April 18th, 2012Top StoryTwenty Citizens' Worth Of Blood Flowed Through Him: A Medic Confronts The Open Wounds Of AfghanistanBy 'Dr. Watts'
A 20-pound jug of homemade explosives will take off one or both legs somewhere between the knee and hip, perhaps breaking the pelvis and shattering vertebrae as the shockwave travels up through the skeleton. After our first Marine was wounded this way—let's call him Patient Zero—he was stabilized by his squad's hospital corpsman and flown to the trauma center, a British base that abuts Camp Leatherneck, the hub for Marine operations in southwest Afghanistan. At the time I was running a forward combat aid station as a general medical officer to a Marine Corps infantry battalion. Standard protocol is to gather the casualty's disembodied limbs and tissue as best you can and place the material aboard the medevac helicopter with him so it can be destroyed in a dignified manner. But explosions have a way of defying protocol, as I learned later that day when Zero's cardboard box arrived at my aid station. The plan was to send the box to the crematorium at Camp Bastion, but I first had to know if the contents had been violated in transit. I opened it. Inside was Zero's disembodied lower leg retrieved—after he had been choppered away—from the roof of a house near the blast. There was a boot like mine and a sock like mine and an ankle like mine. That all made sense. But what followed from there was all wrong. Rising from the ankle was a disastrous stump: The fibula was a muddy jagged tusk; the tibia was a series of chunks, none larger than a domino; both were swaddled in shredded layers of gastrocnemius, tibialis anterior, and a swishing flap of cold, flaccid fat and skin. Other little pieces were there as well, none larger than a quarter. I noted the contents, sealed and signed the parcel, and assigned a senior corpsman as its courier to the ovens at Bastion. As I sat down for a cigarette, I felt the most intense impotence I have ever felt. Zero was our first casualty of the deployment, and looking at what was once his leg, I realized for the first time that I wasn't there to help the severest casualties. Though I was the most highly trained member of our medical team, though I had given up a cushy job to support the fight, though I had put myself as far forward as I could justify, my role was only to look on as others worked. To relinquish control of a grisly situation to a junior team member is contrary to our usual choices. The corpsman and the Marines who ran through the haze of dust and terror to find him in a crater—they were the ones who saved his life first. After them, he was in the hands of the trauma surgeons at Bastion. Me? I'd heard the radio traffic minutes after the explosion and helped coordinate the medevac. To this day I follow Zero's rehabilitation progress, yet we have never met. This was the pattern: The worst cases were all lifted directly from the spot they were injured, and I never did use my hands in their times of need. I was on the distant end of a chain of people trying to keep other people alive. I felt useless. Blood is complicated. An average adult circulates a five-liter slurry of cells, sugar, cellular debris, oxygen-carrying pigments, salts, proteins, and water. Most of you don't interact with your own blood on any kind of tangible level, let alone someone else's blood. When you do see blood, it is often the beginning of a significant emotional event. This spotter was odd in that she was female, and that she was approximately 6 years old. She pointed at the Marines and talked into a hand-held radio, and every time she talked, the rounds got closer. I heard myself say out loud, "Someone needs to smoke that little girl." I was that way, until I started training to be a physician. We in the medical field see and touch enough blood that we don't see that little shadow of our own mortality pass over us in the presence of the stuff. From simple procedures like placing an intravenous line to complex ones like draining an intracranial hematoma, the sight of blood is often a sign we're doing something right. Alllllmost done. Even when unexpected, blood is not necessarily an emotional cue—it's one data point alongside dozens or hundreds or thousands. We interact with it sometimes in the flesh, touching it or tapping it from a vein, sometimes viewing it on a microscope slide, seeking information about its owner. Most often we simply order a blood test and then read the data crunched by laboratory technicians. In training as medical student and as an intern, most of my experience with blood lay in those numbers. I can tell you plenty about the patient by knowing about his labs. Or at least I thought I could. It took three weeks in Afghanistan to make me question what, exactly, I knew. After a few more casualties, the sense of impotence grew less acute. I shifted my focus from the absentees, gone on their helicopters, to the ones who did return to my aid station. Support for Marines after a blast consisted of concussion care and a search for evidence of injury. I removed stones from their soft tissue, checked for ruptured eardrums, and watched their headaches and sensitivity to light subside after a few days of sleep and rest. Support for the corpsmen might be a can of Copenhagen, a refill on supplies, or news from home. But blood would change this dynamic instantly. If a blast injury is high enough, it can break the pelvis and disorganize its contents, including the bladder, prostate, and rectum. One corpsman came into the aid station after treating Patient Five in the field, his own sleeves, pants, and boots smeared with a satanic mixture of blood, mud, and feces. I would do what little I could. "Let's get you a new uniform." And we'd sit briefly, until we both realized there wasn't a goddamn thing I could say. There are boundaries in a conversation with a man who is spattered with his friend's blood. He had just saved his buddy's life by wrenching tourniquets around his femoral stumps, stuffing his scrotum full of procoagulant gauze, and placing his shattered rectum back into his pelvis. I could only bear witness to the aftermath, hide his biohazardous uniform and the fragmentation-shredded boots and trousers of the victims, and provide a separate burn pit where we would incinerate the items in private. It would've been easier to burn the uniforms of the wounded and dead alongside all our other garbage, but we didn't want the Marines to see those items. Nor did we want them to see our base's vast, hundred-foot smoldering burn pit as a crematorium. We kept it separate, quiet. As weeks went by, the corpsmen and Marines were saving one another every few days. I knew this through their stories, their uniforms, radio traffic, requests for resupply of hemostatic gauze, and because my spreadsheet of medevac patients kept growing. Their blood and