by Steven Conte
The third patient was another grenadier, younger than the first, with a shrapnel wound to the groin. His genitals had been spared but he had severe abdominal pain and the muscles of his abdomen were rigid, and when Bauer lowered an ear to his belly there was no sound of peristalsis. The decision to open the abdomen was a grim one, since the forty percent survival rate he and Metz achieved with this surgery was considered high, infection too often undoing their good work. The risk of doing nothing, however, was usually greater. This time Bauer was relieved to discover that the missile, a steel fragment the size and shape of a thumbnail, had severed a vein but narrowly missed the bladder and bowels. Retrieving it was easy. He tied off the vein and closed the wound.
When he returned to the reception room the assurance he projected was more or less real. Zöllner, a non-smoker, lit and handed him a cigarette; Bauer thanked him and took a series of quick, restorative puffs, gave the rest back and then selected another patient. Returning to the theatre he felt he was part of a well-functioning machine, each man knowing his role and, with the exception of Hirsch, performing it to perfection – though to be fair to Hirsch, so far today he’d done well. At the other table Metz was admonishing Molineux for some ribald remark, a soothingly familiar exchange.
Bauer’s next patient was a panzerman, the victim of an anti-tank mine that had mangled his lower right leg. Transfusion had failed to improve his condition, making the decision to amputate an easy one, since nothing killed a patient faster than attempting to save an unviable limb. The panzerman would have to lose his leg above the knee, and so Bauer began by making two vertical incisions in the lower thigh, creating a pair of cuffs which he then folded upwards. The muscle of the thigh he severed with a scalpel, clamping and ligaturing arteries as he went. The femur he sawed. More muscle, a final strip of skin, then the knee and lower leg came away. Pflieger carried off the amputated limb and Bauer turned his attention to the stump, aiming to minimise the risk of painful complications by severing nerve endings as far as possible inside the muscle, and then by bevelling the bone. He then let the skin flaps he’d created fall into place, dressed the stump and protected it further with a plaster cap. In Oryol the unsecured flaps could be sutured into place in a less hurried and more reliably aseptic theatre. Already the patient’s heart rate and blood pressure had stabilised. There was colour in his cheeks.
Bauer had planned to operate next on another burned panzerman, but in the reception room an even more desperate case had appeared, a Landser who had lost his right leg below the knee to a shell and whose thigh had taken on the telltale blackish-green hue of gas gangrene. Bauer selected a site on the thigh for amputation, the highest possible, then noticed swelling in the abdomen, put his ear to it and heard gas crepitating underneath the skin. Immediately he instructed Zöllner to set up a transfusion and hurried back to the theatre to wash his hands, but before he could explain to Hirsch the change of plan Zöllner appeared at the door and told them the Landser had just died.
It was the burned panzerman’s turn, after all. About thirty percent of his body was affected, chiefly his chest and neck and arms, making his prospects for survival better than those of the man Bauer had failed to save the week before, though his neck, in particular, was in a bad way. Zöllner had set up transfusions of both plasma and blood, and Bauer began the grisly task of cleaning the scorched and contaminated skin. When this was done he dressed the affected areas with Vaseline nets and saline compresses. Only time would tell whether these measures would succeed.
As he wrote up his notes he lit a cigarette, then in the reception he devoured a plate of biscuits and knocked back a cup of real coffee – a treat that Winkel reserved for lengthy shifts. The floor was crowded now with the wounded and the stench was bad. Zöllner was as usual tireless, here cradling a man vomiting into a dish, there replacing a blood-sodden bandage, before washing his hands and returning to the transfusions bay.
In the operating room Metz was performing abdominal surgery, and along with the odour of ether the air stank of faeces. Bauer’s next case was also abdominal, a gunshot wound to the upper left of the patient’s midriff. Part of the colon was protruding, and in the wound there was a great deal of faecal matter, which Winkel swabbed away. This in turn exposed a rent in the splenic flexure, too large to close, and so instead Bauer excised the damaged area and mobilised the ends, bringing them to the surface and stitching their sides together to form a double stoma. Later, if the patient survived, this could be repaired and closed, either in Chern or at the base hospital in Oryol. The essence here was speed.
