"He had, maybe, another 10 minutes," said Mazur, the emergency room doctor. "He was on death's doorstep. You can't wait."
The most serious injury was less obvious. His right hand, which looked as if it had been chopped with a dull ax at the wrist, remained attached by little more than an inch of flesh and skin. Maj. Charles Fox, a vascular surgeon, released the tourniquet around Lufkin's upper arm, and dark blood shot from the wounded wrist in rhythmic bursts, indicating a severed artery.
Blood-clotting dressings and modern-style tourniquets are innovations of the war, and doctors said they likely kept Lufkin alive until he reached the hospital. But in the operating room, with those battlefield dressings removed, the surgeons marveled that Lufkin was no longer oozing blood from the many cuts and punctures that covered his body, as he had been an hour earlier. They credited Factor VII for the difference.
As a technician picked up Lufkin's legs to scrub off the dirt and shrapnel blasted into his skin and prepare him for surgery, the doctors stood back and remarked at the absence of bleeding.
"His blood pressure was 80, he'd lost about 40 percent of his blood volume, and in surgery an hour later he's stable and hardly bleeding at all," said Col. John B. Holcomb, Lufkin's surgeon and the Army official largely responsible for Factor VII's introduction in Iraq. "We're learning how to deal with these kinds of massive injuries."
A convoy struck
By about 11 a.m. the next day, as Lufkin was being prepared for a helicopter flight to Balad, Iraq, for transfer to a recovery hospital in Germany, Capt. Shane R. Mahaffee and Staff Sgt. Heath Berry left in a convoy near the southern town of Hillah. Both men, who had been in Iraq only a few weeks, were traveling outside their protected base as part of a training mission with the men they were replacing, to give the new arrivals a feel for the town and the surrounding country.
Unlike Lufkin's unit of young, hardened combat troops, Mahaffee and Berry's unit was a civil affairs battalion, staffed with lawyers and engineers and soldiers whose primary mission was diplomacy, not war. They and three other soldiers were driving along a rural road in the lead Humvee when the gunner spotted what he thought was a roadside bomb.
The discovery touched off a frantic discussion among the vehicle's occupants over whether they should stop or attempt to drive past, Berry said. Mahaffee, in the front passenger seat, called for advice on the radio as 1st Sgt. Carlos N. Saenz continued driving forward. The other occupants, fearing that they would be within range if the bomb detonated, yelled at Saenz to stop, Berry later recalled. But they got too close, so Mahaffee shouted, "Floor it!"
The bomb killed the gunner and a back-seat passenger almost instantly and mortally wounded Saenz, who cried out, "I'm sorry! I'm sorry!" Berry, soaked with blood and tissue, thought he'd been cut in half before realizing that he was covered in the gunner's remains.
Medics rushed forward to treat Berry and Mahaffee, the ground around them littered with candy that Saenz had been carrying for Iraqi children. They tightened a tourniquet around Berry's mangled left arm and slapped a blood-clotting bandage on his neck, and he sat by the side of the road with a loud ringing in his ears. Mahaffee, frantically trying to help the others, refused medical treatment, but then he weakened and had trouble breathing, and waited with Berry for the helicopters to come.
Once they were in the emergency room, Berry garnered the most attention. His left hand, which would later be amputated, looked like pulp, and his blood dripped from both sides of the gurney. Doctors quickly gave him plasma and red blood cells, sedated him, inserted a breathing tube and then injected him with a dose of Factor VII. He was upstairs in the operating room before anyone had done much with Mahaffee, who was partially conscious and writhing in his bed.
Chest X-rays soon revealed that Mahaffee, who didn't appear to be bleeding at all, was in fact hemorrhaging into his chest cavity. Doctors gave him a dose of Factor VII as well, less for the bleeding they could see than for the bleeding they expected in the operating room.
"He needs it," one of the doctors said, "because he's going to bleed like hell."
Bleeding from veins or arteries can ordinarily be fixed with surgery. The type of bleeding Army surgeons fear most is called "coagulopathic" bleeding. It develops more slowly, when a patient's blood uses up all of its natural clotting proteins or becomes too diluted with fluids pumped into the veins to clot. Once such bleeding starts, which doctors say they can recognize from the blood's lighter color and Kool-Aid--like consistency, it can be very hard to stop.
By injecting Factor VII on the mere anticipation of coagulopathic bleeding, Army doctors are working on the fringes of acceptable practice, civilian doctors say. Civilian patients often bleed for hours and sometimes days before doctors resort to using Factor VII. But because Army doctors believe it works best when given early, war casualties in Baghdad often get it within minutes of their arrival at the hospital.
Mahaffee's bleeding appeared to be under control in the operating room as surgeons cut into his upper chest to repair a nick in the artery under his left clavicle. But then blood started to appear in his breathing tube, and his condition and prognosis changed quickly.