From the end of February to the beginning of June 2004, during a period when the U.S. military sustained its highest number of casualties since the Vietnam War, I was the anesthesia provider for the 447 EMEDS at Baghdad International Airport, Iraq. What follows are excerpts from a journal I kept while I was there. My goal is to share a bit of what the experience of providing anesthesia and nursing care in a combat zone was like. For me, the experiences I had in Baghdad were the fulfillment of years of anesthesia, nursing, and medical readiness training. When I joined the Air Force 17 years ago, it was to do this job. It was the greatest honor of my life to be able to work with and care for the troops who routinely took such extraordinary risks just doing their jobs. — Major Steven P. Eby, CRNA, MS
February 28, 2004
As we descend, our C-130 jukes and jumps through the air in ways I never thought possible. Through the porthole-sized windows on the rear of the plane I see the flash of flares popping off like fireworks. People in the plane are bending over, grabbing for the airsickness bags. But it is over in a minute and we are on the ground — a smooth landing. I wonder if it is all part of a routine landing in Baghdad, but the crew scrambles, asking if anyone is hit, then exits the plane to check it for damage. They think we have taken fire (later we learn that the plane was hit by small arms fire). I am so completely exhausted from 3 days of flying that it really doesn’t make any difference to me. We gather on the darkened flightline, inhaling the jet fuel fumes and dust, and look around. I see the terminal of the former Saddam International Airport, now Baghdad International (BIAP), the control tower and other buildings. Above me the stars are bright. The same stars I would see if I looked into the sky at home, 12 hours from here in Alaska, but it feels like I am on a different planet.
March 13, 2004
I have been here two weeks. Now I am the one showing the newcomers around. It seems like more and more people are not on their first deployment — so less of this is new to them. There are inconveniences — a long haul to the dining facility, the laundry closing down because water is short. Inconveniences are a lot better than attacks. I have a bed to sleep in, a fitness tent to work out in. If I complain, just slap me.
We only have four nurses including myself and our OR nurse. I work two nights on, two nights off as the ER/ICU nurse on duty and I’ll do anesthesia whenever it is needed. I have done one local/sedation case for a noncombat injury, and one emergent intubation on a “high value detainee” in cardiac arrest. He didn’t make it. I I did my best for him, just like I would for anyone, even Saddam Hussein.
One night we received an air-evac patient in our ICU. He was a friendly fire victim from the Combat Support Hospital (CSH) downtown, s/p craniotomy X2 (had had brain surgery twice) , exploratory laparotomy. He was intubated, sedated, and had femoral lines and an intracranial pressure (ICP) monitor in place. Oxygenation became a problem before he could get on the plane to Landstuhl. The Critical Care Air Transport Team (CCATT) didn’t think him stable enough for the flight. We stabilized him with ventilator adjustments; he made it on a plane in the morning.
March 22, 2004
One of our patients received the Purple Heart from his commanders today. Last night I did an axillary block on him so our orthopedic surgeon could wash out his elbow. He had shrapnel in his elbow and neck, chest contusions where his body armor was hit, but he was the lucky one — the rest of the people in the vehicle were killed when it was hit by an improvised explosive device (IED, or homemade bomb). Even after this experience, he just wanted to get back to his unit and keep doing his job. We had to send him to Landstuhl for more definitive treatment.
April 2, 2004
A soldier came in with high fever and trouble breathing Monday night. By Tuesday at noon I had to intubate him; we considered him too sick to fly to Germany, even though a CCATT had been arranged. It came down to the internist and me to transport him via air ambulance to the CSH downtown, where the Army had a pulmonologist. We sat in an ambulance on the flightline for an hour waiting for the chopper to arrive, but the flight arrangements had been miscommunicated. In the meantime, the patient’s condition worsened. We could no longer keep him well oxygenated with an ambu bag — he needed Positive End Expiratory Pressure (PEEP), which we could only provide with a ventilator or an ambu bag with a PEEP valve, which we didn’t have.
For the chopper ride, we wore our weapons, flak vest, helmet, and goggles. When the Blackhawk finally arrived, we loaded the patient and climbed in ourselves. I was trying every ambu secret I knew but could not keep his SpO2 above 81 percenteight. Thankfully, the chopper had us at the CSH in 10 minutes and a competent Army team took over the care. On a vent with PEEP, he quickly resaturated.
