Crossings

A Doctor-Soldier's Story
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In Iraq, as a combat physician and officer, Jon Kerstetter balanced two impossibly conflicting imperatives--to heal and to kill. When he suffered an injury and then a stroke during his third tour, he wound up back home in Iowa, no longer able to be either a doctor or a soldier. In this gorgeous memoir that moves from his impoverished upbringing on an Oneida reservation, to his harrowing stints as a volunteer medic in Kosovo and Bosnia, through the madness of Iraq and his intense mandate to assemble a team to identify the remains of Uday and Qusay Hussein, and the struggle afterward to come to terms with a life irrevocably changed, Kerstetter beautifully illuminates war and survival, the fragility of the human body, and the strength of will that lies within.

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In Iraq, as a combat physician and officer, Jon Kerstetter balanced two impossibly conflicting imperatives--to heal and to kill. When he suffered an injury and then a stroke during his third tour, he wound up back home in Iowa, no longer able to be either a doctor or a soldier. In this gorgeous memoir that moves from his impoverished upbringing on an Oneida reservation, to his harrowing stints as a volunteer medic in Kosovo and Bosnia, through the madness of Iraq and his intense mandate to assemble a team to identify the remains of Uday and Qusay Hussein, and the struggle afterward to come to terms with a life irrevocably changed, Kerstetter beautifully illuminates war and survival, the fragility of the human body, and the strength of will that lies within.

Excerpt

***This excerpt is from an advance uncorrected copy proof***

Copyright © 2017 Jon Kerstetter

PROLOGUE

 

Iraq, 2003

 

A soldier lies in the sand, blood pooling beneath his head, mouth gulping at the air. His eyes fixed, head tilted off to one side, legs and arms motionless. He’s a young soldier in his early twenties, late teens, a young man who should be a freshman in college or finding a summer job while deciding what to do after high school. In less than five minutes he’ll probably die right there in the dirt, right at your feet. You will carry his bloodstains on your boots and on the sleeves of your uniform.

 

You possess the requisite medical skills to save his life and your training as a warfighter helps you think and act decisively. You respond confidently, even brazenly, yet you understand that saving a patient with a head injury involves lots of luck. Maybe this is one of those lucky days and your patient survives. You feel good. But you also feel that this soldier with a shrapnel hole in his skull and a bit of brain oozing and lots of blood dripping might eventually wish you had let him die in the sand, thousands of miles from home with the other soldiers looking on. Your gut tells you this one particular patient has a chance of survival. It also tells you if he ever makes it home, he will live in pain for the rest of his life.

 

Soldiers require one kind of breathing, doctors quite another. And soldier-doctors, well, they require a fusion of types: the ability to use one lung for soldiering and one lung for doctoring, a unique chimeric breathing shaped from the twisted strands of wildly dissimilar DNA.

 

It’s natural and unnatural, that genetic code, to know as much about killing as healing, to listen for the sounds of bullets in one moment, then listen for the sounds of the wounded in the next; to love each strand with rabid dedication and to hate them both; to cross back and forth between the two. Pull a trigger—Pack a wound. First one, then the other, the prime necessity of war, that instant crossing from doctor to soldier and soldier to doctor without focusing on the difference between the two, because in the end all that matters is just one thing: breathing like a soldier in one breath, then breathing like a doctor in the next. War—Medicine. Inhale—Exhale.

 

Soldier-doctor breathing requires large, bold breaths. Breathe in war like you breathe in air. Memorize the shapes of all the aircraft. Learn psyops and night ops and commo and intel. Become a student of ballistics and small-unit tactics. Study the beauty and balance of the human body: skin, heart, lungs and brain. Learn the chemistry of blood and the physics of circulation. Observe the mechanics of a perfect gait. Smear camouflage paint on your face and your ears and on the backs of your hands. Let your muscles learn the speed of close- quarters combat. Work them until the movements become natural, like reflexes. Train your mind for war, your legs for battle, your hands for surgery. Teach your fingers to feel the smallest lump of pathology and the steady rhythm of a beating heart, then teach them to feel the knurled steel of triggers and the full metal jacket of bullets.

