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GSACEP Lecture Series: Afghanistan Evacuation Mission Panel Discussion

July 21, 2022 GSACEP Season 2 Episode 5
GSACEP Government Services ACEP
GSACEP Lecture Series: Afghanistan Evacuation Mission Panel Discussion
Show Notes Transcript

GSACEP emergency physicians reflect on the fall of Kabul and the evacuation of Afghanistan in the final days of the US presence.  Featuring Dr. Katrina Landa, MD; Travis Callahan, PA-C ; Andrew Chambers, RN; Dr. Roderick Fontenette, MD; Dr. Matthew Streitz, MD


How to Claim CME for this Lecture:

This lecture is eligible for 1.0 Cat 1 CME Credits. 

1. Go to http://gsacep.cmecertificateonline.com
2. Click on the 2022 Annual Conference - Enduring only link.
3. Evaluate the meeting.
4. Print, download, or save your certificate for your records.


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Kat Landa:

As the emergency physician and OIC in charge of the Special Purpose MAGTF, which is the Marine Corps Shock Trauma platoon that was in direct support of Second Battalion first Marines. And subsequently it was also in support of BLT one eight, because they were co located with us down between Abbey and east gate. So indirects of we're in a forward roll one capacity outside of the normal North HKIA. area. And we did quite a bit of evacuation care.

Rod Fontenette:

Afternoon, again, I'm Rod Fontenette, was the CCATT theater director out of Ramstein, Germany at the time I was there deployed already on a regular six month deployment and then the Afghanistan evacuation happened. The majority of the missions we were doing prior to that day were mostly COVID NPC missions Pinyon patients of downrange that had COVID-19, and transporting them in NPC throughout theater in any other thing that would happen prior to that day, and then things like drastically changed the days from that day for for the rest of my deployment. So happy to chat about it.

Travis Callen:

I'm Travis Callen, en PA, I was at the NPA on the trauma team at HKIA. Role two and I was also the triage officer. Throughout the time, there are a couple through the suicide attack in the days before that.

Moderator:

So the first question here for the group is what diving time into lessons learned. What was one of the greatest lessons learned for you during this

Travis Callen:

so when I first got to HKIA, I started setting up the triage system. And my whole plan was planning for a mass cow because the writing was kind of on the wall and we knew we had the Intel threats that something was going to happen. So I put up trauma towers outside to kind of have an A through E for your march algorithm ATLS setup so people could go right to a cabinet grab what they needed. I planned for a 30 person mass cow. So the biggest lesson I learned was when you're in a situation like that and you are planning with your consumables for TCCC supplies over over plan three times and have things that are necessary and get rid of things that are unnecessary. You don't need size extra small gloves outside, you should have large, you should have plenty of tourniquets, you should have plenty of cric kits, and combat gauze, that kind of stuff was my big takeaway from the triage aspect of that day.

Rod Fontenette:

I think for me from the CCATT side of things, so normally, prior to COVID, there are always three CCATT teams that are deployed in Germany at Ramstein when COVID happened, the Air Force increased the number of CCATT teams that were there, there were the regular three deployed, and then they increased an additional three specifically in theater for COVID transport only, right before my teams and I got there. They sent them with a one of those teams home and made all five teams that were CCATT teams remaining all COVID teams and just regular operations teams. So we got there, we all could do COVID transports and non COVID transports which were great. Right? So but once Afghanistan happened, they sent an additional four teams there. Right. So now I have nine CCATT teams that have to kind of be over in addition to the CCATT teams that are in Qatar much closer to the fight, right. So just being able to move all those resources and making sure that everyone is on the same page and have a good essay was going on was huge. That was the first thing. Second thing and I say this from the very beginning of this mass cow thing I was like quite often when these things happen is the pediatric patients that are really, really heavily affected, right. But what's the what's one thing that CCATT doesn't do that much of pediatric transport, right? Because we're that's just not what we do our smallest ET tube was a six Oh, right. In case we need to like cric somebody for whatever reason, right? I try to put it a kid Oh, that was two and a half years old, eight and a half kilos that six or 8 tube just was not going to work. We had zero pediatric supplies. Right. So that was a huge gap in coverage that we had that we noticed very early on. Right. And so as we go through this, we can talk about, like how did we work to fill those gaps. But I think that was a big deal. And also the team composition. Right? So I was the only I believe em doc on the team. Right? And then we had an anesthesiologist with a pulmonary critical care doc and this was the five teams that were originally there and then we had I think it was another general medicine critical care right so I was the out of the group of the five of us I was the only one that had any pediatric like like comfort right the other ones was like I haven't dealt with a kid and like forever since like residency training. Right? And so that was another thing. Even if we had supplies How comfortable is my team on my team is what even taking care of these really sick kiddos? Right the team in Qatar picked up a kid his kid was I want to say five years old and intubated. When was the last time you had any of these pulmonary guys like set tidal volumes and things on vents? Right? It's just it was it was difficult. So those things we had to work through very, very quickly. And again, as we work through this, we kind of talk about some of those lessons learned. Yes, sir. Let's say the most limiting how many for that? Oh, that I don't know. Not to do it. I know we're trying to wrap up now. But I know we don't have to do it. Yeah, see.

Kat Landa:

I have a lot of lessons learned from generally the entire operation. So I'm not going to go into all of them during this talk. I have a talk on Sunday. But I think the most important lesson looking back, and especially for after that sucker punch from Captain D in, the biggest thing I can I can take from that experience is being engaged with your operational leadership in the planning in the phase zero time piece of all of this while you're planning to plan, we thought we weren't even going into Afghanistan, we thought we weren't going to have to do an evacuation. I mean, from the top down, that was the messaging we were getting from our operational leadership. That being said, being engaged with them put us in a strategic position at the time, to best support the sickest marine that that survived the actual blast. I had a very public disagreement, fine, friendly disagreement with my CEO, more than a month prior to the event, about where we would be located, should we go into Afghanistan, and his position was, I want you at the rule two, I want you to the rule two, I don't want you close to the Marines, because I don't want you to get hurt your team to get hurt. And so we came up with a compromise after a little bit of back and forth. We had similar personalities. And after a bit I said, Sir, we're there to support your Marines. In that case, that we they can't make it that 15 minutes around the flightline. There may be a time that there is someone who's so significantly injured, that they wouldn't be able to survive that ride. And unfortunately, I turned out to be right in this situation. Not that I wanted to be because again, this is a horrible situation. But there was one patient that came to us and many of them bypassed us at our at our role one E. We're calling it because they went straight to the roll to where Fortunately, there were five trauma teams available right there at the roll too. But the corpsman knew we were located a quarter a mile from them. And so when they had someone who was Perrier rest and you know, they didn't have oxygen, they don't have any tools. And they expertly the corpsman expertly recognized that this patient needed help. And Newari were so bummed the extra half an hour or whatever it was that got him to the operating room. And again, that's a credit to that corpsman who recognized that that patient needed help and that he he found us in that in that moment. So being engaged operationally is the key, I think to take from all of this if you aren't engaged with your operational leadership, and that goes across the board, especially in these joint environments where we don't have this like purple model yet. You have to know what the operation looks like, what your plans are and integrate fully with the Marine Corps for us or other operational line leadership. Can you clarify what do you mean by harder sir?

