Bonded in Blood: Ashley Liebig and Noah Galloway. St Emlyn’s

Editor’s note. This blog has been a long time coming. It describes the personal impact of war, trauma, survival and recovery based on Ashley and Noah’s experiences of Iraq in 2005-2006. More than that, it describes a remarkable human being, Noah Galloway, whom I had the pleasure to meet when out in Austin, Texas. Noah’s journey is as challenging as any I can imagine, but despite that he is a beacon of positivity and good will. It’s best that Ashley takes it from here. As always, we are very careful about sharing patient stories on St Emlyn’s. We are very grateful for Noah’s consent to share this story.

Ashley Liebig.

While many of the St. Emlyn’s team was in South Africa for #badEM and The Teaching CoOp Cape Town, I was suffering terribly from FOMO (fear of missing out).  Fortunately, I was invited to lecture in Nashville, Tennessee at the FlightBridge Air and Surface Transport Conference (#FAST18).  This conference, geared to a multidisciplinary prehospital audience, was the inaugural event hosted by the Flight Bridge Education Team.  I was honored to give the closing Keynote address and delivered a lecture titled, “The Patient Experience”.

This lecture is one that had been vacillating in my brain for some time but had dismissed because the content seemed obvious and simplistic.  Recently though, I overheard a patient interaction that reminded me exactly why this message should be shared.  To do it justice I would need a patient, but not just any patient; my very first trauma patient, US Army Sergeant (ret.) Noah Galloway. 

Over a decade ago, I was a medic assigned to an aide station in Yusifiyah, Iraq with the 502nd Infantry Regiment of the 101st Airborne Division. Just a few days after my arrival, Galloway’s vehicle hit an improvised explosive device (IED) not far from the base of operations.  Though there were two others in the vehicle, the driver’s side sustained most of the blast impact and Galloway was severely injured.  He landed in a canal and lay wounded for several minutes until help arrived. He was extricated and rushed to our aide station.

The resus room in Iraq

The Humvee sped through the gate and came to a screeching halt.  I will never forget the moment that I opened the door and, even in the darkness, I could see a heap of a man. I was an Army medic, which consisted of only 16 weeks of medical training, and there I was, staring at this human who was disassembled and near dead. I froze for what was probably a fraction of a second, puzzled at how I would pull these loose tendons and ligaments out of the vehicle without making matters worse. His arm was absent long bones, so I tucked his bloodied hand between my cheek and shoulder like you would a telephone and, with the help of other medics, pulled him to a stretcher and raced inside. 

“Bleeding to death”

The aide station was immediately filled with the noise and chaos of a resuscitation. Not just the kind of resuscitation that we all are familiar with in our departments; one with the kind of emotional intensity that occurs when the patient is a loved one and death is looming. He was grey and hypothermic, his movements accompanied by frantic moans.  At the core, he was a soldier and he was fighting with every ounce of strength that remained.  Between his sounds I could only hear the panic in the room, “Medevac”, “leg is crushed”, “we need blood”, “I can’t get the airway”, “tell them to f-ing hurry, he’s dying”, “I can’t get a line”, “another tourniquet”, “where the f*** are they?”.  

“You’ll be ok”

All I could think to do while I applied tourniquets and drew up medications was to talk in his ear. In a calm voice, I talked over the horrid sounds that hung thick in the air.  I told him he would be ok, that he would owe us beer when we got home, that he was our brother and we loved him, that he would be ok.  Over and over and over again, I promised a man whom I was certain was going to die that he would be ok.

Medevac arrived and after loading him and the other wounded into the aircraft, we returned to the aide station where we met a deafening silence, despite the noise.  Someone was yelling, something about the medevac taking too long and while I could see his mouth moving, I couldn’t actually hear the words. I could only see the faces of men that I adored; shaken to the core in disbelief and devastated.  Unsure of what to say or do, I began to scrub Noah’s blood from the floor, as if I was trying to wash away all that had occurred.

Noah and Ashley

Despite all odds, Noah Galloway woke up days later.  After drifting in and out of consciousness, his first lucid memory was that of his mother telling him that he had been injured, that his jaw was shattered and wired shut, that he was missing his left arm above the elbow and left leg above the knee.  While I have listened to Noah tell a humorous version of this story multiple times, to ease the worries of his audience, I can’t imagine, for a man whose identity was so invested in being an infantry soldier, how painful this news must have been.

