Will a Wounded Girl Be Saved? ‐ U.S. Faces Agonizing Choices in Afghan Drawdown | Wall
Street Journal by Michael Phillips
http://online.wsj.com/articles/will‐a‐wounded‐girl‐be‐saved‐u‐s‐faces‐agonizing‐choices‐in‐afghandrawdown‐
1405117653\
Published July 12, 2014
BAGRAM AIRFIELD, Afghanistan— Keyan Riley answered the phone and reached for his green,
clothbound notebook. He began scrawling notes about the two Afghan girls whose lives had just fallen
into his hands. "5 yr." the doctor wrote of the younger girl. "40 mm grenade."
On the other end of the line was a surgeon from a Special Forces outpost in the Afghan hinterlands. The
girls had accidentally detonated a discarded grenade. The younger one had chest wounds; the second, a
six‐year‐old, was pierced by shrapnel in the abdomen.
Could Dr. Riley send a medevac helicopter, the surgeon asked, to take the girls to the U.S. hospital at
Bagram?
Dr. Riley knew the field hospital treating the girls had no CT scanner to see if fragments had nicked the
younger one's heart. But flying the girls to Bagram would fill beds he might need for wounded American
soldiers.
Such decisions used to be easy when the military here was flush with resources and eager to secure the
allegiance of local civilians. These days, not every injured Afghan will get American medical care. In the
country's volatile east, it falls largely to Dr. Riley, a 41‐year‐old Air Force lieutenant colonel, to pick the
lucky ones.
"Rightly or wrongly," he said, "people look to me like I have the answers."
As America extricates itself from the war in Afghanistan, there are hard choices to be made. President
Barack Obama announced in May he would leave 9,800 U.S. troops in the country after 2014—should
Afghanistan's next president agree—down from more than 100,000 at the conflict's peak.
The drawdown means Afghanistan's soldiers will have to fight with fewer U.S. reinforcements. The
government will have to figure out how to build roads and pay teachers with fewer U.S. dollars. And
many of Afghanistan's sick and injured will have to do without access to the top‐flight medical network
built by the U.S. over 13 years to care for victims of battlefield trauma.
The military won't say how much medical care it now provides to Afghan troops and civilians. Officers
say it has fallen off sharply since the days when U.S. troops operated roving clinics and U.S. helicopters,
red crosses painted on olive doors, picked up almost every seriously injured Afghan.
The U.S. and its allies have closed or handed to Afghan forces more than 90% of the 852 bases and
outposts they held during the war's crest. About 20 field surgical clinics remain. Helicopter medevac
units have been reduced as well, said Col. David Ristedt, the top medical adviser for U.S. forces in
Afghanistan. And fewer people work at the two top‐tier American hospitals, at Bagram Airfield, north of
Kabul, and Kandahar Airfield, in the south.
Allied personnel must treat Afghan troops in danger of losing life, limb or sight, if local doctors can't
provide adequate care, coalition rules say. Civilians injured by U.S. actions are also eligible, as are top
Afghan officials.
In practice, however, U.S. doctors often decide who gets first‐class care and who doesn't. Dr. Riley
consults with colleagues but it is his job to make the call from his small office, which is furnished with a
single bed, a metal desk, a small refrigerator, four phones, a map of Afghanistan and a novelty lamp
shaped like a woman's leg and sheathed in a fishnet stocking.
Dr. Riley grew up milking cows and picking apricots, almonds and persimmons on the family farm in tiny
Penryn, Calif. He learned early to work hard, but military life was still a jolt, he said. He recalled being
surprised to find people yelling at him when he first stepped off the bus as a cadet at the Air Force
Academy in Colorado Springs. Now he is an intense, fast‐talking surgeon on the school's medical staff,
deployed to Afghanistan for six months. Day and night, he fields requests for help from front‐line
surgical clinics.
If the injured soldier is American, or from an allied country, it is an easy decision. Afghan civilian
patients, such as the injured girls in Ghazni Province, southwest of Kabul, require him to interpret the
rules of eligibility to manage beds and lives. Half of the intensive‐care beds at Bagram are set aside for
American or allied casualties. And medevac crews are targets for insurgents, making every decision to
dispatch them a risk.
The Special Forces outpost where the girls were first treated had only one doctor and a nurse. Dr. Riley
figured the field surgeon had stabilized the older girl enough for her to survive with treatment at an
Afghan hospital.
But the younger girl, with the chest wounds, was another question. The surgeon at the field hospital had
inserted chest tubes to prevent air in her chest cavity from crushing her lungs and heart. But without a
CT scan, he couldn't know if shrapnel had scraped her heart or aorta. Such a wound could be fatal.
Dr. Riley agreed to accept her. Medevac crews got the call at 9:45 p.m. and flew about 45 minutes to
Ghazni city, where a helicopter from the outpost met them with a stretcher.
On it was a feather of a girl, with black hair. Her eyes were taped closed to keep them moist while she
was sedated. Her bearded father climbed into the helicopter and watched quietly as the flight medic, 1st
Sgt. Randy Scott, and Maj. Mario Rivera, a critical‐care nurse, knelt on the helicopter floor and worked
on his daughter. The girl's heart rate, blood oxygen and other vital signs fluctuated wildly during the
flight.
After she arrived at the Bagram hospital, a CT scan showed a fragment had punctured both of her lungs,
but missed her heart and aorta. The metal piece was still rattling around in her chest cavity.
