Ruff's War

by K. Sue Roper

  Jeff was scared, and his fear was intoxicating. He had been informed in the triage area that a tracheotomy might be needed to save his life. I introduced myself and told him, “Jeff, I’m going to put a mask over your face to give you oxygen. I’m going to take real good care of you.”

  As soon as I began to cover his nose and mouth with the oxygen mask, he said, “Hold it. Please, please don’t cut my throat.” Having been informed by one of the physicians in the triage area that a tracheotomy might be needed, he fully understood what might occur, and he was begging me to stop the surgeons from performing that procedure. As I looked into his eyes, I could readily see the fear and anguish on his face, and I felt his fear deep within my soul. I said, “Jeff, I am going to do everything I can to get this airway into you. Just know that I am going to take the best care of you that I can.” It was now totally up to me to do all I could to grant his wish of not having the surgeons cut his throat.

  Despite years of training, to a certified nurse anesthetist, a patient with a difficult airway is the most humbling and challenging endeavor that our specialty encounters. Unlike a stateside hospital that is well lighted and safe and possesses ready access to the most advanced technological equipment and supplies, our wartime OR number two included nothing but the barest of essentials. This was the time, the final reckoning that would answer the two questions that had haunted me throughout my many days of deployment. Did I truly have the knowledge, skill, and expertise needed to provide the best medical care to our wounded troops? Would I find the strength to make the best decision and do the right thing?

  After reassuring Jeff, I administered succinylcholine, a rapid-acting anesthesia agent that produces skeletal muscle paralysis. With this administration, I knew I had crossed the bridge; he was no longer capable of spontaneous breathing. I had to get the endotracheal tube inserted and inserted quickly, or the surgeons would have no choice but to perform the tracheotomy. I closed my eyes and prayed, “God, please help me to do this.”

  When I looked down into Jeff’s throat I could not see an opening, just soft tissue, blood, and the bulging hematoma. Relying on my previous clinical experiences, I knew I needed to arc the endotracheal tube a bit more than usual and scoop upward. I just knew the trachea had to be there. God had to be guiding my hand, for when I inserted the tube it miraculously slid down right into his trachea. Jeff now had an established airway in which to administer life-saving oxygen. We would not need to perform a tracheotomy, and his plea “please don’t cut my throat” could and would be honored.

  I immediately hooked him up to the breathing circuit and began oxygenating him. His chest rose bilaterally, indicating that oxygen was entering both lungs, and the endotracheal tube began to fog with his carbon dioxide exhalation. I never was able to visualize his vocal cords before inserting that tube, but I had no doubt, on the basis of the bilateral rise of his chest and the fogging to the tube, that the tube had been inserted exactly where it was supposed to be. When I looked up at the crew in the OR, they all began cheering. They had been standing back, holding their breaths, watching and praying for my success with the insertion of the tube. Their cheers, combined with the grateful look radiating in their eyes, brought me to tears. All I could do was thank God, for he had definitely come through when I needed him the most. He had answered my prayers and the prayers of all who were a witness to this event.

  Because the gunshot had created significant and massive damage so close to the carotid artery (one of two principal vessels supplying blood to the brain), performing surgery under the primitive conditions in which we were surrounded was determined to be too risky. We knew we did not have enough blood should the artery rupture. Jeff could easily bleed to death on the table if such an event occurred.

  I steadfastly secured the endotracheal tube and filled syringes with vecuronium (a longer-acting neuromuscular blocking agent), midazolam (used to produce drowsiness and to relieve anxiety), and various narcotics. I sat there continuously squeezing the Ambu bag and breathing for Jeff as we waited for a chopper to land that would take him farther away from enemy lines to a better-equipped, more sophisticated trauma center.

