Bagram, Afghanistan

March 15, 2011 Published Work


"Why did you choose that tattoo?" I ask the young Air Force officer occupying the bunk next to mine. He glances back at the elaborately inked cross on his shoulder blade and the words "Isaiah 6:8" intertwined with the cross. Then he smiles, and in a soft, east Texas drawl quotes Isaiah:

"Then I heard the voice of the Lord saying, ‘Whom shall I send? And who will go for us?' And I said, ‘Here am I. Send me!'"

It is April in Afghanistan, the time when the snows recede in the Hindu Kush and combat begins in earnest. The village of Bagram, and the neighboring military base of the same name, each approach spring in their own way. One prepares to plow fields and plant crops. The other prepares for more war.

Much of Afghanistan is a world of mountains cut by deep and narrow valleys, few and poor roads, and thousands upon thousands of small villages. Where the land flattens, the summer heat nears the intolerable and irrigation canals, mud walls and vegetation provide cover for the enemy. Waging a counter-insurgency war in such a setting means that wounded troops often must be evacuated from terrain that makes them hard to reach. That makes helicopter rescue and evacuation essential, and a flight surgeon must be on the evacuation team. Few doctors take up the challenge.

One who did is Air Force Major Paul DeFlorio of Ridgefield, Connecticut. Dr. DeFlorio, a handsome, mid-thirties trauma doctor, flies on helicopter rescue and medical evacuation missions out of Bagram. His job is to get our wounded off the ground and out of danger and tend them during the race back to the military hospital at Bagram. To appreciate what Dr. DeFlorio and our medevac teams do, and the risks they take to do it, you need to visualize the ground they walk and the air they fly.

The American base at Bagram sits on the west side of a broad valley cradled on three sides by the ragged peaks of the Hindu Kush. When the air is clear of blowing dust, the sky is deep blue and the highest peaks are draped in cowls of white snow. At five thousand feet above sea level, the Bagram valley is low enough to come alive with spring grass and wild flowers. Down the valley, about sixty kilometers away is Kabul.

Bagram was once a wealthy city on a spur of the silk route. Today commerce depends primarily on farmers and herders, and on the local Afghans who support the American base. Without the base, Bagram would be a small and forgotten place.

The Panjshir River alternately flows and cascades south through the valley. Smaller rivers, some running near the base, join the Panjshir nearby. To the north and west, visible as a distant cut in the mountains, the Salang Pass leads over the Hindu Kush. The pass tops at more than 10,000 feet and is shadowed by white-topped mountains. At times, avalanches sweep across the two lane road that balances on the edge of the pass. When they do, cars and people are swept away. Far below the Salang, Afghan villages cling to ravines that feed snow melt to the Panjshir.

Here in the valley, locust trees are in bloom. They are stubby things with trunks of thick, interlocking ropes of blackened bark. Their white blossoms fill the air with a sweet aroma that mixes with jet fuel, diesel and the always rising dust. The combination of pollen, fuel and dust produces a light paste that covers everything on base. Our troops do their work within an odd perfume of spring accented by the smells of war.

A perimeter road circles the base, and just beyond the road are wire fences separating the base from the treeless fields of the local villages. Rectangles of metal, printed with a skull and crossbones, hang from the fences. In the nearly constant springtime wind, the signs dance against the wire, singing a metallic warning of minefields left over from the decades old Soviet – Afghan war.

At times, local Afghans inadvertently set off mines as they tend flocks and fields. If not killed, they are often treated at the base hospital where Dr. DeFlorio works nights after his day job as a flight surgeon. There are no illusions here about life being easy or taken for granted. Extreme trauma is a given in this corner of the world.

The hospital is named after Heath Craig, an American medic killed during a rescue mission. It is a one story building sited next to a helicopter pad where the medevac helicopters land when bringing in the wounded. A line of tall, thick concrete blast walls separates the pad from the hospital.

The hospital and everything else at Bagram operates around the clock. Dr. DeFlorio flies rescue missions on HH-60 helicopters from a compound situated alongside Bagram's twin runways. The HH-60's can be called out day or night, but the huge C-5's and slightly smaller C-17's that fly in soldiers and supplies do their work at night, the safest time to take a large plane in or out of Bagram. Predator drones, more long-legged winged insect than plane, lift quietly into the sky. Sleek F-15's and F-16's periodically scream down runways to quickly become silent silhouettes against the backdrop of the nearby mountains. The signature sound of each aircraft combines into a continuous background symphony of war.

