Combat Doctor

by Marc Dauphin

  Head injuries are usually not complicated to handle in the ER. You take control of the patient, which means stopping all catastrophic hemorrhage, then, more often than not, you intubate them. Once you’ve got control of the airway you fix the most obvious problems, then it’s off to the magical CT, which will divide the patients into two distinct groups: those who you operate on, and those who you observe. At that point, it’s the neurosurgeon’s ball game.

  Thinking back on it, I imagine that GP wasn’t comfortable handling a child, probably because she wasn’t familiar with intubating little guys. Oh, and with getting a line in. Because you can’t intubate anybody unless you first give them drugs to knock them out and then more stuff to paralyze them (see the appendices). So, getting a line in is always a priority on those casualties. And since children have very small veins, I made sure I had a good, experienced nurse in the trauma bay with me.

  For drug dosages and tube sizes, which greatly vary depending on the size of the child, there is no more memorizing arcane formulas, and no more complicated mnemonics like in the old days. Now we have a Broselow tape. This is an ingenious device: a simple tape that you put next to the little patients, which measures them from head to heel. Their length is indicated as a colour. Every three or four inches there is a different coloured box on the tape, and in that box are written all the dosages for all the drugs for a child of that height. Not only that, the tape also tells you what size tube to use for anything you need to do to your little fellow. Too easy. (Except if you’re colour blind, of course. Just kidding.) The company that makes these tapes even sells corresponding coloured packages that contain all the necessary supplies in the correct size. These bags are stuck on a Velcro tape, which you hang in your trauma bay. You just measure the child, figure out what colour he is, and pull off the corresponding bag. Where was this in the 1970s?

  I don’t exactly remember what the boy looked like when he came in, except that he was out of it — that and the fact that we couldn’t get a line in. No line, no drugs. No drugs, no intubation. No intubation, no control. No control, no CT. So, basically, we’re stuck there until we do get a line in. Of course, if we’re in a bad hurry, we just do an intra-osseous. That’s where we stick a needle-like a steel pin into one of the bones and push until we penetrate to the marrow; then the drugs can be injected through that. It’s hardly elegant, and we prefer not to do that if we don’t absolutely have to.

  That was also before Captain B, our U.S. Navy chief of surgery, arrived. Once we had his expertise in trauma available, our routines greatly improved. The basics we had down fine. But the refinements, the elegant little details that show you’re a trauma pro, no. Not at that time. Anyway, all I remember is that it took us about five or ten minutes to get our line in. When I say “we,” I mean two anaesthesiologists and me. Here we are, with our six large hands, trying to poke that tiny child with those needles. The Danish anaesthesiologist was the one who finally got it in.

  Then it was time to intubate. Intubating is always a scary thing to do. You take a living person, who is breathing fine, then you drug him, then you paralyze him. At that point the patient can’t speak, can’t breathe, can’t move a muscle. And you’d better be able to make that person breathe or else you’ve got a dead person.

  “Dad, how many people did you kill in the war?”

  “None on purpose, son.”

  Anyway, the hard ones are the ones who give you white hair. And I’ve had my share of those. This one wasn’t one of them. Once that line was in, it was just routine. There wasn’t any catastrophic bleeding to control. We had a chest X-ray to make sure our tube wasn’t in too far, which happens a lot in kids. That’s when the tube goes into the right bronchus and you’re ventilating only one lung: not good. You also want to make sure you didn’t pop a lung while trying to get that central line in: also not good. The chest X-ray shows all that, as well as where the central line is. Some parts of this have got to be easy.

  Then we did a FAST (Focused Assessment by Sonography in Trauma) ultrasound to make sure we weren’t bleeding in there, and we were off to the CT.

  (I often use the pronouns we or you when referring to both the crew and the patient. That’s the way we did it. If you identify a team with their patient, subconsciously the crews put even more intensity into their work, so much so that the patient becomes us, and we become the patient. As in “Okay, you’re next to CT,” or “You’re not the worst off. Phil is worse off than you, so you go to the OR second. Just hang in there. You can make it.”)

