1. Boyd, David RN, BSN, CEN

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"No shit there I was in Baghdad." That's how all the stories start out in the Ibn Sina/10th Combat Support Hospital EMT (Emergency Medical Treatment) section. This was one of our standing jokes early in the year, because sometimes little dark medical humor alleviates some of the stress and grim realities of yet another war story.


Little did I know when arriving in Germany in February 2005 that in few months I would be working in one the busiest trauma centers in the world. I was temporarily reassigned from the hospital in Heidelberg to the 772nd FST. We were colocated with the 86th CSH, which later transferred the mission to the 10th CSH.


In December, LTC Groves, the EMT Section Officer-In-Charge (OIC), informed the staff that the neurosurgery team was leaving our hospital and would not be replaced. All neurosurgery cases would now require transportation/transfer to Balad, where the neurosurgery team would now be operating. Until this time most of the medical transports had been handled by the ICU staff, but now the EMT section would be responsible for the bulk of the transfers. This would be a tough job for both the new and experienced staff. Patients with traumatic brain injuries would arrive from the field with multiple evolving injuries and undergo resuscitation and stabilization. Transfer for definitive neurosurgical care in Balad would be the next priority.


The following is a good example of our process, how we worked through issues, and how the transport system evolved. On January 29, 2006, zero hour begins, with radio traffic indicating two urgent litters are inbound with a 5-min or less estimated time of arrival (ETA). The patients were involved in a roadside improvised explosive device (IED) explosion. Both patients have head injuries and at least one patient has an unstable airway. The EMT physician, Dr S.M., and the staff discuss the situation and consider diverting the aircraft to Balad. The flight medic and crew also considered that option but owing to hemodynamic instability and an unstable airway, they diverted the flight to Baghdad.


The flight medic reports that the IED explosion occurred in the Taji area. The patients were injured while riding in an Iraqi armored vehicle but were either outside the hatch or the explosive device penetrated the vehicle.


Dr S.M. and the medic team depart for the helipad to complete a rapid triage and perhaps facilitate getting the patients to Balad more quickly. When the Blackhawk lands, they find two patients. Patient 1 has a Glasgow Coma Scale (GCS) of 13-14 and a possibly compromised airway. Patient 2 has a GCS of 15, stable airway, and vital signs. Both are transported to EMT for further assessment and resuscitation.


On arrival to the trauma room, Patient 2 is placed in Bed 1 and the initial evaluation in unchanged. LT Skates is the primary nurse. She and her medic team go to work doing the algorithm we have all learned so well. ABC's, O2, bilateral large-bore IVs, draw the blood specimens, and get the radiologic exams completed. Later, a CT of the head would reveal an intracranial foreign body and small subarachnoid hemorrhage.


Patient 1 arrives to the trauma room only 5-6 min after arrival on the helipad but his GCS is rapidly decreasing before our eyes. He is now estimated to be around a 7 and his left pupil is sluggish and dilated. Other injuries include penetrating wounds to the left forehead, "peppered" fragmentation wounds to face, anterior and posterior left shoulder, chest, and back area. There is active bleeding from the head wound without any visible brain matter. Within 10 minutes, Dr S.M., LT R., and SPC S. have inserted two peripheral lines, administered rapid-sequence intubation drugs, and successfully secured the airway with a 7.5 endotracheal tube. At zero plus 13 min, a FAST exam is completed and noted as negative. At zero plus 15 min the portable chest X-ray is completed and the patient is transported to the CT scanner. Thirty minutes after the patient's arrival, the CT scan is completed with the results as described in Table 1. In later discussions, Dr M., our chief of service, simplified the explanation as "badness, cracked open bleeding skull fracture." We now know that both patients will need to be transferred as soon as possible

Table 1 - Click to enlarge in new windowTable 1. CT Report for Patient 1

Dr S.M. is on the phone with Dr B., the neurosurgeon in Balad, giving report and arranging acceptance. Simultaneously, the CT results are being pushed electronically to Balad by the radiology staff so Dr B. can review them while we are en route. We also carry a CD of the CTs with the other paperwork on transport just in case there are problems with the electronic transfer. One hour postarrival, neurosurgery accepts both patients and we're off and running!! We begin to package the patients and start the ordered treatment modalities prior to transport. The medications are familiar at this point: mannitol 70 g, fosphenytoin 1 g, morphine, midazolam, cefazolin 1 g, and gentamycin 240 mg.


