This Is Just What We Do

SSG Penn, LTC Bruce, MAJ Baier prepare for patients to arrive

 I find it challenging to put a post together about casualty care. There are plenty of reasons that make it difficult. First, I must respect the privacy of the soldiers (I take careful note not to identify patients.). Second, I need to maintain a level of operational security (I make sure that the stories are generalized and don't include numbers of patients, timing of incident, nor specifics of injuries). Finally, I simply find this part more personal and its just something that we're here to do. However, I appreciate the fact that you folks at home may find this part of my mission the most interesting.

We usually get plenty of warning prior to receiving patients at FOB Shank (At Orgun-E many patients just spontaneously show up at the gate, thus there is no warning). At Shank we have time not only get the team prepared, but it also gives us personal time to get mentally prepared.

LTC Aldridge reveals his slama-jama skills

 LTC Aldridge has his own unique methods of mental preparation. In all seriousness, the mood is generally calm and light prior to patient arrival. By the time a patient rolls into the doors, the team simply begins to do the job they have been well trained to perform.

FST Fluid Warming Technique

We function in an austere environment with only just what we need. It is cold in Afghanistan at this time, and IV fluids must be warmed. Since a fluid warmer is not part of our equipment list, we make due with what we have. So we put IV fluids in the heating ducts. It works well.

LTC Bruce and LTC Hoeppner with patient

We have had patients in this resuscitation area with two teams working, and outside the doors people thought our FST was empty, simply because there was no noise, no shouting, no chaos (past the well known "controlled chaos" of any trauma). The team just performs. Everyone knows their job and just does it. 

Patients in ICU with unit representatives and chaplain present to comfort them prior to evacuation

When the dust settles, we have some time to think and sift through documenting the details of what just occurred. The Army  does a great job of keeping track of their people and allocating resources from the soldier's unit to provide personal care. The chaplain and his/her people are also on 24 hour call, ready to provide a helping hand. Many of our patients are awake and alert after this process, and are able to call home immediately to talk to their family personally (before the family member gets a call from the Army). This is a great benefit to the family, as they don't have to wait in fear, wondering about the condition of their soldier.

Pararescue MH60A Black Hawk arrives with PJ's

 On this day, the soldiers were evacuated by PJ's (AKA Pararescue Jumpers). This is not typical, as the PJ's are not the typical Medevac unit (I will post something for them later). The PJ's are airforce special operations medics. They are a special breed with intense training, not only medical, but in all aspects of special ops warfare.

PJ's lead the way to helicopter

Their mission is typically geared toward rescuing downed pilots or any soldier behind enemy lines. This war is  uniquely challenging for the PJ mission, as there are no enemy lines. Everything outside a FOB is essentially dangerous territory.  I was going to write a bit more about the PJ's, but I think Michael Yon has already done it better than I could. He wrote about the Pedro's in his Online Magazine.

Charlie Med team moves patient to awaiting helicopter

We are fortunate to have a Charlie Med team co-located with us at the FST. They provide invaluable service to the soldiers and to us. They not only get the soldiers to us and evacuate them from the FST, but they also perform all the radiology and lab services, along with any long-term patient nursing care and other sundry functions. They are superb.

First PJ helicopter leaves the HLZ with patient(s)

909th FST begins After Action Review (AAR)

The job doesn't just end when the patients leave. We are committed to improving with every new experience, thus the team sits down and discusses what we did well, and what we could have done better.

909th FST performs after action review

We don't know if we will see a patient today or tomorrow. Its kind of like being a firefighter. We spend the day hoping no-one gets hurt, but if they do, we hope that they call us. This is just what we do.

Snow Day Images

Soldiers taking a break while keeping an eye on local national workers

I had been waiting for a day with good lighting and blue skies. Most days have been filled with inclement weather or just lacked a good blue sky. This day was almost perfect, save for a lingering haze. So I set out with my Nikon and started to shoot.

Village outside FOB Shank, Logar Province, Afghanistan

I have no idea what the names of the villages are outside the FOB. At present time I have no interaction with villagers outside the FOB. Hopefully, this will change in the near future.