On the flight back, I looked out over the ancient city of Baghdad -- my first real glimpse of it. I saw the Tigris River, sprawling neighborhoods of dusty brown dwellings, and some of Saddam’s bombed out palaces towering above everything else. Most streets were empty, but on some I saw crowds of people, some of them dressed in black. It looked like what it was: a wartorn city. Pictures on the news don’t do it justice.
April 4, 2004
About 1030, the insurgents launch a rocket attack on the base. I don’t hear the explosions and I don’t hear the alarm sound over the “giant voice” system. I am sound asleep between night shifts. One of the rockets lands on the roof of the barber shop about 50 yards from the EMEDS tents and doesn’t explode. UXOs (unexploded ordnance) are scattered around Camp Sather and it takes a couple of hours to clear them, during which time we keep our battle rattle (body armor) on and stay under cover. Thankfully, a lot of rockets were duds or misarmed. No one is hurt.
I go back to the tent and try to sleep a little before my night shift. A cool desert wind rattles the tent. I roll around in my bed trying to rest but feel as restless as the wind.
The plan for the evening is for the general surgeon to do an elective procedure on an Australian soldier. He comes in around 1900 and I interview him and discuss his anesthesia options. He drinks a carton of beer a week. “How much is a carton?” I ask. “Twenty-four beers,” he answers.
We get him into a gown and get an IV started on him. We are about to get him into the OR when a call comes in, “How many casualties can you take?”
The elective procedure is postponed and we get ready for the surge. The entire EMEDS staff is called in. Firefighters and other medics from around the camp come in. We set up IVs, make sure the monitors and other equipment are ready. We start getting casualties three at a time from the air ambulances (Army medevac helicopters). Our ambulance meets them at the flightline and brings them in.
Most of the injuries are to extremities. We don’t get any head trauma, chest or abdomen injuries — thank God for helmets and body armor. We quickly fill the bedspace inside the EMEDS and have to start putting the most stable patients on cots outside in the cold. Eleven casualties come to us but it seems like many more. No one has an airway problem. I get IVs in and start pre-oping the ones that will need to go to OR right away. I restock the narcotics cabinet with morphine for the injured and gather the meds I’ll need. We are getting them because the CSH downtown can’t take anymore (a bad sign).
In the OR, we do a fasciotomy on a soldier who has taken a bullet through his lower leg and irrigate and debride (I&D) his other wounds. He’s tachycardic (has a rapid heartbeat) during the case, and is slow to wake at the end. When I extubate him, he obstructs and desats. I have to put a nasal airway in him and his breathing becomes acceptable.
The next case is a soldier who requires an I&D because he has been shot through the forearm and has shrapnel wounds around the knee. His case is very smooth, but when he wakes up he bites the tip of the Yankauer suction off. They all wake up wild. No surprise given their age and what they have been through.
Last, we do an I&D of a six-inch neck laceration. A lucky guy. Whatever it was that dug a trough through the side of the neck missed all of the structures that would have cost him his life if damaged.
While we are operating, eight of the patients get transferred in a big Chinook to the CSH at Balad, where they have three operating rooms and staff to take them. It is near 0500 when we finish with our patients in the OR.
From what I can tell from what these soldiers told us, a humvee on patrol was hit with an RPG. A Quick Reaction Force team in a deuce and a half was sent in to help. This vehicle was blockaded by cars on a narrow street and started taking fire from the cars, the buildings and roof tops. A set-up. The soldiers were diving for cover. Eight soldiers were killed in action. I don’t know how many more were wounded than the ones that we saw.
April 11, 2004: Easter Sunday
“April is the cruelest month” — T. S. Elliot
I think now we have done more cases in six weeks than the last rotation did in four months. Most of them have been in the last week. We have received up to 11 casualties at a time. There is no work schedule anymore — everyone seems to be working all of the time. Sleep is precious, but when I get time to sleep, I frequently can’t. My thoughts race over things here and at home, and it seems like there is no peace in either place. Food and exercise are afterthoughts, too. I have lost five pounds in the last few days, even though there’s no time to work out.
