No Place to Hide

by W. Lee Warren

  I put my hand on Hikmat’s shoulder and said, “I’m sorry for all you’ve been through, and for what happened to Jassem.”

  Hikmat sat up and wiped his tears, but when he turned toward me, rather than the heartsick face I’d expected, he bore a huge smile. He hugged me, and I smelled smoke, sweat, and the unique smell of clotted blood. Apparently, he realized how tightly he was hugging me, because he composed himself and spoke.

  I looked over Hikmat’s shoulder at Saeed. Saeed was smiling too.

  “Hikmat say no, you do not apologize for anything. He say has been best two days, because Jassem alive, and because Hikmat was able to vote.”

  CHAPTER 20

  FREEZING TO DEATH IN A MUDDY HOLE

  That’s twelve,” I said.

  Tim and I had been walking back to the hospital from DFAC II, where we’d gone to eat lunch — neither of us had eaten breakfast, or dinner the night before either — when a mortar landed and detonated close enough to us that we saw the smoke and heard the sound at the same time. We’d scurried into the bunker for safety. Since Election Day eleven days ago, the enemy had been pummeling us with mortars and rockets, and the flow of patients into the hospital was higher than ever.

  During the thirty minutes since the first explosion, as we’d huddled in the bunker, we’d heard eleven more, all pretty close, and all answered by return fire from our guys. Whoever was shooting at us was close enough that we could hear both the launch — a sound closest to booof—and the detonation of the rounds our guys were shooting back.

  So for the past half-hour, we’d felt and heard incoming projectiles with their thud-booms, and friendly fire with its booof-booms. Mixed in with the explosions were the terrifying noise of the Alarm Red sirens, gate gunners letting off fifty-caliber machine-gun rounds, and the steady beeping of our pagers informing us that there were casualties who awaited our arrival and didn’t care about our personal safety.

  It had been raining for days, and the temperature at night was dipping into the twenties. The entire base was a swamp, and this bunker was two inches deep in mud. Earlier that day I’d done an operation while standing in ankle-high water after the hospital had flooded. At the time, I’d been barely aware of it, concentrating on my case, but when I stepped away from the surgical table the squishing of my wet socks inside my shoes got my attention. It was a miserable day, a miserable situation, and to top it all off, somebody was trying to kill us.

  I was amazed when I realized that I was less afraid of being blown up than angry with whomever was making me sit in this muddy hole freezing to death.

  “We’ve got to get to the ER,” Tim said. “That’s the fourth time they’ve paged us.”

  Should we just make a break for it? From here to the hospital was all open sidewalk with no other bunkers on the way. I was freezing, still heartsick over my kids, and hadn’t slept in almost twenty-four hours. A direct hit now couldn’t really make me feel any worse. And, as always, there was work to do.

  “Let’s do it,” I said.

  We ran for the hospital, probably both setting personal records for the two-hundred-yard dash.

  In the ER, we found one of the worst disasters either of us had ever seen. Fifteen Iraqi policemen had been standing in formation when a suicide bomber pressed his switch. Somehow, almost all the projectiles had hit the policemen above the shoulders. All fifteen of the men had serious eye, neck, or brain injuries.

  Augie, the ophthalmologist, was already working his way around the room. He stopped at each bedside to shine his light into the patient’s eyes and assess the severity of the ocular injuries. When he saw an eye that would require surgery, he would put a patch over it and write the patient’s number, which eye, and what he needed to do. He dispensed eighteen patches among the fifteen men. He would be operating all night.

  Joe from ENT was performing a bedside tracheostomy on a man whose entire trachea was exposed by severe face and neck burns. The man was awake, gasping for air, because every time the medic squeezed his oxygen bag, most of the air came out the hole in the man’s trachea instead of making it into his lungs. Joe gave up when he realized that the last breath the man had taken during the bombing had caused him to inhale so much smoke and fire that his lungs were irreparably harmed. After a few more seconds of gasping and flailing his arms, the man stopped breathing.