Not far from the hospital our troops bunk in dark brown canvas tents. My tent is typical. It is a half moon, set flat side down on a concrete pad, and about two-thirds the size of a football end zone. Sandbags colored in Army green are stacked several deep around the outside of all the tents. A small, hand-lettered sign reading "Hotel California" hangs from my tent door. Heavy packs, combat boots, Kevlar vests and gear of all sorts lie at the foot of each metal bunk. Somewhere in the "Hotel California" someone is always trying to sleep, or else is on his way to or from the nearby showers. The showers are one-story communal simplicity. Bare bulbs cast a garish light on gray wooden walls and reflect off sinks and urinals strung in lines of white porcelain.

In sharp contrast, the hospital is clean and modern. And, in some respects, it and its medical team are at the center of this base. It is the one place that everyone here knows they may need, and that everyone hopes to avoid.

A wooden stairway climbs the outer wall of the hospital to a flat roof. Doctors and nurses sometimes climb here for a break. From the roof there is an unobstructed view of the flight line a short way to the east. To the south, just beyond some tents and low buildings, is a bulky, three-story air traffic control tower converted into offices. Our troops call it the "Russian Tower". The Russians built the Tower and an airstrip in 1959 to gain influence in Afghanistan. They built to last, and the white-washed Tower is a hulking, thick-walled presence. In the late 1970's Russian forces invaded Afghanistan. They occupied the airfield and ringed the base with minefields. Ten bloody years later they pulled out, defeated in their Afghan war and about to lose much of the old Soviet empire.

Circling the top floor of the Russian Tower is a narrow parapet of broken concrete enclosed by a rusted railing. It gives the best view of the base. A pair of Army field binoculars rests conveniently on the otherwise empty flight console inside the glass-walled top floor of the Russian Tower.

Across The Base
This afternoon I am meeting Air Force Captain Jean Duggan, a public affairs officer who tirelessly runs her proficient four-person team from a crowded room on the second story of the Russian Tower. Captain Duggan will drive me to the opposite side of the base, to the compound of the Air Force para-rescue jumpers, called the PJs. The PJs are Air Force rescue/medical personnel. Among the military's elite programs, the PJs' training program has the highest dropout rate, often ninety percent. PJs fly with Dr. DeFlorio on every rescue mission. Their ability to fight their way in and out of a rescue can be critical to its success. I will meet the doctor at the PJs' compound.

The drive covers half the distance of the roughly eight mile circuit around Bagram. In daytime the traffic is dense and slow. Military vehicles predominate, but scattered on the road are construction vehicles and numerous brightly painted local Afghan trucks that support the base's supply and construction efforts. Our troops call the Afghan trucks "jingle trucks" for the many small bells that hang from the tops of the drivers' brightly colored cabs.

Local contractors and foreign workers are grading away the potholes and swales that make it a bumpy ride on the all-dirt perimeter road. Construction sites line the route. We pass several large parking lots filled with new construction equipment and military vehicles, sand colored and aligned in neat rows. It is as if dealers in military equipment had set up showrooms on base. The U.S. is building far more extensively and permanently than the Russians ever did. The day will come when we leave behind these symbols of our time here, just as the Russians left their Tower.

Troops (Army, Marines and special forces), weighted down with weapons, packs and armor, constantly move in and out of the base. Red Horse engineering units from the Air Force, together with Army Engineers, build the needed infrastructure. They also build bunkers for cover against the occasional mortar and rocket attacks against the base. The base comes under more serious attack at times. (Not long after I left Bagram, twenty or so Taliban, including four suicide bombers, tried to breach the perimeter at night. They were fought off over several hours by American soldiers.) For this reason, military personnel carry their weapons at all times.

Outside the wire, in green fields dotted with wild flowers, are the rusting hulks of Russian military vehicles. Herds of goats graze on green hillocks in the minefields. Beyond them, women in burkas, often balancing brushwood on their heads, walk with children from their fields to villages of mud brick houses enclosed by mud brick walls.

The Medevac Team
The PJs operate from a two story wooden building. That building, together with some maintenance facilities, form an L that shelters HH-60s prepped to fly a medevac mission on a moment's notice. Each HH-60 is armed with twin cannons that extend from windows set behind the pilot's and co-pilot's seats.

We walk up a fight of exterior steps to the second floor of the PJs' building. Pilots, gunners and Dr. DeFlorio are having lunch in a day room filled with old, battered sofas and easy chairs. No one there knows for sure when these arrived here. They look so bad the Russians may have left them behind. There is an easy banter as the men eat, and there are the usual jokes about military food.

