Helping those in need in a time of war..

patrick1rn, MSN, RN, NP

I was in Operation Enduring Freedom working out of a small forward operating base right outside the town of Herat, Afghanistan. It was early February, 2005. We received notification that a Blackhawk helicopter was bringing us a four year old girl from one of the other bases south of us. Out military was embedded with the Afghanistan Army during both tactical and garrison activities. We were teaching them how to become an Army. The idea was to let the Afghanistan Army handle local national wounded.

The little girl had ingested insecticide. She drank liquid that was used to kill flies and other insects. Insecticide is the same thing as nerve agents are, but on a smaller level. The helicopters were about fifteen minutes out; we drove with our Infantry forces to the landing zone. The Infantry guys formed a perimeter around the landing zone as the helicopters touched down. The patient was cared for on the helicopter by one of the doctors from that base. He gave me a report on her status and what they did for her. I had managed this condition back in the States working as a registered nurse, just not with a small child. The helicopters left and this child was now in our hands. Her father was with her on the journey.

We went to the Afghanistan medic aid station and no one was home, the door was locked. They did not understand that operations occur twenty four hours a day, especially medical emergencies. Typically, the Afghanistan medics take care of their own sick or injured, but now she was my responsibility. I was not a pediatrician. We notified the commander that we had to take this child to the hospital in Herat because none of the Afghanistan medics were around.

Our security forces were already out from the landing of the helicopter, so basically all we had to do was convoy to the hospital in the city. I knew that the drive would take about thirty minutes with good traffic conditions. The father and one of our interpreters were in the back of the ambulance with me, while the other two medics drove up front. I never liked the idea of taking the ambulance out on convoys like this. It had really minimal shielding from a blast. The back of the ambulance had some Kevlar protection. Well, we went to war with the equipment that we had. One improvised explosive device and it would have been lights out for all of us.

I had basic pediatric training from nursing school, but I was used to treating adults, I remembered that in children everything is normally faster, the heart rate is faster, they breathe faster and their metabolism is faster. I had never really cared for a child working as a registered nurse. Other than that, I just wanted this little girl to stay alive when she was in my care.

The little girl was in the back of the ambulance resting on a litter. It was different seeing someone so small on those litters. She had a bag of normal saline infusing at a slow rate with atropine. Atropine was the medication used to treat the insecticide poisoning. In fact, the military uses atropine, because it is the antidote for nerve agent poisoning. I was comfortable with what I was doing; I just didn't want this little girl to die in the back of the ambulance while she was under my care. Her father and the interpreter were watching my every move.

I had a pulse oximetry monitor that I put on her thumb to tell me how fast her heart was beating and it could measure the amount of oxygen levels in her blood. If her heart rate went down too much, I could see it on the monitor right away. It was hard trying to listen to her heart with my stethoscope in the back of the ambulance, but I could feel her pulses with my fingers.

I wanted to keep her heart rate fast, I listened to her lungs and to her abdomen and then I felt her belly. I was worried about her vomiting and then aspirating what she vomited. We had a portable suction canister; typically it is one of those pieces of equipment that gets in the way, except when we needed it.

I had the suction ready if needed. I placed her on a facemask. The most I could do if I had to protect her airway was to insert a small tube called a J tube that moves the tongue so air can get into the airway. She would have to lose consciousness in order to do that. I preferred that she stayed awake. We did not have any airway tubes to insert into the nose to help protect the airway because we typically did not stock those for pediatric cases. She started to vomit. I quickly turned on the portable suction canister and cleared the contents out of her mouth. I sure as hell was not going to allow this little one to aspirate and die over something so simple. I suctioned out the gastric contents. Her oxygen levels were more stable. I was satisfied with her levels after the vomiting.

She closed her eyes and dozed off; her heart rate was below ninety. That was not good; I increased the infusion rate of the atropine and rubbed on her chest. The poor girl started to cry. We didn't have the atropine on a pump like in a hospital or an ambulance back in the United States, I had to eyeball this. I infused enough atropine so her heart rate would go back above one hundred and ten. I asked my interpreter to tell the father to talk to his daughter and tell her to keep her eyes open. I explained to the father that I did not want her to fall asleep in the back of the ambulance. The interpreter translated this for me and the father nodded yes in understanding.

We arrived at the hospital in Herat. The executive officer, a large Army Lieutenant Colonel, took hold of the little girl as we opened the ambulance doors. He carried her in to the emergency room and placed her on an Army litter that was held up by old-fashioned litter stands. I gave a quick report about what happened to the girl to doctor. He was busy as I could see. There were people on litters with amputated legs moaning and blood pooling on the floor. The father could explain the rest to the doctor.

I took a walk around the hospital. It was barely a hospital. There were minimal supplies and lighting. The floor was concrete and to light the place, they used a portable light set and strung lights in different working locations. I almost felt guilty dropping her off here. The rooms, if you could even call them that, were sectioned off by rope and to have some privacy, old green Army blankets were used. We had done the best we could for the little girl. I just didn't want her to die in the back of my ambulance on the way here. I didn't want her to die at the so called hospital either. I heard through the interpreter that the child was released a few days later. That put a big smile on my face!

Helping those in need in a time of war..

About patrick1rn, MSN, RN, NP

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