Lest We Forget (6 page)

Running about 80 meters into the woods I find my patient laying face
-up, covered in fake blood.  The trauma management sequence flows from my mouth like the pledge of allegiance did when I was in first grade.  It was burned into my memory.  My hands complete each movement as my mouth describes in detail what I am doing to my instructor who is standing over me with a clipboard.

"BSI, Scene is safe, I have one patient, Haji and I can handle..."

The instructor echoes back, "Scene is safe, you have one patient, no further assistance needed."

"Buddy
? Buddy are you okay?"

"Your patient responds with a moan and says it hurts."

"Where does it hurt?

"My chest."

"Do you know where you are?"

"Patient responds
, I'm in the woods."

"Do you know your name and rank?"

"Patient responds, Sgt. Smith."

"Do you know how long you've been hurt?

"I've been here for less than ten minutes."

"Patient is alert and oriented to person, place and time"

I check for any major life threats such as arterial bleeds, I have already ruled out airway obstructions as he has been communicating with me verbally.  My rapid blood sweep reveals bright red blood squirting from the patients left inner thigh.  I pull the makeshift windlass tourniquet from my bag.  Even though there was much more advanced versions of this device when I attended SOMC, we were required to make our own out of sticks and handkerchiefs called cravats.  In fact, most of the items in our aid bags at the schoolhouse were hand made.  It taught us resourcefulness.  Plus, if you could get hemorrhage control with one of those antiquated old napkins, achieving it with a fancy CAT2 or ratchet tourniquet would be a breeze!

Tourniquet is in place I call out, "I have homeostasis!"

              My instructor pulls on the tourniquet to make sure that it is in place, "You have homeostasis."

There are critical criteria that must be met under specific time limits.  I make the first time cut off for controlling major life threats and move on.  The assessment continues with airway, breathing and circulation.  My patient also has a tension pneumothorax
, which means that his lung has popped and the air in his plural cavity is keeping it from expanding fully. The immediate treatment involves taking a massive needle and placing it between the ribs just below the collarbone to release the tension. After the primary assessment I will be required to package and transport the patient to our makeshift Combat Support Hospital or CSH (pronounced "cash").  The long-term treatment is to place a chest tube, also known as Tube thoracotomy if you are trying to impress a girl at a bar by convincing her that you're a doctor.  This requires that you place a tube the diameter of your thumb between the 5th and 6th rib directly under the armpit.  Since no one I've ever met would ever volunteer for this procedure we were required to verbally walk the instructor through each point. 

Everyone that has made it to this point in the course was just required to perform this procedure during the live tissue labs for real so our proficiency had already been displayed.  Placement of the
Foley catheter was another procedure that we got to talk through, thank God! (Although, we did have to start the procedure using our buddy’s actual penis.)  Cleaning the site with iodine and preparing for the placement of that huge plastic tube.  Right before insertion, we were allowed to trade out for what we called "The Stunt Cock!"  Most guys made there own out of a container that we would commonly use to place used needles in called a sharps shuttle.  Nothing too fancy, just a container to put the Foley tube in.  One of the guys who was transferring from Ranger Battalion to Special Forces had put a significant amount of time into his though.  I mean this thing was massive!  It was the size of a bottle of Jameson at least, complete with huge nut sack.  He even used IV tubing to make it appear veiny. You couldn’t help but laugh when he pulled that massive fake dick out.  It created levity that was very welcome in the middle of a stressful test.

