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The frantic effort to save lives after a deadly attack on the CIA in Afghanistan

Surgeon Joshua Alley at Centra Lynchburg General Hospital in Virginia. It has been 10 years since he and his military colleagues tried to save lives after an attack on the CIA in Khost, Afghanistan.

EMILY ELCONIN/FOR THE WASHINGTON POST

By IAN SHAPIRA | The Washington Post | Published: December 30, 2019

Joshua Alley and two medical colleagues were getting ready to watch "The Hangover" at their military hospital in eastern Afghanistan when the loudspeaker blared with the worst possible code: Shamrock Black! Shamrock Black!

Alley, an Air Force surgeon from Virginia stationed at Forward Operating Base Salerno, felt confused. Had there been a firefight? A rocket attack? He'd heard no commotion. Shamrock Black meant one thing: His one-story hospital in Khost was going to receive four or more trauma victims. Moments later on Dec. 30, 2009, more intel: An explosion had hit the adjacent Camp Chapman, a small base he'd never visited and knew only as the locale of CIA operatives and other military personnel.

Chapman was just a couple of miles away, so the injured would arrive quickly. Alley, then 33, didn't know it yet, but he was about to be swept into one of the most tragic days in modern CIA history.

"I couldn't fall to pieces because we had so many people we needed to take care of," said Alley, now a general surgeon and father of five in Lynchburg, Virginia. "All my training kicked in. In the moment, you don't process it. You just act and do."

Before Khost, Langley had acknowledged the deaths of 90 operatives since the birth of the CIA in September 1947. The agency's single-worst tragedy came April 18, 1983, when eight of its people at the U.S. Embassy in Beirut were killed by a truck bomb detonated by Hezbollah, the Lebanese militant group.

But after the Sept. 11 attacks, the CIA put itself on the front lines of the war in Afghanistan and the desperate search for Osama bin Laden. It dispatched thousands of officers to Central Asia, some traditional spies, others paramilitary operatives. The first American killed in Afghanistan was a CIA operative: Johnny "Mike" Spann.

The agency also set up bases all over Afghanistan, including one in Khost, named after Nathan Ross Chapman, a Green Beret killed in 2002 in the area while officially detailed to the CIA.

By 2009, CIA operatives at Camp Chapman were helping select the locations of drone strikes and recruiting agents who could help find al-Qaida's chief architect. On Dec. 30, its officers at Camp Chapman were scheduled to meet someone they considered the informant of all informants: Humam al-Balawi, a Jordanian pediatrician who had claimed that he penetrated al-Qaida's highest echelons. The CIA thought he could lead them to the terrorist group's co-founder and No. 2 commander, Ayman al-Zawahiri.

When Balawi was driven to Camp Chapman at about 4:30 p.m. that day, multiple CIA officers arrayed themselves around the red Subaru Outback carrying their supposed golden source. But after he exited the back seat, Balawi, dressed in a shawl and a beige kameez, detonated a suicide vest packed with bars of C4 explosive. The prized asset, it turned out, was a double agent, an al-Qaida operative bent on avenging the death earlier that year of a Pakistani Taliban leader who had been killed by a CIA missile.

Some died instantly, including Balawi, the driver and several CIA operatives. But within minutes, all of them would be flown by helicopter to Salerno, where Alley and a small crew of military doctors would try to save those lives.

———

Everything in Alley's training had prepared him for this moment: The youngest of five children of a Baptist pastor in Lynchburg, Alley studied medicine at the University of Virginia, graduating in 2002 on an Air Force scholarship. By 2008, he was on his first war deployment, in Iraq, where he performed 300 surgeries on his four-month tour, treating soldiers and civilians injured by enemy fire or roadside bombs. A year later, when he was dispatched to Khost, Alley was considered tiny Salerno's most battle-tested surgeon. A sign in red, white and blue advertised the hospital's motto: Care for those in harm's way.

Inside Salerno's low-ceiling fluorescent-lit trauma bay, Alley and a handful of other doctors, nurses, and lab and pharmacy technicians positioned themselves at four beds, though they knew they'd have at least six patients.

The attack itself was still a mystery. Salerno was a frequent target of rockets, earning its "Rocket City" nickname. But soon, confirmation came that Chapman had been hit by a suicide bomber.

