Sunday, March 31, 2019

I Know Where I'm Going... Just Don't Know Exactly How To Get There


“I know where I’m going... I just don’t know exactly how to get there”... said our Argentinian guide, Diego while reviewing maps with me the night before we kicked off our 4 day trek through a ridiculously remote zone in Patagonia.

Isn’t that just the case?
Poignant as hell.

At some point most of us figure out what it is we are shooting for in life with regards to work, play & love... the challenging aspect is determining how to arrive there.

I know one thing for sure... in order to find that place you’re looking for, you are guaranteed to get lost in the thick forest and have to machete your way through the density.

Then, after the struggle and work pay off and you arrive, you realize that it was in fact that arduous journey that you were seeking all along. The battle is what you were craving. Because it’s the battle that defines us... not the end result.

Thursday, February 14, 2019

Everest By Air




“Trust is the glue of life. It's the most essential ingredient in effective communication. It's the foundational principle that holds all relationships.”
Steven Covey







As I peered out the front window of the helicopter, I could see the bank of clouds powering up the valley right towards us with the look of a massive oceanic wave. A wall of thick, white whip cream that contained enough energy to drop a helicopter out of the sky. The weather in the Himalaya was notoriously fickle. Within minutes I have seen it go from perfect blue bird, T-shirt weather to batten down the hatches, put on every stitch of clothing you have and hang on weather. What I saw coming towards us sure had the look of a game changer. 

Our position at Everest Basecamp (17,200ft) was precarious at best… but absolutely necessary. The young Sherpa climber in the back of the helicopter next to me was waxing in and out of consciousness. He would come to, clutch at his chest, flail about for a minute, and then collapse back into unconsciousness. I was fairly certain that he was suffering from a condition called Prinzmetal Angina. This condition is when the coronary arteries spasm from stress, exertion or other factors. It’s technically not a heart attack, but it sure feels like it to the patient and looks like it to the bystanders.

As I was crouching in the back of the helicopter caring for the young Sherpa, his friends, brothers and cousins all anxiously spectated from just outside the machine, each with deep looks of concern stretched across their sunburnt faces. I’m sure they were confused as to why their otherwise healthy colleague was apparently dying right in front of them. They also seemed to understand the urgent nature of the situation and the need to get him down to a lower altitude promptly and how challenging that seemed due to the imposing weather barreling down on us. 

The weather was shutting down quickly and the patient was deteriorating just as quickly. 

The chaos wheel was spinning pretty fast at this moment and I had a sense that things were going to get worse before they got better.  

*

Six months prior, I received one of those “friend of a friend” calls.  My buddy explained to me that an acquaintance of his was part of a consortium of folks trying to put together the first ever Search and Rescue team to operate on and around the flanks of Mt Everest. They had the budget. They had the Sherpas. They had the helicopters. Only thing they needed was a medic. This medic would have a fairly specific skill set of experiences… great familiarity with Everest and it’s flanks, well versed in altitude medicine and a strong relationship with Nepal and the Nepali people. Oh, and also, this medic would need to be OK with flying around in a helicopter in the largest and most daunting mountain range in the world in ever changing weather conditions all the while working on critically ill and injured patients. 

Check. Check. Check. Check.
What could go wrong?
I’m in.

It’s become a fairly typical routine for me over the years… get an invite for some random, daunting project… deeply consider the consequences for a total of perhaps 2 minutes and then sign up. I’m not sure whether that’s admirable or reckless. Either way, it’s this approach that regularly slaps me down right in the middle of some fairly sticky situations. Perhaps one of the strategies I have incidentally stumbled upon is that if I quickly sign on to a challenging objective, I will then be absolutely forced to immediately take the deep dive into the preparation phase prior to putting feet on the ground.  Agree to go… then worry about all the training and prep after the plane tickets are bought.

Now I had spent over a dozen seasons climbing and trekking in the Himalayas… and I had spent several seasons working Search and Rescue on Denali in Alaska… but flying around plucking sick and dying people from precarious positions throughout the biggest mountain range in the world… that makes for a spicy recipe.

I spent the better part of three months prior to departure honing the skills and knowledge base that I would have to pull from during the rescue season operating in the back of a helicopter. 

I went to my Emergency Department and practiced intubating and starting IVs on a mannequin straddled on a stretcher while a friend shook the stretcher back and forth to duplicate the feel of a bumpy helicopter ride. That scene garnered some laughs from colleagues as they passed by the training room. 

I poured over maps and reached out to many of the guide services that would be guiding clients on Everest that season, inquiring about their climbing schedules and guides. I established relationships with the hospitals in Lukla and Kathmandu where we would be transferring critical patients. I did as much on my end as I possibly could so that when the shit hit the fan, I would be the best version of me as possible. 

All of that being said… there would be plenty of elements that would be completely out of my control.

It’s fairly common knowledge that helicopters are an effective method of transportation, especially in the ‘runway limited’ Khumbu Valley of the Everest region. It’s also fairly common knowledge that helicopters occasionally fall out of the sky. Especially with the fickle and powerfully changing wind and weather patterns of the Valley. Storms come out of nowhere and when they hit, they are ferocious, slapping everything around with complete disregard.

Including hovering aircraft.

