What's a Nice CRNA Like Me Doing in a Place Like This?
By Sheryl Dacy, CRNA, ANC, USA, LTC
Second Forward Surgical Team, Helmand Province, Afghanistan
In Afghanistan, 16 years after the U.S. invasion on Oct. 7, 2001, the U.S. Armed Forces are still here, trying to rein in ISIS, the Taliban, the remnants of Al Qaeda, myriads of insurgent groups and many others who travel daily through the mountains that divide landlocked Afghanistan to its nuclear-bearing neighbor to the east, Pakistan. Warlords, soldiers with shifting loyalties, as well as civilians just trying to exist, flow through passes, and sometimes through an extensive labyrinth of caves, via the Hindu Kush mountains, the geographical boundary that separates the two nations.
The military’s role, since its drawdown and reduction in troop levels in 2012-2014, has been that of an advisory one: building up the Afghan National Army with the hopes that Afghanistan can learn how to sustain itself and fight off impending insurgencies and enemies that never seem to give this ancient, almost biblically austere country a break.
Since Afghanistan is a country in turmoil, the U.S. has stayed here for the long haul, and President Trump made it very clear in his recent speech that more troops will be added, the U.S. will not accept defeat and our goal here is to train a self-sufficient Afghan Army and Air Force, and not try to change tribal ways of life that have been ingrained in this culture for centuries.
Adding to the complexity of the problem is Afghanistan’s #1 export: opium, that ends up as heroin. Afghanistan is the world’s largest producer of heroin and where there’s drug money, it is implicit that the levels of criminal activity such as extortion, bribes, money laundering, and even murder aren’t far behind. Afghanistan has been on Transparency International’s list of the 10 Most Corrupt Countries in the World for years now, along with Somalia, North Korea, Syria, etc. A report by Amnesty International in May 2016 revealed that within Afghanistan are 1.2 million internally displaced persons and that there are 2.6 million Afghan refugees living outside its borders.
So, what’s a nurse anesthetist from America’s heartland doing here, along with a team of other medical professionals and ancillary staff? I am serving my country as an active duty officer in the U.S. Army Nurse Corps. My colleagues and I are, for lack of a better word, an assurance policy. Our service members who engage in direct contact with the Afghan National Army during field operations against the Taliban, must be secure in the knowledge that should they be wounded, our medical assets are available 24/7 to restore life, limb or eyesight. We are part of the medical hierarchy in a deployed environment, the second role in a three-tiered system of care. The first level is called the Role 1, which has a physician (usually family practice), a physician assistant, and a core group of medics to handle non-urgent, non-life threatening medical needs of the soldiers, and to some extent, the civilian contractors who are embedded with us. The Role 2 medical facility is staffed with a Forward Surgical team, ready to perform life-saving treatment (or at least life extending) medical/surgical care to ligate bleeding veins or arteries, resuscitate with blood and blood products, offer airway support, and stabilize the patient enough to send them to the next level of care, the Role 3, which has far more staff, imaging capabilities, and laboratory assets to ensure recovery or immediate evacuation back to the U.S. for burn patients and patients that will require long term rehabilitation.
My colleagues and I are on a nine-month deployment from Fort Carson, Colo., in southern Afghanistan’s Helmand Province in support of Operation Freedom’s Sentinel. We are members of the Army’s 2nd Forward Surgical Team, which per Army doctrine incorporates the use of a 20-member team consisting of two general surgeons; two orthopedic surgeons, two CRNAs; three registered nurses; three operating room technologists; three LVNs; three medics; a detachment sergeant and an administrative officer. It has become a common practice in the Afghan theater of operations for Forward Surgical Teams to be split between two locations to allow for more points of access to care in far forward regions to meet the requirements of damage control surgery within the Golden Hour of injury.
This is my second tour of duty as a CRNA in Afghanistan, the first was in 2012. What I found most intriguing about this practice environment is the use of fresh, whole blood. Our Forward Surgical Hospitals do contain a set level of Packed Red Blood Cells (PRBCs), Fresh Frozen Plasma (FFP), and Frozen Cryoprecipitate but the Department of Defense (DOD) has integrated a policy of a Walking Blood Bank in combat environments. Through this, soldiers while in good health are thoroughly screened in our area of operations and if we risk running out of blood and blood products during a massive resuscitation with a patient that is approaching a life-threatening coagulopathy, the call is put out through the encampment for any individual with the specific type of blood needed and the walking donor’s blood is collected right there and brought to me in the operating room. I have used whole blood two or three times and the patient never suffered any reaction except a positive upswing in hemodynamic stabilization.
This deployment is different than my first in 2012. While our primary mission here is the stabilization of critically wounded soldiers, our secondary mission is that of sharing our knowledge and technology with nearby Afghan National Hospital personnel whom we welcome as guests. The physicians, nurses, and I present lectures, with the aid of linguists, and share with them what technology we have. The knowledge sharing goes both ways, as the Afghani physicians, surgeons and staff share their thoughts and techniques with our staff.
We have cared for patients with various levels of acuity here, from those with tympanic membrane rupture to those in extremis. As the weather turns cooler and the days get shorter, I find myself daydreaming of being Dorothy in the Wizard of Oz, clicking those cool red slippers together, with my eyes squeezed shut and emphatically shouting, “There’s no place like home! There’s no place like HOME!” Then my daydream ends, I look down at my ugly brown boots that blend in with the ugly brown sand, shrug my shoulders and wonder if there are any Diet Cokes left in our old refrigerator.