No sooner had we entered the room than we heard an explosion that seemed to come from somewhere close by. I dove to the floor — then looked up to see that the others had reacted only by calmly walking to the racks of body armor. The ICU nurses and techs put on their armor and helmets and resumed working.
Pete extended a hand and smiled. “Let’s go to the locker room and get our armor. That was a mortar. You’ll get used to it.” A few seconds later, the Alarm Red siren began to wail, announcing to the rest of the base that someone had just tried to blow up the hospital. I realized that if I were to die from a mortar or rocket attack, the one that killed me would probably trigger the alarm to save someone else. The siren would be a clanging eulogy for the dead Lee Warren.
Protected by Kevlar, we returned to the ICU. The unit was full of patients, stratified by their degree of injury. Lying in one bed was a burned-up American soldier missing a leg and an eye. In the next bed over lay an Al Qaeda terrorist who’d been shot while detonating the bomb that had caused the American’s injuries. No separation, no delivery of different care based on a patient’s nationality or actions. The nurses and doctors and techs simply delivered care to the injured — injured who’d been brought here by medics willing to risk themselves to bring in the wounded, even the bad guys.
Pete pointed out the terrorist. “Mind changing his head dressing? I’ve got to get the transfer paperwork done so the American can fly to Landstuhl tonight.”
I pulled on exam gloves and reached for the man’s head. As I laid my hands on his blood-soaked bandage, he startled from his morphine-induced sleep. I don’t know what I’d thought I would feel when I first touched a terrorist. Did I expect them to be slimy, reptilian, maybe have horns like the Devil? When I looked down on the young man, I simply saw a person. His skin felt warm, his blood was sticky, and his carotid pulse felt just like the other thousands I’d felt. He had brown skin, brown eyes, and brown hair, with bandages on his head and arms and abdomen from the operations that had saved his life. Groggy from morphine and brain injury, he looked up at me with an unsteady gaze. He had 1841 written on his chest, a tube in his nose, and a catheter in his penis. How had he ended up here? I wasn’t wondering about the bomb-to-Black Hawk-to-Balad pathway, but the philosophical one. What had led him to risk his own life to take someone else’s?
Once I’d removed the man’s bandage, I cleaned his wound and learned something about Pete. The man’s scalp wound was jagged and complex, and had required hundreds of sutures to repair. The knots were all squared, the wound edges were precisely aligned, and the tissue was healing beautifully. It was perfect, the surgical equivalent of a well-played symphony.
I looked up at Pete, who was now standing across from me. “Nice work,” I said. “I’m not sure I could have put that together as well.”
Pete gave an aw-shucks grin and shoved his hands in his pockets. “We’ll see.”
In the tent next to the ICU was a makeshift nursing unit, with twenty or so cots holding mostly Iraqi and insurgent patients and very few Americans. Pete explained that the Americans rarely made it to this ward because as soon as they were stable enough to fly, they were transported to Landstuhl, Germany, before the flight to Walter Reed Army Hospital back in America. The Iraqis and other non-Coalition patients were stabilized in the ICU and then had to be cared for until they were well enough to be discharged home or to an Iraqi civilian medical facility (although there were very few of those left at the time) or, in the case of insurgents and terrorists, sent to a military prison.
One of the Iraqi patients in the ward was a man Pete had operated on the day before I arrived. His head was wrapped in white gauze, with a wire coming out the top. The wire was an intracranial pressure (ICP) monitor, which is used to track the pressure inside the brain. A sign on the wall above the patient read, “No bone on the left. Handle head carefully.”
I pointed at the sign. “What happened, another IED?”
Pete shook his head. “He’s not a war victim, just a bad driver. He wrecked his car. Lucky for him, a bunch of American Marines were nearby. They called for a Black Hawk, and the medics brought him in.”
I thought about this while Pete looked at the chart. American soldiers in a war zone stopped what they were doing and put themselves at risk to help a civilian and get him to the military hospital where a military brain surgeon saved his life. Then they continued their real missions.
