GSACEP Lecture Series: 12 Days in Kabul by Dr. Kat Landa

Dr. Landa shares her experience at Kabul International Airport during the American evacuation and Abbey gate MASCAL event.

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Kat Landa: 1:01

I am Kat Landa and I think I've met everyone here, I'm actually really happy that this is a smaller group, because the larger groups, you have a little bit more pressure. I'm gonna apologize in advance, I have an emotional support coffee up on the front row, I may grab it from time to time, so I apologize in advance for being unprofessional. It will not be the first time I'm called back. So without further ado, I'll move on through this. This is the usual disclaimer, I'm here as me, I don't really represent the ideas and philosophies of the US Marine Corps, the Navy support. So this is not Cobble. This is March 2019, when I was deployed in Kandahar, with Christina Polk who's here. We were at the Kandahar roll three. And it was the last trauma shift of that deployment that I was on it was my very last patient of the night, came in the middle of the night. And he was an Afghan Special Forces guy. And so we took care of most of those during that deployment, lots of Afghan Special Forces. But this happened to be their commanding officer who I'd never met. And fortunately, he wasn't terribly wounded. And I was actually getting ready to discharge him. And as I'm finishing up some of the final handwritten paperwork, the interpreter that's with him, calls me over. And so I come over to the the first bed there and I said, Yes, can I help you. And this afghan commanding officer stands up, puts his hand out to shake it, which is very unusual for an Afghan male, and speaks to me, looks me in the eye and speaks to me in very clear English. And he told me, thank you so much for what your team, the all the teams here, have done during your time, we understand that you're leaving, and I wanted you to hear it from me since I'm here, that we are so grateful for all the care that you've given our Afghan forces in our fight against the Taliban. He said, My men, and I fight so hard, because we know you're here to help us out. The next thing that he said is the part that I wanted to highlight in this, he said, I hope the next time you're in Afghanistan, you're here as a tourist. Because we have a beautiful country, we have a beautiful culture. And we have wonderful people here. He says my true hope that we can get rid of the Taliban. And you can be here as a tourist. And that's what they call foreshadowing, because that was not my last time in Afghanistan. And it certainly was not as a tourist the second time around. So this is the thought that I was having, as we're flying in to Kabul, from Qatar, from Saudi Arabia on the 16th of August. Now, that being said, we weren't deployed directly to go to Afghanistan. So I was on a special purpose Marine Air ground Task Force, crisis response, Central Command, very long title and only the way the Marine Corps will do and the 20 ones for the here, and we deployed in April and I was the officer in charge of the shock trauma platoon Now just as a brief background, a special purpose. Mag Taff is basically a very small, smaller force about 2200 people. And it's a mix of air, ground and logistics. And so the shock trauma platoon was the highest echelon of care that goes with that, which is to ER doctors and to three nurses to pas, and 15 corpsman of various backgrounds, many of which were very junior. And we deployed in April of 2021, initially into Kuwait, and then actually moved the entire Special Purpose mag Taff into Saudi Arabia. And anyone that had done this deployment prior to me, said, You are not going to do anything since, you know, 2013, when they started sending troops every six months on this deployment, many of my colleagues many of which who have come to GSh ASAP over the years, and some of you who have deployed on these, really not a lot happens. And in fact, one of my mentors said, Oh, cat, you're gonna lose these your soul. So you're gonna be so bored. And I was worried about that as an OSC. Because if I'm going to be board, which, I mean, let's be real, it happens easily. My corpsman who are all very junior, to me, in age and maturity level, are definitely on the board and where people get in trouble. So I made it my goal to make sure we're doing lots of training, and I bashfully say that all this training wasn't because I'm super wise or really having like this long term plan, it was like, I'm going to be bored, My people are gonna be bored, they're gonna get in trouble. I'm going to be in trouble. This is going to be just catastrophic, catastrophic event. So I basically as soon as we landed, new e4 Then I said, You know what, we're not just going to train our people, not just these 22 people that I have under me. But we're going to reach out and work with the ground corpsman. Now, there's, you know, it's a battalion of Marines that went with to one and there's about 50 corpsman that are with Then and many of which we've never interacted with before. So we made it our goal, my STP, and I to start doing lots of training. So we did lots of blood training, making sure that every corpsman across that special verse mag, TAF got Valkyrie training at some point in time. And that's what I was demonstrating over here. I did not think they were going to be utilizing with us but I figured, hey, it's a good teacher will see review because you go in depth for a lot of the teacher will see, it's a great blood transfusion review. And guess what worst case scenario, I've got this. So we did a lot of blood training, we did a walking blood bank, that's a picture of one of my corpsman, they're in a walking blood bank, they were utilizing the Valkyrie technique in a walking living scenario. We did a lot of mass casualty training. And as a background to that. That's because I was the mass casualty director on Kandahar. And so I just kind of had done that training my entire time, just two years prior. And so I brought that down to the ground level and said, Okay, well, let's start working together, as the ground as the air and as our group from shock, trauma and how to do mass casualties together, we trained not only the corpsman but started working with the CLS, Marines, the combat lifesaver, Marines, because we were on a crisis response platform, and there were lots of things going on, as there always are in the Middle East. And so we trained with them. And in fact, it was weekly training, big trainings that we were putting on, and I had a great team that was very energetic and wanted to participate. And so we did lots of different trainings like this. Runway Sorry, guys. There's one. So this was a technology never like works for me, I'm probably a grandma. There we go. So we did things like this. This is a like a flying and root care thing, which for the Marine Corps, our usual thing like for Seattle like this, no big deal. But for us, it's like, Okay, let's try this out. So we worked with the C 130 squadron that was there in actually making a flying recessed Bay and basically flying