- Email: [email protected]
911
CHANGE OF SHIFT
911 Vikhyat S. Bebarta, MD, Maj, USAF, MC
From the Department of Emergency Medicine, Wilford Hall Medical Center, University Texas Health Sciences Center at San Antonio, San Antonio, TX.
The views expressed in this article are those of the author and do not reflect the official policy or position of the United States Air Force, Department of Defense, or the United States government. 0196-0644/$-see front matter Copyright © 2008 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2008.07.031
[Ann Emerg Med. 2009;53:270-271] I heard a buzzing. My pager rarely goes off since I am at the hospital almost every day. The page was “911” and implied a surge of patients had arrived without warning and the hospital needed extra help. Occasionally we receive incorrect pages on our rudimentary paging system; however, 911 is difficult to mistype. The pace of this deployment to Iraq seemed busier than the last. I attempted to call the ED, but no one answered; likely they were busy preparing for the incoming patients. I grabbed my bag and dashed to Oliver’s room, another emergency physician deployed with me. He had just fallen asleep after working all night. He also received the page. We headed to the hospital. I made the half-mile dash with Oliver on his bike following behind. As we passed the T-barriers protecting the hospital from incoming mortars, the choppers were overhead, landing 100 yards from the hospital. On this trip 3 choppers landed. I assumed more had already landed and had left to bring more patients. As I ran to the gate, the guard knew the procedure. I pointed at the chopper as I ran toward him; he waved me through without wasting time for the ID check. As I approached the ED door, it was quiet outside. Previously, I was lulled by the silence outside the closed green metal doors. I had been deceived into the surge being nothing, just a few patients, maybe a call “just in case”—for every 10 times you are called in for a patient surge, 3 times it will be real. Communication in war is often inaccurate: “the fog of war.” However, we had been 5 for 5 since we arrived 2 months earlier. I opened the ED tent door. I have yet and will likely never be able to describe accurately the mayhem. Unless one has been to war, the scene is ineffable. It is not “M*A*S*H,” the television show “ER,” or a “busy Saturday night in the ER back home.” As I looked above everyone’s head, I saw blood bags infusing, saline bags hanging, needles held high, and the long arm of the portable radiograph machine lowered over a patient. At eye level I saw everyone’s face aimed down, focused on resuscitating the 7 severely wound patients from the last round of Blackhawk helicopters. On the floor, I saw fresh blood, old gauze, trash, cut clothes, and dirty blankets. People were running through the 270 Annals of Emergency Medicine
room, and the suction machines and helicopters’ rotor noise were deafening. “I need Sux [succinylcholine] and etomidate,” someone yelled to the single pharmacist. “Two more units [of blood],” someone else bellowed. “I need some help here,” one of surgeons announced. Rob, who deployed with me from San Antonio, was the only emergency physician there. “I need you to put him down,” he told me, our parlance for putting a patient on a ventilator. I quickly did that while trying to get in tune with who was critically ill, how many would be arriving, how many had died, and what needed to be done. Rob was overwhelmed but composed. Although this was his first deployment, this was not his first patient surge. Oliver and Jon, our third emergency physician, began evaluating patients. Rob continued to provide care. He asked me to reassess the patients and triage the additional soldiers arriving soon. Triaging and coordinating the care of several critically ill patients was reminiscent of my senior residency year in Denver General (DG), although this event was more exaggerated than I had ever seen back home. Instead of the wall-sized chalkboard at DG, I grabbed a clipboard to track the patients. The resuscitation room was fitted for 6 trauma patients (roman numerals mark the trauma bays), but that day we packed in 12 critically ill patients. We filled our noncritical room with patients who, despite having holes and fragments in their brain, lungs, and abdomen, could wait a few hours before surgery. They were “stable.” Three frenetic, tiring hours later, we cleared the patients through. The OR and ICU teams worked for 8 additional hours stabilizing the patients. Finally, the aero-evacuation and critical care air transport teams spent the night transporting the injured troops to Germany. The sublime experience was mission focused, team centered, and irreproducible in civilian medicine. One of the first patients to arrive was a 3-year-old child. The child had arrived pulseless for several minutes. Her abdominal organs were eviscerated. After a cursory resuscitative attempt, the patient was declared dead. The father cried. The mother was angry, not at us, not at the Americans, but at her own decisions. “We have always worked hard and earned our money honestly, and this is how we are paid,” she bawled through our translator. Volume , . : February
Bebarta
Figure. The emergency department and resuscitation room of the Air Force Theater Hospital in Balad, Iraq.
