Crossings

by Jon Kerstetter

  One of my tasks in the CJTF7 (Combined Joint Task Force 7) Headquarters was to track IED attacks, the numbers of casualties, and the medical responses. I gave weekly reports with an analysis to the task force chief of staff, Major General Jon Gallinetti. The general was a Marine Corps aviator who had flown fighter jets for most of his career. He was a big man, over six feet tall, and when I first met him his commanding presence made me shake just a bit. He was direct and succinct in the way he talked, composed as one of authority, with a voice that could easily carry across a large room. Anybody who worked with him was quick to recognize that he expected his officers and staff to have a precise and complete understanding of the ongoing battle situation and be able to offer reasoned summaries and contingencies when asked. Hardened or shaped as he was by the demands of his career as a Marine aviator and by the demands of his role as a general officer, he nevertheless showed compassion and thoughtfulness for the Marines and soldiers under his charge. He was equal parts tough and thoughtful, firm and compassionate. That made him the kind of leader Marines and soldiers wanted to follow.

  During a particularly rough week in terms of casualties, the general asked me to arrange a visit to the CSH without making it a big deal. When general officers visited a field unit, it usually involved a certain protocol that tended to make that unit’s officers start jumping through hoops to present their unit in a positive light. The general wanted none of that. He simply wanted to visit the casualties and encourage them and the hospital staff.

  Later that week I arranged for a visit late at night. The general, his Marine protection detail, and I made the one-mile trip in our Humvees, checked in at the gate, and entered the hospital unannounced.

  Hours earlier, numerous soldiers had been injured in multiple IED attacks throughout Baghdad. The survivors of those attacks created a backlog of patients who required emergency surgery. In the emergency room, surgeons, nurses, medics, and hospital staff moved from patient to patient at an exhausting pace. They stabilized patients and performed rapid trauma assessments, then transferred patients quickly to surgery in the adjacent operating rooms. Teams of surgeons worked to stop bleeding and repair injuries. Blood transfusions flowed at will and surgical clamps clicked as fast as bullets in a firefight. When one surgery was finished, another began immediately. One operating table held a soldier with multiple orthopedic injuries. In an adjacent room, surgeons removed shrapnel from a soldier’s abdomen. If an observer had watched from the side, the whole scene might have resembled controlled chaos, but a deeper look would have revealed something more. The ER staff moved with their own theme and pace, with a kind of gracefulness that resembled an improvised modern dance. Nurses and medics transferred patients on the count of three. One, two, three—lift. The trauma team identified wounds, started transfusions, infused antibiotics, and initiated anesthesia, then carried patients off to the operating rooms where surgeons responded with their own kind of methodical precision: explore, clamp, cut, and tie. They all moved choreographed to the rhythm of saving a life or salvaging a limb.

  General Gallinetti and I visited the ICU, where the head nurse, surprised by our presence, wanted to notify the hospital commander to accompany us. The general simply asked the nurse to give us a brief rundown on the patients. We stopped by each bedside long enough for the general to pay his respects and lay his hand on a patient’s shoulder if possible, and if not then on the patient’s blanket. He wished the few soldiers who were awake a quick recovery and acknowledged their service. During the visit, I could see the compassionate side of the general. His time at the hospital was not mere protocol, it was personal. To me, he seemed like a father or a doctor to those patients in addition to a general, and he reminded me that soldiers and Marines who needed to be tough also needed to show compassion in the line of duty. As I watched him among the dying and the wounded, he was as comfortable and professional in a combat hospital as he was in leading high-ranking officers in a combat headquarters.

  We walked from the ICU down the hallway to the triage room. One patient lay in a bed, a young soldier, private first class. He had a ballistic head injury. His elbows were flexed tightly in spastic tension, drawing his forearms to his chest. His hands made stone-like fists and his fingers coiled together as if grabbing an imaginary rope attached to his sternum. He breathed in a slow, sporadic, and agonal pattern. He had no oxygen mask. An intravenous line fed a slow drip of saline and painkiller. He was what is known in military medicine as expectant.

