Afghanistan ER

“Hi, Curmudge. I see that Mack copied you on a note to one of his medical colleagues.”

“Right, Jaded Julie. When you read the note, it will be evident that it could only be fully understood by another Army emergency medicine doc who had served in combat. When I asked Mack about some of the terms, he dictated a rather cursory glossary (below). Here’s the note:

‘Hi Ian,
Had a terrible air assault day before yesterday, very dangerous area. One person killed by IED. Also Local National blown up accidentally by our APOB while we were trying to breach through really dangerous IED seeded area. Even though they did the whole procedure to warn the locals and clear everyone out. It was after dark when we crossed after the explosion, the people up front found a guy on the road, huge facial wounds but alive and struggling. I put in a tibial IO, (I carry the mini-drill in my Aid Bag). Hit him with IV Ketamine (in spite of the head wound. I heard that increased ICP with Ketamine was not really borne out by literature. Also only thing I had to adequately sedate him for any extended time). Also used some Versed. Did a cric, balloon failed so exchanged it for new tube over a stylet. Ran 2 Hextends IO for the crappy radial pulse. The guys used their Tac lights on their M-4s for light. Set up hasty LZ and evacd him. Guy made it back to the Role III alive; they did labs, CT scan, everything. He had a brainstem bleed and a depressed skull fracture, so they withdrew care and he died. My two medics and I were covered with blood. Several of us fell into a creek trying to get back to the exfil LZ so had to wait for 3 hours in the freezing cold while wet. We were in PZ posture in the dark; the Chinook almost landed on us. Whole planeload had to dive off 6-foot embankment to keep from being dismembered by the bird, then crawl up the sides of the ditch and run for the helicopter. Still scratched and sore from that.
Anyway, that's my world for the last 3 days. Take care—Mack’”

“Gosh, Curmudge, every note from Mack further strengthens my belief that war is Hell.”

“I believe most everyone can get that impression without the glossary, but here it is anyway:

IED—improvised explosive device
APOB—chain of explosives fired several hundred yards ahead of advancing troops to explode IEDs
IO—intraosseous. An ‘IV’ into a bone instead of a vein.
Ketamine and Versed—anesthetics
ICP—intracranial pressure
Cric—cricothyroidotomy; an incision in the front of the neck to establish an airway
Hextend—colloidal plasma volume expander
Tac lights—very bright, focused, visible light source mounted on weapon
Role III—advanced medical care. A battalion aid station is Role I.
Exfil LZ—helicopter landing zone to extract troops at end of mission
PZ posture—troops lined up in Pickup Zone in order of entry into helicopter”

“The glossary improves my understanding, Curmudge, but it doesn’t assuage my feelings one bit.”

“As always, Julie, you’ve got that right.”

Afghanistan ER

“Hi, Jaded Julie. Mack copied me on his exchange of Christmas notes with his friends, Ernie and Susan. You might find them interesting. Here’s the note that Ernie and Susan sent to him:

‘Christmas Day is just about done where you are, and the grandchildren here are already winding down - all the Santa gifts are opened and being played with. But we wanted to wish you a very merry Christmas and lift you up with a prayer that 2011 will be a year of much more peace - for you in particular and for all of us in general.’”

“It sounds like a classical, peaceful American Christmas, Curmudge.”

“This is Mack’s response:

‘Dear Ernie and Susan,
Christmas has been pretty nice. Today was a nice, quiet day. Just got a cold so spent a few hours napping at the house. The whole camp has had it; I'm like the last one to get it. Just got back from screening a detainee tonight. Christmas Eve was a little more exciting. I was eating lunch when one of my medics ran in the chow hall and told me we had traumas coming. Apparently one of the good Afghanis in a nearby village was the victim of a Taliban motorcycle drive-by. Shot in the chest, head and leg. His cousin brought him to right outside our FOB, with the guy in the back of a minivan. Stokes, one of my medics, and I took the little ambulance and had a hair-raising ride to the gate. Blood everywhere. The van was outside the gate on the highway since they couldn't come in. We drove through the gate onto the highway, usually a no-no since the Ford has no armor (and we were in T-shirts!!) The Ford does have a siren loud enough to peel paint, however.

