"Guys, put me out."

Kandahar, Afghanistan

He was wheeled into the trauma bay in a hurry.  You can always tell when there is someone who is turbo-sick by the way the trauma team staff wheels in the patient, their heads down.

"Guys, put me out."  He was calm, almost too-knowing.  He wasn't looking down at the scene of the crime, his twisted and mangled legs.  He was not crying out, screaming, or moaning.  He was what we call a GCS 15 - a Glasgow Coma Score of 15, out of 15.  Completely with it.

"Guys, put me out."  It was a statement more than a request.

He wasn't at all like the soldier that had arrived a short while before.  That soldier "only" had half his foot blown off, once again prompting us to discuss after the fact: was he lucky or unlucky?  Certainly it's never "lucky" to have part of your body separated from the other good part.  But unlike his compadre now with us in the trauma bay, he was certainly lucky by some bizarre calculus.

"You're alright," someone coaxed.  "We'll put you to sleep in a few minutes.  We need to ask you some questions."  While the interlocuter attempted to engage our newest patient about what medications he was taking, prior medical history and such, the trauma crew descended. Quiet, orchestrated, busy hands.  IV's in.  Clothes cut off.  Cervical collar on.  Drugs drawn up.  Units of blood  and plasma were pulled out in a big box and hooked up to the Level One.  Pneumatic tourniquets were applied to his thighs and the now bloody nylon tourniquets - which had likely saved his life - were cut off.  The radiologist applied a probe to his belly and chest, looking for "free fluid" - a finding that would buy him an exploratory laparotomy to find out where he was bleeding.  Fortunately there was no fluid.

All this occurred in a matter of a few minutes, which certainly must have felt like hours to him.

"Two 14 gauges, in!"
"GCS 15!"
"Tympanic membranes clear!"
The trauma team leader ordered for fentanyl to be given, a powerful morphine-like substance.  "Give 3 milligrams versed!"  The nurse repeated his order as she infused the relaxant into the iv in his arm.

"Etomidate 20 milligrams!  Sux [succynylcholine] 100 mg!"  The time had arrived for him to go to sleep, none too soon.  An anesthetic and a paralytic.  Sleepy-time.  A stainless steel curved, dull blade with a light on the end of it was carefully placed deep into his throat, but with deliberation, to reveal the vocal cords.  A clear plastic 8 millimeter diameter tube was slid through the cords.  An ambu bag was attached and the reassuring sign of vapor in the tube was seen.  We will breathe for you now.  Propofol, a milky-white anesthetic, was hung.  Nicknamed "milk of amnesia," this stuff is now famous as the agent that did Michael Jackson in as a drug of abuse.   Go to sleep, friend.

He would probably be awakened in two or three days, after several trips to the OR, when he got to Germany.  By then he would be a bilateral high amputee.  I think he already knew this by the time he got to the trauma bay.  He was unusually calm.  I would have bet he had thought through this scenario many times before in his mind - the stories are out there.  Some soldiers go out on patrol with tourniquets already applied, though not tightened, around their extremities.  Gruesome thought, gruesome war.