Anbar Waffle House opens for business

A dear friend whipped up a fantastic idea: surgical team waffles! She send out a waffle iron, pancack mix, maple syrup, buttermilk powder, and a can of pumpkin.

All I had to do was "procure" some milk and eggs. Grocery stores, or "Souks" are off-limits. Haven't found any Wa-Wa's or 7-11's yet. No easy task; this took a coalition of the willing and some smooth talking at the chow hall. Worth it. Along with some freshly ground Starbucks, this was the finest "homecooked" meal I've had in months!

Surgical Team says: Thanks Missy!

Slave to the System

"Dude, you're not on the nine-line!"

"What, your kidding me! I'm going to have to go on this one! Either that, or the patient stays on the deck, and we re-submit another request."

"I already have a monitor." The flight medic yells above the roar of the rotors 20 yards away.

I shrug my shoulders, as if to say "What now?"

The flight medic yanks a thumb with a resigned "get in" to the blacked-out helo silhouetted against the soft glow of green landing lights. I grab my flight bag, run ahead, and jump in. The Army evac team, on my heels, carries my patient up alongside, and I help them guide the litter along the carousel skids.

Patient settled in, and vital signs stable. Struggling to quickly get my 5-point harness on before take off. I wasn't fast enough to get buckled in, but no matter: takeoff was soft as butter. Besides, as soon as we are in the air, I have to hop up and start assessing our casualty.
VBIED attack: I follow my patient from the trauma bay to the operating room, and coordinate getting him to the Baghdad CSH just as Martin, Tim, and RH finish repairing abdominal wounds, a blown out knee, and a gaping right shoulder injury.
Anytime a patient is critically ill, and is either unstable or needs to remain ventilated, a flight nurse goes on the mission. We bring along specialized ventilators and monitors, and unless the flight medic happens to be infinitely familiar with our equipment, can become a complicated mess in flight.
Hence, the need for me to be included on the "nine-line", which is essentially a mission tracker that includes casualty identification, flight route, and crew. If I go on the mission, all coordinating services need to know I am on that helo, similar to any flight manifest throughout the rest of the world. Otherwise, if something happens during the mission, the Tactical Recovery of Aircraft and Personnel (TRAP) team won't have any idea who I am or why I'm near a crash site. Wrong assumptions would put me at high risk. Not to mention if I somehow get separated from the aircraft: they won't know to look for me, if they never knew I was on the mission to begin with. I ended up running into complications, but it wasn't anything worse than getting stranded at another base while trying to figure out how to get back to Ramadi.

The patient did well. Stable for the flight, I busied myself with watching his oxygen status, changing out oxygen tanks, and giving IV fluids and some pain medications. Flight medic taps me on the shoulder and signals "two mikes out". I have just enough time to clamp and store his IV fluids back into the "hot pocket" and check the oxygen tank one more time. Once we touch down, it's too late for housekeeping. We count tasks in seconds, and have precious few to spare. Flashes of light off to my right as our Blackhawk launches countermeasure flares. In all reality, I'm too busy with my patient to care. It registers in the back of my mind "Hmm, wonder why we're launching chaffe?" I hear the pilots and crew chief talking over the "comms", and they don't know why it launched either. Our countermeasure flares can be triggered manually, but are always on sensors, too. The helo computer sensed some sort of heat threat, but none of the crew saw anything. Safe assumption it was just excess heat from a roof vent. Sixty seconds later, and the Blackhawk touches down in Baghdad. We carry the patient to a 4X4 "gator" and drive 25 yards to the ED entrance. Patient care is transferred to the Army ED physician, and the medic and I grab flight equipment and monitors for the dash back to the helo.
Here is where my return to Ramadi gets a monkey wrench thrown into the mix. The Blackhawk crew had no idea they were going to have to go back to Ramadi that night, and were caught unprepared. Visibility was closing in to around 2 miles in Anbar Province, so they broke the bad news to me: I was going to Taquaddum with them, and would have to find my own way back. They offered to drop me off at TQ surgical.

Small consolation...and here's where the "it's not just a job, it's an adventure" part kicks in:
Random thoughts as we were targeted with a volley of RPG fire on our appoach to TQ:
"How long can a Blackhawk hold a hard bank at 90 degrees to the Earth?" as the pilot violently pulled the helo left, right, and left again to avoid being hit.
"Can my heart really go this fast?"
"I can't believe I'm not on the friggin nine-line; they'll have no idea who I am if this thing goes down...$%*! figures!"
Sandwiched in between the flight medic (primary job when not taking care of patients: the pilot's eyes on the left, or port, side of the Blackhawk) and the crew chief (starboard eyes), I'm totally reliant on theirs' and the pilots' skill at evasive maneuvers. I'm not sure what I was doing during that wild forty five seconds, but my thighs were burning sore for three days after this one. If there's a way for humans to actually make diamonds, this has to be one of the fastest methods.
We hauled tail to the TQ flight line, pilots cursing and creating new explitives along the way, Cobra gunship straining to keep up, and were met by the ground crew. Spotlights were hastily set up right on the flight line, and aircrew crawled all over the craft to assess for damage. Lead pilot jumps out and says "Whew! There's one to write home about, Doc!"
Truth be told, I'm getting to the point where I would rather write about how many days (82) I have left...







