Memorial Day Past and Present

This article made the rounds of the milblogs about a year ago. As the sad story is being replayed on a regular basis these days, I think it's appropriate reading for us this weekend (h/t to Cpt. B for reminding me of the article)...

The Rules of War

by Col. Brett Wyrick

The first rule of war is that young men and women die. The second rule of war is that surgeons cannot change the first rule.

We had already done around a dozen surgical cases in the morning and the early afternoon. The entire medical staff had a professional meeting to discuss the business of the hospital and the care and treatment of burns.

It is not boastful or arrogant when I tell you that some of the best surgeons in the world were present – I have been to many institutions, and I have been all around the world, and at this point in time, with this level of experience, the best in the world are assembled here at Balad.

LTC Dave S., the Trauma Czar, and a real American hero is present. He has saved more people out here than anyone can imagine. The cast of characters includes two Air Force Academy graduates, Col (s) Joe W. and Maj. Max L. When you watch ER on television, the guys on the show are trying to be like Max – cool, methodical and professional. Max never misses anything on a trauma case because he sees everything on a patient and notes it the same way the great NFL running backs see the entire playing field when they are carrying the ball.

Joe is an ENT surgeon who is tenacious, bright, and technically correct every single time – I mean every single time. The guy has a lower tolerance for variance than NASA. LTC (s) Chris C. was the Surgeon of the Day (SOD), and I was the back-up SOD. Everyone else was there and available – as I said the best in the world.

As the meeting was breaking up, the call came in.

An American soldier had been injured in an IED blast north of here, and he was in a bad way with head trauma. The specifics were fuzzy, but after three months here, what would need to be done was perfectly clear – the 332nd Expeditionary Medical Group readied for battle. All the surgeons started to gravitate toward the PLX which is the surgeons' ready room and centrally located midway to the ER, OR and radiology.

The lab personnel checked precious units of blood, and the pharmacy made ready all the medications and drugs we would need for the upcoming fight. An operating room was cleared, and surgical instruments were laid out, the anesthesia circuits were switched over, and the gasses were checked and rechecked. An anesthesiologist and two nurse anesthetists went over the plan of action as the OR supervisor made the personnel assignments.

In the ER, bags of IV fluids were carefully hung, battery packs were checked, and the ER nursing supervisor looked over the equipment to make sure all was in working order and the back-ups were ready just in case the primaries failed. The radiology techs moved forward in their lead gowns bringing their portable machines like artillery men of old wheeling their cannon into place. Respiratory therapy set the mechanical ventilator, and double-checked the oxygen. Gowns, gloves, boots, and masks were donned by those who would be directly in the battle.

America can bring to the war – were in place and ready along with the best skill and talent from techs to surgeons. The two neurosurgeons gathered by themselves to plan. LTC A. is a neurosurgeon who still wears his pilot wings proudly. He used to be a T-38 instructor pilot, and some of the guys he trained to fly are now flying F-16s right here at Balad. He is good with his hands and calm under pressure. The other neurosurgeon is Maj. W., a gem of a surgeon who could play the guitar professionally if he was not dedicated to saving lives. A long time ago, at a place on the other side of the world called Oklahoma, I operated on his little brother after a car accident and helped to save his life. The two neurosurgeons, Chris, and I joined for the briefing. Although I was the ranking officer of the group, Chris was the SOD and would be the flight lead. If this was a fighter sweep, all three of those guys would be Weapons School Patch wearers.

The plan was for me and the ER folks to assess, treat and stabilize the patient as rapidly as possible to get the guy into the hands of the neurosurgeons. The intel was that this was an IED blast, and those rarely come with a single, isolated injury. It makes no sense to save the guy's brain if you have not saved the heart pump that brings the oxygenated blood to the brain. With this kind of trauma, you must be deliberate and methodical, and you must be deliberate and methodical in a pretty damn big hurry.

All was ready, and we did not have to wait very long. The approaching rotors of a Blackhawk were heard, and Chris and I moved forward to the ER followed by several sets of surgeons' eyes as we went. We have also learned not to clog up the ER with surgeons giving orders. One guy runs the code, and the rest follow his instructions or stay out the way until they are needed.

They wheeled the soldier into the ER on a NATO gurney shortly after the chopper touched down. One look at the PJs' faces told me that the situation was grim. Their young faces were drawn and tight, and they moved with a sense of directed urgency. They did not even need to speak because the look in their eyes was pleading with us – hurry. And hurry we did.

In a flurry of activity that would seem like chaos to the uninitiated, many things happened simultaneously. Max and I received the patient as Chris watched over the shoulder to pick out anything that might be missed. An initial survey indicated a young soldier with a wound to the head, and several other obvious lacerations on the extremities.

Max called out the injuries as they were found, and one of the techs wrote them down. The C-collar was checked, the chest was auscultated as the ET tube was switched to the ventilator. Chris took the history from the PJs because the patient was not conscious. All the wounds were examined and the dressings were removed except for the one on the head.

The patient was rolled on to his side while his neck was stabilized by my hands, and Max examined the backside from the toes to the head. When we rolled the patient back over, it was onto an X-ray plate that would allow us to take the chest X-Ray immediately. The first set of vitals revealed a low blood pressure; fluid would need to be given, and it appeared as though the peripheral vascular system was on the verge of collapse.

I called the move as experienced hands rolled him again for the final survey of the back and flanks and the X-Ray plate was removed and sent for development. As we positioned him for the next part of the trauma examination, I noted that the hands that were laid on this young man were Black, White, Hispanic, Asian, American Indian, Australian, Army, Air Force, Marine, Man, Woman, Young and Older: a true cross-section of our effort here in Iraq, but there was not much time to reflect.

