New Site

Posted: March 31, 2014 in Uncategorized

This will be the last post on whitecoatrevolt.com. I migrated the whole site over to my new blog http://www.thewanderingdoc.com. Check it out, and please subscribe on the new site if you want to keep following me!

We need a new model

Posted: March 12, 2014 in Uncategorized

It’s common language now to say that we have one of the best health care systems in the world, but some of the worst access to care. In my mind this is true, but it’s missing the point. In thinking about healthcare as a business saying that we have poor access to care is basically saying we have a great product, but our potential customers due to various reasons can’t figure out how to use it. We take a passive approach when we start placing the burden of our failing system on access to care alone. Our model is complacent with the concept that the patient will come to us. We commonly accept the idea that our patient’s will negotiate their own insurance, co-pays, and the myriad of other complexities involved in acquiring and utilizing healthcare. In short, we have the potential to offer a brilliant product, but we over rely on our customer to do all of the work to reach what we are selling, and often through a web of tangled bureaucracy.  Our access to care is indeed terrible, but poor delivery is equal to blame. What are we doing as a medical community to offer new innovative ways that would allow our patients not only quicker and more efficient care, but a delivery mechanism that takes the burden of procuring healthcare off patient and more on the infrastructure? 

The answer unfortunately is not much, indeed the case can even be made that as the Affordable Care Act trips and stumbles on it’s self out the gate we are making our delivery to access even more complex and burdensome for the patient. Inside the walls of the clinic all is well. Our patients are examined, diagnosed, charted, and tracked with all the advances in care that the latest evidence based guidelines and protocols can muster. But, what about outside those clinic walls? Where are the evidence based guidelines that show us ways to better reach a growingly frustrated population outside of the brick walls of the clinic? The problem is there are no real guidelines, and we need a new way of thinking, but without the proper medical authority backing every move innovation in the medical industry comes to very cautious and litigious halt. It’s true that the red tape of our payment system is a burden, however I think the fear of reprisal for trying new untested mechanisms of care is a far greater driving factor for our general ineptitude in innovating new methods of healthcare delivery. 

So what can be done? I don’t think we necessarily have to reinvent the wheel here. We only have to take a look, and draw lessons from other industries. Let’s take two well known websites for example, match.com, and amazon.com. Match.com and online dating as a whole function on a simple principal. Two different parties want something, but they don’t want to have to go through the hassle, and uncertainty of dating complete strangers whom they know nothing about to find it. So match.com functions as a medium. It is essentially marketing the product of relationships through innovative transparent people cataloging and networking.  Amazon.com of course is king of hassle free product distribution. With Amazon prime I can easily click my mouse and two days later free of shipping are my shinny new shoes on my doorstep. Amazon is now even starting to predict what you will order next based on what you are looking at and will begin moving those anticipated purchases to distribution centers closer to your house before you even decide to buy. There are even talks now of amazon using ariel drones in major cities to fly your purchase to your doorstep within a matter of hours after ordering. Why battle LA traffic to go to the store when amazon can deliver the product to you faster than you can drive to the store? 

So can we as a healthcare industry figure out a way to match patients and providers as well as match.com matches potential mates, or can we figure out a way to creatively deliver the product of medicine as efficiently and hassle free as amazon.com?  But, the bigger question is, can we afford not to? 

We all know or in one way remember the buddy system. When you were a kid at camp you had a buddy that you had to go everywhere with, or as an adult if you’re walking home at night maybe it’s good idea to take a buddy. Generally we know this concept as a safety in numbers kind of philosophy. The Air Force however has a different approach on the buddy system, it’s called the “wingman concept”, and it’s not just about walking home alone at night from a bar, it’s a philosophy that they want to permeate into every aspect of everyone’s life. It goes beyond being safe in a dark alley, it goes into suicide prevention, co-dependance on your other airman, and in my opinion and many others a very distorted maladaptive way of building what the Air Force considers personal resilience. 

