by Harry Parker
I had done it all before: secured sections of the ribbon, dominated areas of dirt, reassured little labels, ambushed red markers and attacked through clusters of wooden blocks. I had destroyed as my end was pushed down hard and twisted into the ground. I’d drawn lines in the sand that were fire-support positions and traced casualty evacuation routes through miniature fields. I was the master of the model.
After he answered a few questions and everyone around him said they understood their part in the mission, he handed me to another man. This one told them what to do if there was a casualty, what equipment they should carry and how they should stay hydrated. He pointed me at an emergency landing site and circled me around an open section near M13, so I left a mark in the dust.
He pointed me at a man sitting embarrassed in the corner and told him that if he acted like he had on the last patrol, he’d make him wish he had been blown up. The others chuckled but I swept across all of them and he said it applied to everyone. He told them what needed to happen in the hours before they moved down the orange ribbon, then he handed me back to the first man.
‘Thanks, Sergeant Dee. Right, that should all be clear now,’ he said. ‘Just to add to the timings, we’ll do rehearsals at eighteen hundred tonight on the HLS.’
‘Sir, are you sure we need to rehearse this?’ a soldier said from the far side of the square.
‘Yes, until we’re the most swept-up platoon this side of the capital, we’ll be doing rehearsals before every platoon operation.’
The men fidgeted.
‘Listen to me – every one of you,’ he said, his hand gripped tight around me. The men looked up. ‘I don’t give a shit how straightforward this operation is, or how much of a waste of time you think rehearsals are, or whether you’d rather be tossing off in your beds, we will rehearse until every man in this platoon—’ He stabbed me down into the model. ‘We’ve only just got here. The last company had four casualties in two weeks, and this is new ground for us all, so no man in this platoon will cut corners.’
They all stared at him and he wondered if they thought he was a prick.
‘See you at six,’ he said.
He put me down on the model and ducked out under the netting and into the sun. The other men started to drift away. Some collected in a small group and one of them picked me up and pointed me at a spot of earth and talked them through how they would move out to the small wooden block with M13 painted on it.
13
‘You heading to the pub tonight?’
‘Not sure. Can you pass me the debrider?’
‘It’s Mandy’s birthday.’
They talked above the beep of a machine and the hum of a pump.
‘Mandy? Not sure I know her … Cheers.’
‘She works down in A and E.’
‘Can you hold that back while I irrigate? Use those forceps, thanks.’
They stood over the table, their heads covered with masks and bandanas so only their glasses were visible. They wore blue scrubs and worked below an array of suspended lights, bent over pink flesh that spilt from a leg. They cleaned or cut away putrid grey areas, glancing up from the wounds to a screen that showed magnified swirls of red, shiny bulges of scarlet and globules of white.
This mess slopped out of a body splayed on the table. The body’s arms were held out cruciform on padded extensions and the head was obscured by a mask and pipes that fed up to machines. There were other people in the room who monitored the apparatus or handed the men equipment.
I was on a stainless-steel shelf at the side of the room with other things required for specialist operations. The body had been brought in a few hours earlier and rolled past me up to the operating table. They had plugged it into the machines, arranged it on the slab and removed the dressings from the first limb. It was shorter than it should have been. The men had worked on the limb before covering it again.
Then they’d cleaned everything and started on the second limb that still had a foot, swollen but undamaged. They had peeled away plastic sheeting, gauze and bandages to reveal the leg. They’d worked up along the inside, which was unnaturally thin where sections were missing. In some places it had no skin, only exposed flesh that flopped out, unbounded. When they moved up to the calf they started talking again.
‘Not looking great, is it?’ one said.
‘We’ve done a leg in two hours – reckon we should finish before three.’
‘No, I mean, look at this section here. God, it stinks,’ he said and pushed at it with forceps.
‘Doesn’t look too bad to me,’ the other said.
‘There’s so much marginal tissue. We should get Al’s opinion on this.’
‘Why?’
‘Because it might need some drastic action. I think it looks like the infection’s taken hold.’ He pushed two rubber-gloved fingers under the skin and deep into the thigh, along a tract of rancid flesh.
‘Let’s just finish the debridement and cover him up as planned,’ the second man said. ‘We don’t need to disturb Al. He was in surgery most of yesterday.’
‘If we cover him and there’s similar levels of necrosis when we next debride … well, I reckon with this infection there’s a good chance …’
‘What?’
‘I don’t know, I just think it could seriously compromise the patient. I’m going to call him. I want a second opinion.’
‘I’m your second opinion.’
But the first man walked over to the door, removed his gloves and left the tiled room, while the other man sat on a stool and sighed.
A woman unclipped and replaced an empty blood bag that hung above the body. She moved down to the legs and loosened a tourniquet and glanced at her watch.
‘A second opinion can’t hurt, Ben,’ she said.
The man came back into the room a minute later.
‘Al’s on his way,’ he said. ‘Let’s keep cleaning the wounds. How are his levels, Sarah?’
‘Fine. He’s going through a surprising amount of blood, though.’ She looked at a chart.
‘Too much?’