"We'd been hearing all along that the insurgency wanted to target an American military hospital with a suicide bomber, so that whole night, we were a little freaked out," Alley said. "Is this the first wave? That night, all the doctors wore our 9mm Berettas in our leg holsters."

Just outside Salerno's entrance was the helicopter landing pad. Two of the first victims brought in were women, one in her 40s, another who looked like she was in her 20s.

"I thought they were aid workers or journalists," Alley said.

First, Alley assessed the older woman. He was examining, he'd learn later, the CIA's base chief, Jennifer Matthews, a mother of three from Fredericksburg, Virginia, and one of the agency's top al-Qaida experts. But Matthews had no pulse. She had lost her vital signs en route in the helicopter. Her neck, shredded by shrapnel, was purple and swollen. One of her leg bones was exposed.

In this moment, only time was the enemy: Who could be saved? Who could not? Another doctor rushed in with the younger woman, who appeared to have better chances. She had a tiny hole in her chest. Later, Alley would find out the woman's name: Elizabeth Hanson, an accomplished 30-year-old targeter whose intel frequently led to successful drone strikes against key terrorists.

"I was thinking maybe we go full-court press on the older woman, but we had to see what else was coming," Alley said.

He handed off Matthews to another doctor and began working intensely on Hanson, who he thought might survive. He and a team of medics performed an emergency thoracotomy, opening up her chest and ribs like a clamshell. Once inside, what Alley and his colleagues saw was unsalvageable: shrapnel had torn up the vessels above her inactive heart.

"I see my own daughters and out of my mind goes all the data and [mass casualty] triage resource-allocation wisdom," Alley would write on his personal blog that night. "She's somebody's daughter, I think. I HAVE to do something, anything, to give her a chance."

Alley massaged the young woman's heart manually, hoping to circulate the blood in the right directions. He injected her heart with epinephrine.

Nothing worked. He assigned her a time of death.

"Feeling the empty and motionless heart, the empty, collapsed aorta, my own heart sinks," Alley wrote on his blog.

Then, he was told that the older woman, Matthews, might have regained a pulse. He and his team performed a cricothyrotomy, cutting into her neck and inserting a tube to create an airway into her lungs. Then, he pressed an ultrasound probe on her heart. Nothing. No cardiac activity.

"I look again at the neck wounds, the abdominal wounds, the leg wounds, and for the second time in minutes I again realize that I can't fix this," Alley wrote on his blog. "What good is a surgeon that can't fix people?"

He began treating a third victim: a young bearded man on a green stretcher. The man's left leg was fractured and had open wounds vulnerable to contamination. Shrapnel was lodged under his kneecap. A CT scan showed that shrapnel had penetrated his skull and sat on his brain.

By now, Alley had come to understand that many if not all of the victims that night were with the CIA. The brain-injured man before him was awake, alert and could speak coherently. Unlike the women, he had a chance.

An Air Force orthopedic surgeon, Chris Linberg, working alongside Alley, stuffed the man's leg wounds with gauze soaked in Betadine, a golden-brown antiseptic that contains iodine. Then, Linberg wrapped the leg in gauze and attached a temporary splint.

But Alley also knew the young officer required more sophisticated care. He had to see a neurosurgeon — fast. Alley needed to get the officer on a helicopter for an hour-long flight to the much larger military hospital at Bagram Airfield north of Kabul.

One hitch, though. Alley was worried about the flight. What if the officer's brain injury caused him to lose consciousness? It would be virtually impossible for flight medics to insert a breathing tube during the rocky ride.

"This is a thing I second-guess myself about all the time because he was talking to me and alert, and could he really be that badly injured?" Alley recalled. "But we tend to treat that helicopter ride like it's a black box where you can't do anything. If he lost his airway from Khost to Bagram, that would have been on me for failing to protect his airway."

"I told him, 'We have to put you to sleep and put in a breathing tube, and he was like, 'Aw, man,' " Alley said. "Don't worry," Alley told the officer. "You're entering the best worldwide system of trauma care ever. They'll take care of you."

Once Alley had the officer placed under anesthesia and on the next flight to Bagram, he didn't think he'd ever learn how things turned out. More patients needed help. He joined two other doctors trying to save the leg of another CIA officer. Then, he treated others with shrapnel in their backs or shoulders.

