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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000394295.63201.66
Feature Articles

Letters from Afghanistan: Daily Life and 'Dirty' Work

Vanfosson, Christopher A. MSN, MHA, RN

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Author Information

Christopher A. Vanfosson is a major in the U.S. Army Nurse Corps and chief nurse of the 541st Forward Surgical Team (Airborne) in Pul-e-Khumri, Afghanistan. Contact author: The opinions expressed are the author's and do not represent the positions and policies of the 30th and 62nd Medical Brigades, the U.S. Army, or the federal government.

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Editor's note: AJN asked army nurse Christopher A. Vanfosson to file periodic reports on his and his team's work in Afghanistan. This is the third article in this series.

My colleagues on the U.S. Army's 541st Forward Surgical Team (Airborne) and I have established a surgical capability in a region of Pul-e-Khumri in which no permanent medical facility previously existed. We work not on the battlefield but in the Hungarian Provincial Reconstruction Team's compound, along with groups of international soldiers and civilian contractors. Our facilities include many hardened buildings and containerized shelters as well as my team's work and living areas—six tents of various sizes set around a cement courtyard slightly larger than a tennis court. We have electricity and even air conditioning when our generators are operational.

We've acclimatized to the weather here in northern Afghanistan's Baghlan Province, where the temperature reaches 120°F (48.89°C) in August and typically falls into the 30s in winter. The cold weather is our biggest concern, even though the winters here aren't as harsh as in higher elevations (we're at about 2,100 feet, whereas other bases are at 8,500 feet or higher). The cold can be lethal to our patients, whose severe traumatic injuries make them more vulnerable to the combination of hypothermia, acidosis, and coagulopathy known in trauma care as the "triad of death."

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For security reasons, I can't discuss the number of patients we've cared for; however, I can say that so far our clinical responsibilities haven't been overwhelming. When we do see critically injured patients, we provide the necessary care before transferring them to a larger NATO hospital where, ultimately, they'll be evacuated to Landstuhl Regional Medical Center in Germany.

We're performing life- and limb-saving surgery and have the supplies and staff to do only these procedures. Our work is considered "dirty"—it's an unsterile and dusty environment—and our patients receive definitive care only after they've been evacuated to larger medical facilities, where they'll have their wounds redressed and debrided again and undergo computed tomographic (CT) scans to ensure that no serious injuries have been missed. Follow-up procedures may also need to be performed; a bowel that's externalized, for example, must be reassessed and eventually reattached. Moreover, other medical specialties and support services (occupational, physical, and nutritional therapy, for example) are only available at larger medical facilities.

At times, the low patient volume frustrates my team members and me. Surgeons like to do surgery. Nurses like to do patient care. The younger members of my team want to gain clinical experience. Yet, of course, no one wants to see soldiers get hurt.

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We keep busy by conducting mock exercises and familiarizing ourselves with the military's various policies and procedures, including the Department of Defense's Joint Theater Trauma Registry's clinical practice guidelines, which are based on recent military combat and trauma care experiences. These provide guidance, for example, on when we should use fresh whole blood for transfusions—an uncommon practice in the United States but often necessary in a combat zone. Although we have access to packed red blood cells and plasma, fresh whole blood is a better option for patients who require massive transfusions (more than 10 units of plasma or red blood cells). Fresh blood can help warm hypothermic patients, normalize the acidity of their blood, and improve clotting.

Being on a forward surgical team allows each of us the opportunity to cross-train and to obtain experience from our colleagues. I've taught the LPNs and medics, for example, how to reconstitute medications—a simple but essential skill—because I'm not always available to do it and this knowledge will assist them in their careers. In addition, our operating room technician typically wouldn't have the opportunity to start and manage IV catheters, but we've taught her how to do so.

Figure. Inside the 5...
Figure. Inside the 5...
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Almost all of our work in Afghanistan has gone according to our training, but we've had to make small changes based on the evacuation crew that picks up our patients. We learned to keep a stash of German litters (stretchers) on hand, because the American litters don't fit on German aircraft. And the Germans must exchange most of our other equipment for their own before taking off, unlike American crews who simply give us the equipment they've brought and take ours, which are attached to the patients. The Germans also have specific protocols that must be followed with certain patients; those with unstable head injuries, for instance, must travel with arterial lines in place.

