SUICIDE BOMBER

                The page came just as I was heading to the hospital. It read the ED’s phone number, not 911.  That was good news.  However, getting a page was concerning, as I had only gotten 3 since arriving.  I quickly grabbed my bag and headed in.  As I headed to the hospital, I caught a glimpse of Mike, one of the nurses, heading in.  I caught up with him.  They had sent a runner for him since he did not have pager.  We arrived just before casualties. There had been a suicide bombing and they were flying the critically ill patients in now. The KIAs would be flown in later.  We had about 10 minutes to prepare for the group of 6 patients with an unknown number to follow.  I quickly assigned teams, prepared the Belmont, readied the emergency blood for transfusion, and quieted the room.  With a small crew, we had 25 staff in the room for all six patients.  We had seen this many before, but not recently. 

                  They could not fit all the patients on the 2 Blackhawk helicopters, so they flew in a tactical C-130.  Before patients came into the trauma by, a flight surgeon gave us a grief, frenetic report, out of breath from running into the ED, and jumbled with his thoughts.  The first patient rolled in, hypotensive, recieveing two vasopressors to keep his blood pressure up.  In trauma when blood pressure is low, we rarely give medicine to raise blood pressure, we use blood, thus this was an ominous sign. We assessed him quickly and moved him from the NATO liter to the bed.   He had a small hole in his head and tubes in his chest. He was unresponsive and not moving. Before we started his full assessment we started 4 units of blood and hypertonic saline to shrink his brain. Using the bedside ultrasound, we did detect abdominal bleeding or a collapsed lung.  As we stabilized him and prepared him for the CT scanner, the next patient came in, then the next, until we had all 6 in the room.  Three others had severe wounds and fragmentation from the blast but were more stable than the first.  We quickly assessed the others as they came in.  As I looked around, the resuscitations were running smoothly and efficiently, a sign that this team had been here many months. 

                  We dressed the wounds, splinted the fractures, and took everyone through the CT scanner.  As the dust settled, one patient had a nonsurvivable head injury and would be flown to Germany quickly.  Another 3 filled the ORs for abdominal surgery and limb explorations.  The last two were stable.  One patient was crying and anxious, dealing with the concussion, mild PTSD, and acute grief reaction.  The chaplain, his commander, and one of the empathetic technicians tried to calm him. The sixth patient was the medic, who had only a mild concussion.  He gave me the details of the bombing.

                  All 18 soldiers were in a conference room when an Afghan soldier entered the room. He detected the ANA was wrong side of the room, but did not take notice until the ANA moved to the middle of the room and then stopped.  He pulled two cords, said “something about Allah”, and the medic ducked behind the table.  He heard “a firecracker” and saw smoke.  He readied his weapon and was about to stand when a loud explosion went off.  He stood up to fire, and he saw nothing but dust, blood, and debris.  He looked around.  Many were injured.  The rest of the details were from two other less injured who arrived 4 hours later.  The medic did not tell us the details of what he had done.  18 people were in the room, 6 died immediately, 3 were minimally injured, and the remaining 9 were saved due to the medic’s calm demeanor and brave acts.  He acted solely to triage each injured soldier, set up a collection point, placed tourniquets, decompressed collapsed lungs, and reassured the others.  He was the only medic there.  He radioed in for support and saved the lives of at least 6 patients. 

                  Of course the medic’s version of his heroic acts was terse and muted. He just recollected the events of the bombing and the rest was a blur.  His colorful description of the bomber was unvarnished.  As we completed his care, we allowed his commander and his soldiers to chat with him.  His commander, a Colonel, quickly assessed his heroic act and planned to decorate him.  Four hours later, two more concussed patients flew in.  The medic was there to great the patients, take care of them, and offer non-medical support and kinship. 

                  That night we sat on the roof of the hospital. The rain had kept the remaining 3 injured from flying in immediately, but they would arrive in an hour. In the far distance the mountainous landscape was ominous over the flight line. We smoked our cigars and recollected the day, as the temperature dropped.  A C-130 had landed and two troops walked to meet it.  There is only one time this happens, the fallen comrade ceremony.  In the distance, the soldiers lined up behind the open back door of the C-130.  Six modified Humvee’s pulled up.  Everyone on the flight line snapped to attention as the vehicles pulled up behind the C-130, and one by one and the bodies of the fallen soldiers were unloaded.  The memorial service was completed two hours earlier, and in a few hours these fallen comrades would fly home – six soldiers the heroic medic could not save. 

