Paradise General (19 page)

He, too, had been up for hours. We didn't talk much about our stresses, but I knew the pressure of being chief surgeon had cut into his sleep and ability to relax.

It was my day to run the ER; Rick was my on-call surgeon yet we didn't have to remind each other—the message of anxiety was clear in our eyes. We had only known each other for a little more than a month, yet we were already at a point where we could read each other's thoughts without uttering a word. We flew through our ABCs, made sure we had our gear, and then headed over for a meal of powdered eggs, which we simply pushed around on our plates. It seemed like we both knew we were in for it—how we knew I couldn't say—there was just a vibe that surrounded us. Even the usual jokes were missing in action as we made the trek from the chow hall to the hospital.

As I pushed open the ER doors, I mumbled a quiet “See you later.” His answer was a terse “I know.”

I greeted my medics with a quick “How is it going, folks?”

They replied in unison.

“Fine, sir, just another day in fucking paradise.”

“That it is, my young friends. Say, I think I'm going to head over to rounds for a few minutes, page me if there's any business.”

As I walked, I thought about our peculiar brand of work; it was unlike anything any of us imagined. The meat and potatoes of our daily life was trauma, but not like the stuff back home. There, it's a lot of blunt injury from car accidents with an occasional hole from a bullet or blade. Here our life was pulling nails from a car bomb out of someone's back. Amputating limbs hanging by a thread of skin. Trying to keep some guy's intestines from spilling onto the floor as you struggled to examine him. Comforting a young soldier who can't stop stuttering after seeing his best friend's brains splashed throughout the inside of a Humvee.

It could be mentally chaotic, but wasn't the emergency medicine you'd typically see on TV with yelling, screaming, and bedlam. I learned on that horrible first day in the ER that I needed calm. So the dual rules of my desert trauma center were simple, especially for visitors who stood in the peanut gallery: Keep quiet. And stay out of my way. I had lost my medical virginity on that inaugural day when my head went spinning. It was a day that now seemed centuries old. I had changed in ways I probably wouldn't discover until many years and miles passed between me and this hellhole.

I sneaked into the back of rounds and looked at my friends. Rick, Bernard, Bill, Mike, Gerry, Ian, and Blockhead—I rolled a lucky seven when I was put with these guys. They were good at their jobs, they were good to the patients, and they were good to the staff. And they were good to me—all at one time or another holding me by the hand when I was stumbling.

We all brought some piece of medical knowledge to the table, and were always willing to bail out someone who was drowning in a roiling sea of blood. At times, the group had been stunned into silence by the bodies or pieces of bodies brought to us on stretchers, yet none lost our patience or humanity. I saw my colleagues naturally laying a soft hand to the head of a scared, wounded soldier. They would kneel on one knee and gently talk the language of reassurance and confidence into the ear of the injured. And sometimes walk away with deep red indentations of the skin—a place where the frightened had latched on and painfully squeezed tight the arm of the doctor promising to aid them.

I was blessed with an orthopedist I could call out of bed in the middle of the night to look at an X-ray I didn't know how to read, and I worked with surgeons who never got angry when I lagged behind their rapid pace in the OR. I also learned it was not only me who had a good fairy who left food when I missed a meal, or a blanket when exhaustion struck; we all looked out for the one who needed rejuvenation. We trusted each other with our lives, as well as the lives of the
soldiers we cared for.

Rick was in the corner with his eyes pointed at the floor, brow furrowed and stressed. Not paying one damn bit of attention to what was being discussed by the group. Sweat like ice water ran down my neck—something was up. I decided I had better head back to the ER and wait for the other boot to drop. It took less than two hours of nervous toe tapping and three cups of foo-foo coffee before the morning's call came in.

And this is how it went:

09:11:30
I'm asking Major Boutin why in hell we are drinking Blueberry Surprise instead of real coffee. The medics are telling dirty jokes. Sergeant Courage is outside sweeping the sidewalk.

09:12:00
The radio crackles. A firefight has taken place after an IED attack. Estimate two urgent casualties—arrival by helicopter in twenty-five minutes. Condition unknown—so we prepare for four patients and arrival in ten minutes. Information is often muddled when called in from a thundering helicopter. The message sets in motion a frantic cascade of rushing feet, hurried voices, and upset stomachs.

09:12:30
I ask for pages to be put out to surgeons, orthopedics, anesthesia, respiratory therapy, and X-ray. Maybe an extra ER doc or two. We're going to need help with this one.

09:13:00
Staff heads to trauma bays—equipment is checked and double-checked. Suction, defibrillators, emergency drugs. IVs are hung and ready to drip. Chest tubes and intubation equipment placed within reach. I double-check my personal gear: stethoscope, safety glasses, and a pair of gloves. Then stuff more gloves into my pockets in case things are extra bloody. I end the ritual with a quick pat-down of my shirt pockets for my emergency cheat cards. Haven't used them yet but the day I don't have them is the day I will need them.

09:14:00
We go in sets to the unisex latrine. Always have an empty bladder, you never know when you'll get the chance to go. As I stand emptying my bladder, the nurse in the stall next to me asks how my family is.
Just fine, thanks. Yours?

09:16:00
Back in the ER, we share packs of specially designated “trauma gum”—Trident or Wrigley's to keep from getting cotton mouth. We walk, pace, and tell weak jokes. I have a crucifix in my left pocket that has been rubbed raw over the months during these walks. I pace seven steps toward the front door, then back for seven more. We all have our pre-trauma quirks—this is mine. Why seven? Mickey Mantle and John Elway wore No. 7. It has to be good luck.

09:19:00
Like Radar O'Reilly, we sense the vibrating blades of incoming medevacs before we hear them. They are eighteen minutes early. Medics go to the helipad wearing Mickey Mouse-—eared hearing protection. The rest of us line up in our positions. I am at the head of the stretcher in Alpha bay waiting for the most critical case. I stand on the left—anesthesia on my right. Everyone in their assigned position.
It's like a football game. Just waiting to say “Hike.”

09:20:30
Medics come into the ER. Moving fast, not a good sign. Someone shouts: “Three urgents on litters.” Sprinting medics rush in three soldiers. I eyeball the wounded from a distance … as well as the faces of the medics. Their stress tells me how worried I should be.
Shit, they look as old as I feel.
I hear moaning, see blood, and sense death. The worst of the three is blood-soaked and blue in color, he's missing part of a leg and has bright white bone fragments sticking out from his arm—the fragments are pointing oddly at the ceiling.

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.