Author: Frederick (Fritz) Karrer, MD

Wow! It was a crazy week. Starting on the Friday before Ramadan, we started  receiving patients in waves rather than onesie-twosies like previously. And it continued for the next 5 days. We saw and evaluated 69 patients over that 5 day stretch. Since then it has slowed down a bit but still much more active than July. Also, it only takes one bad one to chew up a whole day. A good example is one of the toughest cases of the week.  A soldier came in with GSWs (gun shot wounds) to the butt and leg. He arrived in shock and was taken to the directly to the OR. We evacuated a belly full of blood and found one of the bullets had gone in the pelvis. Those of you with any medical training will realize the vascularity of this region.

The pelvic veins were bleeding too fast to even see where it was bleeding from. We got

Radiograoh of the tibial gun shot wound

some control with ligation of the internal iliac artery, but eventually packed and got out. Problem was, he also had a GSW through the leg with a shattered tibia that we had to deal with. (Pic of his radiograph attached to the right.) All told, he received over 40 units of blood products, 17 of which were whole blood, something you almost never give in the states. Over here, when our blood supply runs low, there is no rapid resupply option. So, we call in soldiers for an on the spot blood drive (everyone’s blood type is on your dog tags) and dozens show up to donate. Fortunately, he survived and was in good shape when he was evac’d about 24 hours later. It’s amazing how well whole blood works (fresh, warm and with all the components). In our case, the bleeding went from torrential to modest. Among the many casualties this week, we saw a 13-year-old kid who was told to move a wheel barrow (filled with explosives) up to a police station. Fortunately, he must have gotten a little ways away from the device before detonation because he suffered only 3 rib fractures, a hemopneumothorax and other minor shrapnel wounds. What’s wrong with these people?

Dr. Karrer and team checking CT scan

Sind Krait snake

The critter of the week is a Sind Krait, scientific name, Bungarus sindanus (see pic). This little fella was discovered just outside the door of our hooch, on the “Welcome” mat by my roommate coming in at about 2400. The adults are a medium-sized snakes about 2 feet long, predominately black with white cross bands. They are supposed to be strictly nocturnal; seldom seen during day. They move quickly and can be extremely dangerous & aggressive at night. Reportedly, they often enter human dwellings and may crawl under sleeping persons. We’ve treated two snake bite victims while I’ve been here. One described the snake as being consistent with a krait. He nearly died, with hypotension, respiratory failure, and pulmonary edema but recovered after about 3 days on the vent. The venom is a potent neurotoxin and the bites may be invisible or barely perceptible puncture marks (as was the case in our patient). The local symptoms near the bite are minimal often lulling the victim and providers into a sense of relief, until the patients begins to have systemic symptoms include ptosis (droopy eyelids), facial paralysis, & inability to open mouth, swallow, or protrude the tongue. Later, symptoms progress to inability to speak,  difficulty breathing, paralysis, shock and respiratory failure. Human mortality rate is as high as 50% even with the use of antivenom. Needless to say, I’m treading a little more carefully after dark.

Sunrise over Salerno, Dr. Karrer's base

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”.

Prudence Mabhena is an inspiration to others. In fact, she is the subject of an Oscar-winning documentary called “Music by Prudence,” which showcases Prudence’s singing talent while documenting her life struggles.

Prudence was born with a genetic disorder called arthrogryposis that twisted her limbs and denied her the ability to walk. In January, the 24-year-old traveled from her home in Zimbabwe to Denver where she received back and hip surgeries at Children’s Hospital Colorado that have enabled her to sit up better in her wheelchair.

“Her way to interact with the world is to sit, because she can’t walk. She can move her shoulders a bit. Not her elbows. Her hips don’t move at all,” said Mark Erickson, MD, in a recent Denver Post article. Dr. Erickson performed Prudence’s surgeries. “Our goal was to get her positioned so her pelvis is level, so her spine comes up as straight as possible. So she can be more up, rather than leaning over to the side all day long.”

While Prudence has been in Denver she has touched many lives – as a result Denver has shown her much generosity.

“It is so surprising to find someone who gives his or her love to a stranger who lives 20,000 miles away, on the other side of the world,” said Mabhena, in the hotel suite in south Denver where she has lived, without charge, since she arrived. “I didn’t believe I would get to a place where people have such full love and care.”

Read more about Prudence in the following news articles:

• The Denver Post: http://www.denverpost.com/newsheadlines/ci_18209193
• KUSA (ch 9): http://www.9news.com/news/local/article/206251/222/Gifted-young-woman-gets-life-saving-help-touches-hearts
• Rocky Mountain PBS: http://www.rmpbs.org/content/index.cfm/program/13117-924
• KCNC (Ch 4): http://denver.cbslocal.com/2011/06/19/denver-doctors-give-african-woman-new-hope/

Author: Frederick (Fritz) Karrer, MD

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.

