Army Reserve Major Charles G. (“Chuck”) Boenig, PharmD, had read the literature: when pharmacists help care for the critically ill, patients prosper. But during his second tour in Afghanistan, that academic knowledge was quickly put to the test.
“I hadn’t even been there for 24 hours when I was told I would be working on the trauma team,” Maj. Boenig told Pharmacy Practice News. “This was not something I had ever done before, but boy, did I learn fast.”
Overseeing drugs administered by trauma surgeons, managing medications in cardiac arrest “crash carts” and even working the defibrillator to administer shocks to coding patients were just a few of the clinical duties that Maj. Boenig had to master.
“I guess some pharmacists would be satisfied sitting back and just giving out medications,” he said. “But in Afghanistan, that wouldn’t have worked. This was a far-forward position with limited resources, and anyone with clinical skills had to quickly become an integral part of the critical care team.”
The location, at Forward Operating Base Salerno, Afghanistan, underscores how different this deployment was for Maj. Boenig. During his first tour, he explained, he worked in a Level 3 Combat Support Hospital that was part of Bagram Air Base. Most of the hospital was located in tents, with 24 beds that were expandable to 42 as needed.Salerno, in contrast, started out “as a real lean, mean surgical outfit, where patients got the care they needed and then moved on,” he said. “There really was no holding capacity.”
Longer-term care was needed for the injured or seriously ill U.S. and Coalition soldiers as well as Afghanis, he said, in part because “the operations tempo of the war had increased pretty dramatically.” So just prior to his tour, Maj. Boenig noted, the Army decided to “2-plus” the forward-positioned hospital and significantly expand available services. “They added in functions such as laboratory testing, expanded radiologic services such as a CT [computed tomography] scanner, and they also ‘plussed up’ the personnel to include me, a pharmacist, along with one pharmacy technician.” The Salerno facility also now had holding capacity—about nine beds for long-term care.
Trauma Care Detailed
The call to join the trauma team was by far the biggest change in duty, Maj. Boenig stressed. As for the type of patient care he helped provide, it was typical for a combat zone—or at least, typical for Afghanistan in the era of the improvised explosive device (IED).
“The first time I was deployed, the Afghan insurgents had not yet discovered IEDs,” Maj. Boenig said. “During this last tour, these devices were unfortunately very common—usually in the form of roadside bombs—and the trauma they can cause is horrible.”
The pharmacist’s role in treating patients wounded by IEDs most often focused on supportive drug therapy, he noted. For example, patients with crushing limb wounds and/or body trauma were given antibiotic therapy to prevent postsurgical infections. Those with severe head wounds could be given mannitol, a sugar/alcohol solution that can be effective in reducing brain swelling.
But when Maj. Boenig first arrived at Salerno, he found some problems with the way medications were being managed. “There were a lot of drugs in the trauma area, but only a few of them were really needed,” he said. “Pharmacy is not a free-for-all; I didn’t like the lack of oversight of medication use at such stressful times, so I changed that practice. Not only did this help streamline care, it also reduced opportunities for error.”
Why was that such an important initiative for pharmacy? “I was there as a medication expert, but I can’t offer that expertise if nobody is consulting with me on the use of drugs,” he explained. “I needed to take control of the medication process, review the medications administered prior to arrival, and then when appropriate, make recommendations and changes to the regimens to ensure safety and efficacy.”
Maj. Boenig added that it was not just his own “take” on what medications were needed in a given situation. The Army has protocols for the most common trauma-related medications, not only for antibiotic prophylaxis, but also for factor VIIa in cases of severe bleeding, he noted. “There are detailed instructions for how these drugs get administered, how they are dosed, how we determine when to use them, etc.”
It didn’t take long for the other caregivers in the Salerno facility to begin relying on Maj. Boenig’s medication management skills, with the crash cart being a prime example. “After one of the first codes I ever did, more than one nurse, including the chief nurse, came up to me and said how good it was to have someone who took care of the code cart because it let her and the rest of the trauma team focus more on the patient,” he said. “If they needed a pressor drip, I could make it right there at the bedside; they didn’t have to wonder about how much to put in, how to compound it, etc. I could hand over medications such as atropine, epinephrine and calcium chloride, all prepared and ready to go for administration. And when we had pediatric patients coding, I had a copy of the Broselow chart so I could make sure that I knew how to make the right dosage adjustments.”
But when a more hands-on approach was needed, Maj. Boenig was ready for service. “I’m not certified in advanced cardiac life support, but I quickly learned how to work a LIFEPACK 12 defibrillator.”
What was it like to “shock” a patient for the first time? “Well, you kind of hesitate, but when you hear a trauma physician telling you to defibrillate the patient and then everybody kind of just stops what they’re doing and looks at you, there’s really no place to hide; you do your part for the trauma team.”
Having the life of a trauma patient literally in your hands brought home, in real terms, “how incredibly needed” pharmacists are in critical-care situations, Maj. Boenig said. “I’ve read articles describing how more and more pharmacists are being used in emergency departments,” he explained. “But I didn’t appreciate just how valuable a team member we can be until I experienced this myself.”
