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Life and Death in the War Zone

An American combat hospital mobilized in Iraq faces a daily drama of wartime treatment. Airing March 2, 2004 at 9 pm on PBS Aired March 2, 2004 on PBS

Program Description

While other reporters were embedded in fighting units during the Iraq War, NOVA was covering the emergency medical response, living night and day with the doctors, nurses, and medics in a frontline Combat Support Hospital (CSH). The program captures a period of the conflict in April and May of 2003 when CSH units faced a deluge of injured Iraqi soldiers and civilians who had little support from their country's collapsed health-care system.

Transcript

Life and Death in the War Zone

PBS Airdate: March 2, 2004

NARRATOR: During the conflict in Iraq, the U.S. military could claim at least one undisputed victory: wounded American soldiers survived their combat injuries in record numbers. In Vietnam, one out of every four wounded died. In Iraq, at times, the number would shrink to one out of seven.

Much of the credit goes to Combat Support Hospitals, or CASH units, which provide state-of-the-art emergency medical care to the troops.

COLONEL JOHN POWELL, M.D. (Commander, 10th Combat Support Hospital): The CASH evolved out of the MASH. I mean, most everyone has seen that television show all over the world—MASH stands for Mobile Surgical Hospital and CASH is Combat Support Hospital. The hospital itself is really geared towards surgery, um, towards battlefield surgery.

NARRATOR: These advanced medical centers are transported in containers and can be set up just about anywhere.

SERGEANT WRINKLE: Basically, what we're setting up is a 44-bed jump package. It is a basic CASH, which is a Combat Support Hospital. Once a casualty is injured on the battlefield they'll fly in via medevac. From the ambulance they'll be brought here to our front door, which is our E.M.T. tent.

DOCTOR: Blood pressure seems to be normal.

SERGEANT WRINKLE: From that point they'll then go into our O.R., our O.R.. ...they'll be prepped.

DOCTOR: That's a big hole, whatever the hell that is.

DOCTOR: My middle finger's what's holding it.

SERGEANT WRINKLE: They'll go into O.R. for surgery. From that surgery they'll then turn around and go to our I.C.U.s, which is our intensive care units.

NURSE: Okay, perfect.

SERGEANT WRINKLE: From that point, they'll then be medevaced and go back to the United States.

NARRATOR: During the Iraq war, five CASHs were sent to the region. One year later, NOVA looks back at the experiences of two of these units.

They had trained to take care of over 200,000 Coalition troops. But what they encountered would test their training and shake their beliefs in ways that they could never have imagined.

DOCTOR: ...maybe two other civilians on the way in. They don't know their status.

NARRATOR: Life and Death in the War Zone, right now on NOVA.

NARRATOR: Five weeks before the start of the Iraq war: at their base in Fort Carson, Colorado, the elite 10th Combat Support Hospital, or CASH, has spent months preparing for a mission to attack Iraq through Turkey. About 550 people, doctors, nurses, technicians & support staff, will uproot their lives to face an unknown danger.

Colonel John Powell is commander of the 10th CASH. A doctor and a paratrooper with a long combat resume, he's trained to practice medicine under battlefield conditions.

COLONEL JOHN POWELL, M.D.: This CASH, is a 296 bed hospital, okay? It's just like a mortar and brick hospital up on the hill, but everything is under tentage. We have gynecologists, we have a dentist, we have a facial surgeon, we have people who can take care of eyes. I mean, we have infectious disease specialists, we have internal medicine physicians. We have to be able to do all the same things that a regular hospital does. But surgery is our main focus, 'cause during battle time, that's the big piece we want to make sure we know how to do.

MALE SOLDIER: Hospital, attention!

MALE SOLDIER: If we've got to call today, where could we call you?

COLONEL DAVE LOUNSBURY, M.D. (Deputy Commander, 10th Combat Support Hospital): Colonel Powell? How about Colonel Powell's cell phone?

MALE SOLDIER: Oh, perfect.

NARRATOR: Powell's second in Command is Colonel Dave Lounsbury. Based at Walter Reed Medical Center in Washington, Lounsbury is the editor of the Army's combat medicine textbooks. Like most military doctors, he joined the service to pay his way through medical school.

COLONEL DAVE LOUNSBURY, M.D.: If you had said to me, when I finished medical school, that 24 years from now you'll still be wearing a uniform and in the service of the Republic, I would have just howled with laughter. I had no intentions whatsoever of making a career out of this—none.

FEMALE SOLDIER: Leave this BAND-AID® on for about 24 hours.

NARRATOR: These doctors and nurses normally work at military hospitals, with jobs just like their civilian counterparts'. Now, on the eve of war, they're supplied with more than just stethoscopes and scalpels.

Most have had limited experience handling any weapon since basic training.

FEMALE SOLDIER: I'm getting an M16.

COLONEL DAVE LOUNSBURY, M.D.: What in the name of sweet Mary and Joseph is a surgeon doing with a holstered nine-millimeter pistol? Why does an O.R. nurse have an M-16 rifle? Incongruous? For sure it's incongruous. Do they feel comfortable carrying a weapon? I think many of them do not—I, first and foremost. I'm not quite sure I know which end of the pistol the bullet comes out of. And I'm sorry you weren't here to see my target practice a couple of weeks ago.

SERGEANT CHRISTIAN RAMIREZ (Chemical Protection Specialist): Nine seconds for your mask and eight minutes for your M.O.P. suit.

NARRATOR: The entire staff has to practice protecting themselves against chemical warfare, at this point considered a real risk. They are preparing to treat mass casualties on a contaminated battlefield.