I was quite aware of these topics when I boarded my international flight for Kathmandu. I squeezed my wife and kid tightly before I left, all of us acutely aware that the unthinkable was a stark reality. One of the helicopter pilots I had flown with in Nepal during the earthquake medical mission had just recently crashed into the side of a mountain killing everyone in the aircraft. My military friends had lost plenty of brothers in helicopter crashes. Turns out, helicopters crash. 

I promised them that I would do my job the best I could. I promised them I would be very situationally aware and not take any unmanageable risks. I promised them I would assess every situation and limit the amount of exposure to danger… as best I could.

And therein lies the tricky part. 

What might seem like a risk for one person might be a lot more manageable for someone else. My wife and I have slightlydifferent levels of acceptable risk. I made my promise to those I love the most with my optic of risk management as my measure. My wife and I were quite aware that flying in the helicopter would be an integral part of this mission and that this element would be 100% out of my control. We feel better when we are in control, that much is certain. But in order for a team to run at its optimum and most efficient gear, there needs to be a level of trust in the process. An understanding that each of has a particular job and if our rope team is constructed, developed and nurtured with compassion and attention to detail, the ability to give our teammates the breadth to operate objectively will be part of the successful executed process.


*

The young Sherpa sat up straight in the back of the helicopter, clasped at his chest and let out an agonal cry. The benzodiazepine syringe that I was holding in my hand dropped onto the cockpit floor as his arm swung around wildly. I located the syringe and with the help of my Sherpa team, got his jacket sleeve pulled back to expose his deltoid. Only a couple minutes after the jab, the Valium appeared to start to lessen the frequency of his painful attacks. All the while, my pilot Andrew was providing me up to the minute weather reports from the front seat, most of which were bleak as the cloudbank surrounding the bird showed no indication of abating. Our flight path from Basecamp would require us to lift off from the 17,200ft landing pad and make our way down valley in between the gargantuan walls of Nuptse, Pumori, Lobuche and Cholatse. The flying is precise and being able to visually identify the flanks of these beasts was critical. I could hear the slight concern in Andrews voice as he communicated back to me over our headsets. He knew the kid was in grave condition and needed to get down to lower elevations and he knew that our jet-A fuel was dwindling. He was also acutely aware of the ‘rule of the rescuer’… do not put the aircraft or its occupants in undue danger.

Suddenly Andrew called over to me on the headset, “Doc, I see a hole and am going to see if I can get us out of here.”

“We are packaged up back here ready to fly when you are”, I replied.

Ten seconds later I could hear the rotors start to spin with a more furious pace and the turbo began to whine in anticipation of lift off. I reached over and clipped the patient and myself into a couple of the cockpit eyebolts… the only option for security since we always remove the backseat when flying at extreme altitudes to cut down on weight. I felt the helicopter strain to lift up in the thin air and the nose start to point down valley. Although I was facing backwards toward the patient, I took a glance over my shoulder out the front of the helo and saw nothing but dense white. Andrew had made the judgment call and although I could not make sense of how we were going to find our way through the clouds, I was confident in my teammate and his decision making and piloting skills.

After a couple minutes of slow, tense creeping down the valley, Andrew spotted a patch of clear sky and shot right towards it. That clear air took us down to another spot of clear air and another and another until we were down somewhere around the 14,000ft mark with nothing but clear skies out the front window. We made our way to the Lukla hospital and within a few minutes after landing, we had the patient on a bed, hooked up to a monitor with a team of Docs and Nurses working to get him stabilized. He would live to climb another day.

*

When a distress call would statically come over our radios, several dozen variants would come into play immediately. Current weather, forecasted weather, current helicopter position, position of patient, condition of patient, potential landing zone and on and on and on. Although I would contribute to each mission discussion with the pilots, the director of operations and the Sherpas on the ground, my job was to be the medic. Not the pilot (he had his job). Not the Sherpa (he had his job). My job was very specific and had enough of its own critical decision making moments that I could not spend critical bandwidth contemplating the nuances of my colleague’s responsibilities. An effective team relies on the profound trust each member bestows on the others to do their job. Working on high-level teams with many moving parts requires each individual to empower those around you to optimize their performance so that you can effectively focus on your own objective.

*

A week after the Basecamp rescue of the young Sherpa, the morning of May 6th dawned. The heart of the Spring Himalayan climbing season was starting to kick off. Teams were all moving and shaking up their respective mountains in order to be in position for a summit attempt when the jet stream lifted around the end of the month. Knowing this would be a busy time window, our SAR team remained vigilant for the pending distress calls from Everest as well as the proximal climbing peaks in the region. Sometime in the late afternoon we received a call that a Spanish climber was close to death at Camp 2 on an 8,000-meter mountain called Makalu. This beautiful but daunting mountain was a solid hour flight from our HQ over a very high mountain pass. Due to the limited daylight remaining, our options were limited to monitoring the situation and check back in the next morning with the hope that the weather was adequate to fly and make an attempt at retrieving the climber.

I woke on the morning of the 7thand with all of the tension surrounding the pending rescue, forgot that it was my birthday. Our SAR headquarters in Lukla (9,600ft) was socked in with a thick layer of cloud cover and a threat of rain. Our inquiries up the valley where our flight path would take us towards Makalu also came back with patchy clouds and variable wind gusts. Not exactly optimum bird flying weather. The status report we received that morning on the Spaniard was that he was in and out of consciousness and only moderately coherent when he was awake. The folks taking care of him relayed to us that basically he would be dead by days end if not evacuated.

