A Visit to the US Military Hospital at Landstuhl The German Front in the Iraq War

Every day, planes land at Ramstein with severely injured US soldiers from Iraq. In the biggest American military hospital in Europe, lives are saved, limbs amputated and gunshot wounds patched up. It's the Iraq War's German front.

When looking for the outer perimeter of the Iraq battlefield, there is no need to travel to the Middle East. The war doesn't cease at Iraq's border with Syria to the west or with Iran to the east. Indeed, one of the battlefield's boundaries is located just eight kilometers (five miles) outside of Landstuhl, Germany. It is here where the broken, shrapnel-filled bodies of American soldiers come on the first leg of their journey back to health -- if they complete the journey at all.

A constant stream of gray, C-17 cargo planes land and take off from the military base's runway, moving men and materiel as quickly as possible. But the planes flying in from Iraq are most often carrying men, and unload their contents onto boxy American Blue Bird buses -- looking like children's toys next to the gigantic cargo jets. The red cross painted on the buses sides indicate their precious cargo -- they help bring the war to Landstuhl at all hours of the day and night.

Once loaded, the Blue Birds make their way across the tarmac and, weaving in and out of rows of parked aircraft, traverse a US Air Force base the size of a small city. After passing through Ramstein's gates they continue along a wide highway marked off-limits to the public, pass Ramstein-Miesenbach to the north, turn onto State Road 363, which passes under the A6 Autobahn, merge onto Saarbrücken Strasse and Kaiserstrasse in the town of Landstuhl, and continue up Luitpoldstrasse to the Kirchberg section of town.

1,598 doses of medication

The buses have arrived at their destination when the street names start becoming more familiar to American eyes: Munson Circle, Walter Reed Drive, Fifth Street. Depending on their point of departure, the passengers inside -- whether they are in a position to realize it or not -- have traveled 3,500 kilometers (2,175 miles) from Baghdad, 5,200 kilometers (3,232 miles) from Kabul or 6,200 kilometers (3,853 miles) from Mogadishu to reach the US Army's largest military facility outside the United States. They have arrived at the emergency room of the Landstuhl Regional Medical Center.

The structure looks like a curved spine from the air. A central hallway 2.5 kilometers (1.6 miles) long connects 14 individual buildings. The medical center can accommodate up to 1,000 beds in an emergency, though only 140 are currently set up. Employees vastly outnumber patients, with 2,200 people working in two shifts in Landstuhl's various departments, including doctors, nurses and drivers. Among the informational literature displayed at the press office is a piece of paper marked "A Typical Day." It details the statistics of a military hospital in a time of war: 1,178 meals, 1,598 doses of medication administered, 2.3 births, 23 newly admitted patients, nine new acute emergencies -- all in a day's work. The number of new acute cases is more than many civilian hospitals admit in the space of two months. They arrive almost directly from the front lines.

Like two Thursdays ago, for example. A small group arrives at daybreak as gusts of wind blow thin sheets of rain across the entrance to the hospital. A receiving committee has assembled in the neon light of the lobby: nurses, liaison officers, uniformed doctors, administrators, and military bookkeepers in combat boots. The chaplain on duty is also there. All are wearing purple rubber gloves. No one knows exactly what to expect.

Two buses arrive shortly after seven. They turn into the main driveway, turn around and slowly back up toward the doors. The hospital's advance guard -- 16 people altogether -- emerges from the lobby through sliding glass doors and quickly forms a cluster around the rear doors of one of the buses. A nurse stands on tiptoe on the outside perimeter, doing her best to hold an umbrella over the bus's double doors, which are now wide open. A stretcher is lifted from inside the bus out into the rain.

"You are safe now"

It arrives in the form of a broken man, a body almost completely covered in gauze bandages, darkened in spots, and connected to various machines -- he is unconscious. The chaplain at the head of the welcoming committee personally greets the new arrival, just as every new arrival at Landstuhl is greeted personally, whether he is awake, asleep or in a coma. The priest stands next to the stretcher and leans in toward the patient, almost as if he were bowing, and, addressing him by his first name: Michael, he says, "you are safe now. You're in Germany."