THE BURNING MRAP

                  These soldiers arrived, with moderate injuries – fractured heel, back pain, bruised spinal cord.  Technology and divine intervention mostly saved them.  They were in MRAP and hit by and IED.  The blast struck under the driver.  He has the fractured foot.  The gunner was knocked out when his canon was knocked back into his head. He lay unconscious in the turret, one of two exits from the vehicle.  The soldier I was caring for, a Mortarman, attempted to escape out of the vehicles’ main door, but the electrical system went out and it would not open. He smelled smoke and realized the vehicle could catch fire. If they did not escape, they’d die from burns.  With alacrity he pulled the gunner down into the vehicle and climbed out of the 2.5’ diameter hole, a hole just wide enough for his broad shoulders and, having climbed through that hole myself, would induce claustrophobia and panic in most.  He reached back in the hole to assist two others out.  Together they pulled the limp and unconscious gunner to safety.  Finally, he pulled the injured driver out and carried him 100 yards to a clearing. With the adrenaline exhilaration and his call to duty, he realized later, he had saved several lives despite a severe lumbar (back) injury we would diagnose the next day. Within 20 seconds of leaving the vehicle, it caught fire. The gasoline tank exploded and flames roared up through the turret, the same tight hole he had squeezed several solider through.  Because he moved quickly and acted with aplomb, he saved 3 lives.  The story unfolded for us in the trauma bay, the soldier still reliving the experience he had been through.  He was shaken, but composed, thoughtful, but not tearful.  Within an hour after arriving, as the nurses and techs cleaned their wounds and completed their x-rays, we pulled the men together, each on their litters, and they joked and relaxed.  One showed us a picture of the burnt vehicle.  Two would fly to Germany, one would fly out later that night.  The other two would stay overnight and return to their FOB (Forward Operating Base) in 24 hours, to start a new mission in a new vehicle. 

FORGOTTEN WARS

 Daily we receive a newspaper called Stars and Stripes.  The free paper is a summary of news from back home whose genesis began before WWII. The publishers collate articles from the Wall Street Journal, Washington Post, New York Times, and local papers such as the State, the San Antonio Express News, and The Herald.   The lead article was “Is Iraq the New Forgotten War?” The author quotes a woman whose older brother died in Iraq last month.  When she tells her brother’s story, most aim to correct her, “don’t you mean Afghanistan?” Her brother died from and IED explosion. We have 43,000 troops still in Iraq with an average of 1 death a week.  However, reading the headlines, of this paper today and each day since January.  Many of us feel that the Afghanistan War may also be forgotten.  Between the headlines of political wrangling, a new iPad release, and Hollywood’s latest gossip, is the news of another US servicemen dead, today. The paper missed the last 5 deaths in the past 3 days.  It missed the 1 death in our hospital.  It forgot the 20 amputated patients we saw in the last 48 hours and the 80 that will be flown out tonight for “minor injuries” that will be evacuated to Germany, return home, and likely never return to war.  The bombs are getting bigger and their tactics are sharper.   Our $900 million MRAP vehicles are sometimes no match to their ingenuity and shear ruthlessness.  The will our troops is humbling.  So when I read the Stars and Stripes, and see the reports of deaths and injuries, I know vividly that many more USSM are injured and dying every day here.  I’ll be reminded when I return home, as I pass the next group in the airport on their way to Afghanistan or Iraq.  I’ll be reminded each work day when I see the amputee running on the treadmill at my gym, when I see the soldier who overdosed in the emergency department as toiling with PTSD, and I’ll see it when I pass the young airman at Lackland or the young solider at the AMEDD who are excited, invigorated, and eager to sign up and go to war.  While the wars of Iraq and Afghanistan may be forgotten, I hope the Marine’s stories, the soldier’s injuries, the sailor’s families, and the airman lives lost are not.

2nd DAY

                  The second day was busier.  Three patients arrived from a dismounted IED attack. Because of the mountainous terrain, many marines and soldiers are on foot and leave their vehicles.  The IED’s leave them with severe injuries, different from Iraq.  The Dustoff helicopter brought in 3 dismounted marines.  Two had severe injuries.  One had 2 amputations and the other an amputated arm.  The third had mild wounds.  After we resuscitated the other two I talked to him.  He was a Marine Lance Corporal.  During the explosion the other two marines were caught in the blast.  He was blown back.  When he awoke, he reached for his legs.  They were intact.  He screamed because he saw blood.  Then he realized the blood was not his. He jumped to feet and found his Marines injured and nearly unconscious. He was their medic and quickly placed tourniquets on them.  I told him that he saved their lives. He did his job well. I thanked him for his service.

                  Later that evening we were discussing a book titled “War”. It details life in an army outpost in the deadliest valley for Americans in Afghanistan, the Korengal Valley.  The Korengal Valley is part of the Kunar Province in NE Afghanistan near the Pakistan border.  The recent Medal of Honor recipient’s service was described in “War” and he earned his decoration in this valley, a location where the US mortality is higher than any other section of the country, including the Helmond Province. 