After a few minutes showing me the compound, Dr. DeFlorio leads me to his "office," really a small closet across from the day room and near the equipment room where each PJ, pilot, gunner and flight surgeon stows his flight gear. We can talk more easily in the office than in the day room. I ask Dr. DeFlorio why he became a military doctor, and he tells me he joined the Air Force for two reasons: "a desire to serve, and the military's willingness to pay for my medical degree". Smiling, he says he got what he wanted.

Soon after completing a residency in emergency medicine, he found himself in Iraq treating battle wounds from a tent with a loaded 45 on his hip. This was in the days of some of the fiercest fighting. The time when Iraq deteriorated into civil war. After meeting his four year commitment, including two deployments to Iraq, and despite having a wife and expecting a child, he opted for a second four year tour, this time as a flight surgeon.

The vast majority of military physicians serve only their minimum commitment. So I ask Dr. DeFlorio why he is different? His answer is short and simple, "I work with some of the most amazing people in the world."

That our troops are courageous is beyond dispute. I have found the medevac teams and hospital staff in this war to be remarkably dedicated. And, Dr. DeFlorio's answer is the same one I have heard from many other doctors serving in Iraq and Afghanistan.

Still, I suspect that the reason for a second four year commitment may be more complex than the doctor's answer. Dr. DeFlorio's mission, to save the lives of American troops, has meaning no matter the outcome of our war in Afghanistan. He treats troops who have taken horrific wounds, and often does so in a live combat zone or in helicopters racing back to Bagram. That combination of extreme circumstances, battlefield danger and personal sacrifice for a greater good is found in only one place, a war zone. The experience can be intoxicating, though that is my word not his.

I ask what he most often deals with as a trauma doctor in a war zone. "Blast trauma; we mostly see blast trauma. We see our people who have been literally blown apart." He explains that it is the massive scope of many wounds that often makes the medical aspects of the job so difficult, and that necessitates an exceptional evac system. The hidden bombs that destroy limbs mean amputations, many being double and triple amps, even some quads. There are so many amputations, some doctors believe they have learned how to tell from the damage whether the soldier was walking slow or fast when he set off a bomb.

A Mission
After lunch, two PJs, Captain James Sluder and Staff Sergeant Daniel Warren, show us around an HH-60, its weaponry and the medical supplies they carry on each mission. The supplies are neatly stored in dozens of transparent pouches hanging from the back wall of the helicopter. The orderliness of their preparations is unnerving.

Standing in a warm spring sun, we lean back against an HH-60 as the two PJs matter-of-factly discuss things that are far from matter of fact. Their missions can put them anywhere, and they always go in heavily armed since PJs will fight their way in and out of a rescue operation if need be. They also fly humanitarian missions, and were early into the Salang Pass when the avalanche hit in February. Sluder and Warren make little of that effort, but it is no small thing to take a helicopter into the thin air at 10,000 feet during an Afghan winter.

As we walk back to the compound a horn blares loudly. Dr. DeFlorio and the on-duty pilots, gunners and PJs rush to gear up and then run for two of the HH-60s. I throw on my Kevlar vest and flight helmet, and a canvas belt for strapping down in the HH-60, and join them. In what seems like seconds, the HH-60's are in the air, noses pointing slightly down and swinging south. We take a run along the valley, preparation for a climb over the lower flanks of the Hindu Kush on the way to Jalalabad.

Below are small rivers, farms and villages. A relatively short way from the base a tributary of the Panjshir drops fast into a deep, steep-sided gorge. The green fields, mud-walled villages and scattered tents of the Afghan herders slowly give way to nothing but rock as we turn away from the rushing water and fly south and east to the steeply rising mountains.

The gunners lean over their cannons, constantly scanning the ground below. Two PJs, one at each of the HH-60's open doors, sit with legs hanging in the open air. Their camouflage pants, bloused into combat boots, whip at their legs as the airstream cuts past. Automatic rifles lay across their laps. Extra ammunition clips hang from their chests. Their entire focus is on the ground skimming past us. As we leave the inhabited areas of the valley, our pilot banks steeply to the left to give one gunner the opportunity to fire his cannon to check its readiness. Tracers spit a dotted red line as rounds slam into a rocky cleft in the mountains only a few hundred yards away. We bank in the opposite direction and the gunner on my side lets off a loud burst. The airstream sweeps gray cartridge clips back from the speeding ammunition belt, and through the open door, where they rattle along the floor of our HH-60. The other HH-60 is flying slightly behind and above us. Dr. DeFlorio is on that flight, with another two-man team of PJs.

