Combat Doctor

by Marc Dauphin

  The visible bullet has hit a major neck blood vessel near to or in the chest. Fortunately, a very cool medic happened to be there to clamp the vessel. Saving casualties is a team effort. All the links in the chain have to be strong.

  After rounds, I make my way back to my office and a wave of sleepiness hits me. I push back from my computer, angle my body so that my butt rests on the edge of the chair, prop my feet up on the desk, and cross my hands over my abdomen. In less than a second I am gone. Sometime later, I am half awakened as someone pushes the door to my office open. Then someone else says, “He’s been up all night. Leave him alone.”

  “Yeah, let him sleep.”

  When I wake up an hour later, my door has been closed and someone has put a blanket over me.

  I can hear the choppers: more incoming. As I get up I can feel my body. Not getting any younger, I guess. I make myself a silent promise: After this, I am never stepping into a trauma room again. Never. There is just so much you can take.

  You find your laughs where you can.

  A civilian has been shot in the chest. As the team is resuscitating him, I walk in to do the FAST ultrasound. I put the probe onto the left side and right away I see blood.

  “FAST positive,” I announce. “Blood in the abdomen and the chest.”

  My contact with the skin is not perfect, so I turn away for a second to slop more gel onto the probe. I am concentrated on my ultrasound machine and don’t notice that they turn the patient slightly to the right side so that his left chest is slightly higher, and thus more exposed and the tube easier to insert. That means that the blood, like any fluid, will now pool to the other side of the chest cavity. So when I turn back to the patient and reapply my probe to his chest, I see nothing. Not realizing that the patient has been slightly tilted, I exclaim, “Hey! Where’d all the blood go?”

  Seeing my bewildered face, the trauma team bursts out laughing.

  Like I said, you get your laughs where you can.

  Eight ANA soldiers. One of those virgin-loving martyr-wannabes drove up to their compound and pulled the switch on a perfectly good Toyota pickup. Now my eight trauma bays are busy. Real busy. There is some tension, but not too much. My main problem is interpreters. I have only one, and each of these wounded guys has something to say.

  My main concern is with the fellow in Bay 1. Phil asked me to put a chest tube in, and I couldn’t. This has never happened to me, and I’m frustrated. Not to mention humiliated. But then even Max, our orthopaedist-slash-surgeon-slash-all-kinds-of-specialist, couldn’t either. We get into the chest easily, but then the damn tube won’t go in. Something is blocking it. And on the left side you don’t want to ram it in. There’s the small matter of the presence of the heart there. It’s not good putting a chest tube into a left ventricle. (Honey, I’ve had a baaaad day …) Well, the CT scan will tell us why, I hope. He goes first.

  Another one has a bunch of holes in his face and head and chest. At least this one they could put the tubes in. I wonder why I couldn’t get the one on Phil’s guy in. CT scan this one after the other one. As soon as he’s ready.

  Muddy comes to me to say that the FAST on the guy in 3 is positive. Okay, Muddy, thanks. Go straight to the OR. Do not pass Go! Do not collect $200.

  The guy in 2 is screaming his head off. Well, I guess he doesn’t have any airway problem (old ER joke). I walk over to Bay 2. Jay-sus! His thighs and legs have holes ripped out of them. Big chunks of flesh and skin gone as if he’s been repeatedly bitten by a shark. No wonder he’s screaming. Knock him under some. It takes a lot of morphine to even dent his pain. No wonder: some of these guys are high on heroin all the time.

  The guy in 6 also worries me. His face and hands are all black, and Tim tells me there’s a hole in his head. Yet the man just keeps on talking in an animated way. We don’t understand what he’s saying, of course, but he looks like he knows what he’s saying. There’s a certain something that emanates from a confused patient that this fellow doesn’t have. I sure wish I had more ’terps. Well, we’re not going to CT him right away. There are two other fellows before him. “Get a plain film of his head, Tim. That’ll at least tell us if he’s got some minerals on his mind.” Minerals on his mind. That’s our new euphemism for pieces of shrapnel inside his brain. It’s amazing how quickly language can evolve. Anyway, I’m also worried that his airway might be as burned as his face. Then the passages swell up and you can’t get a tube down there anymore.

