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Death and Life in Iraq

Death and Life in Iraq I knew that if he wasn’t already dead, he soon would be. We have been in Iraq’s Sunni Triangle, midway between Fallujah and Ramadi, for more than four weeks. Have treated about 60 combat casualties, both American and Iraqi, and most of us knew that sooner or later this day would come. Around 1600 hours, word comes that there is a US Army soldier, shot in the back, being flown in from Ramadi. He is receiving CPR on the flight. We head to the tents that make up our ED and our ORs and wait. I think back to my trauma surgery fellowship at Tulane University and the fabled Charity Hospital in New Orleans. I recall once turning to my surgical mentor in the Accident Room and commenting that it seemed to me that all trauma patients getting CPR on arrival died. As he frequently pointed out when asked such things, he replied, “Yup. But show me the data.” Being the wily old trauma surgeon that he is, he already knew.1 But I fell for it: I looked at our data, and eventually I did show him. They didn’t all die: 0.9% survived.2 Hence the surgical truism that if you haven’t seen it, you haven’t yet seen enough cases. On his arrival, we take the soldier straight to the OR, where we find that he has a lousy blood pressure and a palpable carotid pulse. A thoracoabdominal wound is high in his right flank, in the one spot not covered by body armor, and there is no exit wound. He was reported to be paralyzed from the waist down at the scene. He was intubated and a right chest tube, with minimal output, was placed at the Battalion Aid Station before the helo arrived to pick him up. We rapidly open his abdomen to look for the source of bleeding. While the bullet has traversed his diaphragm and liver and entered the spine, there is only a couple of hundred cc’s of hemoperitoneum, no active bleeding, and his blood pressure is now no longer measurable. Joe, the oldest, wisest, and best of us three general surgeons, proceeds with a left thoracotomy. This is done rapidly, and the descending aorta is cross-clamped. The pericardium is incised, and I start manual cardiac massage. His heart is empty and fibrillating, his aorta is flat: he has exsanguinated. All three of our anesthesia colleagues—Mike, Jeff, and Tim—are hanging blood, bagging, pushing vasopressin and epi like they’re on sale. As I do the compressions, I can see this young man’s unlined face. His heart begins to beat again on its own. I transect the sternum with the sternal knife, while Joe and John, our young surgical all-star, move to the right side of the table. The “clamshell” thoracotomy is completed quickly. He has almost no blood in the pleural space, but the right lung, pierced centrally by the bullet, is completely filled with blood. He has bled out into his lung, not into his pleural space. At this moment, Tim tells us that he can no longer bag the patient and there is arterial blood coming up the endotracheal tube. A clamp is placed across the right lung hilum, effectively isolating the lung and stopping the hemorrhage. But his heart fibrillates again, and cardiac massage is recommenced. The pneumonectomy is rapid, but this time there is no coming back. After 20 more minutes of manual cardiac massage, frank asystole, it is over. Darkness, both physical and spiritual, descends upon our unit. Many, both physician and nurse, have never seen anything like this. Despite years in medicine, some have never lost a patient. Some of our Navy corpsmen, as young as 18, have never seen death and appear to be in shock. Our first death, and a very graphic one at that. I can tell them that they did everything right, that there was nothing we could do, that at the best level I trauma centers in the States the outcome would have been the same. They nod, their ears hear the words, but their eyes show that many do not yet understand. People talk among themselves, they decompress in various ways, but it takes days for the pall to lift. As the only trauma surgeon in our unit, I am probably the most jaded of us all. Between trauma fellowship and every-third-night trauma call for most of my residency during the previous millennium, when the 80-hour week was still a dream to the residents and a nightmare to the staff, I have seen my share of death in the ED and on my OR table. I have seen enough trauma victims die that it is no longer a shock, and I have lost a few “good guys” in my time. I regret that he is dead, but I do not take it as a personal failure. As I flippantly tell my residents, “Remember that you’re not the one who shot him!” But this one was different. We never spoke to him, but he truly was one of us, an American soldier, a brother. And this was a milestone for our unit: some had never lost a patient; some had lost patients but never a “good guy”; some had never before seen death. For some, the war suddenly became real. As in Kurosawa’s Rashomon, we all saw the same thing and yet we all saw something different. But whatever we saw, it is now a part of our collective consciousness and from this day forward, we are truly a team. A month goes by. In that time, we have seen many more patients; we have had mass casualties, as many as 19 patients in an hour. Another casualty with a thoracoabdominal gunshot wound arrives receiving CPR. As we open his chest, dark blood is literally pouring from the wound at his right costal margin. Again the outcome is predictable. Around the room there are somber faces, grim determination, even resignation, but the eyes are different. Now they understand. The darkest of humor has emerged in conversation. To borrow from our Civil War predecessors, “They have seen the elephant,” or at least that part in which he holds his medical baggage. We do our best, but we now know that our best may not be good enough, we must learn from it and move on. I knew in my heart before he arrived that if he wasn’t dead, he soon would be, the odds were so much against him. But 99.1% mortality is not certain death. When our soldiers and Marines face the bombs and the bullets, they need to know that we will do everything we can to save them. We need to know it. And next time, we will see that soldier who is the one percent. Back to top Article Information Disclaimer: The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Navy, the Department of Defense, or the US government. References 1. Hopson LR, Hirsh E, Delgado J. et al. National Association of EMS Physicians Standards and Clinical Practice Committee; American College of Surgeons Committee on Trauma. Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest. J Am Coll Surg. 2003;196:475-481Google ScholarCrossref 2. Stockinger ZT, McSwain NE Jr. Additional evidence in support of withholding or terminating cardiopulmonary resuscitation for trauma patients in the field. J Am Coll Surg. 2004;198:227-231Google ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Death and Life in Iraq