  Tim and I went around the room deciding who needed CT scans first. One by one, we rolled the men into the scanner, and over the next hour we saw a radiologic anthology of wartime brain injuries. Of the now fourteen survivors, six had intracranial injuries. Three were completely unsalvageable; bomb fragments and blast injuries had caused so much damage that no surgery would help. Two had minor brain injuries that would not require surgery, and the last man had a brain hemorrhage.

  “I’ll take care of this one,” Tim said. “Why don’t you take these guys to the holding area and control their pain?”

  “Yes, sir,” I said, acknowledging both Tim’s rank and the fact that he had chosen the more pleasant of the two jobs.

  A few minutes later I was standing with a couple of nurses, giving orders for morphine administration to the dying men. 2240, 2243, and 2251 were all still conscious but fading fast from brain swelling. 2240 had a hole in the side of his head, and brain tissue was oozing out. This is a terrible fact of trauma neurophysiology: when a patient has an injury that is definitely going to be fatal but who also has an open skull fracture, brain pressure can stay normal for a long time because the tissue can escape through the holes in the bone and skin. So one of the things we have to do to keep that patient from lingering in a near-death state for several days is to suture up the holes so tightly that brain tissue cannot swell out. This causes the pressure to rise, ending the patient’s suffering more quickly.

  “Hand me a suture kit,” I said.

  I placed several very tight purse-string stitches around the hole. This is the only technique I ever have to employ that is designed to help someone pass instead of trying to save them. It always causes a guilty nausea to rise in my stomach, because it feels as if I’m deliberately ending someone else’s life — although we’re trained to take the perspective that the injury produced the problem, and we’re simply shortening the time line of its effect. No matter what you tell yourself, though, it still feels awful.

  As I finished that procedure on 2240, I said a little prayer for him to quickly lose whatever consciousness he had left. What he was going through sickened me. His head probably throbbed with rising pressure from bomb fragments and brain bleeding, and he was unable to see anything because of Augie’s eye patches and his lacerated corneas, and the last sounds he would hear in his life were in a language he couldn’t understand.

  I was liberal with the morphine.

  All three men writhed for a while, moaned, moved their arms. Then one by one, starting with 2251, they slid from the conscious world into the solace of stupor and coma, finally ceasing to breathe at last, adding three more victims to the tally of the suicide bomber and the insurgency. Three men who had decided to try to help Iraq reach for freedom had paid the price of doing business against Islamic terrorism.

  “Doc, they need you in surgery,” a tech called.

  Of course they do, I thought. In some ways, this was the hardest part of the war: the incessancy of carnage, suffering, and tragedy, the steady stream of impossible choices. In an average American hospital, a neurosurgeon might have a horrible case with no clear right answer, or some human catastrophe caused by a senseless crime or a random accident, once every few months. In Iraq, you had to suck up whatever the disaster in front of you made you feel, because somewhere down the hall there was something worse waiting for you.

  2243 lasted the longest. I signed his chart, wiped my eyes, and went to the OR.

  EMAIL HOME

  Friday, February 11, 2005

  Good morning, friends, from Mudville.

  Yesterday was a banner day for the bad guys. They blew up another group of I
NGs, and I spent a couple of hours trying to save one of them. I was up throughout the night last night dealing with his severely swollen brain. He’s going to die.

  I saw a good example yesterday of how the press only tells you part of a story. I picked up a copy of Stars and Stripes, the daily military newspaper. In it was a feature article on a US soldier who is back home after receiving his Purple Heart. He is the guy I told you about a few weeks ago who was bleeding to death from his scalp and leg wounds, and I fixed his scalp while Todd the vascular surgeon tried for several hours to save his leg. Ultimately Todd’s heroic effort to save the leg failed, and he had to amputate it. Nevertheless, we no doubt saved his life, and he went to Germany and then home in great shape.

