by Marc Dauphin
Around 2300, as I walked by the radiology screens, I did a double take in front of a chest X-ray. There was a small piece of metal overlying the cardiac silhouette. It wasn’t very big. Still, it jumped out at me. Captain B was coming from the bays.
“Is this the ‘shrapnel-in-the-neck’ guy’s X-ray?” I asked.
Captain B shrugged. We went out to the bays, and, yup, our kid was back in 5, still grinning.
“What’s your name?” Captain B asked without preamble. We rushed back to the monitor. Sure enough, it was his chest up there.
“It’s in his heart!” I exclaimed.
Captain B frowned. “Could very well be, Marc. But then why is it not moving?”
“I don’t know. Maybe it’s stuck in one of them …” The word escaped me. It happens to me often. At first I was afraid that I was losing it, you know, sort of like the early stages of Alzheimer’s. But my wife says I’ve always been like that. My brain is in too much of a hurry, and it thinks in a mixture of French, English, and a couple of other languages. So I mimed the cardiac pillars with my fingers.
“One of them stalagmites!” I said.
“They’re called pillars, Marc. And it could very well be, but that would be very rare, indeed.”
The vascular surgeon edged up to us, accompanied by the radiologist. “I don’t have the right instruments to go in and get it,” he told us. Then, under Captain B’s look, he quickly added, “If it’s in the heart, of course.”
“Of course it’s in the heart, guys! It came in through the jugular, went down in the heart, and now it’s stuck there. I’ll bet you five bucks.”
The CT confirmed it. The shrapnel was stuck behind a cardiac pillar. If it dislodged, it would follow the current to the lung where it could wedge itself. No big deal. But on the way, it could tear a hole into a branch of the pulmonary artery. Bad, but still salvageable if it happens in a place where they can immediately open his chest. The other possibility was that it would stay there. But it’s a piece of metal. Its edges are serrated, and with every heartbeat, it could slowly cut into the base of the pillar. Saw it off and the pillar will flow out, still attached to the valve, and block it, or render it useless, or partly useless. That can be a disaster. Or even worse, the piece can slowly work its way through the heart muscle and pop out the other side, making a through-and-through hole in the heart. Then, blood leaks out into the pericardium, that tough, non-elastic envelope of the heart. The blood leaks out until the pericardium can no longer hold any more. Then the pressures inside and outside of the heart are in equilibrium, and the heart can no longer pump blood. It’s called a tamponade. Not very good.
This soldier had to get out of there, and to Landstuhl, immediately.
I went to the TOC and phoned JPMRC (Joint Patient Movement Request Center), the place where they organized, synchronized, and dispatched all the Air Evacs from the Middle East. That included mostly Iraq and Afghanistan. The validating flight surgeons there knew me. I called them a few times a week to request AE straight to Landstuhl, instead of stopping in Bagram (near Kabul), where they liked to regroup all the patients before sending them out to Germany. I always thought it was a waste of time to do that extra stop in Bagram, and I’d been fighting the USAF since 2007 to get them to fly the casualties straight to Landstuhl from Kandahar. All that had gained me was getting in trouble with our then surgeon general, and probably with a bunch of the colonels under her. Oh well, c’est comme ça. It would have been nice to be a major once more.
Still, I wouldn’t give up on Bagram. Once again, I wanted them to send the soldier straight on. “Bagram can’t do any more than we can,” I argued.
Captain B stepped up and motioned to me. I handed him the phone. “It’s a useless stop. It’ll just make our soldier stay away from Landstuhl that much longer,” he said, after having identified himself.
They knew he was a thoracic surgeon. I could tell that the flight surgeon at the other end was hesitating. I got the feeling that we’d won. Bagram, which had been furiously arguing in favour of a stopover at their place for all Afghanistan casualties, had no arguments on this one. Captain B nodded to me. Yesssss! We’ve won this one. He handed me the phone. The validating flight surgeon at the other end had a few technical questions to ask me. AE is my specialty, remember? That’s what I used to do in Landstuhl. And that’s what I kept doing in Afghanistan. PAO2 = [(PAtm – PPH2O) × FiO2] – (PaCO2 × 1.25). That’s my stuff. I can argue all night about the different parameters in DO2 = CO × Hb × 1.31 × SaO2.
