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Emergency Field Hospital – Iraq

Have you ever written something kind of personal and had it read by a lot of people?  That’s what happened to my blog about my time in Northern Iraq. I wrote it off the cuff, as a way of processing an intense experience, and posted it to a blog which is followed by a limited number of people. I just wrote it in the airport, checked it for spelling errors, publish to blog, done. As it turns out, people read it and linked to it on Facebook. It didn’t exactly spread like “Charlie bit my finger” but it was read by more people than I would have ever imagined. It has been brought to my attention that some of my comments have been construed as negative or critical. This was not my intention. I have a tremendous amount of respect for SP, for the leadership of the EFH and for the colleagues with whom I served.  The Field Hospital took a tremendous amount of effort to make it a reality and everyone who was part of this effort deserves to be commended.  To this end I have edited my post and present an alternative version which can be read or disregarded.  Still…the internet!  What a phenomenon!  How many people have been brought low by a misguided post?  We must be careful of what we write, but there must be some middle ground, where we can be honest. If not, everything we write and share will be sanitized.  Feelings are complex, messy and contradictory.  They might not be universally understood, they are certain to be misconstrued by some.   Nevertheless, they are part of the human experience and should be shared.  There is obviously a balance, but we need to be willing to grant a certain level of grace when someone has the courage to speak from the heart.

Many people have returned from their time in Iraq and struggled to return to their normal lives.  This is not unusual, and perhaps it is part of the sacrifice we make when we accept this sort of assignment. We have been given an opportunity to share in the suffering.  It’s a privilege but it comes with a price.  Share your experiences, but don’t expect that people will fully understand. Communicate with others who were there.  Seek help if you need it.  Know that you’re not alone

Now…my post, with some more thoughtful editing, but still raw.

If you have been wondering whether I’ve dropped off the face of the earth for the past 6 weeks or so, the fact is that I have.  I’ve been serving at an Emergency Field Hospital in Northern Iraq.  It was, and remains a security-sensitive location.  At the moment I am sitting in the airport in Istanbul, wondering how to process this experience.  My apologies for being vague about the precise location of service.  For more information, feel free to access the Samaritan’s Purse website.  This will be a wordy post, I suppose.  In the absence of pictures, I am forced to substitute a thousand words.  Part of me would prefer to say nothing, I suppose, but this was an experience which demands some sort of processing.  It was powerful, horrifying but somehow redeeming.

I got the email out of the blue, asking me to come to a place which my father would have described as being “A great place to be from…a long way from.”  It came from a person I had worked with and mentored.  He probably knew how to push my buttons.  It was, as I recall, something about a field hospital on the plains outside of ancient Nineveh, offering care to the injured from a bloody conflict with an extremist group.  Had I not had a family, or served as the sole surgeon of a needy hospital, I would have immediately said yes.  When you have a wife and a toddler, the decision to travel to a war-zone gets a little harder.  Still, I knew, and I think Lindsey knew, that I needed to be there.  On one level I felt like I had something to offer.  More than that, it seemed like a chance to stand up in a dark place and shine a light.  As a Christian, if you feel that call, it doesn’t seem prudent to turn it down.  Plus, there’s the whole Jonah thing.  He was called to go to Nineveh and declined. It did not go well.  The end of Jonah is a verse that came to resonate with everyone on the team.  “Should I not be concerned about that great city?”

Lindsey kept asking me, “Why you?  Why do you need to go?  Someone else should be doing this.”  It was a valid point.  It wasn’t my battle.  It wasn’t my responsibility.  I had other fish to fry.  I had a hospital that needed me.  I had a wife and a child who needed me.  The thought of leaving them alone in Congo seemed like a betrayal of sorts.  Maybe it was selfish of me, but that hook was in me.  I have been to a lot of hard places in the world, but this was the first time I really agonized over the decision.  It took a sacrifice on the part of the mission hospital which allowed me to go, and on the part of my family.

On New Year’s Eve I found myself in a hotel in a town called Erbil, watching fireworks from the seventh floor, missing my family and wondering if I had made a huge mistake.  The first week, it felt like it.  The opening of the hospital was delayed by rain and by the huge challenge of turning a empty field into a tent hospital.  It was heavily fortified.  It doesn’t take long to realize that you’re pretty close to a war zone.  We drove though that blasted and booby-trapped town, hearing the booms of artillery and the unsettling sound of machine gun fire not so far away.  This was mostly Iraqi soldiers and security personnel amusing themselves.  I told myself that it was merely celebratory gunfire, or bored soldiers but it does get your heart going.  Later on we had the drone scares.  On these days, a small model airplane would be spotted in the sky and the military and security forces would open up with all guns blazing, trying (unsuccessfully) to shoot it out of the sky. There was much discussion regarding whether or not these drones were friendly or unfriendly.  When I saw patients with injuries from drone attacks I became a little nervous.  These toy planes could potentially pose a large threat.   On these occasions we would run to bunkers and huddle together until the buzzing plane went away and we had the “all-clear.”

