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No Place to Hide

Page 14

by W. Lee Warren


  “Raul, ask him about the wire in his thumb.”

  After a conversation I couldn’t understand, Raul said, “Jafar say he was in Baghdad two weeks ago. Terrorist shot him in hand, then Jafar shoot terrorist in head. Army doctor fix Jafar’s hand. He has appointment tomorrow to take out wire. He ask if this can be done here instead.”

  With Raul’s help, I informed Jafar that our orthopedists would be happy to remove the wire in his thumb. Under his bandages, I found several small lacerations and burns on Jafar’s scalp and face, and a very red eye that Augie would need to see.

  “Tell him I’m sorry about his daughter, and that he’s going to be okay,” I said to Raul. I squeezed Jafar’s hand, gave the nurse a few orders, and moved on to the next bed.

  Tim yelled, “I’m going to the OR with this one, the bomber. He’s got a depressed skull fracture and he blew out both his eyes.”

  I watched as the orderlies rolled Tim’s patient out of the ER. He couldn’t have been over twenty years old, and he now had a serious brain injury and would be blind for life. His religion and his hatred had led him to kill and injure a lot of people, and if he had enough brain function left to realize it, his memory would forever hold the last thing he’d ever seen with his eyes: his own hands, just as they crossed the wrong wires. What would the future hold for this young man? A head-injured, blind zealot stuck in an Iraqi hospital or an American military prison, destined to remember the pain and the screams and the death he’d caused, but with no one around to praise him for anything he’d done. Everyone he would hear from for the rest of his life would tell him how wrong he was, how evil. And the men who’d sent him to do their work wouldn’t miss him; they would just replace him with some other kid willing to fight for their ideals. There was no shortage of them.

  I said a little prayer for Tim’s patient, now known to me as 2137 — that he would somehow find peace if he survived his wounds and the operation he was about to undergo.

  “Good luck, Tim,” I yelled down the hall. Then I thought, Only one set of instruments left.

  The next two beds held Americans, but Chris and his partner, Brian, were working on them. There was a lot of blood. Anesthetists started IVs, and Brian yelled to the Czar that his patient needed an OR, immediately.

  Someone shouted, “This one’s for you, Lee.”

  Mitch, an Australian general surgeon, had assessed an American Marine sergeant whose head dressing was soaked in very dark blood. That caught my eye even before I reached the bed. Head wounds usually cause bright red bleeding from scalp arteries, or else the blood clots on the bandage and mixes with dirt from where the patient falls, making a dark brown, almost rust-colored stain. This man’s gauze, instead, looked as if it had been dipped in red wine.

  Mitch was doing chest compressions on the sergeant, whose heart had stopped beating a few seconds before. A nurse was squeezing two bags of saline into a high-pressure infusion pump, a machine designed to refill someone’s circulation quickly when they are losing blood too fast for normal IV lines to drip in the fluid. Mitch yelled for someone to give the man some lidocaine, and to get the blood bank working on some whole blood for him. An anesthetist was squeezing oxygen into the man’s lungs through a breathing tube someone had inserted during the helicopter ride.

  “I ran the whole body survey, and there are no other injuries,” Mitch said while he pumped on the sergeant’s chest. Every time Mitch compressed, the Marine’s dog tags bounced a few inches off his chest, and the sound of his rib cage crunching and the metal tags clinking sounded like a snare drummer hitting rim shots between beats. The tags told me that the sergeant was a Protestant, his blood type was B negative, and his name was Yeager.

  A tech held her hand on Yeager’s groin, feeling the femoral artery to verify that Mitch’s CPR was strong enough to move blood through the man’s body. Mitch stopped after the two bags of fluid went in and looked at the tech.

  “I have a pulse, Doctor,” she said.

  I looked up at the monitor. Yeager’s twenty-nine-year-old, healthy heart had done its job. Hearts are amazing machines, programmed to serve a lifetime as long as you give them enough blood to fill them up. Once the fluid filled his tank again, and with the help of David’s compression and the lidocaine, Yeager’s heart kicked right back into motion. But with every beat, the stain on his head wrap was spreading.