Precipitous mountainsides in tans and browns, spotted with snow fields and sliced by narrow valleys, slide past. Many of these valleys shelter green farms strung along a water course like emerald beads. Mountain streams charge frothy over rocky beds, but we cannot hear their roar over the helo's engines. The green fields are terraced into the sides of the steep valley walls. The terraces eventually give way to barren rock and scree that rises to stony peaks or snow fields. It is an extravagantly beautiful sight.

We rise toward a wind-blasted pass in the mountains. The slopes are laced with narrow, winding goat paths and wild animal trails. Local shepherds walk these trails. So do men who try to shoot down helicopters. The PJs and the gunners stay intently focused on the ground below us.

Crossing the pass, snow fields gleam to our right, brilliant in the bright sun. We swing off the top of the pass and down into a broad valley, also bursting in green, well-tended fields. Less than an hour after leaving Bagram we are cruising only a couple hundred feet over the outskirts of Jalalabad.

As we move over the center city, we can look down into the walled compounds that make up most of the residences. Flowering apricot, plum and apple trees fill many of the compounds. Children run about. Women walk the streets and compounds in dark-hued burkas. The helo slows and we fly lower still over Jalalabad. The burka-clad women look like slow moving chess pawns crafted from freshly dug earth. Towering over the women and children are the white minarets of mosques reaching toward us and heaven. I can imagine the call to prayers being sung from the top of the slender minarets as heavily armed HH-60s skim overhead, the sound of their rotors sweeping away the words. A short way to our left, the Kabul River traces a brown line through the city. In a few places on the main street a modern, glass-walled office building rises to three or four stories, mixing oddly with simple one and two story buildings and mud-walled compounds.

The touchdown at Jalalabad is quick. We are now in a Pashtun town. Since we are nearer to the mountain passes leading to the tribal lands in the north of Pakistan, security is more of an issue than at Bagram. The HH-60s refuel at a NATO base at the edge of town, and we pick up three wounded. One of the wounded is loaded into my HH-60. Dr. DeFlorio is busy at the other HH-60, helping wounded who need him more. The man we have picked up is Afghan Army with a knee shredded by a bullet.

The Patient
The PJs quickly place the wounded Afghan's stretcher in the chopper, securing the stretcher to the floor with canvas straps clipped to holdfasts. Both HH-60s lift off, and we rise over Jalalabad for the return trip. The PJs on my flight kneel by their semi-conscious patient, watching monitors that record vital signs, adjusting blankets and offering hand signals of comfort. An open hand, palm forward, signals patience. A thumbs up signals that all is well. Even without the language barrier, it would be very difficult to be heard above the combined noise of the engines and the wind blowing past the partially-open doors. The hand signals calm the soldier. As we rise toward the mountains, the PJs are again at the doors, weapons across their laps, watching the ground and glancing back to their patient.

The Afghan soldier appears to be about thirty. He is well-tanned on his face and hands, while his chest (exposed to the navel) is a pale white. His face is lean and nicely featured, and he wears a full, closely cropped beard. When the sunlight catches the deep black hair on his head and his beard, individual strands of brilliant red and gold appear. Perhaps only one out of every of hundred is red or gold, but their color is so vibrant they glisten when they catch sunlight.

The soldier winces and tries to sit up, obviously in pain, and the PJs set aside their weapons and adjust the setting on an intravenous line to increase the flow of a narcotic. The patient lies back and his stomach muscles tighten against the pain. His eyes move slowly back and forth between the PJs as they retake their position at the open doors.

At Bagram the HH-60s glide onto the pad near the hospital. Waiting medics and nurses roll out gurneys and take away the wounded. Dr. DeFlorio jumps into our helo for the short hop across base to the PJs' compound. We touch down there with a light bounce and Dr. DeFlorio and the PJs unload the gear used to treat patients and restock with fresh supplies. There will be another call.