Noah and I became fast friends during his recovery.  When I could get to a phone, I would call and check on him. Initially it was so I could update the guys who needed the good news of his progress, but eventually it was because I grew to care about him.  We would email back and forth and I suppose in some way it was therapeutic for both of us.  Over and over again, he asked me to recount the events of that night.  Over and over again, I would share the nightmare. 

United in trauma, this friendship has lasted over a decade.  We have seen each other through marriages and children, struggles and depression, the highs and lows.  He has become the epitome of motivation, running endurance and obstacle races, becoming Men’s Health Man of the Year, appearing on numerous television shows and writing his autobiography. His message is a powerful one; there are no excuses!

But long before he became his own brand, he was my friend.  The friend with the stories that shaped who I wanted to be as a clinician.  Having a front row seat to the challenges of being a healthcare consumer absolutely defined my career and I thought it important to share those lessons learned.

Frightening Words

I’m not sure if that night I talked to Noah to try to calm him or if it was a mechanism to calm myself. What I do know is that if you take a moment to pay attention to the things that we say in and around our patients – the acronyms that we use, the slang terms, the speed and rate with which we communicate –  it can be scary.  Discussing this recently, a friend told me that a family member of a patient overheard “we need to bag him” and thought that meant a body bag and that her loved one had died! Imagine.

The opposite is also true; the things that we don’t say can also be frightening.  Waking up after a surgery or injury hours or days later with no memory of events, waking in pain but not knowing why or being unable to communicate: consider how our patients feel in these scenarios.  It is important to remind and reorient our patients to their situation frequently, especially when pain medication or sedation is involved.  We must remember that our knowledge and assumptions are ours, not theirs, and we have a responsibility to communicate effectively.

Expecting the Unexpected

Click here for more on Noah

You may have noticed that in his story, Noah had no tourniquets. It was required that everyone carried them in a cargo pocket and first responder kits were full of them. Noah thinks that the reason he didn’t have tourniquets in place was because he wasn’t expected to live. Our casualties up until that point had been catastrophic losses requiring DNA or teeth for identification.  Initially I disagreed with his assessment, but then later recalled Hicks and Petrosoniack’s paper from last year and the discussion surrounging team dynamic and performance; “Individual team members are invariably influenced by prior experience and coping strategies, which in turn influences mental posture-the ability to remain flexible problem-solve, and perform under acute stress”.1 These soldiers were, no doubt, incredible infantrymen.  I know that their combat, weapons, survival and navigation skills were all top notch.  They were brave and heroic, they ran toward a hot zone in order to aid their comrades.  They were highly-skilled, well-trained, professionals but Noah was correct in that the casualties to this point did not have survivable injuries.  Perhaps their experience to that point dictated their ability to asses or adapt. 

Another alternative perspective is that in 2005, trauma care was different. I suspect that they were likely only exposed to the practice of, or use of, tourniquets on a few occasions.  It was not part of their daily routine or mental rehearsal.  I believe that there was no tourniquet because in the aftermath of the explosion they were focused on primary security measures: secure, extricate, and move. These are the skills that they trained and practiced and repeatedly.  These were the skills that were mastered and then overlearned to the point of becoming automatic.  Secure, extricate, tourniquet and move, was not the algorithm and thus when their cortisol-drenched brains were functioning in survival mode they relied on automaticity rather than adaptability.

While it is nearly impossible to understand the horrific scenarios that these men faced, it is also useful to consider the possible similarities to how we practice.  In our departments or environments, how well do we rehearse? Do we overlearn so that we have a skill set to rely on? And then what happens when our plan doesn’t go according to plan, how do we adapt? Are we prepared for the unexpected?

 Full Exposure

We always took pictures of our trauma patients, because pictures are worth a thousand words and when senior ranking officials visited, we wanted them to know the hell that resided there.  There were pictures of Noah.  To clinicians, it was documentation of what was endured.  Noah knew this and in one of his emails asked me if there were photos.  I told him that there were but he didn’t need to see them.  He insisted.  I denied him and then he eventually told me that his therapist thought it would be good for him (as we stood on stage in Nashville, he confessed that this was a lie).  I sent him the photos of us working his injuries.  He immediately replied that it “must have been very, very cold in the canal”.  I rolled my eyes at his protest and changed the conversation.  He shared these photos with his surgeon who took them to a conference.  He gave permission, but asked his surgeon to blur out his genitals, but instead, the surgeon placed a tiny white dot.  He then sent the photo back to Noah, who was mortified!  To hear Noah tell the story of the “falsification” of his manhood, is hysterical.  He, once again, alleviates his audience discomfort by making light of the circumstance.  But if we analyze it for what it really is, it was a horrible failure to protect his privacy.  For the umpteenth time in his care, he was reduced to a photo, a story, a symptom, a diagnosis.  At no time was anyone considering the man that was behind the injury or the visual reference and yet, that man was someone’s person. 

