Balad Air Base, Iraq -- The boy was dying much faster now. His blood pressure had skyrocketed, and his pulse was in the 180s. Standing at the foot of his bed, Dr. Heather Cereste could see his heart shudder in his skinny chest.
His father seemed to sense what was coming. It was past midnight, Heather would later recall, and he was still at the bedside of his 6-year-old, who had been shot in the head while playing outside his Baghdad home. The father had been waiting this way for several days, dressed in the same black robe, stroking the boy's shaved head or resting his own head on the child's legs. The ventilator keeping the son alive beeped and sighed; often, the father wept.
A few phrases of translated Arabic - "don't touch"; "show me"; "I'm sorry" - were posted on the hospital's walls to help the American doctors communicate. But even if Heather had spoken the language, she wouldn't have known what to say.
Such moments were the hardest part of life in the tent hospital at Balad Air Base, where mortar shells fell almost daily and fighter jets roared overhead.
In the intensive care unit, Heather encountered the worst of what war could do to a human body, saw toddlers with crushed skulls and young soldiers blown apart.
Now, watching the father mourn his still-breathing son, she knew that war also destroyed souls.
For the hundredth time, she wondered what she was doing here, 40 miles north of Baghdad, in a giant tent filled with beds. How could she practice medicine when so many of her patients were past healing? No matter how good a doctor she was, she could not save this child or soothe this father. Nothing could have fully prepared her for such a place.
And yet, she had seen tears like the father's before. They belonged to a woman named Mary, on the other side of the world. They had met months before and 6,000 miles away, in a hospital where Heather trained to treat the injured in Iraq.
To prepare her for Balad, the Air Force had sent her to Baltimore.
She hadn't known much of anything about the war wounds of children when she arrived in Maryland last fall. Thirty-seven-year-old Heather Cereste was, by specialty, a geriatrician. Back home, at an Air Force base in Texas, most of her patients were in their 80s. Heather was accustomed to dementia and broken hips, to the tissue-thin skin and breakable bones of the very old. The bulk of her knowledge of combat medicine came from M*A*S*H reruns.
But soon, by January, she would be in Iraq. She needed to get all she could out of these three weeks at the University of Maryland's Shock Trauma Center, where she would work with a team of doctors to learn emergency medicine skills. She had never been to Baltimore before. She wondered whether it was like a war zone, the way people said.
Shock Trauma, she knew, was home to one of America's busiest emergency rooms and that it had been training Air Force medical professionals since the beginning of the war, about 30 people each month: nurses, physicians, physicians' assistants, medical technicians and chaplains, many of them bound for the Middle East.
The majority came from small bases, where the closest they got to trauma experience was bandaging sprained ankles, or from specialty backgrounds like Heather's.
Along with a high patient flow and the best equipment, the hospital - which takes the worst cases from across the state - offers an unusual number of "analogous wounds," injuries that look and feel and bleed like those sustained in combat. Gunshot wounds, largely a result of inner-city violence, are the leading cause of death at Shock Trauma. A high percentage of the victims are fighting-age men.
"The reason why we chose Baltimore was, they came in with the highest bid on bodies," Maj. Jeffrey Ball, one of the Air Force administrators, told the military doctors that first day, in a windowless hospital conference room.
It saddened Heather that the people of Maryland would be standing in for the casualties of war. How could violence in an American city even come close to what was happening in Iraq?
As she toured the hospital's figure-eight-shaped floors, though, she was grateful for whatever experience Baltimore could offer her. She was not at all ready for what lay ahead in the desert, where she would be stationed for four months or more.
During a break, she squinted at her reflection in a bathroom mirror - angular face, glasses, a mass of curly brown hair - but she didn't see a combat doctor. She saw a geriatrician who was out of her depth.
It wasn't only that she lacked the skills to do this new job. She also needed strength to witness the horror of war and to face the human misery that followed.
Without it, she knew, a doctor could be traumatized, too.
The first few days she learned the ABCs of trauma management - airway, breathing, circulation - along with more esoteric bits of wisdom. A person can bleed to death through his scalp. Third-degree burns heal from the sides, and second-degree burns from the bottom. A stab wound below the nipples can injure the diaphragm. A missed pancreatic duct wound is often fatal.