One night a soldier came in with his left arm nearly blown off at the shoulder by an RPG. He was still talking when he got to us. We asked him if he had any allergies. “I am allergic to pain,” he said. We started cutting his clothes off. “Don’t move my arm, I’m going to go in shock,” he said. “I need blood,” he said. “We’re going to give you blood,” I told him. “We’re going to put you to sleep and give you blood.” We pushed the amidate and succinylcholine and off to sleep he went and his life was in our hands.
I hooked him up to our RIS (rapid infusion system) and started pumping blood and fluid into him. We shot the x-rays we needed, secured his lines and chest tube and headed to the OR. In the OR, I ran him on a whiff of forane, fentanyl, vecuronium, and versed. I pumped blood and fluid like a madman. I tried to get an arterial line into his good arm and couldn’t. I got a venous stick for labs, but couldn’t get our IStat (all of our lab capability was based on this machine) to work. Our respiratory therapist tried but couldn’t get an arterial stick either. When he got venous blood, the IStat failed again.
I managed to keep his systolic blood pressure in the 80s at best; that with over eight liters of crystalloid and six units of blood. Surgically, everything came off to the shoulder joint and the chest wall was extensively debrided. In recovery, I pumped four more units of blood into him and the emergency medicine doc managed to get a femoral a-line into him after two tries. We still couldn’t get any labs due to IStat malfunctions. We packed him up for a chopper ride to Balad and then an urgent air-evac mission to Germany. He was still intubated and tachycardic. I was afraid he was not going to make it. I said this out loud and then I immediately regretted it; how can you tell when someone will remember something you say? There were good signs, though: he was making urine and his lungs were dry. He was oxygenating well. When I was running back to the ambulance after loading him on the Blackhawk, I cried out to God to be with him and only God could have heard me over the noise of the chopper blades.
A day or two later, a young troop* came in downed by an RPG. He’s intubated by the time I get there. His arms and posterior shoulders are ripped up from shrapnel and he has a bleeding head wound. We line him up and shoot the X-rays and do the things that we can do. On the surface, his injuries don’t look that bad, but his pupils are fixed and dilated — a bad sign. A few minutes after we place a nasogastric tube, clear fluid is draining from his nose — cerebrospinal fluid. In a mass casualty scenario, he would be triaged as “expectant” — not expected to live — with this set of injuries, but he is our only casualty. He needs to go to the CSH for a Head CT. We load him up for the chopper and I go with him. His buddy, a female soldier comes with us. She is distraught. Through her tears she is giving him a pep talk. “Kephart hang in there. Kephart be strong. You’re going to make it, Kephart.”
On the Blackhawk over Baghdad, his blood pressure starts to bottom out. I ask one of the Blackhawk crew to squeeze his IV bags, because I can’t squeeze both the ambu and the IVs effectively. I think we lost one of the IVs loading him, but his pressure comes up anyway. On the landing pad at the CSH, one of the Army crew that meets us checks the patient’s carotid pulse and we rush him to the ER on a NATO gurney. In the ER I give a quick report and swap out the monitors. I am back at the landing pad in less than five minutes, but the chopper has left. There are other choppers on the landing pad but none of them are going back to BIAP. I go back to the ER and let the staff know my situation and they say have a seat. They’ll let me know when a bird is headed back to BIAP.
My patient comes back from CT and I ask how it looked. “Awful,” they answer. He is brain dead. Kephart. He was 21 years old.
An hour later, I am still sitting there. I call the EMEDS to see if they can arrange some transportation. There are phone calls made back and forth for another hour or two but there is too much fighting going on and no air transportation available. The CSH gets hit with a load of casualties. I pitch in to help. I hang a few drugs for them and do what I can. There are nine patients — some of them serious, but most of them stable. They move them out quickly and I take a seat again.
The 31st Combat Support Hospital: 10 trauma bays in their “EMT,” three ORs running 24 hours a day, 60 to 70 inpatient beds. During my time at the CSH, I developed a great respect for their staff. This is the place that is seeing the most and the worst of the casualties.
