The Best American Essays 2013 (22 page)

In the hospital, the numbers of wounded that survived the attacks created a backlog of patients who required immediate surgery. Surgeons, nurses, medics, and hospital staff moved from patient to patient at an exhausting pace. When one surgery was finished, another began immediately. Several operating rooms were used simultaneously. Medical techs shuttled post-op patients from surgery to the second-floor ICU, where the numbers of beds quickly became inadequate. Nurses adjusted their care plans to accommodate the rapid influx. A few less critical patient beds lined the halls just outside the ICU.

The general wanted to visit the hospital to encourage the patients and the medical staff. We made a one-mile trip to the hospital compound late at night, unannounced, with none of the fanfare that usually accompanies a visit by a general officer in the military. After visiting the patients in the ICU, we walked down the hallway to the triage room.

One patient occupied the triage room: a young soldier, private first class. He had a ballistic head injury. His elbows flexed tightly in spastic tension, drawing his forearms to his chest; his hands made stonelike fists; his fingers coiled together as if grabbing an imaginary rope attached to his sternum. His breathing was slow and sporadic. He had no oxygen mask. An intravenous line fed a slow drip of saline and painkiller. He was what is known in military medicine as
expectant
.

Some of his fellow soldiers gathered at the foot of his bed. A few of them had been injured in the same attack and had already been treated and bandaged in the emergency room. These fellow soldiers stood watch over the expectant patient. The general and I stood watch over them. One soldier had a white fractal of body salt edging the collar of his uniform. One wept. One prayed. Another quietly said “Jesus” over and over and kept shaking his head from side to side. And another had no expression at all: he simply stared a blank stare into the empty space above the expectant patient’s head. A young sergeant, hands shaking, stammered as he tried to explain what had happened. The captain in charge of the expectant soldier’s unit told the general and me that this was their first soldier to be killed—then he corrected himself and said this was the first soldier in their unit to be assigned to triage. He told us that the soldier was a good soldier. The general nodded in agreement and the room was suddenly quiet.

The general laid his hand on the expectant soldier’s leg—the leg whose strength I imagined was drifting like a shape-shifting cloud moving against a dark umber sky—strength retreating into a time before it carried a soldier. And I watched the drifting of a man back into the womb of his mother, toward a time when a leg was not a leg, a body not a body, toward a time when a soldier was only the laughing between two young lovers—a man and a woman who could never imagine that a leg-body-man-soldier would one day lie expectant and that that soldier would be their son.

As I watched the soldiers at the foot of the bed, I noted their sanded faces, their trembling mouths, their hollow-stare eyes. I watched them watch the shallow breathing and the intermittent spasm of seizured limbs and the pale gray color of expectant skin. I took clinical notes in my mind. I noted the soldiers—noted the patient. I noted all the things that needed to be noted: the size of the triage room, the frame of the bed, the tiles of the ceiling, and the dullness of the overhead light. I noted the taut draw of the white linen sheets and the shiny polished metal of the hospital fixtures. A single ceiling fan rotated slowly. The walls were off-white. There were no windows. The floor was spotless, the smell antiseptic. A drab-green wool army blanket covered each bed. Three beds lay empty. I noted the absence of noise and chaos, the absence of nurses rushing to prepare surgical instruments, and the absence of teams of doctors urgently exploring wounds and calling out orders. There was an absence of the hurried sounds and the hustle of soldiers in the combat emergency room one floor down. Nobody yelled “medic” or “doc.” Nobody called for the chaplain. Medics did not cut off clothing or gather dressings. Ambulances and medevac helicopters did not arrive with bleeding soldiers.

The
American Heritage
Dictionary
defines
triage
as “a process for sorting injured people into groups based on their need for or likely benefit from immediate medical treatment. Triage is used in hospital emergency rooms, on battlefields, and at disaster sites when limited medical resources must be allocated.” All dictionary definitions refer to the origin of the word
triage
as deriving from the French verb
trier
, to sort. The essence of the meaning is in the sorting. In the context of battle, a soldier placed in a triage room as
expectant
has been literally sorted from a group of other injured soldiers whose probability of survival was deduced by a sort of battlefield calculus implemented by a medical officer or a triage officer. The sorting occurs rather quickly—usually with minimal, if any, deliberation.

A military physician trains for triage situations. I trained to make combat medical decisions based on the developing battlefield situation and limited medical resources. I read about triage. I role-played it in combat exercises. When I first learned about the role of triage in combat, I reasoned,
Of course, triage is necessary. It’s part of war. You do it as part of the job of a medical officer
.

More than twenty years ago, when I was a newly minted captain, I attended the two-week Combat Casualty Care Course at Camp Bullis, Texas. The course was designed to teach medical officers combat trauma care and field triage techniques. The capstone exercise included a half-day mass casualty scenario complete with percussion grenades, smoke bombs, and simulated enemy forces closing on the casualty collection point. The objective was to give medical officers a realistic setting in which to perform triage decisions and to initiate medevac protocols according to standard operating procedures. About twenty moulaged patients mimicked battlefield casualties ranging from the minimally injured to those requiring immediate surgery. Each medical officer in training was given five minutes to perform the triage exercise and to prepare an appropriate medevac request. Providing treatment was not an option: the exercise focused exclusively on making triage decisions.

All the participants could have easily completed the role-play within the time limit. Nothing, of course, is that straightforward in army training. There is always some built-in element of surprise to test how well trainees cope with chaos. In this case, the element of the “unexpected” was a simulated psychiatric patient who was brandishing an M16 rifle and holding a medic hostage while threatening to commit suicide. In order to maintain the element of surprise, the doctors who had finished their turn were whisked out the back of the triage tent, not to be seen again until the after-action review some hours later.

