Combat Doctor

by Marc Dauphin

  The other new admission was an American serviceman with appendicitis. We got two or three of those a month. My boss told me it was the stress. I say it was because they were constipated: taking a crap in those porta-potties in 45 to 50°C heat is quite an adventure. And if you waited till the sun went down, well, you had better bring your flashlight with you. And not drop it into the hole. And all that’s only for the folks who, like us, had access to the luxury of a porta-potty.

  I went back to my office to check my email: there were two from Christine and one from my son. Good. I’d read them later.

  I returned to the hospital, which was divided from the TOC and my office by swinging doors. On the other side, the usual hustle and bustle. One night-shift nurse wanted to talk to me. Okay, after the meetings, I told her. She really should have gone through her shift boss, then the nursing supervisor, then the assistant chief of nursing, then the officer in charge (OIC) of inpatients, but maybe she had a good reason to come to me. They all knew my door was always open. But woe to the one who tried to use that to do an end run around the chain of command.

  By the X-ray monitor, a gaggle of docs was discussing a patient. Something about one of the kids in ICU suffering from blast lung. If that’s the case, I thought, he’s going to have a rough ride. I hovered around, letting my mind wander over the signs posted above the double computer monitor to keep people from using their fingers or pens (an almost irresistible gesture) on the screen to point out something they’d just seen. One stated: SURGEON GENERAL WARNING. TOUCHING WORKSTATION WITH FINGERS, TONGUES, OR FOOD/BLOOD ENCRUSTED INSTRUMENTS OR PENS HAS BEEN LINKED TO GENITAL CANCER, SPIROCHETE INFECTION (SYPHILIS AND LYME DISEASE), LEPROSY AND LOSS OF VALUABLE IQ POINTS. PROTECT YOURSELF AND YOUR LOVED ONES BY AVOIDING ALL FORMS OF PHYSICAL CONTACT WITH THE MONITOR SCREENS. And the other sign showed an X-ray of a hand with amputated fingers. Above it was written NO TOUCH SCREEN — BAD FOR FINGERS. I even got our surgeon general to sign both of them. I suppose the Americans who took over from us took the signs down. (I should have stolen them before leaving. They’re history now. But that’s another story.)

  I wandered off to the lab to check our stocks levels. As in blood stocks. That was a nightmare for us throughout the roto: threatening to run out of PRBCs one day (packed red blood cells), out of FFPs (fresh frozen plasma) the next, and platelets the day after. Platelets are those little pieces of cells that flow through the blood and plug any hole in a blood vessel (see appendices A and C). Like that kid in the story of the dike. It’s an appropriate image, as our platelets came from the Dutch. Get hole in capillaries, got no platelets, you leak out. Clear?

  The U.S. Army blood detachment sergeant was there, cheerful as always. She was a young mother, out here for a year or more. How did she do it? Man, the U.S. Army treats its people rough. At least the U.S. Navy people were there for only six or seven months, like we were.

  “Mornin’, sir. What’s up?”

  “Anything above the eyes, Sergeant. How are we supply-wise this morning?”

  She flashed me that smile. She looked so much like Hilary Swank that I couldn’t help calling it a million-dollar smile.

  “We’re doing okay, sir. We just got a shipment in during the night.”

  Well, that was a relief. At least twenty-four hours without worrying myself sick and without having to negotiate with other MTFs (medical treatment facilities): “Sure, we’ll accept your transfer, but you have to send twenty O-positive PRBCs with him.”

  In the lab, one of the American techs wanted to play fight with me. Jay-sus! His arms were bigger around than my thighs!

  “Find any rare germs last night?”

  “Yeah, but not the wooka-wooka virus.”

  He was from Ghana and had a neat accent. The “wooka-wooka virus” was our term for anything out of the ordinary — the mystical, never-found, rare tropical disease. It was also our running gag, though it hadn’t been quite as much of a laugh since we had lost a guy to Crimean-Congo hemorrhagic fever the month before.

  I headed back down the corridor, and through the trauma bays. They were deserted except for one med tech stocking up number 3. That was probably where they received the “shot in the foot” guy. I paused long enough to admire how we could get so much done in such a little space. In seventy-five by thirty feet (max) we had six trauma bays and a corridor on one side. And, on the other side, was the ward master’s office, the OIC inpatients’ office, the corridor to OR 2, the one to OR 3, and two more trauma bays. And when we got multiples, there could be a hundred people in there, all trying to squeeze around one another.