I am writing you on the 4th of July with the first month behind me now.

It’s been a relatively busy month even for this Hospital. We’ve done over 60 cases since we got here, and that doesn’t count the dozens of sedations for dressing changes, washouts and minor procedures. The inpatient census has been high. We accumulated a few long term players that have occupied inpatient beds for weeks (a 60% burn, “Hot Rod” with soft tissue loss both legs, a post op small bowel fistula). Fortunately, all but a couple were discharged prior to this weekend. Hot Rod has been here so long he’s gone through puberty, but was finally discharged Friday.

The week started off with a series of extremity injuries. Two gun shot wounds (GSWs) to the thigh,  another femur fracture from a fall and then a bunch of minor hand, arm and foot fractures/injuries. Our vascular surgeon, Deepak Deshmukh did a nice job of saving the leg of the Afghan using a saphenous vein graft from the opposite thigh. Unfortunately, the patient was brought to us late (more than 12 hours after injury) with a tourniquet in place. We shipped him Day 3 in renal failure from myoglobinuria, without much sensory/motor function to his foot in spite of good blood flow. I helped the orthopod, COL Jimmy Swanson, place an external fixator for the other GSW femur fracture. External fixators are long screw that hold the bone above and below the fracture allowing realignment and stabilization. Kind of like tinker toys only way more expensive.

We were all sort of holding our collective breath as the 4th of July approached. Often the combatants like to stir things up on our holidays. And sure enough, today we had another  mass casualty (MASCAL). A bunch of Afghan soldiers rolled their vehicle. Although I don’t have the specifics of this accident, the typical vehicle for the Afghan soldiers on our FOB is a standard pickup with a machine gun mounted in the back. Usually 2 or 3 soldiers ride in the cab and another 2 to 4 in the truck bed, unrestrained. Consequently, the slightest mishap can be very hazardous.

Fortunately, none of those 4 were hurt seriously. We also got two Taliban insurgents; one needed a laparotomy for a flank GSW and the other had blunt head trauma. Shortly thereafter, we had 2 from an rocket-propelled grenade (RPG) explosion.  Sadly, one was a 2-year-old with multiple fragment wounds, most non-critical, but one had penetrated her skull. We shipped her off to have neurosurgeons evaluate her. I think she may do alright because it was frontal lobe, no major bleed or shift and she was neurologically pretty intact for the 6 hours we had her. Still, seems so senseless!

One of the finds of the week was the Salerno Golf Club. Well, really just a hitting cage. Although there is no real way of

Salerno "Golf Club"

telling, I’m confident that all of my practice drives are over 250 yards and right down the middle. There are plenty of golf clubs and balls, but the hitting mat is in tatters. My friends, the Dew sweepers at Pinehurst and Kevin Vena, the club pro, have arranged to send us a mat that we can actually hit off of, without having to go chase it up at the front of the cage after every shot. That will be schweet!

One of the objectionable parts of FOB life, is the crushed rock.  Nearly every square inch of the forward operating base (FOB) is covered with crushed rock. It makes for difficult movement from place to place, since the shifting base requires constant micro adjustments in your ankles and feet, it leads to an unpleasant lurching, staggering gate. Very annoying! Seems like it requires more effort of locomotion to get anywhere and in the humidity, that’s a drag. At least the rocks keep the FOB from becoming dusty; or muddy after the rains that seem to come every day now. Although the rains keeps the temp down a little bit, the downside is that it makes for a lot of humidity and mosquitoes. This is an endemic malaria area, for Plasmodium falciparum, so I’m taking my doxycycline religiously. It kind of messes up my GI tract, or maybe it’s just the food from the dining hall (DIFAC).

Well enough for now, more next week. Stay well and stay frosty.

V/R,

COL Frederick “Fritz” Karrer

Author: Frederick (Fritz) Karrer, MD

The OPTEMPO (operations tempo) has remained high in the region this week. We had casualties every day last weekend, including several multiple casualty events (4 or more). One of the MASCALs (mass casualties) was a suicide bombing at the Khost Police Station on Saturday that wounded over 20 and killed 3, including the commander of their QRF (Quick Reaction Force). We received 7 of the wounded from that blast, including a 12 year-old boy who took some shrapnel

through his flank and lost his right kidney as a result. Sadly, May was the deadliest month for civilians in Afghanistan since 2007, according to the UN’s Afghan mission (UNAMA). They documented 368 civilian deaths and 593 injuries in May due to the ongoing conflict. June doesn’t seem to be any better.

