Combat Doctor

by Marc Dauphin

  I practised family medicine in a small town; my family was happy, but I missed the military. So I joined up with the local reserve unit, an infantry regiment. More culture shock. The reserves were another world. There was no money, and no equipment. They had to make do in a country that sometimes believed that if you pretended that the bad guys weren’t there, they wouldn’t be. I had been used to serving in the Reg Force, in Germany, awaiting the Soviet onslaught on Western Europe. There we were provided with a lot of equipment. Our job, as we understood it, was to slow them down on their way to Paris, to give our leaders the time to decide whether to push the button or not. Yup, in those days, we were always a button away from Armageddon. Plus, the Soviet Bloc armies were arguably ten times more numerous than we were. Only our West German allies thought we had a chance to stop them. We listened to them, and shook our heads in disbelief at their optimism. Perhaps, because their country was numero uno in the path of the Soviet juggernaut, the West Germans were simply fatalistic, trying to convince themselves the Soviets could be stopped. Of course today, with hindsight, it does appear that we probably could have slowed them down, maybe even stopped them, but back then our motto was, “In case of war, pull your pants down, bend over, and kiss your ass goodbye.” Every day that there was no war, was one more day we were given to live. You can imagine how we lived. Oh, the parties we had!

  So it was that when I joined that reserve regiment (Les Fusiliers du St-Laurent) as their doc, I found the military companionship I had so sorely missed. And the discipline. Funny to say, but I always had a hard time with civilians. In the military, when you’re told to be there at such and such a time, you generally arrive ten minutes early. When you’re told to do a job, you do it, pleasant or not. That’s the military way. It’s also (mostly) the medical way. Talk about a culture shock, when I dealt with people who happened to arrive whenever it suited them, or who didn’t have the time to do what they had promised.

  Now in the reserves, I didn’t find the abundance of materiel and the intensity of training I was used to back in Europe. What could they do without any money? Although the reserves did try to train as realistically as possible, it was frustrating not to be able to do what you knew you could. So, after five years of feeling poor, I just got out. I’d had enough. Besides, there was absolutely no possibility of advancement for me as a regimental medical officer (MO). Everybody around me was getting promotions, but I had been a captain for eleven years now. For me to get promoted, I would have had to go away and study for weeks at a time, which was impossible. I had a family practice from which I could barely take two weeks off in the summer with my family. Also, if you’re a family physician MO in the CF, and you want to become a major, you have to give up a lot of your clinical time to do administration. You have to graduate from treating patients to treating populations of patients. And that, I would not do. I was a clinician, not an administrator. So, with no prospects for advancement, I got out again.

  During those years, I found out that what I really loved in medicine was the ER. Moreover, I hated family practice. I was good at the first, and very bad at the second. Technically, I had the best hands in my peer group. I could always intubate the difficult ones, and put that central line in (for an explanation, see Appendix C) when nobody else could. What’s more, with hindsight, you can say that I thrived on the adrenalin. Under pressure, I perform. In family medicine, I had little patience for people looking for a magical pill to cure their bad habits (which is still true, unfortunately — I managed to quit smoking cold turkey). I’ll spare you the totally politically incorrect way I had of dealing with that. Think of the worst of Dr. House’s remarks; and imagine mine being worse still.

  Plus, I never hassled my patients to change their destructive habits. Hey, you know you’re not supposed to drink like a fish, weigh three hundred pounds, and smoke like a chimney. Why the heck should I waste my time reminding you again? I know, I know, I should be patient and understanding, but with me, it’s live and let die. On the other hand, if I would not lecture you before your heart attack, why should I lecture you when you actually got it? I always thought that medicine was there to help people. So, even if you weighed three hundred pounds and did everything to bring on a heart attack, when you did get it, I would take good care of you in the ER. No lectures. No preaching. No “I told you so.” Hey, it’s bad enough that you’re fighting for your life without some smart aleck telling you it’s your fault. I wasn’t the type to refuse to treat people who smoked or drank. I was there to help, but I wasn’t going to live your life in your place. Go ahead and drink, smoke, and overeat. I’ll try to diminish the impact of the consequences. And the whiners? I had no patience for them. You can see why I didn’t make a very good family physician.

