Combat Doctor

by Marc Dauphin

  So we used one of our Airbus aircraft. Or a Challenger. If we used an Airbus, we’d piggyback our guys onto a regular flight back to Canada. Put the casualties in the front, and left the passengers in the back. If we used a Challenger, we had to understand that it has short legs; i.e., it has to land many times on the way back home (Scotland, Iceland, Labrador). What if the plane breaks down in Iceland, and can’t make it back home for a few days? What do you do with your patient in the meantime?

  In both cases (Airbus or Challenger) we had to prepare our AE from scratch. We assigned people and custom-built a crew for the needs of those specific patients. We pulled these people from their regular jobs in civilian hospitals for up to a week. All the equipment we had to bring to Germany was from Canada (Trenton). That meant very little flexibility once we were committed (although we did have a knack for thinking outside the box and could improvise, beg, borrow, or …). It also meant that we did not fly stabilized patients back home. We flew stable patients only. What did that mean? It meant that the patient would not become unstable during flight. It meant a lot of pressure on the staff in Landstuhl to make sure their patient was stable before they committed him or her to the plane. And since we had to call in the flight at least seventy-two hours in advance, it meant a lot of crystal gazing by the Canadian staff in the Role 4 hospital in Landstuhl. They had to anticipate how a badly injured soldier would be three or four days down the road. Woe to you if you erred on that call. It was a nerve-wracking job.

  The second reason we didn’t AE our patients back home like the Americans did was that we didn’t generate the same number of patients. Without commenting on the U.S. foreign policy, let’s just say that it is a bit more active militarily than ours. Therefore, they had a lot of wounded soldiers. In 2007, the wounded were coming in by the dozens, many times a week, from both Iraq and Afghanistan. And, with that volume of casualties, it made sense to use a C-17 when you had ten, twenty, thirty, even sixty casualties to AE back to CONUS. At our most active, during previous rotos, we would generate, at most, two, three, maybe exceptionally six or seven casualties a week. Even with seven or eight casualties, it didn’t make sense to use 25 percent of our C-17 fleet to AE a few soldiers back home.

  The overall result was that our soldiers spent a lot more time at the U.S. Role 4 in Landstuhl than did American service personnel, while we generated our missions and waited to see that our patients were stable. Sometimes it took more than a week, but usually slightly less. It made for a more intense stay because for the worst cases we would fly over the soldiers’ families to help with their recovery. That made for an intimate experience, and an emotional one.

  Working in either place was tough. In the Role 4, you lived with the family, you shared their anguish, you travelled up and down the emotional ladder with them as the patient got better or worse. You weren’t getting shot at, but your emotions took a beating. Unless you shut them out. In Kandahar, patients came through and, although it was an extremely intense, stressful experience for the caregiver, it was also a brief one, filled with adrenalin. And five minutes later you had to do it again with another casualty. The emotions in Kandahar were akin to those in an ER.

  In Kandahar, in the Role 3, as soon as a soldier was well enough to talk, the staff there had him phone his family, often from his stretcher in the trauma bay. Either a padre or Major (then) Annie Bouchard, the OC of the Canadian Role 1, would stay in the room to make sure he told his family the truth about his condition. It had happened (I was a witness to this) that a soldier, in order not to worry his wife, had called her and said, “Honey, I’ve just done something stupid. I broke my ankle and I’m coming home.” Technically, he didn’t lie. He had broken his ankle. He just didn’t tell her how he did it: by driving over an IED that injured his entire crew. When another crewmember called his own wife and related the whole story, that wife ran across the street to the first soldier’s house and told his wife what had just happened. It probably didn’t make for a cheerful homecoming for that first fellow. The road to hell is paved with the best intentions.

