 We have a real treat today because instead of having the usual situation where I'm presenting a case, which has its limitations, we have the real, we've got a treat today. We have three surgeons from the US Navy and that is someone who many of you know, this is Commander Paul Roach from the Medical Corps of the US Navy, Lieutenant Commander Thomas Carver also from the Medical Corps of the US Navy, and finally Lieutenant Commander Ken Kingdon and they have all had experiences in Afghanistan, I think all in Afghanistan, correct? And so Paul and I had talked in the past about there were a number of ethical issues that are associated with practicing in such an environment and so Paul was nice enough to kind of organize this and get it everyone here so thank you all for coming in advance. All right so I guess to begin the first thing that we have to do is establish a context a sense of place and so I put together a quick PowerPoint and we'll fly through it just to give you a sense of where we were because it's so different than here you can't even imagine when we got to where I was at was and I got home two years ago and these guys got home just under a year ago I was in not Kandahar province but Helmand province so if you know that's the desert in the south and we were I was with the Marines and these guys were in Uruzgan province which is a bit north and east of us but it's mostly in the east of the country and yours was a bit more mountainous but still in the middle of nowhere so where we were it was like the surface of the moon and where we put our base was probably 15 miles outside of the Helmand River which is where the only green in the in the whole area was there was just sand and both Tom and Ken as well as I we worked in what are called level threes as well as level twos so in the level threes it's sort of reverse from the trauma levels here trauma level one is the highest here in the military a level five is the highest but a level one just means you're you're basically under some trees earn it a single little tent level two is a battalion aid station meaning that there is a guy who or woman who is one year out of med school they've done their internship and they're there and that's a level two then level three is us intense so these are our tents it was a series of eight tents like this that were hooked together and the design is that you can bust it down and move it within several hours and then bring it up and start seeing patients within what eight hours or something like that what happened is after being there for a while it started developing roots because we started putting wood in there and everything else so this is our base and this is the moon dust that we lived in and that was everywhere when you go on a helicopter that's all it was it was a very very inhospitable place in the whole base everything is inside these these circus type tents these are this is casualty being brought to us almost all of our casualties were from helicopters and so the Marines you can see they're wearing their armor because sometimes people have ordinance still on them either intentionally if they're bad guys or unintentionally if they're like one of our guys but you know you have to be very careful so we'd stand behind blast walls and they bring us the casualties you can tell as you're watching and waiting for the helicopter how bad the whole situation was if the helicopter lands a nice smooth landing then you know out might walk like a mom and some children or something like that if it bounces you know really hard landing you know it's bad this is the inside of a tent you know and this same tent is everything its lab radiology patient holding operating room you know but it's just a couple of these tents that are connected side to side and we you could see we started just building stuff we would steal wood and steal tools or bribe and and then that's how it works out there and then this is after a sandstorm we'd have these sandstorms that could last for a day's a day or two days and it was like a snowstorm and you couldn't see but it was you could you couldn't see I couldn't see the end of this hallway at all I mean this room at all it wasn't even half that distance visibility and we get into every nook and cranny this is our base from the air and I'm sure this is just a lot like Karen Totlers these are IEDs and they fill it up with fertilizer whatever else and they would bury them and ignite them and they could ignite them just with a cell phone or just touching two wires together they could be pressure wired and they would explode and they were extraordinarily violent and they just kept getting bigger and bigger and bigger over time our staffing for us and this was just like for Tom and Ken it was three general one plastic surgeon two orthopods we have two we had one orthopod three anesthesiologists three emergency medicine physicians five critical care nurses and for us really if they if they knew where an ICU was in a big hospital that made them a critical care nurse two emergency medicine and two ward go ahead that's a Christmas time and I'm sporting a handsome mustache we all had a mustache growing contest go ahead so this is our lab and you can see we could just do very basic things you know CBC chem seven and they just did it right here in this little makeshift wooden desk that they used radiology department this was our X-ray machine and when you pulled it up it would fall over on the person so you'd have to have someone standing at the