Controlling Pain in ISIS Territory

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Darrin Dixon is a CRNA who was trained in the United States Air Force and has provided anesthesia all across the world in the military and as part of humanitarian missions. He currently lives in Great Falls, Montana, where he is part of a full time OB anesthesia, all CRNA group.

Read Darrin Dixon’s account of his experience working with an NGO in Mosul, Iraq. His descriptions paint the picture of the difficult conditions, limited supplies, and the life or death care provided during his month-long mission.

“I found myself lying alone in my cot, but not really alone. My CRNA partner for the month was snoring peacefully a few feet away and my bunkmate, less than a foot below, kept turning over and elbowing me in the kidney. The hospital administrator was less than six feet away in another bunk, as was a facility manager and an ICU nurse.

It was four in the morning, literally the darkest time, but my hooch was awash in the eerie glow and shadow of sodium lights that lit the courtyard filtering through our small window. The staccato small arms fire from the Peshmerga who guarded us from fourteen feet above, in their towers rang out at irregular intervals punctuating the constant deeper, duller thuds of mortars and bombs less than five kilometers away in Mosul. To add to the otherworldly feel, the Muslim call to prayer wafted in and out on what breeze there was with it’s eerie highs and lows, while one of my hooch mates had just awoken to contemporary Christian music.

It was my first morning at the Emergency Field Hospital. I had arrived mid afternoon the day prior after a somewhat harrowing forty-five mile five-hour journey where we were at one time completely surrounded by cars outside a checkpoint. There we were, stuck inside our vans because vehicles were packed around us so tightly, jockeying for position, while men speaking Kurdish, Arabic, and myriad other languages milled about in various forms of military dress carrying all types of different weapons. Further down the road we met a van from the same NGO we were working for. As we passed, someone hung out the window and yelled, “if you have a surgeon and anesthesia, go directly to the OR!”

After negotiating the four military checkpoints separating Kurdistan from Northern Iraq, sometimes staffed by Iraqi security forces, sometimes Peshmerga, sometimes Syrians, sometimes the Bader Brigade from Iran, we arrived at the Field Hospital. Once there, we were forced to wind our way between several pickup trucks with fifty caliber machine guns mounted in the back, a moat that completely surrounded the EFH, razor wire, another barricade manned with men, and more machine guns. We pulled into a courtyard outside the blast walls that surrounded the compound. We were searched, the van was searched, and our bags were searched because ISIS had vowed to somehow load a bomb in a vehicle and blow up the hospital

After we were finally admitted into the facility, the surgeon and I were told to drop our suitcases in the courtyard, put scrubs on, and report to the OR.

We did. Then we operated nonstop until 0200. After finishing, we collected our bags and tried to find our separate hooches in the dark of night, already mentally and physically exhausted and still severely jet lagged.

Two hours of fitful sleep later, I found myself in my present predicament, missing my home, missing my family, wondering if I could actually do this.

Things I’d already learned on my first “half” day: We had good anesthesia machines. We had very good surgeons. My partner was an ex-military CRNA just like me, and an ex-green beret too. We only had four ICU beds. We only had four ventilators, not including our anesthesia machines. We had one ultrasound machine, and it was portable and used mostly for FAST exams in the trauma room. We had no block needles or pigtail tubing. We didn’t have a nerve stimulator either for nerve blocks or to monitor muscle relaxant. We had Isoflurane and a very limited supply of Sevoflurane. Our hospital was already completely full. Every patient and every surgery was life or death, and sometimes we had to make the decision to choose death over “wasted” resources. Our biggest problem that I could see in that first day was an almost complete lack of narcotics. We had a very limited amount of Fentanyl, but that was going fast. We had Ketamine, we had Lidocaine, we had some Magnesium and Diclofinac which I’d never used. Oddly enough, we had a large supply of IV Tylenol.

This was not at all similar to my experience in the military where we’d had limited supplies of different things, but our supply lines were much more well established and more responsive than the ones I ran into outside of Mosul. My partner and I were forced to make do with what we had. Luckily, although I was not on the forefront of opioid free anesthesia (OFA) at that time, I knew some people that were. Tom Baribeault and Brian Selai were my go-to teachers on the fly from halfway around the world and seven time zones different. Together, we concocted an alchemic mixture that worked better than I’d hoped.

