Pink Mist Written the week of 14 March

If you are a Grey’s Anatomy fan, you remember the Pink Mist episode. We had our own small version of that today. Two men came in after an IED hit about 30 minutes away. They had both been seen at the Forward Operating Base (FOB) where we have Forward Surgical Teams (FST). One had a CT scan there and another had his huge abdominal wound packed with dressings and a gigantic external fixator on his leg to prevent the shattered bones from moving around. The idea of the FST is to do immediate life saving care about 10-40 min from the time of injury and then get them to us as fast as possible. Sometimes it’s over the road, sometimes by chopper, usually by plane. The pt with the head injury was whisked away to the OR. I was in my office picking the brain of one of the Special Ops guys, so I didn’t go to this trauma. Turns out that he had a CT of his head showing a foreign body, but it wasn’t clear exactly what it was.   While the team was in the room prepping him for surgery, the radiologist was looking at the CT we had done. His heart must have stopped. But not for long, because he leaped up and instantaneously found the surgeon and told him what it was. It was what we call a UXO- unexploded ordinance. That can be anything. We are doctors and nurses. We don’t do UXO! We see it, isolate it, and call it in. We practice this over and over again outside looking at stuff lyining in the GRASS during Wing Exercises. You just don’t expect to find one in a guy’s head. So the alert was put out, the OR was evacuated except for essential personnel (by this time the other guy was in the other OR crashing with an undetectable blood pressure), and the personnel who were left had flak vests and helmets brought to them. We set up guards to divert foot traffic away from the OR and called the EOD (Explosive Ordinance Disposal).  On the CT it looked like a 50 caliber bullet, but it had unusual looking stuff in it. Sounds low risk, right? But like I said- we’re doctors and nurses. That is not for us to figure out! The EOD guys showed up and told us yes, that’s what it was. A Russian one, it turns out. On the CT, it looked like a bullet, with a small bit of trapped air in the point, then a pointy bit of stuff behind that (what the radiologist called a “lipstick appearance”- like lipstick in a tube) and then some the casing was full of stuff that was not metal. That’s about all you can tell on xray. The EOD said that it was activated by the projectile striking an object, then the air is forced onto the fuze (yes, that’s how you spell it), which was the lipstick point. Then the fuel inside explodes. This kind of exploding bullet is outlawed by the Geneva Conventions.  He said no worries- just take the thing out and hand it to one of them. I just had one question. What if it does go off for some reason- it drops on the floor or just spontaneously explodes for no reason- what is the worst that would happen? Big explosion or little? They said little. So the doc and the EOD guy go to the OR and the surgeon removes the thing from the guy’s head. It was very impressive on CT- it had penetrated just under the top right side of his skull. It had lifted a piece of bone, like when the dog hides something under the edge of the carpet. He had a small amount of brain bleeding as well. Incredibly, he’ll probably be fine after he wakes up out of his coma. Amazing.




I have never forgotten that Pink Mist episode. In it, the EOD guy explodes in the hallway after carrying the UXO out of the ER. Turns out that maybe our reaction was overkill for just a sdmall exploding bullet. But my pledge was to do my best to get every member of my team home intact- mentally and physically. This was a good opportunity to practice something we don’t do often and we have a few lessons learned to incorporate next time it happens. Most of all though, I was very impressed with everyone’s quick reaction and their willingness to do whatever needed to be done. From the nurse who refused to leave the OR because his patient next door was dying, to the airmen who stood in the hallway with their M-16s, making sure no one got past them into the danger zone, to the surgeon who risked it all to do the operation. I have a great team here. And every day something happens that I have never seen before…I wonder how long that will last?

the 4th one looks like the one we got out of the guy.