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Sun May 24 12:53:27 BST 2009

I received this from our friend and colleague, Gabriel Castillo.
On this Memorial Day I ask that we all read this piece and walk away with a sense of who John Pryor was.  And as we do, let us remember all who went before J.P, and all who will follow in his footsteps, with the same pain and humility that John felt on a daily basis - because he loved his family, his calling, his colleagues, and his Nation - all of these that he and countless others have given their lives for.

Respectfully,
Ronald Gross, COL MC USAR (Ret)

-----Original Message-----
From: Gabriel Castillo [mailto:castill at mail.usf.edu]
Sent: Friday, May 22, 2009 10:32 PM
To: Gross, Ronald
Subject: [Fwd: [CCM-L] A War Surgeon's Perspective On Memorial Day]

Dr. Gross:
This was posted to CCM-L, but as I know you have served (and if I
remember correctly, may have known the author), I thought you might be
interested in this.

On this Memorial Day, I say thank you for your service.

Hope you are well.

-------- Original Message --------
Subject:        [CCM-L] A War Surgeon's Perspective On Memorial Day
Date:   Fri, 22 May 2009 17:28:28 EDT
From:   McEvoyMike at aol.com
Reply-To:       Discussion of Critical Care Medicine <ccm-l at ccm-l.org>
To:     ccm-l at ccm-l.org

/This essay was written by our dear friend and colleague Dr. John P.
Pryor. He was a trauma surgeon who refused to be idle when so many
wounded Americans and Iraqis could be helped by his skills. He enlisted
in the Army reserve and wrote this article after completing his first
tour in Iraq./

   "In other fighting, one marine was killed in the Al Anbar providence
after a humvee he was riding in hit an IED." That was what I read in the
AP news piece. It was one line of several paragraphs that summed up the
days casualties in Iraq during another day of the war that has gone on
for three years now. These reports are so common, most people do not
even read them, or listen to the 30 second blurb that follows, "Another
day of violence in Iraq where..." on the evening news. For us, the reality
is much different, a horrific drama that is played out in the field, in
forward surgery tents, and combat support hospitals every single day.

    Today the warning came over the radio, "urgent litter coming in by
ground" I immediately respond to the ETR where the buzz is usually in
full swing.   "IED, Marines" is all the ETR nurse said as I walked in.
Damn, I thought. One day left - all I asked God for was no more marines
with one-day left on my tour.  The hospital staff went into full swing -
these people are at the end of a yearlong deployment here, they are
experienced, hardened, and cool under pressure. The activity was
programmed and efficient.  I took my position at the head of bed number
one, put my head down and waited.

    Within a few minutes the litter team burst into the ETR with the
first patient. I could see his arms dangling off the stretcher with bone
exposed, and I immediately knew that this was going to be a bad one.
When the litter was pulled up aside the bed, I saw the full extent of
what I was up against. Driver, I thought to myself. The drivers always
seem to get the full force of the IED. There is a pungent smell of
gasoline and burned flesh. My first order of business was to remove the
IBA before we move him over; to do this we have to sit him up in order
to pull the arms through the IBA sleeves. When we did, his arms, broken
in several places on each side, flopped around like a puppet. As we
moved him over, I tried to ignore the massive tissue destruction of his
legs, and focus on potential life threatening chest and abdomen. He was
moaning, actually a good sign, the brain was still getting blood flow.
Anesthesia moved to intubate him, as the emergency medicine physician
started the primary survey. Nurses started lines, lab was there to bring
blood, medics held pressure on bleeding wounds, all in a dance that has
been repeated so many times before.

    The other patients began to file in, eventually filling the ETR. One
soldier in a bed next to ours was calling out to my patient, ignoring
his own gaping wounds "Your going be okay man, hang in there." I began
to focus on the problem and my plan. Both legs had massive tissue
destruction. The left thigh was torn apart and burned with a tourniquet
at the groin. The right leg was mangled below the knee with a tourniquet
above that. There was a neck wound that wasn't bleeding and shrapnel to
the face.  Both arms had multiple levels of open fractures.  The pulse
was weak and the blood pressure was barely readable. We hung blood
immediately. The chest x-ray did not show any thoracic injury. We shot
an abdominal film to look for shrapnel that may have gone into the belly
- none.  As we moved to the OR the hospital commander stopped me to ask
if he was going to make it.  I told him that I was worried that once we
start to resuscitate him, the bleeding would become even worse, and I
didn't know if he would make it. His head dropped as he walked back to
the chaos of the ETR.

    In the operating room we started by getting control of the external
bleeding of the legs.  There was blood coming from everywhere; bright
red arterial blood, dark blue venous blood, and areas where the two
swirled together in pools between the flesh. Two orthopedic surgeons and
I worked frantically to get control of the bleeding, which as predicted,
became worse as we started to resuscitate him. Anesthesia was struggling
to keep a blood pressure, infusing unit after unit of packed red blood
cells, and plasma. I was having trouble finding the source of some
bleeding high on the thigh, and I was going deeper and deeper into the
groin to track down the source. Suddenly my hand broke into a space, and
a gush of blood came out. I realized that I was in the retroperitoneal
space and the bleeding was coming from here. This was the worse case
scenario. Bleeding from this location is the toughest area in the body
to control.  The packing did nothing; blood flowed from the wound in a
constant stream. We opened the abdominal cavity and clamped the arteries
that feed the pelvis, but it didn't help. Bleeding from this area is
almost always from large veins that cannot be controlled with sutures or
arterial control. We packed as tight as we could, and then put a sheet
around the pelvis to pull the bones together in an attempt to tamponade
the bleeding, but it was not enough. His heart went into a lethal
arrhythmia. We shocked him, and pumped epinephrine into his blood
stream. After a few minutes, his heart stopped for the last time.