My turn. I entered the tent at the shove of my evaluator. The mock psych patient was screaming and threatening to kill a nearby medic. Other medics were pleading with the disturbed patient to lay his weapon down and let the wounded get on a helicopter. I was to take charge and get control. I did. I approached the screaming patient with quick, confident steps. I got about halfway through the triage tent when he pointed his rifle directly at his hostage medic and yelled, “One more step and the medic is dead.” I backed off slowly, turned sideways, and quietly pulled my pistol. In an abrupt and instantaneous movement, I reeled around and shot the psych patient with my blank ammunition. “Bang—you’re dead!” I yelled. A nearby evaluator took his weapon and made him play dead. One out-of-control psycho eliminated. I finished the triage exercise within the five-minute time limit. My evaluator laughed. “Damn,” he said.

I felt great. I had control.

In the after-action review, I was asked about my decision to shoot. “Time,” I answered. “I only had five minutes, so I maximized my effectiveness by eliminating a threat. It’s combat,” I argued.

One fellow doc asked if I would really shoot a patient in combat. A debate ensued as to the ethics of my decision. Nobody else had shot the psych case. Nobody else finished the exercise in the allotted time. Some trainees had considered shooting the crazed soldier but had failed to act. Some managed to talk the psych patient into giving up his weapon. Those physicians had taken nearly fifteen minutes to complete the exercise—minutes in which some of the simulated patients died a simulated death. In the end, it was decided that my decision to shoot, while potentially serving a greater need, may have been a bit aggressive, but that it was in fact
my
decision, and my decision met the needs of the mission. All ethical considerations aside, I felt that I understood the necessity and the theory of triage. I understood it as part of my job.

Military triage classifications are based on NATO guidelines and are published in numerous websites and Department of Defense publications. The triage categories in the third edition of
Emergency War Surgery
, the Department of Defense bible of military medicine, are listed below:

Immediate:
This group includes those soldiers requiring lifesaving surgery. The surgical procedures in this category should not be time consuming and should concern only those patients with high chances of survival.

Delayed:
This group includes those wounded who are badly in need of time-consuming surgery but whose general condition permits delay in surgical treatment without unduly endangering life. Sustaining treatment will be required.

Minimal:
These casualties have relatively minor injuries . . . and can effectively care for themselves or can be helped by nonmedical personnel.

Expectant:
Casualties in this category have wounds that are so extensive that even if they were the sole casualty and had the benefit of optimal medical resource application, their survival would be unlikely. The expectant casualty should not be abandoned, but should be separated from the view of other casualties . . . Using a minimal but competent staff, provide comfort measures for these casualties.

The text of
Emergency War Surgery
further notes, “The decision to withhold care from a wounded soldier, who in another less overwhelming situation might be salvaged, is difficult for any surgeon or medic. Decisions of this nature are infrequent, even in mass casualty situations. Nonetheless, this is the essence of military triage.” Triage requires assigning patients to those various categories based upon a rather quick and semi-objective assessment of a patient’s injuries. If the triage officer calculates that a patient falls into the
expectant
category, treatment is withheld in order to allow medical teams to concentrate more efficiently on those soldiers with potentially survivable injuries. Preserving the fighting force is the central tenet of the process.

I have read and reread the official triage definition. I suppose I might have used it in a classroom of medics that I instructed. I am intimately familiar with the words that describe each category and with the professional commentary about the mechanics and ethics of sorting injured patients, yet I repeatedly come back to those words that try to clarify exactly what might be involved in the process of triage. I find the words weak and innocuous. They undercut the gravity and scope of a real-time triage experience. Here’s the rub: the official commentary about the decision process focuses on the essence of triage as being the
difficulty
of making that decision. The difficulty is a given, but I think there is more. I think the essence of military triage is the
necessity
of making the decision when the combat situation demands it. It is the necessity of triage that requires medical staff to assign expectant soldiers to their death in order to provide an accommodation to a calculated greater good—a cause measured by the number of combat survivors. It is an accommodation that has not changed since the trench warfare of World War I.

Modern military medicine provides battlefield casualties with more sophisticated treatment and much faster aeromedical evacuation than in prior wars, but the process of triage remains essentially raw and unrefined as a standard combat operating procedure. Combat physicians encounter an overwhelming number or complexity of casualties. They make a rapid medical assessment, render a decision based on incomplete information, assign a triage category, and move to the next patient. Done. If they are particularly adept, they can triage several critical patients simultaneously.

Saving lives is the endpoint of all triage. Let one life go, save three others, or five, or maybe ten. The ratios don’t matter, the benefits do. And a benefit in war always comes at a cost. On the surface, of course, the ultimate cost of a triage decision is a soldier’s life. One decision, one life; perhaps one decision, several lives. But there are other costs not so easily calculated, like the emotional cost to survivors or the psychological cost to soldiers who make triage decisions. Textbook definitions are silent on how military physicians prepare for, or react to, the demands of making a triage decision. No chapter in a military textbook instructs combat physicians in the multidimensional complexity of decision making that serves to deny life-saving interventions for soldiers. There are chapters on why triage decisions must be made and chapters on how to apply established medical criteria in making those decisions. But what to do next, after the triage decision has been made—not covered. And that vacuum of knowledge leads to a feeling of exposure and vulnerability, both of which cannot be tolerated in war.

The act of triage is subsumed under the assigned duties of medics and physicians. I am not suggesting that the process fall to someone else or that the criteria used to make triage decisions should be discarded for a different process. I know of no other way of quickly sorting and categorizing patients when the critical nature of combat demands that it be done. I am, however, declaring that the practice of triage obligates doctors and medics, whose principal duty is the saving of lives, to perform tasks which share in the brutality and the ugliness of war—tasks that are tantamount to pulling a trigger on fellow soldiers.