"Life in Pain"- A story from the medical front line in Afghanistan

Forward Operating Base Salerno. Afghanistan – (all photos and text by Simon Klingert (c)

“Attention on the FOB, Attention on the FOB, Shamrock Red, Shamrock Red,” a voice calls over the loudspeakers on Forward Operating Base Salerno.

“Shamrock Red” means one patient is inbound for the hospital any minute now. It commands medical personnel to return to their stations immediately.

The trauma bay is a broad corridor lined with medical supply lockers, computers and X-Ray equipment. Four examination tables are lined up diagonally in the corridor, each one with different color markings on the floor, corresponding to the call signs. The staff hurries to their assigned positions, making last minute preparations.

Located on Forward Operating Base Salerno near the city of Khost in Southeast Afghanistan, the 349^th Combat Support Hospital’s (CSH) area of responsibility stretches over six provinces in ISAF's Regional Command – East, with the task is to provide surgical and medical treatment for U.S. and other coalition forces. But treatment is also provided for local Afghan civilians caught in the crossfire. Afghans civilians are often intentionally targeted by insurgents to warn others from working with the Afghan government or coalition forces.

Taking a sharp turn, a military ambulance pulls up swiftly to the hospital’s rear entrance. The face of the paramedic, Sergeant Chuck Farrell, 29, of Laguna Beach, California appears out the rear doors, shouting his initial trauma assessment to the medical staff who run to the ambulance with a gurney.

“Male local national patient, gunshot wound to his back, no feeling in his legs, alert and oriented,” Farrell shouts. As the stretcher is lifted down onto the gurney, the barely covered body of a young bearded Afghan becomes visible, the hot afternoon sunlight reflecting on the white rags that used to be his clothes.

“The first thing I do is to cut their clothes off,” says Sergeant Farrell, “otherwise you cannot do a proper trauma assessment. But it also serves to make sure they [the insurgents] didn't strap a suicide vest onto someone’s body. This way, I make sure they only take me out and not the whole hospital staff," and with a few practiced sweeps, Farrell scans the patient for explosives and he's rushed into the trauma bay within seconds.

The man on the stretcher comes from a local hospital in Khost City. Although his injuries do not seem to be life threatening, vital time has passed. The so called “Golden Hour” is the crucial time according to Colonel Cynthia A. O' Connell, the hospital's commander, that decides if a man's life, limb or eyesight can be saved. This is why the paramedics radio their initial trauma assessments to the hospital while they are still on their way. If too much time has passed, nothing can be done to save a patient. About ten days after this incident, an Afghan National Army soldier bled to death in the CSH operating room, despite the surgeon's frantic attempts to save him. He had been delayed at the local hospital for about an hour.

The stretcher is rushed to a table in the trauma ward. Almost instantly, a team of about a dozen nurses, doctors and surgeons group around the patient. What happens next looks like chaos, with everyone at the table performing a task from almost muscle memory. What is left of the patient’s clothes are cut off, his breathing, pulse, reaction and limbs are checked, infusions are set up and X-Rays are taken.

Meanwhile, down in the corridor, a middle aged Afghan man, the sub-Governor Mohammad Yunus of Jaji Maydan, a district northeast of Khost City, reveals fragments of the patient's story. As it turns out, the patient being wheeled into the CAT room down the hallway is his driver, Bahar Gul, 28, of Khost City. Apparently, Gul was in a car on his way home when he drove straight into an insurgent ambush. Local villagers brought him to a clinic in Khost city, where the sub- Governor was able to get him to the CSH, where he knew better treatment was available.

At the 349^th CSH, 50 to 80 major surgical procedures are performed in the two-bed operating room each month. According to Colonel O' Connell, a survival rate of 98.8 percent for local nationals and a 100 percent for U.S. patients testifies both to the quality of the equipment and the personnel operating it.

But for Bahar Gul, the CAT scan confirms the X-Ray image. A bullet is lodged in his spine, leaving him without any feeling below his waist. A surgeon explains that it is uncertain whether removing the bullet will make things better or worse for the pale-looking man wrapped in white sheets to stop his body heat from fading. Finally, the decision is made to put him on a helicopter and transfer him to Bagram Air Field, a sprawling military base about 45 minutes north of Kabul that is far better equipped to perform neural surgery. It will be up to the surgeons there to take the bullet out.

The rotor wash of the UH- 60 Blackhawk Medevac helicopter kicks up sand and dust on the flight line as it takes off with Gul inside.

Only five days later he returns from Bagram, where the surgeons were able to remove the bullet. Gul now lies on a cot in the ward, and as he undergoes a brief examination by a doctor and nurse, his body spasms. Visibly weakened from the ordeal, he volunteers his story in a soft voice.

Coming from the district center, Gul says he was on his way home when about five kilometers outside the town, he spotted four armed men at the side of the road. Just as he was passing them, they opened fire with their Kalashnikov assault rifles, spraying the sub- Governor's Toyota Corolla with a hail of bullets.

“I remember there was a sudden strike in my back and that I slumped over to the passenger’s seat. The car came slowly to a stop as I could not feel my legs any more”, Gul says.

Local villagers then approached the scene and brought him to a hospital in Khost where the Sub-Governor found him and brought him to the hospital at FOB Salerno.

Even though the bullet was removed, he is still a long way from recovering, and according to Major Stephen Fenton MD, the Air Force surgeon from San Antonio, Texas who first examined Gul when he was brought to the hospital, he probably never fully will.

“In a split second, someone's life is changed forever and there is not much you can do about it,” Major Fenton says, explaining that the bullet lodged in Gul's spinal canal pinched his spinal cord, which caused him to lose feeling in both of his legs. When the bullet was removed, he regained complete control over his right leg, but his left leg is still paralyzed from the knee down. According to Fenton, chances are slim he'll regain movement in this leg, but this is not even the worst problem.

“The hard part is the pain, Fenton says. "While from a medical point of view he is stable, the pain is a residual. Some vital nerves were severed. Without rehabilitation, it is likely that he will lead a life in pain.”

This seems to be a pretty accurate description of Gul's state. Even the slightest movement of his back causes him to moan. Lying immobile, he spends the night in the dimly lit ward drifting in and out of sleep, his hand resting on the forehead. After spending about a week in U.S. care, he has exceeded the average length of stay at the hospital, which is 3.8 days. According to Major Fenton, the 349^th CSH is an emergency or critical care facility, which means it is neither staffed nor equipped to take care of patients on a long-term basis. “The hospital simply does not have the capabilities and resources,” Fenton says, “once they are medically stable, they are released.”

The next morning, Gul lies on his cot, his hands folded together, waiting for what is to come. He knows that his family is waiting to see him. He knows he has to get up, and he knows that it will hurt. He starts to scream as a U.S. military doctor tries to help him sit up. He falls back on the cot in agony, his breathing short. A local Afghan medical assistant approaches and holding his hand, speaks softly to him in Pashto. It takes three men to lift his stiffened body and even then, Gul is hardly able to stand alone. He is put on a stretcher and wheeled outside, where an ambulance is waiting to transfer him to the front gate.

The rear doors of the ambulance are slammed shut and darkness engulfs Gul's fragile body as a few rays of light from the driver’s compartment touch his face. Every time the vehicle hits a pothole, Gul's face contorts. It is a short but bumpy ride. At the outer part of the front gate, a civilian car is waiting for him. Two local Afghans try to fit him in the trunk, with the rear seats folded down. The trunk is too small for him. In the end they lay him diagonally into the vehicle and carefully close the rear door. It will be a painful ride home.