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After the Smoke Clears

Shannon Merkle

Dedicated to the courageous men, women, and families of the US Armed Services who possess "... a firmness & perseverance of purpose which nothing but impossibilities could divert from its direction ...”

Thomas Jefferson

August 7, 2012

Without warning, an excruciating sensation slams into my back and head. It is now dark and eerily still. A loud, shrill ringing fills my ears, and I’m struggling to breathe. My body will not follow my commands. My limbs are surprisingly unresponsive to my desire to move. Someone screaming, “stay down” pierces the ringing in my ears. Finally, my lungs respond drawing in the dusty, stale air that makes me alternate coughing with breathing.

Where is Technical Sergeant (TSgt) Kay? Just moments ago I was standing beside her; we were finalizing details for our upcoming battlefield circulation mission. Again, someone yells, “stay down.” The delayed realization that we’d just been attacked now floods me with adrenaline and finally my body begins to respond to my desire to move.

My eyes strain to probe the darkness, looking for my colleagues. I’m not in the same place I was standing earlier—none of us are. I hear a muffled “boom”—a mortar or rocket. They are still firing at us. Captain (CPT) Walsh is kneeling a few feet away. I suddenly understand that she has been the one yelling “stay down.” She

S. Merkle, M.S.O.T., O.T.R./L., C.H.T. (*)

US Army, US Army Research Institute of Environmental Medicine, 10 General Greene Ave, Natick, MA 01760, USA e-mail: This email address is being protected from spam bots, you need Javascript enabled to view it

© Springer International Publishing Switzerland 2017 E.C. Ritchie et al. (eds.), Psychiatrists in Combat, DOI 10.1007/978-3-319-44118-4_18

Inpatient room at the Concussion Care Center. FOB Shank, Afghanistan, 2012 (Courtesy of CPT Shannon Merkle, OT)

Fig. 18.1 Inpatient room at the Concussion Care Center. FOB Shank, Afghanistan, 2012 (Courtesy of CPT Shannon Merkle, OT)

is yelling at TSgt Kay who keeps repeating the phrase, “I can’t breathe”, and seems to be struggling to get out from under a pile of debris.

Although shock, anger, fear, and confusion begin to compete for attention within me, I take comfort in the fact that she is talking. I know there were three other people here with us—where are they? The world seems to be in slow motion around me. CPT Gardner emerges from the darkness, but I can’t really see his face. I hear someone yell, “MEDIC”!

Somehow the darkness turns into a scalding brightness; the pain sears my eyes. We are all outside of the now flattened tent that was the combat stress team’s office, but I’m not aware of how that happened. I glimpse CPT Gardner helping TSgt Kay hobble away from us. I see CPT Walsh cupping her head, mumbling “my head hurts.” She’s headed in the same direction as CPT Gardner and TSgt Kay. I think they’re headed to the Forward Surgical Team (FST), but I’m not sure. The others that were in the tent with us are already gone. I head toward the Concussion Care Center (CCC), checking bunkers along the way (Fig. 18.1).

I run the Concussion Care Center for the 173d Airborne Brigade Combat Team (ABCT) area of operations (AO). This morning we had expected to be able to finalize the discharge plans for our one remaining Service Member (SM). The wellbeing of Sergeant (SGT) Castro (the Occupational Therapy Assistant who runs the

CCC with me) and the Service Member in our care dominate my convoluted thoughts. We take indirect mortar and rocket propelled grenade fire (IDF) regularly here, and initially I assumed that this incident was more of the same. However, as I try to resist the fog that has invaded my mind, I realize that something more significant is happening.

I find the Service Member I’m looking for in the bunker nearest my clinic—he appears to be allright, but no SGT Castro. Someone informs me he’s at the Concussion Care Center looking for me. I walk the short distance to the Concussion Care Center and find SGT Castro inside the damaged tent. Somehow, I end up back inside the bunker; SGT Castro standing beside me.

Our Service Member and several Afghanistan interpreters who live in the tent beside ours are also in the bunker. Ironically, it is not fear that I feel, but rather relief that SGT Castro and the other Service Member are allright. A wave of nausea washes over me, interrupting my slowed thoughts. I think I’m going to vomit, but no such relief comes. My head is pounding, and I begin to notice the ache in my back and neck. My thoughts are murky and disjointed as I try to make some sense out of what just happened.

I have no real concept of time. I wonder how long we’ve been in the bunker, but apparently it hasn’t been long when I hear, “BREACH!” I look at SGT Castro. What is he saying? I’m getting frustrated trying to make my brain assign meaning to the conversations and chaos around me. “We’re being breached,” he says to me and takes off running back toward Charlie Company, toward the perimeter.

I don’t specifically remember heading to the perimeter but I’m here now—full battle gear and M16A2 in hand. I see Service Members and local nationals stumbling all over the place. I notice Service Members standing on the Hesco walls at the perimeter pulling security.

Those who were roused from bed (night duty and special operations forces) are dressed in some combination of boxers, shorts, and flip flops while wearing their Improved Outer Tactical Vests (IOTVs) and Kevlars. The rest are in more traditional military gear. The perimeter (including the large hole in the perimeter) has already been secured.

“Captain! Captain!” A local national approaches me. He is dressed in primarily white attire, which contrasts starkly with the blood and dirt covering him. “My brother, my brother,” he adamantly repeats and points toward the hole in the perimeter wall. He is pointing toward a group of “Haji Shops” (small shops owned by locals) along the inside of the perimeter. I follow his gaze and for the first time start to take in the destruction around me. The shops on the perimeter are in ruins. Alpha, Bravo, and most of Charlie Company living quarters are destroyed. Debris is scattered everywhere. The Charlie Company medical area is badly damaged. The structures that used to comprise the Forward Surgical Team area and the Combat Stress Center (CSC) have been destroyed. Charlie Company is busy consolidating resources, triaging casualties, and trying to pull survivors (and the dead) from the rubble. The medical evacuation landing zone is the new triage area.

One US contractor and three local Afghans died in the vehicle born improvised explosive device (VBIED) blast that day. Over the next several hours, more than 108 casualties were treated at Charlie Medical Company and at least 38 people were evacuated to Bagram Air Field [1]; others followed over the next couple weeks.

Most of those evacuated from Forward Operating Base (FOB) Shank left theater for additional care. Some who were evacuated to Bagram tried to return to duty on our Forward Operating Base, but many were unable to continue working effectively there and returned stateside for further care.

I was in the Combat Stress Center (CSC) finalizing travel plans to a remote outpost with a member of the Combat Stress Team (CST), when the VBIED was detonated. Five other Service Members (most of them members of the CST) were in the CSC with me at the moment of detonation. We were 75-100 meters from the point of detonation. Most of us sustained relatively minor orthopedic injuries and concussions. TSgt Kay was evacuated from theater approximately 1 week after the blast and later medically discharged from the military. CPT Gardner transferred off FOB Shank and finished his tour at Bagram. The rest of us were treated, recovered in place, and returned to full duty within a couple weeks.

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