A Trip to the Flight Line: MERT

Today had a trip to the Flight Line and got to see up close MERT which has as a platform a 47.  There is A LOT of room which makes casualty care in flight very doable.  Flight crew includes an MD, usually and anesthesiologist, two paramedics, and 4 combat support troops which are trained and also aid in medical care in flight.  Basically on a single severely injured casualty can have up to 7 people doing medical care.  Pretty impressive.
Pic is of MERT back to front. Two anesthesiologists on ends, me and Emergency Med Navy Capt.
Next time we go down to flight line will take a look at US Medical Transport asset just to show the difference in capabilities.

On IED Explosions and Silk Boxers

So this may sound like a funny topic but actually it is a very serious one. The injuries received by our troops from un-mounted IED explosions, as would be expected, generally effect the lower extremities but since the blast is upward, the perineum is also at risk along with those important structures.  These perineum injuries can be as devastating to a young solider as any other part injured.  Interestingly, in alot of cases, the injuries seem to occur from small, but high energy frags.  The Brits have come along with a way to prevent these.  The "first level" protection involves special silk boxers. These are essentially a boxer brief made of 3 layers of dense silk (see pic).

They still maintain a comfort level but seem to afford at least some protection. And they do seem to work. Brits soldiers who ware them seem to have much less injuries in that area. Need to get them for our US Marines that is for sure.  There is a better version that has Kevlar in them  That would be even better

Honor Courage Commitment: The 3/5

Our OIC sent this link out. It is a must read.

I think we here at Bastion Hospital have this connection with the 3/5; as i have said we take care of all of them that come in from Sangin. It is at times so painful. It is a story of such valor and courage that so needs to be told. I don't think people at home have any idea.  The pic in the article is two who were taken care of at Bastion.

Marines pay a price trying to secure an Afghan hot spot

What happened to them in Sangin district of Helmand province shows the sacrifices in a campaign aimed at crippling the Taliban in a stronghold and helping extricate the U.S. from a decadelong war.

Lance Cpl. Juan Dominguez, 26, left, practices using a biometric prosthetic… (Carolyn Cole / Los Angeles Times)

January 22, 2011|By Tony Perry, Los Angeles Times

Marines tell of snipers who fire from "murder holes" cut into mud-walled compounds. Fighters who lie in wait in trenches dug around rough farmhouses clustered together for protection. Farmers who seem to tip the Taliban to the outsiders' every movement , often with signals that sound like birdcalls.

When the Marines of the 3rd Battalion, 5th Marine Regiment, deployed to the Sangin district of Afghanistan's Helmand province in late September, the British soldiers who had preceded them warned the Americans that the Taliban would be waiting nearly everywhere for a chance to kill them.

But the Marines, ordered to be more aggressive than the British had been, quickly learned that the Taliban wasn't simply waiting.

In Sangin, the Taliban was coming after them.

In four years there, the British had lost more than 100 soldiers, about a third of all their nation's losses in the war.

In four months, 24 Marines with the Camp Pendleton-based Three-Five have been killed.

More than 140 others have been wounded, some of them catastrophically, losing limbs and the futures they had imagined for themselves.

The Marines' families have been left devastated, or dreading the knock on the door.

"We are a brokenhearted but proud family," Marine Lt. Gen. John Kelly said. He spoke not only of the battalion: His son 1st Lt. Robert Kelly was killed leading a patrol in Sangin.

The Three-Five had drawn a daunting task: Push into areas where the British had not gone, areas where Taliban dominance was uncontested, areas where the opium poppy crop whose profits help fuel the insurgency is grown, areas where bomb makers lash together explosives to kill and terrorize in Sangin and neighboring Kandahar province.

The result? The battalion with the motto "Get Some" has been in more than 408 firefights and found 434 buried roadside bombs. An additional 122 bombs exploded before they could be discovered, in many instances killing or injuring Afghan civilians who travel the same roads as the Marines.

Some enlisted personnel believe that the Taliban has developed a "Vietnam-like" capability to pick off a platoon commander or a squad or team leader. A lieutenant assigned as a replacement for a downed colleague was shot in the neck on his first patrol.

