*In the not-too-distant past, I was deployed as a Dustoff flight paramedic to Afghanistan. The events below happened on my first point-of-injury (POI) mission. This was our first week on duty, and the second mission of my career. The specific locations, dates, and crew member names have been omitted intentionally to respect the privacy rights of the patients.

“Medevac-Medevac-Medevac!” Our operations sergeant announced a 9-line medical evacuation request just after midnight.

The paradox of working in Dustoff is that nobody wants to see a fellow soldier wounded, but we also relish the challenge of a mission. Primitive human neurochemistry is designed for warfare- slinging clubs and running at full speed. Adrenaline and cortisol are for mobilizing energy and extreme physical exertion. They are ruinous for fine motor skills and critical thinking. Combat, these days, whether you are a medic, fighter pilot or defusing bombs, places survival demands on us that are a lousy fit for our legacy neurochemical milieu. When woken from a deep sleep, we do our best work. The adrenaline devours the fatigue, and the fatigue devours the adrenaline. Perfect balance.

I dressed and grabbed a printed copy of the mission details. The aviation mission commander (AMC) was there getting a copy as well, per procedure. The helicopters were being prepped for mission launch by the crew chiefs and co-pilots. I heard the pop of the auxiliary power units followed by the whine of jet engines. We flew two Dustoff helicopters on all missions. No gunships. I ran to my helicopter and donned my armor, flight vest, helmet, night vision, and gloves. Always in that order. I climbed in to the left crew seat. My medic partner was seated on the back wall. The crew chief announced “droops out” and climbed in, buckling into his harness as we lifted off into the dark night. I turned on a blue pen light and looked at the mission sheet for the first time. Two Afghan Army soldiers were wounded while on a partnered patrol with the Italians. The pilot announced we were 20 minutes out and we started to make plans. We would only land the “first up bird.” Since we had two medics on board, we would be able to treat both while the second up bird flew cover and surveillance. The visibility was poor because of lingering dust in the air from high winds in the early afternoon. Over our headsets we heard radio reports of more casualties. It was not clear whether or not the Italians and Afghans were still involved in an active fight or if the original report was simply inaccurate. We never know why. Most of the time we never even know the identities of the patients – especially when they are Afghans.

We landed in a wide, dry river valley. Our tail almost hit an artillery piece that we could not see until it was too late. Once we were down, the pilots gave us the signal and I hopped out of the left hatch. My headset was switched to my radio.

The terrain was like moguls. I looked back through my night vision goggles and saw my partner walking like Frankenstein over the rough ground. It struck me as odd, but realized he had put on his boots without lacing them, then zipped into his flight harness. The harness is so tight that it’s hard to bend over and touch your feet, so he was walking like that to keep his boots from falling off.

I met an Italian officer who shouted to me and pointed at the patients all lined up neatly. A little farther back, there were a dozen body bags laying in a row. The officer was all alone and the rest of the force was over the ridgeline engaged with an enemy force of unknown size. He called for litter teams over his radio and some men appeared out of the darkness and asked which patients I wanted first. This didn’t seem like the time or place to do triage so I pointed to the first three and gestured to load them up. Once loaded, we discovered the European litters lacked collapsible handles, so the sliding doors of the Blackhawks could not close. We dumped the Afghan soldiers onto the deck of the helicopter and hastily put them on our own.

Switching my microphone back to the crew internal, I told the pilots to land the second up bird. After taking off, the pilots turned hard right to avoid the ongoing battle. We realized that none of our patients had been treated at all. Most patients we receive have already had excellent care by the ground medics – often so good that the flight medics have little to do besides provide pain control and monitor their vitals. These men had received nothing.

We stripped their clothes with trauma shears. The patient closest to me had mangled lower legs. I placed tourniquets on both legs above the knees. I didn’t see any other injuries so I stepped over him to reach the man in the middle. He had a penetrating chest wound. These are rare with American and European soldiers. The body armor usually prevents that. Most Afghans don’t have armor. I placed a chest seal on his wound, checked for an exit wound. He had no other injuries and he was breathing adequately. I placed a finger probe, oxygen sensor on him. When I stepped backward, I stepped on the other Afghan soldier and he shouted loudly enough to be heard over the engines and blades. His pulse was strong and rapid. He was alert. I gave him a morphine auto-injector in the left buttocks and tossed the syringe out of the crew window.

The flight home was fast. Usually after landing, we stay and assist the surgeons. This time, we gave the patients to our off-duty crew members who loaded them on ATVs for a short ride to the surgical center on our small base. When our captain, who was one of the off-duty pilots, grabbed my first patient, pieces of bone and flesh trickled off and down the open ends of his unlaced boots.

During our offload, the pilots topped off fuel. I grabbed some more litters from the side of our billeting and we returned to the battlefield for the last three patients. Upon arrival, there were only two. I asked the Italian officer where the third man was. He did not understand. While pointing to the two men laying on litters I said “uno, duo, …???” He understood my hand gestures to mean “where is the third guy?” He pointed to the stack of body bags and said, “Oh, he a dead man!” For reasons I can’t explain, it struck me as funny. He sounded like the Borat character.

These two men had received medical attention by the time we returned. I only remember one of these patients because his tourniquets were placed incorrectly. One was high near his hip, then the second was placed above the knee. His entire thigh was swollen and tight. I loosened the top one and slid it down to touch the bottom tourniquet and retightened it. He was in pain. I started an IV and gave him morphine every 10 minutes. Our small surgical team was overwhelmed with the first six patients so they requested we take these guys to another base farther away. Once the last two patients were unloaded, we finally flew back to our base. The sun was up and it was starting to get hot. We noticed blood all over the floor of both Blackhawks.

The flight medics walked up to the surgery to lend a hand. Most of the amputations were already complete. We did not have an ICU or the staff to watch six patients for more than a few hours. We received a mission to transport the patients to a larger base. Luckily, a sister platoon was already heading in our direction to relieve us so we would be done flying for the day. I received a radio call that our sister platoon had landed and to prep the patients for movement.

A Spanish Army nurse came and handed me a large biohazard bag to give to the other platoon. I asked in Spanish, “Que es eso” (What’s this?). She said, “Esos son piernas” (These are legs). I switched to English, “Why the fuck are you giving me a bag of legs?!!” She explained something about Muslim customs and burying body parts. I said, “okay” and grabbed the bag. We took the patients and the bag of legs to the helipad where our sister platoon was waiting for us. We helped them load the patients and I handed the bio-hazard bag to a junior medic. He asked, “What’s this?”

“It’s a Bag-O-Legs,” and I laughed maniacally. True story.