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Bringing Back the Wounded With Heart, Soul and Surgery

Vincent Worrell lay shivering on a trauma bay. He felt something in his mouth. He sat up and spat fragments of his front teeth into a bedpan. They were mixed with blood and tissue torn from inside his mouth.

He heard someone say: "Significant laceration to the cheek and lip." And then: "Frag under the eye … frag in the face … frag in the shoulder … possible thumb fracture."

A bomb fashioned from two mortar rounds had detonated a few feet behind Worrell, an Army staff sergeant, as he walked on patrol near Tall Afar on the morning of Nov. 6. Now he was inside the Air Force Theater Hospital, a tight web of interlocking tents set up on packed sand 50 miles north of Baghdad.

Worrell was groggy; he had been given morphine.

He asked a doctor: "Will I need reconstructive facial surgery?"

"Nope, just some new teeth."

Worrell glanced down and was surprised to see a Purple Heart resting between his legs. Somehow the medal made him think of his wife, Jayme.

"My wife's going to be pissed," he told the doctor. "She specifically gave me instructions not to get perforated over here."

At that moment, Jayme Worrell was driving to the couple's ranch-style home in Fayetteville, N.C. She did not yet know that Vinny, the gangly boy she had dated in high school, the restaurant cook who had joined the Army to give meaning to his life, was about to be cut open inside a tent in the Iraqi desert.

The grit and shrapnel in Worrell's face was just a small part of the bloodshed from the first week of November. In a typical week in Iraq, about 110 American troops are injured in action. Doctors, medics, nurses and litter bearers in Iraq fight daily to keep the wounded from joining the ever-lengthening rolls of the dead.

After three years of war, the military has honed a highly efficient lifesaving process that moves the wounded swiftly from the battlefield to emergency surgery in the combat zone, and on to military hospitals in Germany and the U.S. The approximately 17,400 troops wounded since March 2003 have been swept up in a medical effort unmatched in any previous war.

In November, 402 troops were wounded in Iraq. Among them were Worrell and four other men who were delivered the same week, bleeding and in excruciating pain, to the hospital here.

On Nov. 5, an explosion tore into Marine Lance Cpl. Francisco Ponceherbozo, 20, a Peruvian-born Californian, as his squad pursued insurgents in western Iraq. The blast knocked him down and left a hole the size of a silver dollar in his left foot.

On Nov. 6, an improvised explosive device upended an armored Humvee driven by Army Spc. Joshua Griffin, 18, who had joined the Army in Texas a year earlier with his mother's permission. He was on a mission to hand out soccer balls and teddy bears to children near Taji. Griffin's smooth face was blackened by second-degree burns, his jaw was broken in two places and his right femur was shattered.

On Nov. 7, a land mine detonated beneath a Humvee carrying Marine 2nd Lt. Mike Geiger, 24, a military brat from North Carolina, as his platoon in Haditha distributed leaflets advising civilians how to avoid being shot at U.S. checkpoints. Geiger's face was bathed in blood, and his right foot was broken in several places.

On Nov. 8, a grenade tossed by an insurgent exploded at the feet of Marine Lance Cpl. Ryan Buchter, 20, a baby-faced former high school football star from Pennsylvania, as his unit cleared farmhouses of enemy fighters in western Iraq. Shrapnel shredded his left leg, crushed his right hand and ripped into his nostrils.

Those five men, each one an eager volunteer in Iraq, would spend a long winter recovering from the most searing experiences of their lives. The medical care that saved them was extraordinary, but it was only the beginning. They endured dozens of surgeries in five military hospitals on three continents. They returned to their families much different from the fit young men who had set off to war.

For some of them, what happened on the battlefield wasn't the worst of it.

Vincent Worrell's lips were a deep blue. Trauma and blood loss had lowered his body temperature. Despite the blankets covering him, he could not stop shivering. He had never felt so cold.

A doctor hollered for more blankets.

Worrell heard a gushing sound in his left ear, the one that had been nearest the blast. One eye was swollen shut. He asked for water, but a nurse told him he could not have food or drink because he was about to undergo surgery.

"If I can't have water, can we compromise and let me at least rinse out my mouth?" he asked.

He got the water and washed the metallic taste of blood from his mouth.

This was not the first time he had been wounded. In January 2005, Worrell was shot through his right thigh in Mosul, and he had been back on duty just two months.