The child’s father worked as a translator for the Iraqi army. They chose to stay in their village and refused several offers to assist the insurgents, but now “my child is dead.” The child was playing in her backyard when the mortar struck. Rob and a young medic sutured the child’s chest wall together. A nurse cried. Security forces escorted the family to the gate with their child’s body, back to their village for her burial. One week later, one of the medics, a civilian firefighter back home, pulled me aside. Sergeant T had a 3-year-old daughter, the same age as the child who died. He had been having trouble sleeping since the Iraqi girl’s death. He asked mournfully, “All I want to know, doc, is did I do everything I could?” I assured him he had. He remembered his daughter. I consoled him and thought of my eldest daughter, also 3 years old. Now, my then 3-year-old is 6, and I am preparing for my third deployment in 4 years. I have been to Iraq 4 out of the last
Volume , . : February
Change of Shift 5 years. As I prepare for this deployment, I remember the first time I flew to Iraq. I was just a few years out of residency but running one of the busiest EDs since the Vietnam War. I was naïve to what I would witness and brazen to what I could do. I matured quickly. The Vietnam War produced the last generation of combat physicians, but most of them have retired. During the last 5 years, our generation has learned new lessons, imparted pioneering practices, and improved combat casualty care that has led to the lowest mortality rate in history, although we derived our lessons from combat medicine tenets learned in preceding wars. When we deploy, our family sacrifices more than they let on. At times, I find it challenging to balance the needs of my family with the needs of our nation; however, other military members have made greater sacrifices. The soldiers of the 4th Infantry Division, the airmen of security forces, and the marines and sailors of Al Fallujah are a few who have sacrificed their lives. When “bullets meet bodies” is unfortunately the quintessence of war. Although we celebrate national holidays honoring our war heroes—the deceased, the living, and the patriots of independence—the soldier’s, airman’s, marine’s, and sailor’s most celebrated day is reunion home with family. I am thankful for the valiant and resolute troops, their devoted and tender families, and the compassionate and dedicated physicians, nurses, and medical technicians deployed in support of Operation Enduring Freedom and Operation Iraqi Freedom. Address for correspondence: Vikhyat S. Bebarta, MD, Maj, USAF, MC, Department of Emergency Medicine, Wilford Hall Medical Center, University Texas Health Sciences Center at San Antonio, San Antonio, TX; 210-292-3908 or 210-3470509, fax 210-292-7649; E-mail: [email protected].
Annals of Emergency Medicine 271
911 Vikhyat S. Bebarta, MD, Maj, USAF, MC
From the Department of Emergency Medicine, Wilford Hall Medical Center, University Texas Health Sciences Center at San Antonio, San Antonio, TX.
The views expressed in this article are those of the author and do not reflect the official policy or position of the United States Air Force, Department of Defense, or the United States government. 0196-0644/$-see front matter Copyright © 2008 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2008.07.031
[Ann Emerg Med. 2009;53:270-271] I heard a buzzing. My pager rarely goes off since I am at the hospital almost every day. The page was “911” and implied a surge of patients had arrived without warning and the hospital needed extra help. Occasionally we receive incorrect pages on our rudimentary paging system; however, 911 is difficult to mistype. The pace of this deployment to Iraq seemed busier than the last. I attempted to call the ED, but no one answered; likely they were busy preparing for the incoming patients. I grabbed my bag and dashed to Oliver’s room, another emergency physician deployed with me. He had just fallen asleep after working all night. He also received the page. We headed to the hospital. I made the half-mile dash with Oliver on his bike following behind. As we passed the T-barriers protecting the hospital from incoming mortars, the choppers were overhead, landing 100 yards from the hospital. On this trip 3 choppers landed. I assumed more had already landed and had left to bring more patients. As I ran to the gate, the guard knew the procedure. I pointed at the chopper as I ran toward him; he waved me through without wasting time for the ID check. As I approached the ED door, it was quiet outside. Previously, I was lulled by the silence outside the closed green metal doors. I had been deceived into the surge being nothing, just a few patients, maybe a call “just in case”—for every 10 times you are called in for a patient surge, 3 times it will be real. Communication in war is often inaccurate: “the fog of war.” However, we had been 5 for 5 since we arrived 2 months earlier. I opened the ED tent door. I have yet and will likely never be able to describe accurately the mayhem. Unless one has been to war, the scene is ineffable. It is not “M*A*S*H,” the television show “ER,” or a “busy Saturday night in the ER back home.” As I looked above everyone’s head, I saw blood bags infusing, saline bags hanging, needles held high, and the long arm of the portable radiograph machine lowered over a patient. At eye level I saw everyone’s face aimed down, focused on resuscitating the 7 severely wound patients from the last round of Blackhawk helicopters. On the floor, I saw fresh blood, old gauze, trash, cut clothes, and dirty blankets. People were running through the 270 Annals of Emergency Medicine
