Friday, 13 August 2004

oy vey, today is Friday the 13th...

Since everyday is like Groundhog Day around here, it did not occur to me that today was Friday the 13th till later in the day.

It was mid-morning and we were hanging out getting ready for Grand Rounds and M & M when we heard over the radio the two words we hate the most:  "EMT, TOC."  "Be advised we have 4 incoming casualties, IED and small arms fire."  As is frequently the case, that is all the information we get.  Nothing about ETA, nothing about the severity of the injuries, nothing about who the casualties are.  So the medics, nurses, and docs get ready and we wait to see what is coming.

Approx 30 minutes later the casualties arrived by civilian non-tactical vehicle.  The casualties were from a civilian security company.  We see a lot of casualties from this company, I am not sure why.  Maybe it is because they do a lot of high risk missions.  May it is because they drive around in unarmored SUV's without any doors.  I don't know, but we have seen A LOT of serious injuries and deaths from employees of this company.

Fortunately, today the wounds were not too bad...

Casualty number one was the most seriously injured.  He had a moderate size entry wound in his left groin.  Our evaluation revealed that the shrapnel traversed across his pelvis.  We did a RUG (retrograde urethrogram - a special x-ray to look for a urethral (the tube that urine flows through from the bladder to the outside) injury).  The RUG showed that there was a urethral injury.  We are not a major medical center.  Our mission here is to stabilize patients and then get them to a higher level of care where there are surgical sub-specialists such as urologists.  We do not do much definitive care here (although sometimes we do a little more than we should).  At any rate, this patient went to surgery to have a suprapubic catheter (a catheter that goes through the lower abdomen into the bladder) placed and his wounds cleaned out.

Casualty number two must have been sitting in an open door.  He has a gunshot wound that went through his lower leg.  It entered on the lateral aspect of his calf and exited right in front, just below his knee.  It was obvious right away that his leg was broken.  An x-ray revealed he had a proximal comminuted tibia and fibula fracture.  His fracture was fairly complex which resulted in a lot of bleeding.  As a result of all the bleeding, his calf and lower leg were getting very swollen.  When this happens, the major concern is the development of compartment syndrome (when swelling gets so bad it interrupts the blood supply) - this is an emergency.  He went to surgery right away.  His fracture was stabilized with an external fixator.  Once the fracture was aligned and stabilized, the bleeding slowed down.  It seems like compartment syndrome was avoided for now, but he is not out of the woods yet.

The other two injured patients had soft tissue shrapnel wounds of their extremities.  One had multiple extremities involved and he had to go to the operating room to have all the wounds cleaned out.  The other guy had only one injury and we cleaned him out in the ER.

Today’s strangeness carried on to the night…

I took over the ER duty at 8 pm.  There was a patient there who came in about an hour earlier complaining that, while “sitting around doing nothing,” his feet had suddenly gone numb.  The doc on duty (who coincidentally is a trauma surgeon – all the docs here share the ER duty!), ordered some x-rays and was surprised to encounter bilateral calcaneal fractures!  (click here to see the x-rays)  The calcaneus is essentially your heel bone and this bone requires a lot of trauma to fracture.  The typical mechanism is someone landing on their feet after a fall or jump from a high height.  The patient vehemently denied any such fall or jump.  Could this be a suicide attempt?  That is what we were thinking.  A bit later, a senior NCO from his unit arrived, and, after examining the site, he felt the soldier tried to lower himself down to the ground from his second floor room and he slipped and fell, landing flat on his feet.  Why was the soldier trying to hide something?  Who knows why Joe does what Joe does.  We’ll have the psychiatrist see him in the morning.  Sounds like an interesting consult.

Literally 5 minutes after my shift began; two other patients arrived from a local FOB.  One with chest pain, the other with a possible blood clot in his leg.