  The guy in 5 is missing his knee. Only his knee. His leg is there. His thigh is there. But the knee is gone. It’s the weirdest thing I’ve ever seen. His leg is hanging by the skin and flesh behind where the knee is supposed to be. Fortunately for him that’s also where the arteries, nerves, and veins course through, so that they are intact and he is not bleeding much. The rest of him is all right. The man is calm, composed, and obviously not in shock. Some of these guys are real toughs. I guess you have to be to survive here.

  Bay 7 is also worrying me, but I can put him to the back of my mind. Captain B is in there ultrasounding his neck, which is peppered with shrapnel like his face. We will be in need of some reconstruction here.

  Bay 6 gets his plain film of the skull. I walk over to the X-ray monitor. Holy shit! There is a large hole in his skull, but the edges are smooth, well-rounded. This is an old wound.

  “Get me the interpreter.”

  Well, the final result is one patient less. The man was the cook. He wasn’t injured at all by the suicide guy, but his coal fire was whoofed out by the blast, and it’s the coal that is covering his face. And the hole in his head dates from years ago. A Russian surgeon had made it to save his life after he had had a bad fall as a child. You see the damndest things here.

  The CT on the first guy is done. Denis, the U.S. Navy radiologist is already reading it, flipping through the images like a kid playing a video game. Come to think of it, Denis does look like a kid. He is the exact image of the character Danny on NYPD Blue, played by Rick Schroder. A veritable dead ringer. Denis, like that character, also gets ribbed for his youngish appearance. But not right now. He’s been up three nights in a row, and was hoping to catch up on his sleep a little tonight. “No wonder you couldn’t put your tube in. See the pleura? See how thick it is? That’s tuberculosis.” I’ll take your word for it, Denis. He continues, unaware that Max and I don’t see the subtleties of what he’s pointing out to us. At least I don’t. Maybe Max does. Anyway, thank God for radiologists. “That pleura’s at least three times thicker than normal. And it’s all layered out. Like Kleenex. You go through one, but you’ve still got more. You were probably trying to put your tube in between the layers.” Well, I don’t feel as bad at my lack of technical performance anymore. Still …

  Recently there just have been too many. Yesterday, we got one guy shot in the chest. Before we knew it he had passed 1,500 ccs of blood into his chest tube. Go straight to the OR. Thank God for the Level One Infuser.

  Then a civilian shot in the arm. The bullet went through his chest, out the other side, and shattered the other arm. What can a man do in Afghanistan with both arm bones shattered to powder? Well, fate decided that one for us. When they cracked his chest open, his heart just gave out. It had also been torn to shreds by the blast of the passing bullet, and was only holding together by the pericardium, that thick membrane that envelops it. How he made it here alive is still a mystery.

  Then two Romanian soldiers: one has broken, shattered legs, the other one had his eye gouged out by the shrapnel. Not much to do. Put the legs in traction and close the eye socket. You get to play pirate for the rest of your life, buddy. But at least you’re alive. And don’t worry: some girls really like the dashing look of an eye patch. You’ll be all right.

  Next.

  One Australian soldier who had stepped on a mine. Leg gone. Tourniquet on. No shock. “Ye’r all right, mate.”

  Next.

  Then we feel it through the ground before we hear it, a low, rumbling, whooshing kind
of blast. Oh, damn it! Not another suicide idiot! Let’s get some trauma bays ready.

  What’s the news?

  A helicopter crashed on takeoff. One of those huge Mi-26 Russian helicopters. They use them here to ferry cargo and people to and from the FOBs.

  My heart sinks. They can carry up to ninety people …

  Get ready for hell, but don’t break out any perishables just yet.

  Do I call everybody back in for a “Mass Cal”? I step outside into the blindingly hot sun. People are trickling in on their own. People from other Role 1s. Nurses, medics, and doctors. There are Canadians there, Annie’s people. Then the French show up. Then some Americans. U.S. Army folks. U.S. Air Force folks, too. A chopper is going to bring the wounded in, they say.

