Caring for insurgents presented a dilemma. They were the enemy, after all, had committed atrocities against their own people, and by this point in the war many had also killed or wounded thousands of American servicemen. One of us could be next. This was not the ideal milieu for providing health care, but detainee medicine was our stated mission and would require both consummate professionalism and unconditional forgiveness.
My change of heart about insurgents had begun at Abu Ghraib, having realized there that so many insurgents were young boys. Boys who, in many ways, were not unlike my own sons at the same age. Boys who found themselves trapped in wretched circumstances not of their own making. Boys bribed, beguiled, or bullied by older men to commit heinous acts. They were just boys.
Soon after my arrival in Iraq, I had also learned that policy decisions, made shortly after the American military victory in 2003, played a major role in creating the insurgency. One such decision was especially disastrous. Rather than retaining the bulk of the defeated Iraqi army to form the basis of the country’s new defense force, senior American officials disbanded it, creating a new “army” of 400,000 unemployed, angry young men with guns—an instant insurgency. At the beginning of the war we’d been welcomed as liberators—especially by Shia Muslims—for deposing the murderous Saddam Hussein, a Sunni, and smashing his brutal regime. Now, because of the ignorance and arrogance of American leadership, we were detested as invaders, especially by Sunnis.
While the US helping to create the postwar insurgency was bad enough, it would eventually lead to even worse ramifications. Complete American withdrawal in 2011 would enable ISIS, which identified with Sunnis, to arise Phoenix-like from the ashes of a defeated Al Qaeda and spread its own brand of terror throughout the country.
At Camp Bucca, though, there were no juvenile detainees at the base, so my internal medicine practice only involved adults. One particularly poignant case was brought to my attention during my first visitation experience. The wife of an older detainee approached me and, through an interpreter, made an impassioned plea on behalf of her husband. The gray hair in his beard suggested he was about my age—in his mid- to late fifties. His wife said that he was suffering from numerous medical problems, none of which, she claimed, had been properly diagnosed or treated. He had a long history of smoking and was experiencing shortness of breath, intermittent chest pain, and heartburn. After listening attentively to his medical history, I promised that he’d be my first patient in the internal medicine clinic the next day. Both he and his wife nodded, but I got the distinct impression neither believed me. I was the enemy, after all, an American soldier and infidel, while he was a Muslim insurgent. Why would I care about him?
The following morning at 0900, I sent two young Air Force MPs to Compound Number 6 to bring the detainee, Samir Mohammed, to my clinic. Compound 6 was one of about eleven barracks housing detainees in this part of the camp. Given the large number of prisoners at the camp, I guess it should have surprised me little that Mr. Mohammed never expected to see me again. But, a half hour later, the MPs appeared before me with the patient, who was zip-tied and shackled.
“Remove the restraints,” I instructed one of the MPs, nodding in his direction.
“But, sir, he’s an insurgent,” protested the MP.
The insurgent’s eyes darted between the two of us, not sure what was occurring.
“I know who he is,” I insisted. “It’s difficult to perform a good physical examination on someone in restraints—and it’s not very conducive to establishing a trusting doctor–patient relationship. I doubt he’ll cause any trouble, but if he does I’m sure you’ll know what to do.”
With that, the restraints were removed, and I turned my attention to the patient.
“Marhaban [Hello]. Ana tabib amriki [I’m an American doctor].”
My Arab language skills now exhausted, I asked for the interpreter. The patient was good in relaying his history, and the interpreter was familiar with medical terminology, so I was able to obtain a complete medical history and conduct a detailed physical examination. As usual, the medical history was more helpful in suggesting diagnostic possibilities. Mr. Mohammed was likely suffering from emphysema due to his long-standing smoking habit. His intermittent chest pain also raised the possibility of coronary heart disease, and his blood pressure was elevated. I’d need to order a chest X-ray, an electrocardiogram, and a battery of blood tests as part of his initial evaluation. After explaining all this to Mr. Mohammed, I promised to see him again in the clinic the following week to review test results and begin treatment. In the meantime, I had the MPs escort the patient to various sections of the hospital where his tests would be conducted. On my orders, he was to remain without restraints throughout this process.
While Mr. Mohammed was waiting for his chest X-ray, I checked in on him. Seated on either side of him were two younger insurgents who stared at me with evident hostility as I approached. Mr. Mohammed arose and placed his right hand over his heart, a sign of respect and gratitude. Stopping to face him, I returned the gesture. The two young men appeared astonished, undoubtedly wondering why this respected elder would show such deference to the enemy.
