Aero medical evacuation of a wounded marine.

t’s 1 a.m., and the squawking of the code pager abruptly rattles me out of sleep, “Code Blue, anesthesia only, SICU.”

It was a sheer mental exercise in endurance just to be able to open my eyes from the complete physical exhaustion I felt since earlier that day. I spent more than 16 long hours in the operating room resuscitating four injured soldiers with traumatic injuries related to improvised explosive devices and caring for 12 Marines and soldiers with various pain complaints for the Regional Pain Service. In fact this was just another routine Saturday call for this first-year military anesthesiology resident.

Having recently returned from Iraq as Marine battalion surgeon, I have learned the hard lessons of remaining calm and collected when facing crisis situations, such as when I had to execute rapid life-supporting measures in a mass-casualty setting in the combat zone. Therefore, when I arrived at the bedside and saw a crowd of people feverishly resuscitating this soldier, I didn’t feel any different this time than from other previous codes. Instinctively I took over the airway and deliberately started squeezing oxygen into the patient while I assessed this crisis.

Suddenly my heart started pounding, and my hands began to feel cold and clammy. The pulsating din of the frantic monitors and the crowd were replaced by growling armored vehicles and deafening machine gun fires. The many mangled faces of the Marines and soldiers I resuscitated in Iraq reappeared before my eyes. Of course I wasn’t in Iraq anymore, but the sadness and the anger I have been carrying deep inside me since returning home resurfaced as a combat-related stress disorder.

.Injured marine on transfer from initial treatment to a holding area.

In Ramadi, Iraq, attacks on my unit were a daily, if not hourly, affair. Whether it was the improvised explosive devices (IEDs) that hurled shards of cold steel through the faces and bodies of the unsuspecting Marines or the rocket-propelled grenades that tore their limbs into unrecognizable body parts, six hospital corpsmen and I were endlessly triaging and caring for a mounting number of casualties day in and day out. Perhaps it was the fatigue related to seeing so much bloodshed or the surge of adrenaline I constantly lived under, but whatever sadness and anger that I felt first slowly gave way to feeling jaded and emotionally detached. In fact when I saw the bullet-torn face of one Marine who was drowning in his own blood, on April 6, 2005, I mechanically slit his throat and performed an emergent crycothyroidotomy, just as we practiced it on pigs and mannequins. But they were not some random “John Doe” of the inner city hospitals. They all had names and personalities that were all too familiar to me. They were my Marines and soldiers whom I have trained and lived with 24/7 for the past year. I was their doctor, their confidant, their colleague and, most of all, their friend. We ate the same Meals, Ready to Eat, took the same bottled-water showers and suffered the same fury of Iraqi revenge (Montezuma’s equivalent).

.Wounded marine transported from battlefield to Dr. Son’s medical unit.

As soon as I squeezed oxygen into his lungs, he gasped for air and opened his eyes while we hurriedly packed his mouth and wrapped his shattered jaw to stanch the bleeding. He lifted his blood-stained hand and gave me a thumb’s up, as if to give me a sign of approval at what I had just done to help him. I yelled back at him, “Ski, you can’t leave now, you bastard, you have a wife to come home to.” Ski was not only the platoon commander but also a respected colleague of mine who, I later discovered, died during the helicopter medevac due to uncontrolled bleeding.

When I finally returned home, I felt very detached and guilty at not being able to bring my friends back home alive. Moreover I felt very isolated as I could not tell anyone about the tragedies of the war I had experienced. Neither my family nor my friends could possibly fathom what really went on in the war when their experiences were limited only to the sanitized version of the evening news and the daily death toll. Some would offer unsolicited opinions of the war only to find me more irritable and distancing myself from them.

Furthermore I began to have panic attacks complete with a sudden onset of heart palpitation, tingling hands and lightheadedness. Sometimes they were brought on by battle scenes or police car chases on television. Other times they were caused by something as mundane as just being in a crowded place such as inside a mall or a dark movie theater.

I desperately wanted to be alone, silent on a beach or in the mountains. Silence, however, was sometimes my worst enemy. Cleared of distractions, my mind became flooded with vivid images and the cries of fallen Marines and soldiers I took care of in Iraq. Sometimes I would wake up abruptly in the middle of the night to some random sound such as a car door slamming and remain awake until the next morning, wondering if Ski would still be alive if I had managed him differently. Frequently I turned to alcohol to drown out these images. I also started smoking to calm my panic symptoms; my guys and I sometimes found respite in sharing a cigarette in the chaos of the war. But faced with yet another deployment, this time to Okinawa, and with the excitement of my wedding, these images of the past became more dilute as I began making preparations for these new adventures in my life.

In the middle of the deployment, I was given new orders to start residency in anesthesiology at Bethesda Naval Hospital. With my wife and a fresh start in residency, this was the normalcy I needed. The casualties of the war continued to arrive at the hospital, though, and each time I cared for the wounded, I began to have panic attacks. Initially I attributed them to the rigors of residency and my new role as a husband. The symptoms, though, persisted and affected both my professional and personal life.

One day a medical student I was working with told me about a friend who had lost his leg in Iraq on April 6, 2005. He also described all of the difficulties his friend has had after returning home from the war. It turned out that his friend was one of the soldiers I took care of on that fateful day when I lost Ski. That night the injured soldier and I talked on the telephone endlessly, telling each other of the personal accounts of what had happened that day. We laughed about the craziness of Ramadi and Iraq in general. He also told me about his wife who had left him when she saw his injuries, but how he started all over again when he fell in love with his physical therapy technician. He thanked me for saving his life and for this new lease on life.

Suddenly a flood gate of emotions opened up inside of me. Yes, there were people I could not save, but there were a lot more people, just like this soldier, who I did manage to resuscitate and bring back home. Instead of blaming me for the death of one’s loved ones, this soldier actually thanked me and recognized me for what I did, not for what I could have done. With just a simple exchange of these words, I no longer felt isolated and began to feel alive all over again.

As each day passed, more casualties from Ramadi and the rest of Iraq arrived, some of them from my old Marine unit, as one Marine yelled out toward me, “Doc Son, you bastard, where have you been? We missed your acupuncture in Iraq.” With these encounters, I began to heal my own wounds, as I dedicated myself to taking care of my Marines and soldiers like no one else can.