by Marc Dauphin
I turned around and stepped inside the hospital. “They’re all kids!” I shouted, so that they’d get the right equipment out. The first TTL looked at me uncomprehending. That’s what I get for regularly calling all these soldiers “kids.”
Then, in the second trauma bay over, Dave got it. “Children!” he bellowed. “Prepare for children! Acknowledge.”
Thanks, man. Well, so much for quiet.
Outside, the first amputated boy was being wanded by the PAD clerk. “Clear!” he announced.
I looked down. One glance told me all: no blood trail under the stretcher. I lifted the sheet: a tourniquet was in place above the amputation and doing its job. He was full of dust, therefore a land mine (as if the two missing legs wasn’t clue enough), and I couldn’t evaluate his colour because of the dust. He was breathing on his own, and not too fast. I pulled back one lid. The kid was too listless to fight me off, and the inside of the lid was very pale: shock. I touched his forehead: warmish. Good. That took me less than two seconds and I decided to send him to my trauma teams, my star players. Since he was the worst, according to the flight medic (you had to trust your people), he got the fresh trauma team in Bay 3.
Triaging and clearing casualties. John, the Dutch medic, indicates which trauma bay I want this one to go to. Company Sergeant-Major Dave Marshall monitors the area, keeping an eye out for traffic. Off to the right, Colonel Savard watches our activities. All throughout the tour, day and night, Colonel Savard was there, silent, keeping out of the way, ready to lend a hand. Her presence was a constant reassurance to me. She didn’t get much sleep either.
Triaging a small victim from an IED or a landmine while Andy is fixing the stretcher to the rickshaw. The fact that the little fellow is letting me examine him like this is not a good sign. I would rather he have the energy to fight me off. I seem to remember that this boy ended up losing his right arm (he has a tourniquet on here), but otherwise survived his ordeal. The fact that Corporal Dionne is holding up an IV means that a sure-handed flight medic got one on inside a bouncing, weaving helicopter — a difficult task. Those guys are good.
“Three,” I curtly told the supply techs, who were raring to go. Then I turned to the inside of the hospital, raised three fingers, and held them up. Because of the blinding sun I couldn’t see inside, but I knew people were making way for the stretcher. During our first weeks there I ordered a patient to TB 4, and while he was on the way there someone mistakenly countermanded that order and sent the casualty to 2 instead. Still outside, I didn’t know this, and was distributing my patients according to what I thought the situation was inside. That nearly caused a disaster when I needed to send someone in to TB 2, which was now occupied by a casualty of a lesser severity. So we started to do the fingers-in-the-air thing that CNN later caught on tape, and for which I get endlessly ribbed: “Table for two, please!” or “Two beers!” or less respectful stuff.
Second kid, also with a blown-off leg, looked a lot less bad than the first one: he had the energy to whine a little. Still, it was a blown-off limb, a life-threatening injury, unfortunately a daily occurrence there. “Two.”
“Two, roger that, sir.” They set off. My sleepless team could save him easily.
The woman and the pockmarked baby were helped off and she was told to stand in the shade while I triaged the others. The second amb was arriving as the first one departed. Two more stretcher cases. One, a woman peppered with shrapnel. Unconscious. Bad.
“One.” One of the U.S. Army docs was there: Hyram. He was good. He’d know what to do.
Then another kid. Geez, this one’s worse off than the other two. His face was black, burned black. He’d need to be intubated soon, before his airway swelled up. He had all his limbs, but one of his arms had a tourniquet and looked a mess. It’d probably have to come off. “Four.” No choice.
I just hoped they wouldn’t send those seven U.S. servicemen right away. We’d be very hard-pressed.
The woman in the shade was still trying to hide her face, still hanging onto that howling kid. Well, at least there were no airway problems there. Then my heart took a dip as one of my med techs walked up with a tiny aluminum parcel and handed it to me. How small can they get? With sinking heart I lifted away the blanket from the baby. A tiny face (intact) looked at me with great puzzled black eyes, then broke out into the nicest toothless grin. It was so unexpected in that place of suffering that the contrast made my throat suddenly tighten. I mean, you’ve put on your emotional armour, and you’re functioning on all cylinders when Bam! this little kid just breaks it open with one grin and out want to come your feelings, as if a dam had burst. The place was starting to get to me. When we return home, there’s going to be hell to pay. For the moment, I managed to get myself under control. But I couldn’t help but smile back at the baby. “All right, you can wait, little guy.”