  We send André to be the triage officer on site. André used to be with the hush-hush secret forces. He can deal with anything. Plus he’s a Mass Cal expert. The base 9-1-1 ambulance is coming in. They are bringing two of the air crew. They are mangled but still alive. There’s still another one left, over at the crash site. No word yet on how many wounded total. A large black plume of smoke on the western horizon, perhaps a couple of kilometres away, is smudging the brilliant blue sky. Not a cloud to be seen anywhere. Same as yesterday, and the day before, and the one before that, all the way back to April.

  “Mass Cal” has just been called by the base, and medical personnel from all over are coming in. In the distance, additional personnel wait where the helicopter will land. With his arms crossed, Major Pierre Voyer is getting ready to direct traffic. In the foreground, with the black surgical top, is Captain Fiona Thomas, an ICU nurse from the New Zealand Defence Force. The tall fellow is Major Daniel Dupuis, the chief of nursing and my roommate.

  Surgeons, stretcher-bearers, medics, and nurses all wait for the survivors of a helicopter crash. Unfortunately, of the more than thirty souls on board reported down, only five had survived the accident. C’est comme ça.

  Contradicting information comes in. I look at Jimmy and frown. We try to stay calm. There is a lot of electricity in the air. Staff officers are starting to show up. Planes taxi by. Big cargo planes. A Herc takes off. A pair of big ole Chinooks whoop-whoop by us maybe a hundred feet off the ground. Their cargo doors are open and I catch a glimpse of the troops sitting in the hold. Nothing stops the war. The ambulance arrives. Another Russian crewman. His English is not good, and probably made worse by all the pain he’s in. “Hey, Olga! Would you ask him what happened, please? Thanks.” Another ambulance. Two Filipinos, badly burned. They were on their way to a FOB, just taking off when the helo lost power. André calls in:

  “Did you get the two burn cases?”

  “Yup. And three Russians.”

  There is a pause. Then, “That’s all you’ll get. The others all died. Thirty-one of them.”

  I keep my voice matter-of-fact. “Roger that. Five wounded total.”

  I shake my head and announce, “That’s all, folks. We’ll be getting no others. Thanks for coming over. Ward Master, you can close the doors. Everybody else, stand down.”

  Another Sunday in Kandahar. Only twenty-something more of them to go.

  Thursday night, my first week in theatre, and I’m still feeling my way around. We have just received two Alphas and three Bravos. An IED hit an ANA convoy. One guy with both legs amputated. He is stable and talking to us. Let’s run him through the CT. One fellow is jabbering away, seemingly very angry. He half sits up on his stretcher, points to the stump of his leg, and grabs his head with both hands before pointing to his stump again. Well, he’s certainly not in shock. We are busy with the other ones. They all have ball bearings throughout their bodies. One has a hole clean through his femur. A round hole and no fracture; I’ve never seen that. I guess it gets treated as an open fracture without a fracture.

  Then the CT tech calls me over. The first soldier, the one who was making perfect sense, has a large ball bearing embedded in his brain. Ouch! Neurosurgeon, please. Then, as I walk by the radiology monitor, I do a double-take. There is an X-ray up. It is the stump of an amputated leg, yet the contours of the tibia are all rounded, smoothed, and there is cortical bone all around the end of it. This is an old wound! What we have here is a repeat customer! The interpreter walks by. “Come with me, please. What’s this guy jabbering about?”

  They exchange a few words. “He says he is angry that he has lost his prosthesis. He worked very hard to save money to buy it, and now it is gone.”

  I don’t know whether to laugh or cry. And I’ve still got six months of this to go. Well, six months minus six days. I finish sorting the casualties out, and send most of them to KRMH, the ANA hospital. These soldiers won’t even count as statistics because all we count are actual admissions. These fellows weren’t admitted. They were resusc’ed, CT’d, operated on, and transferred out before being admitted. My trauma bays are empty. It is 2330. The casualties arrived at 2230. One hour to process five traumas. Not bad for a start. Pretty good rookies, I’d say.