in to a mass casualty scenario, taking on patients resuscitating them, while we're trying to get them on and continue to resuscitation in the air. And we did a flight with this with this was 22 casualties. So working across the board there. I don't know. missing one slide. There we go. That's what happened. So in the middle here, this is one of our major field exercises there. Because again, while we were not really initially focused on this, there was always talk that we may need to do some type of noncombatant evacuation operation. And starting in June, the beginning of June, they started becoming more and more possible and TAs down to Special Purpose mag TAF to my co there as a possibility for us to plan to. So in July, and I remember because of that birthday, July 3, was the day that they said, Well, we really need to do some very detailed level planning our phase zero kind of planning situation. And under this new construct, as they kind of kept looking at the issue. They said, I think really the best way, if we were to do this, which no one thought we were going to go into Afghanistan, would be to attach the SAP directly to the infantry. Because you know, the infantry will be doing security type stuff, logistics, who we would actually fault we fell under for ad Kaaren would be doing more of the paperwork processing. So how about you, cat Landa start working with two one and figuring out some type of plan. Now again, I want to highlight that the Marines and I'm saying from the colonel down, I really thought this was going to be less than 5% chance of us doing this. And that was coming from Intel. Because the State Department had basically said, we've got it, we've got this, this is never going to happen. So even while we're watching the news and reading the news, and there's lots of super updates that, you know, this is really an unstable place. The line was the State Department's not going to let this fail. It's too much of a big ticket item. So we did plan I was fortunate to work with to one which their name is literally the professionals and they're the most professional Marines I've ever worked with. And we made very detailed plans. Now in the big construct of things we are a small group of people within a giant area of operations. And we fall under several other echelons of higher headquarters. At the highest in the level there was Joint Task Force which included not only US forces try forces here, but also NATO forces. So again, they have tasked us with doing some pretty detailed level planning without actually tying in anyone else really at a higher level on that detailed planning. Furthermore, the 24th meal had been extended and brought to the area rather than going on to further exercise like they were supposed to do, which is a shipboard Marine Corps unit very much like a special purpose mag TAF just on a ship. And in the end of July they said And okay, well now the 24th Me is gonna take over planning, September's next half take over, you know, give all of your plans and send them to the mu, which has a very similar structure in similar resources. So we did that, and then trying to combine those plans together, really fell through right, the muse on a ship, it's very hard to do planning with them. We're on the ground. You know, 51. Five is our higher headquarters for the Marine Corps. But then there's, you know, you I know that there are US Army people that are involved, I know that there are air force people involved. And I know that we have NATO involved. And I've worked with NATO before. So I said, How are we coordinating this? And I sent up a lot of questions. I was probably known for like, I have a question because I had so many questions. So things like, what is the mascot plan for this base, right? Because I remember from Kandahar, people that have been there, there is a very detailed NATO plan, I actually had it in my inbox, from someone who had sent it to me, before I went in, and I dug it through my blue side email and found it I said, this is what a needle plan looks like, can someone find this for me, and I sent that RFI that request for information up the medical side of the house and also up the infantry to that in the house, right, making sure that we were double tapping. And every time it came back to me that this is the plan. And it was only for one tiny sector, the North ah chi area where the roll to is because in reality, that was the only needle area, the rest of us kind of open the Turkish are running things. But again, there's a little strained relationships there. So never could get a full mass casualty plan. So we trained to whatever we could add to one at the special purpose, mag Taff level. And you know, all those questions, many of which went unanswered for various reasons. And kind of that Swiss cheese model. And so yes, we didn't really have a joint plan, but we had a very streamlined plan together. And again, that wasn't the construct of thinking, Oh, this probably won't happen. But hey, we got to pass the time some some way. On the 15th of August, I was called for a very impromptu meeting early on a Sunday morning. And with Second Battalion first Marines are also called me to attend one and he didn't usually call me directly, he called me on like, my cell phone was like, I need you to be here right now. So I walk up there. And it's basically all of Second Battalion, first Marines leadership, which they had kind of been sent out to various places. There were some in Syria. There were some in Jordan, and they had all fallen in. I'm like, Oh, I haven't seen you since April. Okay. Hi. So this is important. And they started saying, you know, it looks like this is going to happen. And the news hadn't come out yet on how bad things were. But I know Kandahar just fall and I knew that people were moving to Kabul. And really, a lot of the information we're getting was like, open source, like, Associated Press was putting it out. And we weren't hearing anything from military side of the house. So I was like, This is not surprising, I think we are gonna go. And during that meeting, it was like a four hour meeting of kind of very detailed planning, and figuring out logistics and, you know, things hadn't gone sideways yet. Now, every 45 minutes, someone to come in and grab my friend, Ben, he was the Operations Officer and be like, I need you for a second. And then they come in and say, well, we got to change that plan. Because, for instance, the tower, the flight tower is no longer manned. There's no one there. And we got to do this. And we got to change that up, because things were just very rapidly degrading on the ground there. And by the end of that meeting ended in Okay, we're gonna need to send a quartering party, which is just a very small group to go forward to kind of figure this out, because it's clear we're gonna be going. And so they asked people just to figure out the logistics for one ask for me, as the officer in charge of this group was, I need two people from your group just to go in and like liaison and figured out your logistics on the ground. Now, that being said, like I mentioned the other