"Why did you choose that tattoo?" I ask the young officer occupying the bunk next to mine. He glances back at the elaborately inked cross on his shoulder blade and the phrase "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.'"
For ten years American troops have fought in Afghanistan. Their commanders, from the Secretary of Defense on down, long ago made them a promise. If you are seriously wounded we will get you to a field hospital, if at all possible, within an hour of being wounded. The troops on the ground rely on that promise. The promise is being honored, and it has saved many lives.
But, honoring the promise is not easy. Afghanistan is a land of rugged mountains cut by deep and narrow valleys, or else flatlands that bake in scorching summer heat. Decent roads are rare, extreme weather is common. The people speak multiple languages, and English is rarely one of them. The nature of Afghanistan means that wounded troops often must be evacuated from places that make extractions hard and dangerous. It is even harder if the job must be done under enemy fire.
The only way to evacuate the wounded within an hour is to use helicopters. That means a flight surgeon must be on the evac team. Few doctors take up this challenge.
One who did is Air Force Major Paul DeFlorio of Ridgefield, Connecticut. Dr. DeFlorio, a handsome, mid-thirties trauma doctor, is also a flight surgeon. A year ago Dr. DeFlorio was stationed at the American base at Bagram, Afghanistan. His job was to monitor the physical and emotional health of our helicopter evacuation teams and, when necessary, to travel with them and tend our wounded during the race back to the military hospital at Bagram.
With the permission of the U.S. military, I spent time with Dr. DeFlorio in Afghanistan in April of last year, and have spoken with him several times since. Before Afghanistan, he served two tours in Iraq as a trauma specialist. Most recently he served in the Mediterranean in support of pilots flying over Libya. He will almost certainly be returning to Afghanistan.
Air evacuation is a job of quiet waiting, then sudden and explosive action. In periods of quiet, Dr. DeFlorio writes fiction based on the reality of his experiences. He shared some of his unpublished written work with me.
To appreciate what Dr. DeFlorio and our medevac teams do in Afghanistan, and the risks they take to do it, it helps to visualize the ground they walk and the air they fly. I can sketch that picture in broad outline. But it is Dr. DeFlorio's writings (extracts of which appear in italics below), that lay bare the day-to-day reality facing our medical teams in Afghanistan and Iraq.
Bagram Air Base
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 highest peaks are draped in cowls of snow that slowly recede in the summer heat. At five thousand feet above sea level, the Bagram valley is low enough to come alive with spring grass and wild flowers. Summer temperatures can exceed 100°. A steady wind grinds fine dust into eyes and mouths. Down the valley, about sixty kilometers to the south, is Kabul.
Bagram was once a wealthy city on a spur of the silk route. Today commerce depends primarily on farmers and herders. Without the American and NATO presence, the valley near Bagram would be a forgotten place of small villages and farms.
A perimeter road circles the base. In places, wire fences separate 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 wind the signs dance against the wire, singing a metallic warning of mines 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 sometimes treated at the base hospital where Dr. DeFlorio worked nights after his day job as a flight surgeon.
The one-story base hospital at Bagram is named after Heathe Craig, an American medic killed during a rescue mission. On a wall alongside the hospital waiting room is a photo of Staff Sergeant Craig, as well as photos of other medics and nurses who died in this war.
Meeting The Medevac Team
I first met Dr. DeFlorio at the compound of the Air Force para-rescue jumpers, called the PJs. The PJs operate from a two story wooden building on the opposite side of the base from the hospital. Outside the PJ's building sit the HH-60 helicopters used on evac missions. They are prepped to fly an evac mission on a moment's notice. Each HH-60 is armed with twin 7.62 millimeter miniguns, or else twin 50 caliber machine guns, that extend from windows set behind the pilot's and co-pilot's seats.
The PJs are rescue/medical personnel. Like Navy SEALS, the PJs' qualifying program has a high dropout rate. In the case of the PJs, it is often ninety percent. The PJs will, if necessary, hit the ground in a combat zone and fight their way in and out of an evacuation while the evac helicopters hover at a reasonably safe distance.