Time goes by and there’s no luck getting out. They put me up in the RTD (return to duty) tent for the night. There is a convoy to BIAP in the morning and that is looking like my only way back. I bed down for the night in a tent full of soldiers. I sleep about 2 hours and the rest of the time lie there listening to the choppers coming in and out — bringing more wounded.
In the morning, I go back to the ER to wait to get on the convoy. One of the sergeants shows me to the chow hall, so I get a meal for the first time in about 24 hours.
At 0900, I go outside to find my place on the convoy to BIAP. It is Good Friday morning. I am only miles from the birthplace of Abraham. A clear blue sky is overhead, but the smell of portable toilets is in the air. Convoys have been getting attacked a lot lately. I watch the soldiers preparing their weapons and I think, “This could be the last day of my life.”
An Army Captain comes out to brief us. He explains that conditions are extremely dangerous and that the CSH commander is taking a close look at which convoys need to be run and that he very seriously considered not sending this one. He says the enemy is out there and won’t think twice about killing us. He explains the tactics they have been using and what our rules of engagement are. We will be riding with rounds chambered and weapons “on red.”
After the captain finishes the briefing, one of the soldiers leads the group in a prayer, and though I cannot quote the prayer, it is the best one that I have ever heard.
I am riding in the front passenger seat of the rear humvee. It has been modified with quarter-inch armor and the floor is covered with sandbags, which doesn’t do much for leg room but I don’t mind. There are two machine guns up top. I have nothing to say. I sit with my M-9 in my lap, ready to load it when we leave the Green Zone. I am still thinking that this could be the last day of my life, but I don’t really feel afraid. I am concerned that if we are attacked, that I will be able to do my part to get us through safely, that I won’t freeze. As we enter the traffic circle past the last Green Zone checkpoint, a call comes over the radio that the route is closed. We turn around and drive right back into the Green Zone. At the CSH, we find out that an IED was found on the route and that the Explosive Ordnance Disposal (EOD) was in the process of destroying it.
As we sit waiting for clearance, the driver is talking to the soldier in the rear seat about not having his ID. He had to run back to his room to get it. He asks how many convoys he has been on and the soldier says it is his second one. I speak up and say that this is my first one. The driver offers me his M-16. It has been 15 years since I’ve shot one, so I ask him for a quick review and he gives me one. He says it’s a good weapon, clean.
Our second trip out the gate is aborted when a weapon misfires. Again we turn back, but just far enough to make sure nothing is damaged and no one is hurt.
Finally, we pass the checkpoint for good and we are on the freeway to Baghdad International Airport. With the M-16 pointed out the window, I watch the cityscape pass warily. In the opposite lane is the burned out hulk of a car. Any merging traffic can be a vehicle full of gunmen and I watch closely as we speed through the interchanges. We swerve under the overpasses where the IEDs and snipers are most likely to be. We approach a van and a car on the shoulder with a crowd of Iraqis around it and it looks like trouble. But we pass and nothing happens. In 15 minutes, we are at Checkpoint 6 BIAP, where we clear our weapons. BIAP has never looked so good. It is the first day in my life that I have prepared myself to kill someone. But it is not until the next day that my hands start shaking.
When I get back to Camp Sather, there is a huge black plume of smoke in the west where a fuel convoy was attacked.
April 20, 2004
I dreamed that I was in some unfamiliar neighborhood of an American city, in the parking lot of a rundown apartment complex. I started hearing explosions. I couldn’t see the blasts, but I could hear them all around and there were a lot of them. When I woke up, it was about two in the afternoon and I found out the explosions were real.
Thirty minutes later the First Sergeant came to get us because casualties were coming in. Twelve casualties in all, Iraqis, from a mortar attack on one of the prisons. This was an Iraqi attack and 22 prisoners had been killed. We received chest wounds, abdominal wounds, traumatic amputations, to name a few. Many of these casualties needed blood.
Our first case was a young Iraqi man with a chest wound — gut in his chest. He was already intubated and had a liter of blood out from his chest tube. I took him to the OR and pumped blood and fluids into his femoral line as fast as the RIS could. He was too unstable to turn any gas on. The surgeon worked on a hole in the stomach, took out the spleen, but never could really get the bleeding under control. I pumped 9 units of blood into him and then we ran out. More blood was on the way. The surgeons packed the wounds and I pumped in saline and hespan and we waited but his hypotension worsened and eventually he was pulseless. All this time I was thinking, “are we wasting all of our blood on a lost cause?” Are we going to lose more people because we used all of the blood on this case?
