Symbiosis

I was on call today in the ICU, and it was quite the busy day. First thing this morning, the 8 year old with burns was extubated and taken off the breathing machine. We had the translator at the bedside so that we could tell her what we were planning to do. Like a champ, she coughed when we pulled out the tube, and continued to cough some more to get the phlegm out of her airways. She did better than most of the adults I have seen extubated! She is a strong, strong little girl, and that has helped her tremendously as she rehabilitates in the ICU. She has had skin grafts to the 40% of her body that was burned, so now essentially her entire body is a huge sore (the 60% of her body which was not burned was harvested so that we could cover the 40% which was burned). Despite 5 trips to the OR, painful dressing changes, and a very different environment than she's used to, she has done beautifully thus far. She has a long road ahead of her (on the order of months, not weeks) which will likely include dozens of visits to the OR, but ultimately I think that she will survive.

In addition to taking care of her, I had two admissions today. One was a simple pre-admission for a 4-year-old boy who will undergo surgery in the morning. (He had an abdominal surgery about a year ago, and the pediatric surgeon will do the second and final stage of the procedure tomorrow morning. In the interim, he has nearly doubled his weight, going from 8 kg to 15 kg. He has also gained the strength to walk on his own!) The second admission took me somewhat by surprise: she is a 2-year-old girl transferred to us from a US hospital in eastern Afghanistan. She was struck by a tactical vehicle two days ago, and underwent surgery at that time to repair her left arm, which was broken in several places. She was transferred today for continued surgical care. Her arm was a deep purplish-blue color, and her hand was ice cold. We could not locate pulses at her elbow or her wrist. She was whisked to the CT scanner, then to the OR, where the surgeons attempted to repair her vasculature to restore blood flow to her hand. As of this writing, we do not know if the surgery was successful; a shunt was placed into the artery at her elbow to keep it open and flowing, and they are planning for another OR trip in a few hours to see if the shunt remains patent. If it does not work, an amputation is in her future.

I heard a very disturbing story when discussing this child with the ICU nurses. Most of them have been at Bagram for several months, and they have seen an endless stream of children come through the doors after losing a confrontation with a tactical vehicle. Rumor has it that families will actually throw their children in front of oncoming US traffic, since the US provides not only medical care but also a stipend to local Afghans injured in the course of this war. (I do not know if the stipend is provided on a one-time or recurring basis.) Apparently, the populace here is so desperate that they would sacrifice their most vulnerable assets - their children - in exchange for US dollars. I find this rumor appalling, but unfortunately believable considering the abject poverty of this country. I will attempt to confirm or deny this theory in the coming days.

Despite the horror of this rumor, my heart has been bouyed by the response of the staff to our little pediatric ward. There are four total patients now: I've already discussed the 8-year-old girl with burns, the 4-year-old going to surgery, and the 2-year-old girl with the mangled arm. The fourth patient is a 2-year-old who has been living in the hospital for a year now after suffering an injury to her esophagus and trachea. She swallowed a watch battery which eroded through these internal structures, and she now has a tracheostomy tube in her neck. She cannot go home with a trach since it requires a suction machine, but her family does not have electricity. She is known as the "Queen of the Hospital" and literally runs around smiling and waving at everybody. She even knows where the snacks are kept in the doc box! All of the hospital staff know Nasi, and we just can't help but smile when she toddles by. The same is true of the little girl with burns - you can't imagine the outpouring of support she has received from all over the base. The medics who picked her up initially from her destroyed home have visited several times; the daughters of one of the nurses drew her pictures for her hospital room then scanned and emailed them; every day I find new stuffed animals on her bed. (She's got quite a collection!)

Our little peds ward is unlike any other place in the hospital. It's known as the place where patients get better, and more importantly, it's the place where we can watch patients get better. With few exceptions, patients fall into one of four categories: (1) US and coalition troops, who are stabilized and air evac'ed to Germany; (2) Afghan soldiers and policemen, who are stabilized and returned to their local hospital; (3) enemy combatants, who are stabilized and returned to the internee facility on base; and (4) pediatric patients, who have the opportunity to stay in the hospital until they are ready for discharge to home. My patients are the only ones that we, as the staff, get to see through the entire course of their illness. We watch with heavy hearts as they suffer despite our best efforts, but then we rejoice when they improve and are able to go home to their families. As a result, we rally around these sick and injured Afghan children. Maybe we rally around them because they remind us of our own little ones at home; maybe we rally to temporarily forget the death and destruction facing us daily. In any case, it seems that we need them just as much as they need us. We treat their pain, help control their anxiety, and feed and bathe them, and in return they provide us with moments of hope, love, and happiness. And nothing could be more important than that!