The Chinook helicopter flies low and fast and banks hard to the right to show us her belly before landing. Inside, a medical emergency response team (MERT) of Army nurses, medics and a physician are desperately trying to keep a grievously wounded U.S. Marine alive.
The report came in 20 minutes earlier: “ISAF male, bilateral amputations, failed cricothyrotomy in the field followed by intubation on the helicopter, now in cardiac arrest with CPR in progress.”
I don’t normally feel tension during the offloading of a patient but every additional second in that helicopter means more dead brain. This is what it feels like to be a surgeon in the Helmand Province of Afghanistan in 2013.
I go inside to put on my scrubs. I know I won’t have a major job in this case, but I run the game plan in my head. I need to get a feel of those tourniquets to see if they need to be replaced or tightened. Check to see if he has a pelvic binder and if so, is it in the right place? Check his neck brace. Check the dressings for bleeding, and be a hand for the guys who are about to pry him open like a sewer cap.
We get him off the stretcher as the MERT team leader barks out vital signs. The medics are working very quickly. As the patient is moved over to the table on his back, I see he has a pelvic brace in place. It is low over his hips and doing its job. I see no open wounds to his penis, scrotum, or hips. I can see a big skin flap lying over his groin. Someone splashed sterilizing iodine on his chest.
Meanwhile, our trauma surgeon Scott is furiously cutting through his fifth and sixth ribs with our largest scalpel. I am standing right next to him with the Finacetti retractor that will keep his chest open. Meanwhile, our most senior trauma surgeon who had no time to scrub in is above the patient with only sterile gloves on. Once we see some daylight in the chest, I put the retractor in and crank it open.
J.R. starts on the right side with scissors, but he can’t cut through the patient’s sternum. He asks for a bone cutter, but the nurse on the back table doesn’t have one. People start yelling for a bone cutter or bigger scissors. I tell one of the other orthopaedic surgeons who isn’t scrubbed in to get us something. I grab a mallet and Lebsche knife and hand it to J.R. By now he has almost gnawed through the sternum with the blunt scissors, and the chest is open from armpit to armpit in about 60 seconds.
Scott cuts into the lining of the heart and no blood comes out. He begins massaging. “It’s not full,” he says. I see a flutter of movement but nothing that I would call a beat. I can see the shape of his heart with veins and coronary arteries contracting when Scott squeezes it with his hands, which look particularly small around it. Then I realize this guy is thick. His heart is the size of a small chicken. For a moment, I’m struck by it. Parts of the top show its yellow fat.
Fluids are being rapidly infused now though something we call a belmont line that has been moved from the patient’s left arm to left chest. In all the commotion, the belmont was wheeled to the foot of the bed, so the line is now blocking the back table behind me where all the instruments are held. This annoys me. I look at the patient’s neck brace again. It’s in place with a bloody dressing underneath that is holding his neck in line.
The Marine’s face is burnt black with crusted blood and dirt from the explosion. He has a goatee with grey hairs. Scott has had one hand above and one hand below this guy’s heart squeezing it every second or so for about three minutes. He says that the heart feels fuller and that we can slow down on the belmont.
Scott adjusts his hands for a moment. J.R. reaches across the table and puts his right hand on Scott’s. Scott looks up at him and pulls his hand away. J.R. flicks the left atrium with his index finger and the heart contracts a few times in a row. I am frozen. He flicks the atrium again and it starts to fucking squeeze and beat for about 30 beats. He flicks it a third time and like a damn lawn mower it just fires up. It’s beating with a coordinated pattern now at about 80 beats a minute. The heart is working now. I put my hand on J.R.’s arm like I had just seen a damn miracle. That heart has fucking light beams coming out of it now. I felt and heard its power.
I pull back the patient’s only sterile drape to look at his legs. His broken legs are like wet noodles below the knees with dressings on. He has combat tourniquets placed high on his thighs. I check them and they are tight. I don’t see any bleeding through the dressings. I put my arm around his thigh to check again for bleeding. The weight of his leg is noticeable. The intimacy of the maneuver even strikes me. I push his scrotum north and pull on the big piece of torn skin. No bright red blood, only exposed muscles. There is no injury to his chest. We have a short discussion about pushing epinephrine to try and stimulate the heart. We push it.
J.R. and Scott begin to open his abdomen using a new knife. Once in, I can smell the rotting tissues. They find no injury to his small or large bowels and there are no obvious bleeding problems inside the peritoneum. It smells like shit and the bowel looks black. As if in unison, the general surgeons sigh. “That’s not good, he has been down a long time,” J.R. says.