day, we'd already planned out and pre staged like a shipping container out on the flightline along with the rest of the infantry on what we wanted to fly in there, like that's gonna fly in. So I've got my quartering party that I'm sending. And Nikki Cook was the other ER doc with me, she had been wanting to get out and do things and I was like, this is a good opportunity, it's a good opportunity for you to get in, be able to roll to kind of see what that looks like forge relationships, and give you some responsibility. So I sent her and I sent my most senior combat tested coordinate with her our leading Petty Officer, so kind of my second in line and the Senior Enlisted Advisor. And so they flew thinking they were doing logistics, I was like, here's the things I want you to do. I want you to liaise them with a rule to figure out the structure there and figure out where we're going to work from if you can, otherwise, I'll figure it when I get on the ground. And I need you to find out a place that we can sleep that's nearby the rule two possible so that our rest cycle teams can be close to the role to whereas if the rest of us are elsewhere, we'll have some people at both locations to kind of help out. So they went in and as they are flying, I'm I'm looking at the news. And what I'm seeing is this. So they flew in to the day that and it says the 16th, because again, this was right afterwards, they flew into this mess here on the 16th. And it was terrifying for them. So Nikki's civilian trained, had gone to Okinawa, is really her first operational anything, and flew in with my agent, one who had been to Afghanistan multiple times. And they both were terrified. They basically landed at dark, onto a dark flightline with planes nearly crashing into each other, with people throughout roars of crowds around them. And into a very unstable situation, they were quickly turned out and told by some of the medical leadership there that they needed to go guard the flight line with the Marines with their pistols with you know, the Marines who are very well trained with their rifles, and so they did that for a short period of time. And fortunately, my h1 was like, this is not where we're supposed to be like, if something goes sideways, this is not where we're supposed to be, we need to pull back. So I pulled back into a farm building I saw briefly when I got there, and set up their backpack medicine in case something went down. And then as things settled a bit, they returned to the role to now it's funny that Travis had mentioned, the guarding of the hospital, right, the prepare to defend the hospital because she gets the role too. It's like, okay, if you were safe, these are medical people. And we find, and they walked in, and they said, prepared to defend the hospital. And so that's what they went into. And so hiding in bathrooms, I mean, it sounded like an insane time. Unfortunately, it doesn't sound like there was anyone that actually got in at that point, you guys did a great job. But it surely was an eye opening experience for them. But they were successful in commandeering some rooms for us to have, which I never really slept in because I was busy once I got there. But rooms remind people to sleep in, which was the most important part. And she did a phenomenal job, Lee's liaising with the role to leadership and especially with the trauma surgeons there and everyone, we flew in the following night, we kind of were delayed, we came in with the at first. At a cutter, we all kind of converged there and flew in and landed early morning hours of the 17th. And actually, when I landed, this is related at night, I took this picture, it was a lot more stable than but there were definitely lots of people kind of milling around. And I thought about that Afghan Special Operations commanding officer telling me how beautiful it is in Afghanistan. And I said, this actually looks kind of beautiful. And I snapped a shot because I was thinking of him. And actually, in reality, the North H kya. where NATO was at was actually very beautiful. So just make sure these rows as well as there that one day I'm going to a meeting. That's actually the role to I think behind it, correct me if I'm wrong, Travis. So beautiful building looks a lot like the one we were in, in Kandahar, in fact, smelled the same look, the same barracks were the same, very weird. And then, you know, I think there's like a chow hall or something out there was a barracks over here. So it was actually very lovely. But it became rapidly clear on the 17th. And the 18th. As we're meeting together that the rule two is having way too many Afghans that are getting sent there while they're you know, on standby for us casualties. There's a lot of just D NBI medicine that needs to be done in addition to the trauma that they went through. And so they were looking for a forward roll money or people to go out and actually be out and about. Now the 24th mu has an STP they had already gotten there just the day before and they'd set up in the packs terminal. I've got a map later. But that's really right there in North HPI. So they were actually quite adjacent. They were like close walking distance from the rural to that was an important strategic spot. Because as they were getting on the flights, they could clear them if there was an issue, make sure people are ready to go. So I volunteered and also finding out that two one was going to navigate. I said, Well, we're going to go with our people like we talked about the other day. And so I got a grid written on a piece of paper that I took a picture of so I had it because I lost it from our intel officer late at night and saying go find something there. I'm pretty sure there's a hardened structure. That's the closest hardened structure you're probably going to find to abrogate. And so we went out there and it ended up being this building here, which was a security complex. A contract security complex was very weird. There. You could actually see out the gates and some videos initially until those went down. The water had been cut off. So you know, we had some very strict like bathroom rules and how we were going to dispose of things and it was it was pretty austere and so the first day When the night before it was empty, because they didn't open those gates yet, the next morning to ones going, so I go ahead with two of my colleagues, one of my nurses, one of my corpsman to get set up. And this is what we walk into. And it is a packed mess, and there's no shade, and they have no water. And they have no food. And they've been there since I guess overnight since I had left. And people were writing and crowding. And they saw us coming in with just backpacks a gear and trying to follow us, seeing us with our water bottles and wanting them. And it's heartbreaking to be carrying water through a group of people who clearly look like they need it, and wanting to give them that but I've got one pack. And I don't know what I'm getting resupplied because we get dropped off. I've got other people coming, but I have no comms with them. Because there's no Wi Fi there's a jammer outside this