We Care: Saving Specialist Gray

By Maj. Kevin J. Cuccinelli
Battalion Surgeon, 1-8 Infantry

While the daily headlines report that we need more soldiers in Iraq, I know one soldier that would disagree. For 22-year old Specialist Roy Alan Gray, there were more than enough soldiers here when the task at hand was to save his life.

Specialist (SPC) Gray is a member of the 1-8 Infantry Battalion, 3rd Brigade Combat Team, 4th ID, otherwise known as the "Fighting Eagles." On September 8, 2003, he was part of a convoy delivering the coveted "hot dinner" to his battalion's headquarters (HQ) area. SPC Gray had just returned to his truck when a mortar round exploded only 30 feet away. Shrapnel from the mortar pierced the truck's metal door and cut up through his left thigh. Smaller shrapnel bits lodged in his shoulder and ear. The leg wound, however, proved to be life threatening.

At his location was the forward deployed aid station for his unit. The medics acted quickly, called for an Air MEDEVAC immediately, and attended to his injuries while the helicopter was en route. The medics initiated this care as more mortars continued to impact around them. They started 2 IVs and began pouring fluid into him. His thigh wound still bled profusely even after their initial treatments so the medics quickly opted for a tourniquet, a common last resort measure. The tourniquet stopped most of the bleeding by blocking all blood flow to his injured leg. While this greatly increased the chances that he would lose his leg, it stopped the more immediate threat of massive blood loss, thereby saving his life. The surgeons would later report that if not for the medic's immediate response, SPC Gray would have been dead on arrival (DOA) by the time he made it to the hospital.

Meanwhile, the MEDEVAC team from the 54th Medical Company, Air Ambulance (UH60, Blackhawk helicopter crew) was already in route to SPC Gray's location. From the time they received the call to landing at the site, they clocked 25 minutes. This includes the mandatory 18 minutes to prep the helicopter, chart their location, and load up. It was only a 5-minute flight, which means the crew was ready to go, from a dead stop, in less than 2 minutes. They did a quick assessment of the tight surroundings and set it down in the only open area, immediately in front of the HQ building. The medics quickly loaded SPC Gray onto the helicopter for the short trip to the 21st Combat Support Hospital (CSH).

The CSH (referred to as the "CASH") is no ordinary hospital. Designed for field environments and quick mobility, it is comprised of numerous long insulated tents attached to one another to form a series of wings. Resources are minimal and cleanliness is a constant battle in the sand covered country of Iraq. Less than 15 minutes after hitting the door, the ER staff completed a rapid assessment and SPC Gray was on the operating room table being treated and stabilized.

The medical staff knew all too well that death was imminent. They started the emergency medical board process, done to ensure that his family back in Iowa received maximum benefits. They didn't think he would live the 3 hours required to complete the board. He had lost almost all of his blood. Hemoglobin and Hematocrit, lab tests that measure blood levels, were at critical levels of 1.6 and 6.2, respectively. Normal levels are approximately 15 and 45. His blood pressure to perfuse his vital organs was unstable but being maintained with the initial IV fluid push.

Now the doctors and nurses began blood transfusions with red blood cells, the cells that transport oxygen. The orthopedic surgeon placeed an "external fixater," similar to a large brace, that locks onto the separate pieces of SPC Gray's shattered femur, the largest thigh bone. This is a temporary fix to stabilize the injury. They also cleaned out his wound and began antibiotics to help ward off infections. In the OR, an arteriogram, which is an x-ray where they shoot dye into the blood vessels to search for bleeding, was done. Discovered sources were controlled. SPC Gray is now breathing through a tube hooked to a ventilator. He is receiving medicine for sedation and pain. He is then transferred to the Intensive Care Unit (ICU) wing of tents where he received round the clock attention from the staff, who managed all his medications, ventilator, fluid balance, blood transfusions, IV fluid replacement, wound care and labs.

Thus begins the intense monitoring of his status. Immediate lab results continue to reflect significant bleeding. The source of the bleeding is still unclear. Was it more open blood vessels or his body's reaction to the donated blood? At times his bleeding was faster than the replacement. The decision was made to again take him back to the OR for exploration as to the source of bleeding. While the wound left a hole in his thigh large enough for surgeons to fit their hands through, the largest artery, vein, and nerve were amazingly undamaged. His condition was tenuous. There was some bleeding, which was controlled; however, not to the extent that would explain the blood loss. The wound is cleaned and packed with special gauze impregnated with substances to help clotting. SPC Gray returns to the ICU. The transfusions had to continue until they could find the cause of blood loss.

SPC Gray's continued blood loss soon led to the problem of replacement. The hospital staff became concerned that they would not have enough. To make matters worse, the red blood cells and plasma he was receiving only represent a portion of all the substances in our "whole" blood. Platelets, another portion, which are necessary to clot blood, were not available in the blood bank. These levels had also dropped to critical levels of 14,000 (normal is 250-450,000).