“I didn’t know we were allowed to treat civilians,” I said.
He smiled. “We treat everybody. We’re Americans.”
Pete showed me the patient’s initial scan, which showed only mild swelling of the brain. Pete had opted for immediate surgery and had performed an operation known as a decompressive craniectomy. This procedure involves removing a huge piece of a person’s skull, which allows the brain to swell outward under the soft scalp instead of swelling inside toward the brainstem. Neurosurgeons have performed this procedure for many years — usually on patients who have failed all other measures for controlling their intracranial pressure.
Once the brain swelling goes down, the bone can be safely reattached to the patient’s skull to protect the brain. In America, we keep the skull flaps sterile and freeze-dry them for implantation later, but in the old days the standard technique was to make a small incision in the patient’s abdomen and insert the skull flap there for safekeeping. I had read about that but had never performed it or seen it outside of a textbook.
I was about to ask Pete where we stored the bone flaps when I noticed a four-inch-long incision on the patient’s right lower abdomen. I pointed it out. “Is that what I think it is?”
Pete laughed. “Yeah, bone flap. We don’t have any way to store them here, and we don’t know if we’ll be here when the patient is ready for it to be reattached, so we just put them in the belly. Same for the Americans, so we know their bones won’t get mixed up with someone else’s or lost on the way home.”
I cringed at the thought of putting in the wrong bone flap. “You’ll have to show me how to do that,” I said.
“Don’t worry. There will be plenty of opportunities.”
Pete turned to the nurse, and I studied the patient’s scan again. To me, it didn’t look bad enough to justify the early surgery. Why had Pete not simply treated him conservatively, giving medicines to control the brain swelling and waiting to see if he could keep the patient from having to have surgery at all? Most people with this patient’s degree of brain swelling could be managed with medicine and several days in the ICU. For me, surgery should be the last resort in treating a patient. If you can keep all the brains God gave you inside your head, that’s better for you. Our rule of thumb is to try to avoid surgery if we can, because the First Law of Neurosurgery is absolute: You’re never the same once the air hits your brain.
Pete’s patient was awake and doing very well, and his postoperative CT scan showed very little swelling and no visible brain damage.
“Why did you go straight to surgery?” I asked. “The first scan didn’t look so bad.”
Pete pointed at the first scan. “You see that little bit of swelling there in the white matter, that mild edema in the temporal lobes? What happens to that in forty-eight hours?”
“It gets worse — unless you give him Mannitol, maybe barbiturates. You could always put him on a ventilator, reduce his cerebral blood-flow needs, control it medically. I doubt he’d ever need to be operated.”
Pete chuckled. “You’re right. In San Antonio or Dayton we’d have one nurse per patient. And that nurse could stand here for the hour it takes to deliver a dose of Mannitol. And he could watch the ICP monitor and call the neurosurgery resident every half hour for new orders when the ICP went up. How many patients do you see in here?”
“Twenty.”
“And how many nurses?”
“Three.”
“And how many neurosurgeons?”
I got the point. “Okay, you’re saying we don’t have enough time or people to
manage these injuries conservatively.”
Pete shrugged his shoulders. “Look, when it’s your turn, you make the call. I’m just saying if you look at a scan right after an injury and you see something that you know is going to get worse for three or four days, you need to remember where you’re standing. And that your luck is about to run out.”
“What do you mean?”
Pete touched his watch. “You’ve been here a day and a half, and we haven’t had a mass casualty situation. So I don’t expect you to have this perspective yet. But probably, two days from now, every one of these beds will be filled with new people, and we won’t have room for anybody who’s only here because we didn’t get them out fast enough. Unless you want to move some of them to your quarters and give them their Mannitol doses there.”
A nurse approached the bedside to change the man’s IV bag. She looked at me sideways with a tight grin, her forehead wrinkling. I felt scolded, like a student whose professor had pointed out how stupid he was in front of the whole class.