I spent two days trying to figure out how to get a flight back to Ramadi. It normally takes two or three days minimum to reserve a seat for a flight. For instance, an Assault Support Request (ASR) requires on average a three day wait. So I tried to get on a routine medical run the next night. The "milk" run consists of a few H-46 helicopters that fly patients back to their units every so often. They made two passes through Taquaddum that night. The first time, I was bumped by a patient and their escort going to Balad. "No problem" they said. "We'll get you when we come back later tonight". Around 2 AM, five hours later, they touched down at TQ surgical again. I was on the flight line standing with 100 lbs. worth of flight equipment and monitors waiting for the signal to hop on. Never happened. They briefly stopped, a Marine ran out of the back (he was returning to his unit), and they kept right on rolling through. I was stood up like an ugly prom date as I watched the helo quickly disappear into the ink black sky.

The next night was equally as frustrating, but a little more fruitful: the Army was able to put in an emergency ASR, and told me to be at the Taquaddum flight terminal at 8:30 PM for a 10:30 PM flight. Caught a ride to the terminal and lugged all my crap to the manifest check in. They had no idea who I was, and couldn't find my flight number anywhere. "Sorry, Sir, but you aren't in our system. If you want, you can go to the billeting tent and we can put you on standby." Completely torqued, I started calling everyone and their brother to find out how I got into this mess. I called Charlie Medical and the Ramadi air terminal: no luck. I disappeared from the system. Great. I called the Ramadi air tracker next, and they found an open seat on a Blackhawk later that night, but it was going to the TQ medical pad. Stranded in the wrong place again! I called TQ surgical and asked if anyone could come back out to the terminal and give me a ride. "But we just dropped you off!" an exasperated corspman defeatedly states into the phone.
"Yeah, yeah, I know. Just a slave to the system."

I may be off-line for a few weeks, and hope to return soon. Your support and readership is appreciated........

Meet Suhad

After two surgeries to repair her liver, diaphragm, and stomach, Suhad finally made it back to Charlie Medical last night. She is the girl that was accidentally shot with an AK-47 a few days ago. Her surgical incisions are healing well, and I found her this morning eating breakfast with her brother, Towad, in patient hold. She had follow-up surgery the day after I flew her to Al Asad, and quickly recovered. Within days, she is ready to be united with family.

With no sign of pain or discomfort, she and her brother talk while she plays with some of the toys and stuffed animals donated this morning. We took some pictures, and her brother asked me if I could print some out for them to take home. They both seemed to like the picture printouts more than the toys!

Their stay with us will be short. After lunch, the Iraqi Police will swing by and pick them up to take them back home. We hope that the care they receive and the genuine concern for their well being will leave a lasting positive impression..........

Operating in the Dark

Twelve year old girl and her brothers were playing around the house, and she was accidentally shot with an AK-47. We don't know the specific circumstances of why or how it happened. It just did. Nor does it matter to us, of course. Not part of the job description. We are here to do all we can irregardless of who, what, how, or why.

The bullet ended up causing some internal damage. Double chest tubes were placed and open abdominal surgery was performed, including liver and stomach repair. Stable for the case but critically ill, she needed immediate MEDVAC to a higher level of care. At the level III hospital, they will be able to perform diagnostic tests that we just can't perform at Charlie Medical, such as an extensive CT scan looking for subtle damage and/or hidden bleeding that won't be found unless you know exactly where to look.

Little known fact: Ar Ramadi is run entirely on generators. Every light bulb, DVD player, TV, you name it is run from a generator. Walk anywhere on base and you will quickly notice the maddening and inescapable drone of a nearby generator. Unlike the stable power grids in Western countries, generator power fluctuates, causing routine brownouts and surges. Brave is the soul who uses a computer on Ar Ramadi without surge protection. Generator power also happens to be a lot less reliable. The picture below was taken as the power went out during the middle of the case. "Grab the flashlights" RH quips as one of the corpsman runs outside to start the axillary generator for our lone OR light. Monitors and anesthesia machine had to rely on battery backup for 20 minutes while we waited for power to be restored. As for our case, not a beat was missed. We kept right on operating in the dark.

Stable for the flight to Al Asad, I was able to give a liberal amount of pain and sedation medications to keep her comfortable for the helo ride. The image below was taken in-flight. I have her in a protective bag we refer to as a "hot pocket" to prevent evaporating heat loss at altitude. The doors are all open, and a lot of air is streaming through during flight. Oxygen tank slipped between her legs, I have the ventilator and monitor placed on a folded blanket pad on her lower legs. We are ever vigilant to ensure anything placed on the patient has thick padding to prevent any discomfort. I left myself an IV port taped on her shoulder for quick access as I give blood and medications during the flight. Just off to the side is my flight bag, an extra oxygen tank, and a portable suction unit. No time to sight see during the flight. It's an endless loop of assessing vital signs, ensuring the ventilator is working correctly, the oxygen tank isn't empty, and checking her to make sure she is comfortable and isn't waking up. For her to awaken in this environment would be a frightening, disorienting, and frustrating experience......so I do all I can to keep her peaceful and blissfully asleep for the ride.