 

Hearing is a form of breathing. Listen. The sounds tell you when to fight and when to weep—even when to die. The sounds are your friends. As long as you hear them, it means you’re alive. Listen to the clamor of surgical instruments or to the prayers of chaplains or to the quiet whispers of Army nurses talking to their patients, even though their patients cannot hear because hearing has left their bodies. Spend your days listening for the monotone warnings of cardiac monitors. And when you hear that flatline sound and it doesn’t stop, hit the silent-mode button, then fill in the official medical forms with checkboxes for DOW and KIA (died of wounds, killed in action). Try to minimize the DOW count. Sleep when you can, but wake to the sounds of incoming helicopters. Wake to the cries of the wounded and to the silent screams of soldiers whose limbs and guts had been burned or torn or separated from their bodies. Respond to the high-pitched wind of an RPG, the explosive rattle of small-arms fire and the bone- breaking blast of an IED. Alert your mind to the rustle of boots and the too-quiet stillness just before a battle.

Fear makes its own kind of sound. Listen for the patterns, the ones that whisper about going home without legs or arms and the ones that mourn the painful deaths of soldiers. Learn to live with those deafening sounds, especially the ones telling you your medical skills may never be enough—that because of you a soldier may die. Shake your fear and keep moving forward.

 

A soldier with a salvageable injury lies at your feet. Iraqi insurgents are attacking your position and you need to clear the area fast. You stop to return fire. Even though you are trained to heal, you are also trained to kill, and that fact makes you a bit hesitant. You lay your hesitation aside for a moment and put your warrior hat on—because, after all, you are in a war. Your gut tightens as you fire a round or two. You grab a soldier by the collar of her uniform and jerk her torso up and off the sand, then sprint as fast as you can for twenty yards.

 

As you run, the soldier’s legs drag and slow you down. Other soldiers help you throw her on a field litter so you can get the hell out of the kill zone. Her right leg dangles off to the side. A medic grabs it and plops it back onto the litter. She screams so violently, you can see the vessels in her neck distend and pulse. The leg is barely attached. It’s covered with dirt and sand. The bones look like broken spears as they poke through her skin and the burned fabric of her uniform. Your patient is losing blood faster than you know is sustainable for life, and you know if you don’t get a tourniquet on her thigh right now—right in the middle of this attack—she’ll just bleed out and die. So you slap one on and tighten it up.

 

You’re in this fight. The tourniquet slips. Bones slice against her open wound. The soldier starts bleeding again. Draw your long-blade knife from its sheath, grip the handle as tightly as you can, then reach down and cut the soldier’s leg off, right from where it is barely attached and dangling—just cut the goddamned thing off and leave it in the sand, and when she keeps crying and screaming, yell at her, “Shut the hell up!” Imagine that she does. When you finally manage to get the tourniquet tightened again, you’re relieved that you made that decision—the one about using your knife, because you had no more time to dink around. You needed to move and the dragging leg was slowing everybody down, and the soldier was better off alive— even without her leg.

 

Learn how your enemy breathes. Study how they do war—how they treat their wounded and gather their dead. Observe where they live and where their poets gather for coffee; know why they write letters to their wives, what they say, what they leave out. Understand their prayers and their dreams and their fears and their families. Learn how they cuss in their native language, how they read their scriptures and their newspapers and their children’s schoolwork. Absorb the color of their land and the smell of their trees. Discover where their rivers bend and their deserts turn to hills.

 

Read the Geneva Conventions. For the record, sign the Red Cross card that identifies you as medical personnel. Rip it and toss it. Learn the law of war well enough to know when to bend it. Study the manual governing enemy detainees and prisoners of war. Know the rules that define how you must treat them, even when they spit on your skin and call you a murderer. Apply escalation of force, but know when to open fire and ask questions later. Learn how to hate your enemy with- out crossing the line between soldiering and savagery. Control your breathing. Use your doctor mind and your soldier mind. Focus. Let them become one. Release your body and mind into the hands of war.