  While I waited, I realized I had formed a deep emotional bond with Jeff and did not want to pass his care off to someone who might not understand how miraculous the insertion of this airway had been or how important it was to keep intact. If this endotracheal tube should become dislodged, I believed there would be no way for it to be successfully inserted again, especially if Jeff was on the helicopter when this happened. Even the possibility of performing a tracheotomy with the rapidly developing hematoma was high risk; the most skilled surgeon could easily cut into the hematoma, and Jeff would then bleed to death. I hated the thought of handing over Jeff’s care to another and decided I needed to provide him with anything I had that might foster his chances of survival.

  Before I left the States, I had taken a Jackson Reese/Mapleson ventilation unit from NMC, Portsmouth, and carried it with me in my Alice pack. This unit had a latex Ambu bag that was more pliable than the hard rubber construction of the bags we routinely used. It allowed easy adjustment to the flow of oxygen, and positive pressure could be applied to it if necessary to keep a patient’s alveoli (tiny sacs in the lungs) open. Less than forty-eight hours into caring for the wounded of this war, I had decided to give up my only special Ambu bag to Jeff without really knowing how many other Jeffs I would need to provide care for. Still, something inside me said, “Give this to Jeff. He needs it,” so I decided it would be my special gift to him along with several oxygen cylinders I had prepared to accompany him while he was being transported.

  A chopper landed, and along with the corpsmen, I accompanied Jeff as four stretcher bearers took him to the helicopter pad. All throughout this transport process to the chopper, I kept breathing for him by rhythmically and steadily compressing the Jackson Reese/Mapleson bag. The blades of the helicopter continued to rotate, kicking up dust and dirt all around us. Little could be heard over the rumble and roar of those massive rotating blades. Still, as we lifted Jeff up into the chopper, I screamed to the receiving corpsman on board, “Keep squeezing the bag! Keep him alive! Keep him alive!” I had written out on a tiny piece of paper when and how often to give Jeff the syringes of vecuronium and midazolam I had drawn up. I tried to yell over the noise of the rotating blades, for I desperately needed to know that the corpsman on board the chopper understood my orders. He gave me the thumbs-up sign.

  Briefly looking over at the pilot who had turned to face me, I could readily see that he was in a rush to take off. He wanted to get this guy in, get him settled, get off the ground, and transport him quickly. For a split second I reviewed in my mind how I had managed to pull off the task of inserting Jeff’s airway. It had taken everything in me, and now I had to trust that these guys would also do everything they could for Jeff. I had no other choice but to believe they would, and as I looked at Jeff one last time, I handed over to the corpsman the Ambu bag and begged him again, “Keep squeezing the bag. Keep him alive! Keep him alive!”

  Turning Jeff’s care over to another was an agonizing and highly emotional experience for me. I had no idea where he was going or whether the corpsman on board the helicopter had heard my plea. All I could do was let him go and pray that he would be okay. I had done everything in my power to honor his wishes and to save his life. It would not be until I returned to Kuwait a month and a half later that I would learn of Jeff’s fate.

  17

  WE ARE “DEVIL DOCS”

  We had been at Camp Anderson for three days, and our mobile tent trauma center had received, evaluated, and treated a total of 106 casualties in the course of forty-six hours. These casualties were a result of fierce frontline fighting between the U.S. Marines and the Iraqi enemy troops. Bravo Surgical Company, along with some of the FRSS and STP units, were the closest medical groups adjacent to the frontline.

  Dr. Sanjay Gupta, the CNN reporter we had encountered earlier, was still
on hand providing medical news and information about the activities of medical personnel as they applied their skills and expertise in an attempt to save lives and repair the devastating wounds of war. I first noticed both Dr. Gupta and his photographer, “Mad Dog,” when we were waiting for transportation at Camp Hasty. Wearing a multi-pocketed vest where various rolls of film and other photographic paraphernalia could easily be stored, and carrying cameras and a tripod, Mad Dog, as all could see, was a civilian. Both Dr. Gupta and Mad Dog were standing with the marines at Camp Hasty, and I was never sure whether they were also waiting for transportation or trying to locate the position of one of our FRSS units.

