BBC Orthopaedic Surgeon Reports from Afghanistan

October 26, 2012

How does a reconstructive orthopaedic surgeon from Bronson Battle Creek find himself in the North Eastern portion of Afghanistan in 2012?  That is what Captain Michael J. Langworthy, M.D. was trained to do.

Dr. Langworthy attended the University of Michigan Medical School on a Navy Health Professions Scholarship. The Navy had him undergo further surgical training at both Michigan State University and at the University of California. In 1998 he lead the orthopaedic trauma division at the Naval Medical Center in San Diego and by late fall had been given a small trailer facility right on the beach in Coronado so that he could take care of Navy Sea, Air, and Land Teams (SEALS) who had been injured during training. 

As a result of his training in Michigan as an advanced trauma life support instructor, Dr. Langworthy was asked to teach at the elite Combat Tactical Casualty Care course that the SEALS use to train their medics and platoons.  The teaching cadre was heading to Thailand to work with the Thais and he was invited to help evaluate some of the wounds and burns that the Thai military had sustained while battling pirates. 

“The wound work turned out to be quite productive and my team was able to
characterize specific wound events and we eventually turned these into a number
of articles that were published concerning wounds and blast injuries,” said Dr. Langworthy.  “These data turned out to be significantly valuable when we went to war in 2001.” 

Last year he was asked to edit a special edition of ‘Techniques in Orthopaedics’ that dealt specifically with combat-related joint injuries and burns.  One of the surgeons at Walter Reed had seen that special edition and invited him to work at the new Walter Reed National Medical Center at Bethesda to help train the new generation of military surgeons.

“I cannot put in words the sacrifice that the young men and women of our armed
services at times endure,” said Dr. Langworthy.  “’Operation Enduring Freedom’ has been the longest war in U.S. history. The casualty care at Walter Reed is phenomenal and truly state-of-the-art.  There are a multitude of dedicated surgeons and ancillary staff that attend the wounded.”  

While on a June rotation at Walter Reed, Dr. Langworthy was promoted to Navy Captain and also given notice that he would likely be deployed to Afghanistan as part of the Combined Special Operations Task Force Alpha (CJSOTF).  This forward surgical team is a small, very specialized unit; his team could go into just about any environment and provide damage control trauma care for NATO troops and their local alliances.

In March, Dr. Langworthy packed his bags and headed off for Army small arms weapons training before arriving in Afghanistan in April.  His Navy surgical team was assigned to a German forward operating base in the Northern Afghanistan territory of Kunduz. 

Marcus Luttrel described the area very well in his book Lone Survivor that dealt with his ordeal while functioning as a Navy SEAL in Afghanistan. The Kush-Hindu Mountains skirt this area and the mountain passages are a common gateway for the Taliban to come into Afghanistan from Pakistan. The Germans, the Dutch, and the United States maintain three trauma teams to provide emergent surgical care for NATO troops as well as local Afghanis.  Since the Germans actually own the rescue medical facility, they made a solid decision to provide care to Afghani locals who would not otherwise receive first world care. 

Dr. Langworthy noted that there is a significant number of Afghanis with chronic orthopaedic problems such as contracted joints from burns, clubfeet, and infected long bones. In many of the rural communities oil is still used on an open flame for cooking and toddlers will frequently pull a pot over on themselves causing tremendous burns to their torsos and extremities. 

“We don’t see neglected burns in the United States and we don’t see neglected clubfeet,” continued Dr. Langworthy.  “The Germans opened the clinic doors to the local community and some of the hardest cases I have ever had to deal with were presented to me in Afghanistan.”

A Tale of Two Sarinas  
In mid May, two seven-year-old girls ‘presented’ with extensive contracted burns to their lower extremities.  Both of their names were Sarina.  Neither child was able to walk due to the shortening of muscles and crooked bones. The Michigan Army National Guard First Battalion, 125th Infantry Regiment had been on patrol when they came across one of the children and they brought her to the attention of the German Rescue Hospital. 

“I took pictures and X-rays of the children’s deformed legs and sent them back to some university friends in the U.S.,” he said.  “No one had seen cases like these but one of my partners in Battle Creek, Dr. William Comai, had some valid thoughts about what to do with the bone corrections and after some extensive discussions with my German and Dutch colleagues, we made surgical preparations.  We would do one surgery on Tuesday and the other the following day. The first child required an operation called an osteotomy (multiplanar distal femoral) where we broke the femur (long, large leg bone) and aligned it in the correct position. 

“We had to meticulously separate the knee cartilage from the scar tissue so that she would have some knee range of motion,” Dr. Langworthy continued.  “We freed up the scarred muscle and put orthopaedic plates on both sides of the corrected bone. School kids always complain that they’re never going to use the geometry they learn in the classroom, but the geometric surgical correction that this little girl underwent came directly out of a high school math book.  Geometry is relevant!”

The second Sarina had a more complex soft tissue problem. The burns she had
received ranged all the way from her hip to her ankle. Her knee was locked at
almost 40 degrees and her foot was tethered to her calf making it impossible for her to apply any weight on this limb. 