 

It’s possible you could end up in the middle of a firefight. Don’t flinch. Soldiers will depend on you to make all the right decisions. You may feel that all the “right” decisions are a blur, even though you’ve spent years in training just so your mind can never get blurred—so you can think without hesitation in the chaos and screaming of com- bat. You trained well, but now you think all those war games and evac scenarios didn’t prepare you. You’re right. How could they? This is real. The fear and the blood and the shit are real. Death is real. War is real. And all you can do is adapt and breathe and try to hold on. So you grasp your weapon and your ammo, your knives and your body armor. You carry them next to your medic bag, next to the bandages and tourniquets and morphine. When you grab your gear, it feels like you’re grabbing fear or emptiness. Despite what you feel, you move out anyway. As you do, you sense that the mysterious alchemy of war has transformed your nature.

 

You’re up for a mission. You jump in a Humvee or a medevac helicopter. Time warps. You hold the bodies of soldiers you will never know except for that brief moment when they look into your eyes. After less than an hour, you hold their dog tags and their final letters home. You recall a chaplain’s eulogy for a soldier: God made us from dust and returns us to dust. It’s true. War proves it.

 

When you think you’ve held enough of war and your hands lack the strength to hold onto anything more, not even the air, then hold on with your mind and with your soul and with your prayers, if you can find them. And if your mind and your prayers are gone, then hold on with the nails of your fingers or with the soles of your boots, and breathe. Inhale—exhale; soldier—doctor; war—medicine.

 

Another patient bleeding at your feet says he managed to re- turn fire and that he might have killed one of those bastards. Then he grabs your arm and asks you if he’s going to make it. You tell him yes. “Damn right you’re going to make it.” And then you tell him to take some real deep breaths and that a medevac chopper is just two minutes out and to hold on just a bit longer. You inject him with morphine and maybe you crack a little smile, to which he responds by asking you to tell his mom that he loves her and to tell his dad that he was a good soldier. You say, “Knock it off. Tell `em yourself.” And you know he knows you have to say things like that because you need to keep everybody hoping for the best. You also know he wants to be real and honest, and you want to be real and honest too, but it doesn’t come easy.

 

Later in the day, you see a soldier who had just arrived in theater and on his third day in combat his brain was shot clean out of its skull. His gray matter embedded itself in the crevices of his Humvee. You did absolutely nothing to save him; instead, you ordered your medics to put him in a body bag.

 

You had another patient last week whose legs literally exploded from his body. He lived less than four minutes—just long enough to say half the Lord’s Prayer. A nearby soldier who had taken the four- day combat lifesaver course stood rigid, numb from panic, frozen in time like a terracotta warrior. He couldn’t remember how to use tourniquets and just started yelling “Oh my God—oh my God!” until you screamed, “Hey! Get your shit together!” And he did. Then he made the sign of the cross and helped you with another wounded soldier.

 

For the sake of argument, suppose you live through these and similar scenarios—some from last week, some from prior deployments. In a moment of reflection, you conclude that as long as war continues there will always be Army doctors who will have patients at their feet. You remember all the soldiers who died, and all the efforts of the medic teams and the medevac pilots, and the nurses, and the surgeons, and whoever else gets involved with wounded soldiers. You realize that despite killing more of the enemy, they are still killing you—and you get a disturbing feeling that war might go on forever.

 

All your experience from multiple deployments has paid off and your medic teams are damn good: the best. You manage to get soldiers into surgery faster than in any other war—before they have a chance to die in the field. All the medical resources and medical staff work as they should and very few patients actually die in the combat surgical hospitals. But suppose some soldiers do die during surgery or in postop care or even months later, stateside. They die of infections or lung complications or breathing complications and you feel if you had done just one more thing, spent one more minute of time, made one more vital decision, things would have turned out differently. Slowly, you begin to realize you never had enough time to do everything for your patients. Your thoughts leave you with a fading image of the doctor you thought you were and you come to an understanding that you know more about the practice of war than the practice of medicine.

