Afghanistan CASEVAC

Updated: Nov 3, 2020

The day, or I should say night in a mid November of 2011 started like any other night in the plywood palace that was our clinic in Afghanistan. Constituted eggs for breakfast, followed by sick call, or as it should have been known, Ambien call. Followed again by constituted eggs for lunch. Somewhere in the monotony the phone rang, and the night got more interesting. A CASEVAC in the SOF world seems to typically be initiated by some guy at a desk that we don’t know, calling some guy at a desk that we do know about some guy in the field that got shot that nobody knows. This was that kind of phone call. The medical planner asked us if we could be ready to go with all of our gear in 15min to respond to a casualty at an out station. Little information was given, he didn’t really know that much just that it was a solider with a gun shot wound to the head that was critical, but stabilized. There would be a plane ready to take off in about 20min!

I think some of the new docs that come into our flight always have a quizzical look on their face when we go into great detail about how all of our zippers have small pieces of cord on them for quick access, how all the tape is ear marked to peel off easy, how all the equipment is kept charging in their boxes to grab and go. The next 15 minutes during that night would have stood testament to why we think this way. Within 10 minutes the truck was loaded with our prepackaged medical rucks, our vests were on, and weapons holstered. The engines on the aircraft were already running when we boarded. The flight time to the aid station was just under an hour. In that hour we started getting our gear ready for a number of possible scenarios. Was the guy intubated? We didn’t know. Did he have an IV? We didn’t know. Most of the time you never know what some ground medic is going to bring you. In a perfect world communication about the status of a patient is better before leaving the ground, but that seems to rarely happen. So we hung IV bags, prepared the ventilator, etc. As we were doing this I was running through my brain all the scenarios that could be wrong with this guy and what kind of drugs he would need in what dosages? Stressful to say the least. When we landed we fully expected a ground team to be at the aircraft with the patient ready for us to accept right at the flight line. Instead there was a couple guys with a pick up truck asking us if we were ready to go to the clinic? Not exactly what we were planning on. Turns out there was a fairly advanced medical team at this outstation and they had already done a fair amount of immediate resuscitative work, so going into the clinic and accepting the patient within their facility and talking with them was clearly the safest route. Just wish we would have know that as we packed all the gear up and threw it on the back of the truck. In the clinic the we found the patient laying on a gurney. He was hooked up to about five IVs, the breathing machine was already hooked up and he had a large amount of bandages wrapped around his head where the gun shot wound was. The down range physician was briefing me about his condition. Generally what happened was he was on an operation going into a hostile village, he climbed over a wall and there was an enemy with an AK-47 there ready to meet him. The bullet found the gap between his head and his helmet and just barely grazed him. The problem with a high velocity rifle round is that the bullet creates a cone of destructive force around it. This blast wave from the bullet essentially was enough force to shatter his skull and send fragments of his bone into his brain. The actual bullet did little damage except graze the skin.

The part that worried me most about this guy was not the immediate resuscitation, that had already been accomplished. It was all the advanced care he was getting, and he was still in a very tenuous state. We have trained with basic IV meds, and know how to work our ventilator so that wasn’t a big concern. The concern was the four IVs that were piggybacking on each other. The platelets, the microdrips of hypertonic saline, it was all a bit beyond anything I was comfortable with, and my IDMT felt the same way. I was learning part of the trick to this job was that if you can’t do then delegate. I found the nurse anesthetist that was part of the medical team and basically demanded that he come with us on the flight back. The trick is to realize when you are undertrained for a situation and have the humbleness to call in for backup.

The next step was to hook the guy up to our equipment and start moving him back to the aircraft. One of the first things we did was to hook him up to our ventilator and disconnect the clinic’s machine. This was a scary moment because this was a ventilator that I always trained with, but have never actually used on a real patient. I mean, I know that if I hook a latex glove to the end of it and turn the dials the glove will blow up, but to have absolute faith that it would work on a human lung was a different story. Sure enough it worked, the world stood still before the machine cycled its first breath and I saw his chest rise and my sphincter relaxed a little bit.

We transported the patient back to the aircraft in some kind of heavily armored ambulance that was designed to either crash through enemy lines, or take gun fire, probably both. On the flight back the CRNA was working some kind of voodoo alchemy with the IV’s. As he worked his magic the IDMT and myself focussed on the head. He was bleeding profusely and soaking through about three layers of tightly wrapped bandages, the blood was bright red which meant it was probably arterial. This was both good and bad, bad because a pulsing bleeding artery is always bad, good because at least it wasn’t bleeding inside his head and building up pressure. I wasn’t too worried about his intracranial pressure getting too high because the blood that was most worrisome to accumulate under his skull pushing down on his brainstem was dripping all over the back of the aircraft.

Once we landed the three of us started getting him ready to transport. Bagram Air base is home to the biggest hospital in the theater, although I had not yet been part of a medivac at the base, I was hoping they had it down to a tee and transport would be waiting. I slightly mis-underestimated this as it was not an ambulance that was waiting on the runway, but an ambulance bus. Literally their ambulance was a school bus converted into an ambulance. There was team of about six medics waiting with pristine uniforms clearly designating their name, rank, and a glow in the dark patch on their arm designating their job title. We on the other hand had our multicam uniforms, with no patches, no names, no rank while wearing a kevlar vest equipped with medical gear and a pistol. It was an interesting contrast. I hopped on the ambu-bus and rode with them back to the hospital. The bus pulled up to the trauma bay. We opened the back door of the bus, got the patient off and then walked into the trauma bay.

The next image is something that will stay with me forever. As a medical student and a resident I was involved in a several traumas, there is always about 20 people in the room and I always felt like I was in the back on my tippy toes just trying to see what was going on. This was the exact opposite. As we walked in the door There was no joke 15-20 people in the room all in blue trauma smocks, anxiously awaiting our arrival and making a path for us to a gurney. One of the docs standing at the front of the group just happened to be one of my internal medicine attending from when I was an intern. It was a very surreal experience. As the medical team descended on the patient we took a step back, gave report and tried to do what we could, but generally stayed out of the way.

The guy was eventually stabilized. He went immediately to the operating room where a neurosurgeon was able to isolate his bleeding meningeal artery, and ligate it off. The next day he was swooped away to Germany and back to the states. I never heard anymore about his final condition. But, I remember looking at the CT scan that showed fragments of bone being peppered throughout the left half of his brain. I imagine the guy lived, but surely has some impairments. His road to recovery I’m sure has been hard and long, but there is some satisfaction in knowing that I served a critical piece in making sure he got there.

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