by Dave Hnida
09:20:45 I am multitasking, again eyeballing the wounded, listening to the flight medic reel off the wounds, blood pressures, and what happened in the field. Medics take the three to appropriate bays. I still have little idea what’s wrong with my guy from my cursory look. Focus, man, focus. I shake off a shiver and my mind goes into a well-rehearsed auto mode.
09:21:00 Like a preschooler, I recite my ABCs aloud: Airway, Breathing, Circulation. Then you worry about the other stuff. My guy fails “A”—he’s not breathing. Check the airway—can’t hear breath sounds when I put my stethoscope to his chest. The breathing tube is in the wrong place—his food pipe, not his lungs. It must have been chaos on the copter. I tell Dean Losee, the nurse anesthetist, to pull it and put in another. The medics are sticking in large IVs—can’t do much until you’ve got a way to run in fluids and drugs. I see blood dripping on the floor from a place where a leg should be. Tourniquet is on—it’s still not enough. Man, this guy has a thick thigh—need to put on another tourniquet and make it tight! Blood pressure 74/46, pulse 166. Bad. Clothing is cut off within ten seconds.
09:21:30 Dean is struggling with the new tube for good reason—the patient’s jaw is in pieces. I reach in and pull out blown-out teeth with a gloved finger while a medic suctions blood. It’s the hardest tube Dean has ever done—he nails it on the first shot as I hold the Adam’s apple and facial bones steady. Listen to lungs—good air, Dean, good job. We’ve got two big IVs—good job medics—but I need a bigger line since one arm is mangled.
09:22:00 Call Rick into bay. He starts a central IV in a neck vein that leads directly to the heart. I have to ignore the missing leg and mangled arm—both have stopped dripping. Don’t get distracted. They can wait. Need to look for smaller, innocent holes that snuck in deep and hit something bad.
09:22:30 Back to the big picture—we’ve got IV access. Airway. Blood pressure still in the toilet. Heart rate still fast. Neck brace on. Need to continue exam. Abdomen is tight—probably bleeding internally. Pelvis feels loose. The bones grate and grind as I push and squeeze. Damn! These bleed fast and will kill him before anything else. Call for a binder to stabilize the pelvis—but sometimes the binders make certain types of fractures bleed more. I look to Ian for an opinion—he nods a go-ahead.
09:23:00 We hustle X-ray in to take some pictures with their portable machine on wheels. Takes six of us to roll the patient—can’t wait for the X-ray to put on binder—fingers crossed. While rolling patient—examine spine. Feel for ridges or drop-offs. Put a gloved finger in rectum—there’s blood—so there’s bleeding inside the pelvis or abdomen. Not good. As we turn the patient back, his blood pressure drops to 46/28 and pulse shoots to 180. Did I make a mistake here? I am now cornered by two rules of combat medicine: you cannot call time-out when things go bad, and there are no do-overs.
09:24:00 Blood pressure up to 88/62. Pulse now 132. Some progress. Binder helped. Finish exam and call findings to trauma nurse. The soldier’s injuries read like a textbook of trauma medicine: shock with dropping blood pressure and racing pulse, the rigid abdomen of internal bleeding, a shrapnel-peppered face and burns that have peeled away skin from his hands and legs. He’s missing chunks of flesh. Bruising over left thigh? Fracture. Billy will need to fix this as well. I peek into the other bays and check on what’s happening—other docs have things under control. Thank God for Gerry and Mike.
09:25:00 One of the medics suctions the blood pouring from the soldier’s mouth while I stick a finger back in—gloves swimming in blood as I try to discover its source. My index finger falls into a deep crevice where the gum used to be; gauze packing staunches the bleeding. Blood pressure continues a steady ascent while pulse slows. I didn’t make a mistake after all. The binder, tight tourniquets, and a few units of blood keep this kid in the race.
09:26:00 Patient starting to move—need more drugs to keep him out because of the breathing tube. I have no idea how bad his head injuries are—I didn’t feel anything when I felt behind his head but I know his facial bones are a mess. Can’t check pupils.