 

From the first day of war to the last day of war, you have these soldiers at your feet. You stand over them and look down. The sand darkens as it outlines their bodies. You hesitate just for a moment, then you move your hands swiftly and decisively—like a doctor. And you breathe. You breathe like a soldier.

Q & A

A conversation with Jon Kerstetter,
author of
Crossings:
A Doctor-Soldier’s Story
 
 
 
You grew up on an Indian reservation in Wisconsin and say that “changing and overcoming a reservation paradigm was not easy.” What do you mean by that?
An Indian reservation is defined by boundaries. Until 1975, tribes were literally confined within those boundaries and their affairs managed by government officials. Those reservation boundaries were not merely geographical; they were cultural, economic, educational, and even spiritual. At the heart of the original paradigm was literally centuries of belief about the presumed social inability or lack of educability among Native peoples. The belief that somehow reservation people deserved something less distorted the way even Native peoples viewed themselves. My own grandfather was branded as “worthless” by the Carlisle Industrial Indian School. My mother was educated to the level of the fifth grade. When I decided to push my education beyond high school, she had no reference point for how to advise me. The Native American academic advisor in college, a Navajo Indian with a master’s in Social Work, told me that Indian students did not do well in the hard sciences. Going to college or thinking of a professional education required a new kind of thinking. Native students in my generation, while not the first to challenge those barriers, represented a significant shift in attitudes toward education as a prime survival skill among Native populations.
 
You became an MD at the age of thirty-seven. When and why did you decide you specifically wanted to become a military doctor?
I always had an interest in the military as a high school student. Maybe it was part of my own warrior mind-set. When I went through medical school, I entertained the idea of a military scholarship and even looked into a Naval medical scholarship. Though that didn’t work out, when I finished medical school and started my career in emergency medicine, I still had an eye toward medicine that involved intensity and risk. There seemed to me a good combination of both in the National Guard, and they offered training in aviation medicine and field medicine that was unavailable elsewhere. What I saw was a niche that I could fit into, the perfect blend of doctoring in the edgy and critical environment of the military.
 
After joining the National Guard, you did three tours in Iraq at the height of the war. How did you reconcile the requirements of being a soldier with the mandates of being a doctor?
The essential tension for military doctors is between killing and healing, and it is a moral and social tension that I bring to light in CROSSINGS. Ultimately, to be a good soldier in any capacity, one must commit to killing when necessary to protect the lives of those who depend on them. For military doctors, that mandate is no different from an infantryman. But soldier-doctors have a binary duty and mandate: heal whenever possible, kill when needed. Being faithful to both is not easy. I negotiated that moral and ethical minefield by understanding that if I did not fully engage the role of a soldier, at least in the crucible of war, I could not effectively gain the trust of my fellow soldiers and therefore would be far less effective in my role as a military physician. In essence, I had to prioritize my dual roles as soldier first, doctor second. Not everybody can survive in the warrior community, but those who choose it must commit to its mandates.
 
You were fifty-two when you went to Iraq, so you were often the oldest person in any platoon you were in. Did that add a unique element to the experience?
Age in the military gave me one very important advantage: perspective in the heat of the moment. All the experience I had gained from being older gave me just enough of an edge of wisdom so that outcomes were altered toward a more humane and reasonable result. During one of my tours, I confronted and almost shot an Iraqi teen. In the midst of holding him in my weapon sights, I realized how much he looked like my son and how he was probably just a non-thinking teenager who accidentally crossed a line when he should have been more diligent. My perspective as a father helped me to understand the situation for what it was and avoid pulling the trigger and killing him.
Elsewhere, my age helped me traverse cultural boundaries, particularly with older Iraqis and especially with those in medicine. I tended to talk with my age-matched Iraqi peers not as a soldier but more as a father or a family man, even as one who struggled with the insanity of war itself. I was friends with several Iraqi physicians whose interests were essentially aligned with my own: to take care of our families, minimize the impact of war where we could, and work together in the complex task of rebuilding the medical infrastructure. Interestingly, a few of the Iraqi military physicians asked me about being an American Indian and the folktales surrounding my culture. It turned out that their own indigenous nomadic tribes had some of the same issues and mystique of American tribes.
 
