Being There: Ramadi 
Carlos Brown Is a Hero (No Matter What He Says)
I’ve known him since the seventh grade, when he was awkward, obnoxious, and unpopular with the girls (okay, we both were). He always said he was going to be a surgeon, and when the Navy sent him to Iraq, I flew there to see him. I watched him work around the clock to save soldiers and civilians, Americans and Iraqis—even insurgents. Through it all, his mission never changed: Ignore the politicians, take care of the patients, kick butt at PlayStation, and get home safely.
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The mission is to provide all the health care needs for the base, which mostly means easy cases like colds and pulled muscles. The drama comes each day when the war breaks out. All of Ramadi’s critical battle casualties come to Charlie Med, the good guys and bad guys and innocent civilians. The unit itself is not equipped for trauma surgery; Carlos’s team is an attachment and technically not part of Charlie Med. But in late 2005, a naval surgical team went to Ramadi at the start of a series of mini-offensives in anticipation of a high number of casualties. When the expectations were met, simple supply-and-demand analysis mandated that a team stay on. Carlos’s guys rotated in last fall, and when trauma cases come in, they take charge. It’s during those instances when Charlie Med soldiers go from being “fobbits”—the COP warriors’ nickname for FOB residents—to heroes.
Trauma care in Ramadi begins where it does in all armed urban conflict, out in the streets. The military categorizes that as Level 1 care, and it starts almost as soon as a warrior goes down. When a squad of soldiers heads out on patrol, walking down alleyways or kicking in doors, a combat medic goes with it. (Or, in the case of the Marines, a Navy corpsman.) If the enemy makes contact, if an IED blows or a firefight breaks out, the medic is there to scoop and move the casualty and then tend to the simple ABCs: airway, breathing, and circulation. As often as not, that all takes place while the fight is still on, in the shadow of a Bradley firing its big gun. The medical decisions are quick and crude. One baby-faced Charlie Med medic put it thusly: “If he’s got open intestines or his heart’s out, we move on to the next guy.” The casualties who still have a chance are loaded onto the medic’s ambulance and moved to Charlie Med, typically arriving in less than twenty minutes.
The Charlie Med trauma room provides Level 2 care. Situated across the slab from patient-hold, it looks as if it was built in a hurry and outfitted with furniture and fixtures from a third-world Container Store. The interior walls, shelving, and countertops were all fashioned out of two-by-fours and three-quarter-inch plywood. Three casualty stations are on the left as you enter, not really beds but waist-high box frames on which the stretchers are laid. Industrial shop lights hang from the ceiling over each bed, square lamps with black-metal-mesh faces on retractable orange arms. Thick electrical cords run from the lamps to the walls.
The room feels busy even when it’s empty. Olive-green strips of vinyl hang on all available wall space with three horizontal rows of clearly labeled pockets holding necessities: gauze, scissors, syringes, needles, scalpels, sponges, rubber gloves, central line kits, slings, splints, Ace wraps, burn dressings, and operating kits. On one counter sits an ultrasound machine that looks like an old green-screen Apple computer with a microphone attached, and in the corner stands an X-ray camera at the top of a two-wheeled dolly that can be shuttled from table to table.
If surgery is necessary, the patient is carried up a narrow passageway and through two offices to the larger operating room. A table sits in the middle, with another in the left corner, and scattered around the room are stools and two rolling tables for the techs to load with surgical instruments. The walls are white, but almost everything else in the room is a soft sky blue or silver. There’s a thin, light-blue rubber pad on the floor to make standing for long periods bearable, and rows of polished instruments that look almost chromed sit on blue sheets that cover the tables. When the patient is opened, the parts of his body not worked on are covered in thin, blue paper sheets, and the docs work in blue gowns and gloves. The only things interrupting the blue are the surgical caps—Carlos’s is burnt orange, with a UT Longhorn on the front—and the blood. It’s in bags hanging at the head of the bed and in pools on the floor.
The job of a Level 2 surgical team like Carlos’s is not to fix patients but to save them, to get them stable and on to a Level 3 facility for definitive care. When a medic reaches a casualty in the field, he asks himself if the soldier is dead or not. The first assessment for Carlos is if he’s dying or not. Carlos takes off the dressing and explores the wound. If the patient was shot through the belly, Carlos opens him up from his ribs to his groin and surveys the damage. He’ll stop the bleeding with clamps and an electrocautery tool, basically a small soldering iron. With the blood out of the way, he’ll check by sight and feel. He’ll stick his arms in the belly up to his elbows and root around as though he’s searching for a pair of socks in a full duffel bag. He might remove some stomach and cut out some intestine, but if he has to disconnect the two for some reason, he generally won’t take the time to hook them back together. That happens at the next level of care. Then he’ll wash out the wounds, but often he won’t even close his incision. He’ll stuff it with gauze and then put sheets of blue plastic over that to keep in the heat on the flight out. To stay warm in the helicopter, the patient goes in a body bag, a sight that terrifies the soldiers who are waiting for word on their buddy. Charlie Med calls the bags “hot pockets” when they’re used for this purpose.