  In this boy’s case, he had a closed-head injury, which meant he didn’t have a hole in his head through which his brain was oozing, unlike the soldier who arrived in the same chopper. What was scribbled on the note attached to our little guy was “Wall fell on head.” What wasn’t written was that the wall fell on the kid because an armoured vehicle had knocked it down. And the reason for that was that its driver had been killed by an RPG.

  C’est comme ça in a war.

  Anyway, our boy’s CT showed that he had a depressed skull fracture. That meant that the neurosurgeon would have to operate on him to pull out the piece of skull that was pressing down on his brain. Since he was a child, I was pretty sure he’d wake up once his brain swelling had gone down. Kids usually do.

  Well, he did wake up. But not like you see in the movies. It took him a while. Actually a couple of days. And since we had to keep him intubated but not too sedated, so that he’d wake up, it was a rather disorderly event. In fact, this earned him the nickname “Mr. Wiggly.” Don’t think we were being sarcastic or unfeeling. It’s just that no one had showed up to claim him, so we didn’t know his name. When he’d been found, the medics had just picked him up out of the rubble, stabilized him, and whisked him off to us on the first available helicopter. So he’d arrived without a name. To us he was just another John Doe and, believe me, we’d had a lot of those. We were in the hundreds. As in:

  “How’s the guy in ICU?”

  “Who? John Doe 251?”

  “No, John Doe 254.”

  “Ah, the big, bad looking Talib guy.”

  So calling him Mr. Wiggly indicated who he was, and differentiated him from the anonymous masses of John Does. Even after he completely woke up and we had ascertained that he was all there and he told us his name, he remained Mr. Wiggly. The name stuck.

  His intense and sometimes violent agitation came from the ever-present battle that goes on in all ICUs in the world. At least the ones where I’ve worked, and the ones in which any of my staff have ever worked. And that’s quite a few. On the one side, you have the nurses who hate having to restrain agitated patients and see those confused, uncomfortable people fighting the ventilators, trying to pull out all their tubes and lines, and generally making themselves quite a nuisance. Not to mention a danger to themselves. The nurses like to see the patients wake up, but in an orderly fashion. Thus, they like their sedation. On the other side, you have the intensivists, who want the patients as awake as possible so that they’ll breathe enough on their own to be extubated and moved out of the ICU. Of course, the intensivists don’t have to spend a twelve-hour shift repositioning patients and reinserting lines and tubes. But that’s another story. Let’s just say that, amid a host of agitated, confused patients waking up, Mr. Wiggly stood out enough to earn his nickname.

  He did eventually wake up, of course, but not without losing a bit of capacity. It seems that those pieces of bone that had been pressing down on his brain had left their mark in a slightly paralyzed left side. So it was that Mr. Wiggly would be seen limping around the hospital with his left arm held in front of his chest, bent at the elbow, and his mostly useless left hand bent at the wrist and sort of flopping as he ambled around.

  He was a serious boy, not very prone to a smile. He may even have been a little shy. I wouldn’t really know: once they were awake, I tended to concentrate on getting them out of the hospital to free up a bed for another patient. Besides which, if you get to know them
it really hurts when you let them go. Afghanistan is not a country where you’re happy to see a kid go home. You never know what dangers lurk out there.

  But the nurses and med techs were all over him, as they were with all the children we had. That week, we had five or six of them, three of whom had no parents visiting. Well, assemble a bunch of parentless, injured kids with a bunch of young men and women of child-bearing-age, and you have a recipe for a fun time. You see, there’s not much going on socially on KAF, so whenever we had orphans in the hospital, the nurses and med techs always found a pretext to come back in after their shifts. This was fine with me, because if ever we got multiple casualties there were always a lot of extra hands around.

  The little girls would get their hair made up ten times a day. The nurses even got them dyes and after a while you couldn’t recognize any of them.

