Paradise General: Riding the Surge at a Combat Hospital in Iraq

by Dave Hnida

  There was a flurry of movement throughout the room and an eruption of noise as the stretcher burst through the door. Holy shit. It was a skinny young kid with a sickly gray cast to his skin. A leg jaggedly pointed at an unnatural angle; actually, what was left of the leg. And a thick bandage around his neck saturated with blood. It had to be a carotid or a jugular wound. As the stretcher moved into the bay, medics quickly scrambled to place IV lines while I stared at the tiny bubbles forming on the surface of the bandage. Each bubble grew large, then small with the rhythmic chest compressions of CPR.

  In my mind, the room went pitch black, with a single, bright spotlight focused on me, and me alone. In the middle of a vast stage, every eye in the audience was now focused on me and awaiting my impersonation of a qualified trauma leader. It should have been about the guy on the stretcher, but no, in my mind, it was all about me and whether I was up to the task of being allowed to perform on the Broadway of the emergency room.

  I simply didn’t know where to start—or maybe I did know, but couldn’t. I just stood there, staring. In the meantime, Major Twomey was at the foot of the stretcher, waiting for me to begin my assessment of the patient—describing, in order, status of the airway, the soldier’s breathing, his circulation, and level of consciousness. It was all cookbook medicine but I couldn’t remember a word of the recipe.

  I could faintly hear Twomey’s voice, but it was like a distant echo, muffled as if we were underwater. There was a racing beep from the heart monitor but I couldn’t tell if it was the patient’s heart hammering away, or my own. Numbers were being shouted out—they could have been blood pressure readings or medication orders, I couldn’t tell. And yelling from the peanut gallery—Don’t touch that dressing! Get some pressure on that wound! Take off that dressing, you’ve got to see where that bleeding is coming from! He needs an airway! Call for blood! Let X-ray get in there!

  Then came a sudden parting of the sea as a mass of doctors rushed toward and then swarmed around the patient—each with their own idea of what needed to be done. Alone in a crowded war, I was literally being pushed away from the head of the stretcher as the bodies crowded into the bay. There were no familiar faces for support or guidance, our new group was relegated to the periphery as the soon-to-depart doctors ordered the medics to wheel the patient straight to surgery. Rick, Bernard, and Ian followed at a distance.

  As the stretcher flew out the door, the medics started swabbing blood from the floor, and Quick went back to mending his ears. All so routine. It was as if nothing serious had happened. As I stood trying to absorb what had just turned my world on its head, I felt someone roughly grab my arm. It was one of the hospital administrators, the “he” I had called a “she” the day I arrived on the base. He yanked me toward the door. “Get out there and talk to his unit. Tell them what’s going on. It’s your job to keep them informed. Now do it!”

  About ten members of the soldier’s unit had gathered just outside the ER, smoking, pacing, and anxiously talking among themselves. The gathering wasn’t unusual; combat units were like a big family, and one soldier’s wound made them all bleed.

  Talking to family members and loved ones was a task I usually did well, but not today. I stumbled and fumbled over words that spilled out in a collection of confusion: It looks like he’s shot in the neck and the bullet hit a big blood vessel. The leg is bad, too. He’s in surgery now. I don’t know how long it’s going to take, it’s touch-and-go right now. I’m sorry but I wish I could tell you more. I just don’t know. So much for the reassuring manner of an experienced physician. I was an embarrassment.

  I stepped away from the flapping blanket of the OR entrance and found a quiet spot between a couple of tents. I was so new I didn’t know where I was, but my stomach didn’t care. First, I threw up my coffee from breakfast, then some green bile, followed by a series of retches so violent there were spots of blood mixed in with the mucus. It took a few minutes for the dry heaves to slow and I weakly wiped the putrid residue off my uniform. I can’t do this shit. I’m going to hurt somebody.

  I had two choices—walk away claiming some bogus illness or do an about-face and face the music of my medical peers. The answer came in the form of a question: what would I tell my kids to do?

  I spun around back into the ER and went straight to Major Twomey.

  Can we speak outside?