09:26:30 Billy checks arms and legs after my exam to get an idea of what is an emergency and what is not. The pelvis is fractured—the binder worked. Ian does a FAST exam—it’s an acronym for Focused Assessment with Sonography in Trauma—basically a quick ultrasound of the abdomen to look for pockets of blood but he already knows this kid needs surgery—fast. I’ve gone through three pairs of gloves. Need to cut away all bandages placed in the battlefield—they weren’t soaked so we had time. Now we’ll look at the small potatoes of wounds.
09:27:30 Doctors all talk—who needs what—who goes first to the CAT scanner—how about the OR? My guy needs to be opened to check for internal bleeding. We’ve run in three units of O positive blood as well as other IVs already but blood pressure still down and pulse still up. Nurses notify OR we are coming fast. There may be shrapnel in the brain but it doesn’t matter at this point—no time to check. Scan later—got to do some Hail Mary surgery and stop the internal bleeding—his brain won’t matter if we don’t get blood flowing to it.
09:28:00 I’m reassessing everything again—to make sure I didn’t miss anything. I ask the head nurse what I’ve forgotten. She tells me we are good to go. The medics have already administered antibiotics and other drugs—we’ve worked quickly with nods of the head and a murmured “Yes” or “No.” There’s a peanut gallery watching the action but they stay out of the way and it’s still fairly calm and quiet.
09:29:30 My guy is wheeled to the OR. Ian and Rick to work on him. Bernard has his hands full with the other two patients. Billy will follow up and work on bones once the damage control surgery is done. Blood pressure and pulse better but still making us nervous.
09:31:00 I call the CSH in Balad—the one with a surgeon who can fix facial bones—and tell him we’ve got a customer after our surgeons are done exploring the abdomen and ortho stabilizes the fractured pelvis and thighbone. We’ll scan the head before we send and hope there’s no shrapnel in it. Other patients go to X-ray and the CAT scanner—they are stable and will wait their turn for Bernard in the OR. I sign forms that authorize giving unmatched blood, a signature that would be medical malpractice back in the States.
I LOOK AT the second hand as it sweeps around the face of the clock on the dull green wall.
It took nine minutes from front door to OR for my patient. Nine minutes where I became a short story in this soldier’s life. I realized he probably wouldn’t remember me and we would never meet again.
Our surgeons fixed his internal injuries—including putting a lifesaving clamp on his large bleeding vessel. A CAT scan after surgery had good news: no shrapnel in the brain. He was stable enough to fly to Balad to have his face repaired, then on to Germany for further surgery. Then home.
By this time in our rotation, cases like this were taking on the feel of routine. Businesslike with a sprinkling of adrenaline-filled panic thrown in for flavor. I was drained but once again thankful for the medics and nurses who mentally pushed me to get the job done. They were my heroes. And heroes to the soldiers they saved.
We had no time to wring the sweat from our uniforms—another bird flew in about an hour later—no warning—it just dropped from the sky with more wounded. Our medics had just wrung out their blood-soaked mops from swabbing the floor when we heard the incoming blades beating the air. The day had just begun.
12
SICK CALL SUNDAY
LIKE ANY HOSPITAL, the pace at Paradise could vary from crazy busy to sluggish slow. On the busy ones, we didn’t have time to pee, while on slow shifts the medics fought boredom by staging scorpion-versus-camel-spider fights, or by watching slasher movies that drew belly laughs for the fake blood splashing across the screen. A few of the females, and even a couple of males, had taken up knitting and crochet. Instead of war souvenirs, they’d bring home scarves and blankets. You also needed to look both ways before crossing the ER to avoid being run over by the NASCAR-like wheelchair races.
By mid-July, business was on the upswing, with a steady flow of patients and even a few periods where our operating rooms had been open around the clock. I had been designated the official “shit magnet” for the weeks before, the term for the doctor who had the highest number of trauma cases when on duty. It was better than being designated “007”—as in licensed to kill. Make a mistake and you were called Dr. Bond until someone else fouled up and stole the title. Fortunately, our mistakes seemed few and minor—and no patients had suffered from our work. Nonetheless, I didn’t want to be introduced as: Bond, Dave Bond.
