by Marc Dauphin
“Nothing else?” I asked Phil, the TTL. He shook his head but couldn’t take his eyes off the boy.
“Must have been some rock ‘n’ roll intubating him, huh?” I said.
Phil didn’t say anything, but when he raised his eyebrows I caught the measure of his respect for Hermann’s cool. It isn’t just being able to stick the tube into the right hole, it’s having the guts to paralyze a kid who, if you don’t intubate him on your first try, you won’t be able to bag; you can’t bag someone if there’s little of his face left.
The CT showed what we had all guessed: there was no more jaw on the right side. It was gone. Pulverized into microdroplets of bone, saliva, tongue, teeth, skin, and blood. Like in those shoot-‘em-up kids’ video games where the victim’s head explodes into a cloud of pink froth. Even on the CT, it sure looked weird to see the tube sticking out through the boy’s cheek.
“How am I supposed to fix that?” asked the oral and maxillofacial (OMF) surgeon. “There’s no bone left. I have to have something to hook up onto, otherwise we’ll never be able to extubate him.”
A scan shows the extensive damage to this patient’s jaw. The modern CT has made the surgeon’s job so much easier.
The difficult reconstruction of a badly damaged face.
I shrugged, not realizing that it was a rhetorical question. “Well, you could start by closing him up,” I suggested. Sometimes I should learn to keep my mouth shut. The look she gave me was as withering as such a nice lady could muster. Of course she would close him up. She had no choice. Then, she probably decided I was teasing her because she gave me that tired smile, the one where she couldn’t hide the kindness in her eyes. That’s the advantage of keeping a straight face when you tell jokes, especially if you’re in the habit of telling self-deprecating ones: when you say something really stupid, people are convinced that you’re joking. Well, that was fine with me, and this time I did shut up.
So, into the OR he went. The OMF surgeon would be helped by the neurosurgeon. They always assisted each other, so that we called them the “Head Team.” It’s a good thing we didn’t have a proctologist and an urologist. Just kidding. Anyway, trouble is that the Head Team had been operating pretty much continuously since the night before. They must have been bushed. I hoped they had taken a nap during the evening. They weren’t going to fix that kid in a few hours. They were on for a looong time.
It was 0400 the next morning when the OMF finally put that last stitch in. I know, because I was there, assisting her and relieving the neurosurgeon. I’d much rather it was me who was bushed than him. Apart from a few rare cases, nobody really needs my hands. Phil could replace me. So could Captain B. Did I tell you my hair was mostly white?
The kid did fine over the next few days. We knew he didn’t live very far from KAF, because his dad was a frequent visitor. Like all Afghan children, the boy was very stoic, never complained. The first few days, he just sat there, with a little basin under his mouth to catch the drool, because, of course, he couldn’t swallow. The OMF surgeon was checking on him daily to figure out when she would go back in to try to start the long process of re-jawing him. That’s when we started finding out what a character we had on our hands.
It started out quite innocently. I was in the ward, taking a picture of some of the nurses because we had just received a case of brightly coloured and patterned scrub tops from some charitable (and very helpful) people back home. The nurses had gone absolutely crazy over them. I guess when your world is coloured with different shades of tan you’ll jump at any occasion to add some variety. Personally, I thought they looked great, and I was taking pictures of them all, as some of these scrub tops were positively wild — fluorescent red, blue, and green — and I thought it’d make for some neat photos with them standing next to one another. To get a good angle, I stood right next to the kid’s bed while I took the picture.
It was later in the afternoon that I discovered my pen was missing. I shrugged it away and grabbed another off the ward. But the next day I put two and two together when I saw the kid was busily writing in his bed — with my pen! I knew it was mine because nobody else had those pens, a supply from my private clinic in Sherbrooke. Bic had stopped making them years back: medium point, plain blue, matte Clickers. I still had a few of them left from my days as a civilian. That’s when I figured it out, remembering that I had stood by the kid’s bed while taking the photo. My scrub tops (Ferrari red, remember?) had pockets on each side, not on the chest, like most tops, but down on each side, close to the belt. It was really practical because when I bent over a patient my pockets didn’t empty onto him. They were also at just about the right height for a quick-handed kid to grab a pen from.