  So, when the chance came, I abandoned family medicine and turned to ER only, in Rimouski. In those days, in a mid-sized town, that was quite a revolutionary move, and was frowned upon by the family medicine establishment in Quebec, the FMOQ (Fédération des médecins omnipraticiens du Québec), the GP union. So a bunch of us made the move as a group. Peer support. Then, for a while, when there was a lack of specialists for it, we also took over the ICU. Those were fantastic years. I wasn’t home much but, as my wife said, “At least he sleeps here once in a while.” It was a far cry from those repeated six- and eight-week training exercises in Germany. For years my buddies and I thrived on this great big wave of intensity.

  Then, one of my friends took command of the infantry regiment, and asked me to come back in. I rejoined. Why not? Socially, we had been hanging out with the regular force staff from the local recruiting centre. My professional life was the ER and the ICU. Our social life was with the military, especially with a solid friend, Christian Bergeron, an infantry officer who is now one of the most decorated soldiers serving in the CF.

  By then, the family medicine establishment had had enough of what they saw as our elitism. At least that’s how we all, from the ER, interpreted it. Our initial triumvirate of ER physicians had attracted a dozen more ER docs. We had had time to work hard, but also to teach, to organize conferences, symposiums. We had a flourishing, solid group, and we were getting to be known in the whole province. I guess that didn’t go down well with the FMOQ people. They wanted to impose an “everybody must do the same practice” type of regime where nobody stood out from the group. No elitism. Geez! Talk about socialism at its worst! To think we were spending gazillions of dollars in Europe to keep the Soviets from imposing that regime on us, and back home people were doing just that: levelling society to its lowest common denominator. So now, in Rimouski, everybody had to do family medicine, ER call, obstetrics, admitted patients, and so on. And this at a time when each one of those sectors was getting so much more complicated that it was becoming nearly impossible to be fully competent in all of them. In spite of the tremendous explosion in medical knowledge, everybody had to strive to be perfect in everything — which, of course, except for a very few, was impossible. There was no question of aptitude, in the establishment’s view. You just had to have the correct attitude. Sounds like the U.S.S.R. in the thirties.

  But those who aligned with the FMOQ were more numerous. They won. One by one, my (I was chief of ER then) ER docs found employment in other towns. It wasn’t hard: ER docs were very sought-after. Our plan to build and run a model ER fell apart. It hurt like hell. I still resent what those union people did. Like a good captain, I got off the sinking ship last, and rejoined my two original ER buddies in Sherbrooke.

  When I moved there, in 1991, my infantry unit transferred me to the local reserve Field Ambulance. Field Ambulance is the name we’ve been using in Canada for a unit that, ever since the First World War, has been like an ER on wheels. It can deploy and operate anywhere its vehicles can transport it. It has medical technicians, nurses, doctors, dentists, pharmacists, and all the supporting branches: cooks, administrators, communicators, mechanics, logistics people (called supply techs), ministers (called padres), drivers, et
cetera. The operational mission of a Field Ambulance is to stabilize and transfer critically wounded soldiers, and to treat the lightly wounded ones. I know. I had been a platoon commander in the most forward one of all, the one in Germany, 4 Field Amb.

  Well, the Sherbrooke Field Ambulance (the 52nd), at the time, was engrossed in first aid. Its medics were training for, living, and competing in first aid competitions, and winning all the Canadian trophies. Good for the unit. It certainly was good for morale. But it isn’t what a Field Ambulance is for. First aid is what the troops do. Medics should give first care, which is way beyond first aid — and way more complicated.

  That mentality was prevalent in Canada in those days. The Cold War was won. There would be no World War III, and there were no more bad guys out there to threaten us. So why maintain an army? Some wag even wrote a book called The End of History. Talk about a short horizon!

