“Dust Off 3, confirmed—green smoke,” the Sergeant said, turning to face the choppers.
They were coming in low and quick, two of them switching from side to side to shake off the dink’s aim. The first Dust Off came in right over the trees and went straight into the ground at over eighty knots. The second suddenly cut out, drifted out over the perimeter, and then, with its engines howling, quickly cut back toward the landing zone. Above the ground fighting, they could hear sledge-hammer blows as the 51’s slammed through it’s thin aluminum skin. The Huey sputtered a moment over them and then skidded heavily into the LZ, collapsing its landing gear. It sat tilted on its broken skid while the pilot, his adolescent face drawn tight and thin, leaned out the window and motioned for them to hurry. He kept his rotors turning while the medics, moving swiftly in the semi-darkness through the great clouds of swirling, choking dust, carried on the wounded and dying. When the Dust Off was loaded, the pilot got it light on its broken skid, lifted it a few feet off the ground, then quickly spun it around. Giving it full power, he got it moving along the ground. At about fifteen feet, it started taking fire—a dark shape moving out across an even darker sky. The troopers on the ground could see the bright greenish-blue tracers bracket it, then lose themselves as if the chopper were some kind of color damper. It kept moving along at the same height until finally out of sight, its engines sputtering, the aircraft, rising suddenly out of the jungle, drifted off to the left and was gone.
A second later, a brilliant flash of yellow-red light broke the darkness behind the NVA positions. Fifteen minutes later the gun-ship arrived from Qui Nhou. Over the rockets and mortars and the intermittent rattling of automatic fire, the troopers could hear the dull thudding of its turbine engine churning toward them through the ever-darkening evening sky. The NVA heard it too and stopped firing. Listening, they raised the sights on their weapons and waited.
Since Vietnam, our helicopters have been continually upgraded and improved. More powerful engines have been designed, and for greater stability in flight, stronger more flexible blades, giving the drooping effect so familiar today on all our military choppers, have replaced the older, less efficient blades. But these improvements in aerodynamics and power have come at a price, the new articulating rotor hubs are incredibly complex pieces of machinery. The intricate hinges and flaps that allow the eight-foot, 1,000 pound blades to rise and fall while they are spinning at 1,800 revolutions per minute are at best difficult to maintain, much less service. Linkages can rapidly weaken, rotors can freeze; the numerous hinges and flaps necessary to allow the blades to twist and turn continually fatigue and wear out and can be damaged by being hit by a round or a piece of shrapnel.
All the complicated physics of straight up flight are still there waiting to be unleashed by a round from an AK 47, an RPG, or the blast from a missile. At eighty knots and up at 8,000 feet that can be exactly the same as dying. Those centrifugal forces that pull at every helicopter have never disappeared and are once again becoming tragically obvious in ever-increasing numbers in the mountains of Afghanistan. That much hasn’t changed.
In fact, that taking over of physics is precisely what happened in 2008 when a Chinook helicopter crashed in the mountains of Afghanistan, killing all eighteen soldiers on board. The official explanation was that the Chinook had been shot down by small arms fire. But at that height and at the distances involved as well as the obvious catastrophic failure within the helicopter, the most likely explanation was a Stinger missile.
The reason for the military stating that it was small-arms fire is obvious. The Taliban are presented as a bunch of unsophisticated tribesmen, not a sophisticated fighting force using modern weapons that put our own troops at a disadvantage. Yet, whatever the official explanation, the most likely reason for the shooting down of our helicopters in the mountains or on the plains of Afghanistan is missiles.
There was an additional startling but not unexpected fact about that Chinook. Every soldier on the chopper who died was over forty years of age. They were all National Guard troops and a number were women, some mothers and even a grandmother. We have sent our National Guard, husbands and wives, grandmothers and grandfathers, to take on the Taliban. We simply do not have, nor have we ever had, enough regular army troops to make this fight and so it is grandparents, neighbors, and friends who are getting shot down and killed.