One of the final procedures that we were required to perform was referred to as the
Digital Rectal Exam or DRE.  Yep, we had to put our finger into our buddy’s ass and check for bleeding.  Like all of the other procedures that were being tested on this day we had performed them in a non-testing environment.  We were all aware that this was something that we were going to have to do from the first day and no one was looking forward to it, well maybe a couple of the Navy guys were.  The first time was about a month before, I partnered with another Ranger named Jake because he was skinny and had little fingers. It was a sober day in the schoolhouse, as I would imagine most of the guys had never had a finger in their ass before.  I say most because well, like I said before, the school had several Seals in attendance. Half of the class stood in a row, shoulder to shoulder and was made to drop their BDU bottoms. We looked straight forward as to not make eye contact with the men to our left and right. The goal of the person performing the procedure was to palpate, or feel, the prostate.  Well let's just say that Jake sucks at finding prostates.  His skinny little finger was in my ass for what felt like the first half of a Monday morning after a weekend bender.  After I notice that everyone else is finished and he is still searching, I yell out, "Are you fucking kidding me right now?  Hurry the fuck up!!"  Jake just laughed.   I would get my revenge when it was time to place nasogastric tube but for right now all I could do was curl up in the fetal position and cry. 

It came time during our trauma lane assessment for me to check my buddy for intestinal bleeding.  Remembering the psychological trauma that I sustained from Jake the finger twirler, I
decided to fake it.  We were told beforehand that if anyone was caught faking this procedure they would have to demonstrate proficiency on themselves in front of the rest of the class, so I was taking a pretty big risk in not going three knuckles deep.  I told my partner before hand that if he wanted to avoid the mild molestation then he will grit his teeth and act like a man that has been penetrated when the time comes.  Success.  The instructor didn't notice.  It was the last skill on my assessment.  My instructor just shakes his head.  My heart sinks into my stomach.  What did I forget?  He signals me over to meet him outside of the CSH.

"So Ranger, what went wrong?"
he asks. 

"Nothing Sergeant, I thought that I did everything that I was supposed to."

"Oh so you think your shit was perfect huh?  300 out of 300?  You are so fucking shit hot that you didn't miss one single thing?  Is that what you think Ranger?"

Now not only did I fail the most important test of this course my teacher thinks that I am an arrogant prick." I take in a deep breath and brace for impact.

"Well," he says, "You'd be right. A perfect 300."

Holy mother fucking shit!  I almost don't believe him.  This was the biggest hurdle they throw at you in this course and I just passed it!  It was like a 2 ton stone was just lifted off of my shoulders.  I grew six inches that day.  We would
still have to make it through a month long clinical rotation and a handful of other tests including the National Registry test for Paramedic but as far as I was concerned I had just made it over the highest mountain in this course.

             
About a week after Jake accosted me during the DRE we were being tested on nasogastric tube.  An NG tube is a long, skinny tube that is inserted into the stomach via the nose.  We were instructed not to consume any food prior to practicing this procedure because it is known to create a significant gag response.  Knowing that Jake was once again going to be my partner I decided that it was time for reprisal.  I ate a half a dozen scrambled eggs with salsa, a huge glass of milk and some yogurt right before we went.  We were sitting up in a chair while our partners fed the three foot long tube down our noses, As the gagging begins I become overjoyed.  Jake got to wear the smell of my untimely snack for the rest of the morning.

             
The most anticipated part of the course is the trauma rotations.  We are integrated into a hospital and ambulance setting where we are able to apply all of the skills that we have learned over the previous five months.  At the time there were three different locations for students to go.  I was sent to Bayfront Hospital in Tampa, Florida. We traveled by bus and arrived in the middle of the night.  We were set to report to the hospital first thing the next morning but as one keen observer noticed, it was only midnight and there was a bar right next to our condos.  Whiskey Joe’s would take a substantial amount of my pay that month.

We hadn’t even set our bags down on that first morning when a call came through saying that there was a gunshot victim
en route.  We were going to be working in three man teams under the direction of the Medical Doctor on duty.  Holy shit!  The three of us are about to work an actual gunshot wound!  One of us would be responsible for establishing an airway, the other an additional IV line and I ended up with “any other” procedures.  When the patient rolled in I was slightly confused.  It wasn’t a fit, early 20’s male.  For months now we had only worked on each other and for all intents and purposes we all had pretty much the same anatomical landmarks.  This was an extremely obese female.  She was bleeding from her abdomen and her clothes had already been cut away by the civilian paramedics. 