  “How’s the little girl with the pneumonia?”

  “Which one, the one with the red streaks in her hair?”

  “No, the one with the green streaks.”

  “Same one.”

  “But she has red streaks.”

  “That was yesterday. Today, they’re green.”

  The little boys, of course, were also spoiled rotten. The ones who couldn’t walk got pushed around in wheelchairs with both pusher and pushee making all kinds of engine noises. But their destination was always the same: the end of the road right by the runway, less than a hundred metres from the hospital. And since KAF is the busiest single runway airfield in the world, they got their money’s worth. And probably destroyed some of their hearing too. You see, all the planes taxi right by our hospital, so close that we have to stop conversations inside the buildings. So close that you’d swear that the wingtip of those big transporters overflies the fence and the Australian Air Force Role 1 clinic there. A few hundred times a day. For little boys, it’s heaven. Fighter pilots would wave to the kids as they taxied by, and one of them (a Frenchman, who else?) would even gun his engines for them. Some days, we’d have six, seven, even more kids there, all bandaged up and aligned by the runway with their mouths half open as they gawked at those big old planes.

  Come to think of it, it was mostly the childless nurses and med techs who spoiled our orphans. Maybe those who had young ones back home knew better than to spoil somebody else’s. Or maybe it hurt too much to be reminded that they were away from their own kids.

  One evening, as I was making my rounds, I was just commenting on how Mr. Burned Head, all of approximately three years old, was really becoming too much to handle, when we heard a loud boom. The whole hospital shook, and dust rained down on the patients from the flimsy ceiling.

  “Shit! That was close.”

  I didn’t have to say anything: our rocket-attack drill, even in those early days, was perfect. We’d had a lot of practice. Although, I’m told, not as much as the roto before ours did. But then, everyone’s roto is worse than all the others. The bad guys light off rockets in multiples, so, after the first one lands, there are usually others. While the siren started its mourning, haunting wail, some of the personnel ushered the walking wounded out to the bunkers while others spread blast blankets over the bedridden, before putting on their own frag vests and helmets to continue to take care of their patients. Then, for me, it was just a question of going around the buildings to assess the damage, and reacting to any threat to the hospital. Such as a bunch of guys trying to gun us all down, or the building next door burning, or anything similarly annoying.

  We nicknamed this little fellow “Mr. Burned-Head.” He couldn’t tell us his name.

  It was while I was checking out the people in the bunkers that the siren announced the all-clear. Returning to the hospital, everyone, both staff and patients, were all smiling, some of them talking a little too loudly. Well, adrenalin does that to you. Being shot at and surviving gives you a high. Some military will tell you that rockets are harmless, and that they rarely hit anything important, let alone anybody, and that on KAF, we’re not in any danger. They’ll even tell you that you have more chance of winning the lottery than of being hit by a rocket on KAF. My people, however, will answer “Talk all you want, but we know better.” You see, my people have seen the damage a near hit can do: heads split in two, guts hanging out of bellies, ripped out lungs. That, and also the fact that two of our med techs got hit as they were walking along the street, and one of them almost died. So, yeah, we know the odds, but we also know that some tickets are winners.

  I guess I was lost in thought as I stood there with my helmet and frag vest on. I wasn’t paying much attention to the individuals in the procession. Then Mr. Wiggly limped past me, walking like an old fellow in one of those old folks’ homes. An old fellow who’d had a stroke. He looked even smaller lost in a crush of adults, his eyes at waist height, looking up, and just following the person ahead with that limp of his. Then, all of a sudden it hit me. It was the eyes that did it. He just ambled along in the crowd, with his useless little arm in front of him, and his half head of curly brown hair, and the staples that closed his semicircular wound in the bald half of his scalp. But the eyes said it all. They were bewildered, looking up at all the adults, asking their silent questions. Where are we going? Why did we go out to that bunker? Why are we going back in? Bewildered, but not panicked; after all, this is all he knew.