Anyway, we had a plane. Time to prepare some of these wounded guys for piggybacking them onto that flight. The docs had to write PMRs (patient movement requests), the forms that the USAF nurses put into the great evac computer and without which no patient would be flown out. The specialists had been busy all day caring for the patients, and they’d have liked nothing more than to take a break. But I needed those PMRs ASAP. And I had to sign each one as originating flight surgeon, after making sure everything was on there and that there was no condition that precluded AE. Well, nobody said it was a restful job. And I still had two months to go … Boy, would I ever sleep this off when I got back home. Sorry, Christine, I won’t be very good company. I don’t think I’ve ever been this tired in my whole life.
Back to the trauma bays, then to the CT scan and a quick check on the ORs. It must have been 0200 or 0300 when the Australians intercepted me. Their journalist, Sally Sara, asked me for a quote. Why not? It’d give me a few minutes off. She started the camera. I was expecting some technical question, but she caught me completely off guard.
“Major Dauphin, what effect does it have on you as a man, to see all these wounded children?”
I was about to give her the pat answer, the prepackaged one, the one the hockey players always give no matter what, the we-gave-110-percent-but-they-were-better-than-us bland answer. But suddenly I was overwhelmed by it all. I couldn’t help seeing that poor father who had lost three sons, with his fourth one maimed and fighting for his life. And all those mangled children’s bodies — the lacerations, the torn-off limbs, the shrapnel-pocked faces, the burned skin. All those visions of blood, and all the screams, all the misery, all the stress, all those soldiers fighting for their life. And the tremendous news that I received that morning, that I’m going to have a grandson, but which I couldn’t decently share here with these people amidst so much suffering. And I was suddenly speechless. I looked up and she was crying behind the camera, not even bothering to hide her tears. That’s when I lost it. I just choked up, said something, and walked off. Jesus, Marc! Get a hold of yourself! Your people need you. Not some slobbering idiot. You can have all your emotions later. LATER! Not now!
Well, I somehow regained my composure and finished the night. When I finally made it to my barracks to take a shower, the sun was starting to illuminate the eastern horizon. Or was it the western one? Where the hell does the sun rise anyway? Just kidding. But I was that tired.
It was some days before we finally managed to download the Australians’ report off the internet. (It can be found at www.youtube.com/watch?v=D6jCrkkL1ns.) And then I started to get ribbed. Mostly by my Americans. I guess they aren’t as touchy-feely as us Canadians. Well, these last years, they’ve had a lot more practice at war and losing guys than we have. Recently. Because in the first and second world wars, proportional to our population, we lost a lot more guys than they did. But that’s another story. This one is about Afghanistan. So I got ribbed. As in, “Do you want to share your feelings with us?” or, “Talk to us about it, Major. It’ll make you feel better.” To which my unvarying answer was “Go eff yourself.” I mean, what can you say? You’re the boss, the leader, and you broke up in front of the camera. Sort of like the guy in Band of Brothers. Except I didn’t lose it completely like that guy. I didn’t get the deer-caught-in-the headlights-I-can’t-take-it-anymore look. Just for those ten seconds, I became a little emotional. Yet, now I have to live with it.
Still, apart
from the breaking-up part, it was a good report.
I guess I won’t ever forget the day the Australians came.
C’est comme ça.
Well, the next day, the Australians came back. They re-interviewed Phil, especially about one of the kids he had received, the one from the culvert bombing. The kid did look okay, but then he started to bleed in his head and died. Nothing we could do about it. C’est comme ça.
And that’s what we did at the Role 3. That’s what my job looked like for six months, day and night. Apart from breaking up in front of the camera, I mean.
* * *
1 At the time of writing, that location has been closed by the local government over a trade dispute, so the CF has had to find another staging base, in Germany this time. I guess the Germans are less likely to close us down on a whim.
