, and a Canadian soldier overhearing our conversation adds that the Canadian Forces stopped distributing candy from moving convoys during the Balkan conflict because the danger to the children. Unfortunately this morning one little boy ran in to the path of a Jingle truck, the driver of which had sped off without stopping. Jingle trucks get their name from the sound made by the chain tassels that hang down noisily from the trucks heavily reinforced front bumpers. The trucks are also usually decorated with garishly painted scenes or phrases. One of the trucks we see around camp displays a huge portrait of Benazir Bhutto along one side.

A huddle of villagers was gathering around the boy. Sergeant Lopez, who resembles a portly, more compact version of Rambo, halted the convoy and got out to examine the child lying crumpled at the roadside. After a year long deployment in Iraq, Lopez has the experienced medic’s ability to make critical triage decisions in the blink of an eye and knew immediately that he could help. He radioed for a Blackhawk helicopter to airlift the boy to medical attention.

As unusual as this may seem, the medics within the International Security Assistance Forces (ISAF) take something of a risk when they try to evacuate non-combat injured civilians to military hospitals. ISAF maintains 4 multinational medical units to cover the southwest region of Afghanistan. Priority of admission to these well-equipped, well-staffed hospitals is given first to injured coalition soldiers, second to injured Afghan security forces, and third to Afghan civilians. The medical air transport controllers are highly selective about which civilians can be admitted and it is nearly impossible for a civilian to gain admission without a strong advocate which in most cases is a medic. A recent example, recounted to me by Dr. Jack Oliver, an orthopedic surgeon from Kelowna, British Columbia, involved an emaciated 12-year-old boy with tuberculous vertebral osteomyelitis whose family had tried and failed to have admitted at the Kandahar Airfield (KAF) hospital until a medic intervened and saved his life. Surgeons at KAF stabilized his rotting spine and provided him with 6 months of antimycobacterial medication. Dr. Oliver sees him in follow up and cheerfully reports that the child is now thriving.

While Maj. Will Patton, the trauma team leader, and civilian Paul MacInnes, the lead nurse, work with the other staff to stabilize the child, Sergeant Lopez at last relaxes enough to remove his helmet and flak vest, then turns to the boy’s silent father and gives him a gentle reassuring squeeze on the shoulder. The compassion evinced by Lopez in this small gesture does not go unnoticed by Dr. Bob Ellett, our vascular surgeon who congratulates Lopez for the kindness he has shown. For only a brief moment, this reservist medic who is a youth worker in civilian life, allows himself to feel the pride he deserves to feel and closes his eyes to prevent several tears from falling.

The boys name is Muhibullah which means “God’s grace.” He has a large scalp hematoma overlying a long linear and comminuted skull fracture. He has a broken rib and a pulmonary contusion, but remarkably he has no immediately life threatening injury and several hours later he is calling out to his father that he wants to go home. Sergeant Lopez has not left Muhibullah’s side since bringing him in. We chat as I write up the admission orders. He shares with me some of the hardships of his army life: he lives in constant fear of driving over an IED. His 24th wedding anniversary passed yesterday and he was not able to call his wife back in the United States because he was out with his unit.

Why does Sergeant Lopez from upstate New York care so much about this injured child from one of the most impoverished areas of Afghanistan? Why did he marshal the full resources of the International Security and Assistance Force to aid a boy he had never met? I’m not sure. Why are people compassionate? There are theologians, evolutionary biologists and clinical psychologists who could provide interesting answers to that question, but because of his actions there may be a few villagers in Zabul who will feel that ISAF is here to offer real help to them when it is needed. And what is more, by demonstrating compassion today Sergeant Lopez is winning one of the hardest battles a soldier can fight — the fight to preserves one’s own humanity during war.

Monday, April 14, 2008

“Stand by Ghost Rider!”

Strolling by the medical imaging console I find Dr. Daniel Lindsay, a radiologist from Winnipeg studying an abdominal CT scan. Only it doesn’t look like any abdomen I’ve ever seen before. The shape is smaller and more ovoid than I’m used to. The liver looks weird and the spleen is elongated and kind of wispy.