"One CIA medic told me, 'Just do me in the morning,' " Alley recalled. " 'You need sleep.' "

The rest of the night, as Alley wrapped up, others sorted body parts, matching them up and placing them in the refrigerated trailer that served as a morgue. There, the remains of the bomber sat alongside those he killed.

The CIA death toll was now official: Seven. Matthews; Hanson; Dane Paresi, a former Green Beret; Harold Brown Jr., a former Army intelligence officer; Darren LaBonte, an ex-Army Ranger; Scott Roberson, a former narcotics detective in Atlanta who was less than a month away from becoming a father; and Jeremy Wise, a former Navy SEAL, whose younger brother Benjamin, a Green Beret, would be killed in a firefight in northern Afghanistan in 2012. Six other CIA operatives were wounded.

Before he finally went to bed, Alley began writing a post for his personal blog — headline "Inferno" — recounting his attempts to save Matthews, Hanson and the CIA officer with the brain injury. His thoughts were revolving around one nagging question: Did I do the right things?

"Most of it is a blur to me now," he wrote in the final paragraphs of his blog entry. "I don't even really have pictures to post; we didn't stop to take any."

———

Two years later, Alley was out of the Air Force and living with his family in Ithaca, New York. Every now and then, he still thought about the CIA attack, which would later that year become the subject of a book, "The Triple Agent," by Washington Post reporter Joby Warrick and depicted in an Oscar-nominated movie, "Zero Dark Thirty."

Three times, he had received emails from victims' relatives via his website — one from Brown's mother, a second from Hanson's older brother offering gratitude, and a third from Paresi's widow asking for details about her husband's final moments.

Then, on Feb. 1, 2012, another Khost email landed in his inbox.

"Dr. Alley," the woman wrote. "My son . . . is the young officer with the brain injury you treated in Khost. . . . He was part of the CIA team that was attacked by the suicide bomber."

The mother said her son nearly died. His ankles were shattered, knees blown out. He had blood clots in his lungs and legs. His fever spiked to 106 for almost a week. After he was flown to Walter Reed National Military Medical Center in Bethesda, Maryland, "we were shuttled into a small room with a chaplain and told to call our family and start making arrangements for [his] funeral," she wrote.

Alley couldn't believe it. He figured that the officer would have recovered fairly quickly once in the United States. As he kept reading her email, he grew more astounded. The mother said she called her eldest son and told him that an airline ticket was "waiting for him and that he needed to come."

When that son arrived the next day, he walked into the ICU and told his sibling that he was there.

"All of a sudden out of nowhere [my injured son] put his left thumb up," the mother wrote. "From that day forward God performed a miracle in [my son]. He kept on fighting to get better. Six months after the bombing our son was back at the CIA. He has ZERO neuro deficits . . . he has never had a headache . . . does have the perfect facelift!!! He will never wrinkle!"

He even went back to Afghanistan, she said.

"My husband and I can never thank you enough for giving us our son back . . . whole," she wrote. "You are truly a hero to us. We are forever in your debt."

Alley appreciated the mother's gratitude but knew her son's life was saved by multiple doctors — not just him. Still, when the officer extended a lunch invitation, Alley agreed.

"When we met, we gave each other a big hug," Alley said. "He had a bit of a limp. He said he had to learn how to walk again. From such a small brain injury!"

The officer was so grateful that he made a donation in Alley's name to a charity of the doctor's choice.

"I'm glad I did what I could do," said Alley, who now spends his days performing weight-loss surgeries, appendectomies and handling the occasional gunshot victim at Centra Lynchburg General Hospital. "He was one of the ones we were supposed to help save."

The officer still works undercover for the CIA. He declined an interview request through an agency spokeswoman but released a short statement calling the medical team that worked on him "the reason there are survivors."

"I'm grateful daily," he said. "I'm able to continue the fight."

The officer is fortunate to be in the fight at all. On the CIA's Memorial Wall, 133 black stars honor agency operatives who have perished in the line of duty. Seven stars honor those killed at Camp Chapman. He came close to being the eighth.
 

Joshua Alley, center, then a trauma surgeon at Forward Operating Base Salerno in Khost, examines a patient in early 2010.
COURTESY OF JOSHUA ALLEY