Your third tour ended when you were injured. Did the clinical distance you’d developed as a doctor in wartime help you deal with your own long recovery?
The clinical distance that allowed me to be so effective when dealing with traumatized patients in war became more elusive when I tried to apply it to myself. I was hurt, but I could not admit it or see myself as a patient. To do so would have meant I was subject to the same vulnerabilities as other soldiers. To me, and to many military doctors and soldiers, that vulnerability cannot exist, because if it does, our combat tasks become too weighty to carry. It is better to believe in a certain invincibility and move toward the battle and the injured, emboldened, if you will, by a certain bravado that is essential in war. After the injuries take hold and while in the hospital, that bravado runs counter to what must happen in healing. Healing requires the ownership of injuries and the full acceptance that recovery is not merely a session. It demands that the spirit, mind, and body stay focused on one mission: healing. 
Achieving that perspective took me awhile because as I tried to view myself with any clinical distance, I saw a brain-injured soldier-doctor who could not go back to the practice of medicine or the practice of war, and that was a lonely and frightening place. Fortunately, I had therapists who pushed me to that place of acceptance over several years, and I was then able to treat myself more as a patient and give myself permission to heal.
 
You describe in vivid detail what it feels like to experience war and a stroke. Why did you choose to be so candid?
In war and in illness, there tends to be an underappreciation of what is involved in both the acute phase and the recovery phase. I knew if I wanted to be true to both war and stroke, I would have to let readers see the failings of my body and mind and psyche. I had put so much stock into the idea that inpatient therapy and long-term therapy would be curative, but it was not, and I wanted readers to see and feel that tension in their own bodies and minds. I wanted them to have the sense of loss and grieving I experienced, not because I need them to acknowledge my loss but to provide a way in which they could relate to losses in their own lives. I was trying to strike a chord that we all have in common: the pain and loss of illness and the hard work of recovery that does not always progress as we think it should.
 
Your stroke quickly ended your career as both a doctor and a soldier, though it took you about a year to admit to that truth. Was grappling with your loss of identity as demanding an experience as the physical recovery?
In some ways it was more demanding. It takes a lot of psychological energy to live in denial.  There were a lot of things I had to distort and believe about the nature of healing as well as my own nature. And then, of course, I had to deal with the team of psychologists and therapists who were all trying to help, but whom I viewed as health spies prying into my private life. The necessity of trusting them was challenging in a way that pushed me to bend and yield and let go. And it was that letting go that was so hard emotionally and often painful and full of grief. What I ultimately learned was that when I finally grabbed hold of the truth, real healing began.
 
You struggled with your PTSD diagnosis and were more resistant to doing that emotional work than your extremely painful physical therapy. Why?
Part of my own clinical paradigm as an ER doctor tended to dismiss PTSD and its emphasis on disorder. There was also an underlying military mind-set that tended to dismiss PTSD as an issue of emotional and psychological weakness. None of that was based on fact, but it did saturate my way of looking at emotional and mental trauma. When I encountered PTSD in the field, I referred the cases to appropriate mental health workers. In my own case, I saw myself as not wanting to admit to the emotional and psychological trauma that I experienced, thinking if I did, it was tantamount to weakness. I needed to remain tough, to face down my physical trauma and cognitive deficits, but in the end, my resistance to PTSD only slowed my progress. I found it hard to trust my team at the VA and invest myself in the whole work of healing. I’ve since learned that for both physical and psychological trauma, the foundation of healing is trust.
 
