By Patricia Yoon, MD

We’ve had an amazing week down here and I can’t believe how quickly it’s gone by! Friday was our last day of surgery, and held our post-op clinic Saturday. Our days have been nonstop from dawn until dusk, and we’ve treated so many children. But with as much as we’ve packed into a few days, I can’t help but think about how much more work there is left to be done!

Maria
We were asked to see a consult at Juan Pablo Children’s Hospital, the only pediatric hospital in Guatemala. Dr. Aguilar, a local ENT physician who works with the Shalom Foundation, asked us to see Maria, a 2- month-old baby who was not able to breathe when she was born. She had required placement of a tracheostomy tube to breathe, but the cause of her airway obstruction was unknown.

Dr. Aguilar knew that Maria required a laryngoscopy and bronchoscopy to determine the cause of her breathing difficulties, but lamented that she did not have the equipment to perform the procedure – one which is performed multiple times in a typical day at Children’s Colorado.  Maria was on a ventilator in the intensive care unit, which was antiquated and bleak, to say the least. Lighting was dim – bulbs were flickering or missing, supply cabinets were empty, cribs were rusty, and duct tape seemed to be the savior of most of the equipment.  

Maria was on a ventilator, yet had a blue pallor to her face, and no oxygen saturation monitor available. Sadly, Maria will have to wait to receive a diagnosis and the care she needs – we could not transport her to our surgery center on a ventilator. Hopefully she will still be around next time.

Anna
Anna was another child who tugged at my heartstrings. She and her mother showed up in our clinic on our first day in Guatemala.  Anna was an 11-year-old girl born with a severe congenital malformation of her jaw. Her lower jaw was so small that she had no chin, and her mandible was fused to her skull so she has never been able to open her mouth.

She was full of love, giving us all hugs and kisses, and her mother arrived full of optimism that we could make her daughter’s jaw “work” and make her look “normal.”

Anna’s problem is complex, and she will need many surgeries by several different teams, using equipment which we do not have here at this time. It was very difficult to tell Anna and her mother they will have to wait, and that we cannot “fix” her this time. Anna and her mother were nevertheless unfailingly gracious and grateful. I hope that we, or another team, can give her better news in the future.

Exhausted but renewed
Our past few days have been packed with so many memorable and moving experiences. We left the surgery center every evening completely exhausted, but renewed in other ways.  It has truly been an honor to have this opportunity. And what we couldn’t accomplish this time will certainly give us a good reason to come back.

By Phillip Tennant

Mission complete.

We wrapped up our work here Friday during our fourth and final day of surgery. The week went by quickly.  The PACU had emptied out by mid-afternoon and our supplies were quickly stored away.

A sense of closure
There was a sense of closure at the end of the day yesterday that we normally don’t experience at the end of a regular day, or a regular week, at work.  All the patients scheduled for procedures had been taken care of as planned.  They all seemed more than happy with the results.  The lights were in the operating rooms were turned off.  There was nothing else for us to do.

As we talked in the late afternoon and evening, however, it was clear that our interpretation of the week’s events was far from complete. Questions remained. Thoughts lingered.

We did the best we could
Could we have done more?  I think this common question is easy to respond to — of course we could have.  We did not use all of our supplies.  We were tired some days , but far from over-worked.   And our last day in Guatemala will be spent not in the operating rooms, but in the tourist town of Antigua, for our one day of rest.

But we turned no patient away in the clinic, except for two or three that we felt we were not equipped to treat. We had the inpatient hospital rooms filled to capacity on the final morning.  We did the best we could, with what we had, in the situation that we placed ourselves in.

The real question might be, from a Guatamalen perspective, how did we do so much in a country that is accustomed to so little?  Why did we do so much?  How can we do surgery for free when they have been unable to afford an operation despite years of saving money?  Do we understand the hope that we have given them?

More more remains
Much work remains here in Guatemala.  It is but a microcosm of the challenging healthcare issues facing much of the world.   The truth is that we can always do more for as long as we live, but there is value for us, whether it is one surgical case or one hundred cases.

The value lies in the idea that we interpret our world through our interactions with the people surrounding us, and for me, that interpretation is magnified in a foreign land within a foreign culture.  In that sense, the value of this trip and of our work as a team here is complete.  We gave people hope and the opportunity for change through our actions.

One in the same
They showed us that the human spirit is still the same across borders and economic boundaries.  There is still laughter here, even without some added laughing gas, and there are still tears here, when they leave their parents to go to the operating room.  We are one and the same in more ways than we knew before, and that is something that I know the Guatemalans would like us to carry with us on our trip home.

by Pam Mudd, MD, chief resident

What an amazing experience Operation Quetzal (the name of the money in Guatemala) has been, with everything running smoothly down in Guatemala City! The team here is incredible. It has been quite an experience for the groups normally working together in and out of the normal operating days to truly function as a team.

We have PACU nurses placing IVs and scrub techs aiding in intubations. Dr. Mohanram (anesthesiology) even attempted to scrub an ear case today! This type of team work will continue as we head back to Children’s Hospital Colorado with a new perspective on the work that goes into each piece of the peri-operative team.

