Crossings

by Jon Kerstetter

  “I didn’t either, but the orthopedic surgeon said it’s complicated. I’ll survive until the new doc shows up; then I can be his first patient.” I chuckled a bit.

  My replacement, a colonel and state flight surgeon from the Ohio National Guard, arrived the first week of February. I briefed him about my own case and he signed the flight surgeon authorization for my medical evacuation. His training on the computerized flight surgeon entry system and transmittals to Fort Rucker were light, so I spent a week overlapping duties to get him familiarized. During that time I received official notification that I had been promoted to the rank of lieutenant colonel.

  A section lieutenant and two medics were detailed to fly with me to Arifjan. The commander gave them orders to assist me as needed. I told him I didn’t need assistance, but my own replacement flight surgeon had overruled me.

  From Arifjan, I would go to the CASF at Ali Al Salem in Kuwait no later than 1400 hours that day and stay in medical hold for two days while awaiting my evac flight to Fort Bliss, Texas, via Landstuhl, Germany. That was typical for a medevac. Ambulatory patients arrived a day or two before their scheduled flight and post-op patients or critical-care patients arrived the day of the flight, sometimes within hours of the departure time. The timing allowed the CASF doctors and nurses to stage the patients according to their needs and triage categories.

  Paperwork in hand, my small entourage drove me to Arifjan. I diverted them to the PX where we sat for coffee and donuts. I offered the lieutenant some final instructions about managing the flight surgeon’s office and we talked about his career. I don’t think my words gave him any profound insights, but that short time together meant something to me, a chance to impart some hard-earned wisdom about medicine and careerism in the military. He listened intently and acknowledged each point I made with a hearty “Yes, sir.” Halfway through our coffee, I wondered if I might have already crossed into that gray zone between relevance and insignificance.

  Afterward, we drove to the flight line and boarded a flight for Ali Al Salem. That short hop would become my last mission aboard a Black Hawk helicopter, the last one as a flight surgeon in the U.S. Army Medical Corps. We left at 1300 hours and touched down about 1330. Before I left the tarmac for the CASF, I watched my fellow soldiers take off and head back to Udairi. Watching them leave gave me a mixed bag of emotions. I felt alone as if I had no colleagues in the military. I felt somewhat pissed that I had been careless and, as a result, injured. I also felt relieved that I was getting the medical attention I needed. In all, I felt conflicted: I wanted to stay; I needed to go.

  The medevac flight to Landstuhl was scheduled for Sunday. I spent Friday and Saturday at the CASF mostly sleeping, reading, and observing the staff as they checked patients and prepared for the medevac flight. Their mission, like mine, focused on aviation medicine, but they prepped an entire hospital full of patients, whereas I rarely prepped more than one or two at a time. Watching them was like watching ants build a nest. The docs, nurses, and medics worked with one objective, move the group (the ambulatory, the critical, the post-op) to the next echelon of medical care and do it without complications.

  On Sunday morning I woke to the sensation of a medic gently shaking my bed. “Sir, wake-up call. Time to get ready—zero five-thirty, sir.” I slowly rose to the edge of my bed by grabbing his outstretched hand. My shoulder and ankle hurt. “What time is it?” I asked. He repeated: “Zero five-thirty, sir. The medevac arrived about an hour ago. A C-17 Globemaster—real nice.” He assured me that we had plenty of time to get ready.

  Ten minutes after the wake-up in the CASF, all the patients were getting dressed—some with slight grimaces, others with no obvious difficulty. My arm sling had tangled in the middle of the night. My ankle throbbed because I could not keep it elevated. A young Air Force medic helped me get my arm situated and secure. He started helping me with my walking cast. I told him I could handle it and he politely told me he had orders to help.

  I was a lieutenant colonel and flight surgeon. The medic was an airman not yet promoted to sergeant. I looked at him, paused, and yielded. He checked the skin on my ankle, gently feeling for swelling. He asked if it hurt. It hurt. Then he grabbed my long white orthopedic stockings, eyed them, and discarded them. “Too dirty,” he said. He broke out a fresh new pair. I joked that I wore a pair of socks for two months straight during my second deployment, and we smiled and laughed together.

