I will never leave a fallen comrade. (Wall in old Role 3 before it was taken apart, plank by plank)
**If you are a bit of a worrywart and have a loved one downrange, you may not want to read further on my Kandahar musings. Just saying. My experience is from a healthcare administrator viewpoint and can seem a bit indifferent. If you’re one of my family members and wondered what it was like, life for me in KAF was not so bad in relation to many others. If you wondered what I did while there, read on.
Today marks a significant holiday in the U.S.A. Memorial Day. It’s no longer just a federal holiday, a day off from work where everyone lines up along side the main street of YourTown, USA, or visit the military cemeteries or lay wreaths on tombs. It’s now a day that officially marks the beginning of the summer season, even though many schools are still in session. It’s a long 3 day weekend, sometimes 4 day weekend, that involves travel, family, friends and BBQ. But for me, today, marks nearly two years since my typical hell-atious nights in Kandahar at the NATO Role 3 hospital.
Original R3 sign, now hanging in the new & improved NATO Role 3
Where else but Afghanistan can any weekend be marked by bombs, gunfire, and mortar attacks?
Flashback to 2010: I worked the night shift at the Tactical Operations Center, as the main night TOC-O (officer), monitoring incoming injuries and trying to predict what might be coming our way. While I was always offered the chance to rotate to the other shifts, I preferred the night shift. I could do my data collecting/reporting when it was a quiet night and I could call home during the day when I was off, something that was crucial to my mental well-being as I had left a husband and a barely year-old daughter. Plus, I am simply not a morning person. Never have been. You’ll be lucky to get a good morning out of me before my first cup of cafe au lait. So if I’m already awake and getting ready to go home, my boss downrange was likely to get a smiling face…as I walked out the door!
Me in the old TOC. Still all smiles because it’s only been 2 weeks since we landed in KAF
It was a 3 man team in my department with me, my patient administration clerk and our Air Evac nurse liaison who worked hard to get our wounded warriors to the next level of care. It was my job to get them to Kandahar and it was the AE nurse’s job to get them out of Dodge. From my isolated position in the TOC, I admired the general teamwork, tenacity, perseverance and sense of humor found throughout the different departments I crossed paths with like the Ward, ICU, lab, Primary Care, OR, trauma teams… it’s wonderful to observe the onesies and twosies individual augmentees seamlessly come together day and night, making it seem like they’ve been working together for years. There are other blogs out there from their point of view, such as Q’s which can be found here.
My Crystal Ball Initially, when I showed up for the night, I tried to predict how slow or busy we would be so I could tell the duty trauma team if they could catch some winks that night. In reality, it was so we could all gauge how to manage our stripped down manpower. You see, the assumption with the night shift is that it is generally slower, which is true. In an ideal place, an ideal war, nights would be the time to catch up on things like patient data collection and analysis, personal correspondence, courses, reading, hobbies. But Afghanistan is not your ideal place. This is not your ideal war. The enemy plays dirty, especially when they think your guard is down. And injuries that occur earlier in the day or evening are bound to need transferring to a higher level of care… to Kandahar and beyond.
So my nights were anything but predictable. If we had more than 2 nights in a row where nothing more than a bellyache came into the trauma bay, then I immediately had my antennae up. No need to be careless and comfortable. There were quite a few nights in that brief six month tour where the whole friggin’ hospital night shift had to cover mass casualties for the first 30 minutes and we were sending corpsmen from the ward to the flight line to pick up wounded because we had no one else to do it.
Emma I remember one of my favorite corpsmen was tagged to augment our regular crew when we needed a 2nd ambulance to go to the flight line. I’ll call her Emma. I knew she and another gal were being sent from the ward to the flight line to pick up patients. They only knew that these wounded warriors were the most critical type of patient and that we needed a few extra hands. When it’s an emergent call to meet patients at the flight line in the middle of the night, it’s never a good thing. I saw Emma coming in straddling one of our troops as he was rolled in from the driveway, performing CPR. I knew that she had probably jumped on top of his lifeless body the second he was safely transferred from the helo to the ambulance. She was in tears immediately afterwards, covered in blood, the exhaustion clearly marked on her young face. He was only 19, the same age as she. She did everything the books taught her to do from the minute the gurney was loaded off the helo and onto the ambulance. But it was already too late. All I could do was let her chief know and the chaplain when he arrived that there were a couple of corpsmen that may need to take a break that night.
