The medics' battle

FORT McCOY, Wis. -- They are full of fierce spirit: hurling practice grenades, slogging through swamp in full combat kit, and howling ``Hooah!" -- the Army's all-purpose affirmative and unofficial battle cry -- on every occasion that warrants and many that don't.

They are fully aware of the contradictions.

``We're not war fighters, we're healers," said Lieutenant Colonel Michael Nott, 51, a registered nurse from Portsmouth, R.I., as he sorted through catheters, ultra-absorbent bandages, and other life saving supplies. ``We're not about inflicting violence. But where we're going, we at least need to know how."

The 399th Combat Support Hospital -- a Massachusetts-based Army Reserve unit of about 470 officers and enlisted personnel, three-quarters of them surgeons, nurses, paramedics, and lab technicians -- is headed ``down range," as the training sergeants say.

To Iraq.

These professionals, many on the cusp of middle age or well beyond, are bound for a year in the heart of a mercurial war that has no clearly defined fighting lines and where most American casualties are caused by powerful improvised explosives or by fanatics outfitted with suicide bombs.

Reservists, like members of the National Guard, are citizen soldiers who normally serve a weekend every month, plus two weeks during summer. But in times of war or national emergency, they can be quickly mobilized for 18 months of full-time duty.

In Iraq, reservists and National Guard represent 20 percent of the 138,000 American military ``boots on the ground." The 399th is undergoing three months of specialized training, from fighting back roadside ambushes to learning to politely greet an Iraqi woman.

``None of us was surprised to get the call," said Staff Sergeant Susan Featherstone, 36, a nurse from North Attleborough, Mass. ``We're headed for a dangerous place. Sure we all have dark days. But most of us, I think, feel pretty fired up to be serving a cause bigger than our individual selves."

In Iraq, the 399th will perform the only war duty that is nearly as arduous, demanding, and soul-draining as combat itself -- stanching blood spouting from ruptured arteries, stitching sundered organs, amputating shattered limbs, plucking chunks of shrapnel from fellow soldiers.

``It's simple. The helicopters bring in the wounded. We try to save them," said Colonel Ed Cyr, 55, a nurse-anesthetist from Bristol, R.I., and father of five daughters.

``We will save them, too. Most of them," Cyr said as he slumped, sweat-soaked, in the shade of a briefing hut after tramping through miles of tick-infested undergrowth on a compass-reading course in 105-degree heat.

``But there will be some we can't save," said Cyr, who in civilian life works at Saint Anne's Hospital in Fall River. ``That's lurking at the back of everyone's mind. The idea that your face might be the last face a horribly wounded soldier ever sees."

Combat support hospitals like the 399th, successors to the MASH units of Korean War and Hollywood fame, are a key component in the streamlined battlefield medical system that has dramatically reduced death rates among American troops wounded in the Iraq conflict, compared with previous wars.

``Our mission is to save life, limbs, and eyesight," said Lieutenant Colonel Bryan R. Kelly, the 399th's commander.

But first comes training. First comes sweltering tents and wake-ups at god-awful hours for field practice humping heavy gear across broken terrain. First comes slithering through thick brush and tumbling out of Humvees under pretend hostile fire. First comes gobbling MREs -- plastic-sheathed ``meals ready to eat" -- and sucking warm water from canteens or the newfangled ``personal hydration" packs called CamelBaks.

``Soldier stuff," the nurses, doctors, and medics call it, half-mocking the drills in marksmanship and blowing things up. But they are also perversely proud that they've got the stuff to plot a way through trackless bogs or lay down suppressing fire while a comrade wriggles for cover.

``We're soldiers first and foremost," said Kelly, 51, who in civilian life is a clinical psychologist for the Barnstable Probate and Family Court. The father of two grown daughters, Kelly has served with military medical units since 1989.

The Army insists that all ``medics" -- in war zones, the term embraces all medical personnel, from neurosurgeons to emergency medical technicians -- acquire at least some semblance of serious battlefield skills. Not a bad idea in a conflict in which any Baghdad street or checkpoint can instantly become the scene of a ferocious firefight. Iraq has become a land where no place and no one is safe.