    The marine was dead.

    There was an immediate silence in the operating room as soon as I
announced the time of death. Most of the staff had tears running down
their faces; this was a long year for them with so many of these kids
dying in this room. I could not physically move for several minutes. I
looked at this young kid, a child, and I apologized to him for not being
skillful enough to save him. As a trauma surgeon every death I have is
painful, every one takes a little out of me. Loosing these kids here in
Iraq rips a hole through my soul so large that it hard for me to
continue breathing.  After a few minutes, I collected myself and began
to direct the care for his final journey home. We closed what we could
of the wounds, and wrapped the ones we couldn't get together. We washed
all of the dirt and oil off his skin, combed his hair and washed his
face.  He was transferred to a litter and brought to a private enclosed
room where we placed him inside a heavy black body bag. The body was
draped with the American flag and a guard was posted. The chaplain
gathered some of the providers and we said prayers over the body.

    There was, and always is, a palpable grief that comes over the
entire staff when we loose an American solider. Everyone is affected,
and everyone deals with it in a different way.  For me, this is not an
objective depressing thing to be a part of; it is very, very personal. I
was the surgeon who couldn't save him. For me the grief is intolerable.
I become the focus of the morning for the staff- people come and give me
a hug. They ask me if I am okay, they pray for me. I appreciate it and
hate it at the same time. Often my misery turns into anger.  Sometimes I
become angry with God for allowing this to happen. I just want the whole
thing to be over, and all of these kids to go home to their families and
live long lives. I have seen so many soldiers and marines die here; I
just want it all to end.

    As I made my way out of the hospital, I saw the marine unit gathered
together. Two humvees where parked, and weapons were leaning against the
vehicle. I notice this immediately because a marine is never without his
weapon, they would never be stacked like that. These were the weapons of
all the marines injured in the latest attack. I spoke with the first
sergeant, the father figure of a marine unit. I know him well, we have
lost several of his marines and had many more injured and treated here.
We arrange for his buddies to come in and say goodbye, something that I
cannot even bear to watch. After a time of reflection, the unit gathers
the equipment and prepares to go out again that night.  This is some of
the raw courage that I talk about, the ability to loose a friend in
battle and go right back into the fight. I love every single one of them.

    The body was eventually taken to the LZ and loaded into a helicopter
with some of his buddies as escorts. He is taken to BIAP where mortuary
affairs prepared the body for transport home. A friend of mine was at
BIAP when the body was loaded onto the   C-130. All activity on the
tarmac stops when the casket is brought onto the airstrip. All personnel
in the area stop what they are doing and attend a 45-minute ceremony on
the airstrip. They tell me that this happens twice to three times a day,
but everyone takes time out to attend the ceremonies. Soldiers
manifested in these flights are going home or on R&R, and as anxious
they are to leave, they all take the time to honor the marine. An honor
guard then brings the flag draped casket onto the aircraft with full
military honors. The casket is situated in the center of the aircraft
with nothing placed on either side or directly in front or back.
Personnel then enter the aircraft and accompany the marine to Kuwait. In
Kuwait the casket is removed first, again with a full honor guard. The
marine will be brought to Dover Air Force Base in Delaware, and then
eventually home and to his final resting place.

    If I could say something to this Marine's parents it would be this:
I am so sorry that you have lost your son. We, above everyone else, know
that he was a true American hero. I want you to know that the Marines,
medics, doctors, nurses and of the 344th CSH did everything possible to
save him. I want you to know that I personally did everything that I
could, and that I am sorry that it wasn't enough. I want you to know
that although we never knew your son, we loved him.  I want you to know
that although he lost his life, we preserved his dignity after death. We
held his hand when he died and prayed for his soul and for God to give
you strength.  I want you to know that he had great friends who cared
deeply for him and that they were also here when he died. He was never
alone for his journey back to you. I also want you to know that I will
never forget your son, and that I will pray for him and all of the
children lost in this war.

        IED - improvised explosive device

        ETR - emergency treatment room

        LZ - landing zone

        BIAP - Baghdad international airport

        IBA - individual body armor

        R&R - rest and relaxation

        CSH - combat support hospital

John P. Pryor, MD was a trauma surgeon at the hospital of the University
of Pennsylvania and a Major in the United States Army Reserve Medical
Corps. He was the general/trauma surgeon for the 344th Combat Support
Hospital in Abu Ghraib, Iraq.  John was killed on Christmas day 2008
during his second tour in Iraq.

Posted by Mike McEvoy

Albany Medical College

Division of Cardiothoracic Surgery

Albany, New York, USA

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