Years ago, crossing a street with my friend Clark, we looked down to see a smear of blood and feathers marginally recognizable as a pigeon. Clark bent over and yelled, “Are you okay?” The line is less funny now but equally ludicrous. A small blood lake expands on the floor. And here is where things go hyper-realistic: Unbeknownst to this corpsman, Caezar is an amputee.? He wears the silicone sleeve over the stump of his leg. When he jerks it around, as he is doing now, it trails an arc of blood. Blood is flying like champagne in the locker room after the big win.
Outside the door, instructors are yelling to get the other wounded “off the X”—out of sight, out of the kill zone. They’re dragged into the room adjoining ours. The floor is men: role-players on their backs and trainee corpsmen crouched around them. One figure stands out for being unusually barrel-chested. This is the Cut Suit actor. You may be familiar with “patient simulators” like Resusci Anne, upon whom first responders practice their skills. The Strategic Operations Cut Suit is a “human-worn” patient simulator. The actor dons a vestlike rib cage with an insert tray of abdominal organs and, over this, a kind of flesh-tone wetsuit—simulated skin that bleeds when it’s pierced, via the same pump-and-tube system Caezar uses for his stump. (It also “heals,” with help from the Cut Suit Silicone Repair Kit.) It’s as though someone crawled inside Resusci Anne and gave her the one thing patient simulators, for all their bells and whistles, will never have: humanity. SimMan may bleed and pee and convulse, his tongue may swell and his bowels may rumble, but he will never sit up, drill his gaze into a student’s eyes, and plead, as Caezar just did, “Get me out of here, this is a bad neighborhood, man!”
Today’s Cut Suit actor isn’t yelling, because his character has been shot through the chest and his lung has collapsed. He takes shallow panicky breaths while a trainee, whose uniform identifies him as Baker, gets ready to do a needle decompression. When a bullet or broken rib punctures a lung, inhaled air begins to fill the cavity that houses the lung. The air builds up and soon the lung can’t expand, and breathing becomes a struggle. It’s called pneumothorax, from the Greek for air and chest, and it is the second most common cause of combat death. Baker’s task is to insert a needle catheter to release the air and relieve the pressure. He’s sweating. His glasses slide down his nose. He holds the needle near the role-player’s collarbone, which is not between any of his ribs, or even part of the Cut Suit.
“Are you FUCKING SERIOUS, BAKER?” You know the exaggerated TV cliché of the scary yelling Marine instructor? It’s not exaggerated. “That’s his clavicle. You almost actually stabbed him.”
Presently the needle finds its mark, an occlusive bandage is applied, and the role-player is loaded onto a stretcher. Baker picks up the stretcher’s front handles without alerting the trainee at the other end, causing the patient and the $57,000 Cut Suit to tumble onto the ground.
“What the fuck is wrong with you, Baker?!”
Nothing, in fact. Just his sympathetic nervous system doing its job. Anything perceived as a threat trips the amygdala—the brain’s hand-wringing sentry—to set in motion the biochemical cascade known as the fight-or-flight response. Bruce Siddle, who consults in this area and sits on the board of Strategic Operations, prefers the term “survival stress response.” Whatever you wish to call it, here is a nice, concise summary, courtesy of Siddle: “You become fast, strong, and dumb.” Our hardwired survival strategy evolved back when threats took the form of man-eating mammals, when hurling a rock superhumanly hard or climbing a tree superhumanly fast gave you the edge that might keep you alive. A burst of adrenaline prompts a cortisol dump to the bloodstream. The cortisol sends the lungs into overdrive to bring in more oxygen, and the heart rate doubles or triples to deliver it more swiftly. Meanwhile the liver spews glucose, more fuel for the feats at hand. To get the goods where the body assumes they’re needed, blood vessels in the large muscles of the arms and legs dilate, while vessels serving lower-priority organs (the gut, for example, and the skin) constrict. The prefrontal cortex, a major blood guzzler, also gets rationed. Good-bye, reasoning and analysis. See you later, fine motor skills. None of that mattered much to early man. You don’t need to weigh your options in the face of a snarling predator, and you don’t have time. With the growing sophistication and miniaturization of medical equipment, however, it matters very much to a corpsman. Making things worse, the adrenaline that primes the muscles also enhances their nerve activity. It makes you tremble and shake. Add to this the motions and vibrations of a medevac flight, and you start to gain an appreciation for the military medic’s challenges.
On top of caring for the wounded, corpsmen are expected to return fire if no one else is able. Like any precision task, marksmanship deteriorates in high-stress situations. The average police officer taking a qualifying test on a shooting range scores 85 to 92 percent, Siddle told me, but in actual firefights hits the target only 18 percent of the time.
The corpsman trainee working on Caezar is having difficulty with the tourniquet. Like Baker, he’s a fine, fumbling example of the downside of an adrenaline rush. An instructor puts his head through the doorway. “What are we doing in here, fuckin’ organ transplant? Let’s go!”
If the scenario were real, Caezar would be dead by now. With a large artery bleed, it can take less than two minutes for the human heart—and, no coincidence, the Strategic Operations Blood Pumping System—to hemorrhage three liters: a fatal loss. The human body holds five liters of blood, but with three gone, electrolyte balance falls gravely out of whack, and there’s not enough circulating oxygen to keep vital organs up and running. Hemorrhagic shock—“bleeding out”—is the most common cause of death in combat.
This is the grim calculus of emergency trauma care. The more devastating the wounds, the less time there is to stabilize the patient. The less time there is and the graver the consequences, the more pressure medics are under—and the more likely they are to make mistakes. In a 2009 review of twenty-two studies on the effects of “stressful crises” in the operating room, surgeons’ performance was reliably compromised: not only their technical skills but their ability to make good decisions and communicate effectively. And the stressful crises of the operating room—defined in this study as bleeding, equipment malfunctions, distractions, and time pressure—are business as usual in a theater of war.
Caezar exits the scene in a fireman carry, draped around a trainee’s neck like a heavy mink stole. Baker follows behind with the stretcher. He’s struggling because his palms are sweaty. He sets down his end in order to wipe his hands on his pants—again, without alerting the guy holding the other end.