I turned around: the A-10 flight surgeon was outside. He beckoned. “If it’s any help, I’m real comfortable with kids, doc.”
“Thanks. You get the howler,” who, I suddenly noticed, was starting to drip blood.
Another little guy went to TB 5 with Dave, the grinning baby to 8, and the last one, a slightly wounded man, probably the father, to 7. Done outside.
I grabbed a flight medic. “How long ago?”
He was covered in sweat and his face was red. He was wearing his flak vest with those heavy steel plates, his huge helmet, his tactical vest with extra magazines and his medical kit, and still carrying his loaded weapon. It was a good thing Dave was in a bay, or this guy would have got a very precise, technical speech about loaded weapons and hospitals. The last thing I needed was an accidental shooting. On the floor between TBs 7 and 8 was a case of water bottles. I grabbed a couple and handed them to him. He emptied the first in one swig. “Anti-personnel mine. Probably Russian. Family returning home through the mountains. Trouble is, there’s not supposed to be any mines there …” He shrugged. “Oh well. Lucky a patrol found them. The trouble was getting them to a place where we could pick them up.” He looked at his watch and shrugged again. “Probably ninety, maybe a hundred minutes ago. Sorry we couldn’t do better.”
I think they did exceptionally well considering where they were, and I told him so. Some infantrymen from that patrol would have a few horrific visions to populate their dreams for a few years. I nodded to him. “Thanks. Take a break. You’ve earned it. And better get your weapon secured before my sergeant-major sees you.”
I could feel the tension in the bays. Not that we were usually very relaxed, but we weren’t usually that tense. I had to break it somehow, but yelling wouldn’t be useful, and it would only distract them from their jobs. Joking? There wasn’t much to joke about right then. Think, Marc. But nothing popped up. Oh well, something would come to me.
A U.S. Army flight medic and a Dutch Air Force flight nurse have just brought in some casualties. They have already drunk a few bottles of water and will down these within minutes.
In the meantime, TB 3: they were already intubating him and they had a surgeon running a central line in. As you know (Appendices A and C), those really large veins are hidden way below the skin. In trauma, there are three preferred ones: the internal jugular in the neck (the IJ), the subclavian (beneath the collarbone), and the femoral (just below the groin). All of them need a certain amount of practice and skill to “hit.” If you don’t know exactly where to stick your needle in, you can poke around for a long time without hitting anything. Especially if the veins are all collapsed through loss of blood. Sometimes you can use the ultrasound, but you’re in an emergency situation and time is of the essence. In the Role 3, we decided that we’d use the femorals preferably. First, to standardize our practice and our equipment. Second, because when someone else is working at the patient’s head, which is where most TTLs like to be, you can’t access either the IJ or the subclavian. And last, because we were going to be putting so many of those central catheters in, in all those traumas, that less experienced perso
nnel would end up doing these interventions, and the femorals are the easiest to learn how to access and the ones that, if you miss, cause the fewest complications. It’s no fun aiming for an IJ and hitting a carotid instead. (Honey, I had a baaaad day at the office …) So I was happy that they had 3 under control.
Now for the woman. She looked bad. My fear made me want to look in on Burn-Face in 4 first (hey, they didn’t have names yet, okay?), but I had to let my TTL evaluate him before barging in. Besides, we had at least another hour before his airway swelled up from the burning gases he’d inhaled. I hoped. So, woman in 1.
“Looks like she doesn’t have anything other than a brain injury, doc,” announced Hyram as I went in. “Apart from all those shrapnel wounds.”
Yeah, well some piece may have gone through the skull and be imbedded in the middle of her brain. Wouldn’t be the first time.
“All right, I’ll get you your FAST and you can go to CT first if the other ones can wait.”