As I sat through the mandatory day long briefing entitled “wingman safety day” a psychologist was speaking and at one point said “resilience is built out of necessity”, and that one statement from this highly trained mental health professional summarized all that the Air Force has backwards about building resilience. The Air Force is a reactive culture, although they would like to think they are proactive in certain measures they never really are, and any preventative measures are usually the reaction from something that went wrong to begin with. The wingman concept is just an example of this and it’s being forced more and more today because of rising suicide rates within the ranks. It’s the idea that if you’re thinking about hurting yourself you should have a strong social network and wingmen (gender neutral term) to lean on. It’s everyone’s responsibility to be a wingman, to look after the man standing next to you. Which is of course a very well intended ideal to have someone like that to call upon in the stressful world of being in the military, but also in life in general. The issue is that we in the military are dependent on this, as a culture we’ve gotten away from the simple concept of personal responsibility, of basically figuring out how to toughen yourself up, the outrageousness of this concept is only enhanced when we remind ourselves that we are in the armed forces. Aren’t we as individuals supposed to be inherently more resilient knowing what we are signing up for? 

  The wingman is also liable if something happens to someone else in their unit. Who is to blame in a suicide? In the civilian world it’s generally not a long thought upon question. In the military the finger is first pointed at the wingman. And wingman is really a nebulous term. It’s not like you show up to a new unit and you get assigned a new shiny wingman equipped with a kleenex dispenser on their shoulder to cry on. Everyone is supposed to be a wingman, and everyone is each other’s wingman. So the burden of blame becomes systemic. But, if you know anything about a large bureaucratic system, especially one that values an overabundance of negative reinforcement combined with people cutting throats to climb a ladder of rank and prestige, no systemic fault can possibly be the fault of the system, and surely there is someone, or some small faction to assign blame to. Who do you think is the least common denominator to put blame on? It’s always the wingman. Where was the wingman? Where was the 19 year old airman that was supposed to identify, isolate and appropriately manage or refer his 19 year old buddy who was dealing with something tough in his life? I’ll tell you where he was. On Mars! Because if this is really the Air Force’s solution to suicide prevention than that’s where this concept belongs.  

Back to wingman safety day. Dim the lights. Whirl up the projector, it’s canned movie time. An old WWII vet comes on screen and begins praising today’s military for it’s abundance of mental health support, philosophy on leaning on your fellow man, etc. He then makes the statement “and you simply can’t do this alone” as the screen transitions to a rock band in some dusty warehouse. The rock ballad begins by telling the tale of a young man on his way to Afghanistan and the lonely family he’s leaving behind. Months of trial and heart ache ensue, “but, she stayed by his side” riffs out the electronic guitar. The music video comes to a close with the solider finally returning home to a small parade of people in his driveway. A loving wife and family run into his arms with welcome home banners drifting in the background. The hallmark propaganda of having a loving support network is completed by scenes of his family going to parks, playing on swings, etc. 

As cheesy as this video was it made a strong impression. The impression was that you should be depressed as shit if you don’t have a perfect nuclear family waiting for you while you’re deployed. In the last three years I’ve deployed four times, and each time I come home I take a cab from the airport to an empty house, I’m still waiting for my driveway parade with banners and small ponies, but it just never seems to happen. But, I don’t need this, and that’s the point. What about all the single airman forced to watch this nonsense? What is the message we are sending here? You’re doing it all wrong! Look at what this beautiful family has! Why are you single? Why are you single and happy? Blasphemy! If you’re not miserable now you soon will be, so you should probably think about just going to see mental health, because let’s be honest, you’re a mess and you just don’t know it. 

 

But, let’s say you do check the family box and have to deploy. Well, than indeed this video is perfect for you. This is a fine example of how your wife and kids will be your best support system. Your marriage will be strong, and your family will always be by your side. There will never be any doubts in your marriage, no no no, don’t worry about that. She will never think about other men. Your 15 minutes a day on the morale phones in Afghanistan will be romantic bliss, and you will be able to enjoy those special moments with the airman sitting two feet away from you skyping his girlfriend. On a special note to those deploying for more than a year, don’t worry about such irrational fears like your kids growing up without you, forgetting you, etc. The video doesn’t teach any of that, so put it out of your head right now. So really no matter how long you’re deployed for, there will be a parade or pure happiness waiting for you when you come home, nothing will change in the time your gone, in fact your marriage will only improve! Just sit still, watch the video, and please don’t kill yourself. 

