I decided to post this just in case you have not seen this story yet...
It's an important story told from the perspective of the military doctors in Iraq. It's not the first time that I've posted about those who tend to the wounded - the story of Saving Specialist Gray is one of my favorites.
This story, however, is not about winning. Unfortunately, it's about "The Third Rule of War":
The Last Full Measure
By Col. Brett Wyrick USAF
– The first rule of war is that young men and women die. The second rule of war is that surgeons cannot change the first rule.
We had already done around a dozen surgical cases in the morning and the
early afternoon. The entire medical staff had a professional meeting to
discuss the business of the hospital and the care and treatment of
It is not boastful or arrogant when I tell you that some of the best surgeons in the world were present – I have been to many institutions, and I have been all
around the world, and at this point in time, with this level of
experience, the best in the world are assembled here at Balad.
Dave S., the Trauma Czar, and a real American hero is present. He has
saved more people out here than anyone can imagine. The cast of
characters includes two Air Force Academy graduates, Col (s) Joe W. and Maj. Max L. When you watch ER on
television, the guys on the show are trying to be like Max – cool,
methodical and professional. Max never misses anything on a trauma case
because he sees everything on a patient and notes it the same way the
great NFL running backs see the entire playing field when they are
carrying the ball.
is an ENT surgeon who is tenacious, bright, and technically correct
every single time – I mean every single time. The guy has a lower
tolerance for variance than NASA. LTC (s) Chris C. was the Surgeon of
the Day (SOD), and I was the back-up SOD. Everyone else was there and
available – as I said the best in the world.
As the meeting was breaking up, the call came in.
American soldier had been injured in an IED blast north of here, and he
was in a bad way with head trauma. The specifics were fuzzy, but after
three months here, what would need to be done was perfectly clear – the
332nd Expeditionary Medical Group readied for battle. All the surgeons
started to gravitate toward the PLX which is the surgeons' ready room
and centrally located midway to the ER, OR and radiology.
The lab personnel checked precious units of blood, and the
pharmacy made ready all the medications and drugs we would need for the
upcoming fight. An operating room was cleared, and surgical instruments were
laid out, the anesthesia circuits were switched over, and the gasses were
checked and rechecked. An anesthesiologist and two nurse anesthetists went over
the plan of action as the OR supervisor made the personnel assignments.
In the ER, bags of IV fluids were carefully hung, battery packs
were checked, and the ER nursing supervisor looked over the equipment to make
sure all was in working order and the back-ups were ready just in case the
primaries failed. The radiology techs moved forward in their lead gowns
bringing their portable machines like artillery men of old wheeling their
cannon into place. Respiratory therapy set the mechanical ventilator, and
double-checked the oxygen. Gowns, gloves, boots, and masks were donned by those
who would be directly in the battle.
America can bring to the war – were in place and ready along with the best skill and
talent from techs to surgeons. The two neurosurgeons gathered by themselves to
plan. LTC A. is a neurosurgeon who still wears his pilot wings proudly.
He used to be a T-38 instructor pilot, and some of the guys he trained to fly
are now flying F-16s right here at Balad. He is good with his hands and calm
under pressure. The other neurosurgeon is Maj. W., a gem of a surgeon who could
play the guitar professionally if he was not dedicated to saving lives. A long
time ago, at a place on the other side of the world called Oklahoma,
I operated on his little brother after a car accident and helped to save his
life. The two neurosurgeons, Chris, and I joined for the briefing.
Although I was the ranking officer of the group, Chris was the SOD and would be
the flight lead. If this was a fighter sweep, all three of those guys would be
Weapons School Patch wearers.
The plan was for me and the ER folks to assess, treat and
stabilize the patient as rapidly as possible to get the guy into the hands of
the neurosurgeons. The intel was that this was an IED blast, and those rarely
come with a single, isolated injury. It makes no sense to save the guy's brain
if you have not saved the heart pump that brings the oxygenated blood to the
brain. With this kind of trauma, you must be deliberate and methodical, and you
must be deliberate and methodical in a pretty damn big hurry.
