Five kids blown up playing with a land mine in the Alasay Valley, northeast of Kabul. The call came late on a slow afternoon, and the medevac crew at Bagram Air Field, the main U.S. base in Afghanistan, waited for the go-ahead to pick up its patients. But just as soldiers have rules of engagement for when and whom they can shoot, battlefield doctors have rules for when and whom they can help. And at this moment, the U.S. military’s Craig Joint Theater Hospital at Bagram didn’t have the room; some beds had to be left open in case wounded coalition troops were brought in.

The medevac crew, call sign Dustoff, grew frustrated. “Sometimes we need to step up and deal with this stuff,” said Staff Sergeant Rob Walters, senior medic for Charlie Company, 1st Battalion, 168th Regiment Medevac, a mix of National Guard soldiers from California, Nevada, and Wyoming. A moment later, a fresh call came over the radio: “You now have three patients. Two just died.” Walters groaned.

The Egyptian military, which also runs a hospital at Bagram, agreed to take the kids, and the Charlie Company helicopter roared off over the mountains. The hospital, housed in plywood buildings, is clean but cramped—think M*A*S*H—and lacks the high-tech equipment of the American facility. Most mornings, 300 or more Afghans queue outside for outpatient treatment, but the hospital has limited ability to deal with complex trauma cases, and these children had been devastated by the blast. One had a sucking chest wound, which the Egyptians would have trouble treating; the Americans agreed to take him, and only him. As nurses prepared the emergency room at the U.S. hospital, Colonel Robert Rush, deputy commander for clinical services, sweat-soaked from a workout, pulled an ER doctor aside. “If they try to bring three patients in here, tell them no. We don’t have the room,” he said.

The American military traditionally treats anyone injured on the battlefield, when time and resources allow. Top priority goes to coalition military, which includes Afghan security forces. Next are civilians injured in fighting, whether the wounds are caused by the coalition or by insurgents. Lastly, the hospital treats charity cases—birth defects, cooking accidents, falls from rooftops.

At the Bagram American hospital, even before the United States recast its focus from killing insurgents to protecting and helping the local people, the staff spent much of its time treating Afghans. Foreign coalition soldiers usually cycle through the hospital within 24 hours, moving on to military facilities in Europe. The Afghans, a mix of soldiers and civilians, might stay for weeks. In a country with poor medical care and an oversupply of the sick and wounded, the need is always greater than the ability to help. And as this year’s fighting season had warmed up, the hospital beds had filled with war-wounded, which raised the entrance bar for new civilian patients. The dismal task of deciding who would be admitted—who would live, really—fell to Rush.

The Dustoff bird landed, and a hospital team rolled the first stretcher toward the ER entrance. Rush stood outside, blocking the door. “Is that the sucking chest wound?” he asked.

“No,” flight medic Sergeant Steve Park said.

“He’s going to the Egyptian hospital,” Rush said. “I’m sorry, but I’ve got do it. We’re red on beds.”

Park’s face flashed from bafflement to anger. “This kid needs [an airway] tube in a bad way,” he said. Rush walked up to the stretcher and looked down at a 10-year-old boy, his lower face a mess of blood, bone, teeth, and flesh. “All right,” Rush said. “Bring him in.”

A half-dozen doctors and nurses descended on the boy, who was awake and terrified. His eyes flitted from face to face. Doctors removed the tourniquet on each leg and slipped a breathing tube through the pulp that was his face. The smaller boy with the chest wound lay on the next table. Air bubbled through a hole in his chest and a piece of intestine poked through his abdomen. The third boy had left by ambulance for the Egyptian hospital. Park stood back a few feet and watched, now a spectator. He does the same work as a paramedic back in Reno, Nevada.

“We do this day in and day out at home, but they fit in nice little parameters,” he had said earlier that day. “These calls just don’t fit in that little box. They’re not normal.” The boys were wheeled off to surgery. Park lingered in the empty emergency room, which was littered with blood-soaked bandages. “Look,” he said, and pointed to a janitor scrubbing spattered blood from the floor. “This is one of the worst calls I’ve ever had in my life,” he said. “How often do you see a kid with his jaw blown off? This will never fit in the box.”

The next morning the boys slept under sedation in the intensive-care unit, strung to a jungle of tubes and hoses. They didn’t look like the same kids, now cleaned of blood and charred skin. And the older boy’s jaw wasn’t missing; it had just been turned inside out. He was whole again, his mouth sewn back together by a plastic surgeon, and he would go home to his village in a few weeks, bearing the scars of the lucky and the cursed.

VIDEO: Watch a short clip of a medical evacuation in Afghanistan filmed and narrated by Atlantic contributor Louie Palu

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