Over the next eight weeks I absorbed an enormous amount about the practical application of medicine from Butch and laid the foundation for a lifelong friendship before heading to Fort Bragg, North Carolina. There the class would finish the course with an intense three-month trauma module on frontline care. We weren’t sure what we’d encounter, but we knew this final segment would piece together the education of Fort Sam Houston and skills we practiced during our hospital rotations with the realities of war.
* * *
Having worked with Army Special Forces in the past, I thought I knew them, but it took nearly a year working side by side to earn the Special Forces medic qualification before I really understood who these men were. Green Berets didn’t enlist to be special operations; rather, they joined to be soldiers, each one proudly serving in the infantry, armor, artillery, intelligence, or combat support. However, somewhere along the way each one of them had a revelation that unconventional warfare was his true calling. Unlike BUD/S, where the average rank and age were indicative of men entering the service, Special Forces recruited from within the rank and file of the army, seeking only the most experienced soldiers, which is the key to their success.
Special Forces sergeants from Vietnam to Afghanistan have led company-sized forces against hardened enemies and won. They do it because they are “intellectual” warriors using judgment and reason to develop tactics foreign fighters can implement to win in battle. For them textbook maneuvers only work if the men they lead understand the textbook, so they are often forced to develop unconventional approaches to nearly everything they do. They certainly did when it came to the instruction of medicine, and all of special operations is better for it.
10
EVACUATION
Perseverance is more prevailing than violence; and many things which cannot be overcome when they are together, yield themselves up when taken little by little.
—PLUTARCH
After graduation I was assigned to a team tasked with training our allies in South and Central America, especially those battling internal threats such as rampant drug trafficking. I’d soon find out that was only a small portion of the adventure that lay ahead.
* * *
We arrived at Soto Cano Air Base in Honduras to help the regional authorities develop the necessary skills to deal with the troubles affecting the territory. We were there as advisers; the local troops handled the heavy lifting. Immediately after touching down, we received orders for our first operation. The mission would take half of the platoon to the shore of the Caribbean Sea, just within the borders of Honduras. We were dropped off by air and set up a base near an airfield that paralleled the sea. As usual, I set up a small clinic, used primarily for the treatment of my guys but also for the foreign troops serving with us. I would also treat the locals if supplies and time permitted. We were ahead of schedule for the first few days, so Dave, our officer in charge, gave us the morning off to enjoy the sun and water. While most of the platoon got up for a morning ocean swim, I opted for alone time at the other end of the compound. I snuck away and strung a hammock made out of parachute cord and jungle netting facing away from the others. I would have hung a DO NOT DISTURB sign had one been available.
For an hour, I enjoyed the rising sun while listening to local music on a small radio and thumbing through medical journals. Just as the sun rose above the eastern horizon, a hulking figure approached and blocked it out. The silhouette told me it was Smitty, a large SEAL who looked like a scruffy Mr. Clean, but with a bad disposition.
“What’s up, Smitty?” I asked, assuming he wanted me to look at someone’s sprain or perhaps a nasty jellyfish sting.
“A plane crashed about fifty meters off the shore,” he said calmly, pointing to the area where it happened. “LT, Norris, Bucky, and some of the others swam out to the wreck and pulled the guys to shore. They sent me to find you and get you to the local clinic.” Turns out while I was looking east the plane was coming in from the west and crashed about a half mile from my hammock. Once I stood up, I could see the twisted tail, wing, and landing gear poking straight up through the receding waves. In a few hours the tide would ebb, fully exposing the plane. Being curious about the extent of the damage, I made a mental note of its location as we ran to the truck.
I closed my door just as Smitty started to explain. Apparently the guys had just finished their morning swim when a low-flying plane hit the beach behind them, finally settling in about four feet of water. Five guys swam out to check if there were any survivors. LT and Jessie dispatched the others to get the rest of the operation in motion. With only swim trunks, fins, and a mask, they pulled the severely injured passengers from the wreckage and brought them to shore. Two others were sent to commandeer vehicles, and Smitty used one of them to find me. As we reached the main road, another unfamiliar truck coming from the opposite direction screeched to a halt directly in front of ours. It was Norris, another teammate; he’d been sent to pick up every piece of medical equipment we’d brought on this trip.
