PATIENT #1

I was eager to get started and fall into a rhythm of treating the injured servicemen.  Each deployment, the ethos is slightly different. I spoke with Jeff XXX. He deployed 4 times, including a stint in Balad.  He’s a trauma surgeon who has practiced many years at a civilian institution before joining the Air Force. He’s well respected for his clinical and personal adeptness.  We discussed how the war is different here than Iraq. While we are learning in Afghanistan, we’re learning less new lessons.  He also commented that the tempo and culture is different here than in Iraq, and particularly in Balad.  In Iraq, mass casualties were frequent and surprise patients with 3-4 tourniquets were routine.  Here, the patient volume is high, but steady.  The terrain and weather limits flight and more patients are sent to a smaller hospital or air station before arriving to Bagram.  We talked for a while and reminisced about Iraq, the food, the tents, and made comparisons to this war.  I was still tired and hopefully working would shake the jetlag.  My first day at work began as expected. The 1^st hour was quiet as we waited for the call.  “Dustoff to Task Force Med Ops…break…we have liter urgent..break… “ They brought in a young marine involved in an improvised explosive device [IED] attack. He was infantry [and proud of it].  He was on patrol when hit unexpectedly by an IED.  The explosion left one marine dead.  Two others received leg amputations and genital injuries, a signature of the dismounted attacks in the rugged Afghanistan mountains where vehicles cannot travel.  He was awake, 1 day post injury and stoic, as most of the young marines are.  His initial injuries were treated at an aid station, a small tent with few resources and one doctor or physician assistant.  He lost one leg and had a fracture of the other.  We assessed his injuries, stabilized him, and then he maundered through the details of the attack.  At times he seemed distant, almost viewing the attack from above, and at others the details were ghastly as he described the screams of some the marines and the quiet, white, blank, dead faces of others.  After the trauma resuscitation quieted and many had left the bay, I resumed a habit I learned from a patriotic physician assistant I deployed to Iraq with in 2005.  I rested my hand on his shoulder, recognized him for his brave work, and thanked him for his service.  He thanked me and silently cried.  The remaining two nurses and doctor approached the bed and the room was quiet. Later that night, the Marine was awarded the Purple Heart in the hospital ward, pinned to his chest by his commander who was bedecked with ample decorations of his own.  The marine was evacuated three hours later to Germany and then to the US where he will likely be retired from the Marine Corps, never to return to war.  

Later that night

I continued to reunite with old friends.  Jeremy, a trauma surgeon, and I had worked together at Wilford Hall in San Antonio. He graduated from the Air Force Academy and had completed most of his training at a civilian hospital, as I had.  He shared his observations.  This was his 3^rd deployment also, and his second to Bagram.  However, he would be leaving in a few weeks, back to San Antonio.

Later I met with Mike.  Mike is a specialty surgeon.  He’s about 10 yrs older than me.  We have overlapped twice in Iraq during our deployment rotations.  We shared stories of our previous deployments, some comical and others humbling.  We attached most of them to the ethos that the soft walled tents of Balad Hospital in Iraq created.  Bagram was new for both of us and he had arrived 2 weeks before me.  Later, I met with Jeff.  Jeff is a Colonel and a trauma surgeon. We also had met over the years.  He was in charge of the entire Theater Trauma System in Afghanistan and Iraq, a daunting task.  He was handpicked to improve our trauma care built on blocks from the last 9 years at war.  We chatted about Balad.  It was like therapy.  Most who have never worked there do not understand. There is an emotional attachment to “the tents” and the care we provided.  That hospital tent received more casualties than any since the Vietnam War.  It the hub for casualties for all of Iraq and we worked there during the busiest time of the war.  We likely we never see that volume of casualties for another generation.  A replication of Trauma Bay 2 is in a Washington Museum and the USAF Surgeon General has a picture I took in 2007 posted in his Pentagon conference room of the ER the day before it closed.  Jeff and I chatted about how busy it was and he enlightened me to the character of the Bagram Hospital (Craig Joint Theater Hospital – CJTH).  While CJTH is one of the busiest and will be so as the Operation Enduring Freedom surge begins, it’ll never reach the volume of Iraq, which is a good thing.  However, the temperament of the combat hospital was different, slower, and more patient.  They had the right to be as the trauma system was more mature, the communication from facilities better, and the smaller facilities better equipped.  At CJTH we typically get warning of patients arriving and with the mountainous terrain and mercurial weather, the flow patients is staggered, so we are not typically overwhelmed.  This contrasted with Balad where, like the TV series MASH, Blackhawk Helicopters would fly in with 1-2 minutes’ notice, often with 2-8 critically ill patients.  Nonetheless, the care delivered at Bagram was remarkable and rivaled or left behind US civilian trauma centers.  The US trauma centers still seek new lessons we are learning to apply to their institutions.  Jeff said he would be travelling to forward operating bases (FOBs) for most of his tour, but would be here once a week.  As we ended our conversation, I felt relieved, like I had therapy.  Someone else resonated my experiences and validated them. I was ready for the next few months. 

