by Marc Dauphin
I’m not an expert in brain CTs, but I could tell this was not good. There was no catastrophic hemorrhage or anything. As a matter of fact, there was no hemorrhage at all. No pieces of shrapnel. No pieces of the suicide-idiot, like that toe we’d just pulled out of the boy’s face. No, there was nothing on that little girl’s head CT. Nothing. Not even what you normally see, which is white matter and grey matter. It was just like channel 173 on the cable: snow. Then the neurosurgeon started shaking his head. I guess behind that cool, professorial exterior, he had feelings too. Captain B, the chief surgeon, understood right away. He just looked at his feet and walked away. He had two other patients to deal with. Plus he was aching to get into that taxi driver’s chest.
Usually, Martin, the neurosurgeon, just waited for the radiologist’s verdict and nodded along, pointing to some subtle sign or other in that low, precise, lilting voice of his, almost as if he was conspiring and didn’t want people to overhear — a voice so low that people stopped fidgeting and bent toward him so they could hear. It was a great way to get somebody’s undivided attention. So it surprised us all when he used his teaching voice to belt out, very loudly, “What you are all looking at is catastrophic anoxic brain injury. This child has been deprived of oxygen for a prolonged period of time, and her brain is now dead.”
Well, it sure wasn’t here that she was deprived. Nor in the helicopter. She arrived with O2 sats of about 95 to 98 percent, which is not perfection but excellent by any standard. The only reason Isabelle intubated her quickly was because her GCS was 3.
Stupidly, I asked the neurosurgeon if there was any hope. Well, I was thinking of how I was going to manage my ORs and my beds. He just looked at me for a few seconds with anger in his eyes; then, realizing what I really meant by my question, he just slowly shook his head. I curtly nodded and went to the OR. There was such a feeling of sadness around that CT scan monitor that I didn’t want to stick around. Besides, it wasn’t fitting for the OC of the hospital to walk around with his eyes brimming with tears.
All right, let’s get our shit together. This is a military hospital and we’ve got two other lives to save. Besides, soldiers could be coming in at any minute.
In the OR, they were joyfully fiddling around with this guy’s chest as the blood of some person from Kansas was helping save a taxi driver from Lashkar Gah. Okay, they didn’t need me in there, and, by the tone of their voices, the guy was going to be back driving taxis within a few months. Provided he had enough money to buy another cab. In Afghanistan, I don’t think there is such a thing as car insurance. Besides, does insurance cover suicide bombers?
Dr. Martin Christie, a great neurosurgeon and a fine man, lectures the personnel on a case. This is U.S. Navy Commander Russell Hays’s trauma team. Canadian PO2 LaKing (a.k.a. “The Po”) is wearing the white scrubs (a PO2 is a petty officer, second class).
This ambulance is either waiting for the Ilyushin to taxi by or it has just picked up a casualty and the helo has flown off. The vehicle is actually under the moving aircraft’s wing. You wouldn’t see that in a civilian airport. Walking back are Sergeants Major Marshall and Normandin.
According to the CT, the boy was doing fine. Though they had knocked him out a bit so that he wouldn’t move around during his exam, he still found the strength to complain about the way we were treating him, and a quick glance at the monitor, as the images flipped through the computer, showed me there was not much happening in his chest or abdomen. A few stitches in the face and he’d be sitting by the taxiway watching those big ole Ilyushins roaring by.
I guess I didn’t have any choice anymore. I’d have to face up to how we were going to handle that little girl. She was back in her bay, and her trauma team were fussing about her in a way only girls can. One was softly stroking her hair, trying to get all that dust out. Another was cleaning her hands and feet with a washcloth. Gently, as if the little girl were conscious. Another was just standing there, looking at the little body, her eyes focused somewhere else, very far away. Maybe she had kids of her own back home. They weren’t nurses, doctors, or med techs anymore, I realized. Not even “girls,” like they called themselves. They were women. Mothers. The mothers they were, or the ones they would soon be.