 Rants about outrageous misguided military propaganda aside. Is there an actual problem with resiliency in our military? The answer is yes. The long war is wearing us out. We are sending people overseas and asking them for tremendous personal sacrifices for reasons that really don’t make a whole lot of sense. It’s not hard to look at the different conflicts we are in and ask the simple question, why? But, most of these deployments make even less sense when you are actually deployed. The main stressors a military member deals with over seas is not the glamours idea of living in a fox hole and dodging bullets. Most likely it’s really dumb shit like being yelled at for a printer that doesn’t work, or not being to get mail, or shitty food at the chow hall. So we try not to think about it, we live these crazy segmented lives of being home for four months and gone for four months and try not to look at the big picture, because it will only make a sane person crazy if we do. This compounded with the “the beatings will continue until morale improves” philosophy back at home creates a cycle filled with a lot of pissed off people. The war we really fight is a war against each other, a human relations war filled with hostile commanders with unchecked egos yelling at subordinates for asinine things out of their control is the real war that is breaking our troops. 

 So what can we do? Can we change it? Nope! Sorry to tell you this, but if you’re active duty and reading this It’s not going to change anytime soon. So we know we are going to have to embrace the suck that is the dysfunctional system we work in. We know that conflict, tensions, and hardships will arise, egos of those we work for will go unchecked and malicious behavior will possibly even be rewarded, and we have to know how to deal with this, how to live with this and still maintain some level of happiness.  But, this is not the same as “resiliency comes from necessity”. We must be more proactive with our warped idea of resiliency. The old adage of learning how to sail during calm seas and not choppy ones applies. So should all airman be forced to go to mental health? Have mandatory cry on a shoulder sessions once a week? No! Because the onus should be on the person to be a stronger more ready and resilient person and not the system! There is a mountain of books and resources out there in this growing field of, well call it what you will, positive psychology, human potential movement, self help, whatever. The point is that the military can’t help you as we’ve seen. So do yourself a favor and work on yourself so your wingman doesn’t have to. 

Contractor Conundrum

Posted: November 8, 2013 in Military
Tags: , , ,

The most terrifying thing possible for a young physician without any considerable post graduate training is to be alone in the middle of Africa with an overweight, hypertensive, diabetic, middle aged male that starts complaining of the tell-tale crushing substernal chest pain. Oh yeah, and without any real cardiac drugs. Spend enough time in one place and the worst case scenario will eventually happen, and it eventually happened to me.

Generally speaking the workload in Africa is pretty laid back. Most of the people I’m with are fairly healthy, and there are not many of them. So my typical day might revolve around a couple sniffles, maybe a sore knee from working out too hard, generally nothing too exciting. The problem of course is what happens when there is something exciting. Most of the places we go to are pretty remote from any western standard of care. We are not on typical military compounds, so my self and the IDMT are the only medics for a given area.  At this particular site the nearest “large” hospital was about an hour and a half away, and the US embassy advised us to avoid it if possible. Generally speaking the go to clinic is typically our little clinic that we set up in a spare bedroom in the house we live in. If someone needs urgent medical surgical care the plan is typically to call International SOS (ISOS), in which case they will dispatch a jet from either South Africa or London that with any luck will get there in hopefully 12-ish hours. So when I got the call at 9am that a fairly rotund military contractor was in the clinic complaining of crushing substernal chest pain, sweating profusely, and having trouble breathing I knew the cards were stacked fairly against me. Speaking in terms of western pre-hospital care, his door to balloon time was essentially fucked from the get go.

We did what we could with what we had, which wasn’t much. Some aspirin, some sublingual nitro, maybe a little morphine, and that’s all we could really offer. I hooked him up the monitor, and got a quick EKG. Now, I would like to tell you some insightful commentary about all the minuscule concerning things I saw on the EKG, but let’s be honest. I haven’t really looked at many EKGs in the last couple of years, so It was more or less  squiggly line squiggly line, sort of normal, not overt heart attack, maybe something about a left bundle branch block, not really sure, what the hell does it matter anyway #Ihavenomeds.

