Fleet Hospital 8

   Just over a year ago, I had finished my assignment as Ship’s Surgeon on board the USS Carl Vinson, and had been deployed to sea multiple times.  My older son had been six months old the first time I left him.  Each and every time I said good-bye to my little boy, it was like an old wound being torn open again.  I would gaze at his face, touch his hair, breathe in his smell as if it was the last chance I might ever have.  I would hang on to that moment for as long as possible, then have to walk away, taking in a long  last look and saying goodbye.  It seems like an eternity will pass before you get to be his mother again.  The loneliness settles down into the depths of your heart until you think its weight will crush you.  I thought I was finished with that.  After completing my time on the ship, I was stationed at Navy Hospital Bremerton.  I was happily doing surgery at Navy Hospital Bremerton and going home to my family nearly every night, which now consisted of my two little boys and my husband.  After that tough year of deployments, I thought my life was finally settled back on track, just the way I wanted it. 

     Fleet Hospital 8 was the mobile Navy Hospital staffed and supported by Navy Hospital Bremerton.  We were the next Fleet hospital up in the rotation for deployment.  When the focus of the military action in the Middle East had shifted from Afghanistan to Iraq in late 2002, plans were made to establish the medical support that would be necessary in the event of a “conflict”.  We were assured that we weren’t going to “war” but would be participating in Operation Iraqi Freedom.  I was just starting my third year of active duty as a lieutenant commander in the United States Navy.  Living on the aircraft carrier, actually leaving home for months at a time, was the farthest thing from my mind when I signed up.  There are some people who thrive on deployments.  I am not one of those people.  Joining the military, especially the Navy, might seem like a poor choice for someone who never wanted to spend large amounts of time away from home.  But as an officer in the Medical Corps, I was supposed to end up stationed somewhere on the coast of Italy or Spain, working at a nice base hospital, traveling Europe and enjoying time with my family.  My recruitment team had assured me chances were slim that I would ever end up deployed to sea.  I don’t know what made me believe them – sleep deprivation from my long hours of work as a resident, simple naiveté, or desperate gullibility because I needed the money and wanted to believe them.  I was just into my third year of active duty and had already spent my first year deployed on the USS Carl Vinson as the Ship’s Surgeon.  I knew other doctors who had been in the military for ten years and had not deployed one time, why was I getting called upon again?  Hadn’t I already paid my dues on the ship? 

     Fleet Hospital 8 received official orders for deployment on Jan 31, 2003.  The task was to provide Echelon III level support for the casualties expected to result from Operation Iraqi Freedom.  As an Echelon III facility, we would provide definitive surgical care, post-operative care, and critical care.  We would determine who needed to return stateside and who could return to their units on the front lines.  Echelon I care was what was provided on the battlefield by hospital corpsmen deployed with the units and fellow soldiers who could apply tourniquets and simple battle dressings and get the wounded off the front lines. Echelon II support came from field stations who could provide blood, fluid resuscitation, and stabilization.  The army had their CSH (Combat Support Hospital) units set up throughout Kuwait and eventually into Iraq where initial care was provided.  The casualties would then come to the level III units.  Fleet Hospital 8 was to set up in Rota, Spain, on the grounds of Naval Station Rota. 

     Shortly after my arrival, a wave of casualties came in, mostly by helicopter.  The kid on the gurney looked like he was about fourteen.  I picked up his packet of papers that were taped across his chest as I introduced myself.  I bent down low, my face close to his ear so he could hear me.  It was noisy in triage, with more casualties being brought in and lined up along both walls.  As usual, most were orthopedic injuries, with blood-soaked bandages on their arms or legs, or on the stumps of their fresh amputations.

“I’m Dr. Sawmiller, one of the surgeons.  You’re at Fleet Hospital 8, in Spain.”

He looked scared, like he wished he was anywhere but here.     

“I don’t know how bad I’m hurt.  Am I hurt bad?  I don’t even know how bad I’m hurt,” he stammered, with a hazy, detached sense of bewilderment.  He was trying to make sense of the last forty-eight hours of his life, but nothing was coming together, nothing was organizing in his brain.  He thought he had been shot, but he didn’t know.  I could see the struggle in his eyes as he tried to comprehend what was happening to him. 

“What happened to the rest of the guys?  Where are they?”  He was just managing to hold back the panic that was threatening to engulf him.

I didn’t know much about him, and I had no information at all on the rest of his platoon.

“We’re going to take good care of you here, don’t worry,” I tried to reassure him.  “I don’t know anything yet about your buddies, but we’ll find out.”

     The information that came in with the casualties was very sketchy and inconsistent.  It mostly consisted of some hand-written notes, maybe some lab work.  Some would show up with a dictaphone device taped to them, and we would listen to a report that the doc or nurse at the CSH had quickly dictated.  The goal at the CSH’s in Iraq and Kuwait was to resuscitate and stabilize the patient and get them out.  This included any surgery that was needed to control bleeding, stabilize fractures, and do initial cleaning and debriding of wounds to control sepsis.  The casualties were then shipped to us or to Landstuhl, Germany.

     My patient was Private First Class MacGregor, 19 years old, with a gunshot wound through the buttock.  He remembered being out on patrol, walking alongside the humvees, when an IED exploded up ahead, towards the front of the convoy.  Then the gunfire started.  He couldn’t tell where it was coming from, and as he dove into the humvee, he felt this searing pain, exploding up through his pelvis.  Waves of nausea started to rumble through him, and that was the extent of what he recalled. 