  When a soldier was so badly injured that he couldn’t call home, staff would call the local base surgeon (B Surg) where that fellow was based out of. The base surgeon is the senior physician responsible for all health services to the military in an area. That means that if a soldier from that area is badly injured anywhere in the world, the base surgeon will be the point of contact (POC) between all the other physicians and the family. That means translating technical mumbo-jumbo into intelligible English (or French) for the families. For doctors in KAF or Landstuhl, our POC was the B Surg, and he or she had to be available at all times. I once called a B Surg in Quebec on New Year’s Day from Germany to tell him that one particular patient had just taken an unexpected turn for the worse and might not make it through the night. I asked that he please coordinate with the family to see to it that, if the soldier lived long enough, we could bring them over (the soldier survived). I called another B Surg on a Sunday night to tell him that the reception for the three wounded soldiers arriving in Montreal on the same plane, but going to three different hospitals, was to be cancelled, and that he should also cancel the two helicopters and one ambulance and arrange for them to go to Quebec City instead, as the flight plan had just changed. So B Surg is not an easy job either.

  Generally, from Kandahar, Major (now Lieutenant-Colonel) Bouchard would talk with the base surgeons back home. I did it when she was on leave. I even spoke with a family myself once (they had figured out how to reach me in Afghanistan — just for their effort, I gave them as much info as I had). As I was writing this book, I was the base surgeon in St-Jean, Quebec, which covers all the military in St-Jean, Montreal, Sherbrooke, and as far west as the Abitibi-Témiscamingue. Fortunately for me (I am lazy), most of our soldiers come from Quebec City and that base surgeon is the busiest one in this part of the country.

  Now, once an injured soldier made it back to Canada, he went to a civilian hospital, and the base surgeon would be put in charge of that patient. I’ve never done that job, so I’ll leave it to the experts in the field, the base surgeons in Valcartier (Quebec City), Petawawa (Ontario), Ottawa, and Edmonton to describe their work.

  The Bicycle

  I had a new bicycle.

  I guess Dave had gotten tired of watching me walk to and from the barracks, a distance of about a mile, and decided to do something about it. In addition to being responsible for discipline in the unit, and the hospital buildings themselves, Dave was also responsible for the well-being of the men and women. If I wasn’t going to take care of myself, he would do it for me. You see, I hadn’t claimed a bike from the unit, as I was entitled to do; when I first arrived, I had been plunged right into the maelstrom and never got around to stopping at the quartermaster’s place during “working” hours. As a matter of fact, I don’t think I ever even checked in (which has the distinct advantage of not having to check out). So, as the unit personnel gradually drifted into KAF, they had taken all the bikes. Soon there had been none left. Oh well, C’est comme ça. Walking was the least of my concerns.

  But Dave, through some trickery, had salvaged a discarded wheel here and a bent frame there, and, out of all those parts, had assembled me a bike. Oh sure, there were no brakes on the back wheel and both tires were cracked, their rubber baked to a crisp under the pitiless Afghan sun. And the seat was loose, so that I could angle it down or back by moving my butt. But when Dave presented it to me one glorious afternoon, after having toiled on it under the oven-like sun, the look of triumph on his face was enough to make me smile. Besides, I had to admit, when you’re called back in every night, it sure saves time to be able to ride like the wind. The bike didn’t have a light and, admittedly, KAF is a very dark place at night, which got me in trouble with the MPs later on. But I’d learned to drive in Montreal, and I can anticipate what drivers are going to do even before they know it themselves, so I can avoid all trouble. I hadn’t come to KAF, avoiding rockets and bu
llets, only to get squashed by some big old truck. And it wasn’t true that I rode like a maniac. It was just the normal way in Montreal. Well, was, but that’s another story. Besides, the rusty chain and the loose gears made enough creaks and rattles that anybody could hear me coming from a mile away, except, of course, those in an armoured vehicle. But any cyclist worth his or her salt knows enough to stay well away from those big blind brutes.

  So it was that for those first few days, as I rode like Pegasus to and from the barracks, people would all smile at me. I couldn’t figure out why, until I realized that I was pedalling with a big fat grin on my face. It’s a good thing Christine couldn’t see me. It would give her another argument when she complains about my lack of maturity. Well, she doesn’t complain, actually. Not anymore. I guess she’s given up.

