US medics brave fire to save lives in Afghanistan

On this holiday weekend, while all at home worry about traffic, bad weather, gas prices, the 2012 elections, etc., a few brave medics look after those at "The Tip Of The Spear "

The MEDIC is the one the Warriors count on and they respond to the tough places where men & women in uniform need help as minutes mean saved lives...and because of their actions, there is one less family that needs to hear bad news today.



US medics brave fire to save lives in Afghan war
AP By KEVIN FRAYER, Associated Press

FORWARD OPERATING BASE EDINBURGH, Afghanistan – U.S. Army medic Sgt. Jaime Adame hauled open the door and lunged from the helicopter into a cloud of dirt and confusion.

He could hear bursts of incoming fire above the thumping rotor blades. Somewhere in the billowing red smoke that marked the landing zone and the choking dust whipped up by the medevac chopper was a cluster of Marines pinned down by heavy fire, and one of them was bleeding badly.

The problem for Adame was that he did not know where.

Adame had dropped into "hot L-Zs" before but this one was especially thick with commotion. Every second of indecision mattered, so he just ran, knowing any direction was dangerous. Only then did the cloud clear enough to bring into view the blurred outline of several Marines' boots peeking out of the vehicle they were taking cover under.

"The fear I have never lost," said Adame, who's from Los Angeles. "It's absolutely risky ... and it will definitely get a lot more dangerous."

With the spring fighting season under way in Helmand province in Afghanistan's volatile south, the medics, crew chiefs and pilots with the U.S. Army's "Dustoff" medevac unit expect a rising number of casualties. Coalition troops are seeing stepped-up attacks, the use of complex weapons systems like multiple-grenade launchers and the continuing plague of improvised explosive devices on the battlefield.

By the war's blunt calculation, the worsening hostilities on the ground mean more medevac flights to ferry the wounded. For an emboldened insurgency, that equals opportunity. Increasingly they are targeting the medevac choppers as they swoop in for a rescue.

"It is kinda the wild, wild West," said pilot Lt. Terry Hill of Kellyville, Oklahoma, the senior officer at Forward Operating Base Edi. "In the back of your mind as a pilot you know that you will most likely be shot at or hit."

The Black Hawk helicopters Hill and other medevac pilots fly are unarmed, though they are always accompanied by at least one other aircraft that is. The "Dustoff" helicopters are distinguished with the emblem of the Red Cross and under international law are supposed to be off-limits to enemy fire.

Afghanistan's insurgents make no distinction.

On one recent medevac run, as the helicopter navigated a firefight to set down in a small courtyard, a rocket-propelled grenade fired from a compound exploded in the air just behind the helicopter. The pilot quickly aborted the approach. Ground units called in air support, and attack helicopters riddled insurgent positions with heavy caliber machine gun fire.

Within minutes, the medevac chopper made a second attempt at landing to rescue a critically wounded Marine who had sustained a gunshot wound near his spine.

On another mission, insurgents fired several rounds from an assault rifle into the belly of the helicopter and its rotor blades.

"They seem to want us to get killed, which is surprising because we rescue everybody, including them.," said Chief Warrant Officer Michael Otto of Irvine, California.

The medevac doesn't discriminate between the war's wounded. Beyond coalition and Afghan soldiers, helicopters and medics also pick up injured Afghans, especially children. They often act as an ambulance service ferrying ill and injured Afghans from remote villages to coalition medical facilities. Enemy fighters are evacuated from the battlefield and treated as well.

With the sound of explosions shaking the air, Adame raced to find the wounded Marine. His comrades carried him on a stretcher from the dusty chaos to the chopper and Adame and his crew chief swiftly set to work.

Cpl. Andrew Smith was suffering a life-threatening arterial bleed from a shrapnel wound. His boots were sliced from his feet with a seat belt cutter. He was losing blood at an alarming rate. The medics focused only on stabilizing the young corporal; there was no time to think about the danger they had just faced.

"If one of those grenades hit us as we're taking off or coming in to land that's close to 17,000 pounds of steel, and hydraulic fluid, and flammables," Adame said. "Falling out of the sky in one of those things isn't going to be pretty no matter how you look at it."