You faced your medical traumas when you were in your fifties, but there are so many young veterans who face incredible physical challenges when their best years are still supposed to be ahead of them. What wisdom do you have to offer them?
I would offer this: Healing is akin to any mission in war. You have to understand the environment of it, the risks and challenges and complexities of it, and then you must align yourself with a team of people who have the necessary skills and insights to pull it off. That includes family support, military support, and healthcare providers. With that team of providers and supporters, the veteran must adopt a mind of resilience. The healing we seek does not always come quickly, nor does it come completely. The body and mind and spirit need time to adapt to new challenges. VA clinicians and the public in general often call the process of soldiers reintegrating into post-war life a “transition.” I don’t think it’s that at all, as nothing we come back to is the same. We change, our families change, our minds and bodies change. What we do in healing is far more than a transition; it is a personal remaking. One of my healthcare team interns jokingly referred to me as Dr. Kerstetter, version 2.0. She was right—only the version was something like 10.0 after years of therapy. If I had a young veteran as a patient, I would say this: “Keep pushing forward, my fellow warrior; you have so much to gain if you do.”
 
How did reading and writing become an integral part of your rehabilitation therapy and help you push past fixed expectations for your degree of recovery?
Good writing demands constant and thoughtful rewriting; and that in turn requires a persistence of deep thinking that pushes well beyond the surface of ideas or memories. In cognitive therapy and rehab, that is exactly what is needed to make new neural connections so vital to the recovery of function and memory. Language is a neocortical activity, but it also draws on the areas of the brain where we process emotion and pain and fear and hope. When we tell a story, we integrate all those areas and that becomes a powerful tool in cognitive healing. It’s that neural integration that helped me recover over time, as well as my willingness to push my writing to new levels of clarity and description. In that attitude of pushing the envelope, my therapist and I discovered that most of my presumed clinical plateaus were not fixed at all but more a moving target.
Reading proved helpful in much the same way as writing. Exposure to stories and the rereading of good writing gave me new insights and perspectives. The more I read, the easier it got and the more skill I recovered and the more brain connections I made over time. None of the recovery in reading and writing was quick or easy. It took time and a degree of patience I had to learn and accept.
 
Because of your cognitive impairments, it took you six years and hundreds of drafts to write this book. What was your writing process like?
At first, the writing was so disjointed it didn’t make sense. Things I wrote one day held no meaning the next. Added to that was the emotional impact of things I was writing about: loss of soldiers, loss of career, stroke, the heavy work of recovery. The VA sent me to an MFA program as sort of an experiment in vocational rehab. What I learned there was the fine art of revision, to clarify and write exactly what I saw in my mind and in memories. Basically, they taught me how to make use of my clinical training of observation and then adopt the craft of writing to present my observations on the page. I would work so hard at the sentence level and then work toward crafting meaningful paragraphs. When I finished a short essay or chapter, I went back and reordered most of the paragraphs because they had no linear sense of a story; everything was more or less a scattergram. So, to overcome the weakness of scattered thought, and hence a scattered story, I wrote and rewrote and did it again and again until a chapter made sense to me. I was also healing, so I leveraged my progress in other cognitive areas into progress in writing. One thing has become clear to me and my neuropsychologist: the process of constant thinking and revising in writing has pushed my recovery to levels we did not think possible in the beginning.
 
How are you feeling and functioning today? Is your recovery complete?
I continue to improve in function and feeling. Therapy does not end, though it is not as labor intensive as it was in the beginning. It has to continue, because if I stop working on my recovery, I will stop moving forward. Physically, I continue with some issues of pain and gait instability, but I am learning new strategies to minimize their impact. Everything in stroke recovery seems to be about managing any particular deficit, physical or cognitive. What I have found is that when I focus on the greater picture of healing, the day-to-day pains, or “stroke blips” as I call them, don’t have the same impact on my life as they used to. My personal one-word value has become resilience. When I was a young man, it was explore. Having now been a stroke survivor for ten years, I think I understand how the two values fit together.