Didn't your mother tell you not to stand behind an RPG?

This poor solider came in two days after our other burn victims. He was hit by the back-blast of an RPG (rocket propelled grenade). When asked how it happened, the story he gives it that they were attacked by Taliban, but more than likely someone either shot it off by accident (accidental discharge is very common around here) or his buddies were playing around trying to hit a bird or something and he happened to be behind it. He is recovering nicely.

This unfortunate gentleman was involved in a diesel tanker fire. He and his friend were brought in late in the afternoon a few days ago. His friend had 75% of his body burned, but he only had about 25-30%. They both came in intubated, but only his friend was on a ventilator. I insisted several times they put him on a ventilator, but they stated, "he is breathing fine on his own, see." I could not believe it. If I had my camera, I would have taken a picture because it is so unbelievable. The one gentleman died early that morning, which I was not surprised, he was in very bad shape. But the tube was out the next morning on this gentleman. When I asked what happened, they stated he pulled it out in the middle of the night. I thought about giving them a straw to breath through and ask how it feels, but I didn't have one on hand. This pic is of them doing dressing changes. He is actually doing good, eating on his own, drinking ensure through a plastic tube because he can't open his mouth very much. I tried to give them praise by saying good job on intubating any and every patient with facial burns, but then STRESSED that they also need to sedate and ventilate the pt. Not sure how much got through as, I also stressed that they needed frequent lab draws that first night they came in, but there were no labs until midmorning the next day. There is no reprecussion for being lazy here. People frequently do not show up for work without any negative effects.

On a good note though, we are continuing the M&M conference and it will be run by Afghan doctors. The next one will be this Sunday on the burn patient that died. I am to review the chart with two doctors tomorrow morning to see what could have been done better. Although I could name 5 things at first glance, we will probably only focus on one, maybe two. Another good note, I have got them to do a system that now has the lab and nurses reporting abnormal lab values in less than an hour!!! Instead of the next day if anyone even cared to look at the labs. It may not seem like much, but that is a huge victory. Praise God!!

This is Mike (OR nurse mentor for the ANA). We are the two clinical medicine mentors at this regional hospital. There are 4 regional hospitals, we are in the west. He is Navy, and will pin on O-3 in a few months.

This patient is a 20-something ANA solider who presented with dysuria (pain with urination), and urinary retention. On ultrasound he had a 5.3cm stone. They took it out the next day. I put the top picture in for you to closely observe the one surgeon's ungloved hand touching sterile instruments!! My partner, who is an OR nurse mentor (Mike), had a kinipshit!! They thought it was funny, but he did not.

Below is the picture of the stone.

Gastroenteritis, are you kidding me?

This 65 year old man presented 14 hours after having constant nausea and vomiting. By the way he passed out last night also. They show me the EKG and want to treat him for gastroenteritis with a PPI (stomach acid suppressor) and antibiotics. This is one of those times you have take a few deep breaths before you start to speak. For those who don't look at EKGs, this is a classic EKG of someone having a heart attack. Despite my best attempts, they did not want to listen to what I had to say. Luckily, I invited an Italian cardiologist to come give a lecture that morning on EKGs (kinda ironic, huh). He walked into the discussion and backed me up. Thank God!!

Top: Sunrise at Camp Stone in the tower. Beautiful!!

Bottom: My room. As you can see, the walls are not that high.

My First Intubation

No problem!! Afghans don't have a lot of redundant tissue.

This unfortunate gentleman arrived at our hospital 10 days ago. He was a civilian hit by another civilian. He was initially taken to the Spanish hospital where they did internal fixation of his badly broken left arm and leg. He also had a 7 x 4 cm subdural hematoma with step-off fracture, but no evidence of herniation when he was transferred. He self extubated about 4 days ago and actually is doing well besides that his leg is necrotic (dead tissue). Today they did a BEDSIDE debriedement without pain medicaiton (that is until I suggested it). On the bottom pic you can see them cutting nonviable tissue. The top pic you can see his bone and plate. I have had a feeling for the past three days that his leg will need to come off. I know there are other options in the states, but I fear his infection will no longer be contained by the antibiotics and he will die of sepsis. We will see what they do. When I ask about amputation, they ignore me, I think because no one knows how to do them?

One of the Navy Chiefs decided he was going to give me a Marine style haircut. It definitely reminds me of my uncle Neil's hair when I was a child. Personally I do not like it, but too late now.

What's wrong with this picture?

The story the ANA solider tells is that he was cleaning his weapon when it "accidentally" discharged, bounced off the wall and into his chest. The lateral does not show up that well as real life, but needless to say it is not at the periphery. I would say it is pretty close to his heart or SVC. He walked out of the hospital a few days later with the bullet still in him. Inshalla!

Extubate?? Really??

This is the CXR of an "enemy" patient who had been shot in the right chest wall and therefore has a hemopneumothorax on that side, and had ESBL K. pneumo on top of that, therefore his left side is all whited-out. On the day this CXR was shot, they wanted to extubate him (take the breathing tube) despite him being on max ventilator settings. The chief surgeon put him on CPAP of 5. Obviously it did not work.