This gentleman turned out to be quite lucky as we just happened to have a plane taking off and heading to the nearest large military facility in Djibouti within the hour. So I pulled some strings and threw him on the back. I grabbed some trauma gear, a monitor with a defibrillator and jumped on the plane with him for the 4 hour and change flight. I think at this point in my short military career I’ve done about 8 or so CASEVACs, and this was by far the scariest. Despite what I could offer his chest pain never really abated, his blood pressure was something in the absurd territory of 190/115. Again, I really didn’t have any decent BP meds to offer him, but oh did I have everything I needed in case he crashed and needed to be shocked, and intubated, so that’s good, right? Oh, and on the flight over he started mentioning to me that before he deployed he was having similar chest pain. He states that he went to the ER in the states and was supposed to have a full cardiology workup, but decided that he could just do it when he got back.

Anyway, he survived the flight and I handed him off to the ER doc in Djibouti, I left him there for a full workup and got back on the plane to return back to where I came from.  About a day later we got word that the ER “ruled him out” for a heart attack, and wanted to send him back. He was scheduled to go home anyway in about two weeks so he would eventually get his workup was their thought. I flipped out, and so did my medical command in Germany. No way was this guy, who we were convinced was probably a walking time bomb going to come back to a place where if something went wrong he would be in a world of trouble. Eventually we won the argument, and he was on the next plane home back to the states. The story concludes with him getting home, and within 48 hours of being back home having a massive cardiac event requiring emergent open heart surgery, quadruple bypass, and a pacemaker placed. So, I guess life saved, maybe not a figure of speech this time.

I would like to say this was an isolated event, that most of the military contractors that we deploy are held to similar medical standards as our active duty population, but that would be a great and terrible lie. The truth is that I’ve seen these examples of medical powder kegs in remote places where they can’t get the care they need before, and I’ll see it again I’m sure. I’ve seen chain smoking asthmatics in the middle of Africa complaining of worsening wheezing, and even a gentleman with a recent blood clot in his lung on heavy blood thinners in the middle of Afghanistan. How are we allowing these guys to ever be cleared for any kind of deployment to any place in the world that doesn’t have a level 1 trauma center down the street you ask? The Wu-Tang Clan had it all figured out in 1993 when the said “Cash Rules Everything Around Me”. Yup, it’s all about the CREAM.

I did some digging, and what I found out was that most of the contractors that deploy in support of military ops have very very loose standards in their “medical pre-screening”. Essentially what I figured out was that they typically go to a civilian doc to get “cleared” to deploy. But, this civilian doc can’t possibly have any idea where they are going, or what kind of resources exist there. In fact I bet if you polled 10 civilian providers, 8 out of 10 would probably say that something that constitutes as a “military deployment” probably means that it’s in a place that’s fairly built up with large M*A*S*H like medical facilities. Which is hardly ever the case anymore. So that heart condition you have? No worries, the mythical cardiologist downrange can take of you. I asked if there was any guidance these well meaning civilians docs were supposed to follow. I was assured their was, I dug and I dug, and nothing standardized every panned out.  So why not change this, have them see military providers to clear them? Because of how the contracts are likely written. I’m sure it’s more cost effective to send them to a civilian provider than have them actually cleared by the military which would be some bureaucratic insurance, contract, money fiasco no doubt. Not to mention, what would happen if we did impose stricter medical standards? I think the answer is clear. We would catch more people that should never deploy, which is of course bad news if you own a large military contract and now a large percentage of your employees are not fit to deploy. So, although my brief conversations with the leads from some of these contract companies lead me to believe they were on my side, and definitely wanted to do everything they could to protect their guys, I smelled CREAM with subtle notes of bullshit, and I smell it everywhere.

No Tiki No Laundry

Posted: October 19, 2013 in Military

I haven’t talked about it in a while, but Gisele’s school in Burkina Faso is doing well, and I thought I would write a post about how it’s grown and some of the grassroots lessons I’ve learned about the hope-filled, but often hopeless act of giving aid.

When I got involved the school had about forty kids, three teachers, and part time cook, and one part time security guard all operating under the same small building which they partitioned into two classrooms. The picture below is the school today. They have six teachers, there are roughly one hundred and thirty kids enrolled, they have 24/7 security, a new playground, a new building for new classrooms, desks, and even uniforms. 