Audience Member:

Given 11 hours notice, why because the person who was supposed to go rangefinder figured out 11 hours before deployment and BB was a curl. Right work for me. I got substituted. As much as we've made headway forward. I think it's important that we understand your conversations where the person earlier happened. About there's advantages and disadvantages, but laid out. What are your toolkit? Nobody better than you.

Kat Landa:

I had the background and strange honor and I hate bringing this up because it feels like every time I have a conversation about this, this comes up I was the first female battalion surgeon for First Marine Division back in 2012. So I went with Third Battalion, fifth Marines at that time for a two year tour and kind of got used to the environment of the division line background so this deployment because I was female wasn't as a large deal to me, because I'm just used that back and forth and just integrating and being myself, despite the fact that, you know, Marines have, especially line division background have their own mentality about women being in combat. I think it was harder for my nurses and my fellow emergency physician, this was her first operational tour at all. Understanding that they may treat you differently. Marines, especially, for example. So I think what you're getting at is my CEO wanted me to be at the role, too. And I had a team of five female officers, and half of my core men are female. And pushing back on that, I think, partially that may have been because we were a group of women, he didn't really want us to be close to combat. But that being said, I had this argument with him like we are there for your Marines, if I can't be there for your Marines, who's going to be there? And so laying that out and just being firm about it. I think that that kind of helped quite a bit. But yeah, there are a lot of operational challenges being when we were the Marines. And it's just one of those situations that you get used to, and I think eventually the Marines will change as we've integrated more and more females. Maybe, maybe not. I've seen a difference, though, at least seeing now. Like female enlisted with the infantry. I'm like, Oh, wow, that's new. But yeah, it's a different situation. I don't know if I answered your question completely, sir. Yes, sir, the boldness is a big piece. And he's saying, he like flippantly said, Well, you are the subject matter expert. I said, Yes, sir. I am the subject matter expert. And this is what I said. And he, we left arguing with each other, and I did what I wanted to do, because at the end of the day

Moderator:

take what I'm hearing from you, as well and from you is, by being at this operation planning meeting, you have to be able to speak their language. So just as we have to talk to each other and communicate with each other on, you know, when you go into your presentations in the hospital, you have to be able to speak a different language to the line and you're not communicating with words they understand. And maybe simpler, it's the Marines are more intellectual with the Air Force. The Army just kind of goes with whatever it is. But, but I think that's really important. And so I think that is an important thing, that either you said, like, Hey, if you want me to treat your Marines and your guys, I need to be there. So like, I think that's something that we can, we should highlight here, especially for some of the residents who haven't had an opportunity to interface with the line, treat it like a foreign language, and you've got to learn the language because you can't speak their language. You're never gonna get any changes. And they boy, Aqua Hancock with policy change, if you can't speak their language, you're not going to change. So I'm kind of talking about lessons learned. He mentioned some of the challenges, what was an unexpected, the greatest unexpected challenge that you faced during this event?

Kat Landa:

That you guys can take the microphone.

Rod Fontenette:

Again, the two for me, were the lack of pediatric supplies and then making sure we had enough blood available, right, because we didn't know what we were going into leaving Ramstein. So what we ended up doing was we worked closely with the blood bank there at lunch to at law MC. In every Seacat team that lifted out of their heading downrange, they left with a Collins box full of blood, right because we just didn't know what all we need. So it helped out tremendously, because there's quite a few patients that ended up getting transfused as a matter of fact, when we went and did a tale to tell with the team that was at Qatar. So they went to Cabo and then we lifted from Ramstein, and we all kind of run the food back at Qatar. We got the two patients from them. I got one off the plane. And then we actually went into the hospital at Qatar and at the second patient, we ended up having to transfuse the patient that we got from them. So again, just making sure you have adequate supplies. What I did on the pediatric side was I remember when I was attacking back in Africa, Djibouti, we had like these blue, kind of like brazo bags, like pediatric bags, right? And so when all this started to spin up, I was like, why can't we just find those PT brazo bags? Right? And no one had I went to the log ease. They have even heard of these things. Typical log e Speedos. Can you give me an SN of that way to have them to put it in their central? I don't have an innocent just readily available. So we went to Lorem see to get another patient and as I'm walking through the ICU, what do I see on the court? The blue brazo bag. I was like that's the bag that that I need. Right and so I call the folks I think is a peds floor whatever wasn't an extra one of those bags. And so they said we have one bag in the SimCenter that we can just give you I was like perfect, right and so the guy was like But everything is expired and I was like doesn't matter just send it right now I have no supplies right and so what do they do? Before he brings the bag he empties everything out of the bag and just bringing the bag which is empty purple in pink and red in yellow empty pouches I was like this helps a lot so then a log he was like what do you have to pack out list that goes in each pouch? I was like again, dude, why am I gonna get this information from so I reached back to Leslie wood kind of wood back with AMC, and I was like Ma'am, I found the bags that I need. Can you get me these bags and she was like I'm on it. Within the next few days. AMC had it like Rush shipped us like three of those bags of respiratory therapists and I we built two bags of stuff that I just felt needed to be in each one of those bags and then every team that lifted to go downrange level one of those bags and I made sure we had enough et tubes and in each one of those bags that we had nasal cannula that was pediatrics. Now we're breathers out of Pediatrics. We had everything that they could possibly need. I found lmao like our anesthesia folks over at alarm. See, I was like, I just need a bunch of pediatric LMH. Right. And and so they hooked us up with everything we could possibly need. In those bags. I found vent circuits that we could put on because right if you're gonna put them on the vent, I can't use an adult vent circuit, right. So I had to go find vent circuits. So we found all those things to make sure those teams are ready. And then we actually had a put together a bunch of didactic sessions, right? Let's just get together with our AE colleagues and say, Okay, now let's talk about vent settings on pediatric patients. So I was presentation in pediatric patients so that all the teams that went to go pick these patients up they were ready. So that was that that was one of the big things we did another thing was so there was this kiddo, right. And so Lauren see they don't have a pick you right so what they did was they found two pediatric dogs find out which hospital they came from downrange, but I think from leaking he and they brought them up to larm see to staff like their makeshift pick you and so that was really really sick kiddo. She was I think this little girl was I think she was the one that was two and a half years old and about eight and a half to nine kilos, right? So a lot of them were very malnourished, right? She had blast lunch, it just she was sick, right? She was intubated. And so they called Seacat was like, hey, when a patient needs to be transferred, transported back to the states to Walter Reed, like, Okay, we'll come round and see the patient. So the C cat team goes and it was anesthesia provider was the doc on that team. So they get to Lauren Z. They're looking at the kiddo and the log roller, right? And when they log roller to get an x ray has sat strapped to the 50s. And they wanted them to take one more, right and so assess dropped into 50s. And it took about an hour for her to re recruit to get back to where she needed to be. Instead of like, nope, she's not ready. She is not safe for flight. Right? And they were like, well, I don't understand how USC cat fill, you can deny transport. And she was like, because this patient's not safe. You can't even log well this character says dropping into the 50s and staying there. Altitude doesn't make that any better. Right? So basic physiology, right? And so there was like fire right? And so this thing blew up. Right? This one star got involved. I mean, it was just so there was a horrible, right and there was like finally it was like okay, fine. MC got involved. And it was like if see can't see the kid Oh, can't go, kid. Oh, can't go. So then they transfer the kid off base to Humber to their actual pick you. So the following week, my team's up now. Right? And I was like shit. So my team is up now. And they're like, hey, skiers ready for transport? I was like, Oh, you fell for that once I said I want to go see this kid. Right. So my RT my whole team and I we get in the car. We drive 20 miles. It's about a 20 mile 30 minute drive to Humber go to the pick you we see the kid right? Kids on clonidine drip medazepam drip on ketamine drip. And something else they had this kid on, right. I was like, well, he she sedated. Right? And so like, there's that. Right. And so I was like, she looks good, but they always look good on the hospital van. Right? I don't transport with the hospital. So I was like, Alright, we're gonna go back to the base, get our 731 Come back, connect the kiddo and see how she does on our vent. Right. And so again, none of them speak English. So trying to like communicate this back and forth. It was like I was like, We'll be back right? So we leave go get the vent. We come back we get the kid on our vent. We get a blood gas. She looks great. Look at the team. I was like, I think we can do this. I gotta think she's ready. So it was like, alright, we'll be back tomorrow the flight because we also had patients at alarm z. So it's just working out the timing piece right to get those patients from alarm z to the plane while we're working on getting this young girl transport on an ambulance back to the base. So we get to the hospital in Hamburg that morning. Right? We put her on the vet on the settings that she had just did great on the day before. Right? We get on the vet. We wait 20 minutes, we got a blog airs. Her pH was I want to say 7.1 and a Ph co2 is like 127 Don't think. And I was like, I don't understand what happened, right? And so if all things were still the same, it's just like less than 24 hours ago how she gets so much worse. Right? And so this were kind of us as the IDI dogs, right? This is what I tell the residents like, we have to be comfortable with that vent, right? Because on the Air Force side of things, our respiratory therapists or respiratory therapist by name, right, we call them cardiopulmonary technicians, right? Not all of them are created equal, because not all of them are dealing with vets every single day. Right? And so we have to be comfortable Manning managing that vent, because they want to turn to us if they don't know what to do next. Right. And so we get on the vet, it looks at me, and he was like, I don't I don't understand what happened. Like, I remember the exact same settings I had yesterday, and she is significantly worse, right? And so I was like, Alright, so let's kind of start do so we start when I started adjusting event. And right as we were adjusting the event, the Homebrew position pops her off the vent squeezes like a whole thing of saline down the tube and just starts bagging, right? Some Artis like looking because the vents alarming, and he's like, What the hell is like, and he looks at the kiddo and notice that she's not on the vent anymore. And he looks at me like she just de recruited everything that she had, like, why would he? Why would he do that? Right? And I was like, just let it go. And we'll deal with it right. And so you get back on the vet, and I'm still confused as to what happened. So then my nurse walks over. And as he's now trying to get the drips transferred over, he's like, you know, this little girl is like, eight and a half kilos. He looks at me and he says, Hey, Doc, do you want to keep this LR going at 100 miles an hour, you want to change that? And I was like, I think I know what happened. I think I know what just happened. And I like you guys to be kidding me. Right? And so as the doc on the team, now I have to make a decision. Because if we package this girl up and put in the back of that ambulance, she's ours now. Right? And she wasn't safe for transport before. But I know that once we leave Hamburg Vamsi has made it extremely clear. We do not want her back here. Right. So once we leave, we can't go to RMC and so I jokingly said we would just turn around and come back. And that Homburg nurse was like, no. Oh, you do speak English. You do speak berming English. He was like He ain't coming back here. Oh, no way. You're gonna know where you go from here. But no, he ain't going ain't coming back here. So he and I continue to adjust the vent. And we got everything to kind of turn around, right? So I started lasix started racing, I adjusted the vent. And finally we looked at each other and I was like, I think I think we're ready. I think it's gonna be a good flight. But I think we will be ready. And she did great all the way back to Walter Reed. I even called to check on it and all went well. Right. So I think one of the biggest takeaways as we have to be current and competent with pediatric stuff, right? Because pediatric Seacat teams don't exist anymore. Right? It's just it's us now, right? It's the regular adult Seacat teams. And in these contingencies when these things spin up as quick as they do, quite often is the kiddos that kind of get roped into this. Right? There was another kid that we transported that she was just one of the regular evacuees. It wasn't even a medical evacuation, right. And so she got loaded up on a C seven T with all the other evacuees and then they had to get screened and have screening vitals as they went through the day in processing tent at Ramstein. Well when they put the postdocs on her her SATs were 50. Right. And so there was like, well, that's that's usually not good. So they got over the alarm, see, and she had a uni ventricle. Right. And so we also would see cat had to transport her back to the States. When I went in the room. She wasn't even an ICU, she was just in a regular room and I went to pick her up her SATs while she was chilling in bed with 60. And we were there to pick her up to put on the back of C 17 and fly to the states. And I was like, well that's she has to she has to go. I mean, there's nothing that we can do for her here. She has to go back to the States. Her mom took off, took off oxygen and walked into the restroom, we were flying and she can like put on a poster SATs with 32 like Eagle just pee on the letter from this point forward because you're not you're not coming off this oxygen anymore. I mean so these are the things that you just you don't think about because we think combat I'm like I'm deploying for sea cat so I'm going to transport a lot of sick adults. And in these contingencies especially like when you think about the things early on which trying to get people moving. These kids get affected by this stuff quite heavily. So I would definitely make sure you read up on your power so what I did was to PD stat right until all the ducks put PD stat on your phone right at the end of the day when you started if you already fumbling through things you already nervous just refer back to PD stat and put the weight in and spit out everything you need and go from their right and that's exactly what they did. They all downloaded PD study we're good to go so Yes, sir. You want to give it to us on our own?