All was ready, and we did not have to wait very long. The
approaching rotors of a Blackhawk were heard, and Chris and I moved forward to
the ER followed by several sets of surgeons' eyes as we went. We have also
learned not to clog up the ER with surgeons giving orders. One guy runs the
code, and the rest follow his instructions or stay out the way until they are
They wheeled the soldier into the ER on a NATO gurney shortly
after the chopper touched down. One look at the PJs' faces told me that the
situation was grim. Their young faces were drawn and tight, and they moved with
a sense of directed urgency. They did not even need to speak because the look
in their eyes was pleading with us – hurry. And hurry we did.
In a flurry of activity that would seem like chaos to the
uninitiated, many things happened simultaneously. Max and I received the
patient as Chris watched over the shoulder to pick out anything that might be
missed. An initial survey indicated a young soldier with a wound to the head,
and several other obvious lacerations on the extremities.
Max called out the injuries as they were found, and one of the
techs wrote them down. The C-collar was checked, the chest was auscultated as
the ET tube was switched to the ventilator. Chris took the history from the PJs
because the patient was not conscious. All the wounds were examined and the
dressings were removed except for the one on the head.
The patient was rolled on to his side while his neck was
stabilized by my hands, and Max examined the backside from the toes to the
head. When we rolled the patient back over, it was onto an X-ray plate that
would allow us to take the chest X-Ray immediately. The first set of vitals
revealed a low blood pressure; fluid would need to be given, and it appeared as
though the peripheral vascular system was on the verge of collapse.
I called the move as experienced hands rolled him again for the
final survey of the back and flanks and the X-Ray plate was removed and sent
for development. As we positioned him for the next part of the trauma
examination, I noted that the hands that were laid on this young man were
Black, White, Hispanic, Asian, American Indian, Australian, Army, Air Force,
Marine, Man, Woman, Young and Older: a true cross-section of our effort here in
but there was not much time to reflect.
The patient needed fluid resuscitation fast, and there were other
things yet to be done. Chris watched the initial survey and the secondary
survey with a situational awareness that comes from competence and experience.
Chris is never flustered, never out of ideas, and his pulse is never above
With a steady, calm, and re-assuring voice, he directed the next
steps to be taken. I moved down to the chest to start a central line, Max began
an ultrasonic evaluation of the abdomen and pelvis. The X-rays and ultrasound
examination were reviewed as I sewed the line in place, and it was clear to
Chris that the young soldier's head was the only apparent life-threatening
The two neurosurgeons came forward, and removed the gauze covering
the soldier's wounded head, and everyone's heart sank as we saw the blossom of
red blood spreading out from shredded white and grey matter of the brain.
Experience told all the surgeons present that there was no way to survive the
injury, and this was one battle the Medical Group was going to lose. But he was
American, and it was not time to quit, yet.
Gentle pressure was applied over the wound, and the patient went
directly to the CT scanner as drugs and fluids were pumped into the line to
keep his heart and lungs functioning in a fading hope to restore the brain. The
time elapsed from his arrival in the ER to the time he was in the CT scanner
was five minutes.
The CT scan confirmed what we had feared. The wounds to the brain
were horrific and mortal, and there was no way on earth to replace the volume
of tissue that had been blasted away by the explosion. The neurosurgeons looked
at the scan, they looked at the scan a second time, and then they re-examined
the patient to confirm once again.
The OR crew waited anxiously outside the doors of radiology in the
hope they would be utilized, but Chris, LTCs A and S., and Maj W. all agreed.
There was no brain activity whatsoever. The chaplain came to pray, and
reluctantly, the vent was turned from full mechanical ventilation to flow by.
He had no hint of respiratory activity, his heart that had beat so strongly
early in the day ceased to beat forever, and he was pronounced dead.