  I unwrapped his head and drew a sharp breath. Most of his scalp was missing. Between tangles of burned hair, through the voids where flesh had once been, were shards of stark white bone, and I could see that the bomb blast and whatever it had slammed Yeager’s head into had fractured his skull in at least five places. I noticed that the blood coming out seemed mostly to seep from under the bone in the middle of his head, and that it was beginning to look lighter. That meant that the fluid in his veins was now composed more of saline than blood. I had to stop that bleeding, or Yeager was a dead man. But I didn’t know yet how bad his brain injury was — whether there was any of what made Yeager Yeager left to save.

  I lifted his right eyelid and looked at his pupil, a dark hole in a sea of clear green. I didn’t have to lift his left lid, because it was burned off, along with most of that side of his face.

  “His pupils are working,” I said. “Let’s get him to CT and see if he’s salvageable.”

  The scan showed that Yeager’s brain was very swollen. Even though this was one of the worst skull fractures I’d ever seen, the brain itself was whole. The bleeding seemed to be coming from a fracture across the sagittal sinus, the large vein that runs from front to back at the top of the brain and is responsible for draining all the blood out of the brain and into the jugular veins.

  “I think we can save him if we get the bleeding under control,” I said.

  By the time I finished scrubbing my hands, Nate had shaved what was left of Yeager’s scalp and prepped his skin. Nate and I draped out the head while the anesthesiologist hung four bags of blood and began to squeeze them into Yeager’s IV. Tim was on the other side of the room, struggling to save the life of the terrorist responsible for Yeager’s injury.

  “Knife,” I said.

  Nate handed me the steel scalpel, and I traced an arc over Yeager’s scalp from just in front of his left ear all the way across the top of his head to his right ear. I placed Rainey clips to control bleeding and peeled Yeager’s scalp forward all the way down to his eyes. There were three holes in the skin big enough to put my hand through, and I knew that if I managed to save Yeager’s life I would then have to try to figure out how to repair his scalp. But holes in his scalp wouldn’t matter if he was dead, so I dismissed the thought.

  “Drill.”

  Nate handed me the gold-colored Midas Rex drill, its green rubber hose attached to a tank of compressed air. My plan was to cut around all the skull fractures and remove most of Yeager’s skull in a big chunk, stop the bleeding, then use metal plates to repair the broken bone before I replaced it.

  I stepped on the drill pedal, expecting to hear the familiar whir and then drill my first bur hole. Instead, I heard a pop, then a burst of air hit my hand. I almost dropped the drill onto Yeager’s head.

  I turned the drill over and examined it. The coupling had exploded at the junction of the hand piece and the hose. The drill was destroyed.

  “Somebody get McDonald. Tell him I need another drill immediately,” I said. A tech ran out to deliver my order, but I could see the clock on the wall, and I knew what McDonald was probably going to say.

  Sixty seconds later, the tech came back in. “Doc, McDonald says it’ll be at least two more hours. The drills are still being processed with your other instruments.”

  I looked down at Yeager’s head, at the pink-tinged blood, mostly saline, still pouring out from under his broken skull, and tried to figure out what to do next.

  “Nate, hand me a mallet and a Langenbeck.”

  Yeager was bleeding out, and with no drill available, I decided to take advantage of his skull fractures.
Nate passed me a small metal mallet and a fan-blade-shaped instrument called a Langenbeck elevator, and I began to chisel around the edges of the fractures, freeing each of them from the little bits of bone that still held them to Yeager’s skull. One by one, I removed the fragments, saving the big one in the middle for last. I knew that the fracture in the middle, the one most of the blood was coming out of, crossed the sagittal sinus and was likely to tear the huge vein even more when I removed the bone fragment.

  A tech ran into the room and handed the anesthetist working with Tim two units of O negative blood from a universal donor, the most coveted blood type because any patient can receive it safely. “Sir, the blood bank says this is the last of the blood. They’re starting a blood drive now, but it will take about an hour to get more.”