“We’ve got a dog in there with hemoperitoneum” he says with eyebrows raised pointing over his shoulder in the direction the scanner.

It’s a quiet morning and out of sheer curiosity I head in to the scanner. Sure enough, a furry black creature is sliding out of the gantry and the camp’s veterinarian Dr. Rance Erwin, a tall energetic US Army Captain is striding across the room with a syringe filled with blood that he has just withdrawn from his patient’s abdomen. “This looks bad. We’re gonna need t’get ‘im over to the vet tent rawt now” he says in the sonorous drawl of his native southern Kansas.

“What happened?” I ask addressing a man who is bending over the dog stroking its neck in silence.

“A Humvee hit him. We were playin’ ball and he ran out in front of the truck to get the ball. He saw it coming and tried to stop, so did the Humvee but there just wasn’t enough time…. The driver was an Afghan guy. He jumped out, seen what happened, froze for a second then took off.” He says this quietly, trying with difficulty to keep his emotions from surfacing.
“You’re his handler?” I ask.

He nods.

“How long have you guys worked together? I ask. “’Bout two years now. We were in Iraq. He’s been a good bomb sniffer, found lots of IEDs and saved my life a time or two,” he says to me never taking his eyes off the dog who lays muzzled and sedated, though not enough to take away the disconsolate look of a sentient creature in pain.

The dog’s name is Patrick. He’s a six year old Alsatian. The health and welfare of these animals is a very serious matter for the US army who regard them as soldiers, albeit of a different species.

Dr. Erwin heads out to prepare for his operation and I help to transfer the animal on to a purpose-made red plastic dog stretcher. While a vet assistant and I each take a corner at the front, the dog’s handler picks up the rear and we hurry out across the road to the vet tent.

When we arrive, the vet is already on the phone arranging for a canine blood donor. “Hi Sir, this is Captain Erwin over in the veterinary tent. We’ve got ourselves a little bit of a serious situation rawt now. We’ve got a military workin’ dog that was hit by a Humvee about two or three hours ago, and he’s got a lot of blood in his belly … Uh huh.... I’m not sure if it’s his spleen or what but I’m gonna have t’open im up and we’re gonna need some blood from another dog. I was wonderin’ if you can send over one of your dogs, one that has a nice-easy going personality ... Uh huh.... You have one that’s a little heavier, maybe 60 lbs or more? ... Sure, she’ll do fine. Thank you. Goodbye Sir.”

In one motion he hangs up the phone and leaps from his chair directing his assistants as he searches for a surgical mask and a pair of sterile gloves. “Stand by ghost rider!” he calls out which is loosely translated from US Armyspeak as “Help is on the way!” He then selects a bottle of isofluorane and begins to fill the vaporizing chamber on his anaesthetic machine. “Make sure you shave him way down. I’m gonna have to make a pretty long incision” he says as two assistants clipper the fur from the abdomen. “OK. Let’s get ‘im up on the table.”

Patrick, groggy from incipient hypovolemic shock and the canine sedative mixture of morphine, medetomadine and atropine, is limp as he is hoisted by three assistants in to a prone position on the stainless steel operating table. While this is going on, Capt. Erwin draws up a syringe of propofol and begins infusing it in to the IV taped in place on Patrick’s foreleg. Moments later, Patrick has drifted into unconsciousness and with the vet techs holding his jaws open and his long tongue off to one side, the Captain uses a strait bladed laryngoscope to pass an endotracheal tube in to position. Once the tube is secured, he is rolled supine. The surgeon pulls back the dog’s upper lip, assessing oxygenation and perfusion clinically by inspecting the colour of the gums and the tongue. Satisfied with what he sees, he sets himself to the next task: scrubbing his hands for surgery. Without the benefit of continuous electronic monitoring of tidal volume, cardiac rhythm, respiratory rate and oxygen saturation, Patrick will be breathe spontaneously for the operation, monitored at regular intervals by the veterinary technician who keeps watch on the pinkness of the tongue, the rate of his breathing, and by stethoscope, the soft “lub-dub-ing” of his heart.
Inexplicably, there is a lull in the action and with the exception of the Captain the others in the room find themselves at a loss for something to do.