Anyone that has ever worked Search and Rescue would tell you that the first order of business is to never put the rescuer in a compromised position, by doing so, potentially adding to the casualty count. But this is the conundrum of working to save our fellow human beings… by pulling people out of deadly and tenuous situations; the rescuer is by default placing him or herself in potentially harrowing scenarios. What does that risk vs. reward equation look like? 

I stood on the heliport in Lukla discussing weather and options with Captain Nischal KC, the helicopter pilot I was working with that week. He was a seasoned and gifted Nepali pilot that had logged thousands of hours flying all over the Himalaya as well as Europe and North America. The week before, in a display of skill and absolute megaballs, he landed his helicopter in the middle of the Everest icefall in order to rescue an injured climber. No pilot had ever even imagined landing a helicopter in one of the most volatile pieces of terrain on the planet. So clearly I trusted Nischal’s decision making with regards to “go” or “no go”.

Our discussion was based on available collected data. Then all of the data was weighted accordingly. We considered all of the pressing variables: the clock was ticking on this guy… another few hours and he’d be dead. The clouds were thick up valley and behind those clouds were very large, immovable mountains. Unlike an airplane that can operate on instruments alone, visibility is paramount with a helicopter.

Our decision to go or not go was very collaborative. We both asked questions of the other. We were transparent and honest in the assessments we provided from a medical and aeronautical perspective. We had to both be all in to make it a go.

After much deliberation, it was decided that we would, at the least, take off and head up valley with the caveat that if we encountered a situation where the soup got too thick, we would bail and return home. 

Out of Lukla, the going wasn’t too bad… with the cloud bank hanging high in the valley there was a fairly clear path down deep between the cavernous mountain walls.  It was when we crested over the hill into the small village of Chukhung that things got a little spicy. The wind gusts began hitting the aircraft like a rattling Mike Tyson punch, lifting and rolling us back and forth. I could feel my stomach lurch up into my chest like similar to that feeling you get on a super turbulent airplane flight… only by an order of magnitude. The cloud cover thickened to the point where Captain Nischal had to move along at a very pedestrian pace, connecting the dots of clear air.

“It’s just a game of connect the dots” I said.

Nischal replied with a spry, “Yep, connect the sucker holes… with consequences.”

As we continued to fly up the valley gaining altitude, the intermittent flashes of brown terrain below us gave way to snow and then, with a full dramatic entrance, the massive glaciated face of Imja Tse filled the entire window of the cockpit. Fluted ridges dropping thousands of feet from the summit, cresting over massive hanging glaciers… all just a few hundred feet from our helicopter. It almost felt like we could reach out and touch the wall.

Nischal made a deft turn to the left to steer us away from the wall as the sky opened up before us. Just as the bird tilted to the left, Nischal’s GPS iPad that was attached to the front window via suction cup, popped off and clattered onto the cockpit floor and to make matters worse, slid up under his seat.

Now, it’s dangerous enough when this happens while you’re driving down the road in your car; but dropping your handheld device under the seat while you are flying a helicopter at 19,000ft surrounded by Himalayan giants is fairly unsettling. With the collected calm of a seasoned pilot, Nischal worked the yaw peddles and the cyclic stick gently while fishing around under his seat with his right hand… a smile across his face.
“Ah ha!” he blurted as his right arm came up from below with the wayward iPad in hand.

I gave out a weak and ever so slightly concerned, “Oh good.”

“Doc, can you hold this for me so I can see where to go?”

As I held the GPS for the Captain to peer over at intermittently, I could see that up ahead another cloudbank blocked what looked to be our intended path. Nischal clearly took note as well as I felt the bird tilt to the left again. We began climbing even higher now, attempting to find a clear route over the pass and over to the Makalu valley. I could see on the GPS that we had just crested over 21,000ft, tinkering close to the high altitude range of this powerful Astar B3 machine. The thwap of the rotors took on that familiar deep sound as they tried hard to dig into the anemic air.

Then Everest came into view, commanding the skyline… her beauty and majesty belying her ferocity and deadliness. Nischal leaned the copter in her direction and then it appeared; a low cut in the ridgeline with clear air. The Captain aimed the bird over in that direction and I felt myself take in a breath and hold it as we crested over the 21,200ft ridge and quickly dropped down into the clear valley below. 

The flanks of Makalu came into view as we rounded a corner and then, up in the foreground, what I assumed was Camp 2. As we approached we could see dozens of individuals on the ground frantically waving their arms in our direction. Looks like we found our guy.

Nischal gently set the helicopter down on the rocky landing zone and I quickly hopped out to assess the patient. His name was Jesus… yep, Jesus… and he was, as advertised, barely conscious. With the help of a dozen Sherpas, we loaded Jesus into the back of the seatless helicopter cabin and I buckled us both in for what I anticipated to be a fun reverse of the trip in.

Jesus perked up a bit when I started speaking to him in Spanish. He was coherent enough to understand me as I detailed what was about to happen. The flight path, the medicines I was about to administer, the hospital that we would reach in Lukla. He voiced understanding as we continued to gain elevation towards the daunting ridge ahead.

