Paradise General

by Dave Hnida

  Brent gave what sounded like a canned spiel about the hospital, and then told everyone to get lost except for the three ER trauma docs. Gerry, Mike, and I sat quietly as Brent explained the cases we would be seeing, and how most of the wounds would challenge even the most experienced trauma surgeon. As family practitioners, Mike and I were terrific at treating colds or giving flu shots, and while Gerry was an actual ER doc he never saw IEDs in Cleveland. There was no question we would be like first-day interns who were suddenly told to perform brain surgery. Colonel Quick sat quietly in the corner of the tent as he waited for Brent to finish scaring the shit out of us. He could clearly read the anxiety on our faces and after giving us a few seconds to let things sink in, told us we could accept our assignments in the ER, or instead, take a more comfortable job staffing the sick call clinic. No questions or loss of respect, the hospital would get by. One by one, we answered. Gerry: yes. Mike: yes. Me: Uh, I’m scared shitless. Quick: That’s the best answer I’ve heard yet. You’ll do fine. Across the tent, Brent’s sad eyes sagely nodded agreement.

  I didn’t sleep well that night, or, for that matter, any night for the next few months. The helicopters returned en masse with their overnight deliveries and I tossed and turned as each one whizzed by our barracks. By now, I had a little better sense of direction—I realized if I simply looked out the window of our rooftop room to the southeast, I could peer over the blast walls and make out the blue landing lights of the helipad at the hospital. It hit me: many of the birds zooming by were actually Cobra attack helicopters or Black Hawks ferrying troops on and off the base, not incoming medevacs. I only saw a few of the speeding shadows make use of the vaguely lit landing zone of Paradise General. But even a few meant the doctors who we would replace within the next twenty-four hours were getting hammered.

  THE NEXT MORNING started with three large cups of weak coffee and a bowl of Cheerios drowning in semiwarm milk poured from a carton with Turkish lettering. Ka-chingg! For $32, I could have had a gourmet breakfast with seconds and thirds back in the States.

  The medical menu for the day showed us breaking into small groups and following our counterparts to finish our right seat/left seat orientation. Gerry, Mike, and I tracked down Brent Smith as he helped another doc clear the ER of a group of soldiers jolted around by an IED. Except for a couple of bloody eardrums, the men looked stunned yet relatively unscathed. Doesn’t look too bad, I thought. Maybe I can do this.

  We attacked the computer system first. Everything was documented in a very standard and regimented format, and it was important that we got this part right. The medical records would follow wounded soldiers to places like Landstuhl Medical Center in Germany, Walter Reed in D.C., and the burn center at Brooke Army Medical Center in San Antonio.

  “Try to make sure you’re accurate. Other docs will be reading what the original injuries were and what you did to fix them.” Brent rapped the desk with his fist for emphasis as he talked.

  “And it’s especially important for disability and brain injuries that everything gets documented—some of the subtle things don’t show up for months after a guy goes home and you don’t want him to get screwed out of benefits and care, especially if he’s in the National Guard or Reserves.”

  His fingers flew across the keyboard as he wrapped up a complete record in less than two minutes.

  “It’ll take you twenty minutes to get it right the first few times. Don’t worry about it—do a few hundred and you’ll be able to knock a medical record out in thirty seconds while taking care of a bunch of bleeders at the same time. Remember how the old Army ran on paper? The new one runs on electrons—all computers. And by the way, forget all that new computer shit they taught you in Kuwait, this is a different system.”

  We then took a quick tour of the ER itself. Although the majority of the hospital was made up of tents and containers, the ER was one of the few structures that actually had a hardened roof—“the best place to be if you get mortared.” The ER was long and narrow, with a door at each end. It had six trauma “bays”—lettered “A” (Alpha) through “F” (Foxtrot). Alpha was furthest from the front door and was reserved for the most severe cases since it was only steps to the OR tent and intensive care unit through the rear door. Over the next few months, I would find myself standing in Alpha straining my neck watching stretchers with the critically wounded traversing the thirty-five feet from front door to me—sometimes they seemed to come too fast, before I felt ready, other times agonizingly slow as life’s blood dripped onto the floor.