“C’mon people, I see a lot of standin’ around let’s go!” says Capt. Erwin. “Let’s get this abdomen prepped. We’ve gotta speed up or this dog’s not going to make it.”

Snapping back to the situation at hand, one of the assistants begins with bare hands to soak 4X4’s of gauze in poviodine and swab them over the dog’s shaved, greyish-pink abdomen turning it a golden yellow colour and filling the warm tent with iodine’s distinctive thick, sour odour.

The Vet calls out for sterile drapes, abdominal sponges and laparotomy tray to be unpacked. He directs a tech to check the pulse.

“125, resp rate is 8 and his colour’s good” comes the reply.

“That’s fine, that’s fine” murmurs the surgeon.

“I think I’m gonna step outside for this part” says Patrick’s handler as Capt. Erwin steadies the scalpel for the first incision.

Dr. Lindsay enters the tent to give Capt. Erwin a full report of the CT. After carefully comparing the dog’s scan with his intimate knowledge of human structure, he has a serviceable understanding of canine abdominal anatomy. The spleen appears intact but the liver looks contused or lacerated — this news is not encouraging, for a splenic injury would certainly be the easiest to contend with.

Dr. Lindsay washes his hands and dons a pair of sterile gloves offering to assist Dr. Erwin. During the rather mechanical skin incision and dissection through the subcutaneous tissues to the peritoneal fascia there is a brief opportunity for small talk, and I learn that Dr. Erwin is an Army Reserve Vet, has been in practice for five years and is married to another vet. At home in the US, he divides his time between two private practices in Kansas.

“How long will you be here?” I ask.

“Six months it looks like. They’ve got it down to six. Use t’be 10 months y’know, but a lot of guys were losin’ their clinics back home ‘cos of those long deployments.”

Within minutes, Dr. Irwin’s fears and Dr. Lindsay’s predictions are confirmed: the spleen is fine. The liver looks quite beat up and to everyone’s surprise there is also a tear in the bladder. 375 ccs of blood have now been collected in the suction apparatus and the need for a blood transfusion is urgent.

My assignment during these events is to try and collect 120 cc of blood from another military dog that has just arrived outside. The donor’s name is Alaska and, rather ironically for a military dog, she is known for her good temperament. She also has an injury of her own. Her left front paw is bandaged up after losing part of it to an insurgent’s bullet that flew through the tailgate of the truck she was riding in. I am very apprehensive about trying to phlebotomize a wounded attack dog, even one in a muzzle with a reportedly good nature. Therefore, following Dr. Erwin’s orders the assistant steadies the hind leg of this docile canine soldier who under different circumstances is certainly capable of chilling ferocity. I inject a mixture of medetomidine and atropine in to the muscle and 10 minutes later the dog lies dozing at his handler’s feet. The vet tech has shaved and prepped the right foreleg and kindly shows me where to put the needle. I can’t find the vein. I try again. Still can’t get it. She tries unsuccessfully. She preps the right hind leg for a different vein, which we’re sure we can feel. We both try again but get back only a tiny trickle before we lose flow. Patrick’s handler is watching and offers to try but the veins elude him as well. I wonder if the dog is a little volume depleted from not drinking enough water in the hot Afghan sun as approximately 45 minutes has passed. I turn back to enter the tent to report that I’ve not been able to obtain the needed blood.

Walking through the door, I see Dr. Lindsay performing chest compressions while Dr. Erwin is delivering a dose of intracardiac epinephrine. CPR on a dog is performed by placing the hands on either side of the rib cage and pushing the sides together. I join in by bagging but Patrick’s tongue has turned to a deep purple, almost black. Dr. Erwin grabs a stethoscope with bloodied hands and listens. The heart is silent.