other end we had a nicer one that was very expensive but it was too big and it wouldn't fit so we couldn't use it we had to use a little one this is our ward you just throw people on these tents this is the ER and that's the ward this oh and this is receiving so they come in they carry the patients on the the gurney and then they put them on here and we would do our trauma resuscitation there and then I think the next picture is the OR that's the pack you this thing is called the Pog portable oxygen generator so that's the lifeline of our of our little hospital is if we can't generate oxygen we're in big trouble so that sucker you'd fire it up about 15 minutes before a patient was coming in and you could create oxygen to put on a nasal cannular face mask or endotracheal to this these things are unbelievable because you can lock them up during the dust storm and then unseal it so that $500 hammer type of thing it actually worked oh so these are the saw horses so you'd put the gurney on those if you needed to use them for whatever you'd operate right there or what we'd also have oh and this is the only monitoring device you have when you're transporting a patient this is our operating room and this is operating table you put them in there the blood would drain underneath there and pretty much drain everywhere these are the arm boards these little red things the lights are fixed onto here and they gave a candle or two here's all the medicines we built this you know and to store things better but it all is designed to just hang off the side you do some horrific operations in there what I don't have is I now I wish I had was we had a walking blood bank so we couldn't store a lot of blood we didn't have any platelets and we really needed platelets so when we had really bad traumas we had a registry of everyone on base and what their blood type was we'd put out the call volunteers would just show up we'd pull it right out of their arms and put it right into the patient and so if you go through 50 units or 70 units of blood you know 30 40 50 of those were from the volunteers right there sometimes we would give our own there's our operating room I'm sure the new hospital here is a lot like this and this is what it's all packed up in these boxes and you put it on the flatbeds and the flatbeds put it onto a plane or wherever and you fly it and then you just set it up within a few hours we actually did that as part of our training to get started so but believe it or not in these little tents we did amazing amazing work when patients got blown up and they got blown up viciously or shot with not just some little inner-city kind of gun but high-velocity weapons that blew huge holes wherever they went with massive massive cavities if they came to us with the pulse 95 out of a hundred times they left to left us with the pulse it was unbelievable our statistics were phenomenal and it's a whole team effort so this is the helicopters that would this was our three helicopters right there and that's the mobile trauma bay we'll just quickly go through that it's really pretty much a suicide machine but it's a little it's all of what you just saw in one connex box type of thing that can yeah he's a friend of ours he's a orthopedic surgeon he was a Marine Marine Corps officer prior to going into med school all right MTV that's we had one rain the whole time I was there and then it stayed like this for a week even the ground rejected the rain and it got muddy and all the Marines played football this is Kandahar this is a regional hospital where we would to see patients and stabilize them and then put them on an aircraft and then they would fly to a hospital with actual walls so that's a level three where ours went up to was bastion and I put these in because this is Kandahar this is where Tom and Ken were that's not an actual rink there was a Canadian it was a Canadian hospital so they made a rink on concrete this is a KRMH so this is the only governmental hospital that I know of in Afghanistan the only one there was others that were staffed by medicine sounds frontier but then they stopped being staffed after a number of those guys got killed by the bad guys so this is KRMH so if you had an injured Afghani soldier you could get them here but if it was an injured Afghani civilian good luck the only place they could go would be Boston one of these medicine sounds frontier hospitals and once those guys got assassinated then that became really impossible and we had to sneak it because if those patients went to boss to that and the Taliban were very heavily involved they couldn't come from they couldn't have been treated by Westerners or else those patients would get killed or whatever so we had to sneak our way to get them into those hospitals so this is Kandahar area from the sky as I was flying over and there we are that little gun it's funny because I started falling asleep during the flight then all of a sudden it was just makes a lot of noise I don't know what they were shooting at but so this is it this is KRMH this is the only governmental hospital that that any of us know about and I there might be something in elsewhere but so this is their ER I think no no not the ER I don't know what this is just utility room we'll call it a couple of their doctors this is their ER and you've got the expectant delayed the categories that we would give people because you're triaging all the time you don't just get a person and give them everything you got because it just doesn't