They don’t understand, I thought to myself. But two men, older and wiser than them, do understand . . . We understood that what unites us as humans is far stronger than what divides us.
I saw many heartrending cases in Iraq—none more so than a teenager who’d been under our care since being seriously wounded months earlier. I first met Faris shortly after arriving at Abu Ghraib prison hospital, at the end of December 2005. While walking through the ICU, his gaunt features had caught my eye, and I initially thought him an older man. As I approached his bed, it became sadly apparent that he was only a boy, who, I would soon learn, had just turned seventeen.
Faris had been shot by American forces, and though I didn’t attempt to learn what he was doing to draw fire, I doubted the cause was entirely his own initiative. Most of these young men, I had quickly discovered, weren’t religious ideologues who hated Americans; rather, they were usually from impoverished families and needed work, oftentimes planting IEDs in exchange for money.
Whatever his motivation, Faris had paid a terrible price for his actions. The bullet struck his right side and deflected off his pelvic bone, severing nearby sacral nerve nerves and perforating his small bowel in two places. He underwent surgery at an American combat support hospital in Baghdad, where an attempt had been made to repair the damaged loops of bowel. The operation wasn’t successful. The suture lines repeatedly broke down, allowing intestinal contents to leak into his abdominal cavity and form recurrent abscesses. Numerous surgical procedures followed, all to no avail.
Faris was left with a colostomy, two persistent holes or “fistulae” in his small bowel, complete paralysis of his right leg, and an inability to control his bladder. He remained bedridden and in spite of the best efforts of the nursing staff, developed a pressure ulcer, or bedsore, over his tailbone. To quiet his bowel and promote natural closure of the fistulae, Faris was placed on a liquid diet. This was supplemented with intravenous nutrition, but he continued to lose weight. In this weakened state, Faris was vulnerable to infection, and his overall prognosis was guarded. Although not his attending physician at Abu Ghraib, I saw him every day. Sometimes his woeful brown eyes and mine would briefly meet, and I would wonder what he was thinking. Is he aware of the seriousness of his condition?
After I departed Abu Ghraib for reassignment to Camp Bucca, I frequently wondered what became of Faris. A few weeks after my departure, my question was answered when he was transferred to our hospital at Camp Bucca. There Faris came under the care of our conscientious and compassionate family practitioner, Dr. William Burch. I also became more involved in his case, occasionally assisting with dressing changes or sometimes just bringing Faris some hard candy.
While visiting Faris one afternoon, he reached out for me. When I extended my hand, he kissed it and began to cry. As I touched his face gently, he whispered, “Shukran,” or “Thank you.”
I felt deeply for this young man, who, as far as I knew, never had any contact with family or visitors of any kind during the many months under our care. His family may have rejected him because of his actions or because they were fearful of showing up at an American military base. All I knew for sure was that his loneliness must have been as difficult to bear as his physical infirmity; he must have been as starved for human interaction as he was for physical nourishment. He lay there helpless and completely alone, with no one to visit him, no one to claim him, no one to call his own . . . no one. Our staff made every effort to ensure he was always situated near other detainee patients in our hopes that they would be willing to converse with him, but it seemed like that effort was casting but a pebble into an ocean of loneliness.
Then we almost lost Faris one night—not to his wounds, but to the MPs. It was 0300 as the shrill phone awoke me from sound sleep. It was a physician in the EMT telling me, “MPs are at the hospital. They have orders to take Faris!” There was an urgency in his voice, at Faris being carted away; he sounded desperate. “They’re taking him to a juvenile detention facility in Baghdad . . . a convoy, a twelve-hour ride!”
I knew that Faris wouldn’t survive that journey. I’d just completed the 350-mile trip myself, and it was grueling. What the hell are they thinking? And a juvenile detention center . . . in his condition?
I ran across the desert sand in the darkness and, bursting into the EMT, was promptly swept up in a confrontation with MPs.
“I’m the chief medical officer,” I declared, “and no one leaves this hospital for any reason without my approval. This patient is not fit to travel.”
“We have orders, sir,” an MP retorted. “You can’t stop us.”
I positioned myself between Faris and the now visibly agitated MP and, turning to the physician on duty, instructed him, “Contact the general’s office in Baghdad. We’re settling this here and now.”