He thought again about his wife, and what the news of this more serious calamity would do to her — and to them. What if he lost his eye, his hearing, or the use of his hand? He was only 25. They had a 5-year-old-daughter. How would they manage?

Worrell wanted someone to tell his wife, quickly, that he was hurt but alive.

Jayme Worrell would not get the full story until later that day, when a lieutenant phoned her from nearby Ft. Bragg. Jayme was so familiar with casualty notification that she warned friends to knock rather than ring her doorbell. She knew that casualty officers delivered news of a dead soldier in person and always rang the doorbell. But a phone call meant an injury, not death.

"I'm sorry to inform you that your husband was injured by an IED …," the lieutenant recited, and Jayme did not hear anything else until she heard him utter the words, " … but he's OK."

She had expected the worst. It was her husband's third tour in Iraq and the odds were against him, given his job as an airborne infantry squad leader.

"I told him very specifically not to get perforated — or shot, stabbed, poisoned, strangled or bitten by dogs," she said later. "Then he gets his head blown up…. I took it better this time. It's weird the things you get used to."

Inside the Air Force hospital, a medical technician rolled Worrell into surgery.

The operating room was inside a metal trailer attached to the tents that make up the hospital. It looked like an operating room at any big-city hospital, crammed with computerized monitoring devices, anesthesiology equipment and surgical instruments.

A Dwight Yoakam song was playing on a portable CD player as Col. Bailey Robertson stared at Worrell's ravaged face. The soldier had been anesthetized, and a blue surgical drape had been stapled to his forehead and cheek so that only his mouth, nose and eyes were visible.

"I need to snatch out a couple of broken teeth and stitch up his lip," said Robertson, a maxillofacial surgeon.

First, Lt. Col. Bryan Angle, an eye surgeon, went to work on the fragments embedded in Worrell's nose and cheek. He used tweezers to pluck out bits of shrapnel from beneath Worrell's left eye. Using the back end of the tweezers, he packed gauze into the ragged hole on the left side of the nose and then pulled it out.

Angle used his little finger to probe inside the nose wound. He squinted through magnifying loupes, which looked like oversized spectacles. This is the first war in which microsurgery is available on the front lines.

Angle fished out a lump of grayish-brown rock, then another. He flushed the wound and sutured it.

Robertson used a retractor to expand the wound under Worrell's left eye. Angle extracted bits of dirt and more rock fragments, lining them up on a sterile field of blue fabric.

"And my rock garden continues to grow," he said.

Next, Col. John Ingari, an orthopedic hand specialist, used a scalpel to slice dying tissue from the base of Worrell's broken left thumb. Dead tissue harbors bacteria; infection is a serious threat in Iraq's unsanitary environment.

A nurse retracted a long, jagged wound on Worrell's left hand as Ingari plucked out a rough brown object, either a rock or bit of highway pavement. Ingari was pleased to see that the digital nerve in Worrell's thumb was intact. "A millimeter over, and he'd have lost all sensitivity in his thumb," he said.

Ingari moved on to a deep wound on Worrell's left shoulder. He probed it with his index finger, extracting two large rock fragments. The explosion had blown pieces of roadway into the shoulder, but no razor-sharp mortar shrapnel that might have caused even more damage. The surgeons worked briskly, commenting on their work as they probed and sewed. Nurses swabbed the wounds with gauze, and Worrell's bright red blood stained the blue drapes beneath him and dripped to the floor.

Robertson irrigated Worrell's mouth, washing out more tooth fragments and dirt. He used a metal tool to latch onto the broken roots of Worrell's front teeth and pried them out with a loud cracking sound. Then he sutured the gums, the roof of the mouth and the fleshy mass of tissue where Worrell's lower lip had been ripped loose.

Final sutures went into the medial canthal tendon beside Worrell's left eye, which keeps the eyelid tight so that tears can flow.

After two hours, the surgery was over. Worrell was wheeled into a recovery room, his face splotched with dried blood, scarlet wounds and black sutures.

Ingari was optimistic that Worrell would regain full use of his left hand and shoulder.

Robertson thought Worrell's face and eyes would heal nicely, with his gums ready for titanium teeth implants to be inserted by specialists in the U.S. "He'll have a scar on his lip," he said. "It'll make him look tough."

