Blast

I sigh as the lights flicker and the room goes completely black.  Silence.  My computer struggles to stay alive, blinking twice, then with a sharp high pitched electrical blip, darkness.  I blink twice.  Nothing.  Pitch blackness.  I feel blindly around the room with my right hand for the locker that holds my backpack, then fish blindly in the top pocket for my headlamp.   A small click, and a circle of light silently illuminates the room. 

I work my way to the door.  It is 9pm, and dark outside.  There is relative silence save the occasional soul-reverberating vibration of a jet tearing off the runway towards the sky...and then its partner.  They always depart in pairs.   The greyish yellow moon is eerily covered diagonally by a dark presence -- obviously a cloud, yet with just an edge of creepiness that makes you wonder what sinister being planned this ambiance tonight.    I wander to the generator that sits silently by the thick cement bunker that abuts my clinic.  I turn the key, and am greeted by a dry metalic grinding.  Nothing.  Enough already, cries the generator, that battled the 135 degree heat all day.  I’m done for the night.   I look at my watch and sigh again.  I rub my eyes.  Yeah.  I’m done, too.

I return to my clinic room, guided by the circle of light, and grab my pack. 

My mind jumps back to the moment before the lights went out, to the man on the computer screen reviewing the subject of “Blast Injuries” -- tonight’s Continuing Medical Education topic in preparation for my upcoming medical boards.  My mind revisits and digests the slide entitled “total body disruption” -- and the photo of a mangled human body, arms and legs torn violently askew, head splayed open like the hollow shell of an old Halloween pumpkin thrown insolently onto your driveway on an early November night.  That was somebody’s son, my mind whispers solemnly to the silent darkness.    Somebody’s brother.  

Total body disruption.

The next slide was a graph, showing expected injuries to “unprotected victims at relative distances from a high explosive detonation”.   At closest range, of course, falls this “total body disruption”, followed by burns, inhalation injuries, toxic inhalations, pneumatic blast injuries of the lungs, bowel and ears, and traumatic amputations.  All those, just from the dramatic shock wave of hot, mobile air that strikes a body after an explosion like a sudden tsunami. 

Traumatic amputations.  Not from being struck by a fast moving object.  But from the force of the air passing by.

“First,” states the speaker, “the violent blast of air snaps the bone.  Then,” he continues, “ it continues past, ripping the soft tissues completely apart and away.”

And finally, secondary blast injury, from the actual fragments of the explosive penetrating soft, intricate, complicated organic flesh.   Turning a fragile miracle of cells and sodium/potassium pumps and calcium channels and hormonal receptors and thermoregulators...into an unrecognizable pile of hamburger meat. 

I climb into my truck.  The steering wheel is on the “wrong side”, but I am getting used to that.   There is a fine dust everywhere, as if I have landed on the moon.  As if someone has come into my car with two blackboard erasers, and clapped them vigorously inside for 5 minutes, then ran away snickering.   I turn on my headlights, and two brownish yellow beams are visible, cutting through the dusty darkness.   I pull onto the road towards “town”.   Dark sillouettes of slowly moving trucks are backlit by a golden misty dusty glow of following headlamps.    Shadows of thick paneled, heavy armoured vehicles lumber toward me in the darkness.

The road is surrounded on both sides by thick cement barriers, and topped with shiny silver razorwire.  And behind that wire... Afghanistan.

During the day, I see birds alight on this wire.  Haven’t they learned?  Don’t they know?   Razorwire.  Are there a multitude of little bird fingers laying at the base of all of these tangled, lethal metallic barriers?   Maybe.  But, apparently not.  These birds seem content as they sit there, oblivious to the the politics that has strung this sharp, treacherous perch. They do not wince, though perhaps a wincing bird is a hard thing to identify. Beaks, you see, are rather expressionless.   I’m glad something can find a peaceful quiet perch in this tightly coiled and defensive situation. 

A dove on a coil of razorwire.    Separating US from THEM.   