  He nodded and led the way to the helipad. We stopped on the first landing pad where I stared at my bloodied boots.

  “I fucked up. Big-time.”

  “Well, it wasn’t the most organized effort, but no, you didn’t.”

  “I know a fuckup. And that was one. I got stampeded.”

  “Listen, you wouldn’t be here if you couldn’t do the job.”

  “Then level with me, what can I do better?”

  “Easy. Be in charge. When we get a case, it’s you, the medics, and me or Boutin. No one else in that room counts. No one. Don’t let anyone cross that red line until you’re ready for them. It was like a circus in there for a bit. You don’t need twenty docs crowding you out of the way.”

  “Man, I screwed the pooch on this one.”

  “Just stop for a minute and look at one thing. We’ve got a guy who should be dead, but he’s not. So you didn’t make any fatal errors. Just go over your protocols until you can do them in your sleep. And be the boss. It’s your ER when you are at the head of the stretcher.”

  “Thanks. And sorry.”

  “There’s nothing to be sorry about. That’s why it’s called the practice of medicine. And at least you give a shit.”

  With that, Twomey abruptly spun on his heels and headed back to the ER.

  Next on my list was Sergeant Courage.

  Can we talk for a minute?

  “Sir, whatever you need.”

  “I need your critique. That was a disaster in there. I fucked up.”

  “Well, I don’t think you fucked up, sir, and I don’t think any other people think you fucked up.”

  “I lost control.”

  “Sir, if you did, we couldn’t tell. You looked nice and calm until the thundering herd of surgeons came into the bay. And they shouldn’t have come in.”

  “My brain froze.”

  “Well, sir, we’ve got a live soldier in surgery right now. So it wasn’t too frozen where you did something wrong. You’ll be fine, sir. Just keep the place calm. We like calm.”

  “Thanks. I owe you one. And the medics, too.”

  “You don’t owe us nothing, sir. Let’s go have a cup of thunder, unless there’s anything else, sir.”

  “No … nothing you can fix.”

  We walked back in through the swinging door and I scanned the room. Looking to see if any of the staff had dirty looks aimed in my direction. Nothing. They just went about their duties as if nothing had happened or, for that matter, had gone wrong. My shift had another eight hours to go and I prayed no more helicopters would be making deliveries.

  I asked Twomey to pull the patient flow chart, which tracked the minute-by-minute happenings of the case. The sterile papers didn’t reflect the chaos that took place in that room or in my head. I saw Twomey had filled in his sections … and mine as well. It all looked organized and clean. He had done a nice job covering my confusion. I sat squeezing the pain and the memories of the case from my forehead.

  About an hour later, Rick and Bernard came out of the OR where they had watched the outgoing surgeons perform their final case.

  “Looks like he’s going to make it, man,” Bernard said.

  “Tough wound, though, transected the whole jugular right in half. Nicked a bunch of other stuff, too,” Rick added. “I’m kind of amazed he didn’t die on the spot. The other surgeons did a good job. He’ll be in Germany by tonight.”

  Bernard looked at me oddly. “What’s up with you, man? You look like shit.”

  “I feel like shit and I did my job like shit. I didn’t exactly know what I was doing. It was like a zoo in here.”

&
nbsp; “Good lord mother of mercy. How many shot-in-the-jugulars have you ever seen? You must have one crazy-assed practice back home if you’ve seen any.”

  Rick now was staring, too.

  “Dave, you look like this ole pregnant mare I had back on my farm. Did you eat anything today? Or you got morning sickness?”

  “Not hungry. And I’ve got all-day sickness.”

  Bernard said, “C’mon, ease up on yourself, man. You did fine. Tell you what, hold down Fort Crazy here, and we’ll see you in a bit.”

  My two lifelines strode from the room, whispering between themselves, leaving me to think, I can’t be trusted to be left alone in here. I know it, they know it, and the wounded probably know it. As soon as the door swung shut, my heart jumped into my throat as I sensed, then felt, the rumbling vibration of a helicopter on approach. Oh God. I saw that the medics were already on their way out the door—Jeez, they had no clue anything was coming—I grabbed my stethoscope off the desk and began to pace. When eternity passed and the door swung back open, my eyes were pulled straight to the smile on the face of one of the medics.

