Hospital in Afghanistan key to trauma victims’ survival
September 16, 2012
ZABUL PROVINCE, Afghanistan — The noise of a helicopter landing in the darkness Sept. 7 signaled the arrival of three small, bloody and bandaged patients at Forward Operating Base Lagman.
The young Afghans, who looked about 8 years old, were rushed to a dusty, white plywood building that serves as the hospital at a base shared mostly by U.S. and Romanian forces.
They had been near Afghan security forces when the Taliban attacked, using a crude, handmade bomb. Now they were collateral damage in fighting that’s raged here all their young lives.
They were swarmed by medical staff giving them the same quality of care they’ve provided to some 250 patients, about half of whom were Afghan soldiers or other security personnel targeted by the Taliban since March.
One of the surgeons at the hospital is Navy Reserve Cmdr. Timothy Weiner, a professor of pediatric surgery at the University of North Carolina. He has taken care of two dozen children in the past seven months, mostly victims of the Taliban’s bombs.
The boys were strangely silent as they lay on stretchers, waiting for surgery.
“The kids here are unbelievable stoic,” Weiner said later. “[They] hardly ever cry, which … can be confusing since this can mask how significant their injuries are.”
One of the boys had damage to the main artery in his right arm, while another showed no distress despite penetrating shrapnel injuries. During surgery, holes were found in his liver and stomach.
“Unique to my experience here is how much damage tiny, fingernail-sized shrapnel fragments wreak on these thin, undernourished kids,” Weiner said.
Secondary fragments from the blasting caps, pressure plates or even shredded aluminum cans that insurgents use in their bombs might be the cause of the children’s injuries, he said, adding that he’s treated a dozen children with tiny entrance wounds that resulted in severe injuries.
Afghan children often step on bombs while tending to animals, while others get curious and pull wires out of the ground, setting off the devices. One was shot in the cheek, he said.
“He went to bed and when they brought him in, alert and talking — albeit slowly — the next day, I could barely find the entrance wound,” he said. “But the bullet in the back of his brain was pretty obvious on the skull X-ray.”
Because the hospital doesn’t have a CT scanner, surgeons have decided that any child with even a small penetration in the abdomen gets checked very closely to make sure there’s not a more serious injury, he said.
“Everyone here is especially motivated when the kids (or military working dogs) come in,” he said. “They also help us reach back to our humanity and balance some of the equivocal feelings we’ve all had when we’ve also had to take care of injured insurgents.”
An important aspect of medical care for children is on a personal level.
“My nurses back home have also sent us some toys, so that helps too, though some of the poor kids have never had a toy, never seen a Beanie Baby, and are sometimes scared of them at first,” Weiner said.
Fewer children are coming to Lagman hospital these days; locals are being encouraged to take them to Afghan hospitals, he said.
“We’ve met with our surgical colleagues at Qalat Provincial Hospital (the closest Afghan hospital to Lagman); they seem eager and competent and (we) have said we will back them up whenever they wish,” he said.
Once the boys were stable, they were transferred to the hospital in Qalat.
“We expect all the kids will do well,” Weiner said. “They have the advantage of healthy tissues and if they can get some decent nutrition, no small challenge in this country, they should heal.”
Shortly before the surgeons worked on the three boys, they had a visit from Lithuanian special forces soldiers who came to thank them for saving the life of one of their comrades severely injured by an insurgent’s bomb in May.
The injured soldier, whom the Lithuanians identified only by his first name — Algimantas — was riding in a Land Rover near the village of Natuli when it struck a roadside bomb. Two other soldiers and an Afghan interpreter were thrown clear of the vehicle and escaped with cuts and bruises.
Algimantas was not so lucky. He was trapped under the upturned vehicle with serious injuries. By the time his comrades freed him and called for a medevac helicopter, he was clinging to life.
While many his age live in retirement communities and work on their golf swing, Navy Reserve Capt. Richard Mullins, 64, is saving lives as a surgeon at the Lagman hospital.
A trauma surgeon since 1980, he deployed to Iraq twice before coming to Afghanistan.
In his civilian job, at Oregon Health and Science University, Mullins deals with plenty of car crash victims, so he’s used to seeing the sort of injuries sustained by the Lithuanian, who had a ruptured spleen, a crushed pelvis, fractured ribs, a severely broken right leg and a suspected brain injury.
In Oregon, Mullins said, he would have done a CT scan and an angiogram — which involves inserting a catheter into an artery — and tried to save the soldier’s spleen, but at Lagman, he removed it immediately.
“We don’t have any options like that,” he said. “Out here, we want to stop bleeding and control hemorrhaging. You have to operate early on people who are in shock.”
A challenge for surgeons treating bomb victims in southern Afghanistan, where the landscape looks like it was sculpted out of dirt, is the dried mud blasted into faces and limbs by the explosions, Mullins said.
“The dirt is rock hard and once it penetrates your skin, it dissolves and becomes mud,” he said.
Surgeons have to strike a balance between getting out as much mud as possible and avoiding cutting up too much of a patient’s flesh.
“A piece of shrapnel would be a lot easier than mud,” Mullins said. “You can’t get it all out, so there is some left and there is a risk of infection. The challenge is finding the right balance between getting rid of the mud without leaving the patient with severe deficits.”
The Lithuanian soldier’s internal injuries were the priority for the medical personnel at Lagman, and that meant they didn’t treat his leg as quickly as they would have liked, he said, and it was amputated later.
“If his leg was the only injury, we might have been able to save it, but you have to focus on the life-threatening problems,” Mullins said.
At one stage, the soldier went into cardiac arrest, with a flat line on the monitor.
“He died … he died,” recalled one female hospital worker.
“We immediately implemented CPR and the team worked together, and it added up to success,” Mullins said. “With medication and external massage, his heart started beating again, but we were very concerned because we knew he had a brain injury, and any time you reduce blood flow to an injured brain, you run the risk of more damage.”
After the patient was stabilized, he was flown to the more advanced hospital at Kandahar Air Field and on to Landstuhl Regional Medical Center in Germany, where his leg was amputated.
The commander of the Lithuanian Special Forces task force in Zabul — who goes by Liutauras — said Algimantas was in a medically induced coma for two weeks, and when he awoke, he couldn’t feel half of his body.
However, he’s made rapid progress in Germany, regaining feeling in his body and talking to his comrades by videoconference.
“He will be transported to a rehabilitation center in San Antonio to get an artificial leg and he will stay for a year,” Liutauras said, adding that members of the unit were heartened when medics told them Algimantas, a former deputy commander of a special forces mountain team, would be able to run and climb again with his artificial leg.
“The support of the U.S. medics was tremendous,” Liutauras said. “They saved our guy and they did more than they had to. Our thankfulness is hard to express in words.”
Soon after, the Lithuanians headed for another base to plan more operations against the Taliban.
“I would not want to go outside the wire in this battle zone,” said Mullins, who expects this deployment to be his last. “There are so many guys who want to kill you.”