As I awaited word of Faris’s fate, I thought of the young boy’s hand reaching out for mine just a few weeks earlier. I wished I had more power over the situation; the Army bureaucracy, at moments like this, made me want to be just a doctor—a doctor with the ability to make decisions for his patient, not a medical officer in a long chain of command.
When I then got the news, I exhaled deeply. I had prevailed and the Army was affirming its policy that no detainee would be transferred from a hospital without medical approval.
I knew our victory was probably short-lived, and if the MPs returned, our staff might not be able to dissuade them again.
On entering the EMT, I encountered a scene out of a nightmare. The entire room was filled with wounded of all ages—men, women, and children, mostly Iraqi civilians intermixed with a few soldiers. The air was heavy with the metallic, almost sweet, scent of blood. There were screams of pain, orders shouted by doctors, and even the whimpering of an animal—a military dog—which would later die of its injuries. I stepped forward and nearly lost my footing on a floor made slippery by blood.
Staring at the confusion and carnage, I was momentarily transfixed by the surrounding horror, unable to respond. For the first time in my thirty-seven-year medical career, I didn’t know what to do.
A nurse ran up to me. “Colonel Horvath, are you all right? Another MEDEVAC just landed—the next patient is yours.” Her face searched mine with obvious concern.
I quickly regained my senses, grabbed a nearby nurse and medic, and instructed them to find a place along the wall that had oxygen and suction apparatus for clearing airways since following an acute combat injury, a blocked airway is one of the main causes of death.
We didn’t have long to wait before I’d need them. Just seconds later, a flight medic burst through the EMT doors pushing a gurney. As it approached, I saw the pale face of an unconscious Iraqi girl, the rest of her body concealed under a green Army blanket soaked with blood. The nurse and medic quickly guided the gurney to the only available open spot along the wall. We knew the routine—remove all clothing, find the “holes,” stop the bleeding, infuse packed red cells and plasma to maintain blood pressure—all to keep the patient alive until an open operating room bed was available.
As I turned toward the gurney, time seemed to slow down—everything happening in slow motion. The surrounding din muffled, and my peripheral vision contracted, eliminating auditory and visual distractions and allowing me to focus directly on the task at hand.
I began to remove the blanket, fearful of what lay underneath. Nothing could have prepared me for what I saw. She was a young girl, no more than fourteen or fifteen years old. Her left leg had been traumatically amputated above the midpoint of her thigh, and it was lying across her abdomen. The nurse and medic gasped in horror. I paused momentarily but then quickly picked up the severed limb and laid it on an adjacent empty gurney. I knew it would never be reattached and turned my attention to a more serious task, saving the girl’s life. She had lost much of her blood volume and was in hypotensive shock; not enough blood was getting to her vital organs. Worse still, the loss of blood had led to lactic acidosis (acid in the bloodstream) as well as hypothermia and clotting abnormalities—the “lethal triad.” She was going to die unless we acted quickly.
Racing against time, we gave her eight units of packed red blood cells, one after another, along with two units of fresh, frozen plasma. Her blood pressure increased only slightly. Something was wrong. I then noticed blood dripping on the floor through an opening in the gurney. She was still bleeding somewhere. We rolled her over and found the source—a small severed artery on the backside of her thigh, which had been hidden from view at the site of the amputation. The single tourniquet already wrapped around her upper leg wasn’t stopping this bleeding. The medic futilely attempted to apply a second tourniquet, but there was so little leg left and its surface was too slippery with blood.
Realizing we were rapidly running out of time, I encircled the stump with both hands and squeezed with all my strength—a human tourniquet. I felt bone fragments poking through the tissues but still, I squeezed harder, my last-ditch efforts the girl’s only chance for survival. I stopped the bleeding just long enough for the medic to secure a second tourniquet. We’d bought the girl a few extra minutes, enough to keep her alive until she was rushed off to surgery.
As often was the case, the MASCAL ended as quickly as it began. Surgeons finished up the last two cases in the OR, all the wounded had been admitted to the hospital, the body of the soldier had been taken to the mortuary, and severed limbs had been deposited in an outside container. Medics mopped up blood on the EMT floor as methodically and dispassionately as a school janitor would mop a classroom floor. There’d been twenty patients in all. Now, there was nothing left to do except complete the clinical note on the girl I’d just treated:
Final impression: Young Iraqi female civilian with traumatic amputation, left lower extremity during a firefight. Exact mechanism of injury unknown, but likely the result of a blast.