  Brent handed us papers with diagrams like football plays—the most important showed our positioning during a trauma case. Most of the bays contained no stretchers—we would use what the patient came in on—and we physicians would pre-position ourselves at the upper-right-hand side of the bay where the stretcher would be parked headfirst. Next to us at the head of the patient would be a respiratory tech or an anesthetist. In various positions around the stretcher would be a medic to insert a right-side IV, another medic for a left-side IV, a circulating medic, a medication nurse, an X-ray tech, and a recording nurse, who wrote down any medication or blood administered. Everyone had a position to play and a job to do.

  “Then there’s the red line.” Brent punched out the words as if they were the most important he would ever say.

  We looked at a long red painted line a few feet away from the foot of where the stretcher would be.

  “No one crosses that line unless you say so. Surgeons and gas passers love to jump in and get their hands dirty right away—don’t let them. Everyone stays behind the line until you do your assessment, get your lines in, and start treatment. Otherwise, it’s like dinner for twenty in a small phone booth. If you don’t hear one other thing today, hear this: you are the boss in this room—get pushed around and someone will die.”

  His words made me shiver. I’d never done this stuff before and now I was supposed to be ordering smarter people around while some kid is gurgling blood.

  With relief, we left the ER through the far door and saw that fifteen steps away after a sharp left turn was the OR. At least we were told it was the OR. All I saw was a blanket covering the opening of a tent.

  Smith saw our openmouthed stares.

  “It’s nothing fancy, but a lot of lives get saved in there. Two tables. Three in a pinch. Plus it’s a close ride on a stretcher.”

  We looked down and saw droplets of blood mark the journey from the ER to the OR blanket. A couple of dots, then a streak, followed by a series of thick beads of congealed red globs. I wanted, yet didn’t want, to know what waited behind that mysterious woolen blanket.

  We took a quick right and walked to a long cavernous tent—the PLX: Pharmacy/Lab/X-ray. Nothing special until we saw the ultramodern CAT scanner, which was very cool to have—until we realized what we didn’t have to go with it: a radiologist. Back home CAT scans were a godsend, and so were the people who could interpret them. Need an image of a brain? I would ask the nurse to order a CAT scan, the test would be done, and then I’d get a report within minutes from the radiologist telling me what the CAT showed. Instant gratification. Now I had a problem of monumental proportion. I had interpreted exactly zero CAT scans in my career, and now I would be on the firing line in the middle of the night, by myself, trying to determine if that little black spot was a simple shadow or bleeding in the brain. I’d give up my firstborn for a radiologist.

  Just then, the tent started shaking as a pair of helicopters skidded in for a quick landing. No warning. We hustled back to the ER in time to see a couple of stretchers come in, blood-streaked arms hanging over the sides as the wheels spun toward Alpha and Bravo bays. Just like the playbook, everyone was in position and ready to work. The activity seemed like a blender—lots of buzzing noise and lots of swirling activity, none of which seemed to make sense. From behind the red line, all I could see was burnt strips of flesh hanging off a pair of legs, bright white shards of bone sticking through bloody holes of clothing, and th
e constant drip-drip of blood onto the floor from a saturated dressing wrapped around a wound in the arm. I stuffed my hands into my pockets so no one would notice the shaking. It would be this group’s last trauma cases of their deployment—at midnight they would hand the baton to us. On quaking legs, I walked back to my room when the cases were finished, tried reading a borrowed copy of CAT Scans for Dummies, and then asked God what I had done to piss him off.

  5

  FIRST DAY OF SCHOOL

  THE HELICOPTER BLADES chopped through the night air, and once again chopped through my sleep. I had maybe one solid forty-five-minute stretch of undisturbed slumber, but even that was infiltrated by a bad dream.

  Through all of my years of schooling and training, I’d had a lot of first days—this one was by far the worst. For every step I took toward the hospital, I wanted to take two steps back. Inhaling a breath of bravery, I pushed open the door to the ER, and must have had a “deer in the headlights” look as I peered in.

  “No, you’re not lost. Glad you decided to come to work today, sir.”

  It was my friendly coffee NCO, Sergeant Courage.