The two Marine Recon
Corpsman that were in charge of airway and circulation jumped right in.  I was always impressed with how they handled a situation, a true credit to their unit.  Marine Recon Corpsman don’t seem to get a lot of credit in the special operations community but I believe that they are some of the most squared away guys that I have ever worked with.  I, on the other hand, was at a bit of a loss as to what my role was supposed to be.  The nurse informed me that the patient was going to need a Foley catheter.  I’m sure that the look on my face was priceless.  This wasn’t a stunt cock.  In fact, the anatomy was completely different than what I had trained for.  There was copious amounts of blood and more flaps and folds of fat than I was accustomed to seeing.  I was instructed to “get in there.”  Go on asshole … lead the way, I thought to myself.  I must have spent five minutes trying to get that fucking tube in place.  Thankfully the nurse jumped in and saved me.  She said some smart ass comment along the lines of, “Don’t worry soldier, it happens to lots of guys their first time.”  It was going to be a long month.

I recall another gentlemen coming into the emergency room whose throat had been diced like a pizza.  Apparently he got in an argument with his neighbor who pulled a box cutter on him and used it without hesitation. When he came in his trachea and carotid artery were completely exposed but undamaged.  His sternocleidomastoid (muscle of the neck) was severed and had rolled up under the man’s jaw. Myself and another medic put over 100 stitches in his neck and chest.  Miraculously the man was awake and talking to us the entire time.  It was a true testament to how resilient the human body is. 

I couldn’t help but think back to this patient years later in another special operations medical course that I was attending in Tacoma, Washington.  We were conducting a hypervolemia lab. The goal was to simulate the physiological event of losing a majority of the blood in your body.  In order to mimic blood loss without actually losing any blood, test subjects (me) took a drug called Lasix, also known as the water pill.  This drug encourages urination.  We then put on a pair of pants that, when inflated, pushed all of the blood to our upper body.  We also took a significant amount of a vasodilator under the tongue to open all of the blood vessels.  We were instructed to stand up as the pants were deflated.  Since all of the blood vessels were wide open, the limited volume of fluid in our system dropped away from the organs and into the legs.  When they checked my blood pressure it was almost undetectable. 

We had successfully simulated the loss of about half of the blood in my body.  The doctor asked a series of questions including my name, rank and social security number.  I answered them without hesitation.  He had me complete a couple of squats, again, no issues whatsoever.  The good Doctor then delivered the moral of the story.  An incredibly fit Ranger or Seal in his early 20’s is going to compensate right up until the point where he dies.  You can have a guy that has been shot, lost half of the blood in his body and he will still be ready to fight.  As a special operations medic this is something that must always be kept in mind.  The
body’s resilience in the face of adversity is absolutely astounding.  The amount of abuse that it is able to take and continue functioning is nothing short of miraculous. 

             
Brian was one of the Marine Recon medics on that clinical rotation.  He was a smart guy and had been in the Navy for several years before attending the SOMC.  He joked with the man as we put well over 100 stitches in his neck and chest.  The two-man job took close to two hours to complete.  When the man asked how he looked Brian just replied, “You aren’t going to be winning any beauty pageants but you’re still alive.”

             
Through the course of my time at the hospital in Florida I was fortunate enough to have scrubbed in on a half a dozen trauma surgeries, assisting the surgeon in the operating room.  I helped deliver four babies, one by cesarean section. I placed limbs in casts and stitched up every part of the human body that you can imagine.  I did central lines and intubations, worked on people having heart attacks and drunken homeless people that had been stabbed.  It wasn’t all work though, I would also estimate that my roommate Brian and I both drank our weight in Jameson and managed to find ourselves in the presence of a couple of college aged females once or twice.  This was not an easy thing, however, because we were given only two vehicles for a dozen of us.  Lack of transportation or time off wouldn’t hinder our efforts, however.