work like that when a patient comes you have to make a calculation can we save them can we not save them do we have the supplies to put into this person or don't we and that's triage that's military triage and it's very difficult we can't spend all of our blood or all of our other things on somebody with you know essentially a non-survivable injury and this is a really difficult situation when you're in it and we've got a couple of cases to tell you about that so sometimes you put a patient in and you just make them expectant meaning you just comfort care immediately you are not going to crack the chest you're not going to do anything and delayed means you'll get to them if you get to take care of everybody else first and then you'll come back but you have to prioritize it's the fact of it's fact of combat surgery so they're here they are operating on somebody and you know that the sterility thing is very different over there this is the medical trainer he's an ER doctor with the Air Force who is there for a year and we always have groups of us will hang out there for as long as a year to train them in orthopedics or emergency medicine I don't know what the official word on how successful it is but the people that we know have done it have a lot to complain about he's the head of the pathology lab very proud of his lab and he's got a microscope bear in mind also I'm sorry to interrupt no no please we we tried at our base as well we tried to mentor well we would go through all these positions and then one day they wouldn't be there anymore and as it turns out they actually weren't doctors and so there's no credentials somebody would walk up and say I'm a doctor and they would get hired by the Afghan government to be a doctor at this base and I mean we went through five or six personnel who we dedicated hours into training and they just actually weren't positions at all if you've been there you're not surprised yeah there's their pharmacy all one but you know 60 square feet important people oh so this is a pediatric case Tom will tell you about it or can he hit an IED they'd hit these playing at their house so this is the sort of thing we would see in this and what do you do yeah this is not unusual this child came in actually talking he was sitting upright and I'll tell you there's probably no stronger people in the world than Afghans they they've been at war for 500 years and they're a little sick of it but they're tough tough people the children are small they're small until they're 20 and then they age exponentially and so a 30 year old will look like they're 80 but this small child was probably like 12 they look like they're six they all you know if you saw an album in over three it was amazing and this kid was playing all from malnutrition just come abject poverty this child was so they've grown up in the era of IEDs this kid was playing with a bomb they were his brother were kicking a bomb because that was their soccer ball and it blew off his left leg and you can see the tourniquet on the right leg and that actually was amputated as well and you can see he's completely eviscerated and this kid came in with a pulse and he came in sitting upright and not crying I think just because he was in such shock and so there's several issues one is first boy is a civilian so should we even be taking care of this child arrived at the Kandahar Hospital at our NATO hospital so civilian pediatric he's going to need an ostomy imagine trying to take care besides the amputations everything else just an ostomy in a place where you can't get ostomy supplies we would hook up people that ordinarily we wouldn't hook up yeah because they didn't have much of a chance with an ostomy pouring on them once they leave our little confines if they're off to the winds you'll never see them again yeah sometimes you might catch them back months later and try it try to save them but anyway so we know what do we do if we had been overwhelmed with casualties this child would have been made expectant because we can't dedicate the resources to this however he was one of three casualties so we take them on and I don't know if it's right or wrong because you are setting this child up at best he's going to be a high AK amputation bilateral in fact I think one of his arms was also injured with an ostomy not to mention all the septic issues and the fact that he'll probably be in our hospital for a month but we but we operated on him and here was at the end of the surgery so AK AK this is all meatball surgery so you clear out as much debris and dirt and everything and his abdomen's got a vac on it and we'll bring them back three or four times before we close them there's so much contamination you can't imagine how far up into the tissues that the dirt and such gets is a lot of them are buried in the ground so you have this upward blast so if it's a soldier or a marine their armor is useless because it all comes from underneath these are what we call this non-idb meaning they're walking so it's underground so you've got an explosion of rocks and if they put in any they'll go put in ball bearings and other pieces of metal coming upwards and it's so let's say their leg is blown off here there's a jet blast that comes all the way up maybe even into their abdomen mud and everything is blown upwards and the planes of tissues are completely destroyed and their genitals will oftentimes be destroyed and then you also have a fireball so it all gets cooked so you've got blast effect you know