After dropping our patient off at the medical helo pad at Al Asad, we fly directly to the "fuel farm". Aircrew told me repeatedly we were "on fumes" as the helo sat on the medical pad, resulting in a mad dash to grab flight equipment and make a run for it. After a top-off, we race back to Ramadi with the Cobra Gunship close behind.

A hot and hazy day in Anbar. Put a little damper on my ride back, since I was hoping to take some pictures. This was my second time flying to Al Asad during the day, and I'm already starting to see some familiar landmarks along the route, crossing over the Euphrates River several times. The desert is made of endless swaths of flats, dunes, crags, and ranges of rustic browns and tans. But for all of her beauty, she is still devoid of greenery or overt signs of life. The only exception being the major bodies of water: lakes, rivers, and their tributaries. Anything small just evaporates in the torrential heat. In these select and reserved locations the desert wells up and seems to burst with life. Thick foliage and luscious date groves reveal a vivid palate of colors as they cling tenaciously to the river bank. Beautiful..........

Surveyed a few homesteads clustered close to the water banks. They have taken advantage of the fertile strip of land running parallel to the water and are actively cultivating small orchards and tending farms along the Euphrates and small tributaries. A lack of equipment, and possibly know how, is preventing any of the farmers from truly efficient irrigation farming, the modern day practice of storing water to tightly control soil saturation. Instead, they have either fallen back, or never stepped forward, from flood irrigation. At least once a day, the family turns out for the "bucket brigade" as they form a chain a short distance from the river to their crops. They just fill the buckets from the Euphrates, and dump it on the fields. Despite the hardships the Iraqi people endure, an encouraging sign that life sustains and thrives........with suffering comes perseverence. With perseverence, character. And with character.......hope.

Update: I receive many curious inquiries as to how our patients fair after they are taken to a larger hospital. The surgical team keeps tabs on patients two ways. First, we have a computer program on a secured terminal in the office that allows us to track patients not only in-theatre, but all the way to Landstuhl or the States'. Second, our surgeon calls the accepting surgeon the day after. He will call daily if the patient is serious or unstable, then passes down patients' status to the rest of the team.

The little girl I flew to Al Asad is doing great. The CT scan showed a little fluid collection around her liver, which is to be expected considering the injury. She went back to surgery the next day and was weaned from the ventilator the day I brought her. My friend at Al Asad emailed and said our girl instantly became the ICU princess.

Hearts and Minds

Some of the top commanders and colonels in the area toured Charlie Medical yesterday. RH, our head surgeon and detachment commander, gave them a tour of the OR and our capabilities. While discussing area topics and patient care for the local populous and Iraqi Forces, the colonel had some genuinely positive encouragement regarding the care we are rendering in Ramadi.

As stated in previous posts about Doha, and her sister Gofran, they are the orphaned children of an influential local family. The colonel said, in no uncertain terms, that the care we are providing to civilians, naming these children specifically, has resulted in a calming effect on the city.
He is quoted as saying those surgical procedures have done more recently to stem the violence than 30 raids could ever do.
Bravo Zulu to Charlie Medical and the Surgical Team......

Darwinian Award

Sitting in EVAC this afternoon. Jarhead just started 5 minutes ago on the Armed Forces Network, and I haven't seen it yet. Rolling past the opening credits, with a phalanx of trucks crossing the desert in a hazy mirage, Charlie Medical reverberates with a detonation. "Wait, that wasn't the TV." This one rattles the windows for about 4 seconds....big one.
We all look at each other and give out a collective sigh...and wait for the radio to start chattering. Within 30 seconds, we start getting some garbled messages, so we hold tight a little longer. Then the bad news cracks across the air waves loud and clear "VBIED".
I walk across the way to my hut to pick up stethescope, trauma shears, and a portable oxygen saturation reader. Others start hauling down our supply of litters as other medics start opening up the mass casualty supplies.
Within ten minutes, all of Charlie Medical is present and accounted for. Trauma bay gets a once over to make sure all monitors have cables, oxygen tanks are full and ready to go. We aren't waiting to hear if we are getting casualties......it's an assumption. The only question is how many and how bad is it going to be.
Sure enough, a patient rolls in with second degree burns over 60% of his body. But the soldiers that bring him say he was burned friday. Huh? Apparently, the patient was seen and released at Ramadi General, but obviously is in need of more extensive care. We are approached by the family, so we see what we can do for him. In the meantime, we are worried about the casualties that will be streaming in any second. Someone echoes what we are all thinking "what's going on here, we should be seeing casualties already?"
As we assess and start dressing the burn patient's wounds and hanging antibiotics, the first sergeant walks through from Tactical Command and tells the surgeon "No casualties from the VBIED".
We all have this incredulous "what the....?" look on our faces. Turns out the VBIED driver only managed to blow himself up. His incompetence has an end result of one death....his own. This is a first for me, and I'll take it as a sign the insurgents are scraping the bottom of the bad guy gene pool at this point.

The VBIED driver gets my nomination for Darwinian Award for the month of May.