By the time we see them in the OR, they often still have their limbs attached and are some semblance of a whole person. The ICU would have patients bandaged or with an eye patch on; whereas, in the OR, I equate it with working in a butcher shop. I lost count of how many healthy legs with boots still on that would be put in biologic bags and would go to the incinerator the next day. We were literally taking apart what had been whole. An hour ago, the same guys were healthy, strapping 18-, 19-, or 20-year olds. Now, they were tragically changed forever. I can still see the heap of biologic bags waiting to be transported to the incinerator, and our OR floor covered in blood as a mass casualty incident transpired. I can smell it; I can see it; and I can hear it. We had a high profile case; a young army soldier held the record for the number of units of blood products he received and survived. I think in Afghanistan at the two hospitals that cared for him, he had over 400 units of blood products.

In my first 2 or 3 months in Iraq I saw everything. I cared for some amputees on the ward for a day or two before they went out on the medevac flight to Landstuhl Joint Services Medical Center in Germany. They were so young, that stuck in my mind the most. The burns from IED [improvised explosive device] explosions were just awful. We had a marine vehicle blown up by an IED, and four marines were fried alive. They didn’t stand a chance. We also had a family that was in a car, and it rolled over an IED. The parents died, and the three little kids were terribly burned, but they lived. Although I was often horrified with the injuries I saw, I was also fascinated with the human body and the healing process. I learned so much as the weeks went by, and I actually volunteered for more interesting assignments. I went on five helicopter runs toward the end of my tour to pick up patients. It was exciting, and I loved flying and I was able to provide the care they needed in route back to Balad.

Before the beginning of the war in Iraq, it used to have to be that patients were stabilized for flight. That was the concept of operations for air evac before the beginning of the war. Now, with the wars, this concept has changed and patients are less stabilized. I had a guy’s femoral artery open up and bleed out on me in flight at 35,000 feet. I don’t know how he did long term, but he made it off the plane alive. I didn’t follow up, I just don’t do that. I can’t force myself to do that.

The CCAT [Critical Care Air Transport] teams usually take care of two or three patients who are critical and on vents [ventilators] on the flight. But we help take care of the other 20 or 30 or 50 patients, and some of those patients need critical care, too, but are breathing on their own. We had a lot of vascular and orthopedic injuries that were splinted but needed watching, and these patients were in pain and needed pain medication. That was a real challenge because these folks were really in pain. It got better over time; because around 2005, anesthesia providers started doing nerve blocks to keep them more comfortable. They came out for the flight with the epidural catheters in and duramorph injected; so, they would be comfortable for the duration of the flight. Some were on PCA [patient-controlled analgesia] pumps so they could control their own pain meds to a point. But that being said, it is just so hard to deal with these terribly injured young people day in and day out. The burns, the traumatic amputations, the open head trauma with parts of the brain missing, the infected abdominal wounds from the desert sand, seeing this every day just gets to you.

When we flew missions back to the States, many of these folks were stable, but had significantly diminished capabilities. I felt really sorry for this one lady. She came and met her husband’s flight when it was being readied to take him closer to home. She had their 3-year-old son with her. She said to me, “I feel like I have two 3-year-olds now.” And she was talking about her husband. He had pretty significant closed head trauma. He couldn’t do much for himself physically and also had significant cognitive impairment. I wondered what these patients lives would be like in the long run. What kind of a life would they have? Would their families be able to cope? How many will never go home again? Will a veteran’s hospital become their home now?

While I was in San Diego, I was able to see one of my corpsmen who had been seriously injured during our deployment, and he had survived. He was terribly injured, and the memory of “one of our own” being injured like that, in the hospital compound, really stuck with me and really “hit home” that no one was safe over there.

I was able to see him, meet his wife and children which was a really important experience for me. It had been very traumatic for everyone involved because he was actually injured on the base from a rocket attack and had essentially died at the forward surgical unit, and had been brought back to life, transfused, and medevaced out. That set a tone during the deployment, because it happened very early on. It helped me to see him, because I could see how they were surviving as a family and so that was a little bit of closure that was helpful. I am still in touch with them, and he’s doing much better. He has paralysis in his right leg. His sciatic nerve was severed. At the time I saw him, he was going through a lot of rehabilitation and was walking with a cane and a special kind of foot support.

One of the things that happened when I was in Iraq was that I wrote a very detailed account of our first few days in Iraq, and it was not meant for publication. It was not something I had done anything with. It was just a personal account of my experiences there because it became very clear early on in Fallujah that this was not a safe place to be. Two of our first casualties were medical staff. They were an army surgeon and an army medic both hit in a rocket attack, and they were killed. They were the unit we were replacing. So, as soon as we arrived, they were literally waiting for our gear to arrive by convoy; so, their unit could pack up and go home. They were within days of going home, and we had a rocket that landed right outside of our medical building, and it killed the two of them and several others became instant surgical cases. I think we medevaced four staff members as a result of that rocket attack. It became very clear how dangerous it was at the time, and we had only been in Fallujah for about 10 days when that happened. These guys were set to go home in about 3 days. It was a horrible thing, but it tested our surgical team. Yes, it was a rewarding deployment. That single event showed me the capabilities of a team to come together and do the mission. [She starts crying.] I guess this was the highest example of that in my career. Seeing that, I think these are lessons that I refer to in my leadership role all the time. When we are trying to get something hard done or meet a challenge where we don’t have enough people, money, or supplies, it is the truest military medicine. That’s the example I was left with. Nothing will be as hard as that.

