Dilemma

"Just what am I supposed to do with this patient?"

"It's not my call to make. Don't know what I can tell you beyond circumstance and treatment."

"Well, was he doing anything before he was intubated?"

"He came in intubated, so we don't have much of a baseline to go on. He seemed to have some upper extremity movement and looked like he was miming a fish's mouth when we lightened anesthesia to attempt to wake him up. I think he's got some outside chance of a recovery, so we wanted to give him that chance."

"Alright, well I know it's not your fault. I just wonder what we are going to do with this guy."

This was part of the conversation I had last night with an ER physician in Balad. Our patient was an Iraqi civilian that decided to gun towards an IP checkpoint, and held heavily armed men in low regard this afternoon. For some reason, this is a common occurence. Civilians really like to speed close to convoys, get their vehicles lodged into convoys, and just plain not pay attention to big signs that read 'STOP, CHECKPOINT AHEAD" or "STAY BACK, DEADLY FORCE AUTHORIZED" in Arabic. From what I gathered from our interpreter, this guy was unarmed, not suspected of being an insurgent, and just wasn't very good at following instructions while wielding a 2 ton weapon on wheels.
As he barreled towards the checkpoint, he was shot in the neck and subdued. We heard about him when it happened, because he was originally supposed to come to Charlie Medical. Instead, we aren't really sure what transpired over the course of the afternoon, but we knew he was Ramadi General-bound. Case closed. Or so we thought....
We commandeered an entire table for dinner, and the surgical team was sitting down to chow. Up runs one of the surgical techs looking for us. He was told by Charlie Medical that indeed the patient was again coming to us, but Ramadi General had him in surgery. Well, this didn't make much sense. We'll roll with whatever comes, so we finished up and started back to medical to wait for his arrival.
Our detachement commander gets a call on his cell. The patient just arrived, is intubated with gastric contents in the breathing tube, and he is obtunded (not arousable). Bob sprints ahead now to assess the airway situation and find out why a previously stable and "in surgery" patient has mysteriously shown up at the door a suddent train wreck.
He quickly assesses that somehow the patient was improperly intubated. The breathing tube was inadvertenly introduced down his esophagus instead of the trachea. However this happened, we now have a patient with a stomach and bowels filled with a whole lot of air, and none to very little in his lungs. How did it happen: don't know? How long has he been deprived of oxygen: don't know?
He still has the gunshot wound to the neck that hasn't been explored or repaired yet, so we rush him to the OR. All major structures intact except some cervial vertebra damage, Martin does the exploration, cleanout, and is closing the wound within an hour.
Which now leaves us with a huge dilemma to sort out. With a superficial and seemingly easily recoverable neck wound, we now have a patient on our hands that is one big question mark. He seems to have been deprived of oxygen for some length of time. It is obvious that he currently has deficits; we tried to wake him up after surgery, but it wasn't happening. With these types of injuries, it is impossible to know what the outcome will be. What function and cognitive ability will he regain? 50%? 80%? The only way to realize what the outcome will be is to give it time. Weeks to months of time....and that is why we made the decision that I would fly him to a bigger hospital. Somewhere with CT scanners and a neurosurgeon on staff. The only place in the Country where he has any chance whatsoever. But we also asked a lot of Balad last night, too. We are asking them to accept the burden of initial and secondary care, giving up limited resources, to a patient that may or may not recover. They accepted, as all of the caregivers out here, to have the patience to see him through, no matter the outcome. Like us, every day they press the "I believe" button and just go with it.

Like my patient, Iraq is a wounded Country. As with a brain injury, there's no quick prognosis and no quick fix to Iraq, either. Standing where we stand, there is no crystal ball to gaze into and give us all the answers. You'd be better off looking for starfish in the Mississippi River. So we have to ask ourselves what will give us the best chance for a secure Iraq? Citizens free to go to the marketplace without wondering if they just palmed their last pomegranate waiting for the place to go up in a fireball. Without Iran and Syria squeezing from the borders like a nerfball in a vice. I don't purport to have all the answers, but I'm intimitely aware of how all wounds heal....with time and patient support.