  Some of his fellow soldiers gathered at the foot of his bed. Except for the captain, they were all young like the patient, late teens and early twenties. A few of them had sustained injuries in the same IED attack and had already been treated and bandaged in the emergency room. They stood watch over the expectant patient. One soldier had a white fractal of body salt edging the collar of his uniform. One wept. One prayed. Another quietly said “Jesus” over and over, shaking his head from side to side. Yet another had no expression at all; he simply stared a blank stare into the empty space above the expectant patient’s head. A young sergeant, hands shaking, stammered as he tried to explain what had happened. The captain in charge of the expectant soldier’s unit told the general and me that this was their first soldier killed—then he corrected himself and said this was the first soldier in their unit assigned to triage. He told us that the soldier was a good soldier. The general nodded in agreement and the room was suddenly quiet.

  The general laid his hand on the expectant soldier’s leg—the leg whose strength I imagined was drifting like a shape-shifting cloud moving against a dark umber sky; strength retreating into a time before it carried a soldier into war. And I watched the drifting of a man back into the womb of his mother, drifting toward a time when a leg was not a leg, a body not a body—to a time when a soldier was only the laughing between two young lovers who could never imagine that a leg-body-man-soldier would one day lie expectant and that that soldier would be their son.

  As I watched the soldiers at the foot of the bed, I noted their worn faces, their trembling mouths, their hollow-stare eyes. I watched them watch the shallow breathing, the intermittent spasm of seizured limbs, and the unnatural gray of expectant skin. I took clinical notes in my mind. I did this whenever I needed to separate myself from the emotional impact of seeing the critically wounded. I noted the soldiers, noted the patient. I noted all the things that needed to be noted: the size of the triage room, the frame of the bed, the tiles of the ceiling, and the dullness of the overhead light. I noted the taut draw of the white linen sheets and the shiny polished metal of the hospital fixtures. A single ceiling fan rotated slowly. The walls were off-white. There were no windows. The floor was spotless, the smell antiseptic. A drab-green wool Army blanket covered each bed. Three beds lay empty. I noted the absence of noise, the absence of nurses rushing to prepare surgical instruments, and the absence of teams of doctors urgently opening wounds and calling out orders. There was an absence of the hurried sounds and the hustle of soldiers in the combat emergency room one floor down. Nobody yelled “Medic” or “Doc.” Nobody called for the chaplain. Medics did not cut off clothing or gather dressings. Ambulances and medevac helicopters did not arrive with bleeding soldiers.

  —

  More than fifteen years prior, when I was a newly minted captain, I attended the two-week Combat Casualty Care Course at Camp Bullis, Texas. The course was designed to teach medical officers combat trauma care and field triage techniques. The capstone exercise included a half-day mass-casualty scenario complete with percussion grenades, smoke bombs, and simulated enemy forces closing on the casualty collection point. The objective was to give medical officers a realistic setting in which to perform triage decisions. About twenty moulaged patients mimicked battlefield casualties ranging from the minimally injured to those requiring immediate surgery. Each medical officer in training was given five minutes to perform the triage exercise and to prepare an appropriate medevac request. Providing treatment was not an optio
n. The exercise focused exclusively on making triage decisions.

  All the participants could have easily completed the role-play within the time limit. Nothing, of course, was ever that straightforward in Army training. There was always some built-in element of surprise to test how well trainees coped with chaos. At Camp Bullis the element of the unexpected was a simulated psychiatric patient threatening to commit suicide while brandishing an M16 rifle and holding a medic hostage. In order to maintain the element of surprise, trainers whisked the doctors who had finished their turns out the back of the triage tent.