But enough of the gruesome side of our work here. I have managed to get into more of a routine lately. I get up at 0430, and the sun’s already up by then. I go to the gym, put in 30 minutes of aerobic (treadmill, elliptical, stationary bike, stair climber or rowing machine) and 30 minutes of weights. Then hit the showers, breakfast at the DIFAC (dining facility) and get to rounds by 0700. We usually have a couple of scheduled cases; dressing changes, wound wash outs, lots of extremity procedures (rods, pins, screws, etc). We usually help each other out (since there are no residents). I like helping the pod (orthopedic surgeon), COL Jimmy Swanson. He’s a high speed, low drag former West Pointer. Very knowledgeable and a good teacher about how to fix broken stuff. I’ve attached a photo of our patient from the first week, who was run over by a local truck and sustained a femur fracture. We call him “Hot Rod” because he is always zipping around the ward in his wheelchair.

"Hot Rod"

During the day, we see patients in the LNC (Local National Clinic), mostly follow ups but occasionally new consults. I usually get asked to see the kids. One was a 10 year-old boy with congenital exstrophy of the bladder (basically an open, inside out bladder just above the pubis). This is a condition that normally is repaired in infancy in the US, but this 10 year-old has lived with his bladder open, dribbling urine his whole life. They have no diapers for him, so he just walks around with his pants wet constantly. He was refused by the school because he smells of urine. We are trying to find a way to help him, but with our high optempo, we can’t afford to tie up a bed. I got some good advice from our pediatric urologist at Children’s Colorado, Duncan Wilcox. We may be able to send him to Bagram, a bigger base and has the regional hospital there, with more capacity, more equipment and a urologist.

Later, barring additional events, we usually watch a movie, hit the computers for email or Skype or read. Thankfully, the nights are relatively quiet, trauma-wise, so being on-call is not overly

Scrub tech, SFC Sharke, on pasta night

burdensome. Even though the DIFAC is decent and has a good variety, it tends to be pretty tasteless and repetitive.

On Thursday night’s, one of the scrub techs, SFC Sharke, does pasta night. She sets up her little kitchen in the hallway outside the OR and has made some amazing meals. Most of the ingredients are sent to us from friends back home. This week, she made chicken alfredo, garlic bread, italian salad and for dessert, cupcakes. Very yummy and a welcome change from the DIFAC.

This week, one of our surgeons, Stuart Johnston, redeployed (that’s Army-speak for went home). Some of the more senior faculty will probably remember him. He was a CU surgery resident, finished in 1997. He’s currently on the Baylor faculty, practicing in a north Dallas suburb. Great guy and an excellent surgeon. Sorry to see him go so soon, but happy for him and his family.

Well, enough for this week. I’m going to show the new surgeon, Deepak Deshmukh (a vascular surgeon from Norfolk, VA) around the FOB. One last thing for the Cornhuskers, a picture of our back hallway (note the Black Shirts flag). Go Big Red!

Author: Frederick (Fritz) Karrer, MD

Within 6 hours of arrival, we got our first patient, an 8-year-old Afghani boy run over by a civilian truck 4 days previously. He had been “treated” at the local hospital, but not well. He had an open femur fracture and extensive soft tissue injury of both lower extremities. All they had done for 4 days was splint his legs and wrap them in Kerlix. Our orthopedic surgeon was taking care of him when the second trauma came in. This was a 25-year-old soldier with a gunshot wound in the right lower quadrant. Fortunately, it was a through and through wound and other than requiring a small bowel resection, missed other important structures like iliac vessels, ureter and colon. He was evacuated the next day to Bagram.

The very next day, we had 3 Afghanistan Nationals (AN) brought in after being injured by an IED. One was a 9-year-old boy who was peppered over his entire anterior surface with shrapnel. He had been asked to roll a wheel barrow up to some of the Afghan security forces. The “bad guys” had hidden explosives in the wheel barrow and when he got close enough, they detonated it. What’s wrong with these people? We found that he had traumatic eye injury (hyphema), a hemopneumothorax, and intra-abdominal foreign bodies on CT scan. After a chest tube and exploratory laparotomy with small bowel repairs/resection and a cholecystectomy for shrapnel perforations, he was evacuated to Bagram because of foreign bodies in the left eye (they have an ophthalmologist up there).

Hope all is well back home and appreciate all the well wishes. Anyway, two days on the job and two serious pediatric trauma patients! Looks like I’m in the right place.