burns yeah projectiles yeah it's every kind of trauma you could imagine in our little pants yeah so this is kind of hard from the air oh this is one we got these other ones Tom will tell you about so we'll think about that other the amputation kit a little bit more later this is another child this is a that's a scalp wound and this kid was another one of those emaciated eight year olds who look like they're four and I've never seen a scalp would get infected this kid came to us as a transfer he had a GCS of seven was actually like a gnashing just gnashing his teeth didn't open his eyes he he was walking a cow he's walking a cow toward you know a source of water the cow got spooked the kid was holding on the cow took off and the kid got dragged behind the cow and so you know imagine bouncing your head along a dirt ground full of manure and such and in Iraq and Afghanistan there's a needle-backed or everywhere and so they just get horrible infections well this kid was brought to level one so there was a PA actually who was staffing this small little clinic hospital tried to staple his head back together tried to support him with some enteral feeds which it probably was just like glucose water and after a day or two he didn't he wasn't getting better because he had such a bad traumatic brain injury and so he got sent down to us and this was purely random we we didn't know he was coming and they pull this little kid off the plane with his dad and so we brought him and we had a huge discussion for I mean we argued over whether or not this is not our mission our mission is to take care of soldiers and Afghan soldiers who are injured in battle and here we have a five-year-old who may or may not live one because he's such a bad TBI two is going to consume our resources we had we had less resources than dr. Roach did we had three nurses with 14 beds and if you take up three or four of those beds all of a sudden that changes your ability to perform your mission and not to mention all the you know all the other resources that we would have to dedicate to this child so we argued back and forth thankfully I won that argument so we spent Dr. King and I spent two weeks trying to put this kid's skull back or you know scout back together that was all pus I mean there's a little about betadine there but it was just soupy you put your hand on there and just it was like a cephalohematoma except it was all pus underneath there and this is like the day that he got discharged was right around Christmas he was there for three weeks took two weeks before he opened his eyes opened his eyes started interacting a little bit he's still you can see he's a little not quite there you can see it in his gaze he's a little disconjugate but this is one of the Korman man that Korman took excellent care of that child and that's his dad he came back maybe a month later because the the local doctors didn't want to take the staples out the staples have been in like a month and you know because we really kind of reefed his scalp back together but this kid jumped into the ambulance when he got off the helicopter and then came running into the hospital when he came back so pretty amazing there's like no end of ones we could show so we're just being quickly trying to just to give you a sense of of what we're talking about Dr. Angelus and I came up with a quick strategy for where we would go this is an Afghani you can tell because all the American military members have to shave seals yeah not the seals right but anyway this was through and through of the chest and we're obviously doing compressions and that's not very good but that would be an example of futile care but it was an Afghani soldier so we gave them we gave them what we could go ahead we got a little baby and we got an old man you know we we sort of people just showed up that little baby had pyloric stenosis but we were able because it took so long to get to us it was already softening so we're just with hydration and tender loving care you know and better lucky than good we didn't have to do a sphincterotomy because he was already beyond that point where it was lethal condition and then you know these old people would show up too and a lot of times it would be a village elder and they're very important within their village and that's very important for our overall mission so we took care of you know hernias that were just like wheelbarrow kind of hernias and what sometimes this is a 15 year old girl I we won't get into her today but she had a through and through of the trachea just from some shrapnel but the unusual thing about this was after I was done with the case I'm all amped and I go to talk to the father but about about about between the the interpreter and the father the father's all upset and I'm like we just you know this is a great thing we just did you know it's just gonna be fine it's all gonna work out father's all upset and then we we part I never find out father was very worried that there that I was male and that I might have seen her chest so that interpreter just had to lie to the father say that it was all women in there and she was covered and I came in just to supervise and she was already covered because otherwise if I had seen her chest she would have this is what the interpreter told me kicked her out of the family out of her town she would have died or had to be a prostitute and that's not this is that's not Islam that's the some of the regional interpretations of Islam so you know so what we did was