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This essay was written by my friend and colleage, Dr. John P. Pryor. He was a trauma surgeon who refused to be idle when so many wounded Americans and Iraqis could be helped by his skills. He enlisted in the Army reserve and wrote this article after completing his first tour in Iraq.

“In other fighting, one marine was killed in the Al Anbar providence after a humvee he was riding in hit an IED.” That was what I read in the AP news piece. It was one line of several paragraphs that summed up the days casualties in Iraq during another day of the war that has gone on for three years now. These reports are so common, most people do not even read them, or listen to the 30 second blurb that follows, “Another day of violence in Iraq where…” on the evening news. For us, the reality is much different, a horrific drama that is played out in the field, in forward surgery tents, and combat support hospitals every single day.

Today the warning came over the radio, “urgent litter coming in by ground” I immediately respond to the ETR where the buzz is usually in full swing. “IED, Marines” is all the ETR nurse said as I walked in. Damn, I thought. One day left – all I asked God for was no more marines with one-day left on my tour. The hospital staff went into full swing – these people are at the end of a yearlong deployment here, they are experienced, hardened, and cool under pressure. The activity was programmed and efficient. I took my position at the head of bed number one, put my head down and waited.

Within a few minutes the litter team burst into the ETR with the first patient. I could see his arms dangling off the stretcher with bone exposed, and I immediately knew that this was going to be a bad one. When the litter was pulled up aside the bed, I saw the full extent of what I was up against. Driver, I thought to myself. The drivers always seem to get the full force of the IED. There is a pungent smell of gasoline and burned flesh. My first order of business was to remove the IBA before we move him over; to do this we have to sit him up in order to pull the arms through the IBA sleeves. When we did, his arms, broken in several places on each side, flopped around like a puppet. As we moved him over, I tried to ignore the massive tissue destruction of his legs, and focus on potential life threatening chest and abdomen. He was moaning, actually a good sign, the brain was still getting blood flow. Anesthesia moved to intubate him, as the emergency medicine physician started the primary survey. Nurses started lines, lab was there to bring blood, medics held pressure on bleeding wounds, all in a dance that has been repeated so many times before.

The other patients began to file in, eventually filling the ETR. One soldier in a bed next to ours was calling out to my patient, ignoring his own gaping wounds “Your going be okay man, hang in there.” I began to focus on the problem and my plan. Both legs had massive tissue destruction. The left thigh was torn apart and burned with a tourniquet at the groin. The right leg was mangled below the knee with a tourniquet above that. There was a neck wound that wasn’t bleeding and shrapnel to the face. Both arms had multiple levels of open fractures. The pulse was weak and the blood pressure was barely readable. We hung blood immediately. The chest x-ray did not show any thoracic injury. We shot an abdominal film to look for shrapnel that may have gone into the belly – none. As we moved to the OR the hospital commander stopped me to ask if he was going to make it. I told him that I was worried that once we start to resuscitate him, the bleeding would become even worse, and I didn’t know if he would make it. His head dropped as he walked back to the chaos of the ETR.

In the operating room we started by getting control of the external bleeding of the legs. There was blood coming from everywhere; bright red arterial blood, dark blue venous blood, and areas where the two swirled together in pools between the flesh. Two orthopedic surgeons and I worked frantically to get control of the bleeding, which as predicted, became worse as we started to resuscitate him. Anesthesia was struggling to keep a blood pressure, infusing unit after unit of packed red blood cells, and plasma. I was having trouble finding the source of some bleeding high on the thigh, and I was going deeper and deeper into the groin to track down the source. Suddenly my hand broke into a space, and a gush of blood came out. I realized that I was in the retroperitoneal space and the bleeding was coming from here. This was the worse case scenario. Bleeding from this location is the toughest area in the body to control. The packing did nothing; blood flowed from the wound in a constant stream. We opened the abdominal cavity and clamped the arteries that feed the pelvis, but it didn’t help. Bleeding from this area is almost always from large veins that cannot be controlled with sutures or arterial control. We packed as tight as we could, and then put a sheet around the pelvis to pull the bones together in an attempt to tamponade the bleeding, but it was not enough. His heart went into a lethal arrhythmia. We shocked him, and pumped epinephrine into his blood stream. After a few minutes, his heart stopped for the last time.

The marine was dead.