Smith remarkably survived and is recovering at a military hospital in Maryland.

It's those successes that give the "Dustoff" crews motivation to plunge back onto the battlefield.

"It's all about saving a human life," said Chief Warrant Officer Joe Rogers of Russellville, Kentucky, the pilot of the helicopter that was hit by assault rifle fire. "And it's definitely worth the risk."

A military hospital's all-encompassing mission...Saving lives, no matter whose

No other way to say it....the Medical Professionals at KAF and across Afghanistan make a big difference for all over there.....God Bless them all.

A military hospital's all-encompassing mission

By David Brown
Washington Post Staff Writer
Sunday, December 26, 2010

KANDAHAR AIRFIELD, AFGHANISTAN - Most of the time, this war-theater hospital crackles with danger and expertise, its staff members working to keep alive people who would be dead if they ended up almost anywhere else in the world.

But some of the time, often in the morning, it's quiet and almost empty, except for a few recuperating Afghans stoically watched over by family members and, today, a young girl in a pink robe exploring the corridor outside her room in a wheelchair.

The hospital, which opened in May and is owned by NATO, is an odd mix of urgency and relaxation. It features patients whose stays inside its $40 million walls are both shorter and longer than any in contemporary U.S. hospitals.

American soldiers critically injured on the battlefield spend only a day or two here, many unconscious and on ventilators, before being sent to Bagram air base, then to a hospital in Germany and on to the United States.

At the other end of the continuum are the Afghans who make up about half the patients.

They also come aboard medevac helicopters. They get the same immediate treatment as U.S. soldiers. Then they stay, often for weeks, until they are well enough to be transferred to a nearby Afghan hospital or discharged.

Some are Afghan soldiers or members of the national police. Many, however, are civilians or Taliban insurgents. It's often difficult to tell the latter two apart, and to the workers at the hospital, which is run by the U.S. Navy, it's largely irrelevant.

Pediatricians in war zone

About 15 percent of the patients are children. Most are here because of the consequences of war. But there's also a steady trickle of patients who have cerebral malaria, burns from kitchen fires, car accidents, snake bites and obstetrical calamities or have fallen from roofs, where families sleep in hot weather.

"Those are probably the hardest cases, when the kids come in," said Cmdr. Eric Peterson, 40, an emergency nurse. "I don't think people expect that when they come over here."

The Navy did expect it, and planned for it.

"This is the first time the Navy has sent a pediatrician as part of a wartime role," said Capt. Jon Woods, 45, a pediatric intensive care physician. "It is a recognized part of our mission."

'New paradigm' in care

Pediatrics isn't the only addition to what is considered possible and necessary in war-zone medicine. The hospital also has an interventional radiologist, who can snake catheters into bleeding sites that surgeons cannot reach. It has a 64-slice CAT scanner that would be the envy of any radiology department in the United States. It has a neurosurgeon.

"This is a new paradigm, having a neurosurgeon in-theater. But I frankly can't imagine not having this capability," said Cmdr. Steven Cobery, 44, a neurosurgeon who did 120 operations between April and mid-October.

One of the consequences is that some Afghans receive care here and at a sister hospital at Bagram that would be unimaginable elsewhere in Afghanistan. In some cases, it would be rare in the United States.

For example, Woods recently flew to a forward operating base where a newborn had been brought after a difficult delivery. The baby, four hours old, had persistent pulmonary hypertension and meconium aspiration - both life-threatening lung conditions. On the flight back, Woods breathed for the child with a squeeze bag and an endotracheal tube and gave her drugs to keep her out of shock. It was ICU care in a helicopter, delivered by a pediatric intensivist.

The child stayed in the hospital for six days, recovered and went home. The alternative destination - if she had survived to get there - would have been Mirwais hospital in Kandahar City, which has a single ventilator for infants.

Of course, many of the Afghan patients would not need heroic medical treatment if not for the U.S.-led war, now in its ninth year. And much of the time the circumstances of a civilian's wounding are unknown or ambiguous.

To accommodate long-staying patients, the workers at the Kandahar hospital have set aside a room for praying. Relatives are permitted to spend the night in the patient's room. Staff members often get food for the families from the dining hall (and hold it until after sunset during the Muslim holy month of Ramadan). When a patient dies, the face is turned toward Mecca, the big toes are tied together with cloth as prescribed by Islamic law, and someone is called to say the proper prayers.

