The Children's War

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The Children's War Page 7

by C. P. Boyko


  A mortar exploded miles away, reverberating like an excerpt of thunder. Hillary wished it would come closer.

  Lying in bed with her eyes open, she realized that she was wrong. Hartner had not examined Private Shibiatisu that day, but earlier in the week. Gratefully she pushed the memory from her mind and groped to recover the correct thread.

  Someone was shouting, “Mass casualties! Twenty twenty-eight and ten. Mass casualties! All medical staff to the PR. Twenty twenty-eight and ten mass cas!” She rolled off her rack, laced up her boots, and stepped, blinking, into bright sunlight. Had she slept all night and all morning? “Sorry,” said a voice, and the light went out. “Sorry.” It was Nurse Hashmi, coming off shift. —Hillary was up on her elbows. “Mass casualties . . . ?” —“Naw, it’s slowing down. Go back to sleep.”

  Someone was shouting, “Mass casualties! Twenty twenty-eight and ten!” Hartner and the others headed toward the scrub station outside the preponderant room. —“Well, doctors,” said Hartner, smiling grimly. —Baltin said, “Here we go.” —Table ten needed a doctor; Hillary hurried over. Nurse Thota and Orderly Mills were trying to place an IV in the arm of a writhing, kicking, groaning boy with a shattered head (blunt cranial trauma). Where his nose had been was a bleeding knot of crushed cartilage; one eye was swollen shut and the other was split open and aimed vacantly at the ceiling; his upper lip, torn diagonally in a grotesque sneer, hung in a flap on his cheek, revealing smashed teeth oozing pulp. He looked as if he’d been hit in the face with a sledgehammer. According to Mills, it had been a rocket-propeled grenade—a dud. Hillary did not know where to begin (what would she do with his eye? pry it out with a spud? suck it out with the aspirator?), but she could at least place an IV and secure an airway. She gave him a shot of succinylcholine in his thigh to relax him enough to allow Mills to insert the IV. Now, lying awake hours later, she stiffened in horror: succinylcholine increased intracranial pressure, which, given the state of his cranium, was probably what had killed him. Nor, given the state of his mouth, could it have been a good idea to intubate him. She should have gone in through his cricothyroid membrane. Well, it hadn’t mattered. They’d placed the IV, oxygenated him, sedated him, and she had just slid the laryngoscope over his tongue when Nurse Thota observed that the patient had expired. “Space on ten!,” Mills shouted, waving. Perhaps it wasn’t her fault. Probably he would have died anyway. Triage should probably have sent him straight to the AR. The next casualty’s clothes and hair were dark with blood; blood suffused his gurney and dripped onto the floor as the clerk’s orderly pushed it across the room. —“Where’s the site of injury?” —Nobody knew. —“Why hasn’t his wound been pressure-dressed?” —No one knew. They hoisted him onto the resuscitation table and cut open his sodden uniform. His eyes were rolled back in his head and his breathing was rapid and labored, sounding sometimes dry and sometimes wet. She told Mills to get a transfusion ready, while she and Nurse Thota searched for the injury. With dozens of laparotomy pads they wiped blood from his abdomen, chest, legs, face, and scalp, but as soon as they had moved to a new area the old area was glistening with fresh blood. He seemed to be exuding blood from his pores. —“Help me roll him onto his front.” —“Forget it, doctor.” —“Help me roll him over!” —“It’s no use, doctor. He’s kaput.” —She never did learn where he was bleeding from. (Now, lying in bed, she felt a stab of anger: there must already have been two liters of blood in a pool on the gurney by the time he got to her; he too should have been sent directly to anticipatory.) Mills came back and changed the table cover. “Space on ten!” Next came three or four major abdominal injuries that blurred together in her memory: at least one from multiple gunshots, one from a bounding mine, and one from what was probably a fragment of mortar shell. They had all lost too much blood to undergo sedation or the extensive surgery required. In every case Mills started IV blood and fluids while Hillary and Nurse Thota stopped the bleeding by packing the abdomen with bowel bags and laparotomy pads. Then, covering the viscera with another bowel bag, they placed chest-tube drains and stapled them to the skin, filled in any gaps with sponges, and covered the entire wound with a drape and an IV bag, leaving the skin open. Then they sent the casualty to intensive care to stabilize, at which point a more comprehensive operation could be undertaken. In the middle of one of these packings, Hartner, behind Hillary on table eight, called to her. She hesitated for a moment, then told Nurse Thota to take over. At Hartner’s table, Nurse Glauberzon was standing a few steps away and scowling. —“Doctor V.,” said Hartner, “with your skilled and steady hands will you kindly hold this clamp in place?” —“Should I rescrub?” —“No, don’t bother.” —She took the handles from him but could not see what she was clamping: the chest wound that he was working in was filled with blood and grayish-pink froth from a ruptured lung. How had he been able to see enough to place the clamp? How could he see now what he was doing? —“That’s it. Thank you, doctor. I think we’ll manage from here.”

