The gray ship eased into the misty sky and slipped off into the gathering dawn, back to the war.
I turned toward the hospital and saw Chris riding up on a bicycle, an odd sight, considering that he was wearing gym shorts, a T-shirt, body armor, and a Kevlar helmet. He wore a backpack over his armor, and I wondered how he managed to balance all that weight on the old Schwinn.
“What’s up with the bike?”
Chris stopped, one foot on the pedal and one on the ground, and pushed his helmet out of his eyes. “I promised my wife I would never be outside without my protective gear on,” he said, “but it gets really heavy walking around like that all day, so I found some wheels.”
He dismounted and left the bike against the concrete barrier outside the ER. We stepped inside together, and he shed his gear. We were headed to the DFAC for breakfast when I heard someone yelling at me from the end of the hall. I turned — a nurse was running toward us. “Need you in the unit,” he said. “The baby’s ICP is really high.”
The monitor read 70 where the 0 had been yesterday. An ICP of seventy is too high for the patient to survive for long. Normal pressure readings are under twenty, and most people have pressures less than ten most of the time. Seventy meant that the blood flow to the baby’s brain was much reduced, and unless it was quickly restored, coma and death were imminent.
My first thought: Why did I put his bone back in?
I checked the monitor’s connections, adjusted it, and turned it off and back on. The screen blinked while it reset, and the reading appeared: 73.
Then I remembered the first rule of patient care: examine the patient.
2013 was still on the breathing machine, since Chris had thought it best to let the boy’s body rest on medications after the stress of his injury and surgery the day before. He was sedated with the drug Versed, which meant I couldn’t really examine him thoroughly. I asked Chris to turn off the medicine drip, and asked how long it would take for the boy to wake up from the chemical sleep.
“Twenty or thirty minutes,” he said.
If the ICP was really seventy, 2013 could die in that amount of time.
I looked at 2013’s pupils. Normal.
Chris looked at the chart. “His vitals have all been normal, and his lab work is okay too.”
“Maybe it’s a bad box,” I said. “Let’s try another one.”
I walked to the supply closet and grabbed another of the Codman ICP monitor boxes, the computers the monitor cables hook up to. The strain gauge monitor sends its information to the computer, where the data is interpreted and turned into a number we can use. We had three of the boxes in the hospital, and one of them was currently unused.
We waited the thirty seconds or so it took to boot up the machine, and I hooked the cable up and hit the button to tell the computer to give me a reading. The whole time we were waiting, I was thinking, I hope my decision to replant the bone didn’t kill this kid.
The number flashed: 80.
I thought, This kid’s gonna die, and it’s my fault. “We better get him to CT. He must be bleeding into his head or swelling his brain.”
We rushed the baby to the CT suite, where we waited ten minutes while the techs finished scanning a soldier’s abdomen, full of shrapnel from an IED.
Then they rushed the soldier off to surgery — leaving no one to clean the blood and dirt from the scanner’s table. In San Antonio, I would have sat at the desk while orderlies cleaned the machine and readied it for the next patient. But here, there was no orderly to do it, and I wasn’t going to put that baby down in someone else’s blood.
I found some paper towels and cleaning spray and wiped the scanner down. Then Chris lifted the baby from his stretcher and gently placed him on the table. The techs returned and set up the scan.
One by one the images crossed the screen. His brain scan was completely normal. There was no new bleeding or swelling. Yet the ICP was now 90.
“What could it be?” Chris asked.
I shook my head. “Venous thrombosis, maybe. If he clotted off the vein of Labbé, he’s in serious trouble. I’ll have to do a decompressive craniectomy, but that might not even be enough.”
In America, we never have to wonder about things like that. I would have simply ordered an MRI, which would have shown definitively whether the baby needed surgery and what was causing the ICP problem. In that desert tent that day, however, I had few options to provide the information I needed to make my decision. WWJD? I wasn’t sure what Jack would do, and I doubted that any of my professors had ever been in this situation.
The number kept climbing. It had been about fifteen minutes since Chris turned off the Versed drip. “Back to the ICU,” I said to the techs. “I’m going to try something.”
They wheeled 2013 down the hall while I ran ahead of them to the supply closet. I opened a new monitor kit, set up a sterile field in the ICU, and shaved a small patch of the baby’s head.
“What are you doing?” Chris said.
“I’m going to put in a new monitor, just to make sure his pressure’s really high. If it is, we’ll go straight to surgery.”
I knew I was taking a big risk. If the monitor was telling the truth, then I was wasting a few minutes of precious time — time 2013 really didn’t have. But I also knew that I had never seen an ICP above thirty or forty in a patient with a normal CT and normal pupils. I couldn’t believe the data, and I wasn’t willing to take a baby back to surgery — especially not here — to find out that he had a bad monitor.
I made a small incision, then used a hand drill to make a pencil-eraser-sized hole in his head and inserted a brand-new monitor. I disconnected the old one from the box and connected the new one.
Thirty seconds felt like hours, but when the screen flashed, the ICP readout displayed: 2.
“It was just a bad monitor. He’ll be fine.”