  During that time, we closed off our bases in Europe (bye-bye staging points), and the government hacked the CF’s budget to pieces. In the Forces, the medical branch was no exception, and it proceeded to implement OP PHOENIX (Operation Phoenix), a prescient name. They closed all our hospitals and transferred the specialized care of our CF members to the civilian world. The only problem with that was that the civilian world was undergoing the same kind of cuts and was increasingly unable to care for the civilians, let alone deal with the extra burden of the military. It wasn’t a resounding success.

  A few years later, the auditor general told us that we (the CFHS Group) weren’t doing a good job. So, instead of whining and looking for excuses, the CFHS leaders of the day tackled the problem head-on. After some intense soul-searching, they came up with a revolutionary plan, very much ahead of its time, called “Rx 2000.” By that time, the aim was to restructure and rebuild what OP PHOENIX had destroyed with a single stroke of the pen.

  But when I moved to Sherbrooke, we were in the midst of the mess caused by Phoenix. The thinking in the CFHS reserve units then was “why train for anything more than first aid, when all we have to do is give first aid and then transport the casualty to a civilian hospital?” So I got out again. I’m sorry to say I slammed the door on my way out. Blame Phoenix for that one. And my short temper. I know some good people who also got out then.

  In the real world ERs, things were moving in exactly the opposite direction. We were training ambulance techs to become paramedics. These techs were to do more and more life-saving interventions on their own, no matter what the lawyers were saying to the contrary. Those were exciting times. I had the chance to work with some of the best (and best-known) ER physicians in Canada. It felt good to be a part of that elite team. We had a great time. These are people I can still call friends.

  Then, some years later, one of my buddies became CO of the local Field Ambulance. He asked me to come back into the military to help turn around the mentality and help train the medics to become paramedics. A real revolution! I accepted, but it would be only for two years.

  That was fifteen years ago, and as I write this book, I’m still in.

  In 2000, after fifteen years full-time and another nine years part-time, I did get out of ER medicine. I had the feeling that, at forty-seven, I’d seen it all in that field, done it all. Besides, there are bad sides to ER medicine: the overfilled beds; the tentacular and inefficient administration; the drunks; the overworked personnel, always in short supply; and the social cases who, for the lack of a better place, end up in your beds. Plus what all those years of not counting my hours had cost me. I felt burned out.

  So I joined an urgent care clinic founded by some friends. I made a good living, working only days and evenings. My kids were graduating from university. We even closed the clinic on Christmas Day. At forty-seven, for the first time in my adult life, I was off for Christmas and New Year’s. I was still in the military reserve, but it was time for this galloping horse to take it easy. I was, after all, middle-aged. My wife and I started to travel again. Times were good.

  Then 9/11 happened.

  We were especially worried because our son, working in the financial world, based in Boston, had recently travelled to New York City and Chicago, and we weren’t sure where he was that morning. Then at 9 a.m. he phoned and said to my wife, all in one hurried breath, “Mom, turn on the TV to CNN. You won’t believe what’s happening. I can’t talk to you any longer because we have to evacuate the building. Bye.” And he hung up. We did as he said, just in time to see the second tower collapse. Then it hit me. “Uh, honey, what city did he say he was in?” There followed a few rather stressed-out minutes before we ascertained that he had indeed called from Boston.

  Well, after a few hours of watching that over and over, I got up, put on my uniform, and reported to my unit. I remember driving down the hill toward the town and thinking, You stayed in the military all those years in case there was a war. Well, you’ve got your war now. This is the first day of your new life.

  Though the CFHS was starting to change its ways, the whole of the CF was in what General Rick Hillier called “the dark decade.” The government had severely neglected to give us adequate financing. The CF had gotten even smaller through the Force Reduction Plan. The CFHS didn’t have enough regular-force MOs, so they had to hire civilian doctors. They didn’t even have enough MOs to deploy, so reserve-force medical personnel were increasingly called up for duty. In fact, if it hadn’t been for the reserve forces, the CFHS couldn’t have met its obligations in Afghanistan.