  (Hartner told Private Shibiatisu that her liver might be damaged. He asked if she often drank alcohol, or whether she had drunk a lot four days ago. She said she never drank: it didn’t agree with her. Then, without further prompting, she asked him softly if her sickness might have something to do with the pills she’d taken. —“What pills were those, private?” —She looked away, abashed. “Headache pills.” —“Did you have a headache?” —“No, sir.” —“How many did you take?” —She closed her eyes and pursed her lips, as if she would not answer. Then she said, “I couldn’t take any more.” —“Any more pills?” —She shook her head. Sweat ran down her face like tears. “Just any more.” —“How many pills did you take, private?” —“Two bottles.” —“How many pills were in the bottles?” —She didn’t answer. Her face became blank, her eyes vacant. She’d forgotten they were there. —Hartner repeated the question. —“All of them. They were new bottles.” —“Ah, fuck,” said Caltavos, “fuck me.” —“I didn’t want to go out again. I couldn’t go out again.” —“All right, private. Get some rest.” —“I’m sorry, doc.” —“Don’t you worry about it. You’ll be all right.” —“Don’t tell Sergeant Psorakis, will you? He’d shit down my throat.” —They moved away from her bed and Caltavos said, “I asked her. I asked her three days ago when she came in if she’d taken anything, if she was on anything. Ah, fuck, I should have caught it.” —“Well,” said Hartner, “there’s not much we can do now but make her comfortable. Let them know in the AR exactly what she’s in for, and maybe they’ll make her properly comfortable. She hasn’t got much to look forward to now but hemorrhage, multiple organ failure, and coma.” —“I should have caught it three days ago and we could have done something.” —“It’s not your fault, doctor. The triage assessment misled you. It could have happened to any of us.” —“But, Christ, you don’t expect the triage assessment to be right.” —Hartner sighed. “Not in this field hospital, you don’t.”)