As the priest's purple-gloved hand forms the sign of the cross in the air above the wounded soldier, the hands of many others are already whisking the stretcher away toward the hospital, where it is loaded into an elevator and taken up to the ICU. The soldier's wounds are critical. Every minute counts at Landstuhl.

Four men are loaded onto stretchers from the second bus. Although their injuries are not life-threatening, they arrive with tubes in their necks and noses, wires in their chests, limbs in casts, skin burned, even with fingers, toes and legs already amputated. Each new arrival is greeted with the same soothing words and given the same blessing. By the time the delivery ends, 10 men have descended from the side door of the bus, some on crutches and others with no apparent injuries. The latter -- men with vacant eyes, eyes blinded by the images of war -- have come to Landstuhl for psychiatric treatment.

Eight thousand soldiers and military personnel have been treated for "combat injuries" at this hospital in Landstuhl's Kirchberg section since the Iraq war began in March 2003. This is the official number. But the real figure is probably higher, partly because the statistic does not reflect patients who have suffered emotional trauma or heart attacks in the war zone -- not even when the victims are young men. But numbers are the tools of politicians. Whether the number of the war wounded comes to 8,000 or 10,000 makes little difference to the day-to-day operations of this hospital not far from Germany's border with France. The staff members at Landstuhl are satisfied if they can survive a single day's work more or less intact.

Iraq and Afghanistan aren't the only war zones supplying the hospital with patients. Landstuhl is the central medical facility for US forces in Europe and is responsible for the US military's Central Command, which encompasses about half of US troops around the world. The hospital has treated 38,000 patients since 2003, most with run-of-the-mill, non-emergency ailments or needs: broken legs, appendicitis, tonsillitis and births. Sixty-thousand Americans have been born at Landstuhl since the hospital opened its doors in 1953. Most, though, come here to escape death.

A typical case

Paul Gillilan lies in his bed in building 10, hallway D, room 225. The room smells of disinfectant and other hospital odors. Gillilan is 24. His father was a soldier, his brother is stationed in Afghanistan and his wife at home is expecting their first child, a girl. Gillilan's speech is slurred from the pain medication being administrated through an IV drip into the back of his hand, but he smiles and doesn't seem to notice. He is a typical case.

Gillilan is based at Fort Carson, Colorado, the home of the First Battalion of the 9th Infantry Regiment, a famous unit in military circles and one of the oldest in the US Army, with a history stretching back to the War of 1812. Gillilan's road from Colorado to Landstuhl passed through Ramadi, 100 kilometers (62 miles) west of Baghdad. That he made it to Germany is a miracle, a result of the combined and coordinated efforts of medics, pilots, nurses and military logistics experts who are continually fine-tuning the US military's battlefield evacuation system.

Gillilan, a sergeant, and his beefed-up platoon of 40 men, including Iraqi soldiers, were on patrol in the night of February 24 in Ramadi's Malab district. They were lightly armed and accompanied by Humvees as they searched for insurgents and arms depots. As the platoon moved along a narrow street, unmanned drones over their heads reported enemy movement. It was one a.m. and the drones reported people walking alongside the platoon on the roofs of the adjacent buildings. A lieutenant told the commanding officer that they were walking into a trap. But the officer ordered the patrol to keep moving. Gillilan continued on with the rest of the platoon until he heard the first shots.

He sought cover, just as he had learned to do, as he had been trained to do for years. He had been in Iraq for five months and knew how to handle himself in hostile surroundings. He had already experienced four or five explosions at close range.

Part II: Of Heros, Nurses and Tears

Gillilan and his men hid behind a wall, but in doing so they were falling deeper into the attackers' trap -- the wall was rigged with explosives. Once the Americans and Iraqi troops were safely behind the wall, the detonator was activated, perhaps using a mobile phone or a rebuilt TV remote control. The wall blew up, triggering several secondary explosions; flying shrapnel and rocks from the explosion seriously injured seven Americans and one Iraqi in Gillilan's group.

