Monday, October 20, 2014

Nurses, Ebola, Hospitals and the CDC

  Texas Health Presbyterian Hospital (THPH) has apologized to it's community for the mishandling of the Ebola patient. Missing, however, is any apology to the nurses who work there for the chaos, incompetent management and lack of leadership that led to two nurses getting infected and more than forty confined to their homes in quarantine. Accountability? I thought that what admins are paid the $$ and why they get the perks.
   The CDC says it is revising its protocols for PPE (Personal Protective Equipment) for nurses caring for Ebola patients to include 100% coverage of skin and hair with impermeable material and the process for removing it. Not to mention how to handle the infectious waste. About time. Do the nurses get an apology from the CDC?
   How about the Lab worker from THPH that was confined to her cabin for the duration of the  vacation cruise she was on?
   The message we get is that health care workers are "little people" who do not count and are expendable, and hey, taking those kind of risk is what they get paid for, right?
While you are here, please scroll down or jump to July 2012 to read a sample of the book "The End of Shift Report". Thank you!

Friday, October 17, 2014

Nurses, Ebola and the CDC

How the CDC handles Ebola in it's lab:
How the CDC handles an infected Nurse's apartment:
How the CDC says nurses should handle Ebola:
This nurse will not care for any Ebola Patient without the same kind of gear the CDC uses for its own people.

While you are here, scroll down or jump to July 2012 and read a sample of the book "The  End of Shift Report" Thank You!

Wednesday, October 15, 2014

Statement by RN’s at Texas Health Presbyterian Hospital as provided to National Nurses United | National Nurses United

Ebola, Nurses and Hospitals

 The reports coming out of the Hospital in Texas from nurses are truly alarming. A picture of a failure of leadership, decisions on protocol being made by clueless administrators which changed on a day by day basis. Apparently, the patient was treated using standard "Contact Isolation" procedures which are totally inadequate for a disease like Ebola. Below is a protocol for Ebola sent E-Mail to the nurses of a highly respected hospital with a national reputation for excellence.
 First, contrast these pictures with what you have seen on TV of health workers in Africa in full hazmat suits being sprayed down with disinfectant after coming out of contact with patients before disrobing. Second, the panel on the sequence for removing protective equipment has a serious error: Instructing one to remove gloves first. Right. Then you touch your contaminated gown etc. with bare hands. Any OR nurse will tell you that you remove your gloves LAST.  Note also the lack of Hoods to cover head and neck, backless gowns, lack of rubber boots or clogs that can be autoclaved (high temperature/pressure sterilization), or any information on how to deal with all the contaminated trash, how to deal with floors and bedding contaminated with all manner of body fluids, etc. They handle all of this better in the bush in Africa.
  If this was how they were dealing with Ebola in Texas, it is a miracle that only two nurses contracted the disease. It is also apparent that nurses were assigned to go straight from the Ebola patients room to care for other patients.
  It is also apparent that nurses are reluctant to speak up for fear of retaliation.
  Lastly, read Richard Preston's book "The Hot Zone" to see how NIH (not CDC) deals with Ebola. That will really open your eyes as to the inadequacy of the above protocols. If either of these nurses dies, the authorities of that Texas hospital should be tried for murder or at least manslaughter.

While you are here, scroll down or jump to July 2012 to read a sample of the book "The End of Shift Report" Thank You!

Saturday, January 4, 2014

A new blog:


Orfyn has started a new blog, another book in progress. Please visit www.carrstale.blogspot.com

While you are here, scroll down or jump to July 2012 and read A sample of the book "The End of Shift Report"Thank You!

Wednesday, June 26, 2013

Amanda Trujillo Part 3

   I recently Googled to find out what has been going on with Amanda Trujillo's case. I had been aware that there had  been a postponement of a board hearing, but had not heard anything else. The news is: 1) The case has been settled with a consent decree with Amanda agreeing to a year of probation and the findings of the Board of Nursing. The facts of the case and a copy of the decree can be seen at http://thenerdynurse.com/2013/01/update-on-the-amanda-trujillo-case-doing-the-right-thing-can-be-subjective.html Thanks to the Nerdy Nurse for an excellent post that the rest of the nurse-online world is curiously quiet about.
   It seems that Nurse Trujillo was not truthful in her on line letters and posts. I know I responded strongly when I first heard of the matter, posting here on a blog centered on fiction informed by my experiences. My response and the outrage of it was due to the fact that I and many other nurses have first hand experience of abuse and assault by physicians which has been aided and abetted by hospitals and the powers that be. That caused me to uncritically rush to a judgement.
   It is true that such behavior by physicians is less common and less tolerated now. I think that this is often more a reflection on the difficulty and expense of recruiting experienced nurses  than anything else. A hospital I know of which was notorius for outrageous behavior by its surgeons recently required all their surgeons to take a class on anger management on pain of losing their block time in the OR. While this is encouraging, one must also recognize the  enormous double standard: Nurses are fired  on the spot for behaviors that  are free of consequences for physicians. And Boards of Nursing can be used as weapons against nurses.
   In the end, I feel that justice has been done in this case. While some of the Board's findings have a feel of "piling on", a year of probation is proportional to the actual offense, and the Board could have been much, much more punitive.