Nischal again repeated the flight path and dropped us down the other side, connecting the dots along the way eventually dropping us down at the Lukla hospital landing zone. Jesus perked up quickly with the sudden drop in elevation and began conversing with me in Spanish, telling me about his family and how this near death event would surely be the end of his climbing career. He was effusive with his gratitude for us and the effort we made to come retrieve him. He was keenly aware of the precarious nature of his condition and subsequent rescue.

I still hear from Jesus on a regular basis as he sends me seasonal photos of him back in Spain with his parents and siblings. 

*

Over the course of my two-month search and rescue stint, every single day was filled with dozens of fluctuating variables, any one of which could be the singular reason a life was lost. It seemed that every day provided a new rescue scenario that carried with it a myriad of mind numbing, mutating factors. Current weather, forecasted weather, current position of ground team, current position of helicopter, current position of the patient, jet A refuel options… and those were just the basics. Then the nuanced dynamics came into play… operational altitude, potential weight of helicopter with pilot/patient/medic, air density changes, snow conditions at landing zone, communications, etc, etc., in addition to patient diagnosis and treatment. Enough to make your head spin.

It’s easy for any of us to become overwhelmed with how so many variables can coalesce and conspire against our best intentions. At times it appears as if each speed bump on our path builds on the previous one until you have what feels like an insurmountable hill of dirt problems. 

In each of our rescue maneuvers that season, I had to calmly but efficiently work through an operational algorithm in my own head… focusing on the decisions that I was directly responsible for, communicating efficiently and effectively with my teammates, and then trusting them to manage their responsibilities; all the while understanding that some of the factors where simply out of our direct control. It was and always will be a matter of applying my bandwidth into the issues that are mine to manage and believing in my teammates that they will perform their tasks effectively.

Rarely a day passes that I don’t reflect on our rescue season in the Himalayas. I think of the patients we rescued: the matriarch grandmother of a small village that broke her back falling 20ft out of a tree. The young Tamang boy that we air lifted from a small village that had an undiagnosed bowel obstruction. The Indian woman that our Sherpas evacuated by sled down from 26,000ft. And of course, Jesus. But mostly I think fondly about my team of Sherpas and pilots who all were dedicated to their jobs and specific skill sets. Two months filled with close to forty rescues, filled with quick decisions, collaborative teamwork, complete with plenty of tense and awe inspiring adventures.

Friday, November 2, 2018

Risk/Consequence Relationship

In the month since I sat with wet palms through a pre screening of @jimmy_chin & his team capturing @alexhonnold climbing off the rocket ship and on to the moon... not a day has gone by that I don't reflect on the layers and optics it took to accomplish that mind bending feat.
For the one fella that is somehow unaware... #FreeSolo documents the journey that Alex took in considering, planning, training and ultimately executing the monumental effort of climbing El Capitan without a rope.
Among other heady topics, the film asks us to consider the risk/consequence relationship. Risk being the chance that something negative will happen and consequence being that negative result itself. Alex showed us that with absolute dedication to a challenging objective, it's possible to mitigate risk, all the while understanding that the consequence will still be profound. The subjective optic we all carry with us provides us each with an opportunity to accept the ratio of risk/consequence. I've done my share of what the world would call 'crazy ass shit'... although it all seemed fairly reasonable to me simply because I was prepared and ready for the task. Although the consequences have been high, I have been able to manage the risk through planning & preparation. Alex takes this strategy to the next level. Dream, plan, train, execute. Repeat. It's a solid learning opportunity for all of us that with enough dedication, we can aim high and manage the risk.
All that being said... I've climbed El Cap and there is no way in hell I'd go more than 10ft off the ground without a rope. So here's to shootin for the moon.
I believe the film is now being shown in theaters around the country and will soon make its way to Europe and beyond. Goes without saying, you should see it... climber or not, you will be required to evaluate what it means to step out into space and consider taking that extra move that scares you.
📸—> @erikweihenmayer and I mitigating risk on the North Face of Mt Athabasca in BC.

Wednesday, September 19, 2018

Teamwork Carry To The Top

Last Sunday was a gift and a privilege. The kind of day that underscores the beauty of a group of individuals coming together to help their fellow human being achieve something big.
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@nerissa_cannon joined a @nobarriersusa event this summer, came away fired up and decided she wanted to climb a Colorado 14er. She was keenly aware that as a high functioning para, she would need to put out a rally cry for a team of folks to help her.
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The community answered her request in full force.
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21 of us showed up predawn last Sunday at the Mt Beirstadt trailhead and over the next 9 hours we assisted Nerissa as she worked her modified off-road chair by pushing, pulling and carrying her and her chair all the way to the summit and back down to cold beers.
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There was laughter, frustration, joy, tears, fatigue, pride, resiliency... all the good ingredients of a solid adventure.
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The most beautiful things take place when we embark on a mission that is uniquely directed at helping someone else achieve their dream.
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Thank you @nerissa_cannon for the opportunity to spend the day with you. What’s next?
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Also proud of @sheepdog_05 who put every bit of his 95lb frame into this mission.
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#beofservice #servantleadership #mountains #mountain #ability #leanintoit #dream #teamwork #teamworkmakesthedreamwork #getoutside #coloRADo #colorado14ers #travel #climbing #climber

Thursday, October 19, 2017

Lessons From Mosul

As soon as the third mortar struck fifty feet outside our trauma bay, we knew ISIS was directly targeting us. The shrapnel shot out at high velocity, a large chunk striking one of our paramedics in the back of the leg sending him to the ground. We all hustled into our makeshift bunker, which was, in more peaceful times, a private home den complete with couches and a table. We listened as the debris rained down on to the corrugated roof outside the bunker. The smell of acrid smoke wafted into our space. In what had been a constant orchestra of small arms fire and explosions all around us for weeks… the entire scene was now eerily quiet.