building. And to have to have to ration that in such a humanitarian crisis is really rough. And that became a running theme there because we had no idea when we'd get resupplied. We were kind of on our own in this location. It was it was interesting. But we set up this little recess area. So this is what we were working out of. Now. I'd mentioned the other day, again, we had all those med supplies planned to come in and the Marines are like they're coming in, they're asked for officers like they're coming in. But we came with our backpacks, right, my nurse had said, and that's actually her about like unit right there, had said, you know, let's just grab these things. So the drop down bags from all the, you know, different exercises we had done. And so we have these drop down bags, one with consumables one with meds, we had this move system, which is basically an oxygen concentrator and a vent and a monitor all put in one, section two, we had another vent, we had like one oxygen canister. And that's really all we had initially. And as I'm there I'm people are banging on the door, one medical care. So we're really triaging them from the door because I can't support much. And there's just three of us for about eight hours while they were figuring out the drive down. There were some issues in the ambulance. So that was a key issue. So we basically convert conformed this into a place that we could take care of people. Here's another picture from the other side, where at least we had a trauma cabinet. And this is actually after our Pro Pack had arrived and things like that. Now a lot of these pictures I'm gonna show are when we were not busy, but the first three days we were busy non stop, I don't think I slept more than maybe an hour to a day during that time. Because we were so chaotically busy. So I put my teams other than Nikki and myself the ER Doc's, they were on 24 hour rest cycles. So they work 24 hour shifts and go back and sleep next to the rule to which had very nice barracks, they could get a shower at sometimes get food, but then the chow hall closed down. So everyone was on Emory's and kind of rest, and the rest of us would stay here and put them kind of sleeping cycles in a different conference room in this building. But we stayed because there were so many patients so much need. So the rest of these pictures are taken when we're not that busy. But we took care of lots of children. So it became really clear very quickly, we needed pediatric supplies, which we already knew we plan for that we had put together this big barn stolen, you know, brazo type kit that was sitting on the flightline in Saudi Arabia, and I think it ended up in Kuwait, take care of these children. So this child over here had been trampled. Fortunately, obviously her airways and tech she's sitting up, but she had a broken leg. This kiddo here had shrapnel to the head from a flashbang and she had actually been tossed over the fence. Fortunately, the Turkish military was very aggressive and they were in the area we were at very aggressive and just grabbing the babies. Because like I said, the other day baby had died the night before we got there. And so this baby was motherless parent list family lists and just brought to us. And fortunately, she was fine. It was all very superficial, we will kind of get it out, clearly meditating normally. And at that time, it was unclear what the medical rules of engagement were, which I had asked for months in advance. And so when we got there, they said, Well, right now, the medical rules of engagement are if we've shot them we can take care of them at the role too, but if we haven't, you can take care of them and then treat them and Streatham and that became a very unclear thing. And we really advocated I have to put it out there. My nurses did a great job because I was busy down here, and making sure that that got done to get those to us. So initially, I'm hanging on to this baby like, you know, it'd be nice for her to be at a higher level of care, but we'll hang on to her. While she's here. We get gassed. There's gas coming CS gas coming under the door, because someone shot a CS gas container at our building to clear the riots because they're riding outside. And we had basically patients it was the status down because people are screaming and banging at our door wanting to come in, you know what's going on. And I'm shuffling the patients we have here and ourselves into a back room which already had a plan as I Get away. area closer calm was. And so we sat back there for a little bit while that went down outside. So we wanted to be ready to actually care for real people for real injuries and knowing that CS gas is not going to kill you, but was a little concerned about a baby with lots of open wounds on her head. A really touching story, I want to just lean into a lot of very interesting and heartbreaking. But also heartwarming things happened during this time. This baby was with us for about four hours. I think the first day we picked her second day we we opened and it was before they figured out what to do with displaced children or unaccompanied minors. I don't know we had called the roll to our context there. But at that time, we had the landline, which went out very quickly thereafter. And the answer another one was like we don't know what to do with them yet. Okay, cool. So I'm gonna hang on to this baby. But fortunately, hours later, as my corpsman who was so sweet with her was like, Doc, I don't think we can hang on to her all day of like, I want to take her home because I think I think we can handle her. A woman or a corpsman came to our door was knocking. And that's the only people we're letting in were people that were speaking English at that time that we could identify, because there was so much bang at our door for people wanting things and needing things. And so we had corpsman out there kind of triaging from one eight, they volunteered their services to kind of weed out who really needed to see us. But they brought a woman to the door and he said, I have a woman looking for a baby, do you have a baby like we have a baby? Is this the baby you're looking for, and just to see the tears of just relief and joy and stress and pain. And the only way I can describe this entire experience and what people had there was just complete despair. With a speckling, maybe a little couple sprinkles of hope. And that was one of those moments. This little boy here, this was during again, when we weren't sure what the medical rules of engagement is. Finally, when we are deciding we know what he needs to go on the road to I don't care, he's going to go. This little boy had come to us three times in probably less than 24 hours with his mom and he was severely dehydrated and we give them fluids and we give him antibiotics. And we get all these things. And they just kept bringing him back and bringing him back. And he was more and more somnolent as he came back. The only laboratory tests we had was an I sat and glucose was fine. But clearly he needed some further workup something was going on. So fortunately, we finally just took this