by Marc Dauphin
Now, a few days earlier, Phil had decided to use an Airtraq, just to try it out. But the nurse had given his patient rocuronium as a paralyzing agent. Phil is used to working with succinylcholine. There’s not much of a difference between the two except that Roc takes a little while longer to act. So your patient breathes on for a little while. Now, when you intubate someone in the trauma room, it is a stressful experience. Even if you’ve done it a thousand times (some wags will tell you “especially” if you’ve done it a thousand times) your adrenalin goes up, and you get very focused. I certainly do. So that’s what Phil did that day. His moves were precise, calculated, and exactly as he does them every time. Except that the Roc still had not acted and his guy was still breathing. Stick an Airtraq down a breathing person’s throat, and it will fog up the little window at the other end of the periscope.2 That’s what had happened to Phil. You’re performing a very tricky, life-endangering procedure, you’re using a new device, and you don’t see anything. So you say “the Hell with this.” Phil resorted to Plan B, which is what you should do in those circumstances. He had just intubated the guy in the traditional way, with a laryngoscope. But I guess that feeling of helplessness when you’re committed and it’s not going well really shakes you, and it stays with you. It had with Phil, because he didn’t even want to look at an Airtraq again. He’s perfectly happy with what he has, and is confident intubating anybody with his traditional tools. Just don’t talk to him about these newfangled gadgets.
So here we are with Mr. Red Man, one of the trickiest intubations in the book. We are waiting for an anaesthetist, but none is available. They are all in the OR. That’s okay. There’s no hurry; Mr. Red Man can wait. He is calm and breathing fine, just sitting there drip-dripping. His lines are up and working. All we have to do is wait. And if something should happen to him while we wait, Phil will perform the tricky manoeuvre. I hover around with my Airtraq — just in case.
Now, Mr. Red Man is our twenty-third of the day. We’re all tired. (In fact, tired must be the most used word in this book. That’s what I remember the most from that record-breaking roto: always being tired.) So I decide to just sit down. And since there are only three chairs around, and they are all in the head nurse’s office, I wander to the back of the trauma bay and sit on the ground behind Mr. Red Man’s stretcher. At the other end, facing Mr. Red Man, and outside the bay, Phil does the same.
Then, I just can’t resist: I slowly pull the Airtraq out of my pocket and show it to Phil while making a face. He keeps on smiling, then slowly gives me finger. We both burst out laughing so that the crew turn to us.
“It’s nothing, folks. Inside joke.”
“This is Tarin Kowt U.S. Role 2” says the voice at the other end of the phone. Hey, it’s my buddy, the major in charge over there. I’ve forgotten his name since, and I’ve never actually met the man, but I will do anything for him. Even now. He thinks and acts just like me: the mission and the patients come first. He’s the fellow I started to horse-trade with for blood and surgical instruments after one of our casualties, a triple-amputee, had drained our blood bank. I guess we started a new fashion. But then, maybe it had been done all along for years and we just think we’re smart.
Well, he has this little girl over there. She’s been in a blast. (What else? — now, am I becoming cynical?) One of her patellas is gone. So are some of her toes. She also has a concussion. It doesn’t look surgical, though. KRMH, the Afghan Army hospital, will take her, but they’ll just send her on down to the civilian hospital, and … well, we all know what that means. If only I would accept her, we could CT her and observe her for a couple of days while she recuperates. I think I can rustle up one of our beds.
“Yeah, sure. We’ll take her. Send her on down,” I say. “But can you spare me thirty PRBCs of O pos? I’m kinda low right now.”
He asks me to hang on. I hear him asking around. Then he returns.
“I can only send you twenty. But I’ll ask the Dutch next door. Need anything else?”
And that is how the horse-trading started.
Plus one little girl’s father was greatly relieved.
We receive this marine. He should be dead, really. But somehow, at that Role 2 somewhere in the north, they kept him alive. They also emptied their blood bank. The troops were reopening a school that we had built a long time ago, in some little village. When the Taliban got stronger, they had kicked us out of the village, closed the clinic and the school. That way, they could keep the people ignorant, and make them believe what they wanted them to. Well, these marines took back the village. After that, they figured on reopening the school. They knew the Taliban would have booby-trapped it, so they got the engineers to look over the doors, the hinges, and the windows. Nothing.
But the booby traps were well inside the school. When they blew up, they killed a couple of guys and wounded some others. This particular marine got it in the neck and both legs. His neck wound was the terror of all surgeons: it included a major vessel. You can’t put a tourniquet on a neck, so you have to really hurry what you’re going to do. That’s what these guys in that Role 2 did. And since they couldn’t get at the source of the bleeding, or there were too many sources, they did what they could to save this soldier’s life. They ligated his external carotid.
There are two carotids on each side of the neck, the internal one that goes to your brain, and the external one, which irrigates your face. You can probably get away with ligating one of these and hope the corresponding one from the other side will compensate through small connections, right to left, at the end of the line. But then, if you haven’t stopped the original bleeding, you will start to bleed again, precisely because of those little communications. This was what was happening with our soldier when we got him. Plus the fact that they had emptied their blood bank into him. Literally. All the PRBCs, all the platelets, all the cryoprecipitate, and all the FFPs.