we flew her to another hospital just to avoid stories conflicting whatever so that's just her operative photo you can go on this is a boy who actually made the New York Times he had tetanus this is another example of what we're describing with mission creep he'd been playing in one of the the little water irrigation ditches and he got sick and he came to us with I think it's here the Reese s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s. and all the things that that her old tetanus even I could figure that one out that it was tetanus but taking care of him was a huge problem and we had a lot a huge major Pow Wow should we because it took weeks of ICU care. We finally did decide that we were just going to do this. You know, it was something that we committed to. We transported them up. He was taken care of for weeks. But we are not, you've seen our tents, we are not equipped to be the regional medical center of the southern half of that country of 25 million people. But every now and then, we did this and some reporter got ahold of the story and it made some news. But we are all happy to do it, but it took every bit of horserum in Southwest Asia. This little fella burnt his hand. I think there's another picture. So, you know, the children just show up. Whether it's Iraq or Afghanistan, they just show up. Bombs could be dropping and they just show up. Families will do whatever they need to do. So we didn't have any pediatric instruments because that's not what we're equipped for. That's not our mission. The anesthesiologists snuck aboard the pediatric stuff that they needed to deliver anesthesiology. And we did everything with adult-sized instruments. Go ahead. Go ahead. And there he is. Little soccer player. So we had lots of these. A little boy who we took care of and took the bullet out of, I don't remember where, but the bullet first had gone through his mother's head. And he didn't know that. And we never told him. So we had him for a week and it was this little secret that we were all carrying. And you know, you can't tell him. So this is my first patient. That's a, I think that's my first, you know, like a two year old or so. It looks big to be two. And it was a thoracodominal gun shuttle. It trans went across. And I don't know how this happened. But it, it didn't, he was moving his legs. So it didn't go through his spine. Belly was out to here. And I thought, and it hadn't been. The corpsman or their medic was very clear that it had been flat when they picked him up. So I always thought it was just going to be a warm autopsy. But it hit. It traveled around. It did not take a straight line. And it exited, you know, out here. So the entrance was actually above the entrance. Sorry, it was like up here on the other side. And it came out right underneath there. So I was sure. But this little fellow had a guardian angel. It's the only way I can put it. Because a high velocity missile. And then it also went into his sister's ankle. And that's us. This is a little girl that I wrote about in these notes. One little boy found a yellow looking toy, brought it inside her older siblings said that's not a toy. That's a landmine. And they started throwing it and it exploded. And we had about five patients at once. Got so hanging out. One little child died. And you're suddenly overwhelmed in your little tents. And then they brought him up to where I was. And we took care of them. I think we've got some pictures. I took care of a couple of these. And this little this little one here tormented me for like a week. I don't know if I said, you know, why count went down to zero or it was horrible. But we did about four surgeries or so. And there she is. And their little sister wasn't so bad. It was just like two holes in her leg. But this is double amputation. Just so you can see what that looks like. We had lots of those and triples and quadruples. And we'll talk about that as soon as this slide shows over. That's a hand blown apart. I don't think even Dr. Gottlieb could do anything with that. This one is interesting because this is an enemy prisoner of war. And a big, big hole in his leg. And so we would take care of enemy prisoners. I mean, we would shoot them and then scoop them up and take care of them. I love you. I hate you. Come close. Go away. We would put in these little plastic shunts because the high velocity missile blows everything apart. It's not just a little we little hole through the limb. It blows it all apart. And so you see there's this enormous soft tissue defect. The vessels are destroyed. So we'd put in we'd put in these little plastic shunts in order to maintain perfusion to the distal extremity. Now it's one thing to do that in UK, Danish, American, service member. Because they're going to get the million dollar everything when they come back. It's another time in the Afghani in the Afghani soldier because they don't have the ability to do all of that reconstructive work or the physical therapy afterwards. We decided, since we couldn't figure out what exactly to do in that scenario, that we were going to do everything the same for US and Afghani. Even though we know once he gets to KMRH, they're probably going to cut it off because they won't be able to do anything else. But we wanted to give them that little bit of chance. However, we knew the conclusion. But we did it this way. Anyway, it also avoids the perception of unequal care and also in Afghanistan, there was a rumor amongst the locals not to go to the US hospitals