kid. And at that point in time, it seemed like medical rules of engagement had been established as in if these people are on this property inside these gates, we will take care of them. And so that was a transition in how we could actually care for people at that point in time. And that was a huge relief to us. Now, that being said, I'm gonna put a little caveat here, just simply in the back of your mind, because it'll come back up later in the talk. I push that information out to the Marines but here we're already you know, three days into a huge operation and my Marines and been busy working 18 hour days, down abrogate trying to pull people who have papers and turn people away, unfortunately, that don't and working nonstop to abrogate. And so I did push that out to leadership, but it never filtered down to the lowest level. That's what happens when we don't have information ahead of time. That's clear. But at this point in time, it was you know, take care of whomever and figure it out. From there, we'll take the pregnant patients that became another huge issue of women coming in, who were pregnant or didn't know if they were pregnant and lots of ultrasounds and again, my butterfly was super helpful. Any type of affordable option would have been very, incredibly helpful. And that's a moment that it was so helpful for things like potential abruption, diagnose that on a woman, just making sure someone didn't have an ectopic or cramping or whatever the issue is, these women hadn't had any prenatal care met, most of them never had a cervix check. So this was kind of like a huge cultural barrier here. But lots of lots of women, so many women, and part of it was emotional physical exhaustion. And part of it was the stress and physical. Basically, assault they had coming in by the Taliban. Part of it was the massive crowds and being trampled. And part of it was, you know, true issues. Like we had lots of people with seizures, or dehydration or hypoglycemia, or coming to us or things that we just didn't know very, I've got a PRO Pack, I can have a five lead, I've got a glucometer. I've got my ultrasound, and I got my hands on my eyes and my ears. And we'll figure it out from there. And so we continue to take care of them. But these women as they felt better, would just cry. You know, they'd oftentimes come in incredibly sondland They're mostly women. We had some men, but a lot of women, when they come to you, they would just cry and hug us. And they are just so happy to see women, I think partially partially be in a place that was safe. And to know that they have that next moment, I'm gonna take my emotional support coffee for a second so we treated lots of lots of these women and again, just making things work right. So slowly but surely we had supplies kind of filtering down. I was telling someone earlier that Germany and Norway and all these other countries started sending like medicines. And so it was a slow roll at first because our huge crisis was really those first few days down at that gate. But as we started moving people, planes coming in, started coming in with supplies, and so the supplies were available at that time. And so the Metformin that someone needed was there and the the insulin never made it down there. But we actually Cal Boyd, I mean, honestly, is what we were at using someone's insulin and just okay, well, you've got extra Are you willing to share? Cool, and we're just gonna go ahead and give this to whoever needs it. The people are beautiful. I have so story about the potential corruption. I did. I don't know if I did tell us that other day. Know, when this woman came in with, with the obstetrician, yeah, so there's an obstetrician there. And she was so kind and so beautiful, and so helpful. But she was only one of many. So before they could actually get us real interpreters, the contracts have gone fast enough. So the first few days when we're so busy, we have no interpreters. And so people would volunteer. Afghans would come in and say, I speak really, they tell you like I speak great English. Can I please help you if I'm stuck here, too. I'd love to help you. And so one woman was a young woman. And she was about to do her master's in international business. She was doing school in Pakistan, had come home for the summer, or whatever it was, it was stuck there and now trying to evacuate. And she was so sweet. And she had helped out a lot. And I asked her when when, you know, she was there for about a day. I asked her I said, Do you mind if I asked you what it's like outside of these gates. And at this time, inside the gate right there where we were at, there were feces everywhere. There were not enough toilets, there's not enough to eat, there's no shade. They're not eating Emory's. There's not enough anything at that time. And they're crowded in like cattle on a on a on a train, right. And she said it makes this place look like heaven. Outside these gates. These people had basically walked run driven. I don't know how I got into Kabul, over days for some of them. And she said in the streets, there's dead bodies everywhere. Taliban is literally just shooting people. There are people being trampled because everyone is so terrorized that they get trampled and laid off to the side. So the smell is horrible. And then once you get to the gates, the Taliban are coming out. And but stalking people which we saw plenty of that, in the face, stealing their things and creating more havoc and terror. And these were people that we were working with at the time. But despite all this, she had a sunny disposition was so helpful and thoughtful, and even trying to offer us things. Another piggy back story, another older woman had one bag with her, and was so helpful are so happy and thankful for the care, she gets out a bag of jewelry, and starts doling out pieces of this to us. And I know in that culture, you can't say no, like I, we went through that we've been there. And so I was like, I don't want to take this from her microbiota trying to give it back. Like you can't do that. And it's got, you have to accept it. So those types of things, these people are absolutely beautiful. And it just really hurt to see them like this in this moment and stuck there. But eventually they started moving people. And at that point in time, we were able to move a little bit more to so then we started getting more serious patients as people are going through and actually getting the seriously ill ones from abnegate from east gate, and being able to evacuate them in our ambulance there. And, you know, in retrospect, all of these patients, these DNDi patients were great practice for what actually ended up happening because our corpsman and our Marines advocate with to one and one eight BLT, who was with us, behind us knew where we work, they knew what our capabilities were, they knew what we did have and what we didn't have the interface with us and act and really became very comfortable moving patients. And so that was a key piece that I think was very helpful. Despite the tragedy of the humanitarian disaster, I think it was very helpful for them to understand