U.S. medics thrown into the breach

KANDAHAR — In a small and crowded tent on the middle of a dusty American military base in Southern Afghanistan — two Afghan men suffering from head wounds struggle for their lives while a third moans in pain — his torso peppered with tiny punctures and a baseball-sized hole just above the knee of his left leg.

Everyday in trauma units like this across Afghanistan, U.S. combat medics are working on Afghan civilians who’ve been caught up in the crossfire.

An estimated 12,000 civilians have been killed in the conflict since 2001, ten times the amount of U.S. troops killed here. And while nearly 6,000 American military personnel have been wounded — non-profit organizations estimate the number of Afghans injured is in the tens of thousands.

Sometimes the only medical care they may receive will come from military units like this one. And while frontline Combat Aid Stations are by design tasked with treating fighting forces first — followed by civilians and contractors — U.S. military medical rules of engagement and training follow triage models in which the most serious patients get treated first, regardless of nationality.

U.S. combat medics, some of them newly deployed in Afghanistan, surround the gurneys, five or six per victim, as if they were hungry animals at a feeding trough. Each renders a service; ventilating with a bag-valve-mask device, registering a pulse oximeter, taking blood pressure, assessing pupil size, pushing medications through an IV or just writing down what interventions are being done at precisely what time.

At this point the facts are sketchy, no one even knows the names of the men. But they are all security workers who either hit a roadside bomb or were attacked by the Taliban while providing protection to a commercial convoy ferrying goods to U.S. military bases in the region. They are the lucky ones so far. Two of their co-workers are already dead, killed in the attack.

While the medics are handling the early morning trauma with fitting competence — none possess the calm conviction of Cpt. Matthew Rodgers and Spc. Michael Piegaro, who look like they’re doing nothing more challenging than the New York Times’ Monday crossword puzzle.

Both spent the last year working cases like this almost every day —more than 350 total in Afghanistan’s most volatile region. Both are on their way home at the end of their deployments — but have responded to one last call while waiting for transport out.

Rodgers, the battalion’s surgeon, is from Dupont, Wash. and is the medical ringmaster of this event. He moves from table to table assessing the interventions, providing clear direction and advise to the new medics, many of whom have sweat beading on their foreheads — in what appears to be a combination of heat and intense concentration.

Rodgers has the experience. During one incident here when there were mass casualties, he said he treated 13 gunshot wound victims with only one other medic. All of them survived.

Rodgers offers simple but sage advice.

“I tell them the most important vital sign they can take is their own pulse,” he said, emphasizing the need for calm.

“For this table here,” he said to those treating the less seriously wounded Afghan, “I know you want to get him more stabilized, but that’s a bird spinning up out there and we have to get him packaged and ready to go… try to find a space blanket, because he’s exposed and hypothermia is a possibility.”

Meanwhile Piegaro, who is from West Palm Beach, Fla. and just 21-years-old, is assisting the incoming doctor, Cpt. John Gartside, pushing a paralytic medication through the patient’s IV — which will make it easier to mechanically ventilate him. While Piegaro’s medical certification level is technically just the civilian equivalent of an EMT Basic, whose normal scope of practice is limited to providing oxygen and minor interventions that don’t include medications or anything that breaks the skin such as setting up an IV, his work here more closely resembles that of am emergency room doctor.

“I work under the guidance of the medical license of a PA,” he said after the event, using the acronym for Physician’s Assistant, “and he’s extremely confidant in my abilities, especially after working so many cases like this over the last year.”

With so much kinetic activity — it might be easy to miss both the minor and major trauma drama worthy of fictional T.V. programs like “E.R.” or “Grey’s Anatomy.”

(Photo by Kevin Sites for GlobalPost)

For instance, when Cpt. Gartside sinks an endotrachial tube into one of the severely injured Afghans, a difficult maneuver requiring both careful positioning and the inflation of a small-balloon catheter to keep it in place, Cpt. Rodgers is concerned it may have gone to deep.

The patient’s stomach is rising with each ventilation rather than his chest, indicating that the oxygen may be pumping into his stomach rather than his lungs, which could cause him to vomit and obstruct the very airway the medics are attempting to keep open.

While the patient seems to stabilize and his vitals reflect the increased delivery of oxygen, Gartside decides to adjust the endotrachial tube by a few millimeters.

At the table with the patient with the leg wound, Sgt. Ben Swob, part of the newly arrived group notices the injury site is beginning to bleed again — heavily. He decides, unilaterally, to apply a second tourniquet just above the first. The Afghan man, sedated with morphine lifts his head and cries out in pain as the additional tourniquet is twisted tightly in place, above the first.

A few minutes later, when Rodgers discovers what Swob has done he steps in and demands to know why.

“Was it squirting,” Rodgers asks. And before Swob can fully answer, moves even closer, “Was it an arterial bleed or was it not an arterial bleed?”

“It was squirting, sir,” Swob replies, a little shaken, “It was an arterial bleed.”

“Ok,” Rodgers said with some suspicion. “Record on your sheet the time you placed the tourniquet.”

Shortly after, Rodgers pulls Swob aside and chides him for making the decision without consulting the doctors. Swob, though surrounded by other people, momentarily appears alone and suspended in time by the gravity of his mistake.

When there’s a delay with the Medevac choppers that will transport the patients to a hospital near Kandahar Airfield, Rodgers asks Swob to remove the second tourniquet and show him the bleed.

As Swob slowly unwinds the tourniquet, there is a small but distinct flow of blood that squirts from the wound, with each pulse of the man’s heartbeat.

“It’s bleeding through,” Rodgers said. He pauses, then smiles. “You made the right call.”

Without looking up, Swob, packs the wound with rolls of Kerlix, an absorbent gauze bandage — and a small, nearly imperceptible look of relief appears on his face as he re-applies the tourniquet.

(Photo by Kevin Sites for GlobalPost)