because we cut your arms and legs off. We cut off your arms and legs. Okay, so that's just to give you guys a sense of the place. What I had done is I sent to Dr. Angelos late though. When I was there, I used to write up this sort of stuff and send it home to my wife and family. Then when I got done, it was like 50,000 words and they're like, you should turn this into a book. So I sent it to the Navy and I'm not gonna, but they approved it. So all of this stuff has been approved by the Navy. But these are just narrative, I don't know, maybe, but Dr. Carver and King didn't keep me busy. We're modest people. Yeah, modest people. Because for every one of us, because I did the same, I have basically a diary as well. And every one of us who's been over there has done the same thing. And you know what? It's okay. It's something you just keep to yourself and share with your family. But it's not, it looks like, it sounds like gloating. And I don't, I don't, I think that's just why we don't all publish what we did over there. Yeah, it's potentially there's books though. There are books you can buy. It's one of them. It's called Wars in Afghanistan and Iraq. And you can get it on Amazon. It goes over case studies and things like that. So somebody's done it. I did as I've shared with you guys with all of you 15 pages or so of it for today. And you can get it from Dr. Angelos online and and you're welcome just to read it. And and so what we'll do the the first one is the issue of triage. We're going to skip over that. But those are the the ghouls sisters and also took care of her pregnant mother, which worked out very well. But that's just triage. And we also had at the same time that they came in, we had a few military service members come in. And who do you take care of first and whatnot is an interesting issue. But we won't talk about that today. And then we want to talk about is a tale of two head traumas. I had this patient who was 12. We'll call him Lando. And he came to us with the story that didn't match his picture. But he had DAI diffuse axonal injury. He had this was when I was at the level two. And he he was neurologically. What should we just say? He was, you know, like a GCS five or so. And the question is, should we just let him die or try to save him? So he was a beautiful little boy, a little muscular fella. And his father was with him. And he meant everything in the world to the father. And the father was there with him day in and day out. And we fought and I was at a British hospital in Helmand. It's a British level two and they're much quicker to pull the plug on patients than than us. Tom was at Kandahar and you had a little fella with DAI as well. So if you read through this whole story, you'll find out that despite my fighting for him, we had to extubate him and let him fly. And overnight, he did very poorly, couldn't handle his own secretions. And we had to send him home to die. And that was very hard. I mean, because I just I had kids this age, the kids were really, really screwed me up when I was there in terms of, you know, that was hard. Tom, though, the better surgeon than I am and better arguer, he managed to save his so he'll tell about that. We were Paul was with Tom and Ken. I should Paul's with the Marines. Ken and I were with the army and we were actually took over a Dutch base. So whereas Paul was living in tents and rolling around in tents, we had hard structures. We had connet boxes. So if you see a train roll by with a shipping container on it, that's what we lived in. And we modified those and they cut the walls out. And that's what we operated in. And that's where we ate dinner. And in, if I never set foot in another shipping container, I'll be too but you know, it's nice about shipping containers. They're somewhat blastproof. And they keep the dust out better than a tent. But we had a different situation. Whereas we had, we did have two feet. We had the army, the army and the Marines just as an aside. Okay, the army and the Marines have a much different mindset about how to go to war. The army is going to bring your couch and the chairs and all the TVs and the Marines are going to bring bullets. And that's how that goes. They bring tents not for not to keep everybody dry. They keep in tents to bring to keep the bullets dry. All right, the army, they bring everything because they can. So we we had the luxury of being in an army base. So we had a little bit more materials. There still was heated debate. And I think Dr. King and I kind of were like, you know, this kid, we can we can do all right, right? But I mean, there was actually a third surgeon with Dr. Carbonite, who was a cardiothoracic who had been our chief when we were younger surgeons. And we had a very heated debate between the three of us about whether it was appropriate to take care of the kiddo from a resource standpoint, which we've talked about a lot. That's one of the big issues. But the other issue is the standpoint of is the family able to take care of the kiddo afterwards? Are we actually causing more pain taking care of the kiddo in the long term than not? That's another big issue. You know, you think it's just life and death, but if they can't handle the kiddo, are we actually just making it worse? Is it going to get abandoned on the side of the road? Is the family going to get killed or these kind of things? So there's a lot more to think about than just life and death of the kiddo. And so that's where the argument came from. And the third