They don’t teach us that

Evelyn M. Potochny
Hershey, Pennsylvania, United States

 

Soldiers leaving combat by plane
Soldiers in line to get in a plane. Photo by Pixabay.

You called in your own medevac. You’d even tourniqueted both legs, or what was left of them. And when the Chinook kicked up all that dust and finally landed, you looked so—calm. Someone read each name and the litany of injuries while we watched each stretcher pass by, yours included—a solemn parade, en route to one of the trauma bays. It always amazed me how quiet we could be as we listened like a life depended on it: twenty-eight-year-old male, double traumatic amputation, improvised explosive device (IED), significant soft tissue wounds; twenty-two-year-old male, lower extremity traumatic amputation from Humvee hitting an IED; twenty-seven-year-old male, penetrating lower extremity wound from shrapnel. I think there were four or five of you who made it here alive that day. Those killed in action, KIAs as we call them, do not enter here. Five male infantry Marines flown to the combat hospital for stabilizing surgery. Everything happens quickly: the doctor’s head-to-toe visual scan to assess life-threatening injuries, IV access, “X-ray is here!” and soon the OR doors swing open.

You were the first one they wheeled back for damage control surgery. Most of the time—at least in my limited experience—if you make it this far (i.e., alive to the combat hospital), you will make it home to the continental U.S. Our medics and corpsmen are wizards in the field, and the surgeons here—mostly Brits, some Danes and Estonians, and three Americans—are, too. They were taught to be—taught to stabilize the bleeding quickly and leave the rest for later. And you and your comrades, brave and swift, bandaged your own hemorrhaging bodies, despite the blast, the noise, the mayhem. And you, miraculous, rattled off all nine lines for a medevac request: location, radio frequency and call sign, patients by urgency, equipment required, number of patients, security of area at the pick-up location, method to mark the location, nationality of the wounded and if civilian or military, and whether there is nuclear, biologic, or chemical contamination present. They taught you that.

Those first stabilizing surgeries go fast. Some tightly choreographed work by the surgical team to replenish blood volume and clotting factors, restore proper pH, balance electrolytes—and then, for the patient, some rest. Maybe a return to the OR in the next several hours for more debridement, and then, home. To the United States. That’s how it goes for most that make it this far. Only, not you.

You are here with me. It’s chilly, within these high, white walls. Can you feel it—or is it just gravity that has drained my body heat? My hands ache when they are cold, and sometimes they turn red, white, and blue. Like now. But yours look much, much colder. They are dusky, mottled, ashen gray with just a few salmon swirls. We made sure you had several blankets in that flurry of activity, getting you settled. At least it’s quiet now.

The nurses outside your door criss-cross fervently past one another. They don’t have time to deal with this aftermath. Too many lives just outside still need vital signs checked and IVs hung. A combat hospital isn’t like most hospitals back home—just a handful of beds in a big open space, with only a few small isolated rooms like this one. The surgical and diagnostic capabilities are quite advanced, though. The OR can fit three surgical tables, and there are two CT scanners, and a ROTEM—a technology that helps guide the surgical team for when to transfuse cryoprecipitate instead of platelets or plasma or packed red cells. The orthopedic surgeon who first showed it to me called it a “scro-tem,” because the clot tracing looks like a phallus. He is there in the OR for this round of casualties, stabilizing the hemorrhaging, setting broken bones, doing what they taught him. Soon, he and the other American doctors will leave the hospital to cross the dusty road for the ramp ceremony. There they will load your fallen comrade’s body into a C-130. That sole Marine who did not arrive here alive. A hymn, some words from the chaplain, a salute. A hallowed final farewell to a fallen hero. It’s very moving, and somewhat dizzying, when you’ve seen too many.

Sometimes, if I am at the hospital, I watch from afar. I’m just the doc for another battalion. Your docs, though, they’re all far forward now, like you were when you stepped on that IED—“outside the wire,” as they say, at a small outpost, stepping beyond the gates of the base to conduct patrols. I’m the lucky one, staying inside the wire to take care of the day-to-day primary care needs from my aid station tent, reporting here occasionally to assist when the alarm sounds for incoming mass casualties. Rarely, I help conduct those initial injury assessments, but more often I scribe, jotting down the battlefield injuries, annotating what combat gear was worn when certain wounds were sustained, and what fluids or blood products were administered in the field. Things we may be able to learn from later, gleaning useful knowledge to teach the next generation. I’m there mainly as a liaison, finding out who will make it on the next medevac home so I can update your Commanding Officer. Whom did we lose? Whom did we save? What happened?

What did happen? I think it was all the things they taught me later—during residency and fellowship—that got you. The lethal triad from all that blood loss: metabolic acidosis, hypothermia, dilutional coagulopathy. They gave you saline in the field—before they’d later teach us that blood is better. And you there, you were amazing—but not even you can tourniquet those kinds of wounds. That’s what the anesthesiologist said, days later, when we were eating lasagna in the chow hall: “Between you and me, I don’t think blood sooner would have helped. The soft tissue trauma was just too extensive.”

So that brings me back to us two, here. The Marines say, “Never leave a buddy behind.” Right now, Corporal, I’m your buddy, even though we’d never met before this morning. Alone, together, in a British-run NATO hospital in the middle of the Afghanistan desert. The chaplain, “Chaps” as we call her, thought I’d join her for the ramp ceremony, but I said no, thinking you didn’t have much time. I heard what the surgeons said when they were leaving the OR, eyed your blood gases. I tried to imagine if I were you, the one far from home and family. I imagined I’d want someone near me. I’m thinking about that scene from a movie where a woman is dying at home, her husband beside her. A poem or a witty line. Then a shotglass through the window, shattering on the street below. But you can’t talk. And your loved ones are not here. And there’s only one floor with no window.

I rehearse in my mind a few scenarios before I settle on this one: to sit upright in my chair beside you, silently, and breathe with you until you stop.

 


 

EVELYN M. POTOCHNY, DO, is a pathologist at Penn State Health Milton S. Hershey Medical Center, with fellowship training in blood banking/transfusion medicine. She previously served in the U.S. Navy as a medical officer and deployed to Afghanistan with a Marine Combat Logistics Battalion in 2008. She would like to acknowledge Dr. Kimberly R. Myers for her valuable critique of this essay.

 

 

Highlighted in Frontispiece Volume 13, Special Issue– Fall 2021

Summer 2021  |  Sections  |  War & Veterans