Sergeant Christian Ramirez, a paramedic, is an expert in chemical and biological weapons.

SERGEANT CHRISTIAN RAMIREZ: A lot of the doctors are very knowledgeable about the effects of the actual agents, biological and chemical, and how they react with the body. But as for actual hands-on training, they're not as familiar as, like, soldiers of the CASH that are here on a permanent basis. Now's the time to get them ready.

COLONEL JOHN POWELL, M.D.: I think the fear of the unknown's the worst piece of it. And I think there's always, in the back of your mind, even though this is a hospital, there's always the potential that something could happen to the hospital, and we'd have some people in the hospital get hurt or even get killed. And I know my children are very concerned about what's going on, and I know my wife is, too.

NARRATOR: Sergeant Ramirez isn't worried about leaving his family behind; he's married to another member of the 10th. The couple will be going to war together.

SPECIALIST CHRISTINA RAMIREZ (Preventative Medicine Specialist): We dated about four months, which is kind of short, but, we kind of...we've been inseparable since we did meet, so...and we just went to the Justice of the Peace for now. We hope to have a nice ceremony later, but since all this stuff came up, then...

SERGEANT CHRISTIAN RAMIREZ: But when you stop to think about the reality of, what can real...what can happen, it's...you don't want to go into that. I mean, I don't want to get shot. I don't want her to get shot, you know? I don't want any of my friends to get shot. I don't want to see, you know, 18-year-old boys, coming in missing limbs, you know? Bleeding from bullet wounds, and... But, at the same time, you know I do want to go. I'm scared, but it's not going stop me. I'm, I have a mission, and that's my focus.

COLONEL JOHN POWELL, M.D.: Their training is complete. They know what the briefings are about terrorism and about personal protection. And they know how to get their MOP suits on. And they have been issued all the gear they'll need to take with them. So basically, they're ready.

NARRATOR: But on the 3rd of March, after three months' intensive preparation, the 10th CASH's mission is put on hold when Turkey refuses access to American forces.

ARI FLEISCHER (White House Press Secretary): There's no question that the Turkish approach would have been a preferable approach, but other approaches are available. There are other options, from a military point of view, and the President has every confidence that those other options will indeed be militarily successful.

NARRATOR: The 10th is forced to watch the first advances on television. Finally, the unit is assigned a new mission, to support the army invading from Kuwait.

COLONEL JOHN POWELL, M.D.: Take your seats. Everybody's got questions about the mission. So do I, okay? Everybody remembers Somalia and what happened when you get a small group of people who are really determined to keep you out, okay? Now, I suspect those folks are all right, that's home for them. It ain't for us. All right? Thanks again for all your attention and for your smiles and your patience.

NARRATOR: On the 30th of March, two weeks after the start of the war, the 10th Combat Support Hospital leaves for the Gulf. Despite all their preparation, what they encounter will be completely unexpected. In the first two weeks of the war, it's already clear that U.S. casualties are relatively light. As American troops take Baghdad on the 9th of April, there have been 87 U.S. soldiers killed, and a few hundred wounded in action.

MALE SOLDIER: Turn round, kneel down.

NARRATOR: The survival rate for the coalition wounded is high. For the first time, ceramic body armor is worn by most combat troops, and total air supremacy means any casualties can be quickly evacuated.

News reports reveal the appalling conditions of the Iraqi health care system. They have no power, no water, no drugs, and the morgues are overflowing. The little that's left is taken by looters as law and order breaks down.

While the 10th CASH waits in Kuwait, another Combat Support Hospital, the 21st, based at Fort Hood, Texas, gets the order to enter Iraq.

Even though Baghdad has fallen, skirmishes and ambushes are common along the way.

CAPTAIN MICHAEL REYES: All right, my mission is to get you up north 100 miles, approximately 100 miles north of Baghdad, in a safe and sound manner, so you can execute your mission. Cool?

NARRATOR: Major Chris Niles, an anesthesiologist, has left a wife and two daughters back in Florida. He's relieved to finally have a mission.

MAJOR CHRISTOPHER NILES, M.D. (Anesthesiologist, 21st Combat Support Hospital): There's a lot of opportunity for us to do some good to help the people here of Iraq, 'cause it looks like they've been just brutalized and had no health care, no infrastructure. And I think there's going to be a chance for us to really help a lot of people. So I'm definitely looking forward to it, getting back and doing my job.

CAPTAIN DALLAS WALKER: All right, let's pray. Our gracious eternal Father, at this time, we do need to call upon you to watch over each one of us. For we have a long journey ahead, oh, Lord. And yet we understand that you have already marked out that path for us. And for that we are eternally grateful to you. God bless us. Protect us in your holy and precious name, Amen.

NARRATOR: Without any escort, the staff of the 21st CASH heads for a captured airbase in Balad, northwest of Baghdad. The three-day drive takes them through the heart of the recent fighting.

At rest stops, the CASH has its first contact with Iraqis, civilians begging for food and water or trying to trade bundles of the local currency for a dollar.

For Captain Suki Quattlebaum, a nurse, it brings back painful memories.

CAPTAIN SUKI QUATTLEBAUM, R.N. (Ward Nurse, 21st Combat Support Hospital): I was born and raised in Korea, right after the Korean War, and things were very scarce. Water and food was very scarce. And when I see these kids, they remind me of when I was growing up. I was doing the same thing in the street, begging for food and water from G.I.s. And they were nice enough to throw out chocolates and candies and water, and they just made my day. So it gets very emotional when I see these kids. So my heart breaks when I just pass by them without giving them anything, because I know that was me. That was me.