How do you mentally prepare our young caregivers for those sights and sounds? How do you forget them yourself? How do you keep your anger at an invisible enemy in check so it doesn’t cloud your judgment when a possible enemy combatant becomes your patient? Aye, there’s the rub. Some folks, like our incredible medical staff, followed up with the patients from beginning to end, nearly taking a very personal interest in each and every one or just a select few. Others vented their frustrations and pent-up energy on the indoor football (soccer) field or field hockey arena or volleyball court. There were possibilities of a decent social life and some even managed to, gasp, date. Personally, I reveled in keeping to myself for the most part, not letting more than a handful too close, because then saying goodbye would be less traumatic. I didn’t want to get close to patients, especially our precious little Afghan patients who were classified as Battle Injuries (blast wounds, gunshot wounds, and so forth). I hated knowing enough about the culture to know that a one-armed little girl was worth less to her family. What about the triple amputee who needed daily care? What of her? I didn’t want to be indifferent to their innocent plights of being in the wrong place at the wrong time. Okay, there’s enough for another post entirely.
When Chaos ruled It was one of those chaotic nights, where we had but a few minutes warning that an incoming helo was inbound with several patients from a nighttime firefight in the City. The call from the Canadian gent with the rolling “R’s” in the Tower “Role 3, 3 minutes”. What do you mean, 3 minutes? Who the hell is coming in? That’s about when the medical ops officer or medic from some high OPTEMPO unit comes in to say, oh, by the way, you have X # patients coming in from this (fill in the blank with some really f#@!ed up scenario). At least we got SOME warning, even if it was a few minutes before the helo landed. Thankfully, it usually didn’t happen that way. I’d have, oh, about an hour or 2 or 3 hours warning that something was going down. The issue would always be: “they are in the middle of a firefight in the city (or the orchards). Once they can be safely extracted, they’ll be here in a few minutes.” Yeah, a few minutes to get everyone needed to the flight line and the trauma bay. That could be the difference between life and death.
So the secret was to prepare a backup to the backup to the backup and hope that God was on our side. And act like you knew what you were doing the whole time instead of throwing the Hail Mary pass. In the chaotic first moments, there was very little time to give all the pertinent information to the trauma team leader whose responsibility it was to make the tough calls, who to call in and when, and sometimes no need to call for backup from our slumbering day crews 15 minutes away in their barracks, who also needed their rest since the day shift can be super busy in the warm bloody months of war. So usually it meant that we relied solely on the creative role management skills of the super-excellent providers who I had the honor to work with at night. It also meant giving the staff enough warning about what was about to go down, but not too early of a warning. For instance, there’s no reason to call a neurosurgeon in for a head injury until the CAT scan’s been done. It really didn’t take our neurosurgeon all that long to get to the hospital, whether he was running, riding his bike or coming via duty van (he did all 3 modes of transportation). Sometimes the best answer was the simplest and most obvious. You’ve heard it before, the KISS method. Keep It Simple Stupid/Silly/Schmuck. Whatever you want for the last “S”.
The City over the mountain. I never had a desire to visit Kandahar/Qandahar City. Although it was only a few minutes by air, it was a couple of hours by uparmored vehicle. You had to travel very s-l-o-w-l-y, looking for roadside bombs and other such Afghan road accessories that had no respect to life, infidel or believer. The City seemed to always be in the headlines when we were there, probably because I noticed it more. There were times when there was a firefight or an attack in the City at dusk or at night and you could see the lights in the sky over the mountain range. Urban warfare in a former Taliban stronghold is not a pretty sight from the receiving end of the patient spectrum. Gunshot wounds and mortar attacks, vehicle borne explosives, roadside bombs.
Dear Diary In my diary that I kept that year, the weekend before Memorial Day’s holiday weekend was full of excitement and not the good kind. Memorial Day weekend in comparison was slightly calmer. We were scheduled to move on May 23rd from the old, beloved, well-worn and thoroughly tested Canadian built and managed tent and plywood hospital. If you’ve seen MASH, you have a good idea what it looked like. If you’ve seen the Canadian tv show “Combat Hospital”, the set is very closely based to what we worked in for the first part of our stay in Kandahar. The storyline, not so much.