Our wards get full, then empty as patients are flown to Germany or, if Iraqi, discharged into the local medical system—a health care nightmare we call the kennels. The wards quickly refill and the cycle repeats itself.
Though the majority of patients we’d get were the wounded, I was surprised at the number of everyday medical problems similar to what we saw day to day in the States. Overall, 77 percent of soldiers evacuated to Germany or the United States had noncombat problems that bought them a one-way ticket out of the war. Bad backs, high blood pressure, and bum knees beat shrapnel as the chief reasons combat commanders had trouble keeping their units filled with warm bodies. As a full-service hospital with an oversized welcome mat, we also took care of a lot of contractors. They also had bosses who growled when we had to pull their workers off the schedule because of an ache, pain, or something more serious.
There had been a regular flow of patients with appendicitis, several each week, as well as a steady stream of kidney stones. Both problems were probably due to the searing heat and the fact it was nearly impossible to swill the ten to fifteen big bottles of water needed to head off dehydration, especially for the soldiers who went outside the wire in full battle gear. Migraines were another big-ticket item as well as, of all things, heart attacks. It was the rare soldier who had a heart problem, usually it was overweight contractors in their forties and fifties who smoked like chimneys and ate like pigs at the trough.
Then again, a number of the soldiers we saw would also easily qualify for the cover of Weight Watchers. The food here sucked, but there was plenty of it, especially cakes and pies, so that average ten-and-a-half-pound weight gain made the weight control program one of the busiest in the war zone.
Sundays were the worst days in the ER. The sick call clinic was closed, so in addition to the combat trauma that landed on our helipad, we got the pain-in-the-ass stuff. And this day, Sunday, I drew the short scalpel, and got to juggle IEDs with constipation. And listen to a bunch of contractors who suffered from “Acute Ambien Deficiency” plead for piles of the precious sleeping pills.
It was a far cry from a day filled with the adrenaline-pumping pressure of trauma cases—not that we wanted trauma cases but the routine had become torture. So we broke up the monotony of the Sunday routine by making the diagnosis with the fortune-telling Magic 8-Ball. When a soldier asked when they’d feel better, we broke out the ball, gave it a shake, and hoped it didn’t return an answer of “Outlook not so good.” In that case, we were forced to shake, and shake, and shake again until we got an answer that eased anxiety. And for the stubborn “Ask again later,” all we could say was: go to sick call tomorrow if you want a look into your future.
Another tactic was to use libido in place of drugs to affect a cure. Think of it as alternative medicine in a war zone. Nonmedicinally natural. For a male with a nonserious case of “something that won’t kill you,” we pulled out the latest edition of the New England Patriots cheerleader calendar for a curative leaf-through; the females got the NYC Firemen of the Year, bare-chested edition. Or we simply pulled out a picture of Bernard.
But this day, before commuting the quarter mile to work, I had my weekly business meeting during breakfast with Rick. Basically, it was a time for two grumpy old men to clear the air and start the week on a fresh footing.
Rick had the first item on the agenda.
“You know, I think you curse too much. So the least you can do is give my virginal ears some peace on the Lord’s day.”
I rolled my eyes.
“What the hell are you talking about? You curse, too.”
“But not on Sundays.”
“Bullshit.”
“How about ‘male cattle manure’ instead? It would make God happy.”
I almost spit out my coffee.
“I’m sure God is really worried about my language. And I’m really sure God wants me to say stupid stuff like ‘male cattle manure.’”
Rick gave me a serious look. “I bet you can’t do it. In fact, I will give you twenty bucks if you can get through your shift without cursing. However, if you fail, you owe me a dollar a curse. Plus, you can forget about lunch.”
“You’re on. Today. Only.”
“Thanks, Dave.”
“You bet … penis cranium.”
He did the verbal translation and gave me a nasty scowl.
“Okay, Dave, your turn to moan. How did I bother you this week?”
“You’re ugly.”
With that final insult, I grabbed my tray and raced out the chow hall to face my day of hell, or in this case, let’s call it “heck.”