The truth is that Afghanistan is not a very good helicopter war. Choppers do not work well at over 9,000 feet. Even with the newer more powerful engines, the air is too thin at those heights to give much lift. And in the hot summer weather the rising air is even thinner, offering less lift and less maneuverability.
And the difficult mountainous terrain with the steep canyon walls offers little opportunity for choppers to take evasive action, and so they are easily targeted and easily shot down as they enter or leave the different valleys. In some of the more remote areas, poor lift and poor maneuverability have made med-evacs difficult or simply unavailable. The choppers simply cannot get in to pick up the wounded. That so called “golden hour of survival,” when bleeding can be stopped and blood and fluids given, is gone. Our marines and soldiers have to carry the wounded down off the mountaintops on stretchers. The same mountains where in the Nineteenth Century the British lost a whole army, 20,000 troops, in the Second Anglo-Afghan War. The troops were ambushed and massacred in those passes early in 1842, the wounded killed even as the few survivors tried to carried them down the mountains.
The rest of his patrol was still fighting. A Black Hawk medevac helicopter flew above treetops towards him. Bullets cracked past. The chopper banked this way and that and hovered dangerously before landing nearby. The week before a Black Hawk on a similar med-evac mission had been shot down by a rocket-propelled grenade, and the four members of the crew had been killed. Their escort aircraft buzzed low-elevation circles around the landing area, gunners leaning out. The bullets kept coming.
If all this keeps up, we will be losing choppers in Afghanistan at rates not seen since Vietnam and, like Vietnam, the numbers of casualties will once again begin to approach the numbers of deaths. No longer will the ratio of casualties to deaths be sixteen to one but closer to two to one and three to one. That is not a virtue. A colonel in the Third Infantry Division said much the same thing early in the Iraq war when he muttered under his breath after a particularly bloody day for his troops in the Sunni Triangle, that, “Those in charge of this war have the three qualities virtually guaranteed to cause a disaster: arrogant, incompetent, and in charge.”
7.
THE CHANGING FACE OF MILITARY MEDICINE
Combat injuries have always tried the efforts of physicians and surgeons to keep a step ahead of catastrophe, not only for individuals but for armies. Swords, lances, and arrows could be lethal enough, but the use of gunpowder brought a new dimension of both death and injury to warfare. Medicine has been trying to figure it out, or at least keep ahead of this new lethality, ever since the first spears and arrows, as well as the first cannon and the first blunderbuss were fired at the beginning of the Sixteenth Century. The military barber-surgeons were startled by the extent and severity of gunshot wounds. They were most amazed at the sudden appearance of purulent drainage and the rapid spread of what was call “corruption” throughout the gun-damaged limbs and the massive abdominal and chest injuries.
The idea quickly spread that the corruption was due to the poisoning of these wounds by the gunpowder that had contaminated them and was best treated with hot oils. The treatment was to pour the hot oils into the wounds to clear out the poison. It was the practice of the day but it was very painful, adding to the misery of the patients while further damaging the surviving tissues. But even 600 years ago accepted medical practice trumped basic observation, with surgeons expected to do things, even if doing things amounted to pouring hot oil into open wounds.
It was during the 1537 campaign of Francis I in Piedmont, in the war between the French and the Holy Roman Emp
eror Charles over lands disputed by the King and the Emperor, that Ambroise Paré, a French surgeon, ran out of hot oil and began using only clean bandages and soaps. He quickly noticed that patients treated without the hot oils did better than the patients treated by the standard practice of the day. Paré had the temerity to trust in what he saw rather than what was taught and to advocate his new treatment against the established medical practice.
A keen observer, Paré went on to make other battlefield discoveries that led to what medical historians finally called the era of “rational surgery.” Leaving aside the discovery that simply cleaning a wound was the best possible care of gunshot wounds, Paré’s most memorable service to military medicine, and his most enduring legacy, was the introductory use of ligatures to tie off blood vessels leading to damaged or missing limbs. This new surgical innovation not only led to less (and in many cases what was usually fatal) blood loss, but directly to the more effective and life-saving use of amputations to deal with the ever-increasing numbers of shattered and useless limbs resulting from both the increasing use of the arquebus and ever more effective and efficient cannons.