Stockinger, Zsolt T.
JAMA , Volume 294 (1) – Jul 6, 2005
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References (2)

Publisher
American Medical Association
Copyright
Copyright © 2005 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.294.1.17
Publisher site
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Abstract

I knew that if he wasn’t already dead, he soon would be. We have been in Iraq’s Sunni Triangle, midway between Fallujah and Ramadi, for more than four weeks. Have treated about 60 combat casualties, both American and Iraqi, and most of us knew that sooner or later this day would come. Around 1600 hours, word comes that there is a US Army soldier, shot in the back, being flown in from Ramadi. He is receiving CPR on the flight. We head to the tents that make up our ED and our ORs and wait. I think back to my trauma surgery fellowship at Tulane University and the fabled Charity Hospital in New Orleans. I recall once turning to my surgical mentor in the Accident Room and commenting that it seemed to me that all trauma patients getting CPR on arrival died. As he frequently pointed out when asked such things, he replied, “Yup. But show me the data.” Being the wily old trauma surgeon that he is, he already knew.1 But I fell for it: I looked at our data, and eventually I did show him. They didn’t all die: 0.9% survived.2 Hence the surgical truism that if you haven’t seen it, you haven’t yet seen enough cases. On his arrival, we take the soldier straight to the OR, where we find that he has a lousy blood pressure and a palpable carotid pulse. A thoracoabdominal wound is high in his right flank, in the one spot not covered by body armor, and there is no exit wound. He was reported to be paralyzed from the waist down at the scene. He was intubated and a right chest tube, with minimal output, was placed at the Battalion Aid Station before the helo arrived to pick him up. We rapidly open his abdomen to look for the source of bleeding. While the bullet has traversed his diaphragm and liver and entered the spine, there is only a couple of hundred cc’s of hemoperitoneum, no active bleeding, and his blood pressure is now no longer measurable. Joe, the oldest, wisest, and best of us three general surgeons, proceeds with a left thoracotomy. This is done rapidly, and the descending aorta is cross-clamped. The pericardium is incised, and I start manual cardiac massage. His heart is empty and fibrillating, his aorta is flat: he has exsanguinated. All three of our anesthesia colleagues—Mike, Jeff, and Tim—are hanging blood, bagging, pushing vasopressin and epi like they’re on sale. As I do the compressions, I can see this young man’s unlined face. His heart begins to beat again on its own. I transect the sternum with the sternal knife, while Joe and John, our young surgical all-star, move to the right side of the table. The “clamshell” thoracotomy is completed quickly. He has almost no blood in the pleural space, but the right lung, pierced centrally by the bullet, is completely filled with blood. He has bled out into his lung, not into his pleural space. At this moment, Tim tells us that he can no longer bag the patient and there is arterial blood coming up the endotracheal tube. A clamp is placed across the right lung hilum, effectively isolating the lung and stopping the hemorrhage. But his heart fibrillates again, and cardiac massage is recommenced. The pneumonectomy is rapid, but this time there is no coming back. After 20 more minutes of manual cardiac massage, frank asystole, it is over. Darkness, both physical and spiritual, descends upon our unit. Many, both physician