The American Soldier album details the physical and emotional effects of combat experience. This song relates what it's like to be in a war zone. Vocalist and chief songwriter Geoff Tate explained on AnybodyListening.net: "The title of this song came from a something a soldier's dad had said on the eve of his son's deployment. He asked his son to be careful because he was going into hell. The soldier wrote back to his family a month after being overseas and told his dad, 'You were right, I'm in the middle of hell.' A soldier named Anthony was on humvee patrol in Baghdad. His vehicle was blown up with a buried mine and Anthony was severely injured and almost died. He said that patrolling the streets was incredibly tense because every time the vehicle would stop there were hundreds of people surrounding you and they didn't seem happy. They didn't want soldiers there. Everyone was dressed as a civilian so how do you know who the enemy is? How do you deal with that? You're on constant alert, watching for something out of the ordinary. He also told a story about being back home from his tour of duty and was pulled over by the police. When he asked what he was doing wrong, the officer said that he was driving down the middle of the road. Anthony said he was sorry, but he'd just gotten back from Iraq, where they couldn't drive in the actual lanes because that's where the bombs were. That inspired the line in the song, 'We drive straight down the centerline. No mistakes, not like last time. You don't want to be on the wrong side of Hell.' The chorus says, 'I'm all right. I'll be all right,' and that's a mantra these guys constantly repeat to themselves. They may have lost an arm, a leg, and an eye, but they'll still keep telling themselves they're going to be all right. Musically this turned out very hypnotic, it's very representative of driving. I put down a saxophone solo that Michael plays off with the guitar, intercepting and colliding at different times so the song has a mesmerizing feel with an underlying tension."
The 12 songs on American Soldier were inspired by numerous interviews that Tate conducted with fans who are veterans. The singer's own father served in the Korean and Vietnam Wars. He told Billboard magazine: "My father was a career military man, but until very recently he never spoke about what he went through. I think that reticence is true of a lot of veterans, which means most people never truly understand what it means to be a soldier at war. Hearing what he and some of our fans have endured made me want to share their stories with the world. This is an album about the soldiers, for the soldiers, as told by the soldiers themselves."
Like most of the songs on the album, "Middle of Hell" seeks to explore the complexities of war without openly endorsing or condemning it. Although the narrator ends up wounded, perhaps fatally, he isn't bitter or angry, instead closing the song with an optimistic sentiment "I'll be all right. I'll be all right." However, the final repetition is a simple, less lucid "all right," possibly suggesting that he's slipping away and dying.