"We try to be as culturally sensitive as we can, given the mission," said Lt. Cmdr. Timothy Broderick, a nurse who heads the intermediate care ward.

Saving lives, no matter whose

Although the hospital is important to the "hearts and minds" campaign, the military realizes the openness of the doors could compromise the main mission of saving troops' lives. Consequently, if a certain number of beds are filled, the hospital will not take civilians unless they have been injured in combat. Except for the exceptions.

"We always take neurosurgical cases," said Capt. Michael D. McCarten, 58, the commanding officer. "If there is a potential for a life-saving intervention, we'll take them."

In the spring, an Afghan man arrived with his 14-year-old son, who had fallen from a tree. The man had taken the boy to one forward operating base, been turned away and taken him to another. ("Just like in the United States, parents here are very persistent," Woods said as an aside, as Cobery, the neurosurgeon, told the story.)

The boy had a skull fracture. Cobery removed a section of the skull to decompress the swollen brain. He put the skull fragment under the skin of the boy's abdomen, where it would survive until the brain had fully healed. Three months later, the father returned with the child. Cobery put the piece of skull back where it came from. Case closed.

The care and solicitousness extends to Taliban fighters, as well. The only difference is that they are under armed guard until they are handed over to other authorities.

Cobery said, "Not one time has it come into my medical decision-making not to do something for someone because he's a bad guy. To someone, he's a good guy."

Several months ago, the hospital treated a man in his 20s, reportedly a Taliban fighter, who had had one leg amputated very close to the hip joint. The stump had become infected, and the infection had begun invading his pelvic cavity, an ominous development. The doctors told him that they were not sure they could save him.

"He started to cry," Woods recalled. "He said he just wanted to see his wife and kids again."

The orthopedic surgeons mixed bone cement with two antibiotics and fashioned the concoction into small beads. "In the States, this stuff is manufactured. We were our own manufacturing plant here," Woods said. The doctors packed the wound and the pelvic outlet with the beads, then put the patient on extra-high-dose intravenous antibiotics.

He survived.

"God was truly watching," - Flight Medics make the difference for our Marines, Soldiers and all in need on the battlefield

A U.S. medevac helicopter arrives to evacuate Spc. Jeremy Kuehl, 24 of Altoona, Iowa, and from the 1-320th Alpha Battery, 2nd Brigade of the 101st Airborne Division, who was seriously wounded when he stepped on an improvised mine near Command Outpost Nolen, in the volatile Arghandab Valley, Kandahar, Afghanistan, Friday, July 30, 2010. .

No other way to put it....Medivac teams are the difference between life and death for our troops, especially when they need to get to a CSH (Combat Surgical Hospital)

God Bless them as they fly into the hot zones and put their own lives at risk so that others may live.

Medevac team saves lives in Afghanistan
By BRENNAN LINSLEY The Associated Press
lacrossetribune.com Posted: Sunday, December 5, 2010 12:01 am

EDITOR'S NOTE: Associated Press photographer Brennan Linsley recently spent a week embedded with Charlie Company, from the U.S. Army's Dustoff Task Force Shadow, of the 101st Combat Aviation Brigade. He describes the work of Army medevac teams in the war zone of southern Afghanistan.

HELMAND PROVINCE, Afghanistan — It was pushing dusk when the call came: "One Category Alpha." The voice crackled over the radio, urgent but matter-of-fact. Translation: One man badly wounded, medical care needed right away.

The medical evacuation team - a pilot, co-pilot, crew chief, flight medic and, on this day, an AP photographer - scrambled into the Black Hawk helicopter. In a few minutes we were zigzagging at more than 150 mph, the fields and mud compounds blurring past like a movie in fast forward. The crew chief held up two fingers: Distance from landing zone, two minutes.

As darkness fell, the Marines ignited a colored smoke grenade to mark the landing zone. The Black Hawk touched down only to be fired on by insurgents hiding nearby, despite the clear red cross marked on its nose and sides. It rose again and circled.