As supplies ran low, the doctors began an impromptu blood drive. They simply walked from room to room in the hospital asking for personnel with 0 positive blood. Every available person with O+ blood capable of donating did not hesitate to do so. Additionally, SPC Gray's company commander, CPT Kevin Ryan rapidly mobilized the soldiers of his company, known as "Team Hammer." He and I returned from the hospital to brief the worried soldiers that were his co-workers and friends. They were notified that SPC Gray was likely going to die, but that the people taking care of him were doing everything possible to give him a fighting chance. This included the need for blood, which the hospital did not have enough of. Everyone with O+ blood was asked to go to the hospital and donate. We stay to answer some questions and return to the hospital less than 5 minutes later. To our surprise, we find 30 soldiers already lined up outside the lab ready to donate. This group also included members of the North Dakota National Guard whom CPT Ryan had called for help. None of them knew SPC Gray personally. They simply knew what uniform they shared.

Now that a large source of blood donors was available and 12 more hours passed without improvement in his stability, he was taken to the OR for a 3rd time. It was only after a third trip to the OR that doctors were able to determine the source of the continued bleeding. They were less delicate this time, opening the wound wider to enlarge the exposed area. Tissue was sacrificed in deference to the ultimate goal. They finally located the source - a 'pumper' coursing backwards, hidden behind the bone and buried beneath most of the tissue in his thigh. Doctors quickly tied it off. Other slow seeping bleed sources were cauterized (burned). And, as a final effort to stop the blood loss, doctors applied a new substance, called "Quick Clot" in a non-conventional fashion. They spread it over the surface to concentrate the blood seepage, thereby assisting with the wound's overall ability to clot. It is not typically used in this manner, but the surgeons wanted to take all precautions.

2 hours later, for the 1st time in 36 hours, SPC Gray's blood levels were stable without getting any additional blood products. The nurses continued to check frequently. The next lab results were even higher. His blood pressure was no longer falling and he did not need medication to maintain it. Other indicators of organ perfusion and function were also good. His clotting indicators improved and stabilized. His kidneys were working. A pink hue returned to his face. He required lower doses of medications. His blood pressure and pulse normalized.

In the early morning hours of September 11, the Air Force transported SPC Gray to Baghdad and shortly afterwards to Landshtul, Germany. Still unconscious and reliant on a respirator, his condition remained critical. His parents were flown in to be by his side. The medical staff at Landshtul continued his care and treatment, cleaning his wounds, treating infection and monitoring his condition until September 24th when he was flown to Walter Reed Army Medical Hospital in Washington, D.C. On September 27th, he regained consciousness to discover all the fuss he caused . His broken leg will require further care. He still has much ahead of him.

A total of 47 units of blood products were given. Our bodies have about 6 liters of blood; therefore, this represents approximately 2 complete replacements of his blood supply. This does not include the 24 liters of IV fluid he received, representing another 4 total volume replacements. 61 people were on the blood drive, including members of his unit, soldiers he didn't know from other units, medical staff taking care of him and others who just heard about the situation.

By all accounts, SPC Roy Gray should not have survived. Had he not been injured right next to his aid station, or his fellow soldiers and medics not raced out to his aid, or the helicopter not arrived in time, or the doctors not been able to find the source of his bleeding, or the blood drive not succeeded, then you would have heard that we lost another soldier on the evening news back home. Instead, by last count, 113 people took direct part in the care of SPC Gray from point of injury to his evacuation from Iraq. It took that many "cogs in the wheel" to accomplish this improbable save. There were many individual cogs, that if any failed, SPC Gray would have died.

Keep in mind that this count does not include the second Blackhawk crew that flew him to Baghdad, the C-130 aircraft crew that flew him to Germany, and his hospital staff there, or his final flight crew that returned him to Washington D.C. so that yet another medical staff can nurse him back to health. This number does not include those who indirectly supported his care, such as hospital personnel who keep the hospital running, flight coordinators, supply personnel, etc. What about keeping all these people fed, sheltered and paid? Who made sure all the equipment in the ER/OR/ICU was stocked and available for use? Who kept all the vehicles involved in working order? Who is helping the families back home?

SPC Gray's case is representative of the esprit de corps of those in uniform out here in Iraq. There are many people involved in keeping us alive and working for freedom in Iraq that are never seen. The Army's doctors, nurses, medics, pilots, crews, lab techs, National Guard soldiers, and Airmen are, more often than not, in a combat support role, much like SPC Gray . They too risk their lives, left their families and friends and sacrifice. They are not likely to be the ones that find Saddam. They do not man the checkpoints or conduct the raids, but they do see the casualties. They understand truly that "Freedom isn't free" and witness its price. They can only stare at the daily horrors of the war and negotiate for a lower price. They spend all day, everyday, attempting to get all the "SPC Gray's" home to their families, alive and well.

Interestingly enough, on September 8th, the national news back home reported "there was little action in Iraq today…"