I round a corner in the darkness where the border of US and THEM becomes nebulous.  Here there is a gap in the wall on each side of the road.  On the right, representing US, is a tan, thickly armored American Humvee protecting a 300 foot gap in the wall.  On the left, a small green SU, emblazoned with swirling Persian characters, represents THEM.  

Of course, at this most nebulous turn in the road, where US meets THEM, as I tentatively drive the football field of tarmac that stretches between, the air raid sirens begin to wail.

Of course.

A calm Austrailian sounding woman, not unlike your imagined childhood nanny, known as the Giant Voice, in a stern yet somehow calming tone, announces sweetly, almost seductively,

“Rocket...Attack.    Rocket...Attack”   Then, more sinuous wails from the siren.

“Shit,” I mutter to myself.

I am supposed to pull over and stop my truck.  I am supposed to climb out and drop to the ground, preferably in a ditch by the side of the road, and lay on my face, protecting my hands beneath my body, directing my feet in the direction of the attack (with the idea that it is better for the blast -- and I suppose shrapnel -- to first impact my feet, and then my head).   I am supposed to lie there, face down for 2 minutes, and then cautiously proceed to a bunker.

I look at the side of the road.  Curling razorwire lies in the drainage ditch where I am supposed to fling my body. 

Continuous wailing sirens.  Someone is dropping bombs on us.   Somebody thinks of US as THEM.   I’m a THEM.   An anonymous THEM.  And so, have become part of the nebulous political situation.

This is not a new experience, this rocket attack.  I am strangely unafraid, nearly unaffected.  This calm sensation, I suppose, is denial.

If I do not see the blast here; perhaps it hit back there?  Did it hit near my clinic that I only left 5 minutes before?   Will there be one more?  Or two or three or six?  I think of the nice fat concrete bunker I just abandoned to hop in my truck and come this way.   I think of my coworkers.  My patients.  Are they okay?  I think of the people scattered about the airfield.  Are they okay?   I hear the screaming of an ambulance siren.   Four blue light flashing police cars scream past me going in the other direction.

Is everybody okay?  

Possibly not.

My mind flashes back to tonight’s lecture.  Total body disruption.

I look left...toward the gap in the wall known to me as THEM.   I look right, towards the gap that is US.   There is no place to pull over, no ditch in which to cower.   I see no evidence of an explosion here.     I gun the engine of my truck, deciding the best strategy -- the illegal strategy -- is to drive quickly away from this place.  My eyes strain in the darkness.   The siren wails.  

Where do I go?  Where do I go?  My eyes search the roadside in the darkness.

Where is the nearest bunker?  Where do I go?

At least I have the potential of a bunker.  

My mind flashes to the film “Restrepo”, by Sebastian Junger -- a shockingly bold documentary which follows a troop of American army soldiers as they attempt to overtake a Taliban stronghold in a valley in southeastern Afghanistan.   In the documentary, the Americans call in an air attack on a target.  Later that day, they march into the newly bombed village.   An Afghani man, with a long dark beard and long white robes, walks towards the foot soliders.    He has the form of a lifeless child -- perhaps four years old -- draped in his arms.  He is screaming angrily at the soldiers.

“What have you done?!” screams the man, gesturing at them with the flopping body of the dead, bloodstained child.    “Does this look like Taliban to you?” he accuses angrily, gesturing with the floppy body of the child.   He repeats, screaming accusingly, hoarsely, “What have you done?  What have you done??  Does this look like Taliban to you?!”

The camera turns eventually to the troop’s commander.  A young man, perhaps 10 years my junior.  Way too young for this massive burden dragging on his shoulders.   He looks flatly into the camera.   He acknowledges that this was a mistaken target.  His eyes are blank. Hard.  Emotionless.  Tightly locked down.  Resisting compassion.  His jaw is clenched.   A rock.  Because, when confronted with the pale bloodless face and hollow black eyes of a ragdoll child flopping lifelessly in her grandfather’s arms...how can he be anything else.  He has become a rock.