In fact, each of our patients is someone’s person.  Sure, we may have the good sense not to take or share photos of injuries, but how far does this go?  As the stretcher is being rolled across the road from the ambulance bay have we covered up the undergarments of the 80 year old female patient who had a 12 lead ECG?  Have we stopped to pull the curtain surrounding the trauma or medical patient exposed in the Emergency Department? Have we walked past the admitted ETOH abuser who is now asleep with his hind end exposed?  

Professional Sadness

The thing is, the photo debacle wasn’t this first time that I felt this terrible sadness. I felt it tenfold when Noah shared the story a year later about the nurse who had cared for him when he woke up and it’s one of the few stories that he does not make light of.  I was in nursing school when Noah told me this story and while it broke my heart then, even a decade later, it continues to do so. Noah remembers waking up in horrific pain on Christmas Eve.  He heard the voices of children singing but instead of joy, he felt the phantom pain in his limbs.  He tried over and over to get someone’s attention.  He found a call button on the bed and frantically pushed.  He was scared, he couldn’t speak, his jaw was wired shut and he could only recall the rumors that the IED blasts could be so hot that they would fuse the bones together.  He was sure that his bones were fused, he couldn’t understand why the arm and leg that he was commanding, were not reacting and he was in pain… more pain that he had ever felt in his life.  He recalls, very specifically, a nurse coming to his bedside. He recalls this nurse saying “We are away from our families at Christmas, there are children here singing carols, and you are being very rude!”

This makes my blood boil.  The rage that comes over me when I hear this is unexplainable.  My best friend, my person, MY patient, was in pain, was scared, was confused, was alone and someone… someone who was not injured, nor confused, nor in physical pain, had the audacity to speak to him this way! I wish I could find that nurse.  I wish to this day that I could meet that nurse.  I would tell him what he did to my profession that day he decided to berate a patient.  I would tell him what he did to me as a nurse when he decide to lack compassion.  I would tell him what he did to Noah, the day that he decided that he wasn’t worthy.

I hope your blood boils too.  I hope you find your heart hurting. I hope that you never allow yourself to be this clinician; the one that has stopped caring, the callous and sad practitioner that no longer remembers that this person is human, that this human being is someone’s person. 

 “The Silver Lining”

Noah would be angry if I didn’t close with a happy story.  He ends every interview I have ever heard him give with gratitude.  While we can learn a great deal from his negative encounters as a patient, we can learn so much more from the positive ones.  As much as he recalls the bad, he celebrates the good.  He remembers the kind voices of the flight physicians and nurses.  Despite not seeing their faces, he describes, with tears in his eyes, their kindness, that he felt safe, and that he knew he would be ok.

I think of this often, especially on those days when I have given all that I have and it still seems as though it wasn’t enough.  Sometimes kindness and humanity is enough.  Noah attributes his life to the cascade of good people involved in his care, from the soldiers who fished him from the canal, to the current day prosthetists who keep his racing leg in good condition, and everyone in between.  Let that be the story of our patients as well, that our commitment to them leaves a positive impact. 

And to Noah – Thank you.

Thank you for being an exceptional teacher, your experience has taught me some of the most valuable lessons of my career, and I am a better provider for it.  Thank you for your friendship, for always finding the bright side and for being my person.

And finally, to all of us. Remember to be kind, even when we are stressed and under pressure our words have power. Be positive and respectful with your patients and you will make a huge difference. Be critical and it can have a terrible effect on your patient and on how you are perceived by your colleagues. Be kind, be respectful and be the clinician you know you can be.

Ash

@ashleyliebig

More on Noah

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References

1.
Hicks C, Petrosoniak A. The Human Factor: Optimizing Trauma Team Performance in Dynamic Clinical Environments. Emerg Med Clin North Am. 2018;36(1):1-17. [PubMed]

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