Next was a landmine wound to a lower leg, the foot so severely pulped there was no question of saving it, though he thought the knee could be preserved. Accordingly he amputated at the ankle, closed the artery but otherwise left the stump unsutured, protecting it for travel with a plaster cap. In his notes he recommended a revised amputation below the knee.
The following case was a shell wound to a thigh. The femur was broken, its fractured ends protruding from the back of the leg, so that at some point during the evacuation one of the shattered points had pierced the canvas of the patient’s stretcher and snagged. Bauer’s first thought was to amputate, since a fractured femur was a perilous wound, prone to both haemorrhage and infection. This particular wound was grossly contaminated; however, the break was simple and so he decided to repair it, resigning himself to the painstaking task of debriding the dead and dirt-riddled flesh. When finally the wound was clean he set the bone and encased the thigh in a plaster splint, another technique he had learned from Metz, who had himself discovered it in a paper by Trueta, who had been with the Republicans in Spain – proof that when it came to honing his surgical skills Metz was smart enough to set ideology aside.
In the reception room Bauer ate a sandwich, gulped down a coffee and smoked a cigarette before scrubbing up again and returning to the fray. He resumed with a nephrectomy of a kidney too damaged to save. Followed it with another shotgun wound to a lung. He had to amputate both legs of a Landser who had been machine-gunned in the thighs, causing Pflieger some dismay, as the entry and exit wounds looked positively tidy, the real damage being maceration from the pressure waves of the transiting bullets. He sutured multiple rents in a small intestine, and one large tear in a liver. He plucked spicules of skull from a brain. He stabilised a panzerman whose field medical card had both of its side-strips torn off, rhyming grimly with his torso, which was deprived of arms. He excised shrapnel from a shoulder. Drained fluid from a knee the size of a football and injected it with sulphonamide. Plastered a second fractured femur. Amputated a hand. Inserted a catheter through the abdomen of a Landser in great agony from urine retention caused by a paralysing gunshot wound to his spine. Looked up and in amazement saw that night had come, thought of stopping for a meal but kept working. Alongside him Metz seemed indefatigable, and there were casualties still coming in, the reception room as crowded as it had been at the start.
Another Landser arrived, this one with gas gangrene in an arm; Bauer amputated and the patient rapidly improved, only to deteriorate again forty minutes later and die of renal failure caused by protracted shock. ‘Another one gone to Valhalla,’ Pflieger said – an allowable blasphemy, Bauer decided, as he worked on clearing the airways of a red-headed grenadier with a gunshot wound to the face. He followed this with exploratory surgery on an officer who was showing signs of intra-abdominal injury from a shell wound to his back, and to his relief discovered only bruising to the posterior wall of the belly. He sutured another liver. Reassembled a shattered forearm. Selected, with deep foreboding, a third gas gangrene case, this time in a knee, amputated at thigh level and then an hour later experienced a surge of elation at the news that the patient had woken, was speaking and looked likely to live. This was the reason for his being, he thought: a life saved, a soul plucked bodily from the flood.
‘A break, sir?’ Winkel asked.
‘Why? Are you tired?’
‘I thought you were, sir.
You didn’t answer when I spoke.’
‘I didn’t?’ He checked his watch and saw that midnight was approaching, looked at his men and saw they were exhausted. ‘Very well, gentlemen, let’s break for a meal.’
In spite of fitful attempts to keep it clean, the floor was a shambles of dirty bandages, scraps of uniform, spent ordnance, body tissue and poorly mopped-up blood. Bloody footprints formed paths around the tables, from the tables to the instruments and autoclaves and towards the door. Bauer removed his mask and scrubs and instantly felt poleaxed by fatigue. He could scarcely stand, and yet Pflieger and Demchak were getting a broom and a mop. How he loved these men, he thought. Loved them like brothers. Even Hirsch, he realised. Hirsch, who had laboured alongside him for eighteen hours at a task for which he wasn’t trained, mostly performing well enough and certainly without deadly consequences.