I walk up a fight of exterior steps to the second floor of the building. Pilots, gunners and Dr. DeFlorio are having lunch in a day room filled with battered sofas and easy chairs. No one there knows for sure when these relics first arrived. They look so forlorn the Russians may have left them behind, and the Russians pulled out twenty years ago, humbled after ten years of war.
There is an easy banter as the men eat. There are the usual jokes about the food.
After a few minutes showing me the compound, Dr. DeFlorio leads me to his "office," which is actually a small closet across from the day room. We can talk more easily in the office than in the day room.
I ask Dr. DeFlorio the obvious, why he became a military doctor. He says he joined the Air Force for two reasons: "a desire to serve, and the military's willingness to pay for my medical degree. " Smiling, a bit ironically, he says he got what he wanted.
Soon after completing a residency in emergency medicine, he found himself in Iraq in 2005 treating traumatic battle wounds in a tent hospital with a loaded 45 on his hip. This was in the days of some of the fiercest fighting when Iraq collapsed into civil war. American troops took heavy casualties.
"One of the three heavily equipped medics pumped furiously on[the young GI's] stripped chest. In seconds he was deposited in front of me. He had no IV and no endotracheal tube. The medic's rushed report: IED blast, intubated but they had lost his airway during the transfer. He had arrested en route.
I looked up, told Hickman to put in a cordis, and again felt for a pulse. Nothing. I quickly scanned the man. He was remarkably intact, his dark skin was smooth save for a few small punctures of his chest. He looked alive."
Dr. DeFlorio, and all our medical personnel, see trauma wounds that can only be imagined in most civilian trauma centers. High caliber rounds and high energy explosives are brutal on the human body. Yet, sometimes, it is just a sliver of metal tumbling randomly through space at high speed that finds its way past an armored vest or a Kevlar helmet. When the luck runs bad for a soldier, the evac teams and trauma doctors are the first to try to reset the odds.
Despite the personal cost of two deployments to Iraq, and with his wife expecting their first child, DeFlorio opted for a second four year enlistment. The vast majority of military physicians serve only their minimum commitment. So I ask Dr. DeFlorio why he is different.
He admitted that it was a hard call. He was prepared to leave the service. But, the Air Force wanted him badly enough to guarantee he would be based in England. He had family in England whom his wife could rely on for some support when he was away. Then he added, with emphasis, "And I work with some of the most amazing people in the world."
That the troops he serves are courageous is beyond dispute. And those troops get extraordinary dedication from our evac teams and hospital staff in Iraq and Afghanistan. Dr. DeFlorio's explanation for what his service means to him is a common refrain among doctors and nurses serving in Iraq and Afghanistan. Still, the reason for a second four year commitment may be more complex than the doctor's straightforward answer.
His mission is to save the lives of American troops. That mission has meaning no matter the outcome of our war in Afghanistan. We may win, or lose, or suffer some vague middle ground of long-term presence and sacrifice. But, whatever the outcome of the war, he treats men and women who have taken horrific wounds, and may do so in a combat zone or in helicopters racing back to Bagram.
The experience can be intoxicating, though that is my word not his. The experience is, without doubt, powerful.
"I grabbed a scalpel and made a deep, foot-long incision from the sternum, around under the pec , and down to the man's flank. He skin leapt apart, like dish water film running from a drop of soap. His chest musculature and subcutaneous fat layer flayed open before me. I grabbed a clamp and shoved it in between his ribs. Through this hole I jammed my finger, pushing it inside him, feeling his lung. In thirty seconds, I'd have the entire left chest open, and be able to attack the man's malfunctioning heart. [A surgeon, my senior officer, walks in] and immediately protests that we were ‘desecrating the body,' a phrase that I had never heard come from a physician's lips. It sounded remote, alien, like a dead language that hadn't been uttered in a thousand years. [I answer] ‘It's not going to hurt him any! He's already dead! Let's just do it and make sure we can't fix this."
"Fix this!" Every parent hears those words from a child who has fallen, a child with a skinned knee. After a few tears, a hug and a colorful band-aid, your child is happy and well.
Children grow up. It is young men and women whom we send to Afghanistan. Parents are a world away. It is the military doctor's job to "fix" what is wrong. But, out here doctors see much that cannot be "fixed" by hugs, or band-aids or the best medicine in the world.