The latter patient had just returned from his R & R, spending a good portion of the last 24 hours on an airplane.  He was also a smoker.  Both of these facts are risk factors for deep venous thrombosis, better known as a DVT (a blood clot in the deep veins of the extremities, most commonly occurring in the legs).  DVT’s are a bit of an emergency because the blood clots could possible break loose and travel to the lungs.  This is called a Pulmonary Embolism or PE and is often a lethal event.  He had pain in his right calf and said he felt veins bulging out.  After examining him I felt that he probably had some cramps from the long plane rides, but I called the radiologist in to do an ultrasound just to be safe.  To everyone’s relief the ultrasound was normal – no evidence of DVT.  Cool.

The first patient was a 34 year old male with a history of hypertension and obstructive sleep apnea on a CPAP machine (more on that later) who developed sudden onset chest pain and trouble breathing.  Based on his story, his vital signs, his physical exam, his EKG, and his labs, we felt that this was probably not cardiac chest pain.  However, given his comorbidities (high blood pressure, overweight, sleep apnea, heavy smoker, and a probable family history) we admitted him for observation and decided that he needed a treadmill stress test.  Unfortunately, we do not have a treadmill in theater to perform stress tests, so he will have to be AIREVAC’d to Germany.  Can you believe that?  A special treadmill stress testing apparatus costs about $20,000 to $25,000.  What do you think it costs to send a patient to Germany and back?  Probably around $8,000 to $10,000.  We probably AIREVAC 2 to 4 patients with chest pain per month to Germany for treadmill testing.  You do the math.  We have requested a treadmill for our CSH, somehow I doubt I’ll see that before I redeploy.

Now, back to the CPAP machine.  CPAP stands for continuous positive airway pressure.  This is a machine that plugs into an electrical outlet and delivers air pressure via a large facemask to the mouth and nose of the user.  People who have obstructive sleep apnea (OSA) have problems breathing while they sleep because their airways collapse.  The air from the CPAP machine prevents their airways from collapsing and significantly improves their sleep.  The CPAP machine is a wonderful thing for people with OSA, their sleep markedly improves and their daytime sleepiness vanishes.  However, is a deployment to Iraq a smart thing for a guy with OSA on CPAP?  I personally don’t think so.  What is he going to do if we lose power for a prolonged period of time?  Why are physicians approving people like this to deploy?  Are we hurting that much for bodies over here?  Isn’t a healthy body much better than a broken one?  Well, now this guy needs to be sent back from Landstuhl for a cardiac evaluation.  And, I bet anything that he will be back here within two weeks for more fun.

Let me reflect a moment…  A month or so ago we had quite a few heat injuries in one day.  The most severe of them was a female soldier who was unconscious for about 20 minutes before she finally came to.  Her temperature in our ER was not excessively high, but her loss of consciousness was consistent with a heat stroke.  When she was more coherent she admitted to a history of over 10 previous heat injuries with over 10 previous hospitalizations!  Who in their right mind would allow her to come to Iraq where the average daily temperature during the summer is 110 to 120 degrees F?  She said that she told the physicians before she deployed and they still allowed her to go.  We MEDEVAC’d her back to Germany with the recommendation that she be redeployed back to her home duty station, not to return to Iraq.  Wouldn’t you know it, she was back here two weeks later.  What would prompt a physician to send someone like that back to the desert in the middle of summer?  I just wish I could get some explanation of the reasoning behind their decision. 

The reason I had to add that anecdote was to further display some of the frustrations we have with the evacuation system.  One of the main problems is that we do not get any feedback regarding the patients we AIREVAC to Germany.  As a result, patients return to theater and we never get an accurate report of their evaluation and the decision to send them back.  However, I think that a lot of the physicians making some of these medical decisions have never deployed and therefore do not fully understand the conditions in which we live and work.  They do not understand the degree of heat here, the constant daily stressors, the lack of days off, the frequent wearing of body armor, etc.  If they understood these things, certainly some of these “broken” patients would not deploy or return to theater.