There was an immediate silence in the operating room as soon as I announced the time of death. Most of the staff had tears running down their faces; this was a long year for them with so many of these kids dying in this room. I could not physically move for several minutes. I looked at this young kid, a child, and I apologized to him for not being skillful enough to save him. As a trauma surgeon every death I have is painful, every one takes a little out of me. Loosing these kids here in Iraq rips a hole through my soul so large that it hard for me to continue breathing. After a few minutes, I collected myself and began to direct the care for his final journey home. We closed what we could of the wounds, and wrapped the ones we couldn’t get together. We washed all of the dirt and oil off his skin, combed his hair and washed his face. He was transferred to a litter and brought to a private enclosed room where we placed him inside a heavy black body bag. The body was draped with the American flag and a guard was posted. The chaplain gathered some of the providers and we said prayers over the body.

There was, and always is, a palpable grief that comes over the entire staff when we loose an American solider. Everyone is affected, and everyone deals with it in a different way. For me, this is not an objective depressing thing to be a part of; it is very, very personal. I was the surgeon who couldn’t save him. For me the grief is intolerable. I become the focus of the morning for the staff– people come and give me a hug. They ask me if I am okay, they pray for me. I appreciate it and hate it at the same time. Often my misery turns into anger. Sometimes I become angry with God for allowing this to happen. I just want the whole thing to be over, and all of these kids to go home to their families and live long lives. I have seen so many soldiers and marines die here; I just want it all to end.

As I made my way out of the hospital, I saw the marine unit gathered together. Two humvees where parked, and weapons were leaning against the vehicle. I notice this immediately because a marine is never without his weapon, they would never be stacked like that. These were the weapons of all the marines injured in the latest attack. I spoke with the first sergeant, the father figure of a marine unit. I know him well, we have lost several of his marines and had many more injured and treated here. We arrange for his buddies to come in and say goodbye, something that I cannot even bear to watch. After a time of reflection, the unit gathers the equipment and prepares to go out again that night. This is some of the raw courage that I talk about, the ability to loose a friend in battle and go right back into the fight. I love every single one of them.

The body was eventually taken to the LZ and loaded into a helicopter with some of his buddies as escorts. He is taken to BIAP where mortuary affairs prepared the body for transport home. A friend of mine was at BIAP when the body was loaded onto the C-130. All activity on the tarmac stops when the casket is brought onto the airstrip. All personnel in the area stop what they are doing and attend a 45-minute ceremony on the airstrip. They tell me that this happens twice to three times a day, but everyone takes time out to attend the ceremonies. Soldiers manifested in these flights are going home or on R&R, and as anxious they are to leave, they all take the time to honor the marine. An honor guard then brings the flag draped casket onto the aircraft with full military honors. The casket is situated in the center of the aircraft with nothing placed on either side or directly in front or back. Personnel then enter the aircraft and accompany the marine to Kuwait. In Kuwait the casket is removed first, again with a full honor guard. The marine will be brought to Dover Air Force Base in Delaware, and then eventually home and to his final resting place.

If I could say something to this Marine’s parents it would be this: I am so sorry that you have lost your son. We, above everyone else, know that he was a true American hero. I want you to know that the Marines, medics, doctors, nurses and of the 344th CSH did everything possible to save him. I want you to know that I personally did everything that I could, and that I am sorry that it wasn’t enough. I want you to know that although we never knew your son, we loved him. I want you to know that although he lost his life, we preserved his dignity after death. We held his hand when he died and prayed for his soul and for God to give you strength. I want you to know that he had great friends who cared deeply for him and that they were also here when he died. He was never alone for his journey back to you. I also want you to know that I will never forget your son, and that I will pray for him and all of the children lost in this war.

IED - improvised explosive device
ETR - emergency treatment room
LZ – landing zone
BIAP – Baghdad international airport
IBA – individual body armor
R&R – rest and relaxation
CSH – combat support hospital

John P. Pryor, MD was a trauma surgeon at the hospital of the University of Pennsylvania and a Major in the United States Army Reserve Medical Corps. He was the general/trauma surgeon for the 344th Combat Support Hospital in Abu Ghraib, Iraq. John was killed on Christmas day 2008 during his second tour in Iraq.

Posted by Mike McEvoy
EMS Editor
Fire Engineering magazine

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posted by Mike McEvoy
5/22/2009 05:20:00 PM

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