Pfc. Caleb A. Lufkin landed on the helipad at about 12:30 p.m., screaming at the sky as a small all-terrain vehicle carried him past the palm trees and concrete bunkers to the emergency room. Doctors inside cut off his blood-covered boots and prepared to sedate him and insert a breathing tube, and he pleaded with them to keep him alive.
"Don't let me die," he said.
"I won't let you die," answered Capt. David Steinbruner, an Army doctor. "I promise. I give you my word."
Lufkin was bleeding from multiple blast injuries and compound fractures, so the medical team at the 10th Combat Support Hospital gave him red blood cells to replace his lost blood and plasma to help him clot. But they quickly concluded that he was on a perilous course toward a massive transfusion and that his odds of survival were decreasing with each minute that he continued to bleed.
At 12:41, without waiting to see if surgery or more transfusions would be enough to stop the bleeding, they ordered a 7.2 milligram dose of Recombinant Activated Factor VII.
When Lufkin arrived at the Army's combat hospital in Baghdad on May 4, he was the first of three American soldiers brought in over a 24-hour period, each with injuries severe enough to require blood transfusions and emergency surgery. Like more than 1,000 of the war's seriously wounded troops, each was treated with Factor VII, a powerful and largely untested blood-coagulating drug that the Army considers a wonder of modern trauma care, but which researchers have linked to deadly blood clots that lodge in the heart, lungs and brain.
All three soldiers left Baghdad alive, their doctors anticipating full recovery. One experienced no problems and later said he was grateful for whatever steps were taken to save his life. But two later suffered unexplained blood clots and died from subsequent complications.IraqIraq[From Page 1A]
Some doctors worry that the Army, in its effort to push the limits of modern trauma medicine, is going too far with its enthusiasm for Factor VII, that giving it to the war's casualties could be doing more harm than good. But the physicians in Baghdad say that a war is no time to be cautious and that they'll consider any new advancement or technique that might save lives.
"All we can do is give these guys the best chance we can, with the best equipment and training we have," said Lt. Col. Bob Mazur, who served as the chief emergency room doctor in Baghdad that day. "This is war, and bad stuff happens."
Private Lufkin's injuries
Lufkin, 24, was wounded just before noon on a busy street in downtown Baghdad. He had joined the Army a year earlier after trying odd jobs that all seemed to be dead ends. He hoped that military service on his resume would help him land a job as a professional firefighter, but mostly he just wanted his life to go somewhere.
He still lived in his hometown of Knoxville, Ill., in the flatlands near the Iowa line, and he had a reputation for always smiling, even at odd times. In his yearbook from basic training he's the only soldier without a frozen scowl. He loved his friends and fishing and playing the banjo, his relatives say. And he hated Iraq.
"He believed in what he was doing, but he couldn't understand how some of the people in Iraq loved them and how some hated them," said Pat Houston, Lufkin's grandmother. "The hate bothered him a lot."
Lufkin's unit, the 5th Engineer Battalion out of Fort Leonard Wood, Mo., had one of the most dangerous jobs of the war: driving around Baghdad at 5 mph in search of roadside bombs. But he told his mother not to worry, that the oversized armored truck he rode in - a fortified mine-clearing vehicle called an RG-31 - could withstand anything, particularly an improvised explosive device.
"He said, `Mom, I'm telling you, these things are built to survive the blast,'" said Lufkin's mother, Marcy Gorsline. "He'd been hit by IEDs I don't know how many times before and said it'd always just blow out a tire."
The one that hit him May 4 wasn't a typical IED, but a military-style bomb designed to pierce armor and inflict maximum damage.
The blast injured one soldier only slightly, but killed two others and left Lufkin bleeding so badly that he was certain to die without prompt medical care. With the vehicle still burning, Lufkin's platoon leader dragged him out through the gunner's hatch, medics quickly placed tourniquets on his arms and legs, and a helicopter lifted him out minutes later.
The Army's hospital in Baghdad is inside a former Baath Party medical center, down the street from the main palace in a section of the city that American officials call the International Zone but which nearly everyone else calls the Green Zone. Many of the signs are still in Arabic, but otherwise it looks much like any small hospital in the United States, right down to the harsh lights and the green tile.