Without an exceptional evac system, many fewer of our people would be saved. Yet, despite the finest combat evac system ever developed, not everyone is saved.
"I stood back, my eyes re-fixing on the small lacerations in the man's side. They had doubtless [been the entry point] of some tiny fragments of metal. Traveling at thousands of feet per second, a shard has sliced away his life before we ever had the chance to save him.
There was complete silence. I looked around at my nurses, techs and the assorted hospital ensemble who had rushed in to help. A quart of blood stained the dusty concrete floor under the stretcher. [Splashed hither and thither, a monochromatic Pollack.]"
Dr. DeFlorio has paperwork to do, so we break off the interview and I take the opportunity to have two PJs show me around an HH-60. The two powerfully built men move with the easy grace of athletes as we walk around the HH-60. They explain its weaponry and flight characteristics, but their real focus is on the medical supplies and equipment they bring on each mission. The supplies are stored in dozens upon dozens of carefully labeled transparent pouches hanging from the inside back wall of the helicopter. They hang in readiness, within easy reach. The orderliness of these preparations is unnerving.
Suddenly, a horn blares. Dr. DeFlorio and the on-duty pilots, gunners and PJs grab their gear and run for two of the HH-60s. I toss on my Kevlar vest and flight helmet, and a canvas belt for strapping down in the HH-60, and join them. In only moments the HH-60s are in the air, noses pointing slightly down as they swing away from the base and to the south. We run along the valley in preparation for a climb over the lower flanks of the Hindu Kush on our way to Jalalabad.
Below are small rivers, farms and villages. A relatively short way from the base a tributary of the Panjshir River drops fast into a deep, steep-sided gorge. The green fields and mud-walled villages of Afghan farmers, the 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 scanning the ground below. Two PJs, one at each of the HH-60s 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.
We rise toward a wind-blasted pass in the mountains. The slopes are laced with narrow, winding paths that pick their way among mountain boulders. The views from those trails must be stunning. Local shepherds walk these trails tending their goats. So do men who watch the sky and try to shoot down helicopters. The PJs and the gunners are 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 toward a broad valley, also bursting in green, well-tended fields. Less than an hour after leaving Bagram we are cruising 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 our heavily armed HH-60s skim overhead, the noise of our rotors sweeping away the words. A short way to our left, the Kabul River traces a brown line through the city.
The touchdown at Jalalabad is quick. We are now in a Pashtun town. Since we are near 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 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 swing away from Jalalabad on our return trip.
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, nicely featured and framed by a 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 positions 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. Our medevac flight was uneventful; there was no enemy fire and no wounded died in flight.
Dr. DeFlorio jumps into our helo for the short hop across base to the PJs' compound. We touch down with a light bounce. Dr. DeFlorio and the PJs unload the gear used to treat patients. The PJ's restock with fresh supplies. There will be another call, and it could come at anytime.
A Doctor's Thoughts
One morning near the end of my stay at Bagram, unable to sleep and wanting a last look at the Afghan night sky, I walk my side of the base in expanding circles. The spring air is cold. Through the mist from my breath the Hindu Kush is outlined by the pale light of a half moon. Eventually I find myself in the gym, a tent loaded with weights and running machines set up near an old Russian air control tower. Open 24/7, the gym is always busy. After a few minutes, I notice Dr. DeFlorio walking toward me. He stops to say hello and mentions that he just came off-shift at the base hospital. Also unable to sleep, he hit the gym. We exchange some pleasantries, and with a touch to my shoulder and a smile 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 tell me why Dr. DeFlorio worked into the early morning. His patient was a U.S. soldier 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 and managed to bring him back. The soldier was in bad shape when he arrived at Bagram. Dr. DeFlorio had stood by him.
That back story to why Dr. DeFlorio was working out at 3 a.m. and not sleeping reminds me of an experience the doctor said was common. He was attending a Marine who had been hit by an explosion. The Marine had multiple injuries, including open fractures, and had been brought 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.
Concern for one's buddy over self is so common 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 message designed for a war zone: "You can go home now, and go home proud. You did your job. You did all you could."
Perhaps the conviction that someone must be at the front to give that message is as good an explanation as any for why doctors like DeFlorio not only stay in the military but also volunteer to deliver front-line care.