A colourful picture with some Canadian nurses: Lieutenant (N) Julie Harvey, Captain Joëlle Beaudoin, and Captain Caroline Cameron.
A pen wasn’t much, but if he filched something else, it might be a problem. So I asked the nurses to pose and smile while I took another picture from the same spot as the day before. They were decked out in bright yellow, white, and vivid pink that day.
“Keep an eye on the kid while I take a picture of the girls, will you, Jimmy?” But the kid had made me, and didn’t lift a finger at the proffered bait. As soon as I finished taking the picture, however, he raised his hand and pointed at my camera, saying “Gnh, gnh.” Well, I suppose you can’t do any better if half your tongue has been shot away and the other half is a raw wound. So, thinking he wanted to see the picture I had just taken, I showed him the screen on the camera. He didn’t give a damn about the picture, though. He wanted the camera. When I recovered from my surprise and told him no, he just shrugged and went back to writing with my pen. If I couldn’t provide him with a camera, he wasn’t the least bit interested in me.
A few days later, he was operated on again. They put an external fixator on what was left of his jaw. That’s an external device that keeps broken bones in position better than a cast. Besides, you can’t put a cast on a jaw. Nor is it recommended to put one over an open wound. An ex-fix goes on like this: you drill long, metallic pins into the good bone on each side of a fracture, and let them stick out through the skin so that it looks like you’ve been to a very sadistic acupuncturist. Then, you slide some metallic joints on the pins and insert rods that will connect the pins together, paralleling the skin. You then bolt the whole thing together tight, and with just the right angle that you need. The result looks like a building game we used to have in the fifties called Tinker Toys. So this poor kid had this metallic scaffolding sticking out from his jaw. Must not have been very comfortable, but it probably beat the hell out of having all those bone pieces loose in there, grinding against your gums, your cheek, and what’s left of your tongue.
Many people come to visit in a military hospital. VIPs, not-so-VIPs, commanders, chaplains, journalists, Red Cross staff, volunteers, family members — there was always somebody. Well, the kid sure knew how to play them all. The bullet that had gotten him had also removed some of the skin, so the OMF surgeon had had to cheat a little when putting him back together. The result was that his lower eyelid on that side had been a bit pulled down, which increased his lopsidedness. But if he never complained, he quickly figured out that we Westerners had a soft spot for children, especially injured ones. I guess in Afghanistan, unless they’re yours, people just shrug off kids when they die. At least the Taliban do. Well that boy sure milked those visitors for all they were worth. He had this thing for watches. By week three, he must have had half a dozen of them. But still he asked any and all visitors for theirs, with his “gnh, gnhs” and his agile fingers. I remember one senior officer brought him a brand new watch, and gave it to him with tears in his eyes. Had I known, I would have intervened beforehand, but when I saw him giving this watch to the kid, I just didn’t have it in me to step in. What could I have done? “Sorry, General, but this kid already has a least a half-dozen watches, and by the way, please watch your pockets, sir, because his fingers are real agile
.”
I don’t think the general would have appreciated being exposed as having been made a fool of by an eleven-year-old champion kleptomaniac. I don’t really care about my career, but I also don’t go out of my way to get in trouble. So I just looked the other way. Watch? What watch? What general?
When visitors were nice, we’d warn them about the kid’s fingers. But occasionally we wouldn’t say a word, and out of the corner of our eye we would just watch a professional at work.
Our kid had quite a stash of loot hidden in his covers and under his mattress. I wonder if he ever slept or if he just kept watch over his riches. Come to think of it, it couldn’t have be easy to sleep anyway, what with that contraption sticking out of his face.