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This deployment is a new experience for me but not the first time I've been in a war zone. I was in Iraq in 2003, during the initial invasion, working at the 28th Combat Support Hospital, which quickly became the Level 1 trauma center for the entire country. As a medical–surgical nurse (later working in critical care), I cared for patients who'd already been resuscitated by a forward surgical team. They were recovering from orthopedic surgeries or minor abdominal injuries, for example, or had medical issues: pneumonia, allergic reactions, abdominal pain, nonsurgical infections. Many of these patients (both Americans and Iraqis) stayed with us until they were better, which was usually a few days to a few weeks.

In Pul-e-Khumri, by contrast, my colleagues and I represent the first surgical capability available to patients, and our actions can be life saving. One recent evening, a Humvee drove onto the compound unannounced. Lying across the hood was an American soldier who'd suffered severe injuries to his face. His fellow soldiers knew we were nearby, so they'd put him on the hood, with a medic beside him, and drove toward our compound, arriving within minutes. Only a couple of our team members were there when they pulled up. Most were in the compound's gym; another was in the shower. When I saw the Humvee, I instructed a contractor who was nearby to alert my colleagues. A few of us began the primary survey, as we'd practiced so many times, rapidly assessing the patient's life-threatening injuries.

Within minutes our entire team was present and we moved the patient into the operating room, working frantically to secure his airway and stop the bleeding. The nurse anesthetist inserted an endotracheal tube orally, using direct laryngoscopy. This was relatively easy, because the oropharynx was wide open due to the patient's injury, but it was also difficult, because the airway was cluttered with blood and misplaced tissue. Once the airway was secured, we worked to ensure that all bleeding had stopped and to salvage any facial vasculature. We also cleaned his wounds. Because of the mechanism of the injury and its location on his body, we had to consider that he might have a traumatic brain injury. We put him in a cervical collar, elevated his head as best we could, and monitored for signs of increasing intracranial pressure (namely, posturing and changes in his pupil responses).

Just a few hours after the injured soldier's arrival, we had stabilized him and he was evacuated by helicopter to a large combat support hospital. There he'd undergo a CT scan to screen for traumatic brain injury and have his airway assessed to ensure that it was still adequately maintained. However, little more would be done for him, assuming he had no neurosurgical concerns, before he returned to the United States for plastic surgery.

This patient's fellow soldiers recently told us that he's alive today because of our efforts to resuscitate him and protect his tenuous airway. I'm humbled by the knowledge that because of my team's work, one soldier made it home to his family.

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An unexpected and rewarding aspect of our mission has been the time we've spent with our international colleagues on the compound. They usually visit us in our tents—we're always on call and don't wander too far, even on this small compound—where we watch many "famous American movies," as one Hungarian physician refers to them. We've introduced our colleagues to card games like spades and euchre. By far the most popular game, however, is dominoes, which we try to play at least once a week. In turn, the Hungarians are teaching us to play soccer, and three of us—a surgeon, an operating room technician, and I—are learning to play "foot-tennis," a hybrid of soccer and tennis. We've also asked our international colleagues to teach us about the culture and history of each nation represented at our camp.

Soon after our arrival, a Swedish medical team stayed at the compound for 10 days to support a maneuver in the area. The five-person team consisted of one surgeon, two anesthesia providers (a nurse and a physician), an operating room nurse, and a critical care nurse. They received their first patient—an Afghan soldier who'd had a traumatic amputation of his right arm—while staying with us. Until then, they'd only trained for such a situation. This was the first time they worked together as a team.

Figure. Major Vanfos...
Figure. Major Vanfos...
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Their presence was a learning experience for all of us, as we took turns treating patients and observing each other's work, offering constructive criticism. Interestingly, though our Swedish colleagues were experienced clinicians, they were always deferential to us and valued our input. This may have been because they were civilian contractors (not members of the military, as we are) or because they'd previously had little formal trauma training as a group. When they left, they gave us a wonderful parting gift—their national flag, signed by all members of the team.

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I miss my wife, Kelly, and our four children dearly since leaving the United States for Afghanistan. I receive e-mails from Kelly, who's also an RN, almost daily, and talk with my children on the phone every Saturday before they go to their swimming lessons. But, in the past couple of months, I've missed my eldest son's first communion, countless swimming firsts, school events, and so much more.

Of all the sacrifices I've made for my country, my family has made more for me. I love them all so much and can never repay them for allowing me to do the job I love.

© 2011 Lippincott Williams & Wilkins, Inc.