  “Incoming mass casualties! Eighteen twenty and four mass cas!” —“Christ,” said Martoskif, who had been at the front, “I wish they wouldn’t shout ‘incoming’ like that.” —Hillary’s next casualty was awake and couldn’t stop talking. His ears were leaking blood, and his face, scalp, and shoulders were covered in a pox of tiny puncture wounds, some with slivers of shrapnel still protruding. “Shit—I’m lucky we overload our air-burst shells, or I’d be dead right now. Fucking short round came down right on my fucking head! I don’t know what the hell happened to my helmet. Must’ve knocked it off when I hit the ground. I guess they’ll give me a new one, won’t they? You know, aside from some ringing in my ears I feel great. Yeah, all that powder we put in them just rips those shells to shreds, thank God. How soon till I can go back?” He was pale, his extremities were trembling, and he started whenever they touched him. She was worried about central nervous damage caused by the blast, but since he was awake and his pupil reaction was normal she could not justify spending more time on him now. She sent him
to the NPR to have the shrapnel removed, his wounds cleaned, and his ears flushed. She ordered antibiotics and magnesium and recommended an eventual X-ray of his head. (Had she missed something? Why had triage sent him into the preponderant room at all?) Next came the screamer. She had heard him outside in the triage tent, but without realizing that she was hearing him; his screams had become background noise, like the helicopters landing outside, the artillery fire in the distance, the hissing of respirators and aspirators and the clacking of metal instruments on metal tables. Now, at close range, his wails of agony, interrupted only for breath, penetrated her skull. He had been shot in the shoulder. She peeled away the medic’s pressure-dressing. The wound was not severe, though the bullet had pierced the suprascapular nerve. —“Mills, how about a little sedative?” —“I’ve just given him a 150-milligram push of ketamine, doctor.” —“Oh. That’s rather a lot, isn’t it?” —“I sure hope so.” —“Well, let’s give it half a minute.” —They stood and waited with their hands on the patient, less to soothe him than to constrain him. But he continued to bring up from deep in his belly deafening howls of anguish, as if he were being burned and flayed simultaneously. Nurse Thota giggled. —“Okay,” said Hillary, “that’s enough. Let’s try some etomidate.” —“Thirty milligrams?” —“On top of the ketamine? Are you kidding? Maybe ten.” —“Fifteen?” —“Okay, fifteen.” —Caltavos and Baltin looked over from their tables in awe and consternation. The man continued to scream. —“Are you sure you’re in a viable vein?,” Hillary asked. —“Well,” said Mills, “it’s going somewhere.” —“Give him another fifteen of etomidate but let’s put in a new IV while we’re waiting for that to kick in, just in case.” —Nurse Thota said, “Maybe he’s immune to ketamine and etomidate.” —Hillary shook her head; she’d never heard of any such thing. The second dose of etomidate had no effect, so they tried a hundred milligrams of propofol in the new IV, then another hundred. Hillary said, “I’m afraid he’ll expire before we can sedate him.” —“Well, his heart’s still racing, so I wouldn’t worry about that.” —Martoskif came over and suggested they try thiopental. —“No,” said Hillary, “not on top of everything else. First let’s try another 150 of ketamine.” —“In which IV?” —“It doesn’t matter.” —The second dose of ketamine seemed to have some effect; at least, the breaths he took between screams lasted longer. —“Okay, another one-fifty in the same IV.”

  —Smiles were seen all around the preponderant room when, at last, the man’s screams diminished to groans and finally, after another injection, to whimpers. —“This guy’s a fucking sponge,” said Mills admiringly. “He can’t be more than eighty kilograms, either.” —Hillary debrided, flushed with hydrogen peroxide and saline, and dressed the wound, then sent him to the recovery ward with a note on his chart: “Resistant to sedatives.” She looked over her shoulder. Hartner was still working on the same casualty. “Space on ten!” Intensive care sent back a major abdominal injury who was not stabilizing: they could not get blood and fluids into him fast enough; he needed a central venous catheter. Hillary had performed several of these during her residency, all under supervision and all successful. Since arriving on the island she had bungled four, all unsupervised, and now dreaded them. The procedure was done percutaneously, without an incision, and was therefore considered elementary; but it was this fact, that she could not see what she was doing, or where exactly her needles and wires were going, that inflamed her imagination with visions of ravaging error. A guidewire was threaded through a large-bore needle into the subclavian vein of the shoulder, around a corner, and down into the superior vena cava, just centimeters above the right atrium of the heart; the needle was then removed, the puncture enlarged, and the catheter slid into place over the guidewire, which was then withdrawn. The main danger was entering instead the artery, which ran alongside the vein just below the clavicle. Usually one knew when one had done this, because the blood that entered the syringe was bright red and pulsating; but in casualties with low blood oxygen, low blood pressure, or (like this one) low blood volume, venous and arterial blood were not always easy to distinguish. Hillary, Mills, and Nurse Thota began by placing drapes, leaving exposed below the shoulder a square of skin which they scrubbed for a minute with povidone-iodine before injecting a small amount of lidocaine. Then, placing her left index finger on the sternal notch below the trachea and her thumb on the middle of the clavicle to guide her, she inserted the needle at a shallow angle into the groove between the deltoid and pectoral muscles. She advanced it carefully in the direction of the sternal notch, pulling back lightly on the plunger of the syringe with her thumb. The needle went in five, seven, nine centimeters, but still no blood entered the syringe. “Must have missed it,” she said, and tried again, this time half a centimeter closer to the clavicle, and therefore to the artery. This time she struck blood after only four centimeters. She felt a gust of panic, for though the blood was dark, almost purple in color, it seemed to be entering the syringe in spurts. She withdrew the needle; but now blood welled and spilled from the site slowly and steadily. Nevertheless, she applied pressure to the spot for five minutes (as one would do with an artery puncture), then tried again (as one would not do with an artery puncture). This time the blood was dark and did not pulsate. She advanced the needle another half centimeter and unscrewed the syringe, placing her thumb over the hub of the needle to prevent air from entering the vein. Nurse Thota handed her the curved guidewire, and Hillary fed it a centimeter at a time through the needle and ostensibly into the subclavian vein. This guidewire, unlike those she had used on the mainland, had no length markings, so she stopped when she guessed she had reached seventeen centimeters—eighteen being the textbook standard. However, while she was removing the needle, sliding it back over the guidewire, which she held as steady as possible, Mills noticed an arrhythmia on the heart monitor. She must have pushed the guidewire all the way into the heart. Then Hartner was addressing her, and for a moment she believed he was chastising her for her mistake.