“I’m callin’ this,” says the veterinarian, fatigue and sadness clearly evident in his voice as he adds “Damn! He was lookin’ so good there for a while.”

Dr. Lindsay and I look at one another and are at a loss for words as we consider the surreal events that have lead a radiologist and an internist from Canada to be standing beside the lifeless body of an American Army dog. Dr. Erwin composes himself and leaves the tent to break the bad news to Patrick’s handler.

“We lost him” he says directly, extending a hand of condolence towards the handler.

“Are you fuckin’ serious?!” yells Patrick’s handler slumping to a bench and burying his face in his hands.

Dr. Lindsay and I also try to offer condolences to the handler but his thoughts are elsewhere. In the manner of those who are suddenly and unexpectedly bereaved he is all alone in a maelstrom of memory and regret.

Thursday, April 3, 2008

CME in Afghanistan

This morning we went to visit the Kandahar Regional Military Hospital (KRMH). We had been invited to attend a weekly continuing medical education (CME) session for the doctors, nurses and technicians at the hospital, which serves members of the Afghan National Army (ANA). The hospital, although within the security perimeter of the Kandahar Airfield (KAF), is a 10 minute drive outside the main boundary of the camp.
I will not soon forget my ride there in a Bison armoured troop carrier. The security threat is deemed low and I am permitted by my wary military chaperones to ride with my head poking up through a hatch at the back of the Bison. Poking his head out of the hatch beside me is Capt. Marc Descoteaux an extremely likable emergency physician from the St. Jean, Quebec garrison who makes no attempt to hide his obvious excitement and pride at being a military physician on one of his first excursions beyond the main camp at KAF.

“I enrolled in the military specifically so I could deploy here to Afghanistan” he says grinning from behind his reflective ballistic eyewear.

This moment seems uniquely Canadian as we commiserate about the similar medical experiences and ethical end-of-life challenges we have had working in intensive care units back home. As a unilingual Anglophone I am a little envious of his perfect English accented in a musical Quebecois. We both have 8-year-old sons and it makes me happy to think that my son who is in French Immersion will one day be as comfortable in both official languages as Capt. Descoteaux. As we roll along through the outskirts of camp I ask him for his evaluation of public support within Quebec for Canada’s mission here.

For him the answer is very personal: “First I am a Canadian. Second I am a Quebecer. When I completed all my military training and received my commission many people came to me after the ceremony to say how much they support me and what Canada is doing here.”

His ardour for the mission here is so obvious that I sense he feels a little confined even here in KAF. “I really want to see what’s going on out there...” he trails off, looking out over the apocalyptic scene speeding past us.

Scattered all around lay the bombed out remnants of former neighbourhoods and commercial areas. One wrecked apartment block known as “the Russian village” is in fact still a home to a number of families despite the fact that it has no running water or reliable supply of electricity. That such conditions exist almost within site of KAFs diesel powered electrical generators leaves me feeling both angry and embarrassed.

Approaching the ANA camp’s perimeter we see a bone yard of old rusting Soviet tanks and rocket launchers, an unsettling reminder of only the latest unsuccessful attempt to forcibly pacify this virtually ungovernable frontier. The Bison disgorges us out on to the parking lot of the impressive, newly built hospital — a testament to the capacity the US Military is building with the fledgling ANA. The support is staggering. The US is spending 100 million dollars a year to construct a network of more than 120 hospitals and health care centres across Afghanistan to serve 80 000 Afghan army personnel and their dependants. A few weeks ago, this hospital received and triaged nearly half of the 100 casualties from a Taliban suicide attack in Kandahar city. Such capability would have been unthinkable a year or 2 ago.

The CME sessions were instigated in part by Canadian Col. Colin McKay, one of the previous Commanding Officers of the KAF hospital. The idea was to foster an educational partnership between our hospital and the KRMH with whom we often share patients. The leader of this outing is an American army major who has volunteered one morning a week to these CME sessions.

