I haven't written, you will notice, in some time. If you have followed the news and know the pace of a Combat Support Hospital (CSH, pronounced "cash"), you will know that we have had it up to our eyeballs. I don't think anything I experienced in Balad rivaled this in intensity and duration.

The news accounts of the various happenings can be found here in the LA Times and here on Yahoo!, among other places. I've included some excerpts here from my journal to relate a little of what we experienced starting on December 30th. I've edited some for operational security, but almost all of the details can be found online.

“The gym at [Forward Operating Base] Chapman just got a direct mortar hit,” they said, walking down the hall toward us. “We’re getting an unknown number of casualties.” A chill went through us; it could just as well have happened here, the gym being a frequent afternoon ritual for many. I changed into scrubs and donned a burnt-orange surgical cap and made my way to the trauma room. Long shadows and late-afternoon orange light filtered in through the open hospital door. “At least its not cold,” I thought, since hypothermia can be deadly for a trauma victim.

More of the story filtered in: a suicide bomber had struck at Chapman, and we were told to prepare for at least 6 casualties. Little clusters of medics formed around each trauma bed. Lab techs, pharmacy techs, respiratory therapists all went through their paces in preparation, automatic, efficient. One of the bearded special operator medics who we saw frequently while working out quietly showed up, donned latex gloves, and went to the hospital ward to make beds and check supplies, doing the unglamorous and critically important.

And then they were here. Choppers landing. Dust. Noise. Fading daylight. The first two casualties roll in, Dr. N and I taking them and starting our assessment. “What’s your name?” "Do you have medical problems?" "No." "Ever had surgery?" "Appendix," he rasps through gritted teeth. The automatic questions to ask in the conscious patient, the need-to-knows, just in case they’re in no condition for us to ask them later.

I just then hear our internist Dr. L, “Josh, she’s got a chest wound.” I turn to see them rushing a stretcher in, the girl on it no more than 25, it seems. I see my own daughters and out of my mind goes all the data and MASCAL triage resource-allocation wisdom. “She’s somebody’s daughter,” I think. I HAVE to do something, anything, to give her a chance. The pea-sized hole in the middle of her chest disguises a larger injury inside. “I need a thoracotomy set!” Starting CPR. At the head of the bed I see a familiar face, a paramedic. “Can you get an ET tube in her?” He can, and does. I'm handed a knife and K is standing beside me opening the thoracotomy set. Slicing through smooth white skin, muscle, rib. A finger into the chest cavity, then it is open. One of our NCOs is beside me, cranking open the retractor. Feeling the empty and motionless heart, the empty, collapsed aorta, my own heart sinks. My index finger, feeling, nudging the pleural membrane away from the aorta enough to slide a clamp across. Squeezing, pumping the heart. “Epi!” I call. Someone hands it over. Sliding the long needle into the ventricle, emptying the full syringe into the heart. Squeezing, pumping. The flight doc is across from me, putting a chest tube in. Bright red blood, lots of it, spills out into the tube. I extend the incision and I reach up to the upper chest, where a shredded mass of vein and artery tell me that I’m out of options.

Dr. L reaches me then. “I’ve got two belly wounds out here. Can you salvage her?” I shake my head. We’re done. “Does anyone know her name?” I ask. She’s somebody’s daughter.

I reach the next one, scanning and assessing the injuries, taking it in within seconds: neck swollen with two gaping wounds, abdomen with a pea-sized wound, but distended, tourniquet on one leg with a big wound below it. We move to the OR. CRNA M and I hear gurgling from the mouth with each breath given. “I don’t think the airway is in.” He slides the “scope” in to find gaping wounds on either side of the airway. Sgt M hands me a knife and within seconds we have a tube into the trachea, through the neck just below the mangled larynx. I reassess, and by now there is no pulse. I press an ultrasound probe over the heart, and mine sinks once again when I see no motion. I look again at the neck wounds, the abdominal wounds, the leg wounds, and for the second time in minutes I again realize that I can’t fix this. “What good is a surgeon that can’t fix people?” I think to myself. On to the ones that I can help.

Dr. L comes and finds me, telling me about one in the “overflow hut” with a possible vascular injury and a tourniquet on his leg. I walk out into the cold air and to the hut, where the temperature hovers around 50 degrees inside – potentially deadly for a trauma victim. The special ops doctor has assessed him, but I have to find some people to draw blood for labs. I send him along to the CT scanner.

I walk to the ward to find another young man with a complex leg injury. I look over his CT scans and realize he has a penetrating brain injury – pieces of shrapnel have penetrated his skull and lodged in his brain. He’s doing remarkably well for that, awake and alert. I decide he needs a neurosurgeon more than he needs me. I talk to him quickly, explaining that he has a brain injury, and that it will be necessary to intubate him, inserting a breathing tube in his throat to protect his airway in case he loses consciousness during the hour-long flight to Bagram. He would be dead if that happened, because a maneuver as complex as putting a breathing tube into the airway is next to impossible in a dark, cramped, noisy, rattling, moving helicopter. He makes a face when I tell him that he likely won’t remember anything more until he is stateside. “Don’t worry,” I reassure him. “You’re entering the best worldwide system of trauma care ever. They’ll take care of you.”

I join our orthopod, Dr. C, in the operating room, as be begins stabilizing the fractures on the young man from the overflow hut. Drills, pins, bars, erector-set-like, his leg re-assumes the form it was meant to have. And then slicing, red, the muscle bulges and swells out as we free it from its fascia straightjacket, no longer dying in the strangling tight compartment.

We've barely started that when I am called across the room to join Dr. N at the other operating table. "There is a lot of bleeding from the leg here." I lend an extra pair of hands as she and I isolate the wound to the big vein in the thigh. We elect to tie it off rather than repair it. Life preservers, not swimming lessons.

...and so on, for ten days. Most of it is a blur to me now. I don't even really have pictures to post; we didn't stop to take any. Sleeping when we could, stubbly faces, sweat-soaked scrubs. Grabbing the occasional bowl of cereal or cold food from the chow hall. Popsicles. Crack-sickles, we call them. Little frozen bits of sugar and water never tasted so good as they do between surgeries in an 85-degree operating room.

And now I'm going to get a bit of that precious commodity, sleep.