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We sort of got our asses kicked today.  It was crazy.  "EMT, TOC."  "Two patients inbound five minutes, IED blast, unknown injuries." 

A few minutes later, "EMT, TOC."  "You have 6 patients coming in by ground, unknown injuries, unknown ETA."  Oh shit, another one of those days.  And, appropriately, it was my shift in the ER...  So we called in the extra forces and got our gear ready for a mass casualty situation.

The first two patients arrived.  One was seriously injured with a laceration on his face and a badly broken jaw.  The other patient had a shrapnel wound to the shoulder, fortunately nothing serious.  We quickly stabilized the first patient, moved him to the ICU, and prepared for the next batch of patients.

A few minutes later a Stryker vehicle pulled up.  A Stryker team was doing a patrol through town and a car drove up and two shitheads with AK-47's open fired on them.  The back door of the Stryker dropped and they carried the first patient out.  The first thing I noticed was that he had A LOT of blood on his leg and he was not moving.  That was not a good sign.  He came in the door and he was not breathing.  No pulse.  Oh shit.  Start CPR.  Intubate.  Epinephrine in the ET tube.  We checked his pupils and they were fixed and dilated; a really bad sign.  We continued our resuscitative efforts, but to no avail.  His injuries were too severe.  He had massive injuries to both his legs and he had essentially bled to death.  Friggin' horrible.  We eventually could do nothing more.

The second patient came in breathing and moving.  But we quickly realized he was not responding properly.  He did not have any major bleeding, but we quickly recognized that he had a bad head injury.  Oh shit.  We started our resuscitative efforts with a great deal of urgency.  Time is important.  Oxygen, start an IV, give fluids, sedate the patient, and intubate (put a breathing tube in).  Start medicines that will help keep a good blood flow to his brain.  He needs to see a neurosurgeon ASAP, the nearest one is in the Army hospital in Baghdad.

As we were conducting our organized chaos attending to the first two patients, three more patients rolled in.  I broke away to check on them.  The third patient (overall) had a large wound to his right wrist.  He was in a lot of pain, but he was hanging in there.

I moved on to the fourth patient.  "What are his injuries?" I asked the medics who had started to get his vital signs and start an IV.  "Doc, he cannot move."  Oh shit.  He could not move both arms and both legs.  He had lost sensation from his chest down.  I checked him out and noticed an entrance wound on the side of his neck.  Oh shit.  "What the hell is going on here today," I asked myself.  His blood pressure was low, his pulse was normal.  He was entering spinal shock.  I grabbed one of our general surgeon's and said to him, "Dude, we are getting our asses kicked here.  I need some help with this guy."  We quickly put in a central line (a large iv that goes in the groin that allows us to infuse large amounts of fluid) and started fluids.  He too would need to go to Baghdad to see the neurosurgeon.

Patient number five was the least injured of them all.  He had an injury to his left forearm near the elbow.  Our only patient thus far that was actually stable.  X-rays later revealed a fractured ulna (one of the two bones in the forearm) with the bullet fragment still in there.

As we were attending to these patients, a sixth patient rolled in with what appeared to be a chest wound.  He seemed quite alert and seemed to be breathing quite well for someone with a chest wound.  Apparently a bullet skimmed across the front of his chest tangentially.  He was very lucky that the bullet did not penetrate his chest.  He had a few smaller wounds on his abdomen and back, so he had a CT scan to see if he had any internal injuries.  The CT scan revealed that he had a piece of shrapnel right next to his left kidney with some possible damage to the left kidney.

"TOC, EMT"  Not again.  "MEDEVAC inbound, 3 litter patients."  What next? 

Meanwhile, as soon as the soldier with the head injury and the soldier with the neck injury were a bit more stable, they were loaded onto a helicopter for transport to Baghdad.  Our anesthesiologist went with them to provide care en route.  I would not want that job, two critical patients on ventilators in a helicopter.  He was going to be busy.

The helicopter landed and out came the Korean physician (see 06 SEP)!  He accompanied three of his soldiers down here who were electrocuted.  They were doing some plumbing and they fell through the floor onto a live wire.  One of them had direct contact with the wire, and the other two were electrocuted trying to pull the first guy off of the wire.  Ironically, it was the third guy that was the most seriously injured.  He was having some significant breathing issues; either he had pulmonary edema (fluid in the lungs) or he aspirated (choked on his own vomit).  He too needed to be intubated.  The other two appeared a bit drowsy, but otherwise did not have serious injuries.  They would have to be admitted to the ICU for observation to make sure they do not have any heart rhythm problems.  These two guys did really well overnight and were discharged the next morning.  Also, the next morning we were able to extubate the first Korean patient.  He is doing quite well, except for some minor issues with short-term memory (probably from a little bit of oxygen deprivation to the brain).

So after things finally calmed down in our ER and everyone had all the x-rays and CT scans that they needed, the guy with the wrist injury and the guy with the elbow injury were sharing a stall in the ER and they were already joking around and harassing each other.  Then their buddy with the chest wound returned and was placed in an adjacent bed.  His first words were, "you guys want to see something really gross?" as he tore of the dressing on his chest wound, proudly displaying his battle injuries.  I just stood there and smiled and admired their bravery, their spirit, and their mental and physical toughness.  These guys had just taken a beating, been through some version of hell, and here they were bragging about their wounds trying to figure out whose was the "grossest."  This is why I am proud to be a physician in the Army, because I get to take care of great Americans like these guys.