Indirect Fire

Updated: Nov 3, 2020

One of the ultimate hypocrisies I’ve noticed in the military is the obsession with preaching safety when at home. Driving 15mph on base, wearing a reflective belt in inclement weather, not running with earbuds in, the list goes on. On the surface you might think, this is great, they really care about keeping people safe and mitigating our risk, and would never put us in harms way. Then you get to a combat zone and you have this realization that there is not a reflective belt in the world that will protect you from an incoming mortar, a stray bullet, or some crazy ass Afghan solider that decides one day to point his rifle at the wrong team.

The contrasting realities of safety at home vs safety in theater came to a lesson one evening in March. We were all sitting around watching TV, eating something the Army thought resembled food and out of nowhere there was a loud powerful explosion that sounded like a cannon had gone off outside. In fact it was so loud and given the percussion I felt in my chest I couldn’t be sure if it had actually hit our little plywood building or not. We all looked at each other and instantly knew that an IDF (indirect fire) had hit somewhere very close. There were four of us sitting upstairs when this happened, myself, two medics and a Family medicine Doc. We all went downstairs in crouching position. My IDMT and I without hesitating went into our little supply room and grabbed our trauma gear, armored vests, and helmets. We hurried outside to access the damage unknown what kind of patients we would find or what dangers still persisted.

As with most bases, our base in Afghanistan houses people in these dinky little wooden building called B-huts. Not 40 meters away from the clinic was a row of B-huts, and I could see a lot of commotion going on around one of them. We hurried over in the dark, as we got closer the damage became apparent. The mortar round had landed about 10 feet in front of this B-hut. When an 88mm shell hits it basically makes a sizable hole in the ground, but more importantly sends a burst of shrapnel in every direction. The front of this B-hut looked like Swiss cheese as we approached it. The hole in the ground was still smoking as we rounded the corner of the B-Hut to inspect the nearby bunker. In the confusion two guys appeared out of the dark, they were obviously disorientated and were being supported by a couple friends.

Outside of the obvious blast and shrapnel, the other thing to worry about in a mortar attack is the over pressure wave. If you imagine being in front of the largest speaker you’ve ever seen and the bass turned way up, and if you times that feeling by about 100 then you start to get an idea. When you get hit with one of these blast waves the injury can range from just getting your bell rung to severe brain injury and internal organ damage. These guys on first appearance were on the milder side of that scale. We rushed them back to the clinic were they would get a full look over and eventually get transferred to the hospital to start an extensive mild Traumatic Brain Injury (TBI) work up. I remember talking to one of these guys later and he told me that he was in the reinforced bunker next to the B-Hut, but he stuck his head out when he heard a high pitched whistling sound to see what it was. Of course this was the sound of an incoming shell, and he obviously learned his lesson.

After we handed them off we went back out to the site to see if we could find any more patients. A young kid came up to me that looked like he was basically in the same condition as the other two we had just brought in, pretty dizzy and slightly confused. As I got him to the clinic he mentioned to me that his back hurt. I looked at his back, noticed a little bit of blood on his uniform and quickly took his shirt off. Sure enough there was about a 1 inch size hole in his back were a piece of shrapnel had caught him. With a declaration of urgency I pushed everyone out of the way in order to give him priority for the one clinic bed we had. We quickly slapped a chest seal on the wound. The concern in battle field trauma with any penetrating chest wound is that the wound will basically create a one way flap, letting air into the space surrounding the lung on inhalation, but nowhere for it to escape on exhalation. To combat this we slap a seal on that theoretically allows the movement of air out, but not in.

I listened to his breath sounds and he had none on the entire right side of his chest. He then said it was getting progressively hard to breathe, and his oxygen saturation was starting to drop. He was starting to experience what’s called a tension pneumothorax, he had an injury to the inner lining of his lungs that was allowing air to escape into the space surrounding his lungs every time he took a breath. With each breath more and more air was getting trapped in this space. Without any intervention each consecutive breath would continue to compress first the lung, then the heart, and would basically in about 15-20 minutes lead to heart failure and death. If you have ever seen the movie “Three Kings” with George Clooney then you know the treatment. You have to take a long needle and stick it into this expanding space to release the pressure. In the text books, doing this is sometimes followed by a wooshing sound as air escapes. I’ve done this once or twice before and have never had the satisfaction of hearing this, but when we stuck the needle in this kid’s chest there was definitely a woosh of air.

The young Airman was eventually transferred to the hospital were they placed a chest tube and further stabilized him. He got a CT scan of his chest and sitting 1cm away from his pulmonary artery was a nice honking metal object. Needless to say he was a pretty lucky guy.

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