After about six weeks or so, it was time for him to go. The bone was re-growing, the wounds had healed, and he could eat again. He had even started to try to pronounce a few words. The day before he left, he asked his dad to bring some stuff for the nurses. It was cheap stuff — costume jewellery — probably the best the local economy could furnish. He had tin hair clips, earrings, and brooches. And as he gave each nurse hers, every one of them was touched by his thoughtfulness. I never thought girls were so easy, but there they were cooing in that touched-you’re-so-nice tone of voice. Hell, he was probably going through their pockets with his other hand as he was giving the stuff to them.
Anyway, the best part was when he was at the back door, getting ready to board the ambulance. As he was leaving, he spotted one of the med techs who worked on the ward. He gurgled at the medic (he still couldn’t talk) and extended his right hand. Touched, the medic extended his hand for a shake, but the kid irritably waved it away and pointed to the sandwich the medic was eating.
It had been a long time since I’d laughed like that.
Well, good luck, kid. Here’s to you. I’m sure you won’t have any problems making it out there in the world.
Mr. Rice Man
For sheer adrenalin, that Saturday afternoon sure was one of the best. Or worst. Depends on your point of view, I guess. First, we had an U.S. Army colonel visiting. He was responsible for standards of medical practice in Iraq and Afghanistan. (Medically, Canada has agreed to apply the JTTS Clinical Practice Guidelines [CPGs] the U.S. Army has put together and keeps up to date. In fact these CPGs are so up to date that they’re the way people are going to manage trauma in civilian hospitals five or ten years down the road. They are rigorously based on best evidence, best practices, and the intelligent application of North American quality assurance standards modified to the combat context.) So I wanted to impress him. Well, I don’t really know if we did, but it sure wasn’t for lack of trying.
The arrival of some ANP casualties was announced as soon as the colonel set foot in the hospital. So we revved up our teams. As the casualties came in, with him looking over our shoulders, I triaged them and quickly headed to the trauma bays. As soon as I got to Bay 1, I could tell the doc was going to need me. His patient was going. Fast. I stepped in and intubated the guy with the first tube I found. Just like that. No drugs, no paralysis, no knocking him out. He was already circling the drain. Then, as I looked away from his larynx, I heard the monitor behind me go Beeeeeeeeeep. The guy was in arrest.
One of our surgeons stepped into the bay and asked me, with exaggerated politeness, “Would you like me to open his chest?”
One quick look at his chest and abdomen, which were peppered with holes, and the decision was easy. “Please do, sir.” Also with exaggerated politeness.
U.S. Army flight medics on their way to Trauma Bay 1, to give their report to the trauma team leader. Notice all the trauma teams, calmly staying in their respective bays. There is no running or milling about. People don’t appear tense, just focused and business-like.
The U.S. Army flight medic gives her report to USN Commander Russell Hays, the TTL who will receive the patient in the next few seconds. Commander Hays, like most ER docs, is writing the info on his hand rather than a clipboard. You can’t misplace your hand.
And whack, whack, whack, just like that (sounds like Dr. Seuss, doesn’t it?) his chest was open. But not that one-sided chest opening you see on TV. No sir, none of that for this surgeon. He did a clamshell. It goes like this: you open one side, front to back, then the other, and connect the two openings through the front by cutting across the sternum. That way, you have a lot of room to correct whatever it is that’s going wrong in there. Well, it was the first time in my life that I could ventilate a patient and actually see both his lungs inflating. Cool. During that time, they revived his heart with a shot of epinephrine and a few transfusions, and he was off to the OR. Just like that.
Then Russell needed an extra pair of hands in 3. Well, in for a penny …
His guy had been shot in the head and his entire face and head was swathed in thick, dirty bandages. Oh, and the blood. Lots of it. Plus, the guy had eaten rice for lunch. Lots of it. Yeah, rice mixed in with blood. That earned him the name Mr. Rice Man. So we had to intubate him before his CT scan. The trouble was going to be to ventilate him once he was paralyzed, and before intubating. What was I going to put the mask on? He had no more face. I know it all boils down to a few critical moves. Simple, no? Come to think of it, football is like that too: run or pass. Or both. Anyway, we got our stuff together, I got my courage up, but then, just before we were about to paralyze him, he spoke. The interpreter bent down as far as he dared (what with all that rice and blood) and asked the policeman to repeat what he had just said. I was expecting something dramatic like “Tell my wife I love her,” or even “The guy who shot me is called so-and-so,” but when the interpreter translated, I knew it was one of those moments when, if your eyes met someone else’s, we were all going to break out laughing and we’ll lose control of the resusc. What the man had said was, “I have a terrible headache.” Luckily those moments, as I knew, don’t last long, and in an instant the life-and-death drama took hold of us again.