  Thank God for Dave. He was our company sergeant-major, or CSM. And he looked every inch the part, down to the handlebar moustache. And the voice. You didn’t want him to have to yell at you. The decibel level alone would keep you awake at night and cringing for a month. A sergeant-major is responsible for the discipline in a unit. Dave also ran the trauma-bay floor and the sort-of-courtyard outside the rear doors where we unloaded the casualties and triaged them. He took these areas personally. Woe to even the general who overstepped the lines we painted on the floor and the asphalt. There was no misunderstanding when Dave explained something to you. He used to serve in the Airborne, which explained the arms the size of tree trunks, the moustache, and the volume. He also used to be a medic on a submarine. Thus the crisp, clear verbal communications in a tone of voice that left no place for misinterpretation.

  Like I said, thank God for Dave. He was also my day-to-day confidant, the one who kept me from getting in trouble when my temper flared up. (Thanks, bro.)

  I stopped my daydreaming and crossed over to the ICU, pausing in front of the door to OR 1. They were already on a case in there. In addition to the anaesthetist, his assistant, and the OR nurses and techs, I noticed an orthopaedist and a general surgeon. Hmmm. Wonder what kind of case that is. Ah, the “shot in the foot” guy probably, and the general surgeon was just helping out. It beat doing a Sudoku in the coffee room.

  Into the ICU I went: three patients, all on ventilators. We had a simple rule: if you weren’t on a vent, you weren’t in the ICU.

  Bed one, the kid with the blast lung. No name. She arrived without an adult escort. So she became Jane Doe 351. She was three years old (so they told us at the other end), but she looked like a one-year-old back home. She looked so tiny in the huge bed designed for soldiers. She had blond hair, surprising in this country — something about Alexander the Great and genes from a long time ago, I’m told. To us she just became “Blondie.” She also had shrapnel in various parts of her body, a large piece of which our neurosurgeon had taken out of her neck, where it had lodged by the spinal cord at the level of C4. You don’t want your surgeon to sneeze while taking that out. I looked at her numbers: the pulse; the O2 saturation (O2 sats); the blood pressure (BP); the vent settings, the most important being the FiO2, or percentage of oxygen in the air given to her — you want this as low as possible (not forgetting that inspired air contains 21 percent for an FiO2 of 0.21); and her PEEP (positive end expiratory pressure), the pressure that keeps her alveoli from collapsing on expiration, and then being popped back open when the vent shoves air down her windpipe. The numbers were not great. The nurse looked up at me and said something I didn’t understand. Just before I uttered a what? I replayed her words in my head and understood.

  “I saw her chest X-ray and it wasn’t too bad,” I replied.

  The nurse was from New Zealand and had asked about the kid’s “cheast eeks ray-i.”

  She nodded silently and we both gazed down at the child fighting for her tiny life. What kind of threat was she to the Taliban that they’d want her little body maimed in this way? Like Phil used to say, “I just don’t understand them.” Phil was the Canadian OIC of Outpatients. He was also my best trauma team leader. He merits the greatest accolades one ER physician can give another: “He’s got no nerves.” Nothing frazzled the guy. But, every now and then, one would catch a glimpse of the man behind the armour h
e had to wear, and the ever-present smile would fade just a little, and the pain show through for a fleeting moment. I guess it was like that for all of us.

  In Bed 2 is a Talib, a huge man in a land where most people are so skinny it hurt to just look at them. I thought of well-nourished knights in the Middle Ages surging out of the forest to massacre the other knights’ defenceless, skinny peasants. And then, once one noble’s serfs were exterminated, the knights would sign some kind of treaty and go off and drink together to celebrate their newfound friendship, none of them any the worse for wear — “I’ll lend you twenty families of serfs to compensate for the ones my people massacred last week.”

  Is this how it’s going to end here?

  I walked up to the man. The SF, or Special Forces, shot him in the chest, in the neck, and in the legs, and he still wouldn’t die. “It’s like he didn’t have a subclavian artery!” exclaimed the surgeon, after finding out that the bullet that got him in the neck had shattered his collarbone but left the subclavian vessels underneath, a vein and an artery, completely intact, before exiting through the back of his neck, shattering the side of a vertebra but leaving the spinal cord untouched. He was lucky. And, judging by the scars he carried, he was a repeat customer.

