Death and Life in Afghanistan

It has been four years now since I last wrote about war.¹ That was Iraq; this is Afghanistan. I’m not sure if this is the same war or a different one, and from my perspective as a trauma surgeon, it really doesn't matter. Death is still death, life is still life, and I know which side I am on.

When last I wrote, I received a surprisingly large correspondence in return. Most correspondents were very supportive of what we in military medicine are doing out here. Some reminisced of different wars in different times that were, ultimately, still the same. A few viewed my opus as antiwar sentiment at its finest and lauded my courage in “raging at the machine.” My motivation for writing is my own, but someone once said that after the piece is written, it belongs not to the writer but to the reader.

They told us that Afghanistan would not be Iraq. From where I sit, on an endless plain of nothing known to the locals as the Desert of Death, I beg to differ. The inside of my operating room, again a tent, looks the same. The dust on everything is the same thickness. The mangled bodies bleed, then stop bleeding, as before. The body bags are still black.

The medical team is different, yet the same. Again I am the only trauma surgeon and, until Rob arrived recently, the only physician with any real deployment experience in a combat environment. I am still surrounded by 19-year-old corpsmen, full of the optimism and indestructibility of youth, but seasoned with enough old hands that they have people to turn to, rely on, and commiserate with. The nurses are all rookies in this game. We have moved a few times since we arrived in Afghanistan, so we are either comfortable with the uncertainty or inured to our discomfort, as individual personalities dictate.

After 200 patients or so, Death is no surprise to us, although it is certainly not a daily visitor. Its first victim here, only a week after we had set up, was a shock only in that the soldier survived long enough to reach us, his body as shattered as it was. Even those who had never seen such destruction had harbored no false optimism, and their grief, while real, held no sense of failure. Since then we have won more than we have lost, those passing the final curtain being only the truly hopeless cases that we nevertheless tried to save.

Another Marine comes in, receiving CPR, and we go to work. Multiple IED fragments to the neck and leg, but the miracle of modern body armor has preserved his torso. Between compressions, ultrasound shows some little cardiac activity. My team, once tyros, are now well practiced, and within two minutes we have bilateral subclavian central lines and a large-bore IV in place, with blood being pumped in everywhere. A few minutes more and we have a blood pressure, admittedly poor, but then it had nowhere to go but up. He now has enough volume on board to exsanguinate, again, from his neck.

I hold pressure on the arterial bleeding from his neck wounds while Deb and Rob scrub. Rob is the grizzled veteran of many wars: Desert Storm, Operation Enduring Freedom, Operation Iraqi Freedom, and others in-between. Deb is the youngster now blossoming as a trauma surgeon, who will teach more than she is taught once she starts her fellowship. Me, I’m the middle guy along for the ride.

The neck is a bloody mess, no surprise. Bilateral neck explorations are done, the lacerated external carotid is ligated, fragments and rocks are removed, numerous venous bleeders are attended to, and all surgical bleeding is controlled. While we have been doing this, Doug the orthopod has placed an external fixator on the open femur fracture and washed out the wound, cursing bitterly that our other Rob, the “trauma pod,” isn't here right now to help. John, Jeremy, and Monte, our trio of gas-passers, have given 45 units of blood and blood products, filling the tank for the hour it took for the surgeons to plug the holes. But we're caught up and the man's alive.

He is flown out by helicopter Medevac, Jeremy in attendance and still resuscitating. But he makes it to the next rung up the long ladder of medical care in the Global War on Terror, or whatever we are calling it these days. There, we learn he receives another 100 units for his coagulopathy, but lives. And on to the next stop, and the next, and finally, hopefully, home. Home alive.

He and his family do not know our names, nor do they need to. We are just a few of the hundreds of people who make up the many links in the several-thousand-mile-long chain of medical care for our wounded Marines, sailors, soldiers, and airmen. If one link breaks, it all fails. So either we all get the credit, or none of us does. Remember that, the next time you see someone at some meeting beating his chest or blowing his trumpet. It's a team sport.

I wrote before of working to save the “one percent,” that small fraction of trauma patients receiving CPR who survive. He is our “one percenter,” who by all rights should have died, and probably would have died even at the best Level I trauma center in the United States. He is the justification for why we do what we do. We still pull out all the stops for them, as we do in every war, because we have to. We do it for them, for their comrades, and for ourselves. Because when these young men and women go “outside the wire,” they need to know that we will. There is no “futile care” here. And the next one will be a “one percenter” too. He has to be.

And whether Afghani or American, we treat them the same. Because death is still death, life is still life, and we know which side we are on.