Later that morning I learned I was scheduled for a C-17 flight to Ramstein Air Base in Germany. We would leave that night on a medevac flight bringing wounded from Bagram to the U.S. military hospital at Landstuhl. I have been on long-haul medevac flights. I know the drill, and the pride of the medevac crews that fly the long evacs. But, even this close to flight time, no one could say how many wounded would start their trip home.
As it turned out, a dozen or so patients were on the flight. Three of them were severely enough wounded that a critical care air transport team, which includes a flight surgeon, specialty nurses and technicians, came with them. The team (a C-CATT) works only on the C-CATT patients. Dr. DeFlorio's patient of the night before is one of those three. Another was a young Army medic who took a blast to his face, chest and legs. His armor saved his life, but his body was shattered.
During the flight I am told 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. They deserve their reputation for courage in going forward whenever someone yells "doc!" They are hugely respected by the men and women with whom they serve. The movie Restrepo (by Sebastian Junger and the recently killed Tim Hetherington) was shot at a forward operating base called Restrepo in the Korengal Valley of eastern Afghanistan. Like the Heathe Craig hospital at Bagram, Restrepo took its name from a medic, Juan Restrepo, who was killed in action.
As I watched the C-CATT tend the wounded medic, the thing that gave meaning to that medic's courage and sacrifice seemed so clear. The word "doc" is not just a guttural sound easily shouted and understood in the chaos of battle. That simple word stands for something fundamental and selfless. If it does not exactly stand for love, it stands for something quite close.
The word 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 rescue the wounded, and it means PJs trained not only to fight, but also to rescue and provide care. The word "doc", when used in the deadly mountain tracks and village streets of Afghanistan, means a fierce commitment to your people.
[My senior officer's] position was that the man was ‘clearly' dead [as I worked on him], and that ED thoracotomies ‘never' work and were ‘futile'. I responded that it was indicated by published guidelines, and that I had seen it work, and there was simply nothing to lose. ‘Sir, I'd cut his fucking head off if it meant a one in 10,000 chance of saving his life.'
Dr. DeFlorio believes he works with, and provides care for, amazing people. He knows that his patients are volunteers doing a hard job in a brutal place. Many do the job over multiple tours. He believes they deserve the world's finest combat evac system and the caregiver's fullest measure of effort. They absolutely deserve people who care as much as Dr. DeFlorio.
Of course, the intensity of caring deeply can be a burden. Caring can exhaust a caregiver, particularly when the injured are predominantly young adults and are often badly wounded. But, doctors, nurses and medics in this war take on that burden because of what they see is given by the troops they care for.
These troops must excel at fighting an often unseen enemy, then find a way to do good works in the local Afghan communities. Two jobs, often in conflict with each other. They try, but Afghanistan is immense and unforgiving, the jobs are intensely difficult and failure has brutal human consequences.
It would be gratifying to believe that if our troops, 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 in Afghanistan had any illusions that we will bring the Afghan people a fully honest government and a peaceful society. Still, they keep trying, while remaining fiercely committed to the men and women with whom they serve.
Dr. DeFlorio, and physicians like him, have the great benefit of certainty. They do not doubt that their efforts produce results. They can save lives and begin to repair shattered bodies. They will win their share of battles, whether or not we as a nation ultimately salvage from Afghanistan something that we will call "victory."
It is no surprise that many of us, living busy lives at home in the States, want to know little of the Afghan war. Ten years is a long march, and the news from Afghanistan seems always to be perverse while the endgame remains frustratingly in doubt. But, it matters that we take time to reflect on the personal cost to those who serve in our name in Afghanistan. Not only our combat troops, but also their caregivers. If we do not appreciate that cost, we may not provide the support (jobs, health care and patience) needed when they return.
The costs to our combat troops are significant, even for those who return whole in body and spirit. The costs can be just as significant for all the Dr. DeFlorio's, nurses, PJs and medics who stand by them.
Certainly the costs were profound for that grievously wounded young medic flying home unconscious in the steel belly of a C-17. Costs incurred because he, like all our people in Afghanistan, stepped forward and, like a present day Isaiah, volunteered.... "Here am I. Send me."