MALE SOLDIER: All right. If you don't know, we're about to go through Baghdad. If something were to happen, you need to be divided into two sections. If we need to fire, this side will fire towards your side, and this side to that side. Let's not crossfire. It's not a nice thing. All right? Keep your KEVLAR® on, stay down, and hopefully nothing will happen. Stay safe. God bless. Here we go.

NARRATOR: The 21st CASH is split into two units. The smaller unit goes to northern Iraq, while the larger section will set up here, at the Balad airbase.

The hospital is packed inside 48 milvans, or military containers. The CASH has just three days to build a 44-bed hospital from what's inside them. As a sandstorm whips up around them, they mark exactly where each tent will go.

The hospital will be made up of interconnecting tents and hard containers, which fold out to form rooms and wards. Once everything is in the right place, the priority is getting the emergency medical treatment sections set up. Medical workers become construction workers.

SERGEANT FIRST CLASS RENALDI TOLEDO (Senior Medical Noncommissioned Officer, 21st Combat Support Hospital): Take it all off.

NARRATOR: The man in charge is Sergeant First Class Renaldi Toledo. A senior medic with 22 years' Army service under his belt, Sergeant Toledo was just two weeks from retirement when he was mobilized to come to the Gulf.

SERGEANT FIRST CLASS RENALDI TOLEDO: What we're doing here is we are erecting the Emergency Medical Treatment section, very much the equivalent of a civilian or military fixed facility emergency room. Once we get started, once these milvans hit the ground and we crack the doors open, we have 72 hours to receive patients.

MAJOR CHRISTOPHER NILES, M.D.: After this goes up, then we'll start setting the operating room up, and then the nuts and bolts of the hospital will start falling into place after that. So this is a big step for us. I mean, this is great. We can start seeing patients soon.

NARRATOR: The operating room is in one of the containers that folds out to form a space three times its original size.

MAJOR JOSEPH ENDRIZZI, M.D. (Urologist, 21st Combat Support Hospital): This is our operating room suite, and there'll be two operating room tables where we can do two surgeries simultaneously. This is all a positive pressure environment, which means clean air is pumped into here, so that none of this surrounding dust gets in there. It's going to be a nice, sterile operating suite.

NARRATOR: But this is still dangerous territory. During the night, the base comes under attack. After a sleepless night, many are trying to recover from their first encounter with hostile fire.

FEMALE SOLDIER # 1: I'm in denial right now.

FEMALE SOLDIER # 2: ...trying to pretend it's something else.

FEMALE SOLDIER # 1: Yeah, it's just firecrackers.

FEMALE SOLDIER # 2: It's getting louder, but we're, we're in denial so we don't get freaked out.

FEMALE SOLDIER # 3: I'm not too worried personally, 'cause I know it's off of the gates, and there are guards up there. I'm not worried. It'll be dealt with.

NARRATOR: The CASH's sleeping quarters don't provide much protection from enemy fire or from the elements.

FEMALE SOLDIER # 4: ...roughing it like we never have.

FEMALE SOLDIER # 5: They like to tell us that we're in austere conditions, but I don't think I was really expecting it to be this bad, where we're not even going to be able to describe to our family and friends how bad it really is here.

FEMALE SOLDIER # 4: Mosquitoes everywhere.

FEMALE SOLDIER # 5: You can be covered up, in your sleeping bag, with your sleeping bag over your head, the dust got in, the dirt got in, and the mosquitoes got in.

FEMALE SOLDIER # 4: Half a mile walk to the bathroom again, in the middle of the night with ditches everywhere...good times.

FEMALE SOLDIER: Yeah.

FEMALE SOLDIER: Yeah.

NARRATOR: All the living conditions are primitive. The latrines are nothing more than a public hole in the ground.

MALE SOLDIER: You've got a couple of techniques. One is facing the lumber and hanging off over the backside, and the other one is with your backside to the lumber trying to shoot between those slats. And you can see some people have had a little trouble with their aim.

NARRATOR: In time, the 21st will get proper latrines, showers and laundry facilities, but creature comforts take second place. The priority is getting the hospital ready to treat casualties.

Even the senior surgical staff help get the O.R. up and running. After 48 hours the different departments are starting to take shape. Colonel Bob Lyons is a plastic surgeon. In times of peace, he specializes in breast reconstruction following mastectomies; at the 21st CASH, he's the senior physician.

COLONEL BOB LYONS, M.D. (Deputy Commander for Clinical Services): Right now, we're in our emergency medical section tent. This is where most of the acute injured patients will arrive. Then they'll be assessed by our, our emergency medicine physicians and prepared for surgery if they need surgery, or sent to the ward if they are just, uh, medical patients. This is on line with the main line of the hospital. As you pass through this line, the next thing you'll see is the pharmacy being set up off to our left. It's right off the main section of the hospital that's accessible to the emergency section, the operating room or the ward sections for whatever medications the patients may need. We have everything a standard hospital would have. We have anesthesia, we have surgeons, we have nurses. We have an emergency room, we have a laboratory, we have...there is no difference for all intents and purpose.

NARRATOR: By the afternoon of the third day all that's left is to put the finishing touches on the hospital. With just a couple of hours to go until the 72-hour deadline, the commander of the CASH, Colonel James Bruckart, makes a final inspection.

The last test of the hospital's readiness is the O.R. Is it prepped to perform surgery?

COLONEL JAMES BRUCKART, M.D. (Commander, 21st Combat Support Hospital): It even smells like an operating room, doesn't it? Aaah. You're going to get some perhaps really sick patients come through here.

