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I haven't written in ten days.  I keep hoping that I would be able to write something positive that was not related to a bombing, shooting, death or dying.  I am still waiting.  

So much has happened since my last update that it is difficult to keep the events in order.  There have been so many IED blasts and shootings and wounded Afghans and civilians that it has almost become a blur.  I have realized that I am beginning to steel myself emotionally.  I still have empathy for my patients and give 110% in caring for them but have become more emotionally reserved.

 At home true tragedy is uncommon and I have come to the realization that I don't guard my feelings in the same way as I am starting to do here at Salerno.  Here tragedy is an almost daily occurrence and I don't think you could survive long if you were not able to keep your emotions in check.  I have also noticed that the hospital staff is starting to become a little irritable.  The tempo is high and fatigue is beginning to show.  Sleep continues to be irregular and in short supply.

Last week two of our surgeons MAJ W. and MAJ B. rotated home.  Our new surgeon is LTC Stuart J. from Dallas, TX.  Stuart and I are old friends.  In 2002 we served together in Bosnia for four and a half months and were both in the 5501st USAH reserve unit out of San Antonio, TX.  It was a surprise when he showed up and it was great to see a familiar face.  I am sure he felt the same way.  I was able to give him the nickel tour and tips on how to get things done on the FOB.  It took him about a week to get his days and nights on track but we are all now on the same cycle.

In my last update on 03 April I mentioned the LT that was killed by a rocket attack on the FOB.  Since it has been reported in the news I can now mention his name.  1LT Robert F. Welch III. He was an ordnance officer and I had met him when touring the artillery battery.  I learned that he made it home to his family in Dallas.   Stuart's wife said it was on the local Dallas news but not outside the Dallas area.  MJ also confirmed that she has been hearing nothing about the war in Afghanistan.  The major media outlets seem to no longer report what is happening here.  It may have been going on for 10 years and is old news but for every soldier that is killed or wounded it is very much here and now.   

After 1LT Welch was killed last Sunday it appears that the artillery battery here on the FOB was finally able to get a firing mission.  Almost the entire day on Tuesday there was outgoing artillery fire.  It was great to hear.  We were sending the Taliban a message from the 1LT.  Since that time we have only had one rocket attack on the FOB.  That is one rocket attack in ten days.  We have averaged an attack every other day for the last five weeks so I am hopeful that the artillery will keep up the pace.  

We had a fairly light schedule the five days following the LT's death.  No major trauma with ER admissions being mild shrapnel injuries and MTBI's (mild traumatic brain injuries).  Surgical cases until today were routine consisting of burn debridements, washouts of shrapnel injuries and some elective cases for the local nationals.

Saturday morning started off quiet as usual.  By 10am we had a "dragon black", four incoming patients.  We were told they were all American soldiers.  As usual, everyone hurried to the ER and made sure our stations were ready.  Scott was 1st call and took the red bed, I took the white.  Tensions were high, the last time we had a "dragon" involving American soldiers we had a death.  We were silently praying for minor injuries.  Within five minutes we received an update that all the patients were MTBIs and were coming in to be evaluated and held at the TBI clinic for observation.  The relief could be felt immediately.  All arrived awake and stable with only minor injuries from and IED blast.  One bullet dodged for the day.  Thank you back home for the prayers.

About an hour later we got a "dragon red" call.  One wounded.  Two GSWs (gun shot wounds) to the chest.  This was not good.  That he was still alive was amazing.  Scott and I teamed up on the red bed and prepared for the worst.  The blood bank immediately began thawing plasma.  All hands on deck.  When he arrived we saw that he was an Afghan soldier.  He was conscious.  Two bullet holes in his left upper chest about two inches apart.  We rapidly established IV lines, drew blood for the lab and gave him drugs to put him to sleep.  Scott intubated his trachea and we had a secure airway.  Follow the routine.  Make him naked, roll side to side, look at everything and shoot a chest x-ray.  

LTC Stuart J. put in a left chest tube and blood immediately began draining from his chest.  

Within five minutes of arrival we were in the operating room. Scott and I had our big Belmont rapid infusers primed and were giving blood almost immediately.  

By this time we had become a well oiled machine and things began happening like clockwork.  Monitors applied, connect to the anesthesia machine, ventilation, anesthesia drugs, arterial line, central line and continually reassess.  More blood, plasma, platelets, fluids, lab and blood bank.  

Over and over the resuscitation continued.  LTC J. and MAJ Mark T. from Melbourne FL opened his left chest and started trying to control the bleeding.  The bullets were through and through.  The had entered his left upper chest and exited his back.  They ripped to shreds his left upper lung missing his heart by and inch.  The bleeding was controlled quickly and he started to stabilize.  We were catching up.  He was young.  Maybe eighteen years old.  His youth was in his favor.  The upper lobe of his left lung was destroyed.  J. and T. removed the upper lobe and repaired as much as possible.  

He was still oozing blood but they had done all they could.  It would be up to him now. Two chest tubes were placed.  They had difficulty closing the chest due to the broken ribs not providing much support.  He would have a flail chest on the left.  That would make it difficult for him to breath.  We moved him to the ICU and he was placed on a ventilator.  He still had a large amount of blood coming from his chest tube and we continued giving blood in the ICU.  The case was fast and lasted just over an hour.  We had given 12 units of blood and 10 units of fresh frozen plasma and one 6 pack of platelets and several liters of IV fluid.  He was not out of the woods.  The next twenty-four hours would be critical.

After things calmed down we talked with members of his unit.  Apparently the wounds were self-inflicted.  He had only been in the Afghan army about a month and had not even had basic training.  He told a fellow soldier that he was looking into the barrel of his M16 when it slipped and his finger accidentally hit the trigger.  Hard to believe that he had a loaded weapon, with the safety off and on 3-round burst mode and was looking into the barrel.  I don't think I have ever heard of anyone shooting themselves with a rifle twice in the chest.

Sunday was quiet.  The first Sunday since my arrival we did not have trauma cases.  A big thank you to the artillery battery.  Our young Afghan soldier is holding his own.  The drainage from his chest tube is slowing and is less bloody.  Good news.  We are now becoming optimistic about his chance for survival.  He is still on the ventilator.

The rest of the week continued to be eventful but I will save that for the next update.  One day seems to flow into the next and it is very easy to forget what day of the week it is.  Events that you think happened last week were actually only a day or two ago.  If I don't write down what happens I loose track of what occurred on what day.  I can see all of their faces and remember their wounds but will forget what group of casualties to which they belong.  Has this really been going on for ten years?  

It seems unbelievable.