A Dutch vascular surgeon and Dr. Langworthy spent the better part of Tuesday night rendering and re-rendering complex combinations of four-coupled Z-plasties (surgical procedure to restore or replace part of the leg) on paper in preparation for the second Sarina’s surgery.  The Z-plasties would allow the surgical team to remove underlying scar tissue while providing soft tissue coverage from her hip to her ankle.

Dr. Langworthy takes a lot of pictures to document what he does surgically, which the children found a little unsettling so one afternoon he turned the two of them loose so they could shoot pictures of the rescue hospital and staff.  He said after seeing the photos the children took, he could certainly see how all of the uniformed hospital staff could look frightening to a little child.

Both Sarinas did very well and are walking and even riding bikes now.  When Dr. Langworthy reviewed the surgical team that provided the services to these children in this very austere environment, he didn’t lose sight of all of those who made these types of medical procedures possible.  The Universities of Michigan, Michigan State, Duke, Howard, Berlin, and Amsterdam all provided training for the talented individuals the NATO/ISAF military had made available for this mission.

In early October one of the special operations teams was engaged in a firefight receiving multiple casualties.  One of the operators was mortally wounded and two sustained multiple penetrating injuries that required extensive surgery. The entire Kunduz Rescue Hospital responded to the trauma alert and Dr. Langworthy’s team had both German and Dutch medical support crews standing by to ease this poly casualty event. His trauma team evaluated the first casualty; sadly there was nothing to be done.  He was pronounced dead. 

It is a tradition that no deceased soldier is ever left alone.  Dr. Langworthy would have posted members of his surgical team to stand with the body until he could be picked up for transport to the United States, but there were still two critically injured service members to care for needing limb-saving surgery.  The severity of the injuries required the entire seven-member surgery team in addition to several of the German surgeons in order to address and save the extremities of the wounded. 

“I had no choice but to pull one of the deceased service member’s platoon mates to stand in attendance,” he said.  “I don’t like to do this because of the emotional toll it has when one member of a platoon survives and another has been killed, but I had no choice as I needed all of my surgical team covering both of the rooms to operate on the critically injured. Some of the Germans overheard me talking to the young American service member and they could see he was visibly upset. One of the Germans came over to me and asked if they could also stand guard over the body and I welcomed his support.”

Other Germans and some of the Dutch medical military members also went out to a prepared area and stood the watch with the young American service member as the American Flag was draped over the coffin.  Dr. Langworthy watched for a few minutes as more and more NATO personnel from Germany and the Netherlands filtered out of the hospital to stand the watch with the young American. He then returned to the operating room where his team operated on the injured patients. 

They operated all night and sometime after daybreak they got their first chance to go and check on the watch detail.  There were more than 50 NATO members from Germany, the Netherlands, and Belgium standing watch, consoling American platoon members that had now made their way to the holding area.  Late in the morning the wounded were evacuated and both ended back at Walter Reed. 

Dr. Langworthy offers a special thanks to the staff at Southern Michigan Orthopaedics and to Bronson Battle Creek who provided support and comfort toys for the children that were operated on at the Rescue Hospital in Afghanistan. Some of those children are very poor and had never seen such a thing as the stuffed toys that were generously provided by the Battle Creek medical community. The dressing changes for burn victims can be exquisitely painful and the toys were clutched tightly for comfort. 

Also special thanks to the Bronson Battle Creek Hospital innovators with names like Brad, Jack, and Sally who helped develop the Mayo stand drainage system.  It is being used all over Afghanistan now and has greatly helped with the irrigation and treatment of wounds. 

“A special ‘Bravo Zulu’ to my partners as Southern Michigan Orthopaedics who have never complained about my service obligation and the coverage of Walter Reed and Afghanistan,” said Dr. Langworthy.  “You have been readily available to offer advice on some very complex cases for which I will always be indebt.”

Bronson Battle Creek is a 218-bed hospital that provides full outpatient and inpatient acute care including robotic surgery, diagnostics, and rehabilitation services; 100% all private rooms.  It also offers world-class diagnostic capabilities including PET/CT imaging, freestanding ‘open’ and traditional MRI, CT (16- and 64-slice), and 3.0 Tesla MRI.  Bronson Battle Creek has been recognized nationally as one of the safest hospitals, and has been a leader in the development of electronic health records as evidenced by multiple honors as one of America’s ‘most wired’ and ‘most wireless’ hospitals. The Commission on Cancer of the American College of Surgeons recognizes the Bronson Battle Creek Cancer Care Center as a Comprehensive Community Cancer Program, and the only hospital in Michigan to receive the CoC’s Outstanding Achievement Award three times in a row. Specialty services include inpatient behavioral health, the county’s largest accredited sleep center, and a wound-healing center with hyperbaric oxygen therapy.  For nine years, Bronson Healthcare has been included on Working Mother magazine’s 100 Best Companies list as a leading family friendly employer. 

Dr. Michael J. Langworthy, a member of the Bronson Battle Creek medical staff, is a board-certified orthopaedic surgeon, and a partner with Southern Michigan Orthopaedics.  He has been published and lectures nationally and internationally with special skills in cartilage damage. 


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