The two most dreaded words came over the radio system.  "Be advised you have three litter urgent casualties, 20 mikes out."  Translation - three patients, injured bad enough that they could not walk, requiring urgent attention, approximate time of arrival 20 minutes from now.  Sometimes it is frustrating that with all this communication technology we have, we cannot get more information; like who are the casualties, what are their injuries, or what is the cause of their injuries.

About 30 minutes later the casualties arrived by helicopter.  They were insurgents and they were pretty messed up...  Our MP's from here at this FOB were out doing a routine patrol.  They were hanging out in a particular dangerous area of town with their lights off, just observing.  This car drives up and sticks a mortar tube (metal tube like structure used to launch mortars at Coalition FOB's) out the window.  Oops, bad timing.  The MP's opened fire on this car and wreaked some major havoc.  When they were done, somehow 3 of the 4 bad guys were still alive, although not doing so well.  Because these low-life's are now DETAINEE'S (later to become EPW's or enemy prisoners of war) they get to go to the Army Hospital for their medical care instead of the Iraqi Hospital.  Lucky us.

So, three guys arrive here.  I believe each of them were named Mohammed (or at least had a Mohammed in their name). 

Mohammed #1 was the most severely injured, with wounds to both sides of his chest.  He was in shock when he arrived, probably from severe bleeding inside his chest.  He quickly received IV's and IV fluids.  It was obvious he needed to go to surgery, so he was intubated in the ER and then two chest tubes were placed, one on each side.  The chest tubes will help drain the blood from inside his chest and help his lungs re-inflate.  Next stop, the OR (operating room)

Mohammed #2 was probably the luckiest.  He had two wounds on his back, over his scapulas; this could mean a chest wound.  His lungs sounded ok, but definitely a little less air movement on the right.  His breathing was not labored and his oxygen saturation (the amount of oxygen in the blood) was good.  He had a bad injury to his left hand; there was a bullet entry wound on the back of his hand and the hand was swollen bigger than a softball.  Other than that he had a bunch of small lacerations probably from glass and pieces of car that were flying around from the destruction caused by our MP's barrage of bullets.

Mohammed #3 was not so lucky.  He fractured each of his extremities.  His right arm had a really bad humerus fracture (the bone between your shoulder and elbow); it appeared so bad it might be irreparable.  His left arm had ulnar and radius fractures (the two bones of your forearm, between your elbow and wrist).  His left leg had a severe angulated and displaced tibia and fibula fracture (the bones between the knee and the ankle), with what appeared to be a large segment of the fibula missing (where did it go?  Nobody knows).  His right leg was the least injured, with only a fibula fracture (the smaller of the two lower leg bones, a non-weightbearing bone).  He was going to have to go to surgery rather quickly as well.

So, for only the third time since we have been here, we had both operating tables going at the same time.  Our capacity is one operating room with two beds.  We do not like to occupy both beds at the same time in case a casualty suddenly appeared that needed immediate life-saving surgery.  But, when both beds are needed, we have to do it.  One thing that made the decision easier, was that the OR in the new hospital is BIG.  So, if needed, although we only have two beds, we could easily set-up something quickly to make an additional bed.

While Mohammed 1 and 3 were in surgery, I saw Mohammed 2's chest x-ray; it showed that he had a lot of blood in his lung and his lung was a little bit collapsed.  He also had a fracture of his scapula.  He needed a chest tube as well.  He was already in the ICU so we went there to put the chest tube in.  When I stuck the forceps through his chest wall, a LOT of blood came squirting out.  Could he have a serious bleed in his chest?  We shall see.  Basically, you put the chest tube in and wait.  If the chest tube puts out more than a hundred or so cc's of blood per hour, or the output continues to increase instead of decrease, then the surgeons need to open the chest to find the source of the bleeding.  Fortunately for 3, his bleeding gradually increased.

Mohammeds 1 and 3 came out of surgery pretty much at the same time.  However, they were not out of the woods yet...

Shortly after arriving in the ICU, Mohammed 1's oxygen saturations dropped suddenly.  Then, his heart rate increased significantly.  He then developed a heart rhythm called ventricular fibrillation (v-fib) - if not treated very quickly he would definitely die.  CPR was started.  We were about to shock him when his the v-fib stopped and turned to a flat line (i.e. the patient was dead).  We continued CPR and gave some epinephrine.  For fear that there was a major bleed in the chest, our cool-handed surgeon cut the chest open and started searching for a bleed.  He was assisted by one of our orthopedic surgeons (that is what happens in our CSH, everyone helps each other out).  There appeared to be some bleeding coming from the lung.  He clamped the blood vessels that come and go from the lung.  We continued with the CPR, epinephrine, and rapid blood transfusions.  Suddenly, we had a pulse, and a blood pressure.  With the pulmonary blood vessels clamped, the surgeon removed the lung.  Most of you will go your whole lives without seeing a lung being removed from a live patient in the ICU; in fact, I will probably never see that again.  The large chest incision was sewn up over a chest tube, but we knew that this was not a good sign.  Patients who have to have their chest's cut open urgently like that rarely do well.  Over the next several hours, his blood pressure slowly dropped, and at about 0800 he expired.

Mohammed 3's right arm injury involved serious damage to a major artery.  Even in a major medical center in the US, the repair of this artery would be extremely difficult, especially in the face of his multiple other injuries.  So, it was decided to amputate the right arm, just below the shoulder.  Moving along in the surgery revealed another bad artery injury of his lower left leg.  Another amputation - the left leg was removed just below the knee.  I guess you could say those mortars cost Mohammed an arm and a leg (sorry, couldn't resist that one...).  A cast and and external fixator (a large metal contraption that is on the outside of the body with screws that go into the bones that is used to immobilize fractures) was placed on the left arm.

After Mohammed 1's lung was removed, we were checking out 3 and noted that his stomach was VERY rigid.  A quick ultrasound by the bed side revealed a lot of fluid at the bedside.  Could he have an abdominal injury?  Back to surgery to find out.  An open laparotomy (a cut from the bottom of the breast bone all the way down to the pelvis in order to explore all the abdominal contents) was performed to identify the source of the problem.  What was found was quite interesting, there was no abdominal trauma, but the patient had developed abdominal compartment syndrome.  The bowels had become extremely swollen from the massive amount of fluids the patient required.  Without the laparotomy, portion of the bowel would surely have died.

At this point it is 0700 and all of us have been up all night long.  Mohammed 2 still needs to go to surgery to have his hand fracture repaired (fortunately this does not take too long).

Well, now is the time to get some much needed rest.  During residency one of my ten most important rules was, "Sleep when you can, eat when you can," for you never know when that next wave of patients are going to come rolling in...