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When I first stumbled upon the school two years ago it did not require a lot of monetary aid as Gisele had a really well paying job as a translator and cook with the embassy, unfortunately due to some cut backs right as I was starting to get entrenched with the project she lost her job. The fate of cash flow into the school suddenly fell in my lap, so a few of us started pumping cash into the school just to keep it open. It would have been considered a small amount of money by our standards, just a couple hundred dollars a month, but that was a small fortune in West African monies. The issue back then was that the parents were not contributing as much as we thought they could. It was a frustrating condition that Gisele attempted to explain by stating that they just didn’t care, or wouldn’t care if they knew they were getting a hand out. I didn’t understand how to deal with this back then. So like most hope-filled hopeless aid we kept pumping money in, and the money worked. The school became “propped up”. It was enough cash flow to make sure Giselle could pay the staff, keep the doors open and still have extra money left over to invest in projects to better the grounds. As we were flooding the school with the money it needed we started to frantically come up with ways to make it self sustaining. It wasn’t hard to see that we had now adopted the burden of keeping a village school in Africa open, and we desperately needed some kind of long term goal (cough cough…exit). The contributions of the parents fell out of our mind as our focus was more about how to keep the external cash flow coming in. We searched for the best primordial bake sale between fund raisers, benefit concerts, and pleading for pocket change with facebook fundraising apps. To an extent this worked, but the effort did not justify the outcome in my opinion. Even if we raised enough money for a couple of months with a small fund raiser, the issue still remained. The school was non-sustainable without an external flow of cash. You might be reading this right now and thinking “Duh”! The school needs a way to sustain money internally and not rely on external Aid! But, this is not as obvious as you would think. The next time you buy magazines from the kid going door to door for some random charity or give a dollar to the random charity that is collecting at your local coffee shop think to yourself are you really helping those people fend for themselves, or are you just enabling an open hand willing to take, but not work for what they need!

There were a few ideas we were considering going with to get the school sustainable on it’s own two feet without the help of outside dollars. It came down to microeconomics. Why couldn’t the parents contribute? What was the real root cause? Did they have a good job? Could we set up micro loans and kickstarter fund raisers to help them start small businesses that would ultimately feed back income to the school? Unfortunately we never made it this far. On my second trip back to Burkina the infinite wisdom of the military command decided they didn’t want me to be involved with this project anymore. There were a variety of really lame reasons, the most ignorant of which was they didn’t want me to start something that could potentially fail, and that failure could look bad on the DOD. Probably should have thought of that a couple years ago guys! It was infuriating and something that was as involved as getting into the community to build small businesses for the parents was off the table.

The situation became depressing as we kept blindly sending money, and we weren’t sure where to go, and then we noticed something that was a shimmering beacon of hope. The parents were starting to contribute more and more each month. Our best guess, which we think is accurate is that the school started off as something small, and dilapidated. Now it was becoming a legit product. It had a name, it had gates, uniforms, books, burnt wooden structures had been turned to hardened steel. Basically we think the community was starting to take it serious. They saw one of there own building something that was working and they started to contribute more because I think they started respecting it. I also think a key element here was that we stayed relatively opaque in the background. If we had a more transparent image in the school, the parents may have thought, “Ah the Americans are paying for this, I’ll keep my money thank you very much”. Unfortunately even though the parents were stepping up, the school was growing and it wasn’t enough.

This is where I give thanks to Jack Nicholson for his role in The Departed, “no tiki, no laundry” became the solution. The parents needed to know that if no pay money then no school for kids! We pumped money into the school for a year and built a legitimate product for the community, now if we threatened to take it away they might listen, and to be honest if they let if fall, then that is their choice. The second lesson in all this is that we can’t give people something they don’t want. The community that is receiving whatever charity be it a school, roads, church, etc has to want it! You can’t force feed it to them.

Stepping away completely to test this theory was a bit to risky I thought, so we took a middle ground for a year. We started price matching the parents. Whatever they contributing I promised to match. This seemed to work well and we were able to cut contributions by roughly 75%. Something else happened over the last year as well. The embassy, peace corp, and outside NGOs started to take notice of the school. Giselle was sending me budget sheets and status updates every month. There were mysterious contributions coming in from outside sources, and random european teenagers were coming to work and volunteer at the school. It was gaining visibility.