How can a rock ever stop being a rock?

How does a grandfather...or a soldier...ever move beyond this moment?

Likely they cannot.  And never will.

My mind returns to the present moment, where warning sirens continue to wail.  I pull my truck, finally, into a patch of sand off the side of the road.   It is pitch black outside.  Still I do not see a bunker. 

I cautiously get out of the truck.  Before me, on the roadside, looms a large towering tree, one of very few trees that are found here.   And suddenly, my breath catches.  And I  am struck.

With wonder. 

The shadowy form of the giant tree is swarming with a cloud of birds.  Hundreds...possibly thousands.  They squack and chirp and sing and call to each other in a tangle of voices, audible now that the wailing siren has momentarily stopped its wavering shrill.  Like black mangos, filling an overripe tree, these seemingly thousands of chirping creatures are shocking in their numbers.   They seem agitated and restless, chattering excitedly.  Is this where they flee in a rocket attack?  In this land of dust and grime and giant rumbling metal machines and rock-like men with blank staring eyes and loud thunderous planes and rockets dropping from the sky and total body disruption and US and THEM and burning garbage and open sewers wafting noxious putrid stench...when I am supposed to be lying on my face in the ditch at the base of this tree...awaiting the gigantic boooooom and the hot tsunami wind and shrapnel and the next command from the Giant Voice....I instead stand, fixed to this place, upright, head raised curiously, arms hanging uselessly at my side, staring entranced at this strange, living, singing dark grey profile contrasted against the night sky. 

A singing tree. 

It sings to me.

“What’s going on?” their warbling and confused mix of voices seem to ask me.  

“I wish I could explain,” I respond silently.  “I wish I understood.”

I stare up at them.  Two thousand eyes stare back at me.  In the darkness.  Under the light of the sinister orange dusty half moon.  In the midst of a rocket attack.  For a moment... struck motionless by this sweet wonder.  Somehow comforted by their innocent eyes and musical voices.

Another truck pulls in beside mine.  A young female soldier jumps out with her rifle. 

“Do you know where to go?” she asks, anxiously, nervously.   “Have you seen a bunker?”

My eyes are pulled from the tree.   I look around, and finally spot a potential shelter across the street.  

“Let’s go over there,” I say, pointing. 

She is too young to be here, in this place.   This sweet voiced, angel-faced feminine near-child dressed in digitalized cammo, hefting a complicated black metal rifle on her thin boned shoulder.

Too fragile.

Too innocent.

Aren’t we all.

“Let’s go,” I say.   I glance back one more time at the tree… then turn to run across the road.

A thousand small, sweet tangled voices and two thousand dark eyes follow us into the blackness.

Child Suicide Bomber

Why am I even writing these words, one after the other: 

Child Suicide Bomber.  

What has our world come to?

****

It is sunset, and I am driving on the west road.   Between me and Afghanistan stands a foreboding chain linked fence, topped with a threatening spiral of sharp razorwire.   Dust creates orange hazy halos around objects, silhouetted by the gigantic setting desert sun.   There are square houses of stucco mud, scrawny trees, scattered green desert brush. 

There are rows and rows of rock topped dirt mounds,  where unskilled laborers have walked, outside the fence, tapping long sticks on the ground, looking for remnant land mines from the Soviet war era of the 1980s.     Each mound represents a suspected land mine. 

The Soviets, apparently, upon their withdrawal, "lost" the maps which indicated where they had laid these mines.  Current military forces are trying to identify them, and somehow deactivate them.

There are hundreds of mounds, just outside the fence.  Perhaps thousands.

Goats and goathearders roam this land, taking their chances.  Because...what other alternative do they have?

This is, perhaps, a horrific picture.  But it is not new to me.  The view has become, morbidly, commonplace.

But today, on this drive there is something new.  Something unexpected.

