Author: Frederick (Fritz) Karrer, MD- Written Aug. 1, 2011
Another busy week medically but, thankfully, none of the MASCALs (mass casualties) that we had in the prior week. There was however a major suicide bombing of a hospital in Jalabad yesterday and one of our surgeons may be temporarily re-positioned up there to help out.
The week started off fairly routine, but this weekend, the tempo has kicked quite a lot. Beginning Friday, we began to receive patients in waves. Several from IED (improvised explosive device) attacks, and two separate bunches from IDF (In direct fire). IDF differs from IEDs in that it involves launched explosives (mortars or rockets). None of the instances occurred on our base, but we take in casualties from the whole Khost basin, a big valley (over 4000 sq. km.) here in southeastern Afghanistan. Many of the patients we received were seriously injured but none critically. But if they come in more than 5 at a time, it can tax the resources of our little hospital. We only have 4 beds in the ER. Command then puts out an overhead message on the “big voice” to the whole base that notifies all medical providers and other designees to go to the hospital. Dozens of helpers (Docs, Vets, PAs, medics, nurses and just regular soldiers) descend on the hospital to pitch in. Many just help out with moving litters or crowd control/security. Some get pushed into roles that stretch their comfort zone, but all in all it is an amazingly well-run operation.
Fortunately, with explosions, unless you are pretty close to the epicenter, the wounds are mostly small shrapnel wounds. The patients typically have dozens of small wounds to the extremities and torso, lots of fractures from either shrapnel or secondary falls. Only two required exploratory abdominal operations so it could have been much worse. Two had eye trauma (globe rupture) that required evacuation to Bagram for an ophthalmologist. Most required washouts, debridements and lots of orthopedic surgery. Saturday, we had cases lined up waiting and we did them two at a time in the same OR until everyone was taken care of. I don’t know if these events are clustered randomly or are related to some kind of ramp up to Ramadan which starts Aug 1 this year. Ramadan is based on a lunar calendar, so the Julian dates change every year. It is a month-long religious event for Muslims during which they fast (no food or drink or even chewing gum) from sunrise to sunset. They also refrain from smoking or sexual relations. Those practicing usually rise before dawn and have a larger than normal breakfast and then have a large meal after prayers at sunset. Children (pre-puberty), women who are pregnant or nursing, the elderly and the sick are exempt from fasting. It is intended to teach patience, spirituality, humility and submissiveness to God.
Fortunately, we received only a couple of kids in all this mayhem and neither was seriously injured. I also saw several Afghan children in the LNC (Local National Clinic) this week. Another child with massive splenomegaly from thalassemia and a 2-year-old with a communicating hydrocele. I hope I can get them done before I leave, but unless things slow down, they may get cancelled. Our last splenectomy came back for follow up and is doing great with increased energy and color in his cheeks for a change. “Hot Rod”, our boy with soft tissue loss from a truck vs. pedestrian accident returns twice weekly for dressing changes. His wounds are healing in and he is walking around with only a little cane now. The girl with the injured hand from picking up explosives is doing well and fully closed now.
One of the more unusual cases this week was an Afghan soldier, that had a colon resection and colostomy a couple months ago for a GSW (gun shot wound). He had been doing well, but returned with terrific abdominal pain. Cat scan revealed free air and fluid in the belly so we re-explored him. We waded through some adhesions only to find what looked like a drain that had been left behind by the previous surgeons. We all jumped back a foot or more when we realized that it was actually a worm that had eroded through the bowel and was writhing around in the upper abdomen. Yick! Ascaris, fairly common in this region, is an intestinal parasite acquired by ingesting the eggs in contaminated food or water. Since only 1% of the population in this part of the world have indoor toilets, I imagine that the human waste ends up in the water supply or on the crops for irrigation. Once in the intestines, the eggs hatch and the tiny larva migrate through the intestinal wall into the blood stream where they find their way to the lungs, burrow into the airways, are coughed up and swallowed. The adult worm then grows in the gut and can reach 12 inches in length, as big around as a soda straw. They attach to the wall of the bowel and feed off the nutrients in the partially digested food of the host. This big fella must have found his way through one of the enterotomies, because he had a silk tie around his neck? Suffice is to say, I won’t be dining at the Afghan restaurant on post any more. Creepy!
Myna bird
I will leave you with a picture of another one of our frequent post visitors, the common myna bird or Indian myna (Acridotheres tristis). These guys are kind of like a starling except they have a distinctive yellow patch behind the eye. Friendly little critters, they are all over the post and quite noisy with a wide variety of screeches and calls. They are a popular caged pet because of their vocality and ability to “speak”.