Day 228: Practice

As the "doc" I'm tasked with finding creative ways to train our troops in the art of combat medicine and first aid. Funny thing is...I'm no expert myself! Lucky for me, I have a team of medics, all with different experiences, to help me put the training evolution together. We brainstormed the course outline, and our goals for the students (16 total). Because we only had 1-2 hours available per day, we had to spread the course out over 4 days. Here was the break down of our class.

Day #1 - Combat Lifesaver Bag - What's in It?, Principles of Managing an Airway, Triage, Catastrophic Bleeding - Tourniquets

Day #2 - Chest Trauma - Managing a Tension Pneumothorax, Primary/Secondary Assessments, How to Call a MEDEVAC


Day #3 - IV Training and Litter Training - A change of pace from the death-by-powerpoint portion of our training workshop. Primarily a hands-on day. (see the poking above!)

Day #4 - What we call the "Capstone" event of our training workshop. The medics and I planned a "real" mass casualty scenario to familiarize our students with what a multi-trauma emergency can feel like on Camp Clark...here's the scenario...

We have a convoy which just left Camp Clark when an IED exploded just as they left the gate. 1 vehicle was directly hit, and the driver was still able to turn the truck around and come back to base. Apparently, everyone in the vehicle is severely wounded. The truck is now arriving...


The team is on standby as the truck roles in. We have 3 victims - the driver, gunner, and front passenger, all severely injured. The picture above is one of our "victims" with a severe neck wound. One of the students as well as my interpreter, Latif are assessing his "injuries" and transferring him over to a litter (what we in the civilian world would call a stretcher). The primary treatment area is the Troop Medical Clinic (TMC)...


...we pulled the 3 victims from the vehicle, and they have been carried over to the TMC by litter. We have one with a severe neck wound, another with a chest wound, and the other with severe wounds to his R arm/leg. Tourniquets were placed prior to arriving at the TMC.

While in the TMC, the "victims" are being assessed. All were given large bore IVs, chest wounds were treated, airway maneuvers were performed, and a Medevac was called over the radio. The bird is going to land in less than 15 minutes, we need to hurry and get the patients loaded for transport.


As you can see, we could only fit 2 of the 3 victims in our ambulance so the team was able to improvise in order to get the third patient transported successfully (see pic below).


There's our third "victim", strapped onto a litter and placed right on top of the hood. I thought that was an excellent method for transport.


The team did an excellent job from start to finish, from getting the patients out of the vehicles all the way to transporting the patients by ambulance to the helicopter landing zone. A job well done! If anything happens to us on Camp Clark...we'll be ready. Class dismissed!!

Day 227: Seventy

Today, marked the largest humanitarian clinic we have hosted since I arrived at Camp Clark. Over 70 patients, primarily children, were able to be seen today, and we also had enough help to distribute book bags, coats, shoes, AND soccer balls! Although we had our work cut out for us, we all came together to make the clinic day a success.

Terry and his forklift to the rescue!

A special thanks to our maintenance shop for pumping enough soccer balls, and to our contract forklift driver, Terry, for transporting the box of soccer balls over to the clinic. One of the few times that a forklift truly saves the day!

The Garrison Commander and his entourage

On the ANA side, we had a larger-than-usual ANA contingent to include 3 medical providers, 1 medic, 8 security soldiers, and a a surprise visit from the ANA Garrison Commander and his staff. I think the sea of Afghan children may have overwhelmed him.

Dr. Zahid and his patients

I can recall several clinic experiences where the patient load was less, but my stress level was more. But, for some reason today was a great day. I really felt like we all came together to work as a team. From the US troops, US civilian contractors, interpreters, and ANA soldiers/medical staff - everyone contributed a significant part to the success of today's clinic.

Medic Said Kamal enjoying his time in the coat room

It's days like this that make me feel like I'm making a difference. To see US and Afghan soldiers working together...that's what this mentoring mission is all about. Unfortunately, feel-good days like this come few and far between out here, so for now I'll take it!

"Let the children alone, and do not hinder them from coming to Me; for the kingdom of heaven belongs to such as these."
Matthew 19:14 NASB

Day 220: Shura

Shura is the Arabic word for "consultation". Many Muslims believe that Islam requires that decisions made by and for Muslim society be made by shura of the Muslim community. They believe that that is the basis for implementing a representative democracy. With that being said, the elders of Khost province felt it necessary to hold a shura between community leaders and the Afghan National Army in Khost in an attempt to discuss the security issues in our area, more specifically the increased enemy activity occurring along the KG Pass. Over 800 local leaders, Afghan Army leaders, and US Army leaders attended the shura (what we would probably call a "conference") in hopes of finding solutions to the growing security problems in our area. High profile events such as shuras, that bring together local leadership, often make prime targets for bombs, so I hung around the shura grounds praying that the meetings would be conducted without any uninvited interruptions.

