Page 158 - JSOM Spring 2018

unusual that I was asked by the surgeon to oversee one table Major abdominal or thoracic surgeries were conducted with
receiving anesthesia by my trainee, while at the same time per- an inhalational technique with halothane using supplemental
forming delayed wound closure on multiple smaller fragmen- oxygen and endotracheal intubation and ventilation. At the
tation wounds with my own patient receiving light ketamine time, operative and postoperative epidural/spinal analgesia
anesthesia sedation to maintain spontaneous respirations. techniques were generally not used in this environment be-
There were just too many patients! cause of risk of infection. As mentioned, we did not have a
specialized ICU or postoperative care unit, so timing of anes-
I have been a trauma and military anesthetist most of my pro- thesia emergence to the end of surgery was extremely impor-
fessional life and since my ICRC deployment in 1985, I have tant. We needed a patient who was responsive and breathing
had no doubt that Ketalar (the racemic R− and S+ ketamine) spontaneously, to minimize nursing requirements. All patients
and S-ketamine are the most important and useful drugs for were transported after surgery to the ward while positioned
austere anesthesia as well as emergency care analgesia and an- on their side or stomach. Looking back, one really can wonder
esthesia. Use is extremely safe, and the adverse effects are min- how well it went, taking into consideration how postoperative
imal and easily treated. Since 1985, I have been continually care protocols and units in modern hospitals are considered
surprised that the mainstay battlefield analgesia has continued so important.
to be smaller, ineffective doses of morphine and now I hap-
pily see the Tactical Combat Casualty Care committee now Patients with thoracic wounds received thoracic drainage,
recommends that first-line analgesia use S-ketamine. European and the three-jar suction technique was routinely used on the
Special Operations combat medics are now taught to use S- wards. Only a few patients with severe thoracic or abdominal
ketamine for both analgesia and lighter anesthesia. But for wounds needing surgery survived the ordeal of long evacua-
Peshawar, at that time, Ketalar was certainly not a drug that tion from Afghanistan.
was routinely used in a modern anesthetic department in Den-
mark; its use was mostly confined to ear surgery in children! Availability of blood products in war surgery is crucial. During
war and conflicts, the requirement to produce large quanti-
During our 3-month deployment in Peshawar, the two teams ties of blood often exceeds the ability to collect, prepare, and
conducted approximately 1,000 surgical procedures, with distribute sufficient quantities of donated blood. This was
most being conducted with Ketalar, mostly because of minimal even truer in the ICRC environment in Peshawar, where blood
resources of oxygen supply. Most surgeries, especially minor products were seldom available in large quantities. Blood
surgery, was conducted with intravenous (IV) Ketalar 1mg/kg transfusions were organized by the hospital’s laboratory, and
IV for induction and the classic half dose every 15 minutes blood was provided by patients’ relatives. There was a cultural
without supplemental oxygen and with spontaneous breath- issue about donating blood and our supplies were usually too
ing. We did not have infusion pumps, so controlled total IV low. Therefore, ICRC used relatively low hemoglobin as strict
anesthesia with Ketalar was usually not possible. If we had a criterion for transfusion.
longer procedure (e.g., longer than 2 hours,) I normally mixed
a 500mL saline bag with 500mg of Ketalar 1mg/mL and ran it The primary reason for the lack of donors was fear, poor
as 1mL/kg/h. If the patient seemed to be emerging, he was just knowledge, and inconvenience. ICRC focused primarily on
bumped up with, for example, 50mg of Ketalar. family members and friends to donate blood. Each patient had
at least one person supporting them at the hospital. ICRC de-
To mitigate salivation adverse effects in some patients, we usu- veloped a method to provide assurance and education to these
ally gave 1mg of atropine IV as an adjunct. During Ketalar family members.
anesthesia, free airways are important to maintain. We just
used the jaw-chin thrust method or an oropharyngeal airway. In one study of the use of blood products in an average ICRC
During emergence, the patient would normally just spit out hospital, the average number of units per patient transfused
the airway, at the same time signaling that he was awaken- was 2.9. The quantity of blood required for every 100 patients
ing. If necessary, we could give 10–20mg of morphine over was 44.9 units. The low consumption of blood is probably re-
10–15 minutes for postoperative pain relief toward the end lated to long evacuation times with high mortality of severely
of surgery. We also inducted anesthesia with Ketalar adminis- wounded, the availability of blood, and the strict ICRC crite-
tered by mouth, intramuscularly, and even rectally in smaller rion for transfusion.
children.
Our two teams were working overtime during the summer
I have been teaching this method to Special Operations Forces and autumn of 1985 and nearly reached an overwhelmed
medics in Europe for years. More elaborate algorithms are fine stage. Occasionally, I had the opportunity to enjoy a small
but much more complicated and probably not necessary with whiskey and a real hamburger (the only place in Peshawar)
regard to Ketalar or S-ketamine, in my opinion. S-Ketamine at “The American Club” in University City Peshawar—a real
is supposed to be twice as potent as Ketalar and have fewer relief from the blood and desperation of the war wounded at
emergence adverse effects (i.e., agitation, confusion, or hal- the hospital. I was sitting there by myself one late evening in
lucinations). However, in austere practice, this difference is August 1985 after our usual day’s work (maybe feeling a bit
difficult to recognize, and I can only suggest the aforemen- sorry for myself having 20-hour workdays the last 5 weeks!?).
tioned cocktail if all else fails. To minimize agitated emergence Suddenly, a mysterious American turns up and asks to sit at
phenomenon, we did not routinely use a benzodiazepine as an my table. He was talkative and asked what I did for a liv-
anesthetic adjunct; we used it only in the postoperative phase ing. I said I was an ICRC anesthetist at the Hospital for War
as needed. We found the incidence of emergence agitation in Wounded and, I must admit, I told him I just couldn’t see the
Afghanis to be much lower than that described in western end for all the destruction and suffering of the Afghanis. He
hospitals. nodded, leaned forward, looked around, and said, “The war

152 | JSOM Volume 18, Edition 1/Spring 2018