Saturday, June 12, 2004

Galen's Log recently had an excellent post about the practice of medicine in Iraq. Sounds as if the equipment we take for granted is at a premium:

The plastic laryngoscopes are bad. The blades repeatedly fall off the handle while in the patient's mouth. We are trying to order a good old fashion metal set. I have a set that I acquired from a previous deployment. I won't be leaving that behind. Also, the plastic sets have only one 4MAC and one 4Miller, no peds sizes.

Angiocaths are another hot item, not those "ProtectIVs" that we use in the hospital. We use those to start subclavian lines, then use a RIC Kit to convert it to a 7FR line. We have acquired/borrowed some.....

Individuals who do not know how to effectively use ultrasound are going to lack a diagnostic tool. John and I have ultrasounded over 100 casualties in less than 3 months. The surgeons with us depend on us to do it.

Xray is very limited. Chest tubes are put in based on clinic exam, not xray. What is a post-intubation xray? Xray after subclavian line placement? Practice patterns change based on the environment. I do not feel we are practicing bad medicine, on the contrary, I am practicing better clinic medicine than I probably ever have. As I told one Internist out here, at Camp Pendleton you can order whatever you want, here you can maybe get a simple CBC and drip your own urines. Then you have to make a decision.

Another take on medical adventures in Iraq can be found in the March 2004 Bulletin of the American College of Surgeons which tells the story of the Forward Surgical Team:

We were actually the first forward surgical team to parachute into combat since World War II......The need for a small, easy-to-insert surgical capability became evident during the U.S.-led invasion of Grenada in 1983. At that time, the smallest Army unit that could perform surgery was a mobile Army surgical hospital (MASH). Because of its large weight and size, the first MASH did not make it into Grenada until four days after the invasion started. This prompted the Army to develop the FST to meet the need for a small, readily deployed surgical team that could perform resuscitative trauma surgical procedures on U.S. soldiers from the moment the fighting began. By 1986, Army surgical squads were organized and actually jumped in with U.S. paratroops during the invasion of Panama in 1989. These small squads had to wait for aircraft to land before they could access their operating tables, anesthesia machines, and other heavy equipment. The U.S. Army fielded the first airborne FSTs in the early 1990s. These units had the advantage of being able to parachute their heavy operating room tents, generators, and equipment into the combat zone ahead of the paratroopers on parachute-rigged Humvees. This system ensured that wounded GIs would have immediate access to lifesaving trauma resuscitation within the “golden hour” from the moment the fighting started. The FST also enabled U.S. casualties to survive long-distance air transport back to larger hospitals located in Germany and in the continental U.S. Each FST in Operation Iraqi Freedom consisted of 20 personnel: four surgeons, five nurses, a medical operations officer, and 10 enlisted medics who specialize not only in trauma surgical procedures but also in the pre- and postoperative care of combat casualties. All surgeons and nurses were board-certified in their respective specialties and used state-of-the-art equipment and techniques to provide the best trauma care to U.S. troops who happened to be injured in the line of duty. "By far, the most useful item was the Sonosite portable ultrasound," says Dr. Rush. "The FAST exam was very useful as a triage tool, as the injured paratroopers we work on have tremendous physiologic reserve. This diminishes the reliability of routine vital signs in making triage decisions. We also used the Sonosite to screen for traumatic pseudoaneurysms, assess the adequacy of vascular repairs, and eventually even assess congenital heart defects in young Iraqi children."

A friend of mine who finished a few years behind me is currently serving as a navy surgeon in a far outpost of the realm. They have no neurosurgeons or thoracic surgeons. The personel there told him to do as many thoractomies and craniotomies as he could so he would be prepared. He has done about four of each in trauma patients since he has been there. He likes it, but probably not enough to re-enlist.
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