that. And also, as we were less busy with so many like smaller D and bi patients, we were able to actually kind of provide the logistics came in so the formula came down to us we were able to start making bottles, those were my Korean making, making baby bottles and doling out diapers. And we're able to get out to the gates and actually check on our corpsman and see how they're doing. And this is the trash that was left, right outside the gate and it breaks your heart that people like brought one bag, and we're wanting to bring the little 12 month tag to take their baby picture with her on social media. But it cleared out we were able to kind of reorganize and figure out what we had left and still be prepared. And so that was a kind of nice transition. As we got closer Sir to the 26th, which again was a surprise. So the night before the 26th on the 25th, one of my nurses who had been off and then they're off time they were really going to meetings that I couldn't attend. She came down late, and she wasn't due to come back till the next morning, you know, when my chief which is my senior and listen, advisor, and said to one is asking if we can push our ambulance down to abrogate there's an increased threat of an IED. They're asking we can push them support over there. So absolutely, that's what we're here for. So we spent that night, a group of four one group care nurse, one enroute care corpsman, and then two other corpsman one as a driver and one as an assistant driver, but also that extra hands on the ground, if necessary, down to the gate. And they started doing 12 hour cycles. So the next morning, they were replaced by another set. And this is kind of where they were at. So this is our location here. I don't think I'm a pointer. But we're kind of here on the right hand side. That's where the CCP was over abrogates, we're very close to five minute walk two minute drive. Again, this is us over here. And here's the CCP. And in this one I've marked where the blast site was at the sniper tower. Just for kind of situational awareness. The role too, was up there at the top, and the Meuse STP was over close to the flightline at the packs terminal. Of note we had tried to initially the very first day I'd gotten there, see if we could jump the flight line if there was ever an issue. And it actually became more of a hazard to try and clear the flight. So going around was the only way and it would take about 15 minutes without anyone in the roads, which plays into the actual mass casualty because there's lots of people now they're a 15 minute drive from this, the CCP abrogate over to the rule two in about 12 minutes from where we're at. So the morning of the 26th was beautiful actually didn't take that this is so the morning the 26th is 530 in the morning, there was actually a really beautiful morning. And it was very quiet, which is always a bad word in the ER. Very quiet. And 24th Mu had stopped by because they loaned us some equipment and said, Hey, I think we're all pulling out today. So we need our equipment. Like, you know, there's an increased threat like oh, yeah, we're gonna move out before that. So they grabbed their things. And we were left with that move system and those bags and things that were in that picture. That's where we were left with at the time of this mass casualty. And so as the day went on, pretty nonchalant. And again, there was that kind of talk like oh, yeah, to what Mike pull out. But as they went forward, they wanted to continue those Marines wanted to continue because this is what it was like this is actually the CC CC P point. You can see this is Abby gate as you're going in. There are some letters right there. And around the corner there was like a mini bas which is a corpsman Ron bas. This is it this is this is the beginning abrogating the tower, the sniper tower, you can see the very far back there in the middle behind this young man's head, that farm distance that's the same for tower. And for the Marines. Actually, there were so many, so many people outside those gates still, they chose from tier one to stay there and continue working despite the fact that they knew there was an increased threat level, because they had been so touched and hurt in the moral injury was already there, right. They're just trying to do their best at this point in time. And do as much good as possible. So at about 1736, we felt and heard a very large explosion. And within seconds, my Camarines I had two of them. One of them comes out his radio, he's like there's been a blast abigai And I was like, Okay, this is what we've been preparing in my mind. Like all the expletives. This is what we've been preparing for, but I didn't think was gonna happen. So send a text to the roll to like there's been a blast. I don't know about the casualties yet. Pending, get get our litters outside, get your bags open, get your PPE on, let's get going here. And within a couple more minutes, it was clear there were lots of casualties and US casualties came over the radio. And within minutes, we had a few patients coming to us. The first two had kind of airway neck type injury. So these corpsman were worried about airway and worried about driving them around, and also wanting to get back because they knew there were lots of other casualties there. And we got the US casualties. They basically pivoted to the US casualties from the Afghans. Even though the Afghans were many of the casualties as corpsman that's their jobs, they pivoted to those people first, although the children oftentimes would get thrown in with the Marines too. But our first group, many of which these trucks had already gone by so I knew they were going to roll too there were some seriously injured and many which were actually dead on arrival and they got there. But we got a couple airway ones, you know massive soft tissue injury, which is classic trauma airway, which is like hey, if I eat can sit up and talk, or at least attempt to talk, you're gonna be okay. Now there was an expanding human toll on the neck, which was a carotid artery injury from Prag. And so as I'm finishing my trauma assessment on the soft tissue injury, and I'm like, You look pretty good, I'm hearing screaming from outside the door, and the door was here, I had it propped open, because I wanted to be able to hear what's going on. And it was one of the corpsman I recognize from the sniper group. And there's box structures a moving truck, and they're pulling a man out on a riot shield. And this is a ashen gray person. So I'm basically throw this marine with soft tissue injuries on the floor, like you need to move, wipe down my arm, all the blood that's all over my my table, and basically get ready for this other patient. Now, as a just a reminder, we have divided up our people. So there are only five of us two doctors and three corpsman in this area at the time working on multiple patients. And also our ambulance is still actively engaged at the gate. And we're trying to flag down a ride. So we were able to get through this, this patient who was so critically ill and get to work on him. And I'll go more into that story in