Angle thought Worrell looked much better going out of surgery than coming in. "This guy is pretty lucky," he said, "if you call getting whacked in the face by an IED lucky."

The wounded in Iraq receive better and faster medical treatment than in any previous conflict. Often, soldiers are rushed to the operating room within minutes of being unloaded from Black Hawk medevac helicopters.

During the Vietnam War, where the nearest combat support hospital was in Japan, it took an average of 45 days to move a wounded soldier from the battlefield to a U.S. hospital. In Iraq, it takes less than four days.

Medevac helicopters are able to fly quickly over the flat desert landscape. Surgeons say no wounded American in Iraq is more than 30 minutes from a combat hospital, where treatment is as good as at any U.S. trauma center. In many ways, it is better. In a single busy night, combat surgeons can repair a greater number of ghastly and complex wounds than a big-city trauma surgeon might see in a year.

In a war with no fixed front, military hospitals in Iraq are closer than ever to the places where American troops are felled — most often by roadside bombs, but also by rockets, mortars and gunshots. There are four major combat hospitals in Iraq: The Air Force hospital in Balad, and Army combat support hospitals in Baghdad, Mosul and Tikrit.

Many of the most seriously wounded would have died in previous wars. In Vietnam, soldiers often bled to death before reaching a hospital. Because the wounded in Iraq are evacuated so quickly, 96% of those who make it alive to the Balad and Baghdad hospitals are saved.

On the battlefield, medics are better-prepared. The lowliest grunt is given specialized lifesaver training, particularly in the use of tourniquets to control bleeding. New blood-clotting agents and improved field bandages have helped save lives.

Despite the destructive force of roadside bombs, the rate of wounded who die is lower in Iraq than for any war in U.S. history. Since the war began three years ago, about 10% of those wounded have died of their injuries, according to the Pentagon, down from 24% during the Vietnam War and 30% during World War II. The highest lethality rate was 42%, during the Revolutionary War.

In 2005, the number of wounded in Iraq increased by 1,200 from a year earlier. Yet the number of dead remained virtually the same, 844 versus 848 in 2004, dropping the lethality rate from 9.6% to 8.4%. Just over half of those wounded have returned to duty.

Ballistic goggles — like those worn by Worrell — have protected the eyesight of thousands. Although body armor has saved more lives, it leaves limbs, necks and armpits exposed. A recent Pentagon study found that improved armor could have saved as many as 80% of Marines who died from upper-body wounds.

The amputation rate in Iraq is double that of previous wars. Many soldiers face the rest of their lives without arms or legs, or with severe brain damage. Even for the wounded who will walk again, and perhaps return to battle, the physical damage, and the psychological scars, last forever.

Mike Geiger was wheeled into the operating room, his fractured right foot heavily wrapped. Geiger's narrow face was a sickly greenish-gray — not from shock, but from road dust and smoke that had filled his burning Humvee after it was crumpled by the land mine.

Geiger's cheeks were streaked with blood from tiny shrapnel wounds, and there was a nasty gash under his chin. He was alert and talking. He had flashed a thumbs up as he was being rolled in from the Black Hawk.

As a platoon leader, Geiger had always worked hard to prepare his men for calamity. He had a plan in place in the event any of his men were wounded. But when it turned out that he was the one injured, he lost his bearings.

Many of the wounded describe an unbearable interlude, seconds after going down, when one cannot comprehend what is happening. They are surprised by the way time seems to stop as they lie bleeding, and by the suspended moment of utter quiet that follows an explosion.

Some say they feel disconnected from their injuries, as if they are watching something terrible happen to somebody else. Others say they feel vaguely foolish or incompetent for allowing the injury. Getting wounded is always something that happens to the other guy.

Geiger remembered a rush of emotions and confusion as he considered ordering his men to form a security perimeter. He did not realize that they had already taken their positions after yanking him out of his Humvee. Geiger screamed that his leg was killing him, and the unit medic injected him with morphine.

Now, in the operating room, the pain had eased. Geiger did not know whether he would lose his leg; the doctors weren't saying. He tried to stay positive. "As long as I can dance at my wedding, I'll be OK," he told the surgeon.

An anesthesiologist peered down at Geiger's discolored face and the dirty black rings his goggles had left around his eyes. "Wow, man," he said. "You have great eyes."

Those were the last words Geiger heard before the anesthesia took effect.

