----- Original Message -----
A fitting follow up
to Bob Kaldunski's article.
Joliene
Olson
The Last Full
Measure.
5/30/2005
By Col. Brett Wyrick
USAF
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. 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.
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