The airborne projectiles shattered the soldiers' bones and ripped into their tendons, muscles and feet. One man lost both legs. Gillilan was severely injured when his right lower leg was severed just below the knee. He could have bled to death at the scene. But instead he was in Landstuhl within 48 hours. Instead of dying on a street in Ramadi, he was saved by a medic -- a "91 Whiskey" -- who treated the wound on site as best he could under enemy fire, and managed to stop the bleeding. He was saved by the staff of a forward aid station consisting of two doctors, several nurses, operating tables and beds. He was saved by the helicopter pilots who flew him to Balad, a US base north of Baghdad. And he was saved by the doctors on board the C-17 who monitored his condition while he was being flown to Ramstein.

All eight of the men wounded that night in Ramadi are here, distributed among the corridors: 23-year-old sergeants, 24-year-old lieutenants. Gillilan says: "I'm happy to be here with my guys," and tears well up in his eyes for a moment. When asked about his leg, he says: "It won't change my life much. You can even play basketball with that kind of thing nowadays. You know, I love basketball." He smiles. He has no misgivings. He seems optimistic.

The German front

The stories of many patients in this hospital are similar to Gillilan's, but others are worse off. Married couples are admitted who were wounded together. Brothers have been admitted, one to die and the other to become so despondent that he loses his will to live. In one case, a woman was flown in to say goodbye to her dying husband, only to learn of the death of her own mother at his bedside. Landstuhl says a lot about war and little about peace.

In Landstuhl, a city of 20,000, and throughout the region known as the "Kaiserslautern Military Community," America is more than the land of George W. Bush. Here America is everyone's next-door neighbor. Fifty thousand US citizens live in the area, and not just behind fences at the bases in Ramstein and Vogelweh. Many have settled in the region, playing tennis at German clubs, donating items to their children's kindergartens, getting married and spending their evenings eating popcorn at the Broadway Movie Theater.

It's hard to be anti-American in this region. "We have been living with and benefiting from the Americans for more than 50 years," says Landstuhl Mayor Klaus Grumer, who has held the office for the past 13 years. A few months after the Iraq war began, he and several other local officials traveled to Washington, where they were received at the Pentagon. They wanted to show the Americans that their friendship would outlast the vagaries of politics. Grumer invites the officers from the base to the town hall for important events, and they return the favor whenever they have something to celebrate in Kirchberg. The city's hotels wouldn't survive without US military personnel, and soldiers make up the majority of patrons in local bars. Most Germans have no objections, as long as the GIs don't become too rowdy.

Landstuhl feels like a German front in this war. People in the city have a sense of what goes on in the hospital up on the hill. Even the Western Palatinate Peace Initiative, which stages prayer sessions at the hospital gate and distributes flyers against the war at the weekly farmers' market, makes a point of opposing war in general but not "the Americans."

Landstuhl has felt the consequences of war for decades, even with the wars and conflicts happening far away. The victims of the 1986 terrorist attack on Berlin's La Belle nightclub were taken to Landstuhl. Two years later, after the Ramstein air show accident, more than 500 wounded were admitted within two hours. In times of peace, Landstuhl was the place where the victims of attacks on US embassies, attacks on ships and bombing attacks on US citizens were given medical treatment. Now is a time of war, and yet most of Landstuhl's stories are of miraculous survival.

Extending "the golden first hour"

The military doctors have become so good at their jobs that nine out of 10 soldiers wounded in the field survive. In the Vietnam War only seven out of 10 made it home alive, and in World War II the success rate was even lower. Stephen Flaherty, a colonel and the chief surgeon at Landstuhl, has nothing but praise for the army's training programs. Nowadays every fifth soldier in US units receives additional training to become a "Combat Life Saver," which qualifies him to administer first aid to other soldiers during battle. "This allows us," says Flaherty, "to make that 'golden first hour' last longer and longer." Flaherty, 44, has co-authored books on emergency medicine. An enormous US flag hangs in his office. He is a stern, proud, battle-hardened man. He has served twice in Iraq and twice in Afghanistan, and he has seen unimaginable wounds. Flaherty and his team of 13 surgeons have eight operating tables at their disposal here in Landstuhl.