When it landed the second time, the crew chief threw open the side door to a storm of dust. Within seconds the Marines hauled aboard their comrade, who had a gunshot wound to the head.

The helicopter flew off, low and fast under fire. The medic went straight to work. But the wound was too severe.

The Marine died. Lance Cpl. Ross S. Carver of Rocky Point, N.C., was 21 years old.

------

At least 1,310 U.S. soldiers and Marines have died since the Afghan war started, and at least 8,530 have been wounded. But the toll would be even higher if not for the medevac teams that swoop in to rescue the wounded and deliver them to relative safety.

Medevac teams work at about 20 locations in Afghanistan, where they serve as a net of sorts for soldiers and Marines caught in a high-wire act every day. The medics save everybody - U.S. soldiers and Marines, Afghan civilians, even Taliban fighters. The Helmand-based medevac team I traveled with - Charlie Company, from the 6th Battalion and 101st Aviation Regiment, known as Shadow Dustoff - is among the busiest in Afghanistan. Since the team arrived this spring, they have gone on more than 2,000 missions and have evacuated more than 2,500 patients.

In just five days, the team I was with picked up two Marines who died and five more who were wounded, as well as several wounded Afghan soldiers and civilians. The crews described it as a slow week.

The Army considers medevac crews to be among the most prone to post-traumatic stress because they see so much pain and carnage. Their job is dangerous: The medic and crew chief must often walk out to stunned or grieving soldiers over uncleared ground and take quick control. Crew members say it messes with their heads when soldiers are maimed.

"Sometimes we feel guilty. But it's just not your fault," says Staff Sgt. Audrey Ramos, 28, a flight medic with a Shadow Dustoff team. "You have to let it go. If you harbor it, if you carry it with you to the next mission, then you won't be able to give everything you need to give to the next soldier who has a chance to survive."

Ramos doesn't think about the politics of those she picks up - a life is a life. She says the job is the closest she can get to being on the front line: Injuries are intense, adrenaline runs high and soldiers look at you and the aircraft as a beacon of hope.

"I think that they see us as saviors," says Ramos. "It's humbling. I like to be a part of something bigger than me."

The vast majority of troops wounded in Afghanistan survive, thanks to the medevac teams. But that doesn't make it any easier to see somebody die.

When a soldier or Marine dies, it makes the war horribly real, very suddenly. As I was photographing the dying man half my age, I thought about all the things he would never see or do. I wondered about whether he had children back home. (He did, a son.)

But the words of soldiers and Marines I've patrolled on the ground with echoed through my head, always some variation of this: "The people back home don't have (any) idea what we're going through here. You can show them.

"You should've been here last week. My friend was blown up right in front of me."

------

The day before, a bomb had indeed exploded near a young Marine, Pfc. Justin Turner, 20, of Flower Mound, Texas.

Turner, who had been on a foot patrol, was scheduled to be promoted that day to lance corporal. The improvised explosive device, apparently detonated by remote control, spared his foot but left behind a shrapnel wound.

At first Turner didn't even know he was hit. His ears were ringing loudly, and there was a huge dust cloud. He tried to walk, but his foot felt as though it was broken.

That's when he noticed that his sock felt wet and blood was coming from his right boot. He was more angry than scared.

Staff Sgt. Richard Jarrett, a flight medic, ran to the wounded Marine, about 50 yards away from the landing zone. Arm in arm, Jarrett and Marine infantrymen helped Turner hobble toward the Black Hawk. The ground was rough, and one Marine tumbled into a deep irrigation ditch and became mired in mud.

As Jarrett checked and rewrapped Turner's bloodied-but-whole right foot, the two men joked and smiled at one another, yelling over the deafening roar of the airborne Black Hawk. Perhaps both were just relieved that Turner was one Marine who would be OK that day.

One more step, and he would have been killed by the blast.

"God was truly watching," Turner later said.

------------

It isn't always that way. On another rescue for Jarrett's crew the same day, the helicopter landed in a dusty haze to pick up two Marines said to be in potentially critical condition.

The first, shot in the chest, was carried unconscious to the helicopter by his comrades and gently laid on the floor.