Emotionally numb, my eyes drooping from lack of sleep, I managed to complete the remainder of my paperwork. Grabbing three bottles of hydrogen peroxide to wash bloodstains off my uniform, I began to make my way outside. Before reaching the door, I bumped into Major Ian Diaz. Diaz, in his early thirties, was the youngest of our thirteen physicians, which meant he often wound up with disagreeable tasks—like pronouncing obviously deceased people dead. That was the case two weeks earlier, when he’d been faced with a ghastly dilemma. A pickup truck, retrieved from the scene of a helicopter crash, unexpectedly arrived outside the EMT. It was filled with body parts from dismembered Iraqi soldiers. Asked to determine the exact number of fatalities, Ian could think of no better way than counting the boots and dividing by two. Proud of his resourcefulness in such gruesome circumstances, he related the tale with clinical detachment and his usual trademark smile. Today his face bore a more solemn expression.
“Ian, where have you been?” I asked. “We could’ve used you here in EMT.”
“I was in the acute care area,” he responded in a flat monotone voice, “caring for some of the less severely injured . . . and pronouncing those who came in DOA.”
He went on, his voice now breaking and on the edge of tears, “He had only a face, sir.”
“What are you talking about?”
“The little boy in the body bag . . . he only had a face . . . most of the skull and brain were gone. His eyes were still open, sir, staring at me. He was the age of my own son. I can’t get the image out of my mind.”
“Ian, don’t open any more body bags,” I cautioned. “Let me take care of that from now on.”
I then stepped outside, and on finding a suitable location, began pouring the hydrogen peroxide on my bloodstained uniform. Pink foam bubbled up and fell onto the ground in clumps. Within seconds, it was absorbed by the sand, disappearing without a trace. The physical evidence from the night’s senseless carnage was washed away. If it were only so easy, I thought, to wash away the memories of this night, but I knew those stains could never be removed.
News reports over the next two days explained why the MASCAL had occurred. A raiding team, variously identified as “US troops” or “a coalition force,” conducted an operation during the early morning hours in nearby Tikrit, targeting the home of Al Qaeda’s chief IED maker. After taking intense small-arms fire that caused multiple casualties, an airstrike was called in, which destroyed the target home, nearby structures, and several vehicles. The firefight continued following the airstrike, with armed terrorists using civilians as human shields—my young patient probably among them. The main suspect and three other males were killed, along with at least seven innocent civilians, including a local judge, three women, and a child. Most of the wounded civilians were transported to our hospital. We later learned that one of the wounded was a relative of Iraqi Prime Minister Nouri al-Maliki.
These reports, from the Associated Press and Army Times, didn’t tell the whole story. During the MASCAL, I’d noticed a British soldier sitting outside the EMT in a bloodstained uniform. This seemed unusual, but I gave it no further thought until it occurred to me that all the military casualties—one dead and three wounded—turned out to be Brits; that body bag I almost tripped over did not hold an American.
The following afternoon, a soldier in a British uniform strode into the EMT and sat down next to me. “Good afternoon, old chap, how are you doing?” he asked with an unmistakable accent.
“I’m fine,” I replied. “How can I help you?”
“You know, we were never here, right?”
“Who was never here?” I responded, playing along with the charade.
“SAS, Special Air Service,” was the response. “We were never here.”
“Oh, I get it, but you’re in the wrong place,” I said with a wry smile. “This is the hospital. The disinformation department is located outside around the corner. I’m sure they’ll be able to assist you.”
“Thanks, old chap,” was all he said, and promptly left.
I wasn’t quite sure why this particular operation required deliberate misidentification of the raiding team, since British forces were known to be in Iraq. I suppose the SAS, like Navy SEALS and Army Special Forces, preferred to keep their activities and locations unknown to the enemy. And so they would remain. Meanwhile, press reports continued to describe the raiding team as “US troops” or “a coalition force,” with no mention ever made of the SAS.
A few days later, two British helicopters arrived to pick up their injured personnel. We watched from the hospital entrance as our medics transported them to the waiting choppers. After all the wounded were safely on board, the first aircraft took off. The second, only about ten feet off the ground, stopped in midair, turned to face us, and dipped in salute as an expression of respect and gratitude, before being on its way.