Next we try to decide which personnel mix is right for the flight. It's always the same question, who is going with the patients? Can we get the required seats on the aircraft? Which team combination is the best? Can the MEDEVAC crews transport the patients without medical attendants? We finally decide on a nurse and medic team and to transport both patients on the next available aircraft. I am the charge nurse today and have no patient assignment, so lucky me, I get to go!! We have been rotating the assignments and it's my turn. I try to maintain my composure but I always get a little adrenalin pumping when preparing for a transport. I had worked as a flight nurse in Atlanta earlier in my career but it was nothing like this experience. In fact, I really thought this part of my career was behind me.


Packaging the patient involves placing the SMEED (see Figure 4) on the litter over the lower extremities. The litter is padded with extra blankets and the head is elevated as much as possible. Hypothermia can become an issue for trauma patients even in a desert environment, so we wrap the patients in multiple layers of blankets. Ventilator tubing, IV lines, arterial lines, and monitoring cables are carefully secured and taped in place. It is now 60 min postarrival and the Patient Administration office has notified the 30th Medical Brigade of the MEDEVAC request. The local dust-off unit is now en route to our helipad. Ninety minutes postarrival, the patients are transported to the helipad and loaded on the aircraft. The medical team consists of SPC C. and me. A colleague of Patient 2 is talking with SPC C. as we approach the aircraft. She's worried and asking us to take good care of her friend. It's a tense moment, you would like to take the time to reassure the friends but the bird is ready and we are in hurry. Time is brain in these cases and we want to get off the pad as soon as possible. I check out the aircraft as we are loading. It is an "H" configuration with right stretcher load area. Patient 2's litter is secured on top and Patient 1 is on the bottom of the aircraft. The crew chief shuts the door and we are belted in and ready to go. We lift off the pad en route to Balad.


Five minutes into the flight, Patient 2 crumps. His O2 saturation is steadily dropping. I hope it will rebound and that it is a false reading due to vibration or the oximeter being dislodged from the finger. SPC C. and I signal the crew chief we are coming out of belts and need to get to work. I fear airway complication or obstruction. The flight medic and SPC C. take the head and start running the ventilator tubing and checking tube placement. I'm at the foot and check the ventilator, O2 tank, ventilator tubing, and oximeter placement. The O2 saturation drops to 88% and ventilator failure is confirmed. The cause is unknown and irrelevant at this point, the ventilator is discontinued and replaced by the bag-valve-mask. The chest rise is good and there is intermittent vapor in the endotracheal tube. The O2 saturation starts to rise. The patient is now also hypotensive. The mean arterial pressure has dropped below 70 and the heart rate is 124 and climbing. A 500-ml bolus of normal saline is infused. The vital signs finally begin to stabilize and the flight medic signals that we are 2 min from Balad. I have been intermittently tapping Patient 1 to assure him (and myself) that everything is okay. He nods and mouths that he is okay. It's a good thing, two patients in distress would have been a serious problem and difficult to manage in this environment. We land on the pad and the patients are unloaded by the Balad staff. We make our way into the EMT section, where at least 15-20 people are waiting. The physicians identify themselves and I begin to give report, rotating between the beds. We collect our equipment and make our way back to the aircraft. It is approximately zero plus 120 min. Two hours from initially receiving the patients in Baghdad until drop-off in Balad, including 20 of the longest minutes of my life on my knees, working in the back of the aircraft. We are on our way back now and I reflect over today and the past few months. It's nice too know the old man can still do the work and now, for a little nap!!


Lessons were learned from this flight and many others. Collaborate with your friendly neighborhood neurosurgeon early and often, by the time March rolled around we had it down to a science. Dr B. had assisted us with the acceptance issues, we had standing medication protocols, CTs were received and reviewed prior to the transport. And, based on data that showed no improvement in outcomes with immediate transport, our goal for transporting patients changed from as soon as possible to a goal of having them on the OR table in Balad within 4 hours.


The system issues outside the medical protocols, treatment modalities, and local training were more difficult change. We realized the MEDEVAC system and flight medics needed our help. The system and training was great for field trauma and stabilization. But in cases like those above, something more was needed. An organized transport team and all the equipment and support that come with it were needed to successfully transport this patient population. Predeployment training and planning issues were also identified and communicated through the command and training chains. These messages were not always well communicated or received, but change in any system is usually painful and slower than clinicians would like. All in all, this was a clinically challenging, and rewarding experience. "No shit there I was in Baghdad[horizontal ellipsis]"