I had the Afghanis in the van lay the guy by the side of the road and I did a "cric", which is a surgical airway where I cut a hole in his throat and put in a breathing tube, right there on the road. Fortunately no snipers. We put the guy in our ambulance and took him back to the aid station. Unfortunately he died; had a pulse of something like 29 when we got him on the table, but I think we got some I/O points with the local population for trying.

We had a beautiful candlelight Christmas Eve service in the chapel (tent) last night. I played the piano for it like I do for most of the church services.

Today Major General Terry (RC South Commander) flew in to visit everyone for Christmas. We enjoyed meeting him very much.

Anyway, I'm guessing you guys had a pretty nice Christmas Eve service at church. Feel free to read this letter at Sunday School if you want, so they know we had a good Christmas as well. Stay in touch and God bless. -----Mack.’”

“Curmudge, the FOB (Forward Operating Base) must be a fortified island of relative safety amid a sea of anarchy. So why am I shuddering? Maybe if I put on a warmer sweater…”

Afghanistan ER

“Good morning, Jaded Julie. You may be interested in the news bulletin (below) that I saw on the Web yesterday:

‘Six American soldiers were killed and more than a dozen American and Afghan troops were wounded on Sunday morning when a van packed with explosives was detonated at a new jointly operated outpost in southern Afghanistan. The soldiers were inside a small mud-walled building near the village of Sangsar, north of the Arghandab River, when the bomber drove up to one of the walls and exploded his charge around 9 a.m. The explosion blasted a hole in the thick wall, causing the roof to collapse on the soldiers inside. Others quickly arrived and clawed and pulled at the waist-deep rubble to free the buried troops. The building had been occupied by the Americans and Afghans for only a few days, an American official said, and was beside a narrow road. It was not immediately clear how the van managed to get so close without being challenged or stopped.’”

“Doesn’t sound good, Curmudge. We’ve heard about mud-walled buildings before. Did you send a note to Mack asking about it?”

“I did, and here is his reply:

‘Yes, that suicide bomber was for us. It occurred on Sunday morning at a small outpost, happened to one of our platoons, one that I have been out with a number of times and been at the exact same type of outpost with. Good I wasn't killed in a blast, but frustrating that I wasn't close enough to do anything to help. I was sent out there quite quickly by the command, but when I got there, all the dead and worst injured had been already evacuated. They were just digging through the rubble; I took care of a couple of Afghan Army folks. I've been busy checking out the remaining folks here, also there is a huge emotional toll since 6 guys were killed like that. Been busy, up until 0200 last night just talking to distraught guys.
Jim Slone, my PA, has gone on leave, so I can't really leave the Aid Station on base to go on missions, since we have to have at least one care provider on hand.’”

“My feelings are a mixture of thankfulness and rage, Curmudge.”

“Mine also, Julie. Mack said that with winter coming on, the Taliban chiefs will sit at home by the fire in the security of Pakistan and send out the young jihadis to become martyrs. I guess he’s right.”

Afghanistan ER

“Here’s Mack’s latest note, Julie. I’ll read it to you:

‘We did have a huge Thanksgiving dinner. I literally ate too much. Our mission that you mentioned was successful in that we accomplished what we set out to do. We went into one of the worst Taliban areas, found improvised explosive and burned and blew it up. We also found a Taliban Aid Station and burned it down. The real sad thing was that the other platoon was moving and an Afghani soldier moved off the cleared path and stepped on an IED, blew both his legs off, also injured an interpreter. Some of our guys were carrying him to the helicopter and the enemy apparently had a buried remote-controlled IED ready. When the stretcher bearers passed over it, they blew it up, killing two of our guys, injuring several more, and of course killing the Afghan guy on the stretcher. I was six hundred meters away with the other platoon and couldn't go help them since all the ground between us was not cleared and likely seeded with plenty more explosive devices. It was extraordinarily frustrating to not be able to help. Everyone was furious and despondent at the end of an otherwise tactically very successful mission. Memorial service was yesterday.