  “Just a blood run from Baghdad, sir. No business for us.”

  It was simply a helicopter replenishing our blood supply. I weakly smiled back, then went outside and threw up again.

  By the time I cleaned myself up, Bernard and Rick were back waiting at my desk.

  “The medical literature well documents a growing boy has got to eat. And you … are that growing boy,” Bernard said with a hint of a smile.

  Rick added, “Yeah, you gotta eat more than that royal shitburger you just got shoved down your throat.”

  On top of the desk was a buffet line of sandwiches, burgers, spaghetti, cake, even a puddle of chocolate ice cream that didn’t survive the trip from the chow hall. My two friends tried to look tough and force me to take in some nourishment.

  As they watched my mouth struggle to force down even the smallest bites, Rick said, “Now don’t start thinking we did this because we like you. But if you die, then we all have to pick up extra shifts. And that ain’t going to happen.” It was a contest where make-believe glares lost out to grown-men giggles.

  I was grateful for the gesture of nourishment and later realized it was the start of a ritual that lasted the next three months. I had lunch hand-delivered every day I worked an ER shift. And always made sure the surgeons had nourishment when they worked through mealtime.

  I stayed until seven that night, and saw eight more patients. None were blown into pieces or had been shot; most had simple wounds or problems I could easily handle. I had survived day one, as did the shredded ears and the torn jugular. But there was no way I wanted to go back to work the next day; I almost wished for some near fatal disease to suddenly strike, the million-dollar illness—and with it, a ticket home. But that would be letting my friends down. My family down. Myself down.

  6

  HOT TAMALE

  IT WAS ONE of those times I really missed having a dad. Someone to talk to, get advice from, maybe even to deliver a well-

  intentioned slap to the side of the head. I thought back to my terrifying night in the ditch back in ’04; tonight I was in my ditch of 2007, crawling around feeling trapped and surrounded by fear.

  I knew I couldn’t leave. The fork in the road was well defined and I needed to choose the path of honor and decency, but I didn’t know if I had the courage and the guts.

  I pulled out my dad’s wallet, and with it, a couple of pictures I hung under the top railing of my bunk. The first was a picture of a happy and innocent twenty-three-year-old in uniform sporting a wide grin. It was taken the day before he shipped out. Next to it, I hung the picture of him the day he came back—bandage on the forehead, dark circles surrounding hollow eyes, and a look that no words existed to describe. I stared at the pictures, begging for advice, some guidance, or words of encouragement. I wanted the easy answers, but they didn’t come. Instead, I kept hearing what I didn’t want to hear: Dave, choose the tough path—honor and decency.

  What about my penance? I felt a duty to those I had failed in the past—the kids of Columbine, my daughter Katie, my own family, and the memory of my father. And the last now carried an extra burden. In reading my father’s notes from his wallet and logbook, I had come across some scribbling on the tops, sides, and margins of several pages. By themselves, they made no sense; together they painted a clear picture of the pain he felt and the debt he believed he owed. A debt he briefly referred to during our long car ride to Philly, but gave little detail about as he quickly changed the subject. Now I understood, and here I had the chance to do what he couldn’t. I could pay his sixty-year debt if I swallowed my fears and did my job.

  I walked over to my footlocker and ripped open a packet of index cards. On each, I drew a series of flow charts for every conceivable situation that might show up in my ER. I knew I couldn’t get them all, and I knew I probably wouldn’t even have time to fumble through a big stack and pull out the right one when the shit hit the fan—but I would carry those cards with me at all times like a heart patient carries nitroglycerin to put under the tongue for sudden chest pain.

  Before they went into the pocket of the uniform I’d wear tomorrow, I recited the protocols again and again—like a schoolchild repeating the newly learned alphabet—making sure I knew, by rote, the steps I would take, and the orders I would give when something came through the door. Even if I didn’t do everything perfectly, I would at least do something—there would be no freezing, no chaos, in my ER ever again. I thought back to what my dad had told me about the first night he led a group of men on a patrol.