The interpreter came in and gently, in a very low voice, said the final prayers from a religious book written in Arabic that he treated with reverence, and the pages of which he flipped backward (it wasn’t the Quran — too thin). We all just stood around with heads bowed and hands crossed, looking awed as always by the presence of imminent death. The interpreter softly blew in the child’s face and said a few more prayers, then gently touched her forehead and walked away. How he could keep smiling every time he did this, I never understood.
The little girl didn’t need a respirator. She was breathing fine through the tube, and looked as if she could just go on and on. Then Isabelle looked up at me. She had been called up from home in June just as she was returning to work after her maternity leave: “Captain, there has been a problem in Afghanistan,” they had told her. “You’re leaving for four months next week. Sooner if you can.” And she’d wound up here, fresh out of med school, fresh into motherhood, and precipitated with little preparation to one of the worst places on earth.
The plan had been to keep her in Outpatients for a few days, seeing colds and back aches to acclimatize her. Then, we would “trade” her to the Role 1 in exchange for John, a grizzled veteran physician who’d only joined the Canadian Forces at the end of a civilian career, and who’d practised anaesthesia as a family physician. He was experienced and very cool, precisely what was needed in a trauma bay. But then Isabelle, in her quiet, self-effacing way, had proved to be such a strong physician and leader that I had decided to keep her, and I never regretted it, not for one second. Sorry, John. Maybe some other time.
Well, Isabelle was looking at me now for guidance. It wasn’t fair that she’d be stuck with the decision. “Okay, I’ll do it,” I said. Somebody had to pull the tube out or that little girl was going to go on breathing like that forever. Keeping her intubated would only prolong her agony. She was never going to wake up. She was brain-dead, so she’d get dehydrated and starve, and it wouldn’t be pretty.
When I saw that all eyes were on me, I stopped. I couldn’t read their minds, but I knew I had to say something so they wouldn’t feel that they were participating in killing a child. I focused on the little girl’s face, willing myself to be strong and not to let the visions of my mother’s face creep in, and said: “After all, if I could do it for my own mother, I can do it for this kid.” Well, just the year before, I hadn’t actually pulled the tube on my mother: the nurses had been kind enough to do it. But I had made the decision, given the final okay, the final medical okay. “It comes with the territory,” my mom used to say. Yeah, Mom, I suppose if you want to be an ER physician, you have to face up to that kind of situation. Well, I guess she was watching over me from up there. Watching over us.
I hadn’t managed to keep all the emotion out of my voice, although I thought I had, because Isabelle reached out and stopped my hand. When I looked up, she just smiled in that calm, almost serene way of hers and nodded that she’d do it.
Well, that was one strong child, because she just kept on breathing normally, even with the tube out, and we were just standing there, knowing that it could take hours. One of us had to stay with the child, yet we could be needed somewhere else at any moment. One of the only rules I gave my staff when we had started training, almost a year before, in Wainwright, Alberta, was Nobody dies alone. And I must have said it and repeated it with enough force that it was respected. So there we were, just standing there, marvelling at that child’s strength, not knowing what to do.
That’s when Shrek showed up. He’d been up all night and should have been sleeping, but somehow he’d heard about the situation and come right over to the hospital. He just walked into the bay and took charge. “Let’s take those IVs out,” he said quietly. Then, he gently sc
ooped the little girl up in one huge arm and took her away.
It took her many hours to die. Yet Shrek never faltered. He sat down in the head nurse’s office, turned off the light, and just rocked that little girl as tenderly as if she could feel him, talking to her, smoothing her hair, even humming. Once in a while, one of us would go in the office and sit down next to them and stay for ten or fifteen minutes, not saying anything.
Later, we learned that she hadn’t been injured at all from the blast. In a last reflex, her mother had tried to shield her from the explosion, and had succeeded. That’s where the soldiers had finally found her: under a pile of bodies in the wrecked taxi cab. That’s where she’d suffocated.
Just about the time she gasped her last breath, four U.S. soldiers, victims of an IED, came in, and the show started again. Rock ‘n’ roll time, people, let’s go!