But a chopper came in 30 minutes later with 30 units of blood and we started the next case: another young Iraqi with an abdominal wound. He was getting blood on induction but bottomed out on induction and though I pumped six units into him as fast as the RIS would deliver it, I could not get his pressure up. Finally the surgeons went to work in the lower abdomen and found the problem: his femoral line was just pumping everything into the abdominal cavity. It was no longer in the vein. He responded well to blood in his vascular space and made it through the case. Then we cleared them all out. Choppers took them to the CSH in Balad so we would have room to take American casualties.
One night a week or maybe a year or another life ago, the soldiers brought an Iraqi man and two children to us. The story was that the man had shot down an Army Apache helicopter with an RPG, killing the crew. In the pursuit, the Iraqi man was shot in the lower abdomen, and one of the boys had an elbow wound. We heard that the boys’ mother was killed. It was said that the Iraqi man was the boys’ father, but with the language barrier and the fog of war, who knows for sure.
We took the father to the OR and fixed him up. His case went well. Then we prepared to ship all of them up to Balad by helicopter. When I got out of the OR, the children were laughing and joking with some of our staff — who was doing their best to keep them entertained in spite of the language barrier. I couldn’t understand it. How could they be laughing if what I had heard was true? Could they just not comprehend it yet? They were about the age of my sons — maybe a little younger and beautiful kids.
May 16, 2004
Last night there were a couple of small explosions and then a loud one — the ground and chest rattling kind. I put my helmet and body armor on and waited — for another explosion, for the attack warning alarm to sound — for the phone to ring with news of casualties coming. Nothing more happened.
This afternoon the visibility was less than a half mile because of the dust. I went walking the perimeter jogging trail for three hours — ten miles. While I was walking, I thought about rockets and mortars. Because I carry a radio on these walks, I could call back to the hospital if I was hit. I imagined that experience: wounded and waiting for help.
Tonight I thought about soldiers I had taken care of who had lost their friends. One soldier lost the gunner and an Iraqi passenger when the humvee he was driving was hit by an IED. Another soldier lost the gunner to an RPG in the humvee she was driving. This would be the hardest experience to get over, I think — losing someone close — surviving something that killed them. This is the worst thing that I can imagine happening here: having a rocket or mortar take out one of our own. We would have to hold it together to take care of them. How hard would that be? I don’t want to know.
May 29, 2004
Yesterday a friend and I were sitting on the EMDS observation deck, facing the flightline and enjoying the dusty hot evening wind. We were talking about various things: his optimism about the mission in Iraq, my pessimism, movies, being home with our wives, and finally, the way that we respond to explosions. I told him that explosions gave me a double adrenaline/anxiety rush — would the next one land on me? If not, would the phone ring with casualties coming? He said that he felt that way in April when explosions seemed to happen all the time. Then five WHOOMPFs came in rapid succession to our right. I looked that way, and couldn’t see where they hit, but the sound was way too loud and too close for comfort. Then across the flightline, more WHOOMPFs and I saw the smoke rising as I turned to run down the steps and into the bunker. The Alarm Red siren wails. Six of us hunkered down in the bunker telling jokes and throwing rocks through the rebar loops sticking out of the concrete bunker wall until the camp was cleared of UXOs. It took two Dr. Peppers for me to recover.
Everyone is thinking of going home now. I try not to count days, try not to count on anything, because you never know when you are deployed. Plus I think counting the days just makes them go by slower.
June 5, 2004
After 2 days of flying, we step out of the Atlanta airport. I take a deep breath. I am surrounded by running cars and diesel shuttle buses, but the air smells so sweet. I could kiss the ground. Tomorrow we’ll be home.
February 21, 2005
*Please read the story of Spc Kephart on the Stars and Stripes website, "21st TSC Honors First Member Slain in Iraq." I mention him by name because I think his story is well worth knowing. I will never forget him.