  The article talked about this brave soldier’s work and family, and what a good person he is. It was very well written. When it got to the part of the story about his war injuries, it said, “He was injured, taken to a hospital in Iraq, and then on to Germany.”

  The article wasn’t about his injuries or us; it was about his life, so they didn’t need to go into all the things we did here for him. I just thought as I read it, “Wow. There’s so much more to this guy’s story that they glossed over.” I remember talking to him on the way to the OR and him asking me about the other guys in his unit. I remember him asking me lucidly if he was going to survive. I remember his piercing eyes as he went off to sleep in the OR, and him saying out loud, “I trust you guys.”

  The next several hours of that man’s life were in the hands of surgeons and God. He came very close to bleeding to death from blood loss. My part was very small — he had a major scalp artery bleeding deep in his temporalis muscle that was hard to control, and then I fixed his scalp wound after I got the bleeding controlled. Todd, however, really did miraculous work for this man, saving his life and going the extra mile to try to save his leg when every other surgeon would have just cut it off. He really cared and wanted to try and very nearly saved the leg.

  I tell you that story to remind you to tell your friends who are down on the war because of the media that they don’t know the half of it.

  Pray for all of us here and outside the wire, for my patient fighting for his life right now, and for me to fight off this fever and chill that I have today. I feel like the bottom of a shoe.

  I love you all.

  Lee

  EMAIL HOME

  Sunday, February 13, 2005

  Hello, friends.

  After lunch yesterday, I was paged to the ER to see an Iraqi man who had been the target of an assassination attempt. He had three bullets in his chest and one in his head, and we went off to CT scan. I can’t tell you who he is, but I used the word assassination, and there were apparently several Iraqi officials and high-ranking military officers hit yesterday.

  The scan showed a horrific and non-survivable injury. I had to make the call to not operate on him, and to let him die. A noble man dying in the service of his country, gunned down by cowards in hiding. In my opinion, they are not soldiers.

  Several of our interpreters came up to me later and asked if I would talk to them about one of the men we had operated on earlier in the week. It turns out that he’s a friend of theirs, a shopkeeper from Balad. Another innocent victim of a car bomb.

  We fear that we now have another generation of young men and women in the US military, much like some of their fathers after Vietnam, who will never again feel completely comfortable in a crowd. Their minds will always wonder if that person in the long coat is hiding a bomb, if that car on the corner is about to detonate, if death lies in wait on the other side of this door. If you figure that there are 150,000 or so US troops here thusly affected, imagine for a minute the long-range impact on every citizen of Iraq, Israel, and other places in the world touched by terrorism. You could argue that even Saddam’s military was nobler than these insurgents. At least they wore a uniform and fought and died under their flag, identifiable as Enemy. These people blend in with the citizens and cause untold numbers of them to be injured or killed simply because our troops, when they react with force to protect themselves and other people, can’t tell the insurgents from the civilians. So if you run a checkpoint, you are going to die. If you get too close to the gate, you will die. There’s no other way to prevent the next Mosul DFAC bombing or car-bomb-too-close-to-the-hospital.

  Last night at 7:30, nine (yes, nine) people showed up for movie night. A double feature: We had Band of Brothers, episode 7, and Napoleon Dynamite (repeated because many had not seen it). Afterward, John and Greg and I played guitars and sang through the set for today’s worship. It was a great way to end the evening.

  I went to sleep at about midnight and was paged to the hospital at 0300. A terrorist was shot trying to assassinate the mayor of Mosul, and they called me to look at the scan to see if he was salvageable, so that he could be transported here, a three-hour trip, for me to operate on him. He was not, and by the time they got his scans over the Internet to me, the weather had gotten too bad to fly him here anyway.

  That’s a big difference between Americans and these socalled insurgent “soldiers”: when we shoot somebody, our guys risk their lives to pick them up, rush them to the hospital in the same helicopters we use for our own fallen soldiers, and treat them with all the resources we have to try to save them. The insurgents will, instead, burn your body and drag you through the street and film it for the media to play over and over to say terrible things about America.

