By Bonnie Hartstein, M.D.

The day we saved our Marine started off the same as every other day for us, just as it probably did for him.

A vast black, star-filled sky slowly illuminated by a rising ball of fire. About 13 hours later, that same sun would mark the start of the day in Texas, where my two small children and husband would wake. Amazing, this new world that was now our home was so still, quiet and desolate. Sand, dust and gravel in every direction as far as you could see. It was a monochromatic panorama. All things tan—tan tents, tan earth, tan uniforms, tanned faces. It was a perfectly bland backdrop against which could erupt a flurry of activity in a second. But so far, in the first month of our deployment, it hadn’t.

That morning, like the last, was calm. Breakfast came after a morning run and consisted of an oatmeal bar from a care package sent to me from a childhood friend now living in Los Angeles. I sauntered into the emergency department (ED) ready for my morning shift.

A few patients straggled in for sick call—a civilian contractor with a chest cold, a medevac helicopter crew member with an angry leg rash from wearing pants tucked into boots all day, every day. It was business as usual, which meant the minutes ticked by as we continued our daily dance. We were slow, and while constantly poised for the worst at our combat support hospital in Afghanistan, the reality was we were both blessed and cursed by the ebb of fighting seen in winter and the success of the surge a year or so prior. Drill as we may, we hadn’t seen much action.

I may have been headed to my tent to prepare for an afternoon exercise break when my frequently silent radio crackled to life.

Attention in the hospital. Attention in the hospital. Incoming CAT A, U.S. Mil, concussion and hand amputation.

CAT A meant category A, designating our inbound casualty in the most urgent evacuation classification.

While the information flowed directly from the field, we never really knew the true extent of injuries until we saw them firsthand. No matter—someone was coming and it at least appeared they were pretty hurt. A few seconds later, my pager reiterated the same information, notifying the wider hospital community to rally to the ED.

In quick succession, members of the team assembled in the ED to don disposable blue paper gowns, surgical hats, masks and gloves and take their places around the trauma bay. The bay consisted of a dark green stretcher set up on a wheeled chassis, also known as the NATO litter.

Minutes later the earth began to vibrate with the rhythmic beat of the approaching medevac helicopter. Looking like a large green fly, the helmeted air crew medic entered the ER from the flight line just in front of the patient. He gave his hand-off report, “Dismounted IED blast. He’s got tourniquets in place right and left leg, right arm.”

This was the worst we’d seen—the kind of trauma we had all anticipated. Now, it was on.

I was running the trauma, which meant I was like the coach on the sidelines, calling the plays while my all-star team—in position and ready—went to work.

While trauma medicine was not new to most of us, recruited from the best Army stateside emergency centers, it wasn’t long before we realized that this was different—a whole different league of trauma care.

One is taught to approach every trauma the same.

“A,” check the airway. Our patient was actually awake and talking.

Airway is OK.

“B,” is he breathing?

“Yes, breath sounds equal bilaterally,” I’m assured by my partner doctor.

“C,” check circulation and bleeding.

As there are multiple tourniquets in place, he is not actively bleeding. But, his blood pressure … what is it? Where can we place the cuff? As his left arm is lifted I notice his left hand is half gone and his forearm flopped outward like a rag doll. He was fast becoming less awake and was no longer talking. We needed an intravenous line right away. But we had the same issue as the blood pressure situation—his limbs were not an easy option. One of our junior surgeons was attempting a line in his groin. After a few passes of the needle I jumped in to help. Calm washed over me and, as if guided by someone else’s hand, I took the needle and redirected the angle and stabbed just a bit deeper.

Maroon blood filled the syringe, marking the vein and victory. “I am in.” I tried to sound calm, but inside I was doing an end-zone dance.

The head ED nurse grabbed the clear plastic tubing and connected it to a rapid transfusion system.

Restorative, lifesaving blood started flowing. We had one task accomplished and were one important step closer to saving our Marine’s life.

Gazing through the crowd, my eyes found the monitor, a digital display that bleeped out his heartbeats and gave the latest blood pressure reading. I watched it like the scoreboard at a bowl game, praying for my team’s victory and, as his blood pressure began to rise, I felt my heart pounding and my mouth go dry.

I took a step back—physically and figuratively—to reassess the patient and the situation.

His injuries were devastating. His right lower leg was gone and the other was tethered fragilely to his thigh by an area of flesh that was open, dirty and badly damaged. His left hand was shredded, half gone and a few fingers were obviously pointing the wrong way. I called to our orthopedic surgeon, asking him to take a look. Team members broke from their focused individual tasks to come together as we rolled our injured warrior onto his side to perform the inspection of the underside of his body. We take no chances at missing hidden injury.

How difficult it was to remove all his clothing and completely expose his injuries when his bloody frayed uniform was affixed to every wounded limb with a solid tourniquet. The orthopedic surgeon helped inspect the tourniquets, changing some over to a pressurized cuff, which would be helpful during surgery. Based on the severity of his injuries—and the anticipation of moving him to the operating room (OR)—the anesthesiologist had already placed him on a breathing machine. Now, the surgeons were ready for the handoff.

