by Marc Dauphin
Okay, one last word.
Ultrasound (US)
It has made a dramatic progress in ER medicine in Canada, largely through the efforts of one guy called Ray Wiss, who is one of the leading ER docs in Canada and also a brother in arms. Ray has written a couple of books about his two times in Afghanistan. You can find them on Amazon.ca, and I strongly encourage you to do so (FOB Doc and A Line in the Sand). Ray is from Sudbury, Ontario. He has pioneered the use of US in the ER in Canada. To use the US in the ER, we do what we call a FAST (Focused Assessment by Sonography in Trauma). What this does is tell us if there is any internal bleeding. We check a predetermined number of areas inside the body to see if we can identify any fluid, which, in trauma, is generally blood. So now, instead of relying on methods that take time (CT scan) while the patient can be bleeding to death, or on aggressive methods (in the eighties we’d poke a hole in your belly and stick a probe in to see if it brought up blood — I got to be proficient at this and could do it in less than thirty seconds). But these did not always yield good results. Now, with Ray’s technique, we can do a complete ER US assessment in less than 120 seconds, and know if you’re bleeding inside. What’s more, even if you’re not bleeding at 1545, you might be at 1555, and we can find this out by repeating the FAST as many times as we want. The main difficulty with FAST is not in interpreting the images, it’s in generating them. That takes a lot of practice. In the TBs, every casualty got a FAST and a chest X-ray. The TO has to coordinate that with his personnel, too. Sometimes, when there were not too many casualties, I’d do the FASTs myself.
So that (if you’re still with me) is what we do for a casualty. It’s even more complicated than that, but if you understand a little of what you’ve just read, you’ll have a sense of what we are trying to do in those precious minutes following a major trauma. Coordinating the efforts of a team of dedicated pros was the highlight of my career. I’m proud to say I have worked with all these people from nine different countries: the U.S. (Navy, Air Force, and Army), the U.K. (also tri-service), Netherlands, Denmark, Romania, Germany (well, Bavaria, actually …), Australia (talk about cool, unruffled people), New Zealand, and, of course, Canada (both French and English). We worked together as a team, and in spite of there being a lot of top people in their professions there, there were no prima donnas, and there was extremely little negative interaction.
Ramstein
October 2007
It’s a cold, overcast morning on the tarmac when I first meet the war. In the distance, the huge transport planes await, grey and indifferent, all facing west, as if they didn’t want to see, over the horizon, their brethren on their way here with another load of pain and misery. The tarmac is so wide you need a car to go out to the planes.
“I should have brought my coat,” mumbles our driver as he halts the minivan by a stop sign, incongruous in the middle of the vast expanse of smooth concrete. In the middle of nowhere, it seems. How did he know to drive up to the sign? He and the front passenger, a USAF lieutenant-colonel, hop out and walk around the vehicle, inspecting the tires. I glance at the stop sign: LOOK OUT FOR FOD it says.
“Foreign Object Debris,” says the driver, climbing back behind the wheel. “Gotta make sure there ain’t no rocks in the tires. Suck one of those up them big ole engines on takeoff, and somebody’s gonna have a bad day at the office.” A gust of cold wind assails me before he has time to slam the door.
It’s then that I notice: there are coloured lines painted on the concrete, and our driver follows them. Like when we were kids, playing on the floor, we would follow, with our little cars, the patterns in the carpet, making believe they were streets.
The C-17s keep getting bigger. Soon, we are driving slowly between two columns of the giants. Their tails rise up five storeys, with those big elevators soaring on top. Suddenly, the enormity of this enterprise hits me. Around me are parked ten of the giant beasts, with a trio of even bigger C-5s further on; some have their crews working on them, preening them, like ants on a sleeping animal. Canada bought four C-17s, the U.K. and the Australians six each. The Americans have ordered more than two hundred.
“Just remember, major, no hats on the tarmac,” says the lieutenant-colonel as the driver stops the van fifty feet from two dark-blue converted school buses with red crosses on the sides. They are backed up to the rear of one of the C-17s. I’m starting to feel the seriousness of it all. The ICU told me they were expecting four new cases from this flight. “You can take pictures, but please respect the intimacy of the wounded.” I suddenly feel like I have no business here. That I am a voyeur invading somebody’s privacy. My camera feels heavy. I slip it in my pocket. “It’s okay,” I mumble, “too cold anyway.” I’ll take it out later, when I feel more comfortable.