Travis Callen:

Right. I think the biggest challenge I had was going from but over my deployment I was inside of a hospital and that's where I trained at I did fellowship out at UMC and Nellis Air Force Base. So I trained in trauma Bay's and emergency departments on the 26th. We had our first marine come in and he's very sick and unfortunately despite our efforts, he was a casualty. At that point, I went outside to assume my role in the triage Bay And I kind of went from being an indoor cat to an outdoor cat. And I had to practice medicine outside on the ground, without oxygen without suction, without nurses to help. So it was my first time really just working with corpsman with stuff that was laying on the ground next to me. I remember that challenge being like, Well, this guy, because we had one Marine that was on his side in the recovery position that was going to lose his airway soon. So we, I was immediately like, This guy needs suction, and he had terrible wounds to his face and jaw. But suction wasn't an option. So we put them on the side, and we started spilling the blood out of his mouth. And I tried to take a 60 cc syringe with a 18 gauge Kathrada to suction out his mouth and quickly learned that doesn't work. But luckily, I was able to wave down our DCCs, the colonel Bruce Lynch, who got the marine inside and he was taken care of inside, we avoid doing a crike outside. But I immediately went from that scenario to re evaluating the other other patients we have, they're already categorized. And we use the NATO system. So there's your T one that go inside right away, T two, that would be like our delay, and T three would be minimal. So I was making my way through the T twos and T threes because the T ones had special operators and other foreign surgical teams taking care of them outside. So I felt I was best utilizing readdressing tourniquets going back through primary and secondary surveys. And while I was doing that, it was incredible to me what was in our T three and minimal areas. Like there was a young girl probably like she looked like an like an American 12 year old. So she was probably like an Afghan 16 or 18 year old but very medium size with penetrating trauma to her abdomen. And I pushed on her abdomen, it was really hard as a rock, obviously paramagnetic and she yelled at me screamed at me. And this young girl didn't go to the O R for six more hours to say so you can understand the mechanism injury that day that our people went through. She was back in the T three area, which would be walking wounded if we're at an airshow and something happened, right. So the biggest challenge for me was saying, okay, Travis, she's she would be a T one back in the States right now she's a T three. So reassess Do you can eventually she'll get the care she needed. Same thing with the the airway patient that was losing his airway quickly, he was T two, and there was people in front of him, they were T one, because of the panic I had, and probably not enough field experience, honestly, because if I was a field trained medical probably just would have cracked him and maybe saved a bed inside for someone else. We got him inside. So the challenge I've dealt with since then, is kind of accepting what I failed at as far as not acting sooner with him. And realizing where I can improve as a provider. Your most unexpected challenge?

Kat Landa:

Yes, there was a major one, again, that this is reflected kind of the bigger picture of the entire process, because we were already multiple days into the evacuation at this point, and actually move people pretty quickly by the 26th, from where I was, as opposed to earlier in the operation. But when we were doing our plan to plan again, we had a bunch of medical equipment that we had on the flight line along with the rest of the marine stuff that was going to fly into Cabo from Saudi Arabia, where we were for the deployment. And fortunately, one of my nurses as we're getting ready to go because they said okay, don't worry about it, your equipment will fly. And right after you, one of my nurses, like let's grab all of our scalable stuff out of that quad con, which was fortunate was Bella, who Christina Polk and I deployed with at our prior deployment. And fortunately for her foresight, and again, just being anxious because I just I don't have a good feeling about this. Let's just grab our stuff. And because we had been practicing being scalable, and utilizing smaller teams, we had very limited but some medical equipment when we showed up. And in a true Navy fashion as the admiral had pointed out, we did beg borrow and steal, highlight steal from the rural to and also from the 24th Mu who was located and in North H kya. At the terminal, some of their equipment. Unfortunately, it 24th Mu came on the morning of the 26th and said we want our stuff back that you stole from us because we're about to pack up and go home. So on the day of the mass casualty in that evening was around 530 at night. We only had one canister of oxygen, one monitor, One vent, one suction and we've got four Pretty sick casualties right off the bat. I mean, two are airways that were able to, if you just position them they'd be okay. Kind of like the one you had mentioned initially at least one that was it like a penetrating injury to the arm. And then the the fourth one, which is this very sick gentleman. So, again, resources that we didn't have I mean, the pediatric stuff was huge earlier on in the mission and we had kind of made up some field type care for babies and children, for the evacuees, because there was a lot of medical care that happened prior to the mass casualty that we tried to keep her in the role too, you guys were getting inundated. So that's actually one of the requests they had for us was can we start seeing those patients, but the lack of care, lack of supplies that we had available, like available to us at our site. For the mass casualty, we were working on our backpacks, which fortunately, I had phenomenal faculty and mentors, some of which that are in this room, during my residency about you know, making sure that you're able to be scalable and make sure your backpack has your, you know, otusa and all these other things that you that you need, and we ended up working out of those. The additional piece was the human resources. So to one had asked us to push our ambulance which again, we were only a quarter mile, but push one of our ambulance was some enroute care resources down to the gate in response to increased threat level, the night before the mass casualty so I actually split my team. And our teams were kind of doing cute 24 hour shifts with one nurse on each team. Myself, the other ER doctor, we actually just lived at the roll. One, we didn't really go back. And the team that was off was actually helping out with the ambulance triage at the time. But I only had three corpsman and one other ER doc myself at our role one during the actual mass casualty my team that was at abrogate was a nurse and three corpsman. And they were actually triaging at the gate doing that mass casualty at point of injury. But again, not having a nurse. Again, there's been there's some faculty that are here that told me as a resident, you may not have a nurse, get used to, you know, doing your own vitals and being comfortable just doing the nursing procedures. And that was definitely the case. So those were two huge things, resources were incredibly limited for this particular region and the type of teams that I had for such a large number of casualties.

Moderator:

I'd like to take this opportunity. I have some more questions. I'm sure you had enough facility time questions with me. But once I open it up to the group here any questions or comments from the audience?

Audience Member:

Just assaulted myself. I'm I'm Andy. I'm one of the third year residents at mod again. First, I wanted to thank you, sir, for kind of asking that question before as like one of the more junior physicians here. And like someone who's just about to graduate, it's really encouraging to have male leadership actually acknowledged the fact that women do have, you know, oh, obstacles, although they might be like unseen, but it's just an additional burden that we carry. So I appreciate that, but kind of along that line, I'm going operational next year. And, uh, kind of wanted to see if you guys had any advice for not just as a female, but as just like a junior medical officer, when you're having conflict with your chain of command that may not be medical, and kind of how you stand up for yourself, how you stand up for your medical team, the needs of the mission of yourself and your medics in line with, you know, the rest of the unit that's not medical, because it kind of you sounded, it sounded like Dr. Lander that you alluded to that there was, you know, disparities in your vision of moving forward. So

Kat Landa:

I think the key piece is coming back to being able to speak that operational language. But even if you can't do that, if you can put your potential patients if you can put those people first, if you can say I think this is a risk because of XY and Z, or I recommend this because I'm concerned about if you can phrase it in the way that you are concerned about their soldiers, Marines, sailors, airmen, if you can phrase it in that way, even if you can't speak the language that should come across. Now that being said, I have lots of other things we could talk offline about, which is also about you know, decreasing emotionality of things. So you can state your concerns without actually getting emotional about it because at the end of the day, the operational commanding officer, the line person, what they say goes, right? So you can have these conversations, but no, at the end of the day, their decision is their decision. So I did have this kind of like back and forth. But I also acknowledged that, sir, if you want me to be there, and this was an AAR, it's an after action report for exercise we had done that this came up, said if you if we do this, and you say, you need to be at the role to I will go there. But if you don't tell me that, I'm going to do what I what I think is right, and he was like, well, whatever you think, Doc, and that was that. But again, taking the emotionality out of it, and putting your future patients first is probably the best way that I've learned to deal with any type of leadership challenges, and that's on the line. And that's also even in the MTF, as a department head. Same thing, if I could explain it in a way that I was concerned about future patients, and actually describe why and what risks I was seeing that always seems to at least help you in your mission to be the best physician you can to these people. Did that answer your question?