Metz looked up from his patient. ‘Leaving already?’
‘For a bite to eat,’ Bauer said. ‘The men, you know.’ Immediately he felt ashamed of this evasion, though if it made Metz think of his own team it would be no bad thing. They looked exhausted, even Molineux, whose wisecracks had long since petered out. Clearly Metz’s men weren’t benefiting from whatever boost Drexel was administering to their boss.
When twenty minutes later Bauer returned, Metz relented and gave himself and his men a break. Without them the operating room seemed tranquil, an effect also of the hour, the dead of night – a time of lowered vitality for all, not least the wounded, further endangering their lives.
The next patient had a gangrenous knee, not the gaseous kind but if left untreated just as deadly in the end. However tired he was, Bauer reminded himself, he had to give this man the same care and attention as the first. Loves or is loved, he thought constantly as he amputated, concerned less about the truth of the incantation than its usefulness in keeping him alert.
The next patient, a gnarled looking sergeant in his forties, had had the left side of his chest punched in by shrapnel, his efforts to breathe causing a triangle of skin to flap on the wound. He was heavily sedated, presumably because some medic had thought he would die before reaching a surgeon. This was a desperate case. The morphine, the eleven hours that had elapsed since his wounding – everything counted against him; but having made it this far, concluded Bauer, the man deserved a chance to live.
‘Look there,’ Winkel said, gesturing at a scar on the patient’s chest, right beside the sternum, faded evidence of an old gunshot wound. ‘The last war?’
Bauer nodded. ‘So it seems.’
‘Poor sod,’ Pflieger said.
‘Or born lucky,’ Bauer countered, taking up his scalpel and entering the wound. From the thorax the shrapnel had travelled diagonally into the abdomen. Using a series of incisions, Bauer found and methodically repaired the lacerated lung, the left kidney, the liver and the small intestines, choosing thoroughness over speed, the dangers of a lengthy operation outweighed in his mind by doubts that the patient could survive a second surgery.
When Metz returned he paused to watch what was happening, and when the patient died, at the forty-four minute mark, he left his own patient to come over and put a hand on Bauer’s shoulder, an unprecedented act. ‘Bad luck, Captain. You did your best. You did well to get him as far as you did.’
Bauer mumbled his thanks, close to coming undone. To pull himself together he went and washed his hands, wondering if he’d been wrong to draw out the surgery. Could he have packed the liver to contain the bleeding instead of painstakingly under-running each haemorrhaging vessel? Rather than suturing the small intestine, should he have excised the damaged portions and created stomas? He could only put the failure behind him and press on, though what he yearned to do was rush outside and bellow into the darkness for this to stop, for someone to take pity and in the name of everything true and good bring this slaughter to an end.
The next patient’s injury was if anything worse than the dead sergeant’s. At least, this was Bauer’s instinctive reaction to the sight of a bloodied pubis, the genitals shorn off by shrapnel. The 23-year-old victim, like the sergeant, had been heavily dosed with morphine, and though his life was in no immediate danger there was presumably a distinct risk of suicide, men preferring, as a rule, to lose both legs rather than their genitals. Bauer felt that way himself, proof of the strangeness of the human condition. Hirsch administered the anaesthetic, while Molineux, noticing the wound, came over to the stretcher and swore. ‘Thought I’d seen everything,’ he said. ‘Bits shot off, destroyed. But pussified? That’s something else.’
Unwillingly Bauer saw that the resemblance was real: a ruff of pubic hair, lips of remnant flesh. ‘Hermann, of all the vile, abhorrent things to come out of your mouth, that is by far the worst.’
Molineux guffawed, and suddenly all of them were laughing, Bauer too, so violently that he doubled over, tears streaming from his eyes. Metz was yelling at them, demanding quiet, but though appalled with himself Bauer couldn’t stop. For more than a minute he laughed, and when finally it was over he felt abashed but relieved, wrung out, exhausted but calm. He gathered his thoughts, did what he could for the patient then called for the next.
