The Limits of Our Obligations

Abstract

26 Narrative Inquiry in Bioethics • Volume 13 • Number 3 • Winter 2023 my life, because I think that my story can add selfconfidence to other people in a military conflict and humanitarian crisis. B The Limits of Our Obligations Ryan C. Maves Disclaimers. No funding was utilized for this manuscript. Dr. Maves is a retired U.S. Navy officer, and the opinions contained herein are his own. The opinions in this manuscript do not reflect the official opinion of the Department of the Navy, Department of Defense, nor of the U.S. Government. I n 2012, I was a commander in the United States Navy, deployed to the NATO Role 3 Multinational Medical Unit in KandaharAirfield (KAF), Afghanistan. The KAF Role 3 began as a tent hospital under Canadian command, built along the flight line at Ahmad Shah Baba International Airport as part of an expanding NATO base. By the time of my arrival, it was a small but capable brick-andmortar building under U.S. Navy command, with four operating rooms, two CT scanners, and a busy intensive care unit (ICU). Not long before my deployment, the KAF Role 3 was described as one of the busiest trauma hospitals in the world. Casualties arrived every day, usually by helicopter. Blast injuries from improvised explosive devices (IEDs) were common, ranging in severity from concussions in passengers in armored vehicles, to multiple amputations from blast injuries with concomitant thoracic, abdominal, and pelvic trauma. KAF had a daytime population of over 30,000 in 2012, and our hospital was effectively the referral center for the region, so patients with non-surgical diagnoses were similarly common: myocardial infarctions, seizures, pulmonary emboli, and endemic infections, to name a few. As an infectious disease (I.D.) specialist, I functioned mainly as a hospitalist, managing patients postoperatively, but I also provided any consultative support when needed. During mass casualty events, the intensivists and I would act as backups in the trauma bay, freeing up the surgeons for the most acutely injured patients. It turned out that an I.D. doctor’s skillset lent itself well to acute trauma evaluations; we are well known for having an eye for fine details, combined with low-grade paranoia. These traits served me well during what I came to describe as “my involuntary trauma fellowship.” Our patients could be divided into five key groups: Afghan National Security Forces (ANSF, including the army and national police), nonAfghan coalition military (mostly U.S. and other NATO members), Afghan civilians, NATO civilian contract staff, and the Taliban. Our approach to each of these groups was different. For all patient groups, we would provide the same emergency care, including acute resuscitation and immediate life-saving surgery. It was after this emergency care period that our management plans diverged. For coalition forces, our next priority after acute resuscitation and stabilization was to assess whether a patient could remain in theater. Stable patients with relatively minor injuries could often undergo rehabilitation at KAF; many personnel could subsequently return to combat duty with their units. More seriously-injured patients would be transported out of Afghanistan within 24-48 hours (if not faster). Usually, this would involve stops at BagramAirfield near Kabul and then Landstuhl Regional Medical Center in Germany before reaching a military hospital in their home countries. There were few limits on whom could be transported. Dedicated critical care air transport teams (CCATT) included intensivists, respiratory therapists, and critical care nurses, who could manage the most unstable patients on board what was effectively a flying ICU. The “lung team” in Landstuhl could fly to KAF to start patients with severe respiratory failure on extracorporeal membrane oxygenation (ECMO) and then fly them out on maximal support. NATO civilian contractors would receive comparable care, although the exact details of how they would be transported out of theater would depend on their home countries and the nature of their  Healthcare Under Fire: Stories from Healthcare Workers During Armed Conflict 27 contract. We cared for one civilian contractor with newly-diagnosed HIV infection whom we were able to stabilize on the ventilator, get him extubated, start on initial antiretroviral therapy, and transport him home with a referral to his local HIV...