  “Doctor V., will you please come with me?”

  “Of course,” she said automatically, but looked down at her bloody gloves holding the guidewire—a guitar string emerging from a disembodied shoulder.

  “Doctor V.? We need to talk to the senior triage officer right this instant.”

  Martoskif and Baltin were with him; so she dropped the wire and followed them out of the preponderant room.

  There were only four casualties in the triage tent, and they were all islanders. —“Where are the rest of the casualties?,” Hartner demanded. —“This is what’s left,” said Latroussaine. —“I thought there were thirty-eight nonwalking wounded altogether.” —“Yes. Two were retriaged nonpreponderant, and two self-triaged.” (By this he meant that they had died while awaiting treatment.) “Your staff has dealt with or is dealing with the rest.”

  From their conversation, and from movements around her in the PR of which she had been half aware, Hillary understood that the casualty Hartner had been working on for over an hour had expired, and that Latroussaine had sent him an islander as a replacement.

  “Oh,” said Latroussaine, feigning afterthought, “there is one mainlander left. But I thought it best to leave him till last. I’m sure you’ll agree.”

  But Hartner did not agree; and after ordering the triage clerk to fetch someone from ordnance disposal, he led his three doctors outside to the empty sandbagged shed where the soldier with a grenade in his belly lay alone.

  He was conscious and in pain, and aware of his plight. Gripping the sides of the gurney, the tendons of his neck popping out like cables, he warned them not to enter. “I’m likely to blow up.”

  “Nonsense,” said Hartner, laughter in his voice. “If it wasn’t a dud, it’d have gone off already. Right, private?” He sent Hillary and Martoskif for gloves, eyewear, anesthetic, an instrument cart, and a resuscitation box. “But nothing else. No heart monitors or ultrasounds or anything fanc
y with an electronic signal, all right?”

  They crossed the dusty, sun-drenched compound in silence.

  The soldier reminded her of Andrew. Why?

  Returning with the equipment, which rattled and yawed across the macadam, Martoskif said, “Hartner’s a crazy old bird, isn’t he?” There was amazement, and admiration, in his tone.

  Later, back in the PR, Martoskif and Baltin were exuberant, like naughty boys who had escaped punishment; they spoke loudly, laughed, and struck doctorly poses over their resuscitation tables. But Hillary felt no exhilaration—only a hollow remorse, as if she had left matches in reach of a child. While debriding wounds that afternoon, she kept expecting something to detonate every time her metal hemostat clicked against a metal fragment. Her belly tingled for hours afterwards, the skin there still quivering with the expectation of being ripped open by bursting shrapnel. Why her belly, and not her equally exposed chest or face? For some reason, she had pictured the grenade exploding in a horizontal fan, like a bounding mine—perhaps because the casualty himself had first been cut open by a bounding mine, before being penetrated by the rocket-propeled grenade while he lay on the ground bleeding. Was she identifying with the casualty, then? She recalled Hartner’s words of weeks ago: The operating table is no place for sympathy; sympathy is the response of the layman, who can give nothing else. Had she been reduced to sympathy?

 

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