My success story is definitely not for the opioid free purists. I will be the first to admit that in Iraq, I practiced garbage anesthesia, as one of my instructors had called it twenty-three years ago while I was in training. I didn’t have IV pumps to drip infusions slowly into the patient in a controlled manner. I didn’t have time to set up such elegant mixtures anyway and I certainly didn’t have all the cool drugs. I was much too busy trying to keep them alive during the surgery, with shockingly no charting. I literally had only a few minutes from the time the surgeon was finished to awaken the patient, extubate them without really knowing their state of paralysis or strength relying only on my last dose timing and the surgeon’s feel of “tightness,’ throw them onto a transport gurney, and send them on their way before another transport team brought me my next patient.

That next patient may have died if it took me longer. They then threw them on my OR “table,” along with a latex glove on which my fiery, five foot tall British nurse had written vital signs; NPO-ish status, weight, and major injury, and on occasion, she brought me a “spot of tea” to keep me going.

We didn’t have oxygen for transport. Most of the time, I didn’t even have time to accompany the transport team to the stepdown tent. We didn’t have oxygen in step down anyway.  Our oxygen came from oxygen mixers and we had a very limited supply to run our anesthesia machines and our four ICU beds.

So, we made do. Between Tom and Brian and my CRNA partner and I, we made do. My usual induction went something like this: 100mg Ketamine, somewhere between 50-100mg Propofol, and a syringe full of Lidocaine and Succinylcholine. After intubation, I did my best to titrate on more ketamine and at least a gram of magnesium while also doing my best to keep these severely injured and terribly volume depleted patient’s blood pressure high enough to perfuse their brain. In several, I can also remember running double strength Neo and Levophed drips wide open through peripheral IVs to maintain a blood pressure while infusing typed or non-typed blood as fast as I could from our limited blood bank. A blood bank that really consisted of our workers walking around with needles in their arms donating while working.

A word about blocks: I thought nerve blocks would be the thing for war surgery in this setting. Turns out, they weren’t. Most of our patients had all four extremities shredded by bombs or hand grenades or mortars and shrapnel in their bellies too. There was no way we could block everything.

We had what I consider, miraculous results. While I was there, for twenty-one days, my partner and I did approximately one hundred major, life or death, general surgery cases, and just as many ortho cases. We did five median sternotomy thoracotomies, two in the ER, along with one clamshell thoracotomy with a wedge and my laryngoscope handle for a hammer in the trauma bay. All for gunshots or shrapnel to the heart. We did two enucleations. Almost all of the general surgery traumas ended up with huge midline belly incisions. Many of the ortho cases were multiple amputations and huge fasciotomies for dirty blast wound injuries.

Our clamshell thoracotomy, where my partner had to plug the hole in his heart to keep him from bleeding to death, left our hospital on foot in seven days. Seven days! No pneumonia, even without incentive spirometry. No infection, even though we used non-sterile instruments to crack his chest, a non-sterile finger in his heart, and non-typed blood coursing through his veins.  Finally, most interesting to me, we did it with no pain.

Now, the other side of the story: It is very difficult to use my experience as a “gold standard,” because I wasn’t able to use a recipe. I used what I had on hand, period. Sometimes this, sometimes that. Neither can I compare my patient population in Mosul to my population in the States. My patients in Mosul have known pain their entire lives. They have grown up with it and grown old with it. Their idea of “pain” is much different than ours.

But this I know, something worked. Without narcotics, I would have expected a pain disaster. But it didn’t happen. Regardless of the Iraqi people’s skewed sense of pain, I would have expected so much more pain, but they didn’t have it. Very few of our patients, horribly injured as they were, remained in our facility more than four days. They couldn’t have recovered as miraculously if they hadn’t been relatively pain free. And I chalk that up to what little knowledge I had of Opioid Free Anesthesia (OFA) and the immense amount of knowledge my friends on the cutting edge have and were willing to share.”

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