The first incoming mortar had landed twenty minutes earlier about 100ft from our position. We knew from the sound of the explosion and the rattling of the walls around us that this one was different from the hundreds of rounds that had been outgoing around us for weeks now. This one was coming in and it was close. That being said, we knew we were close to the front line in the middle of a combat zone and random mortars can land anywhere at anytime. We paused for a second and then got back to work taking care of the four or five patients that were prone on our trauma beds… each of them with significant penetrating trauma.

Then 10 minutes later the second one struck… seventy-five feet from our position. Damn.
That was close enough to feel the blast shock. This one sent a ripple of fear through all nine of us. Two incoming mortars within 10 minutes seemed strange.

But it wasn’t until #3 hit that shit got real. It was at that moment that we realized that this was an intentional grid. The mortars were progressively coming closer and the next one could be the last one they needed. We all moved towards the back wall of the “bunker” and a few nervous laughs fluttered up.

Then someone caught sight of several members of our security detail carrying in the lifeless body of one of our special operator security guards. They dumped Asbad on one of our trauma beds and screamed for help.

X

Three months prior, I received a call from Phil Suarez, one of the founders of a world class NGO (non governmental agency) called NYC Medics (www.nycmedics.org). I had met Phil two years prior as I was preparing to deploy with NYC Medics immediately following the devastating earthquake that took place in Nepal that killed close to 10,000 people… more on that later. Phil told me that he had an “interesting” assignment bestowed on them by the World Health Organization and wanted to know if I would use my 20 years of experience as an emergency medicine physician assistant to lead a team of nurses and paramedics. He mentioned something about Iraq… ISIS… Front lines… Combat zone…high volume of penetrating trauma.

Sweet. I’m in.

Turns out, I probably should have asked my wife.

The initial pushback from Merry Beth was pretty heavy. My first pitch to her that I wanted to go to Iraq to volunteer in a combat zone didn’t go over too well.
She knew what she was getting into 14 years prior when she agreed to marry an international mountain guide and she was quite prepared for the biannual, 2 month long climbing expeditions that I typically jaunted off on to the Himalaya or the Andes. But this was totally different and “not cool”.

I explained to her that this would be a unique experience for me to work in a theater that was new to me and would challenge me in new and interesting ways. I would be able to practice high-level trauma medicine for the first time in awhile and would be embracing an opportunity to lead a team in a chaotic environment…. something I gravitate towards.

“That’s all great and exciting, honey… but how about the fact that the most evil dudes in the world would only be a few hundred yards from you and would love nothing more than to kill a handful of Americans that are aiding their enemy. How about that?”

She had a good point.

I passed along to her the same safety criteria that Phil had provided me. I assured her that we would have high level security surrounding us at all times and that we would actually be directly embedded with the Iraqi Special Operations Forces (ISOF). And in fact it was our own US Special Operations teams that trained ISOF. So these guys are the best of the best. High-level operators. No problem. Safe as can be.

The old, “respect my spouse’s wishes but still be true to myself” balancing act. I’m fairly familiar with this particular syndrome… but sometimes it is more profound than others.

Over the next week we discussed the proposition. We brought our 11-year-old son into the conversation and listened to his concerns.  I canvassed several of my Ranger, Delta and SEAL buddies that had all spent time in the “sandbox”. Generally I heard, “Dude, why on earth would you want to go over there? It’s a shitty, dangerous place. Just stay home safe with your family.”

I Googled down the “ISIS in Mosul” rabbit hole to gain some clarity on who was fighting who and why.  I learned that ISIS had swooped into Mosul in 2014 and almost overnight claimed “possession” of both east and west Mosul. At the time there was very little pushback as the Iraqi Army and Federal Police (Fed Pol) were caught with their pants down and provided no push back. Several years later, supported by our own US military, the ISOF and Fed Pol were taking the fight to ISIS in an effort to retake the city of Mosul. The East side of the Tigris River was secured and the Kurds had reestablished it as “Kurdish” territory. Now the Iraqis were fighting to win back their half of the city. We would be embedded with ISOF and providing direct trauma support for ISOF/Fed Pol and the occasional civilian.

My SEAL Team 6 buddy hit me with something that had lasting power. He said, “OK, I know you. I know you’ve already made up your mind that you’re going and there’s nothing anyone can say or do to keep you from going. So, let’s get you as prepared and capable as you can be so that you come back in one piece.”

That was a man that knew how to operated within the scope of realities and that’s why he served in the highest level of warfare and intelligence for close to 2 decades. I will always be grateful to him for his insight and contributions he provided to our teams as we prepared to deploy.