While you are here, please scroll down to read a sample of the book "The End of Shift Report" - the first four chapters.

Sunday, July 8, 2012

A sample - Chapters 1 to 4


Dedicated to R.O. the lodestone and polestar of my life’s journey
The Final Edition of the End of Shift Report

   Chapter 1: The EMTs and Another World


It was just turning twilight as Uli drove up the parkway, the radio playing a light rock station, Uli grooving to the sound of Adele. Uli’s daughter had recently added several of her favorite songs to his MP3 player, a change from the music of the seventies and eighties which were Uli’s usual fare. Of the songs she added, Uli especially liked the ones by Adele. Uli caught a rapid movement in the periphery of his vision, and as he turned his head to the left he saw another car just an instant before it hit square on the door next to him. He was instantly thrown violently to the right, his waist folding over his seatbelt. His car hit the curb, throwing him back into the door which had deformed inward, and just as the impact had registered in his mind, the car began a sickening roll over with a speed and force reducing his body to the limpness of a rag doll. Then the car smashed sideways into a tree just as it came upright again, and Uli suffered a last fling to the right, bouncing back to a more or less upright position in his seat.

Stunned and in a state of immobility, Uli’s brain stalled. His vision began to be taken over by the small multicolored speckles that accumulated to obscure his vision of the crackled windshield in front of him. In this dreamlike state he saw mists and fogs and he could hear an approaching singing voice, high pitched and sustained. Uli clung to that voice, no; it was two voices, vibrating with harmony, then pulsating, then rising back to the impossibly long sustained notes. Uli wanted to hang onto the sound of these voices which drew him in with a compulsion that could not be denied, but the mists thickened the sound became softer, and Uli felt as if he was drowning in the fog. His last thought before he lost consciousness was of the flashing red and blue lights glowing through the fog, and the song of the sirens.

********

Joyce Circe and her fellow EMT partner Jack Gordon arrived on the scene of the accident and went straight to Uli’s car. Uli was very nearly upright in the driver’s seat, restrained by his seatbelt. Joyce began her initial evaluation. Reaching in through the shattered driver’s side window, she immobilized Uli’s head with one hand and felt for his carotid pulse in his neck with her other hand. Simultaneously she placed her ear over Uli’s mouth and nose to listen and feel for breaths. Sensing both pulse and breath, she then turned her head to face Uli so that he would not be tempted to turn his head or neck and spoke to him, pitching her voice low and loud. Until they knew otherwise, they would assume that he had neck injuries. Getting no response, Joyce tried again. “Positive for pulse and respirations, not responsive to voice or touch” she called out to Jack. She focused her penlight on each of Uli’s eyes in turn. “Pupils equal and reactive to light” she added. The fact that Uli’s pupils were of equal size and that they both contracted in response to light indicated that he did not have a severe brain injury.

Jack tried the door, but it was jammed tight. “I smell gasoline” he observed “I’m going to disconnect the battery.” They wanted no source of sparks before they started the process of extricating their patient from the wreckage. Joyce affirmed his comment and turned to immobilizing Uli’s head and neck in a more stable manner with soft rubber covered foam blocks and tape.

Jack pried open the hood of the car with a crowbar and cut sections out of the battery cables with a bolt cutter. He returned to Joyce who had completed the immobilization of Uli’s head as best as she could. “It’s going to take a bit of time to get this door open, so I’m going in to further evaluate him.” Taking a large hammer from their tool kit, she went to the rear of the car and smashed out the rear window. Joyce crawled in, trailing her medical kit bag.

Reaching Uli, Joyce placed a BP cuff on his right arm, clipped an oxygen saturation sensor on his right ear, and connected them to the small portable monitor in her kit bag and turned it on. “He’s tachy (tachycardia or rapid heart rate), blood pressure 100 over 70 and his 02(oxygen) saturation is only 88%” Joyce called out. She got a stethoscope out of the kit and listened to each side of his chest, out of concern over the low 02 saturation. “I can’t get any breath sounds on the left” she called out to Jack, and then she placed a rebreathing oxygen mask on Uli’s face. Joyce opened the valve on the oxygen bottle in her kit, heard a satisfying hiss and then connected it to the tubing from the oxygen mask.

On the monitor the numbers for the oxygen saturation climbed to 92%. Joyce was satisfied with any number over 90%, but would have loved to see something over 95%. 98% or better would be a normal O2 saturation. If her patient was a smoker, 92% would be about all that could be expected. She was still worried about the lack of breath sounds on the left side of Uli’s chest. The door to Uli’s side of the car had been deformed well into the interior, causing Joyce to expect significant injury to the left arm, leg and probably the chest as well.