Just another day in Afghanistan.
C’est comme ça.
Darn pilots.
Can We Try …?
It was a bad day for Trauma Team Foxtrot. They’d already lost three. The last two were catastrophic head injuries. Unsurvivable, I mean. Then, there had been the guy with a crushed chest. A container fell on him. His heart basically exploded like a burst balloon. There were a few minutes when we started to resusc him to send him to the OR. But the instant we put him under, his BP crashed, and from then on, we were fighting a losing battle. But we tried. Heck, we had two heart surgeons in there. But the hole was at the back of the heart, right where the atria and the ventricles join. They gave the guy about sixty transfusions, but he didn’t make it. Like I said, it was a losing battle. Maybe if we’d had a bypass machine …? But even then …
TT Foxtrot was an interesting bag. The TTL was American. Navy. He came in with little experience in trauma, but he was a perfectionist. One month after his arrival, he took Team Charlie. Or Delta. Or was it Alpha? Anyway, it was his second trauma team. We changed them every thirty to forty-five days because they got exhausted. The team always wanted to keep going because they fed off the adrenalin, but it was better that they changed. Oh, they wouldn’t be making mistakes and all that. When you’re running on adrenaline, your thinking is very clear. But as soon as the crisis had passed, I could see it in their eyes. They just weren’t there anymore. They call it the thousand-yard stare. And that’s when mistakes happen. When your body doesn’t succeed in cranking up that adrenalin high. Little things. Nah, it was better to rest them. Captain B wanted to keep them going and got in all kinds of states every time I announced a change. It was the only thing we ever disagreed on. But, like I said, “This ain’t no democracy.”
So, Team Foxtrot, they gave themselves nicknames and even had corresponding name tags made. They all wore U.S. Army scrub tops, so their name tags also had the flag of their home country on them. Very nice. You had a Canadian “Athena,” an American “I Pity the Fool,” a Canadian “PO,” and an American “Reaper.” They even tried to write their TTL’s name on the floor in front of their favourite trauma bay, but he quickly wiped it off: “I’m happy you guys are proud of me, but the hospital doesn’t belong to us.”
They were all just kids, really; younger even than my sons. What that war was doing to them I couldn’t imagine. I’d liked to have sent them all away from there. Go have a few beers on me. Get yourself a normal life. Get the hell out of this place!
So, that morning, when they announced another incoming casualty, one member of the team innocently asked the TTL, “Please, sir, can we try and save this one?”
C’est comme ça.
Like I said, some stick in your mind more than others.
Mortuary Affairs
One of the bad parts of my job was that I sometimes had to go to the morgue. They called it “Mortuary Affairs.” It was really two units. One was NATO, and it took care of all the dead, civilian and military, except American ones. The staff was all civilian Danish, but their boss was Norwegian. Or was it the other way around? I’ve forgotten. The other part of the unit, with a much bigger facility, was American, as in U.S. Army American. Both staffs took their job very seriously, but the atmosphere in each was quite different.
My job, when called over, was to pronounce the deceased officially dead and provide a likely cause of death. I hated it. So did all the other physicians.
Annie, Major Bouchard, the OC of the Role 1, did a lot of the Canadian dead. On other rotos, it used to be the job of the OC of the Role 3 (me, at the time), but Annie took it off my shoulders because I had so much work. Thanks, Annie. Lieutenant-Colonel Wojtyk, as task force surgeon, also took a lot of the others off my shoulders. So it was that I didn’t have to go there more than once a week, which was fine with me. I bet Lieutenant-Colonel Wojtyk would have a lot of stories to tell you.