We are in our new Aid Station, which was just completed. It is beautiful and three times as large as our old one in the old stone Afghan building. The new place is by the helicopter landing zone; can be windy at times. Also too close to the trash burn pit, and I am lobbying hard to get the burn pit moved. Anyway, after I got back from the mission I pretty much just slept all day while the medics moved everything from the old building (none of them were out on the mission like I was). It was sometimes exhausting out in the field, climbing over the stone walls in the grape fields with full packs, weapons, etc.’”

“Golly, Curmudge, it must be awfully depressing for the troops and for the folks back home at Fort Campbell for the battalion to be losing at least two soldiers per week to IEDs.”

“Julie, I seem to recall reading about medieval times when battles were stopped to allow the wounded to be removed from the field. I guess now we are fighting an even more primitive civilization.”

“Civilization? Aren’t these the guys who condemn women to death by stoning?”

Afghanistan ER

“Another note from Mack. It’s rather short:

‘Pretty busy over here; lost some guys to a suicide bomber in the field. These were guys I had just been on the same mission with for 6 days. Then I went back in to check up on things at the aid station. Next day, guys I was just walking with out there were blown to bits by a s_ _ _-a_ _ with an explosive vest. Also three injured. I can't stand the fact that I was with them; then the moment I leave to go back here to work, this thing happens. Memorial service tomorrow.’”

“Do you have any comments, Curmudge?”

“Nothing that isn’t profane, Julie.”

Afghanistan ER

“Well, Curmudge, after spending the past couple of days thinking about Mack’s letter in our last posting, do you feel any better?”

“I don’t feel better, Jaded Julie, but I understand better. Mack is living out his belief that wounded soldiers should receive the best medical care available at the point of injury. And he has determined that he will be available. As long as he has a good PA back in the aid station, Mack will practice battlefield medicine literally in the field. He may be setting a new standard for infantry battalion surgeons.”

“I can just hear the platoon sergeant announcing, ‘Listen up, guys. I have some good news and some bad news. The good news is that the doc is going with us on this mission. The bad news is that that means our platoon has the toughest assignment and we are the most likely to sustain casualties.’”

“Let’s hope the good news outweighs the bad and that the bad news doesn’t actually occur.”

“But Curmudge, isn’t a physician too valuable to go out into the field like Mack does?”

“I’m sure, Julie, that every parent feels that way about their 20-year old rifleman son.”

“Mack said that he and the medics carry M-4’s and act like riflemen until someone is wounded. I thought that medical personnel were noncombatants and had red crosses on their helmets.”

“That was another war, Julie. To the Taliban, a red cross—especially a cross—would look just like a bull’s-eye.”

“Curmudge, wouldn’t a physician feel out of his element in the field carrying a rifle along with his aid bag?”

“That might be true for a lot of docs, but not Mack. When he first went on active duty in the mid-1980’s, he was an infantry platoon leader. That was before a lot of today’s young soldiers were born.”

“Finally Curmudge, do you still get that knot in the pit of your stomach when you read notes from Mack?”

“It’s there all the time, Julie, and it will remain there for the next several months.”

Afghanistan ER

“Curmudge, a few weeks ago, on October 11, you shared a note from Mack describing injuries that he and the troops sustained from improvised explosive devices (IEDs).”