Next came the other, shot twice in the arm. He walked aboard without help. The pilots took off full-throttle, accelerating and zigzagging - called yanking and banking - to evade enemy fire.

The Marine with the arm wounds had a tourniquet tightly applied and was sitting up, in pain but alert.

Jarrett focused on reviving the other man. He made an incision in the Marine's windpipe to put an oxygen tube through, in a complex tracheotomy. Wincing in pain, the other Marine used his able hand to help seal the tube.

But there wasn't enough lung tissue for the incoming air to reach, and the oxygen simply left again through the many holes made by the bullet.

Minutes later, we landed at a field hospital. The two patients were rushed into the trauma ward.

A short time later, the Marine with the chest wound - Lance Cpl. Joshua T. Twigg of Indiana, Pa. - was pronounced dead.

After a death - referred to as a KIA for Killed In Action, or often as an Angel - there is a marked silence among the crew, a sadness that hangs heavy. There are none of the usual jokes about how tight the landing zone was, or how deep the mud turned out to be, or where the ground fire was coming from. Medics often go away to be alone for a while, but there's never far to go since they must stay near the helicopter.

Crew members go through their routines, refuel, shut down their craft, examine it for battle damage and clean out the blood, used gauze, airway tubes, needles and other medical refuse, getting ready for the next emergency call.

It could come at any minute.

Combat Medics go into the battlezone and pray, "God, help me get to those who need my care"

On the Battlefield, the one person you want close by and able to respond when you need them is the Medic. Most go by the moniker " Doc" and have the task of responding at a moments notice....Doesn't matter whether they are Army, Navy or Air Force, it is always one team-one fight. and the fight is to save lives. Period.

Medics handle routine issues. Upset stomachs, rashes, small abrasions - no different than what your local clinic would see at sick call....

THEN, there are the moments where a Medic is the only person who is going to make sure that a fellow warrior is going to see another day. Many warriors are trained in the basics of combat medicine, (I myself was certified as a Combat Medic prior to being deployed to Fallujah in 2004) but the really serious work of bringing them back alive falls into the hands of those who make Combat Care their raison d'etre or "reason for being "

The prayer they most use is the The Combat Medic's Prayer

Oh, Lord
I ask for your divine strength
to meet the demands of my profession.
Help me to be the finest medic,
both technically and tactically.

If I am called to the battlefield,
give me the courage to conserve our fighting forces
by providing medical care to all who are in needs.

If I am called to a mission of peace,
give me the strength to lead by caring
for those who need my assistance.

Finally Lord,
help me to take care of my own
spiritual, physical, and emotional needs.

Teach me to trust
in your presence and never-failing love.

AMEN


I salute these dedicated professionals along with the aircrews that fly the helicopters for their uncompromising focus on flying into the fires of hell and placing themselves in harms way, all that others may live...

Read on and gain insight in a small glimpse of what they do at "just another day at the office".


Military medics combine ultramodern and time-honored methods to save lives on the battlefield

By David Brown
Washington Post Staff Writer
Saturday, October 16, 2010; 8:14 PM

IN FORWARD OPERATING BASE WILSON The first sign this isn't a routine pickup is the rhythmic right and left banking of the helicopter.

It's the kind of thing kids do on bikes to feel the thrill of heeling over. Only this is done to make the aircraft a less easy target.

At 6:09 p.m., Dustoff 57 has just left this base deep in Taliban-infiltrated Kandahar province, headed for a POI, or point of injury. On board are two pilots, a crew chief and a flight medic, as well as two litters for carrying the wounded and numerous black nylon bags stuffed with ultramodern medical gear and some of the oldest lifesaving tricks of the battlefield. That combination of new and old - of specially developed porcelain-powder gauze and old-fashioned tourniquets - is key to keeping gravely wounded soldiers alive in the minutes before they get to the hospital. It's also the basis of evolving frontline strategies that may eventually trickle down in modified form to civilian ambulances, emergency rooms and trauma centers in the United States.

Somewhere ahead of the aircraft is a soldier who minutes earlier stepped on an improvised explosive device, the signature weapon of the wars in Iraq and Afghanistan. All the helicopter crew knows is that he's "category A" - critical.