In the frustrating days before we officially opened, the medical staff spent the days organizing and reorganizing the equipment and supplies.  There were different opinions about how where the needles or gauze should go, whether the OR table should be oriented obliquely or at a right angle.  I personally witnessed the casting cart get completely rearranged four times.  In the absence of patients, doctors and nurses can focus on minutiae.   It was a good time for the team to get to know each other.  The more I got to know my teammates, the more I started to wonder how it was going to work. We had plenty of good intentions, but did we really know how to run a trauma center on the outskirts of a war-zone?  Most of my colleagues came from a practice in the developed world. There was varying degrees of experience with health care in resource-poor settings and varying degrees of experience with the types of injuries that warfare produces.  I’m not saying that I knew any better.  Truth be told, no one was fully prepared for the challenges we were to face.  My own predictions about what we would do were completely wrong.  I kind of figured that we would be receiving a lot of patients with extremity injuries who were not mortally injured.  That is what I generally see in Africa.  I don’t see patients shot in the chest or abdomen, because they die before they could arrive at a hospital.  I see the ones who survive for a day or so and then come in with an open fracture or a complex wound.

Regarding my colleagues, I will say that that they heard the call and responded. They gave 100%. Together we worked and laughed and cried. We witnessed unspeakable horrors and acts of heroism and mercy. I know of no finer teammates and I count it a privilege to have served with them.

The first day we were open, it set the tone for the what was to come.  We received a bunch of seriously ill patients at one time.  They were mostly children who had been injured by an explosion.  Imagine having 6 patients at one time, all of them peppered with tens, if not hundreds of holes from shrapnel.  There are two operating rooms and limited means.  The triage system attempted to grade patients according to severity of injury.  Green meant they were not seriously injured.    Yellow meant they were injured, but did not require immediate intervention.  Red meant they needed urgent life-saving intervention.  Black meant they were too severely injured to merit extensive care.  Black patients were placed in a quiet corner and essentially left to die.

So, here’s the tricky part:  who is what color?  The greens are easy.  They come in walking and talking (but injuries can still be missed!).  Yellows don’t look so bad, but what about the tiny hole which has penetrated the abdomen and nicked the bowel?  Miss this and the patient will get very sick and possibly die. Reds are generally bleeding actively or have airway problems.  Often there was a fine line between the Red and Black.  On a busy night, with six patients awaiting surgery, a Red might start to look a little more Black.  On a slow day, a Black might become Red and get the full-court press because we had the manpower and OR time.  These “maroon” patients were tough. There were times we operated on patients who did not need surgery.  We did extensive operations on patients were obviously not going to survive, sometimes at the expense of patients whom we might have saved.  Tensions ran high as various medical personnel discussed the appropriate course of action to take.  The first night we spent several hours operating on a little girl whose organs had been shredded by shrapnel.  We were too slow, did too much.  It was a lesson for all about the time and place for “damage-control” surgery.  This is an approach where you don’t try to “fix” anything.  You just get in, stop bleeding, control contamination and pack the abdomen with towels.  If the patient survives, you have a chance to warm them up, correct the loss of blood and clotting factors, and come back later.  Of course, she didn’t survive and we saw our first patient die.  It was heart-breaking, but a wake-up call for the realities we were to face.

I didn’t always make the right decision. To pretend otherwise is simply not honest. On several occasions, I made a choice which contributed to the death of a patient. To anyone who wishes to preserve the illusion that doctors don’t make mistakes, stop reading and seek a more sanitized version. One night we received a man who had a penetrating injury through the neck. He was a big guy.  We got him in the OR and intubated him, a victory in itself. I began to explore the neck. What I found was a devastating injury to the carotid artery, with a hematoma.  One of my colleagues helped me and we used a large vein patch to repair the carotid. It was a great operation, or so it seemed until the second night, when it blew out.  Do you have a mental picture of what a blown-out carotid artery looks like?  Audible bleeding, we call it.  I found a couple of hemostats and ligated the carotid artery at the bedside. It was not pretty.  Anyway, the man died a few days later. Should I have just ligated the artery at the initial operation?  In retrospect, yes.  Not sure whether or not he would have lived.  A piece of shrapnel through the neck is a devastating injury.  As medical professionals we have to ask the question and sometimes it keeps us up at night.