The window of my truck is rolled down in the scorching heat, and as I drive along, I hear the sound of... singing?   I slow, and my eyes search;  off in the distance, beyond the rock topped mounds,  I spy five girls, 100 meters from me, in flowing female dress, standing upon a rocky elevation, dancing and singing and waving their arms above their heads.  They see me, in my truck, and appear to be trying to get my attention.   They sing and laugh, and wave happily, excitedly.    

I am reminded of the Haitian children who used to chase our medical truck through the back neighborhoods of Port au Prince.    "Hey, You!" they would call excitedly as we drove past, sometimes chasing us with child-filled delight.  "Hey, You!" I would call back, and we would laugh at each other, and wave in that small moment of human connection.

I stare at the girls as I slow my truck slightly.  They are different ages, I can see, different sizes, silhouetted against the sun.  In the darkening light of sunset, I can see that their clothing is colorful, pretty, female, beating slightly in the evening wind.  They are barefoot.  They are graceful and feminine as they dance against the sunset.

I have never seen an Afghani woman here.  I have never seen a girl.   Just men and boys, who stare at me sometimes with palpable negativity, due to my unscarved head, and the multitude of political and cultural and religious violations that it represents.

They are beautiful, these female creatures.  The energy of children.  I wave back at them through my open window.  Suddenly, they start to jump up and down; I hear their laughter and squeals accelerate, as they realize they have made contact.  They wave more vigorously.  I laugh, too. 

"Hey, You!" I whisper, with a smile.

I wonder if they can see, from their vantage, that I, too, am a girl.  I wonder if they can see my long hair.  I wonder if that makes them wonder...   Or, am I just another truck passing by.

"That's so awesome," I say as I pass them.

And strange. 

And unexpected.

And extremely suspicious.

My companion in the seat to my left says, "Be careful.   They might be trying to get you to slow down, so someone behind them can shoot you."

Oh.

Afghanistan.

****

I am walking into the Military Hospital to check on a patient.   A nurse is guiding five figures out the front door towards a parked truck.

"Are you all doing okay?" she asks with matronly concern as she turns back briefly to glance at them.

I walk past them as I enter the building.  They are soldiers, dressed in desert camouflage and blank distant stares.   They look grim.  Empty.  Perhaps shattered, emotionally.  They do not meet my eyes.

Their faces are covered with multiple small lacerations.

Shrapnel injuries.

They are likely being guided towards the Warrior Recovery Center  -- bunks where soldiers involved in explosions go for mandatory monitoring, and to receive rehab of possible traumatic brain injuries.  They appear shell shocked.

What happened to these men, I wonder.  An IED?   What is the cause of their blank, grim stares.  Is this emptiness brain injury from concussive force?  Or soul injury, from seeing a best friend killed in front of their eyes?   The most common traumatic injury seen in this hospital are lower extremity amputations from walking over or driving over explosives.  These men are walking away.  Do they ponder the ones who could not?

I walk down the hall to the 10 bed ward where my patient is resting.  Yesterday it was empty, save my patient and another man.  Today it is full.

I look around. More shrapnel wounds visible on exposed faces and extremities.   Bandages.  Grim faces.  

"Boy, it was busy in here last night," one of the older patients tells me.

I look around at the beds.  One face is the clean shaven face of an Afghani man.    He appears kind.  He is a local man, a translator, putting his own life at risk to work with the ISAF.  A trusted and essential colleague of the American forces; their only voice to communicate effectively with and understand the local people.

He had one final translation before he ended up in this hospital bed.  One final searing, life altering conversation.

He was standing with a group of American soldiers, who were stopped for a rest on an afternoon patrol.  The unit was approached by a teenage boy.  As the boy came closer, he suddenly stopped, and revealed to the soldiers he was wearing a bomb strapped to his chest.

Immediate stunned silence.

The translator called out to the child to stop.   Stop!    He tried to negotiate with him.    Stop, stop, STOP!    You don't want to do this!  Why would you do this?!    He tried to talk the boy out of it.