For the rest of the night he operated in a kind of trance, fuelled by cigarettes, coffee and the knowledge that he had no choice but to press on, that he and Metz were it, there was no one else, and that to stop would cost men their lives. His hands were sore, his neck was sore, his feet and legs were in pain, and increasingly he envied Hirsch’s seated position and fantasised about changing places with him. Between procedures he forced himself to take detailed notes, knowing that the moment he put down the pencil the last surgery would vanish from his mind.
Towards daybreak, in a gloomy corner of the reception room, he encountered a patient he was in no danger of forgetting, a supply sergeant with an enormous furrow across his abdomen. Where previously there must have been organs, all that remained were tags of fat that Bauer guessed were mesentery or omentum. Amazingly the man was conscious. Carefully Bauer put the field dressings back in place then surreptitiously shook his head to the medics who had brought him in, prescribed morphine and had them carry him off behind the curtain.
They had learned the day before that a major offensive was underway, but it was only when daylight arrived and the flow of casualties increased that Bauer became preoccupied with its progress. Reports varied, but as the day went on it became clear to him that regardless of the outcome, the division was being destroyed. No city could be worth such a sacrifice. By late morning even these thoughts fell away, his world narrowed to the patient in front of him, until this too was beyond him and he could only cope with acts. Now I am ligaturing, he told himself. Now I am picking up these forceps. Now I must open my mouth and ask Hirsch to titrate the ether. Twice Winkel had to prompt him when he forgot what he was doing, and so when Hirsch fell asleep in his chair Bauer let him doze, completed the operation then lay down under the instruments table and let himself sleep. Fifteen minutes later, as instructed, Demchak shook him awake and he went back to work, feeling partly restored, though by the time the others had each taken a nap he felt just as exhausted as before. It was like operating drunk, and he was terrified of killing someone. But there was no one else, he thought. No one else.
Night was falling for a second time and the wards and the corridors were choked with post-operative cases when at last the reception room began to clear. Bauer felt like an automaton, halting, slow. He spoke little. Dreamed of sleep. Of home. He commenced his final surgery. Finished it. Stepped away. He had operated for thirty-six, almost thirty-seven hours. Winkel too. Demchak, Pflieger. They had performed magnificently and he thanked them for it, then because words seemed insufficient he shook each of them by the hand, felt a rush of emotion and had to turn away. Luckily Metz then called him over and, sounding irritable, asked for help with some suturing. His hands were trembling, Bauer saw. Fortunately it was a simple task, and quickly he was able to hand the patient back. He wrote
up the notes from his last operation and then took the precaution of checking the reception room. Zöllner was still there, tidying up with an attendant. Bauer thanked him, told him he’d done a fine job, and was turning away when a beefy face appeared at floor level between the curtains in the corner.
‘Oi, doctor! What about me?’
Bauer walked over and pulled the curtains aside, revealing a big man on a stretcher.
‘Since you saw me last night they ain’t done nothing for me,’ he said.
Bauer was about to deny having seen him at all, but hesitated, lifted the man’s blanket and instantly recognised the field dressing on his abdomen. The supply sergeant, he recalled. With some difficulty he peeled off the dressing and re-examined the enormous transverse wound, first with dread and then incredulity, followed by mortification and suppressed hilarity. The sergeant was immensely fat, and what in poor light and deep fatigue the night before Bauer had seen as an evisceration was in reality a deep trench through the adipose layers of the belly, the tissue he had mistaken as mesentery and omentum no more than shreds of fat. This was a flesh wound, albeit a gigantic one, not the mortal injury he had taken it to be. Immediately he called for Winkel and the others to help him get the fellow into surgery, and there he cleaned up and tidied the wound. A delayed primary suture in Chern or Oryol would not only restore the sergeant to health but also to a trimmer version of himself.