In the five weeks I served, we treated nearly 600 patients.  The injuries ran the gamut from trivial to devastating.  I lost track of how many patients I operated on, but it was a lot.  As the surgeon with perhaps the most amount of field-experience I tried to play the role of prioritizing patients and providing counsel, rather than seeing how many operations I could personally  do.  We did countless laparotomies, amputations, external fixators, vascular repairs and debridements.  We experienced the ominous “blast injuries” in which patients did well initially, but suddenly decompensated, as organs shut down and lungs filled with fluid.  Some survived.  Some did not.  We all had patients that seemed like victories and other that seemed like personal failures.  It was an intense time, and I can say that I’ve never seen anything quite like it.

I could tell lots of stories, but I would rather speak about the lessons I learned.  The stories were all the same, to some degree; soft bodies and hard bits of metal.  These aren’t exactly earth-shaking revelations, but realities that took on special significance during my time in Iraq.

All flesh is like grass.  It’s so obvious, but our bodies are made of weak stuff, no match for flying bits of metal.  In the beginning everyone in the OR wanted a piece of shrapnel as a “souvenir”.  As time went on, no one wanted it.  We grew so tired of bits of metal in the brain, the bodies of children and women riddled with fragments, strong young men who in a fraction of a second were reduced to lumps of bleeding flesh.  It wasn’t only our patients who were frail.   We all had moments of weakness.  I had one at 2 AM, when I just felt like I couldn’t go on.  I wasn’t strong enough, smart enough, capable enough.  Sometimes it seems like we spend our lives trying to convince ourselves of our invincibility.  The last 5 weeks showed me another reality, and it was humbling.  One surgeon arrived recently and I saw him get launched into a heavy night of shrapnel injuries.  He was a seasoned veteran with years of experience, someone who was highly regarded.  After 3 or 4 difficult cases, cutting off fingers, amputating bleeding limbs and dealing with blasted bones, I heard him mutter, “There’s nothing good I can do here.  I just want to go home.”  I could sympathize.  No one in his own power could do much, but somehow, as we worked together as a team, humbled and weakened, we accomplished something meaningful and beautiful.

There is something evil in the heart of man.  I don’t think I ever had such a strong feeling about this.  Nearly every wound we saw was created maliciously by a person who wished to kill and maim.  Mortars were launched into schools.  Drones dropped bombs on food distributions.  A man walked into a crowded restaurant and blew himself up, killing dozens in the process.  I just can’t get my head around this sort of thing.  One night each bed in the trauma unit was occupied by a child under the age of seven.  I amputated two arms of one girl.  She died.  One child of 9 months had both legs amputated.  There were countless kids with shrapnel in the brain.  Why?  What can possibly be the point?  The militant group planted thousands of IEDs in homes when they withdrew.  Everything was booby trapped.  Pick up a toaster, step on the carpet and Boom!  The western side of the city has yet to be liberated, and things will probably get even worse.  We had two patients who came in with a question of UXO (unexploded ordinance) in their bodies.  I operated on a man with a piece of a suicide vest embedded in his neck.  We removed it gingerly and then dealt with the torrent of blood which followed.  Another had a circular piece of metal which entered his abdomen.  This was initially thought to be an explosive device, but was later found to be a part of the car which exploded from the VBIED (vehicle-borne improvised explosive device).  Initially it seemed far-fetched that we could be attacked with an IED implanted in an injured patient, but this is not out of the realm of possibility.  In the former city of Nineveh, a battle is taking place between the forces of evil and the forces of good.  We were on the front lines and every day we saw its grim reality.  We are sometimes tempted to believe the lie that all people are good at their core and that evil does not exist. I do not believe this is true.

The love of God is powerful.  There is no way to fully describe this.  I saw God working through a very difficult situation to bring souls to him.  I saw the love of God played out in the ways that nurses cared for patients.  When I passed by the “Black corner” I saw patients in their final minutes prayed for, sung to and loved.  There was something beautiful that happened with these poor folks.  They died with someone holding their hands, speaking words of peace in their ear.  Maybe it wasn’t a logical or strategic thing to do, but it was a manifestation of God’s love.  I was focused on the Reds, but maybe it was with those Blacks that something powerful took place.  Anyway, I’m not going to tell you that everyone became a Christian.  I know for sure that a seed has been planted in that place.  People encountered God. I saw miracle patients.  There were patients we thought would never survive, who walked out praising God.  For all the ugliness and the suffering, I left with a feeling that God was at work, showing mercy, revealing his love to people.  I am grateful to have been a part of it.

So, I’ve written more than I intended, but less than it would take to communicate what this experience meant to me.  I feel spent, but I’m happy I went.  There are places in the world which seem too messed up for Gods grace to work. They aren’t. There are people who seem too far, too hopeless, too steeped in darkness for Gods love to reach.  They aren’t.

I write these last words sitting outside of the arrivals at Entebbe airport. I’m waiting for Lindsey and Emmanuel to arrive.  Tonight we fly to Thailand for a medical conference and a bit of down-time. My sincere thanks to all who prayed for us and supported us during this difficult time of separation.


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