Village outside FOB Shank, Logar Province, Afghanistan

The counterinsurgency operations demand that we engage these people and forge long lasting secure relationships. Obviously this is extraordinarily challenging given that Afghanistan remains very dangerous for any coalition force. Thus, our soldiers move through these areas in full body armor, looking rather ominous. At some point the interaction between our forces and the locals will require that we show some level of trust with a more approachable appearance that allows for easier personal interactions.

FOB Shank, Logar Province, Afghanistan

105mm Howitzers

UH60 Black Hawk landing

UH60 Black Hawk landing

Black Hawks, Chinooks, Apaches along with a number of non-military helicopters land and take-off from this FOB all day and sometimes into the evening. It remains the only means of travel to and from FOB Shank.

Guard Tower

To get many of these photos required me to gain some elevation. The guards were kind enough to allow me to use their vantage point.

Afghanistan National Security Forces (ANSF)

I suspect the guards were a bit bewildered by my desire to take their picture. They did not know English, and I certainly couldn't speak Pashto or Dari.

View From Guard Tower

The tower had evidence of some previous hostility. These bullet holes could have been there for more than a year.

Christmas tree planted outside one of the tents by the previous FST (8th FST)

The snow has melted since these photos. Currently its raining and warming up slightly. It remains cold at night and in the morning, but by afternoon its quite comfortable. Maybe this tree will survive in this rocky soil. But it will need help.

Don't Give Me Any Flak, Jack

PASGT "Flak" Jackets worn by 909th FST members - OEF, FOB Salerno 2003

There is significant controversy swirling around any gear fielded by the US military and body armor is no exception. There are numerous stories of public concern that our government isn't doing enough to protect our soldiers. These concerns have validity in some respect. I believe that it is a good thing that concerned citizens put pressure on our government to do better. This has likely helped to ensure that we have a better equipped military than when I first served over 25 years ago. However, I also believe that our military is doing a much better job at getting supplies and equipment to our troops faster and better than ever.

During the 1980's the latest technology for the soldier was the Personal Armor System for Ground Troops (PASGT) vest pictured above and the PASGT helmet AKA "K-Pot" (I only wore the old "steel pot"). This system was the first time the military fielded Kevlar protection for its soldiers. However, the vest and the helmet were only good enough to stop relatively slow projectiles, such as shrapnel.

 LTC Bruce wearing IBA

By 2003 the PASGT equipment was phased out (although was still seen throughout Iraq and Afghanistan) and Interceptor Body Armor (IBA) was now the frontline issued equipment. This was a significant advance in protection. IBA combined with ceramic plate inserts provides protection against direct fire from weapons with calibers up to 7.62mm (a standard enemy assault rifle caliber). Even still, there were numerous reported problems with this armor. Not withstanding the weight (over 35 lbs with the side plates and all components), there were reports of the armor not being able to stop the caliber rounds for which it was rated.

 

Improved Outer Tactical Vest (IOTV)

Amidst the controversy surrounding IBA, the Army moved forward to field the Improved Outer Tactical Vest (IOTV). This vest is definitely a significant improvement over the IBA. Not only does it weigh less, but it distributes the weight much better than IBA, thus making it much more comfortable to wear. This may sound like a small deal, but I can tell you from personal experience that wearing IBA for short periods of time was painful. IOTV, on the other hand, is easy to wear through the day without significant discomfort. For the combat soldier it means something even greater. The average load of the combat soldier is 60 lbs and can double for long periods out in the field. Shaving the weight off of any gear is a top priority and soldiers are already beginning to experience the benefits of this push.

  

The IOTV Quick Release System

Another important added feature is the quick release system. In times of emergency (such as need for lifesaving medical care), the armor can be quickly shed into its component parts by pulling a single release tab located in the front of the vest. Prior to this, the only way to remove the vest for medical emergencies was to cut the vest off.