At the confluence of two rivers in Helmand province in the country's south, Sangin is a mix of rocky desert and stretches of farmland where corn and pomegranates are grown. There are rolling hills, groves of trees and crisscrossing canals. Farmers work their fields and children play on dusty paths.

"Sangin is one of the prettier places in Helmand, but that's very deceiving," said Sgt. Dean Davis, a Marine combat correspondent. "It's a very dangerous place, it's a danger you can feel."

Three men arrived in Sangin last fall knowing they would face the fight of their lives.

Above is reprinted from the below link and all rights are reserved to that entity. See the link for full article which is pretty amazing

http://articles.latimes.com/2011/jan/22/world/la-fg-afghanistan-marines-20110123

Taliban vs Kids Day Once Again

Yes it was Taliban vs kids day again yesterday.  Six injured only 5 made it to the hospital. Another died on the OR table.  Seems that Special Forces were meeting with the elders of a village with a bunch of kids around and the Taliban tossed a granade.  End result as above.

Some more on how Resuccitation is done here at Bastion

Ok. So I have said the big difference that I have seen is how resuscitation is done here.  Let me give you an example and I remember this case really distinctly and it has stuck in my mind of how different it is here. Marine comes in basically triple amp (hi aka's on lower ext =commonly what we see) pH 6.8 BE -25, core temp about 31 deg C.  Gets resuscitated in ER then goes to OR emergent Proximal Vascular Control (more on that later). Within 45 mins of being in OR his temp is close to normal (36 deg C) his BE is like -1 and he has a normal ROTEM (more on that later too, basically it means he has normal cloting and is NOT coagulopathic).  He then goes to CT where the resucc is continued then back to OR for 2-3 more hours of dedridment of his wounds which is absolutely essential to having a good outcome. The key is NONE of the normal indicators to do damage control surgery are present at any time in the OR, ie: normothermic, normal clotting, not in shock with a normal BE).  It is truly amazing.  The patient goes to the ICU basically resuscitated! He may need more ongoing in the ICU but when he leaves the OR it is pretty much as good as it gets. Just going to have to say when I get back home there definitely needs to be a change in the paradigm of how resuscitation in the ER and OR is done.  They have clearly demonstrated here that patients don't need to go to the ICU to get resuscitated.  Pic is of OR team working on injured patient from dismounted IED blast

Rain in the Desert

Yes it actually is raining here in the desert! Not just a mist but occasionally actually hear rain drops!!

More on the 3/5

This was a recent NY Times article on the Marines in Sangin which basically are the 3/5.  We are the "receiving" hospital for pretty much all casualties from that area


NY Times Article on the 3/5
http://www.nytimes.com/2011/01/18/world/asia/18helmand.html?_r=3&partner=rss&emc=rssMarines in Sangin

OP Herrick 13B

Ok..I am not totally sure how things work here...but we are currently OP Herrick 13, meaning I guess this is the 13 iteration of operations here.  Not sure exactly how long a particular "version" is here. But...we are do for a change: towards the end of the month the majority of the Brits here including most of the admin staff are going to change.  So...maybe we will be OP Herrick 13B.  Anyway..this has been, and will be one of the difficult things here.  The Brits in general only rotate out here for a relatively short period. For instance the docs are here for only 7 weeks or less.  Whereas the Navy is here for 7 months.  OUCH!!  It makes it kind of hard.  Just when you are getting settled with the group...they end up leaving and you have to start over with the new ones!  OH WELL

Amazing Resuscitation – The Key to the Bastion Way

So as I have said one thing very amazing about this hospital is the resuscitation that happens with these severely injured patients.  It starts in the ER-trauma bay and continues thru till the patient is in the ICU (or ITU as the Brits call it = Intensive Trauma Unit).  What is unique from a US point is that the anesthesiologists do the resuscitations TROUGHOUT this trip, again from ER to ITU; usually one to two of them (or more) plus anesthesiology assistants (OPDs). Plus there are up to two (one for each Level I rapid infusers) teams to run the Level Is, and of course the resuscitation is 1:1 = one prbc to one ffp with some plts and Calcium and other stuff thrown in.  Pic is of ER team receiving report from MERT (MEDIVAC) just prior to patient coming into Trauma Bay. 