Unknown:

Yeah, thank you.

Audience Member:

Good afternoon, everybody. My name is Dane Davidson with Zolo medical. I'm a former Navy guy, but I converted Coast Guard and ended up retiring Coast Guard, do work with Zoll medical and a couple of things that have hit me, I've been in this role. I'm a paramedic by train. And the first thing I want to say is that as a paramedic, we strongly believe that everything starts and ends with physicians, we can't practice without your signature. And at the end of the day, when we have a critical patient, we're bringing them to you. So to us, it's all about you. And as the Admiral said, Who better than you. And I say that to bring up two other points that the captain in his presentation a while ago talked about the devices where the monitors failed, the batteries failed. Other kinds of significant equipment, issue failures, as well as with Dr. Fontan net talking about the options of you know, folks weren't exactly comfortable with the possibly with some of the settings on doing ventilation, whether that's pediatric adult, whatever the case may be. I say all this because I want to bring to you a resource that we're here for you. Zoll medical right now our ventilators are aspirators, or monitors, or defibrillator is there, four of five very critical things that you all carry in field medicine, roll one all the way through to the to the MTF. There's seven of us on our team, that our whole goal and role is we're very passionate about coming out in ensuring your readiness and your training. It doesn't cost you a dime, all you have to do is reach out to us. We will come to you we go everywhere we could see you in Korea, we can see you in Japan, we can see you here in the States anywhere. And I know some of you were here to hear that earlier. But I know we didn't have all the room after hearing some of these other stories and I want to say that we do get calls a lot with people in the field that have had what could be a catastrophic failure on their equipment, but was actually very preventable and very simple. If they would have looked at it on the forefront and I say that to you as the physicians use us as a resource to come help you and your teams all you got to do is call us we're here to help thank you

Moderator:

hospital, every hospital every ICU every er every aid station, so project nature camps dirty with equipments, right so a lot of that's the magical uniforms of the nurses and medics and forming that we work with but you as a physician that guidance. You're already trying to figure out how to turn it on.

Unknown:

makes everybody walk into a room you think about things you didn't do or you do this long enough. You're who you are. As long as you're absolutely going to be able to pretty good look at it.

Audience Member:

Nobody says especially with extreme circumstances. Last Name, questioners. This is where we don't talk about. We'll talk about we'll talk about we'll talk about configuration. So I walk around with a dog it's pretty nice to do my job. But without a doubt, there are things I like to say. If you go do what I did because African British there All right I want you all to take a collection from the old man and ever know how are they not us we were in the field when you look at those my class though they have different inside of giveaway the biggest thing that grabs these packets that are actually watching and once it's out there I was thinking the same thing all said oh my god you can share your goals that are normal each other in time we had a lot of my PTs in the background keep up with three year old cigarettes or car accident those things Travis stood up here I apologize we're not going to get rid of genders Yes, you are some disadvantages. Oh my god did you actually manage? On top of what

Laura Tilley:

we're offering to our clients we have go through trauma and trauma and so the needed mental health professionals revered were that it acceptable. Growing our bandwidth and being able to vote

Unknown:

yes, something dramatic happens. But there are new things. And we can get to the other side. You don't have to get smarter about how we get and there's so many new they're coming for the free plugin is EMDR therapy that is very one of them. You don't have to be nervous. Yo Yo

Audience Member:

you talk to them. They're saying it's going to change the person. But PTSD for sure. But I'm like

Laura Tilley:

everyone for everything. You had a question?

Audience Member:

To follow those two comments. First, thank you for sharing your personal experiences, because it's less than a year ago and so we appreciate that. So there's a lot of discussion on pediatric or lack thereof interventions and training in you know, were all in charge of resuscitation. My question is more in the operative management that damage control surgery. Did you all see any barriers to treating pediatric surgical patients at your location or even post op surgical patients during the actual, you know, intervention during the operative intervention, whether orthopedic or general surgical and then have a follow up.

Rod Fontenette:

So by the time you made it to us in Ramstein, larm see if there were like there was one kiddo that he was like five years old, pretty severe traumatic brain injury intubated. Like literally when that kid landed at Ramstein, he was airlifted in the Hilo of base to Hamburg. So I mean, they will move in those cases pretty quick out of there if they needed something more definitive, because we obviously we didn't have like a pediatric neurosurgeon and all that stuff at Lorenzi So as soon as that kid landed me within like an hour or so he was on a helo going. So they moved him pretty quickly. And that was the only severe trauma when then I had the rest of the world medical stuff.

Travis Callen:

So we had, I think there's at least three pediatric X labs that were done at the role too. And I mean, our surgeons, I didn't hear of any complications, and all those kiddos end up getting transferred out without any big issue. And in the recess Bay, we're really we're really blessed to have em physicians that also moonlight and do like the teaching agreements between civilian hospitals. So they see pediatric patients outside the base. So when it came to resuscitation of a pediatric child and hemorrhagic shock, it wasn't something new or they weren't on their back foot, they were able to do it. My doc, Eric molesky, put in a pediatric central line, like in 30 seconds like, and I think that that's a really a big testament for the active duty folks, like if you're at Bamse, or if you're at like Tripler or the other bases that are seeing a big patient population, you probably don't need as much, but the smaller institutions, I think you can't beat the training agreements with local hospitals and getting your Doc's and hopefully, someday the mid levels, the PAs can also get out and do some of that stuff as well. But to answer your question, sir, the damage resuscitation surgery, and the recess in the trauma areas for pediatric patients, as far as I know, went well.

Unknown:

Great, and were there any army F RSDs or fsts? At your locations?

Travis Callen:

Yeah. So um, so we closed Bagram 20, June went to H kya. And we joined a army FRS table, either the 9/75, or ninth 23rd, which was a half of their team, the other half was in Kuwait or, or Bering, and then the other half joined them. And then, after the 15th of August, when stuff started, go belly up, half that team retrograde, and the other half stayed there. So there was half an frst with us, as well as a bunch of other special operations, conventional and partner nation surgical teams. I think the final number was around eight or nine.

Audience Member:

Just a quick question. So if I understand this correctly, and I think I do so we had Marine combat lifesavers, who handed off patients to a navy role, one who handed off patients to an army role two, that were evacuated out of country by an Air Force Seacat team. So my question for the group is, had you met each other beforehand? Had you ever had a training opportunity between the services and if not where our gaps in our blind spots?

