FORWARD OPERATING BASE SALERNO, Afghanistan -- They are the invisible casualties of this war, the 2,194 Americans who have been badly wounded in battle here. More are coming.
Stunned, torn and bleeding, they are extracted from dusty battlefields in wild, shouting chaos, and because they are so quickly rushed into the hands of trauma nurses and surgeons, more of them survive than in past wars.
But their wounds are often grievous, even more severe than those inflicted in the Iraq war. It is not uncommon for a casualty to arrive at a combat surgical hospital with two, three or even more immediately life-threatening injuries. Simultaneously drawn to the soldier's side will be specialists in setting broken bones, repairing deep abdominal wounds, attending to crushing chest injuries and cleaning the stumps of amputated limbs, while a neurologist works to assess brain damage.
The battle dead, deservedly, are venerated and honored by name. They are memorialized by their comrades in formal, intense, battlefield ceremony, honored as their remains are carried past rows of saluting troops onto waiting aircraft, and their sacrifices are sanctified again during and after their various journeys home. Their deaths are announced by the Pentagon and recorded on gravestones.
The wounded receive no such recognition. They are moved swiftly and anonymously; their names and sacrifices are not publicly recorded by the Department of Defense, which effectively bans interviews and photographs.
But as they are tenderly passed along -- from the combat medics who bandage them and the dust-off pilots who fly them away under fire, to the surgeons who perform emergency battle-zone surgery and the aero-medical evacuation pilots and crews who fly them toward home -- they are known and respected, honored, and treated with urgent compassion.
Darting through mountain passes like an angry hornet, Army Capt. Thomas Lemmons drove his UH-60 Blackhawk helicopter toward the landing zone where two badly wounded soldiers lay. Short of the landing zone, he started taking heavy enemy fire despite – or perhaps because of – the red cross emblazoned in a white circle on the fuselage. He backed away while a pair of Apache attack helicopters made their strafing runs. Afterward, Lemmons slid in to the LZ, touching down in an immense cloud of brown dust, and as his medics dashed out with litters, he started taking fire again, calling out to the Apaches, "Targets at my ten o'clock! Targets at my four o'clock!"
One soldier had been shot through the throat and was barely conscious. Working feverishly, medics applied a gauze pressure bandage and the blood gushed from an exit wound. They swathed him in bandages and sprinted with him on a litter through the dust and bullets to the helo. The other soldier had a clean upper chest wound; he was loaded in and Lemmons lifted off.
Minutes later they were touching down in bright, clear sunshine on the concrete ramp of the joint theater hospital at Bagram Air Field, the major U.S. base in Afghanistan. As the rotors coasted to a stop, the aircraft was swarmed with blue-gloved trauma nurses, medics and orderlies. The throat-wound soldier had died in flight, bled out. The soldier with a chest wound was rushed into surgery.
Tom Lemmons is a 35-year-old California National Guard pilot who volunteered to fly medevac choppers, known as "dust-off" missions in Afghanistan. In private life he runs a construction company in Livermore, Calif.
U.S. military field medicine treats all wounded – Americans, Afghans, French, Brits . . . and, yes, even enemy insurgents, who get the same priority medical care as American troops. One time recently, the "dust-off" birds retrieved a pair of casualties, one American, one insurgent, wounded in the same battle (and perhaps by each other). They were loaded into the helicopter side by side ("We sedated 'em pretty good so they wouldn't wake up and start fightin' again,'' said a medic) and went into surgery on adjoining gurneys. The enemy fighter was then taken to a separate recovery room, in restraints and under armed guard. "Some of them are amazed and grateful,'' said a doctor, speaking of the enemy wounded. "Some of them, you know they'd kill you in a heartbeat if they had the chance. We treat them all the same."
The Emergency Room
Scott Russi is working out at the gym when the call echoes across Forward Operating Base Salerno. "Attention on the FOB! Attention on the FOB! Shamrock Black, I say again, Shamrock Black!" The code signifies multiple casualties, inbound. And the Combat Surgical Hospital's chief surgeon is sprinting, barely in time to throw on a camouflage-patterned hospital blouse and draw on gloves before medics burst through the hospital doors with men in blood-soaked dressings writhing on their litters.