FIRST DAY

The 1^st day was a day of mixed feelings.  I was elated that I had survived the 4-day trip of broken airplanes, airport waiting rooms, and enduring jetlag.  I was eager to get started on this deployment, apprehensive to find if it would be as rewarding as the others, and sad to be leaving my family behind.  I travelled with a Colonel (Jim) from Norfolk to Afghanistan.  He was a guardsman from the Midwest and an Anesthesiologist.  He had had joined the guard 18 years ago and was on his last deployment, his final stint away from his full time practice and his close knit family.  He reminded of the Physician Assistant I deployed with in 2005, a Captain who signed up for the service on Sept 12, 2001.  Both were patriotic, practical, and clinical experts.  Jim has practiced more than 20 years, likely 10 more years than anyone in the combat hospital we were heading too.

            After a dizzying 2 hrs at the PAX terminal, we collected our bags and were waiting for our ride.  It helps to travel with a Colonel.  I would have waited another 3 hours otherwise.  The temperature was hot and the air dusty, more dusty even than Iraq.  Prefab buildings, rundown structures built by the Russians, and a large tents were everywhere.  It felt crowded and busy.  We pulled our 3 bags from the sea of 150 identical military green bags.  Our driver (who came for the Colonel, not me) took us to our living quarters first. 

The “b-huts” were next to the combat hospital.   B-huts are plywood shelters with aluminum roofs.  Approximately 4 to 8 individual rooms are in each of the buildings.  The rooms measure 10 x 8 feet, or about the size of my daughter’s closet.  While humbling, it could be worse – 30 strangers in a tent with a cot and with a cover.  After dropping our bags, we walked to the hospital.

The hospital building was “modern” compared to the green, floppy tents I had worked in for 11 months during previous deployments to Iraq.  The building in Afghanistan was similar to the Balad Hospital that was built in Iraq during my last deployment.  It was a sturdy, well-lit, spacious building.   After arriving, the superintendent took us through the building for a whirlwind tour.  We passed by and said to hello to people I don’t remember due to my jet-lagged state.  Over the next few months, I saw I was not the only one who arrives in that state of amnesia. 

In the emergency room I met some of the staff and was greeted by a few guys from my hospital in San Antonio, Wilford Hall.  It was good to see their familiar faces in a sea of strangers.  Leslie, a recent emergency medicine graduate, took over my tour from the Superintendent.  She introduced me to the other Emergency Department staff and to the physicians and surgeons from the other departments.  It turned out to be a mini class reunion.  Since leaving the USAF Academy, the few of us that went on to medical school (12-18 per year/1000 cadets) dispersed to different medical schools, residencies, fellowships, and then assignments across the world.  On occasion we bump in to each other at professional meetings or in a hospital setting.  But that day, I saw classmates I hadn’t seen in 15 years.  There were 4 grads from my class (30% of those that went to med school my year), 3 from the year prior, 2 from two years below me, and 3 others who were grads from other years.  In that room, I saw more USAFA grads than I had seen in the past 7 yrs and 2 deployments.  Again, it was good to see familiar faces. 

LEAVING HOME

After a tearful goodbye to my wife and 3 kids at the San Antonio airport, I arrived in Norfolk, VA shortly after midnight.  Now, on my 3^rd deployment in 4 ½ years, I fell into the roll of mentor to a young captain on his 1st deployment.  I took a moment to reflect back to my mentors during previous deployments (Corey H., Craig R.) and was grateful to be able to return the favor. After securing rooms, we visited the military airport and booked tickets to Afghanistan, then we settled into our quarters for a few hours.  I was in for a long day, beginning at 3 am and ending 48 hours later. 

I waited in a simple airport. Many of my 150 travel partners from across the US had deployed before.  The innocence and fear seen during previous deployments were absent.  Many of us faced this deployment scarred and matured, but not jaded by previous wartime experiences.

The plane was a mix of people and experiences.  There were the young enlisted who deployed 4 times in 6 years and were prepared for what they were about to encounter.  There were the senior officers and senior enlisted who had never deployed and were evidence of a flawed deployment system.  Many were here to cap off their career with a combat deployment. I wondered where they were for the last 20 years.  Finally, the guardsmen were with us.  Notably, they had sacrificed their full time job, additional salary, and their family to go to war.  Most had spouses who are supportive of their deployment, but keenly aware their sacrifice.  A few joined the military on Sept 12, 2001 and others who have been in for 30 years and had lucrative careers as physicians, lawyers, and dentists. 

During the last two legs of the trip, the plane was full of energy.  Compared to previous deployments, it was more sobering and almost casual, a reflection of the seasoned servicemen and women and how long this war has gone on.    

INTRODUCTION

This blog is a collection of my thoughts and observations from my deployment to Bagram Air Field at the Craig Joint Theater Hospital, one of the busiest combat hospitals in Afghanistan.  The comments are unvarnished and unedited.   I am an active duty emergency physician on my 3rd wartime deplyment.  The opinions in this blog do not reflect the official policy of the US Air Force, DoD, or US Government.  The patients’ and staff’s names and dates may be changed; however, their commitment and sacrifice for the mission is accurate.  I am thankful for the valiant and resolute troops, their devoted and tender families, and the compassionate and dedicated physicians, nurses, and medical technicians deployed in support of Operation Enduring Freedom and Operation Iraqi Freedom.