The system is based on the allotment of time and resources. Carlos is wanting for both, especially when multiple casualties come in at once. His team has only two surgeons, himself and Lieutenant Commander Clark. The hospitals they send patients to, in Balad and Baghdad, each have seventeen surgeons, including all kinds of specialists and subspecialists. They do the actual repair work and then send the American patients to a military hospital in Landstuhl, Germany, and ultimately home.
Dave Vazquez, a pediatric surgeon who worked with Carlos in San Diego ten years ago, was deployed last fall to Balad. It was a busy time in Ramadi, and a great many patients went directly from Carlos’s table to Vazquez’s. “We routinely saw people with absolutely fatal injuries that were going to live because of what Carlos had done,” he said. “I remember one patient with horrible injuries. Both legs had been amputated, and he had multiple open fractures to his arms. His genitalia was mush. He was just a mess. As soon as he showed up, we had eight people operating on him at the same time, two orthopedic surgeons, five general surgeons, and a urologist. Carlos had essentially operated by himself. And considering his injuries, the guy was in fantastic shape.”
“Untie Me and I Will Slit Your Throats.”
FOR PEOPLE THE AGE OF CARLOS AND ME, joining the military had nothing to do with going to war. We became aware of the world as the last troops were leaving Vietnam, and as we grew up, things like the draft and dying for your country were altogether unknown. We registered for Selective Service on our eighteenth birthdays conscious that our signatures didn’t have to mean anything and certain that anybody who tried to explain conscription to us had fallen from a time capsule that had been shaken too hard. Oliver Stone’s Vietnam nightmares had nudged John Wayne’s World War II heroes completely out of the cultural discourse. The images of war that we saw were either surreal or all too real, and always damning. The Deer Hunter. Apocalypse Now. Platoon. Full Metal Jacket. For us, war was Vietnam and Vietnam only. A mistake. And one that would never be made again.
When Carlos accepted his naval commission, the harm he saw in his way was his own impatience at waiting ten or fifteen years to start his career. “I joined because I needed something to pay for my education,” he said. “I had some kind of military-ish memories from being a child in D.C., and I thought serving my country was an honorable thing. But when Desert Storm started, I was a second-year medical student, and it was over before I interned. I was a battalion surgeon with the Marines in Okinawa in 1999, but we were not at war.
“And then I went back to California and just being a surgeon. It was a job.”
When his deployment became inevitable early last summer, Carlos talked to colleagues who’d already been to Iraq to get some idea of what awaited. It sounded like fiction. A friend from medical school had accompanied the Marines during the initial push into Baghdad. He described the life of a battlefield surgeon, of having to set up a tent and be ready to operate in less than an hour, of sleeping under the stars within a mile of the fight and moving his cot to the far side of an armored vehicle to feel safer. When he finished with patients, he’d write a shorthand description of their injuries with a Sharpie on their bodies for the docs at the next level of care. When he performed amputations on Iraqis, he’d leave the severed limbs under their cots so they could take them when they were released. That was part of his understanding of the Muslim faith. And most counterintuitive for a practitioner of the healing arts, he’d had to train a gun on people.
Since Carlos was going to work on a FOB, his experience would be different, but the Navy made little distinction in the two weeks of training drills he attended with his team at Camp Pendleton, near San Diego, last June. The first week was medical, making sure everyone knew the equipment and how to set up a tent, then running them through mock mass casualty, or mass cal, events. The second week was war training, officially known as rear-area security. “It was combat for noncombatants,” Carlos said. “Land navigation, learning how to set up a perimeter, how to set up and fire a machine gun. Do you know how long to hold a trigger for a sustained burst? You squeeze it, say, ‘Die motherfucker die motherfucker die,’ and then let go. If you want a short burst, you just say, ‘Die motherfucker die.’ It was stuff like that.”
This was all foreign to Carlos. “We had a sniper talk to us about killing people. He said when you shoot somebody’s head off, it just explodes in a pink mist. You see a guy, take a shot, and boom, pink mist. I guess that’s their term for a head shot.
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