As Lance Cpl. Ryan Buchter lay bleeding in the Iraqi desert, his fate hinged on the efficiency of a medical lifeline that stretches halfway around the world. From that moment forward, hundreds of strangers would work to save him.
Buchter's platoon was in a village called Husaybah on Nov. 8, searching for the enemy. He was standing in the doorway of a farmhouse when an insurgent inside rolled a grenade at his feet.
The explosion shredded Buchter's left leg as superheated shrapnel tore through muscles and tendons. More shrapnel crushed his right hand and sliced into his nasal cavity.
Buchter groped for his nose but couldn't feel it. He thought it had been blown off. He leg was so shattered that he was certain he would lose it, and he imagined being left crippled at age 20.
"And not once did I cry," he recalled later, "until I thought, like, I was going to lose my leg and stuff."
A Marine applied a pressure bandage to Buchter's leg, trying to stop the bleeding. Another wrapped his hand and pressed gauze against his pulverized nose. The Marines quickly loaded Buchter into an armored vehicle, which delivered him to a medical aid station nearby.
Buchter survived the "golden hour" — the 60 minutes following a serious battlefield wound, when the speed and competence of emergency treatment can mean the difference between life and death. Ordinary fighting men teamed with doctors, surgeons and nurses to keep him alive.
His fellow Marines — what the military calls his "battle buddies" — were able to stanch his bleeding by putting their combat lifesaving training to quick use. Exsanguination, or bleeding to death, is the leading cause of death for American troops in Iraq.
As a military doctor examined his leg inside the aid station, Buchter was alarmed by the concerned look on the man's face.
"If I lose my leg, I'm coming back to get you," he told him.
The doctor assured Buchter that his leg would be saved. "You've got my word," he said.
Then a surgeon arrived and warned Buchter that he might indeed lose his leg. The best option to save it, he told him, was a very painful and sometimes disfiguring surgery called a fasciotomy, the extensive cutting and cleaning of the wound.
"And I was like, 'Cut me up if you have to. I just don't want to lose my leg,' " Buchter recalled.
The medical odyssey of this Marine was just beginning. Buchter was now a patient in a virtual assembly line of care. It begins with soldiers and medics on the battlefield and shifts quickly to helicopter crews who pluck the wounded from kill zones. It continues to surgeons and nurses and X-ray technicians at desert facilities, and to virtual flying hospitals that airlift the wounded from Balad to a U.S. military hospital in Germany.
It leaps the Atlantic to major military medical centers in Texas and Washington, D.C. It passes through military hospitals from New York to California. It culminates with months of painstaking physical and occupational therapy in hospital wards and private homes. About 17,400 wounded have been treated since the war began three years ago.
The fulcrum for treatment in Iraq is the U.S. Air Force Theater Hospital in Balad. In addition to the troops brought directly to the hospital, any seriously wounded American must make a stop in Balad to be flown for treatment in Germany. The facility is housed inside three dozen tents and three trailers on the packed sands of a former Iraqi air force base 50 miles north of Baghdad. Sandbags, concrete blast walls and concertina wire provide protection from insurgents, car bombs and mortars.
The military says no injured American is more than 30 minutes from Balad or one of three combat support hospitals operated by the Army.
The rapid evacuation of wounded troops begins with Black Hawk medevac crews of four — nicknamed "dust-off" teams — trained to respond rapidly to distress calls from the battlefield.
From their dusty tent base about a mile from the hospital, the Army air ambulance companies keep three helicopters and crews ready at all times. The copters occupy a corner of the air base, the thumping of their rotors competing with the roar of F-16s taking off and the low hum of armed reconnaissance drones.
The crews are called to action by "nine-lines," the emergency radio calls from the battlefield that provide nine essential bits of information: location, number of wounded, whether the landing zone is "hot," or under fire, and so on. In most cases, the crews say, their helicopters lift off within eight to 10 minutes.
At the sites of injuries — most often caused by improvised explosive devices or car bombs — the pilot and copilot remain in the helicopter. The crew chief provides security as soldiers on the ground help the medic load and strap down the wounded.