  Commander Fontana and some of the other more senior Bravo Company officers began talking with them. We then learned that both Dr. Gupta and Mad Dog decided to travel with us to Camp Anderson, where they would spend every moment of those three horrific days with us providing live, on-the-scene reports via videophone to CNN viewers stateside.

  During one of the first reports that Dr. Gupta broadcasted, the medical personnel of the Bravo Surgical Company were referred to as “Devil Docs.” The origin of that moniker dates back to World War I. During the battle of Belleau Wood, the U.S. Marines fought so fiercely against the Germans that the enemy referred to them as Teufel-hunden, or “Devil Dogs,” a reference to the vicious, wild mountain dogs of Bavarian folklore. Soon afterward, marine recruiting posters depicted a snarling English bulldog wearing a U.S. Marine Corps helmet. The tenacity and demeanor of the Devil Dog depicted in this image took root with both the marines and the public. The marines were proud to adopt this nickname for themselves, and the name Devil Docs was a natural extension applied to the medical personnel who provide care to marines on the battlefield. We, the members of the Bravo Surgical Company, readily embraced this sobriquet, for it was a perfect fit with what we were doing inside the hellhole into which we had entered.

  We knew little of the specific content or nature of Dr. Gupta’s reports being broadcast to our friends and families in the States, but we respected him and believed his reporting would be factual and just. We knew we were doing everything we possibly could to save lives in extremely brutal conditions and under horrific circumstances. Our hope was that through his reports, our loved ones at home would know where we were and that we were safe and working diligently to repair the wounds of war. Dr. Gupta’s news reports had become our only means of conveying information that might allay the fear of those we loved back home.

  The respect we had for Dr. Gupta went well beyond his role as a news reporter. He was a skilled surgeon, and as we had noticed earlier, he did not hesitate to assist us in the OR despite the role conflict he experienced with being an objective journalist detached from the story he was covering and actually becoming a participant in that same story. Whenever the need arose for him to switch into the role of surgeon, he was there for us, and we were all very appreciative. The source of his motivation was the same as ours: make the right decision, do the right thing, and perform whatever role was needed to save the lives of others. Not much else really mattered.

  Dr. Gupta stuck with us during those tumultuous three days at Camp Anderson and beyond. We developed a close, collegial relationship with him. He was a good guy: modest, warm, gentle, caring, highly skilled, and not afraid to do the right thing even though pundits and others might criticize his decisions and actions. He soon became our friend, and we considered him to be one of us, just another Devil Doc in the sands of Iraq doing all we could to save the casualties of war.

  We knew that part of his responsibility in his role as a journalist was the development of one of the “Special Edition of CNN Presents” programs. This program would document the journey and actions of the Bravo Surgical Company during our days in Iraq. I could not fathom how a one-hour video would be able to capture the true essence of all we had experienced at Camp Anderson and would continue to experience for the forty days we would spend in Iraq, but I trusted that he would do us justice.

  Dr. Sanjay Gupta was one of us. He was just another member of the Bravo Surgical Company, and he would remain at our side as we packed up and moved forward, ever closer to Baghdad.

  18

  SURVIVING IN THE WAKE OF DEATH

  The process of packing up our surgical company began the evening of 5 April. The personnel in OR number one closed early that evening to begin dismantling their tent and equipment so they could be packed in ISO containers. OR number two remained intact, and we continued performing surgery on all casualties as they were brought to Camp Anderson.

  Those of us in OR number two worked until 2:30 the following morning. We cared for five patients and performed such surgical procedures as exploratory laparotomies, bowel resections with colostomy (surgically creating an anus by connecting the colon to an opening in the abdominal wall), and the removal of some damaged tissue from a knee that had been shattered by gunshot. We were exhausted as we found our way to our cots located outside the OR tent walls. As I removed my boots, something I had not done for sixty hours, my socks were dripping in sweat, and my feet were raw.