That's why Lieutenant Kathy Ryland, 42, a registered nurse and mother of two Eagle Scouts, recently found herself clamping combat helmet to head with one hand and clutching her M-16 infantry rifle with the other while ducking into a maelstrom of chaff thrown by the whipping rotors of a Chinook CH-47.

It was a ``hot load" drill, a fast hustle of troops onto the monstrous helicopter as it bucked and surged at full throttle. A sergeant's instructions were lost in the shriek of 8,000 horsepower. The machine roared skyward the instant the last soldier was aboard, banking sharply before swooping out across the fecund fields of Wisconsin at a bit higher than treetop level.

Later, Ryland, from Camas, Wash., reflected on why nurses might need to shoot. ``If we're in a medical convoy that gets ambushed, or if the hospital itself ever comes under attack, we may have to defend patients. That will be our duty," she said. ``But if you think I feel natural slinging an M-16, you've got another think coming. This isn't the kind of shot nurses normally give."

She grinned ruefully, brushed an imaginary speck from the black barrel. ``Well, I'll just have to get used to thinking of it as a very sincere form of patient advocacy."

Call-up came June 10.

On a day of drenching rain, the soldiers of the 399th gathered with their families in a cavernous hall of the Bayside Exposition Center in Dorchester for a send-off ceremony at which military rituals -- posting of colors, formation of troops -- served as backdrop for teary farewells. A brass band played bright jazz. Dunkin' Donuts had laid on a spread of pastries and coffee. But nothing could undo the melancholy of the occasion.

``The critical task ahead for our soldiers is to sustain one another," Kelly said at the gathering.

Unit members wore snappy black berets and a hodgepodge of uniforms, from jungle-green camos like those worn in Vietnam to the tan ``desert combats" of the Persian Gulf War to the new combat dress uniform designed for Iraq and Afghanistan. The tough fabric is printed with thousands of tiny ``computer squares" replicating the grays of arid region rock and shrubbery. So many reservists have been summoned into service in recent years that the military is hard-pressed to keep them in current uniform, although most 399th soldiers should be outfitted in the latest camouflage garb by the time they reach Iraq.

The soldiers hugged their dear ones. They uttered the same promises made by generations of soldiers through millenniums of warfare:

``I love you."

``I'll be safe."

``I'll be back."

Not everyone was saying good-bye: Sergeant Brian Yeager, 27, an emergency medical technician from Haverhill, Mass., is married to Specialist Alison Yeager, 22, a nurse with the 399th. They met in the military and were married in May. Both will serve in Iraq.

``We're just a normal married couple starting out in a fairly abnormal way," he said. ``We're bracing ourselves mentally for a tough year ahead. I guess our dream is to come back in one piece knowing we've done some good."

Come July, the 399th was immersed in training at Fort McCoy, 60,000 acres of pine, bog, and artillery range in central Wisconsin. An intense heat wave and record humidity levels lent a surreal quality to maneuvers. Soldiers spat dust and sweated buckets.

On a day of triple-digit temperatures, Staff Sergeant Kirk Wolloff, 30, an X-ray technician from Medway, Mass., trained in ``moving under direct fire," scrambling on elbows and knees through dirt troughs, coarse grass, and stinging nettles. All the while keeping his M-16 ready for suppression bursts. ``It's great, it's wonderful, `' he said with deadpan expression. ``I really love swallowing sand and grit. It adds crunch to my bland life."

In sunbeams slicing through jack pine, Captain Stacey York, 37, a registered nurse from Mechanic Falls, Maine, practiced ``cooking" a grenade: Roll into prone position, pull the pin, pop the spoon, let 2 seconds sizzle off the 6-second fuse, then heave the bomblet through the hole of a mock bunker. Ka-boom!

``The idea is to go in prepared for anything," she said. ``That's how we will win."