The boy told the translator that the Taliban had promised him, if he blew himself up in a crowd of American soldiers today, that his family would receive US$300,000.

And so.

With a click of a hand-held triggering device.

In a crowd of American and Afghani soldiers and translators...

He did.

****

The newspaper said yesterday that in a Southern Province of Afghanistan, a suicide bomber attacked a group of ISAF forces, causing an unknown number of casualties, including a number of suspected deaths.

There were no other details.

The story was never revisited.

It did not mention that the bomber was a child.

****

AP News:  February 2012, in Kabul, Afghanistan: 

Afghan police have intercepted 41 children whom insurgents were planning to use as suicide bombers, an Interior Ministry spokesman said Tuesday.   Four suspected insurgents were about to smuggle the children across the mountains into Pakistan from eastern Kunar province on Friday, said Sediq Seddiqi, the spokesman.

"We strongly believe that the children were being taken to Pakistan to be trained, brainwashed and sent back as Afghan enemies," Seddiqi said.

The children are aged between 6 and 11, he said.

A Mind Stretched

Shell-shocked US marine, Hue, Vietnam, February 1968. Photograph: Don McCullin

"A mind that is stretched by a new experience can never go back to its old dimensions.” Oliver Wendell Holmes

It is nighttime, and I am sitting in a plywood building full of computers, separated by short plywood privacy walls. There are perhaps 20 computers in the room. Soldiers, with black metal rifles strapped to their backs, sit on metal folding chairs staring at computer screens. Some wear headsets, and speak in one-sided conversations to the images on the screens in front of them. A 45-minute wait in a line out front allows a 15 minute call home via the miracle of Skype. As I scrape back my metal chair to take my seat, I glance sideways and see the face of a young infant, magnified ludicrously and filling the big computer screen to my right, big blue baby eyes and a crinkling smile. A single tooth visible in the smile. A bit of drool. The soldier, from behind, so intimidating in camouflage and boots and rifle, now in my side vision wears a similar smile, with similar shining eyes. He is entranced.

"Hi, baby..." he croons softly, very unwariorlike, to the smiley image on the screen, as if it is just the two of them in the world. "Hi, there baby..."

When was the last time he held his baby?

Has he ever held his baby?

I sign onto the computer, and from behind me, another soldier, sounding angry and distraught, the volume of his voice escalating.

"Baby, I'm just asking you to listen to me. I need you to listen to me....Do you think I'm not thinking about you? How the f*** can you think that...You don't understand a f****ing thing..... Do you know what my f*****ing life is like right now. Baby, I just need you to f***ing think about me for a minute...... Do you have any f***ing idea?!" 

He escalates. In my mind, I cringe. I close my eyes briefly and sigh for the irrational, aggressive, desperation that is his tone. 

His fifteen minutes to call home. 

Quickly spiraling downward into a f***ing disaster. 

Where has this soldier come in from today. Where has he been? What front line? What mundane or hideous or unspeakable situation. What has he seen or done, that makes him beg his girl -- ungraciously, yes -- to think about him for just... one... minute. 

"You obviously don't f***ing give a sh*t.... You don't want to give me the f***ing time of day...Like I don't f***ing think about you..."

Don't do it, I think. Calm down, I think. Pull it together. Don't do it...

"Well, f**k you..." he yells. "F**k... you..!!" 

The last word cracks, in what one might interpret to be a small sob. I hear a slamming on the keyboard behind me. The slamming of a headset onto the dusty plywood table. A giant, angry, frustrated expulsion of breath, and the scraping of metal chair legs against the floor. The stomp of exiting feet.

No one turns to look.

And so, the call is terminated. The call to the girl whose photograph probably sits, crinkled, inside of his helmet. Or in a pocket, always against his heart. The face on the paper he pulls out and stares at on his lonely nights lying in his bunk, or his pit in the sand...his connection to peace and normalcy and home and what used to be. That time from before. That place that he cannot quite return to...perhaps, ever again. 