Rod Fontenette:

Because I hadn't, I hadn't personally I had met, had met anyone that we came into contact with, for many of the other services. That was all just kind of melding kind of went from there. But I had never met any of the other folks that handed patients off to us. So

Kat Landa:

now, there were no joint joint trainings, even the planning for it, a lot of the planning that was involved prior to going in was very COVID focused rather than actually mass casualty. I kept asking for mass casualty planners, just north each kya. And I was like, well, that's the whole base. I don't think we're gonna be there if we go there. So there's none and actually is going into my talk. So thank you, Kevin Dean for bringing that piece up. But yes, more to fall, it's a huge lesson learned is that we do need to do a lot more joint integrated, big picture picture planning, from the top down would be helpful so that we're not just throwing things together. Now, that being said, I think the teams worked well together, for the most part, especially for you guys over at the World Tour was phenomenal. Obviously, there's always some friction when you've got new forces coming in, and we're trying to move people over there. And who was this? And why is this? It was It was chaotic. I mean, there was clear on the news, I'm sure. And on the ground, it was certainly exactly that. But yes, it would be a great place to start, especially when we're at committee for teacher we'll see, for example, the mass casualty piece for that, building that out. And again, that's kind of alluding to my talk on Sunday, which is we need to target how we actually work as a purple force on mass casualty planning and prolonged casualty care, all these other pieces that are huge.

Moderator:

So I think I think part of this and I think this is what GSA said was one way to do this. There are certainly other organizations and other ways to bring people together. You've got to show up and step up and pass with the table. Because if you're not at the table, you're not making the decision. So now, he can't have any impact. We can't you certainly can't complain if you've never even tried to sit at the table. But use these opportunities to sit down, meet the Meet the Air Force meet the army people like Rob are smart, right? And so make these connections start working through these things. There's no reason to reinvent them. feel. And so, again, we're here is GSAs that but like whatever my capacity is, and wherever I work, if I ever can help in any way, if there's a problem has probably already been dealt with, maybe the army hasn't dealt with it maybe just was two years ago. So this is why this is the value of the military, right? It's a huge real, even people that have never met together with one another never worked before. And it happens, right you I've heard you were talking about this, you just brought up with like, individuals you never meet until two seconds before you're now running past counseling for years, and that is the military to use these opportunities to get to know each other. And then also use GSA staffer use, whoever your friends are at reach back and say, Hey, I need help. I'm more having this problem. How can we solve it and get smart people in the room and come together with we will add anything I'll just say to plug here about the table is with Adam Hancock, it talks about leadership and being that person and being that doctor that's going to make the change, you've got to take those roles, because if you don't take them, other people will and then do policies that if you don't like or are not the best people to make those policies. So just gonna put a plug in to kind of maximize your time this weekend, take advantage of the fact that we're finally not behind a zoom screen and get to know each other because you never know when you're going to end up on a flight line or a fob or a ship. You're very afraid. I think I need to become a better swimmer after this morning's talk. But you just never know where you're gonna run these people. So

Rod Fontenette:

I think and one of the things that I think frustrated a few of us is that once we noticed that we were moving a lot of sick kids. We had a an Airforce pediatric intensivist that was deployed. And she was at Djibouti, right? And she's ck, right? With the special ops folks. Right. And I was like, what she's not, I mean, she's not going to be used there, we could definitely use a here right to transport some of these really sick kids back to the states for these long flights. And so I mean, we tried and try it and try it and they would not let her go. Like Alicia would not release it. I'm like what that doesn't like she literally there has not been a secret mission at that spot. And 18 months, it ain't gonna happen this week. And I can promise you so I'm gonna let her go and let us use the way she can actually be used there without her leadership specifically told her Don't ask again. We're not letting you go. Yep, I was like this, just this makes zero sense to me. Zero sells to me. So it's just those things that are just so frustrating. I mean, we kept trying to push it up higher and higher. Even the AE folks got involved because it was like this makes sense. Just bring it here. We could obviously use it. They will not they will not let it go. Actually, finally, just the redeploy the whole team back home because their deployment had ended. And she was like, I'll extend and it was like now it's time for you to go home. And they will not release it. That was just so frustrated. So frustrating. Like we have these amazing resources all over the world. And she works. She worked in a unit and Bamse so she was like I see kids all the time. Like this is what we do. Like why why do we have to jump through so many hurdles when we have this resource that's readily available already in theater in just one release? Like that's just that's crazy to me.

Moderator:

There was no layover and H KY on her way back. How I got to this plane and I ended up stopping here my way back to Texas. I think this question.

Audience Member:

And this kind of goes back to more of the joint question. Captain you alluded to there were some special medics and stuff available to you. When you're going if you're Moscow planning Did you know what resources you had available in the local area both internationally as well as nationally for like joint medical 18 Delta's as well as what those resources are actually capable of?

Travis Callen:

Yes, ma'am. That's a great question. I actually, I present on the triage system quite a bit. And the one on my lessons learned for challenges. It's inter service communication and planning. So when you like when we have a mass cow, and it's announced the way it goes out over the loud voice, right, have a camp and all your medical personnel show up. And when stuff started going crazy at HQ, we start getting a lot of units showing up. And so we had a little mass cow practice one night where there was five people that were shot outside the wall. So we stood up off for trauma team. So we technically just activated our mass Cal plan. And a bunch of bearded medics showed up and corpsman showed up that you know, we hadn't interacted with yet and a bunch of army medics showed up. So we kind of started to get adjusted. And you know, we've laid the groundwork, hey, we'd like to talk to you guys. So we can talk about planning. Well, that didn't happen because we were seeing so many traumas every day leading up to the 26th and the 26th happened and obviously you hear a big kaboom and mass Cal goes out. Every medic on that base is gonna go and help out at the role too. And so what that turned into was at least at least 40 to 50 medics and I say medics, but it was paramedics 18 Delta's soccer moms corpsman and then bearded physicians. I'm assuming people that were wearing hiking clothes and had ultrasound strapped to their arm. Oh, So, yeah, so

Laura Tilley:

I didn't matter who they were because you don't need me. You are just

Travis Callen:

very appreciative. They were there. But to answer your question, there wasn't a lot of planning for the 26, just because the units weren't there yet. So before the 15th of August happened, everyone started going, we started to figure out what our medical assets were in there were planning for, like, the Alamo and like where the fallback was going to be and where other teams could go. But ultimately, we I personally didn't have oversight over every medical asset that was there. So when I was doing my planning for triage, the whole plan was to triage was with what we had in the facility. Because when we had practice, initially, at the role to before stuff went crazy, we were told you're going to have what you have. Our medics are going to stay with the line side. And that didn't happen when when push came to shove the medics once their job was done, the line came and helped us so. Yeah, so if that answers your question,

Audience Member:

no, it does. And it just goes to anybody else in the room that might find themselves in those specialty units or in charge of medics in the specialty units, make friends with your frst make friends with your muse and everything, make sure that they know what resources are there. Say hi beforehand and that credentialing is who cares about that? It's just making sure that you know what resources you actually may actually have.

Laura Tilley:

wander around and make friends.