Pete tapped the monitor, his index finger pointed at the ICP tracing, which currently read 0. “What do you think that number would be if I’d chosen not to operate?”
I thought about the hundreds of these patients I’d seen over the years. Surgery was always the easy answer, because you could so reliably eliminate ICP issues. But conservative treatment works, if you’re patient, and you can save people the risk of removing part of their brain. But Pete was right, because the ICP would still be higher even on Mannitol. “Fifteen or twenty,” I said.
Pete nodded. “Still normal, but a lot of work for everybody. And he’d still be here three days from now. Let’s go. Pretty soon you’ll agree with me.”
I nodded slowly as Pete walked away. I looked at the still-smiling nurse, who seemed to enjoy watching me be schooled by Pete. The ICP tracing bounced around from 0 to 1, and I thought, We’ ll see.
We finished the tour, passing the lab, the radiology department with its field CT scanner, and the physical therapy clinic where soldiers with minor injuries were evaluated to see whether they could stay in the fight or had purchased their tickets home with the price of some disability. I met three interpreters, Iraqis chosen for their strong command of English and their willingness to help us converse with patients who spoke only Arabic. These men were Muslims, but they understood capitalism. They had a commodity we needed, and they were willing to sell it to us. This attitude wasn’t universally accepted among their neighbors and family members, and while I was in Iraq, more than one of them would pay dearly for their perceived collaboration with the enemy.
Back in the surgeons’ lounge area, the Christmas tree still twinkled with tinsel and blinking lights. But someone had removed the angel from the top, replacing it with cardboard cutout numbers: “2005.” It was now a New Year’s tree, a couple of days early.
Pete had to meet with the squadron commander for a few minutes, so he left me in the lounge to watch TV, assuring me that he would return shortly to walk me to dinner.
The sleeping surgeon on the sofa was gone. In his place was a young soldier. His helmet and body armor sat at his feet. In his arms he cradled his M – 16 rifle, pointing toward the floor. His eyes were locked onto the opposite wall of the tent as if looking for something far away — the “thousand-yard stare” of shell-shocked World War II soldiers in old movies. His knuckles were scraped and bloody, and he had a small abrasion on his forehead, as if he had struck his face on something.
I sat next to him. “Are you okay, soldier?”
He turned and leaned closer to me, then shook his head and pointed to his ear. “I can’t hear you, sir,” he shouted. “What did you say? My ears are still ringing.”
Now that he had turned, I could see that the other side of his face was burned slightly, and several small square pieces of skin were torn off. The pink-white squares against his dark complexion made a checkerboard pattern on his face. He smelled like a campfire.
I spoke louder. “What happened?”
His hands were shaking. He saw me looking at them and gripped the rifle tighter. “Land mine. My lieutenant’s in there.” He nodded toward the ER.
I squeezed his shoulder. He was the first American soldier I touched in Iraq.
“I’ll check on him for you. Stay here.”
I turned and walked into the ER, where four people stood around a bed. A pile of clothing — bloody DCUs and underwear — lay on the floor next to the bed. An anesthetist was trying to intubate the patient. I smelled a horrible combination of burned flesh and stool. Vic, the general surgeon I’d met earlier, was talking to an ER doctor who had his hands on the man’s groin, putting pressure on the femoral artery. I looked over his shoulder and saw the jagged edge of the lieutenant’s femur, stark white bone in a sea of red, muscles and arteries and flapping ligaments barely attached to the lower portion of his leg. The other leg, missing below the knee, was tied off with a tourniquet around his thigh. A long laceration curved up from his groin into his lower abdomen, and from the smell it was obvious that there was a bowel injury.
There was blood all over the bed and all over the ER doctor, but none seemed to be coming out of the patient now. I looked at the injured man’s face. Pale, listless eyes stared at the ceiling. He had sandy hair and burns on his face and neck. I guessed he was in his early twenties.
