Paradise General (10 page)

I walked over to my footlocker and ripped open a packet of index cards. On each, I drew a series of flow charts for every conceivable situation that might show up in my ER. I knew I couldn't get them all, and I knew I probably wouldn't even have time to fumble through a big stack and pull out the right one when the shit hit the fan—but I would carry those cards with me at all times like a heart patient carries nitroglycerin to put under the tongue for sudden chest pain.

Before they went into the pocket of the uniform I'd wear tomorrow, I recited the protocols again and again—like a schoolchild repeating the newly learned alphabet—making sure I knew, by rote, the steps I would take, and the orders I would give when something came through the door. Even if I didn't do everything perfectly, I would at least do something—there would be no freezing, no chaos, in my ER ever again. I thought back to what my dad had told me about the first night he led a group of men on a patrol.

“It was pitch black and we walked right smack into a German ambush. Lots of gunfire, guys hit, screaming for medics. I wanted to burrow into the ground and stay there forever. Then my gut kicked in. You know, all those nights training and studying paid off. It's like memorizing your A
-
B-Cs.”

It was 4
A.M.
when I finally finished my homework and even then couldn't sleep, realizing there was one main command I would have to voice in every situation … and wondering if I had the courage to do it. Tomorrow knew the answer.

T
HE PAGES OF
the ER logbook filled quickly as the desert sun rose; we were hit with patients early and often. The first few were like being home—dehydration, migraine headache, and a kidney stone, cases caused by the heat of the desert and that would become repetitive over the course of the summer. I was nervous, but hid it well. A few jokes here and there, busting Major Boutin over his choice of Cherry Walnut as the coffee of the day; even on the walk over to the hospital Rick said I still “looked like shit but at least had a dynamic stride.” I didn't even know that he knew the word “dynamic.” My thoughts of Rick's vocabulary were interrupted by a medic's tap on the shoulder.

“Word from Warhorse, sir. They're sending an overdose by chopper.”

“What? Overdose?” I was trying to ready myself for gunshot wounds and blown-off limbs, but hardly expected I'd be treating a soldier who ODed.

“Forward base Warhorse, sir, about an hour up the road. I'll give Major Villines a heads-up.”

Todd Villines was the only cardiologist in Iraq and was stationed at our CSH. Regular Army from Walter Reed, he didn't travel with our group of reservists. His expertise was caring for complex medical cases. But I wasn't thinking about him or Warhorse. I was wondering,
Overdose
?

When the chopper landed and the doors to the ER blew inward, the bluest human I had ever seen was having CPR done.
Jesus, whatever he took killed him.
I took a deep breath, fingered my cheat cards listing resuscitation protocols, and went to work. Shock to the chest, breathing tube inserted, heart drugs administered—I didn't need
to look anything up, and best of all didn't act like a frozen statue.

After ten minutes of sweat, I finally had the time to take a big-picture view of the patient. Just a kid. His ID said twenty-one years old, and who knows what he put into his system and why.

“Man, he is one dark shade of blue.”

I looked up, it was Dr. Villines.

“Know what he took?” he asked.

“No clue. I do know the tube is in the right place and pumping in lots of nice fresh O
₂
. Heart is now beating on its own with a stable rhythm but he's still blue as a berry.”

“No kidding, he looks like a Smurf.” Villines's eyes flickered from chart to patient to me. “Good job, Dave. Let's get him over to the ICU.”

And with “good job” ringing in my ears, I walked back to my desk. Pulling a picture of my kids from my wallet, I thought about the Smurf. Does his mom or dad carry a snapshot of him in their wallet? Do they know what he just did and how close he came to needing a casket? And with that dark blue shade, he still wasn't out of the woods. Some scattered pieces of information from his unit suggested the overdose was intentional—the kid recently broke up with his girlfriend. Lab tests would later tell us what pills were sucked down to do the job.

I stood up to head outside for some fresh air and was nearly bowled over by a group of medics sprinting toward the landing pads. I never even heard the bird until it was seconds from landing. A pivot and slow trot brought me back to Alpha bay.

“Gunshot wound on the way, sir. One litter.” The medics prepped the bay for the casualty as I grabbed gloves, clear protective goggles, and fingered my index cards like a rosary.

