Commemorating the Heroes at Abbey Gate

Though the metaphor “tip of the spear” is frequently applied to combat troops, the backbone of the military “spear” comprises the men and women who provide the substance and weight, without which the whole weapon is ineffective. Included in this backbone are medical personnel who selflessly place themselves in harm’s way to care for those injured while defending our country and freedoms. On August 26, in that narrow valley high in the Hindu Kush, the US military medical personnel's skills and stamina were profoundly tested. Many of those present during those attacks are members of the ESS. Some of the actions that day are truly legendary.

Thirteen American Souls

Eleven US Marines, one US Navy corpsman, and one US Army soldier—these were the American lives lost at the hands of an ISIS-K suicide bomber at the Abbey Gate of Hamid Karzai International Airport (HKIA) in Kabul, Afghanistan on August 26, 2021, 5 days before the deadline for the US military pullout from Afghanistan. The official Department of Defense (DoD) numbers report suggested that at least 39 more US armed forces personnel were injured, many of them critically. In the weeks and months after the attack, that number grew as the fog of war slowly cleared. All told, this single event proved to be among the deadliest attacks of the entire conflict.

Coalition forces had been embroiled in combat operations for 2 decades at the time of the drawdown. Even before that fateful evening of August 26, masses of civilians had gathered at the airport, hoping for the opportunity to board a military flight to freedom from the looming Taliban takeover of Afghan governance.

By August 2021, the only DoD medical presence in Kabul consisted of two Role II facilities and two Role I facilities postured at HKIA, after Task Force-Medical (TF-Med) had vacated Bagram Airfield around the middle of June that same year. A North Atlantic Treaty Organization (NATO)-led Role II was housed in a building on the north side of the flightline, and a separate Role II, Army Forward Resuscitative Surgical Detachment (FRSD), was positioned approximately 1 mile away in a separate building known as “Camp Alvarado.” On paper, the medical teams were well equipped, including access to a laboratory, pharmacy, two operating rooms, computed tomography capability, and an Aeromedical Evacuation Liaison Team. 

There were challenges. The Army FRSD had been deployed to HKIA in support of the 82nd Airborne Division’s Immediate Response Force, arriving a week prior to August 26. Due to logistical constraints, this team had been separated from most of its equipment. However, they worked quickly with the NATO facility to close their equipment gaps, and by the time of the attack, they had managed to establish a remarkably functional presence at Camp Alvarado.

Training and Discipline

By any metric, the HKIA personnel were ready for nearly any contingency. Prior to the Abbey Gate attack, they had been designing and conducting MASCAL (also known as mass casualty) drills with the surgical teams for months, which was a commitment to rehearsing the worst-case scenario that would prove to be both ominously prescient and immeasurably valuable. Surgeon Colonel Bruce Lynch, MD, (USAF) was in charge of those preparatory efforts in his role as the Deputy Commander for Clinical Services.

The vest bomb detonated at 5:36 pm local time, and the first casualty was received at the TF-Med facility within 15 minutes. For the next several hours, capacity was expanded to accommodate dozens of injured service members, including at least 19 with life-threatening wounds.

Sergeant First Class (SFC) Adam Peters was performing his daily rounds in a two-litter frontline ambulance that evening, checking on the nonmedical units defending HKIA when the blast occurred. Within minutes, a cadre of Marines informed him of the explosion at Abbey Gate. Though smoke was still in the air, he was told of an estimated 30 casualties. He rushed back to the hangar where troops were being housed to mobilize all available combat medics and the battalion surgeon before striking out to the site. They arrived to find more than 100 casualties, and apart from scattered line medics, his team was the first medical asset on scene. Three severely injured Marines lay on kick boxes, all with cardiopulmonary resuscitation underway. Without hesitation SFC Peters and his crew loaded them in the back of their vehicle, and a treatment noncommissioned officer (NCO) and battalion surgeon each claimed a patient and got to work as the ambulance sped toward the Role II Military Treatment Facility (MT), which waited at the end of a 15-minute drive to the other side of the flightline. Vehicle after vehicle, all carrying wounded compatriots, followed close behind. According to SFC Peters, “The casualties were overwhelming.” He and his crew would return to Abbey Gate multiple times over the coming hours to accommodate the growing number of injured.

Cool Heads, Fast Decisions

“There isn’t a single person there that day that didn’t put every ounce of effort, expertise, and love into caring for our casualties that day and night,” said Major Omar Rokayak, DO, FACS, MC, a Special Operations Surgical Team (SOST) surgeon. “We very rapidly went from a collection of multiple teams housed in the same facility, to a facility housing a single, large team composed of completely interoperable and interchangeable teammates…it was truly miraculous and humbling.” The first casualty received in the NATO Role II trauma bay that summer evening was a young Marine, recounted Major Harris Kashtan, MD, FACS, another SOST surgeon. “He was pulseless and unresponsive with a penetrating injury to the left neck. We opened his left chest and found it full of blood.” There would be several more casualties like this one before the morning.

