Ruff's War

by K. Sue Roper

  Dr. Sanjay Gupta, a CNN reporter and skilled neurosurgeon, was at Camp Anderson developing medical news reports to be broadcast on CNN. We did not have a neurosurgeon among our ranks, and Dr. Gupta was asked to assist with the surgery of this gravely injured toddler. Unfortunately, despite six long hours of tedious and delicate surgery, the efforts of the surgical team, headed by Dr. Gupta, proved to be futile. The child did not survive.

  By 12:30 PM we had successfully set up the essentials of our surgical trauma unit: a triage tent, two ORs, and an ICU tent. The triage tent was immediately adjacent to an area designated for the landing of the helicopters. To the rear of this tent were the two ORs, with the ICU tent located immediately behind them. A ward tent was still in the process of being erected and would be situated alongside the ICU. This setup provided for quick transfer through the triage tent into one of the ORs, the ICU, or the ward. We scarcely had an opportunity to eat a snack from our MRE packs when the first choppers landed at the camp, carrying the first of the many wounded and dead who would arrive that day.

  One after the other those choppers came. It was now my time to take action and do all I could to help save the lives of all those who had been severely and brutally wounded as a result of this cruel and devastating war.

  15

  SAVING LIVES

  As soon as the choppers began to arrive, I was ready to administer anesthesia in OR number two. Both Commander Sheppard, my battle buddy and fellow nurse anesthetist, and I had been assigned as the anesthesia providers for this OR designated to care primarily for those with chest, abdominal, and head injuries. OR number one would care for those who had sustained orthopedic injuries. We knew most of the wounded would have multiple injuries, but if the primary wound had been sustained to the chest, abdomen, or head with secondary wounds sustained to the limbs, the patients would have surgery performed in OR number two. If the primary wound was orthopedic, the individual would have surgery performed in OR number one.

  My first patient was an older Iraqi gentleman with multiple gunshots to the abdomen, arm, and leg. These horrendous, bloody wounds had torn deep through his flesh, internal organs, and bones. I performed my first anesthesia procedure using field medical anesthesia equipment that consisted of a vaporizer with tubing that extended from the vaporizer to a mask placed over the patient’s nose and mouth. Midway along the length of this tubing was a reservoir bag that I would manually squeeze in order to provide oxygen and anesthetizing agent/vapors to the patient. In essence, I was breathing for the patient, regulating the inhalation cycle and ventilating him by continuously and rhythmically squeezing the reservoir bag.

  The surgeons would work more than six hours on this first patient. They performed an abdominal laparotomy (a surgical incision opening the abdominal cavity) to explore the internal organs for injury or sources of bleeding. Because of injury to the bowel, they needed to perform a bowel resection, which involved excising and removing the damaged portion of the bowel and reconnecting the healthy ends of the upper and lower portions of the bowel to one another. The severe damage to the left brachial artery (the chief blood supply to the arm) would ultimately result in the amputation of the patient’s left arm despite the surgeons’ painstaking attempt to repair this critical blood vessel. The surgeons also needed to realign the patient’s thighbone and then stabilize it by inserting long pins through one side of the outer leg, through the femur, and then out through the other side of the leg. Throughout this long surgery, I manually breathed for him using the field anesthesia equipment.

  After his surgery was completed, I transported him to the ICU. Shortly after arriving in the ICU the patient began to exhibit brady-cardia (slow heart rate) and dysrhythmias (irregular heartbeats). I responded immediately when the ICU staff yelled, “Get anesthesia in here!” and I quickly administered atropine followed by epinephrine, emergency drugs used to stimulate the heart’s pumping action and prevent the patient’s blood pressure from falling. We began cardiopulmonary resuscitation (CPR), and when the anesthesiologist arrived shortly thereafter, he ordered us to stop the CPR efforts. The tremendous amount of time and supplies we had invested in this individual and his rapidly deteriorating physical state did not warrant the continuation of heroic measures. The patient would be pronounced dead twenty minutes after arriving in the ICU.

