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Emergency Medicine News:
doi: 10.1097/01.EEM.0000442777.75078.a3
Breaking News

Breaking News: The Arm

Dauphin, Marc MD

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Dr. Dauphin, now retired, was a Canadian emergency physician and a reservist for 27 years before being recalled at age 54 to serve in Afghanistan. He and his international staff maintained a 97 percent survival rate, a record for all wars. Combat Doctor, Life and Death Stories from Kandahar's Military Hospital, from which this excerpt is published, recounts his experiences overseas and his personal struggle with PTSD upon his return home. Combat Doctor was published by Dundrun Press (2013) and is available from Amazon.

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It was a balmy 95° evening; the boy was one breath away from death. We gazed down at his tortured little body. He couldn't have been more than 11. We couldn't understand how he had managed to survive up to now. He had already been operated on in Mirwaïs, Kandahar's main civilian hospital. While there, the surgeons had tried to reattach his left arm, which had been almost severed just below the shoulder. The wounds had been badly closed, and now the raw, dried, rotting flesh under the skin was exposed. The external fixator had been clumsily installed. I didn't need to check the pulse in the arm: there wouldn't be one. The swollen, blackened flesh below the wound was just a jumble of dead cells. That the surgeons had failed to save the arm was obvious. Except to the boy's father, who kept pleading with us to save it.

With more than 30 years' experience with maimed and torn bodies, I had never seen a totally black limb. Frostbitten, dead toes, yes. But a whole arm? This was not gaseous gangrene, the infection that kills in a few hours. This was “dry” gangrene, the black, drying, mummifying transformation of cells into parchment. The boy didn't have an IV. He was dehydrated and unconscious, and he was dying fast.

As I contemplated the boy's situation, I marvelled at the resilience of the human body. But resilience, no matter how strong, is no match for death, the ultimate winner. Everybody — there were perhaps a dozen of us around the stretcher — was standing motionless, waiting for my decision: to accept treating the boy or to send him on to an Afghan institution. Our hospital was full and, as an officer focused on caring for our soldiers, I was thinking that I should probably send the boy away. Our mission was to treat the sick and injured soldiers of the NATO coalition.

We could also care for Afghan civilians injured as a direct result of the war. Then, only if we had the space and the resources, we could care for other civilians as a goodwill gesture. With our advanced technology and super-competent, can-do, resourceful specialists, we could perform what to the Afghan people looked like miracles.

But saving this boy's arm was beyond even the most advanced medicine in the world. Besides, we had to prepare for more wounded soldiers in the hours to come; we knew a large operation would begin during the night. But his father kept pleading with me. He thought we were still “negotiating” to save his son's arm. In my mind, we were deciding — I was deciding — whether to try to save the boy's life.

That there was no pleading from my people to try to influence my decision was a tribute to how far we had come from being those well-meaning but unknowing do-gooders who had arrived in country only a few months earlier. My staff at the Kandahar Role 3 Multinational Medical Unit was by then a disciplined, tough, if somewhat ragtag bunch of professionals who were now among the best in the world. If anyone could save this kid, they could. We could.

Pondering, I pursed my lips and looked at my people. Standing behind them, ensuring she was as unobtrusive as possible, my Commanding Officer, Canadian Col. Danielle Savard, was waiting for my decision. I knew she would back me up, no matter how hard or inhuman my decision might seem. But she could also tell, by my hesitation, that I was leaning toward taking him. When I turned a patient away, the decision usually came fast, loud, and clear.

In my head, I was trying to figure out how much of a hill the boy had to climb to get back to health and what the drain would be on our hospital. Were his kidneys shot from the dehydration and the massive amount of toxins generated by the dying muscle cells? If so, his care would be complex and our resources were finite. Did he have other injuries that we didn't know about? That would complicate his care. What if a dozen injured soldiers arrived while we were immersed in trying to save the boy?

This hesitation probably lasted less than two minutes, while the staff stood motionless at the stretcher's side. If any one of us were to lay a hand on the boy, he would be in our care for keeps. While I was thinking, I tried to explain to the father that we were talking about saving his son's life, not his arm, which was hopelessly too far gone. I tried to prepare the man for the possibility that we would turn him and his son away. But a father's love does not lend itself to reasoning, especially through an interpreter, and I realized I was wasting my time.

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At that moment, my eyes met Colonel Savard's, and she immediately read my unspoken question. Her response was the very briefest, discreet nod, which meant, “What the hell, Marc? In for a penny!”

Greatly relieved, I sighed and turned to the interpreter. “All right, tell the father that we are going to try to save his son's life. But the arm has to come off right away. It's killing him. We need his okay to do this.”

The staff sprang to life, plugging in the monitor, putting up an IV, drawing blood, installing an oxygen mask, inserting a urinary catheter, asking for x-rays, calling the OR team in. I stepped back to give them room to work. That's when the father grabbed my sleeve and said something.

“He says he's willing to give his son his arm if you want to transplant it.”

That just about did me in. Speechless, I could only bite my lip and pat the father on the shoulder as I shook my head.

I turned to the interpreter.

“Please tell him that we're not that good.”

Wolters Kluwer Health | Lippincott Williams & Wilkins

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