Kat Landa:

That's the key piece there. So I that's basically we did we sent someone in because we weren't in the role to we weren't working out of the role to but literally sent someone in my other cohort. Nikki cook, I sent her ahead of time to go make friends go say hi, this is us. We don't know we're gonna be we're around we'll be sending you people. Despite that, even when we're communicating in the days leading up to 26. With them to send them patients, Afghan evacuees, there was still some friction, like who are you guys, and there were just so many different teams there that depending on who you're talking to, it was never Travis he was actually very kind every time we spoke with them on the phone. But there was a lot of there was some push and shove with that for those of us that weren't actually at the role to because they had their huddles, everything like that the rest of us were kind of spread out there was a special ops team or Alvarado. the flightline is big, and we were kind of the south part. And then there was the North H kya. Group, which is where the roll two was. So it was a little different. And then you brought up communications. I just wanted to highlight that a little bit too. So within the role two, there were good comps, and I know the Air Force and the Army, and then everything for Seacat. I'm sure that's great comps, but for those of us that were not there. comps was really difficult. So comps between medical units that are not attached, and especially because these aren't the same service at all, was incredibly difficult. So we went from the days leading up to we didn't have cell service where I was located. I was in an old security building that was abandoned that I took from the Turkish military and converted into a clinic flash recess area. And yeah, it was jammers right outside because of security building. So there's no cell no Wi Fi, which is what you guys were on signal. And most operations even for the operational side was on WhatsApp, and signal, right, so we have no comms with that. Fortunately, I had grabbed a couple Marines they had given me from to one to have green gear between ourselves and to ones who had comms always with them, fortunately. But as it went on my Camarines jerry rigged a printer router into Wi Fi to give us Wi Fi to actually communicate with the roll to and that is the only way that we actually announce to you guys that there was a mass cow, it was actually text message that we did on signal. My first one was like, same time that the mass cow actually happened because we got it right on the green gear. There's an attack on abbeygate casualties pending, and then Nikki put one out mass cow and she got when we're done with our patients, you know, two hours later, she's got these nasty grams from one of their trauma surgeons like you can't announce mass cattle like, Well, we did. You had 58 People coming to you, you know, like, so that's kind of the friction to that you see, between units that aren't actually attached are actually in the same structure or working together on a daily basis. And then also the communication piece. So there was I mean, we went through a, there was a time that a landline was working, we were able to call with just the evacuees, hey, we're sending a patient blah, blah, blah, nothing about the patient or the time or the location or anything like that. But yes, signal and WhatsApp was the main source of communication if you don't have access to that because you don't have Wi Fi because you're not on North. Ah kya that was an issue. So I was very fortunate to have these junior Marines that just seriously were heroes in their own realm

Audience Member:

talked about the fact that you know, you had all these people show up when it's wonderful to have all these people show up. You know, I talked a little earlier about, you know, blood use and making sure it was great they showed up, but particularly in that region at the time, the TTPs that were out there, you guys weren't expected to get one you were expected there is going to be at least three. So there's a lot of danger in that emotional reaction, right to people flooding to a problem. And that's where that discipline, and that's where these relationships and understanding where I applaud your work free. But really, there's got to be a lot of discipline there. Because you get hit, you get hit again. And early in the war in Afghanistan, one of the best TTPs they had was putting IEDs under dead bodies and shipping them in is an all of our medics would rather flip them over. And now we had a big problem. But again, it's just one of those things where talk him through, I will say at the last time, and then I'm probably going to be leaving here. But nobody better to do this today. Right in this conference. But more importantly, when you go back, I mean, how many people that are currently in Fort Bragg have been diligent. How many people in Louisiana been to Fort Bragg? It's an hour drive hour and a half. And I think the beer is cold in both places. Thank you, I did want to ask about security. And so asking just in the resources that were available, and how that was handled. And if that was one of those things that you could offload have somebody addressed or whether you need to interject yourself in ensuring that that was taken care of which location? I think that will look different in each of your components. And so if you could each address it, that would be helpful to us. Thank you.

Kat Landa:

I'll start out point of injury for my team that was there. The Marines themselves had security. So they were kind of taking care of that at my location. It was just the corpsman myself. That was it and our Camarines, which, actually when my calm Marine, Lance Corporal showed up, I said, and we were riding outside, we were getting gassed, there's all kinds of stuff. This is before the 26th. I was like you are the most senior marine here. So when it comes to tactical things, you are the man and he was like, Yes, ma'am. And he went to town, making sure that building was secure along with my corpsman too, but he took his job very seriously as a Marine. And I appreciated that a lot about him. And so at the time of the actual mass casualty, we also knew that there was there was Intel for multiple blasts. And that was a little concerning. And so we weren't trying to go outside. But that being said, we're also trying to help offload patients that are coming to us to help out so it was limited the day of the mass cow prior to that we had Marines that were actually securing our building because we had a lot of evacuees trying to get in, which was a different situation completely.

Rod Fontenette:

But us for security. The big issue was whenever we will fly, like to HKIA, or even hit Qatar to replace the CCATT Team. We would obviously the Ravens with us, right? So the Ravens will fly there with us get on the plane with the Qatar team, and then they would then go forward to the sky. So they always had security on the plane if they were going kind of into the actual area in and of itself. One of the other issues that we had early on was just it was so many evacuees that even we like we would have like a few patients on the plane. And then the rest of the pain plane would be filled with evacuees, right. So you just just making someone had done their sweeps and that everyone was safe as possible was always a threat. But if we knew we were going actually into h Ky, then the Ravens would just get on the sea 70 with us and just fly with us for security. So then we were landing and they would go out and kind of spread out and do their thing on the flightline and then before we burned out they would all come jump back on the plane and then we'll go back home so we always had security's.

Travis Callen:

Pre 15th August, there was a International Military Police on the base it was a NATO base. Luckily 310 from the 10th Mountain Division from the army provided a lot of security for us from the period in between there and the the mass cow once the perimeter started getting breached H kya all army resources from the 82nd. In that time, I think most of 110 had ripped out except for Joey Griggs and Sloane Kelly, which were two medical officers that stayed and helped us a lot during the that two week period. So it was the 82nd and the Marines that provided for base security for the hospital itself. We have the Norwegian Defence Force medical folks and they send people with personal defense weapons like little 5.7 submachine guns, so it with them that guarded the door and also escorted Norwegian civilians to the flightline and then ourselves so the Day of the Day of the perimeter breach. A sergeant major from the from the army came to us and basically looked at me and two army medics and said prepare to defend the hostile but all our guys are busy. So which was very understandable, because the flightline, if you haven't seen a picture of H kya has no fence between civilian side and a military side, it's a run. And if you can do that 400 meter dash and you're from Kabul, that might mean you can get on a plane. And obviously the news showed that. So the SAR major told us that we grabbed them fours and M nines, we put an ambulance in front of the door of the ER, which we then discuss this but bad idea if somebody's getting side that gets shot. So we moved it. And we defended the hospital. Luckily, no one came but we we were essentially our security. Later on before the 26th there is an increased threat of suicide vest IEDs standard protocol prior to the fall of Qubool was to call God Turkish God and IMP God would search the patient after that it was on our staff so myself, I remember these these guys were burning stuff they weren't they didn't have any bad intentions. But these Afghans civilians were burning some cans, cans explode and pop and they got some penetrating shrapnel to their bodies. So the lights are out at this point, the concrete overhang of the roll too. So you can't really see out there we see cameras we see guys coming up there Afghan locals, I step outside with one of my Norwegian nurses and ask like what are you guys doing? We're hurt. We want to come inside get looked at. Okay, so myself and Kim American Camp we've I can't remember her name. But we went over and strip searched a guy in a blast bunker with Sergeant Smith who was a reservists from the army. I asked him to stand by with them for away from us. But looking at his buddies while we were searching him before he came into the hospital, we did have those metal ones, but they just beep all the time, no matter what you're scanning. So it didn't really help. Luckily, that was the only time I had to Pat someone down. But at that point as like the triage person after after Sloan Kelly had left who is a another PA, that was the main triage person during the actual Mezcal itself. I did search people before they came into the hospital and a handful of times. Luckily, nothing happened. But the security for the most part was self provided outside of the Marines and the soldiers that were our primary security for the base, if that makes sense. So structure security.

