Q&A with Chris Coppola, MD
Dr. Chris Coppola, a United States Air Force pediatric surgeon twice deployed to Iraq in support of Operation Iraqi Freedom, expected to care for combat soldiers, but ended up also treating horribly injured Iraqi children, who arrived at Balad Air Base by the dozens. Although the memories of what he saw could not be erased from his mind, he sought release by writing letters to family and friends describing the people and events he witnessed. His letters have been stylized into a New York Times acclaimed memoir: Coppola: A Pediatric Surgeon in Iraq, published by Chicago-based NTI Upstream. Dr. Coppola can be contacted at firstname.lastname@example.org.
Your book is based on letters written during your first deployment in 2005. At the time, did you ever think they would become a book?
I wrote the letters as a way to settle my mind and deal with my insomnia, and as a way of reaching out to touch the people I loved back home. About halfway through the deployment, when people were forwarding the letters on to friends to keep the story circulated, I began to hear, "You should make a book out of this." When I went back for the second deployment, I kept a blog so people could see the letters without me having to email them, and that became the final product covering the whole experience. This was a self-published benefit--a fund-raiser for Fisher House, the Ronald McDonald House equivalent for military families.
Did you have previous writing experience?
I've always enjoyed writing letters when I travel to keep in touch with people back home, but they were the typical tourist things like, "We saw an old church today." This was the first time I'd had something so shocking and vibrant going on around me all the time, so even though I wasn't an experienced writer, the events were so compelling all I had to do was relate it. The story essentially wrote itself. It's probably apparent in some chapters that it's a stream of consciousness from a very tired man trying to get something straight in his mind.
Were there any restrictions on what you wrote? Did you need permission from your superiors?
I didn't ask any permission, but, from the very start, I attempted to censor myself for two reasons. One was for mission safety and operational security--to make sure I never wrote down something that would give the enemy critical information. The other reason is, as a physician, part of my duty is to keep private the suffering and illnesses of the people I care for. I tried to carefully disguise names and conditions because, not only was it not fair to share things I learned at a patient's bedside, but also because the Iraqi civilians who were treated at our hospital were often targeted by the insurgents for being in some way collaborators by coming to get emergency care for their injuries. There was a time when my superiors were critical because I wasn't having my letters reviewed, and from that point on, whenever I sent out a letter I would forward a copy to our hospital commander.
You went to Iraq as a pediatric surgeon. Did you ever think you would see so many children, or did you just expect to treat adults?
I thought I was going to be a combat-support surgeon taking care of American soldiers. I had no anticipation of taking care of children, which was a very ridiculous and naïve point of view. My very first patient was a child. It was always very troubling and shocking for me to have a child die in my care. I lost more children during my 4-month deployment than I had in 5 years of treating children before that. One nice thing about being a pediatric surgeon in the U.S. is that my patients are mostly tough, hardy little kids. There are illnesses like cancer that we can't do anything about, but it's rare when we can't save a child who survives long enough to make it to the hospital. In Iraq, I was seeing child after child suffering multiple serious injuries across all their body parts. In a war time setting, many of these children had been displaced from their homes, so they were malnourished and some had chronic infections, so they were receiving serious injuries at a time when they were already weak. The greater number of children I saw die was because of the nature of those war wounds.
Did you always have an interpreter available?
Any hour of the day I had an interpreter; what I was able to do would have been impossible without one. Our interpreters on my first deployment were Iraqi citizens--most of them young men who had been college-educated abroad and had chosen to throw their lot in with the Americans. Unfortunately, these interpreters' families were frequently targeted for attack. As time went on and the U.S. was able to catch up with some of the needed resources, our military began hiring U.S. citizens with Arabic language to replace the Iraqi citizen interpreters. Frequently, when those Iraqis returned to their own communities they could not live in Iraq anymore because life was too dangerous for them.
You worked in the ER a lot. Could you comment on the work of the field medics and how they interacted with hospital staff?
I'd be willing to bet that a lot of your audience has prior military service, which is where many of them get their medical training and take it back to the civilian world. The reason we had such success keeping alive 97% of the troops who came to us was that the medics--mainly the air evacuation helicopter medics in the Blackhawks--landed while the firing was still going on, scooped up their patients, gave them a trach and a chest tube, and got them to our hospital at Balad within 20 minutes from any corner of the country. I kept alive patients with gunshot wounds to the head and gunshot wounds to the chest, which are injuries I've seen kill patients in the civilian world because of long transport times. Because of the extra piece of prehospital care, we were able to save people we wouldn't have saved otherwise. Your paramedics and EMTs will understand this. It's easy to sit in a hospital OR with everything clean, well-lit and being able to hear. Our military medics do the job in the middle of a dark helicopter with 120-decibel noise, so I'm really impressed with what they do.
Did your own practice change when you returned to the United States?
Absolutely. I've told people I came back from Iraq 10 times the surgeon I was when I went there. For example, I'm taking care of a young man right now who was with family members while they were cleaning an AK47 when it accidentally discharged and hit him in his abdomen. We've taken him through 14 operations, and I think my experience in Iraq has enabled me to keep him alive through that injury. Earlier this year, I took care of a child who had a severe infection that caused gangrene in her limbs, and it required amputating all four limbs. Once again, I think the work I did on the amputation was helped by my experience while serving in the Armed Forces.
What has the reaction been from readers?
It's been very satisfying for me to hear people say, "I didn't know we were doing that. I didn't know we've been able to rescue people with such severe injuries or that we are saving Iraqis." Some of the most rewarding things I hear are from military members' families. One woman wrote to me, "My husband went over there and I was very worried. He doesn't write many letters, and I had no idea what it was like for him. He lets me know he's OK and that's it. I read your book and felt like, 'OK, he's in a place with friends; in a place where he gets a hot meal and a place with roads and cars and Humvees. A place with everyday life.' Just hearing about the details made my mind sit a little easier." To me, that was one of the most rewarding things I could have heard about my book.
