An Army surgeon tells of war on our own turf

John P. Pryor directs the trauma program at the Hospital of the University of Pennsylvania

I didn't hear the cars screech to a halt, but one of the trauma nurses did. He ran outside with two emergency department medics to find several people in a car, all of their clothes soaked with blood. The passengers were screaming for someone to help the young man in the front seat, who was unresponsive. The team threw the limp victim onto a gurney, one of several that stand waiting for these types of scenarios, which occur almost nightly at our trauma center.

As the gurney rolled in, I saw a lifeless young man with more gunshot wounds than I could count. I was poised to start a resuscitation effort when a voice behind me announced that three more were coming in. As the team started CPR and checked for cardiac activity, the second and third victims were wheeled in.

A young girl had a gunshot wound to the abdomen that made her writhe in pain. Her movements were slow and her mental functioning impaired, signaling to me that she was in profound shock - she was dying. I caught only a passing glance of the third patient, who had a gunshot wound to the neck and was coughing up blood. Those brief images were enough for me to sum up a desperate situation; I pronounced the first patient dead to concentrate resources on the other critically injured.

The nursing staff rolled the dead man's body into a bed and readied the stall for the fourth patient, who had three gunshot wounds to his right arm and two to the left. With the emergency medicine physicians, surgery residents and medics working on the two critical patients, I assigned the fourth patient to a capable medical student who courageously accepted the battlefield promotion to intern.

In the swirl of screams and moving figures, my mind drifted to my recent experience in Iraq as an Army surgeon. There we dealt regularly with "mascals," or mass-casualty situations. In Iraq, ironically, I found myself drawing on my experience as a civilian trauma surgeon each time mascals would overrun the combat hospital. As nine or 10 patients from a firefight rolled in, I sometimes caught myself saying "just like another Friday night in West Philadelphia."

The wounds and nationalities of the patients are different, but the feelings of helplessness, despair and loss are the same. In Iraq, soldiers die for freedom, for honor, for their country, and their buddies. Here in Philadelphia, civilians die without honor, without purpose, for no country, for no one.

More young men are killed each day on the streets of America than on the worst days of carnage and loss in Iraq. There is a war at home raging every day, filling our trauma centers with so many wounded children that it sometimes makes Baghdad seem like a quiet city in Iowa.

Unlike the Iraq conflict, this war is not on the front pages of America's newspapers or on CNN. You have heard of the Washington area sniper shootings and the massacre at Virginia Tech. I am sure fewer readers outside Philadelphia have heard about the "Lex Street massacre," in which 10 people ages 15 to 56 were lined up and shot, execution-style, in the winter of 2000. Seven were killed, three critically injured.

They haven't heard about this tragedy because it happened to inner-city poor people in a crack house in Philadelphia. Imagine, for a moment, if this had occurred in a suburban shopping mall, or if a Marine unit in Iraq had been involved. There would be shock, outrage, 24-hour news coverage, Senate hearings, a new color of ribbon to wear.

That double standard, that triage of compassion and empathy, is why the war on the streets continues unabated.

I am on call Wednesday. The statistics indicate that that night I will once again walk with the chaplain to a small room off the emergency room. I will open a heavy brown door and make eye contact with a room full of people; a mother, perhaps a father or a grandmother. They will look at me with tears welling up, their knees weak, and lean forward while watching my lips, bracing for news about their loved one. I will remain standing and reach out to hold the mother's hand.

My announcement will be short and firm, the tone and intonation polished from years of practice. The words will be simple for me to say, but sharp as a sword for them to hear. "I am sorry, your son has died."