Nurses, including York, and other 399th specialists are also undergoing intensive predeployment brush-ups meant to transform them from civilian healers to combat medicos. Nurses break from Fort McCoy's obstacle hells and shooting ranges for a few weeks of immersion at burn and trauma wards at Brooke Army Medical Center in Texas. Others undertake flight medical training at Fort Rutger, Ala.

The 399th's victories will be won with scalpels and sutures. With field CT scanners and rapid blood transfusers. With ``Israeli" bandages -- high-tech absorbents impregnated with coagulants developed to treat bombing victims -- and Gore-Tex sealers that allow wounds to remain open, protecting the injury but preventing dangerous swelling. With advanced cardiac stimulants and fluid treatments for burns.

``Fighting for lives, that's going to be our real war," said Lieutenant Colonel Joseph Blansfield of Sharon, called to duty from his job as trauma program manager at the Boston Medical Center.

``In a civilian center, 80 percent of what we see is `blunt trauma' injury, from car accidents," he said. ``In Iraq, that will be reversed. We'll be dealing mostly with deep penetrating wounds from high- velocity bullets or fragments from IEDs," improvised explosive devices -- the most lethal insurgent weapon.

The depth of experience in the unit suggests that the 399th's doctors and nurses will be able to handle the most horrific individual wounds. The nightmare scenario, however, is of mass casualties, rare at even advanced civilian hospitals, but commonplace in armed conflicts. A platoon caught in an ambush. A chopper down.

``Big numbers at the door are any hospital's dread," said Blansfield. ``Training for mass casualties is a real challenge. The best training, as always, will come when the going gets rough and real."

A 2004 study in the New England Journal of Medicine found that 9 of 10 US soldiers wounded in Iraq survive their wounds, meaning a death rate of 10 percent of casualties. That's a stunning improvement over the survival ratios in Vietnam and Korea, where fatality rates were about 25 percent of wounded.

``In Vietnam, if we'd known just half of what we know now, we'd have saved twice as many lives," said Gary Germanson, an emergency medical trainer at Fort McCoy who served two combat tours in Vietnam as a corpsman, or medic, with the Third Marine Division.

Part of the improved survival rates is speed. Medevac helicopters with IVs, morphine, and highly trained crews perform medical lifts so efficiently that, on average, a wounded soldier or Marine will hit the surgical table at a combat support hospital within 30 minutes of being injured, according to the military.

``Care starts with your buddy slapping on a bandage, then accelerates through increasingly advanced levels," said Specialist Glenn Bangs of Portland, Maine, a nurse who was training at Walter Reed Army Medical Center on Sept. 11, 2001, when hijacked American Airlines Flight 77 smashed into the Pentagon. He was among the nurse trainees drafted into triage duty at the smoldering site.

In Iraq, the worst-wounded soldiers are stabilized at combat support hospitals and then -- sometimes within hours -- bundled aboard Air Force C-17 ``flying hospitals" for the Brooke or Reed military medical facilities in the United States or the US-run Landstuhl Regional Medical Center in Germany.

``Getting a soldier quickly out the back door [of a combat support hospital] is now seen as being just as medically crucial as getting him quickly through the front door," said Blansfield, the 399th's chief nurse and a specialist in emergency and trauma care for nearly a quarter century.

He added: ``War is terrible, a breakdown in our humanity. But war does spur medical advances. Going to Iraq will not make us better human beings. But most of us will come back to our hospitals and communities with higher levels of medical skill and new ideas on saving lives."

Combat support hospitals are assembled from mobile, modular units offering facilities as sterile and technologically advanced as might be found in a major metropolitan trauma center.

The 399th, when it reaches Iraq in mid-autumn, will break into two hospitals, each with two operating tables, two 12-bed intensive care units, and a single 20-bed intermediate care ward. One hospital is expected to be near Baghdad; the location of the other remains classified for now.

The medical composition of the 399th hospitals is still being planned, but each will include orthopedic surgeons, vascular surgeons, a neurosurgeon, oral surgeon, eye surgeon, radiologist, and general utility doctors, together with nurses, lab technicians, and pharmacists. Most of the unit's energies will be spent in the hospitals, but some personnel may assist on medical flights.