In spite of the tragic losses, it was a critical thing to have happened because it showed that we were a team. None of us have ever done that before. Even if you work in surgical trauma, which wasn’t the background of a lot of people in our unit, even if you had had these skills, they were not exactly the skills you needed in a place like Fallujah. In an inner city trauma center, you might deal with a gunshot wound but that was a far cry from what you get in Fallujah. There was such serious multisystem trauma. Traumatic amputations of multiple limbs, everything you can imagine, heads with chunks of skull and brain missing, everything, everything, your worst clinical nightmare!

There were horrible things that were occurring at the time I was in Fallujah. Do you remember the contractors who had been captured? They had been badly brutalized, and their bodies were hung upside down and burned. They became fodder for TV and propaganda. We were the unit that got their remains. So many horrible things were happening at that time [crying].

I saw patients come in with terrible injuries with exposed bone with infections that were not dealt with. Fractures were sometimes put back together incorrectly in surgery so the patient lost the use of that limb or joint permanently. When I questioned the surgeon about the placement of the screws and angle of the bones, he said “That is close enough.” I am a CRNA [certified registered nurse anesthetist], not an orthopedic surgeon, but I’ve done enough anesthesia for ortho cases that I know when the bone alignment and screw placement is not correct. I’ve seen them manipulate a compound fracture of the leg of a 20-year-old policeman without administering any pain medication. This kind of stuff just breaks your heart. It just made me sick to my stomach, and it still does when I think back.

There were some pretty catastrophic injuries we cared for over there. A lot of the worst injuries were from IED blasts and suicide bombers. People had burns, multiple amputations, eye sockets blown out, open head trauma with brain tissue oozing out, and brain tissue and skull parts missing. There were lots of gunshot wounds to the head and chest. We had five triple amputees that we did surgery on in our operating room suite. I had never seen anything like these injuries. It was hard to deal with emotionally, especially when the patients were little kids. Bullets and bombs don’t discriminate between soldiers and innocent civilians and children. Some of this was just so hard to take, and so tragic.

I was in Afghanistan for almost 7 months. I volunteered for deployment. I was in three different locations during my deployment. I mostly did trauma nursing for the majority of my time in Afghanistan. Then, I had 6 weeks of ICU, so it was kind of trauma “after the fact.”

I got there on my birthday. I took a Blackhawk helicopter from Bagram to Bostic. We got off the chopper and went into the FST [Forward Surgical Team] building, and there was a mass casualty going on. I took my top off, I had a T-shirt on, I put gloves on, and I just started working on patients. There was a little kid they had been working on that was “expectant,” but I decided to pop a line in him and give him fluids. He got shipped out to a place called Kia, it’s a French-run hospital. I think it’s in Kandahar. So, they accepted him as a patient. Then a month later, he came back to us, and he was good. He had lost an eye, and his head was kind of caved in, but he was neurologically intact. You have to understand that in Afghanistan, the sons are really important. The daughters are expendable, but the sons are really important. So, it was really good that the kid made it.

I spent my last 3 months in Afghanistan at FOB [Forward Operating Base] Fenti. It was a really good experience at Fenti, but every place I went there were bombings and serious injuries and a lot of amputations. In December, Fenti got attacked at the gate. The first bomb was close to our dorms. It was always the same shit; when you spend a lot of time with the army, you swear a lot [laughs]. My commander lived right across the hall from me. The bomb went off, so I jumped right out of bed and got on the floor. You have to wait and see if there is going to be another one exploding. When we figured out that it was clear to run across to the FST, which was a hardened facility, we took off running. We kept our “battle rattle” [protective Kevlar vests and helmets] in the FST. So, we put it on and waited for casualties. But the bombing kept going on for 4 hours. We looked out the front of the FST, and there was a gunship [armed helicopter] in view and we could see the war right in front of us. It was less than a mile away. The gunship, which was one of ours, was right there fighting back. That day, we had about 25 casualties. One of them was an American contractor who had just gotten there. He was a retired Green Beret, and he had only been there a week. He got hit. It was one of those head wounds where his pupils were blown. You knew he wasn’t gonna come back, but you kept him alive so that his wife had the option of pulling the plug when he got back to the States. We saw just horrible wounds and burns at FOB Fenti. Many patients died at Fenti. We were in the thick of it.