She also studied the dead.
One afternoon, Heather's class was led across the street and down a flight of steps to the University of Maryland cadaver lab.
There, the bodies of two old people, a man and a woman, lay stretched out on metal tables. Everyone took turns cutting into them, pushing chest tubes between their ribs and slicing their throats to insert breathing tubes, a last-ditch maneuver that they might need to use to keep soldiers alive in the desert.
"Remember, you could be doing this anywhere," the instructor said. "You could be doing it in the dark."
Heather had never performed some of these procedures on a human body before. Her hands hovered over the male cadaver's withered neck, which had been cut several times so that a thin layer of yellow fat was exposed. She searched for the right spot between the thyroid cartilage and the sternal notch.
The idea of death wasn't what scared her about combat medicine. Unlike many of the other young Air Force doctors who trained in Baltimore, she was at least used to seeing people die. Her patients in Texas often passed away in her care, after long lives.
What terrified her was the prospect of violence, the way it broke the natural life cycle, causing so much suffering.
Growing up in rural Maine, the oldest daughter of a power plant worker and a librarian, Heather excelled at almost everything she put her mind to, starred on her high school basketball team, brought home straight A's, presided over the student council.
But as much as pushing herself, she liked caring for others, particularly her grandparents. She sensed early that her desires to solve problems and help people made medicine a natural fit.
After college, though, it had taken her time to decide on medical school. She had always been a reflective person. Even as a teenager, she stayed up late wondering what the future held for her and whether she would make the best of her life, start a family, find happiness.
She dabbled in other careers: business, phlebotomy. She traveled a lot.
At last, in her mid-20s, she took out loans to get her medical degree and never looked back.
Geriatrics also seemed an obvious choice. It was a neglected field, and Heather loved old people, even the patients whose minds were going, the ones who lectured their reflections in the mirror. Many reminded her of her own grandparents. They broke ribs rolling over in bed, but they were also so strong, the survivors of past wars.
It was sometimes hard to accept that war could also be a part of her job.
She had gone on active duty with the Air Force in July of 2006, hoping for financial stability to ease her out of her debts, the chance to serve her country and the opportunity to be stationed in different parts of the world.
Her family was troubled by the choice, even her father, who had been a Navy technician on submarines during the Vietnam War. Didn't she know there was a war on?
But Heather assumed that geriatricians had no place in conflicts waged by young men. Don't worry, she told her parents, they won't send me.
She hadn't realized then that although the military relies on many kinds of specialists to treat the wounded, it also draws from a deeper pool of internists to serve in more general roles such as monitoring recovering patients in intensive care units.
One day, Heather recalled, her commanding officer sat down in her office. I'd like for you to come to Iraq with me, the officer said with a smile, as though deployment were a privilege.
But now that Heather was preparing to leave, she was worried, not so much about losing her own life - she had no husband, no children to fret about - as about the bad memories that she might carry back to San Antonio.
She dreaded disfigured faces, mangled hands, nightmarish injuries that the patients would wake up to.
She feared the knowledge that every soldier she failed to save was someone's child, that human lives are entwined so that one bullet can pierce a hundred hearts. She feared grieving parents she would never meet and damage that went deeper than the flesh.
But that was what she was in Baltimore to get over. She had to concentrate on the task at hand. A human body lay on the cold metal table before her.
Her hands, young and strong, grasped the scalpel.
She cut into the dead man's throat.
When the phone on the hospital wall wailed, Heather was already on her feet, listening as the basics came across on the radio. A man had been shot multiple times in Crofton. The helicopter would need nearly half an hour to reach Shock Trauma.
"Twenty-five minutes and five holes in him?" a nurse said. "He'll be dead by the time he gets here."
If he lived, he would be Heather's patient.
It was her second night on call in the hospital's trauma resuscitation unit, a semicircle of beds and machinery on the second floor. Heather tensed up each time the phone rang, signaling that a new patient was on the way from the ambulance entrance on the street below or from the helicopter pad on the roof.
Anyone could come through the doors: a teenager with a broken neck, his jacket pockets bulging with Miller Lites, a hemorrhaging drug dealer, a woman whose throat had been slit into a smile. They weren't soldiers, but they were victims of violence just the same.