I should point out here that the US military has been able to research, purchase and field hundreds of thousands of units of body armor in a very short period of time. There has been rapid transition from PASGT to IBA and from IBA to IOTV in only 6 years. Currently we are in "Generation II" of the IOTV body armor with continued research activity underway for better, lighter weight armor in the near future.

Soldiers of the 173rd Airborne BCT with IOTV prepare for mission in Logar Province, Afghanistan

Mass Transit - Army Style

 

 MAJ Sucher prior to CH47 flight to Orgun-E

In Afghanistan, the safest way to travel is by helicopter. When doing so, you "suit up" into your "battle rattle" and wait for the bus to arrive (I plan to write an article about the body armor soon).

  

 The "Bus" passengers on the "Green Ring"

Our "bus" is the venerable CH-47 Chinook. This airframe has been in service since 1962. Originally designed by Boeing Vertol to replace the CH-37 Mojave, it has continued to serve in every theater of war since Vietnam. It is the fastest helicopter in the US Army (at least compared to the UH60 and AH64). In the picture you can see that there are many differing types of passengers along this route.

  

 Flying south from FOB Altimur

The M240 7.62mm machine gun is mounted on the rear door and the two forward side doors. Thus far I have not seen them fired. I am told they often test fire the weapons at the start of each day.

  

 Refuel stop at FOB Sharana

When we got to FOB Sharana it was time for refueling and stretching of the legs.

  

 Flying to Orgun-E from Sharana

When we lifted off, there was quite a change of scenery. Massive ravines gashed through the open terrain. Moving through this terrain by ground would seem to be a miserable adventure. It is obvious why the Grand British Army of 1838 required 30,000 camels to mount a campaign into Afghanistan (losing many of them along the way). Not to mention why the Russians of the same period lost nearly all their 5,000 camels trying to move through the terrain in the north.

  

 Flying to Orgun-E from Sharana

 These small enclaves pop up seemingly out of nowhere. They are in valleys, up mountain sides and along the barren plains. The villagers literally walk miles to get water. How they subsist remains a mystery to me.

  

 Some actual trees!

As we entered the Paktika province, I began to see trees. Prior to this flight I have not seen any evidence of trees. Wood is hard to come by in Afghanistan.

  

 More trees!

  

 Village near Orgun-E Paktika Province, Afghanistan

Nearing FOB Orgun-E more modern villages begin to appear. There is obvious evidence of farming as well as some modern buildings that would appear to be consistent with industry.

 

Village near Orgun-E Paktika Province, Afghanistan

 

 FOB Orgun-E Wall of Heroes

 I arrived at FOB Orgun-E sometime around 1PM. I was a bit tired and hungry. But as I stepped off the flight line, it was impossible to notice the "Wall of Heroes". The unit crests of all prior divisions and Brigade Combat Teams appear overhead. Below are the names of fallen warriors. They are all remembered here.

Are We Engaged?

Charlie Med team prepared to receive Medevac patients

Combat soldiers are challenged by the limitations of their "Rules of Engagement" (ROE). So too are the medical providers with our Medical-ROE (MROE). In a country like Afghanistan, our military fields the highest level of care available. However, our services would be quickly overwhelmed without clear MROE. MROE comes as a double-edged sword. It protects our services from becoming overwhelmed, but it puts the providers of care under significant duress by creating situations whereby the clinicians must deny our services to those that need it.

MAJ Baier and LTC Aldridge leading ATLS team assessing patient

All coalition forces are treated no matter the circumstance. Afghan National Army (ANA) and Afghan National Police (ANP) are provided emergency and further acute care service when injured in the line of duty. The Afghanistan government and their local hospitals will provide care for their soldiers whenever possible. All enemy combatants and any civilians are also provided medical care if injured or wounded due to combat actions associated with coalition forces. We make no distinction of enemy vs coalition forces when it comes to emergency care. Those in most emergent need, get the care first.

LTC Hoepnner preparing patient for anesthesia induction

The true challenge comes when local nationals need emergent care that is not related to coalition action. Such is an everyday need throughout this country. The citizens present with pneumonia, malaria, tape worms, lice, farming injuries, broken bones, animal bite wounds, cancer of all types, hernias, bowel obstruction, pregnancy and congenital birth defects. Many of these medical issues are well within the scope of the expertise that we have. However, we must turn most of these people away.

