Day 23: Spring offensive is here

Tomas blogs about surgeries and normal life in the field in Northern Afghanistan.

Tomáš wrote this post in March 2015. 

Ratatatatatatata, Ratata ... tata, boom, boom ...

6:09 wake-up call.

After one hour of sleep.

Firstly, there is the sound of barking Kalash guns. Then machine-gun firing, followed by several explosions. No, they're not celebrating today. This lasts three minutes, which is suspiciously long.

At 16:32 the same thing happens, but this time much closer. One kilometer? The project coordinator announces no movement for two hours... Someone knocks on the door during our joint dinner. I say that it’s probably a fighter coming to check out our dining menu. Tension is released by a little hysterical laughing.

During our joint dinner which takes place once a week, we usually discuss topics related to particular languages and nations. Last time we talked about Italian gestures and the end of the debate, as usual, slipped to the most vulgar words in each language. Today it was much more philosophical. We tried to characterize our own nation. I’ve already discussed Italians. They’re quite self-critical and they are able to make fun of themselves. The French are always the best ones at everything, especially in their eyes. Smaller nations such as Irish, Icelanders or Hong Kong people have healthy self-esteem. But how can the Czechs be characterized?

Presenting ourselves as the good soldier “Svejk” - a national character from Czech literature: an ordinary soldier, who survived every change of politics, because he didn't have an opinion and took whatever came, adapted to everything that happened, simple minded and good hearted - is outdated. The term “waitees” came to my mind. In my opinion we still wait for something. Especially for the moment, when other people do something instead of us. For a true national hero, for the change of political representation, what others will do when somebody frees us… Briefly: 'we survived what was and will survive whatever will come', 'the morning is wiser than the evening', 'we’ll have a smoke break and we’ll see what comes' underlines it all. Beer and hockey is an exception, which underscores the rule. I thus finally successfully responded to the difficult graduation exam question of my Czech language teacher at high school.

Four urgent laparotomies (abdominal surgery) following shootings in less than 24 hours is really too much! I definitely stopped in having an idea what time is it. I don’t know when it’s morning, when it’s evening, I don’t remember the last time I ate and drank, where all the patients are, how many days it has been since the patients undergone the surgery, when and to whom I wanted to take the drains out.

When I finished the first abdominal surgery of that day in late afternoon while everyone else was enjoying at least a little time off during 'local Saturday', which is Thursday, I was looking forward to being in my bed. A short film before sleep.

A half past one wake-up call, the second abdominal surgery in a row. A shot spleen, which I take out; half-shot kidney, which I’m stitching and I’m praying not to have to go in there for the second time, because the fragile tissue of kidney simply cannot be hermetically stitched.

At three o’clock in the morning when I’m leaving the hospital, the third gunshot wound to the abdomen comes in. Fortunately, it’s a quick procedure, mainly the chest was affected and it only irritated the abdomen, so thoracic suction.

At half past five in the morning, I’m finally going to bed. I’ve been thinking of not going anywhere in the morning, it’s a local Sunday! But my brain doesn’t let me rest so I’m going to check the incoming night patients and all others as well. I’m done with the ward round of the critical ones in one hour. Nobody’s dying and all of them are getting closer to recovery, either by smaller or bigger steps. But - when I’m leaving at eleven in the morning, there is the fourth abdomen…

Dude! Uff! Should I say the orthopedist Samsoor can do it? He can handle it. If I was already at home, I would surely call him and talk him into it, but I’m still here in the hospital. That’s too bad. No one justifiably cares about the fact I haven’t slept for three weeks as no one has around here has slept since the Kunduz Trauma Centre opened four years ago. So I do this as well with a bit of tension.

I have a resolution – it’s going to be a surgical Metallica – quick cut. Otherwise I'll fall asleep. I play U2 on my tablet while I go from the xiphoid process under the ribs to the pelvic buckle. This is how it should look during damage control surgery. As quickly as possible, as efficiently as possible, the largest view possible. The view is mainly because you are standing at the operating table alone, only with a nurse.

During these couple of years, I've invented a couple of originalities, a systematic approach and quick dance steps. Firstly, I put the small intestine on a piece of laparotomy pad, which I tie at the base of the intestine and I put another laparotomy pad on it, making a kind of a small bag for the intestine lying outside the body so it’s not blocking my view. If there’s a hole somewhere, I ruthlessly but cautiously put a temporal clamp on it (pean or soft intestinal clamp), with the least possible damage to healthy tissue. I use the space I made in the abdomen to first look at the spleen or the liver, depending on the direction of the bullet. This is the area where the largest blood losses occur.

I always suction it to the last blood cell, I quickly rinse it and I put lap pads there whether there is a hole or not. The first investigation provides time without which the patient would bleed to death and which I can dedicate to other organs. In the second case, the lap pad works as a 'policeman'. If it’s redder than it should be when we remove it later, it’s still bleeding somewhere.

I generally divide the abdomen into four parts and I systematically go from one to the other – exactly as you do when you play the Ludo board game. It is always necessary to suction the blood and the excrement, rinse it, put a lap pad on it, find out the extent of injuries and determine the urgency of any solutions. If there’s a stuck large intestine somewhere, I again help myself by using the intestinal clamp so poop doesn’t spill further into the abdomen and don’t cause subsequent sepsis. Finally, I check Douglas’s space at the very bottom of the pelvis, where the most blood is located, but usually only because it flowed in there. I put the lap pad there anyway.

When I finish going through it all, which should not take more than five minutes, I’m done with the surgical tactics and I start with the strategy. First of all, I have to focus on what is endangering the person most. Bleeding. The liver, spleen, kidney, small or large intestine, urinary bladder, uterus, stomach, pancreas, ovaries. It may be in this order.

If there’s a bruise below the abdomen, I go in there as well and I check the large vessels. The large intestine usually follows afterwards, because if there is a hole in it, it means contamination. Exceptionally, I stitch the primary anastomosis [joining two ends of intestine after removing a damaged section] without the securing stoma. If it’s necessary I take out the right, or the traverse colon, or the left one instead of stitching various holes at the same time as that takes much more time and it doesn’t belong to the schema of the first surgical aid – Damage Control Surgery. It usually ends with some intestinal colostomy [connecting the undamaged section of intestine to an external pouch on the abdomen allowing the damaged tissue time to heal].

As the very last, I focus on the small intestine, which I rinse with warm water in the meantime and I thus keep it well nourished. I re-stitch the smaller holes, the bigger ones I solve by resection of the wounded intestine and by anastomosis. I prefer to reconnect not more than three parts, otherwise it’s very risky. If the patient isn’t stable, I do nothing, I tie the holes or I do one stitch so I can have the second look later.

Then I check it all over again. I usually pour about ten liters of water into the abdomen. Subsequently the drains follow, I’m generous with them as well, usually three or four. I’m old schooled when it comes to drainage. The drains are other policemen, which look out of the abdomen and tell us when there’s something wrong. Then I go through it all again and we count the lap pads. I usually use about fifty of them. I close it. I try to do it in one hour; if I sew the anastomosis, it usually takes me about ninety minutes. If it’s just a quick ride aiming at stopping the unstoppable bleeding, it takes couple of minutes. But I’ve never done this yet. I just fix it most of the time. The end.