  I understand the sensitivities of church and state and all that, I really do. But don’t you think that our Founding Fathers’ ethics and belief systems have something to do with the fact that 230 years later we are still the kindest and most compassionate nation on earth, even to people who are trying to kill us?

  When I started this letter, it was dry outside. Now it’s raining cats and dogs (camels and jackals?) again. So much for no more mud!

  I’ll talk to you all tomorrow. Thanks for listening, and for the prayers. I love you all.

  Lee

  CHAPTER 21

  THE AMERICAN SOLDIER, THE TERRORIST, AND THE BLOOD DRIVE

  And finally, some news about supplies,” Colonel H said as he wrapped up the staff meeting he’d called this morning. He sighed and pushed his reading glasses up his nose with his long index finger. I’d seen his hands do some very elegant work back in San Antonio during cases we’d done together. I respected him as a surgeon and had come to see him as a capable leader in the war. But meetings were meetings, and I was hungry and irritable and bored out of my skull.

  “The rainstorms have grounded incoming flights. We won’t get our weekly resupply for a few more days. That means you surgeons have to conserve everything: make every suture, bandage, and catheter count. We can’t afford any waste.”

  I cast a sideways glance at Tim, who was already mouthing the words “We’re nearly out of ICP monitors and drill bits” to me. I was flooded with a feeling I’d never experienced in the States: fear of needing a surgical supply I couldn’t get.

  Colonel H continued. “The only good news is that the weather is so bad today that the Black Hawks can’t fly either. So maybe we’ll have a slow day or two.”

  In my mind I tried to channel a seething, hate-filled Islamic insurgent. I saw him: six feet tall, five percent body fat; a bearded, black-hearted bomb maker with Russian-made artillery shells wired together around a canister filled with fecal-smeared batteries and rocks and pieces of barbed wire. I could just see him waking up this morning, planning how he would plant his IED and hide in the bushes for Americans to wander by so he could kill them using his cell-phone switch to detonate the IED. But when he woke up, giddy after dreaming all night of the mayhem he would cause, he looked out the window and saw the weather. His smile faded, and his warm mattress called out to him. Is raining outside, he’d think, maybe I hit snooze button and take day off.

  I was jolted out of my daydream by a nurse crashing into the conference room. “Casualties in the ER, sir,”
she said.

  I guess the enemy didn’t sleep in after all.

  Four Humvee-ambulance crews arrived bearing the victims of a series of early morning car bombings in a nearby town. Over twenty Iraqi civilians and some American Marines were among the first casualties to arrive. We reached the ER and began our now-routine process of sorting them out.

  “Three open head injuries,” the Czar shouted across the room.

  I ran over with Tim, and we chose the two who seemed the worst. “Heading to CT, sir,” said Tim, as we pushed our patients to radiology.

  My patient turned out to have a tennis-ball-sized metal fragment in his frontal lobe and a large blood clot in his brain to go along with it. I was still operating on him when Tim stuck his head into my room.

  “My guy had a skull fracture and a little bleeding. Didn’t take long. I’m going to take the third guy to surgery now. He’s deteriorating quickly. When you finish, head back to the ER. There’s another ambulance coming in a few minutes.”

  “Sir,” I said.

  Tim left and I tried to speed up my case. Once I had the fragment out and I’d stopped all the bleeding, I put the man’s bone flap in his abdomen and was about to start closing his scalp when I saw the Australian general surgeon Mitch walk in.

  “Lee, the other patients are here. The Czar wants you in the ER. I’ll close this guy for you.”

  Mitch scrubbed in and I showed him how to place the ICP monitor. “Thanks for your help,” I said.

  “No worries. I’ll do a triumphant job.”

  I’d noticed that Mitch had a habit of declaring all of his operations to be triumphs. Good to be confident, I thought, but as I walked out of the operating room a cold dread hit me in the gut. If I was right, what I was about to find in the ER would not end triumphantly.