a little bit. But it was very chaotic, trying to get him on the radio to get us a vehicle. And he ended up going into a vehicle with Nikki because I had her bagging him. I said do not stop, do not let them stop you in the trunk in the ambulance bay, take this patient immediately inside. But fortunately, we had two units of blood that we'd stolen from the roll to and put in our fridge. So he got blood there, he got bilateral chest tubes, he got lines, he got oxygen. And that's what he needed to make it the next 30 minutes to get to the next level of care. This is our room afterwards after we cleaned. So it's gonna be a reminder of how nasty this can be. So we saw a total of seven patients at our site of us people that were from our own battalion we were supporting. And then I went outside as I'm seeing some pickup trucks going by to do some kind of enroute just kind of check in on Afghans as they're in the back to make sure they're okay to get up there. My other team that was off had gone to the ambulance bay. And I don't know if you had seen them, Travis, but they were helping out with the meds and T Triple C and things like that. So we're actively engaged there, too. And then we basically depleted all of our resources. And by three in the morning, I'm packing this up and saying, you know, we've got our enroute care here, but I've got nothing else I can do at this site. So we're gonna close it up. And if there's any secondary blast, they're gonna have to come back around to the roll too. So, lessons learned for future operations. So this I mean, every time I tell this story, I'm like, Well, why am I telling this story? Again? What's, what's the purpose of this? And why don't you may be thinking that too, because I get I get tired of hearing myself. But in the realm of everything, especially as we're looking at what's going on in the Ukraine and in Eastern Europe, and as we're looking at indo PAYCOM, I'm like, how does this apply? You know, this is like the end of an era. Right? We closed out CENTCOM, we finished Afghanistan for 20 years. So how does this apply in this new era? And sometimes I get a little jaded. I'm like, I don't know if this will ever really benefit. Like, what how does this benefit? This is not CENTCOM anymore. We got, you know, shipboard missions, and how does this work? So this has been my challenge of really trying to figure out what what can we make out of this? Like, what, what lessons can we actually learn? And the first one is this. I'll tell you story. So that very sick patient, and I'm trying to do a full trial resuscitation basically by myself, because my other ear doctor is fully employed. One of her corpsman is fully employed. The corpsman that wasn't, is a prev, med tech, who looks completely out of his out of his mind. And I'm like, drop the meds. I know, I know, we taught you this, drop the meds. And watch these other patients. I've sat down on the floor. The one corpsman I had with me, who's a very junior corpsman, who I know we had trained and I know he was able to do these things I know that he was capable, could not perform. In this moment. He could not perform. In fact, he pulled out a line that he couldn't get in that by the grace of God, a soft medic was walking by Do you need help? I said yes, absolutely put this line in. And as I'm drilling in a IO into the the one leg that's available, and also trying to put oxygen on a patient also try and turn on the oxygen and this one corpsman just crumbled. And so the one senior corpsman that was with us, literally was bouncing between two beds and she was a rock star. Why? It wasn't because she was senior is because she had had prior experience, O CONUS. Er experience and also had been an ER tech before her Navy career. My junior corpsman Despite the fact we had put him on some er shifts, before we deployed had been an admin corpsman at Med battalion. As many of these med battalion corpsman are, as many of our medics are, they do admin jobs, or they'll do vital signs. But they don't see true trauma patients. And it's one thing to see trauma patients. I was like, I've seen trauma, I've done trauma. I've been already been to Afghanistan, it's no big deal. But when they come in wearing your uniform, your exact uniform, it is a different story. So I can only imagine for this corpsman who's never seen this, he's 22 years old, is a goofball. Like, he fell apart. And I can only blame myself doesn't How can we get these corpsman into more trauma training. And fortunately, there was that soft medic that was able to help. And this patient did die, because I truly thought he did. Invest in your Corbin, invest in your medics, get them into trauma scenarios, get them in with sick patients, get them into the hospital. They have to be exposed to sick patients, they have to be able to get in lines and people that are difficult. Well, that's an old lady with crappy veins who's septic or someone who has zero blood left because that patient I keep coming back to when I pointed his finger thoracoscopy there's no blood, there was no blood coming on his leg. He actually ended up having a what the anesthesiologist who took care of it the role to and really truly saved his life. He had a non what they consider a non survivable injury and iliac artery transaction. But he bled out on the field. And in fact, I found out a couple months ago, as I was talking to some of the two one guys, they were like we found him under a pile of dead bodies, which is why he came to you so late, which is why he was really bad. Invest, invest time, invest energy invest the fight into exposing our people, not just ourselves, not just our nurses but our corpsman and medics into trauma scenarios in sick patients. The second lesson I've taken out of this is standardizing mass casualty training. Now I keep coming back, I was very frustrated with the fact that I was having a hard time figuring out who's who in this giant umbrella of who's supposed to be responding here. And what the big picture mass casualty plan is. And that's going to change from place to place. I'm not going to harp on that, while it was frustrating. That is over. But what's not are the future conflicts and the different ayos we're gonna be going to. And so mass casualty training can be standardized. And in fact, I was really encouraged when I went to the committee of T Triple C last month. And they're talking about making a T Triple C mass casualty plan. And I think that is so brilliant. And so I want us as military emergency medicine leaders to be at the forefront of this in pushing this because it's not just training for us. We can figure it out in the day like we have the skills for this. And it's not just our corpsman. It's actually teaching mass casualty training, to our ground forces, to our logisticians to the line, these are the people that need to know this. And it's not just in the military, it's also for our civilian, right, we've had plenty of terrorist attacks, we've had plenty of incidental things that happen natural disasters, and everyone should know this and the military, we should be the subject matter experts. And when I