More amputations at Bastion Hospital as trauma surgeons fight to keep troops alive

CAMP BASTION, Afghanistan — Flags for the international fighting force were flying at half-staff outside the military trauma hospital the morning of our visit, in remembrance of the latest troops killed in the war.

A wounded British soldier is comforted by the grip of a fellow soldier at the Bastion Hospital in Helmand province, Afghanistan. Photo by Nelvin C. Cepeda

Some die here on the operating tables, despite the best efforts of British and American surgeons. Others succumb to their injuries before arrival. What surprised me, given the horrendous wounds inflicted in combat, is that so many sent to Bastion hospital live.

Quantum leaps in battlefield medicine made during a decade at war have contributed to a more than 90 percent survival rate at the British-run facility, which includes a rotation of U.S. Navy doctors among its international staff. The hospital is on the British base in Helmand province adjoining Camp Leatherneck — headquarters for 20,000 U.S. Marines who make up the bulk of the NATO coalition in southwestern Afghanistan.

Many Camp Pendleton Marines have gotten their last look at Helmand from Bastion hospital, which is the busiest trauma hospital in Afghanistan.

Union-Tribune photographer Nelvin C. Cepeda and I spent the final reporting day of our recent six-week trip to Afghanistan at Bastion hospital. Warm spring weather had ushered in another fighting season, and a dust storm the day before gave insurgents cover to hide homemade bombs.

It turned out to be the hospital’s busiest day in months.

First thing that morning, medical evacuation helicopters flew in four Afghan policemen ripped apart by gunshot wounds, then a British soldier with his leg shredded by a grenade blast.

Wave after wave of patients arrived after that. By the afternoon, their scrubs were soaked in sweat and the night shift nurses had been rousted from bed to help. A Navy doctor dozed off sitting against the wall, stealing a few winks until the thump of rotors or the shout of “five minutes!” signaled the next helicopter load of patients.

I don’t know how the Bastion staff find the stamina to maintain their concentration and composure amid this daily onslaught of gravely wounded men, women and children.

U.S. Navy Cmdr. Angela Earley, who finished her general surgery training in 2002 at San Diego Naval Medical Center, took over in October as officer in charge of a new American team at Bastion. The portly Afghan officer she operated on that morning was lucky.

One bullet shot into his belly and exited without penetrating his guts, while another exploded out the side of his leg. Such girth is “unusual for an Afghan,” Earley said. She cauterized the wound to stop the bleeding, sending a contrail of smoke and the smell of burning flesh wafting toward her huge blue eyes. “It probably saved his life.”

Dr. Mansoor Khan, a British medical resident who helped treat the policeman, said “The trauma you see here is unlike trauma anywhere else. If a military-grade bullet hits bone, it blasts out the other side, destroying everything around it.”

On the neighboring operating table, the British soldier’s mangled leg appeared to my untrained eye to be unsalvageable. Three orthopedic surgeons worked on the leg while a plastic surgeon reconstructed his hand and a clutch of nurses and technicians orbited the periphery.

The commanding officer of the hospital, British Army Col. Mark Pemberton, watched over the controlled chaos of his staff rushing to and fro, the blood sloshing on the floor, the sweet smell of plasma and disinfectants, and the hushed voices under fluorescent lights. “Each day is a herculean effort — impossible injuries, impossible conditions, and yet remarkable results,” he said.

Many of these patients would have died in earlier conflicts, before improvements in body armor, evacuation procedures and combat medicine.

Today, life-saving treatments begin instantly on the front lines. Each Marine carries four tourniquets and knows how to use them. Navy hospital corpsmen, medevac flight personnel and forward surgical teams at battalion aid stations all help resuscitate patients, so that breathing is restored and blood loss stops as soon as possible within the “golden hour” of effective trauma care.

As the U.S. military was ramping up in Afghanistan two years ago, Defense Secretary Robert Gates promised troops stationed there that medical providers would be pushed closer to the point of injury so they could administer critical care within an hour, as they were in Iraq.

Today Pentagon officials say that “golden hour” standard has been achieved in Afghanistan, where patients are transported to advanced stateside military hospitals in as little as three days, versus a month or more on average during the Vietnam War.

At Bastion, fresher blood products administered in a one-to-one ratio to replace lost blood reduce the risk of lung problems associated with using saline. Two powerful 64-slice CT scanners produce three-dimensional images of the organs, bones and vascular system, helping doctors pinpoint the most severe injuries rapidly.

Earley and her American team began their deployment at Bastion in October the same month that Camp Pendleton’s 3rd Battalion, 5th Marine Regiment took command in Sangin, an intensely violent area of Helmand province.

They performed about 60 leg amputations and more than a dozen to the arm, hand or groin in October. “We had trial by fire very quickly,” Earley recalled. “We had to step it up … to get over the shell shock of what we were seeing and try to save these guys’ lives.”

Earley worked in Iraq in 2007 treating Marines, when it wasn’t as common for those with double or triple limb amputations to survive, she said. (Last year, the San Diego Naval Medical Center treated 31 patients who had lost extremities, three times as many as the previous year.)

But the tissue trauma and contamination caused by insurgent bombs in Afghanistan, which result in wounds embedded with mud and bolts used as makeshift shrapnel, is more severe than she encountered in Iraq; and none of the other doctors on the American team had served in either war zone.

For them, the perseverance of the 3/5 Marines despite heavy casualties was heroic inspiration. “It kept us motivated to keep going,” Earley said. “No one should have to lose so many.”

The international medical team was sponging blood off the policeman’s skin when Earley’s beeper sounded with another trauma call. Six more patients were on the way, including several more British soldiers, a U.S. Marine and a child all hit by insurgent bomb blasts.

The Marine rolled off the ambulance had a deep gash in his arm that had been partially stitched. He was keyed up still from the attack, and belligerent. The British soldier Earley evaluated was in a morphine-induced calm. They cut away his blood-soaked uniform and checked for swelling and shrapnel. Afterward, another soldier leaned over the injured trooper, gripping his fist and talking softly to him for a long time.

The exchange was touching, a private moment between two brothers-in-arms that unfolded while the buzz of medical care moved off to more seriously wounded patients.

When staff got word of several injured Afghan civilians who drove over a roadside bomb, they scrambled to form an all female-unit to treat a woman in the group. Last year an Afghan man murdered his wife after she was treated because foreign men touched her, a British nurse said.

They ended up operating on 18 patients that day, for a total of 38 hours of surgery in four operating theatres.

Two killed in action were flown home from “Rose Cottage,” the hospital mortuary, but Bastion medical staff were grateful that the chaplain didn’t have to say a prayer in the operating room that day for a patient who died under their care. “Sometimes I think it’s as much for us as it is for the soul of the person,” Earley said.

Earley and the others kept working past midnight, some until 3 a.m. They amputated the legs of a British soldier that night, and the first trauma alert beeped the next morning at 7:30 a.m. for another double amputation — on an American Marine.

The U.S. medical team at Bastion was fortified during their tour that ended two weeks ago with the knowledge that they saved lives and improved battlefield care each day they served in Afghanistan, when they helped rewrite treatment guidelines.

“It is unfortunate we have to see so many young men getting hurt for this,” Earley said, but as a trauma surgeon, “this is professionally the most rewarding thing I have ever done.”

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