Improving Care in War-Torn Afghanistan

Benjamin T. Daxon, MD, was an active-duty anesthesiologist with the U.S. Army in Afghanistan when he experienced one of the most humbling moments of his life. It was 2016, and Dr. Daxon was the medical director at the primary NATO hospital in Kabul. One day the medical team treated an Afghan civilian who was working with the U.S. Special Forces when he sustained a gunshot wound to the chest. Because of ongoing fighting, he hid for approximately 12 hours before being transported to the hospital.

Dr. Daxon evaluated the patient and could tell he had lived a hard life. He appeared to be in his early 50s. His family did not know where he was or if he was alive—and, for that matter, he did not know if they were alive either. One week later, his recovery stalled, so Dr. Daxon emailed colleagues in the United States for a consult.

The next day, he found out that the patient who appeared to be 53 or 54 was actually 34—the same age as Dr. Daxon. The patient showered that day, and Dr. Daxon saw a different person. “At that moment, for the first time, I could see that he did indeed look 34 and that I could be in that bed instead,” he said. “Even though I was deployed and away from my family in an austere environment, I thought how fortunate I was. I was surrounded by great people who had become close friends. I knew my family was safe and provided for. I didn’t have to worry about my next meal. I had ready access to the Internet and easy entertainment. I had a warm bed to sleep in every night. And on and on and on.”

The patient, meanwhile, did not speak the same language as anyone in the hospital. He hated the food. His room had no windows. He was bored. “Frankly, I felt pity for him,” Dr. Daxon said. “And I felt guilty for how good I had it and how bad he had it, especially when I considered how much more he had risked helping our cause in Afghanistan.”

He wanted to help, but he had to be a little creative. He leveraged the ABCDEF bundle elements—developed as part of the Society of Critical Care Medicine’s ICU Liberation Campaign—to treat the patient. He had an interpreter come in to teach the nurses basic Afghan words to assess the patient’s condition, as well as his pain and delirium. The interpreter helped Dr. Daxon and the team learn about the patient’s likes and dislikes in food, games, and other interests.

Armed with this information, the team changed their plan of care. For example, the patient loved backgammon. Dr. Daxon asked the nurses to learn how to play the game, then required each nurse to play two rounds during each shift. The patient was fascinated by a jigsaw puzzle, so the team brought in a 5,000-piece puzzle for him to work on. Several members of the team pitched in for food from a local market and subtitled DVDs they could play on their laptops.

Objectively, it was difficult to say how these changes impacted the patient’s recovery, but subjectively, it seemed like a turning point. He was more engaged and alert. Initially, he had been quite lethargic, but by the time he was discharged, he was active, with good strength, minimal pain, and a pleasant demeanor.

The treatment impacted more than just the patient. Dr. Daxon saw how the nurses caring for him looked forward to the backgammon games and built a bond with the patient. As for Dr. Daxon, who today is a fellow in the anesthesia critical care fellowship program at the Mayo Clinic in Rochester, Minnesota, USA, he realized how little value he had previously placed on caring for the patient as a person. “Before, I was so focused on lab values, I didn’t think much about asking how the patient was doing beyond rating their pain on a scale of 1 to 10,” he said. “Now I am more apt to assess the subjective experience of the patient and to try and mitigate any anxiety, grief, or angst.”