  The helicopters carrying the wounded would come and go. Some choppers brought in patients while others medevaced those who had been stabilized to another location for further care. We never knew when the choppers would be arriving, so we used the time in between surgeries to clean instruments, equipment, and gear. Preventing our equipment from being destroyed by the dirt being thrown up and into the ORs by the takeoff and landing of the helicopters was a constant struggle.

  Conditions within the ORs were less than ideal and anything but sterile. Flies and dirt seemed to find their way onto and into everything. We tried to keep our equipment covered with tarps to prevent small granules of dirt and sand from impregnating and destroying them, but we would eventually lose the use of a few portable ventilators because of this dirt and sand contamination. Instead of having separate suction equipment—one for the surgical procedure itself and one for use by the anesthetist—the same noisy suction machine and equipment were shared by both the surgeons and the anesthesia provider.

  Lightbulbs strung across the ceiling provided the lighting in these rooms. These bulbs, powered by generator, would flicker frequently and would periodically die out completely. Many times we would have only our headlamps to illuminate the anesthesia area and the surgical field. Intravenous fluid bags were strung up by ropes to whatever we could find in order to keep them elevated. Because the rooms were erected on dirt floors, clearing the blood that had flowed from the patient and soaked into the ground required nothing more than shoveling it up and pitching it outside the tent.

  Although we lacked many surgical instruments and supplies that would normally be used to perform the same surgeries in a stateside hospital, we learned to improvise, devising ways to reuse items and conserve resources. The abdominal pads normally used only once to soak up blood and fluids from wounds were wrung out by the surgeons and reused on the same patient. We had no idea how long we would be at Camp Anderson, nor did we know how many casualties would be brought to us for care. The quantity and availability of supplies and resources were constant worries for us.

  That first full night in Camp Anderson, we experienced brief periods when we could rest in between the arrivals of the casualties. Because no berthing tents had been set up, we simply located a place outside one of the tents where we placed a cot and stowed our personal gear. I chose a spot next to OR number two so that I was readily available for the arrival of any incoming wounded or to relieve Dave Sheppard from a case with which he might be involved.

  Friday, 4 April, arrived. The temperature quickly rose to more than one hundred degrees, creating a sweltering, suffocating environment within the ORs. Despite the boiling outside temperature, we kept the OR tent flaps down to prevent flies from coming inside. This caused the operating rooms to become even hotter, but we worked on.

  The choppers continued arriving, bringing us more and more wounded. We saw untold gunshot wounds that had resulted in severe, devastating injuries to the head, face, neck, torso, abdomen, arms, and legs. Gaping, bloody holes were torn through every part of the body. Limbs dangled from bodies, held by a slight thread of flesh, or they had been ripped off completely. Faces smeared with a mixture of blood, sweat, and dirt were recognizable as human solely by the piercing eyes looking up in fear and pain. Others were suffering from sucking chest wounds, charred flesh, shattered bones, or partially blown-away skulls—their brain matter was missing, but the individual continued to breathe because the brain stem remained intact. Even small, relatively harmless-looking external bullet holes to the abdomen would reveal extensive internal damage to the bowel, bladder, stomach, liver, and spleen. It was a horrible, gruesome, and heart-wrenching sight.


  We received and treated all those who had become a casualty of this war: American fighting men, Iraqi soldiers, and the innocent Iraqi women and children who were at the wrong place at the wrong time. Their screams of excruciating pain filled the air, and the stench of destroyed flesh and death was revolting as it intensified in the sweltering Iraqi heat. I thought I had entered hell when I arrived at Camp Guadalcanal with its primitive conditions. Now I believed I had moved ever deeper into hell, for I had truly entered the hell of war.

  As the wounded continued to arrive and the scenes of overwhelming and incomprehensible human devastation and destruction seemed as though they would never cease, I realized we were struggling and doing everything in our power to keep these people alive while others were struggling just as hard to kill them. This was war—a war being fought just as diligently within the canvas tent walls of Bravo Surgical Company’s trauma field hospital as it was being fought on the battlefield. The question was, who was really winning?

