Gunner's Blog

Camp Fallujah, central Iraq
Written by: An Anonymous "Navy Surgeon"

The hot dust descended on us yesterday. Through the day the winds blew furiously although the air was so hot you had to wear sunglasses just to protect the eyes from the heat not to mention the sand. Nothing moved most of the day.

After dinner most of the medical staff was sitting listening to one of our twice weekly lectures when a corpsman opened the tall plywood door of the "overflow area" and told us we had injuries incoming. Twelve, maybe more Marines were injured by a vehicle borne IED which had lifted the 7 ton truck off its wheels with the explosion.

We quickly assumed our positions and used all the staff we had to man up the triage tents outside the clinic and all the trauma tables we had available inside the clinic. Within minutes a 7 ton truck loaded with injured Marines rolled up into the dust. Stretchers came off of the truck in every direction nearly simultaneously and the hateful sounds of the badly injured and dying could be heard, felt and instantly understood. I ran from stretcher to stretcher to triage, sort out the incoming in a minute, no more. I marked on their foreheads 1, then 2 then 3 for the beds I wanted them to go to. The walking wounded gimped in holding their injured arms or sides and crying with tears coming down their blackened faces. At first look it was apparent most all the patients had grotesquely blackened faces from 2nd degree burns. Most all were breathing now but were crying out in a way we sensed meant their airways were closing down on them. And most all were women. We received 15 Marines hurt all but two were women.

The 7 ton truck that was hit was transporting women Marines responsible for performing the pat downs of the Iraqi women who present at the checkpoints in town. Being "culturally sensitive" the Marines opted to have women do the pat downs of the Iraqi women for explosives and weapons. Our female corpsmen at the trauma center had been part of this team and had been riding this truck to and from the city just weeks prior. A vehicle borne IED with a suicide driver drove a car into the truck on the main highway leading from the Camp to Fallujah. In the car the insurgents had packed many cans of propane in addition to the explosive charges. The force of the explosion was so great it caused the 7 ton truck to fishtail and roll off the road in a blast of flames. As the survivors hustled to help the injured they came under small arms fire and the Marine I placed in trauma bay #1 was hit with gunfire through his back and into his chest.

This Marine was a very big man and it was suspected as he bent over to help one of the injured women the round snuck around the rear SAPI plate of his flack jacket and entered his chest via his left scapula. He went directly into the operating room. His chest tube drained over a liter of blood. A thoracotomy and resection of the upper lobe of his left lung was performed by our surgeons. They took out the shredded tissue that was his upper lobe and closed him for transport to Baghdad. He had lost a significant amount of blood and we transfused him with 6 units of packed red cells before we initiated the walking blood bank for a whole blood transfusion.

Another team of doctors led by our Emergency physician worked on trauma bed two, a young girl with no pulse. She arrived about 10 minutes after the first group of patients had been sent into all the trauma bays. A Humvee pulled in with a Marine yelling for help hanging out the windows. The back door of the vehicle was flung open and a poor young girl with a horribly swollen head lie there bleeding. We rushed her into the trauma center and made way for her in trauma bay #2 by displacing the patient who had been there and who was slightly better off. This female Marine had a penetrating fragment injury to her neck midline just above where her throat protector would be expected to be. She had another wound to her jaw that damaged the lateral third of her tongue sending clots of blood into her throat. The anesthetist had a difficult time intubating her but did eventually get air moving into her lungs. Her heart was in asystole on our monitors and after a few more minutes of convincing ourselves this poor young girl was pronounced dead, 21 years old. Later we thought the injury to her tongue may have penetrated her brain, causing her death.

Two girls with blistering facial burns and inhalation injuries needed to be emergently intubated. They were sedated and tolerated the intubations well. We moved all our respiratory complicated patients into one room we designated our ICU with a nurse to watch them on monitors. Three others had similar injuries of terrible burns to their faces and hands with inhalation injuries on oxygen now with face masks. We held off intubating them as the helicopter wouldn't be able to accommodate easily all 5 with intubation requiring vents or corpsmen "bagging" them. Besides, we only have 4 ventilators. One girl had a huge open laceration to her right thigh as well that was packed and just oozing blood.

Three more were hospitalized to monitor and to provide pain control. They all had badly burned hands. We applied silvadene dressings and wrapped them in gauze, started IV fluids, gave them morphine and went back to the more seriously injured patients. Four others were triaged as minimal injuries and were sent to a Battalion Aid station to be sutured up and looked over. They were loaded into a Humvee and sent off to clear the beds in case more injured came in later. One other we xrayed, rehydrated and consoled before we sent her to her barracks to follow up with us in the morning.