I began to organize the sequence in my head. In the corridor I met Muddy. She was an X-ray tech and an officer; an oddity, as all our techs were non-commissioned. Oh, did I mention that she’s New-Zealanderish … er, New-Zealandish … er, New-Zealandian … or whatever? (Hey, I’m French — how should I know?) Anyway, she was from New Zealand, and, yes, she did a lot of “cheest eeks ray-is.” She was also the best one, apart from the radiologist, to do trauma ultrasounds, those famous FASTs. As mentioned in appendices A and C, the difficulty in FAST is not in interpreting the images on the machine’s screen (although I am a notorious over-reader — which is because I’m also a worrier), but in generating those images. You see, the probe’s first one or two centimetres of image are worthless, of no use to us, just gobbledy-gook. So the trick is to position your probe so as to shoot through some other organ, usually the liver, although muscle will do fine. And, most important, don’t shoot through air. Air is your enemy. It makes the picture look like channel 173 (at least, on my TV): snow. Hence the gel that the ultrasonographer will slather liberally on his or her patient to do away with any air between probe and casualty. The second trick is to go like its name: fast. This exam is a part of the TTL’s evaluation, and must not deter nor slow such said evaluation. There.
“Okay, Muddy, start with 1, then see if 3 needs you. Then 2. Then the other ones as they’re ready.”
“Yip.”
Yip? Oh, yeah, “Yep.” I shook my head. It’d take me years to understand them down there. Come to think of it, maybe that’s their way of discouraging immigration into their stunningly beautiful country — just make sure to be so difficult to understand that no one will think of moving down there. A veritable language barrier.
Okay, a quick look in 2. As expected, the guys had the kid under control. He had a central line in and a unit of uncrossed blood was already flowing in, slowly. No need to use the Level 1 infuser (Appendix C) on a child. He hadn’t lost that much blood. Well, he had lost some, before some GI put a tourniquet on his leg, out there in the mountains. But his blood volume was not so big that we needed to rush gallons of the stuff in. So, no Level 1 for him. Amazing machine, that, although I always worry that the pressure with which it squeezes those bags of blood will somehow scrunch those delicate red blood cells, but, hey, didn’t I tell you I was a worrier?
Okay, 3 now. Things were not going well. Pulse way up; BP not very good either. And, despite being intubated, his sats were not good, hovering around 90 percent. Captain B, the chief surgeon, looked worried. “All right, to OR 1, now.”
He turned to me. “I’m taking him into surgery, but I don’t think it’s going to help much. His chest X-ray looks okay, but he’s probably got blast lung, maybe a hemo too. I want to see if fixing his leg might help. Besides, we’re going to have to take that tourniquet off at one point. Might as well do it in the OR.” I nodded. He was the expert. “Oh,” he added, “Have you seen his blood gas?”
The arterial blood gas, or ABG, is a measurement of several parameters. You take some blood from an artery (or a vein) and it will tell you about the oxygenation and the quantity of CO2 in the blood. In trauma we use it to evaluate the quantity of acidosis. Remember the cells that try to live without oxygen (Appendix C), and the toxins they spew out as they suffer and die? Those toxins cause metabolic acidosis and it can be measured by the ABG, telling us how deeply the casualty was in shock, and for how long. And it also tells us what size of a hill we have to climb to get to healthy. Or how fast we are circling the drain.
I looked at the lab result the note-taker handed me. The pH was 6.85, and the Base Excess, or BE, a direct reflection of the acids circulating in the kid’s little body, was at –15, a shockingly high number. “Some of the acidosis is respiratory, though,” I said, to lessen the impact of what I was seeing.
Captain B nodded and asked me: “What’s the lowest pH you’ve seen anybody survive here?” I didn’t answer. It was a rhetorical question. We both knew this kid was dying. His heart, lungs, kidneys, and maybe his brain were still good, but the rest of his body was already mostly dead, the agony of its cells screaming at us in those numbers.
I nodded at Captain B and we both looked at the little fellow losing his battle for life. “The other kid, the one in 2, is as stable as a rock,” I told him.
He nodded. “They probably stopped him from bleeding before his brother.”
