One life saved - February - June, 2010

We have a wonderfully committed and talented Afghan staff working at the U.S. Embassy in Kabul. Many of them work at peril to themselves or their families, such that no one knows outside of their immediate family where they work. This lowers the risk of threats, violence or ransom-related kidnappings. American Embassy employees rely daily on the language skills, local knowledge and commitment to improving life in Afghanistan demonstrated by our loyal local staff.

A story of caring for our staff is an uplifting counterpoint to the daily news of terrorist attacks. Let me share it with you. Abdullah (not his real name) is a young married man and new father, 26 years old, who has worked in an Embassy office for over five years. He was seeking advice from an Indian physician about his 15 month-old daughter, but found himself in the wrong place at the wrong time.

On February 26, 2010, terrorists attacked an Indian guest house several miles away from the Embassy. The initial blast from a suicide bomber could be heard and felt inside my concrete apartment building early on a Friday morning. This was followed by a gun battle of Afghan police/army forces and the terrorists. The battle lasted several hours, with all the terrorists killed or captured. A number of Indian physicians visiting Kabul for a conference were killed. Abdullah was shot in the abdomen as a bystander.

Afghan National Army (ANA) soldiers were able to transfer Abdullah to the nearby ANA Hospital where he received heroic initial care. He was losing blood rapidly from internal injuries and had several gaping abdominal wounds. Doctors were able to quickly establish IV lines and begin IV fluids and rapid blood transfusion. Most people would have died from the initial blood loss, but Abdullah – all 150 pounds of him – was strong and determined to survive. After all, he had a beautiful wife of two years and precious toddler waiting for "padar" (papa) to come home.

He was taken immediately to surgery where his wounds were found to be complex – massive injury and perforation of part of the large intestine, multiple small perforations to the small intestine, a rapidly bleeding tear to part of the spleen and more. Despite the fact that Abdullah was not an ANA soldier (doctors did not know he worked at the U.S. Embassy at all) doctors worked for over four hours to remove part of the colon, close perforations of the small bowel, sew the torn spleen and rinse, rinse, rinse the abdominal contents of all the bowel spillage that spelled certain infection. Without the heroic efforts of the Afghan physicians, working in a hospital with rudimentary equipment and short-stocked on meds and supplies, Abdullah would have died within hours. Following surgery, his journey to health would be fraught with dangerous challenges, but he now had the chance to take that perilous journey.

I received a call late that day from the head of his section of the Embassy, concerned about his employee’s progress and dangerous prognosis. Was there anything I could do? Having never been to the ANA Hospital, I was concerned that my involvement would be met with resistance – a meddling U.S. doctor who is not a trauma surgeon, walking in to the top Afghan military hospital in Afghanistan to scrutinize the care given. What could a country family doctor do in a situation like this?

Anxious to help but hesitant to “make waves”, I called in my health unit colleague, an Afghan physician who had once worked at the ANA hospital and had many long-standing friends there. “Dr. Ahmad” was a tremendous help in getting me access to the hospital and introducing me to Abdullah’s care team. I met an American naval surgeon who was serving as a mentor at the ANA hospital. He quickly informed me of the lack of resources for this large hospital, but also of the hard-working commitment of the local Afghan military physicians.

Abdullah was doing poorly when we saw him; he drifted in and out of consciousness, in severe pain when awake. He had a colostomy bag on the right abdomen following removal of much of his colon. He had a high heart rate and rapid breathing. He developed a fever within 12 hours of the surgery. He continued to require additional blood transfusions to replace blood loss prior to surgery.

Abdullah's father implored us to intervene – to have him transferred to our top American military trauma hospital in Bagram (one-hour drive or fifteen minute helicopter ride away). The father felt certain that his son would not survive if he stayed at the ANA hospital, but had full faith that “the American doctors” could bring about a miracle. Doctors agreed that I could help by supplying additional medications. The 300-bed hospital was very poorly supplied and did not have any more morphine for pain control. They lacked the strong antibiotics that could help fight the expected life-threatening infection from bowel spillage internally. They lacked high-tech internal monitoring devices, and the one CT scanner installed a year earlier sat idle, awaiting replacement parts that never arrive.

It was clear to me that without additional intervention, Abdullah would die within days. I was able to share morphine and strong antibiotics from our supply at the Embassy health unit. I contacted the chief of trauma at the American field hospital at Bagram. They are permitted to treat local civilians when they have excess capacity (low incoming wounded Americans) but this would be a challenging case and occupy a bed for longer than desired or typically OK’d. I gauged the feelings of the Afghan physicians who were proud of the work they had done to save him, and knew they lacked resources, but felt he “should be watched” to see if he gets better. By this time I had the interest and support of Ambassador Eikenberry and many top leaders at the Embassy who encouraged all to “do what it takes” to pull Abdullah through.

By the second post-op day, Abdullah was doing worse. He now had a 104-degree F temperature, rapid, faint heartbeat, and more labored breathing. No CT scan was available, but his chest x-ray showed fluid building up in the right lung. It was time to take action. Here is where “medical diplomacy” comes into play, along with experience of arranging rural to urban transfers of very ill patients and keeping the many involved parties informed.