The anesthetist managed to get the breathing tube in. I looked at the monitor — his blood pressure was low and his heart rate very high. He was in shock from blood loss and probably becoming septic from the bowel injury. The bacteria in his colon were in his bloodstream now, and would soon cause an overwhelming infection if Vic and the others couldn’t stabilize him in time. But at this point blood loss and shock were bigger threats to him.
Vic bumped me out of the way. “Move it — we have to get him to the OR.”
I watched as they rolled the stretcher through the lounge and into the operating room.
When they passed the private, he stood and watched his lieutenant go by. The private stood and reached his hands toward his officer, then dropped them to his side. “LT,” he softly called the officer’s name.
I put my arm around the private and guided him back onto the sofa. When he looked at me, his eyes trailed down to the caduceus symbol over my left pocket — the snake-and-staff icon that identified me as a doctor. He looked into my eyes, shaking in the aftermath of what no eighteen-year-old should ever have had to witness.
“He gonna make it, Doc?”
“They’re doing everything they can for him.”
He turned his head and leaned closer, raised his eyebrow.
I said it again, louder.
He put his face in his hands, sniffed hard, and began to sob.
“Where’s the rest of your squad?”
The private straightened and blew out a long sigh. “They’re dead. We were on a four-man patrol. We came to a little wall, LT told Juarez and me to go right, and he turned left with Sarge. I took about two steps before I heard the explosion. I woke up, Juarez was on top of me, LT was screaming at me to call the medics. Sarge was . . . was just gone.”
He put his face back in his hands and continued to cry.
I thought of all the things people say when someone dies. When I was growing up in a small town, funerals were places where church people shook the widow’s hand and tried to say something encouraging. All of those phrases seemed wildly inappropriate at the moment. Somehow I didn’t think that Well, he’s in a better place now or At least he didn’t suffer would comfort the private.
I looked at him, just a kid, probably with permanent hearing loss now and certainly with lifelong psychiatric issues, and I felt impotent. Most of the good things I’ve done in my life I’ve done with my hands while someone was anesthetized. I didn’t have an instrument for this, couldn’t cut this out of him or make it heal. Medicine was not what he needed.
I wrapped my arm around him and pulled him closer.
Vic walked out
of the OR and stopped in front of the couch. He wore a look I’d seen in too many waiting rooms, had worn myself too many times, but with an extra layer of sadness that went beyond what a doctor feels after losing a patient. It would take me a few days to understand that look, but I think I was already feeling the beginnings of the difference between losing a patient to cancer or an aneurysm and losing a soldier because of someone else’s hatred.
Vic knelt, put his hand on the private’s shoulder, and looked him in the eyes. “We did our best, but your lieutenant’s gone.”
The private nodded and wrung his hands, which had begun to shake again.
Vic walked away, leaving me there with the private, and again I didn’t know what to say.
Then the soldier in him took over. I saw it happen. He straightened, wiped his eyes, and gathered up his gear. The expression on his face tightened as if he had decided it was time to move on. When he turned to look at me, I saw resolve and strength mixing with the tears and pain.
He stood and slung his rifle over his shoulder. I squeezed his arm and said, “Hang in there, Private. It’s gonna be okay.”
I have no idea why I said that. In retrospect, it seems silly for me to have chosen those words, because at the moment it appeared that it was decidedly not going to be okay. But my words hung in the Iraqi air like one of those patronizing Christian metaphors I had just decided not to use.
The private squinted and slowly nodded, made a chewing motion like he was taste-testing the merit of my words.
“Roger that, Major,” he said.
He stepped past me, put on his helmet, and walked away.
I never saw him again.
CHAPTER 4
NO SKULL BONE ON LEFT, HANDLE CAREFULLY
I stepped into the hazy afternoon and strapped on my helmet. A blast of smoky wind brought the smell of burning chemicals, and the blowing sand stung my eyes. I squinted and dug in my pocket until I found my Wiley Xs, the dark wraparound sunglasses the Air Force issued to all of us to prevent eye injuries from IEDs.
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