That was when it hit me. I sort of knew it, but I didn’t want to think about it. Captain B continued as I closed my eyes to bear the brunt of it: Four brothers and four cousins … That was eight kids. We only had six. I opened my eyes and Captain B was looking at me, his eyebrows raised and his head cocked. He nodded again: “Yeah, two dead brothers, and the two others have lost a leg each. That man has just lost two of his four sons, and now he’ll lose a third one.”
I caught the anaesthesiologist’s eye as he emerged from Bay 3. I jerked my head toward the next trauma bay. “The kid next door is going to need to be intubated. He’s all burnt in the face.” The anaesthetist nodded and crossed over to 4.
The tension was still up in the bays, centred around 3 and 4. In 4, Muddy was having difficulty generating images for her ultrasound and it was taking her a long time to do her exam. On top of that, the kid’s airway was starting to swell up. I could tell by the sounds he was making as he inhaled. This was not going to be easy. Besides, if the kid was too burned, that was not survivable there. Our cut-off for survival was 50 percent of your total body surface area. Any more than that, and … well … you understand. A soldier we could Air Evac (AE) out to a burn unit back home, but an Afghan had to stay, and there were no burn centres in the country. I could always keep him there, but with all the dust and unsanitary conditions, he was sure to get infected. Hell, it was a plywood building, and even if the floors were washed three times a day it was still unsanitary. And if I had an infected case in my hospital, he’d infect my other soldiers, and that was contrary to my mission. Oh, we did have a little negative-pressure isolation room that one of our intensivists (who also happened to be an engineer) rigged up, but it was meant for respiratory infections, not infected burns. So, of this kid’s survivability we would have to debate. One of the trauma surgeons, Julien, who used to be in the same reserve Field Ambulance as me (in fact, there were thirteen of us in KAF, including a pilot and an MP), was waiting to examine the kid thoroughly once he was intubated. Julien had already put the femoral line in.
Meanwhile, Muddy had a look of concentration on her face and was biting her lower lip, which was a signal that she was having trouble. Then it hit me. “Hey Muddy,” I called out. “It’s called a ‘FAST’!” It had the desired effect. Everybody in the bay and the next one was startled. Muddy didn’t look up from her screen, but her left hand slowly rose in the air, middle finger extended. There were a few gasps of surprise, then all eyes were on me. I was prepared, and put on my widest grin. Instantly, everybody relaxed. Not too much, but just that little bit needed. Julien caught my eye and winked. The tension had
fallen. Yeah, there’d be time for the emotions later.
In Bay 5, Dave was finishing the evaluation of his little guy. “Lots of shrapnel, but stable as a rock.”
“Thanks, Dave.”
Stable as a rock, I think. We all use that phrase, but it doesn’t mean anything. My mom’s as stable as a rock too, but she’s been dead more than a year.
Okay. I had pretty much got everybody settled in my mind. The mother in 1 went off to CT to evaluate her brain. The kid in 2 will go to the OR when there is a place for him, but he was in no immediate danger. The kid in 3 was on his way to the OR but would probably die. The kid in 4 may or may not have a survivable injury; we’d know in a few minutes. If it was survivable, he would go into the OR also. But maybe to CT first. It depended what they found. The kid in 5 would eventually go to the OR, but there was no hurry. What about 6?
I made my way over to where the USAF flight surgeon was caring for that one. The doc grinned at me. The child was howling with gusto. His IV lines were all up and the doc looked relaxed in spite of the noise. The woman was standing next to the stretcher, still trying to hide her face. “This little girl is fine. She has wicked wounds on her feet and her face, but it’s all superficial.” Which, for us, meant a crippled foot and horrible scars, but no immediate threat to her life. Okay, but she would get a CT before going to the OR. I’d seen Afghan Army soldiers who talked fine but had pieces of shrapnel in their brains.
So, in Bay 7 was the father, and he looked fine. Except, of course, for having lost two sons, having a wife in a coma, being about to lose another son, and having the rest of his family all going to be operated on this afternoon. But apart from that, he was basically fine. Poor guy.
And in 8, the grinner was great. The U.S. Army physician assistant who was the TTL was holding the baby in front of him, and making cooing noises to keep it quiet. Somehow the contrast between this kid and the others was too great to bear. Get him out of here. I motioned to the woman across the way. She could take care of the child somewhere else. Out front, they’d provide her with some food and water.