BAGHDAD, Iraq-- --The young soldier would die, a fate ensured by the bullet that entered his right eye and shredded his brain. But unlike many other patients on the beds and gurneys of the U.S. Army's main combat hospital, this one would die quickly, without any heroic attempts to open his skull or take over his vital functions with machinery, without the chance to remain alive until his family or friends could gather.
If the doctors thought he had a chance of survival, they might have treated him differently. But the soldier's medical care was not determined solely by his injury, but also by his nationality. He was Iraqi.
The evolving nature of combat in Iraq - the persisting violence and the increasing responsibility heaped on Iraqi army and police forces - is creating a logistical and ethical tightrope for the American medical centers in Iraq, which exist to treat injured American service members but are seeing large numbers of Iraqi patients brought to their doors.
Military doctors and nurses try to remain blind to the nationality of each patient. But they cannot ignore the conditions on the ground, including the huge disparity in follow-up care available to American and Iraqi patients.
Americans, for instance, can expect prompt evacuation by helicopter and military jet, multiple surgeries in four or more hospitals, and a long and comprehensive rehabilitation, regardless of the cost. Iraqis get the same initial treatment in the U.S. military's emergency rooms and operating rooms but might next face a late-night handoff to Baghdad's overworked and under-equipped civilian hospitals. With injuries such as severe burns and head wounds, which require long, resource-heavy recoveries, death can mark the difference between the two groups.
American doctors say the system pushes the boundaries of medical ethics by making some of the most complicated, high-risk treatments available to only the American patients. For instance, with aggressive treatment the wounded Iraqi soldier might have lived for six months, albeit unconscious and on a respirator, and died near his home and family. Instead he would die in an empty side room of the American combat hospital in Baghdad.
It is a consequence of wartime medicine that American medical teams throughout Iraq say they find troubling and sometimes heartbreaking, particularly given the growing number of Iraqi patients with severe injuries being treated in the U.S. military's hospitals.
"If we were really going to treat them exactly the same, we'd fly every Iraqi casualty back to the United States," said David R. Steinbruner, an emergency room doctor at the hospital. "But we can't do that. It's really difficult, some of the decisions you have to make."
While Steinbruner spoke, a 13-year-old Iraqi girl named Hadeel was resting on a bed behind him, as doctors tried to diagnose what was apparently renal failure. A team of Marines had arrived at her house west of Baghdad a few days earlier conducting a census, and her father asked them if they could help his daughter. She was the fifth of his nine children to suffer the same symptoms. The other four died.
The doctors promised to do what they could but knew that Hadeel's prospects were dim if she required dialysis or some other expensive, long-term treatment. Her father, who goes by the single name Hamadi, understood the limitations but said he had nowhere else to turn, despite the danger inherent in seeking help from the Americans.
"The American medical care is the only thing that can help her," he said, still looking off-balance from his ride in a Marine Corps helicopter a few minutes earlier. "This is not a matter of armies and nations, it is about my daughter's life. Of course I will trust them. I am grateful."
The hospitals in Iraq were once among the most capable in the Middle East, but years of economic sanctions followed by three years of war have erased that distinction. The Medical City complex in Baghdad, a full-service teaching hospital that serves as the city's primary civilian health clinic, is badly under-equipped and frequently a target of attacks, American doctors who have been there say. Many of the well-trained Iraqi doctors and nurses available when the war began have since been scared off or even assassinated.
Realizing this, American military officials make all of the U.S. medical facilities in Iraq - and helicopter and ambulance services - available to Iraqi soldiers, civilians or anyone else, even insurgents, injured within sight of American forces. Military medicine has approached combat care the same way in all the modern wars - treating soldiers, civilians and the enemy the same.
But only to a degree. Wounded Americans typically leave Iraq for the Landstuhl Regional Medical Center in Germany hours after they are injured, often with their bellies or heads still open from surgical procedures. The Iraqis must stay in Iraq to recover. And once they are stable enough, they are sent outside the security perimeter with translated instructions, perhaps a few week's worth of supplies and often with uncertainty about the subsequent care they will receive.
The problem is particularly acute 50 miles north of Baghdad at the U.S. Air Force's Theater Hospital in Balad, the busiest American hospital in Iraq and a way station for every U.S. casualty being evacuated to Germany. The tent hospital's rural location yields fewer American military casualties from the field. But it absorbs endless waves of injured contractors, bleeding civilians and wounded soldiers - often dozens of trauma patients a day, nearly 80 percent of them Iraqi.
The intensive care unit reserved for American and coalition casualties was empty during one typical day last month, yet the two adjacent ICUs overflowed with bandaged Iraqi soldiers, motionless Iraqi children tethered to blinking boxes and blindfolded Iraqi insurgents under armed guard.
Maj. Steven Bowers, an Air Force surgeon at the Balad hospital, ticked off a list of his patients who will require some degree of complicated follow-up care - a civilian woman with a perforated bowel, for instance, and an Iraqi police officer with a colostomy. The Air Force hospital will treat them again if they live close enough and can negotiate through the tight security at the Balad Air Base, but many can't. The hospital's Iraqi liaison to the local hospitals quit and fled to Syria after receiving death threats for working with the Americans. Translators at the hospital say the patients receive death threats, too, but many try to return anyway.
