Culture of Violence

GilaRRT

I walk down the spiral staircase from my third-floor room to the operations room, the nerve center of our operation. Our operations coordinator is busy talking on the phone while he feverishly types in data on his computer. One of our doctors is standing by, while one of our medics sits at our small conference table. Both are listening to the conversation with great interest. I notice the three large screens on the far end of the operations center are turned off and silent. Unusually quiet from their brightly lit activities that beam the news, clinic information, and Google earth information into the center. Among this silence, I instantly know something is up. My quiet day is about to take a turn in the other direction.

We have a mission. The operations coordinator in his relaxed yet concise speech gives us the details of the mission. A person has sustained critical injuries from a gun battle. The military is asking us to assist with the operation. A military helicopter will transport the patient to the airport and our team will take over care and transport the patient to a local hospital for ongoing care. My partner, a newbie to our operation is a South African paramedic. While new, he has an aura that radiates confidence. The kind of feeling you only get from a highly seasoned provider. My deeply buried insecurities are at ease knowing he will be on this mission.

The third member of the team is a local Afghan physician. He is thin and looks to be a new intern in his late twenties to early thirties. However, his external appearances are deceiving as he is most likely in his mid-forties. I remember the stories he told about fighting Russian troops in the steep mountain ranges of Afghanistan when he was a young medical student. He knows the country well and will be an asset when we have to communicate with the Afghan physicians at the receiving hospital.

The typical rituals are completed without incident. We quickly check and load our medical equipment into a small Toyota van modified to perform the duties of an ambulance while blending into the local flavor for added security. Our backpacks that we call rollout bags are loaded. These bags are loaded with survival equipment in the event we end up on foot and have to survive long enough to escape the situation. It is cold comfort, as the grim reality is we would most likely not live long enough to use these supplies in the event of a major incident. I also don a soft vest of Kevlar body armor and place my plate carrier over the soft vest. The carrier contains steel plates that may stop rifle rounds from penetrating the soft Kevlar and flesh underneath. Most of my colleagues choose not to wear armor; however, I find cold comfort and a little hope that it could make a difference.

Finally, we are loaded and bouncing along the pothole infested streets. Our driver tries to avoid the deep holes with limited success while our bodyguard and Afghan physician shoot the breeze in the local language of Dari in the front of the vehicle. My partner and I sit in the back of the ambulance. Silent observers of this world, we are alone in a city of millions. A concept that I never fully grasped among my fellow Americans back home.

We finally reach the pickup point. I make contact with the guards to the entrance of the military base that is located next to the airport. They only speak French. I do my best to remember fragments of French that I learned as a high school student. Too many years have passed, however. I manage a feeble, " Bonjour, mon nom, je m' appelle Chris, " followed by the name of my company. Luckily, they have been briefed about our mission and allow us to wait for the patient at the gate.

The patient arrives several minutes later loaded into an old Army box ambulance. The medical providers speak limited English and cannot give us an accurate report. The patient has a family member present as well. Our local doctor makes contact with the family member to gather additional information and brief the family member on the situation.

Once again, I hear the unfamiliar Dari phrases. Once again, I am reminded that I am very much a stranger in a strange land. The feeling is brief as the patient is in rough shape. The injuries are critical and the sending facility was required to place a tracheostomy in order to secure the airway. The patient is receiving bag valve mask ventilation on room air. My partner assembles the scoop stretcher and vacuum mattress for packaging the patient while I assess the airway and verify proper placement of the tracheostomy. I note lung sounds in all lobes with rales throughout, thick secretions surround the tracheostomy site, I also place a colorimetric carbon dioxide detector and am pleased to note the familiar and reassuring yellow color change. The patient appears pale as I place a pulse oximeter, hook the patient to a cardiac monitor, and obtain baseline vital signs.

The patient is young. Much younger than me, with strong chiseled facial characteristics common among the people of Afghanistan that would have made the patient an instant hit among the social crowd if this were the United States. I briefly wonder what this patient would have been able to accomplish in another place and another time. Would this patient have had to work a dangerous security job in the most violent areas of the world?

Instantly, I know the patient is in distress. The pulse oximeter and blood pressure readings are critically low. My partner continues the packaging process with the skill of a professional while I hook the bag valve mask to high flow oxygen and ensure a reservoir is attached. I suction the purulent secretions from the tracheostomy and look for IV access. Only one IV med lock is present on a distal extremity. All of the extremities are grossly swollen and I suspect the IV is worthless.

Finally, we load the patient and begin the long and bumpy journey to the hospital. While in route, we continue to suction and ventilate with high flow oxygen. The doctor takes over the bag valve mask while my partner manages the suction machine. We have a transport ventilator, but it is forgotten in the frantic activity. I am able to place an IV among the bumps and sudden stops among the chaotic traffic. My partner already has a line of saline spiked and tape torn. He congratulates me on a good job; however, I know it was luck.

My partner is able to suction additional secretions and bring the patient's pulse oximetry reading into the mid-nineties. He asks about the blood pressure, it remains low. We verbally go through a list of problems that could be causing the low pressure. We rule out pneumothorax, a condition that can be caused by aggressive ventilation. Finally, we arrive at a tentative conclusion. The patient is most likely septic. This explains the lung sounds and secretions.

Upon arrival at the hospital, we are met by an old run down building that is no different than the surrounding buildings. The medical unit is on the fourth floor. However, no elevator is present, and we are required to carry the patient up several flights of stairs. Luckily, the hospital staff is keen to assist. We are able to negotiate the narrow stairwells and make it to the unit. My heart sinks as I see the hospital bed. Limited supplies are present; staff members scramble to find one of the few vital signs monitors present. Even with such Spartan conditions, the staff seems determined to take care of the patient.

After the mission, I ponder all that I have seen thus far. Such senseless violence. Why is it so hard for people to get along? Why do so much hate and disrespect for life exist over here? Then, I am struck with an even more sullen thought. How is this any different than what I have experienced in the United States? How is this any different than the racial violence, drug wars, gang violence, and school shootings that occur all too frequently in the United States?

The only answer I can conjure is, "it's not." I have come to realize that this "culture of violence" is not isolated to the Middle East or even so-called third world countries. No, the "culture of violence" is a disease that has infected every country and every society. Violence is not simply a problem with "them." It is a human problem that will require human solutions.

Is there any hope? If a South African paramedic, an American Nurse, an Afghan physician, a French soldier, and a rundown hospital in Afghanistan can put aside their differences to help a patient they do not even know, then perhaps there is hope.

Culture of Violence

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