dismemberment, always out of my reach, had become abstractions. Physicians in stateside practice seldom link blood to vengeance or thoughts of a killing they'd prefer to see. The most hostile patient in a normal U.S. practice might decide to sue you. Or maybe if you're in the county E.R., a patient from the jail might headbutt you while you're stitching his shank wound. A day's work doesn't typically involve wishing for the death of a child, nor for a former patient to try to work to kill you. I had my first of each coming. One day I was back at the command outpost listening to the radio traffic: A group of well-concealed gunmen, aided by an unarmed spotter, had pinned down one of our patrols. It was not unusual to have spotters telling shooters where we were located—this spotter was odd in that she was female, and that she was approximately 6 years old. She pointed at the Marines and talked into a hand-held radio, and every time she talked, the rounds got closer. Hearing this play out, I heard myself say out loud, "Someone needs to smoke that little girl." Then I paused, stood, and left the tent to consider the idea that I was, in that instant, advocating the killing of a child. Not some abstract child in an ethics discussion question; no, I meant that particular little girl, the one who had come menacingly alive for me over the crackling of the radio. I wanted a 5.56mm round from my friend's rifle to split her throat so that our Marines might live. It wasn't my most Hippocratic moment—the Marines wound up returning unharmed and without having killed the girl—though I'd like to think it was counterbalanced by my service to our detainees. My corpsmen and I processed dozens of locals who'd been arrested for a countless acts of shadiness. We provided medical exams and documented any marks, scars, or injuries on them before and after questioning. They would arrive with a grape-juice-colored stain across their fingers and palms, from the test for chemical traces of homemade explosives. We wondered: Is this mouth I'm peering into breathing tuberculosis into me at this moment? Were these eyes viewing Marines throguh a Kalashnikov sight earlier? Will these hands make bombs tomorrow? The answer was very often yes. By the end of our time, I knew I had touched bomb-builders. I can't fathom their restraint now. Each one had spent untold days working to kill people like me, yet there we sat, having a conversation about the sores on his feet. What was he thinking, I wonder? I remember one man who was released from questioning; shortly after, his DNA was found on the remains of detonated IEDs that had nearly killed two of our Marines. He got his wish, as we would get ours. Marines killed him later that year. The Camp Bastion trauma center is a United Kingdom facility. Severe casualties are treated by U.K. surgeons and receive U.K. blood products. American troops are kept alive by units, liters, sometimes gallons of British blood. One Marine from my unit lost both legs high on the femur in an instant, and the blast opened his pelvis. Marines and a corpsman were at his side in seconds, and knew where to find his arteries to stop the bleeding from his gaping groin. His circulatory system no longer circulated—his arteries and veins were a nest of open-ended tubes draining away from his heart. The team at Camp Bastion stabilized his injuries, and in the process gave him more than 100 units of blood. Twenty citizens' worth of blood went into him and flowed out his wounds again before he was stable. Last summer, I found myself in a political squabble with a Briton in a bar in San Francisco. He thought American servicemen were in the grip of a narrow mythos of self-reliance. I told him about the Marine, and all the blood that had passed through him. "Your blood brings us home," I said, and I thanked him and his countrymen. We're Facebook friends now. Months after we had returned home from that deployment, I saw one of my corpsmen in a bar. He was the one who had rendered field aid to that Marine, Patient Six, keeping him alive long enough to receive those more than 100 units of blood at Bastion. The injuries had required considerable anatomic knowledge, and it took considerable nerve to stanch arterial bleeding that high in the groin. We had gone together to visit the Marine in the hospital. Six was missing both legs, a testicle, part of a hand, and his wife was filing for divorce; yet he was happy to see his doc. Not me—he had never seen my face, nor had I seen his. He was happy to see the corpsman. In the relative quiet of the sparse tiki patio bar, the corpsman and I discussed him again. I told my corpsman how proud I was of him, and how, from my post in the aid station, I wished I'd been able to do more. "The stuff I had to do to save him, Doc—you taught me that," he said. "My hands were on him, but you were right there. You saved him." It was difficult to believe him; nonetheless, I still cling to that statement and the embedded possibility that I had helped. We are between deployments as I write this. The pendulum has swung. Again I experience blood as the numbers on my computer screen. The blood is harvested at my request, having been drawn by indifferent phlebotomists; transported by hungover house staff; processed cold, unseen, unsmelled, and clotted in a sterile tube by laboratory technicians. I see numbers; I am comfortable. When my unit returns to Afghanistan, I will again pace the floor by my desk as Navy corpsmen and Marines run through plumes of dust to find their shattered brothers at the bottom of craters. I will be on call for 200 consecutive days, ready to receive such an injury should it come to me. Chances are the injured will go to the helicopters, as before—subject not to my direct treatment, only to my proxies. Those in the field will treat the wounded. I will do whatever I can, blood no longer a comfortable abstraction. Young Americans are still losing legs, hands, eyes, testicles; still burning, bleeding, or exploding to death nearly every day in Afghanistan. My brother once hypothesized that the American public would not realize the scope of the war until a confusing number of young amputees started walking American streets. I think he was right. When you inevitably meet one of the million troops who have served abroad in the last 10 years, perhaps even one of my patients, he or she will walk with some measure of tragedy that does not happen on accident. Someone was out for blood. Someone wanted this. The pseudonymous Dr. Watts joined the Navy in 2006 during medical school and is still serving with the Marine Corps infantry battalion referenced in this story. He enjoys hunting for residency programs, reading about the Afghanistan force draw-down, stitching hand lacerations, and teaching Marines about their foot rot. Image via Getty.  |
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