BAGRAM AIRFIELD - Maj. Alan Todd is no stranger to what can happen on the battlefield.
For three years, Todd worked at the military hospital in Germany that treated wounded troops brought out of Afghanistan and Iraq by U.S. planes, including the C-17s based at Charleston Air Force Base.
But, a month ago, the Charleston native deployed to Craig Joint Theater Hospital here.
At the Bagram Airfield hospital, the wounded are brought in wearing their bloodied and torn uniforms, not the clean gowns and pajamas Todd's patients wore in Germany.
Medics' field dressings cover wounds as tourniquets keep blood from gushing from torn arms and legs. The acrid smell of gunpowder and the stench of sweat and grime permeates every thread of the wounded troops' uniforms.
"It's just so fresh to me that it's shocking," said Todd, a nurse anesthetist.
Todd is among the S.C. airmen assigned to Craig. It is the first stop for the critically wounded before they are airlifted to hospitals in Germany and other locations as the S.C. lifeline to this war winds it way from Afghanistan back to the United States.
At Craig, the staff works to stabilize the condition of the wounded troops before they are flown out by Air Force transport planes.
"If you still have a pulse when you get here, then you have a 99 percent chance of surviving," said Col. Joseph P. Chozinski, commander of Joint Task Force Med-East, which includes the Bagram hospital.
EVACUATIONS CAN BE DIFFICULT
Getting the wounded to Bagram with a pulse is the problem.
American wounded have to be evacuated from mountain ranges and remote outposts, where much of the Afghan fighting takes place. The average medical evacuation in Afghanistan takes nearly two hours, compared to an hour in Iraq, where the terrain is flatter and the transportation system is more developed.
Trying to shorten the time needed to get the wounded to a hospital, Defense Secretary Robert Gates earlier this year ordered more helicopters and planes sent to Afghanistan.
"The difference between Afghanistan and Iraq is that, here, I worry as much about the environmentals - the terrain and altitude - as I do the enemy," said Lt. Col. Sean Choquette, commander of an Air Force search-and-rescue squadron based at Bagram.
"Here, the earth is trying to kill you, and you're out there flying very challenging missions," said Choquette, of Durango, Colo.
When a rescue helicopter reaches its destination, Afghanistan's mountainous terrain often forces para-rescue jumpers to be lowered to care for a wounded soldier or downed aviator, said helicopter pilot Capt. Andy Gray of Tampa, Fla.
Hovering above the scene, pilots worry about setting off land mines.
"You're hovering and beating the ground into submission (with the downforce from the helicopter's propellers), and mines can go off," Gray said.
MORE TROOPS, MORE WOUNDED
Since a surge of U.S. troops earlier this year doubled the American force to some 65,000, the number of patients at the Bagram hospital has soared.
So far this year, 252 U.S. troops have died in Afghanistan, far surpassing the previous record - 155 - set last year, according to icasualties.org, an independent Web site that tracks U.S. and coalition fatalities.
The soaring number of wounded prompted the Air Force to erect a 100-foot-long, air-conditioned tent next to the hospital. Called a Contingency Aeromedical Staging Facility, the tent - four 25-foot-long sections bolted together - is staffed with nurses and technicians.
In the tent, the staff triages the wounded arriving from the battlefield into those needing immediate care and those who can wait, if need be.
The tent also is used as a holding area for those waiting to be evacuated to other military hospitals.
Besides Landstuhl, the U.S. military has two hospitals in the Persian Gulf region that treat troops, said Maj. Louis Gallo, the facility's commander.
Those who go to Landstuhl have wounds that are life-threatening or involve the loss of a limb or eyesight.
From Germany, the wounded are transferred to military hospitals in the United States.
To gauge the flow of wounded, Gallo counts "patient moves." One patient can count for up to four moves: arrival at Bagram, transfer to the hospital, transfer back to the casualty facility, and, finally, departure to another hospital.
In July, when the facility opened, there were 488 patient movements, said Gallo, of Louisville. That was double the hospital's July 2008 tally. August's total was about 500. September hit 599.
NO BEDS? IMPROVISE
To ensure there are enough beds to care for the wounded at the Bagram hospital, sometimes the staff has to improvise.
"One day all our beds were taken, so we put five cots between beds," Chozinski said.
The space crunches, though, are short-lived, because wounded U.S. and coalition troops are moved in a matter of hours to other hospitals better equipped to care for them.
The hospital, which has a four-bed trauma bay, three operating rooms and a dental clinic, serves U.S. personnel in Afghanistan as well as NATO and Afghan army troops.
In addition, hospital staffers treat Afghan civilians who live in nearby villages, wounded enemy fighters and inmates at the Bagram prison.
"We give them the same level of care as our own," said Master Sgt. Lekisha Johnson, an Air Force surgical technician and Sumter native.
Caring for the Afghans - many of them children - has been an eye-opener for the South Carolinians.
Many children arrive at the base's gates, carried by their parents, who are begging for help.
Some of the children have been caught in the crossfire of warring forces and are missing a limb or an eye. Others have been burned by a bomb blast.
Todd recalled a girl, about 6, who had been asked by a Taliban fighter to carry a fruit basket to her father. The basket concealed a bomb. It exploded and the girl lost her eyesight.
"You have to deal with kids who are being exposed at a such a young age to these traumatic events. It's heartbreaking," Todd said. "You have to wonder how this will affect them the rest of their life and how they will view us."
Just as heartbreaking are the children suffering from sepsis, pneumonia, meningitis or diarrhea, often caused by drinking or swimming in water polluted by human and animal feces. Such illnesses are common in Afghanistan, where nearly 3 out of 10 children die before their fifth birthday.
The airmen also treat enemy fighters jailed at the nearby Bagram prison or wounded on the battlefield.
"It's disheartening to think this is someone you have to care for, but he doesn't have your best interests at heart," said Tech. Sgt. Troy Inabinet, a physical therapist technician from Orangeburg.
Still, Inabinet said it is his job to help the prisoner recover.
When caring for Taliban fighters, prisoners and local civilians, the hospital staff struggles with language and cultural barriers.
For example, the staff recently was battling to save the mangled legs of a 14-year-old boy, said Chozinski, who is from Luke Air Force Base, Ariz.
"He was terrified because he had been told Americans wanted to steal his organs," Chozinski said. "His father had no idea if he should trust us."
The days are long with more than enough grief and gore, the airmen say.
"You have a job to do. That's more important than your feelings," said Sumter's Johnson. "That's what keeps us going."