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.

Ramadi all-nighters

1:06AM brings a loud rap on our door "11 in-bound. Mikes unknown".

Knocking the fuzz out of my head as we all stumble around the room putting our uniforms back on. Hopping around on one foot, I avoid a collision with D squared just as someone flips the lights on.

Feeling like I'm floating to the back of Charlie medical, I run down a mental checklist of how many patients, where we are going to triage them, and making little bets in my mind that this could be a long night.

15 minutes later, the TOC announces "Casualites are being diverted to Ramadi General". This is the local civilian hospital. They must be closer to the scene than we are, but are a little less cabable. We have been supporting them with supplies and keep in contact with them, but the back of my mind is telling me this is going to be more than they can handle.

Most of the staff drifting off. Trying to quickly re-capture what they missed of slumberland, and I don't blame them. A few, including myself, decide to stay awake for a while to see what develops.

1:36AM and I hear the tell-tale drone of armored track vehicles. Several of them. Eric says "well?" I'm throwing my stethescope back around my neck "This can only mean one thing. Lets get busy."

Two M-113's arrive filled with casualties. They bring along a full compliment of humvees and Strykers filled with heavily armored and weaponized soldiers "IED blast!" they say. "We thought Ramadi General was taking this one?" "Hey, just following orders. We don't know anything" they say as we immediately start unloading patients and begin triage. Two walking wounded hop out: this is an encouraging sign, even though their tuniks are splattered with blood. They are quickly ushered to the side, and a few medics start tending to some superficial wounds. Then we start hauling stretchers out.......here we go.

Eric and I take station two. Iraqi casualty is on his stomach and moaning something so incoherent even the interpreter has no idea what he's saying. His entire lower back is covered in a makeshift damage control bandage. Eric starts taking it off to assess what the heck it is, when unmentionables start spilling out. I tell him "Umm, you better put that back!" He agrees promptly, as I gather some sterile supplies to re-dress the gaping wound. I quickly re-pack his back, and five of us struggle to turn him over: we need a proper assessment, IV lines, and vital signs. On his stomach, I can't even tell if he's still breathing. We get him turned over, and I'm finding abnormalities all over......arms and legs aren't supposed to be jello in my hands. "X-ray! I need films as soon as you get a chance." Get an IV, Eric is assessing his airway. RH, our head surgeon, is looking over my shoulder "bring him back to the OR now. We have our first case." The X-ray tech is asking me what films we want. "chest, KUB, better get a pelvis, oh, and all estremities, too. Just get everything..." My patient is sliding downhill, so RH decides abdominal surgery needs to happen sooner rather than later so we can visualize and repair damage. We perform multiple bowel resections and Chad flies him to Al Asad as soon as possible. He was unstable for a bit, but does well for the flight.

This was the beginning of the end of our sleep. We get word of more incoming casualties during the first case: American unit hit by an IED next. At least one "urgent surgical". The lone OR is tied up with Iraqi Police, so we tell the Army Tactical Command to set up a landing zone to fly the American casualties to Taquaddum. A short flight, and it makes sense to tap into other Anbar medical resources. More Iraqi's pour in throughout the night: a GSW victim is in the trauma bay, so I break out of the OR to assess: our two surgeons are scrubbed in, and they need a discriminant eye to hover for a few minutes to see if he needs to be taken back to the OR. We already have another patient on standby and waiting to come back. GSW to the chest, and the Army PA (physician assistant) and our Independent Duty Corpsman are placing a chest tube on the affected side. They drain any blood and avert a hemothorax. Two PA's and I use an ultrasound to assess his heart, and the pericardial window is void of blood: fantastic sign. We are sending him to Ramadi General now that he is stabilized.......thankfully the bullet didn't hit anything major.

With no end in sight, we have another trauma case come in with more penetrating abdominal injuries just as we are finishing another case. The room is quickly sterilized to the best of our ability just as we roll the next patient in. He's in good shape, considering, and doesn't appear to be in too much pain. More bowel resections, and we finish our last patient for the night as the sun gently crests over the horizon signaling a new day in the Anbar Province. The surgical team cleans the OR for the last time tonight, washes up, and we meet behind Charlie Medical for breakfast to cap an exhausting night. The chow hall is a welcome site: eggs, gravy, biscuits, and fresh fruit. Bellies full, stamina depleted, we simultaneously collapse into bed ever ready to do it all over again.

Salvation Council's Tough Stance

An interesting interview took place a few days ago in Baghdad with the head of the Anbar Salvation Council, Sheik Hamid al-Hais. He eludes to the surge in police recruits over the past few months in Anbar Province, and has some hard-hitting statements about our struggle with Al Qaeda in the area. We have the local and regional sheiks aligned with us, and the results are impressive and cannot be discounted. Critical daily incidents are down significantly in the area compared to a year ago, and the emergency response units we are guiding through training on-base are the reason. Loyal to their tribes, these men are patrolling their lands and protecting their own from Al-Quaeda's purposeful targeting of innocents and attempts at destabilization. Our success in Anbar is directly tied to theirs...

"We have our own tribal legal system and this is constant and cannot be changed. Murderers must be killed under tribal law and unless we use this force against terrorism, terrorism will continue to rise."
The Salvation Council is part of a movement called the Anbar Awakening run by Sheikh Abdulsattar Abu Risha, whose alliance of tribal leaders united against the threat posed to Anbar province by Al-Qaeda's militants.
Anbar's mainly Sunni population once largely supported attacks on US forces and Iraq's Shiite-led government.
Many, however, have become sickened by Al-Qaeda's attacks on civilians and tribal leaders and are angered by the insurgents' interference in the region's traditional ways of life.
Since October, sheikhs have funnelled thousands of tribal fighters into the police and "emergency response units", which now fight alongside US and government forces while retaining their loyalty to their sheikhs.

Hais, who despite his tough talk looks urbane and cosmopolitan in his smart business suit and neat moustache, says he can now field 15,000 armed fighters, most of them now nominally in the police but still under his orders.
How many of these were once in the resistance, fighting the Americans? "Fifty percent and maybe more," he said.
And why did they change sides? "Because of the behaviour of Al-Qaeda. Al-Qaeda did not distinguish between the innocent and the guilty. They killed the resistance, they killed sheikhs, they killed everyone," http://news.yahoo.com/s/afp/20070515/wl_mideast_afp/iraqunrestsecurity