‘Not sure,’ she said. ‘I don’t think so.’
They worked on the body until another man, dressed in blue scrubs, backed through the doors with his hands held in front of him. He came over to the table and they started to discuss the body.
He nodded a few times and then delved into the soft tissue. ‘You were right to come and get me, Mike,’ he said.
‘What do you think?’
‘The infection has spread much farther than I would’ve anticipated.’ He stood back and wiped across his eyebrows with his forearm. ‘Ben, can you go and get Dr Shakoor, please?’
‘Calling the cavalry, are we?’ He unhooked forceps from the front of his bloody scrubs.
‘Yes, Ben, quick as you can, please.’
Soon the room was crowded with people peering down at the body and talking through options. Some of them wore head torches that bathed the wounds in hard light.
‘The infection’s too aggressive and I’m not sure it’ll respond to anti-fungals,’ he said. ‘Have we taken swabs and samples again?’
‘Already taken, Al,’ a nurse said.
A female surgeon had joined them. ‘So we debride aggressively along the length of the leg and hope we cut it all out?’ she said.
‘I’m not sure there’s any point, Nadia. He’ll get very little function from the leg. None of the grafts we attempted last time have taken.’
‘On balance, my advice would be to try and save the limb; at least give it another few days and see if it improves,’ she said. She had lifted a flap of muscle to inspect a cavity.
‘I don’t want to lose another to infection. I think there’s a real danger this could spread quickly and there’ll be very little we can do once the infection reaches his abdomen.’
‘Okay, Al. It’s your call.’
‘Mike, can you get the team together and prep.’
‘Sure.’ Some of them went for new equipment,
fluids and blood bags. One walked towards me and started to arrange implements on a trolley.
‘Al, I’m a bit worried about blood loss,’ the woman near the body’s head said. ‘His temperature’s dropped again.’
‘Okay, Sarah, show me.’ He moved up to the machines. ‘Bit of time pressure now, everybody. Do we know where the parents are? I’d better go and talk it through with them. Nadia, can you start an assessment please? We want as much function as possible but really need to get rid of this bloody infection. Back in a mo.’
‘I’ll help you track them down,’ the nurse said. ‘They could do with an update. We told them this would be a routine debridement so they might be a tad worried by now.’
‘Wait, Al.’ The female surgeon was peering into a cavity.
‘What is it, Nadia?’ He walked back and looked over her shoulder.
‘It must’ve haemorrhaged as this section was cleaned.’ When she moved a flap of flesh, blood gushed out from behind it over the slab and dripped onto the floor.
‘Right, no time to lose. Sarah, get more bloods prepped. We’re going to do it now.’
*
It happened faster than normal. I was picked up and rattled onto a stainless-steel trolley spread with tools that had been carefully lined up, but the knives and forceps spun and slid about as it was quickly wheeled over.
I was now at the end of the table next to the body.
‘Someone go and tell the family.’ He lifted the leg and inspected it, moving the puffy flesh.
‘How high?’ he asked. No one answered. He was over the body, still assessing it and the others looked at him and over his shoulder, waiting for his decision. He glanced at the body’s head and paused.
‘Al, we’re a bit low on blood. Pressure has just decreased dramatically.’
The woman was watching a machine.
‘How can we be low, Sarah?’ He looked up at her. ‘Well, go get some more. And can someone please clean this off the floor? I’m slipping.’
He then spoke very little and the team around him started to move to each command he gave. A man cleaned the floor, smearing sweeps of blood by his feet, but he ignored them as more blood dripped down onto the tiles.
‘Right, I’m going to do it around here.’ His finger traced a line of blood over the intact skin of the thigh. ‘There’s no muscle in this region to do a myodesis, so I’ll use what’s left of the vastus lateralis and femoris to wrap over the distal limb,’ he said as the flesh wobbled in his hands. ‘We can use this skin to cover it and avoid too much exposed tissue. We then graft up the inner thigh. That should provide good function.’
‘Al, his levels are stable, but I advise we get a move on.’
‘Right, let’s do it. Scalpel.’
He slashed decisively across the skin, smoothly splitting the flesh apart. The cuts of the scalpel swept down through the subcutaneous tissue and fascia, deep into the flesh and through muscle and membrane that covered the bone. He slid the blade around and through dead and dying flesh; blood paused after each cut before seeping out the ends of the vessels. He asked for the tourniquet to be tightened.
He went carefully in some areas and created a flap of muscle that hung down. He dissected the sciatic nerve proximally. Sweat showed on the bridge of his nose. He used absorbent sutures and then repositioned the grey sheaths of nerves with prods of his finger.
Then he told them he was now going to address the femoral vessels and the woman helped him transect an artery and two veins. Dark red blood pulsed out and the tubes collapsed. One slipped free and disappeared into the mess. She swore and delved in with forceps to pull it out. He asked for a stick-tie for the double ligation, which he manoeuvred with long metal tweezers before letting the sutures clamp around the rubbery tubes.
He grunted that he wanted the electrocautery forceps, and a small machine resting next to me on the trolley was handed to him. He placed it against the arteries and it sparked as it cauterised the ends of the vessels. He told them they had achieved haemostasis and the smell of burnt flesh wafted up.