I explained to the Afghan doctors that we have the ability to work in teams, finding the best resources available, and building on the care already given. Additional resources (CT scanner, ICU, monitoring equipment, not to mention highly trained U.S. trauma surgeons and critical care specialists) could be available to help Abdullah. From the surgical team at Bagram, I received permission to transfer the patient, after making a direct request on behalf of the American Ambassador -- but a helicopter was not available and Abdullah would need to be driven by ground ambulance over one of the very dangerous roads in Afghanistan. I prayed for a safe journey, that Abdullah would survive long enough to get to Bagram.

He made it. Upon arrival a CT scan was performed. It revealed previously unknown injury to the diaphragm, blood filling the left side of the chest, and large fluid (blood and pus) cavities developing in the abdominal wall and inner abdomen. He was taken straight to the operating room for an additional four hours of surgery and came back to the ICU on a ventilator, with two chest tubes, abdominal drains, and on multiple modern meds given via calibrated infusion pumps.

Abdullah made it through the next few days, fighting, fighting for life. He recalls none of the first two weeks after being shot.

He required over nine trips back to the operating room and remained at Bagram hospital for six weeks, the first week on the ventilator in an induced coma. He battled infection in the abdomen, a breakdown of his abdominal incision, pneumonia, and other complications. He had a family member (father, brother, or cousin) stay with him – sleeping on the floor – to offer support, encouragement, and prayers. Abdullah’s weight dropped from 150 to 127 pounds. His nutritional state remained complicated since his bowel did not function as it had and his appetite was poor. Yet he needed protein to allow new tissue to heal and skin cells to regenerate to close the gaping abdominal wound that had had to be left open. Intravenous nutrition and later a feeding tube worked to strengthen him. Eventually he was able to receive a skin graft to the abdominal wound, was able to regain eating and could tentatively start to get out of bed and begin some strengthening.

He was receiving great support from the Embassy during this time. Ambassador Eikenberry visited him early at the ANA hospital and received frequent updates from me on his progress. In addition to daily phone calls and frequent email updates to Embassy leaders, I was able to travel to Bagram to visit him and confer in person with the physicians that had pulled him through. They called Abdullah “one of our miracle cases”. During my visit, Abdullah remained weak, tired and discouraged that he would never get out of the hospital. I helped him focus on his future, his family, his daughter’s need of a strong father. His strong spirituality gradually helped him feel a sense of purpose – that he must get better to do important, positive work in his life. His medical and emotional condition gradually improved and he was readied from transfer home on April 12, after more than six weeks of multiple surgeries and touch-and-go episodes.

I was able to provide his ongoing care in the Embassy health unit with every-other-day wound care, nutritional support, pain management, teaching ostomy care, and offering emotional support. Slowly he gained strength, could manage to walk without support and transfer out of bed alone. He began to smile often. How we cheered when he finally showed a three-pound weight gain! Abdullah was a man reborn, so thankful for his life, his family, his hopeful future. He began bringing in family pictures and talking of returning to work in the weeks to come.

It took another month of frequent visits for his skin grafts to fully heal, colostomy to function just right, diet to get back to normal and to become independent in daily cares. At the end of May, Abdullah was finally able to return to work at the Embassy for partial days and is now working full time. But his story is not yet ended.

The army hospital has agreed to see Abdullah once again in October, 2010, when he will be strong enough to undergo additional surgery. He will be able to have his large intestine “reconnected” and will get a graft to the front of the abdomen that will fix the wound hernia that developed as an expected result of his earlier wound breakdown.

For the heroic work done by all the doctors involved, Ambassador Eikenberry wrote special commendations for the Afghan physicians and nurses from the ANA hospital, without whose efforts Abdullah would have died. It was a special day when I represented the Ambassador at an award ceremony at the ANA hospital and could speak of successful collaboration on this very challenging case. What could have been an uncomfortable loss of face for the Afghan medical staff as we “pulled their patient out of their hospital” turned out to be a celebration of cooperative resource-sharing between two hospital teams that had rarely worked together before. The Afghan team was extremely proud of their work and the recognition from the Ambassador and the very appreciative Embassy community. Abdullah attended the ceremony with me, offering a tearful and sincere thank you to the military doctors for giving a son back to his parents, a husband back to his wife, and a father back to his small daughter. All eyes in the large room were moist.

I was also able to travel back to Bagram to present Ambassadorial awards to the American care team. During that visit I shared the story of Abdullah’s journey, family, and valuable work at the Embassy. So busy are the miracle-working American military physicians that they rarely get to actually know the stories behind the many patients whose lives are given back to them. They heard how their intervention cemented the loyalty of hundreds of Afghan Embassy employees who now truly believe our guiding principle – "One Team, One Mission".

Taking on just a small role in coordinating the care of Abdullah has been the most rewarding experience of my tour in Afghanistan. I will never forget Abdullah and his young family, facing the future with thanks to the United States and full of hope for Afghanistan.