  “I bet you could go for a nice hot cup of coffee, huh, sir? None of that foo-foo shit today—we just got in a shipment from home of Dunkin’ Donuts high-test.”

  “Thank God. That stuff yesterday was like water from the bottom of a flower vase. What kind of coffee surprises do you guys hide in here?” I asked.

  “Pumpkin Spice, Cinnamon Tulip, French Butternut, and all that kind of horseshit.” He swiveled his head toward the staff. “They like it but give me a cup of regular java anyday. Nothing like liquid artillery to welcome the morning.”

  The place looked like a foreign land, and as I scanned the room, I was surprised at how young the medics were. Some of them looked like they had just been introduced to a razor. With an average age of maybe twenty-three, they had already seen enough carnage to last several lifetimes. Many had no background in medicine before being deployed; some were carpenters, some were schoolteachers, and others full-time college students. All were reservists and all had volunteered to spend fifteen months of their lives saving lives. And they were very good at it. The hospital boasted a survival rate of more than 95 percent, which meant we new docs were under some serious pressure to perform. They silently stared and tightly nodded greetings as Courage handed me my full cup of high-octane. As I nodded back, I could read their thoughts: Is this guy stupid or smart, arrogant or cool? And what about the rest of the doctors? Just who and what were they? It wouldn’t be until the first trauma case that we’d all truly find out.

  I wandered the narrow room, shaking hands with each of the medics lounging in folding chairs—they were all young enough to be my children.

  “Hi, I’m Major Hnida but you can call me Dave.”

  “Yes, sir, glad to meet you.”

  “Welcome to our little corner of the universe, Dr. Hnida.”

  “Hello, Major, how are you?”

  So much for informalities. I didn’t do well with the “Major” label, was uncomfortable with the “Sir” business, and the only one who called me “Doctor” was my overly proud mother. I’d have to work on this name stuff.

  Next up were staff nurses—all worked in emergency rooms back home and probably had more knowledge of trauma medicine in their pinkies than I knew altogether. Just like home, I knew a doctor’s best allies were the nurses. All you had to do was listen and they’d guide you safely down unknown paths.

  Last to be introduced were the head nurses in charge of the department. Both held the rank of major. Roger Boutin was a firefighter and nurse from rural Massachusetts. With thick-rimmed glasses and a high and tight crew cut, Roger looked like a rigid throwback to the Army of the Cold War—but I would learn he had a love of the classics, the eclectics such as Jack Kerouac, and was responsible for the bottomless supply of foo-foo coffee that kept everyone mellow.

  Boutin was the assistant to Jack Twomey, a stoic figure whose imposing demeanor told me his ER ship was a tight one. Twomey was an ER nurse in one of Boston’s busiest trauma centers and probably could staff this department all by himself—no doctors needed, or for that matter, even wanted. It would take weeks for me to learn the motives behind Twomey’s firm expectations—for now, I worried he would eat me for lunch, then spit the bones out after picking his teeth.

  As the introductions finished, Sergeant Courage tapped me on the elbow.

  “One firm rule in the ER, sir, all weapons go into the lockbox at the front desk. We’ll show you where we hide the key.”

  That made sense. In the confusion of a busy emergency room you didn’t want any weapons within reach of a insurgent, or for that matter a pissed-off soldier who has just seen his buddy blown up. I foggily recalled part of a briefing during orientation the day before. Not only was everyone disarmed in the ER, every patient brought in was relieved of their firearms and grenades, and in the case of an Iraqi—insurgent or otherwise—strip-searched for weapons and things like suicide vests before leaving the helipad. Sometimes the enemy was obvious, but a few of the bad guys hid in the uniforms of Iraqi police or army and caution was the word of this war. I reached down, unstrapped my pistol, and locked it away. It was a place I would learn to lock my emotions as well.

  I set my stethoscope down and got the nickel tour of the ER from Courage. Although I had been here before, now the view was different, like seeing it from the playing field instead of the grandstands. I had combat patches on my uniform from my first deployment that caught some attention as we strolled down the narrow row of six trauma bays. But to hell with the patches: if I didn’t perform well in those trauma bays, this crew wouldn’t want me soiling their turf.

