email from Iraq

Steve Gilliard posted the following email from a medical professional stationed in Iraq. I think it should be required reading. Unfortunately, with all the MASH reruns, we have forgotten the horror that attends this sort of grueling but necessary work:

This is an e-mail a reader sent me. It's from a friend of his in Iraq

The daily news reports are somewhat antiseptic and it's easy to lose track of the meaning of the words. Those in our positions should not.This is a note I received this morning from a colleague working in Iraq. This is what it's like. Today. Last week. I've taken the ID off of it, but it's a trustworthy source from my immediate sphere of friends and I know him well.

GSW is gunshot wound. EPW is Enemy Prisoner of War. IED is Improvised Explosive Device (a roadside bomb). KIA is Killed in Action.

Subject: Casualty reportHello,How is everyone at [Deleted]? I suspect things are all still going well and the clinic continues to run smoothly. Apart from a sighting of the bat in the bat cave, things in general are about the same out here. The bat was a trip, as it flew around in circles in the hooch like, well, a bat out of hell I guess. The casualties picked up some this week which was too bad, and we had one day in particular which was a bad one. Otherwise life out here has developed a routine, and it seems as though the time is starting to go by faster. The team itself is getting better and more efficient with each resuscitation, and we all seem to work well with each other for the most part. Our surgeon, although for the most part a really good guy, can get a little uppity sometimes if things don't go exactly how he says they should (he seems to think the only person in the room with any clinical judgement is him), but even that isn't really a big deal. It's just a bit of an adjustment stepping out of the role of being in charge and being the boy again. I'm good at being the boy and can do what I'm told as well as anybody else, but it has been a bit of an adjustment.

Anyway, I thought I'd drop you a line to let you know we've seen over the last couple of weeks or so.I'm not sure if I told you about the family who came in I think a little over a week ago (time out here is a weird thing and hard to keep straight). The story is a little muddled, but apparently they ran a check point. It's unclear whether they confused stop with go or if they were really running the check point, but regardless of the specifics they ran a check point and were taken under fire by a combination of M-16's and at least 1 50cal machine gun. The car was apparently a wreck and we had 5 casualties come into us. There were apparently 2 or 3 KIA at the scene, including a young child who I think was 8 (they don't bring the civilian KIA in to us thank goodness). The guy I took care of had his right foot nearly taken off by a 50cal round. It was hanging by tissue and sinew, and ultimately got amputated. Apart from now being a legless old man, he otherwise did fine. The other casualties included an old woman with a GSW to the L chest who had a large L sided hemothorax with 800cc of bloody drainage. She eventually developed respiratory distress and got intubated, but otherwise didn't have any injuries. She was transferred to Al Asad, but I have no idea what happened to her after. Another woman had a GSW to her L flank, and despite maybe having a hemotoma around her L kidney on FAST exam was otherwise hemodynamically stable and did fine while she was here. Another guy had a GSW to his L shoulder and developed a tension PTX (picked up on follow up exam as subQ air). He had a chest tube placed and his shoulder dressed and did fine while he was here. He was also sent to Al Asad. The 5th guy had a some superficial wounds but did fine.

We had a couple other Iraqi civilian/EPW casualties related to check point violations around the same time (I'm not sure if this was because the Marines have been jumpy recently, or there was some kind of insurgent offensive going on).One guy was driving a water truck and had both feet nearly completely taken off by a 50cal round. Impressive injuries which shattered the bone and left his L foot dangling, but he was amazingly neuromuscularly intact. He kept both legs, and after having on external fixater placed on his L leg he was sent to Baghdad for definitive repair. Another guy had several GSW to his chest but had amazingly had no significant injuries and didn't require any procedures. Bullets are funny things and seem to have a mind of their own sometimes.

