Despite the assurances of the medic (“Everyone’s fine, sir; it’s just you”), despite the fact that one leg was maimed and the other was elsewhere, White kept trying to get up to check on his soldiers. Appraise the situation. Be the commander. The medic had to strap him down. For better or worse, this kept him from taking more detailed stock of his injuries. In the immediate aftermath, he had seen that the tip of his penis was “flowered out” but was unsure how deep the damage went. (The verb to flower has found an incongruous home in descriptions of IED injuries. In the typical underfoot blast, leg muscle is blown out away from bone, and into that open bloom shoots a dense, fast-moving cloud of bacteria-laden dirt. The blossom then closes over the soil, making the wound hard to clean and prone to stubborn infection.)
White would have thirty-nine minutes to think about it. That’s how long the medevac helicopter took to arrive. “At one point I was like, ‘If my dick is gone, just leave me here.’ I was half-serious. I don’t have any kids yet. I didn’t want to have to go back without anything to do that with.” His men tried to reassure him. “They were like, ‘Your dick is fine, sir.’” I’m guessing that that’s White and his soldiers right there, in those five words: The formality and respect of “sir” with the easy slang of “your dick.”
“I was like, ‘Bullshit, I saw it. I just want to know, Is it fixable?’”
It’s fixable. Some urethral scarring and tightening has slowed urination and created some erectile torque, but surgery this week should remedy both, as well as some minor cosmetic damage.
Though the pain was heavy enough that White asked a medic for a second dose of fentanyl (“I can’t, sir; you’ll die”), he has little to say about it. “Honestly, I was more focused on my soldiers.” Though they were physically unharmed, a kind of psychic unraveling occurs when a leader falls. White could see how shaken they were, and tried to joke around with them: “Guess my running career is over, heh. Never really was any good at it.”
It’s hard for me to imagine: worrying about the emotional state of other people when you yourself have just lost part of both legs and possibly some of your genitalia and on top of that your pelvis is broken. White told me his platoon sergeant said to him recently, “Maybe it happened to you because you’re the kind of person who’s tough enough to handle it.” I think White is plenty tough, but I don’t think we’re talking about toughness here. This is some kind of blinding selflessness, the sort of instinct that sends parents running into burning buildings. The bonding of combat, the uncalculating instinct of duty to one’s charges and fellow fighters, these are things that I, as an outsider, can never really understand.
I emailed White the night after we met. It began as a thank-you, but came around to a sort of grasping fan letter. My world is full of people, and that includes me, who never have to put their lives and bodies on the line for other human beings or for things they believe in. Hero has always been a movie word, a swelling orchestral soundtrack word. A Walter Reed hallway word. Now it has something under it.
SURGERY PATIENTS are announced like guests at a ball. An orderly wheels them in and recites from the paperwork: name, age, procedure, body part. To be sure the surgeons are in the right room, with the right patient and the right piece. In White’s case, you might otherwise wonder. A nurse is swabbing the surgical site, applying the standard antiseptic man-tan, but she’s at his face, not his groin. Major Molly Williams, the almost comically pregnant assisting-surgeon, explains that a replacement stretch of urethra will be built from a strip of tissue harvested from the inside of White’s cheek. Mouth tissue makes an excellent urethral stand-in. For one thing, it’s hairless. Urine contains minerals that, were there hair growing in your urethra, would build up on the strands. The stony deposits are troublemakers, obstructing flow or breaking free and getting peed out in a blaze of pain.
The surgeon, James Jezior, has been over at the scrub sink going at his nails. He joins us now, hands front, drying. He has blue eyes and fine sandy hair and a mischievous wit. I would use the adjective boyish, but on paper he is very much not a boy. He’s a chief (of the Walter Reed urology department), a director (of reconstructive urology), and a colonel.
“Also,” says Jezior, “the mouth is tolerant of pee.” He means that the mouth is built for moisture. It’s possible to create a urethra from hairless skin on the underside of the forearm or behind the ear, but the frequent wetting from urine can degrade it. A kind of internal diaper rash may ensue. Inflammation eats away at the tissue, tunneling an alternate path for the waste, called a fistula. Now you are dribbling tinkle from a raw hole in your skin. Just what you need.
White’s face has been draped with a blue sterile cloth with a single opening, reminiscent of an Afghan burqa. In this case, the opening is positioned over the mouth, not the eyes, as though the patient belonged to some esoteric spin-off sect. Retractors square White’s mouth, pulling it wide to either side, the way kids will do with their fingers to frame a stuck-out tongue. Jezior outlines the graft with a surgical marker and uses an electrocauterizing tool to cut it free. A vaguely familiar aroma, somewhere between brazier and burning hair, hits the air. Jezior is indifferent to it but reveals that the prostate, when cut open, releases a distinctive scent that’s kind of nice.
Using long-handled forceps, Jezior passes the dangling tissue to Molly. They look like a couple sharing a Chinese entrée. Molly drapes the graft over one gloved thumb and, with her other hand, snips away bits of fat and tissue to make it thinner. It takes time for new blood vessels to grow in and service a graft. For the first couple of days, the cells of the graft are nourished by a broth of serum. If the graft is too thick, only the cells on the surface will thrive, and those on the interior will die. For this reason, larger skin grafts, like the ones on the back of White’s remaining leg, are run through a mesher. The holes of the mesh create more surface area for the business interactions of cellular life: nutrients in, waste out.
If replacing part of the urethra doesn’t resolve the problem, another option would be perineal urethrostomy. Here the surgeon would excise the damaged portion and thread the shortened urethra through an opening in the perineum—the no-man’s-land between scrotum and rectum. “Then they have to sit to urinate, like ladies do,” says Molly.
How big of a deal is that? Jezior makes the point that someone whose reproductive organs have been damaged by an IED has typically also lost one or more limbs. Having to sit down to urinate probably doesn’t rank high on the worry list.
Molly tilts her head to face me. “It’s huge.” Depending, to some extent, on culture. Some years back, she attended a session on perineal urethrostomy at an international urology conference. The Italian surgeons were aghast. “You can’t tell an Italian man he’s going to have to pee sitting down.”
Molly was one of two female urologists at the meeting. She notices the disparity, but it doesn’t faze her. On the upside, she never waits for a toilet during session breaks. “I’ve been the only one in the women’s room at some of these urology conventions.”
“Same here,” deadpans Jezior.
The piece of cheek is ready to begin its new career. A nurse pulls a sterile drape from White’s hips and begins rubbing his skin with the antiseptic wand. Such is the vigor of the youthful male that even under general anesthesia, even when it’s a ChloraPrep sponge bestowing the caress, the penis responds. It is a less robust response than normal, perhaps, because Jezior has prescribed something to temporarily blunt erections. Surgical incisions are sewn up while the organ is flaccid; erections stretch the incision. They hurt. However, erections bring more blood into the penis, which speeds healing, and they also help prevent scarring. The latter is important because scarring—especially in erectile tissue—can make erections crooked and uncomfortable. For this reason, sexual activity is sometimes encouraged postoperatively as a kind of physical therapy for the penis. Walter Reed nurse manager Christine DesLauriers, whom we’ll shortly meet, convinced the intensive care unit staff to establish a daily “intimate hour,” during which no medical staff would visit the patient’s room, just spouses and partners.