Members of the regular staff, wearing scrubs as pink as their bloodshot eyes, barely looked up from their computer screens while a nurse stood beside a giant whiteboard, scrawling information phoned in from first responders.
But Heather found it hard to stay relaxed in a setting where everything happened so quickly, where teams of doctors and nurses pounced on new patients, cutting off their clothes to save time.
Until now, she had been spared the worst of what Baltimore had in store. Most of her cases had involved relatively minor wounds, cuts and bumps. She had put a chest tube into a drunken driver from Harford County, which had been nerve-racking because, until her experience in the cadaver lab a few hours earlier, she had performed the procedure only on a goat. When she finally wedged the tube all the way in, it was as though the pressure was relieved in her own chest.
This new patient, though, might be different. And she would be leading a team of doctors and nurses through emergency procedures still new to her.
Slowly, she reached into her lab coat and pulled out her trauma manual. She opened it to the section on gunshot wounds.
"Seven minutes!" someone called out.
Heather tied on a blue smock and a mask with a plastic visor. Nurses scrambled to gather materials, preparing to hang bags of saline and blood.
She pulled on a second pair of surgical gloves. Someone ran to get a shock cart.
The building trembled slightly as the helicopter touched down.
He came in feet first, his white socks soaked with blood, as though he had walked in it. His face was young, his hair buzzed into a crewcut. Tears puddled in the corners of his eyes. A set of dog tags was tattooed on his chest. "R.I.P." one of them said.
The victim had interrupted men robbing his home. There were a lot of bullet holes, the paramedics said as they wheeled him to the doctors. They thought five, but weren't sure.
"Are you in any pain?" Heather bent down to ask the man.
"I gotta piss," he whispered.
The team moved like a nest of snakes, a dozen hands striking at once. "You've got to get control of his airway!" a surgeon called out. Heather started counting wounds, checking the man's powerful, limp body. She found thimble-sized holes in his pelvis and chest.
Great trauma doctors are systematic, racing through an established series of tests to define an injury and determine a course of action. But this man's wounds were so severe that Heather could barely decide where to begin. She needed X-rays, full body scans, CAT scans. She needed to make sure that the patient's spinal cord was intact and that there was no bleeding in his belly. She needed to get him sedated and intubated.
For a split second, she hesitated, and the team's energy crashed over her like a wave, overwhelming her. She was losing command. The surgeon watched her every move.
Then he looked up sharply: She had missed a bullet hole in the man's neck.
Heather sucked in her breath.
"I mean, as team leader, I didn't know anything," she muttered to a resident when the patient was hustled away for imaging. "I was in the middle of everything but not in control."
She looked over at the space where they had been working, now empty, the floor smeared with blood and strewn with syringes.
But she couldn't dwell on it now. Time was speeding up again. She had to get in touch with the head and neck specialist. And someone saying she was the patient's mother was in a panic downstairs.
"I forgot to call ortho," she said. "Damn it. And how do I order four units of blood?"
As she scrambled to get the job done, part of her wondered who that patient was and what kind of life he would return to if he survived. He might succumb to his injuries bit by bit or slowly come back to life upstairs in the intensive care ward, Either way, he probably had a long road ahead of him.
Nights when she wasn't on call, Heather went home to her spare apartment on Eutaw Street and studied the War Surgery Manual, the bible of combat medicine.
"Our most fervent hope," the prologue says, "is for mankind's dream of peace and the exercise of his better Angels ... whereby this Handbook becomes altogether unnecessary."
It goes on to diagram shock waves and tanks engulfed in flames.
She studied the manual to be ready for whatever Iraq had in store for her. In the Balad intensive care unit, her job would be to keep the sick and dying alive until they were transferred.
Sometimes she wondered whether she would ever be ready, even after Baltimore. Over her nights on call, brutal 30-hour stretches of sleepless labor, she hadn't made any more major mistakes. But in Iraq, she might be working alone. What if someone died because of her?
She scoured the manual, looking for the skills to help her cope.
As the days passed, though, she also realized that Baltimore could prepare her and her classmates in ways that textbooks couldn't. For the extraordinary resilience of the human body, which she witnessed in her gunshot patient over the next few weeks, as he recovered sufficiently to flash a thumbs-up sign. For the sheer wickedness of someone who could leave strangle marks on a pregnant woman's neck.