A Doctor's Thoughts
Unable to sleep, and wanting a last look at the night sky before I leave the next day, I walk my side of the base in expanding circles. The night air is cold, and through the mist from my breath I can see the Hindu Kush outlined by the soft light of a half moon. Eventually I find myself in the gym tent near the Russian Tower. Open 24/7, it is as busy as ever. After a few minutes pushing up some weights at one of the machines, I notice Dr. DeFlorio walking past. He stops to say hello and mentions that he just came off-shift at the hospital. Also unable to sleep, he hit the gym. We exchange some pleasantries, and he thanks me for coming to Bagram to get "eyes on." Then, he is out the door for a few hours' rest.

That afternoon, hospital staff explain to me why Dr. DeFlorio worked into the early morning. His patient was a U.S. soldier badly wounded in a rocket attack on his forward base. The soldier's injuries were so extensive that before being air-evaced to Bagram he lost all vital signs. A surgeon at a forward base opened his chest to bring him back. The soldier was in very rough shape when he arrived at Bagram, and Dr. DeFlorio had stood by him.

That back story to Dr. DeFlorio's three a.m. workout reminds me of a story the doctor said was emblematic of his experience. He was attending a Marine who had been hit by an explosion. The Marine had multiple injuries, including open fractures, and had come in with a wounded platoon mate. "I ask the Marine sergeant about taking some morphine. He answers, ‘I'm fine doc, how's my bro.' I come back with ‘Let's focus on you, you just got blown up.' " But, the Marine continued to insist on someone first helping his wounded man. This concern for a platoon mate over self is so common for American wounded the doctor has a standard response: "We know you're hurting, we're already seeing to your men. You can relax now and take some meds. You're going home, not as a man out of the fight – but as one of the heroes." It's a front line message. Perhaps the continuing need for someone to give that message is the best explanation as to why doctors like DeFlorio stay in the fight.

A few hours before dawn tomorrow I will catch a C-17 to Ramstein Air Base in Germany. It will be a medevac flight, bringing wounded from Bagram to the U.S. military hospital at Landstuhl. I have been on medevac flights so I know the drill, and the pride of the medevac crews that fly the long distance evacs. But, even this close to flight time, no one knows how many wounded will take the first leg of their trip home.

As it turns out, there are a dozen or so patients on that early morning flight. Three of them are so badly wounded that a critical care air transport team, which includes a flight surgeon, specialty nurses and technicians, flies with them. The team (a C-CATT) is dedicated exclusively to the care of the C-CATT patients. Dr. DeFlorio's patient of the night before is one of those three. Another is a young U.S. medic who took a blast to his face, chest and legs. His armor saved his life but the blast left his body shattered.

During the flight I learn that the medic was hit as he went to aid one of his men taken down by enemy fire. Medics are easy targets. They know that. Their reputation for quality medical care, and for courage in going forward whenever a man yells "doc", is deserved.

As I alternately sit and pace the floor of our C-17, watching doctors and nurses tend and comfort the wounded medic, it becomes clear to me that the word "doc" is far more than a guttural sound easily shouted and understood in the chaos of battle. That simple word stands for something fundamental and selfless. It means a young medic who runs into the open to aid a man down. It means a flight surgeon who leaves wife and newborn to fly into hot combat zones to care for the wounded. It means PJs, trained not only to fight and to rescue, but also to provide care. It means each doctor at the Heath Craig Hospital at Bagram and at all our forward operating bases in Afghanistan. The word "doc", when used in the confusing, deadly pathways of Afghanistan means unbending commitment to the troops.

Dr. DeFlorio is right. He works with, and works to save, amazing people. We ask those men and women to excel at fighting an often unseen enemy. Then we ask that they do good in the local Afghan communities. Two jobs, often in conflict with each other. They try, but Afghanistan is immense and unforgiving, the job is close to impossible and failure has brutal human consequences.

It would be gratifying to believe that if our people, despite the danger and the long odds, somehow deliver substantially more good than harm, then our Afghan enterprise will be worth the cost. But these "boots on the ground" do not control Afghan graft, tribal politics, religious fanaticism or the Afghan people's fervent wish to not be caught in the middle of a war. Few soldiers I met have any illusions of what we can achieve. Still, they keep trying. The response when asked about their experience is nearly always the same, "We are doing our job, sir." Ten years doing the job, ten years of trying. Standing by these people are doctors like Major DeFlorio.

Few of us back in the States can know, or even find time to reflect on, the personal costs to all the Dr. DeFlorio's, the PJs and that grievously wounded young medic. Costs incurred because each of them, unlike most of us, stepped forward and said... "Here am I. Send me."

Several photos of Dr. DeFlorio are attached, and show him in an operating theater and in flight with the medevac teams on an HH-60 helicopter.