  “Can’t do that here, sir,” he said, still smiling. Carefully he put the new compression stockings on my feet and then smoothed out the last of a few wrinkles around my right ankle. “I wanna make sure we don’t get any friction rubs,” he said. I nodded in agreement. He grabbed the walking-boot cast and carefully put it on my foot, then cinched all six black Velcro straps, but not too tightly. He double-checked the fit by having me stand, then ran his fingers around the edges of the boot where it might cause pressure points. His smile made me grin. “How’s that feel, sir?”

  “Feels good,” I replied, grateful for his concern.

  After breakfast at the DFAC across the street, I shuffled back to the CASF. As I reached the doors, I looked back toward Iraq one last time. The morning light cast shades of orange over the buildings of Ali Al Salem. A hand-painted sign pounded in the sand read simply: DFAC. When I glanced at it, I remembered the DFAC at FOB Marez, near Mosul. In December 2004, a suicide bomber attacked it, killing twenty-two people, soldiers and civilians, and wounding more than sixty others. In another incident an insurgent using a cell phone GPS targeted our DFAC at Key West. His coordinates were wrong and we escaped harm.

  My eyes shifted to the line of patients returning from breakfast. They looked like ducks with broken wings, waddling back and forth across a busy war. I caught myself chuckling at the procession. Sometimes, for no reason at all, war made you laugh or say bizarre things, like you were an actor in a theater of the absurd. I commented once to my medics that a dog tag embedded in a dead soldier’s throat was “interesting.” During my tour at Caldwell, my roommate fell on his ass while climbing out of bed during an RPG attack. I laughed. During the first tour, Gibbons, the former champion collegiate wrestler from Iowa, had a nightmare. He rolled out of his cot and grabbed the soldier next to him, rousing half the company in the tent. I laughed at the commotion. Some of the other soldiers started laughing too, while others yelled to keep it quiet. Gibbons fell back to sleep as quickly as he had awakened.

  As I sat and waited on my bed, a half dozen medical staff quickly attended a new patient with IED injuries who had arrived from one of the field hospitals. As I watched, the CASF turned bone quiet. Medics transferred the patient to a waiting gurney in the center row next to the other post-op patients. I could tell he had received aggressive treatment and that the distinction between his death and his life had been a very thin line—or maybe not even a line at all.

  He was sedated. His face puffed out from shrapnel lacerations. His left leg was amputated above the knee. Clear plastic tubes, monitor wires, and catheters connected him to medicine, fluids, and machines. A cardiac monitor traced his heartbeat and other vital signs. The Air Force flight surgeon checked the tangle of lines and the array of monitors, rechecked his dressings, and listened to his breathing.

  I felt useless as I watched from my bed, as if my injuries had erased my credentials and forced me to stand in a corner, observing only, unable to contribute. I wanted to move to the side of his bed and explore his wounds, stitch him up, gather dressings, and administer antibiotics. I possessed knowledge and desire and skill. To me, the final patient in the CASF became the universal patient and I became the universal doctor, yet all I could do was watch from the edge—nothing more.

  —

  I gradually looked away from the new arrival and glanced around the CASF. Everybody who could was looking at the last patient and then looking away. There were quilts on the walls above each bed that volunteers had sent. I wanted to take one off the wall and cover the final patient as if to sa
y, “This will keep you safe. Hide under here. The quilt will protect you from war.”

  A flight nurse finally came to my bed to confirm my name on the flight manifest.

  “Kerstetter, Jon R., Lieutenant Colonel.”

  “Yes, that’s me. I’m a doctor too,” I interjected.

  “Yes, sir,” she continued without hesitation. “Let me reposition your arm sling. I’m going to add an elastic wrap around your chest so there’s no chance of movement or dislocation during flight. We need to get one more set of vitals. We scheduled you for a pain shot before the flight. Are you ready, sir?”

  I answered quietly, more nodding my head than speaking the words. “Yes, I’m ready,” I lied. I imagined myself continuing in my flight surgeon’s mission, making critical decisions, attending to the needs of soldiers. No matter, the flight was ready even if I was not.