     When he arrived at the CSH, a bullet wound was identified next to the anus.  As he dove head-first into the vehicle, a bullet had managed to come straight through his buttock.  The soldiers all wore FLAC jackets that protected their chest and abdomen from bullet wounds, but they were not well-protected between the legs.  This was a one-in-a-million shot, the perfect alignment of the bullet trajectory with the timing of the patient diving head-first into the vehicle, exposing his one vulnerable area.  He had an x-ray at the CSH that showed no fractures of the pelvis, so the bullet must have gone right through the soft tissues, missing the surrounding bone.  There was no mention of any exit wound.  So where did this bullet stop? I wondered.

     They had noted blood draining from the rectum, and a rigid scope inserted had revealed blood throughout the rectum.  This meant the bullet must have gone through the rectum, ripping it and causing the bleeding.  If this injury is limited, sometimes draining and cleaning the site will allow it to heal.  If there is any leakage up into the abdominal cavity, however, more extensive surgery is needed to control infection.  The surgeon at the CSH had debrided and cleaned the peri-anal wound, leaving a big drain in place.  At the time, his abdomen had seemed fine – soft, not distended or tender.   

     I did a quick exam on him.  He had some nausea.  His chest looked fine.  His abdomen was distended and a little more tender than I thought it should be.  There were no wounds.  I rolled him and did not see any exit wounds in his back.  The dressings around his anal area were a little soiled with drainage, so I changed them and repacked his wound.  I ordered some bloodwork on him and an abdominal x-ray, and wrote some orders to get him tucked in on the ward.  He was definitely one I needed to keep my eye on.

     I moved on through the growing crowd of casualties.  As they came in the front, they were sorted and tagged according to their injuries.  There were always lots of “ortho” tags, and “ortho with vascular” tags.  The pattern of injuries being seen in this war was different from any of the previous wars the United States had been involved in.   This conflict turned out to have a much higher rate of extremity injuries and amputations than any other war.  IED’s, or improvised explosive devices, were commonly used.  In previous conflicts, these explosions were often fatal.  The chest and abdominal injuries that these devices caused were not survivable.  But over the last ten years, great advances had been made in body armor, and lighter-weight FLAC jackets made of Kevlar were developed and widely used by troops on the ground.  These provided great protection for the trunk, but left the extremities vulnerable to injury.  All these soldiers coming in with devastating extremity injuries and amputations would have died in earlier conflicts,but now survived.  Strangely enough, the troops’ survival was actually advantageous to the enemy.  In military battles, it is better to wound your enemy than kill them.  A wounded soldier takes more of your enemy’s personnel, time, and resources to get off the battlefield and care for than a dead body does. 

     As a result, there were always lots of orthopedic and vascular patients, and only a few for the general surgeons.  Three other patients were tagged for me.  One had undergone an abdominal exploration for a shrapnel wound, with no significant injuries identified.  He had a midline abdominal incision that looked good.  One had some superficial soft tissue loss along his left abdomen extending around to his flank.  He just needed some good wound care.  The third was a kid who had developed right lower quadrant pain suspicious for appendicitis, so was sent back to us.  His pain was gone already, and he looked great.  I’m ashamed to admit I was disappointed.  I remembered back to my time on the aircraft carrier, when a kid had come down to the medical department with right lower quadrant pain.  I was so excited to be able to do an operation, to actually use my training to benefit someone.  I was so ready to feel useful, to utilize the skills I had developed during ten long years in medical school and residency.   I wanted someone to have a surgical problem to justify my being there, to provide some good reason for my separation from my family.  I had that exact same desperate feeling now.  But I wasn’t going to get that satisfaction from this kid.  He was fine.

     I went over to radiology to check on the x-ray from my first patient.  We could see a bullet lodged in the right upper abdomen.  The bullet had passed through a good portion of his abdomen, putting everything between the anus and his right upper abdomen at risk.  His aorta or vena cava, in which case he should have bled to death by now.  His ureter or kidney, in which case he could be leaking urine into his abdomen.  His pancreas.  His small intestine or colon, in which case he would leak bowel contents and slowly go into septic shock, with low blood pressure, rapid heart rate, difficulty breathing, fevers.  His white blood cell count would rise.  As these thoughts went through my head, I got a call from the ward.  The nurse reported that Macgregor’s blood pressure was low, his heart rate was running up in the 120’s, and he had a fever to 102.  His blood work was back, showing a high white blood cell count. 

“Give him a liter bolus of normal saline now, I am on my way,” I told her, now worried that I had a real problem on my hands.

     This is what I’ve been waiting for, I thought as I rushed through the corridors.  But I had a little feeling of trepidation lurking in the depths of my consciousness.  What if this was something I couldn’t handle?  What if he had a pancreaticoduodenal injury that needed some major resection and reconstruction?  What if he had a contained hematoma with a vena caval injury and he bled to death as soon as I opened him up?  He was nineteen.  I had not done a major trauma since I was a resident three years ago.  Did I remember everything I was supposed to do?  What if I screwed something up?  I had these mixed emotions of dread and excitement running through me. 

     As I approached the bedside, I was relieved to feel at ease, in the middle of familiar territory again.  Everything else about this place seemed unnatural to me, like it belonged in someone else’s life – running around wearing fatigues and combat boots, sleeping in a tent with twenty other women, reporting to duty every morning to a hospital made of poles and fabric.   But as I stood at the bedside of a patient going into septic shock from an abdominal injury, I was right back in my comfort zone.  I knew exactly what to do.  It was like riding a bike, snapping back into that automatic progression of rapid patient assessment and resuscitation.  This kid needed a general surgeon to open his abdomen up and fix the problem.   For the next two hours, in the operating room, we focused on the single patient in front of us.  I knew exactly why I was here and felt like I was right where I belonged.  We resected the portions of his colon and small bowel that had bullet holes through them, washed him out and created a colostomy.  He was not going to like this, but he would survive this injury.  This was one soldier who would make it home because we were here.