Now, today, October 2013 we have stepped away. This will be the first year the school is running on it’s own. It has the attention and backing of the community and local NGOs, and department of state have taken notice. I made a one last contribution to Gisele to send her to college for a year to study English so that she might hopefully find a well paying job, but otherwise our Aid contribution has come down to a trickle. We still send some small money, really as a “feel good” donation for ourselves, but nothing that would sustain their operations. It will continue now as determined by the will of the locals, and in my opinion this is how it should be.

 

event date: Nov 2011

The day, or I should say night started like any other night in the plywood palace that was our clinic in Afghanistan. Constituted eggs for breakfast, followed by sick call, or as it should have been known, ambien call. Followed again by constituted eggs for lunch. Somewhere in the monotony the phone rang, and the night got more interesting. A CASEVAC in the SOF world seems to typically be initiated by some guy at a desk that we don’t know, calling some guy at a desk that we do know about some guy in the field that got shot that nobody knows. This was that kind of phone call. The medical planner asked us if we could be ready to go with all of our gear in 15min to respond to a casualty at an out station. Little information was given, he didn’t really know that much just that it was a solider with a gun shot wound to the head that was critical, but stabilized. There would be a plane ready to take off in about 20min.

! I think some of the new docs that come into our flight always have a quizzical look on their face when we go into great detail about how all of our zippers have small pieces of cord on them for quick access, how all the tape is ear marked to peel off easy, how all the equipment is kept charging in their boxes to grab and go. The next 15 minutes during that night would have stood testament to why we think this way. Within 10 minutes the truck was loaded with our prepackaged medical rucks, kevlar on, and M9’s holstered. The engines on the aircraft were already running when we boarded. The flight time to the aid station was just under an hour. In that hour we started getting our gear ready for a number of possible scenarios. Was the guy intubated? We didn’t know. Did he have an IV? We didn’t know. Most of the time you never know what some ground medic is going to bring you. In a perfect world communication about the status of a patient is better before leaving the ground, but that seems to rarely happen. So we hung IV bags, prepared the ventilator, etc. As we were doing this I was running through my brain all the scenarios that could be wrong with this guy and what kind of drugs he would need in what dosages? Stressful to say the least.
! When we landed we fully expected a ground team to be at the aircraft with the patient ready for us to accept right at the flight line. Instead there was a couple guys with a pick up truck asking us if we were ready to go to the clinic? Not exactly what we were planning on. Turns out there was a fairly advanced medical team at this outstation and they had already done a fair amount of immediate resuscitative work, so going into the clinic and accepting the patient within their facility and talking with them was clearly the safest route. Just wish we would have know that as we packed all the gear up and threw it on the back of the truck.
! In the clinic the we found the patient laying on a gurney. He was hooked up to about five IVs, the breathing machine was already hooked up and he had a large amount of bandages wrapped around his head where the gun shot wound was. The doctor was briefing me about his condition. Generally what happened was he was on an operation going into a hostile village, he climbed over a wall and there was an enemy with an AK-47 there ready to meet him. The bullet found the gap between his head and his helmet and just barely grazed him. The problem with a high velocity rifle round is that the bullet creates a cone of concussive destructive force around it and in it’s trail. This blast wave from the bullet essentially was enough force to shatter his skull and send fragments of his bone into his brain. The actual bullet did little damage except

