Ramadi all-nighters

1:06AM brings a loud rap on our door "11 in-bound. Mikes unknown".

Knocking the fuzz out of my head as we all stumble around the room putting our uniforms back on. Hopping around on one foot, I avoid a collision with D squared just as someone flips the lights on.

Feeling like I'm floating to the back of Charlie medical, I run down a mental checklist of how many patients, where we are going to triage them, and making little bets in my mind that this could be a long night.

15 minutes later, the TOC announces "Casualites are being diverted to Ramadi General". This is the local civilian hospital. They must be closer to the scene than we are, but are a little less cabable. We have been supporting them with supplies and keep in contact with them, but the back of my mind is telling me this is going to be more than they can handle.

Most of the staff drifting off. Trying to quickly re-capture what they missed of slumberland, and I don't blame them. A few, including myself, decide to stay awake for a while to see what develops.

1:36AM and I hear the tell-tale drone of armored track vehicles. Several of them. Eric says "well?" I'm throwing my stethescope back around my neck "This can only mean one thing. Lets get busy."

Two M-113's arrive filled with casualties. They bring along a full compliment of humvees and Strykers filled with heavily armored and weaponized soldiers "IED blast!" they say. "We thought Ramadi General was taking this one?" "Hey, just following orders. We don't know anything" they say as we immediately start unloading patients and begin triage. Two walking wounded hop out: this is an encouraging sign, even though their tuniks are splattered with blood. They are quickly ushered to the side, and a few medics start tending to some superficial wounds. Then we start hauling stretchers out.......here we go.

Eric and I take station two. Iraqi casualty is on his stomach and moaning something so incoherent even the interpreter has no idea what he's saying. His entire lower back is covered in a makeshift damage control bandage. Eric starts taking it off to assess what the heck it is, when unmentionables start spilling out. I tell him "Umm, you better put that back!" He agrees promptly, as I gather some sterile supplies to re-dress the gaping wound. I quickly re-pack his back, and five of us struggle to turn him over: we need a proper assessment, IV lines, and vital signs. On his stomach, I can't even tell if he's still breathing. We get him turned over, and I'm finding abnormalities all over......arms and legs aren't supposed to be jello in my hands. "X-ray! I need films as soon as you get a chance." Get an IV, Eric is assessing his airway. RH, our head surgeon, is looking over my shoulder "bring him back to the OR now. We have our first case." The X-ray tech is asking me what films we want. "chest, KUB, better get a pelvis, oh, and all estremities, too. Just get everything..." My patient is sliding downhill, so RH decides abdominal surgery needs to happen sooner rather than later so we can visualize and repair damage. We perform multiple bowel resections and Chad flies him to Al Asad as soon as possible. He was unstable for a bit, but does well for the flight.

This was the beginning of the end of our sleep. We get word of more incoming casualties during the first case: American unit hit by an IED next. At least one "urgent surgical". The lone OR is tied up with Iraqi Police, so we tell the Army Tactical Command to set up a landing zone to fly the American casualties to Taquaddum. A short flight, and it makes sense to tap into other Anbar medical resources. More Iraqi's pour in throughout the night: a GSW victim is in the trauma bay, so I break out of the OR to assess: our two surgeons are scrubbed in, and they need a discriminant eye to hover for a few minutes to see if he needs to be taken back to the OR. We already have another patient on standby and waiting to come back. GSW to the chest, and the Army PA (physician assistant) and our Independent Duty Corpsman are placing a chest tube on the affected side. They drain any blood and avert a hemothorax. Two PA's and I use an ultrasound to assess his heart, and the pericardial window is void of blood: fantastic sign. We are sending him to Ramadi General now that he is stabilized.......thankfully the bullet didn't hit anything major.

With no end in sight, we have another trauma case come in with more penetrating abdominal injuries just as we are finishing another case. The room is quickly sterilized to the best of our ability just as we roll the next patient in. He's in good shape, considering, and doesn't appear to be in too much pain. More bowel resections, and we finish our last patient for the night as the sun gently crests over the horizon signaling a new day in the Anbar Province. The surgical team cleans the OR for the last time tonight, washes up, and we meet behind Charlie Medical for breakfast to cap an exhausting night. The chow hall is a welcome site: eggs, gravy, biscuits, and fresh fruit. Bellies full, stamina depleted, we simultaneously collapse into bed ever ready to do it all over again.