Shura Attendees

Thankfully, the shura was conducted without incident and everyone left safely. As high-profile as it was, it seemed that the local leaders were more interested in eating and dancing more than listening to the speeches on security. You should have seen the excitement when the Afghan marching band came out, a sea of Afghan soldiers dancing the Afghan national dance...reminded me of line dance routines from a wedding reception, only without women!

The National Dance of Afghanistan

It was a site to see indeed, not just the dancing, but to see Afghan soldiers, in the middle of a war, taking the time to simply have fun.

"There is an appointed time for everything, and there is a time for every event under heaven.. a time to mourn and a time to dance." Ecclesiastes 3:1,4

Day 216: Warehouse

Being a mentor to the Afghan National Army (ANA) has it's share of trials and triumphs. Sometimes it feels like I'm taking 2 steps forward followed by 3 steps back! The US mentor I replaced gave me a forewarning of not to expect too much when it comes to advocating for process improvement. In other words, change even when it is indeed necessary, is not always welcome. In the eyes of the ANA, they are thinking "if it isn't broken, why fix it?", but the reality is that everything is broken and everything needs fixing. Also, even if the ANA know that there is room for process improvement, sometimes just plain old laziness makes for a successful roadblock to any suggestion for change. Nonetheless, the mentoring mission must go on, and the hope for lasting positive change still remains. So to contrast my cynicism...let me share my warehouse experience.

The medical team along with some interpreters scoping out the damage

Well, if there was any mentoring project that was passed on to me with the words of "good luck!", it was the medical warehouse! Actually, the 10,00o square foot storage facility was nothing more than a gigantic stockpile of medical equipment simply tossed into a large building, with the idea of organizing, cleaning, and taking inventory being nothing more than an afterthought for the last several years. Just check out the pics!

More damage that needs scoping

As a clinical mentor, I never thought I would be sweeping floors, moving extremely heavy boxes, or organizing a warehouse full of medical equipment. It's really not that fun. In addition, I never thought I would get my ANA medics to eventually take over the upkeep of the warehouse once we got it all cleaned up. Once again, even less fun. The moment they began to see the progress, I then found a more motivated group of ANA medics willing to take charge. Several weeks later, I was watching my ANA clinical staff taking inventory and organizing the equipment all on their own. Talk about an ANA mentoring triumph!

The ANA medics and US medics bringing about change!

The Fruit of Our Labor

"With people this is impossible, but with God all things are possible."
Matthew 19:26 NASB

Day 213: Pashtun

Many deployed physicians spend their time on a large base doing mundane clinic work which often feels no more different than working at a clinic back home. One of the unique aspects about my particular job is the many opportunities to directly interact with the Afghan people. The humanitarian clinic provides a significant portion of those interactions, and allows me to better understand the Afghan culture, particularly the Pashtuns.

Although people from Afghanistan are called "Afghans", like the American "melting pot", they also have different groups such as the Uzbeks, Hazaras, Turkmans, and Pashtuns just to name a few. Each group has their own unique subculture, language, and appearance. In our region, the majority of Afghans are of the Pashtun group which makes up more than 45% of the population. Pashtuns gained worldwide attention after the Soviet invasion of 1979 as well as after the rise and fall of the Taliban. Pashtuns are primarily situated in the Southern and Eastern portions of Afghanistan that border on Pakistan as well as Western Pakistan. Insurgents, such as the Taliban and their allies, are of Pashtun origin which can explain why the region I'm deployed in is considered very dangerous. The closer we are to the Pakistani border, the higher your chances of being surrounded by Pashtuns who are members of the Taliban.

On a more informative note, understand that not all Pashtuns are terrorists. In fact, Pashtuns are a very beautiful and strong-willed people. What I first noticed about the Pashtun children was their eyes...

Just having them gaze into the camera as I took their picture provided almost a calming and soothing affect to rest of my day. Beautiful, simply beautiful...

Now on with the education portion of this blog...Pashtuns are known for their unique language, called Pashto, and their practice of Pashtunwali which is their living philosophy and traditional code of conduct and honor. Pashtuns tightly embrace these codes of honor as they provide a traditional, spiritual, and communal identity. Here are a few of their principles for living:

1. Melmastia (Hospitality) - Showing hospitality and profound respect to all visitors, regardless of distinctions of race, religion, national affiliation as well as economic status and doing so without any hope of repayment or favour. Pashtuns are widely considered to be the most hospitable people in the world and a pashtun will go to great extents to show his hospitality, so much so, that in very many recorded cases it has been observed that a they have even provided enemies with sanctuary.
   