DOCTOR: What are you going to do?

COLONEL JAMES BRUCKART, M.D.: I'm going to open up 12 beds and tell them the hospital's functioning tonight.

NARRATOR: It doesn't take long before the first serious U.S. casualty arrives.

PRIVATE FIRST CLASS DAVID MASON: Oh! Right on the pain button!

NARRATOR: Private First Class David Mason, from the 101st Airborne division, has broken both his ankles in a bad fall. The orthopedic surgeon is concerned that he will face long-term disability.

COLONEL CLARK SEARLE, M.D. (Orthopedic Surgeon, 21st Combat Support Hospital): It's a very severe injury. The top bone of the foot is shaped as a dome with a snout that sticks off the front. And he fractured where the snout meets the, the top portion through here.

...because the longer this stays like this, the higher your risk of having problems down the road. What is likely to happen once this is all said and done, is you're probably going to have at least some achiness in both your ankles, probably forever. So road marching and running long distances and that sort of stuff may not be something that you're going to be able to do in the future.

NARRATOR: David's career as a combat soldier is over. He has to be evacuated because the CASH is not equipped to provide the complex operations and long-term care he needs.

Anyone needing treatment taking more than a week is stabilized and airlifted to hospitals in Europe or the U.S.

David was injured near Mosul, 160 miles to the north. With a population of just under two million, Mosul is the third largest city in Iraq. In the months to come, Mosul will be the site of several deadly attacks on American soldiers, including the downing of two Blackhawk helicopters, but for now, late April, 2003, things are relatively quiet.

A forward unit of the 21st Combat Support Hospital is just outside Mosul. Iraqis injured in the fighting over the last several weeks, who can't get treatment in their own shattered hospitals, are now lining up at the CASH, but only some will get in. According to Army policy, CASH units will provide emergency care to any Iraqi who's in immediate danger of losing life, limb or eyesight or who's been injured by American forces.

Ala, an Iraqi soldier, is a typical case: he was badly hit in both legs during the fighting. He's come to the CASH because the local hospital cannot treat his wounds.

MAJOR DOUGLAS PREVOST, M.D. (Orthopedic Surgeon, 21st Combat Support Hospital): He's been treated in a hospital, apparently here in town, for the last 28 days. That's what his father told me. They don't have any access to medicines, they don't have any access to orthopedic instrumentation, orthopedic hardware.

NARRATOR: Major Doug Prevost is the chief orthopedic surgeon for the 21st CASH's Mosul unit. The son of a special forces Sergeant Major, he's a graduate of West Point and is a father of five, himself.

MAJOR DOUGLAS PREVOST, M.D.: This is always a bit of a surprise for us. We haven't had a chance to really see his wounds yet. This is a little bit like opening up a Christmas package, and you really have no idea what's in there, because it could be anything.

NARRATOR: Ala has endured three weeks without any antibiotics, and Major Prevost soon detects that his wounds are dangerously infected.

MAJOR DOUGLAS PREVOST, M.D.: As we stand here and look at this wound, we can smell a fairly characteristic odor of a certain type of bacteria called "Pseudomonas," which is a fairly difficult infection to clear in these types of injuries.

Taking care of war wounds is quite a bit different than taking care of normal trauma that we see. Typical war wounds are much more contaminated, and they're much more high energy, and the soft tissue is damaged to a greater extent to what it would be if there was a car accident. So one of the things that we've learned over the years is that to close a war injury the first time you're there is a mistake. These wounds tend to become infected if you do that. What we need to do is leave them open and let them drain for a long period of time, and let them fill in on their own. Rarely do we close war injuries definitively like we would normally. Oftentimes people want to see the skin edges back together and everything closed, but that really is a mistake to do that.

NARRATOR: All that Major Prevost can do is clean the wounds of all shrapnel and cut out any infected tissue. Clean conditions and antibiotics may help control the spread of the infection. After so long without proper treatment, the outlook for Ala is poor.

MAJOR DOUGLAS PREVOST, M.D.: He'll probably end up with amputations on both sides below the knee.

NARRATOR: The CASH has not had to deal with the mass U.S. casualties they'd prepared for. So far, the injuries are mostly minor: scorpion stings...

DOCTOR: You know the scorpions here? Nobody ever dies from them.

NARRATOR: ...a variety of cuts and bruises, and several heat-related injuries. These are the typical cases on May 1st, when President Bush addresses the nation.

PRESIDENT GEORGE W. BUSH (President of the United States): My fellow Americans, major combat operations in Iraq have ended. In the battle of Iraq, the United States and our allies have prevailed.

NARRATOR: But even after May 1st, seriously injured Iraqis continue to appear at the CASH, seeking care. In the middle of the night a young Iraqi is brought in, critically injured by a grenade. This is the kind of life or death combat casualty that the CASH is set up for. Shrapnel has torn into his body. He is dying from blood loss through multiple wounds. His heart stops before he reaches the operating room. Major Betty Kim, a cardiothoracic surgeon, cuts his chest open and massages his heart by hand.

She gets it started; he now stands a chance. Although he's an Iraqi soldier, the surgeons fight as hard to save him as they would an American.

DOCTOR: Guys, we don't got an option. We're going in 'cause he's bleeding.

NARRATOR: It is now a race against time to find the source of the bleeding and stem the flow.

DOCTOR: All right I've got my finger on it right now.

DOCTOR: What is it?