The weather was not in our favor. Due to the dust we waited nearly 4 hours before a helicopter could be sent to pick up the patients who needed urgent surgical skin grafting and ICU monitored care. We talked about ground convoys for a while but waited patiently until nearly midnight when a helicopter was finally able to travel in the waning dust. We packed 5 badly burned women with inhalation injuries onto one helicopter and the other helicopter carried the Marine straight out of our OR to Baghdad.

Four other women were brought back to our mortuary affairs tent bypassing the trauma center, KIA. At 0230 we received a message from Baghdad that the big Marine, the truck driver who was shot leaning over a wounded fellow Marine in the road, died of his wounds in their ICU. A total of six young Marines, 5 women and the male 7 ton truck driver were killed tonight.

In the midst of this chaos a two year old boy who had fallen down and struck his head and who was somehow connected to activity at the Marine checkpoint came in with his Father and Uncle. The little boy was alert and crying when we took him away from the Father to examine him. We examined him thoroughly and found nothing amiss. We declared him well and put him back in his grateful Dad's arms. We reassured the Dad through our interpreter and we were more grateful than the Dad was that he did need a tremendous amount of our sparse energy at the moment.

Our female corpsmen were very upset seeing the death and injuries of these girls tonight. It was thought to have been a well planned attack with the combination of a suicide bomber on the route and small arms fire to follow. It was further thought to have been a deliberate attack on the women's 7 ton truck as so many other trucks had just passed through the area. The terrorists know Americans and know our special sensitivity toward harming a woman in our culture, and they exploited that as a weakness.

The new day started quietly and with a clear sky. I walked slowly over to our laundry service and stopped to note the olives growing ever larger on the tree, reassuring me further that time is truly passing here. I turned in my laundry and talked to the Philippino laundry workers who had heard of the deaths and expressed their condolences to me. Back at our room we all tried to shake it off.

Unfortunately we got little time to sit and reflect and later that afternoon a Marine corporal came in with a severe lower back contusion in a great deal of pain. An Iraqi civilian's car had raced in front of the Marine's Humvee and tried to slow it down dramatically by jamming its brakes on in the highway. The Humvee crashed into the rear of the car and the Marine our patient was the Gunner sitting atop in his turret which swung wildly hitting him in the lower back. After a good examination and xrays of his lumbar spine we elected to keep him overnight for pain control. There were two Iraqi brothers in the car and they were brought in under confinement. The Marines brought them to us as well as they complained of hitting their heads while their car crashed to a halt. One brother had a large occipital laceration, on the back of his head that needed sutures, and his brother needed IV fluids for rehydration but not much else. They both wore goggles and scuffled a bit with the Marine guards as they came in. It was the second time these two had been picked up trying to stop the progress of a convoy probably trying to set them up for small arms fire. We discharged them to the detention center.

Just moments after the PUC's left another message was relayed to me that a Marine corporal was incoming with a severe head injury from an IED blast. We waited patiently in the triage area under the overhang that was built for us by the Seabees. It was hot and very windy, an odd sort of combination. The eucalyptus trees swayed in the breezes. The dust blew across the gravel lot. The corpsmen stood in small groups with their latex gloves on waiting to run out and bring the stretcher in to start the care that may save this patient's life.

A half back Humvee, with its back cut off giving the look of a pick up truck, came skidding into the lot. The patient stood up in the back of the truck with a blood soaked bandana over his head and looked at us in an odd sort of way. The Marines were packed into the back of this truck and their weapons were in the way of the patient being able to sit down onto the stretcher. His comrades in the truck sort of twisted him by the shoulders and he fell down on the stretcher so we could pull him down off the Humvee. He could not speak words to me, and we grabbed the blood soaked bandana and kept it in place over the left temporal area of his head. He spontaneously could open his eyes and he was breathing. Quickly the corpsmen hustled into trauma bay #1. We gave him a Glasgow Score initially of 12 or 13 when he entered. He was intubated via rapid sequence. I felt the endotracheal tube pass under my fingers as I applied cricothyroid pressure on his neck. He had no other injuries. We put in a foley catheter, and looked quickly at his wound on his head. It was an open skull facture at least 2-3 inches in diameter. Bony fragments we saw stuck to the bandana as we pulled it off his head. Someone brought his kevlar helmet over to us to look at it. It had a 2-3 inch diameter hole blasted in the left side above where you would expect his ear to be. The desert colored straps and cloth on the helmet was stained a deep burgundy color with blood clots caked on the inner surface of the helmet. We gave the patient IV mannitol in repeated doses and estimated in the 10 minutes or so that we watched him his GCS had dropped to 8-9. His pupils were sluggish now and were becoming more constricted. He had a severe head trauma and needed a neurosurgeon and a CT to assess what damage was happening and had happened to his brain. He did have a large hole in the side of his head to allow some pressure to escape but the pressures were surely mounting in the other side of his brain. His pulse had been only in the 40's at presentation, a Cushing effect it is called, as the brain adapts to increasing intracranial pressure by lowering the heart rate and raising the blood pressure somewhat. The dust again was not our friend and kept him grounded with us for almost an hour and a half before we were able to send him to Balad to the Air Force neurosurgeon and ICU. He sat there in relative peace with his ventilator on, in his hot pocket for the helo ride, IV's dripping in with his chest rising and falling to the sound of the ventilator. His commanding officer stood by the door of the room and paced as we waited for the medevac and debated sending him via convoy. The convoy might take 3 hours, the helo ride 20 minutes. Finally he was carried out and slid up into the back of our Humvee ambulances. I sighed as the helo could be heard flying out to Balad with this Marine aboard, another poor young kid who was very unlucky.