  Well, he was now an American detainee. I looked at his face. Even sedated into unconsciousness, he still managed to look mean. I wanted to walk up to him and jerk his head to the side so he could look at the little girl in the next bed. “Hey, shithead! See what you did to this kid?” But he probably couldn’t care less.

  If you’ve watched the TV series Combat Hospital, you may remember that in the first episode they have the newly arriving doctors mop the floor of the trauma bay after a casualty has been resusc’ed. This is because nurses and medics know where to get the supplies to replenish the trauma bay, which is the top priority, and the doctors don’t. The producers and writers got such a kick out of that little bit of reality that they couldn’t resist putting it in the show. Here, RCAF Captain Philippe Parent does his part. No job is too humble or demeaning for us in the Role 3.

  A tiny casualty of war in the ICU.

  Aaron was his nurse. Aaron, a.k.a. “Shrek,” is also a huge young guy with a shaved head. At home, he has at least one kid like that little girl in Bed 1. He had seen my involuntary gaze toward Blondie and smiled at me.

  “Too bad we can’t settle the score, right Aaron?”

  Somehow I felt that he wouldn’t hesitate one second to twist that guy’s neck if I gave him the okay. “Died from wounds. Too bad.” It would be so easy. After all, wasn’t that what the SF guys were trying to do when they shot him?

  I just shook my head. Even thinking about killing patients. What was that country doing to us?

  “We’ll probably be able to pull out his chest tube this morning,” Aaron informed me. “It’s been outputting only a hundred cc’s in the last twelve. Then we’ll extubate him and release him into the loving hands of the SF.”

  I could only nod. “Yeah, thanks, Aaron.”

  Bed 5 was occupied by an American soldier. Just a kid really, but hey, at my age, they all seemed like kids. He had come in the evening before with a bunch of his comrades after their vehicle hit an IED. He was confused and agitated. We classify head traumas according to a numerical scale called the Glasgow Coma Scale, or GCS. You get points for opening your eyes: four if your eyes spontaneously open, three if they were closed but you open them on command, two if they were closed and you won’t open them on command but will open them in response to pain, and one if you won’t open them at all. I guess even some people back home wouldn’t score very high on that scale. Same for your verbal response: points are given a decreasing scale from five all the way down to one if you have no response whatsoever. And last, six points for your movements, all the way down to one if you don’t move at all. Then we add up the points to get your GCS. If you’re dead, you still get a GCS of three. I guess it was invented by someone who didn’t want the dead people to get low self-esteem by having a score of zero. I’d hate to meet that guy’s children.

  There are guidelines (remember those CPGs in “Trauma 101,” in Appendix C?) that tell us that with a GCS of eight or less you automatically must be intubated. You are then sedated so that you don’t remember what happens next, then paralyzed so you so you don’t resist, and you’re completely dependent on the skill of your intubator to find your vocal cords and insert a plastic tube between them, down there.

  When this kid came in, I knew right away he had to be intubated. His GCS was above eight, but he was agitated and very confused. He was trying to get off the stretcher to obey some past or imaginary order from his captain and warn his buddies about something. He was going to need a CT scan to rule out a clot or some shrapnel that we could remove from his brain and he would need to be sedated for that. And also so we could assess him. How could we be sure he wasn’t silently bleeding in his chest or abdomen? We couldn’t do a FAST ultrasound if he was trying to get off the stretcher. Even if his GCS was ten or eleven, we would have had to take control.

  By the time he came in, his comrades, all worse off than him, had already been assigned to other trauma bays, so I sent him to a bay where the leader was young and inexperienced. She was with another MD though, and I figured that between the two of them they would be able to manage to intubate this guy. I was very busy with the other four casualties, so I was doing my usual, walking around assigning this soldier to get an X-ray, this other one to go straight to OR, this one to CT as soon as he’s stabilized, and that one to get a chest tube. Every time I’d pass by this soldier’s trauma bay and see them trying to assess the guy in spite of his agitation, I’d shoot them a curt “intubate him” before walking off to the other bays. I did this three times before realizing that I was probably asking these two young docs to do something that would give me, a thirty-year veteran, some added white hairs. So I stepped in as gently as I could and took control of the airway.