So the guy was paralyzed, and it was all I could do to ventilate him with the bag and mask. By that time, we were all covered with blood and rice. I looked inside with the laryngoscope and had a pretty decent view, so I suctioned for all it was worth. Then with the sats falling, I pulled out and bagged the guy some more. Mustn’t be hasty.
Then I noticed that the colonel was in the bay with us, wearing gloves and ready to step up, so I stuck the laryngoscope back in. Pretty good view, but the larynx was way anterior. There was no way I was going to get the tube in that way. So I backed out and bagged the guy again, then positioned something under his head to align his airway. No panic: we were sat’ing close to 100 percent all the time. Lifting his head was kind of yucky as all the bones in his skull seemed to be shattered, and I had the feeling I was manipulating a sack of marbles. It was a miracle that he spoke to us and knew enough to tell us he was in pain. Those guys were tough.
Okay, so time to go back in … great! The alignment was much better this time. I grabbed the tube. Damn, the vocal cords are only half open. Okay. No problem, I’d just wedge the tube in edgeways. Shit! The damn thing was so slippery from my hand being slick with blood that I couldn’t shove it in. The hell I can’t! One quick wipe on my thigh and my hand was dry. The tube slid in. We’re home! Okay. Listen down there. All good. Time for me to go check on Bay 4.
They were doing okay. But Captain B was came down the hallway wearing OR scrubs and shaking his head. He was covered with blood. I guess the first guy, the one with the clamshell thoracotomy, didn’t make it. “Massive head wound,” he said. Then John MacDonald, the Canadian anaesthesiologist, came out and wagged his finger at me. “You intubated him, Marc?”
“Yeah, I did. It was real easy. Something wrong?”
“Not with the intubation. But you didn’t check his head after?”
Damn. I had been too busy gawking at the open chest to check the back of his head. John raised his fist to show me. “A hole this big in the back of his head. Unsurvivable.”
“Oka
y, okay. I got the message, Johnny. Sorry about that.”
He softened up.
“Nah, don’t worry about it, Marc. It wasn’t until ten, fifteen minutes after I’d been working on him that I noticed his brain was oozing onto my shoes.”
We both shook our heads. What a day! C’est comme ça.
An hour later, Lieutenant-General Lessard came in. He was the CO of CEFCOM, Canadian Expeditionary Force Command at the time, responsible for all the Canadian missions outside Canada. That included Haiti, the Sudan, and a half-dozen other missions that were all going on at the same time. He was accompanied by Lieutenant-Colonel Wojtyk, the TF surgeon. The general shook my hand and asked how we were doing. I just glanced down at my boots and back up at him. They were covered in blood and rice. When our eyes met, General Lessard raised his eyebrows but didn’t say a word, he just kind of smiled and nodded.
CF Major John MacDonald, a superb anaesthesiologist and a great comrade, and civilian Dr. Michael Kenyon, an intensivist from B.C. and a kind, great man. When you get the opportunity to work with professionals such as these, you bless your luck. Thanks again, gentlemen.
A few months later, the general was back and there was a little ceremony at which he handed out coins. Yup, coins. Each CO had some personalized ones made and gave them out as tokens of a job well done. As he got to me, he handed me the coin, shook my hand, and said, in French, “In spite of your boots, Major.”
Well, I don’t know what got into me. You shouldn’t quip at a three-maple-leaf general if you value your career, but hey, what could they do to me? Down-rank me back to captain when I got back? It was going to happen anyway. Send me back to Afghanistan? So I just sort of blurted it out: “General, Sir, because of my boots.”