Factor VII arrived there in early 2004 after Army officials got a look at results from a clinical trial suggesting that it was safe. But as military doctors have embraced the drug, which is approved by the U.S. Food and Drug Administration only for certain patients with hemophilia, doubts about its use for trauma patients have grown. The FDA warned in December of risks to non-hemophiliacs, citing reports of deadly blood clots in patients who got it. Many civilian trauma centers use it only as a last resort.
The needle with Factor VII went into Lufkin's arm 20 minutes after he arrived, just as he received his fourth unit of blood. Then he was wheeled to an operating room upstairs for emergency surgery.
"He had, maybe, another 10 minutes," said Mazur, the emergency room doctor. "He was on death's doorstep. You can't wait."
A Kevlar helmet and body armor had protected Lufkin's head and torso, but the rest of him was peppered with burns and puncture wounds, some of them serious. His right ankle was fractured, and his left kneecap was shattered so completely that doctors said it contained nothing but pink tissue and "bone dust."
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.
Suspecting an injury to his left lung, the surgeons cut an L-shaped opening in his chest, from his neck to his abdomen. One of them grabbed the lung and twisted it, pinching off the airway and blood supply so he would no longer bleed into the respirator. An anesthesiologist was called to insert a two-pronged airway tube, which could isolate Mahaffee's right lung and let him breathe freely while doctors worked on the left.
The surgery, which took several hours, required doctors to replace roughly half of Mahaffee's blood supply. Capt. Ronald White, the anesthesiologist, used blood tests to monitor Mahaffee's clotting capability, which remained normal. But he injected two more doses of Factor VII to be certain. The bleeding never got out of hand, and doctors said the drug made the difference.
"With these poly-trauma patients, once they start to get oozy, they can just spiral downhill," said White. "You can't wait for that to happen."
Within hours of his surgery, Mahaffee was awake in the hospital's intensive care unit, unable to talk because of his breathing tube but scribbling notes on a clipboard of white paper to his friends and the hospital staff. A page taped to a machine behind his bed, said simply: "Thank you."
To Capt. Matt Lawton, a friend who had gone through training with Mahaffee and went to his beside, he scrawled: "Tell the guys I'm OK." To others in his unit he wrote: "This job is not done." On yet another he scratched: "Hold all calls."
"That's the way he is," Lawton said. "Being funny and thinking about everyone else."
A 36-year-old lawyer from Gurnee, Ill., with a wife, two young children and a successful general law practice back home, Mahaffee never imagined even eight months earlier that he would be working for the Army in Iraq. He had finished his stint with the Army in 1999, retiring after eight years in the Reserves, and he hadn't drilled or worn a uniform since.
But in October of 2005 he came home from vacation to find a FedEx package from the Pentagon calling him back to service. Like many retired soldiers, he was still part of the Individual Ready Reserve, a limbo status that allowed the Army to reactivate him. The program is so rarely used that few soldiers give it much thought, but the Army, suffering a desperate shortage of junior officers, summoned him out of retirement.
His wife and colleagues say he never complained, figuring he'd been trained by the Army and wouldn't turn his back when they needed him.
"He should have just been in the military anyway, to tell you the truth," said his wife, Jennifer. "He was worried about his law office, and about leaving me and the kids, but I don't think he was worried about himself. He supported the president and the president's decision, and said, `OK. This is my job.'"
Mahaffee left home on Jan. 8, headed for the Army Training Center at Fort Jackson, S.C., and then to civil affairs training at Fort Bragg, N.C. The local newspaper ran a photo of him kneeling down in the airport, looping his arms around his 5-year-old daughter, Adelia Rose, and kissing her goodbye.
"The Army talks about this warrior ethos, of never quitting, of putting the mission first. And to most people I'm sure it's just something written on a little card they give us," said Maj. Lisa Forsyth, who served with Mahaffee in Iraq. "But you look at Shane, he's it."
Like Lufkin, Mahaffee and Berry flew out of Baghdad within a day or two of their injuries, first to the U.S. Air Force Theater Hospital in Balad and then to the Ramstein Air Base in Germany for transfer to the Landstuhl Regional Medical Center.