Sam, our anesthesiologist, has been so fucking busy since we got the patient on the table that I only now hear his voice. A tall, soft spoken, college swimmer with a big nose, Sam is now screaming for somebody to get him some damn insulin. He wants to know why it is taking so long. His fellow anesthesiologist Andre is helping him and directing traffic with the runners.
At this point, this Marine has made it farther than almost all patients. When his heart kicked back in, I had a lump in my throat for a split second. Of course, no one saw my face because I had a mask on. “We might get a win here,” I thought in that moment of delirious joy.
Unfortunately, I know that a win means getting him on a plane home to the states so his family can take him off life support. Dying in some God-forsaken wasteland like Afghanistan was not what he had planned, but neither was dying in Bethesda.
Our problem was stopping the bleeding that was pouring out of every open space — a telltale sign we’re losing him. We keep looking inside his chest, but can’t find any large bleeders. We tie off several arteries and veins. I lift up the heart to kink the major vessels and see if we missed something. Nothing. The lungs, diaphragm, bowel, liver, spleen, kidneys are not bleeding. After furiously tying off veins, arteries we thought to just close up his chest and maybe it would stop the bleeding. Just as we had some big sutures around the ribs, closing it up, his rhythm dropped off into what I knew was an agonal, junctional rhythm. He was running out of gas and everybody knew it.
“Does anyone think we should continue on?” asks the Deployed Medical Director, a British Navy captain who had been watching the surgery along with nearly a dozen others, including a general. “He has received units of blood, platelets, and life saving drugs. He was down for 40 minutes before return of spontaneous cardiac rhythm. He is bleeding uncontrollably out of everywhere.”
Nobody says a word.
I feel rage. A child hearing his mother walking to the TV room before dinner time knows this desperation. They often beg. But this time, there was no begging. My feet were soggy with the Marine’s blood and my thighs chafed from wet scrubs. I’m angry and frustrated we are quitting.
We move instruments between our hands without making eye contact. I finally look at Tom, a British trauma surgeon of multiple deployments who looks like a 50-year-old version of Eddie from The Munsters.
“At least he could have his guys with him when he dies,” I say.
Tom, who breathes and sleeps for patients, looks at me with his big eyes. “Say it again.”
“If we are going to let him die, then why don’t we go and ask his guys down the hall if they want to be in here when he dies?”
The captain immediately shakes his head.
“There is way too much blood in here,” he says. “This isn’t the place for somebody to see.” I hear him tell someone else that was how “people get PTSD.” I start to walk off when another surgeon reminds me, “You are an orthopaedic surgeon. It’s different. He’s not you.” I was halfway to the locker room at that point. I was changing when someone asked me about what happened, and all I could say was “bullshit.”
I tell myself later that it’s not my fault. The truth is that I couldn’t save him and too many others in Afghanistan. Yet some nights when I’m back home in Colorado, I wake up and think about that Marine on the operating table. I think about his wife and children. And I wonder if their pain will ever subside.
They and other military families who have lost someone should know that someone was holding the hand of their son or daughter during that difficult time. I feel guilty for not being there. Caring too much sucks sometimes.
I wish I would have had the strength to walk back over to stand with him. I feel good about having the balls to say my peace, but on the day of my judgment, when I stand before God, will he ask me why I didn’t stand with this Marine? Will he look at me like I could have done more?
Only circumstance brought us together and he was one of many deaths I saw. But we should have given his team the opportunity to be with him.
What gives us the right to not even offer this to them? The situation was grim in the operating room, but we’d have no reservations about having those guys with him on the battlefield. Those friends down the hall were the closest thing he had to family that day.
Years have passed and with each surgery I still think of that Marine. We saved many others. But I remain broken hearted and think of him each Memorial Day. He is with me and gives me strength. I think one day we’ll meet. All I can do then is thank him for what he has taught me.
Dan Possley is an orthopedic spine surgeon in Denver, Colorado. He was a U.S. Army Major. He loves taking care of people, especially veterans. Contact him at firstname.lastname@example.org or www.drpossley.com.
Featured image: U.S. Marines and corpsmen with 3rd Platoon, Company I, Battalion Landing Team 3/8, Regimental Combat Team 8, medically evacuate Afghan civilian Ghamay Ghilgi, brought to 3rd Platoon’s patrol base in Kakar village, Helmand province, Afghanistan, March 7, 2011, onto an International Security Assistance Force helicopter. Ghamay, a local farmer, was injured by an insurgency improvised explosive device. The Marines and sailors see locals approaching them for help as a positive sign of eroding support for the insurgency. Elements of 26th Marine Expeditionary Unit deployed to Afghanistan to provide regional security in Helmand province in support of the International Security Assistance Force. (Photo by: Lance Cpl. Kevin Hassett)