Dr. Rokayak and his team had just finished a fatiguing “house call” shift and were settling in for some much-needed rest when they received the alert. The team’s first task, however, was to navigate a chaotic and unsecured environment, tactically making their way from the barracks to the medical facility, uncertain if the attack was ongoing. Upon arrival, they received more casualties, which were now pouring into the treatment area in multiples. “My team and I set up a second OR using our backpacks and a stretcher,” he recalled. With both formal ORs already in use, this simple act joined a long list of other seemingly simple acts that almost certainly saved many lives.

Major Alex Paladino, MD, a Critical Care Air Transport Team (CCATT) physician on deployment at Ramstein Air Base in Germany, in August of 2021, and his team were on the runway at Ramstein as the device was detonating, taxiing for takeoff on a regulated (scheduled) trip to HKIA. As they traveled down the tarmac, “we began receiving messages that there had been an explosion. We went back to the Aeromedical Evacuation Operations Team, and for a while, we didn’t know if we were going to fly or not.” They did go to HKIA, touching down in Kabul approximately 12 hours after the explosion. He shared vivid memories of his crew sitting on their body armor for the descent into Kabul, uncertain of the security situation on the ground.

Upon arrival, Major Paladino’s team was given 30 minutes to prepare their patients for departure. “That felt unrealistic, but we had a job to do,” he stated. The team was initially directed toward one group of patients that had been identified for evacuation, but it was clear there were rapidly evolving transfer priorities in the fog and friction of the unfolding MASCAL. Major (now Lieutenant Colonel) Remealle How, MD, FACS, was the acting HKIA Trauma Czar at the time of the bombing. “[Lieutenant Colonel] How really deserves recognition for her actions that day,” said Dr. Paladino. Without hesitation, she re-triaged the remaining casualties, instructing the CCAT team to refocus their attention on the most urgently injured, including one patient who was actively in surgery. That young Marine had multiple severe injuries, including an iliac artery injury that had just been shunted. The team had brought some blood products with them from Germany, but now realized their supply could not meet the casualties’ needs. Just before their arrival, HKIA personnel had, under the leadership of Lieutenant Colonel How, activated a “walking blood bank.” As a result of this foresight, Dr. Paladino’s team was handed a bag of several fresh units.

“Sir, use this one first,” was the instruction he received from the British anesthesiologist working the operation as he removed a freshly used IV and tubing from his own arm and handed Dr. Paladino a warm bag of whole blood. That bag finished infusing into the wounded Marine as they rolled him up to their waiting aircraft.

Army vascular surgeon Jigar Patel, MD, FACS, was sitting in a hangar elsewhere on base when the attack occurred. In a flash, they piled into a pickup truck and headed toward ground zero. On the way, they encountered multiple “Gators” (medical evacuation aircraft) flying by them, all destined for the MTF carrying casualties, one with a soldier desperately performing chest compressions on his brother-in-arms. They arrived at the facility to find it full of wounded servicemen; all six trauma bays were occupied with the most severe patients. “We used our eyes and ears to determine where we could help,” Dr. Patel said.

Skills and Fidelity

Dr. Patel recalled three soldiers placing a casualty on the ground within 15 feet of the door. The young man was unresponsive but breathing, bearing the marks of multiple penetrating injuries. Aware of the clamor around them, Dr. Patel’s team carried him inside to a dark hallway, shielded from the chaos outside. It was clear the soldier needed an airway, but could not be intubated due to a horrific jaw fracture. Without hesitation, Dr. Patel pivoted to a cricothyroidotomy. Suspecting penetrating chest trauma with hemothorax based on the injury patterns, the team proceeded to insert chest tubes on both sides. Blood erupted from the tube on the right. Checking for pulses following this intervention, he felt none. Kneeling on the ground in that dimly lit hallway, he executed a clamshell thoracotomy. Multiple penetrating injuries to the right lung came into view. Lacking a clamp to quell the bleeding, he resorted to a hilar twist, and hemorrhage was controlled.  

While a teammate obtained central IV access and started resuscitation, Dr. Patel made a small laparotomy incision on the floor of that darkened corridor to assess for abdominal bleeding. Relieved to find no blood, word came that an OR had become available, and the team rushed the man to the waiting table. As the soldier’s blood pressure began to improve, the bleeding from his right chest increased. Now, with the aid of operating lights and equipment, they achieved definitive control through a series of sequential tractotomies. He slowly untwisted the right lung and was rewarded with a dry field. The patient stabilized shortly thereafter and was soon on the first evacuation flight out of Afghanistan.