2 At the time of writing, Trish, another great nurse, was also in Afghanistan after having done six months in Landstuhl in 2009. As far as I know, we are the only three to have done both.
Quiet Members of the Team
Up to now, this has been about our trauma patients, their fate in those few hours when their lives were in the Role 3 team’s able hands. But, even though major trauma is what the Role 3 was all about, there were other duties that we also fulfilled.
Physiotherapy
A physiotherapist was at the Role 3 all the time. This physiotherapist also had an assistant with her or him. The physio team’s job was mostly to help those members of the military with minor musculoskeletal conditions to get better. Although much less attention-grabbing, theirs was a silent, essential job. They undoubtedly helped many a soldier stay on and do the job in Afghanistan. Plus they helped in the hospital with our longer-term Afghan patients, by keeping their limbs from stiffening up, or their muscles from going flabby, or giving respiratory therapy to those with chest conditions.
If push had come to shove and we had received an overwhelming number of casualties, the physio team would have helped with triage and care of minor conditions. And maybe also major conditions. So they were always on standby. Thanks, physio, for a job well done.
Outpatients
Because many people in KAF didn’t have a Role 1 (think of all the contractors), we at the Role 3 had to provide that care. There were a lot of people there that summer on KAF. I can’t say how many, but think tens of thousands. That meant at least a hundred visits per day, and sometimes even several hundred (as when we got hit with H1N1 — yeah, we got that too — before they figured out a vaccine for it, and while it was killing people by the hundreds in Mexico). It takes a lot of people to do that, day in, day out. After hours, our Outpatients was the only facility open on base. Plus, never forget that many severe conditions will present at the Outpatients, either by mistake, or by self-under-reading (like the guy who thought he had stomach problems, but was having a heart attack). Conditions such as a myocardial infarct, an exploded heart (crushing injury of the chest), bilateral leg amputations (that juice-vendor brought in by the Afghan Army soldier who picked him up), malaria, appendicitis, et cetera. A lot of docs, PAs, nurses, and medics worked there 24-7. That’s where our amb drivers and landing pad medics worked when they weren’t busy around choppers or the trauma bays. They all did a superb job, whether CF, U.S. Army, U.S. Navy, or British Army.
Phil was in charge of Outpatients (called “Primary Care”). He had to ensure that it was properly manned and that the personnel there did their job appropriately. That meant monitoring and evaluating all the clinical personnel, and picking up the damage when a mistake occurred (as it invariably does in any OPD in the world — no human activity is ever 100 percent perfect). It also meant ensuring proper manning of the place; not an easy job, especially when, as in June, we were short of docs and PAs. As for medics, well, we were always short. It also meant that Phil did many of the shifts himself, in addition to his splendid work in the trauma bays. Many a time when he was in charge of a patient in his trauma bay (I often sent the worst ones to Phil) he hadn’t slept much the night before.
And Phil was the one who organized the “Wainwright Training” for the U.S. Navy personnel who replaced us. I guess he was tired when he came back. I was way too tired to appropriately thank him. So here it is: I can now do it publicly. Phil, you’re the man. We owe you a lot.
Mental Health
Our Role 3 Mental Health (MH) Team was there to evaluate and treat not only Canadian patients, but also all NATO military members who needed their expertise. And with the surge in U.S. Army and Marines, some of them on their second or even third one-year deployment to Iraq or Afghanistan, that meant a lot more patients. Plus, when they could, the MH people deployed to the FOBs, either as a crisis intervention team or just to see our troops over there as a part of the resilience program. In addition, they evaluated all our concussed patients as a part of the CF minor traumatic brain injury (mTBI) program. That was a lot of work. And it was not easy work. As one member of the MH team once told me, “When you are doing a debriefing for the comrades of wounded or deceased soldiers, you get to hear the same event described over and over by each different individual, each one filling a blank left out by his comrade, until at the end, you have such a precise and complete story of the event that it’s almost as if you’ve lived it yourself.”
Like I said, it’s not an easy job. And, like the MH people say, not as spectacular as putting in a central line or intubating, but just as essential.