“I got your bag, Doc,” Norris shouted over the noise of the engine. “I can see that,” I answered. “Just get in, we need to roll!”
Like Smitty, he was clad in nothing but a wet T-shirt, shorts, and sandals, but his appearance wasn’t any indication of his adeptness with trauma. Norris understood the importance of the golden hour. He had taken a couple of rounds during Operation Just Cause nearly six years earlier and wasn’t about to waste time looking for apparel when minutes were worth more than gold. Nor was it any surprise to me that he wanted to help in the treatment of these men. I’ve always found that those who come close to losing their lives have a zest for preserving others’ in situations like these, and Norris was certainly among that group.
Smitty and I jumped into the vehicle just before he gunned it and tore off down the rocky road toward the clinic.
“One guy isn’t too bad, a couple of broken legs and possibly some minor internal injuries, but the pilot has a cracked skull, broken ribs, broken leg.”
“He’s just real f***ed up, Doc,” said Smitty, interrupting Norris.
“Exactly, what he said. Anyway, LT is with them at the local hospital. What a dump that place is,” Norris said.
“Gents, I hate to tell you this, but I don’t have the equipment to treat these types of injuries, and even if I did, there’s a good chance they’re way beyond what I could do for them anyway,” I said, holding on for my life. The “road” was actually a glorified cattle path that ran through a city built on a series of hills, yet Norris was driving it like a NASCAR track.
“We thought about that. Bucky’s getting an aircraft right now,” Norris replied.
“What do you think he’ll find?” Smitty asked. Norris smiled and shrugged.
I could tell from Smitty’s voice that no one knew if he’d find anything or anyone to fly it, so I just kept quiet for the remaining minutes of the drive, hoping the procurement of an aircraft and pilot wouldn’t lead to an international incident.
We arrived at the hospital moments later, and it was just as Norris had described; a primitive three-room concrete building intended as a family practice clinic. LT was on the scene, trying in vain to calm a panicked midwife nurse and assist an overwhelmed doctor unaccustomed to this level of trauma. The clinic was clearly used for treating stomachaches and snotolgy, and his staff had zero experience with blunt trauma.
The aircraft passenger was stable, so I had Norris and the LT immobilize his legs with fracture splints while I did a quick assessment of the pilot’s condition. It was obvious the local doctor wasn’t familiar with treating the severe hemorrhage that generally accompanies scalp lacerations, but he did a great job controlling the bleeding from the pilot’s linear skull fracture just the same. However, the pilot’s airway and breathing were starting to go downhill fast. Blood from a large gash to his nose, cheek, and upper lip was pouring into the back of his throat, affecting his ability to breathe. LT had placed him partially on his side to fac
ilitate drainage and keep his airway open, but there was simply too much blood pooling in his mouth. Eventually we’d need to pack the wounds to prevent further blood loss. After conferring with the doctor we agreed intubation, which is the placement of a flexible plastic tube into his windpipe, would be the only way to adequately maintain his airway while we worked to control his bleeding. I’d been taught endotracheal intubation at the army’s Special Forces Medical Sergeants Course and practiced the technique with the anesthesia department at Portsmouth Naval Hospital, so I wasn’t too concerned about our performing the procedure. The big problem was a puncture in his chest. Although it was only a small hole, it was large enough to allow a slow stream of air to seep into the pleural space that separates the lung from the chest wall with each breath he took. Since there was no way for the air to escape once it entered, the built-up pressure would eventually cause the lungs to collapse upon themselves.
