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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“But the interesting thing,” he continued, “is that a doc in Balad told me that they are going to start treating Iraqi patients to an Iraqi standard of care.” Clark and Junker perked up on that point, one that Junker and Carlos had explained to me earlier. Iraqi hospitals don’t do much in the way of long-term care. Breathing tubes are typically removed the day after surgery, and patients who can’t breathe on their own are allowed to die. To preserve resources—supplies, time, and manpower—Level 3 American docs would start working within those same limits, meaning they would no longer treat Iraqi patients who had that kind of prognosis. The implication was that Carlos needn’t send any more casualties like Rania.
Junker thought out loud. “It seems like we’ve been sending a lot of patients who will be extubated the next day, who by the Iraqi standard are going to die. Is that worth it? I agree we should still do everything we’re doing, but some of these cases use a lot of our resources.”
Clark spoke up. “We could run into the problem where we don’t have the ability to treat other patients.”
Carlos shook his head. “I have a hard time with an American hospital being the first level of care that a family sees, and we say, ‘Yeah, there’s nothing we can do.’ So many dead people come in here, and we have to say that so often anyway. This girl was clearly alive when her dad brought her in. Now, what if she comes in with four other patients? Okay. Then she has to wait. But we didn’t burn up a huge amount of resources on her. So I think we press on.”
There was no further comment, and with the serious topics exhausted, the team retired to another night of PlayStation.
Mass Cal
THE SUN WAS OUT AND THE GROUND finally dry when Carlos and I dropped off a week’s worth of laundry at the cleaners after Sunday mass. We were walking back to his car when Carlos’s cell—what he calls the Bat Phone—went off with that distinct Cingular theme song, which Carlos hadn’t figured out how to reprogram. “For the rest of my life I’m going to be hearing people’s phones go off with that ringtone,” he said, fishing the phone out of a pocket on the side of his pants, “and I’m going to think something terrible just happened.” He looked at the phone. “Dammit, I hate that song. Hello?”
He stopped walking and put a finger to his free ear to listen to the caller. “I’m just at the cleaners,” he said. “I’ll be there in two minutes.” Then he shoved the phone back in his pocket and started hustling to the vehicle. “A car bomb went off at an IP station. We’ve got eighteen casualties coming in.” He punched the gas to get the car on the road, cruising past many more joggers than usual on the quarter-mile drive to the hospital. “My guess would be they’re coming to help out at the hospital,” said Carlos, as I listened to the announcement coming over the PA: “We need all available litter carriers and interpreters for medical assistance immediately.”
The scene when we arrived looked like utter chaos. Framed by the hospital on the left and a row of four IP trucks idling without drivers to the right, the slab was a blur of green camo and gray Army workout gear, almost everything moving except for a dozen bloodied Iraqis on stretchers on the ground. At least one hundred Americans had converged, some standing over patients but most in motion, carrying bodies from the trucks to the slab or going back to the trucks to get more bodies. People ran in and out of the hospital, taking patients in and returning with supplies to set up improvised triage stations: saline bags, blankets, big metal oxygen bottles with masks and regulators, sawhorses to make the stretchers into tables, chairs for patients who came in on their feet.
The slab was packed like an elevator at lunchtime, with people squeezing past you. Sounds wove in and out of one another, engines running, nurses barking vital signs, metal tanks dropping on concrete, docs announcing the urgency of patients’ conditions, and always the undertone groans of dazed Iraqi casualties. The wounded had swollen faces, almost all still conscious and coughing, covered in dirt and ripped clothing or, if their clothes had already been cut off, with little crimson pockmarks where frag had entered their bodies. Over the din a car horn blasted, and in the driveway, Charlie Med’s first sergeant, Donald George, held a walkie-talkie to his ear with one hand and reached through a truck window with the other, screaming for the drivers of the pickups to get their vehicles away from the slab. He had more ambulances with more wounded trying to get in.
Carlos went first to find Clark and Junker. The casualties had started arriving as soon as the call came in, and the two docs had been floating through the incoming, determining who needed what until Carlos could take over. The earliest report had been ten IPs hurt, but the first bunch alone had contained more than that. By the time Carlos arrived, a second wave was being unloaded and George’s third wave was waiting. The estimate of eighteen that Carlos had received was meaningless.