Flight medics provide oxygen, IV lines and morphine. They carry instruments for measuring oxygen saturation, respiration, heart rate and blood pressure. They check bandages and tourniquets applied by medics or soldiers. Often, they are obliged to calm frantic patients, or members of their units who have just seen their friends go down.
"They're scared; they're pumped up," said Staff Sgt. Jerry Bickett, whose 18-helicopter unit flew 3,200 missions and evacuated 6,000 patients last year. "We have to be the voice of reason. I'll tell them, 'I'm Jerry, the flight medic. I'm going to take care of you all the way in to the hospital.' "
The most difficult missions are those involving KIAs: troops killed in action. The medics call the dead "angels," and treat them with reverence. Their bagged corpses are transported as carefully as if they were alive, and rarely on a helicopter carrying wounded troops.
Medics collect and bag body parts of the dead and wounded. "I don't want their buddies to have to do it," said Sgt. Tomas Chavez, a flight medic stationed in Balad.
On the afternoon a Black Hawk delivered Lance Cpl. Buchter to Balad, a major offensive, Operation Steel Curtain, was underway in western Iraq. Helicopters brought in a steady stream of the wounded; the copters' blades stirred up a swirl of sand, stinging the faces of waiting attendants. The trauma tent's doors swung open every few minutes as medics rammed in stretchers with more injured soldiers.
Nurses and doctors clustered around each new arrival, cutting off uniforms and boots, inserting IV lines, pumping in morphine, probing for wounds. More medical technicians burst through the doors, screaming, "Two more!" and "This one's priority!"
For Buchter and thousands of other wounded troops, the Balad hospital is the midpoint on the journey from battlefield to recovery. A staff of 350 cares for about a thousand patients a month. Doctors perform about 400 surgeries monthly in three operating rooms set up inside the trailers. There are 40 ward beds and 20 intensive care beds. Eight patients at a time can be hooked to ventilators. It is the only military hospital in Iraq that offers neurosurgery and head-trauma specialists.
The Balad hospital's interior looks very much like any trauma center in the U.S., with its crush of doctors and nurses, CT scanners, digital X-ray machines and an intracranial monitor. The operation is streamlined — surgeons can study CT scans and X-rays by walking a few paces, and patients are rushed into surgery in a matter of minutes.
There is no indoor plumbing; portable toilets are set up outside. Generators provide electricity. Patients are tracked via a computer network. Meals are trucked in from well-stocked mess halls on the vast Balad air base, home to more than 20,000 U.S. troops.
On call are four orthopedic surgeons, a neurosurgeon, an eye surgeon, an oral surgeon, a maxillofacial surgeon and two hand surgeons, all with years of experience in U.S. trauma centers. They are backed by nurses, medical technicians, anesthesiologists and radiologists.
The most complex and delicate operations are possible. The day Buchter was treated, emergency brain surgery was performed on an Army master sergeant whose head was lacerated by shrapnel from a roadside bomb. Surgeons carefully removed three ragged skull fragments to relieve brain swelling. The soldier was flown to Germany and on to Walter Reed Army Medical Center in Washington, D.C.
The Balad hospital can do anything that a major medical center in the U.S. can do, except solid-organ transplants such as heart or liver, said Col. Elisha T. Powell IV, the hospital commander at the time.
"I have people fight to get here so they can do this job," he said. "These are the most highly skilled surgeons in the world, and they're doing something that is so righteous. They know they'll never have a chance to do this again their entire life. And they don't want to leave."
About 60% of the patients are Iraqi soldiers, police and civilians, including the very people who set the bombs that kill and wound Americans.
Powell operated on an insurgent who had been shot through the hip on the same day Buchter underwent his surgery. The hospital sometimes treats insurgents in the same trauma room as Americans they have just attacked. Doctors also tend to detainees with serious medical problems; they can be seen shuffling through the corridors in jumpsuits and shackles, accompanied by armed military police.
Troops are often disturbed and occasionally enraged by the treatment afforded their enemy, Powell said. But medical workers say they make no distinctions. They compare treating insurgents to treating wounded cop-killers or drunk drivers in U.S. hospitals.
"You're not the judge or jury in the emergency room — you're a doctor," Powell said. "It's irrelevant to me what a patient's status is. I'm going to do what I'd do for an American."