Chris didn’t restart the Versed drip, and in a few minutes the baby opened his eyes and began to move his arms and legs. Later that day we removed his breathing tube, and 2013 began to smile and interact with us.
I wondered afterward how many years of my life that broken monitor stole. I suppose I was the only person in the hospital who knew how scared I’d been of making the wrong decision, of costing that baby his life by my decision to put his bone back in or by waiting too long to take him back to surgery. Because when you’re not sure what Jack would do, you just sell it, baby.
CHAPTER 12
A VERY ODD SKULL
I ran most of the way to the hospital from my room. The day had dawned cold and cloudy after the long rainstorm of the night before, and every step of the nearly mile-long route I took that morning led me through either standing water or an inch of mud. But the wet weather somehow hadn’t kept the sandstorm from battering us that morning as well. If I’d thought about it, I would have found it curious to be wet and covered in mud and at the same moment having an asthma attack from breathing in the dirt-filled air.
The door to the emergency room lobby was a welcome sight, but I had to throw my weight to shut it behind me, the wind was blowing so hard. I’d wrapped a scarf around my head in a mostly futile attempt to filter out the sand, I had my dark black Wiley X sunglasses on, and I was wheezing like an old man with tuberculosis. I needed an inhaler.
“What’s up, Lawrence of Arabia?”
I looked up and saw one of the new emergency room doctors staring at me. I realized how ridiculous I must have looked, so I unwound my scarf. I was covered in mud up to my knees, but there was sand sifting off my head and neck, and I felt like that kid in the old Peanuts cartoons, Pig-Pen, who always had a cloud of dirt around him.
“Sandstorm,” I said between coughs. “I’m Lee, the neurosurgeon. You got any albuterol?”
He laughed. “Yeah, I wish I could sell the stuff. Everybody on base has asthma or bronchitis right now, between the sand and the stuff they’re always burning. I’m Chuck, by the way.”
He had a point about the burning mat
erial. Along with the constant noise, explosions, blowing sand, and mud, there was an ever-present smokiness in the air. Huge trash fires were burning almost all the time at several locations on base, and there were also frequent smoke clouds blowing by from distant oil field fires. It was like being in Los Angeles on a smoggy day, only a lot worse.
Chuck went into the pharmacy and returned a minute later with a couple of inhalers. I took a puff, inhaled deeply, and held the medicine in my lungs as long as I could stand it.
“Thanks. Sorry about getting your floor dirty.”
“No problem,” he said. His face got more serious. “I’m sure we’ll be mopping it soon anyway. There are Black Hawks inbound with some US troops. IED blast. Could be our first mass casualty.”
I felt two things at the same time: amazed that I was no longer afraid of those words, and amazed that even though I’d only been in Iraq for four weeks, I was at that moment the only doctor in the hospital who really knew what a mass casualty was.
I put my hand on his shoulder. “It’ll be okay. You guys are well trained. We’ll handle it.”
I wondered whether, on my first day, I had looked as uncertain to Pete as this guy looked to me now. He stared off into the distance for a second, then turned back to me and said, “Hey, while we’re waiting, could you look at a patient for me?”
He led me into the ER, where a skeleton-thin Iraqi man lay on one of the beds. He wore a robe and sandals and had a thick black beard and curly hair. A technician had the man’s belly exposed and was performing an ultrasound. Two nurses and another doctor, one of the new general surgeons named Brian, were looking over the tech’s shoulder, peering at the screen. They seemed to be arguing about what they were seeing.
“What’s going on with this guy?” Chuck asked me. We approached the patient, who looked down disinterestedly at the circus-like atmosphere his own abdominal ultrasound was creating. There was a vague sadness in his eyes. I noticed now that he also had a major skull deformity — I had missed it at first, because the man’s full head of hair camouflaged the shape of his head, but he clearly had a very odd skull shape. I probed the deformity gently, felt the concave lines of his skull and the softness underneath. He looked at me blankly, as if he had little interest in anything going on around him.
“He walked up to the gate and told the guards he had a stomachache, and that he was supposed to come here if he had any problems,” Chuck said. “He had a letter with him, written in Arabic. We sent for one of the translators already. He’s got some kind of mass in his abdomen, and that’s why we called the surgeon. But we also noticed his head.”
Still probing the patient’s squishy scalp, I tried to remember all the types of cancer and infection that can cause the skull to erode. The patient was going to need a CT scan so that I could tell how extensive the damage was.
The more I thought about the combination of a collapsed skull and a painful abdomen, the more I felt that there was an obvious diagnosis, something that I should know but that was staying obscure in mind, dim, just out of my reach.
“Hello, Doctor. It is good to see you.”
I looked up and saw Isam, one of the Iraqi translators. He was tall and muscular and looked like a young Omar Sharif.
He spoke to the patient, then shook his head at the man’s reply. “He’s not making any sense, Doctor. The words he speak, they are, how you say? Like gibbering.”