Smooth surgeries, grateful families
The operative cases have been flowing smoothly and on Wednesday we successfully aided two children with multiple failed cleft palate repairs to improve speech and closed a beautiful 5-month-old baby girl’s cleft lip. The gratefulness of the families and patients is beyond compare. The patients themselves are so strong!

The culture of Guatemala does not support the use of narcotics in patients in the post-operative period for multiple reasons- but we have seen our patients do well with Tylenol alone and they are smiling and drinking, blessing us, and thanking us all. There is also a cultural belief here that the tonsils can cause many ailments from headache to bone pain to cold hands! We have signed up about 17 tonsils +/- adenoids for this week (for real indications of course).

Teaching and training local medical residents
The teams of MDs were able to meet Wednesday evening with the pediatric residency program at the local children’s hospital to teach some of our specialty training and to learn about some of the differences in management which is so helpful for us to help the understanding to manage our patients here.

Assistance from the community and beyond
The patients we are working with here have no means to receive health care and are traveling hours to be seen in our clinic for operations. There are so many groups donating to make our efforts possible with private radiology groups doing CT scans on the same day for less than $20, discounted medications, rushed pathology, and Ronald McDonald house supporting our families that are not safe to travel hours away!

Beyond this there are so many local volunteers that have come to help the Shalom Foundation and the Moore Center for Pediatric Surgery. We have plenty of volunteer students helping us with translation and aiding the patients and the parents in the peri-operative time. Even lunch for the volunteers, medical team, and support staff has been donated by a local restaurant (which is fantastic!). We are blessed in so many ways. I speak on behalf of the entire group when I say that we feel so privileged to be here in Guatemala City serving this population of patients who are in such need!

More surgeries await
I must sign off now as I have to rest – 15 surgeries on the schedule Thursday with two large neck and facial masses, a bilateral cleft palate, an obstructed nose, an open ear, and many obstructed airways to attend to!

Thank you all for your support of  Children’s Colorado’s global health initiative and the team here at Shalom Foundation and their Moore Center for Pediatric Surgery!

We welcome your prayers, thoughts, and questions!

By Greg Allen, MD

Health care providers have an innate desire to help those in need. It’s part of why we got into this business in the first place! In our complicated health care environment it is not uncommon to experience frustration and think, “I just want to take care of kids, why does all this stuff get in the way?”

Encouragement is what I have found providing medical care for children internationally. I find myself relying on core medical principles and practices that allow me to provide the same high quality care free of the complexity.  As the team lead of the upcoming Guatemala ENT trip I am very excited about being part of this team of amazing people. This initiative aims to pave the way for others at Children’s Colorado to participate in future medical missions. We want to involve the whole community! Our aim is to provide an opportunity for everyone, providers and support personnel alike, to be personally involved.

Packing party
On Saturday, Jan. 7, the team spent most of the day in basic information sessions and a “packing party”. This is an integral part of any trip of this type; getting all the supplies out and visible and then replacing stuff in various suitcases. Making sure everyone had a bag as full as possible and as close to the 50 pound limit as possible.

It was obvious that some people are much better planners than I am! What you would never know is that some of these people have NEVER been on a medical mission trip before. Everyone dove in head first and worked their tails off… we were finally a team, working together, laughing together, being nervous and anxious together. The excitement was palpable!

The team will use this forum to communicate with our friends and supporters before, during, and after our trip. We welcome your interest, support, and prayers during this time. In the coming days and weeks, you will meet and hear from other members of this remarkable team.

During the trip, updates will include photos and personal stories from team members. Please stay tuned, and check back often. Subscribe via Facebook or Twitter to get updates.

By Sandra Diaz-Castillo

Perspective is what I get every time I go abroad. I see Mario happily playing soccer barefoot in a dirt field with broken glass. I see his house made of blankets hanging from the trees. His mom cooking over wood and willingly offering us to eat. I see Angelica who graciously shares their outhouse (a hole in the ground with blankets on wire to cover them). Even in these circumstances, they are so happy and grateful for their lives; perspective is what I get when I serve abroad. I am humbled.

I know I am not alone, over the past couple of years at Children’s Colorado I’ve had the opportunity to meet wonderful people committed to helping children and families living in extreme poverty. Many go abroad on their own time to give children and their families a better quality of life. I think of Faith Beazer who coordinates cardiac surgery trips to Nicaragua alongside Drs. Da Cruz and Jaggers. I think of Drs. Berman, Hayes, Niermeyer, Deleyiannis, Bruny, Allen and so many more who have dedicated endless hours for the health and well-being of children and families internationally. I think of Jerrod Milton, who has gone above and beyond coordinating care for international patents here at Children’s Hospital Colorado. Many of us are serving in more than 25 countries world-wide. 

In the heart of our community
Global Health is in the heart of our community. For this and many more reasons, Children’s Colorado is launching a Global Health Initiative — a collaboration between the University of Colorado Center for Global Health — to formalize our global health activities in order to maximize our efforts.  As part of this effort, Children’s Colorado will partner with two to three international locations over the next several years to engage in activities around our mission while building capacity in a developing country.  Guatemala has been identified as our first country of engagement. 