That posed a problem. The doctors’ first job in a mass cal is to prioritize the injured. Patients with no threat to life, limb, or eyesight get sent to patient-hold to wait to be treated. Those with immediate needs go into the trauma room for resuscitation, evaluation, and possible surgery. And those with injuries that would require an inordinate amount of time and resources are categorized “expectant.” They’ll be treated only after the others are stabilized. Usually they are moved out of sight and made comfortable while they die. The determinations are relative; a severe head wound who comes in alone gets the attention of the whole team, but one who comes in among five others might get no attention at all. There was the difficulty. The ten beds in trauma and the sick bay had been filled in the first wave. George told Carlos to expect the wounded to keep coming.
Carlos sent Clark to ride herd over patient-hold and asked Junker to go to the trauma room and start necessary intubations. Then Carlos went from table to table making quick decisions and moving on. At table one he looked at the physician’s assistant directing the four other providers working the patient. “He’s got a head wound and he’s not responding?” said Carlos. “He’s expectant. Let’s get someone on this table we can work on.” The Charlie Med pediatrician running table two said his patient had blunt trauma wounds to his chest and thighs, but X-rays were negative and an ultrasound showed no internal bleeding. “Let’s get him ready to evac,” said Carlos. And so on through the hospital.
A more vexing problem emerged. Almost every Iraqi brought in had difficulty breathing. In patient-hold, men were sitting against the walls passing breathing masks back and forth. These were casualties with no obvious injuries, no bleeding or broken bones, no soot or singes on their faces to indicate smoke inhalation. Word spread through the hospital that the truck that had blown up had contained chlorine tanks to maximize injuries. On the slab, interpreters were telling patients to try to breathe slowly. A number of Iraqis were sitting up on their stretchers and vomiting over the side.
Nothing slowed down, but a sense of order emerged. As you looked from station to station, you noticed that one person was in charge of each table. The fifth time the guy with his T-shirt on inside out and backward ran by you, you noticed he was dropping off oxygen bottles at different tables. Groups of soldiers gathered with stretchers at either side of the slab, not milling about but standing in formation. Amid the commotion in patient-hold, a walking blood bank got started, and away from all the activity, across the driveway in front of the Charlie Med garage, an area was dedicated to expectants. Four IPs lay there, covered in blankets on stretchers on the ground, while a chaplain and a corpsman tried to make their last minutes peaceful.
After an hour and a half the tide of incoming abated, and Carlos got Clark and Junker and headed to the operating room. He’d identified four operative cases and sent for the surgeons who work at the FOB’s detainee facility to help out. His own team moved quickly, with none of the usual joking around. The first patient had frag wounds to his chest and abdomen. In no time Carlos had him open and his bowels out on the table. The patient was bleeding from a hole in the spleen, so Carlos took it out, and then he and Clark ran every inch of intestine through their hands as if they were looking for knots in a rope, checking for hematomas as they fed it back inside. With that patient stable, Carlos moved to the other table, only to cut that patient open and find no internal injuries. While Whitehead sutured that patient shut, Carlos moved back to the first, who’d started bleeding heavily into the drainage tube coming out of his chest. Blood vessels were damaged on the left lung, and when Carlos opened his chest, he found blood bubbling on the lung’s surface, making a sizzling sound like butter burning on a griddle. “His lower lobe is destroyed,” said Carlos. “He’s not doing very well.” Then he removed the lobe and called for another patient.
The next casualty had a frag wound to the right side of his neck. Earlier, in the trauma room, Carlos had stopped his bleeding with an improvised fix, inserting a small balloon in his neck and blowing it up with a tube intended for a urinary catheter. Now with the balloon out and the neck opened, the patient began bleeding profusely. His carotid artery had been hit. The typical solution would have been to insert a temporary shunt and let the Level 3 surgeons do the actual repair. But the damage was too close to the aorta to patch it like that. By this point, the other surgical team was working on an abdominal wound on table two, and Carlos got one of the doctors to come pull two inches of vein from his patient’s thigh while Carlos and Clark opened his sternum. Then Carlos grafted the vein onto the artery, a simple thing to say but the kind of procedure that would have the halls of any stateside hospital buzzing the rest of the day.
It was nearly five-thirty when he finished the graft, five hours after he and Clark had scrubbed in for surgery. Outside, things had finally slowed down. Radakovic was preparing to fly to Balad, and the patients who could fly without him were already gone. Rogero told Carlos that dinner, burgers in Styrofoam boxes from the chow hall, was waiting in the Man Cave.
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