In Afghanistan, military surgeons must also confront civilian casualties

“The facility I was working at was essentially a plywood-type structure,” begins Col. Richard A. Schaefer, MD, describing the hospital at Bagram Airfield, Afghanistan, where he held the post of Chief of Surgical Services from July 2006 to January 2007. “It had deployable operating rooms attached to the main structure. Although it wasn’t meant to be a permanent facility, it had been there for a few years. We had monitors, ventilators, digitized X-ray machines, and even a computed axial tomography scanner.”

As an army surgeon, Dr. Schaefer was primarily responsible for treating wounded U.S. soldiers—débriding their wounds and stabilizing their fractures so that they could be transported safely to Landstuhl, Germany, for more definitive care.

Yet U.S. military doctors also have a second mission—providing humanitarian medical treatment to civilians in a country with few other options. The Bagram hospital serves as a referral facility for Afghan patients with life-, limb-, or eyesight-threatening conditions. They often travel for many miles over treacherous terrain or are brought by helicopter to be treated by the American physicians.

Crossing mountains in wheelbarrows
The injured walk, or their relatives carry them to the hospital. With a shortage of wheelchairs in the country, some patients arrive riding in wheelbarrows. Their injuries—mostly traumatic—cover a wide range of musculoskeletal conditions.

“We saw patients who fell from heights, who had fragment wounds, gunshot wounds, some industrial accidents, a farmer whose hand was caught in a wheat grinder, a worker whose hand was caught in an industrial device that was like an asphalt crusher,” recalls Dr. Schaefer.

Land mines remain a significant problem in Afghanistan. “Some people collect scrap metal to make some money,” explains Dr. Schaefer. “It’s a very poor country, and they pick up what they think is scrap metal, and it might turn out to be an unexploded mine.

“It’s my understanding that the number of mine injuries increases during the spring, when people go out and plow the fields. I think during the colder months, people just aren’t out as much.”

The surgeons do what they can to address the problems. The injured farmer, for example, lost his hand, but the surgeons saved his life. “We felt fortunate to get the amputation treated and closed without infection, and we actually provided him with a very rudimentary prosthesis. He was very concerned about being able to provide for his family. I’m unsure as to what kind of support he would get when he went back home, but hopefully, family and community members would be able to help him out.”

International collaboration, challenges
Working with Dr. Schaefer at the hospital were two younger surgeons, Maj. Rick Ursone, MD, and Maj. Shawn Hermenau, MD.

“Dr. Hermenau was a former resident of mine, so it was particularly gratifying to work as his partner and his chief of surgery in a combat zone,” says Dr. Schaefer. “Both are talented, skilled surgeons, and we did a number of challenging cases together.”

Dr. Schaefer’s humanitarian cases also gave him the opportunity to collaborate with an international group of military physicians from Egypt, Korea, and Afghanistan.

“We provided training to rotating Afghan military physicians and nurses at our facility,” he says. “We held weekly continuing medical education conferences and monthly international case conferences to share information with our international medical colleagues.

We frequently collaborated with Egyptian orthopaedic surgeons, sharing ideas and operating together.”

Language, local customs, and religious belief systems were among the issues surgeons had to address in dealing with both patients and their international colleagues. “An Afghan civilian woman with a recurrent giant cell tumor of bone was referred to me,” recalls Dr. Schaefer. “We had some excellent translators, but the medical and surgical terminology was challenging. Her brother was with her, and initially I spoke to him about her condition. When we brought in a woman translator, we were able to speak more directly and I think she may have been a little more comfortable speaking to another woman.”

Working in a war zone also forces physicians to confront unusual, sometimes heartbreaking situations.

“One of our pediatric patients, a boy of about 5 or 6 years old, had an open fracture of the forearm,” recalls Dr. Schaefer. “When he was first brought to the forward facility (before transfer to Bagram), the injury was already infected with gas gangrene, a condition we rarely see in the states. While my U.S. military colleagues were unable to save his arm due to the severity of the infection, they did save his life with an emergency amputation and resuscitative care.”

Courage and attitude
Now serving as Chief, Orthopaedics Division, Norman M. Rich Department of Surgery, at the Uniformed Services University of the Health Sciences in Bethesda, Md., Dr. Schaefer is no stranger to war injuries. His 6-month deployment, however, increased his respect for the military personnel who put their lives on the line.

“American soldiers, sailors, airmen, and Marines are experiencing hardships, but continue to display courage, bravery, and an amazing attitude,” says Dr. Schaefer. “One soldier I operated on had been shot in the arm during a firefight. Even though he had been injured, he kept doing his job, directing fire on the enemy. Later on, I heard that he had reenlisted. His story is very inspirational, because it shows the courage and the attitude of these soldiers in the midst of battle. It’s a privilege to be part of our military medical system and to support such brave young Americans.”

As a military surgeon, Dr. Schaefer can be deployed to wherever the army needs him. Does he think it’s likely that he’ll be sent back overseas anytime soon?

“That’s the first thing my kids asked when I got home,” he laughs. “None of us knows how long the wars in Iraq and Afghanistan are going to continue. I’m just one of many military orthopaedic surgeons, both active duty and reserve, who have gone or will go, but for now, there are no imminent plans for me to return.

“From a personal standpoint, one of the hardest days of my life was when I said goodbye to my wife and children at the airport. One of the best days was when I met them at the airport 6 months later. Although the family separation is challenging, it was really great to return and appreciate some of the simpler things of life after the deployment,” he says.

The AAOS contribution
Dr. Schaefer is especially grateful for the support the AAOS provides to military surgeons like himself, both in terms of education and general good will.

“I’m very impressed by the interest in supporting military members, as evidenced by the two extremity war injury research symposiums and the support for the Orthopaedic Extremity Trauma Research Project,” he says.

“One of last year’s Media Orthopaedic Reporting Excellence awards, presented during the National Orthopaedic Leadership Conference, was given to the producers of the documentary, Baghdad ER, which highlighted Maj. Merritt A. Pember, MD, a military orthopaedic surgeon who served in Iraq,” remembers Dr. Schaefer. “Dr. Beaty asked him—and all military members—to stand, and we received a standing ovation from our colleagues. It was very heartwarming, to feel that sense of appreciation from our AAOS colleagues.”

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org