He told them he was happy so far and he glanced down at me. He stretched his back and said that he was getting too old for this.
He asked for a Cobb elevator. A small metal implement was picked off the trolley and he cleaned away soft tissue from the bone until the white showed. He shaved away a thick ridge and all the periosteum he could get to.
The soft fleshy areas of the leg were now held apart by a bar of bone that was dry and hard between them. Two others helped him position retractors that pulled the flesh out of the way so the bone was clear. They had worked faster than I had experienced before.
He asked for the oscillating saw.
I was passed to him. He gripped my handle and placed a gloved finger on my metal trigger. He held me like a weapon, and down at the end of my barrel was my flat stainless-steel blade, with its sharp teeth pointing forward in overlapping rows. He pulled my trigger and my motor whirred and my blade-end blurred.
This was when I became useful.
He said he was happy to make the cut. He asked one of them to hold the limb. His masked face looked down over me and his head torch lit my matte surface. I was in the valley between two banks of flesh, pointing straight down at the exposed shaft of the femur.
He pulled my trigger again and I made my blade vibrate so that its teeth distorted together as one. He pulled harder until my blade was cycling sixteen thousand times a minute. My high-pitched buzz was new in the room and the men and women shifted uncomfortably.
He held me an inch above and then lowered me so my ninety-millimetre-wide blade touched the bone. The pitch changed as I started to cut down. My blade heated quickly and they squirted saline solution onto me and into the cutting face. It evaporated in steam that swirled around the bone and prevented me from overheating.
He let my weight descend. My blade-end cut through the bone, flashing splinters and dust from the thin trench I gouged out. The juddering of bone passed through the pelvis and into the body so that its skull trembled. The sound of my blade changed tone again as I cut deeper and into the marrow. A small pile of dust and shards grew on the table below me.
He concentrated, his hand steady around me as I cut smoothly down. And then I was nearly through and the trench started to pull open under the weight of the limb. He told them to support it firmly until he was through.
Suddenly I jerked down and was oscillating free in the air. The bone pulled apart and the leg and its foot moved away, the gap widening until it was no longer below the body but being placed on another trolley that was quickly wheeled away. The body had no feet.
He released his finger and my motor stopped. It was quiet in the room and the beep of a machine returned. I was placed back down.
‘Make sure we take samples from that,’ he said, nodding at the leg being pushed through the door.
I had changed the body’s proportions for ever. It no longer filled the space it should. The bone stuck out of the muscle and tissue, the end flat with deep red marrow and surrounded by the sharp white where I had mutilated it.
He told them that he was pleased so far but wanted to get everything closed up before anyone took a break. He asked for the rasp to remove the sharp edges I had left. And then the woman near the body’s head told him something wasn’t going according to plan.
‘Al, I think he’s crashing.’
‘What? Why now, Sarah?’
‘I’m not sure.’
‘Is he going into arrest?’
‘Just keep going, but you need to be quick.’
‘Mike, irrigate now,’ he said. ‘Get as much bone dust and fragments out as you can. And let’s check ligation quickly, release the tourniquet.’
One of them poured water over the wound and brushed the pearly mass with a hand. Someone released the tourniquet and the vessels showed red and pulsed. ‘Looks good.’
‘No, that one’s split.’ Blood seeped and then burst out in a sudden rivulet. ‘Quick, tou
rniquet back on.’ He worked rapidly and re-clamped the vessel, holding his breath as his hand shook.
‘Well done, Al. Shall we rasp the sharp edges?’
‘No time, Nadia. I’m going to perform the myodesis now. Drill.’
The drill next to me on the trolley was given to him. He placed it against the femur and drilled holes through the end of the bone.
‘Sutures,’ he said. They were handed to him, and he threaded them through the holes and into the centre of the bone. He passed the curved needle back through the holes so six lengths of thin white cord lay out across the table.
‘Nadia, get the medial hamstring ready. I’m going to do it straight away.’ She used forceps to stretch a white band out of the tissue. The needle was squashed through the tendon and the white thread followed until the band was pulled tight across the end of the bone.
‘Secure?’ he said.
‘Looks good,’ she said.
‘Sarah, how’s he doing?’
‘The quicker the better, Al. His cardiovascular system is stressed.’
They worked as quickly as they could. The rhythm of the machine faltered and the woman updated them with numbers and the body’s condition.
They cut the excess tendon away and stitched a flap of muscle to it with tugs of the white cord that made the flesh wobble. The bone was covered now.
They pulled in other pink slabs of muscle and sutured them together, drawing the slippery mass around the bone. They discussed whether there was a good balance in the stump, if he would have good function. But she interrupted them and said he wouldn’t have any function at all if they lost him on the table.
They started to stitch layers of flesh, using surgical staples to pinch the mess together. The stump took shape and the skin closed around it. They talked to one another as they worked together across the opening. There wasn’t enough skin left to cover the whole of the wound, and wet areas remained along the thigh. He told them they would leave the wound open for now and graft once they were sure there was no infection.