  But I’m ahead of myself here.

  You know the rest. As Canada, and with it the CFHS group, gradually woke up, and we went into Afghanistan, slowly at first, then with more and more intensity, it became evident that we were ill-equipped to fight a war. So the government started to fund us properly.

  The busier it got in Afghanistan, the more I felt that a guy like me, with that ER experience, could contribute even if he was rusty. When the CF moved down south into the Taliban strongholds and the lists of wounded started getting longer and the cases heavier, I felt my time had arrived to contribute. So when the CF came to me with a request to go to Germany for six months to help stabilize our wounded guys for Air Evac (AE) back to Canada, I accepted. My wife accepted this also. Her reasoning, for which I thank her, was that I had left the CF years earlier to be with my family, but now that our sons were adults and on their own I had achieved that. It was only fair that I should grab this second chance to do what I loved. This is the way she would explain it if you asked her about it today. But on the evening I emailed her with the possibility, her reply was more direct: “When do we leave?”

  I wanted to include those months in Germany in this book, because what happened there and what happened in Afghanistan are intimately related. In fact they are the same story, continued over two years. But I ran into two major problems. The first is that to adequately tell the story of my time in Germany I’d have to write in detail about the patients. It’s their story, in which we just happen to play a part. But to do this, I would have to describe their conditions, including their mental conditions, at a time when they were at their most vulnerable. I couldn’t do that. Not because their story shouldn’t be told. In fact, it should be told. The Canadian people should know the extent of the sacrifice done in their name. But I was a caregiver, bound to secrecy by my oath; an oath taken thirty years before when, as a young physician, I was out to save the world. As my wife said, watching me wrestle with this moral issue, “Buddy, once you swore that oath, you closed that door.” I can’t relate patient encounters. As Colonel Savard puts it: “When they’re ready, they can tell their own stories.”

  Still, for a while I did think I had found a way to do it. I would tell the story of composite patients. None could clearly be identified by his injuries, or his rank, or his name. My characters would have different stories from the ones that really happened. I could use the same trick in talking about the nurses I worked with over there (five in all. Am I that hard on them?): they (she) would be a compos
ite.

  But that brought the second problem. The book would have no unity. It would, in fact, be two books: one about Germany; one about Afghanistan. So, my wife once again came to the rescue: “Just write about Afghanistan, while it’s still fresh.”

  So here it is. The stories that follow are not in chronological order. I didn’t take many notes over there, and since every day felt the same as the last, I don’t remember precisely when things happened. In fact, I don’t even remember much of the last two months over there.

  *Note: if you want to enjoy your reading to the fullest and understand the complexity of trauma care, you may want to go to Appendices A and C before you continue.

  Mr. Wiggly

  It was during the week we called “The Festival of Head Injuries” that this little guy came in. They just kept bringing them in. Relentlessly. Day and night. We received “Hit by Car,” “Dragged by Cow” (no kidding), and “Kicked by Donkey.” And, of course, the usual “Fell Down Well,” “Shot in the Head,” “Shrapnel to Brain,” and “RPG to Face” (yup, still alive, though not exactly kicking). Our poor neurosurgeon was almost worked to death. Yet he never complained, and always remained professional and calm.

  I had been in Afghanistan for a week, maybe a little more, and I was still finding my feet, both as an ER doc (hadn’t done any heavy ER stuff for nine years, and had to concentrate so I wouldn’t forget anything), and as the leader of the hospital.

  So that afternoon, when RC(S) announced two more head injuries, one of which was a child, the GP assigned to that trauma bay told me she didn’t feel comfortable handling pediatric trauma. So I just took over the bay. It wasn’t the most diplomatic thing to do, but hey, like Lieutenant-Colonel Wojtyk always said, “This is not a teaching hospital.” In retrospect, that was an odd thing to say about a place where you learn so much. But at the time, we all thought it sounded real cool.