By Cmdr. Mark Lenert and Lt. Cmdr. Ian Valerio, Role 3 Multinational Medical Unit, Kandahar, Afghanistan
The pager goes off. It is a Trauma “A” alert, “IED blast casualty with multiple wounds”… another reminder of being in a warzone, and part of the daily life of the medical care team at the Role 3 Multinational Medical Unit in Kandahar, Afghanistan.
The staff wonder if it is a U.S. or coalition member? An Afghan National Army or Police member? An Afghan local? What are the injuries?
The medical team, composed of an anesthesiologist, emergency room physician, a general surgeon, a trauma surgeon, two nurses, and two corpsmen, rushes to the ER to prepare and receive the casualty. Other medical personnel stand behind the “red line,” immediately available if their skills or assistance are needed.
The patient has been medevac’d to the flight line, was quickly transferred by ambulance from the airfield to the ambulance bay, and then moved from the rickshaw to the trauma bay bed for evaluation. Then, a rapid and thorough evaluation of immediate life-threatening injuries occurs. This is a Trauma “A” patient, a coalition service member suffering an improvised explosive device blast with bilateral lower extremity trauma including soft tissue and bony injuries…the field tourniquets are in place and functional. The left arm has devastating soft tissue and bony wounds with active bleeding. A corpsman quickly reinforces and secures the arm tourniquet, effectively controlling the bleeding. The ER physician orders that pain medicine be given intravenously, as the orthopedic surgeons’ assess the patient for possible surgery.
Simultaneously, a nurse records the patient’s vital signs. A general surgeon shouts “right subclavian cordis central line in. Start the Belmont Rapid Infuser.” Other members of the team draw blood for laboratory tests and for type and cross matching of blood.
The radiologist quickly performs an abdominal ultrasound.
“FAST negative,” he shouts.
The X-ray technician soon acquires films of the chest, abdomen, legs, and left arm.
In rapid succession the patient is then sedated, intubated, and made ready for immediate transfer to the CT scan prior to transitioning to the operating room. Multiple bowel injuries are noted on the scan.
After CT scan and rapid evaluation by the complete trauma team, the patient is taken to the OR, where up to eight multidisciplinary staff surgeons await. The neurosurgeon and the Oral Maxillo Facial (OMFS) surgeon work together on the scalp injuries. Two general surgeons perform an exploratory laparotomy to investigate the bowel injuries noted on CT. Because of the blast injuries to the extremities, five orthopedic surgeons and a plastic surgeon work on each of the patient’s limb injuries. The resuscitation associated with such massive injuries requires two anesthesiologists, an anesthetic nurse, and an intensive care unit nurse dedicated to operation of the Belmont rapid infuser. All of these specialists work fluidly and simultaneously to ensure the best care for the patient. Attention to detail in addressing all the wounded warrior’s injuries and stabilizing the patient is of utmost concern. This initial point of care is the start of the patient’s road to recovery, and may be the most important in the survival for this combat casualty patient.
The above scenario highlights the professionals involved in the Role 3 Multinational Medical Unit in Kandahar, Afghanistan, currently being overseen by the U.S. Navy Medical Corps. The various actors and actresses in this drama hail from at least 3 different NATO nations, and represent the Army, Navy, and Air Force. Among the U.S. personnel alone, at least seven different hospitals are represented. Each of the staff work simultaneously to save this soldier’s life, and to ensure his highest quality of life following recovery. The OR time is not prolonged, however. Most casualties are in and out of the OR in less than two hours. Subsequently, they recover in the ICU, where they await the Air Force’s CCATT (Critical Care Air Transport Team) personnel to transport them to Bagram and then on to Landstuhl for further definitive care. Ultimately, this patient will be flown to the U.S. to a Level V facility so that further surgery can be performed, when needed, and recovery and family reunion can occur.
** Earlier this year Vice Adm. Matthew L. Nathan, U.S. Navy Surgeon General visited the NATO Role 3 Hospital.