There is no easy way to deal with the dead, or with those who survive when others have not. The flight crews in the air, and the surgeons and nurses on the ground, are confronted daily with the shifting boundaries between life and death, hope and despair.
Every day, Black Hawk helicopters deliver maimed Americans to trauma bays in the Air Force hospital in Balad, the last four digits of their Social Security numbers and their morphine loads scrawled in black marker on their chests or foreheads. The endless flow of terrified soldiers leaves its own lasting trauma.
Capt. Carl Impastato, assisting a surgeon struggling to save the mangled hand of a soldier, glanced at the slick floor one night and said, absently, "I've stood too many times with my feet in an inch of blood."
Col. Powell, the hospital commander, stared down at bits of road, dirt and uniform embedded in the shrapnel-pocked legs of a sergeant hit by a roadside bomb. "You just don't see injuries like this in the U.S.," he said. He paused and added: "I don't ever want to see injuries like this."
Chavez, the helicopter medic, remembered arriving at the scene of a roadside explosion outside Balad and screaming at dazed young soldiers gathered around severed limbs: "Is this one guy or two?" He remembered, too, trying to keep pressure on the bleeding groin of a mortally wounded soldier, who kept yanking Chavez's hand away.
Sgt. 1st Class Lou Bruneau, head nurse at the Army combat hospital in Baghdad, recalled helping surgeons try to save a critically wounded soldier. The soldier died on the operating table, and Bruneau took the disfigured corpse to the morgue. As he filled out the death certificate, Bruneau realized the dead man was a friend; he rushed back to the morgue to pay his final respects.
"I try not to think about it too awful much," he said of the death and suffering he witnesses.
Sometimes, as Bruneau found, hope and tragedy flow from soldiers wounded in the same attack.
On Nov. 2, a young sergeant with the Army's 101st Airborne Division arrived at the Baghdad hospital writhing in pain. He had been struck by a roadside bomb that ripped through his convoy near Baghdad. Two other soldiers were badly injured in the same explosion.
"Take this tourniquet off my leg! It's killing me!" the sergeant screamed at the medics who brought him in.
His pelvis was crushed. Flaps of meaty tissue drooped from his left leg. The skin around his right knee was peppered with oozing shrapnel holes. His left elbow was broken in two places.
He was naked and shivering under heavy wool blankets.
"Why am I shaking so bad?" he yelled.
"Your body temperature is down from blood loss and shock," a doctor said flatly. He stole a look at the sergeant's pale young face and quickly added: "But you're going to be just fine."
At the trauma room doorway, a medic ran up to Bruneau, whose boots were caked with dried brown blood. The medic reported that a second helicopter had just landed with the other two soldiers.
"They're both FUBARd," the medic said, using military slang meaning fouled up beyond all repair. They were dead.
The wounded sergeant was rolled through the doorway past Bruneau, headed for surgery. His gurney was intercepted in the corridor by his battalion commander, a lieutenant colonel, and by his command sergeant major. Their fatigues were covered with dust. They had just arrived from the battlefield.
The wounded sergeant grabbed the colonel's arm. "What happened to me, sir?" he asked.
"You were doing your job, buddy, that's what happened," the colonel said. "You're going to be OK."
"Everybody else in the convoy OK?"
The colonel looked at his sergeant major, who said nothing. There was a tense, empty moment.
"Hey, we don't know yet," the colonel said finally. "We'll find out for you after surgery."
They watched the gurney roll down the darkened corridor to the operating room, where surgeons saved the soldier's leg and his life.
Bruneau watched it too. "We're going to have to tell him his two buddies died," he said. He stared at his messy boots. "But not yet."
Hospital surgeons say 96% of the troops who make it to Balad survive their wounds. In some cases, skilled surgeons using high-tech tools perform near-miracles. In others, even the most heroic efforts can fail.
Army Spc. Corbin Foster arrived in Balad on Nov. 5 with a hunk of shrapnel lodged a fraction of an inch from his spinal column. A roadside bomb had exploded somewhere behind him, slamming his 190-pound body against the frame of his Humvee and drilling a piece of shrapnel the size of a cigar butt deep into his neck.