  Reveille was sounded at 5 AM, allowing us a brief two and one-half hours of sleep. Because we had no water for washing ourselves, I cleaned up as best I could with hand wipes. We continued to wear the same clothes as those we wore when we began our journey into Iraq on 2 April: green T-shirts, MOPP pants, and underclothes, all of which were stained and encrusted with dried blood, sweat, and what seemed like a ton of dirt. Cleanliness and personal hygiene were not issues; we were all filthy, and we all reeked of old dried sweat and foul body odor, but we knew we could do nothing about it. We also knew we would just become more grubby and soiled as the day wore on.

  We immediately began dismantling OR number two, hauling, dragging, pushing, and pulling the equipment and tenting to be stowed in ISO containers. It was strenuous, hard work compounded by physical fatigue, windy hot weather, and sore, battered feet.

  By noon the entire camp was packed, and we began the wait for the trucks that would take us to Camp Chesty, forty miles to our north and approximately seventy miles south of Baghdad. Both our mission and our goal were the same: to stay within a short distance behind the advancing troops of the 1st MEF in order to continue providing surgical damage control to the wounded.

  Despite the danger of traveling through Iraq in a convoy, we had little choice. At least this journey was scheduled for the daylight hours, and we would have more protection from marines armed with M-16s riding with us. One marine was assigned to ride in the back of each truck that was carrying personnel, and one would serve as a driver. This arrangement did not provide a lot of protection, but it was twice as much as we had had when we made our perilous journey from Camp Hasty to Camp Anderson.

  Sitting on our Alice packs in the exposed and harsh Iraqi landscape beneath a blazing sun, we waited and waited to board the convoy trucks. Hot, tired, miserable, and filthy, we could do little more than sit there breathing in the stench of the pit that had served as our bathroom and as the place we had burned discarded body parts, human tissue, and bloody rags. We had sustained ourselves on small snacks from our MREs, but the heat, combined with the stench, left us with little appetite.

  As I sat waiting for the convoy trucks to arrive, I reflected on the past few days since our arrival in Iraq and what we had accomplished at this first temporary hospital. I thought about Jeff and the little nine-year-old boy and wondered where they were and how they were doing. I also wondered what the future would hold for us. How many casualties would we care for? Would we have enough supplies? What would our next camp be like?

  The trucks arrived, and we began boarding at 2:30 PM. The convoy comprised thirty vehicles: seven-ton trucks to transport ISO containers and personnel, ambulances, and marine security vehicles that would drive at the front of the convoy. Each of the seven-ton trucks towed a cart behind it, which is where we would stow our Alice packs and our one seabag. We were told that our journey north was expected to take
four hours and that we would be going through an area around “the canal,” which was infested with enemy snipers. We all wore full MOPP gear, Kevlar vests, and helmets, with our loaded pistols strapped to our sides.

  I sat with Dave Sheppard and one of our OB/GYN doctors, Cdr. Ken Singleton, on hard, thin metal benches lining the sides of the truck’s bed. Unlike the one in which I had ridden to Camp Anderson, this truck was covered with a canvas canopy, and the interior was sweltering hot and suffocating. Still, at least we were leaving the hellhole of Camp Anderson, and we believed anything could be endured for four hours.

  Our convoy journey began at 3:20 PM, and we slowly rumbled our way north. We passed several dead camels lying on the roadside and saw the shattered remains of several bombed-out buildings. Interspersed among the building ruins were flowers, a sight I had not seen in months, and I thought they were beautiful.

  Many of the small villages we passed through had been deserted, but others were full of small children trying to sell us cigarettes. We remembered the previous warnings about the children approaching the trucks and about not interacting with them in any way. These children could be nothing more than decoys used to draw us out of the trucks where we would become easy targets for a sniper’s bullet.

  At 5:15 PM, our convoy stopped abruptly and sat idle on the road. We had not arrived at any particular destination; we simply stopped. As I sat in the back of the seven-ton truck, I began to hear the sounds of heavy artillery fire and then watched the sky light up from the explosions of rockets and missiles being fired from the ground and from Cobra and Apache aircraft in the sky. The convoy we had been closely following was being ambushed by enemy troops.