“Who's first call for surgery?” I asked.

“Colonel Reutlinger.”

“Please page him and give Dr. Stanton a heads-up. Let's get ready for some business, ladies and gentlemen.”

The words flowed with a confidence I didn't feel. As the stretcher rolled in, several staff members closely followed, gawking and craning for a look at the wounds.
Hurry up, Rick
, I mouthed silently.
This is a trauma-palooza and I could use a hand.

The patient was an Iraqi soldier, blown up by an IED, and then shot as he got out of the vehicle. Medics kept pace with the stretcher at perfect speed, cutting off clothes and giving me a report as the wheels revolved through small pools of blood.

“Multiple shrapnel wounds. Gunshot to left chest. Partial amputation right leg. BP 90/50, pulse 150, respirations 30. Ten milligrams of morphine on board.”

I gave a quiet nod at Twomey as the stretcher came into the bay headfirst and my eyes went to the body writhing before me. There was blood everywhere and crooked splinters of bone where a leg used to be.
Easy as A
-
B-C, Dave.
I quickly scanned the patient and forced myself to ignore the missing leg. A snug tourniquet had that problem under temporary control, but the bone splinters lying upon a blood-saturated sheet were a magnet to the eyes.

Reciting my lessons aloud to Major Twomey, I followed the trauma protocol to the letter.

A.
Airway intact and open. No obstruction.

B.
Breathing—good breath sounds bilaterally. Trachea midline.

C.
Circulation—skin warm. Heart sounds are clear. Capillary filling less than two seconds.

D.
Deficits to neuro are none. Patient alert. Glasgow Coma Scale 15 of 15.

The voice coming from my mouth wasn't my own but Twomey scribbled the words onto the trauma log. I methodically moved around the stretcher. “How are our lines? Good ones? You guys are great. Check that tourniquet, please.”
Keep it calm. Take your time.

Next came a check of pulses, abdomen, and pelvic bones. My hands slid up and down every inch of what was left of the Iraqi's limbs. My fingers rose and fell over rough skin peppered with
shrapnel, and the small bumps where the tiny pieces of metal hid just under the surface.

As I recited my findings, the noise level in the room seemed to rise to a dull incomprehensible rumble, just enough to keep us from hearing each other around the stretcher, and me from hearing myself think. I then felt the jostle of extra bodies coming to the stretcher to take a peek and a poke at the patient. I was now being pushed to the edge of the cliff and the ground below me was starting to crumble. I was going to lose control.

Looking up, I said, “I need everyone who isn't in this bay to button it up, and if I didn't ask you into the bay, please get out and get behind that red line.” It was the order I had worried about, the new guy telling people to get out of his way. But it was an order of necessity; the only cure for chaos was calm, even a false calm. And I worried how it would be received coming from me. Today, the response from the uninvited was a wilted bouquet of looks—dirty, confused, and sour. But when I looked across the room at Rick and Bernard, both of whom were still waiting quietly on the spectator side of the red line, I got a pair of welcomed winks. I finished up my exam, gave a few medication orders, and stepped across the room as I snapped off my bloody gloves.

“Rick, I think this guy needs a look-see of the belly. Feels like some of that metal is deeper than it looks, he's a little on the rigid side. Hey, Bernard, waiting for the bus?”

“I just was wandering by when this helicopter tried to give me a haircut. Sweet Jesus. Nice job in there, man. Say, did you eat this morning?”

“Yes, Mom.”

“And how much did we eat?”

“Enough, Mom.”
God, the thought of food makes me want to retch.

Next, I walked over to Bill Stanton, who also was patiently waiting his turn.

“Hey, Billy, I'm getting films of both femurs, maybe the left hand and wrist. Anything else right off the bat?”

“Dude, not from a distance. Finish up the real-doctor stuff, then I'll step in. I'm cool.”

As the patient went off for a CAT scan and X-rays, I crawled to my desk, imitating a man who has just finished a marathon through the steaming jungles of the Amazon. I was spent and, I now noticed, sweat-soaked.
But the patient had survived, I had survived, and like an animal had staked out my turf.
I prayed it would be enough to get me through the bad days ahead.