  “It was pitch black and we walked right smack into a German ambush. Lots of gunfire, guys hit, screaming for medics. I wanted to burrow into the ground and stay there forever. Then my gut kicked in. You know, all those nights training and studying paid off. It’s like memorizing your A-B-Cs.”

  It was 4 A.M. when I finally finished my homework and even then couldn’t sleep, realizing there was one main command I would have to voice in every situation … and wondering if I had the courage to do it. Tomorrow knew the answer.

  THE PAGES OF the ER logbook filled quickly as the desert sun rose; we were hit with patients early and often. The first few were like being home—dehydration, migraine headache, and a kidney stone, cases caused by the heat of the desert and that would become repetitive over the course of the summer. I was nervous, but hid it well. A few jokes here and there, busting Major Boutin over his choice of Cherry Walnut as the coffee of the day; even on the walk over to the hospital Rick said I still “looked like shit but at least had a dynamic stride.” I didn’t even know that he knew the word “dynamic.” My thoughts of Rick’s vocabulary were interrupted by a medic’s tap on the shoulder.

  “Word from Warhorse, sir. They’re sending an overdose by chopper.”

  “What? Overdose?” I was trying to ready myself for gunshot wounds and blown-off limbs, but hardly expected I’d be treating a soldier who ODed.

  “Forward base Warhorse, sir, about an hour up the road. I’ll give Major Villines a heads-up.”

  Todd Villines was the only cardiologist in Iraq and was stationed at our CSH. Regular Army from Walter Reed, he didn’t travel with our group of reservists. His expertise was caring for complex medical cases. But I wasn’t thinking about him or Warhorse. I was wondering, Overdose?

  When the chopper landed and the doors to the ER blew inward, the bluest human I had ever seen was having CPR done. Jesus, whatever he took killed him. I took a deep breath, fingered my cheat cards listing resuscitation protocols, and went to work. Shock to the chest, breathing tube inserted, heart drugs administered—I didn’t need to look anything up, and best of all didn’t act like a frozen statue.

  After ten minutes of sweat, I finally had the time to take a big-picture view of the patient. Just a kid. His ID said twenty-one years old, and who knows what he put into his system and why.

  “Man, he is one dark shade
of blue.”

  I looked up, it was Dr. Villines.

  “Know what he took?” he asked.

  “No clue. I do know the tube is in the right place and pumping in lots of nice fresh O2. Heart is now beating on its own with a stable rhythm but he’s still blue as a berry.”

  “No kidding, he looks like a Smurf.” Villines’s eyes flickered from chart to patient to me. “Good job, Dave. Let’s get him over to the ICU.”

  And with “good job” ringing in my ears, I walked back to my desk. Pulling a picture of my kids from my wallet, I thought about the Smurf. Does his mom or dad carry a snapshot of him in their wallet? Do they know what he just did and how close he came to needing a casket? And with that dark blue shade, he still wasn’t out of the woods. Some scattered pieces of information from his unit suggested the overdose was intentional—the kid recently broke up with his girlfriend. Lab tests would later tell us what pills were sucked down to do the job.

  I stood up to head outside for some fresh air and was nearly bowled over by a group of medics sprinting toward the landing pads. I never even heard the bird until it was seconds from landing. A pivot and slow trot brought me back to Alpha bay.

  “Gunshot wound on the way, sir. One litter.” The medics prepped the bay for the casualty as I grabbed gloves, clear protective goggles, and fingered my index cards like a rosary.

  “Who’s first call for surgery?” I asked.

  “Colonel Reutlinger.”

  “Please page him and give Dr. Stanton a heads-up. Let’s get ready for some business, ladies and gentlemen.”

  The words flowed with a confidence I didn’t feel. As the stretcher rolled in, several staff members closely followed, gawking and craning for a look at the wounds. Hurry up, Rick, I mouthed silently. This is a trauma-palooza and I could use a hand.

  The patient was an Iraqi soldier, blown up by an IED, and then shot as he got out of the vehicle. Medics kept pace with the stretcher at perfect speed, cutting off clothes and giving me a report as the wheels revolved through small pools of blood.