What was not lost in all this was the fact that Paré was adored by the army as well as esteemed by successive French kings, while at the same time all of his innovations were not only challenged, but opposed by the medical establishment and the faculties of the medical academic centers of Europe. It may be true that in medicine, as in most sciences, the advances proceed more funeral-by-funeral than idea-by-idea.
Amazingly, much of the same antagonism and arguments used against Paré’s innovations are now occurring among physicians and surgeons regarding the best treatments for our newest battlefield injuries—blast injuries to the body and the brain— that so conflicted and confounded the contemporaries of Paré when first faced with gunshot wounds.
Once again, the battlefield has yielded up medical questions whose solutions will eventually affect all of us, whether or not we are deployed and whether or not we ever pick up a weapon or fire a machine gun. The concentrated suffering and deaths on battlefields have always, though at a terrible price, been the workshops for better medical and surgical care.
The Second World War gave us, and the world, plasma, nutritionally effective K-rations, and the wide use of the sulfa and penicillin antibiotics that had been discovered in the late 1930s. The Vietnam War gave us, and the world, methods of rapid evacuations of the wounded and the ability to keep victims alive during that golden hour after an injury when ultimate survival still exists. All this commitment of effort, steadfastness of purpose, and splendid behavior in the face of unbelievable danger, is a quintessential American thing. Nobody really told anyone to do it. It was done just because it was a better and right way to do things and because the need was there. So we did it.
There has always been an implicit sense of practicality to Americans. It was something Alexis de Tocqueville noted in his travels through the United States in the early Nineteenth Century and remains today a part of our national character. Americans will always do what works, whatever the sacrifice.
In World War II, Korea, and Vietnam, it led to a bravery and self-sacrifice that became as commonplace as it was scary. The medics in Vietnam did what they did without complaint, because they understood that minutes did matter and keeping soldiers alive long enough for the choppers to get in did work.
At a time when dissent was becoming a way of life and rebellion was growing into an attitude, the continuing courage and self-denial of the medics was an extraordinary thing to witness. Even within an army being abandoned at the very edge of empire, the medics successfully struggled to keep their own alive.
Looked at objectively, what the medics did in Vietnam was not that sophisticated. No one expected the medics to devise a comprehensive treatment plan or make any detailed medical assessments. They were not expected to do brain surgery or put in an arterial line. They were doing ambulance medicine: pack the wounds, stop the bleeding, give fluids, maintain blood pressures, try to keep the heart going and keep everyone breathing until the med-evac choppers flew in.
Courage, determination, sacrifice, and bravery made it all work, but the lynch pin both emotionally and operationally of U.S. combat medicine in ’Nam was the anticipation of both a rapid and a timely evacuation of the wounded. For the next twenty-five years, that was the universal standard of battlefield medical care. There was no thought of changing procedures, and certainly no effort to change the training of combat medics.
All of that ended on the afternoon of October 3, 1993, when a search-and-rescue team rappelled down from a hovering helicopter into the streets of Mogadishu, Somalia. What should have been no more than a rescue mission protecting the distribution of foodstuffs by the United Nations to refugees of the Somali civil war, had morphed into a search-and-destroy mission to capture or kill one of Somalia’s major warlords.
The “can-do” attitude of the military had merged with the hubris of our government, sending an undermanned unit—with a lack of armor and fire support—to take on the Somalis in their own city, in the worst of all possible combat zones: the narrow streets and alleys of a crowded urban center.
Those U.S. Army Rangers and Special Forces troopers who rope-dropped into Mogadishu quickly found themselves under a siege that would continue uninterrupted for three days, becoming the longest and deadliest firefight involving an American combat unit since the Vietnam War. The battle fought in those narrow streets and alleys changed everything in both the theory and practice of U.S. combat medicine.