The night of May 22nd was my last night of a weeklong mid-shift (3-11pm). I was heading back to the night shift the following week and looking forward to it. It was also the night of a full-force ground attack on the airfield that actually made it to the international news, thanks to an embedded journalist who was reporting “live” from a bunker. One of the gates was under attack and there were also mortars coming in from the nearby mountain and fields. The majority of the day shift had already headed out to supper, or to the gym, or to celebrate a couple of birthdays at the bigger eateries on the Boardwalk. Then right at dusk, the Big Voice and the alarms sounded. Ground Attack, Ground Attack… and all the bells and whistles that go with that general alarm sounded for what seemed like hours. I put my clip into my 9mm, put a round in the chamber, gave the sole flak vest and helmet to my corpsman (that was drama in itself as he was trying to be a gentleman and I was trying to be the officer) and hunkered down to monitor the battlespace. (My flak and helmet were in my barracks room… hey, we NEVER needed it until then… lesson learned) I had 3 critical patients flying in from the west within 30 minutes and I had to try to get the pilot NOT to land.
It may sound easy enough to call off a plane, but not so much in a war zone. At that time, we had no less than a dozen ways to communicate in the old Role 3. Each of our major partners had a special way to communicate from satellite to secure phones and mobile phones and our air support had radios. So my mind raced to figure out how on earth to stop a plane in mid-flight? I called the tower who was already on it and trying to get the pilot to land mid-way. Every time the rocket attack alarm came on, I got down prone on the dusty wood floor with the red phone (British) to my ear trying to gauge what was coming in so I could pass the word to our trauma team on duty who was OUTSIDE the hospital, hunkered down in a bunker. Oh, did I mention that the old hospital was tents and plywood? During a rocket attack, there were only a handful of staff left. Those who were the Rocket Nurses, tended to the patients who could not be moved, ensured that they were blanketed for safety. And the TOC officer and the patient admin clerk. Everyone hightailed it to a bunker until safe to return to duty.
Unfortunately, one of the patients, an Afghan civilian who was injured in a market attack in Bastion, was crashing on the flight so the pilot chose to take the risk and land on the airfield that was still heavily at risk of a mortar attack. Here’s how I would like to think the conversation went but I think there was probably a bit of strain to my voice and the Tower’s and the pilot’s: “Hallo there, we’re under a rocket and ground attack. Could you please turn the plane around? (pause) Yes, I understand that you have patients on board. But our ambulances are not going to be allowed on the airfield and I really don’t want to risk my crew going out there in the open. Oh, you can’t? The patient is crashing?…” and so the plane landed, my crew managed to get to them safely and our first 3 patients of the night entered the trauma bay.
As the alarms continued, the mortars landed. One of them hit the Boardwalk, shortly after the “all clear”.
Boardwalk early morning light
And then the injured started coming in from all over the airfield. And thankfully, so did our staff who managed to make it past the armed security checkpoints manned by very big, very formidable European soldiers with big guns (Romanians, Bulgarians, French). I was grateful for the appearance of the rest of our TOC team within an hour of the first alarm. There’s something comforting about being in a bad spot with others and finding you are all on the same page. We had a full house in the trauma bay and a full house of walking wounded in our primary clinic. We had medics from other units in Kandahar who were also running/walking a mile from their hooches to help out where they could. A lot of our folks had to figure out how to get out from the safety of our NATO barracks and literally low-crawl to the duty vehicle which was assigned to make rounds to get as much of our staff back to the hospital. It was an all hands on deck evolution. (Thankfully, I managed to get hold of my awesome roomie, G, who brought along my flak and helmet. I didn’t look forward to being unprotected any longer nor did I like having to tell every senior officer who came in for an update why I didn’t have my flak on.)
Oh, have I mentioned that we were due to move to the brand spanking new brick-and-mortar hospital the very next day? That meant that our inhouse supplies were at minimum and most of our supplies were about 300 meters away. If I didn’t know better, I would have thought that the enemy knew that we were stripped down to the bare minimum. (Yes, I was tempted to take the route of the conspiracy theory) The stars aligned right that night for them but not too well, because we adapted and overcame that challenge.