NARRATOR: After fifteen minutes, it's clear that major blood vessels behind the bowel have been severed. Another surgeon, Major Yong Choi, pinches the leaking vessels to stop the flow, but even this is not enough. The man is hemorrhaging faster than they can squeeze plasma into him. Then his heart stops again. As a last resort they try to shock it into action...

DOCTOR: He's dead. He's dead.

NARRATOR: ...but to no avail.

Members of the family are waiting outside.

CAPTAIN ANGELA WINN, R.N. (Emergency Room Nurse, 21st Combat Support Hospital): The first death that I saw was very hard on me. I had such a close relationship with the patient. This is when I was on the ward. After that, I, I hate to say it, you kind of distance yourself a little bit, from that, so it doesn't hurt you as much, but it does affect you every time someone dies.

NARRATOR: After three days, the doctors' efforts have made a remarkable difference for Ala, the young Iraqi soldier with wounded legs. The cleaning and antibiotics have saved his limbs.

PRIVATE FIRST CLASS TORIN HOWLING WOLF (Medic, 21st Combat Support Hospital): If he had stayed where he was in the condition he was—personally, if I'm just going to go ahead and lay my cards on the table—I don't think he'd have lasted another six weeks. I think he'd be pushing up daisies.

NARRATOR: Private First Class Torin Howling Wolf is a Cherokee who grew up in the White River Tribe, in Kansas.

PRIVATE FIRST CLASS TORIN HOWLING WOLF: The Cherokee have a really strong tradition of training their people as warriors and healers. I mean it, it wouldn't do any good to just run willy-nilly through the countryside, maiming, slaughtering and killing, because we are, we are not, that's not our goal here. Our goal here is to help an oppressed people. Our goal here is to restore one of the most ancient and beautiful civilizations of all time.

NARRATOR: Howling Wolf and his colleagues have saved Ala's legs and made a friend out of an enemy soldier. But Ala needs long-term rehabilitation and further surgery. The CASH is not set up to provide this. He'll have to be sent back into the devastated Iraqi healthcare system that has failed him once already.

When American soldiers need long-term care, they are evacuated to U.S. military hospitals in Europe or back home. David Mason, the Airborne private with shattered ankles, is ready to fly out.

PRIVATE DAVID MASON: I guess I'm going to Germany, to a hospital there. I'm going to get surgery and get screws put in, and probably go on home. It's a good thing I'm going home, but it's a bad thing I'm not going with my buddies. I mean, I want to go home, but I'd rather go home with all my buddies, go through this, go through this whole war with them.

NARRATOR: David is flown down to Baghdad, where he'll be put on a plane to Germany.

Back at the Balad Airbase, more and more wounded Iraqis, who cannot get treatment locally, keep arriving—the issue of who the CASH will or will not treat is becoming more acute. Among them is a fourteen-year-old girl. She is not critically injured, but the guards on the gate took pity on her and let her through.

CAPTAIN ANGELA WINN, R.N.: We don't know if it was unexploded ordnance or if it was some type of powder she was playing with that...and had a big flash, and that's what caused her burns. She's got burns on her right side of her face, her right side of her body and on her chest.

NARRATOR: The medics aren't quite sure whether they should be treating this girl.

MAJOR BEVERLY BEAVERS (Operations Officer, 21st Combat Support Hospital): We have certain guidelines that we have to follow. One of those guidelines is that she be, before she becomes a patient, she needs to be needing to be treated for life, limb or eyesight loss. The other instance that she would be required, for us to treat her, was if she was injured due to something that we American soldiers had done to her. And in this particular case, that's not what happened.

CAPTAIN ANGELA WINN, R.N.: We're going to put some bacitracin ointment on her. And on her face, since she can't really bandage that up, we're just going to put that on her face as a cream. We did give her some pain medication though, before we started this treatment, because it is awfully...there are some secondary burns which are very painful. But we're just going to do the best we can and then send her, probably, on her way home.

PRIVATE FIRST CLASS TORIN HOWLING WOLF: If I had, you know, a magic wand to poof...I have got, you know, all the gauze I could handle, um, sure, I would love to be able to treat everybody, um, you know? There's only so many of these kids, as you can see, walking around in tattered clothing and malnourished, which you could take before you have to close your eyes and turn away from it, or it's going to make you sick.

NARRATOR: The doctors, nurses and medics, by training and inclination, would treat everyone, but the choice is not always theirs to make. The Army provides guidelines, but how they're enforced on the ground is left to the discretion of the CASH commander.

For Colonel James Bruckart, Commander of the 21st CASH, his mission is clear.

COLONEL JAMES BRUCKART, M.D.: The primary purpose of the hospital is to take care of our soldiers. But we will provide emergency treatment to stabilize a local or even our enemy. But we're very selective. What we try to do is wait for somebody who we can save their life, we can save their eyesight. Those are the ones we think are most needing of our care.

NARRATOR: Today, officers from the Army's medical brigade, which oversees the CASH, are on their way to the local hospital in Mosul. Iraqi doctors are hoping that they'll approve the transfer of some injured patients to the CASH.

MAJOR ANDREW WIESEN, M.D. (Civil-Military Affairs, 62nd Brigade): The military can only provide care for very specific circumstances, and those circumstances are immediate threats to life, limb or eyesight. So, for instance, if somebody happened to have a grenade explode on them right out in front of our gate, and we're there, well of course we're going to take those people and stabilize them. If we were...had...some of our troops were in action with some other people and innocent bystanders or other soldiers from the opposing side were injured, we would take care of them to stabilize them.

NARRATOR: The hospital has survived most of the looting intact. Many of the doctors are highly skilled, but their expertise is useless without supplies.