End of shift came quickly. The only patients who came through were minor—at least for me. A shrapnel wound to the hand of an American who was able to walk in on his own after a helicopter ride, a guy who got his bell rung by an IED, as well as a potpourri of cuts, scrapes, and bellyaches. Rick came by to pick me up for dinner and we decided to stop by the ICU before chow to check on the Smurf. Todd had the ventilator settings pushed to the max, yet the kid was still a dark blue.
Not going to make it. Shit.
As we pushed open the doors to leave, the words came out of our mouths simultaneously: Let's stop and call home before we eat. Just a quick reassurance that our own kids are okay. The lines were short, the calls went quickly, and we left the phone tent with the temporary solace that our kids weren't fighting the battle to stay alive in a war zone.

Halfway through our $32 gourmet meal of dead pork chop in congealed gravy, Rick's beeper chirped.

“Looks like we've got a kid with a hot appendix. Want to help?”

It was a no-brainer. “You bet I do.”

I looked forward to working a scalpel; more importantly, I was eager to see just what the OR was really like behind its mysterious blanketed entry. So far, my duties had been taking place in an ER that really wasn't too ugly or dirty, just red with blood and overflowing with tension.

The OR, on the other hand, was the great unknown of the hospital complex. The tents and containers that made up the operating rooms had literally been shipped by boat and constructed after we captured the base in the early months of the war. For me, the fifteen steps from the ER to the OR was the medical equivalent of a leap across the Grand Canyon.

We pushed through the dusty blanket and walked to the cheap plastic scrub sinks. A small push-pedal on the floor forced a miserly flow of water through the faucet. I mirrored Rick's every move, and tried to work my hands into a lather with the flimsy scrub brushes.

“Where are the scrubs?”

“Aren't any.”

“Booties?”

“Aren't any.”

“Lockbox for my pistol?”

“You're wearing it. C'mon, let's pop the hot tamale out of this kid's belly and go home. I bet we can do this in three minutes and thirty seconds. That's my record.”

A thin set of doors with small plastic windows provided the last barrier between what was supposed to be a sterile operating room and the swirling dirt of the outside world. We swung them open with our elbows and hips, keeping our hands up and away in the classic surgical pose. Gown pulled on, gloves tugged over semiclean hands, and we were ready to cut. Almost.

“Hey, how about some music in here?”

The surgical tech replied, “What would you like to hear, Dr.
Reutlinger?”

“How about some Billy Joe while we're working.”

My eyes peered over my masked mouth and nose.

“Billy who?”

“Billy Joe. I got him on my iPod. Love him.”

“You mean Billy Joe Bob Willie or some other hick?”

“No—B-i-l-l-y J-o-e! You know, like ‘Piano Man' or something.”

“You mean Billy JOEL, Rick?”

“That's what I said the first time. You deaf?”

By the time I rolled my eyes from the back of my head to the patient, Rick had already made the first incision and more. I'd never seen anyone surgerize so quickly, and so well. Skin, muscle, fascia, and peritoneum expertly sliced and separated.

“Now where is that little—?”

The sentence was interrupted by the sudden bang and rumbling boom of a nearby shell. The scalpel in Rick's hand swung up and cut through air, missing my biceps by an inch as the tiny OR shook and our legs staggered.

“What in hell's bells?”

“Rocket or maybe an IED just outside the gate, Colonel. Had to be close.” It was the surgical tech, who'd been jostled by scores of similar blasts during his year-long deployment. He never flinched.

“Jeez, that'll wake the neighbors,” Rick said.

The tech responded, “Want more anesthesia, Colonel?”

“No, thanks, I think I'd better stay awake for this one,” came the nervous quip.

We were only a few hundred yards from the gate, far enough to be safe, close enough to be introduced to the limb-tearing blasts our troops challenged every day. A big breath later, we were back at work, faster than ever. I had a hard time keeping up, especially cutting the knots Rick speed-tied as the appendix was snipped out and the abdomen closed.

As I watched the express train of a surgeon zoom along, I realized, with the exception of the rattling blast, this operation was no different from any other. Tight quarters in a container, cheap plastic scrub sinks, packing a pistol—none of it mattered, or for that matter, was even noticed. My focus zeroed to a patient, a scalpel, and an abdomen. Once gloved and gowned, you were automatically transported into the mystical world known as surgery.