Thankfully, when they pulled him from the water someone cleverly tried to prevent air from entering into this space by securing three sides of a plastic 4" × 4" zip-lock bag over his chest wound. This makeshift device acted as an occlusive dressing and flutter valve, allowing air to escape but not enter. However, as he continued to slip into shock his skin became so cold, clammy, and wet that the rigger’s tape (olive drab military duct tape) no longer stuck to his chest. Even if it had, it wouldn’t have solved the problem. He’d eventually need a chest tube, so as the doctor and I placed the airway I asked LT to pull out the thoracostomy tube and Heimlich chest drain from my bag. Then, as I reached for the suction device, I noticed how grimy the clinic was and decided it might be best to try to relieve the pressure with a needle, at least until we had time to appropriately clean and anesthetize our patient.
“You going to chest tube him, Doc?” LT asked as he pulled the equipment out of the bag and Norris splinted his limbs.
“I might, but I don’t think it’s a good idea right now. This place is filthy, and I don’t want to risk a serious infection getting into his chest cavity or making matters worse.” I looked at the local doctor as I said it, hoping to get some direction, but he just continued to secure the newly intubated tube to the pilot’s good cheek while the nurse began assisting the pilot to breathe with a bag-valve device. I don’t know if the doctor didn’t understand what I was saying or was simply avoiding responsibility. After all, we had no idea who these people were. Regardless, getting oxygen to the tissues was still the critical issue, and we hadn’t yet seen the full effect of the new airway, so when Norris brought the portable O2 unit in from the truck, I had him hook it to the reservoir on the bag-valve device while I prepared for a needle thoracostomy.
The pilot might have needed a chest tube; I just wasn’t sure now was the right time or the place. I’d learned from Dr. Anderson, my physician preceptor during the 18 Delta course, that even the simplest procedures can become complicated in an austere environment, and just because a medic was trained to perform a procedure doesn’t mean he needs to do it. The body is far more resilient than most people believe, and sometimes all it takes is a little bit of help for it to save itself, so before I started barreling on to the next procedure I thought I’d wait and see the effects of the direct flow of oxygen to the lungs.
The increased flow of oxygen provided some relief almost immediately, and by the way he was starting to improve I knew my decision to attempt to decompress the chest with a needle versus a tube was a sound one.
Although I had placed plenty of chest tubes during 18 Delta and assisted with a few on the hospital ward, I’d never done a needle decompression on a live patient, so I asked Norris and LT to listen closely while I inserted the needle. “I’ve been told if done properly we should have a whoosh of air and notice an immediate improvement in the patient’s breathing,” I told them, which was fairly close to what we got. Rarely does anything in medicine prove to be textbook by either definition or result, but in this case it came close enough to give us all some optimism about his outcome.
With his breathing steadily improving, I decided to move him to the runway. I still wasn’t sure how we’d get him to a trauma surgeon, but for sure he wasn’t going to get any better staying here.
As luck would have it, just as we began to package the patient for transport Bucky called over the radio that an aircraft had arrived from God knows where ready to take us to Tegucigalpa. Knowing I’d be traveling with limited supplies, I tried to secure the catheter portion (or plastic covering) of the needle I used to decompress the chest in place. My thought was to allow a continued outlet of pressure to prevent the problem before it occurred. I fabricated a one-way valve from the finger of a surgical glove, just as I’d been taught in school, to release the trapped air and secured it in place before we carried him out the door. Unfortunately, the rough ride to the airport managed to kink the catheter, rendering it useless. So much for utilizing classroom tricks in the field environment. Lesson learned!
The failure of the catheter meant I either needed to place the chest tube or keep an extremely close eye on his breathing during transport, as I might need to release the pressure again and again to keep his lung from collapsing.
As we neared the airport I caught a glimpse of the small, unpressurized two-seater plane idling on the runway, and it became obvious to me that I’d be battling the altitude as well as the patient’s injuries on this flight. Increased elevation associated with a decrease in atmospheric pressure produces a number of medical concerns, most notably hypoxia (a term describing the lack of oxygen in the tissues) and, perhaps more worrisome considering his pneumothorax, the expansion of gas. The physiological aspects of either of these are life-threatening enough, but coupled together they’re perilous.