  My turn. I entered the tent at the shove of my evaluator. The mock “psych” patient was screaming and threatening to kill his hostage. Other medics were pleading with the patient to lay down his weapon and let the wounded get on a helicopter. I was to take charge and get control. I did. I approached the screaming patient with quick, confident steps. I got about halfway across the triage tent when he pointed his rifle directly at his hostage and yelled, “One more step and the medic is dead.” I backed off slowly, turned sideways, and quietly pulled my pistol. In an abrupt and instantaneous movement, I reeled around and shot the psych patient with my blank ammunition. “Bang—you’re dead!” I yelled. A nearby evaluator took his weapon and made him play dead. One out-of-control psycho eliminated. I finished the triage exercise within the five-minute time limit. My evaluator laughed. “Damn,” he said.

  I felt great. I had control.

  In the after-action review, the other medical officers asked about my decision to shoot. “Time,” I answered. “I only had five minutes, so I maximized my effectiveness by eliminating a threat. It’s combat,” I argued.

  One fellow doc asked if I would really shoot a patient in combat. A debate ensued as to the ethics of my decision. Nobody else had shot the patient. Nobody else had finished the exercise in the allotted time. Some managed to talk the psych patient into giving up his weapon. Those physicians had taken nearly fifteen minutes to complete the exercise—minutes in which some of the simulated patients died a simulated death. In the end we decided that my decision to shoot, while potentially serving a greater need, may have been a bit aggressive; but it was in fact my decision, and it met the needs of the mission.

  Emergency War Surgery, the military’s bible of war medicine, defines triage as the assignment of patients to four categories of treatment based on the severity of injuries: Minimal, Delayed, Immediate, and Expectant. Assignment to the expectant category means that a soldier has no likelihood of survival. Based on that single calculation, a physician decides to withhold medical treatment. On the surface, the ultimate cost of that decision is a soldier’s life. One decision—one life, perhaps even several lives. But there are other costs not so easily calculated, like the emotional cost to survivors or the psychological toll on soldiers who make triage decisions. Textbook definitions are silent on how military physicians prepare for, or react to, the demands of making a triage decision. No chapter in a military textbook instructs combat physicians in the multidimensional complexity of decision making that serves to deny lifesaving interventions for soldiers. There are chapters on why triage decisions must be made and chapters on how to apply established medical criteria in making those decisions. However, what to do next, after making the triage decision—not covered. And that vacuum of knowledge leads to a feeling of exposure and vulnerability, neither of which can be tolerated in war. That doesn’t suggest that the process fall to someone else or that the criteria used to make those decisions should be discarded. There is no other way. In the end, the practice of military triage obligates doctors, whose principal duty is the saving of lives, to perform tasks that share in the brutality and the ugliness of war—tasks that are tantamount to pulling a trigger on fellow soldiers.

  In the triage room, with this one particular soldier, I clearly saw the disparity between the simulated triage decisions of my training and the real decisions of combat. And it occurred to me that wartime triage tended to hit more like the force of a bomb blast. In an instant, fragments of stone and metal exploded through the air with such velocity that when they hit a human target, even if the target was not killed, it was stunned and bleeding and breathless. It was in that context that military doctors made live-fire triage decisions and stood against the ethical force of their consequences.

  —

  In the process of making notes about the expectant patient, I paused and moved closer to the bed. I put my hand on the patient’s leg, just as the general had done. I laid it there, let it linger. From where I stood, I stared directly into the expectant soldier’s face. I watched his breathing, a long sighed breath followed by an absence of movement, followed by three to four shallow breaths. I matched his breathing with my own. I timed the slowing pattern with my watch. I made mental calculations, then looked away. Once again I noted the quiet of the room and the whiteness of the walls. I noted the empty beds and the ceiling and the antiseptic smell. Again I watched the expectant soldier, who was oblivious to all of my watching.

  I stood at the triage bedside thinking, If this were my son, I would want soldiers to gather in his room, listen to his breathing. I would want them to break stride from their war routines, perhaps to weep, perhaps to pray. And if he called out for his dad, I would want them to become a father to my son. Simply that—nothing more, nothing less—procedures not written in Department of Defense manuals or war theory classes or triage exercises.