Most casualties spend only a few days at the hospital in Landstuhl; when relatives try to visit, the Army tells them not to bother. If family members are encouraged to come to Germany, it usually means that the patient is too unstable to fly, which is almost always bad news.
Jennifer Mahaffee was told not to come. Her husband had been progressing well and was scheduled to fly to Washington soon after he arrived in Germany. But the day he was to leave, a blood clot lodged in his healthy lung.
The clot deprived him of adequate oxygen and forced his doctors to get "aggressive" with artificial respiration, according to Air Force Maj. Tim Woods, the surgeon who treated him at Landstuhl. With his condition listed as "critical but stable," Mahaffee's wife, his father, and his mother and stepfather were soon on their way to Germany.
Trauma specialists know that clots in the lungs, called pulmonary embolisms, sometimes afflict severely injured patients. But the clots typically travel to the lungs from the veins of the legs - a condition called deep vein thrombosis, or DVT. Doctors in Germany had checked Mahaffee's legs for DVT with an ultrasound machine, but the results were negative. So the source of his pulmonary embolism was a mystery, Woods said.
But others say multiple doses of Factor VII would be a leading candidate if they were trying to determine the source of blood clots in a patient.
"When you give a patient a powerful clot-promoting medication, you may well induce a clot some place you don't want one," said Dr. Rodger L. Bick, a University of Texas blood specialist.
Mahaffee was unconscious as his family gathered around, alternating shifts between the lobby and the chairs by his bed. He remained on a breathing tube, but doctors were encouraged by his condition and offered hope that the tube would be removed.
He developed pneumonia a few days later, however, and the last hints of optimism gradually melted away. On May 15, the doctors said they were running out of options and told the family to prepare for the worst.
In desperation the doctors reopened Mahaffee's chest in his hospital room and massaged his heart by hand while his father offered prayers nearby. Mahaffee's wife said she stayed in the room as long as she could bear it.
Mahaffee's death was attributed to complications from pneumonia and infection, but his doctors said it was the ventilator that likely prompted the infection, and it was the clot that put him on the ventilator. He would probably have survived his injuries in Iraq, they said, if not for the "second hit" he suffered with the blood clot.
Lawton flew back to the United States for the funeral and read Mahaffee's notes from Baghdad during the service. Jennifer Mahaffee, who spent much of the day carrying Adelia Rose and 2-year-old Ethan, said the last of her energy had been drained.
"I had a very bad feeling about his injury from the beginning," she said afterward. "I don't know why. Even when other people were being optimistic, I just didn't think he was ever going to come back."
Sergeant Berry's recovery
Berry's recovery was largely uneventful. At Landstuhl someone hung a sign behind his bed saying he was a Marine, creating some confusion among the Army and Marine Corps ambassadors who roam the hospital every day and visit the wounded men and women from their branch of the armed services. Berry thought it was funny and was too drugged up on fentanyl to care.
Besides, the sign was half-right. Berry, 28, had been in the Marine Corps five years, joining right out of high school. But he never liked it and quit as soon as he could. Once back home in Philadelphia, Tenn., he went to a technical college and earned a degree in computer graphics design, and then joined the Army. Soon after arriving at the hospital from Iraq, he'd decided to leave the Army too.
"I just want a different life, after all this," he said.
Berry's only medical complication was a high fever that struck at Walter Reed Army Medical Center in Washington a few weeks after he was injured, but the doctors controlled it with antibiotics. He needed skin grafts and surgery on his arm, and he had bruises all over his body that took some time to heal. But by summer he was content and looking forward to going home, surfing the Internet from his hospital bed in search of a one-handed video game control built for amputees.
He had never heard of Factor VII, had no idea he'd been injected with it, and never suffered any clot-related complications. He was grateful for everything the Army's physicians had done to take care of him in Baghdad.
"I wish they could have saved my arm," he said. "But I'm happy they saved my life."