graze the skin. The part that worried me most about this guy was not the immediate resuscitation, that had already been accomplished. It was all the advanced care he was getting, and he was still in a very tenuous state. We have trained with basic IV meds, and know how to work our ventilator so that wasn’t a big concern. The concern was the four IVs that were piggybacking on each other. The platelets, the microdrips of hypertonic saline, it was all a bit beyond anything I was comfortable with, and my IDMT felt the same way. There was a moment of guilt and a true certainty that now the charlatan would truly be exposed and someone would die due this farce I had been living. But, as I was learning part of the trick to this job was that if you can’t do than delegate. I found the nurse anesthetist that was part of the medical team and basically demanded that he come with us on the flight back. The trick is to realize when you are undertrained for a situation and have the humbleness to call in for backup. We can’t be the ones to blame that the Air Force takes GMO flight docs and throws them in situations that require the skills of experienced critical care trained provider. The next step was to hook the guy up to our equipment and start moving him back to the aircraft. One of the first things we did was to hook him up to our ventilator and disconnect the clinic’s machine. This was a scary moment because this was a ventilator that I always trained with, but have never actually used on a real patient. I mean, I know that if I hook a latex glove to the end of it and turn the dials the glove will blow up, but to have absolute faith that it would work on a human lung was a different story. Sure enough it worked, the world stood still before the machine cycled it’s first breath and I saw his chest rise and my sphincter relaxed a little bit.

! We transported the patient back to the aircraft in some kind of heavily armored ambulance that was designed to either crash through enemy lines, or take gun fire, probably both. On the flight back the CRNA was working some kind of voodoo alchemy with the IV’s. As he worked his magic the IDMT and myself focussed on the head. He was bleeding profusely and soaking through about three layers of tightly wrapped bandages, the blood was bright red which meant it was probably arterial. This was both good and bad, bad because a pulsing bleeding artery is always bad, good because at least it wasn’t bleeding inside his head and building up pressure. I wasn’t too worried about his intracranial pressure getting too high because the blood that was most worrisome to accumulate under his skull pushing down on his brainstem was dripping all over the back of the air plane.

! Once we landed the three of us started getting him ready to transport. Bagram Air base is home to the biggest hospital in the theater, although I had not yet been part of a medivac at the base, I was hoping they had it down to a tee and transport would be waiting. I slightly misunderestimated this as it was not an ambulance that was waiting on the runway, but a ambulance bus. Literally their ambulance was school bus converted into an ambulance. There was team of about six medics waiting with pristine uniforms clearly designating their name, rank, and a glow in the dark patch on their arm designating their job title. We on the other hand had multicams, with no patches, no names, no rank while wearing a kevlar vest equipped with medical gear and a pistol. It was an interesting contrast. I hopped on the ambu-bus and rode with them back to the hospital. The bus pulled up to the trauma bay. We opened the back door of the bus, got the patient off and then walked into the trauma bay. The next image is something that will stay with me forever. As a medical student and an intern I was involved in a couple

of traumas, there is always about 20 people in the room and I always felt like I was in the back on my tippy toes just trying to see what was going on. This was the exact opposite. As we walked in the door There was no joke 15-20 people in the room all in blue trauma smocks, anxiously awaiting our arrival and making a path for us to a gurney. One of the docs standing at the front of the group just happened to be one of my internal medicine attending from when I was an intern. It was a very surreal experience. As the medical team descended on the patient we took a step back, gave report and tried to do what we could, but generally stayed out of the way. The guy was eventually stabilized. He went immediately to the operating room where a neurosurgeon was able to isolate his bleeding menengial artery, and ligate it off. The next day he was swooped away to Germany and back to the states. I never heard anymore about his final condition. But, I remember looking at the CT scan that showed fragments of bone being peppered throughout the left half of his brain. I imagine the guy lived, but surely has some impairments. His road to recovery I’m sure has been hard and long, but there is some satisfaction in knowing that I served a critical piece in making sure he got there.

Too Close For Comfort

Posted: January 6, 2013 in Military
Tags: ,

One of the ultimate hypocrisies I’ve noticed in the military is the obsession with preaching safety when at home. Driving 15mph on base, wearing a reflective belt in inclement weather, not running with earbuds in, the list goes on. On the surface you might think, this is great, they really care about keeping people safe and mitigating our risk, and would never put us in harms way. Then you get to a combat zone and you have this realization that there is not a reflective belt in the world that will protect you from an incoming mortar, a stray bullet, or some crazy ass Afghan solider that decides one day to point his rifle at the wrong team. If they had the same obsession with safety downrange that they do at home maybe they wouldn’t make me live in a plywood box with no reinforcement, but I’m starting to think that is about as likely as them issuing me a giant metallic hamster ball that I can roll around in fully protected from all forms of flying metal objects.