And the last Iraqi civilian was a poor old woman who came in last night at around 0400. The Marines were apparently conducting a house to house search, and this woman didn't answer her door right away. Can't blame her really because at 0400 we didn't answer our door right away either when they came to tell us about her. She apparently did answer, but not in time, for as she was reaching to open the door the Marines blew the lock with a shotgun. It appears as though she took most of the shotgun blast to her L arm, for when she came in the L distal L humerous and proximal radius were shattered with no complete loss of structural integrity to her L arm. Although the arm was vascularly intact, she had no sensation and ended up losing the arm. I got to intubate her in the OR, but otherwise all of these stories are pretty tragic and sad, and events like these unfortunately will not go far in the campaign to win the hearts and minds of the people. It's difficult to really explain the emotions they conjure (other than sadness I'm not sure I had to many), but one question comes up over and over again when I see these types of accidents- "What the fuck are we going out here?" I guess that's not really for me to ask right now though. I don't place any blame on the Marines for this stuff. They are doing their job, and if I went out everyday with the prospect of getting killed by an IED or some other unseen enemy, I would most assuredly shoot first and ask questions later in the wake of any suspicious activity. It's a dangerous place, and one can only hope that it gets better over the next few years.

We've also unfortunately had some Marine casualties. On Monday (at least I think it was Monday), we had a slew of them. We got two guys initially with superficial shrapnel wounds sustained when their Humvee was hit by an IED. They had minor wounds and did fine.

About an hour later we got two Marines from different locations. One guy had taken a head shot by what people think may be a sniper out there. He had a GCS of 3 and was initially intubated, but after a more thorough exam was found to have a transcranial injury with a fixed and dilated L pupil and was triaged to expectant. He was given morphine for comfort care, and eventually died an hour later. The second guy ran over a mine in his Humvee. He had some facial burns and had sustained by bilateral lower extremity wounds. His R leg was twisted at impossible angles and pulseless, and had open fractures to his L foot and I think he may have and an open femur fracture. He was intubated for airway protection in light of his facial burns and had a disarticulation of his R leg at the knee, the L leg was just splinted, and he was transferred to Baghdad. Apparently they fixed his L leg somehow, and Pete is probably now taking care of him in Germany.

While that guy was in the OR we got a call about another guy who was coming in as an urgent surgical (really sick). He unfortunately had also sustained a head shot from a sniper (who knows if it was the same one or not), and he died before he got here. When we saw him, the back of his head was shattered and you could feel the bones floating around. While moving him into the body bag, his bandage slipped off his head, and I found myself looking into the young man's eyes. He had big green eyes, and appeared to be looking right through me. What he was asking me I don't know, and will probably never know. Although I had his blood all over my boots and pants and was a bit shaken as I was washing it off, he has not haunted me the way some of the others have, so I don't think he was angry with me in any way. It was a bit disturbing and capped off a shitty day.

The last 2 Marines we had come in the other day. Their tank was hit by some kind of missile, and I think these were the guys up in the turrets. One guy came in KIA with the left side of his face blown away, and his left arm missing. I didn't go see this guy (I don't know but maybe I needed a break). The other guy came is with an open fracture of his L humerous with exposed muscle and the like all up the back of his arm, and open fractures of several of his R metacarpals with avulsion of most of the skin off his R hand. He had a small L neck hematoma and some superficial facial lacks, but he had a GCS of 15, was talking to us, had bilateral breath sounds and was hemodynamically stable. Our anesthesia provider and I both thought his airway was intact, and felt that although he needed to go to the OR for debridement and the like, he was not in need of an emergent airway. I suppose because of the neck hematoma, our surgeon disagreed and started to tell us to intubate him in that pompous holier than thou kind of way all surgeons seem to have. Despite his urgings, we took the opportunity to finish our exam before placing the ET tube, to which he took further exception. The guy eventually got intubated and went to the OR for a successful debridement of his wounds and arrived in Baghdad without incident. The surgeon, however, made a big deal about us not following his instructions to the letter when he told us to, sqwauking about he was the resident expert on trauma (he is), how we were making him look bad in front of the corpsmen, and how we were hurting his feelings by questioning his clinical judgement (like we don't have any of our own).

We had a meeting about the whole thing which resulted in people deciding that because he is the resident expert we will do whatever he tells us to do. Hence my earlier comments about being the boy. I guess that's just surgeons, but the fact that he cried like a woman because he didn't get his way irked me for a few days. He's really a good guy and I've gotten over it. I'll just be the boy. I am the junior guy with the least experience in this stuff after allAnyway, that's all I have for you guys. I hope you are all well. I'll keep sending periodic updates about what is happening over here. Hopefully things will slow down some.