A clot during surgery
Lufkin threw a blood clot on May 18, three days after Mahaffee died, during surgery at Walter Reed to repair his left leg. The clot lodged in his lung, and doctors had to stop the surgery, then put him back on a respirator and wheel him into intensive care. They didn't know where the clot had come from, but clots almost always break free from veins in the legs, and Lufkin's left leg was a mess inside and out.
He'd been recovering well. His mother took her first airplane ride to visit him at Walter Reed on May 8 and was horrified at the extent of his injuries and the glassy look in his eyes, but she went to work spoon-feeding him and cleaning the dirt from his fingernails.
"Try to imagine walking through that door and seeing your perfect child lying there, blown apart, with cuts and pieces of shrapnel all over him and his eyes just lifeless," said Gorsline, his mother. "I'd never felt so angry before."
His teenage brothers came, too, then his grandmother and other family members, feeding him cookies and Subway sandwiches. He was in pain much of the time, made worse by bouts of intolerable itching, but the son and brother he was before Iraq began to slowly emerge from the wounded soldier in Room 5733.
He talked about the attack. A child on a bicycle rode alongside the vehicle just before the blast, and a huge crowd of Iraqis gathered as the injured soldiers lay bleeding on the ground. He remembered lying there thinking he had to survive to see his brothers, Lance and Taylor.
A sergeant from his unit visited and photographed him holding a sign that said "Keep Kicking Ass!!" and then sent the picture back to friends in Iraq. The man known for his smile frowned as he stared at the camera, the same look he had for much of his time at Walter Reed.
Doctors rescheduled the surgery on his leg for May 25 and on the day before told Lufkin he wouldn't have to stay in Washington for physical therapy but could move closer to his home in rural Illinois. It was exciting for him, and he started planning a cookout with friends, right down to the menu. But he didn't stop there. He talked about taking a trip to Australia and planning new adventures. It was, family members said, one of the happiest days since he'd come back from Iraq.
"He was starting to finally come to life," Gorsline said. "He could see an end to all of it."
Lufkin crashed again during the second surgery, with the same symptoms as before, but this time doctors couldn't revive him. Gorsline was doing a crossword puzzle in the lobby when a team of doctors and counselors invited her into a private room, then said her son had gone into cardiac arrest on the operating table. In that room, she said, they cried with her.
The doctors never explained how he had died, and an autopsy report the family asked for later offered little clarity. During surgery doctors performed an echocardiogram that indicated that Lufkin had an air bubble in his heart - a rare occurrence, often caused by problems with a catheter in the veins. But a cardio-thoracic surgeon who was called cut into Lufkin's pulmonary artery in search of another clot, even after being shown the echocardiogram.
No clot was found, the records say, and pathologists ruled his death "consistent with an air embolus" but never performed tests to confirm it. Lufkin's official cause of death was "complications of blast injuries," according to the autopsy report.
"To say 'complications of blast injuries,' that's just a worthless statement that obscures what the real cause of death is," said Dr. Joseph I. Cohen, a former New York City medical examiner and now chief forensic pathologist in Riverside, Calif. "It sounds like they don't have an answer."
"No one's ever been able to explain to me how someone so young and so healthy could die of a heart attack like that," said Gorsline, a cardiac-care nurse.
Lufkin, like Mahaffee and many soldiers killed in Iraq, was awarded the Bronze Star at his funeral, a medal given for bravery, heroism and meritorious service. Firetrucks from the surrounding towns used their ladders to form an arch over his funeral procession, and family members stood for 10 hours shaking hands in front of his casket.
UUnder the flag
His mother selected a grave site next to the flagpole at the municipal cemetery in Knoxville, Ill., because it is illuminated 24 hours a day and because she heard the flag snapping in the wind as she walked around the site with the funeral director.
"I looked up and saw that flag flying and said, `I want him right here, right under that flag,'" Gorsline said. "He died for that flag, and everyone who comes here will hear it flapping in the wind."
The Sun made repeated requests with the Army to interview Lufkin's doctors at Walter Reed or view the official records about Lufkin's and Mahaffee's injuries and deaths, but each request was either denied or did not get a response. The only information available publicly says the same thing about the two soldiers - that they died of injuries received when an improvised explosive device detonated near their vehicles.
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