Twelve Hour Sleep
I shuffle back to my temporary home and climb into bed. The display on my pager by my head reads 11:00 AM. I plan to sleep eight hours and wake in the evening to stay up all night. Two hours later I open my bleary eyes to the afternoon sun streaming through the shutters. The time stamp on my pager indicates it has been going off for half an hour.
I'm in the ER in minutes. I see three young American soldiers wheeled in, trails of blood splashing across the floor as grim medics rush past the line of beds in the ER. There is blood flowing from the soldiers' limbs, blood seeping through the mesh fabric of the NATO litters, blood everywhere. Abe and Bill quickly go to work. One soldier soon has large IVs in each arm and is receiving an emergency transfusion. The team pulls off the tatters of his clothing and examines him for wounds. One leg is severely damaged, with shards of shattered bone visible; the other leg has several gaping wounds where bleeding muscle shows through bare, pulverized flesh.
The next man looks good, a little shaken up, but awake and strong with good color. I look him in the eyes and ask, "What's your name?" "Adams, sir." His left leg is injured. A fragment of metal entered the thigh on the outside and came so close to shooting out of the inner surface I can see it bulging under the skin. It was so heated from the explosion of their Hummer that a patch of burned skin marks its location. I lift his leg and he cries out, flinching. His femur is broken. I splint the bone, give him some IV fluid and move on to the third man.
The nurses and techs have already undressed him and started an IV catheter. He is hurting but talking. This man is the Hummer commander, in charge of the vehicle when it hit the IED. He used to be a tanker; and after the way his vehicle got shredded today, I bet he wishes he still was. All three soldiers look like they are barely out of their teens. He asks me, "How are my men, Doc?" I tell him I've just come from Adams and he is doing well. He responds, "They are both named Adams." I lie and tell him they are going to be fine.
He is worried that the first Adams in trauma bay II is going to lose an eye; I'm concerned he is going to lose his life. For the moment, it is best to let him think that. It may be the only way he will keep his calm. I look over the commander's injuries. A fragment of Hummer the size and shape of a Swingline stapler is embedded in his right arm. The flesh is torn away, and I can see the shiny ends of his bones where the elbow joint has broken open. At the scene of the injury, this man applied a tourniquet to his own shoulder and then crawled to where the first Adams lay bleeding to death. With his good arm, he tightened tourniquets around both of Adams' thighs. He then kept talking to the soldier while waiting for the Blackhawks to arrive. I give him morphine while putting him through the painful task of removing his uniform sleeve from around the embedded chunk of metal. As the powerful narcotic takes effect, I see his pupils constrict. His speech slows and his responses become drawn. As I work he winces weakly, but I can see that he is protected from the worst of the pain.
Abe is in charge as the trauma czar. He motions to the first Adams and directs, "Get him to the OR and take his leg off." Adams needs an amputation of the left leg, and the wounds on the right leg cleaned. I hurry him into the OR, turn care of the Hummer commander over to vascular surgeon Brent, and get ready to amputate the soldier's leg. I have performed amputations since I was a surgical intern. Often they were on aging veterans who suffered gangrene. The operations were scheduled, and it was apparent to everyone, including the men, that the rotten leg was doing them no good. Amputation was a chance to get rid of a festering infection and shuttle the patients out of the hospital quickly and in better health. However, I have yet to perform an amputation at Balad. Orthopedic surgeons perform most of them, but these patients came in so fast and critically ill the orthopedics had not yet arrived at the hospital.
Looking down at this young man's muscular legs, I see his left leg is blown apart above the knee, attached only by a strip of skin and gristle. I take out a set of shears, exactly like the one I keep in my kitchen to quarter chickens, and cut his leg off with two snips. Larry lends a hand and together we move the man to the table, leaving his destroyed leg behind on the litter. After his skin is prepped with iodine, I find the stumps of severed arteries in his thigh and stop the bleeding. Working quickly and methodically, Larry and I cut away dead chunks of muscle and crack off the sharp shards of his thighbone until the cut end is short and smooth. Sally keeps him alive by pumping blood and warm fluids into his IV catheters. We clean the wounds on his right leg and identify his broken right femur. When orthopedic surgeon Tom arrives I help him use pins and graphite bars to stabilize the broken right thighbone with an external scaffold.
While we operate, Brent brings the Hummer commander with the injured arm to a second table in the OR. Soaked in blood, the tourniquet pinches into his bicep, and metal shards and ends of broken bone jut from the bloody tissue at his elbow. His hand belongs on a corpse. He has held onto his responsibility as long as possible. From his NATO stretcher, he has watched over his men like a hawk, inquiring after their status and directing care to them whenever he could. But now the morphine and Versed are starting to submarine his will. The cords of muscle in his face and neck relax, and he reclines fully for the first time since arriving. As his eyes lose their focus, he suddenly seems much younger, like the recent high school graduate he is. His cheeks and lips soften; his eyelids gently close. Stripped of his uniform and intubated for surgery, he no longer appears to be a toughened commander--just a young kid in a deep dreamless sleep. This soldier who saved the life of the man on the table in front of me needs to have his arm amputated. We cut it off.
Bloody and sweaty, we clean their wounds and wrap their limbs in dressings. All three men survive, and we wheel them to the intensive care unit to await evacuation to Germany.
I suppose I could state the obvious. I thank God these brave men survived what could have been lethal injuries. I am proud that the assembled expertise at our hospital made the difference between sending home corpses in flag-draped boxes and sending home three heroic men with their whole lives ahead of them. Still, I want it over now. Why can't the last death really be the last death?