  I finally moved to the head of the bed and placed my right hand on his chest. My hand rested there with barely any movement. I turned to the other soldiers, gave them an acknowledgment with a slight upturned purse of my lips, then looked away. I lifted my hand to the patient’s right shoulder, let my weight shift as if trying to hold him gently in place. I half kneeled, half bent—closed the distance between our bodies. I noted the fabric of his skullcap dressing and the blood that tainted its white cotton edges. I prayed for God to take him in that very instant. I whispered, so only he could hear, “You’re a good soldier. You’re finished here. It’s okay to go home now.” I saw the faces of my own sons in his. I was glad they were not soldiers.

  I finished, stood up, and walked to the foot of the bed. One of the soldiers asked me if there wasn’t something I could do. I said no. I meant no. I wanted my answer to be yes. I faced the captain and put my hand on his shoulder, told him that we were finished, that his soldier did not feel pain, that he would be gone soon, and that everybody had done everything they could. The tone of my voice was neither comforting nor encouraging, neither sorrowful nor hopeful. It was, as I remember, military and professional. The captain said “Yes, sir” to the things I said and the way I said them. And the things I said had their own pace and rhythm; they flowed like the movement of triage itself, shaped by the needs of survivors. After a few moments of silence, the general and I quietly left the triage room and the hospital.

  —

  I remembered that expectant soldier so often after our hospital visit. I knew I’d seen his name in his hospital chart or was told his name by his commander. I did not take the time to write it down anywhere—and that bothered me. It bothered me because as the weeks and months went by, he remained nameless like so many other soldier-patients I encountered. And that namelessness seemed like a form of abandonment for which I felt personally responsible. I understood, in a professional sense, that the patient was not abandoned, that his triage was purposeful, and that it provided the ascent to medical efficiency, which ultimately saved other soldiers’ lives. But I also understood that the theory of triage quickly eroded when confronted with the raw, human act of sorting through wounded patients and assigning them to triage categories. In my mind, the theoretical and the practical waged a constant battle, so that whenever I participated in a triage decision, part of me said yes, and part of me said no.

  Military doctors usually stick to the practice of medicine, but they also train to engage and kill an enemy if the need arises. In pre-deployment stateside weapons training,
I fired tight clusters, hitting right in the middle of a cardboard target’s head or chest. If my aim was off, my shots tended to strike the left cheek or left eye socket, or the left side of the thorax and a little high—just below the collarbone. I tended to pull off center when I was rushed.

  At Fort Bliss, Texas, close-quarters combat training simulated enemy encounters expected in Iraq—contact in confined spaces and distances of less than ten yards or so. One range scenario involved two groups of stand-up targets. The primary group contained two simulated Iraqis located twelve feet directly in front of me. The secondary group, three insurgents, stood at my ten o’clock position, twelve yards farther back. One insurgent had a red-checkered keffiyeh tied around his neck. The instructor always briefed me. “Okay, Doc,” he would say. “Focus on the center of mass. Kill your targets.” Then he gave a quick sharp command. “Engage!” Without hesitation, I shot the first two targets, ejected the spent clip, then reloaded a seven-round magazine. If the instructor yelled “Alive!” I hit the first two cardboard Iraqis again—one bullet each, just to make sure they were dead. I then rushed five yards toward the secondary targets, squared my shoulders, and opened fire. The goal was to fire the first lethal shot before the enemy had time to respond.

  The live-fire drills were rigorous and thrilling in a way that medicine was not, especially in the way they mimicked combat risk. Medical risk primarily flowed one way, toward the patients. Risk in confronting an enemy flowed both ways—toward the target and back toward the shooter. An enemy always fired back. Soldiers reduced that risk by killing targets. And their weapons training and live-fire drills taught just that: killing—precise, quick, and efficient killing. Some instructors freely used the word “kill” on the range. “Kill the target.” “Kill them before they kill you.” “Get the kill shot.” “Think one-shot kills.” Kill. Kill. Kill.