It wasn’t that I didn’t pay heed to everyone else’s advice and input. I valued the opinions of everyone I talked with about it. I chocked away every suggestion and commentary that I was provided, knowing that each tidbit could be useful at some juncture. But the crux of whether to go or not was going to be based on my own personal dive into my motives. As I’ve grown and matured, I’ve learned to do an honest self-inventory on what my intentions are with every action I take. This clearly hasn’t always been the case… especially in my more spontaneous and void-of-consequences approach to my 20s and 30s. I suppose most of us have made this metamorphosis as the years pass. Some of us more expeditiously than others… I’m on the “mid-40s figure it out plan”.

In this case I had to truthfully ask myself… why am I really doing this? Is it to get my thrill-seeking rocks off in some way? Is it to fill some guilty void for not serving in the military when I easily could have? Is it to have more subject matter to write about in a book?

In that self discovery phase (some call it prayer, some call it thought meditation, some call it self inflection… I call it lifting the hood), I will typically find the answer. Sometimes I’ll like it. Occasionally not. And either way is OK. What’s important is to ask those questions.

In this case, I suppose it was a little of all of those posits. But I truly felt committed in my mind that taking on this mission was the right thing to do. That although I felt no particular affinity for the Iraqi people in the way that I do the Nepali, I still felt obligated to do my part to make the world a better place. And that by helping a group of warriors take the fight to pure evil, I could at least contribute in a small way.

Oh… and I kinda wanted to get my thrill-seeking rocks off a bit.

X

Upon landing in Iraq, I was introduced to my team… a collection of highly seasoned New York City paramedics and critical care nurses. Although the personalities varied from gregariously outspoken to quiet and mousey, we all seemed to generally get along, especially once the work began in earnest.

That first evening as we made the drive from the airport in Irbil across the Tigris River over to West Mosul, we entered the combat zone. Multiple Humvees were being dragged and towed back from the front lines, all of them inoperable, blown to pieces. Ambulances screaming away from the front lines carrying the dead and injured. Apache helicopters buzzing overhead firing out dozens of 70mm rocket rounds just a couple miles away. A fleet of trucks with mounted rocket launchers was parked a half mile away, constantly sending off “lob rockets” which were basically 107mm ass-thumping missiles.  We all found ourselves ducking whenever an outgoing round would shake the ground as it fired off.

As we were getting the hand off from the outgoing team, the patients started pouring in. A five-year-old girl got placed on an open trauma bed screaming in agony. I quickly determined that she had a through and through gunshot to the hip. Fortunately it appeared the bullet had missed her vital organs but the pain was absolutely immense. Beside her laid an Iraqi Federal Police officer (a sort of 2nd tier Iraqi soldier) that had also been shot… blood pouring from his leg. Large outgoing rounds continued to shake the building with small arms fire zinging off within a few hundred yards. This was all within 20 minutes of arriving at our trauma stabilization point (TSP).

Welcome to Mosul.

X

The days flew by with dozens of casualties each day, mostly military and a handful of civilians. The fighting would start right after the morning prayer call to prayer. Choke down some oatmeal, sip on some NescafĂ© and watch the firework show kick off. Typically within thirty minutes of the first few explosions we would receive our first ambulance. Gun shot wound to the abdomen. Then another… IED explosion, lower extremity amputation. And another… multiple gunshot wounds to the thorax. And so on and so on.

Our team worked heroically and tirelessly day after day… just as a patient was packaged and moved on to the next level of care or placed in a body bag, the blood mopped from underneath the bed and the equipment restocked… another ambulance would scream in with several more critical patients. All the while… explosions raining out from nearby positions.

After a little over a week of a fairly constant flow of high acuity trauma, the volume started to wane slightly. Although we appreciated a mild respite, we knew we were there for a job and wanted to be in a position to aid as many casualties as possible. And right on cue, the head of ISOF, General Abbas stopped by our trauma base and sat down for a pow-wow with Kathy, our head of logistics and operations. After what appeared to be a rather lengthy and detailed discussion, Kathy gathered up our team and presented us with an option.

The front line was advancing. Although the toll was high, ISOF was pushing ISIS back, city block by city block. If we wanted to be within that 10 minute golden window of saving lives impacted by severe trauma, we would need to move forward to follow the fight.

“How close to the front line?”, I asked.
“500 meters”, Kathy replied.
A collective “Whoa” went up from the group.

Kathy went on to explain that ISOF had identified and secured a trauma base for us in an abandon home garage area and we would be setting up residence in a different home across the street from the trauma bay. Both the residence and the trauma bay would have access to concrete reinforced subterranean bunkers. And now there would be an even higher level of security detail surrounding us 24/7.

The deliberation amongst the team was brief. We knew what we had to do. Twenty-four hours later we were rolling out in a 25-vehicle convoy of trucks, Humvees and Jeeps with all of our medical gear, trauma beds and personal affects loaded up.

Right after pulling up on the street outside of our new digs it became clear to us all… this was different. We were now really in the shit. Now instead of hearing exclusively outgoing rounds, we could now discern the difference between incoming and outgoing rounds. Turns out, impacting ordinance make a much different sound than a round firing off. The rockets that the Apaches were letting loose were landing MUCH closer now. The smells, the smoke and the sound were all turned up to 11. The fighting was four or five solid tee shots away.