  Just then, a pair of fighters took off on afterburners, and the noise was so loud it was painful. Instinctively, I looked up to see if they were armed to go after the rocket-launching guy. When I looked down, Mr. Wiggly was already gone and the moment had passed.

  A couple of days later, someone found Mr. Wiggly’s father and the man came down to fetch his son. We got more wounded kids and life as we knew it continued in its Groundhog Day sameness.

  But I’ll never forget those eyes that night, that dark, bewildered gaze, looking for a place to latch on to, to get some sense of stability. What was he thinking of his world? What was he thinking of our world, of our powerful weapons, of our ear-splitting jet planes, of our miraculous medical technology, of all our toys and stuffed animals, of those smiling, nice young nurses and med techs who have the time to hug you, and who smell like soap and perfume? Did he understand anything of what the adults were doing to his country? To his brothers and sisters?

  I’ll never know, of course, but the look will always haunt me, lost, hurt, scared, and not understanding.

  Oh well, c’est comme ça.

  You just have to get over it, I guess.

  The Day the Australians Came

  It was a day just like any other. Another Groundhog Day — sunny and glorious. To think that, in the past, I’d paid hard-earned dollars to be able to enjoy days like this in the Caribbean. Well, at least there we had the sea.

  I looked up just as a convoy of Brit Special Forces roared by, the soldiers impassive under their Palestinian-style scarves, which covered the lower part of their faces. Their sand goggles and compact helmets turned them into giant insects. Their roofless Jeeps — well, Land Rovers, actually — stirred up a storm of dust as they went out to meet their destiny. Whatever awaited them out there had better be armed, because these guys had 50-calibre machine guns sticking up from the rear seat of their windshield-less vehicles.

  “Mornin’, sir.” Coughing up another batch of that ever-present dust, I acknowledged the greetings from outgoing nurses and med techs, and incoming dental techs, mental health people, and the pharmacist’s mate. Once in my office, I turned on my computer and changed into my scrubs. Ferrari red, I called them, although some wags said they were tomato red. In any case, it was so that I’d stand out in the crowd in the trauma bays, because when we got multiples, things happened fast and all at the same time. The folks who treated the casualties needed to have immediate access to me.

  Without forgetting to strap on my pistol, I went out and across the hallway into the TOC, the tactical operations centre, the brain of the hospital. I greeted the TOC duty officer, also called the TOCO — and yes, they
turned that into “the Taco,” and added “the Salsa” (the PAD, patient admissions and discharge clerk — although how they turned PAD clerk into Salsa beat me), and “the Guacamole,” the senior USAF AE nurse. I think it stands for “Government of the United States of America something-with-a-C Aero-Medical Officer Liaison Expeditionary.” They had name tags made with these titles, and on the walkie-talkies they even used the nicknames: “Taco, Salsa, over.” “Salsa, Taco, send, over.”

  Brian was Taco that morning. I loved working with Brian, but he was so cool under even the worst of pressures that you couldn’t tell by looking at him whether things were going well or badly.

  “There seems to be a pretty big op going on in the northwest, but so far, no casualties,” he told me.

  I thanked him for the info. It was never when the big ops were on that we, the medical, would get hammered. It was when the guys were coming back home after the battle. That’s when stuff happened. Bad stuff. I made a mental note to check on that battle later in the afternoon. For the moment, I put it out of my mind and turned to the patient board: three ICU beds occupied and twelve intermediate care beds. Too many. If we were going to get casualties, we were going to need the space. Two had been admitted during the night. One was an Afghan National Army soldier with a gunshot wound to the foot. Probably shot himself. And not intentionally. We got three or four of those a month. Those guys didn’t know why there was a safety on pistols. But they did know they weren’t supposed to shoot themselves, so their story always was, “Taliban shot me.”

  Yeah, sure. A low-energy bullet entered the top of your foot and exited through the bottom fracturing only one bone, and the exit wound is the same size as the entry wound. What were you doing? Lying on your back with your foot in the air?