He was describing a neurological disorder called aphasia, which meant that the patient was unable to produce intelligible speech. Not too surprising, considering that the caved-in side of his skull was the left, and in most people the left side of the brain controls speech and language function. Either something was eroding the patient’s skull and destroying his brain, or he had a brain injury. This also explained his apathy toward what was happening to him; people with left frontal lobe injuries frequently have something called abulia, where they seem to not care about anything.
This case was getting more and more interesting. The diagnosis now felt a little less remote. In my mind I could see the textbook on my shelf in San Antonio I would have normally reached for. I thumbed mentally through the chapters on disorders of speech and thought.
My subconscious library trip was interrupted by another comment from Isam. “Oh, this letter explains the problem,” he said, holding the paper the patient had presented to the gate guards. “This man’s name is Adnan, and he is an Iraqi from Balad Village. He was injured in a bombing last year, and was treated here by the Army doctors. It says his chart number was 1255.”
A few minutes later, I had retrieved and was reading Adnan’s chart. The diagnosis I’d been reaching for was completely wrong. “Guys, I think I know what your abdominal mass is,” I said.
I spent the next thirty minutes giving the emergency room staff and all the new surgeons a lecture on decompressive craniectomy and letting all of them feel Adnan’s belly, so they could learn what a piece of someone’s skull feels like after it’s been in their abdomen for eighteen months.
An Army neurosurgeon had saved 1255’s life, buried the removed portion of his skull bone in his abdomen, and eventually Adnan/1255 had been discharged from the hospital into the care of his family. At that time, and still up to the point I arrived, the general consensus among military neurosurgeons was that replacing the bone flap in the tent hospital environment would lead to a high infection rate. Thus, once the patient was stable enough, he was discharged with his bone still in his belly, in the hope that after the war the Iraqi health care system would recover enough to take care of those patients.
An Iraqi physician had written the letter in Arabic and told Adnan to carry it with him at all times, because his brain injury kept him from being able to communicate his medical history — or much of anything else. The Army doctor had told the patient to come back to the hospital if he ever had any problems, so when he started having abdominal pain he just walked up to the gate.
Adnan’s belly problem turned out to be nothing serious, but the case of the rock-hard abdominal tumor and sunken skull was definitely the most complex diagnosis the new team had yet faced. As doctors facing life-and-death situations constantly are prone to do, we saw the dark comedy in the situation and got a good laugh at our own expense, joking about discovering a new disease known as “Skull Belly.”
The mass casualty we expected never materialized that day. Instead, we had a day of working up a medical mystery with an amusing and thankfully happy conclusion.
The next day would not prove to be as humorous.
CHAPTER 13
“GET THAT CAT OUTTA HERE!”
A thick black mix of smoke from oil field fires and burning trash, along with blowing sand, stung my eyes, burned my lungs, and obscured Tuesday morning’s sunrise. Another day, another breathing treatment, another dose of whatever Iraq had to offer in my graduate course in trauma surgery, terrorism, and teamwork. What’s new?
That mental question was answered as soon as I entered the ICU for rounds. Everything was new.
President Bush’s Coalition of the Willing had received its major support from Great Britain and Australia. And some of those willing to help were Australian medics. Half of the new nurses and anesthesia staff were Aussies, along with an orthopedist and a general surgeon. The ICU nurses from Down Under had come in last night — and put their stamp on it. A huge Australian flag hung along one wall, and stuffed wallabies and kangaroos were positioned around the tent in strategic locations. One of the nurses had a rugby jersey on over her scrubs. No one actually said, “G’day, mate,” but it wouldn’t have surprised me.
It was our first day with only the new staff in the hospital, and the boss was going to make rounds with us. Someone at the Pentagon had decided that when they rotated medical staffs in their field hospitals, they needed to replace everyone at once, including the command staff. And so not only were we about to enter our first day of the war with an almost totally rookie team, we also had no leaders with combat experie
nce. I thought, This could be a disaster.
I surveyed the room; people huddled into groups, staying close to the people from their own bases and specialties. It occurred to me again that my having to come early had robbed me of really belonging to either the old staff or the new one. At least I knew a few of the folks from San Antonio, like Colonel H, the new hospital commander. He was a plastic surgeon back home, and we had operated together a few times. I knew he was a good man, and I was glad he was here. But I’ve always hated when administrators make rounds. It’s torture.
Colonel H insisted that the entire team — all the surgeons, ICU doctors, the therapists, a pharmacist, a dietitian, and several interpreters — round together on every patient in the hospital. The idea was good, making sure we all knew everything relevant about the care of every patient. But in practice, it was an inefficient traffic jam of differing philosophies, training biases, and egos vying for their own specialty-specific goals or pulling rank-over-experience power plays.
“Wow — whoever closed that belly was pretty sloppy,” said one general surgeon.
I looked at the patient’s wound, remembering the night Vic saved his life. An IED had gone off, and we had five INGs and a couple of Americans show up at once around two in the morning. I was operating on a young Marine, and Vic was working on this ING captain three feet away from me. Vic removed most of his large intestine and part of his liver in about thirty-five minutes.
Halfway through our operations, a loud explosion shook the operating room, and the lights went out.
“Everybody hold still,” said Vic, his voice never cracking. “The backup generators will kick in in a minute.”
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