BE Techs
BE tech stands for Biomedical Engineering technician. We just call them BE techs (actually we call them BMET techs, but the correct term is “BE”). Those guys were amazing. They’d fix up anything that we used, from a monitor to a ventilator to even the most sophisticated CT scanner. And mostly at night, because that’s when it got a little quieter.
For example, one day our CT broke down. We had sort of been expecting it, I mean, what with all the use (and abuse) we had put it through. And the dust. After taking it apart, the BE techs concluded that they needed a special electronic part, so they got the higher-ups in the CF to put all possible pressure on the company to get us that part ASAP. Seven days was the best they could do, they said. We were going to have to make do without a CT for a whole week. Those of us who had practised medicine before the advent of the CT dusted off our memories and tried to recall the old techniques. The neurosurgeon and I worked with the ultrasound machine to attempt to recreate some of the brain ultrasounds we used to do back in the seventies.
Finally, we resigned ourselves to sending our head team to Bastion so that, collectively, we could continue to give the best care possible.
That evening, one of the young BE techs came to me and announced, “The good news is that I think I’ve fixed the CT. The bad news is that the photocopying machine won’t be working for a little while.” Well, I’ll be damned if that kid hadn’t figured out that a circuit from the photocopier could work in the CT, and jury-rigged it so that it would.
I saw the darndest things over there.
What Happens to Our Soldiers
After the Role 3?
I already mentioned that soldiers who were transferred out went on to a Role 4 in Germany. But how? And what happened once they were there?
In August 2007, I was sent to Landstuhl in southwest Germany to the U.S. Role 4 hospital there. It wasn’t my first time. In the seventies I had been posted to Lahr, Germany, as a platoon commander in 4 Field Ambulance. They called it a company (about 150 guys), but it was really a platoon (more like thirty people). And when we worked in the local Canadian hospital (one of my sons was born there, he who was now an expectant father — talk about coming full circle), sometimes we would send our sicker people to Landstuhl. I remembered it as a large, dark hospital with wooden floors and wooden walls. Well, it sure had changed. It was all modernized then, though it was still huge. You had to walk around a lot because it was on two floors only, so it was spread out. If you were in a ward, you could walk three hundred metres just to get to your office
at the other end. Do that ten times a day, and add a few detours to the ICU, and you’ll stay healthy and trim. You’ll even lose weight. No comments on the American food — which I, unfortunately, love.
When they left KAF, wounded soldiers were taken to Bagram Air Force Base near Kabul. Usually they travelled in an American C-130, a Hercules, that workhorse of the U.S. and Canadian air forces. It was only a short ride, but it was fraught with the same perils as any Air Evac (AE). It was noisy and bumpy. Your fractures better be well-stabilized.
If the patients had become unstable along the way, or if they required urgent surgery in Bagram, it was attended to there. Once the patients were stabilized again, they could begin the long trip back home. First stop: Landstuhl (see Appendix A).
In Landstuhl, things were not as hurried. U.S. patients were kept there from twenty-four to seventy-two hours, and then transferred back to the U.S. (CONUS — for continental U.S.) on a C-17, that big Cadillac of the sky. For this transfer, they would put up to fifty patients on a single flight. When they geared up a C-17 for an AE flight, they would load on one of those little containers in which they had all the necessary medical equipment, complete with fridges filled with blood products, so if anything happened on the way home, they could respond to it. Therefore the Americans could AE patients who were only stabilized, as opposed to stable.
We Canadians couldn’t do that. Our AE system had less capacity than the U.S. one, for two reasons. One was that Canada spends a lot less money per capita on its armed forces (1.3 percent of its GDP) than does the U.S. (4.3 percent of a much larger GDP). That’s almost five times more per citizen. So, even in proportion, we have fewer people in uniform and, in turn, these people need less equipment. Therefore less equipment was available to us. As an example, Canada bought four C-17s, those big strategic transport aircraft. To be proportional, as they are ten times more numerous than us, the U.S. should have bought forty. Well, they didn’t. They ordered more than two hundred. By now you get the picture. The Americans could afford to use a C-17 to carry their wounded back home. We didn’t have enough of them.