say we, we as an all services we as in the VA, we isn't everyone here and the most junior person from the Marine Corps should be able to speak the same language, if they're out of mass casualty, as the PFC from the army as whatever your most junior thing in the Air Force airman in the most senior airman in the Air Force, you know, we should all be on the same page. And I'm also encouraged, I'm hopeful, and I'd like to try to get in on this is that this teacher will see mass casualty training, if we can do it. Well, we can pull this off well, it'll go to the masses, just like our normal basic teacher, we'll see. We'll just like de use it and border patrol and the FBI and every other interagency so we can all be on the same page going forward to these global crises. I see almost no promise. Lastly, prepare for prolonged casualty care. Now, I want to highlight that there were multiple multiple multiple trauma teams and when I say trauma teams, trauma surgeon, orthopedic surgeon anesthesia, ER doctor, they ran for hours, like they basically divided two or ORS into four different areas. And were able to take care of all these surgical patients. I mean, they had over 50 casualties that needed actual acute care, many of which ones the or over time. But so we didn't have to do prolonged casualty care. But what we didn't do is model something that can be used. So I was talking about it with most of you. I won't harp on it too much. The morning after the mass casualty. This is 12 hours up to the blast. A loudspeaker call goes out for walking blood Make. And my NYC Vela keuning was the ERC nurse down there. And she hears that a bunch of the Marines are trying to leave. And she's like, well, well, wait, wait, wait, wait. Like, don't we have Valkyrie kits? We've got about Graeca? How many do we have seven cool. Seven Marines are a little tighter, I'll get over here. And the corpsman and the CLS Marines gather their blood. They sit them out here at their CCP, that's this kind of darker picture is you see them grabbing blood, they put their units into an emery box and transport them around the flight line. That map you saw you saw in 37 minutes, they got seven units have fresh, low titer Oh, blood into the lab. And I know this for a fact because my lab corpsman was in the lab at the time, deliver it there while they've just drawing the six unit from their walking blood bank that's not low titer Oh screened. And so in my opinion, this is superior blood. And they did it faster than a huge walking blood bank. Why? Because we have the right people with the right training, we have the right resources, we're able to do it. So if we're able to do this for walking blood bank, a distant one that kind of didn't disrupt the operations at that gate, and got them out of there on time. We can give this to every other person in the military, right? This is something we can do. It's something that's teachable. Last thing whenever go over right here is just letting you know that there was a huge moral injury and no mass casualty, we prepare for mass casualties. We prepare mentally for combat trauma, we prepare for the fact we're gonna see people that are in uniform injured, even though it is traumatic. But a lot of the moral injury came from doing this. There's two one Marines. That's one eight Marines. And they're they're telling children that they can't come in there. They're having to return people outside. I had to even and I saw just a snippet of it. I when I went down to the gate after we kind of before the gas casualty. And after we had so many patients, I was able to go down to the gate to check on my Marines. There's a woman that seizing, I'm like, well, we probably should grab her. Let's just toss her in the ambulance. And I talked to the soldiers standing there like what's going on? I don't know, it's just started happening. I'm like, can I take her like, well, she was actually supposed to leave. I said, Well, I will bring her back. She's care. So we put her in the back of the ambulance Long story short, she gets some benzos. I don't know why she was seizing. But she wakes up screaming about the Taliban, that they're gonna kill her. They're gonna kill her family, they've already killed her parents. That even if they don't kill her physically, she has no brothers, she has no Uncle, she has no men in the family who can go out and actually provide for her. And she claws into my hand, as she's telling this story story and telling me to not let her go. So I need a dog. So these boys went through a lot more, a lot more. And so as the people will take care of them. Please understand that if they are here they're gonna need help. Last time, I know I'm up for time. Oh, there we go. Practice in medicine area. practicing medicine is not the practice of medical leadership. So we talked about the practice of medicine. We're talking about caring for patients in front of us being provisioned Our jobs are Kshs, right? We're talking about us, right? And how we perform and how we do and, you know, we all like to be rock stars, right? Everyone wants to be a rock star. But the practice of medical leadership is caring about patients that you may never see. It's caring about people that you may never take care of. It's caring about your forces that are on the ground. It's having the foresight to look forward and you things like creativity. I tied to this on this one Wargaming imagination was gonna keep plugging, curiosity, utilizing things that we don't usually associate with military leadership, or with you know, always with medical leadership, right? These are oftentimes very hard sciences and, you know, tactics and things like that. You have to use your imagination. You have to use your curiosity. You have to build relationships, you have to be able to work outside the box and get things done as a medical leader. And that's not something that's teachable for many people. So the last thing I want to leave it's been catastrophizing, put that on there just because we spent like, maybe 25 minutes once a week to catastrophize going into this, figuring things out. I want to leave you here. I'm sorry, I've gone over time. But how do we inspire our colleagues from medical leaders because by the selection of us coming here, I know we're medical leaders like this is like, oh, yeah, I've heard this before. Great. We are in medical leaders, right? But how do we inspire our colleagues that don't want to be in the military world who are stuck here? Who are inevitably going to be deployed and need to step up to the plate? How do we inspire them to be a medical leader in those situations? How do we inspire the people that did civilian residency who have no idea what they're doing and are going straight out to them? That battalion are getting deployed? We have all these NADs grads, right? Like how do we teach them to be a medical leader in the military? And that's what I want to leave us with today. I'm sorry, I've gone over time. That's all I've got. Any questions. Soon as there are any additional questions, we can go to time we'll just put a barrier. Right. So we'll have to do email updates. More now