s a newly graduated female Army anesthesiologist, I have to admit I felt some trepidation about my fast-approaching six-month assignment to Afghanistan. Fortunately I was given plenty of advanced notice and had the benefits of receiving numerous lectures and “lessons learned” from my colleagues. Unfortunately there is nothing that can really prepare you for living with 250 strangers in close proximity and performing your life-saving job with limited resources in a plywood box on a gravel lot. Having completed my task successfully and returned home safely, I can now say that it was one of the most rewarding experiences of my life and something that I will actually remember fondly.

Living quarters (B-Huts) for the 14th Combat Support Hospital staff.

A view of one or the 14th Combat Support Hospital operating rooms.

As the sole Army anesthesiologist sent to Operation Enduring Freedom (Afghanistan theater), I was based with the 14th Combat Support Hospital (CSH) at Bagram Air Field, which is roughly 30 miles north of Kabul. I was not a permanent member of the 14th CSH unit, which is based in Fort Benning, Georgia, but was sent as a professional filler, as were many of the other hospital staff, specifically for this deployment. We all had about a month of training in Georgia together, during which time we managed to at least learn each other’s names and fields of expertise.

Our trip began in February 2006, so the weather was actually quite pleasant, and we arrived to temperatures in the 50- to 60-degree range. The most striking thing about the country when you first step off the plane (and of course after the sun rises) is the absolutely magnificent snow-capped mountain ranges towering 360 degrees around you. It was something pleasantly surprising, and it made a nice retreat for sitting outdoors during precious free time.

Farewell celebration with my Egyptian anesthesiologist colleagues (from left: Dr. Yasir El Taher, Dr. Liz Javernick, Dr. Hany Salem).

Our hospital itself was perioperatively staffed with three to four nurse anesthetists (depending on what outlying forward bases they had to cover) plus myself, a pediatric intensivist (specifically requested for this location given the historic acuity of pediatric patients), two orthopedic surgeons, three general surgeons (two happened to be fellowship trained — one in CT surgery, the other in laparoscopic surgery), one ENT/plastic surgeon, one ophthalmologist, one oral surgeon and two emergency room physicians. We ran two O.R.s, which are called iso-shelters, basically large metal boxes resembling rail cars that expand with folding walls on either side, each containing two beds/machines available for anesthetics. Fortunately our largest mass casualty consisted only of six patients from a school explosion, and we did not face the issue of operating on more than one person at a time in each O.R. We were actually only a half slice of a full CSH, and our total inpatient bed space consisted of 11 intensive care unit (ICU) litters and 15 ward litters, with the ability to expand into an overflow area with six more beds (which we often used as an isolated area for detainee patients).

A typical day in the 14th Combat Support Hospital Intensive Care Unit.

Our equipment was in surprisingly good shape, and we were able to do most adult and pediatric cases. Some of the things we did lack were Swan-Gantz catheters or the ability to monitor cardiac output, including TEE, pediatric fiberoptic scopes, certain blood products such as platelets and cryoprecipitate, MRI and, obviously, the ability to perform cardiopulmonary bypass. From time to time, we would run low on basic items such as circuits, but we were usually replenished before we reached desperate levels. Logistics does, however, remain one of the most challenging aspects of running a smooth operation out in the field, and it was not uncommon to run into obstacles with computer systems being down or finding the correct product in the system to order.

As expected, the majority of our surgical and ICU care was done on Afghan citizens, both civilians and soldiers/police. Of those a fair percentage was pediatric care encompassing mostly trauma from being unfortunate victims of land mines or other common accidents such as motor vehicle crashes and falls. We did, however, do a few elective cases, such as cleft lip/palate repairs and other surgically correctable congenital deformities, as well as care for a handful of interesting life-threatening pediatric medical problems that I had little experience with at my home practice. One patient in particular was a young girl who presented at the front gate in respiratory distress with upper-airway bleeding and a massive mandibular tumor that turned out to be a rare ameloblastoma. One of the benefits of being in such a small community is that all the consults you need are only minutes away, and we quickly decided that she would best be treated with an awake tracheostomy. She tolerated the procedure well and ended up staying with us for about four more months for resection and closure. Another unusual patient we cared for was an 8-year-old boy who was brought to us through a neighboring medical facility with a decreased mental status and an obvious chronic cyanotic condition. He had significant clubbing, was very small (as are most of the children there) and hypoxic. He was found to have a large cerebral abscess, and through some basic work-up with CT, was thought to have a transposition of the great vessels. He stayed with us briefly to have his abscess drained, but unfortunately, with the little resources in the country, definitive care is often impossible. To my astonishment, the vast majority of Afghan families were overly appreciative and sincerely grateful for all the care we gave them, and it really changed a lot of the prejudices and biases I felt prior to deploying.

11-year-old Afghan girl, Latifah, with massive maxillary tumor diagnosed as an ameloblastoma.

Latifah recovering after resection of her ameloblastoma.

Thankfully serious surgical injury in U.S. soldiers was not a large part of our business at Bagram, unlike working in Iraq; however, when it did come, it definitely took the most life out of us. Still the most common war traumas are extremity wounds, including many traumatic amputations, and abdominal injuries. Advanced ballistic body armor has significantly decreased the amount of chest and head trauma seen on the battlefield today, although they are certainly still present as well. Whole blood drives were initiated early for any anticipated massive resuscitations, and volunteers were often more than willing to donate.

2-year-old Afghan child with significant edema after suffering a presumed venomous bite on the face.

We did have the capability to place and send patients stateside with peripheral nerve catheters and epidurals, but they were not a huge part of our practice either because patients were too sick or did not really seem to need them. Patient-controlled anesthesia authorized for flights out of the country was introduced while we were there, and it was invaluable in aiding flight crews with pain management in patients who didn’t have regional anesthesia.

We did have the opportunity to do a little nation-building and work side by side with providers from other countries as well. Specific to anesthesia, there was an Egyptian field hospital on our base with surgical capabilities aimed mostly at treating nonemergent civilians; however, they did aid in trauma care at times when our hospital overflowed. I had the chance to share my experience and learn from two Egyptian anesthesiologists in particular. It was quite inspiring to see the enthusiasm they had for learning new techniques, and I enjoyed teaching them my skills with difficult airway equipment. It also was quite interesting to learn about their culture, military and civilian medical practice and training. I left having made far-away friends, and I’ve kept in touch with at least one of the anesthesiologists to this day.

Our unit also was involved in establishing a rotation for Afghan nurses, surgeons and anesthesiologists from Kabul to spend two-week blocks with us to learn more about our practices. Overall I definitely felt like we were making a local impact on improving quality of care in the facilities to which many of our patients were being discharged. Many other countries were represented throughout Afghanistan in a medical capacity working for NATO forces in other cities, and perhaps as the forces become more integrated there with the handing over of military forces, we will have even more opportunities to work with the British, Australians, Germans and French, to name a few.

Looking back, I think early in my career was a great time to be deployed. I feel like I have developed a better appreciation for my abilities, developed a sense for effectively working with nurse anesthetists, been able to promote my specialty in a fulfilling way and have been rewarded with kindness from people who were genuinely thankful for my help.

Elizabeth N. Javernick, M.D., is a staff anesthesiologist at Walter Reed Army Medical Center, Washington, D.C.