  I looked at the blood seeping out of Yeager’s head; it was red again. Everything we were putting into Yeager was coming back out as soon as it reached his brain. There was no more blood to give him, and no more time.

  “Two more liters of saline. Watch his pressure, because he’s probably about to lose a lot of volume,” I said.

  I picked up the Langenbeck and cracked through the bone from Yeager’s left side, then carefully began to lift the fragment toward his right side. I looked under the bone as I lifted and tried to gently separate it from the covering of the brain so that it would not tear the sagittal sinus. Despite my care, as soon as I lifted the fragment, a huge gush of blood shot out of the sinus. I pushed the bone back down, and the bleeding slowed again.

  “His sinus was torn in half by the fracture,” I said. “I have to pull this piece of bone off to repair the sinus, but when I do he’s going to bleed a lot.”

  “I’ll push some neo — that should help,” the anesthetist said. Neosynephrine is a drug called a pressor, which causes arteries to constrict and raises the blood pressure.

  “Adson elevator,” I said. I felt the pop of the bone-lifting instrument when Nate handed it to me.

  I lifted the bone fragment and slid the Adson underneath to separate the bone from the covering of the brain. When the piece came off, a gush of blood shot out of Yeager’s head, hit me in the neck, and poured down the front of my chest, underneath my gown and onto my skin.

  “Sponge,” I said, taking a cotton sponge from Nate and covering the hole in Yeager’s sagittal sinus to stop the bleeding.

  “Pressure’s sixty over palp.”

  Yeager had lost so much blood in the three seconds it took me to remove the fragment and compress the sinus with a sponge that his diastolic pressure was unreadable, too low for the machine to detect.

  “I’m going to try to sew it up. Give him more saline and neo.”

  I took a suture from Nate, planning to throw a stitch in the sinus and then replace the sponge until anesthesia could catch up with the blood loss. I would repeat this move until the sinus was repaired.

  I lifted the sponge. Another splash of fluid from Yeager. Only now it looked about the same color as the saline we were giving him.

  I went back and forth several times between placing sutures in the paper-thin sinus and ordering more fluid into Yeager. Blood was coming, but not fast enough. Every time I moved the sponges, blood-tinged saline squirted all over me.

  But the worst news was that the sutures weren’t going to hold. His sinus was so thin that the stitches were pulling through. In order to save him, I would have to put in a shunt. I ordered the tech to go get a vascular shunt, a Gore-Tex tube used to replace an artery or vein.

  Just as she left the room, the anesthetist yelled at me, “Doc, he’s gone into V-fib. Pressure’s dropping.”

  This meant that Yeager’s heart had developed an unstable rhythm, when the muscle in the ventricle quivers instead of contracting. Whatever fluid was in his heart was just getting jiggled around, rather than pumped into the rest of his body. He was going to require CPR again.

  “Look at his pupils,” I said.

  The anesthetist pulled up the drapes and looked into Yeager’s eyes.

  “Blown,” he said.

  Yeager was gone. His pupillary dilation meant that his brain was shutting down for lack of oxygen, and his heart was refusing to pump. I tried one more time to close the sinus with another type of stitch, but when I moved the sponge, one last spurt of fluid shot me in the face again — and then it stopped. His tank was empty.

  The tech ran in with the shunt in her hand.

  “Don’t open it,” I said. “Someone else might need it. Yeager’s dead, KIA. Mark the time.”

  I stepped away from the table, and for the first time in my surgical career I felt like I would vomit. I sat on the edge of the anesthesia machine as the anesthetist flipped the switch to stop monitoring Yeager’s vital signs. I reached down and felt his wrist just to make sure: no pulse.

  “I’m going back to the ER,” Tim said from behind me.

  I turned to see him finishing up the head dressing on his patient’s head. 2137 — the terrorist who had killed Yeager, Jafar’s daughter, and so many others — was still anesthetized. I knew that he was about to receive a couple of hours of state-of-the-art ophthalmological surgery by Augie, who would do what he could to remove the man’s destroyed eyes and repair the holes, prevent infection, and improve his appearance. And I saw the red tubing running into his arm, the last two units of universal donor blood in our hospital.