surgeon really thought that we might be doing a little bit more harm. And we really just sort of flipped the coin basically, I think Dr. Carver was on when the patient came in. So that's how we decided what to do. And I think that'll bring us to our next. Did you guys want to, are we just talking and is that okay? Or did you want to jump in if you? All right. So, oh, this is the little child. And the issue is with the children, what we call mission creep, which is we're sent there to do a mission. And that mission isn't to take care of everybody in that country. It's to take care of the fighting forces. And you have to do that. And you have to be disciplined and stick to that. But what are you doing? You got a child with a gunshot wound, you know. So that's a really difficult ethical issue that we all dealt with pretty frequently. We just tried to treat everybody the same, right? And that sounds like an easy thing to do, but it is not. And I think one case, and we didn't bring up a lot of this, but head injuries in Afghanistan, in Kandahar and Bastion had neurosurgeons, right? So the neurosurgeons would do these operations. Not only at Kandahar. Oh, Bastion didn't have it. I did four craniotomies, but that was me. You're the local neurosurgeon. We had a neurosurgeon. We had a lot of head injuries. We would save them. And Kandahar, bear in mind the hospital in Kandahar, which is a beautiful structure and is as capable as Cook County in terms of trauma. In fact, we did more massive transfusions and Kandahar than they do at shock trauma or at Cook or anywhere else in the world for that matter, except maybe South, you know, South Africa. The head injured, we would get them to a point that they would, you know, from our standards, they would be ready to go to rehab. And we would move them to that KRMH that Dr. Roach was talking about, and they would die in three or four days. Because there is no possible way you can maintain that amount of care. Even just tube feeds, even just IV hydration, let alone aggressive OT and PT and speech therapy, which doesn't exist. You know, occupational therapy is feed yourself. And if you can't feed yourself, you're going to die. And so, you know, we talk about these hard decisions that we make, the hard decision was, do we let this poor child just expire with a morphine drip, which in some ways, may be better, or do we get them to the point that, you know, they have a survivable injury now, but they died because the local resources cannot handle, you know, the basics. So here's one I was in my tent. It was my last day before I was coming home. And a pack comes in a patient comes flying in. And I get the story when he arrives, he's covered head to toe, young guy, he's still alert, and he's looking and he's quiet. And he's look, he's got this look about himself, like what is going on? And he's covered head to toe and in gauze. And the translator tells me the story was what he thinks is that he got doused in gasoline and pushed into a campfire. So I go to take off his dressings and it's just too painful. And I'm stressed. I'm actually, this one is really stuck with me. I know what's going to happen. I know how this one's going to play out. I'm going to have to tube them in order to do his dressing changes. And then I'm stuck with a tube in them. So I wasn't sure what to do. But you know, when you're out there, one of the other things that happens is just the current, the momentum. Even though you're not necessarily busy, you handle things pretty quickly, typically, because you might be real busy the next moment. And you don't sit around and you don't have the luxury of an ethics conference about what to do with this guy. And you don't have, you know, any, any time to to think. So I looked at him. And I before I took off his his dressings, I made my piece with it as best I could that that he's going to die. And it's going to be through me. Because there's no way we couldn't just put him in our tent right there and let him dehydrate slowly or die horribly. You know, you can't just do that. And there was no way we were going to get a helicopter because they would not fly an Afghan civilian who has been assassinated or partially assassinated to anywhere. And even if they could fly him to anywhere, no one's going to take him. So I told the translator an incomplete amount of information. And told the guy that we were going to I told the translator what we're going to do. But I didn't tell him the impact of this. And we told the patient and the patient nodded with the tube in took off his dressings. And it just got worse and worse and worse. And he had 95% burns, almost all grade two and grade three. There was really no grade one. The only thing that wasn't burned really was this little section right here. And there's nothing you're going to do about that in Afghanistan. So I gave him a morphine drip. And I took him off the machine. And I dealt with it as much as I could. And this one really hurts because that was a human being he was in his 20s. You know, but what can you do? You are stuck now you've seen the pictures and you've seen the environment if anyone has a better solution that's what I'll do next time but you know, it's hard to know it feels to me like euthanasia or a coup de gras. But you know, right, it wasn't it wasn't where I took his dressings did a dressing change, and then let him wake up and just put him in a corner and let him sort of, you know, or gave him what therapy we could. We took over a Dutch base. The