[Ann Emerg Med. 2006;52:304-305.]
The patient volume in the emergency department in Balad, Iraq, usually increases in late morning, once the insurgents' raids begin; however, attacks occasionally occur early in the day. Today was such a day. We had received warning that one of the local infantry units had been attacked. A watchtower guard had witnessed the incendiary explosion. We could not confirm the details of the event by another source; however, because similar calamities had occurred recently, we prepared to receive several patients within the next 20 to 30 minutes.
We waited restlessly for 10 to 15 minutes for confirmation of injuries—nothing. Finally, over the radio, the inexperienced and panicky medic called in, “Caretaker ED [emergency department], we have 2 patients. … Um … they were injured. … Um … they are critical … I repeat, crit … urgent… . We'll be there in 2 mic [minutes].” The medic was clearly frightened.
A new crew of Army flight medics had been deployed to our base; this was his first combat mission and he was likely taking small arms fire from insurgents while trying to rescue these critically ill patients. These medics are expected to rescue and resuscitate patients while receiving mortar and small arms attacks. Because medics are noncombatants, they should not be fired on; unfortunately, “the rules of war” do not always apply.
When the helicopter landed at the hospital, we were ready, although we never know what will come through the ED doors. In the United States, I have a similar feeling working in a busy ED; however, I usually have several minutes to prepare, additional medical resources, and a general idea of what to expect based on the paramedics' radio call. Working in a combat zone, the feeling of uncertainty is amplified due to combat-related cofounders. Anything could come through those swinging green doors: an eye abrasion injury, improvised explosive device (IED) survivor with bilateral leg amputations, or a gunshot through the head could all be considered “urgent”—life, limb, or eyesight.
The condition of the patients we received today was dire; they were near death. An IED had exploded beneath their Humvee while they were in the vehicle. The vehicle flipped upside down, landing on the gunner's chest. The other soldier was trapped inside. Both patients were now in traumatic arrest. I tracheally intubated both patients and placed 3 large chest tubes to decompress my patient's chest. My thoracic surgeon placed the fourth chest tube lower on the patient's right side.
The other soldier had severe leg and arm injuries; tourniquets were placed to stanch the bleeding. The other patient's emergency physician and surgeon had finished a femoral cutdown and were desperately resuscitating him.
My surgeon and I continued to treat our patient, who was still in arrest. We infused blood, cardiac medications, and fluids and performed chest compressions, but we still could not restart his heart. What were we missing? We had worked for 40 minutes; we could not let this valiant young man die. We hoped that maybe just a few more minutes, another epinephrine dose, or another unit of blood would suffice to restart his heart. Unfortunately, after 50 minutes, he died.
The other team resuscitated their patient. They had stopped the bleeding and stabilized his blood pressure. The emergency physician and the surgeon obtained radiographs and transferred him to the OR. Unfortunately, because of his severely fractured pelvis, he had uncontrollable bleeding in the OR, and he, too, died.
This combat unit had been here for 1 year. These 2 soldiers would have returned home in 1 week to their families and friends had this catastrophe not occurred. Worse yet, their peers were notified of their deaths while attending a memorial service honoring 2 of their troops who died the previous week.
Most physicians, particularly emergency physicians and surgeons, would say they are calloused to death. I do not think it is that easy. It is difficult, particularly at war and with a surge of patients, to “call it” and declare the patient dead. Numerous war colleagues, surgeons and emergency physicians, have been unable to do so and are a testament to this observation.
To declare the patient died is not only a personal loss, but also against the grain of how we are trained. However, as one acclimates to combat care, one learns to weigh these feelings against futility of care and limited medical resources. This hesitation and reckoning is what makes the 2 to 3 seconds (which is all the time you have) feel like 2 to 3 minutes. Am I making the right decision? Is there anything I have left out? Do I have other patients coming in that I can save?
Delivering the news of death to patients and families is also difficult; the best of words do not ameliorate the shock and sadness. Several years ago, my residency director at Denver General provided me his chronologic paradigm to deliver this melancholic news: what happened before he arrived to the ED, what we did to resuscitate him, and what to expect during the next few hours and days. I still use it; it is still not easy.
The troop commander and his first sergeant (senior enlisted soldier) took the news well, initially; however, they could not hold in their grief. Seeing these strong, valiant men crying and grieving is difficult. I hugged men I did not know; they were weakened by the repeated attacks on their soldiers, their friends, their “adopted” family.
One week later, one of our young medical technicians, Sergeant J, who was from the same part of Pacific Rim as the combat troops, attended the funeral for the fallen soldiers. Many of the soldiers, whom he did not recognize from the calamity in the ED, recognized him and offered him many accolades for his effort. I talked to him about the funeral when he returned. Although he was saddened by the event, his pride and confidence were apparent. It was healing for him, and I was glad he had gone. I asked him to notify me when the next funeral is, so that I can attend.
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