“In the absence of any other proof, the thumb alone would convince me of God’s existence.”
—Sir Isaac Newton
He was the gunner in a Humvee on patrol and woke up on the ground. He didn’t even notice the pain till he tried to stand. His shattered ankle collapsed beneath his weight, but his buddy was still in the vehicle, now aflame in the worst explosion he’d seen—and he’d seen many. Crawling through the dirt to the vehicle, he was able to reach in to grasp his friend’s hand. The driver glanced up, smiled, and was gone.
“I haven’t looked at it yet,” he confessed to me from beneath the baseball cap pulled down over his eyes. Just 21, with a wife and a child back home, all he longed for was a human touch from a loved one. This had been his third improvised explosive device (IED) incident and the one that cost him his lower leg. Two days later, he was able to peek from beneath the cap at where his leg had been, but only because it was safely disguised by the dressing.
Many reconstructive surgeries awaited the young soldier—attempts to salvage a usable stump of hand. Luckily (if referring to luck makes any sense), the injury was to his nondominant hand. The blast had pulverized most of its structure, smashing the metacarpal bones and blowing the pieces through the dirt. His thumb was barely attached, with a miraculously undisturbed blood flow. He knew that having a “normal” hand again was unlikely, but he did not want to hear something he already knew from one more health care provider.
After several interim surgeries, he at least had tissue coverage over the massive contaminated soft-tissue wounds. What lay ahead was more reconstruction, utilizing bone from his thumb, which would undergo completion amputation, and explanting and reimplanting his index finger to function as a thumb.
Given the enormity of many of the injuries that come through Landstuhl Regional Medical Center in southwestern Germany, one might easily dismiss this case as “only” a thumb on a nondominant hand. But this young soldier, I knew, was experiencing serious loss and physical as well as emotional pain, anticipating a long recovery that would involve multiple surgeries and months of rehabilitation.
Landstuhl, a level II trauma center, serves to route US casualties from battle injuries sustained in Iraq, Afghanistan, and other overseas conflicts or at overseas locations. Both interim care and definitive care take place here. Our stated mission is to “provide world class comprehensive and compassionate care to our Nation’s Warriors, their families, retirees, and all other directed beneficiaries, while maintaining unit and personal readiness to meet the demands of our Nation.” And our vision is to “maintain a trained and ready health care force that seeks, thrives on, and embraces change while accomplishing the health care mission, utilizing outcomes to drive medical decisions. We will excel at providing the best medical care anywhere to the best our Nation has to offer: her Warriors and families.”
It’s been my privilege to be associated with this facility, providing orthopedic care to these warriors, since July 2007. Already, it feels like a lifetime. As a civilian health care provider, I was initially drawn here for selfish reasons—the perks of an easy adjustment to living in Europe. Once my agreed-upon year of service was completed, however, I could not imagine moving on. My devotion to caring for these selfless men and woman is deep and overpowering, far outweighing the difficulties of working within a system that doesn’t always run smoothly.
Often my interaction with patients is brief, since we are the intermediary facility between the battlefield and our soldiers’ evacuation back to the States. At a minimum, this involves irrigation and debridement of major orthopedic injuries, and occasionally definitive fixation. For most soldiers, the average stay with us is two to four days.
The degree of damage inflicted by the various offenders is difficult to describe: IEDs and EFPs (explosively formed projectiles), rocket-propelled grenades, gunshot wounds, mortar attacks, and even a fall from a 40-foot guard tower all provide unimaginable devastation to human tissue. Bones are shattered, tissue and bone are lost, and wounds are littered with filth and contamination. Heat creates its own degree of tissue trauma beyond burns. The soft-tissue wounds are massive. Out of necessity, orthopedic surgeons here have become adept at muscle flaps and skin graft closures—if they get to that point. Contaminated wounds involve multiple irrigation and debridement procedures, with ongoing necrotic tissue loss usually requiring debridement every 24 to 48 hours, until some sort of definitive fixation is appropriate.
One particularly bad day brought three ICU patients, among them a bilateral lower extremity amputation, an open femur fracture with an external fixation device applied, an upper extremity amputation at the shoulder, open radial and ulnar fractures, a disarticulation at the wrist, intestinal evisceration, and 70% burns. Yes, this is only one of the three patients that day brought to the ICU. Standing there in the unit, I couldn’t help but be struck by the paradox that all these spaces were filled with men and women younger than 30.
With six years’ background in cardiac and thoracic surgery, followed by 12 years in orthopedics, I felt more than prepared to offer the mechanical and medical interventions that this assignment would entail. But the level of personal gratification I experience has come on a much simpler level. It’s the privilege of being involved in the care of these dedicated young men and women. Some of the most deeply satisfying moments occur when I am invited to enter into their stories; even hearing the snippets are an honor. Sharing their experiences, I believe, is the best I can offer my patients.
Often the greatest difficulty lies in not minimizing a patient’s injuries while acknowledging the tremendous losses he or she has suffered. The caring, trusting environment I try to maintain makes the sharing possible.
And that’s what I was offering to that young IED survivor who had lost his lower leg—and possibly the thumb of his nondominant hand. As he looked at me, then around at the other patients in the unit, I thought I sensed a wave of guilt pass over him—remorse over seeking any emotional support for his loss. “I guess I’m lucky,” he told me, with tear-filled eyes, “when I think of what happened to my buddy.”
When a patient is able to talk like that about what happened or about his or her fears for the future, I feel as though I’ve provided something greatly needed. Time rarely permits me to follow my patients through the end of their surgeries. But in my allotted time, I offer analgesics, years of orthopedic experience, an attentive, watchful eye, and a caring ear—the greatest gifts I can share.
Nancy M. Giunta practices in the Department of Orthopaedics at Landstuhl Regional Medical Center, the US military hospital in the German state of Rhineland-Palatinate.