A day later we were all set up and patients began flooding in. Ambulances and Humvees would screech up in front of our trauma bay and several soldiers would then carry in semi-conscious and sometimes lifeless bodies and plop them on our beds. We would secure the airway, stop the bleeding and intervene where we had to. In many cases it was enough… in many others, it was not.

Day three rolled around and things started to get weird. Around noon, thousands of civilians started walking down the street away from the combat zone. They had all been log jammed for days several hundred meters away as the Federal Police and ISOF did “background checks” on everyone and even finger printed fighting age males to determine whether they were on a supposed ISIS sympathizer list. Once the gate was opened, an endless stream of displaced locals ambled down the dirt road 100 meters from our position. We watched with a mix of sadness, pity and an urge to help. But I’m not gonna lie, we also felt fear. Our Spidey senses went to full tingle mode with the thought that any of these civilians could run towards us at any moment and wreak havoc with a suicide vest. We did our best to trust the system and focus on the work in front of us.

From time to time a family of civilians would be permitted to walk towards us carrying and in some cases pushing a loved one that had been shot or injured from shrapnel. Often times these injuries were over 24 hours old, and in some cases already gangrenous.

We continued to be vigilant, expressing our concerns to the head of our security team. He dutifully listened and nodded approvingly… but this was a man that had grown up in a war-ravaged Iraq and seemed fairly unimpressed with the proximity of combat and threat. He reassured us that we would be fine and no person would be permitted through the check point unless they had been thoroughly screened and absolutely no civilians would be allowed into our space unless their injuries were life threatening and they had been cleared of weapons.

It was evident that we were experiencing a variation in subjective optics. Haseeb was not sensing that the situation was at all ominous, whereas the Americans all felt like the scene was spiraling out of control, destined for chaos. This discrepancy in perspective is a common occurrence in life and can frequently lead to conflict. Truly listening and being effectively heard both require a deft set of diplomacy skills that are built from years of dealing with complex relationships. In this case, Haseeb was the expert and it was his experience and voice that we would lean on. We just needed him to listen to us and the reservations that we were feeling.

Day four in our forward position dawned after five hours of fitful sleep. I stepped outside the residence with my cup of coffee to take in the scene and greet the security guard, Asbad that was posted up by our front gate. We were exchanging broken Arabic/English morning salutations when a civilian male came running through the security perimeter with a lifeless little girl in his arms. The team quickly mobilized and ran across the street to the trauma bay where the little girl had been laid down. The father was inconsolable. His daughter had been shot in the back of the head by an ISIS sniper 20 minutes prior as they were fleeing for the safety of ISOF controlled terrain. There was nothing we could do. I will never forget the sound of the fathers wailing in what can only be imagined as the worst scenario any parent can ever imagine.

I stepped away from the bed and for the first time since arriving in Iraq, I cried. It felt as though I had placed a restrictor cap on my emotions in order to operate effectively in such a chaotic and violent atmosphere. And now I had to let it out. But not for long. I wiped away the tears as the first Humvee screamed around the corner and dropped two patients at our door. It was 7:30am on a Tuesday.

Early afternoon hit and the fighting seemed to intensify. Dozens of patients came in and out… with a high level of immense penetrating trauma.

Then the first mortar struck. We flinched.

Mortar number two slammed down 10 minutes later. We cringed.

Mortar number three exploded 50 feet away and we knew that we had just crested in to the realm of directly being targeted. They knew we were there and they were coming for us. As the debris was still raining down on the tin garage roof, we all took refuge in the bunker with a clear view out in to the trauma bay and the entrance to the street.

Smoke still hung in the air as I noticed a group of soldiers carrying what appeared to be the lifeless body of another soldier. They were screaming “Musaeada! Musaeada!” Arabic for “Help!”

Even from 10 meters away I could recognize the face of the limp body they were carrying. It was Asbad and he appeared to be dead.

It was one of those moments when everything slows down and becomes very still. Although chaos is raining down from every angle, the optic with which you are viewing the scene becomes quiet and clear. I’m familiar with these moments. I’ve experienced them in the big mountains of Alaska and the Himalaya. Essentially, life gets distilled down into a basic question… go or don’t go. We stay in the relatively safe confines of the bunker and wait out the barrage or we charge out into the maelstrom and execute the job we had been tasked to do.

The smoke and dust hadn’t even settled from the mortar strike. The sounds of screaming and small arms fire were bouncing around under our corrugated roof adding to an extremely hectic scene. Without a spoken word, the team moved in unison through the door of the bunker up into the chaos. We surrounded Asbad and quickly began assessing his condition. He had a faint pulse, pale skin, muted respirations and was completely unresponsive. He was, for all intents and purposes, dead.

After he was stripped down, I identified an entry wound on his upper right chest. It wasn’t particularly large but with the limited breath sounds from that right lung, I was suspicious that he had what’s called a hemothorax. This condition is a build up of blood in the pleural space (lung cavity) that ultimately inhibits the lung from fully inflating with respirations.  In this case, a piece of shrapnel from the mortar had pierced Asbad’s chest wall and caused massive amounts of bleeding into the space where his lung would typically expand.

The prognosis for a profound hemothorax? You die.