Now that the US is at war, there are some days when all eight operating tables are in use. "It's a great honor to me," says Flaherty, "to care for our people from the front lines. They're good people who are doing good things. When somebody like that is lying in front of you, it's a special feeling for a surgeon. It's like family, and it has a quality of its own."

It's impossible to visit Landstuhl without hearing stories about heroes. "It's an incredible privilege to me to be able to welcome these soldiers," says Stephen Stavoy, the priest who met the bus of patients in the morning. Stavoy is a man who doesn't look you in the eye. His hair is too white for his age, and every sentence he utters sounds like a prayer. He speaks of the respect he has for soldiers who risk their lives to save others.

There are now eight military chaplains at Landstuhl, compared with two during times of peace. All the wounded who are brought here from the front lines, anywhere from 240 to 400 a month, need support, encouragement and help. "They feel guilty," says Stavoy, "and it drives them crazy. They're convinced that they have failed. They believe that they have let down their fellow soldiers. They're ashamed to be here, in safety."

Americans are quick to characterize someone as a hero, and it is difficult for civilians, especially Germans, to share their fervor. But Landstuhl is a place which challenges un-reflected assumptions. Those who carry protest banners through the streets that read "Soldiers are Murderers" can learn here that soldiers are also victims -- men and women shot at from behind or wounded through treachery.

Not yet fallen, not yet saved

And anyone who runs into Dawn Garcia, the chief nurse in the ICU, in the hallways at Landstuhl has to wonder whether this soldier might not be a hero, after all. Colonel Garcia is in charge of the 75 nurses and nurses' aids in Landstuhl's ICU, the nucleus of this hospital. The patients admitted to one of the ICU's 18 rooms along a narrow hallway arrive from the war zones in critical, life-threatening condition.

Eight beds in the ICU were occupied 10 days ago. One of the patients had burns on 70 percent of his body, and the only part not covered by bandages was his throat, which was being held open with clamps. Comatose men and men with multiple wounds were being treated in other rooms, surrounded by doctors and machines. They were veterans from Ramadi and Baghdad -- they had not yet fallen, but they had not yet been saved either.

Dawn Garcia, a 40-year-old native of Texas, is difficult to overlook. She exudes a sense of kindness that changes every room she enters. She lives in Landstuhl with her husband and two daughters, has been in the army for 18 years and clearly loves her work. She is a remarkable person.

Garcia worked in Iraq for an entire year in 2004, the year of the battles for Fallujah. She worked in operating rooms resembling slaughterhouses, often under fire and during power outages. She saved hundreds of lives and comforted dozens of dying soldiers, held their hands, wept and prayed with them, promised not to leave them alone and never broke her promise, even when the war was raging around her.

On some days in Iraq, when blood supplies were low, she would donate her own blood up to two times a day. On other days 18-year-olds died in her arms, and all they could say was that they wanted to protect their country and hoped that their efforts hadn't been for nothing. Dawn Garcia sat by their sides like a mother, selfless and courageous.

She does her job. "My family is my support system," she says, "and I run six miles a day. That helps." When asked how she keeps herself from despairing when faced with so much suffering, she says: "You have to be able to cry when it's time to cry. That's important."

The chaplains occasionally organize outings for the hospital staff -- boat rides on the Rhine River to Lorelei Castle or trips to the Roman ruins at Trier. These outings often turn into almost frantic celebrations of life. Outside in the fresh air, in the sunlight and away from the dim corridors, hushed sounds and pungent smells of the hospitals, these nurses and doctors manage to forget about their everyday lives, and after spending a day or two in bucolic Germany they can return on Monday morning to their patients' bedsides, calm and relaxed once again.

Unable to get the war out of their heads

Lieutenant Colonel Gary Southwell, who recently returned from a year in Iraq, is a member of the hospital's team of psychiatrists. He is an honest-looking man, 57 years old, and he speaks quietly and clearly. While in Iraq he treated prison personnel who worked in a camp in southern Iraq where 12,000 prisoners were being held. The personnel, including many women, were constantly subjected to cursing, humiliation and physical attacks. Even though working in the prison was not considered combat duty, says Southwell, it involved the full "stress of combat."

