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.


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 ( 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.


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.


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.


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.