She saw so many disturbing cases: an elderly assault victim with blood on her slippers, a rosy-cheeked, brain-dead teenager.
She watched police handcuff a stabbing victim to his hospital bed. His thigh was split almost to the bone, revealing bright watermelon colors.
She heard the snare-drum heartbeat of an unborn baby that survived its mother's car crash.
She gazed into the eyes of a 20-year-old Baltimore man who had been stabbed in the head with a steak knife. The young man stared back, his eyes brown and sad beneath the silver blade.
The skills would come with time, she told herself. More than anything, she needed to be ready mentally. She needed to be prepared to see people in pain that she would not be able to relieve, no matter how hard she worked. She needed to recognize what could be fixed and what couldn't.
She didn't know how the Shock Trauma doctors did it, when each night on call they confronted the same tragedies. Despair was always present at Shock Trauma, and the surgeons who could patch ruptured aortas could not heal broken hearts.
The three weeks at Shock Trauma passed in accordion time, sometimes stretching out, sometimes compressing. Election Day, Veterans Day. With each night on call her confidence in her skills grew. She examined her first pelvic fracture. She got used to putting in central lines again, gliding through layers of fat and skin and avoiding the rock of bone. Bit by bit, the medicine was coming to her.
It was raining hard the night the young woman came in, her eyes huge and blue and blinking. Her eyelashes were long and pale. Her toenails were painted red. As they sliced off her clothes, the change in her pockets splashed to the floor.
Her name was Mary.
Had she been driving too fast on the wet roads? Was she drunk? At the moment, it didn't matter; she was Heather's patient. The doctor focused on the task at hand, making sure Mary's airway was clear. By now she had done the procedure several times.
Her hands skimmed over the Baltimore woman's naked body, searching for wounds.
"Oh, God, please make it stop hurting!" the woman cried.
"No breath sounds on the right," Heather called over her shoulder to another doctor. "Any pain in your belly, Mary?"
"I'm going crazy, please!" the woman said through bloody lips. "I can't calm down."
Heather worked methodically, calling out injuries. "Abrasion of the right knee! Abrasion of the right ankle!" Her surgical gloves tangled in the patient's long blond hair.
As she worked, Mary recited her memory of the accident like a litany.
"I was sliding and sliding," Mary was saying. "I think I passed out."
Heather sedated the whimpering woman. She squeezed the jewel-blue ultrasound gel on her stomach, then peered into the undersea world of her abdomen.
No internal bleeding there - in fact, everything looked good. Relief washed over the doctor. A few broken ribs, maybe a broken sternum. She would have to put in a femoral line, of course, and get some X-rays of that ankle. Nothing life-threatening. Nothing she couldn't handle.
"Where is my daughter?" Mary asked.
"Where was your daughter?" Heather replied, taken aback.
"She was in the truck with me," Mary said. "She's 2."
For a moment, Heather froze.
"We don't have an update on that right now," the doctor finally said, turning back to the work. The child probably had been taken to a pediatrics hospital elsewhere in the city.
But the patient continued to cry out, louder now: "Will someone please tell me my baby's OK?"
She was too agitated, Heather decided; the only way to calm her down was to get information. Heather walked over to the other doctors to ask.
"What about her daughter?"
"Don't mention it in an acute setting," the resident said, without taking his eyes off an X-ray.
"Well, do we know?"
"Yeah," he said, looking up at her now. "She's dead."
"Oh," Heather said. "Oh."
She left the task of telling Mary to the two uniformed men who had been waiting in the emergency room almost since she had arrived. Heather couldn't hear what the officers said, but soon there was the sound of sobbing, shaking and low.
"Baby," Mary murmured. "Baby."
Tears dripped off the side of her face, soaking her hair. She wept on and on, her breath growing ragged, long into the night.
Heather listened without knowing what to do. She stayed back where Mary couldn't see her, absorbing the cries.
Very early the next morning, she went to check on her sleeping patient, who had been moved upstairs. Mary's face was still raw from crying all night, but the pattern of her breath had evened. Heather crept past the curtain and over to the bedside. She wondered how the young mother would recover from her daughter's death. How could anyone? And there was nothing a doctor could do to make the loss any easier.