                  I had just read the book and sharing the story in the emergency department with another surgeon and nurse when the patient behind spoke up, “Hey doc, that book.  That book is about my company, C Co. [Charlie Company], that’s my platoon.”  He went on to tell us that the book was written about the guys deployed there in 2007.  Today, he said, it is much worse.  He was deployed then, assigned to the Korengal Valley. After his enlistment he returned home to seek a new life and left the Army.  However, when he went home he couldn’t sleep.  He couldn’t stop thinking about friends who he had fought with for 2 years.  He volunteered to come back and rejoined the same unit.  “Now I can sleep”. 

                  His injuries required him to go to Landstuhl Medical Center in Germany for an additional brief operation and a short course of rehabilitation.  He pleaded me not to send him Germany.  “My guys are back there. I don’t want to leave them”.   I reassured him they would get him back to war in a few weeks and could rejoin the fight.  He had already extended his stay with his unit 4 more months.  He discussed the movie Restrepo (a National Geographic documentary about the book “War”).  He said it was well done and covered their daily lives living behind a brickwall for 40-90 days at a time while receiving enemy fire mortars.   He said, “maybe the guys back home can see what the soldiers are doing and how good we are.  Maybe they’ll care”.

                  He told me about two other books that describe the valley and its lethality in previous wars (The Bear Goes Over the Mountain).  “I’ll have it in my bags at my FOB.  I redeploy in April. I’ll bring it for you to have when I come back through here.”  Yes, I said.  Bring them back as you head home.  “I’ll see you in April” (god willing).  I thanked him and wished him well as he left for his flight to Germany. 

PATIENT #1

I was eager to get started and fall into a rhythm of treating the injured servicemen.  Each deployment, the ethos is slightly different. I spoke with Jeff XXX. He deployed 4 times, including a stint in Balad.  He’s a trauma surgeon who has practiced many years at a civilian institution before joining the Air Force. He’s well respected for his clinical and personal adeptness.  We discussed how the war is different here than Iraq. While we are learning in Afghanistan, we’re learning less new lessons.  He also commented that the tempo and culture is different here than in Iraq, and particularly in Balad.  In Iraq, mass casualties were frequent and surprise patients with 3-4 tourniquets were routine.  Here, the patient volume is high, but steady.  The terrain and weather limits flight and more patients are sent to a smaller hospital or air station before arriving to Bagram.  We talked for a while and reminisced about Iraq, the food, the tents, and made comparisons to this war.  I was still tired and hopefully working would shake the jetlag.  My first day at work began as expected. The 1^st hour was quiet as we waited for the call.  “Dustoff to Task Force Med Ops…break…we have liter urgent..break… “ They brought in a young marine involved in an improvised explosive device [IED] attack. He was infantry [and proud of it].  He was on patrol when hit unexpectedly by an IED.  The explosion left one marine dead.  Two others received leg amputations and genital injuries, a signature of the dismounted attacks in the rugged Afghanistan mountains where vehicles cannot travel.  He was awake, 1 day post injury and stoic, as most of the young marines are.  His initial injuries were treated at an aid station, a small tent with few resources and one doctor or physician assistant.  He lost one leg and had a fracture of the other.  We assessed his injuries, stabilized him, and then he maundered through the details of the attack.  At times he seemed distant, almost viewing the attack from above, and at others the details were ghastly as he described the screams of some the marines and the quiet, white, blank, dead faces of others.  After the trauma resuscitation quieted and many had left the bay, I resumed a habit I learned from a patriotic physician assistant I deployed to Iraq with in 2005.  I rested my hand on his shoulder, recognized him for his brave work, and thanked him for his service.  He thanked me and silently cried.  The remaining two nurses and doctor approached the bed and the room was quiet. Later that night, the Marine was awarded the Purple Heart in the hospital ward, pinned to his chest by his commander who was bedecked with ample decorations of his own.  The marine was evacuated three hours later to Germany and then to the US where he will likely be retired from the Marine Corps, never to return to war.  

Later that night

I continued to reunite with old friends.  Jeremy, a trauma surgeon, and I had worked together at Wilford Hall in San Antonio. He graduated from the Air Force Academy and had completed most of his training at a civilian hospital, as I had.  He shared his observations.  This was his 3^rd deployment also, and his second to Bagram.  However, he would be leaving in a few weeks, back to San Antonio.