  —

  The patients rode to the boarding area via ambulances and buses. A short ride to the airfield and there on the tarmac the Globemaster came into view. Large. Gray. Beautiful. “Real nice,” just as my medic had said. If it was possible to feel love for an aircraft, then I felt love for the C-17 Globemaster. I admired its perfect size and shape, its wing camber, and its talon-like undercarriage. When I watched one take off, I stared at its outline against the sky. I loved how the Globemaster carried me to war, how it hauled me around in theater, how it brought water and food and medical supplies. I loved that it lifted the wounded out of war.

  I viewed military aircraft as the icons of power. They attacked enemy positions, transported supplies, evacuated patients, spied during the night, and delivered troops. I saw them as tactical extensions of the minds and bodies of soldiers and military doctors, as extensions of me. Often during my tours, just before sunrise, I walked the flight line where the aircraft were lined up parallel to the runway, wheels chocked, perfectly aligned just waiting for a mission. The morning sunlight painted shifting colors on their frames. I let my eyes linger on the dark, olive drab and gray-green metal skins of aircraft, on the malted browns and the dirty tans of vehicles edging the flight line, and on the dusty white of stenciled numbers and warnings. I could identify each aircraft by its silhouette and the patterns of its colors and by its chipped paint and oily stains. I watched the aircraft crews as they performed their maintenance tasks and their morning preflight checklists. They advanced methodically toward completing a mission launch or engine replacement or aircraft configuration. Occasionally, I walked up to the side of a helicopter and just touched it for no reason at all, moving my hands across its warm skin, feeling the rivets and seams. The scent of JP-8 jet fuel mixed with hints of turbine oil, and flight line dust often lingered in the air over the runway. I breathed it in, that scent of aircraft and side-mounted rockets, the scent of war. It drew me in nearer to the mind of battle. The ritual functioned like a liturgy of sorts. When I was finished, I felt restored in my soldier faith and restored as a military doctor. The experience made me bold to the point that I laid claim to an aircraft. This is my helicopter. No other doc in the entire Army has this aircraft. It belongs to me. It’s my office. It’s where I go to war.

  —

  On the tarmac, the flight medics assisted the patients up the loading ramp. A medic greeted me and took me to my assigned seat, right side, midsection of the aircraft, about six feet from the center row of litters.

  The ambulatory loaded first, post-op patients last. The arrangement mirrored the beds in the CASF, ambulatory patients on the sides, critical and post-op patients in the center row.

  The center-row patients were each loaded with packets of their medical records, op notes, and orders for the flight. The packets usually rode on the litter in a zippered waterproof pouch placed between the patient’s legs. If the patient had no legs, the pouch rode at the foot of the litter. The nurses quickly flipped through the packets and ran a checklist. They cross-checked names with patients’ wristbands. The usual post-surgical array of clear plastic intravenous tubes and monitor wires connected the patients to machines and medicine. White surgical gauze and beige elastic bandages clung to heads and limbs and abdomens. Oxygen flowed via dual-pronged nasal tubes or light-green plastic masks cinched around heads and faces. These were the kinds of patients that I had sent on medevac flights over my three tours in the Iraq War, the ones who occasionally asked if they were going to make it—to whom I always replied in the affirmative.

  The soldier who arrived last in the CASF was finally loaded. When the loadmaster got his litter clamped into place, the patient began to wake. I suspected all the moving and jarring from the transfer roused him. He started to move his arms and head, then he mouthed some words to his nurse through his oxygen mask. His right arm started to flail, and he pulled the mask from his mouth and nose so it lay off-center, feeding oxygen to his cheek. He raised his head enough to glance toward his feet. His nurse signaled a medic to help. They held his arms and repositioned his oxygen mask, then she bent over and placed her ear close to his mouth. She cradled his hands in both of hers. He managed a garbled question. The nurse replied with a single word: “Yes.”