  It wasn’t fair, and in that moment I wanted to hate this guy, 2137. But we had all spent years of our lives training to help and heal, and when someone is in front of you needing both of those things, you can’t just walk away. I suppose this is the biggest difference between trained hospital personnel and teenage guards at a place like Abu Ghraib — attitude reflects leadership and training. Stick us in a prison and tell us to guard a bunch of bad guys who’d been shooting at us and blowing us up, killing our friends, and then undertrain us and leave us to our own devices, and some of those same behaviors may have come out in a herd mentality — the first time someone mistreated an inmate, everyone else would feel a little permission to do the same. But in a medical facility full of professionals who have dedicated their careers to caring for others, and led by someone who preached every day it was not our job to discriminate between our patients, the peer pressure of everyone else doing it right kept us all in line. Right then, watching the precious O negative blood drip into 2137, I wanted it to be different. I felt worse than when I treated drunk drivers in San Antonio, who always seemed to survive the car wreck they caused that killed someone’s wife or daughter. At least those drunk drivers didn’t wake up the next morning glad for what they had done. I knew that 2137 would feel remorse only that he’d been caught, and that given the chance he would do it again.

  I remembered reading in the Bible that in Jesus’ eyes, there is no difference between Jew and Greek, slave and free, man and woman. I supposed that extended to there being no difference in God’s eyes between American Marine and Islamic terrorist, but at that moment I asked God why. Why Yeager and not the terrorist? Why Jafar’s daughter and not this merchant of death?

  God did not answer my question, so I went to the locker room and sat on the bench, soaked to my underwear in Yeager’s blood and twelve liters of saline that had poured out of his head onto me. I cried, prayed, and slammed my fist into the locker.

  Then my beeper went off, reminding me that we still had patients to take care of.

  I changed scrubs, threw away my socks, and went back to the ER.

  CHAPTER 17

  I SAW IN 2137 EVERYTHING I HATED IN THE WORLD

  EMAIL HOME

  Friday, January 28, 2005

  Good morning, everyone.

  Please pray for the Iraqi people. This weekend they will hold their first free elections as they attempt to become a self-governed, elected democracy. Pray that these brave people won’t cave in to the terrorists and their tyranny. From what I can see, the Iraqis are a smart and proud people, and they deserve better than they’ve had.

&nbs
p; We are getting a little nervous about this weekend, but not as nervous as we would be outside the wire. We’re making appropriate changes around the base for security, and our guys are prepared for anything. It’s still weird to see the big freshly covered ditch where the rocket landed just outside the hospital. Scary.

  This experience is making me realize what a privilege it is to just have a routine — to get up every morning knowing basically what will happen in your life that day. Of course there are surprises, but for the most part you know. You are sure that if you want a vanilla latte from Starbuck’s, you’ll be able to get it. Here, we can’t count on having milk tomorrow, or even electricity, Internet access, telephone service, or safety.

  I can’t even imagine what it would be like to live your whole life in a place where such uncertainty was constant. I think about these Iraqi folks I see every day. They can’t stand on a street corner without fear. They can’t go to Walmart and buy toilet paper or milk. They take what they can get.

  And to think that I get upset in the OR at home if somebody changes brands of a sponge without asking me; here, I use every corner of every sponge until it’s absolutely soaked because there’s not enough to allow us to be wasteful. If we drop an instrument in the OR, it takes three hours to resterilize it — so we don’t drop them. At home, surgeons get mad about something and refuse to use it, or they throw it across the room if it doesn’t function properly. Here, if you threw something you’d just have to do without.

  To my fellow surgeons out there: you really can get these cases done without all your preferences being exactly met. I can do a trauma case here in the same amount of time as at home, without any of my fancy instruments. We are very spoiled in America.

  Last night I was called to the ER to see an Iraqi policeman who was shot in the face at point-blank range. Amazingly, the bullet went through his sinuses and completely missed both eyes and his brain. He’s going to be okay. It’s sort of like he had sinus surgery done. He must be living right.

 

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