In another OR, a fellow Army surgeon, Colonel David Hardin, MD, FACS, was operating on another casualty with a major vascular injury deep in his pelvis. After Dr. Patel dropped off his patient at the intensive care unit (ICU), he quickly scrubbed and assisted Dr. Hardin in successfully temporizing the hemorrhaging pelvic injury, and another life was saved.

The theme of synergism is common in the stories of the medical personnel who were there that day. All were struck by the presence of Lieutenant Colonel How and Colonel Lynch, both of whom were unshakable in their situational awareness, redirecting attention to where it was most needed. “It’s hard for a trauma surgeon not to lay hands on patients during a MASCAL,” said Lieutenant Colonel Evan Richards, MD, a SOST member who had only recently arrived in theater. “He saved way more lives by overseeing everything and having the special operations forces personnel do surgery and anesthesia. I attribute a lot of the success of that day to him. He was a good leader.” When, at one point, Dr. Patel asked, “How much blood do we still have?” Colonel Lynch’s reply came swiftly: “It doesn’t matter, we have enough to do everything that needs to be done.”

Despite many of the personnel having never worked together before, there was palpable nostalgia regarding the fluidity with which one team member was able to pick up where another left off. Not so much as a dance, but more as though these actions were captured by a common rhythm. Without missing a beat, every member of this newly formed group stepped out of their comfort zone in support of a unified purpose. Dr. Patel attributes this to the intensive training all had received—training that is only available in a military context. As a seasoned vascular surgeon, life-saving interventions had become second nature to him; but these were circumstances like no other. The team’s radio operator, with no medical background and functioning solely at the direction of instincts, independently retrieved a thoracotomy tray before the need had become obvious. Without that single, almost unnoticed act, one less human life would have survived that day.

All told, the Army FRSD outpost at Camp Alvarado received 10 casualties, including injured Marines, Afghans, and young children. When learning about the blast, the team immediately implemented their own MASCAL plan, which is yet another testament to the meticulous training of US military medical personnel. Emergency medicine physicians, physician assistants, nurses, certified registered nurse anesthetists, and medics triaged and stabilized incoming casualties, while the surgical teams began treating those most seriously injured. According to Major Joe Bozza, MD, an Army surgeon with the FRSD, many team members were on their first deployment in what amounted to nothing less than a “baptism by fire.”

Facing critical shortages of essential surgical equipment, teams successfully managed some of the most challenging injuries imaginable. Medics and OR technicians repeatedly rose to the level of these challenges, performing above and beyond their typical roles with the confidence of personnel of far greater experience. Major Bozzay, MD, FACS, speaks with genuine pride when he recalls how, after all the casualties had been evacuated, the FRSD rapidly set about sterilizing their equipment, restocking supplies, and activating another walking blood bank. A quiet tension filled the space, accompanied by a deep, uneasy awareness of the uncertainty that hovered over them. When others might have used the opportunity to ease up, take a satisfied breath, and reflect on the events of the preceding 24 hours, they opted for preparedness.

“I could not be more impressed with our entire team, including nonmedical and medical personnel,” said Major Bozzay. “The situation was never chaotic. We were focused on the situation at hand and seamlessly worked together to take care of the injured. At one point, I looked up from a case and saw one of our CRNAs (Major Micah Krishnan, MD) simultaneously manually bagging a patient, administering total intravenous anesthesia to him, and squeezing the bag of blood, keeping him alive. Everyone rose to the occasion despite their constraints.”

As aeromedical evacuation (AE) and CCAT teams began to arrive to start the daunting task of evacuating the injured, the enormity of the job only grew more apparent. More contingencies began to arise, with some approaches driven as much by experience as they were by knowledge. The young man on whom Dr. Patel and Dr. Hardin had worked together to staunch the bleeding in his pelvis, for example, had the vascular shunt they had placed clot off, a casualty of the coagulopathy triggered by a litany of injuries. With worsening hyperkalemia and acidosis, and now at risk of losing the leg due to ischemia, decisions such as whether to prioritize the preservation of life over saving the limb of a young soldier facing a several-hour transport became uncomfortable realities. Faith sometimes has a say, and that young man was safely delivered to the next phase of care with his life and his leg.

According to the official Department of Defense (DoD) account of the events of August 26, 2021, within 14 hours of the bombing of Abbey Gate all casualties had been evacuated in a breathtaking display of medical, surgical, and aeromedical evacuation expertise. Surgical teams had performed 13 operations, including thoracotomies, laparotomies, external fixation of fractures, fasciotomies, and peripheral vascular interventions. While we mourn those whose lives were lost that day, a DoD review of the medical response concluded that none of these deaths had been preventable. This is of little consolation to their families and loved ones, save for the knowledge that many others were spared the same anguish. The sheer magnitude of the undertaking defied credulity, but the fact that it had been accomplished with such undeniable effectiveness is a story that will be celebrated for decades to come. 