So now we receive this soldier who is bleeding from every small vessel in his body. He has literally run out of coagulating factors. Drip-drip-drip-drip, drrrrrrrrrrribble go the drops of blood from his stretcher. We put in two units, but he bleeds out three.
We immediately activate the Walking Blood Bank. It’s around 2200 hours and probably most people are in bed, plus he had the rarest blood type. I hope we can get at least a dozen donors. Hundreds show up. Radio-Canada gets some of the donors on tape, as they’re waiting outside to give blood. I am impressed. I’m actually quite overwhelmed. I even take a picture of the last forty donors waiting in the night. It’s about 0200 in the morning, and these people have been patiently waiting for hours to give blood. You can’t find any more love than that.
Plus many medical personnel from the other Role 1s show up to help harvest the blood. And they stay up all through the night. (Thanks, guys.)
Well, our surgeons and radiologists work miracles on this fellow, but they can’t save his legs. Then the ICU guys get to work on him, “fixing the numbers.” And I get on the phone to JPMRC, and they get him a C-17 to take him directly to Landstuhl. Twice more we have to activate the WBB to get him more blood. A lot of us don’t sleep (and hardly eat) all the time he is here. Then his kidneys clog up. Still, when he leaves, there was a good chance that he will make it.
(I hope he did. I never found out.)
C’est comme ça.
Preparing to CT an injured soldier who has lost both legs above the knee. One can tell the bleeding/seeping is “medical” by its location in the bandages. Note the Canadian flag; our allies were understanding and polite about our sometimes ebullient patriotism. As a matter of fact, many of them wore our flag or our patches as a show of unity, of which I was very proud.
Another Role 2 sends us a kid about seven or eight years old. He’s been shot in the belly. Twice. By the Taliban. His father never tells us what the boy did to get them angry at them. Maybe he refused to throw a stone at a passing military convoy. Or maybe something worse, like laughing when he shouldn’t have.
&
nbsp; Anyway, they had tried to save him up at the Role 2. One of his major problems was that they’d tried to patch up one of his ureters, those ducts that take urine from the kidney to the bladder. They figured they hadn’t done such a super job, so ten days into his recovery they asked us to see what we could do. Well, we do have a vascular surgeon, and a ureter and an artery are sort of the same, aren’t they? So I said sure, send him on down, we’ll see what we can do.
The boy is in trouble. He just keeps throwing all sorts of complications at us. One morning he has a fever, and Julien takes him back to the OR. He’s busted his gut. One of the connections has let go. So Julien fixes that. Then something else happens and Julien fixes that, too. Then something else. Then something else. After a couple of weeks it’s clear that the boy is not going to make it.
All through this, his father stays at his side, night and day. This is his last son, he explains to us. The Taliban had taken a dislike to all his sons, but they had done a better job of marksmanship on the others. So the bearded, wrinkled man just sits here, gently wiping his son’s face and eyes, and mostly staring at him and nodding, and smiling at the nurses, medics, and physicians. It gets so that he’s part of the hospital. He is witness to all the patients coming and going, most of them getting better. His son just keeps getting worse and worse. But the father never stops smiling.
When we tell him we can’t do anything more, he cries a bit. His last request is that we take a picture of his son’s body so that he can have something to remember him by.
C’est comme ça.
The day the Australians came, the father of that family lost all four of his sons. Yet he still thanked us for the effort we had put into trying to save them. The Australian journalist asked him how he felt. His answer: “If, by dying, my sons could have stopped the war, I would gladly give them up again.”
I guess there’s not much I can add to that.
Morning Commander’s Brief, and the TOC officer is giving his daily report:
“… twenty-eight by air yesterday. Just a typical day …”
Funny how you can get used to everything.
I’m on my morning rounds, before everybody else. As I wander through the ward, I notice one of the Russian pilots, who had his appendix taken out last night, is walking around, smiling, not even twelve hours after his general anaesthesia. I guess there’s no place for the weak in Russia either.
I see him with some of our children, one who had a piece of shrapnel taken out of his brain, and his little brother, I think, who had his elbow put in an external fixator. Through one of the interpreters, the pilot is showing the kids how to write.
Another small instant of grace.
“Spasiba, gaspadin pilot,” I say. (“Thank you, mister pilot.”)
I know the gaspadin is very respectful. I guess he appreciates that, because he gives me a wide grin and goes back to his teaching.
A lucky kid: he was burned over about 40 percent of his body. We decided we could care for him anyway (we’re not supposed to take in burn patients — they get infected) because none of his second-degree burns were full thickness, and thus none would necessitate a skin graft. Well, not many of them …
And the kid made it. Now he is being pushed around the hospital in a wheelchair. After two weeks of being exposed to the worst trauma possible, he doesn’t seem to notice anymore, so he gets to go all over the place. His face looks like the bark of one of those plane trees they have in France. You know, with different patches of colour? There’s that new pink skin, and patches of dried, burned-brown skin, with patches of paler skin that moulted the week before, and patches of red where the new skin has been irritated. His hair is starting to grow back on the top of his plane-tree head. The funniest part is his voice. The fire also burned the inside of his airway and we had to intubate him when he arrived, so that when it swelled up from the burn he wouldn’t choke. Well, once extubated, his voice became the squeakiest thing you’ve ever heard. And if someone else is even whispering when the kid talks, you can’t hear the boy. He just doesn’t have the volume anymore. Maybe he didn’t have much to begin with, I don’t know.