The sun is down but there is still a little pink in the western sky. Beneath the helicopter, the ground is made of what the troops call "moon dust." Fine-grained and dry, it is a color not as dark as dirt and not as light as sand.

The aircraft weaves over compounds enclosed by mud walls and surrounded by fields of grapes and vegetables. Farther away on the sere, unirrigated plain are the domed tents of herdsmen, their cooking fires glowing like terrestrial stars.

The trip out takes nine minutes.

The helicopter lands, stirring up a cloud of moon dust that nearly obscures six soldiers kneeling and standing around the wounded man, 50 feet from the aircraft. Their headlamps make tiny blue searchlights. The 28-year-old flight medic, Sgt. Cole Reece, runs toward them.

Cpl. Deanna Helfrich, 22, the crew chief, climbs out of her window and walks around the nose of the aircraft trailing a communication cable that allows her to talk to the rest of the crew. She stands near the open door where the wounded soldier will be brought, holding her rifle.

The weapon is a reminder: The crew is here to save lives, but Rule 1 of the Basic Management Plan for Care Under Fire is: "Return fire and take cover."

There is no enemy fire this evening, but there is so much dust in the air and the rotors are spinning so fast that the leading edges of the blades light up like sparklers, flint on steel.

Fifteen minutes have now passed since the soldier was wounded. The details of how it happened don't matter to Reece. There are a limited number of things he can do between this nameless spot and the hospital at Kandahar Airfield, where they will soon be headed. What he needs to know he will see and feel for himself.

Speed, simplicity and priority have always been the hallmarks of emergency medicine. The new battlefield care that flight medics like Reece and others on the ground practice takes those attributes to the extreme.

Gone from their repertoire are difficult or time-consuming maneuvers, such as routinely hanging bags of intravenous fluids. On the ground, medics no longer carry stethoscopes or blood pressure cuffs. They are trained instead to evaluate a patient's status by observation and pulse, to tolerate abnormal vital signs such as low blood pressure, to let the patient position himself if he's having trouble breathing - and above all to have a heightened awareness that too much medicine can endanger the mission and still not save the patient.

Four people run to the helicopter with the stretcher holding the wounded soldier. He lies on his back partially wrapped in a foil blanket. His chest is bare. In the middle of it is an "intraosseous device," a large-bore needle that has been punched into his breastbone by the medic on the ground. It's used to infuse fluids and drugs directly into the circulatory system when a vein can't be found. It's a no-nonsense technology, used occasionally in World War II, that fell out of favor when cheap and durable plastic tubing made IV catheters ubiquitous in the postwar years. Until they were revived for the Iraq and Afghanistan wars, intraosseus devices were used almost exclusively in infants whose veins were too small to find.

On each leg the soldier has a tourniquet, ratcheted down and locked to stop all bleeding below it. These ancient devices went out of military use more than half a century ago because of concern that they caused tissue damage. But research in the past 15 years has shown that they can be left on for two hours without causing permanent harm to limbs. Now every soldier carries a tourniquet and is instructed to put one on any severely bleeding limb and not think of taking it off.

Tourniquets have saved at least 1,000 lives, and possibly as many as 2,000, in the past eight years. This soldier is almost certainly one of them. They're a big part of why only about 10 percent of casualties in these wars have died, compared with 16 percent in Vietnam.

On the soldier's left leg, the tourniquet is above the knee. Both bones below his knee are broken, and the limb is bent unnaturally inward. The tourniquet on his right leg is lower, below the knee; how badly his foot is injured is hard to tell from the dressings. His left hand is splinted and bandaged, too.

Whether he will need an amputation is uncertain. The hospital where he's headed treated 16 patients in September who needed at least one limb amputated. Half were U.S. soldiers, and the monthly number has been climbing since March.

The man is covered in moon dust, and pale beneath it, but conscious and able to pay some attention to Reece. He's gotten 10 mg of morphine, not a lot.

First thing, the medic hooks a plastic tube to an oxygen tank and leans forward and puts a face mask on the soldier's head. He tells him over the din of the engine that he'll be okay, that they'll be at the hospital in 10 minutes.

After three minutes on the ground, the helicopter takes off.