room, and the suction machines and helicopters’ rotor noise were deafening. “I need Sux [succinylcholine] and etomidate,” someone yelled to the single pharmacist. “Two more units [of blood],” someone else bellowed. “I need some help here,” one of surgeons announced. Rob, who deployed with me from San Antonio, was the only emergency physician there. “I need you to put him down,” he told me, our parlance for putting a patient on a ventilator. I quickly did that while trying to get in tune with who was critically ill, how many would be arriving, how many had died, and what needed to be done. Rob was overwhelmed but composed. Although this was his first deployment, this was not his first patient surge. Oliver and Jon, our third emergency physician, began evaluating patients. Rob continued to provide care. He asked me to reassess the patients and triage the additional soldiers arriving soon. Triaging and coordinating the care of several critically ill patients was reminiscent of my senior residency year in Denver General (DG), although this event was more exaggerated than I had ever seen back home. Instead of the wall-sized chalkboard at DG, I grabbed a clipboard to track the patients. The resuscitation room was fitted for 6 trauma patients (roman numerals mark the trauma bays), but that day we packed in 12 critically ill patients. We filled our noncritical room with patients who, despite having holes and fragments in their brain, lungs, and abdomen, could wait a few hours before surgery. They were “stable.” Three frenetic, tiring hours later, we cleared the patients through. The OR and ICU teams worked for 8 additional hours stabilizing the patients. Finally, the aero-evacuation and critical care air transport teams spent the night transporting the injured troops to Germany. The sublime experience was mission focused, team centered, and irreproducible in civilian medicine. One of the first patients to arrive was a 3-year-old child. The child had arrived pulseless for several minutes. Her abdominal organs were eviscerated. After a cursory resuscitative attempt, the patient was declared dead. The father cried. The mother was angry, not at us, not at the Americans, but at her own decisions. “We have always worked hard and earned our money honestly, and this is how we are paid,” she bawled through our translator. Volume , . : February
Bebarta
Figure. The emergency department and resuscitation room of the Air Force Theater Hospital in Balad, Iraq.
The child’s father worked as a translator for the Iraqi army. They chose to stay in their village and refused several offers to assist the insurgents, but now “my child is dead.” The child was playing in her backyard when the mortar struck. Rob and a young medic sutured the child’s chest wall together. A nurse cried. Security forces escorted the family to the gate with their child’s body, back to their village for her burial. One week later, one of the medics, a civilian firefighter back home, pulled me aside. Sergeant T had a 3-year-old daughter, the same age as the child who died. He had been having trouble sleeping since the Iraqi girl’s death. He asked mournfully, “All I want to know, doc, is did I do everything I could?” I assured him he had. He remembered his daughter. I consoled him and thought of my eldest daughter, also 3 years old. Now, my then 3-year-old is 6, and I am preparing for my third deployment in 4 years. I have been to Iraq 4 out of the last
Volume , . : February
Change of Shift 5 years. As I prepare for this deployment, I remember the first time I flew to Iraq. I was just a few years out of residency but running one of the busiest EDs since the Vietnam War. I was naïve to what I would witness and brazen to what I could do. I matured quickly. The Vietnam War produced the last generation of combat physicians, but most of them have retired. During the last 5 years, our generation has learned new lessons, imparted pioneering practices, and improved combat casualty care that has led to the lowest mortality rate in history, although we derived our lessons from combat medicine tenets learned in preceding wars. When we deploy, our family sacrifices more than they let on. At times, I find it challenging to balance the needs of my family with the needs of our nation; however, other military members have made greater sacrifices. The soldiers of the 4th Infantry Division, the airmen of security forces, and the marines and sailors of Al Fallujah are a few who have sacrificed their lives. When “bullets meet bodies” is unfortunately the quintessence of war. Although we celebrate national holidays honoring our war heroes—the deceased, the living, and the patriots of independence—the soldier’s, airman’s, marine’s, and sailor’s most celebrated day is reunion home with family. I am thankful for the valiant and resolute troops, their devoted and tender families, and the compassionate and dedicated physicians, nurses, and medical technicians deployed in support of Operation Enduring Freedom and Operation Iraqi Freedom. Address for correspondence: Vikhyat S. Bebarta, MD, Maj, USAF, MC, Department of Emergency Medicine, Wilford Hall Medical Center, University Texas Health Sciences Center at San Antonio, San Antonio, TX; 210-292-3908 or 210-3470509, fax 210-292-7649; E-mail: [email protected].
Annals of Emergency Medicine 271