Moderator:

So we've got about 10 minutes left in this discussion, I wanted to give you all an opportunity, if you have any. I know you have a talk on Sunday that you can get some more details, but there's anything else that you would like to say, to our group?

Travis Callen:

Yeah, um, earlier today, when Captain Deaton talked about, we're here for the service members, that's our job. Really, just remember that our job is take care of service members when they get shot, or blown up.

Rod Fontenette:

Nothing the other patient demographic that we saw quite a bit of was OB patients. So much so that the Air Force actually deployed OB teams to be on all those flights. I mean, there were a lot of pregnant patients that we transported. And that was I mean, they were like, very pregnant, right? I mean, one that we transported, she was like G nine P whatever, at 40 weeks with twins. I was I mean, we had turbulence, we're screwed, right? So I'm like, this is not gonna be good. It's gonna be horrible, actually. And she was probably like one of like, five pregnant patients on Wednesday. What are we gonna do it all he's like, this is a lot of people. And so that was another issue right? As I do have OB kits, like I know, we have a big procedure bag, but Oh, no, there's OB kits in this thing. So now we have two patients, right? And so it's so all that we need more blood, right? And so then when OB Doc's got there, they were like, Hey, do you guys carry Pitocin? I was like, see cat, bro. Okay. It says, like, you don't get out much do you? Like is like, you know, you don't have that? No. Right? So he might, he might want to go to alarm, see and see if they have some of that stuff. Right. So again, just talking to these folks that we've never deployed with, right? They don't know what we have. I did not know what was in the backpacks they had. So we had to come together and just kind of do like a sharing session of like, okay, what do you guys actually flying on the back of the plane with? And then how can we from see can better assist you? Right? And if mom does deliver, right, I'll take the baby and you make sure mom's okay. And then once you make sure mom's okay, if mom has any airway issues, and I'll step in and help with the airway issues. And then we'll all make sure the baby's okay. Right. But yet we had to plan before it was time to actually go out and do the mission. Right. And so again, if all these teams have never ever worked before, and is this a leader of the two he had never flown before, they never deployed before. So this was the deployment in and of itself was new, right? That experience was new. And then now they throw all of these pregnant patients out there, they have no idea what their, like prenatal history was, right? And so now they're trying to find all this information out and it was just so the pregnancy in the OB piece was was pretty robust. as well as as well. So flexibility.

Kat Landa:

Evacuation. Yeah, I'll say most of my other comments from my talk, but kind of piggybacking off this because we're not really talking about the evacuation piece, which in itself was huge before the mass cow. A lot of pregnant patients and I just want to put a large value on making sure you have your ultrasound. I love that you said there was bearded guys with ultrasounds start soon because mine was in my grenade pouch. I had a butterfly ultrasound that I had purchased myself prior to deployment. And that was phenomenal, especially because we had just so many pre patient pieces that were pregnant, they would come to us in the days leading up to the mass casualty. In fact, there was a day that there were no kidding 11 pregnant ladies waiting outside to be seen by us. And these are women that never had prenatal care. These are women that didn't know how pregnant they were. And one of them had a placental abruption. And there's no OBGYN there. Fortunately, there was an Afghan OBGYN behind me with her father who needed insulin, which again, we didn't have, but we borrowed from someone else who had it. That's another story of the cowboy medicine that went down. But, yes, so anyways, we were able to kind of source some of these things from the Afghans themselves. And this lovely, lovely Afghan OBGYN, agreed to go to the role to to kind of help facilitate planning or delivery if it needed to happen for this 27 week, or with a potential eruption that I'm like, that doesn't look right on my ultrasound. So that was something else before even beforehand that we kind of ran into. But again, a lot of incredible, just trying to make things work in the days leading up to it was just something that no one could have been prepared for, unless we had all the equipment that we could ever desire at the time, but the pediatric stuff, the OB stuff, that was all stuff that doesn't come in your STP kit, right, it doesn't come in combat trauma, it's all stuff I was like the first day like, and I make an IO out of an 18 gauge for a baby because they were throwing babies over the fence. And in fact, the location I was at, I wanted that location one because it was told I needed to be in that proximity, but to a corpsman from one eight, basically had a dead baby had a baby that died in his arms at that location at east gate the night before. So if no other reason I said if there's nothing happens in the Marines, thank goodness, that's amazing. But I want to be here for the corpsman because in this situation, they're not trained to care, pediatrics, or non trauma. And a lot of these, a lot of these Afghans had, like dehydration, seizures, hyperglycemia, just complete exhaustion, they have been trampled on their way into the gates, they've been assaulted on their way into the gates. And then there was, you know, the infectious issue around us with diarrhea and human feces everywhere. It was beyond anything you can imagine at those gates. And so just knowing that you may need to care for these things and keeping all those, you know, DNDi skills like Admiral Hancock and Kevin Deaton both mentioned, those are huge issues that we need to not only know how to do ourselves, but the captain Deaton had said is passed on to our nurses pass on to our corpsman because now a lot of these corpsman and even steel, US Marines were taking care of a lot of the patients before they ever even came to us or to you guys. Thank you.

Moderator:

Great. I you know, listening to you all over the past hour and a half has been very enlightening and very much an honor to hear what you all have done. I think what is amazing to me listening to this is all of you are emergency medicine trained. And I think that willingness and ability to kind of think outside the box and think in your feet is something that we pride ourselves in our specialty, along with being military medical officers. And so I want to applaud your efforts of you know, making work where you have reacquiring objects from other places, supply sergeants are the best friends you can find to make things appear when there are none. So really, you know, thinking on your feet beat saving lives. And also what else I heard throughout this conversation was that taking care of yourselves but also taking care of your others looking out for your your colleagues, your medics, your corpsman, you know is really inspiring to hear. So again, thank you all for talking about this topic. And thank you everyone here for your thoughtful questions. So our next lecture is going to start at 1520 which is in 15 minutes, so I'll see everyone back here at 1520. pay it off Do I still do all like for separate