Roadside bombs, or IEDs, are the principal cause of injury in Afghanistan, and the numbers are rising – tripling in the past three years in this region. The initial blast can collapse lungs and rupture eyeballs, bowels and other internal organs. Shrapnel slices through tissue. The blast flings its victims about, causing blunt-force trauma. Burns and smoke inhalation often follow.
Four gurneys are in the emergency room. Four casualties, attended by a throng of nurses, surgeons, orderlies, specialists, and a babble of urgent, yet calm and confident, voices. Russi, still wearing a ball cap and his gym shorts, snipping off a sodden uniform, inserting a chest tube, probing for additional unnoticed wounds, quarterbacking his team as he manages multiple trauma wounds, repairing enough to get the patient wheeled down the hallway and into the operating room.
Within 15 minutes of the Shamrock alert, the emergency room is virtually empty, with only orderlies cleaning up blood-stained bandages, scrubbing down the floor. Three patients are in surgery. One soldier had arrived dead. He is covered with a sheet and gently removed.
Hours later, Russi is walking to dinner, musing about his life here. Back home in Colorado Springs, Colo., he is an Air Force colonel and runs hospitals, clinics and a large medical staff. Here, he works out at the gym and saves lives. "This is the most rewarding work I have ever done in my life, helping people who are trying to make a difference," he says in the twilight.
He tells of a young Afghan girl brought in, comatose, from Khost city hospital near the U.S. military hospital here. She'd been hit by a car. Russi and the staff worked on her for three weeks while her father slept at her bedside. Now she is almost fully recovered.
"If she'd been left at Khost [hospital] she would have died,'' says Russi. "It is important that the interaction with Afghans shows them what America is really about – caring for each other. I still believe we are a good people – I guess I still bleed red, white and blue,'' says Russi, 48, who volunteered for six months away from his wife and six children. This is his second combat deployment. "This is the way life should be,'' he says. "Everybody working together, not like in the U.S. with all that pervasive superficiality.''
The Trip Home
"We have people horribly wounded,'' a nurse told me. "And yet . . . we had a Marine in here the other day. He'd lost one leg and the other was cocked at an odd angle. We asked him if he'd like something for the pain, and he said, 'Ma'am, I surely would appreciate that."
There are also the wounded who are not obviously wounded, the ones who may be dazed or momentarily stunned by an IED blast, but who shake it off.
"These are the ones that worry me," says Col Joseph P. Chozinski, a psychologist and Air Force flight surgeon at Bagram Air Field. "They go through multiple IED blasts and may have severe headaches but they press on, and not until they get home do they begin to have problems."
One doctor, not entirely in jest, has proposed that anyone blown up by an IED four times automatically gets to go home.
Once the wounded are stabilized, they are flown out of Afghanistan aboard specially outfitted aircraft that are essentially airborne Intensive Care Units. Air pressure and temperature are carefully adapted to individual patients' needs (burn patients need heat; chest-wound patients often can't fly at high altitude). For the medical and flight crews, these are emotional missions.
"It really hurts to see how young these wounded kids are, some of them terribly wounded, on ventilators and with horrible head wounds,'' Lt. Col. Jeffrey Briere, a pilot with the Nebraska Air National Guard, told me at the start of one such 21-hour mission.
"Helping these guys on their way home is the most terrible, and rewarding, mission we do."
On one flight, among the patients was a military working dog, used to hunt for explosives. The dog had been wounded in a firefight. He was in a body cast on which was written: "Taliban tastes like chicken."
All military medical staff, from medics to surgeons and pilots, are on call 24/7, and they jump to the sound of an alarm -- most often a "nine-line'' radio request for casualty evacuation from a soldier or Marine kneeling for cover in a firefight. They work 12- to 14-hour days with no days off. It is a high-stress business.
"We've seen some gruesome things, but luckily your mind is wonderful in the way it can absorb things,'' Madelin Schwitzke told me at Bagram Air Field. She's an Air Force master sergeant and medical logistician on her fourth deployment away from home in Charleston, S.C. She is accustomed to running to the sound of incoming medevac aircraft.
"When you get home, some time you'll hear a plane and you'll go through a moment of emotional crisis,'' she said. "And then you will go on. That's what we do.''