Although the wound was life-threatening, Foster, 36, was alert. He calmly listed the futile precautions he had taken to avoid being injured: sitting on the heavy groin protector from his body armor, and tilting his head at an angle away from the Humvee window so that any explosion would not catch him full in the face.
His surgeons were confronted with a difficult decision. The shrapnel would have killed Foster if it had penetrated another few millimeters. Trying to remove it surgically might also kill him, or leave him with serious neurological complications.
Foster could hear the surgeons discussing whether to try to go after the shrapnel. They mentioned the risk of a stroke or hematoma. Foster understood his medical situation. He was the convoy medic, and he had been a hospital nurse before joining the Army two years earlier.
Foster sat up. "All things being equal," he told the doctors, "I'd strongly request that you take it out."
Maj. Greg Wiggins, a neurosurgeon, and Maj. Chris Connaughton, a general surgeon, decided to try to remove the object through microsurgery. The shrapnel had left a remarkably clean wound track. The entry was a perfectly round hole surrounded by a circle of pink welts on Foster's sunburned neck.
In the operating room, Foster joked with the anesthesiologist just before he went under: "If I say, 'Bartender, round two,' hit me again."
One of the surgeons held the wound open with a retractor while the other probed inside with a hemostat. There was a sucking, gurgling sound. Suddenly, Connaughton withdrew the hemostat. Its jaws held an ugly piece of gray shrapnel.
"Nice," Wiggins said.
The two surgeons bumped fists in celebration. They were just five minutes into the surgery.
They flushed the wound, cauterized it, tucked a flap of skin back over the hole and packed it with gauze. It was over. One of the nurses rinsed blood off the shrapnel with peroxide and dropped it into a plastic pill container as a souvenir for the wounded medic.
Foster was promised another souvenir the next day. Lt. Col. Keith Knudson, an F-16 pilot, visited the ward and promised Foster he would drop a bomb on his behalf. The pilot was providing close air support for Foster's airborne unit.
That evening, Foster received an e-mail photo showing a 500-pound bomb marked with a message: "Return to Sender. Yours Truly, SPC Corbin Foster, 101st Airborne."
The next night, medics carrying a critically wounded Marine burst through the rear doors of the trauma room. The young man was unconscious. A roadside bomb had lacerated his spleen and broken his left leg in two places. He was in shock and losing blood.
Surgeons at an aid station had removed the Marine's spleen. They also had stapled his bowel to limit the damage there, and had packed his abdomen with dressing to control his bleeding. The two wounds on the Marine's leg were still bleeding despite a tourniquet and heavy bandaging.
Maj. Alan Murdock, the chief trauma surgeon, examined the wounds. He ordered the Marine taken to the operating room. Murdock had been at the hospital only two months, but he had treated enough critically wounded soldiers and Marines — and emergency room patients at trauma centers in the U.S. — to recognize instantly that this man was near death.
The Marine's blood pressure had dropped precipitously. His pH level — the acid-base ratio in his bloodstream — was 6.6. As his muscle and other tissue died, his blood grew more acidic. A level under 6.8 is usually fatal.
In the operating room, Murdock turned to three anesthesiologists and two surgeons gathered with him around the surgical table.
"If he survives, it'll be a miracle," he told them.
Murdock, 37, has lost count of the number of surgeries he has performed in Balad. He struggles each time to maintain a professional detachment, to separate his emotions from his intellect.
"I try not to think about the patient being a person sometimes," he said later, as he recounted details of the Marine's surgery. "If you're thinking about him as somebody's son, you know, it's very difficult to try to be emotional and yet take care of the patient. It's not possible."
The Marine was being kept alive by cardiac stimulants dripped into his system through a catheter inserted into the vein beneath his collarbone. Murdock ordered blood and fresh-frozen plasma. Doctors and nurses bolted from the room to fetch the fluids from an adjoining tent.
The blood and plasma were run through a machine that warmed the fluids. The Marine continued to bleed, and the doctors and nurses kept running down the corridor for more blood — 10 units in all. Murdock added a clotting factor to slow the bleeding.
Over the next 90 minutes, the Marine fought for his life. An older man, or any man not as superbly conditioned as this one, Murdock thought, would have died by now. He was surprised the Marine had survived this long. His pulse and blood pressure would inch upward for a few moments, then crash back to critically low levels.