The men and women of the 399th hail mostly from Massachusetts, Maine, and Rhode Island, although the unit includes medical specialists and support personnel from 37 states and Puerto Rico. Iraq is the unit's first overseas deployment since a 2001 posting to Kosovo. The 399th is the first New England-based Army Reserve combat hospital to be deployed to Iraq.

At this Midwestern training installation, the New Englanders get some ribbing. ``So, this is the 399th from `Bahston," huh?" a training sergeant demanded in a Dixie drawl, glancing at his muster sheet.

``Taunton! Hooah!"

``Where people eat `lobstah?' Where people eat `chowdah?' "

``Hooah! Hooah!"

``Where the tunnels collapse?"

``Hooah!"

``Well, a good thing you aren't engineers."

Most are high achievers and highly motivated. Many seem to have a good grasp of the politics of the Middle East. They seem curious about Iraq and deeply sympathetic to its inhabitants.

``I'm hoping to learn some Arabic," said Sergeant Nicole Chadbourne, 24, of Assonet, Mass., a combat medic. ``I'm hoping that anything we do over there somehow makes things better for Iraqi people."

Mostly the 399th will treat American casualties. But not always. The unit's secondary mission is the treatment of wounded Iraqi soldiers and police, as well as civilians bloodied in the crossfire. Even insurgents can expect top-notch care: In the occasionally bizarre theater of war, the fight to salvage a wounded enemy's life is waged with the same medical intensity as the military fight to kill him. ``If they bring us a wounded terrorist, we'll patch him up just as we would a wounded soldier," said Kelly.

While the doctors and registered nurses all practice medicine in civilian life and are typically at the peak of their professions, the majority of paramedics work in other fields -- as police officers, teachers, firefighters, plumbers, truck drivers, computer technicians, and bureaucrats.

``I'm pretty relaxed about the deployment, in general. But also anxious that my lifesaving skills are up to the mark," said Master Sergeant Charles Boisseau, a police officer from Warwick, R.I., breaking briefly from a session on treating ``sucking chest wounds" in the field.

And so through a hot summer of drilling with real weapons and dressing simulated wounds, the 399th readied for Iraq's fields of war .

``I haven't carried this much weight since I was pregnant," said Major Diana Hoek, 48, a dietitian from Sherborn, Mass., whose duties will include monitoring the nutrition of patients. She'd just shed her heavy combat gear in favor of jogging shorts and T-shirt marked ``ARMY." She was lashing up sides of her tent for ventilation.

``By day, I'm re learning to shoot with accuracy," said Hoek, who first fired an M-16 in basic training 15 years ago. ``By night, I'm re learning the craft of writing real letters to my husband and family. I'm hoping I'll write more letters than shoot bullets."

They take courses on Arabic culture and Iraqi sensitivities. They train in treating prisoners with dignity and respect. They train in wounds of the flesh, wounds of the spirit.

``Not all damage comes from bullets or IEDs," Todd Fanta, a first aid instructor, told the 399th. ``The most sophisticated CT scans won't show the psychological pain of a soldier who has just lost a best friend. But the pain is real, the wound is terrible. You had better treat it with compassion and professionalism or you will lose that soldier."

The military demands discipline and devotion to duty. Medicine makes similar demands. But the 399th is basically a unit of high-achieving individualists uncomfortable with the lockstep mind of what they sardonically refer to as ``Big Army." Still, they understand why it works that way.

Said Lieutenant Colonel Nott, the 399th's executive officer: ``It's pretty difficult for medical folk to psych themselves into being `Hooah' soldiers. But we're headed for a land of war and high danger. We're training, in the final analysis, to work together to serve the shooting soldiers. We need cohesion and a sense of common purpose. That's what will really count. Teamwork and absolute confidence in one another."

The Globe has asked to embed with the 399th periodically during its time in Iraq and is awaiting a decision from the Pentagon. James F. Smith of the Globe staff and correspondent Holly Fletcher contributed to this report.