  A half-hour later, an ANP pickup drove over a mine. The driver and the man next to him in the cab are dead. The three fellows who we get were riding in the box. They are all broken up, but none of them requires life-saving, immediate surgery. Our luck is holding up. We have two in the OR now.

  0200 hours: We receive three transfers from a Role 2, I forget which one. One had his arm ripped by small shrapnel. He has an arterial injury somewhere between his axilla and his hand. They tried to fix it but couldn’t find the break in the line, so they sent him here for our vascular surgeon to work his wonders. The patient is still intubated from his time in the OR. It was easier to transfer him that way. I fully agree. An ICU nurse stays at his side while we wait for a place in the OR. He is stable. I grab an ultrasound machine.

  “Going to FAST him, are you, Major?”

  “Yeah, I need the practice. Besides, he was in a blast, and anybody who was in a blast should be CT’d and or FASTed.”

  I slop some gel onto the probe and gently apply it to his upper abdomen, and angle it upward to see his heart. I can’t generate a good image. Hmmm. That’s strange. But it’s two in the morning, and I’m not thinking fast. So I just do a cardiac window, where I put the probe straight on the chest, right next to the sternum, and aim my beam between two ribs. Yes, yes, I know I’m not supposed to do this, but expediency dictates that I do.1

  Okay, nice picture. Nice heart. No fluid. Now for the abdomen, and … holy shit! This guy is full of blood. His guts are literally swimming in it. Get me the surgeon! But if he’s bleeding that much, why isn’t he in shock? Ten minutes later, the surgeon arrives and does the holy shit thing also. To the OR. It was his gut that had been perforated. That wasn’t blood in there. It was his supper. They both look exactly the same to the ultrasound. Good thing that I repeated his FAST.

  The other two are relatively stable, but will also have to go to the OR.

  Another transfer: he goes straight to the ICU. Thanks, guys.

  0500 hours: We have been going at it all night long. The sun is rising outside, when five come in with the Special Forces. We are triaging them, dead on our feet, when they announce another seven. Jay-sus! At that moment, the Head Team comes out of the OR where they have taken a big piece of metal from that soldier’s brain. They get the news. I see everybody deflate. These people are exhausted. So I make my speech, the one I’ve been saving for just this moment. I just hope I hit the right notes. Too pompous, and I’ll never hear the end of it. I’m also worried that we are rather early in the roto. It’s only been six days.

  “All right people, listen up. I know we’re tired. I know we haven’t had any sleep for hours, days even, for some. But these soldiers coming in have no one else to turn to. We’re it for them. What we’re about to do for them will change their lives. It will change your lives. Remember when we were training hard in Wainwright? Remember what we were feeling then? How we were getting ready for tough times? Well, those times are now. Not in the future. Not next we
ek or next month. Now, right now, on this shitty Afghan morning, is what we have been training and preparing for, for the better part of a year. Now are those moments that, fifty years down the road, you’ll be telling your children and your grandchildren about. You’re living them right now. You’re preparing your future. You’re writing your story. You’re writing history. This is it, people. This is it …!”

  I pause, making sure I look every one of them in the eye. I hope I didn’t sound too much like “Win one for the Gipper!” Then I say, “That is all. Let’s make ready seven trauma bays.”

  I never knew if I was going to make that speech. I had just prepared it in my head for when the going might get tough. I hadn’t expected that to happen in our very first week. Well, they put their heads down, hunch their shoulders, and we treat all those incoming casualties. By noon, they’re all done and I send everybody off to bed.

  As for me, well, I still have the hospital to empty, AEs to organize, requests for admissions and transfers to accept or refuse. Next sleep: six months. Minus one week. Hey, that’s true: I’ve been here a week now.

  (No wonder I came home exhausted.)

  July 2: As ordered by Colonel Savard, we are opening the new ward. It’s a tent on a wooden floor. It has double canvas to help insulate it against the merciless sun. And an air-conditioning unit that is just not up to its job.

  We try to get the engineers to come and fix the A/C, but it’s a no-go. “It’s a NATO installation, so you’ll have to call in NATO.” Then NATO says, “It’s an American A/C, so call in the Americans.” And so on, back and forth.