So Heather did the one thing she could think of. She pressed her stethoscope to the woman's chest and listened to her heart.
Several months later and 6,000 miles away, Heather stood at another bedside, watching another parent grieve. The pupils of her 6-year-old gunshot patient were sluggish and nearly fixed, and he didn't respond to pain. He had suffered a stroke, and the swelling in his wounded brain continued. His father's long vigil was drawing rapidly to a close. He searched Heather's eyes, she later recalled, as though they held a cure.
She administered an anti-hypertensive medication to lower the child's sky-high heart rate and blood pressure. She gave him morphine to help with the gurgling congestion she had heard in his lungs and with any pain he might still feel. She changed the settings on his ventilator and stopped his intravenous fluids, did everything she could think of.
She told the father to hold his son's hand.
But she knew it was useless. Now the boy's arms were stretched out by his sides, stiffened, the wrists twisting out: decerebrate posturing. The child will never come off the ventilator, will never go home, Heather told herself.
There was much about Balad that Baltimore had not prepared her for. The way the hospital flooded in the rainy season, for instance. How the tents billowed when the choppers touched down. The chemical stink of the burn pit, where the base's garbage went up in smoke, leaving what looked like a strip of blacktop across the sky. The sand that came in on soldiers' boots and in low, rolling storms, covering everything.
The wounds were different, too, Heather realized when she arrived at the drab concrete and gravel base in January, after flying in on a cargo plane from Qatar. Baltimore had no IEDS - improvised explosive devices - which obliterate bone, burn, blow open abdomens, and destroy the brain. The bleeding was tremendous - a soldier's blood volume would sometimes be replaced half a dozen times or more, and the doctors sometimes gave their own.
But human misery was the same on both sides of the globe. In this respect, Shock Trauma had prepared her well.
Her Balad patients were mostly Iraqis, it turned out. The hospital is a way station for American casualties, who are treated and then within hours flown to Germany and the United States. She saw them, fresh from the football fields of high school, chubby-cheeked Marines blown apart. She cared for them for a few hours or overnight, but very quickly they were gone.
The Iraqis, though, often lingered for days or weeks, in separate wards guarded by men with machine guns.
There were Iraqi soldiers, insurgents and civilians, some of them too young or old to know about the war. All told, they seemed to her a proud, stoic people, yet many of them wept in her presence, as though no longer able to hold back.
She watched a policeman sobbing over his lost eyes. They had been pulverized in an IED explosion, and nothing remained. The moisture seeped from beneath his sutured eyelids.
She saw the tears of an ethereal 11-year-old, dabbed neatly away with a napkin. The child - nicknamed Princess Jasmine by the hospital staff because of her resemblance to the Disney character - cried for her parents and her brother. All three were believed dead, shot by the same gunmen whose bullet blew away three inches of the girl's thigh bone.
She heard the moans of husbands and grandchildren, of babies whose burned skin reminded her of candle wax, of the little girl who screamed each time they changed her dressing. Sometimes she was so overwhelmed that she felt she could not stand to witness any more pain.
But every evening, more Blackhawks and Chinook helicopters touched down outside, unloading the wounded and the dead.
At certain moments her own life felt snuffed out on the drab base. She did all that she normally did back in Texas - ate, worked out, finished rounds at the hospital, e-mailed friends - but nothing was the same. Food didn't taste good after she heard that one of her patients had been shot in the head during an attempt to procure lettuce for the mess halls. She was so lonely; she missed home. She drank bad coffee just for an excuse to talk to people.
And she had nightmares. The dreams were so terrible that she shivered in her sheets, even though it was 90 degrees outside. Back at the hospital for another night on call, she sometimes felt as though she had never slept.
That night, at the bedside of the dying 6-year-old, a sudden thought stopped her cold.
Heather realized that she wanted the child to die. For the first time in her career, she wanted a patient's life to end. The thought went against every instinct, every impulse she had ever had, but she could not shake it. The child had been through too much; his father had been through too much. She wanted the hope to leave the father's face, for acceptance to begin. Because there was nothing she could do to stop their pain.