 As you know, our first trip will be Jan. 21- 29, 2012, with an ENT focus, providing a range of procedures from vent tubes to cleft-palate repairs.  To help facilitate this pilot trip, several OR staff members have been invited to participate in this inaugural trip. Our goal is to provide staff with the opportunity to participate in any of Children’s Colorado sponsored trips, which we hope will be two to four times per year. 

A life-changing program
This pilot trip has been and will continue to be a great learning experience in the establishment of our Global Health Initiative. We are aware and recognize some of the generous and creative efforts from our staff to make this trip a reality. Staff from all departments are contributing to make this trip a success and we thank them for that. 

I am looking forward to this Global Health journey at Children’s Colorado. I know going on this trip with provide me with new insights and perspectives to bring back to others that will inspire and energize us as we grow this life-changing program.

How you can help
You too can contribute to the success of this trip and become part of Children’s Colorado’s Global Health community:
• Donate now: Every dollar helps towards purchasing supplies, such as multi-vitamins and vitamin C and Zinc for the children receiving surgeries, sending the supplies and sponsoring a team member. Giving at every level will help Children’s Colorado raise at least $5,000 for this trip. Click here to donate.
• Stay in touch: Follow Global Health Institute activities during the trip through this blog and on Children’s Colorado’s Facebook page and Twitter feed.

By Jessica Ennis

Familiar with providing care to international patients, Children’s Hospital Colorado has made several efforts over the years to influence these patients’ care and long-term health.

One of the hospital’s most elaborate efforts occurred in early 2011, when it hosted five children from Chile who received urological surgeries here in Colorado. It was one of Children’s Colorado’s greatest international outreach efforts – until now. This month, the Global Health Institute at Children’s Hospital Colorado, in an inaugural medical mission trip, hopes to provide surgical care to approximately 40 children in their home country of Guatemala.

Consistent with its patient care mission, Children’s Colorado will sponsor short-term medical missions in partnership with the Moore Pediatric Surgery Center, a local surgery center in Guatemala City.

The Moore Pediatric Surgical Center is a cooperative venture between several U.S.-based children’s hospitals to serve extremely poor children in Guatemala by providing access to life-changing surgical procedures. The Shalom Foundation operates the Center; they provide humanitarian assistance to children and their families living in extreme poverty.

Creating a village
“As a founding member of the center, we have the opportunity to provide leadership around pediatric surgical efforts,” said Amy Casseri, chief strategy officer at Children’s Colorado. “It’s like creating a village around one of the poorest countries in Central America with the long-term goal of capacity building.”

Fifteen members from various departments at Children’s Colorado will leave for Guatemala City, Guatemala on Jan. 21. They will spend a week at the Moore Pediatric Surgery Center, a modern surgical facility, performing ear, nose and throat (ENT) surgeries.

The team held a kick-off event held on Nov. 17, where they were briefed on what would need to be completed prior to embarking on the eight-day trip.

Gregory Allen, MD, and Patricia Yoon, MD, both ENT surgeons, are the team leads. A resident, two fellows, an anesthesiologist and several nurses will participate in the trip. Additionally, two members of the Global Health Institute and Amy Casseri, chief strategy officer, will travel with the group.

“Every time I go on a medical mission, I feel I receive so much more than I am able to give,” Dr. Allen said.

Late Sat., Jan. 21 the team will depart to Guatemala. Early Sun., Jan. 22, the team will begin to screen more than 60 patients during the pre-operative clinic. Surgeries will be performed Jan. 23-26 and patients will be seen a post-operative clinic on Jan. 27.

It will be a very busy week for all those involved, with an anticipated 45 procedures including, but not limited to, cleft lip/palate and branchial cleft repairs, tonsillectomies/adenoidectomies, ventilation tubes, neck mass removals and others as needed.

Earlier this year, a partnership formed between the Center for Global Health at the Colorado School of Public Health and Children’s Hospital Colorado to establish the Global Health Institute at Children’s Colorado.

Contributing to success
The Center for Global Health and the Global Health Institute strive to contribute to improving the health and welfare of the world’s poorest populations, focusing on family and child health. The institute will be the central point of contact at Children’s Colorado to support international activities.

Activities include partnering with one or more organizations to build capacity within identified international communities and delivering on-going clinical services (e.g. continuing consultative support, training and education). Support will also be given to the evacuation of children in need, either due to a natural disaster or on an individual need basis.

You too can contribute to the success of this trip and become part of Children’s Colorado’s Global Health community:
• Donate now: Every dollar helps towards purchasing supplies, such as multi-vitamins and vitamin C and Zinc for the children receiving surgeries, sending the supplies and sponsoring a team member. Giving at every level will help Children’s Colorado raise at least $5,000 for this trip. Click here to donate.
• Stay in touch: Follow Global Health Institute activities during the trip through this blog and on Children’s Colorado’s Facebook page and Twitter feed.

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