Fatal Inaction

Steadying himself against the Humvee, Sams hopped back to the rear of the vehicle. There he found Hart dead with a bullet hole in his neck and Williams sitting unharmed, head down, arms wrapped around his legs. Sams thought Williams might be in shock; Williams said he wasn't. Sams told Williams to pick up Hart's machine gun, reload and stand guard. Williams searched Hart's body for more ammo. In the dark, Williams couldn't figure out how to remove Hart's ammo case, so he tore the bullets out in strips, hurrying in case they were attacked again.

Sams went back to kneel beside his lieutenant. "My pants legs were instantly covered, drenched in blood," Sams says. The bullet had severed Bernstein's femoral artery. The lieutenant was going to bleed to death if they didn't tie a tourniquet around his leg fast. But they hadn't been issued tourniquets.

Eight months earlier, a committee of military medical experts had urged the Pentagon to give every soldier in the war a tourniquet. Bleeding to death from an arm or leg wound is the most common cause of preventable death in combat, the Committee on Tactical Combat Casualty Care reported. Quick access to a cheap, simple modern tourniquet could save many lives, military doctors had concluded. Yet it would be two more years before the U.S. Central Command, which runs combat operations in Iraq, adopted a policy saying all soldiers in combat should carry a tourniquet. Even then, the policy was moot because the Army didn't widely distribute tourniquets for several more months. An investigation by the Baltimore Sun spurred that distribution and documented one reason for the delay: Military procurement specialists were studying what kind of pouch to carry the new first aid kits with tourniquets in.

That left Sams, in October 2003, in much the same position as a soldier on a Revolutionary War battlefield: trying to improvise a tourniquet with a length of cloth and a stick. Only Sams couldn't find a stick in the Iraqi field.

"I was looking for anything hard," Sams recalls. He and Williams found a fuel-can nozzle in the Humvee. Sams wrapped a fresh field dressing around Bernstein's leg and used the gas nozzle to try to twist the dressing tightly enough to staunch the arterial bleed. As Sams twisted, the strings on the field dressing broke.

Desperate, Sams cut the strap off an M4 rifle and tried again. The strap didn't break, but it was too short. It kept coming untwisted, Sams says. So he tied a dressing on top of his improvised tourniquet to keep it in place. Bernstein still had a pulse, but he'd stopped moaning, Sams says.

Sams didn't have time to feel relieved when he finally spied his platoon leader and a few other soldiers -- a scouting party from the convoy -- walking toward their crash site. He checked the lieutenant's neck and could no longer find a pulse, he says. He tried to perform CPR, but with his wounded arm couldn't apply much pressure. He let one of the newly arrived soldiers take over. Sams leaned against the Humvee, exhausted, and watched a sad succession of privates and officers pound Bernstein's chest long past knowing their efforts were futile. Roughly an hour after the attack on the convoy, a Blackhawk helicopter arrived to evacuate Bernstein and Sams, according to interviews and records.

Sams, now a long-haul truck driver, never regained the feeling in his left arm. Bernstein, one of West Point's finest, a genuine hero educated for military brilliance at a cost of more than $400,000 to taxpayers, died without a $20 tourniquet.

John Hart -- who loved the celebratory soldiers' anthem "When Johnny Comes Marching Home" -- never would.

THE NEXT MORNING in a tan clapboard house in Bedford, Brian Hart knew even before he saw the Army officer, policeman and Catholic priest standing stone-faced on his front stoop. He could hear Alma screaming, "N-o-o-o-o-o-o-o-o-o-o!"

It wasn't long before the Harts' house was jammed with mourners. Camera crews camped out front. Brian and Alma knew scant details about how John and Bernstein had died. They knew their son and the lieutenant had the sad distinction of being the 103rd and 104th soldiers to die in Iraq after President George W. Bush declared an end to major combat. Brian and Alma didn't draw the drapes on their grief. They held impromptu news conferences on the lawn. They still believed in the war, Alma, then 45, told the Boston Globe. "You know, it's just a dirty job that's got to be done." John understood the risk when he enlisted, and went to Iraq "eyes open," Brian, then 44, told the Associated Press.

The Unitarian church pastor, the Rev. John Gibbons, arrived to offer condolences to the family that had opposed his congregation's peace banner; he found them, he remembers, looking dazed at the center of a chaotic throng. Earlier that morning, Gibbons had taken the pulpit to say that issues of war were no longer abstract for Bedford. The town of just over 12,000 had suffered its first battlefield casualty since World War II.