April 12, 2010 -- "I think we have a problem."
Those were the words that Lt. Col. Anthony Terreri, a doctor and chief radiologist at the Craig Joint Theater Hospital at Bagram Airfield in Afghanistan said he uttered to his CT scan technologists before racing to the operating room to inform the surgeon that his next patient had a bomb lodged inside his head.
Desperate situations are no rarity in any emergency operating room, of course, but rarely does the threat of a bomb come so close to the edge of the surgeon's knife as it did last month, when an Afghan National Army soldier arrived with the explosive embedded in his skull.
Following media reports last week on the incident, the doctors involved offered their first-hand accounts of the operation -- and no one knew of the explosive until Terreri had inspected the images from the CT scan.
"The first thing I did was try to adjust the contrast of the image to get a better look at the object and realized the center was not made of metal and I could see through the metal jacket," Terreri said.
What he saw was the trademark architecture of an unexploded shell. The 2.5-inch unexploded ordnance had become lodged under a portion of the patient's skull during an improvised explosive device attack.
"I went straight to the [operating room] to inform the neurosurgeon of the situation as there are procedures that have to be followed in these instances -- non-essential personnel must leave the OR, explosive ordnance team must be notified, the surgeon must wear body armor, et cetera," Terreri said.
'A Case of Murhpy's Law'
The scene that unfolded would later be described by Tech. Sgt. William Carter, a medical technician at the hospital, as "a case of Murphy's Law coming into play" -- an explosive device in an area where a full evacuation was all but impossible.
"We had an [operating room] full of trauma cases and we had people in other rooms who were busy taking care of patients," Carter said. "It was really an all-hands-on-deck event."
Major Jeffrey Rengel was the anesthesiologist who attended to the wounded soldier after the CT scan was performed.
"At the time, we were unaware of the unexploded ordnance in the patient, and proceeded as I normally would in monitoring the patient's vital signs and administering medication to provide a general anesthetic for the patient," Rengel said. "Within 10 minutes of arriving in the operating room, we were told of the potential unexploded ordnance in the patient, and the [operating room] was evacuated except for myself."
Rengel was told to don his body armor and a helmet. He then proceeded to switch off every electrical device in the operating room to decrease the chances that the device would detonate. This included all of the patient's monitoring devices, so Rengel resorted to a manual blood pressure cuff and used a portable, battery-operated pulse oximetry device to keep track of the soldier's heart rate and oxygen levels. He placed it on the patient's foot, as far from the explosive as possible.
To estimate how much anesthetic the patient was receiving, Rengel had to manually count drips per minute.
"There was a moment where I contemplated what was happening," he said. "In all honesty, I allowed myself a moment of worry, thought of my wife and kids, said a quick prayer, and then thought about how our brave men and women put themselves in harm's way every day far and above the position I found myself in right now."
Meanwhile, Maj. John Bini, the 455th Expeditionary Medical Group-Task Force Medical East trauma director, prepared for surgery.
Explosive Removal 'Anotehr Day at the Office'
"When [the explosive ordnance disposal team] arrived, we went to radiology and reviewed the CT scan again," Bini said. "They confirmed that this was indeed an explosive round that had not detonated."
Explosives experts told Bini that the impact detonator on the round meant that if he dropped it, it could explode.
"Their advice to me was 'don't drop it,'" Bini said.
While such surgical situations are a rare occurrence, Bini said the situation is something that Air Force doctors are told to anticipate.
"This is something we train for, and I train others for, albeit an uncommon event, and to this point the team functioned perfectly," he said. "Everyone did their job very well as a result of training and experience."
Bini, as well as the other Air Force doctors, said that while the operation was a delicate one, nerves were not a factor.
"I did think about my wife and children and was going to tell someone that if anything happened to let them know that I love them," Bini said. "I didn't though ... that's the surgeon in me coming out, we can be a superstitious lot."
As for the patient, even though the explosive did not detonate, the right parietal lobe of his brain was injured. Though it remains to be seen how much function he will lose as a result of the incident, the doctors said he will continue to recover, at least partially.
"The patient has subsequently been discharged from the hospital," Bini said. "He will be able to return to independent living, although he will have some left-sided motor deficits and possibly some minor cognitive deficits.
"When it was all said and done, it was just another day at the office. That's what good training, a strong supporting cast and great teamwork get you -- a positive outcome."