IRAQI DOCTOR ONE: Everything, we need everything. We need antibiotic, enough drugs for patients, enough I.V. fluid, enough oxygen, enough power, enough water, everything we need.

NARRATOR: In contrast, the CASH is well equipped, so the Iraqi doctors are eager to transfer any patients that might meet the Army's guidelines. This soldier was shot in the stomach a month ago. After multiple operations, his wounds still have not healed.

IRAQI DOCTOR TWO: It's a difficult problem, this is a bullet, and it passed through the body, making different problems in the body, multiple perforations in the intestine.

NARRATOR: The doctors are worried that without clean dressing and antibiotics, the patient will die from his infected wounds. He was shot by Kurdish coalition fighters under the control of U.S. forces. But that doesn't appear to be enough.

MAJOR ANDREW WIESEN: Well, there's no real connection to the U.S. military in this case. It was the pesh merga fighters in this case, that injured him in the first place, right?

IRAQI DOCTOR: Yeah.

MAJOR ANDREW WIESEN, M.D.: The U.S. Army doctors will probably not take this case.

NARRATOR: In this case, injuries caused by America's allies don't guarantee admission to a CASH. This young man has been partially paralyzed from the neck down. He is one of Iraq's Christian minority.

MAN: The doctor say many shells affecting the neck. He say that one of the shells is still inside 'til now.

NARRATOR: This time, it seems, U.S. forces are directly involved. His mother says their village was bombed by American planes.

MAJOR ANDREW WIESEN, M.D.: The attackers...who were the aggressors in that? Do we know?

MAN: Yes, U.S., U.S. rocket. She say that a bomber plane, a bomber plane attacked the house by rocket.

MAJOR ANDREW WIESEN, M.D.: Okay. This is the same as we were talking about, the other soldier. The U.S. military probably won't do this case, but we can facilitate getting the non-government organizations and other government organizations to get the appropriate equipment here.

PATIENT'S MOTHER: Thank you.

MAJOR ANDREW WIESEN, M.D.: You're welcome.

Yeah, well it's the same situation as in the beginning. They were, you know, certainly weren't targeted as combatants, but, you know, aerial warfare, that does happen, you know? And we try and atone for our mistakes the best we can.

NARRATOR: Even though coalition forces may have contributed to the injuries, the medical brigade concludes that both patients are in stable condition, so the CASH, designed primarily as a trauma center, is not the place for them.

MAJOR ANDREW WIESEN, M.D.: The U.S. government's policy is that the most fair and equitable way to get help to those people is not through military sources. The military is there to provide a safe and secure environment for the other governmental and non-governmental organizations, the humanitarian organizations, to provide that care. Sometimes our army is funded to do humanitarian assistance missions, but it wasn't from the military budget. Congress really maintains control over that. And you'll see, certainly, with the Combat Support Hospital, they really want to help. And I think these constraints are put on us, financial constraints are put on us, because there are many, many, many things we could do here.

COLONEL BOB LYONS, M.D.: The frustrations in who we can treat and who we can't treat are enormous. There are many illnesses we've seen—especially in developing a relation with the local Iraqi hospital—there are many situations that are easy for us to treat. Many situations they confront in their hospital that we could treat easily in this hospital, yet I cannot use these resources to affect those changes. That's very frustrating.

NARRATOR: But when two young Iraqis arrive with life threatening burns from exploded ordnance, there are no questions asked. They're in good hands: Colonel Bob Lyons is the chief plastic surgeon at Brook Army Medical Center in San Antonio, home to the military's only specialized burn unit.

COLONEL BOB LYONS, M.D.: This young man is burned more seriously than the other, with 60 percent total body surface area burns. We calculate those surface areas because it helps us with managing their fluid requirements. We debride off all this dead skin so our antibiotic ointments can help protect the wounds from getting infected. As you can see, his face is all debrided right now. You can see his legs are all debrided of the dead skin. In America or Britain, the prognosis for this guy would be very good. He may need skin grafting of these feet, but he would get aggressive burn treatment and physical therapy.

NARRATOR: But that won't happen here. There's no fully-functioning burn unit in all of Iraq, even at the CASH. After cleaning him up and giving him antibiotics, all the doctors can do for the patient is try to ease his pain.

MAJOR CHRISTOPHER NILES, M.D.: He is extremely critical. These burn patients have a tough time. They have a lot of, a lot of issues going on with thermal regulation, their temperature, their fluids in their bodies. It's a huge shock to them and he's, he's extremely critical right now

NARRATOR: To keep the patient completely still, the doctors would like to use a paralytic agent called "vercuronium," but it's in short supply.

COLONEL BOB LYONS, M.D.: We have a dying patient in there now. I have a certain amount of a certain drug that I can't consume on him because I have to be able to operate. So I had to make the decision that we don't use that drug on him. We'll use other drugs, maybe not as effective, but I have to be able to save other people's lives. I have to make those decisions for the other physicians. That's my job.

NARRATOR: Three days later the badly burnt young man dies.

Most Iraqis seeking treatment at the CASH are soldiers wounded by U.S. forces. But others are civilians hurt in accidents, some by unexploded ordnance or simply sick. The ethical dilemmas this produces are troubling the doctors.

MAJOR CHRISTOPHER NILES, M.D.: We raced up here with not, really, a true mission. Obviously we're going to take care of our troops as best we can. But then, after that, what do we do? What's our mission? Is it humanitarian? Is it not? It's been very frustrating because we have local Iraqis coming to the front gate asking for us to help them, and us not being able to give it.