  The flight nurse continued to stroke the patient’s forehead. She hailed the flight surgeon with a wave of her other hand. He shifted to the center row and checked the patient’s monitor. I could tell from his lips that he said “morphine.” He held up two fingers: two milligrams. He added additional orders. I imagined fentanyl or some other narcotic that made a patient unconscious. The morphine worked quickly, like a medical coup de grâce. The patient slept again and the nurse leaned over him and continued to hold his hand and stroke his forehead. I saw that a lot in the field hospitals, nurses holding the hands of fully sedated, critical patients, stroking their foreheads and sometimes whispering to them even as they slept. I did it on occasion—wished I had done it more.

  —

  Once all the patients boarded, the loadmaster raised the loading ramp. It closed with a thud that shook the aircraft. The crew performed one last check of seatbelts. The engines started with a low, throaty growl that made the seats vibrate. After a few minutes the aircraft began its taxi to the runway. As we taxied, most of the patients just sat and stared across the cargo bay to the other side, staring in unison with the jostling of the runway.

  The Globemaster finally taxied into position at the end of the runway and waited briefly for takeoff clearance. The four jet engines powered up and we began to roll. Within seconds the thrust pushed us sideways in our seats, and we held on to the sides of the seat frames. The C-17 made an uncomfortably steep combat assent. We were airborne.

  The flight to Landstuhl was approximately five hours, during which the flight nurses and docs made frequent rounds checking on their patients. If I didn’t know I was on a medevac flight, I could have been fooled into thinking I was still on the ground at the CASF. Nurses administered medications and gave shots; they hustled to their next patient, checked vital signs, listened to patients, and made progress notes on medevac charts.

  Most of the patients looked around the aircraft, and when we caught the eyes of other soldiers, we quickly looked at our boots or off to the side. I tried not to stare at other patients, especially those in the center row, but it was difficult to avoid. The wounds and dressings and casts and wraps seemed to mesmerize the rest of us. Some bandages held a tinge of blood and some bulged from underlying gauze. I was relieved that I was not in the center row of patients. And I felt guilty for feeling relieved.

  A young soldier with an eye injury sat in the seat to my left. I looked—tried not to stare. I made a clinical assessment: soldier in his early twenties, shrapnel injury to the face, puncture wound to the eye, probable loss of eyesight—soldier frightened and alone. His cornea looked dull. I assumed shrapnel had penetrated his eye. The black eye patch he was supposed to be wearing hung down around his neck. I don’t know why he wasn’t wearing it. I didn’t ask. Maybe the pressure caused pain. Maybe the patch reminded him that he had a blind eye. Maybe it made him self-
conscious or embarrassed or made him feel less like a soldier.

  About two hours into the flight, I leaned over and asked him if he needed anything. He said he was fine. A bit later, I finally got enough courage to ask him what happened. He said an IED had showered his face with shrapnel and that he already had one operation to remove fragments from his face and eye. He told me how lucky he was that shrapnel didn’t hit his brain, but that he had to have eye surgery to keep him from going blind.

  “The doctors say I’ll be okay with another operation,” he said. “What happened to you, sir?”

  I told him my story. He responded with a low-toned, elongated, “Oh…,” and then looked at his boots.

  As we talked, I got a better look at his eye. It looked dead. I wondered if his doctor had really told him he was going to be okay. What I noticed more than his eye and his facial injuries was his mood. He kept staring at his boots. He planted his elbows on his knees, and his hands formed fists where he rested his forehead. Sometimes he shifted and cupped his chin in the palm of one hand and let the other hand fall between his legs. He stared that thousand-yard stare depicted in black-and-white photos of shell-shocked infantrymen in World War I. When he looked down, he looked like he was trying to adjust his eyes to the light in order to see the floor more clearly. He finally leaned back into the webbing of his seat, fixed a blanket over his shoulder, and rested his head on it and slept the rest of the flight to Landstuhl.

  Watching him, I tried to imagine what he might be feeling—or fearing. I knew in a clinical sense that he might become one of those soldiers treated for post-injury depression and PTSD. I wondered if he would become one of the soldiers whose war experience would end in suicide. Whenever I encountered depression or suicide in the field, it always made me wonder where psychological injuries began. I drew no conclusions, but as I looked around the Globemaster, it seemed as though that seed might take hold during a medevac flight.