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Old July 11th 05, 12:35 AM
Burr
 
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Default A Ture Letter

BALAD, Iraq - 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.

All of the resources - medical, mechanical and technological that 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.
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.


 
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