Out of Afghanistan
Soldiers Take Circuitous Route to Medical Care
ARMY SGT. RICARDO PADRON was on
duty in Afghanistan when the fingers on his left hand were almost
severed by a knife during what this necessarily secretive special
operations service member will only describe as an accident.
Although his injury occurred in Afghanistan, his treatment
crossed three countries and thousands of miles, ending in the US
at his home base of Ft. Campbell, KY, where he is now in
rehabilitation to recover use of his fingers.
Padron is one of more than
approximately 1,000 service members and government workers who
have been flown out of Afghanistan because of serious injuries
received in combat or in nonbattle-related incidents. The crucial
stop along this medical route is Landstuhl Regional Medical
Center (LRMC) in Germany the largest American medical
facility outside of the US.
Were the catchers
mitt for all of Europe, northern Africa, and southwest Asia, and
for contingency operations like Operation Enduring Freedom (OEF),
says Col. David Rubenstein, the medical centers commander.
All OEF patients come here. Weve received Afghans,
Bosnians, Canadians, Brits, Norwegians, Australians, as well as
Army, Air Force, Navy, CIA, and State Department [personnel], a
fascinating mix in this particular operation.
LRMC receives four to six flights
a week of service members with nonbattle-related injuries from
Afghanistan, plus any wounded service members from combat or
military accidents that occur in the mideast country. The medical
route out of the war on terrorisms front lines to Landstuhl
can be circuitous, with patients receiving higher levels of
military medical care at different points along the route. That
care might be provided by Army, Air Force, or even Navy nurses,
physicians, or medics stationed at different strategic locations.
The level of care received varies from basic first aid to
sophisticated intensive care in aeromedical evacuation aircraft.
It Begins on the
This chain of care begins at the
place the injury, illness, or accident occurs in Afghanistan. The
service member, if conscious and capable, provides initial first
aid, or self-care, to himself if no one else is around to help
Padron, a medic for the New York
City Fire Department in the Bronx, was more qualified than most
to treat his own injury. He applied a pressure dressing to his
fingers and irrigated the wound with normal saline. He used the
saline to further cleanse the area because he was planning on
suturing it himself, he says. But he quickly noticed the blood
vessels had been cut and he was losing feeling in three of his
Had Padron not been a medic, his
care would have proceeded to the second step in the chain
buddy care supplied by a fellow service member until a
unit medic arrives. Buddy care essentially consists of more first
When a unit medic arrives at the
patients side, he or she administers more advanced care,
such as starting an IV line for fluid replacement or giving pain
medication. At this point, the goal is to evacuate the service
member out of the battlefield to the nearest military medical
unit. This can be done by aeromedical evacuation by a military
plane or a helicopter or by a land vehicle, depending on the
location of the aid station and the severity of the injury. The
medical unit might be a specialized mobile Air Force or Army
Because special forces
medics have advanced medical training, Padron was first taken to
his units makeshift hospital. The hospital is run by
medics, who determined Padron needed more complicated surgery
than they could provide. Special forces medics function like
physicians assistants or surgical assistants and are
capable of doing advanced medical procedures.
Padron was transported to an Army
forward surgical team (FST) at Bagram Air Base in Afghanistan,
where a surgeon operated on Padrons hand and, as he
describes it, saved my fingers.
A Stop in the Desert
The ultimate goal of military
medical care is to return service members to their units. But if
the injury or illness requires more extensive care, follow-up, or
rehabilitation than a military field hospital can provide, the
service member is flown to Germany. However, en route from
Afghanistan to Germany there usually is another interim mideast
stop first. Padron was was flown by an Air National Guard unit to
an Air Force base in Oman where an Air Force expeditionary
medical support team (EMEDS) is located. His wound was cleansed
and the dressing changed. Patients may also be flown to other
locations, such as Turkey or Uzbekistan.
Welcome to Landstuhl
Regional Medical Center
Hospital staff refer to patients
flown in from Afghanistan as OEF patients. An OEF patient who
does not require intensive care is usually given a bed on the 43-bed
medical/surgical unit 14 CD. By the time patients reach Germany,
they have received care at one or two field hospitals and are
medically stable, says Lt. Claude Fourroux, RN, a staff and
charge nurse on 14 CD. They are ready to begin physical and
occupational therapy before being sent to a larger medical
facility, such as Walter Reed Army Medical Center.