Minutes later, Lt. Col. Jim Keeney, an orthopedic surgeon, cut two long incisions into the top of Geiger's badly swollen foot to relieve pressure. Thick red blood drained into a pan. Keeney bent down to study the wounds.

"Um, this is a significant trauma," he said. "This young man didn't show a lot of pain, but this is a very painful injury."

Keeney used tweezers to remove temporary stitches along Geiger's big toe, sewn earlier that day at a unit aid station before a Black Hawk flew him to Balad.

Keeney cleaned and dressed the wound. A nurse wiped the grime and blood from Geiger's face. She disinfected the gash on his chin with rust-colored Betadine. Barring a serious infection, Keeney said, Geiger would not lose his foot.

"He may need some skin grafts," he said, wrapping up. "But he'll be walking again in six to eight weeks."

In the intensive care ward hours later, Geiger called home on a satellite phone provided by the hospital. He reached his mother, Patricia Geiger, a retired nurse, at home in Fayetteville, N.C.

He began, "I'm OK. My Humvee hit a land mine."

He listened to his mother for a few moments, and answered her questions. She was weeping. He murmured in a low voice, "I love you, too," and hung up.

Geiger wanted to reach his fiancee, too, before someone else told her. He was engaged to Ensign Kate Shawhan, a Navy nurse at Camp Pendleton. By his own admission, he had been a wild kid in high school — so wild his parents had sent him to military school. That, and the Marine Corps, had matured him. Marriage was the next step.

He punched in Shawhan's phone number. He got her answering machine.

"Hey, gorgeous," the lieutenant said casually. "Just wanted to let you know I'm on my way to Germany tonight and I'll probably be home soon…. I love you."

Geiger hung up and thought for a moment about what he had done. He lowered his head. "That," he said, "was a terrible thing to leave on an answering machine."

On the same ward, Francisco Ponceherbozo was awaiting a flight out that night to the U.S. military hospital in Landstuhl, Germany. He felt uneasy. He wasn't certain the deep wound in his left foot was serious enough to warrant a trip out of Iraq.

"It wasn't like my arm got blown off or I had a sucking chest wound," he told Lance Cpl. Justin Summers, who was being treated in the next trauma bay. "I mean, it hurts like hell, but it doesn't seem all that urgent."

Summers had suffered a slight leg wound in the same explosion that felled Ponceherbozo. Their platoon was engaged in heavy fighting in Operation Steel Curtain in western Iraq, an effort to seal insurgents' infiltration routes.

"Looks like I'm not going back out," Ponceherbozo said.

"Sorry — damn, that sucks," Summer said, and he limped out of the hospital, his boot unlaced, on his way back to the front.

Ponceherbozo was rolled into surgery and given anesthesia. Lt. Col. Scott Russi, a general surgeon, studied X-rays of his foot. The second metatarsal was fractured. A shard of shrapnel was lodged in the side of the foot. Russi decided not to try to cut it out.

"I'd only create even more tissue damage if I tried to go in and get it," he said. It would likely work its way to the surface later on.

Russi washed out a shrapnel wound on Ponceherbozo's shoulder and packed it with gauze. He probed the foot wound, opening the ragged hole slightly to get a better look.

"Oh, that's a good-sized wound," he said. "Goes all the way to the muscle. It'll probably need a skin graft at some point."

He flushed the wound and packed it. The corporal was ready to be shipped home.

In the intensive care ward later, Ponceherbozo sat up in bed, his slender form overwhelmed by huge white dressings on his shoulder and foot. He was making plans for combat tattoos: the word "Steel" on one shoulder and "Curtain" on the other, in honor of the offensive that left him wounded. He loved the Corps — he had joined right out of high school.

His main concern at that moment was replacing the thick, ugly, military-issue black-framed spectacles he was wearing. They were on loan from a buddy after Ponceherbozo broke his prescription glasses. He asked a public affairs sergeant on the ward if she could find him something other than what he called "nerd glasses." She promised to try.

A nurse brought over a satellite phone so the corporal could call home. He had spoken to his mother just three days earlier to warn her that he would not be phoning again for a while because of the upcoming offensive.

Ana Maria Whitley is a native of Peru who came to the U.S. 12 years ago. She had agonized over her son's decision to join the Marines. She was so worried that she asked a Roman Catholic bishop who patronizes her housecleaning service to pray for Franco, as she calls him.

