FORT MYERS, FLA. American surgeons who were stationed in Afghanistan during the early phase of the U.S. military operation in 2002 quickly learned to expect the unexpected, according to a presentation at the annual meeting of the Eastern Association for the Surgery of Trauma.
For example, a U.S. Air Force field transfer hospital that was established solely for stabilizing U.S. military personnel had to accommodate local Afghans needing surgical care, which forced surgeons like Dr. Henry J. Schiller to quickly do more with less.
"We were a reserve combat support hospital. We were not outfitted to take care of indigenous personnel," said Dr. Schiller, who is now on the surgery faculty at the Mayo Clinic in Rochester, Minn. Because of the minimal health care structure in that country, however, "we ended up taking care of everyone," he said.
Surgical management of injuries from land mine explosions was not what surgeons initially expected, either. "We dealt with a lot of kids who stepped on a land mine. The foot that steps on the land mine often gets blown off," Dr. Schiller said at the meeting, which was jointly sponsored by Wake Forest University.
Surgeons soon learned that although most entry point wounds were small and rather innocent looking, they often masked a great deal of debris. X-rays were of limited value because most debris was not metallic.
"The force of the explosion blows grass, dirt, and other debris up into the leg, so there is a large level of contamination. The contralateral limb would be affected as well," Dr. Schiller explained.
"Battlefields are very contaminated places," said Dr. Donald Jenkins, a U.S. Air Force colonel and trauma medical director at Lackland Air Force Base, Texas, in a separate presentation at the meeting.
In some cases, infection already is disseminated when a patient arrives. "In Afghanistan, there can be hours or days before they present, versus the typical 30 minutes in Iraq."
Initial surgical management consisted of limited debridement and wound closure, but many patients developed infections from the extensive contamination. Experience taught the surgeons to make linear extensions to expand the wounds for debridement, to debride frequently, and to leave wounds open whenever possible.
For example, one Afghani man presented as acidotic with a gunshot wound to his groin. His wound was then closed two or three times, Dr. Schiller said. "Finally, we left the wound open and it healed with secondary intention."
"Open wounds are safeit was a difficult question when to close, if to close," Dr. Schiller said. Open wound management was adopted for most land mine injuries. "Circular amputation is pretty common with land mine injuries," he said. "We leave skin and muscle flaps and let it heal by secondary intention." However, it is not foolproof; another land mine patient who seemed to be doing well developed necrotizing fasciitis and ultimately was lost to multiorgan failure.
"We did sharp debridement," Dr. Schiller said. "Even saline was in short supply." Surgeons debrided wounds each day in the operating room, the most sterile area of the hospital, and used analgesia liberally.
In response to a question about antibiotic therapy for these patients, Dr. Schiller said, "We used Bactrim; we had a fairly good supply."
Dr. Jenkins agreed with Dr. Schiller that the reality was different from what he expected. "Our phrase was, 'We knew what it was supposed to be like with blast injuries, but we didn't know what it was like,' "he said. "It would be akin to [people] without kids reading a Dr. Spock book and watching a nephew for a weekend, and saying they know what it's like to be a parent."