  With the rapid and constant arrival of casualties, we had little time to ponder our thoughts or our feelings. All of our efforts were focused toward saving as many lives as possible with whatever supplies and equipment we had, and despite the less-than-ideal environment in which we were working.

  One of my patients was an Iraqi man who had been shot in his abdomen. His colon had been ruptured, and his abdominal cavity was filled with human waste. For some reason I could not maintain adequate oxygen saturation for him despite my constant manual ventilation using the reservoir bag and administering doses of ephedrine and epinephrine to open his airway fully. His rapid loss of body fluids and blood was being replenished intravenously, yet his blood pressure would rise only to fall a moment later. A chest tube had been inserted and connected to suction, and there was no evidence that the patient was bleeding from a thoracic injury. Still, I knew something was not right. The patient’s oxygen saturation level, which should have been 95 to 100 percent, had fallen to 89 percent. I told Cdr. Mark Fontana, the surgeon who was performing the procedure, “The oxygen saturation levels are down to 89 percent. I’m not sure what’s wrong. I hear breath sounds bilaterally [indicating that both lungs were being ventilated and receiving oxygen], and I am ventilating him but not oxygenating him. Something’s wrong.”

  A decision to stop the abdominal procedure and open the thoracic area was made. It was a drastic decision, but a necessary one. Once the chest was opened, we saw a tennis ball–sized hole on the upper portion of his right lung, and he was oozing blood. I was ventilating him with the reservoir bag, but the oxygen was not entering his bloodstream; instead, it was being blown out through this large, gaping hole in his lung. He exhibited no obvious symptoms, such as subacute emphysema, crepitus (crackling, crinkling, or grating feeling or sound around the lungs due to the infiltration of air), or bleeding that would indicate such a significant wound had been sustained.

  Once the surgeons saw this devastating, fatal wound, they looked at one another and said, “This surgery is over. We can’t help this man anymore.”

  I looked at Commander Fontana and said, “It’s over? What am I suppose to do?”

  “You’ve got to let him die, Cheryl,” he said, and began backing away from the table.

  The only thing that was keeping this man alive was my effort to ventilate him continuously by squeezing the anesthesia reservoir bag. I was breathing for him, and his life was literally in my hands.

  The surgeons stopped the procedure, moved away from the table, and removed their gowns. Still, I could not stop squeezing the bag. This was not something one learns in anesthesia school, and I was not prepared for such a gut-wrenching, decisive, and final act. The OR nurses began cleaning up, and all the surgeons had left, but I still continued squeezing the bag. I could not stop myself despite the continuous decline of this man’s oxygen saturation levels. I realized that he was dying, that his brain was being deprived of oxygen, and that nothing more could be done to save his life. Still, I continued to squeeze the bag.

  A few of my colleagues entered the OR and said, “Cheryl, the surgeons aren’t coming back. We’re done; it’s over.” Still, I continued to squeeze the bag. I needed time to convince myself that I had no choice but to stop this man’s life. I was fully in charge of him at that moment, and my action was the only thing sustaining his life.

  As I sat there, I experienced a memory flash from a time when I was stationed on board the USNS Mercy. We had talked about what we would do if the ship was hit by enemy fire and we had no way of taking our patients to safety before the ship sank. We did not want them to experience the abhorrent death by drowning, so we developed a plan where we would dose the patients with morphine to provide them with a peaceful death before they went down with the ship.

  That memory gave me the strength I needed. I administered ten milligrams of morphine to my patient and began to slow the rhythm with which I was squeezing the bag. Eventually and very gradually, I stopped squeezing the bag. My patient was dead. I could only pray that his death was a peaceful one.

  I then asked the OR nurse to get Commander Fontana to come back into the OR and officially pronounce the death of this man. When she returned, she said, “Cheryl, the doctors can’t come back in right now. It’s your call.” This task was way beyond the normal scope of duties and responsibilities for a nurse anesthetist, but we were not functioning in normal times. I pronounced his death, and as I completed my anesthesia record I wondered who, if anyone, would ever read it. I was emotionally exhausted and physically spent.