Mortuary affairs was about four hundred metres from the hospital. We had to walk by the OPD, through our ambulance parking, then out on the taxiway, turn right, and then we were there, at a large tan and white concrete building with a bunch of refrigerated sea cans (shipping containers) aligned two-high along one side. Walking over there, there was always trepidation. The first part was unease about leaving my hospital behind, no matter how short my absence would be: trouble happened real fast in Afghanistan. The second part, as I was pulling farther and farther away from my hospital, was worry about what I would find once I got there. It seemed funny that, when I was far away, I never bothered too much thinking about what I was about to see, but when I was about to get there, I got nervous. I wonder if embalmers and such feel the same thing. And you should know that, as a civilian, I was a coroner for twelve years, from age twenty-eight to age forty. And as an ER doc for a quarter of a century, I’ve seen my share of dead bodies. Still, they affect me in an emotional sort of way, maybe by reminding me of my own frailty. Or maybe because of the finality of it all. Of its permanence.
That day, we had four U.S. soldiers who had died in a minefield. Mortuary affairs came by and asked for a doc. I happened to be there, and things were under control in the hospital, so I volunteered. Linda, the head doc of the Dutch Air Force Role 1 was around, and she wanted to come too. Sure, kameraad. Why not?
The walk over on those big ankle-twisting rocks and under the pitiless sun (at 60°C, that’s not a cliché — it’s the truth) was not pleasant. The U.S. main processing room was huge. It could contain hundreds of bodies. I didn’t know if I was shuddering thinking about that fact or because it was so cold in there. Cold, as in f---ing cold. F---ing Canadian cold. All right, let’s get this over with.
The staff appeared a little confused and they sort of stood around, as if waiting for an order. They looked eager to work, but they also look like they hadn’t got a clue what they had to do. Only their sergeant, a very young man, seemed to have it all under control as he gave out his orders with a fluttering of hands and a continuous stream of encouragement for his deer-caught-in-the-headlights soldiers.
The body bags were wheeled out onto one of those conveyors with metal rollers like they used to have in the grocery stores when I was a kid. You know, the ones on which they’d put those cardboard boxes with your groceries, and trundle them all the way to the pickup at the other end of the store, and you’d come by with your car to load them on. (Don’t play with those rollers, Marc! You’ll get your fingers caught and we’ll have to cut them off.)
The bodies were maimed; no wonder they died.
The first one I examined didn’t die right away. One of his buddies had obviously tried to put a tourniquet on his thigh, but he had died anyway. Both legs had been ripped off, one of them all the way up to the groin. He didn’t have a chance. His face was not too messed up. He probably breathed on his own, and screamed as long as he could. I tried not to conjure up too many mental images. Cause of death clear.
Next.
The second one died of one single sharp piece of something. Probably metal. Very little dust on him, although the first one was caked in it and his wounds had been filled with it.
I tur
ned and asked, “Were they all in the same incident?” Upon getting a nod, I concluded, “So this fellow was in a vehicle, and the other one was dismounted.”
For an answer I got a blank stare. I just shrugged. I palpated the body’s feet. Through the skin, they felt like a half-filled bag of sand.
“Definitely in a vehicle.”
Those were IED feet, where the heel bone (and probably most of the ankle bone, too) has exploded and been reduced to a pile of pebbles. If that soldier had survived, he would have lost both his legs. In spite of the skin of his feet having remained intact, we would have had to amputate them. Either there, or in Landstuhl.
Moving on to the wounds.
A single piece of metal had torn up the inside of the man’s calf, then up his thigh, slicing through his femoral artery. He didn’t have much of a chance just there. I pointed out how it had sliced open his boot. He had been sitting down when it hit him. When I bent his knee and his hip, the wounds aligned. The piece had then torn up the side of his abdomen and chest, and sliced his neck from bottom to top, taking out his right ear. He never had a chance. It was either a piece of the floor, or a piece of something that was lying on the floor when it blew up. And I could tell he hadn’t been wearing his body armour, either. Or it was loose on him.
Next.
The back part of his head was gone. So were his buttocks and the back part of both his thighs. His back had been turned away, or he had already walked on past it. Killed instantly.
Because the personnel on duty in the hospital could not attend ramp ceremonies, we would gather by the edge of the taxiway, where we could watch the ceremony a few hundred metres away, and pay our respects to our fallen comrades. You will recognize American, Canadian, and Dutch uniforms.