“Right, Julie. It brought the war in Afghanistan awfully close to home. He recently provided more details about the mission in a letter to an old friend from Appleton. Mack sent me a copy; I’ll read part of it:

‘Dear Joe,

The last 5 months have been quite an adventure. It would take quite a while to detail everything, and I can tell you stories on end if you are interested. I will tell you about the mission where the IED attack happened. To start with, I am a ‘battalion surgeon’ in an infantry battalion. The term ‘surgeon’ in this case, means the chief medical officer for a military unit as opposed to being a surgeon who takes out gall bladders, etc. As you know, my specialty is Emergency Medicine, i.e. working in an ER.

I have gone on all the major offensives/missions. What happens is I usually go with whichever platoon or company looks like they will encounter the most resistance and have the greatest potential for casualties. I carry an M-4 (it's a shortened M-16 with a collapsible stock like the riflemen carry) and function pretty much like a rifleman the way the medics do until something happens. There is a combat medic in each platoon and I "plus up" the given platoon in these situations.

This particular mission was a Clear and Hold, where we move through the countryside, clearing houses/ compounds to ensure no enemy there and identify/destroy any IEDs that are found. The second evening we were settling down to eat a meal and sleep when the radio call came in that one of the guys in the next platoon over had stepped on an IED and had lost a leg. I ran with the company commander who was with our platoon up to the area where they were, (a grape field). The guy was pretty messed up, one leg gone, open pelvic fracture, severe rectal and pelvic injuries. The medics and I got the guy stabilized and we called in a helicopter to fly him out. We were somewhat shaken up by what had happened to him. I went back to my platoon and we went to sleep. The next morning we were to move to a new compound (Afghani houses, or compounds are mud-walled courtyards with individual rooms built into the walls as opposed to the whole building having a roof like an American house), and we packed up and moved to the place. It had been searched to ensure no bombs were rigged or anything. We had just moved inside when the first bomb went off. It was about 15 feet from me, but it was inside the foyer and I was just around a corner so that protected me from shrapnel. In the explosion guys were thrown through the air, lots of smoke, etc. and lots of confusion. I was checking out the guy who landed right in front of me; then people started shouting that someone was badly injured. I yelled that everybody who could walk should go toward the walls and bring the badly injured to the middle.

We were working on this guy who had shrapnel to his face, legs, etc, left middle finger partly blown off, fragments in right elbow, etc. in the middle of the courtyard when the second bomb went off along the wall. My medic and I fell across the guy to keep the dirt chunks/ fragments, etc from falling on him, then got him wrapped up to fly out. Because of the concussion there was an increasing number of people vomiting, losing balance, etc. I sent out 5 on the first helo, then 12 on the next one. We sent out some more on a convoy that brought the battalion commander to the scene later. By this time the platoon was not really combat effective, so the rest of us flew out late that night on a Blackhawk. My medics at the base camp with my PA checked the remainder of the people out including me. I just had a headache and jaw ache the next day, then pretty much felt back to normal aided by my pounding max doses of Tylenol. My parents did get a call the next morning from Fort Campbell saying I had had a mild ‘TBI’, but fortunately I had e-mailed my dad late the night before so he know I was still coherent.

I hope that wasn't too laborious a read. This week has been somewhat difficult as we lost two guys who were killed outright by IEDs. My PA and my medics and I were in the Aid Station three nights ago when the locals brought in two girls (age 4 and 7) who had been badly burned in a gasoline explosion. Apparently the parents had bought what they thought was diesel fuel but turned out to be gasoline for their heater. When they filled it and lit it, Boom! Burns about 80-90% of bodies. We intubated the kids, dressed the burns, and flew them out. Apparently they both died the next day, judged by the hospital to be not survivable burns, changed to comfort care only.

I should be home next spring/summer and certainly plan to stop to see you the next time I'm in Wisconsin.

Take care---Mack’”

“What’s the lesson, Curmudge? It sounds as if the good guys took it on the chin.”

“Julie, when I read this, my only feeling is the knot growing in the pit of my stomach. Let’s think about Mack’s letter and talk more about it in a few days.”