Adjusting to Kandahar: The Civilian's Top Ten List 

Michael D. McKee, M.D., FRCSC, Professor,
Division of Orthopaedics, Department of Surgery
St. Michael's Hospital, University of Toronto
Toronto, ON

I was fortunate to spend one month as a volunteer civilian trauma surgeon in the Canadian-run hospital (MMU-3) at Kandahar Air Field (KAF) in March / April 2007. I would suggest the following must read 'top ten' list for anyone travelling there in a similar role:


  1. Expect the ride to Kandahar in a military Hercules to be hot (full body armour), loud (everyone wears earplugs), dusty, smelly, and certainly not executive class Air Canada. To make things worse, the load master-sergeant will rudely ignore your request for a refill of your mixed nuts.
  2. Everyone is armed everywhere they go - get used to having discussions with military doctors and nurses wearing sidearms. Your medical point doesn't carry as much weight when you are the only one in the discussion not packin'.
  3. Even though it is crowded with soldiers carrying assault rifles, Kandahar's Tim Hortons remains a solid place to hang out. Working as I do at St. Mikes, I am probably in line with armed individuals at Tim Horton's all of the time without knowing it, so that part wasn't much of a change. The sign on the cash register stating that they close for all rocket attacks (re-opening 15 minutes after the all-clear) was a bit of a wake-up call.
  4. It is blisteringly hot (40˚-50˚ Celsius is not unusual) and dusty. Keeping hydrated is an important part of your daily routine. After you feel whacked walking from your barracks to the hospital in that heat, your respect for our soldiers in the field humping 80 lb packs will increase dramatically.
  5. Here like nowhere else you have to plan your next step right from the start. Your space and time are extremely limited. Coalition forces get thorough debridement, external fixation, the occasional minimal open procedure for an irreducible fracture or dislocation, and rapid transport to the US base at Landstuhl, Germany. Locals (Afghan National Army or Police, the occasional civilian) get basic but definitive orthopaedic care when conditions allow, then rapid discharge. Remember that an external fixator (a sure sign of coalition intervention) can be a death sentence for a local in a Taliban-held village or roadblock.
  6. You may be a very experienced civilian trauma surgeon, but blast injuries are inherently different from anything you have routinely dealt with before. There is impacted debris and dirt far up in tissue planes where you least expect it, and degrees of soft-tissue damage far out of proportion to that seen with civilian injuries. I once saw a lower limb progress from an essentially normal exam to a full blown compartment syndrome (pressures 80+ mm Hg) in 30 minutes.
  7. There is no booze on the camp. After a brief period of withdrawal, you will appreciate this fact when you think back to some of your own teenagers' house parties and see numerous similarly-aged, like-minded individuals from National Guard units armed with M-16's arguing in the mess tent beside you.
  8. The weekly (or daily) landing of rockets (mostly improvised Russian 107 mm howitzer shells) in camp is a fact of life. They are like a bad surgical resident: not terribly accurate, but quite destructive. Wear your body armour when you can, cross your fingers, and hope for the best.
  9. The nurses and support staff are first rate. Never once were there any grumblings about finishing time, breaks, schedules, etc. They are there for the same reason you are: to get the job done as promptly and efficiently as possible, until all the work is finished. Period.
  10. You will never feel the rapport with your patients that you do here. Regardless of your political bent, you cannot help but recognize that these young men and women put their lives on the line in a crappy place for something that your country has decided is important. And when they are hurt, they are truly appreciative of your efforts and for your being there for them. It is an honour to look after them.
Sign on the cash register at the Kandahar Tim Hortons.

Wounded Canadian soldier's tattoo.

An Afghan National Army soldier's fractured humerus (from an AK-47 round) treated with irrigation, debridement and external fixation. A few days later, definitive fixation with some shortening (for bone loss, which also facilitated primary repair of a disrupted radial nerve) was performed.

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