  I then went through each bay and opened drawers, studied equipment hanging on walls, and tried to get a sense of the trauma gear that bulged out of every nook and cranny. One of the medics stopped me as I finished my inventory.

  “You’re the first doctor I’ve ever seen do that, you know, check out the gear. That’s good, sir, you must know what you’re doing. We’ve had a couple of real losers come through here. Don’t get me wrong, almost all of them were great docs but one or two fucking sucked. Made our lives hell.” A heartbeat of a pause. “Sir.”

  I murmured a weak thanks and wondered how I’d be judged when our last day came in a September I couldn’t even see on the horizon. I wondered if any of them could see through my veneer of confidence. If they only knew how scared I was, how poorly equipped I felt to do this job, how I wondered how I got myself into this mess. If they only knew.

  We didn’t get a lot of time to socialize before my first case came limping through the door. It was a soldier who sprained his ankle playing basketball at the camp gym. My head spun for a second: I came to Iraq for this? This is the same crap I see at home. The medics did a mini-exam and ordered an X-ray.

  “Looks negative to me, sir, I think we can just give him some ranger candy and send him out.”

  “Ranger candy?”

  “Ibuprofen, sir. They gobble it like M&Ms.”

  I doubled-checked the ankle and the X-ray and agreed.

  Patient number two was a young soldier with “desert cough” that was keeping him awake all night. Once again, a mini-exam and a trip over for a chest X-ray. So far, I had been in the clinic for almost an hour and had done little except sit and watch everyone else care for patients.

  It took only five more minutes before I got to taste the first appetizer of what my next few months would serve on a bloody platter. I was just resigning myself to the painful task of looking at the medical records system on the computer when the metal doors swung inward with a bang. I looked up to see a group of American soldiers half dragging in a moaning Iraqi soldier with bloody ears that were hanging by thin threads of skin. Insurgents had been slowly slicing the ears off in the back room of a small house when a group of American troops burst in to save the day.

  In the States, the Iraqi would have been sent to a special
ist. Here he came to me. Not only were the ears barely attached, but what was left hanging had been sliced and diced with a sharp blade. The cuts looked like the roadmap to hell and the strips of skin looked like they would flutter in a stiff breeze. I stared at the ears, not knowing what part was supposed to go where. The main pieces were still bleeding so I knew I still had some vessels attached—now all I needed to do was quilt the bloody puzzle back together. I tried to hide my panic from the staff and set out to work, praying the doctor fairy would miraculously come through the door with an Ear, Nose, and Throat specialist.

  As I cross-stitched and knitted away, word came over the radio of my first American trauma case. A soldier shot through the neck by a sniper. The estimated arrival time was twenty minutes. But I couldn’t hear the rest of the details. The loud rotor blades of a landing chopper and the pounding of running feet drowned out all conversation. Show time … and I hadn’t been to rehearsal. I looked up to see Greg Quick walk through the door.

  “Sounds like you’ve got business, hmm?” He shot a quick glance at the ears. “This will take me five minutes, you take care of the important stuff.”

  Five minutes to fix the ears? Important stuff? American shot through the neck? I thought they said twenty minutes. I was drowning in confusion.

  I scrambled to Alpha bay and took my place at the head, where the stretcher would roll to a stop. As I slipped on gloves and work goggles, I saw our little ER quickly fill up. News travels quickly when an American is coming in by chopper and every doctor, clerk, administrator, and staff member hustled in for a front-seat view of the action. Even the doctors we relieved came over from their quarters—their plane wasn’t due to leave until tonight. Plus, I realized Quick didn’t come over to help me mend some ears—he’d come to watch my performance.

  There was a flurry of movement throughout the room and an eruption of noise as the stretcher burst through the door. Holy shit. It was a skinny young kid with a sickly gray cast to his skin. A leg jaggedly pointed at an unnatural angle; actually, what was left of the leg. And a thick bandage around his neck saturated with blood. It had to be a carotid or a jugular wound. As the stretcher moved into the bay, medics quickly scrambled to place IV lines while I stared at the tiny bubbles forming on the surface of the bandage. Each bubble grew large, then small with the rhythmic chest compressions of CPR.