One thing for sure, we needed to keep this flight as low to the ground as possible. Just going from sea level to the typically low altitude where a plane like that flies can expand trapped air by over 30 percent, which could be fatal.
I knew I needed to place a chest tube and prep the patient for air transport, but time was quickly running out. The plane was on limited fuel, and burning it on the tarmac while I performed a procedure wasn’t an option; we would be taking off as soon as we reached the plane. That meant when the aircraft got to altitude the change in pressure would cause the air remaining between his lungs and chest wall to expand, requiring another decompression and constant monitoring of his airway. I had to make sure I was situated in a position to address these problems but would be unable to do much else.
“SEALs don’t travel alone, swim buddy,” Norris piped up as the truck hit the tarmac and headed toward the plane. “I’m going with you, Doc.” I needed help managing these patients, so someone had to go with me, and among the operators Norris and the LT were the best medical folks in the platoon. LT certainly couldn’t go; they needed his leadership here, and his ability to seamlessly switch from being the boss to assistant as he did in the medical clinic made me realize how fortunate I was to have Dave as my officer.
“Norris, LT will have to make the call, you know that,” I yelled back at him as the wind hit my face. “Hey, he loves me. Face it, Doc, I’m your buddy,” he said with a sarcastic smile and wink. Just as we stopped next to the plane LT got out of the other vehicle and started issuing orders while he assisted with prepping the patients for transport. “Bucky and Smitty, load the copilot into the passenger seat,” he said as I threw my medical bags in the back of the plane. “Norris, you’re going with Doc. You’ll need to wedge yourselves and the pilot in the rear cargo hold. They’ll need your weight in back of the aircraft.” Norris looked at LT with an “I’ll make it work” smile.
We loaded the patient in feet first and toward the rear of the aircraft in a manner that would allow us to account for possible increase of intracranial pressure from mechanical forces from the takeoff and landing. Then Norris jumped in, kneeling between the patient’s legs. Finally I crawled in toward the front of the plane and straddled the patient at his waist. The noise, vibrat
ion, and low-level flying rendered the stethoscope and other monitoring devices nearly useless, and the plane’s cabin was so tight it forced me to spend most of the trip bent at the knees and waist to make sure I’d be able to reach his chest and airway.
The flight was rough but mercifully shorter than I expected. I managed the patient from the waist up, while Norris took care of the lower limbs. He also insisted on goosing me every ten minutes, either to add some levity or piss me off. I never could figure out which, but I suspect it might have been a little bit of both.
We finally made it to the major medical center and turned the patients over to the hospital staff. When the dust settled, Norris and I were left standing in front of the hospital; he was dressed in shorts and T-shirt, and I was in camouflage bottoms and a T-shirt, both of us covered in blood. I thought about how much had happened so quickly and how resourceful everyone had become in an instant. Every man in the platoon contributed to saving those men’s lives, and did so without orders from some command back home. They reacted instantly and performed brilliantly, and I was once again amazed at the unselfish heroes I had the honor to serve with.
This is exactly what the skipper meant when I first stepped aboard a SEAL Team. Other COs reiterated similar guidance, but it all amounted to the same thing. Accomplish the mission!
“Norris, I don’t know if you realize this but I don’t have a wallet, a radio, or a passport on me,” I said.
“Neither do I,” he said with a smile.
“You think they’re sending a car to get us?”
“I hope not, Doc. There’s a casino about ten minutes from here by foot, if my memory serves me, and I think I need to show it to you.”
* * *
Like all other special operations warriors, SEALs are extremely detailed in their planning, but they’re also the most resourceful men I’ve ever known when it comes to executing strategy. My CO had mentioned this when I checked on board my first SEAL Team. He encouraged his men to have an “out of the box” mindset but within the limits of guidance from above. His words really didn’t click at first, but after a series of events similar to the plane crash in Honduras, I realized just how ingenious and dedicated these men could be.
Battle Ready: Memoir of a SEAL Warrior Medic Page 10
