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The patients arrived shortly thereafter by helicopter.  We quickly recognized he first patient.  He was a civilian medic who had been hanging around our ER for a few days waiting for one of his co-workers to be discharged from our hospital.  Now it was his turn to be the patient.  He had a lot of what appeared to be small shrapnel wounds on his face and neck and side of his head.  He was wide awake and joking with us, definitely a good sign.

The other patient was not so fortunate.  He arrived intubated (a breathing tube down his throat into his lungs to assist his breathing).  He was completely unresponsive.  He had a pulse at the neck, but essentially no pulse at the groin - a sign of very low blood pressure.  His injury was very bad.  He had a large hole in the back of his head with a lot of brain tissue protruding.  This was not good, he had an unsurvivable wound.  I previously discussed the triage system and the expectant category.  This patient was clearly expectant.  We took him to the ICU, provided comfort measures, and let nature take its course.  Again, it is so hard for physicians to take a patient and do nothing and watch him die.

Next we found out that there was another person killed in that same mortar attack.  Apparently, it was not the mortar that killed these guys, but a piece of the mortar hit a fire extinguisher which then exploded sending high velocity metal fragments everywhere. 

The first patient was taken to the CT scan and we were sort of shocked with what we found.  A small piece of shrapnel had penetrated the back of his head and entered his brain.  The guy had almost no neurologic abnormalities.  The only finding we noted was that his left pupil was a bit sluggish compared to his right pupil, but it still got smaller when light was shined in it.  Additionally, he had a lot of shrapnel all around his neck.  The most concerning was a piece of shrapnel right behind his carotid artery...  Apparently this piece entered the neck from the right-front and took a course just right behind the carotid artery (that big blood vessel in your neck that pulsates).  It is weird to say this, but this guy was incredibly lucky.  Anyway, not having a neurologist here, we stabilized the patient and sent him to another location where neurosurgical assets are available.

After things calmed down, I stopped in the icu to see how the chest pain patient was doing.  He was resting comfortably in bed with a big dip of tobacco in his mouth.  I was shocked.  I did not know whether to laugh or scold the patient.  I ended up doing both.  When you show a sense of humor you don't look like such a jerk for telling a patient they are not allowed to do something.  I am sure that as soon as I left he put another one in anyway...

Several hours later the third soldier arrived.  It frequently is our job to identify the bodies and prepare the death certificate and other paperwork.  It is an awful job that we despise doing.  This person's cause of death was an open head injury.  I believe that is the first time we have seen three major head injuries from one mortar attack.

Later on tonight, as we were leaving the hospital to go back to our hootches, we got called back to the ER stat to see an Iraqi "who wasn't breathing."  Upon arrival we noticed that he did not have a heart rate either.  On closer inspection, he too had a rather large hole in the back of his head with brain protruding out.  There was no life left in his body and there was no way we would ever bring any back to him.  The Strykers told us that they were on their way back to the base when this guy starts driving right at them with his lights off.  They flashed their lights, no response.  They fired some warning shots in the air, no response.  So, they did what they are trained to do and they shot this guy.  His car drove off the road in a ditch.  I am not sure if they thoroughly searched his car, but I have a high suspicion he probably had a car bomb.  This is the tactics the insurgents use.  On top of that they found four or five packets of a white powder in his pockets.  I did not look at his genitals.  Don't laugh.  The radical Muslim suicide bombers like to shave their genitals before they do their "sacrifice."  They truly believe that when they blow themselves up into little pieces they are going to heaven to be with 99 virgins, so I guess they want to look good...  What do you think a guy thinks about in the morning on the day he decides to blow himself up?  These people are unbelievable.  I wonder how many dead and injured soldiers these Stryker guys just prevented.  Hoo-ah.  Strong work.