MAJ Sucher completing an operation from a blast injury

While we have the emergent care ability to treat many of these people, we lack the ability to treat them for any prolonged period of time. We have acute care beds that can hold patients for some short period of time, but they would be immediately overwhelmed by the local population. Additionally, if we took on the care of all the local population, then the local government would have no impetus, nor ability to learn how to provide care for themselves. Therefore, we must make the hard choice each day to turn people away from our gates towards their local healthcare system. There are exceptions to the rule. These exceptions are based on many variables, which include the locality and circumstances surrounding the need. Therefore, whenever possible, we render care to those who need it.

CPT Timms returns from a Village Medical Operation (VMOP)

In our particular area it remains dangerous to provide care "outside the wire". It takes an enormous amount of resources to render any kind of medical care outside the FOB.  Medical care in this austere environment is very basic and very hard to deliver without proper security. Our Charlie Med recently visited a remote village (remote in this context is extremely remote) which required 2 CH47s to deliver the medical assets and provide security (most was security). Notice that CPT Timms was required to go as well armed as any other combat soldier. This village hadn't seen any foreigners since the Soviets had left (1989). Our forces simply stumbled upon the village. Contact was made and our higher command made the humanitarian decision to provide some basic medical care. The health of the village was very poor by any standards. CPT Timms saw 55 women personally. At some point it became clear that everyone needed about the same thing.. Tylenol for the aches and pains, antimicrobials for the lice and tapeworms and vitamins for the severe malnutrition. While CPT Timms felt medically unsatisfied (because there was little that she felt she could do), she did at least feel personally gratified that she did the best she could do for the people in need. So there it is. We satisfy ourselves with the little things that we have control over. We engage whenever possible. For our mission is to render the best medical care possible.

Some Days Start Out With A Bang But Go Out With A Winter

Crew preparing 105mm Howitzer

FOB Shank is home to varying troops of all types (not just medical). Here, we came upon the artillery folks preparing to ensure their systems were appropriately calibrated. They continually train and remain constantly prepared for any mission. On this day, we spent just a little time with the men as they explained to us the specifics of their weaponry and ammunition. But, as they began to fire, the weather began to move in. Before we new it, the temperature dropped significantly. It was time for us to move on (The artillery men remained and completed their mission).

Tom Baier getting his "high and tight" at one of the local barber shops.

Tom and I walked for a while and found one of the well-liked barber shops. Each has their own reputation. This particular one is rather nice. It is staffed by all women that we believe to be Uzbekistanian. As we left the barber shop the snow had begun to fall in earnest.

The "Surgical Associates" tent.

We quickly walked to the tent which houses our partners. The wind was blowing and the snow was falling (along with the temperature).

But it was nice to see the Army flag unfurled and waving in the wind as the sun went down.

Graphics courtesy of Sam "Mo-Flo" Aldridge (Vascular Surgeon Extraordinaire)

The snowflakes were big and soft... immediately sticking to the ground.

Within 15 minutes we had some decent accumulation.

Within an hour we probably had an inch... and it was sticking to anything; stationary or otherwise.

FOB Shank, Logar Province, Afghanistan following snowfall overnight

The snow fell through until the late evening, finally subsiding. I don't know what the final low temperature was... but I can tell you it was rather darn cold. But, as usually is the case here... after a good snow, the next day is followed by bright blue skies. Despite the still chilly temperatures and cold wind the snow began to melt away just as quickly as it had dropped.

A day so easily forgotten. There are many like it... some interrupted with work for us to do. But still important in its own little way. I may leave you wondering if we do anything within the assigned task that we have been asked to perform.... and why haven't I written about such things. The simple truth is that writing about casualties will eventually be recorded here... and when I do write about such things, it will be with complete professionalism; preserving the privacy and honor of those whom may appear here. Additionally, I will do my best to ensure that anything posted here will be for educational purposes, or at least for purposes of learning some lesson.