Where does she sit? It what city or small town. Had she awaited this call for days, weeks...months? What series of words triggered his reaction? Was it warranted? Or just an explosion of stress and emotion from a person who otherwise has very little outlet for emotional expression. She cannot pick up the phone to call him back. And, as evidenced by the empty metal chair sitting askew behind me, she will not be hearing back from him tonight. 

Does she know what happens after the profanity and the cutting of the connection. Did she hear the crack of his voice, revealing the inner desperation? Is she now sitting at home, helpless to reach out to him? Does she know he storms outside, to pace in the nocturnal, dusty, putrid smelling stench of sewage that wafts outside this building, perhaps lighting a cigarette and taking a giant drag, wanting to explode, but unable to go anywhere to explode? Does she sense his probable almost instantaneous regret of his uninhibited words? 

My thoughts are interrupted by a sharp sudden "BOOOOM" to the wall to my left. The plywood rattles and releases a cloud of fine dust. Like startled deer in a field, all heads turn suddenly and stare at the wall, breaths halted. Frozen. Three solders are on their feet in an instant. Two have hit the ground on their hands and knees in a blink of an eye.

"What the F**k was that??!" one of the standing soldiers asks the room in a low, aggressive tone.

"Soccerball," someone declares from the side. "They're playing soccer outside. Must'a hit the wall."

Grumbling curses erupt across the room. Eyes meet each other, sheepishly. The three standing soldiers sit down. The other two get up, dusting off their knees with slapping hands. And also sit.

Soccerball.

Around me is the cohort of men and women who, if they safely return home to the United States after their time in this war, will struggle to adapt in the culture shock that is mundane, main stream America. Returning home to families, who have gone on with life, effectively, without them. Trying to reintegrate; trying to once again find their place in a peaceful, uneventful world. Trying to reacquaint with their wives and their children. Jumping at the sound of a backfiring car. Madly swerving and accelerating at the site of a shiny object on the side of the highway. Trying to harness the tangle of hypervigilant, animalistic, sometimes terrifying, caffeine and tobacco and jet engine and rocket driven, mundane, lonely, solitary, base emotions that are, in part, Afghanistan...and shove them effectively back down into the subconscious...and go on living.

I have met this returning soldier, in my family practice, in Alaska. Several times. And so, I am sure, have you.

The US Department of Veteran's Affairs has surveyed members of the Army and Marines who have served in Iraq and Afghanistan. Of events considered by the government to be "combat stressors", the following stats reflect the experiences (in a 2003 study) of returning marines: seeing dead bodies -- 95%, being shot at -- 97%, being attacked/ambushed: 95%, receiving rocket/mortar fire -- 92%, know someone killed or seriously injured -- 87%.

Since the beginning of these wars, more than 1 million Americans have served and returned home. Of these, 46% have sought medical care in the Veterans Administration hospitals -- and of these, 48% have been diagnosed with mental health conditions directly related to combat. That's nearly a quarter of a million returned soldiers, diagnosed with mental illnesses -- including depression and post traumatic stress disorder (PTSD). And that is just for those who presented for care. Many more fail to seek help, due to fear and negative perceptions of a diagnosis of mental illness, or due to lack of access to mental health services.

Of course, it is not only Americans and NATO soldiers who suffer such sequellae. One recent study of Afghani women living in combat regions found an overhwelming, a distressing, but perhaps not surprising, 98% suffer the effects of PTSD.

If you wonder how you can help reduce the reverberating impact of this war, consider the following:

Advocate for improved access for mental health services for war veterans. Particularly in rural America, mental health services are limited and frequently completely inaccessible.

Know that PTSD is very real, and has broad reaching impact on our society. Not just on returning soldiers, but on their families and communities. It is very treatable with counseling and medications. And if untreated, can be devastating, in the form of depression, suicide, substance abuse, and family violence. The first step is considering the diagnosis. The second is encouraging the one suffering to seek help. The third is working to remove the stigma of accessing mental health services.