  When Iraqi civilians or EPWs died or arrived at the camp dead on arrival, we would take whatever identification we could find on them and send it to the Iraqi government. Their remains were taken to a trench on the far side of the road that bordered the camp. They were then placed there with deep respect in accordance with their religious customs. The precise location of their remains was recorded using the global positioning system, and that location was reported to the Iraqi government. Following the demise of my patient, I could do nothing more than watch as the corpsmen gently and respectfully removed this man from the OR and took him to his final resting place, the trench on the other side of the road.

  Despite the heart-wrenching experience I had just endured, my work was far from complete. More casualties arrived, and we soon realized that this war was not one in which only the fighting troops were being killed and injured. A nine-year-old boy arrived with half of his face blown off. Where he once sported a nose was now nothing more than shredded tissue. His right eye was gone, as was most of the right side of his face. He was in excruciating pain, had only half a mouth, yet he cried, screamed, and called out for his mother. Even though he spoke a different language from our own, the cry for “Mom” was universal. We knew what he wanted and what he needed, and we did everything we could to comfort him.

  I saw this young boy in the triage area, where he was being evaluated by anesthesia because of his seriously impaired airway. We had little pediatric equipment on our Authorized Minimum Medical Allowance List (AMMAL) because children are not considered to be frequent victims of war. Fortunately, a small endotracheal tube was located, and Capt. James Chimiak, an anesthesiologist, expertly inserted it with his skilled hands. The vision of that helpless, innocent, mangled child still haunts me and will remain with me forever in my dreams and in my nightmares.

  I had never been exposed to such an overwhelming degree of human destruction or been a witness to such terrible, horrific wounds. What I was witnessing was far beyond the accident victims and single-gunshot-wound casualties I had cared for in my past. The sights we witnessed were haunting, and the smells of this hell invaded our senses and penetrated deep into our very souls.

  For forty-six hours we continued to care for incoming casualties, many of whom required surgery. During that period OR number one performed ten complicated and extensive surgeries on two EPWs and eight marines. Those of us assigned to OR number two performed fifteen surgeries on fourteen EPWs and
one marine. Because our U.S. Marines were equipped with armored vests, many of them were spared being wounded severely in the chest and abdomen; instead, most of their wounds were to the arms, legs, and lower torso. As a result, more marines were operated on in OR number one, where their orthopedic wounds were surgically repaired. They would then be medevaced to the EMF.

  All the surgical cases for which I provided anesthesia care in OR number two, whether Iraqi civilian, EPW, or marine, were memorable ones. Still, one marine who was brought into our OR after he had sustained a gunshot wound to the neck would prove to be one of the most unforgettable and emotional cases I would experience throughout my entire twenty-five year career in the navy.

  That young marine’s name was Jeff.

  16

  CARING FOR JEFF

  Jeff was brought to Camp Anderson in a helicopter after sustaining a wound to his neck. He was swiftly removed from the chopper and carried to the triage tent on a litter. Prompt evaluation of his wounds revealed the need to establish an airway as quickly as possible because his trachea was already moved off center.

  Jeff was awake and alert when he was placed on our table in OR number two. His sparkling blue eyes were filled with pain and fear as he looked up at me. The wound he had sustained was severe, and he was gasping for breath. A hematoma (a mass of clotted blood) had formed around his carotid artery, causing pressure against his trachea and deviating it. He was able to breathe, but the deviation of his trachea was so severe that endotracheal intubation, or the insertion of a tube into his mouth and down into the trachea to provide an open airway for the administration of oxygen and anesthetic, would be difficult if not impossible.

  Prior to Jeff’s arrival, we had received a brief report of his condition from the triage personnel and were prepared to perform a tracheotomy, an emergency procedure requiring the surgical formation of an opening into the trachea through the neck to allow the passage of air. Commander Fontana, the surgeon in the case, said, “Cheryl, we are getting an airway casualty in, and I plan to trach him (perform a tracheotomy) if you cannot get a tube in.”