Outside those improvised MTFs at Hamid Karzai International Airport on the morning of August 27, 2021, in that narrow valley high in the Hindu Kush mountain range, it was daylight again–the dark of night had come and gone. Fifteen hours had passed, but to most of the dedicated men and women there, it had been no longer than the blink of an eye.

For their part, Lieutenant Colonel How and Colonel Lynch emphasized the importance of teamwork as critical to what was achieved that day. “Looking back, it really was the ultimate collaboration,” said Colonel Lynch. “We had conventional and special operations units from all three medical services, as well as multiple partner nations, seamlessly functioning to accomplish the mission.” Lieutenant Colonel How offered the highest praise for the nurses, medics, advanced practice practitioners, and techs. From the medics who kept scores of patients alive outside the door of the MTF as they awaited room in the facility, to the nurses (Captain Katie Dore and Captain Jessica Dietz) who held open the chest for Dr. Patel as he worked on the lung of that patient we met on the floor of that darkened hallway, “This was a team effort from bottom to top—every service, every Air Force Specialty Corp member and medical officer, that made this all possible.” 

“For most, the deployment was short,” said Dr. Hardin. “The mass casualty event only lasted 15 hours. Despite this, some 4 years later, reflecting upon the event remains painful. We tend to remember our losses much more vividly than our wins. Many of the providers, nurses, medics, and patients have developed lasting friendships and a mutual support network that remains today. Take care of your team. When you find yourself in a similar MASCAL, and you are feeling inadequate for the task, understand the choices you made long before the event that placed you there. A commander once told me, ‘Every decision you have ever made in your life has led you to this point tonight. You’re the right person. Get in the fight and stay in it until it’s over.’”

One final story seems uniquely appropriate in this context, offered by Colonel Lynch. Sometime around 2 in the morning, amid the ongoing evacuation efforts, he received a call from one of the platoon leaders. A young woman had gone into labor and birth appeared imminent. As fate would have it, a surgeon with one of the international partners had experience in obstetrics. Using one of the few spaces available, the child was safely delivered in that same dim hallway, already familiar to us, in nearly the exact spot where the young serviceman’s life had been saved just hours before.  

Every day, surgeons are reminded we can’t do everything ourselves. Casualty care simply cannot be accomplished alone, even in the most ideal of conditions. There has been a lot written about the combat readiness of our military surgeons in recent years. Of course, we ought to talk about readiness. Our most urgent mission is to ensure that the next generation of military medical personnel is prepared to serve as the backbone of that military “spear” of which we speak. Yet, there is an element of “readiness” that cannot be taught, measured, funded, or perhaps even defined. A combination of willingness, resolve, honor, and courage—it is a collective mental state that can only be called upon when needed.

And when summoned by those Heroes at the Gate, that hallowed, undefinable quality arrived in abundance.

US Service Members Lost at the Abbey Gate Attack

• Marine Corps Staff Seargent Darin T. Hoover, 31, of Salt Lake City, Utah
• Marine Corps Sergeant Johanny Rosario Pichardo, 25, of Lawrence, Massachusetts
• Marine Corps Sergeant Nicole L. Gee, 23, of Sacramento, California
• Marine Corps Corporal Hunter Lopez, 22, of Indio, California
• Marine Corps Corporal Daegan W. Page, 23, of Omaha, Nebraska
• Marine Corps Corporal Humberto A. Sanchez, 22, of Logansport, Indiana
• Marine Corps Lance Corporal David L. Espinoza, 20, of Rio Bravo, Texas
• Marine Corps Lance Corporal Jared M. Schmitz, 20, of St. Charles, Missouri
• Marine Corps Lance Corporal Rylee J. McCollum, 20, of Jackson, Wyoming
• Marine Corps Lance Corporal Dylan R. Merola, 20, of Rancho Cucamonga, California
• Marine Corps Lance Corporal Kareem M. Nikoui, 20, of Norco, California
• Navy Corpsman Maxton W. Soviak, 22, of Berlin Heights, Ohio
• Army Staff Sergeant Ryan C. Knauss, 23, of Corryton, Tennessee

Bibliography

Bozzay JD, Murphy TP, Baird MD, Dingle ME, et al. The last days: The medical response of United States and allied military teams during the Afghanistan Exodus. J Trauma Acute Care Surg.2023;95(2S Supplement 1):S13-S18. 

US Naval Institute Staff. US Central Command Report on Fatal Afghanistan Airport Attack. February 8, 2022. Available at: https://news.usni.org/2022/02/08/u-s-central-command-report-on-fatal-afghanistan-airport-attack. Accessed August 7, 2025.