  I remember the morning that I got the bike because, when they announced a trauma case, one of the Dutch medics came to see me to ask if he and his pal could be on the trauma team. But it was a bad casualty coming in, and I needed my best people in the bay. (This was early on in the roto, before we had permanent trauma teams. Every time they announced incoming, we would assemble teams as people showed up. That’s the way it had always been done in the KAF Role 3. A few weeks later, as the number of traumas and their severity increased exponentially, we had to get better. We had to graduate from gifted amateurs to professionals. At least, that’s how Captain B and I saw it. But that came later.)

  Well, that Dutch medic was at the end of his tour and going home in a few days. He wanted to be able to say he had been taking care of traumas, not just emptying bed pans. He was such a nice kid that it nearly broke my heart to tell him no. Then he asked if he or his pal, just one of them, could be on the team, and the other one would take pictures to prove it. Even to that, I had to say no. Like Lieutenant-Colonel Wojtyk had said, this place ain’t about learning or training, it’s about doing. You do your learning before you deploy. Well, he doesn’t use the word ain’t, but the point he makes is the same. So I had to say no to that also. Maybe later, if we got a less severe case.

  Then, the trauma came in. A penetrating head case that bled like the rain in Quebec City in November. Drip, drip, drip from the stretcher. They had to intubate him real quick, and send him to CT ASAP, then to the OR to control that bleeding. Those Dutch kids wouldn’t have had a chance. You have to know what tube to prepare, and what angle to give the stylet inside, and to attach a 20-cc syringe filled with air to the end, and how to place the tube with a flick of the wrist exactly a certain way in the doc’s hand so that he doesn’t have to take his eyes off the vocal cords and doesn’t get all snagged in the syringe and the cuff connector. You have to be able to give the nurse the blood test tubes and know which ones to hand her, and in what order, because once she has her vein she can’t look up either. You have to manage the bag-mask apparatus and unhook the bag from the mask without being told to, but only when the tube is in the right place, which the doc doesn’t always tell you. You have to be able to control the delivery of oxygen, and be able to secure the tube so that it doesn’t go in too far or, worse, be pulled back just the few centimetres that take it out of the larynx without anybody’s noticing. You have to be able to manage the monitor and its eyes and ears — the electrodes we stick onto the casualty’s chest — and the O2 sat probe, and know when that’s too tight or too loose, and what to do about it if it is, or know if it’s not picking up a reading through no fault of your own, but simply because the casualty is in shock. And where to place the BP cuff, and how often to ask the machine to cycle it, and to stop it from cycling when the nurse is doing something with their IVs. And what buttons to press to tell the monitor to shut up when it starts screaming, which it invariably does at least a half-dozen times during a resusc, but without turning off all those precious numbers or changing the whole setup. Then, you have to be able to manage the ventilator — where the settings are, what they mean, and which numbers your doc is going to want. And this was just a head case. No chest tube with all its apparatus, no central line with all the complicated extra kit.

  No, those inexperienced Dutch kids wouldn’t have stood a chance. And, worse, having them in there could have affected the outcome. So Glenn Stryker took the case. His reassuring calm was a boon to me more than once.

  As soon as the head trauma was in the OR, the TOC called me because some Canadians were coming in. In those early days, it was still a big thing when Canadians were expected. But somehow it struck me as disrespectful when the crew got agitated for Canadians, but were run-of-the-mill for Americans or Brits or Dutch. Once, early on, I caught them being ho-hum when it was Afghans that were coming in. I had even heard a doc saying he’d like to get his hand back in by taking a few Afghan cases before getting “real” casualties. That pissed me off. I had to do something about it.

  So one day, when we were expecting two ANA soldiers, I had assembled my best people. “Who are we getting, doc? Some of ours?”