A Few Good Pharmacists
How did Maj. Boenig join the Army Reserves as a pharmacist? “I was at a point in my career where I’d done hospital and retail pharmacy, and also was the director of the dispensary in a free health clinic for a couple of years. I was looking for a new challenge, so I got commissioned 10 years ago, at age 38.”
Maj. Boenig said he chose the Army because of the high demands it places on clinical personnel.
“Don’t come into the Reserves and expect to get called up to work at Walter Reed [Army Medical Center] or in the Office of the Surgeon General,” he said. “That does happen, but make no mistake: your mission as a pharmacist or a pharmacy technician in the Reserves is to deploy and potentially serve in a combat zone. So when we train on weekends, we train to deploy.”
That training does touch on some clinical skills. “But it also involves soldiering skills,” Maj. Boenig said. “We have to know how to react to hostile fire and how to lay down a field of fire, when appropriate. We even train how to evacuate a HumVee after a rollover.”
Army reservists also are trained to develop something called “situational awareness”—the ability to be tuned into your surroundings to detect threats. Those skills were not top-of-mind when Maj. Boenig was caring for patients in the main Salerno facility. But the time came when those soldiering skills were in fact needed.
Directly outside the gate of the American hospital, he explained, there was an Afghan gate, and in the intermediary zone, a clinic had been built for treating injured or ill local Afghanis. “When you drove into that middle zone, you had to have your full body armor on, you had to have your weapon and you definitely had to have your situational awareness on high alert, because the threat risk increased dramatically.”
Hearts and Minds
Making that excursion, although risky, proved to be one of the most rewarding aspects of Maj. Boenig’s latest tour of duty. When he first arrived at the Afghani clinic, he said, the local physicians had almost no resources and only a minimal understanding of how to provide medications and care to patients.
“Basically, I had to build a pharmacy from scratch, with desks, shelves, etc. Then I had to stock it with medications from the local economy and teach the staff how to create and then maintain a basic drug formulary.”
Those efforts triggered an interest in American pharmacy practice that was so strong among the Afghani physicians—many of whom were working as translators—that Maj. Boenig set up a one-day training program that covered even more aspects of medication management. “I taught them how to compound sterile IV admixtures, how to calculate pediatric and adult drug dosages, how to determine diluents and infusion times, and how to counsel patients about the administered drugs,” he said. “They were absolutely fascinated by all of this, and really were great students.”
Another initiative that Maj. Boenig said he was particularly proud of was the creation of a tetanus vaccination program. All Afghan patients who came into the hospital with traumatic injuries would get a tetanus vaccination, which was usually the first one they had ever received. “I had one of our medics teach me how to administer the tetanus shots, so basically I just drew it up in a syringe and it I’d stick the patients and say, ‘tetanus given’ and then step back from the table.”
But the vaccination program didn’t stop there. In many cases, Maj. Boenig said, patients who had been vaccinated came back to an outpatient clinic in the hospital weeks or months later for follow-up. That’s when he realized that he needed to create a system for administering and tracking booster vaccinations.
“One shot does not confer immunity; they needed the entire series,” he explained. So, working with an Army doctor, he established a vaccination series for both adults and children, and then had a local printer make up cards that said in the local language, “Tetanus Record.”
“We gave the cards to the patients when they left the hospital and said, ‘If you ever see any doctor, if you ever come to a U.S. hospital or facility, bring this card,’ with the hope that they could continue this series and build immunity for tetanus.”
A Few Caveats
For pharmacists thinking of joining the Reserves, Maj. Boenig offered a few caveats. “The Reserves didn’t repay my student loans, they don’t pay you very much money, and if you join, you owe them significant time—for me, it was eight years,” he said. “But what they do give you is the opportunity to serve your country and work to save lives with some of the most talented, dedicated people that you will ever meet.”
Maj Boenig also pointed to the stress that comes from prolonged deployments. “You will have to be mentally and physically ready to leave, sometimes on short notice, and your family has to be prepared for you to be away from home for quite a while,” he said.
During his first tour, Maj. Boenig was gone for six months. During his latest tour, he was gone for one year. Although he was able to come home for one visit, other, more creative strategies were sometimes needed to keep the family connection strong.
“I actually participated in a parentteacher teleconference call during my last tour,” he said. “I’m not sure how much good it did—it can be frustrating to not be able to step in and be there physically for your loved ones—but you do what you can.”
Maj. Boenig said he always tries to take away life lessons from his tours of duty, summed up in mottos. “During my first tour, my motto was, ‘Work the Problem,” because there sure were a lot of them and they could overwhelm you if you let them,” he said. “This time around, my motto was, ‘You Can Always Do More.’ When I felt tired or frustrated, I repeated that motto and it really helped me get through some tough times.”
The bottom line for being an Army Reserves pharmacist? “This is an incredibly valuable service that we provide—one that we should all be proud of.”