"She got lucky, but we couldn't have known that without a CT scan," Dr. Riley said a few days later. The
girl's recovery was helped along by a stuffed dog and a DVD of Walt Disney's "Aladdin." Her father sat at
her bedside, encouraging her to blow bubbles, an exercise to help restore her lung capacity.
Abdul Rauf, an Afghan soldier, wasn't as fortunate. A gunshot tore through his bowels and hit his spine
in May, leaving him paralyzed from the waist down and unable to breathe without a mechanical
ventilator. He fell into septic shock, with a 15% chance of survival, said a doctor familiar with his case.
Mr. Rauf spent several days at Bagram—until Dr. Riley decided he was as stable as he would get without
a prolonged stay. Already occupying beds in the intensive‐care ward were a 3‐year‐old girl with shrapnel
wounds to the head and a young woman recovering from a lung operation.
Dr. Riley put Mr. Rauf on a medevac flight to the Afghan National Military Hospital in Kabul. Before the
man left, Dr. Riley met with nurses to assure them he wasn't giving up on the wounded soldier. "It is a
matter of doing the most good with the resources the American taxpayers have given us," he recalled
saying.
He said he knew the patient was "dropping a level of care." The Americans weren't sure whether the
Afghan hospital had a working ventilator for Mr. Rauf, and they didn't want to risk losing theirs by
sending it along.
Just before landing in Kabul, the medic and nurse aboard the helicopter disconnected the electronic box
that monitored Mr. Rauf's pulse, blood oxygen and blood pressure. They unhooked the breathing
machine and attached a blue plastic bag to the tube that went down the man's throat. One of the U.S.
soldiers aboard rhythmically squeezed the bag to send air to Mr. Rauf's lungs.
"It's what we have to work with," said Maj. Jason Montgomery, the in‐flight critical‐care nurse.
Back at Bagram, the decision haunted Dr. Riley for days. "During the height of the war," he said, "we
could keep people here 100 days."
Mr. Rauf, however, recovered as well as could be hoped. The Afghan army hospital put him on a
mechanical ventilator in its intensive‐care unit, and pumped him with antibiotics, said the doctor
familiar with his case. Within weeks, he recovered enough to transfer to a regular hospital bed.
"We've been at war for a long time," said Afghan army Col. Yaqub Noorzai, a urological surgeon at the
hospital. "Our doctors have lots of experience treating trauma."
In the course of a week, Dr. Riley accepted an Afghan policeman who had picked up a booby‐trapped
radio and lost both hands and an eye in the blast. He turned away a 19‐year‐old Afghan man who
suffered a lacerated spleen and a perforated small intestine while clearing mines. Dr. Riley concluded
the field surgeon had stabilized the man without the need for more surgery, but said, "If he were an
American guy I'd probably go back and take another look."
Dr. Riley faces another pressure: As the U.S. pulls back, American doctors don't want to undercut their
Afghan counterparts by taking on all of the difficult cases—even if patients would likely fare better
under U.S. care.
"It doesn't do them any good for us to take care of all of their patients and not give them the
opportunity to improve their own health‐care system," said Col. Gary Walker, commander of the
Bagram facility. Formally known as Craig Joint Theater Hospital, the facility was named for Staff Sgt.
Heathe Craig, a medic who died in 2006 when a helicopter hoist failed as he was trying to rescue a
wounded soldier.
Afghan military doctors and their U.S. advisers say the country's military medical system has improved
since 2011, when The Wall Street Journal reported that the National Military Hospital in Kabul was so
riddled with corruption that patients had to bribe doctors and nurses. Maj. Gen. Mohammad Mussa
Wardak, the Afghan surgeon general, was brought out of retirement to clean house.
Despite their hard‐won experience, Afghan hospitals aren't as good as the major U.S. facilities here, U.S.
and Afghan military doctors said. The Afghans lack doctors and nurses for adequate postoperative care.
In eastern Afghanistan, Afghan doctors and medics handle 86% of the military casualties; another 9%
qualify for U.S. treatment under the rules; and 5% are treated by U.S. doctors because Dr. Riley agrees
to accept them.
"You go to medical school because you want to take care of people and take care of everyone," said Lt.
Col. Christian Meko, command surgeon of the 10th Mountain Division, the main U.S. force in eastern
Afghanistan. "So to be put in a position where you have very limited resources and have to make tough
decisions is difficult and requires balancing compassion, eligibility guidelines, and medical judgment."
Saying no to injured children has been the toughest part of the job, Dr. Riley said. Early in May, he got a
call from a nearby Korean military hospital about a badly scalded 8‐month‐old Afghan girl. Dr. Riley
asked the hospital to email a photograph of the injuries. The gruesome image showed a child burned
over 20% of her body.
Dr. Riley brought nurses and a pediatrician into his small office. They reviewed the baby's medical
records and looked at the computer‐screen photo. They debated whether to use an intensive‐care bed
on a child they suspected was at death's door.
"What is the right thing to do here?" Dr. Riley remembered asking the medical team. "I think she'll die
within a few hours."
Dr. Riley decided to walk across the base to the Korean hospital, which handles charity cases, to see the
baby in person. He would make up his mind there, he thought. He changed from scrubs into his uniform
but caught himself as he walked out of his office door.
"This is stupid," he thought at the time. He knew there was no chance that after seeing the girl he would
refuse to treat her. He ordered her brought to Bagram's intensive‐care ward. She died that night.
"The rules of eligibility are written down," Dr. Riley said, "but how do you say 'No' to that little baby?"
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