Later I met with Mike.  Mike is a specialty surgeon.  He’s about 10 yrs older than me.  We have overlapped twice in Iraq during our deployment rotations.  We shared stories of our previous deployments, some comical and others humbling.  We attached most of them to the ethos that the soft walled tents of Balad Hospital in Iraq created.  Bagram was new for both of us and he had arrived 2 weeks before me.  Later, I met with Jeff.  Jeff is a Colonel and a trauma surgeon. We also had met over the years.  He was in charge of the entire Theater Trauma System in Afghanistan and Iraq, a daunting task.  He was handpicked to improve our trauma care built on blocks from the last 9 years at war.  We chatted about Balad.  It was like therapy.  Most who have never worked there do not understand. There is an emotional attachment to “the tents” and the care we provided.  That hospital tent received more casualties than any since the Vietnam War.  It the hub for casualties for all of Iraq and we worked there during the busiest time of the war.  We likely we never see that volume of casualties for another generation.  A replication of Trauma Bay 2 is in a Washington Museum and the USAF Surgeon General has a picture I took in 2007 posted in his Pentagon conference room of the ER the day before it closed.  Jeff and I chatted about how busy it was and he enlightened me to the character of the Bagram Hospital (Craig Joint Theater Hospital – CJTH).  While CJTH is one of the busiest and will be so as the Operation Enduring Freedom surge begins, it’ll never reach the volume of Iraq, which is a good thing.  However, the temperament of the combat hospital was different, slower, and more patient.  They had the right to be as the trauma system was more mature, the communication from facilities better, and the smaller facilities better equipped.  At CJTH we typically get warning of patients arriving and with the mountainous terrain and mercurial weather, the flow patients is staggered, so we are not typically overwhelmed.  This contrasted with Balad where, like the TV series MASH, Blackhawk Helicopters would fly in with 1-2 minutes’ notice, often with 2-8 critically ill patients.  Nonetheless, the care delivered at Bagram was remarkable and rivaled or left behind US civilian trauma centers.  The US trauma centers still seek new lessons we are learning to apply to their institutions.  Jeff said he would be travelling to forward operating bases (FOBs) for most of his tour, but would be here once a week.  As we ended our conversation, I felt relieved, like I had therapy.  Someone else resonated my experiences and validated them. I was ready for the next few months. 

FIRST DAY

The 1^st day was a day of mixed feelings.  I was elated that I had survived the 4-day trip of broken airplanes, airport waiting rooms, and enduring jetlag.  I was eager to get started on this deployment, apprehensive to find if it would be as rewarding as the others, and sad to be leaving my family behind.  I travelled with a Colonel (Jim) from Norfolk to Afghanistan.  He was a guardsman from the Midwest and an Anesthesiologist.  He had had joined the guard 18 years ago and was on his last deployment, his final stint away from his full time practice and his close knit family.  He reminded of the Physician Assistant I deployed with in 2005, a Captain who signed up for the service on Sept 12, 2001.  Both were patriotic, practical, and clinical experts.  Jim has practiced more than 20 years, likely 10 more years than anyone in the combat hospital we were heading too.

            After a dizzying 2 hrs at the PAX terminal, we collected our bags and were waiting for our ride.  It helps to travel with a Colonel.  I would have waited another 3 hours otherwise.  The temperature was hot and the air dusty, more dusty even than Iraq.  Prefab buildings, rundown structures built by the Russians, and a large tents were everywhere.  It felt crowded and busy.  We pulled our 3 bags from the sea of 150 identical military green bags.  Our driver (who came for the Colonel, not me) took us to our living quarters first. 

The “b-huts” were next to the combat hospital.   B-huts are plywood shelters with aluminum roofs.  Approximately 4 to 8 individual rooms are in each of the buildings.  The rooms measure 10 x 8 feet, or about the size of my daughter’s closet.  While humbling, it could be worse – 30 strangers in a tent with a cot and with a cover.  After dropping our bags, we walked to the hospital.

The hospital building was “modern” compared to the green, floppy tents I had worked in for 11 months during previous deployments to Iraq.  The building in Afghanistan was similar to the Balad Hospital that was built in Iraq during my last deployment.  It was a sturdy, well-lit, spacious building.   After arriving, the superintendent took us through the building for a whirlwind tour.  We passed by and said to hello to people I don’t remember due to my jet-lagged state.  Over the next few months, I saw I was not the only one who arrives in that state of amnesia. 

In the emergency room I met some of the staff and was greeted by a few guys from my hospital in San Antonio, Wilford Hall.  It was good to see their familiar faces in a sea of strangers.  Leslie, a recent emergency medicine graduate, took over my tour from the Superintendent.  She introduced me to the other Emergency Department staff and to the physicians and surgeons from the other departments.  It turned out to be a mini class reunion.  Since leaving the USAF Academy, the few of us that went on to medical school (12-18 per year/1000 cadets) dispersed to different medical schools, residencies, fellowships, and then assignments across the world.  On occasion we bump in to each other at professional meetings or in a hospital setting.  But that day, I saw classmates I hadn’t seen in 15 years.  There were 4 grads from my class (30% of those that went to med school my year), 3 from the year prior, 2 from two years below me, and 3 others who were grads from other years.  In that room, I saw more USAFA grads than I had seen in the past 7 yrs and 2 deployments.  Again, it was good to see familiar faces.