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
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?
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.