On the side of the road in Iraq

IT'S 3 a.m., and in our Humvee, Sgt. 1st Class Smith is shouting to the gunner to fire: "Get his ass, gunner! Get his ass!" Hot steel linkages and spent brass cartridges from the belt-fed weapon are cascading down into the truck. Many of them fall on me. For some reason, I find myself oddly preoccupied, in the middle of a firefight, with sweeping them into a neat little pile as angry bullets bounce off the Humvee's armor.

We've stopped a convoy of pickup trucks, farmers moving their food to market, and they have fired on us because they think we're stealing their food. Naturally, we do what Americans do best--shoot back with superior firepower.

The noise is deafening. All four of our Humvees are opening fire on the pickup trucks, targeting the tires and engines. Sgt. 1st Class Smith is the platoon sergeant, known among his men as "Gunny," second-in-charge of this convoy, and when he says to move, there is no question about it. He and I dismount, along with Pfc. Devon Listerman, and together, we creep up on one of the damaged vehicles, under cover of the Humvee, and I tell Sgt. 1st Class Smith that the driver is no longer in the vehicle.

There's a strange smell, something sour and metallic that sits on the nose and the tongue. We come around the other side and realize the driver is lying bleeding on the ground. I get Sgt. Joseph Bautista to cover me, and I head in. I am the only medic within 20 miles. The smell I noticed before is now overpowering, and I realize it's blood. For the rest of my life, I will never forget that smell.

I do a quick visual assessment as I get ready. This man has been hit by three U.S. 7.62-mm machine gun rounds, one of which went through his driver-side window, and two of which hit the chassis of the truck and expanded to football-sized clouds of murderous shrapnel.

His right leg is opened up at the femur, and the space between his hip and his knee is just so much hamburger. From the size of the pool of blood he's lying in, he's already well on his way to stage-three shock. I drop a knee into his high femoral, cutting off blood flow to his leg while I get out my gloves and a tourniquet.

The gloves don't work, and after a few moments of struggling, they rip and fall apart. I work on him anyway.

I throw a tourniquet on his leg and clamp it down, and then move up to his head. He's talking, a vague guttural utterance of Arabic that I can tell is hard for him. I try to converse with him, asking him where he's from, and who he thinks will make the playoffs this year, if for no other reason than to assess his level of consciousness and to keep my head in the game, but he doesn't understand me at all.

All he'll tell me is that he is tired, and that he thinks he's dying. I notice he's holding a hand over his chest, which is covered with blood. I try to move it, but he won't let me until I tell him I'm a doctor, having no better word for "medic."

Underneath, his hand is a fist-sized hole, leaking bright red blood and making a loud gurgling noise. A sucking chest wound. I log roll him and check for an exit wound, but don't find one. I apply pressure with my hand, clean off the surrounding area and seal the wound.

I send Spc. Nathan Maston to tell the platoon leader that this patient will die without immediate medical evacuation, and to call for a helicopter and advise me of any further casualties. Word comes back to me that there are two dead and one that ran away wounded.

I recheck his pulses, and I don't get a radial one. That means his systolic blood pressure has dropped to a level so low, his body can no longer circulate blood. With Sgt. Bautista assisting me, I prepare to give him a Hextend IV, which will spike his blood pressure and allow his blood to circulate to his limbs at the risk of blowing any clots that have formed.

THE QUICK Reaction Force (QRF) arrives, and with them, another medic from our battalion named Soto. I am elated to see him. As I begin inserting the needle in my patient's arm, I look him over quickly and notice his tourniquet has slipped its cradle--probably still effective but not stable--so I ask Soto to retighten it. He balks, wanting gloves.

Listerman pushes past him and tightens it, soaking his $80 gloves in blood. Once I've got the IV flowing, I direct Soto to dress the leg wounds. In addition to the large wound on the right leg, our patient has a large chunk of flesh missing on his left calf, showing bone, but not life-threatening. I hand Soto Kerlix and Israeli dressings, and together, we get the leg wounds taken care of.

The IV is finished, so I disconnect the bag and insert a saline lock into the catheter to maintain venous access while I ask about the status on the medevac. I try to talk to the patient again, and he's having difficulty breathing.

I check his oxygen saturation, and it's at 82 percent. Time for drastic measures. As I prepare to perform a needle decompression, two Apache attack helicopters roar overhead at barely treetop height, raining spent 30-mm cannon shells on the pavement all around us.

The Apaches are following a truck that has escaped and are punishing it with cannon shells and Hellfire missiles. They send a missile through the passenger door, and it explodes inside. They turn their lethal attention to a nearby house. Explosions rock the night as the house caves in. They kill four people in this encounter and injure another who I will treat later.

Meanwhile, 800 meters south, I insert a chest dart into my patient's right lung to perform a needle decompression, withdraw the needle, hear a quick rush of air and cover the catheter with an Aschermann's. I take Listerman's tape from him and cover the patient's chest in a gigantic mass of tape, just to make sure none of my work comes off.

Even still, with all the blood, there's a leak somewhere. I can hear his chest gurgling. So I apply manual pressure and give the order to bag. Soto assembles the Ambu BVM from my aid bag, and he and Listerman give him forced ventilations while I call off timing and continue to work on the chest wound.

The patient doesn't understand that we're trying to breathe for him, and he struggles for air. We don't know the words to explain it to him, so we keep at it, make exaggerated deep breathing gestures and hope he understands. Eventually he does, and he calms down.