Today, one the nurses is wheeling him around the hospital. No going outside with that fair skin. It’s a good thing that the nurse makes plenty of truck-like noise to accompany his travels so that we can hear him coming. They taught him some English, of course, and everybody pretends to be startled when he squeaks a warning for us to give him way: “Make a hole!”
The kid just laughs and laughs.
Another rare moment of levity.
“Make a hole!”
“Thank you so much, Major.” The medic just squeezes my hand with both of hers. Her eyes are alight with happiness. “You just saved me so much trouble.”
I have absolutely no idea what she’s talking about. I begin to protest but she cuts me off.
“Now don’t go all humble on me, doc. If you hadn’t intervened, I would of never have gotten that fixed.”
And before I can say anything, she’s off, still grinning.
Okay … I’ll take it for the times nobody noticed. Still, I wonder what her problem was. Maybe I did do something and I’m just getting senile.
Shit! We got some casualties just as we were moving that head wound to Bay 8 to be palliated. We were so busy with the casualties that we forgot about him. I hope he’s not …
I tear away the curtain isolating Bay 8 from the rest of the trauma room. The casualty’s sheet has been pulled over his head. Damn! Too late. Despite my vow not to let anybody leave this world unaccompanied, I failed this ANA soldier. He died alone.
I feel a presence behind me. It’s one of the night-shift nurses.
“What are you doing here? Go and get some sleep.”
“When I saw that you guys were busy with the traumas, I stayed behind.”
An immense wave of relief washes over me. Thanks, Brenda.
Four ANA soldiers were hit way out in the desert. It took more than two hours to get them in. They are all extremely dehydrated. It’s the holy month of Ramadan, and they take no food or water by mouth during daylight. Out in the desert, under the sun, it can climb to above sixty. Yes, sixty — six-zero. If you touch metal with your bare hand you will incur a second-degree burn.
They don’t have much in the way of injuries. One has a graze on his head. A few stitches ought to take care of that. Plus the five litres of fluid we give him. Out of habit, I order them to do a CT of his head.
A half-hour later, the CT tech comes to me. “Hey, doc, you won’t believe this: he’s got a piece of shrapnel the size of a two-dollar coin right in the middle of his brain.” Out of the corner of my eye, I see the patient arguing with the interpreter as he is being told that he’s going to get his head cracked open.
I shake my head. These guys are tough.
Late Saturday afternoon. One incoming. U.S. Army. Closed-head injury. The helo lifts off. The ambulance turns the corner. The driver just drives. He’s supposed to tell us what he has on board. The ward master gets irritated and signals “What have you got?” with his hand. Nothing. The driver just keeps on coming. The ward master asks again. Still no response. Then, just as the ambulance gets to us, the driver throws both his hands in the air palms up, hunches his shoulders, and purses his lips in that international “How should I know?” gesture. Then he breaks out in the widest grin and signals “One stretcher, stable.”
We get the casualty offloaded and into the trauma room. The ward master, cursing in “Newfie-ese,” takes off his latex gloves, rolls them into a ball, and throws them at the laughing driver, who is busy closing the amb’s doors. The driver, a British soldier, has been here for months now. He can’t be a day over twenty and looks like he’d belong more in a high school than in one of the busiest trauma centres in the world.
Like I said, you get your laughs where you can.
Dust-off chopper takes off to refuel in a gathering sandstorm. The personnel on the left have noticed something: anoth
er incoming helo?
It’s late evening, and the temperature is in the mid-thirties. I have finally made it back to my barracks. Outside the back door, on the gravel, there are some picnic tables. There they are, some smoking cigars, some playing chess, others playing Risk on a computer, still others sitting apart, deep in a serious conversation, while others are watching a TV show on another computer. The scene is the same every night — peaceful, almost domestic.
I look at every one of them: dedicated people who could spin professional wheelies around most university professors. Yet here they are, dressed in whatever they’ve found — shorts, T-shirts, others still with their army pants and boots. One wears a cap backward. Another one has what we call a “funny hat,” but is really a floppy hat. A nurse wanders out. They give her a bottle of near-beer. She takes it, sits down to watch a few chess moves, then gets up and walks away.
It is all so calm, so peaceful.
These are my comrades, my precious comrades.
I savour the moment.
So tranquil. Well, that is, apart from the transport planes landing one after the other, and the fighters taking off in pairs on afterburners. Apart from the Chinooks flapping by menacingly and the convoy roaring by on the road at the other end of the barracks, either returning from or going out on patrol. And apart from the smell. We’re so used to it that we’ve stopped noticing. Tens of thousands of troops generate a lot of excrement, and in KAF it’s funnelled to large ponds at the end of the base. In the evening, after the sun has set, the breeze blows the other way — from the ponds to the base.