Staunching the blood

The interior of the helicopter is lit by a single overhead light, headlamps and the glow of instruments. Reece tells Helfrich to check the tourniquets; things sometimes move in transit. He then pulls back the foil blanket and inspects. A tangle of dry grass lies directly over the soldier's navel.

The medic sees that a laceration in the soldier's left groin is still bleeding. This, too, is a signature wound of the two wars - a deep, dangerous injury just outside the protective veil of body armor and unable to be treated with a tourniquet. It's a wound from which a person can easily bleed to death. Death from blood loss has always been the greatest hazard of war wounds.

A recent analysis found that of soldiers deemed to have "potentially survivable" wounds, 80 percent died of bleeding. Usually the wound site was a part of the body where a tourniquet couldn't be applied.

The best option - not ideal - is to stuff the gash with Combat Gauze, a battlefield treatment new to the current wars. It's a bandage impregnated with a kind of powdered porcelain that stimulates clotting. The medic on the ground had already packed the wound with it. Reece unwraps some more, lays it across the injury and asks Helfrich to apply direct pressure.

He undoes the Velcro sleeve of a blood-pressure cuff and puts it on the soldier's right arm. He puts three stick-on EKG leads on the man's chest and abdomen, a right triangle. The man reaches up and touches his forehead, a self-confirming gesture. When he's done, the medic gently takes the hand and puts on the ring finger the toothless plastic jaws of a pulse oximeter - a device that measures the oxygen content of the blood through the skin. The soldier has lost a lot of blood. If his breathing falters and he can't oxygenate what's left, he will die.

The first blood pressure reading is 96/40. Normal is 120/80. The soldier's heart rate is way over 100, but the exact number is irrelevant. Nobody who's just had something blow up in front of him has a normal heart rate even if the blast has done nothing to him.

Every minute or so, Reece puts his right hand, which is in a black rubber glove, onto the soldier's head and rubs the center of his forehead. This is to stimulate him and gauge his level of consciousness. It may also reassure.

The pulse oximeter gives a reassuring reading. Several minutes into the trip the medic senses the soldier becoming drowsy and inserts a green plastic tube into his left nostril. This "nasopharyngeal airway" will make it easier, if the man becomes unconscious, for Reece to keep him alive.

While blood pressure somewhat below normal is considered all right - and even preferred - in severely injured patients, a diminishing level of consciousness is not a good sign.

Reece reaches for a 500-milliliter bag of Hextend - an intravenous fluid containing starch molecules that help boost blood pressure by preventing the watery part of blood from leaking out of vessels, as often happens in massive trauma. He squeezes the bag to make it run in more quickly through the device in the soldier's breast bone.

The soldier's next blood pressure reading is 116/71.

Just two minutes away, Reece leans forward and tells the patient they're almost there.

Communication glitch

Eleven minutes after lifting off from the POI, the helicopter lands at the so-called Role 3, or fully equipped, hospital at Kandahar Airfield, about 30 miles to the east of the also well-fortified Forward Operating Base Wilson. There, surgeons will take care of the injuries before transferring the patient, probably within two days, to the huge military hospital in Landstuhl, Germany, and there, after a week or so, to the United States.

But something has happened in the usually smooth communication between dispatch center, aircraft and hospital. No ambulance pulls up to the helicopter. Reece and Helfrich wait.

They wait.

The pilots radio the dispatcher that they've arrived with a critically injured soldier. Reece and Helfrich, helmeted and inaudible, gesture wildly to people outside the emergency room door to come over.

Two other patients have also recently arrived. But that's not the problem. There's an available ambulance 100 yards away. But it doesn't move.

Five minutes after touchdown, it finally drives up and the injured man is rushed into the back. Reece says later he was one minute from having the crew carry the patient to the emergency room themselves, even though running that distance with a trauma patient on a litter is just about the last thing you want to do.

It's been 28 minutes since the helicopter left Forward Operating Base Wilson. The ambulance, with Reece in it, disappears into a pool of greenish light at the hospital entrance.

In 10 minutes, the medic returns and the helicopter takes off to begin the refueling, restocking and cleaning that will make it ready, in less than an hour, for the next call.

It's for an Afghan man, described as a Taliban fighter, who has stepped on a land mine.