Our hospital was a series of beige tents connected by tent hallways, paved with green rubber flooring. Only from overhead, could one see the red cross painted on the top. The OR was a quick litter roll from the ED at the opposite end of the tent. Internal flaps of heavy reinforced fabric were rolled up and secured with Velcro to make way for the parade of equipment, tubing, medics, nurses and doctors.

The ORs were fully stocked containerized units attached to the tent-like appendages. Peering into the OR window I felt my body relax. A new team was now in charge. I pulled off my hot paper gown, feeling freed and relieved, and bathed in the coolness of the hospital’s internal ventilation system. Back in the ER, I found my partner, the other ER doc.

“That was the best line of my life.”

I couldn’t help myself. I just had to take a moment. He raised his arm to fist-bump me—that was his thing instead of high-fiving. “That’s one for the ER team.” he said. “Good job.”

My brief moment of rest was soon over.

Coming out of the OR, our chief surgeon ripped off his face mask and approached me. He was a skilled trauma guy from Landstuhl, the Army hospital in Germany, that received patients from the Middle East. Now it was his turn to work at the very front of the fight.

I was acting as the hospital’s chief physician, so he was looking for me.

“This guy is pretty bad,” he said. “He’ll need a massive transfusion. You’d better activate the Walking Blood Bank.” And, with that, he turned on his heel and disappeared back behind the olive green doors of the OR.

I stood up.

Massive transfusion. Activation of the Walking Blood Bank meant standing up an on-the-spot blood donor center with fresh whole blood samples run to the OR for immediate lifesaving use.

The outgoing hospital team had assured us repeatedly during our hand-off drill that we would “never ever have to do this.” Thank goodness we had prepared ourselves and drilled anyway, just in case.

The hospital’s Tactical Command Center or “TOC” sent word out to the base that we needed A+ blood, fast.

The ICU nurse in charge of the Walking Blood Bank ran in, out of breath. He was a slight fellow, bald and older in years than his rank of lieutenant would suggest. A Georgian, he was mild mannered, always very polite and I’d never seen him appear stressed—until now.

“Do you know how to do this?” I asked him.

“Yes,” he reassured me, as he flipped through a few stapled pieces of paper of our Blood Bank “SOP” or standard operating procedure.

I looked at the lieutenant. We looked at the tubes, and empty blood bladders and back at each other.

“Teach me how to do this and I will help you,” I said as calmly as I could.

Onto the gurney climbed one of our ward nurses, the first volunteer with the correct blood type. I applied a rubber tourniquet and, at the instruction of the good lieutenant, stabbed a needle the size of a cocktail straw into a wormlike vessel in his arm. He showed me how to tape it in place and tap, tap, tap the bag as it filled with deep red blood.

Then, soldiers, Marines and airmen from on-post started to come, along with the U.S. civilian contractors, foreign nationals and interpreters. Suddenly our break room looked like the train terminal at Newark.

One by one, the cadre of younger nurses, new to this skill set, was taught how to collect the whole blood donations.

One by one, Americans, Jordanians, Pakistanis, Afghans and people from all over the globe working on our camp answered our call and filled our chairs to give their blood to save our Marine.

We ran the warm red packets to the lab, for quick screening, then to the OR.

I was stopped in the hallway by a clean cut, fairskinned, broad-shouldered man about my age with a worried look.

“How is he?”

He wore the distinctive computer camouflage pattern with slanted breast pockets. I saw the glimmering silver eagle on his collar and realized this must be the injured Marine’s commander.

“Sir,” I said, “he’s in the OR. He’s pretty badly hurt.”

We formalized our introduction and I filled him in on the situation.

The Walking Blood Bank had successfully delivered 10 units of blood to the OR and had 20 more on hand as needed.

Our warrior’s surgery went deep into the night before he was finally stabilized and moved to the ICU. His wounds would change his life forever, but he would live to recover and return home. When I came to see him in the morning, he was sleeping peacefully, still sedated and intubated, but his monitor showed he was doing well.

An Air Force Critical Care Air Transport Team was already on the way to get him and take him to Germany. Our trauma surgeon had called his buddies there to give them the story.

The Air Force team came, delivered out of the sky on the full-scale runway that was our backyard. The team lifted our Marine brother and strapped him to the litter, snug for the flight—tucked in and covered with blankets. We would follow his progress in Germany, and ultimately at Walter Reed, and learn of his slow, but successful, recovery.

We will forever remember those frantic few hours that we fought to save him.

On my run the next morning—the night turning day—I felt the same longing for home, facing the realization of another day spent far away. But, welling up inside me was a growing pride in my team and our mission. A pride earned in the heat of battle, along with a humbling at the weight of that duty and the knowledge that there is more to come.

–Army Lieutenant Colonel Bonnie Hartstein, M.D., deployed with the 10th Combat Support Hospital from Fort Carson, Colorado, as Chief of Emergency Medical Treatment Section and Acting Deputy Chief of Clinical Services. She is currently assigned to Brooke Army Medical Center, Fort Sam Houston, Texas, where she serves as the Chief of Family and Community Medicine. Dr. Hartstein is board certified in Emergency Medicine and Pediatrics.