Dutch had a, you know, it's interesting, they're active in euthanasia. And they had a poster or like a pathway on the wall for these severely burned severely head injured patients, where you kept tight trading up the out of van and morphine to the point that they eventually were at me. And I think it was more as a ramp it up so that we don't use all of our resources and let this patient who is going to die. Inevitably, they're gonna die. Let's speed that up so we don't keep drips and fluid and stuff going. We didn't adopt that path, but it was on the wall in the ICU, which will bring us to the last one. I'm sorry we're going over. But this is this is one of my patients. He had he was crossing a bridge. And the bridge had a IED underneath it and somebody I don't know if it was pressure plate or remote detonated but blew him up. He comes to me and he's got two high amps. Well, he I mean, you saw the he comes a complete mess. But he leaves me with two high amps, an amp above the elbow here, and then an amp here. And then I put a shunt in the brachial artery and vein as well, so that he could at least have one joint. And when he came to me, oddly enough, he was screaming hellfire. It was the most horrible scream of my life. And he was wide awake. Of course, there's no place to put an IV. So I put in subclavian catheter, you know, just you just he's already hurt so bad, you don't bother with the lidocaine, you just put it in. And we tanked him up. And then the guy on the other side of the table is able to get his. And when I was done, because when it happens, you just go. And then when you're done, and you're cleaning up because you're covered in blood. You're thinking, Oh, my God, what have I just done? It was horrific. This is just the most horrific thing. And so it wasn't until I was preparing for this that I just googled his name. And and it hit me. It was this unbelievable release. He's on web pages. He's got interviews with Gary Sinise. Some foundation is bottom of house. You know, he's apparently got this incredibly positive mindset. But that was two years that I've always been wondering, in the end, life is still life. And whatever we can do, we owe it to these people. And we will, you know, we're working in a combined VA Navy hospital. And we see the Korean vets, if they're still around, the Vietnam vets go for one. And they have a lot of issues. So I'll just end with this. In terms of ethics that I think as a nation, we are morally bound to take care of these vets. And it's not always easy, especially with all the psychological stuff. As you've seen from the events of last week, the psychological trauma is horrible for a long, long time. But thank you all very much. Sorry to keep you late. If you have any questions, just grab us afterwards. In the field, there are now combat, psychological teams that are in the field at some of these bases. Certainly, we're Tom and I were at it most of the level twos and certainly level threes that they can come and see. And there are certain automatic things that when they a certain experience occurs, they're automatically supposed to be sent by the commander or by folks to see these teams, not just healthcare workers, but anybody. But some of that's very dependent on who the commander is and who they're around. So it's, it can be shoddy. It's supposed to be automatic. But you know, in the tides of war, things, things get mixed up a little bit, I would say. But we had a plywood wall between the OR and our recovery room. And, and in the plywood wall, we had just written all the names of the guys who had gone through and who we had operated on and who had died. You know, and a lot of times they would bring us somebody and we knew they were dead. But they had gone through such an ordeal to get to get that person to us. But we knew they were gonna die. You know, we would do the operation anyway, just because they were there, hoping, you know, it would be completely demoralizing not to do this. So it was in one sense, feudal care. But in the other sense, you can't demoralize these people because they have to go right back out. In fact, anybody who came into us who was at least US military, we would treat them no matter what, at least for a short time, that's for unit morale, essentially is what he's talking about, so that their fellow soldiers don't think, hey, the doctors just gave up on them. Yeah, regardless of what you thought, they would follow them in. You guys, you would have to pry them away from their friends sometimes just to get help. So with a big thick sharpie, we put their names in unit and and so we had this list here. And then on the other side, this list there. And it was something of a shrine before people would leave, they'd come and they'd say goodbye to their friends on that wall. And it was brutal to watch. And we'd always clear out. If there was any way we could clear out, we'd get out of their space, because it was very important for them. And you'd have a cluster of them and they'd be going down and they'd be talking about each guy. Let me thank you guys very much for coming. I think that you know, the level of issues that you're dealing with is so unlike anything that we deal with here. And I absolutely would echo Dr. Kaplan in thanking you for, you know, for coming here, but thanking you also for what you do for for us as a nation. And I'm sure if anyone has additional questions, these guys would be happy to answer them. So thank you guys very much. Thank you so much for coming.