And so, at 9 the next morning, when they took the boy off the ventilator, she was not sorry. His chest continued to rise and fall for almost a day.
When it rose no more, she felt only relief.
Yet at times life seemed more precious than ever. Anything stirring in the desert was a cause for celebration. She bent to take pictures of a weed that she saw poking out of the pavement, rejoiced over the barest hint of green. She made excuses to walk past the mosque on the base, just to see the doves and pigeons nesting under its roof.
And she took every chance she got to hold the baby.
Only a few weeks old, Baby Hussein, as the staff called him, had a tiny prune of a face, wild black hair and brown eyes that rolled greedily when they fed him. He was born about the time Heather arrived in Iraq and had spent most of his short life in the tent hospital.
Stethoscopes hung like mobiles above his crib.
The baby wasn't injured in the war; his body was at war with itself. The doctors diagnosed an autoimmune disease that caused chronic infections and a buildup of fluid around his heart.
His parents had brought him to the hospital because, like many of the people in the countryside around Balad, they had heard that the American doctors could work miracles. He was so tiny that he had to be given aspirin with a syringe. Heather and the other doctors loved holding him; staff members sometimes slept through the night with his little body in their arms.
One night, during the long, rainy winter, the baby tried to die.
A few hours into her call, Heather recalled receiving an urgent call from a nurse: The baby's blood oxygen was plummeting. She raced over to the crib and peered in. He was gasping and so pale that he was practically transparent.
No, she thought, not him.
She tried to determine what was wrong. Had he breathed food into his lungs? He looked as if he was choking. She ordered chest X-rays and blood gas labs. While the tests were being processed, she hovered by the crib, watching him grow listless.
She asked every doctor she could find for advice. She called specialists at a base in Germany. She was a geriatrician; what did she know about pediatrics? No matter what she tried, the baby's oxygen level did not rise. He continued to wheeze. The X-rays showed a progressive decline in his lung fields, patches of white where there should be black.
But this patient, unlike so many others, was not a lost cause. She told herself over and over that she had the power to help him.
Finally, close to dawn, she and another doctor decided to take extreme measures. They would intubate the baby, let the ventilator breathe for him. It was risky, particularly with such a small patient. She barely breathed herself as the surgeon, as gently as possible, moved the baby's tongue away and guided the tube through his vocal cords. It was always a brutal procedure; on the tiny baby, it looked like an act of violence.
Now his airway was open, and oxygen flowed into his lungs.
Heather was exhausted. She took the next day off.
Five nights later, on Heather's call, the baby tried to die again. Again, Heather struggled to keep him breathing. And the baby lived.
This was the root of medicine, facing the same battle night after night, the same ailments in different patients, new ailments in the same patients.
To Heather it wasn't always satisfying; sometimes it was deeply grim. But the fight for this baby was one she felt she could win. His suffering was physical, and his illness might be treatable. He had a chance to grow up and not remember her, the hospital, any of this.
She felt her new strength keenly when gazing into the tiny baby's face, but this stubbornness of spirit had been growing in Heather for some time, pushing up through her consciousness like a weed through concrete.
It was there that night in Baltimore. Mary's daughter was dead, and the doctor felt the cutting loss, the sickening waste of it.
But she still had a patient to tend to. She had put her own cares aside and listened to Mary's heart. This basic gesture was the essence of a doctor's task. No matter what horror she witnessed, what techniques she learned or remembered or forgot, she simply had to keep performing, day after day.
She must keep working now. She stole one last look at the slumbering infant, so peaceful in sleep. And then she went on with her rounds.
About the article
Reporter Abigail Tucker and photographer Monica Lopossay observed Dr. Heather Cereste for three weeks last fall as she trained at Maryland Shock Trauma Center and then in March followed the doctor to Balad Air Base in Iraq.
Many scenes in this article are based on what Tucker witnessed. Others are reconstructed through Cereste's diaries and multiple interviews with the doctor. Interviews with Cereste's family, friends and co-workers, as well as Shock Trauma doctors and other students, provided background for the piece.
Staffed through the University of Maryland School of Medicine, the Shock Trauma program is a collaboration between the local hospital and the Air Force.
Cereste served in Iraq from January until May this year. She has since returned to San Antonio and resumed her geriatrics work.