Marines, MRAPS and Foxes

On a lighter note,sometimes you just have to remember that these Marines are still "kids" The other night a group of 5 came in after taking their 1 million dollar MRAP over a 15 foot embankment. No one really seioursly injured, MRAP ok. Turns out the driver saw a fox run in front, tired to avoid smushing it, missed the fox, but not the cliff. They will NEVER live this down. In a way it is like, i am not sure what word to use...maybe cute..Big tuff marines not wanting to smush a fox. They would kill me if they knew i said that

The Brits

Ok so here it is...the shot heard round the world....JUST KIDDING.  As I said this is a British run hospital and so far one of the neatest parts of being out here in the Afghan desert is working with them here at their hospital.  You know...one people separated by a common language.  And yes...at times understanding them can be trying.  For instance the new Ortho Registrar (what the Brits call their residents although I am not sure exactly how that works since it seems they are that till like 40) is a really neat "kid" but with a Brit accent (not sure exactly what...seems like they have names for all of them ) which is pretty neat to hear but when he gets fired up and going fast...well...you just kind of look at him and nod. 
All kidding aside it is exceptionally rewarding and fun to work with them here.  They are different in some ways (OMG Cricket...HELP ME....the friggen games last for days) and we get to have Sunday Savories...which is nice. But for the most part we are very similar They are warm and very gracious about having a large American contingency here, and I am sure we Americans can be trying at times...we have however, seemed to gel into a pretty cohesive unit, which as I have said, does some amazing work.  If I had to be somewhere over here I could not think of another place I would rather be. Pic is of OR "Crew" , Brits and Americans on Christmas.

The 3/5 DarkHorse

The 3rd Battalion 5th Marines Regiment 1st Marine Division...better known as the 3/5 Nickname DarkHorse.  They were sent over here to help the Brits in Sangin in Helmand province and it has pretty much been hell for them. They are are a group of approximately 1000 marines, and their Battalion is one of the most decorated in the Marines, receiving more Navy Cross Awards for Gallantry in Combat than any other unit in the Marine Corps. Since they have been over here they have lost 25+ of their members and at least that many more to casualties.  A marine who was seriously injured had lost one of his buddies in the same incident. In talking to the psychiatrist who takes care of these guys she said he was depressed because he now had to go home and he felt like he was deserting his comrades.  The actions of these young men defies comprehension.

Kids and War

Seems like it was Taliban vs kids today. A bunch came in. One I got to operate on.
I think I have talked about the "I have never done that before" list. Well can add this one: exp lap on a one year old with penetrating abdominal frag wounds. And to think I was worried about doing an appy on a 9 y/o. 

It is a small world

 Ok so had a "its a small small word" incident here. A marine SSgt from the 3/5 (the 3/5 has been really getting the worst of things here it seems) came to us with a GSW to the face but it essentially missed everything!! (yes he is the luckiest marine in SW MEF).  In talking to him turns out he is from LI (south shore) and...is a NYPD police officer working in Brooklyn.  I told him I was a NYPD honorary police surgeon and we had a laugh.  I will have to tell the police commisioner that I am taking care of his boys even out here

The Bastion Way

The New Year is pretty much underway and we are gearing up it seems for upcoming events.  One of the more amazing things that is done here is the resuscitation of the trauma patient from the moment they hit the door.  Well actually it starts even before the patient hits the door in the form of advanced medical transport.  Basically the Brits have developed and invested in a very high level medical air transport system for this Helmand region.  It comprises helicopter transport (a BIG helicopter) combined with high level of medical assets on that: an anesthesiologist or specially trained ER physician and other critical care trained support personnel ie nurses or corpsman.  They can in essence supply Level 2 echelon medical care while en route back to the hospital. What this does is start the clock at resuscitation not when the patient gets to the hospital but when they land and pick up their patient at the incident. They can do most ER interventions and we have seen patients come with bilateral chest tubes, intubated, give drugs like Calcium and TXA and have already received 4 units of prbcs and 4 units of ffp all in a 30 + min flight.  WOW! Pic is of MERT heading off for pick up. Bad pic because we are not really allowed pics of flightline