  To which I answered a curt yes, and left it at that. When the casualties arrived, one of the staff said, “They don’t look much like coalition troops. More like Afghans.” To which I responded with my famous slow burn: I get up real close to the offender and speak exaggeratedly slowly, and exaggeratedly calmly, while making sure everybody within earshot is aware of every nuance in my tone. “You asked me if they were ‘ours,’ to which I answered yes. The Afghan Army soldiers are ‘ours.’ They are our brothers-in-arms. They are courageous soldiers who wouldn’t hesitate a second before putting their lives in jeopardy to defend us should the hospital be attacked. So, yes, they are ‘ours’ and they will be considered such as long as I am the officer commanding this unit.”

  I withheld the “Is that clear?” which would have been quite Hollywood, but would have served no purpose except to further demonstrate my irritation for their attitude.

  About halfway through my tirade … (admittedly, this is a bit short for a tirade but it was probably my longest speech of the roto — I really get off on that German U-boat captain’s speech in the movie Das Boot: once the crew are assembled on deck to hear his address, he asks them, “So, men, is everything in order?” To which they answer, “Jawohl, Herr Kaleu,” and he responds by dismissing them: “All right, carry on.” Best speech I’ve ever heard.) So, about halfway through this tirade, I stopped looking only at the staff member who had asked the offending question (by now you’ll have figured out that I had set him up), and looked at each member of both trauma teams in turn in the eye as I spoke (I had purposely placed myself between the two bays for largest audience and max effect). Well, that took care of that. Wish all problems were that easy to solve.

  The other problem, I thought, demanded a little more subtlety. What I did was pick out a couple of “spokespersons” in the group, those who had the gift of the gab and who, consciously or not, helped shape the opinions and attitudes of their comrades. Trauma bay lawyers, you could call them. Then, purely by chance, of course, I happened to run into them on a one-to-one basis and proceeded to confide my inner feelings to them.

  As in, “You know, I’ve noticed that when U.S. soldiers come in, the Americans on our staff don’t get all worked up emotionally. Same with the Brits. But us, we get all touchy-feely-I-can-feel-your-pain huggy and distraught when it’s Canadians. I wonder if the others aren’t going to get irritated by these girly Canadians. And I don’t know what to do about it.”

  I knew I had played that card right when both of them commented that that attitude also annoyed them. Would this simple intervention be enough to change the whole team? We all did have acquaintances, friends, brothers, even husbands out there. It could be one of them who was injured, or even killed, as happened more than once.

  I knew I had won when, a few days later, a Canadian newspaper reporter asked one of my crew the standard question, “What does it feel like when they announce Canadian casualties coming in? Does it make your heart race that much more?” To which the med tech answered, “We treat all c
asualties as if they were Canadian. If our heart races a little more, we keep it inside. We’re professionals.” Tadaaa! Point won.

  I told you we were getting better at this.

  Nevertheless, if you knew what to look for, you could see and feel the tension when multiples were expected.

  When we had permanent teams, I remember the boys’ team was easy to read (aren’t guys always like that?). Two Canadian med techs — Eric Dionne, not exactly a little guy, and Troy Schwager, nicknamed “Monster-Boy,” a huge man; plus one USN ICU nurse, Aaron, a.k.a. “Shrek,” at about the same weight and totally fatless. Then there was their “diminutive” leader, Phil, at only about five-eleven, but lean and mean. For relaxation, Phil liked to run halfway to China and back. And then there was Rémi, the unit photographer and the team’s note-taker. At about six-four or six-five, he was very strong.

  Me with the guys’ trauma team. I would trust my life to these men. Canadian Captain Rémi Pelletier, RN (who took most of the pictures in this book); USN Lieutenant Aaron Ojard, RN (a.k.a.,“Shrek”); Canadian Master Corporal (now Sergeant) Troy Schwager (a.k.a., “Monster Boy”), med tech and fellow Detroit Lions fan; Canadian Corporal Eric Dionne, med tech; and Captain Philippe Parent, MD.

  With “The Five-Foot-Two Crew.” Another group of people with whom I’d trust my life. Canadian Captain Brigitte Barthe, RN; Canadian Captain (now Major) Isabelle Paquin, MD; USN Olga Nazarova, Med Tech; and Canadian Lieutenant (N) Kristi Velthuizen, RN.