2. Badal (Justice/Revenge) - to seek justice over time or over space to avenge a wrong. This applies to injustices committed yesterday or 1000 years ago if the wrongdoer still exists. Justice in Pashtun lore needs elaborating: even a mere taunt (or "Paighor") is regarded as an insult - which can only usually be redressed by shedding of the taunter's blood (and if he isn't available, then his next closest male relation). This in turn leads to a blood feud that can last generations and involve whole tribes with the loss of hundreds of lives.
3. Dod-pasbani (Protecting Pashtun culture) - It is obligatory for a Pashtun to protect Pashtun culture from disintegration. Pashtunwali advises that in order to successfully accomplish this, a Pashtun must retain the Pashto language since Pashto is the prime source of Pashtun culture and its understanding isn't just important but essential. Not being able to speak Pashto is often translated by Pashtun society as the inability to understand Pashtun culture, values, ethics, history and community.
4. Nang (Honour) - The preservation of honour entails the defence of one's family and one's independence, while upholding cultural and religious requirements.
5. Hewad (Nation) - Love for one's nation in Pashtun culture isn't just important, it's essential. A Pashtun is always indebted to their nation and must strive to perfect and improve it. A Pashtun considers it his obligation to defend his country against any type of foreign incursion. Defense of nation means defense of honor, values, culture, tradition, countrymen and self.

As you can imagine, the ability of Pashtuns to either be allied to or enraged with the US presence in their country is primarily based on their personal interpretation of the moral code. In the end, as long as they perceive that what they believe is in line with Pashtunwali...they are in the right.

As I thought about the concept of honor codes, I thought about the principles that I myself have chosen to live by. After getting married, one of those principles is to never leave the toilet seat up:) But, one of the most important principles is the understanding that I am not the best judge of what is truly right vs. wrong. That wisdom comes from a relationship with a living and loving Creator. And unlike Pashtunwali, His code is founded on forgiveness and reconciliation for ALL people no matter how undeserving.

What codes have you chosen to live by?

"This is good and acceptable in the sight of God our Savior, who desires ALL men to be saved and to come to the knowledge of the truth. For there is one God, and one mediator also between God and men, the man Christ Jesus."
I Timothy 2:3-5 NASB

Day 212: Artillery

Every once in a while when I get to see Maxwell on the webcam we sing one of his favorite songs together...the Infantry Song. I'm sure many of you may have heard it at church or during Vacation Bible School. It starts out...

I'm too young to march in the infantry
Ride in the Cavalry
Shoot (clap) the Artillery...
I may never spy on the enemy
But, I'm in the Lord's Army
Yes Sir!

Today, I was reminded of that childhood song as I enjoyed the amazing experience of providing medical coverage for a field artillery firing mission! The word Artillery, took on a whole new meaning as I have never really seen the "big guns" so up close and personal before. First of all, it is the loudest thing you will ever hear...ever!! I near jumped out of bed the first time I heard these guns go off thinking we were under attack. The guns fire out 155 mm (for reference, a handgun bullet is 9 mm) rounds that can reach targets up to 30 miles away. It takes a lot of explosive power to send those rounds down range.


Here I am holding a bag of explosive material used to fire the artillery. Don't let the small, compressed size fool you...it packs a huge blast!! Aside from tampering with unfamiliar explosives, I also asked if I could pull the rope that causes the guns to fire...that really got me excited. Unfortunately, the target area was invaded by a herd of goats which stopped the mission for the remainder of the day. Oh well...there's always next time.

Day 205: Medevac

Since being out here I have been involved in the care of numerous casualties related to explosives. Although I'm not an adrenaline junkie, I must admit that there is a side of me that gets excited. Heart pounding rapidly, the smoldering anticipation, the rapid preparations made for a multi-victim trauma, and diving right into treating the soldiers who are fighting this war...that's the excitement of being a physician in a combat zone.

Without giving away specifics, I just wanted to show you some pictures from our most recent trauma case as this resulted in a Medevac (Medical Evacuation)!

The patient was part of a routine patrol in the Khost-Gardez or "KG" Pass when they were hit by a roadside improvised explosive device (IED) not too far from our base. There were multiple victims but only one was sent to me. We treated him for minor head trauma, shrapnel in his leg, and a large cut right next to his right eye which concerned me. This prompted my decision to ask for Medevac to ensure that his eye and head were thoroughly evaluated since I have no fancy slit lamps (for eye trauma) or CT scanners (for head trauma).


Coincidentally, we had a visiting Chaplain that day and he wandered into the clinic helping us out. Here is a shot of him praying over the patient. I thought this was a peaceful moment just before we transported the patient to the LZ (aka landing zone).


Here are a few of my medics keeping the patient comfortable as we transported the patient in the not-so-comfortable ambulance.


There was the helo waiting for us at the primary landing zone ready to fly. I put this picture in here for Maxwell...he loves helicopters! After a bumpy ride in our ambulance, we arrived at the primary LZ and quickly brought the patient over to the helicopter. It was cool indeed...

One of my favorite shots...just after the helo left. Just another day at the office!

To add closure to yet another blogger adventure, I just wanted to add that the patient ended up doing very well. No permanent injuries and he is already up and going about his business. Mission accomplished!!