The Marine had a heart rhythm, but it was disorganized and soon degenerated into ventricular fibrillation. Murdock and the other surgeons took turns performing intermittent CPR, each man grunting as he compressed the chest. They watched an arterial monitor, which showed the Marine's arterial line rising with each compression but then falling right back when each round of CPR halted.
The doctors carried on for many long minutes, compressing the chest and pumping in more warmed blood and fluids. Still, the Marine was not able to sustain his blood pressure or pulse. Medical technicians rushed into the room with fresh lab results on the patient's blood, and each time the numbers were worse.
The surgeons reviewed their efforts. They analyzed the lab numbers one more time. They looked at the monitor. It showed a flat line. There was no pulse.
It was Murdock's call.
"Is there anything we're missing?" he asked the surgeons and anesthesiologists. "Is there anything else we can correct?"
Each man shook his head.
"Unless anybody objects, the best thing would be to call it — and not continue any further care," Murdock said.
The doctors and nurses peeled off their gloves and scrubs and walked from the room, beaten and drained. Murdock felt miserable and empty. He went to fill out the death certificate and recorded the cause of death: hemorrhagic shock.
The medical technicians stayed behind, surrounded by deflated blood bags and discarded dressings. They gently wiped and cleaned the body of the young Marine for his funeral, for his family, for everyone who had tried to save him.
Lance Cpl. Ryan Buchter, the Marine injured by a grenade, had an air tube down his throat as he lay in one of the Balad hospital's trauma bays. Bandages obscured his nose and eyes. There was tape below his mouth, and the last four digits of his Social Security number were written in black ink across his forehead. He was in shock and still bleeding.
Doctors ordered digital X-rays, then decided that Buchter's leg needed a "washout and redress" procedure to keep the deep wound free of infection, a leading complication in the deaths of troops in Iraq's septic environment. Buchter was rushed into surgery.
Lt. Col. Jim Keeney, an orthopedic surgeon, irrigated the 15-inch leg incision and packed it with gauze. He excised decaying tissue from Buchter's right hand and removed shrapnel from his nasal cavity.
There was a low whirling sound as a "wound vac" pumped blood and fluids from the wounds to help them drain. The fluids gushed through a plastic tube and emptied into a plastic container on the floor.
The surgeon and nurses worked methodically, exchanging instruments and cutting rolls of gauze. Buchter, swathed in blue surgical drapes, his leg tied to the ceiling with muscles and tendons exposed, seemed more like an object on an assembly line than a strapping former football player.
"You always have to remember that this is a person you're working on," Keeney said as he operated, "and what you're doing right now will affect him the rest of his life."
Nurses wrapped Buchter's wounds with fresh dressing, then wiped blood and rust-colored antiseptic from his face and leg. They untied his leg and rolled him toward the intensive care ward.
Buchter remembered nothing of the surgery.
He had suffered serious muscle and nerve damage to his leg, Keeney said. The shrapnel had probably reduced the strength of the limb by half, he said, but Buchter might be able to rebuild it through months of physical therapy.
"The good news," the doctor said as Buchter's gurney disappeared into the next tent, "is that he'll keep his leg."
About This Series
More than 17,000 American troops have been wounded in Iraq since the U.S. invasion in March 2003. This series, which began Sunday, tells the stories of five men injured during the same week last November. Reporter David Zucchino and photographer Rick Loomis followed them through a system of military medical care more advanced than in any previous conflict. Loomis also contributed to the reporting.
In Tuesday's Times: Back home.
Find Sunday's installment, an interactive photo gallery and a reader forum at latimes.com/wounded.
On the Web
Hear the voices of the wounded and of the medical crews working to save them. See an interactive photo gallery. Share your thoughts at a reader forum. All at latimes.com/wounded.
In harm's way
The 16,653 Americans wounded in Iraq from March 19, 2003, to Feb. 4, 2006, were most often white, active-duty enlisted men younger than 25 in the Army. Those wounded:
Marine Corps 32%
Navy/Air Force 3%
24 and younger 48%
31 and older 20%
Active duty 74%
National Guard/Reserve 26%
* Multiple races, American Indian, Alaska Native or unknown
Source: Department of Defense.