The biting wind makes me zip up my flight jacket and hunch my shoulders. Couldn’t they put a collar on those things?
Thirty or forty American service personnel are milling around behind the buses. They will be the stretcher-bearers. An hour ago they were at their workstation, behind a desk, or cleaning a floor. Some are joking, the younger ones jostling. Others stand apart, lost in thought. They are from all services, and of all sizes, all genders, all races, and all ranks. I spot the eagle of a colonel among them. Some of our folks in Ottawa should see this: the lofty humbly helping the wounded. The APUs (auxiliary power units — turbines that supply the aircraft with electrical power when the engines are not running) are howling so loudly that I slip my earplugs out of my pocket and put them in. Communications are by sign language here.
I follow my guide as he approaches the beast and halts us by the right rear corner. The ramp is being lowered, its hydraulics whining smoothly, like the sound of those robots in the movies. A crewman stands gingerly on the end, riding it down like some circus artist. As soon as the ramp is secure, he nods toward the dark cavern. Flight personnel emerge from the giant and walk down to the tarmac without acknowledging the people on the ground. They look tired in their tight-fitting sand-coloured flight suits. They do not wear name tags. With a shudder, I imagine why. One, a young woman who couldn’t possibly be more than twenty, is carrying empty bags of blood. She is pretty, but has lines under her eyes. The stethoscope around her neck indicates her role on the plane. She places the empty bags on the tarmac not far from the plane, and next to a pile of charts that flutter in the wind. A gust catches a strand of her hair and plays with it. She absently replaces it before walking back toward the plane, the gesture touching in its feminity in the middle of all this hardness. Her steps are brisk, but her gestures reveal her weariness. She has been up all night.
“This one’s in from Iraq,” my companion shouts into my ear, talking about the plane. “But it’s the same when they’re in from Afghanistan.” He nods to reinforce his declaration. He pronounces it Eye-ra-ayk. In spite of his friendliness, I suddenly feel very foreign and ill at ease. I have lost all desire to pull out my camera.
As if obeying some invisible signal, the stretcher-bearers are gathering and putting on their gloves.
At the top of the ramp, a female officer is standing, consulting a clipboard, her back to the plane. Next to her, a middle-aged man paces restlessly across the inclined plane. He is wearing a red fluorescent vest over his uniform. When he turns away, I can read the word Chaplain in yellow letters on his back.
On a sign from a flight crew sergeant, the personnel on the ground slowly amble to the left side of the ramp. The female officer faces them holding her forearms crossed in an X in front of her face. She keeps glancing back over her shoulder, to the inside of the aircraft. Everybody is expectant. I throw a look at the school buses, whose rear doors are open. Half-bent personnel with serious, tense faces are looking out expectantly.
Now things happen quickly. The ramp officer nods and shows six fingers. The man of God steps back as six personnel walk up into the aircraft, their miens serious. No more joking now.
They disappear inside the belly of the plane. I can feel the ten
sion. I look up at the giant tail above me. On it is silhouetted a man wearing an eighteenth-century hat and carrying a flintlock. Just below it, the word Mississippi, the tails of the esses twirled together in a fancy pattern. How far from the rice fields of the delta to this cold and inhospitable tarmac!