"We're basically the center of gravity right now for the Iraqi health care system," Bowers said, taking a midday break after his second surgery of the day. "I personally really enjoy treating the Iraqi patients. It's good for Iraq, good for the nation, good for the Iraqi soldiers, and I think we're having an impact. How can you expect the Iraqi soldiers to go into battle without medical support?"
An hour later the hospital's tent walls started thumping with the familiar rhythm of helicopter blades, and soon the white concrete floor of the emergency room was splattered with the blood and torn clothing of six patients brought in from the war, all of them Iraqi civilians. Bowers rushed back into surgery with a woman shot through the abdomen, while a man with a head injury was wheeled off for X-rays.
As usual inside a combat hospital, the details of what happened were scarce and contradictory. A pair of soldiers in full battle gear nearby said they'd been riding in a convoy outside Ramadi when they came under attack, but one of the patients, a young man with a mild gunshot wound to his arm, stared into the tent's ceiling and mumbled an alternative explanation in Arabic.
"I asked him if they had done something hostile, something wrong, and he said no, that they all know the procedure when the American convoys come by, but this one just opened fire on them," said Muhammed Habib, one of the hospital's staff interpreters. "You can't be sure, because they all say something like that. But he seems upset. He says his father was killed instantly."
The medical teams consider it a luxury of serving wartime duty in a hospital, not having to know or care who they are treating or what the patients did that got them there. That professional indifference to the war can be particularly useful when treating anonymous Iraqis, they say.
Patient No. 6117 was a good example. The Army's 57th Medical Company, the helicopter medevac crew at Balad, picked up the teenage boy from an overgrown field in the Iraqi countryside, a bullet wound in his buttocks and his intestines piled on top of his abdomen. They bandaged him, hoisted him onto a litter and flew him to the Air Force hospital, where Bowers rushed him into an emergency exploratory surgery. No one knew his name, his age or any of the circumstances behind his injury.
Only later, in the ICU, did an armed guard appear, along with a sign designating patient No. 6117 as an "EPW," or enemy prisoner of war. The guard, a young U.S. Army soldier, said members of his unit had shot the boy after seeing him detonate an improvised explosive device near one of their vehicles.
As a suspected insurgent, the boy would likely be moved later to the medical facilities at Abu Ghraib prison outside Baghdad, to recover under the care of American and Iraqi doctors there.
"We take care of our own guys, pretty messed up a lot of times, and then three minutes later an Iraqi guy who was involved comes in and we start working on him, too," said Tech. Sgt. Gil Mendez, an Air Force medic who works in the emergency room. "You get angry about it sometimes and think we ought to just leave them out there to die. But then you think, 'That's what they would do. That's not what we do.'"
Most of the American medical personnel in Iraq are on temporary leave from jobs at military hospitals in the United States. The equipment and supplies they work with in Balad and Baghdad are essentially the same as those back home, they say.
But medicine in a war zone certainly has its peculiarities. In Balad, Army Col. Jeffrey Faulkner performs surgery with a pistol strapped to his right leg, for instance. In Baghdad, the doctors and other staff members carry M-16s and wear helmets, goggles and full body armor just to cross the street. The nurses say they can tell whether patients were blown up inside a Humvee or a Bradley fighting vehicle, just by the smell.
You can sometimes tell who is being treated inside the Baghdad emergency room by the uniforms of the people congregating in the hallway. The Iraqi army soldiers huddle and whisper in the corners, waiting for word about their injured colleagues, just as the American soldiers and Marines do.
The patients are harder to tell apart once they are inside the rooms of the hospital, a former Baath Party medical center, though occasionally telltale signs emerge.
Upstairs in the main operating room one day last month, a U.S. Army captain and a suspected Iraqi insurgent lay side by side, with American doctors reaching inside both to keep them alive. That one was a suspected insurgent was apparent from the blindfold wrapped around his face, a standard precaution so he won't remember the places or the faces he's seen - including the faces of the men and women who saved his life.
But sometimes you can tell the Iraqi patients by the care they get.
The prognosis of the Iraqi soldier with the gunshot wound in his head, revealed by brain scans, was death. He was surviving on his brain stem alone, which kept his heart pumping and his lungs moving but would not last for long.
Still, if he'd been an American, the doctors say, they would probably have intubated him, performed an emergency craniectomy to relieve pressure in his head, and tried to keep him alive at least through the flights to Balad, then Germany, then to his family in the United States. He might have even lived six more months.
But as an Iraqi, the man had none of that support network available to him and no more options beyond that gurney in the American combat hospital. Army Lt. Nickie Lacer, an emergency room nurse, emptied his bladder, gave him pain medication then pulled a chair up next to him and sat down to wait.
"I'll try to keep him comfortable," she said. "And I'll just wait here with him."