However, like Padron, some
patients may require more sophisticated surgery. At Landstuhl, a
vascular surgeon and a hand surgeon reattached the nerves and
tendons in Padrons fingers. Padron underwent two weeks of
intensive occupational therapy and was transferred to Ft.
Many of the injuries resulting
from combat include traumatic amputations, fractures, burns, and
shrapnel wounds. There are also nonbattle-related injuries from
landmine explosions, motor vehicle accidents, and hard helicopter
landings. Some of these injuries would not ordinarily be seen in
civilian medicine, even in a big city hospital.
Ive seen gunshot
wounds at Madigan (Army Medical Center in Washington state), but
the damage inflicted by blast injuries is horrendous, says
Capt. Gregory Hubbs, RN, BSN, a certified critical care nurse in
the ICU. You would never see muscles just left on bones the
way they are in traumatic amputations.
Psychological Needs Not
The medical staff is also acutely
aware service members injured in combat may need more than just
physical care. Service members and their families are supported
in many ways from the moment they arrive at Landstuhl, from
providing them free phone services and e-mail to offering support
from psychologists and chaplains.
Often, service members who have
been in battle together have not had a chance to talk with their
fellow service members until they have arrived at Landstuhl, says
Army psychologist Lt. Col. Sally Harvey, chief of psychology
services at LRMC. When they are ready, we try to get them
together in a group, she says. Often its the
first chance theyve had to fill in the gaps.
Harvey, Air Force psychologist Maj.
Linda Broeckl, and the hospitals chaplains are unobtrusive
and make sure the service members basic physical and
emotional needs, such as pain relief and contact with family, are
met first before approaching them about their battle experiences,
The nursing staff, says Harvey, is
highly trained and critical to providing emotional and
psychological support to battle-wounded service members. Air
Force Lt. Tina Hall, RN, who arrived at LRMC in September before
the attack on the World Trade Center, says, They are doing
something great, and we try to give them whatever they want.
Walter Reed Army Medical
Center The Last Stop
Col. Jean Dailey, RN, MSN, chief
of the surgical/neuroscience nursing section, is notified ahead
of time when OEF patients from Landstuhl are being transferred to
Walter Reed Army Medical Center in northwest Washington, DC, to
continue their treatment and rehabilitation. A team of nurses,
physicians, psychologists, social workers, and occupational and
physical therapists are prepared to meet any physical or
psychosocial needs service members may have.
Before a wounded service member
arrives at Walter Reeds wards 57 (orthopedic/physical
medicine and rehabilitation) or 58 (neuroscience neurology
and general surgery), Dailey learns what military unit the
service member is from and the service members current
medical status. She also reviews the care the service member has
received at Landstuhl and if the service members family has
any special needs, such as lodging in the area or transportation.
As at Landstuhl, service members
who have been injured in a combat situation are grouped together
on a unit to provide added moral support, says Dailey.
Many of the combat injuries
service members receive are to the limbs because bullet-proof
body armor has reduced injuries to the abdomen. Almost every
service member (about a dozen) who has lost a limb from combat
injuries in Afghanistan has received care at Walter Reed, which
has gained a national reputation in this speciality. It has one
of only two on-site prosthetic laboratories at Army hospitals and
has about 600 outpatient visits a year.
OEF patients are high profile
guests at Walter Reed the Armys premier hospital.
Deputy Commander for Nursing Patricia A. H. Saulsbery, RN, and
medical center commander Maj. Gen. Kevin C. Kiley, MD, are
briefed on a regular basis about OEF service members
treatments and conditions. These patients also have high profile
visitors, from Atlanta Falcons quarterback Chris Chandler,
who visited a wounded service member with the same name, to Sen.
Hillary Clinton to the Armys chief of staff Gen. Eric
Shinseki, who awarded medals to some service members.
2nd Lt. Ron Stephens, RN, a staff
nurse on ward 58, says as an Army nurse he is grateful to the
service members for whom he has cared. Ive learned
the real price of freedom, he says.
Service members in turn are
thankful for the military medical care they receive, whether at
Landstuhl, Walter Reed, or small Army hospitals throughout the
country. Of the military medical treatment he underwent, Padron
says, The care I received from beginning to end was amazing.
I cant begin to thank the people involved for saving my
hand. I will always be indebted to them.
Janet Boivin, RN, is
editorial director of the Greater Chicago/Tri-State edition of