Signs of PTSD in someone you know, or someone you love:

Re-experiencing the traumatic event

• Intrusive, upsetting memories of the event
• Flashbacks (acting or feeling like the event is happening again)
• Nightmares (either of the event or of other frightening things)
• Feelings of intense distress when reminded of the trauma
• Intense physical reactions to reminders of the event (e.g. pounding heart, rapid breathing, nausea, muscle tension, sweating)

Avoidance and numbing

• Avoiding activities, places, thoughts, or feelings that remind you of the trauma
• Inability to remember important aspects of the trauma
• Loss of interest in activities and life in general
• Feeling detached from others and emotionally numb
• Sense of a limited future (don’t expect to live a normal life span, get married, have a career)

Increased anxiety and emotional arousal

• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance
• Feeling jumpy and easily startled

Can a mind that is stretched... ever go back?

Could you?

Afghanistan

Photo by James Nachtwey, war photographer

This photograph hangs on the wall of my clinic in Afghanistan.

It reminds me daily of why I work here.

The first time I saw this picture, in Life Magazine, my eyes began to blur. Partially from tears. Partially from a chemical reaction. I was sitting in the office of an ophthalmologist, having my eyes dilated as part of a pre-deployment physical. In preparation for a retinal scan. Earlier in the day, I'd had a panoramic dental x-ray, and a DNA test. Independent biological identifiers. Required for deployment into a warzone.

I remember staring into the eyes of this young man, as mine lost their ability to focus. Such eyes.

How would you define his emotion? His clenched brow. His distant stare. The tear in the corner of his eye. The clenched right hand. Is this pain? Is this fear? Is this devastation? What you do not know, when you first look at this photograph, is that this young solder has just had both of his legs blown off in an IED explosion. Minutes prior.

I hate this picture. For the invasion of this man's privacy, in this perhaps most intimate moment of his life. And yet, I am so very grateful for this glimpse. For this reminder of an event that happens here in Afghanistan...nearly every single day. Sometimes to soldiers, sometimes to local Afghani citizens, just trying to go about living their lives in the middle of an incessant warzone.

IED -- improvised explosive device -- injuries are generally devastating. The force of the explosion, frequently experienced from below, by a person in the front seat of a vehicle driving over an explosive, causes massive blast injury. Bilateral lower extremity amputation is common. As are pelvic injuries, genitalia injuries, and massive internal injuries. Every soldier wears a tourniquet on the shoulder of his or her uniform -- in the event of such an encounter. They are taught how to apply these devices to themselves. Because the military has studied the causes of death in soldiers in Iraq and Afghanistan in the past decade, and have determined that death from exsanguination from blast injuries is the most common preventable death...if dealt with immediately...with a tourniquet.

When I went through my predeployment training, I was taught how to put on a tourniquet. I am an emergency medicine provider. I know how to put on a tourniquet. And in my 13 year career, I have had to to this only once. Most injuries will stop bleeding with direct pressure and elevation. But, not blast injuries like these, in which the anatomy becomes a tangled mess of barely identifiable flesh. These injuries are, at times, inconceivable.

Five days ago, 25 miles north of my clinic, a young soldier on a night patrol, stepped on an IED. He was a 15 minute helicopter flight from our airbase. Fifteen minutes from a trauma surgeon. An imbedded journalist reported on the events. In confusion in the night, he'd stepped off a path that had been cleared by the company's bomb sniffing German Shephard. Moments later, an explosion. A buried IED. The young solder sustained devastating injuries. In the millisecond which was the explosion, he lost both legs and one arm. Instantaneously.

His fellow soldiers acted immediately, applying tourniquets to his extremities. The injured solder, incredibly, remained alert and oriented. He complained that the tourniquets were too tight. He continued to speak to his comrades as they carried him to an improvised landing zone, and called for a medevac helicopter.

And so begins the Golden Hour of trauma. The hour in which one has to get to a surgeon, to stabilize life threatening injuries, before one bleeds to death.