NARRATOR: Some of the doctors are asked to be gatekeepers, to judge who gets treatment and who doesn't. Major Nhat Nguyen-Minh, a general surgeon who escaped Vietnam to come to America in 1978, goes to the front gate to assess a patient.

MAJOR NHAT NGUYEN-MINH, M.D. (General Surgeon, 21st Combat Support Hospital): We are going to one of the gates. Apparently there's a, a two-year-old child that's coming in, that she has some type of burns. They say it's a second degree or a third degree burns over her...

PARAMEDIC: I know that it's second degree for sure, but...

MAJOR NHAT NGUYEN-MINH, M.D.: Sorry, baby. I'm sorry, I'm sorry, I'm sorry. I think we cannot bring her in. She has a ten-days-old burn.

MAN: But what can you do?

MAJOR NHAT NGUYEN-MINH, M.D.: This is not life, limb or death.

SOLDIER: Apparently they went to the one in Baghdad, and they told them they couldn't be there, because there was some kind of virus or some stuff.

MAJOR NHAT NGUYEN-MINH, M.D.: Yeah, so they need to go to the Balad hospital, Balad Hospital.

MALE SOLDIER: They need to go to the Balad.

MAJOR NHAT NGUYEN-MINH, M.D.: We cannot take...I'm sorry, we cannot take care of her here.

You know, there's a lot of emotion involved in that. You know, you see a little child, you don't want to be leaving her. You know that most likely she won't, she won't, get the medical care that she will get like she will here out in the Balad or any local hospital. So you would like to take care of her, but she doesn't meet the criteria. And if we are going to start bringing these, these in, we are going to be...they are going to...everybody around this area is going be bringing them in. And we're going to end up taking care of all these local Iraqis, and then we won't...you know, we'll soon be running out of the resources to take care of our own soldiers.

MAJOR BEVERLY BEAVERS: What happened?

MAJOR NHAT NGUYEN-MINH, M.D.: No, we, we saw them, and we sent them away. We told them to go to the Balad hospital.

MAJOR BEVERLY BEAVERS: Oh, beautiful.

MAJOR NHAT NGUYEN-MINH, M.D.: Yeah.

MAJOR BEVERLY BEAVERS: Excellent. Thank you.

MAJOR NHAT NGUYEN-MINH, M.D.: They may whine and cry about it.

MAJOR BEVERLY BEAVERS: That's what...yeah, that's the right thing. Thank you.

MAJOR NHAT NGUYEN-MINH, M.D.: All right, sure. Okay.

MAJOR CHRISTOPHER NILES, M.D.: Who do we let in the gate? Literally and figuratively? Do we let this child but not this child or these adults? And so it's been very frustrating for those who've had to go out to the gate and look at a patient, look them in the eye and say, "No, we can't help you," and send them away. I think it sends a mixed message to the Iraqis. We're here to help them and make them better, and yet we turn them away.

NARRATOR: While Major Niles struggles over how the resources of the CASH are deployed, another fully equipped American hospital is sitting, unused, in the Kuwaiti desert. Weeks after arriving in the Gulf, Colonel Powell's 10th CASH is still waiting for a mission. Colonel Lounsbury hasn't treated a single combat casualty.

COLONEL DAVID LOUNSBURY, M.D.: There's a humanitarian disaster of some sort going on north of here and no one attending them. The hospitals are full, and the care is inadequate, and it makes me feel terrible. I think we have a role to play. I think we could do it, do it well and do it effectively, do it efficiently. And we could relieve some of that agony and suffering. For God's sakes, let us be part of that experience. Let us be part of taking care of those people.

SERGEANT CHRISTIAN RAMIREZ: We want to get up there, set up, start treating. We went from a combat mission to a humanitarian mission. Hey, you know, either way, we're doing our job. You know, we're all ready. Everybody's ready to go do it.

NARRATOR: The staff of the 10th CASH were never given the humanitarian mission they craved. After four months in Kuwait, the 10th Combat Support Hospital will be sent back to Colorado, though some staff and supplies will go to Iraq.

Back at the 21st, the life, limb and eyesight policy has allowed the CASH to admit Najla. Her mother says the eight-year-old was injured when a U.S. missile blew up an Iraqi tank. Najla was trapped at home for several weeks, her family too scared by the fighting to venture out. Now, on top of her original injuries, she's severely malnourished. She's in such bad condition, the doctors appeal for help from back home, and the University of Michigan Trauma Burn Center agrees to take Najla.

MAJOR CHRISTOPHER NILES, M.D.: If we can get her back home to the States, they will be able to get some big I.V.s in her and start getting her fed and getting her better. So I think her only hope right now is to get her back to the States and get her taken care of.

NARRATOR: It's a challenge to help Najla in a combat hospital equipped to treat soldiers, not children, but no one wants to back away from this case.

MAJOR CHRISTOPHER NILES, M.D.: It's hard. It makes you feel bad. It makes you go home and say your prayers and thank God that your kids are okay. I've got two little girls at home, and I see her and her parents, and it breaks my heart. It's terrible. So it's, I guess, a little extra motivation to try and do the right thing.

NARRATOR: A plane is due in the following day to take Najla to America. If Major Niles can get her stabilized overnight, she will get the best care in the world.

Seeing the conditions endured by children like Najla is starting to affect many in the CASH.

MALE SOLDIER: Pretty sad though, seeing little kids over there, hungry and stuff.

MALE SOLDIER: It kind of made me think about my kids, you know?