A Marine Corps Major General stopped by the clinic unexpectedly later in the evening and we talked for a few minutes about the recent increased activity at the trauma center. He was a nice man who gave me a pat on the shoulder and thanked me for caring so much for the patients. I appreciated him coming in to talk, and I especially appreciated the fact he had left his entourage at home and had not told anyone he was coming making it a more meaningful visit as I was concerned. The rest of my shift was uneventful and as I turned over the watch a messenger came down to tell us he had word of at least 6 more injured incoming, another IED attack. We mobilized the entire staff as we thought there may be more injured than advertised. We all waited in the darkness under the triage overhang and after an hour or so the crowd drifted inside to sit in the coolness of the clinic and nap a bit. After almost 2 hours we dispersed thinking it must be a false alarm. I walked across the street to the barracks tired, dreaming of dreaming.

We had been asleep for 15 minutes or so when the knocks on the door woke us and got us up and lacing our boots and running back to the clinic. A total of 5 patients were brought in, all Iraqi ISF soldiers. One was critical, the rest were ambulatory. Omar was there to help us get all their names. I took care of two brothers from Najaf. They had minor lacerations on their fingers and small 2nd degree burns on their calves and thighs. They were skinny, had terrible teeth and were 21 and 23 years old. The dust on their hair made them look falsely older and as they talked the dust floated down onto their shoulders. They didn't seem to even notice the dust in their faces. The critically injured patient was very badly burned by the IED. They were passing on a bridge over a canal near the city of Zaidan, in the rural countryside outside of Fallujah. There were 11 soldiers riding in the back of a half back Humvee. The fireball that occurred only mildly injured everyone on board with exception of the one patient we had in our trauma bay. An Iraqi officer who was standing nervously in our hallway told us he had seen the patient go up in flames and jump off the bridge into the canal to extinguish the burning flames. The rest of the crew had pulled him out and he was alive when he got to us. We very quickly intubated him with the probable inhalation injury and his chest was rising and falling with the ventilator. His native olive skin was ashen, blackened by the fire. He had second and third degree burns totaling 77% of his body surface area. The rule of 9's applies when estimating the burns on a trauma patient, 9% for each arm, the head, 18% for the trunk, etc. The percentage of patients to survive a burn of 77% of body surface area may only be 10-20 % or so, in a good burn referral center. We had low expectations for him. We put in a central IV line and poured fluids into him. We use the Parkland formula for estimating fluid resuscitation of burn victims, named for the hospital in Dallas that created the concept, and he needed every cc we could pour into him now. We called for another helo to take this critically injured soldier to care at Baghdad and the others we sent home with splints and silvadene dressings. As the Iraqi officer left he shook my hand and placing his left hand over his heart he thanked me for taking care of his men.

It was past 0200 when we flipped off the lights again to think about sleeping. At nearly 0500 we were woken up again to see a patient who had come in quickly with a massively bleeding gunshot wound to his neck. He was quickly taken into surgery where his external jugular vein was ligated and the hemorrhage was stabilized. The patient was an Iraqi civilian, at 0430 racing through a checkpoint, his car full of false identification cards. We set up quickly the walking blood bank for him and got the 10 donors he needed in a number of minutes, his blood type was O+, the most common type. He was medevac'd as the day began and we didn't have the energy to think twice providing care to this patient, probably an insurgent, but always too hard for us to distinguish precisely.

The new day was bright and beautiful but we could only think of our cool room with the sandbagged darkness and sleeping this day away, preparing ourselves for another night like the two before it. Life reorders itself when you need sleep badly. We debriefed the activities of the past several days after we woke up, and went to Mass in the early evening luxuriating in the cool chapel thinking about anything to help untangle the mess of violence we had been subjected to in recent days.

And as we go to sleep tonight I prayed that this night we will not have to see the death of, or bad injuries again to the young men and women we have grown to care so very much about. At least not tonight.