It is likely a blast, that is so forceful it tears your limbs from your body, has devastated more than your limbs. Pneumatic injury to air filled organs -- lungs, intestines, ears -- can lead to their rupture. Blast injury to solid organs -- liver and spleen -- can cause them to bleed uncontrollably. And, in this war, we have discovered, the force of the blast on the brain leads to axonal disruption, in which the very cells that make up the brain are shifted and sheared -- leading to closed head injury and possible lifelong neurological compromise.

If you look back at the photograph that hangs on my wall, you will see the medic with one hand on the young man's chest, and one on his wrist. In the back of a medevac helicopter, finding a shallow pulse, and distinguishing it from the pounding of the chopper's rotor blades, is a true challenge. A too- fast beating heart, palpable in the medic's palm, is a sign of impending death in the race against time. An absent pulse in the wrist serves as a second warning sign -- that the body has chosen to conserve its remaining blood for the vital organs, and no longer perfuse the extremities. You might even see the medic raise his fingers to his own neck...to determine if the racing pulse he feels is his patient's, or that of his own antagonized heart.

I think back to the tourniqueted soldier, lying in the field five nights ago, 25 miles from me. His fellow solders kneeling beside him, in desparation, awaiting a medevac. He is talking. What does he say? What do his fellow soldiers reply? Are they 18, 19 years old? Twenty? How have they been prepared for this day? For this conversation?

There was a delay in the helicopter dispatch on that day, because an armed escort chopper needed to be located before the medical crew deployed. It took 60 minutes to get to the soldier. The golden hour expired. And, tragically, so did he.

When I walk home to my bunk at night, sometimes the flag has been lowered to half mast. It was, that night. It sits in quiet communication that another American soldier has died today in Afghanistan.

Yesterday, on the runway here, I spotted a C17 cargo plane from McChord airforce base, with a big green Shamrock on the tail. I know this plane. It is the very one that used to carry me from Antarctica to New Zealand, when I used to fly medevacs out of McMurdo station. It is the plane that was diverted from the Iraq military theatre 6 years ago, when we had a mid-winter medical emergency on the Ice requiring an emergency medevac. It took them nearly a week to get to us, due to weather conditions. I remember, after sitting desperately with that patient for nearly a week, the miraculous, beautiful site of this very C17, cutting through the Antarctic sky, and swooping down to our blue ice runway. Like a gigantic grey angel dropping down from heaven. I remember the back cargo door opening, and a medevac flight crew disembarking, wandering across the snow to our ambulance, to accept our patient. Our patient's salvation.

I stared at the familiar grey plane. Surreal. What are the chances of us meeting here, I asked it silently? What are you doing here today?

As I watched, its back cargo door dropped open once again. This time, soldiers slowly marched in unison towards the opening. They formed a line on each side, and then stood at attention. A sand colored military vehicle then slowly appeared from off the side of the airfield. It was intercepted by a group of soldiers in dress uniform. As the vehicle turned slightly, the situation was revealed. A coffin, draped in an American flag, was now visible on the bed of the vehicle. Six soldiers slowly lowered the coffin onto their shoulders. And, in unison, turned and quietly marched their precious cargo into the belly of the C17. The two lines of soldiers paralleling the plane's cargo door slowly raised their right arms in salute as the casket was carried past. From my vantage point on the side of the runway, the sound of taps could be heard wafting past softly in the warm desert breeze.

A dignified transfer.

What is in their minds, these men and women, as they bear this weight, this flag, upon their shoulders? What is in their minds, as they steady their guns back on their shoulders, and slowly march away. I stare at their young faces.

My eyes begin to blur again.

Please, look into the eyes of the young soldier in my photograph. See his pain. His fear. His desperation. His sacrifice.

And remember him.

Did you remember, when you awoke today, that our country is fighting a war in Afghanistan?

Please don't forget.

Please work for peace.

Please pray for peace.

صلح