The six emerge slowly from the plane, carrying the first stretcher. In spite of the roar from the APUs, I could swear it’s grown quieter. As they tread carefully down the ramp, every one of their steps seems an effort. The load is heavy, the ramp uneven. It is difficult to make out the human being in the midst of that twirl of tubes and wires entwined like some giant bowl of spaghetti above the injured soldier. A board clipped to both sides of the stretcher crosses above the man’s belly. I am reminded of some ancient bridge with houses on it. Only these are not houses on the board, these are monitors, a whole array of them, all alive, their squiggly lines indicating the man’s status. My clinician eye is drawn to them. Instinctively, the ER physician in me takes it in all at once and draws a pattern from it. There, the blood pressure, there, the EKG; anyone can recognize those. The ICP (intracranial pressure) and sats (oxygen saturation in the arterial blood) on the other lines tell me what’s happening: head wound, intubated, sedated. Two Pleur-evacs hanging under the stretcher, and half full with blood: chest tubes, bleeding lungs. Bad. The ICP, I can tell, is running too high. Bad, bad. The respirator is next to the monitor. At this distance, I can’t make out the settings and want to take a step closer. What’s your PaCO2? We’ve got to lower it. Increase the frequency. Max the FiO2. Lower your PEEP, if you can. This guy’s not doing well. But I am not in charge here. I must remember that I am just a spectator. So I stand back and rock on my heels, my arms crossed, uneasy with this unaccustomed and imposed inactivity.
As the team walks down the ramp, one of the carriers falters a bit but quickly recovers. They all stop. He lifts a hand from the stretcher and waves it, silently telling his comrades: “Sorry, I’m okay.” Some of the onlookers had instinctively stepped forward. The ramp officer waves them back and shoots an admonishing look at the stumbler.
I am not a physician anymore, just a spectator. Instead of jumping in and tackling the clinical problem, my mind is free to wander. Who is this man? Does he have a wife? A girlfriend? Surely he has a mother. My throat tightens. I have two adult sons. I am not used to considering the incredible suffering of the wounded, burdened as I usually am with the responsibility of caring for them. This emotion is new to me. This helplessness. With nothing to do, I am free to suffer with the wounded man. Or as a father.
Now, I can make out his head, swathed in white bandages that contrast with the greyness of the plane, the sky, and the tarmac. There is a large bloodstain on the bandage. A red bloodstain, therefore fresh. Bad, bad, bad. I have become a clinician again, and I can shove my emotions back to where they sprang from. It makes me less uncomfortable.
But just as suddenly, I spot some skin in the midst of all these white sheets and white bandages. Part of the man’s upper arm has become exposed in the transport. It is large. He must be strong. There is an ugly tattoo on it, the cheap kind, done in blue ink in a back room, at the end of a drunken evening. An American eagle. Without warning, tears well up in my eyes, as I am almost overwhelmed by the emotion. I look away, embarrassed.
I look at the other stretcher-bearers, the ones waiting to climb aboard. Some of them can’t watch. A young woman glances quickly at the wounded man, then looks fixedly at the ground, her face set. In anger, perhaps. Or, like me, she doesn’t want to show emotion. As soon as the first casualty is off the ramp, the officer flashes another six fingers and six more stretcher-bearers walk into the belly of the plane.
Three crewmembers follow the patient on the tarmac. A CCAT team: a critical care physician, an ICU nurse, and a respiratory tech. I can tell who’s who. The physician has that look, the one where you try to appear calm, but you know your man is dying. The soldier is loaded onto an ambulance that had been waiting behind the buses, and the CCAT team hops on board. The vehicle’s doors quickly close and it moves off slowly, lights flashing, no doubt following the coloured lines on the concrete.
This man has to be in surgery within the hour or else his brain is going to be squished out of the hole at the base of his skull. Just like toothpaste.
A second patient emerges, wrapped in bandages, tied to monitors. He, too, is intubated, but I can distinguish his face. It is pockmarked: shrapnel. I suddenly realize that, under the board with the monitors, his body is shorter than it should be. A lot shorter. This soldier has lost his legs. Then I notice his hands, wrapped in thick bandages. A vision of him six months down the road comes to me, quite vivid: a young man in a wheelchair with no legs and stubs for hands. My throat tightens. My eyes blur. My nose is running and I have to sniff. Must be the cold wind.
My mind races along paths it has never taken. How can these people do this every day? How can I have done that for more than thirty years? Somewhere inside my head I feel an immense hurt, waiting to well up, a great reservoir of pain just trying to gush like an oil well. How can I not have seen this before? What a cold-hearted bastard I must have seemed with all my talk of ICPs and O2 sats.