and nurse, have never seen anything like this. Despite years in medicine, some have never lost a patient. Some of our Navy corpsmen, as young as 18, have never seen death and appear to be in shock. Our first death, and a very graphic one at that. I can tell them that they did everything right, that there was nothing we could do, that at the best level I trauma centers in the States the outcome would have been the same. They nod, their ears hear the words, but their eyes show that many do not yet understand. People talk among themselves, they decompress in various ways, but it takes days for the pall to lift. As the only trauma surgeon in our unit, I am probably the most jaded of us all. Between trauma fellowship and every-third-night trauma call for most of my residency during the previous millennium, when the 80-hour week was still a dream to the residents and a nightmare to the staff, I have seen my share of death in the ED and on my OR table. I have seen enough trauma victims die that it is no longer a shock, and I have lost a few “good guys” in my time. I regret that he is dead, but I do not take it as a personal failure. As I flippantly tell my residents, “Remember that you’re not the one who shot him!” But this one was different. We never spoke to him, but he truly was one of us, an American soldier, a brother. And this was a milestone for our unit: some had never lost a patient; some had lost patients but never a “good guy”; some had never before seen death. For some, the war suddenly became real. As in Kurosawa’s Rashomon, we all saw the same thing and yet we all saw something different. But whatever we saw, it is now a part of our collective consciousness and from this day forward, we are truly a team. A month goes by. In that time, we have seen many more patients; we have had mass casualties, as many as 19 patients in an hour. Another casualty with a thoracoabdominal gunshot wound arrives receiving CPR. As we open his chest, dark blood is literally pouring from the wound at his right costal margin. Again the outcome is predictable. Around the room there are somber faces, grim determination, even resignation, but the eyes are different. Now they understand. The darkest of humor has emerged in conversation. To borrow from our Civil War predecessors, “They have seen the elephant,” or at least that part in which he holds his medical baggage. We do our best, but we now know that our best may not be good enough, we must learn from it and move on. I knew in my heart before he arrived that if he wasn’t dead, he soon would be, the odds were so much against him. But 99.1% mortality is not certain death. When our soldiers and Marines face the bombs and the bullets, they need to know that we will do everything we can to save them. We need to know it. And next time, we will see that soldier who is the one percent. Back to top Article Information Disclaimer: The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Navy, the Department of Defense, or the US government. References 1. Hopson LR, Hirsh E, Delgado J. et al. National Association of EMS Physicians Standards and Clinical Practice Committee; American College of Surgeons Committee on Trauma. Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest. J Am Coll Surg. 2003;196:475-481Google ScholarCrossref 2. Stockinger ZT, McSwain NE Jr. Additional evidence in support of withholding or terminating cardiopulmonary resuscitation for trauma patients in the field. J Am Coll Surg. 2004;198:227-231Google ScholarCrossref

Journal

JAMA – American Medical Association

Published: Jul 6, 2005

There are no references for this article.