Across the patient, the three of us look at each other, and the chatter begins. Soto complains that this guy didn't deserve to get shot. Listerman looks sadly at his $80 gloves. I realize for the first time that I'm covered in blood.

We get the word--medevac is three minutes out. With that news, we perform final checks and get ready to package him for transport. Listerman's going with the patient to secure him, so I make sure he knows everything we've done so he can brief the flight surgeon.

The Apaches sweep by to make sure the landing area is secure, and then the Blackhawk touches down on the northbound lane of Tampa. We're lying on top of our patient, shielding him as best we can from the flying dust and sand. As soon as it's on the ground and the rotors stop blasting us, we move in to the helicopter.

WHEN IT'S away, it's painfully quiet. I walk to the Humvee, with so little energy left that I'm dragging my aid bag behind me, and I sit inside. I'm more or less in a state of shock after all my adrenaline bled away. Soto notices my odd behavior and chats with me for a few minutes until I am functioning again.

I get out, look sadly at the ruins of my aid bag, and try feebly to put it back together. I start to take mental notes on what I'll need to replace, which is a lot. I look around and realize that when our call went out for QRF assistance, ours wasn't the only force that responded. 1/37 Infantry sent a few tanks up to help us, and nothing says "roadblock" like an Abrams sitting in the middle of the road.

Silence reigns, and we mop up. I walk alone, slowly, around the area where I treated my first patient. His blood is all over the road, a silent testament to something I'm not sure I understand. His truck is still there, and I notice for the first time that it's carrying grapes. Several soldiers are taking handfuls of the grapes and eating them.

I am so filled with rage at their disrespect that I want to shoot them. I examine the truck, touching the jagged holes in the metal and staring silently at the bloody handprint on the doorframe. I see the splashes of blood on the embroidered throw rug that covers the seat and imagine how the driver must have felt, suddenly realizing that he's bleeding horribly, and he's alone.

I envision him, there in the truck, trying desperately to stop the bleeding and having his life flash before his eyes, wondering if he would ever see his family again. I see a large chunk of leg tissue on the passenger side seat and the handkerchief he must have used before he realized he wasn't going to be okay and dragged himself out with every expectation of dying there on the road.

Later that day, Listerman carries word back from the OR that if it hadn't been for me, Aziz would have died. They said he'll make an excellent recovery. They removed a chunk of his lung, and he'll never walk again without assistance. But I saved my first life. And somehow, that doesn't make me feel any better.

In the aftermath, I am roundly criticized by everyone from the squad- to the battalion-level echelons of my chain of command because I worked on the casualty without gloves. I defended this action by standing up for the value of my patient's life, but my objections were brushed aside. The life of an Iraqi citizen is openly deemed less important than that of an American soldier.

Later, an in-depth investigation reveals that the men we shot were all farmers who thought we were trying to steal the crops they were moving. A misunderstanding. That's all it was. I wonder if that matters to Aziz while he walks around with a cane for the rest of his life.

I STRUGGLED for a long time with the implications of what happened that morning. I was haunted by the face of the man I saved, wondering for months if I really did all I could for him. I see the faces of the dead, and for the first week, I cannot eat steak or use shaving gel because they smell like blood to me.

For almost six months after I knelt in a farmer's blood next to his truck full of grapes, I would fly into a panicked state any time I smelled the scent of grapes nearby. I lost sleep and felt I was a danger to others.

On one occasion, I attempted suicide by chambering a round into my rifle, inserting the barrel into my mouth, and flipping the selector switch to burst. The only reason my squad leader found me in time was that I was contemplating whether the rifle would get off all three rounds before I lost muscular control, whether one round would be enough, and whether I would have time to feel the bullet enter my brain.

None of this meant anything to my chain of command or to military doctors. I saw numerous psychologists and "combat stress" personnel, all of whom accused me of lying to get out of work or to receive sympathy and ordered me returned to work. I was ridiculed by my peers and my supervisors for "being crazy," and I was assigned babysitters at all times. I could not go anywhere alone, all the while being hounded by my own humiliation instead of being given real help.

After a while, I realized that the military medical system did not want to help me, and I would never receive any sort of assistance from them. I stopped trying, bottling up my rage, fear, frustration and psychoses so I could be a face in the crowd.

I returned home to find the cork working its way out of the bottle. I had panic attacks, outbreaks of blinding anger, and a battle with alcoholism and addiction to Percocet. I overcame these things through personal struggle.

Neither the Army nor any other government agency ever once lifted a finger to try to help me, placing the blame either on me or "post-deployment readjustment." They said it would go away in a few months and offered me no advice or treatment for the intervening time. They were wrong.

One of our newest soldiers, a headstrong young private named Destor, was operating a .50-caliber machine gun during the firefight and had the dubious distinction of literally removing an Iraqi's leg from his body from 100 yards away. At the time, Destor crowed his satisfaction, but several weeks later, during his scheduled R&R leave at home, he refused to return to Iraq.

As he was preparing to contact news agencies with his story, we were getting a stern lecture in Iraq condemning Destor's actions, and that if any of us got it into our head to play silly little-boy games like Destor was doing, we would regret it. The explicit statement was made that anyone refusing to return to war, regardless of what he had seen in the course of it, was not a real man.

Destor eventually returned, but I could never see again in his eyes the youthful exuberance he had once brought to the unit. There was something missing in him, something he had left behind on the side of the road that day. And I was saddened to see it go.