I walked in just as the medics were throwing out the first patient of the day. It was a soldier who said his back had been sore for a month. The medic absentmindedly rolled a pencil off the desk. Sergeant Sore Back easily bent over to pick it up. A nice gesture that determined his prescription: You can wait. Go to sick call tomorrow.
The next guy wanted to quit smoking. A surefire ticket to better health in a war zone. The chief medic asks for his cigarettes, which are then thrown on the floor and stomped on. “Don’t buy any more before sick call tomorrow.”
Our third winner said he had a painful nostril.
“I have a sore inside my nose that’s been there for three weeks and I can’t get it to go away.”
“How did the sore get there?”
“I was picking my nose. And every time I pick my nose it gets sorer.”
“Well, here’s the latest clinical research on a cure: stop picking your nose. Now get out.”
Sounds brutal but there was a good reason to keep the not-very- urgent cases from causing a traffic jam in our ER: we needed to keep our stretchers open for the more serious cases that showed up with little warning. Within minutes, the radioman stuck his head in and confirmed that “Please come back tomorrow” was indeed a wise policy.
“Business coming. One urgent on a litter. Burns from blast. Estimate fifteen mikes.”
Mikes-minutes-months-millenniums. I lived in a world of mil-speak and secret codes. I chuckled. This must be Gerry’s idea of heaven. Then I quickly felt bad when I realized there was a wounded human on the other end of that chuckle.
Twelve mikes later, the medics rolled in our patient. From a distance, he didn’t look so hot. He had a tube in his throat and the medics were bent at 90-degree angles over the stretcher as it squeaked rapidly across the cracked linoleum.
We did some quick calculations: burns over 60 percent of his body. Not good. Singed mustache and soot around the mouth—
inhalation injuries to the lungs. He’d also suffered blast injuries: some of his bones were pointing north, others south. I gently pulled on his arm to open a path to wiggle my stethoscope onto his chest. The skin from elbow to wrist pulled off in one long solid piece—like a glove being removed. I was afraid to tug on anything else for fear it would just slide off into my hands.
I took my time with a portable ultrasound, his belly was becoming increasingly firm and tight, and the scan confirmed blood leaking inside the abdominal cavity as the reason why.
The complexity of his wounds swallowed a chunk of time. From exam to X-rays to treatment, it took close to a half an hour before I
was ready to turn the patient over to Ian. I was glad he’d drawn the surgical on-call straw for the day. He’d need to find, then fix, the source of the bleeding in his abdomen—I suspected a chunk
of shrapnel plowed its way into something important. But Ian was also the best guy we had in burn care, so he’d start removing the worst of the crisp tissue, then repeat the process over the next few days.
Then Bill would have his turn, setting and straightening crooked bones. Finally, our internist would fiddle with the respirator to find the right settings that would push needed air into the scorched lungs. That, and finding the right antibiotics to protect a now fragile body from infection.
I actually thought the guy would make it … if he were an American. But he was an Iraqi soldier, so even if we saved him today, he’d be transferred to an Iraqi hospital where the care was so bad the odds pointed to a quick death.
As he was wheeled to surgery, the doors to the ER were roped open to let in fresh air. Blood has a sticky sweet smell—often more nauseating to see than smell—but the odor of a bad burn is something else. It attacks the nose and throat and won’t let go. It attaches itself to your nostrils, and at times, like today, leaves a horrible taste in your mouth. No amount of brushing or gargling can cleanse away the bitter tang of charred human flesh.
Now that our Iraqi soldier was gone, we screeched from bedlam to boredom. The next few hours morphed into a blenderized mix of the routine: ingrown toenails, infected bug bites, a slip and fall in the shower that resulted in a nasty gash to the back of the head—a wound easily and quickly stapled together, to the surprise of the soldier who owned the head.
“You’re going to do what to my head?”
“Staple it,” I answered.
“What do you mean staple it?”
“What I said. Staples. Little metal things that attach piles of papers. Make believe the cut on your head is a loose pile of papers. We’re going to staple the papers back together.”
“No you’re not.”
Snap. Snap. Snap. Snap.