I would have appreciated that metal hamster ball one night back in March. Like any other night, we were all sitting around watching TV, eating something the Army thought resembled food and out of nowhere there was a loud powerful explosion that sounded like a cannon had gone off outside. In fact it was so loud and given the percussion I felt in my chest I couldn’t be sure if it had actually hit our little plywood building or not. We all looked at each other and instantly knew that an IDF had hit somewhere very close. There were four of us sitting upstairs when this happened, myself, two medics and a Family medicine Doc. We all went downstairs in crouching position. My IDMT and I without hesitating went into our little supply room and grabbed our trauma gear, armor vests, and helmets. We hurried outside to access the damage unknown what kind of patients we would find or what dangers still persisted. As with most bases, our base in Afghanistan houses people in these dinky little wooden building called B-huts. Not 40 meters away from the clinic was a row of B-huts, and I could see a lot of commotion going on around one of them. We hurried over in the dark, as we got closer the damage became apparent. The mortar round had landed about 10 feet in front of this B-hut. When an 88mm shell hits it basically makes a sizable hole in the ground, but more importantly sends a burst of shrapnel in every direction. The front of this B-hut looked like Swiss cheese as we approached it. The hole in the ground was still smoking as rounded the corner of the B-Hut to inspect the nearby bunker. In the confusion two guys appeared out of the dark, they were obviously disorientated and were being supported by a couple friends. Outside of the obvious blast and shrapnel, the other thing to worry about in a mortar attack is the over pressure wave. If you imagine being in front of the largest speaker you’ve ever seen and the bass turned way up, and if you times that feeling by about 100 then you start to get an idea. When you get hit with one of these blast waves the injury can range from just getting your bell rung pretty good all the way to severe brain injury or internal organ damage. These guys on first appearance were on the milder side of that scale. We rushed them back to the clinic were they would get a full look over and eventually get transferred to the hospital to start an extensive mild Traumatic Brain Injury (TBI) work up. I remember talking to one of these guys later and he told me that he was in the reinforced bunker next to the B-Hut, but he stuck his head out when he heard a high pitched whistling sound to see what it was. Of course this was the sound of an incoming shell, and he obviously learned his lesson.

After we handed them off we went back out to the site to see if we could find any more patients. A young kid came up to me that looked like he was basically in the same condition as the other two we had just brought in, pretty dizzy and slightly confused. As I got him to the clinic he mentioned to me that his back hurt. I looked at his back, noticed a little bit of blood on his uniform and quickly took his shirt off. Sure enough there was about a 1 inch size hole in his back were a piece of shrapnel had caught him. With a declaration of urgency I pushed everyone out of the way in order to give him priority for the one clinic bed we had. We quickly slapped a chest seal on the wound. The concern in battle field trauma with any penetrating chest wound is that the wound will basically create a one way flap, letting air into the space surrounding the lung on inhalation, but nowhere for it to escape on exhalation. To combat this we slap a seal on that theoretically allows the movement of air out, but not in. I listened to his breath sounds and he had none on the entire right side of his chest. He then said it was getting progressively hard to breathe, and his oxygen saturation was starting to drop. He was starting to experience what’s called a tension pneumothorax, he had an injury to the inner lining of his lungs that was allowing air to escape into the space surrounding his lungs every time he took a breath. With each breath more and more air was getting trapped in this space. Without any intervention each consecutive breath would continue to compress first the lung, then the heart, and would basically in about 15-20 minutes lead to heart failure and death. If you have ever seen the movie “Three Kings” with George Clooney then you know the treatment. You have to take a long needle and stick it into this expanding space to release the pressure. In the text books, doing this is sometimes followed by a wooshing sound as air escapes. I’ve done this once or twice before and have never had the satisfaction of hearing this, but when we stuck the needle in this kid’s chest there was definitely a woosh of air. I think for half a second we all kind of looked at each other, nobody said it, but the look in everyone’s eyes spoke the same phrase,  “holy crap, I can’t believe that actually worked”.

The young Airman was eventually transferred to the hospital were they placed a chest tube and further stabilized him. He got a CT scan of his chest and sitting 1cm away from his pulmonary artery was a nice honking metal object. Needless to say he was a pretty lucky guy.