In an acute trauma scenario the treatment for this condition is to cut a whole into the chest cavity, place a tube inside the pleural space and drain the blood out so the lung can get back to normal function. I quickly cleaned the space between Asbad’s 4th and 5th rib and grabbed a scalpel. I made the incision, inserted my finger into Asbad’s chest cavity and immediately got doused with at least a liter of blood as it evacuated all over me and on to the dirty concrete floor.

Like the scene from Pulp Fiction when Uma Thurman’s character sprang to life, Asbad dramatically took his first full breath in several minutes as the blood dripped from my elbow.

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The shit is gonna hit the fan. That much we know. Things go sideways all the time. As simple as a flight being cancelled and not being able to get home for dinner or as paradigm shifting as receiving a Stage IV lung cancer diagnosis at the age of 45. Life is full of chaos, change and adversity.


Every day that passes for each of us, we broaden our scope of how adversity and chaos can provide us an unadulterated butt whoopin. How we operate in these situations and environments is a direct cross section into who we are as individuals and teammates. It’s not about being super tough in the face of adversity or hiding your fears from those around you. Real situations call for real emotion. Hiding or faking emotion can ultimately backfire and leave us gasping for air at critical junctures. It comes down to manifesting forward movement while still in the realm of uncertainty. Allowing the focus to be on what can be done as opposed to what can’t be. Nurturing the good in the situation instead of allowing the dark to soak up the momentum. If executed effectively, growth is guaranteed.

Thursday, March 16, 2017

Being of Service On The Front Line


Tough to know where to begin.
I'll start with stating this has been potentially the most intense week of my life. And those that know me understand the magnitude of that statement.
I can provide the synopsis here. It will take months to process and effectively document the experience and all that came with it.
As I commented at the beginning of the week, we moved up towards the front line as the Iraqi Special Forces continued to push ISIL back. We were told we would be as close as possible to the fighting but still have at least a 2km buffer. Although this is short of organizational policy of 5km, our team unanimously agreed to accept the implied danger. For reference, US military trauma units are mandated to be 15km from front line conflict.

We settled into our house and established our trauma bay across the street in a garage bay. The mortars and small arms fire were now over our heads and the house and ground would regularly shake with the larger explosions. Not 10 minutes would pass without gunfire or explosions. 24 hours a day.

We were surrounded by Iraqi special forces with humvees blocking each entrance to the road in front of our house/clinic. The neighborhood was mostly evacuated. The General of the ERB group posted up on our same block. We felt vulnerable but relatively safe.

The volume of critical patients was steady. We treated dozens. Most were salvageable. Occasionally we took cover in a subterranean reinforced basement as debris rained down on our tin roof.

Then yesterday happened.
The exodus of displaced locals began. Thousands of Iraqi civilians began filing down the street just 100 meters away from our clinic. Many of them needing care but all posing a security threat to us and our location. The security team did their best screening critical civilians and sending the rest down the road to some unknown location. The tension level went up as civilians were delivered to our trauma bay on wooden carts and broken wheelchairs. 

Right out of the gate we lost a civilian little girl... the absolute barbarism shook us all up.
Then we got a save on a civilian with extreme mortal injuries. Without providing details, he was hanging on... and out. But we stabilized him, packaged him and he will live.

Then it began.
The front line began to pulse back towards us. A mortar landed in the yard next to us which we would later come to find out was a locator.
We had been outed.
Someone, we are unable to confirm who... most likely a civilian passing by or glassing us from close by, passed our location on to ISIL and they began targeting us directly. The mortars started dropping in... each one closer. They had a bead on us and would have loved nothing more than to take out a group of Americans caring for their enemy.
The big one hit on the sidewalk just outside the gate to our house. One of our paramedics caught a piece of debris in the back of the leg. We took cover. 30 seconds later our security team carried in the soldier that was posted in front of our gate. He was lifeless.
Our team moved quickly on to him as heavy fire rained around. We decompressed his chest, threw lines in him and I placed a chest tube, which immediately improved his situation.
Two of our medics loaded him into the ambulance with blown out windows and screamed out of our location to a military OR. We all retreated to the basement and held tight as the mortars landed in our yard.

2 hours later we evacuated in the blown out ambulances and returned to our first location well out of mortar range. We built a little fire in the yard and sunk down as the adrenaline oozed away.

Prior to finally laying down around 11pm we set up 3 beds and our trauma rolls... thankfully.
We were awakened at 3:30 this morning. A massive IED had gone off a couple miles from our forward house. Eight ERB soldiers were killed. We began receiving ambulances in succession. Several amputations and shrapnel wounds. All will live.

I tried to go back to sleep a  couple hours ago but it's useless. Tough to slow down the mind at this point.

We will re establish our trauma bay at a new location tomorrow. Further back. The new team arrives Sunday. We will set them up for success. I go home on Monday. And I will rest.

I am honored to have served with this team. So talented and committed. An absolute privilege.

Hug your loved ones. Be compassionate. Be generous. The world needs more of that.

Addendum.... just got word they caught the local guy that was calling in the mortar strikes to ISIS. Dude lived 3 houses down from our house and was releasing pigeons to alert the ISIS mortars to our exact position.
He is in custody now in our former side yard. I saw a photo of him. He has a bag over his head. I am told he will be dealt with accordingly. That makes me happy.