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This Computerized Axial Tomography Scan shows the placement of a 14.5 millimeter high explosive incendiary round which was removed from the scalp of an Afghan national army soldier at the Craig Joint Theater Hospital, Bagram Airfield, Afghanistan.


BAGRAM AIRFIELD, Afghanistan -- March 18th, 2010, became an anything but normal day for the trauma team at the Craig Joint Theater Hospital here when they were called upon to remove unexploded ordnance from a patient's scalp.

The patient, an Afghan national army soldier, was involved in an improvised explosive device attack and had a 14.5 millimeter high explosive incendiary round with approximately 5 grams of explosive lodged in his scalp.

"We were informed a few hours ahead of time from the forward operating base at Salerno that we had some patients coming in who were victims of an IED blast," said Maj. John Bini, 455th Expeditionary Medical Group/Task Force Medical East, trauma director.

The initial report stated this particular patient had a metal fragment retained in his head as a result of the blast.

Bini, deployed from Wilford Hall Medical Center, Lackland Air Force Base, Texas, initially assessed the patient in the emergency room trauma bay where he was stabilized and taken for a computed axial tomography scan to assist the medical team in further evaluating his condition.

Once the patient received CAT scans of the head, chest, abdomen and pelvis, the team moved him to the operating room to prepare him for surgery.

Lt. Col. Anthony Terreri, 455th EMDG/TF MED-E radiologist, viewed images from the CAT scan and didn't initially see anything unexpected for an IED trauma patient. He explained initially patients received a scout scan, which is a snap shot of the whole body. Then a more thorough scan is performed starting at the head, and the radiologist and surgeons review the images to formulate a more thorough diagnosis of injuries and how to proceed with surgical operations.

"Initially I thought it was a spent end of some sort of larger round," said Terreri, also deployed from Wilford Hall Medical Center.

"I saw that it was not solid metal on the inside," he added. "I then looked at the scout image and could see there was an air gap on one end and what looked almost like the tip of a tube of lipstick at the end and decided this didn't look quite right."

Terreri, a Tonopah, Nev., native explained when reviewing scans, the radiologist may come across images that reveal information for which the surgical team must be prepared and a UXO is one of those cases.

He immediately went to inform the neurosurgeon who had already left to prepare for surgery.

"I went directly to the operating room and evacuated all unnecessary personnel," said Bini. "I had the anesthesiologist remain in the room in his Interceptor Body Armor to monitor the patient."

Bini then notified his chain of command and the explosives ordnance disposal team and began to secure areas of the hospital to protect patients and staff.

To add another twist to this already intense situation, Bini explained there was another surgical team operating on a patient with multiple life threatening injuries in another operating room and they couldn't safely evacuate as the patient was in critical condition.

"It was kind of a case of Murphy's Law coming into play," said Tech. Sgt. William Carter, 455th EMDG/TF MED-E noncommissioned officer-in-charge of central sterile processing and a medical technician deployed from Wright- Patterson AFB, Ohio. "We had an OR full of trauma cases and we had people in other rooms who were busy taking care of patients and it was really an all hands on deck event."

Carter explained one of the greatest difficulties the teams in the other operating rooms faced was the ability to pass through the cordoned area to gain lab work and blood products. "We donned our IBA and made sure the individuals in the other operating room did not have to pass through the area and had everything they needed." He referred to it as a tag team effort and the team ensured their ultimate goal, which is to save lives, could still be accomplished.

When the EOD team arrived at the hospital, Bini took them to review the CAT scan images. He then proceeded to the operating room, donned his IBA and removed the round from the patient's head.

After the UXO was removed from the patient and given to EOD, the areas were reopened to normal operating room traffic. Bini turned the operation over to the neurosurgeon and the operating room team to complete the operation.

The procedure from the patient's initial arrival to completion of the neurosurgery took more than five hours, Carter said.

The major pointed out that everything that transpired from the surgery to the recovery was a success. "The patient does have a traumatic brain injury, but his neurologic condition continues to improve on a daily basis," he added.

"You hear about this type of thing on television and read stories about it in the news, but to actually see the way people react in this type of situation is remarkable," said Carter, a Fort Myers, Fla. native. "It was a real concentrated effort on everyone's behalf to ensure that we were all safe and the patient was safe as well."

"This is something that I train and teach," added Bini, who is the course director for the Air Force Emergency Warfare Course at Wilford Hall. "It is, however, an extremely rare event."

Bini pointed out that there have been similar cases where a potential UXO had to be removed, but as far as he knew since the beginning of Operations Iraqi and Enduring Freedom, this is the first confirmed case and in the past 50 years of modern warfare there have been less than 50 cases of this type.

Although this was a unique situation from even a trauma medicine standpoint, for these professionals it was just another day at the office.

The operating room doctors do not care whether patients are coalition forces, local nationals or U.S. military servicemembers; everyone receives the same level of top notch care, said Bini.

"What we did is what we are supposed to do," said Carter. "We do this every day. We may not pull a UXO from someone's head but we save lives."

For U.S. military servicemembers who come through their operating room, they have a 100 percent survival-to-discharge rate and for coalition and local patients the rate of survival-to-discharge is 96 percent.

"This is what we train to do," said Bini. "It is no different than what we do every day. It was something that needed to be done and the team did their job."


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