SERGEANT FIRST CLASS GLENN PAULINO: We come over here and we see what they don't have, and we think about where we came from, where we live, how we live. And then we think about all the stuff that we take for granted back home. And there's a lesson learned for a lot of us. And I bet you that when we go back home, a lot of the stuff that we take for granted...we're going to just stop and smell the roses every now and then.

NARRATOR: The next morning, Najla is getting worse. Major Niles and the team are now struggling to get her ready for her flight to America.

MAJOR CHRISTOPHER NILES, M.D.: What do we know about her flight home, do we have any information about it?

DOCTOR: Got an update. Colonel Sigmen is on the phone right now.

NARRATOR: There's a medevac plane on its way, but Major Niles is worried Najla may be too ill to travel. Her extreme malnourishment could lead to complete organ failure.

MAJOR CHRISTOPHER NILES, M.D.: Right now, we're just trying to see if we can keep her well enough to send her back to the States. The University of Michigan has accepted her, um, and we just need to make sure we get her taken care of and set to go, so we can get her home and get her taken care of.

Okay, Princess. Oh God, help us.

NARRATOR: With no time to lose, Major Niles asks for blood tests to ensure that Najla will survive the trip.

MAJOR CHRISTOPHER NILES, M.D.: How much do you think you need?

WOMAN: I don't know.

MAJOR CHRISTOPHER NILES, M.D.: Let me take it all with me. Can you hold on here? And let me run down to the lab real quick and...I want to make sure I can get what I want, all right? Here's the deal.

NARRATOR: He asks the lab to test for electrolite levels to check her metabolic condition and for arterial blood gases to see if she'll be able to breathe unassisted on the plane.

MAJOR CHRISTOPHER NILES, M.D.: Bonnie, I'm going to run down and see if I can get this, would you mind waiting here and bringing this down to me?

MAN: No problem.

MAJOR CHRISTOPHER NILES: Thank you, appreciate it.

NARRATOR: When he comes back to the intensive care ward, it's too late.

WOMAN: I can't take these children coming in, man.

WOMAN: This is the hard part.

MAJOR CHRISTOPHER NILES, M.D.: This is why I don't do peds. There's no way.

WOMAN: No more.

WOMAN: Do we have anyone to sit with her?

MAJOR CHRISTOPHER NILES, M.D.: Can we, can we get a couple of screens or little curtains that we have? Maybe ask Debbie at one of the wards, and just give Mom some privacy? Just at least around here, so the whole world's not...

We did everything we could.

MAN: Yeah.

MAJOR CHRISTOPHER NILES, M.D.: I know. It's never easy though. She was, you know, as we suspected, very sick, and kids have a pretty good reserve. They can go for quite a while 'til they hit the edge of the cliff. And she just fought as long as she could. She was a fighter, and she did very well for how sick she was. Not a good day to be a doctor. Not here.

NARRATOR: After NOVA left Iraq in May, 2003, attacks on American soldiers increased dramatically, and the wounded flooded the Combat Support Hospitals in the region. Since they opened their doors, the two units of the 21st have treated more than 30,000 patients.

At the same time, the 21st CASH has been working closely with local Iraqi hospitals, where conditions are gradually improving after the devastating effects of sanctions, Saddam and the war.

Many CASH personnel appearing in this program remain on active duty in Iraq, while others have returned home. On NOVA's Web site, hear from several CASH members on what's happened to them since they were filmed. Find it on PBS.org.

Broadcast Credits

Life and Death in the War Zone

Produced and Directed by
Dimitri Doganis with Callum Macrae
Executive Producers for Stone City Films
Bryn Higgins
Clare Duggan
Additional Producing for NOVA
Julia Cort
Narrated by
Will Lyman
Edited by
Paul Dosaj
Additional Editing
Harlan Reiniger
Camera
Hugh Hughes
Neil Harvey
Music
Colin Winston-Fletcher
Production Manager
Tessa Pemberton
Online Editors
Adam Grant
Mark Steele
Colorist
Katherine Grincell
Animation
Sharon Spencer
Audio Mix
Matt Skilton
John Jenkins
Assistant Producer
Angelique Arnold
Production Assistants
Julie Bower
Judah Chivian
Anna Lee Strachan
Archival Material
ITN Archive
CNN ImageSource
U.S. Department of Defense
ABC News - Good Morning America
ABC News - Nightline
ABC News - World News Tonight
The producers gratefully acknowledge the participation of the men and women of the 10th & 21st Combat Support Hospitals, U.S. Army
NOVA Series Graphics
National Ministry of Design
NOVA Theme
Mason Daring
Martin Brody
Michael Whalen
Closed Captioning
The Caption Center
Publicity
Jonathan Renes
Diane Buxton
Senior Researcher
Ethan Herberman
Production Coordinator
Linda Callahan
Unit Manager
Lola Norman-Salako
Paralegals
Nancy Marshall
Gabriel Cohen-Leadholm
Legal Counsel
Susan Rosen Shishko
Post Production Assistant
Patrick Carey
Associate Producer, Post Production
Nathan Gunner
Post Production Supervisor
Regina O'Toole
Post Production Editor
Rebecca Nieto
Post Production Manager
Maureen Barden Lynch
Supervising Producer
Stephen Sweigart
Producer, Special Projects
Susanne Simpson
Coordinating Producer
Laurie Cahalane
Senior Science Editor
Evan Hadingham
Senior Series Producer
Melanie Wallace
Managing Director
Alan Ritsko
Senior Executive Producer
Paula S. Apsell

A NOVA Production by Stone City Films Ltd. with Raw TV for WGBH/Boston.

© 2004 WGBH Educational Foundation

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