  I prepared my stuff: a laryngoscope, the metal instrument that looks like a handle with a butter knife at right angles with a little light at the end. I made sure I had the right length of blade and that the light worked. Then I had to pick the right-sized tube — for this strong, healthy young soldier, a size eight or an eight-and-a-half would do. I then filled a 20-cc syringe with air, attached it to the end of the tube, and test-inflated the cuff at the other end of the tube. Then I prepared plan B — just in case. Especially in a case like this one, as he could have had a fractured cervical vertebra. If I moved his spine the wrong way, “Pop!” he’d be paralyzed. So I had to protect the cervical, or C spine, either manually or with a collar. This soldier, in spite of his agitation, had managed to keep his collar on. That meant I had less leeway to look down his throat to find his vocal cords. But I had an ace in my pocket: an Airtraq device. This has got to be the most ingenious invention in a loooong time. It’s a periscope with a channel in the side to put your tube in. The trick is that the periscope’s eye and the channel are angulated just so that both are pointing at the same place. It had never been used there, in the Role 3, but I had practised it on a mannequin enough times that I felt confident using it.

  Teamwork to save a life. On the right side of the picture is the trauma team, and in the background the PAD clerk makes sure of the identity of the casualty. Muddy is getting ready to do the FAST ultrasound under the watchful eye of USN Captain Bennett, and Olga takes notes. Everyone is focused and intense. Not a word is spoken.

  RCN Lieutenant (N) Kristi Velthuizen, an ICU nurse, prepares her drugs before the arrival of a casualty. She has to have everything ready in advance because things happen fast in a trauma bay.

  When I was ready, Kristi, the nurse in the trauma bay, another very cool customer, gave the sedation I asked for. The guy settled down a bit but wouldn’t let me assist his breathing. I was afraid he might vomit and I wouldn’t be able to protect him. Get some of that stuff down in your lungs and it’s a bad complication, one that can very
well kill you. (Honey, I had a bad day at the office …) So time was of the essence, especially since head injury victims are very liable to upchuck. If you’re a parent you likely already know this.

  I turned to Kristi and asked her for a specific paralytic agent. There are a half-dozen different ones, and every doc is familiar with one or two.

  Her answer was quite firm and appropriate to the tense situation — but she sure got ribbed for it for the rest of the roto, and I don’t think I’ll ever see her again without thinking about it: “Rocuronium is what I’ve got, and fifty milligrams of it is all you’ll get.” She just set her mouth then, not looking at me, and stuck the syringe in the tubing, waiting for my order to shove the medication in. This wasn’t the time to be picky, and I nodded to her to go ahead. Besides, I’m married to a nurse, and, since they always have to take charge, I’m used to being bossed around. Plus, it would have taken forever to get some other paralytic from way down at the other end of the trauma room. Nah. She was right all the way.

  Well, Marc, the roc’s in, and you’ve got a soon-to-be paralyzed soldier on your hands now. Just pray to God he doesn’t puke. Oh, and have one of your assistants press his cricoid cartilage down against his esophagus. Theoretically, this could prevent gastric contents from flowing back into the mouth and then down into the trachea. After having seen the strength with which pizza comes back up, I had little faith in this manoeuvre, but hey, every little bit helps.

  So, at that point the soldier was not breathing, and his muscles were tremulating, contracting in a disorganized way as the paralytic agent did its job. So I bagged him. One of my hands held the mask down on his face with two fingers while the other three lifted his chin into the mask. It takes a lot of practice, and I’m always surprised by some men who can’t get a good seal in spite of being stronger than me. I made sure the soldier’s sats were at 100 percent, then, as always, I entered the red zone, the one where everything slows down and your mind becomes incredibly focused. For some reason I just grabbed the Airtraq instead of the laryngoscope and tried to put it down him. It wouldn’t go unless I turned it sideways first. I must make a note of that. Then, it went in but pushed the tongue back. We can’t have that. I pulled back the tongue with a flick of my wrist. Hey, I’m getting the hang of this. Then I was down. I pulled it up gently and looked around. What the hell! For a fraction of a second, I didn’t recognize anything. Then, just before panic set in, I realized that everything is so much smaller in the periscope. There were the vocal cords, clear as day but really small and far away. So I pushed the tube forward and watched it go in. Just like that. Then, I detached the tube from the Airtraq and pulled out the Airtraq without pulling out the tube. I took a quick glance at the sats: still 100 percent. Then inflated the cuff, detached the mask from the bag, attached the bag to the tube, and checked how far we were in: 21 centimetres. Perfect. I bagged the patient a few times while somebody listened to the lungs: both good. I handed over the tube to the medic who was going to secure it so it wouldn’t get pulled out. Then, my job done, I walked out of the trauma bay.