Ponceherbozo dialed his mother's number in Southern California. It was 4:15 a.m. on the West Coast. Whitley was awakened from a deep sleep.

"It's Franco," the corporal said. "I just want to tell you I'm OK, but I'm just a little casualty of war. I caught a little shrapnel to my right shoulder and left foot … "

He could hear his mother sobbing.

"You know what shrapnel is, right?" he went on. "It's like fragments of metal."

He told her he was coming home, and he heard her say through her tears: "Thank God you're alive."

Later that night, as the yellow lights from the tented hospital glimmered in the black desert expanse, a bus loaded with patients pulled away. It lumbered for just a mile, easing past sentries at a security checkpoint that leads to the Balad air base tarmac.

Looming in the dark was a specially equipped C-17 medical transport plane, its big rear belly opened wide to receive patients on their way to the U.S. military hospital in Landstuhl.

The bus parked next to the plane. Six men and women in Air Force uniforms stood behind the vehicle in two neat lines. An airman shouted out cadences as each wounded man, wrapped in wool blankets and connected to tubes, was lowered to waiting arms and loaded into the plane's belly.

In the previous two months, the planes had evacuated 1,500 wounded troops. More than a hundred were considered critical — each accompanied by a doctor, nurse, medical technician and tangles of portable medical equipment.

"We're basically a flying hospital," said Air Force Lt. Col. Scott Vandehoef, who commands the evacuation service.

Among the patients that night were Ponceherbozo, Worrell and Griffin. Buchter and Geiger had just arrived in Balad that day, and both would leave for Germany the next night.

Griffin was among the critical patients traveling with three caregivers. His face was so bloated that his right ear had disappeared. His eyes were narrow slits. Dried brown blood was caked on his eyes and mouth. His broken jaw was swollen and aching. A tracheotomy tube snaked down his throat. He had emerged from major surgery just hours earlier.

Unable to speak, Griffin wrote down phone numbers for his mother in Texas and his sister in Germany, and gave them to the nurse accompanying him. He wanted his mother to know what had happened to him. He wanted his sister, Megan, an Army private in Germany, to meet his plane.

The nurse phoned Renee Hickman in Humble, Texas. Hickman had already received a call from her son's rear detachment, telling her that Griffin had been wounded. But she did not know the extent of his injuries, and she felt a curious wave of relief when the nurse described them. They sounded serious, but not hopeless.

"I had assumed the worst," Hickman said later. "As bad as it sounded, he was alive. Just hearing her voice, knowing she was there with him, helped me get through it."

A few minutes later, Griffin wrote a note thanking the nurse and everyone who had treated him. Then he wrote that his head and foot were hurting terribly.

A medical technician bent down close to Griffin's disfigured face. "I hope you're not going to cry," the technician said. " 'Cause if you cry, then I'll start crying."

Griffin held back his tears.

Earlier, nurses had described his wounds to him, but Griffin now wanted to see for himself.

One of his doctors agreed, reluctantly. She handed him a mirror.

Griffin stared at his image for a long time. He coughed through the tracheotomy tube — a raspy, guttural sound. The doctor gave him a tissue and he wiped his eyes.

The soldier took a pen and a notepad. He scribbled something and handed it to the doctor. It read: "I'm scared."

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About This Series

More than 17,000 American troops have been wounded in Iraq since the U.S. invasion in March 2003. This series tells the stories of five of them, injured during the same week last November. Reporter David Zucchino and photographer Rick Loomis followed the men through a system of military medical care more advanced than in any previous conflict. Loomis also contributed to the reporting.

Today: Wounded in Iraq.

Monday: The golden hour.

Tuesday: Back home.----

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(INFOBOX BELOW)

Improved care

The percentage of Americans who died from wounds before World War I ranged from 42% in the Revolutionary War to 19% in the Spanish-American War. The percentage for the conflicts in Iraq and Afghanistan is the lowest in any U.S. war:

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Iraq/Afghanistan (2001-present): 10%

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Persian Gulf War (1990-91): 24%

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Vietnam War (1961-73): 24%

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Korean War (1950-53): 25%

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World War II (1941-45): 30%

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World War I (1917-1918): 21%

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Source: Department of Defense

Copyright © 2014, Los Angeles Times
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