Southwell speaks pragmatically. He says that the important thing is that people must first accept their suffering. "We tell them: It's normal that you're depressed, and it's normal that you don't feel well. That isn't sick. It's healthy." But it becomes dangerous when the frustration does take hold and people begin to lose it. The military, says Southwell, is a unique organization.

"Thoughts of suicide in an environment where everyone carries a gun are serious right from the start," he points out. According to the research, says Southwell, 18 to 20 percent of all soldiers develop post-traumatic symptoms while deployed in war zones. Once they are back home, they withdraw from the civilian war because they are unable to get the war out of their heads. To them, the popping of champagne corks can sound like gunshots and the slamming of doors can seem life-threatening. A package on the side of road can cause them to react by turning their cars around at full speed. All suffer from "combat stress," but it's part of being a soldier. "But the good thing," says Southwell, "is that we know these things now. In Vietnam and in earlier wars, no one even asked these questions." He says that he too found it difficult to return from war. "My wife and I spent a year living like single people. Now we have to find our way back into our marriage. It's difficult. It takes work."

A second meeting scheduled for late in the afternoon with Sergeant Gillilan, the soldier who lost part of his leg in Ramadi, is cancelled. A sister at the front desk says: "No way. He's in pain. He isn't feeling well." Some of his fellow soldiers are in a room a few doors down the hall. Their names are Berninghausen, Hightower and Nick McDermott. McDermott, a native California, is 23. He has lacerations on his face, two broken legs, is missing the big toe on his left foot, and his skin is "peppered" with grenade fragments. This isn't his first time at Landstuhl.

He sounds nonchalant as he tells the story of the first time he was wounded, also in Ramadi, and also in a trap that involved explosives. "Getting blown up is part of the job. That's why it would never occur to me to leave the army." He's building a model car, a red Chevrolet Camaro, one of the many donations from back home that the chaplains administer.

"Hard for outsiders to understand"

Entire barracks on the facility's grounds are filled with donations, with toothpaste, T-shirts and tennis shoes. Drawings from schools and kindergartens hang on the walls, colorful drawings of sunflowers with inscriptions like: "We thank our American heroes." Nick McDermott says that he always wanted to be a hero, a "G.I. Joe" who fights for his country, killing America's enemies. "It's hard for outsiders to understand." He is spending his last hours in Landstuhl. McDermott will be transferred the next day. Patients rarely stay at Landstuhl more than five days. In most cases they are quickly sent to the Walter Reed military hospital in Washington, DC, which had a good reputation until its director was fired after veterans were found living in degrading conditions in the giant facility, in mice-infested rooms with mold on the walls and excrement in the beds.

McDermott and his fellow soldiers will leave Germany the way they came. When they are loaded onto the same clunky Blue Bird buses and travel back down Luitpoldstrasse, it's on a recent Friday, a gloomy day. The bus takes them onto State Road 363, passes underneath the highway, passes Ramstein-Miesenbach to the north before arriving at Ramstein Air Base.

It takes a while for the patients to be loaded onto a McDonnell Douglas C-17. The plane's cargo area is 27 meters (89 feet) long, and loading it will take until shortly before takeoff. McDermott's stretcher is attached to a stand to the right of the center aisle, below another wounded soldier's stretcher. A space of about a foot separates the two men. About two dozen soldiers on stretchers are part of the flight's cargo.

McDermott becomes highly agitated shortly before takeoff. His body shakes and he fights back tears, perhaps because he has just now realized that he was saved. He says: "My God, I'm glad to be going home." Then he falls asleep, looking like a sick child.

The scene around McDermott is hectic as people walk around minutes before takeoff. The officer in charge of loading the plane stands on a box issuing orders to a crowd of about 50 or 60 military personnel on their way to Washington -- officers carrying briefcases, women with rows of decorations on their jackets, passengers wearing the uniforms of the US Navy, Air Force and Army. It's an American scene, a scene from a country at war. A scene from the edge of the Iraq war zone. In Germany.

Translated from the German by Christopher Sultan

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