Our worst rocket attack injuries came from folks who were on the Boardwalk and rather than go to a secure bunker after the first alarm, decided to walk around and were caught by a rocket that hit a section. We had minimal shrapnel type injuries as well and the only casualty (death) was one of the 3 patient transfers that flew in from Bastion. Thankfully, we didn’t lose any of our folks from the Expeditionary Medical Facility in Kuwait, who’d come to help us settle into the new facility, some of whom had arrived only that day. One of the guys’ flak was shredded by shrapnel when one of the mortars hit the temporary tent they were assigned to (his flak was on the top bunk and thankfully, he was on the ground or in a bunker, a little freaked out but none the worse for wear).
We were able to finally leave around 3am, with orders to report back at 7am so we could finish moving to the new hospital. To say I was functioning on fumes was an understatement. But we all made it through that weekend, ready for the next big mass casualty. And I don’t think anyone will ever forget that weekend for the rest of their lives.
The following week was more of the same kind of action. The enemy was definitely voicing their opinion, like a bear waking from hibernation. I described the night of the 27th of May into the morning of 28 May as “busy busy”: 3 US troops…a gunshot wound to the head, another to the chest, a 3rd “grazing” wound. Later, 2 more came in as a transfer from another FOB south of us. This time 2 head and neck injuries from an IED blast. Then it slowed down…we only had 2 Afghan patients to transfer over to the Kandahar Military Regional Hospital nearby. And that was a typical night. The next night was slow until the last couple of hours of the shift… when we had 4 more warriors come in after being wounded by a Suicide Vehicle-Borne Improvised Explosive Device attack. 2 more came within the hour from gunshot wounds. And then it was quiet for 2 more nights… then hell broke loose again… then quiet… then hell… and so it went for the rest of the summer.
Blast wounds Of all the wounds we had come through our trauma bay, I came to hate blast wounds. When it was a quiet and still night before our ambulance pulled up from the flight line, the moaning and sometimes Ketamine lollipop-induced yelling would break the quiet. Why did I so hate blast wounds? They would not only take away limbs but pock-mark exposed body parts and significantly affect hearing, at least initially. (more stories, tongue in cheek may be in order, but in a later post) But it might not just be one injured person, it could be several. It could be a blast in a marketplace or a roadside bomb or a policeman’s wedding.
I’ve seen the haunted look in their eyes when their buddies are still in surgery after a dismounted IED blast. Among the worst are the daisy-chains. The most heart-wrenching stories are from the survivors. The trio of buddies who made it all the way from boot camp to the same squad downrange and ended up being wardmates. One of them hit a mine or IED while walking to investigate something in a nearby field as they were on patrol. Another one went to help and hit another mine. The 3rd… well, you get the picture. All 3 were thankfully wearing ALL their flak, protective gear, that protects their nether-regions and critical body parts, and leaves extremities exposed. Each lost a limb or part of one. All had shrapnel injuries. The worst part of these injuries is how filthy the shrapnel is… I can still smell the blood mixed in with mud and burning flesh. There’s nothing quite like it.
I admire the trauma teams and specialists (super awesome neurosurgeon from Boston, orthopedic surgeon, opthalmic specialists, radiologists and so forth) who I had to call in to fix these guys when they came in. They may have been awoken from a restless slumber. They may have already been up. Regardless, sleep was now the last thing on their minds. They had the look of fierce determination to save the patient, friend or foe, alike. Okay, their patience was sorely tempted when they got the occasional enemy combatant, especially the nutcase who kept spitting at them. I actually walked over to see the Spitter (those were the days in the old tent hospital, where the trauma bay was within a 30 second sprint of my computers). Detainees get a well-deserved bad rap. But when you spit on the faces of the people who are trying to fix you up, even if you were trying to set a bomb in that field over yonder, we may just have to send you over to the Afghan military hospital down the street. (Detainees definitely didn’t want to go there…I suspect it was a bit like oh, torture.) I’ll have to write about some of the detainee-centric memories in a later post…they are a lot like flashes of memory in my sometimes swiss-cheese brain.
Stay tuned as the memories coming flooding back, waiting to finally be put down, virtual pen to virtual paper.