The patient needed fluid resuscitation fast, and there were other things yet to be done. Chris watched the initial survey and the secondary survey with a situational awareness that comes from competence and experience. Chris is never flustered, never out of ideas, and his pulse is never above fifty.

With a steady, calm, and re-assuring voice, he directed the next steps to be taken. I moved down to the chest to start a central line, Max began an ultrasonic evaluation of the abdomen and pelvis. The X-rays and ultrasound examination were reviewed as I sewed the line in place, and it was clear to Chris that the young soldier's head was the only apparent life-threatening injury.

The two neurosurgeons came forward, and removed the gauze covering the soldier's wounded head, and everyone's heart sank as we saw the blossom of red blood spreading out from shredded white and grey matter of the brain. Experience told all the surgeons present that there was no way to survive the injury, and this was one battle the Medical Group was going to lose. But he was American, and it was not time to quit, yet.

Gentle pressure was applied over the wound, and the patient went directly to the CT scanner as drugs and fluids were pumped into the line to keep his heart and lungs functioning in a fading hope to restore the brain. The time elapsed from his arrival in the ER to the time he was in the CT scanner was five minutes.

The CT scan confirmed what we had feared. The wounds to the brain were horrific and mortal, and there was no way on earth to replace the volume of tissue that had been blasted away by the explosion. The neurosurgeons looked at the scan, they looked at the scan a second time, and then they re-examined the patient to confirm once again.

The OR crew waited anxiously outside the doors of radiology in the hope they would be utilized, but Chris, LTCs A and S., and Maj W. all agreed. There was no brain activity whatsoever. The chaplain came to pray, and reluctantly, the vent was turned from full mechanical ventilation to flow by. He had no hint of respiratory activity, his heart that had beat so strongly early in the day ceased to beat forever, and he was pronounced dead.

The pumps were turned off; the machines were stopped, and the IVs were discontinued. Respectful quiet remained, and it was time to get ready for the next round of casualties. The techs and nurses gently moved the body over to the back of the ER to await mortuary services. And everyone agreed there was nothing more we could have done.

When it was quiet, there was time to really look at the young soldier and see him as he was. Young, probably in his late teens, with not an ounce of fat anywhere. His muscles were powerful and well defined, and in death, his face was pleasant and calm.

I am always surprised that anyone still has tears to shed here at Balad, but thank God they still do. The nurses and techs continued to care for him and do what they could. Not all the tubes and catheters can be removed because there is always a forensic investigation to be done at Dover AFB, but the nurses took out the lines they could. Fresh bandages were placed over the wounds, and the blood clots were washed from his hair as his wound was covered once more. His hands and feet were washed with care. A broken toenail was trimmed, and he was silently placed in the body bag when mortuary services arrived as gently as if they were tucking him into bed.

Later that night was Patriot Detail – our last goodbye for an American hero. All the volunteers gathered at Base Ops after midnight under a three-quarter moon that was partially hidden by high, thin clouds. There was only silence as the chief master sergeant gave the Detail its instructions. Soldiers, Airmen, and Marines, colonels, privates and sergeants, pilots, gunners, mechanics, surgeons and clerks all marched out side-by-side to the back of the waiting transport, and presently, the flag-draped coffin was carried through the cordon as military salutes were rendered.

The Detail marched back from the flight line, and slowly the doors of the big transport were secured. The chaplain offered prayers for anyone who wanted to participate, and then the group broke up as the people started to move away into the darkness. The big engines on the transport fired up, and the ground rumbled for miles as they took the runway. His duty was done – he had given the last full measure, and he was on his way home.

The first rule of war is that young men and women die. The second rule of war is that surgeons cannot change the first rule. I think the third rule of war should be that those who have given their all for our freedom are never forgotten, and they are always honored.

I wish there was not a war, and I wish our young people did not have to fight and die. But I cannot wish away evil men like Bin Laden and al-Zarqawi. These men are not wayward children who have gone astray; they are not great men who are simply misunderstood.

These are cold-blooded killers and they will kill you, me, and everyone we love and hold dear if we do not kill them first. You cannot reason with these people, you cannot negotiate with these people, and this war will not be over until they are dead. That is the ugly, awful, and brutal truth.

I wish the situation was different, but it is not. Americans have two choices. They can run from the threat, deny it exists, candy-coat it, debate it, and hope it goes away. And then, Americans will be fair game around the world and slaughtered by the thousands for the sheep they have become.

Our second choice is to crush these evil men where they live and for us to have the political will and courage to finish what we came over here to do. The last thing we need here in Iraq is an exit strategy or some damn timetable for withdrawal. Thank God there was no timetable for withdrawal after the Battle of the Bulge or Iwo Jima. Thank God there was no exit strategy at Valley Forge. Freedom is not easy, and it comes with a terrible price – I saw the bill here yesterday.

The third rule of war should be that we never forget the sacrifices made by our young men and women, and we always honor them. We honor them by finishing what they came to accomplish. We remember them by never quitting and having the backbone and the guts to never bend to the yoke of oppression.

We honor them and remember them by having the courage to live free.

Col. Brett Wyrick is commander of the 154th Medical Group, Hawaii Air National Guard, and is serving as a surgeon in Balad with the 332nd Expeditionary Medical Group. This column is part of a series of email reports from Iraq that Wyrick has been sending to his father, a Vietnam-era fighter pilot, who in turn distributes them to a circle of friends and acquaintances.