“We’ve finally convinced some of our Afghan medical friends to stop giving antibiotics for pain,” he tells me conspiratorially as we walk towards a comfortable conference room that is filling with eager, exclusively male Afghan health care workers.

During the visit, I learn more about the current state of medical and nursing education in Afghanistan from Col. Ed Fieg an emergency physician from Ohio who has been assigned to be a clinical mentor to the fledgling KRMH. Col. Fieg seems straight out a scene from M.A.S.H. with a gum-chewing, straight-talking swagger that conceals a fierce intelligence and genuine concern for the people of this country.

In 2001, the country had just over 4000 doctors and just over 4700 nurses. For its 32 million people Afghanistan has 8 medical schools each with different entrance requirements offering a 7 year curriculum with variable objectives and requirements for graduation. The medical training system has a dire shortage of qualified professors. Moreover, actual exposure to real patients in a clinical setting doesn’t take place until the final year. Consequently, most physicians here are essentially “textbook” doctors. Following graduation, doctors serve a 1 or 2 year rotating internship the quality of which depends entirely upon the dedication and competence of their mentors. The system is also marred by the fact that where a doctor’s reputation is concerned, age and political connections are of greater importance than actual clinical skill. In fact, says Col Fieg, younger physicians will defer judgment to elders even when the younger physician has more knowledge and training.

The state of nursing education is no better. Decades of war have left Afghanistan with a critical shortage of trained nurses. Training programs are unstandardized, varying in length from 2 months to 3 years. As with their medical counterparts, there is limited exposure to patients in nursing school. Nurses are poorly respected by the medical community and are regularly assigned to non-nursing roles such as patient registration clerks, librarians, logistics providers or cleaning staff. There are a lack of policies and procedures governing work hours, standards of care and scope of practice. Medication administration and other bedside activities are not considered to be essential duties of a ward nurse. Patient assessment skills are rudimentary and there is essentially no nursing documentation. Col. Fieg has witnessed only limited evidence of patient education, discharge planning or collaborative case management. Overnight staffing at the hospital is dangerously sparse.

Perhaps worst of all, the nursing profession is heavily male dominated in a culture with very conservative restrictions governing male-female interactions. Male nurses, perhaps considering such tasks unbecoming, are not keen to attend to the hygienic needs of their patients, almost all of whom are also men.

During a break, I chat with an American nurse anesthetist seconded to this hospital. Trying to impart her considerable knowledge to colleagues who are sometimes many years her senior, she feels a sense of exasperation. “They have read a lot and have some good factual knowledge but haven’t had enough clinical experience to correctly apply what they know from textbooks. Next week, I’m giving a talk on how to interpret vital signs because the other day we had a patient in shock who was tachycardic. I had to convince them to give fluids for the tachycardia rather than digoxin which they wanted to use to slow the pulse.”

The foregoing comments notwithstanding, attendance at the rounds is excellent, much better in fact than medical rounds at my own hospital back in Canada. To one side of the room sit the Americans and Canadians in their military dress with pistols holstered at their sides while along the opposite wall and around the conference table are 14 Afghans, most dressed in shalwar kameez and sandals. The topic today is chest trauma and, specifically, recognition of tension pneumothorax, needle decompression, chest tube insertion and management. There is excellent audience participation from both the NATO and Afghan staff. Laughter and learning occur in equal proportion and 3 hours later we pile back in to the Bison and head back to KAF.

Along the route home we see a few children walking along the roadside. I love how they smile and wave spontaneously. These children have so much to teach us about resilience and hope.

During the last few weeks, largely because of the commitment of Col. Fieg and Dr. Jack Oliver the Canadian civilian orthopedic surgeon, we have started to see signs of a more lasting collaboration between our hospital at KAF and the KRMH whose surgeons are now operating together with greater regularity. Today I spent time discussing our management at the bedside of a badly burned patient with 3 doctors from the KRMH who had come to visit for the morning. This is something new from last year when I was first here. Hopefully, this connection between NATO’s doctors and the ANA’s doctors will continue and eventually grow to include physicians from the local civilian hospital in Kandahar City.