The minute-by-minute specifics of the battle were described by the journalist, Mark Bowden, in his Blackhawk Down. During what was really a seventy-two-hour gunfight, eighteen Rangers and Special Forces troopers were killed, two helicopters were shot down—showing once again the dangers of using vulnerable helicopters in the narrowed spaces of an urban landscape—and over a hundred of the 170 U.S. soldiers involved in the battle were wounded. Thousands of Somalis were killed. What had begun as a simple search-and-arrest operation quickly became a desperate fight for survival.
The medics who, along with the Rangers, rappelled down to the first crash site, came under intense fire the moment they hit the ground. Several members of the rescue team were hit while the medics, a number wounded themselves, had to deal with more and more casualties as the battle continued.
True, the original mission had nothing to do with combat but rather with the distribution of humanitarian aid. But there was “mission-creep” and the mission quickly morphed into one of capturing a Somalia warlord—becoming a combat mission that was attempted without tanks, armored personnel carriers, or up-armored Humvees. It was simply forgotten or ignored that during actual combat armored units are usually necessary for long-term survival.
Apparently, neither the Department of Defense nor the Joint Chiefs of Staff thought there would be any prolonged battles, or that tanks and armored personnel carriers would be necessary. The siege of the U.S. troops was lifted only after the American command was able to borrow armored personnel carriers from Pakistani units on the other side of the city.
Through that first afternoon and night of the siege, the entire next day and night, and most of the rest of the next day, the medics had no choice but to care for the increasing numbers of wounded on their own. Additional choppers could not get in to reinforce the surrounded troops and bring in more ammunition and medical supplies, nor could the medics get the casualties out.
In the words of one of the medics, “I gave IV fluids to people who had uncomplicated gunshot wounds in the arms and legs. They were fine, but I wasted time starting IVs and I wasted fluids and then when I had someone with a pretty significant vascular injury, I was out of fluids. What we did was stupid.”
There is a maxim in the military that “you fight the way you train.” What happened in Somalia was not stupid as much as out-of-date. Apparently while no one had been looking, the kind of wars we had begun to fight had changed. Our government a
nd the Pentagon had sent our troops and medics into Somalia having been trained for the past.
In the setting of urban warfare, where choppers are at even greater risk than ground troops, the medical practices that had begun in World War II, and were fine-tuned in Vietnam— maintaining airways, stopping bleeding, giving intravenous fluids to maintain vascular volumes, and blood pressures, all focused on the goal of a rapid and effective medical evacuation—suddenly proved worthless. Within hours of rope-dropping into the streets of Mogadishu, the medics had used up all their IVs, all their plasma, all their tourniquets, and all their morphine, leaving nothing for the wounded they could not get out and nothing for the increasing numbers of new casualties coming in. It was not the training that had lost its effectiveness; it was the battlefield that had changed. Mogadishu was clearly the tipping point, the final wake-up call, forcing the military to abandon the last of its practices from Vietnam: the care of its wounded.
The 1991 Persian Gulf War never really tested the established medical doctrine of stabilization of casualties, followed by rapid chopper evacuations. There was no need. That war was fought out in the open, with half a million troops spread through five heavy divisions and dozens of armored regiments with complete battlefield and air superiority. As then Chairman of the Joint Chiefs of Staff, General Colin Powell, explained at the first press conference after the start of the war, the focus was to be on, “Finding Saddam’s army, fixing them in place and killing them.” The war lasted only 100 hours, with less than 300 deaths and a large percentage of those killed the results of friendly fire. Overwhelming military force proved the effectiveness of what was called the Powell-Weinberger Military Doctrine, named for both Colin Powell and Secretary of Defense Casper Weinberger, that basically stated: no war without putting in place adequate resources to accomplish the reason for going to war.
Broken Bodies, Shattered Minds: A Medical Odyssey From Vietnam to Afghanistan Page 6