The pumps were turned off; the machines were stopped, and the IVs
were discontinued. Respectful quiet remained, and it was time to get ready for
the next round of casualties. The techs and nurses gently moved the body over
to the back of the ER to await mortuary services. And everyone agreed there was
nothing more we could have done.
When it was quiet, there was time to really look at the young
soldier and see him as he was. Young, probably in his late teens, with not an
ounce of fat anywhere. His muscles were powerful and well defined, and in
death, his face was pleasant and calm.
I am always surprised that anyone still has tears to shed here at
Balad, but thank God they still do. The nurses and techs continued to care for
him and do what they could. Not all the tubes and catheters can be removed
because there is always a forensic investigation to be done at Dover AFB, but
the nurses took out the lines they could. Fresh bandages were placed over the wounds, and the
blood clots were washed from his hair as his wound was covered once more. His
hands and feet were washed with care. A broken toenail was trimmed, and he was
silently placed in the body bag when mortuary services arrived as gently as if
they were tucking him into bed.
Later that night was Patriot Detail – our last goodbye for an
American hero. All the volunteers gathered at Base Ops after midnight under a three-quarter moon that was partially hidden by high, thin clouds.
There was only silence as the chief master sergeant gave the Detail its
instructions. Soldiers, Airmen, and Marines, colonels, privates and sergeants, pilots, gunners, mechanics, surgeons and
clerks all marched out side-by-side to the back of the waiting transport, and
presently, the flag-draped coffin was carried through the cordon as military
salutes were rendered.
The Detail marched back from the flight line, and slowly the doors
of the big transport were secured. The chaplain offered prayers for anyone who
wanted to participate, and then the group broke up as the people started to
move away into the darkness. The big engines on the transport fired up, and the
ground rumbled for miles as they took the runway. His duty was done – he had
given the last full measure, and he was on his way home.
The first rule of war is that young men and women die. The second
rule of war is that surgeons cannot change the first rule. I think the third
rule of war should be that those who have given their all for our freedom are
never forgotten, and they are always honored.
I wish there was not a war, and I wish our young people did not
have to fight and die. But I cannot wish away evil men like Bin Laden and
al-Zarqawi. These men are not wayward children who have gone astray; they are
not great men who are simply misunderstood.
These are cold-blooded killers and they will kill you, me, and
everyone we love and hold dear if we do not kill them first. You cannot reason
with these people, you cannot negotiate with these people, and this war will
not be over until they are dead. That is the ugly, awful, and brutal truth.
I wish the situation was different, but it is not. Americans have
two choices. They can run from the threat, deny it exists, candy-coat it,
debate it, and hope it goes away. And then, Americans will be fair game around
the world and slaughtered by the thousands for the sheep they have become.
Our second choice is to crush these evil men where they live and
for us to have the political will and courage to finish what we came over here
to do. The last thing we need here in Iraq is an exit strategy or some damn timetable for withdrawal. Thank God there was no timetable for withdrawal after the Battle of the Bulge or Iwo Jima. Thank God there was no exit
strategy at Valley Forge. Freedom is not easy, and it
comes with a terrible price – I saw the bill here yesterday.
The third rule of war should be that we never forget the
sacrifices made by our young men and women, and we always honor them. We honor
them by finishing what they came to accomplish. We remember them by never
quitting and having the backbone and the guts to never bend to the yoke of
We honor them and remember them by having the courage to live
Col. Brett Wyrick is commander of the 154th Medical Group, Hawaii
Air National Guard, and is serving as a surgeon in Balad with the 332nd
Expeditionary Medical Group. This column is part of a series of email reports
from Iraq that Wyrick has been sending to his father, a Vietnam-era fighter pilot, who in
turn distributes them to a circle of friends and acquaintances. The column was
forwarded to DefenseWatch. Send Feedback comments to email@example.com.
This was emailed to me today from Seamus. I "Googled" it and found, of course, that the Freepers site published it on Memorial Day. From there it was originally published at Soldiers for the Truth.