Still, somebody had to do it. And to be good, one had to be cold-hearted, rational, devoid of emotion. Yet now, on this cold, windy, desolate morning in Germany, I start to feel the toll I have unwittingly paid to my unforgiving taskmaster. The price for all that adrenalin, that power over death, and for my steady hands that have never let me down. I gaze at them now, and suddenly feel old. It’s as if thirty years of repressed emotions have suddenly been released.
Yet I have seen mutilated bodies before. Why do these ones do that to me?
It’s the uniform. Before, the mutilated bodies were someone else, “the other guy.” He wasn’t part of my life, but of a place “out there” beyond the limits of my ER. But here, these soldiers are my brothers. They are part of my world. My people. They are of us. They are us. My brothers. Me. My eyes focus on the horizon beyond the tarmac, I nod silently to myself. I realize I have crossed a line, one that I can never cross back over. Instinctively, I know I can never do that job again.
Somehow, with the sadness comes relief. I still feel old, but light, liberated. An enormous weight has been taken off my shoulders.
Another ambulance takes the second soldier away.
Now a third wounded man is emerging, his legs elevated on the stretcher. In spite of the blankets, I can make out the complex pattern of metallic rods and pins that juts from his lower limbs. External fixators. Bad fractures. This soldier is awake. The chaplain stops the stretcher halfway down the ramp and bends over the soldier. The clergyman’s lips move as he squeezes the soldier’s dirty hand. Smiles and greetings are exchanged. The patient is moved away, but his head turns back toward the priest and nods. The lips are white, compressed from the pain, but the look says it all: “I’m in Germany, now. I know I’ll be okay.” This man is the first one for the buses. The stretcher party moves up to the back door and stops. In a series of gestures too often practised, they all turn as one to face the patient. “Prepare to lift … lift!” someone yells. I can hear him above the din of the APUs. The patient is suddenly above the shoulders of the stretcher-bearers. Pairs of hands emerge from the back of the bus and draw the wounded soldier inside. The move is smooth, not jerky. These people are good.
Another soldier arrives on a stretcher, then another. Soon the bus is filled and leaves to climb the hill toward Landstuhl. One more takes its place.
Between the wounded, nurses and doctors climb up and down the ramp, their pace brisk. In spite of their obvious tiredness, they deftly avoid the slower-moving stretchers, like motorcyclists weaving in and out of traffic. They empty the plane of its medical kit and pile the gear on the tarmac. Some consult, clipboards in hand. It is a well-rehearsed ballet.
Soon, the last bus is backed up to the C-17. The ramp officer waves lazily toward the inside of the aircraft, and the walking w
ounded emerge. One has his arm in a sling, his desert-coloured shirt half off. He must be cold in the brisk autumn breeze. The bandages that cover his wound are also bright red. It’s been a rough ride. Night storms over Turkey, I was told. My eyes keep coming back to that half-dressed man. He is so pale that I’m afraid he’s going to faint. His jaw is tense and his eyes are fixed on his feet. When he suddenly falters, hands instinctively grab his good arm. Without looking, he wrenches free, too proud to accept the proffered support. The helpers back off, mouthing apologies. I can tell they are surprised. The air crew member following with the wounded man’s baggage looks at them and just shrugs. He waits while the proud man climbs agonizingly slowly onto the bus.
Another wounded man carries his own baggage. His tattered uniform is covered in caked blood, his head wrapped in a clean bandage. I can distinguish his rank. He is a major, like me. Ever the leader, in spite of his condition he is talking to a pair of wounded soldiers. I can’t make out the words, but the body language tells it all. He is comforting them, encouraging them.
The last ones off don’t seem to have any wounds. Their uniforms are not tattered or bloodstained. They have no baggage. They look down at their feet, not acknowledging their surroundings. When they trudge along, their arms don’t swing, but just hang limp, useless. I don’t need to read their medical charts to know what ails them. Perhaps their brain has been battered in an explosion, or they have simply seen too much.
The plane is empty. It has finished disgorging its load of pain.
I turn to my companion. He too has problems with his eyes. I bend down toward him and yell above the racket of the APUs.
“Some wind, eh?”
He smiles. The Canadian “eh?” is our joke. The same way I expect him, as an American, to say “Y’all.”