Jack had gotten the prongs of a hydraulic device wedged into the seam between the door and the door frame. The device could be used as a jack to lift a car or it could be used to push things apart as it was being used now. It could be operated electrically or manually and could generate over fifteen tons of pressure. Jack deselected the electrical option and selected the manual mode, no sparks wanted. He fitted the handle and began to pump the device. The tortured metal began to groan as he pumped, the seam growing wider, the metal then squealed as he continued to pump, and finally it gave way with a loud crack. Jack opened the door the rest of the way and began cutting through the seat belt with a large folding knife that he drew from a pocket on his coat sleeve.

Joyce said “The O2 is up to 92%, but his pulse is rising and his BP is falling (classic signs of shock). I’m going to get an IV started”. Just then the two EMTs who had been looking at the driver of the other car came over. “The other one’s gone” they said, and joined Jack and Joyce in getting immobilization boards under Uli in preparation for getting him out of the wreckage of the car.



********

Uli, responding to the increased oxygen supply, began to emerge from the fog. He heard the rushing sound of waves washing in and out over a sandy beach. He found himself on a cold, wet beach in the dark of night. His head was cradled in the lap of a woman whose face he could not see clearly in the dim starlight of the moonless night. “Don’t move” she said her voice a dulcet tone as she told him “You have been shipwrecked on my island. My servants are coming to take you to shelter”. Uli felt himself lifted onto a litter, then the uneven jostling of the litter being lifted and carried from the beach. The sound of the waves receded and the sound of the servant’s footsteps indicated that they had transitioned from the soft sand of the beach to firmer ground. He sensed the woman walking next to him.

There were two servants carrying lanterns, one in front of the procession and one in the rear. Uli could not make out much of the passing landscape; his impression was of a tropical seashore area. His rescuer was walking alongside and seemed to be attired in riding clothes, her boots crunching on a roadway of crushed shells. The procession was now passing along a wrought iron fence in the form of gleaming black spears set about a hand span apart, and perhaps ten or twelve feet high. They came to a gateway formed from two stout stone columns and twin wrought iron gates with the figure of a crowned bearded man wielding a trident, mounted on a leaping dolphin. They proceeded up a long curving drive, and Uli had the impression of carefully manicured gardens on either side. After some time, the glowing lights of a stately mansion came into view. Uli counted five stories and rows of many windows golden with light. As they got closer and closer, the mansion became larger and larger, and Uli revised his estimate of mansion upward to palace. It occurred to Uli that his rescuer must be a person of great wealth and power. They entered a portico the depth of a great room, with gleaming figured bronze doors a full story high. Two liveried footmen opened the doors into a great marbled foyer with sweeping curved staircases climbing upward on either side. His rescuer issued some quiet instructions to one of the footmen and departed through a doorway to the left. Uli glimpsed a large room filled with floor to ceiling book cases and a massive, ornate desk before the door was closed.

Uli was taken to a large tiled bath, was washed and his wounds dressed with salves and bandages. He was dressed in silken pajamas and taken to a bed chamber with a very large curtained and canopied bed. The servants lifted him into the bed, and he was served a heavy silver tray with fine china. A bowl of broth, a baguette of fresh bread with butter and a tall glass of milk filled the tray. Uli ate with the hunger born of surviving being tossed and battered by the sea. It seemed nothing short of miraculous that he now found himself reprieved and in the lap of luxury. He was given a cup of fragrant tea. The maid serving it said that it would help him sleep. The lights were extinguished and Uli fell into a deep sleep, and his dreams came in swirling disjointed images.

First to emerge was the visage of Penny, his wife. The central part of the image was her eyes, their color that of pale green jade, with flecks of rust circling the iris. They were eyes in which he frequently found himself entirely lost in their depths. About the eyes, her face began to fill in, a face of beauty, but not quite as perfectly symmetrical as a fashion model, and her complexion, not quite as porcelain smooth. And yet, the very sight of her hit his heart with a force greater than any arrow from Cupid’s bow. Shakespeare’s Sonnet CXXX came to mind:

“My mistress’ eyes are nothing like the sun;

Coral is far more red than her lips’ red:

If snow be white, why then her breasts are dun;

If hairs be wires, black wires grow on her head.

I have seen roses damask’d, red and white,

But no such roses see I in her cheeks;

And in some perfumes is there more delight,

Than in the breath that from my mistress reeks.

I love to hear her speak, yet well I know

That Music hath a far more pleasing sound;

I grant that I never saw a goddess go,

My mistress when she walks treads on the ground;

And yet, by heaven, I think my love as rare

As any she bellied with false compare.

Uli gloried in her less than perfect beauty. She was a love most rare indeed. Actually, Penny was far more attractive than would be implied by Shakespeare’s parody of the love sonnets promiscuously penned by the swains of his day. One time Uli had walked behind Penny down the street as an experiment after the two of them had had a conversation about the way men looked at women on the street. Uli had been astonished at the attention and turned heads that followed Penny when it seemed she was unaccompanied. He had never seen these reactions when he walked beside her. Somehow it was different when it appeared to men that she was unaccompanied. It came as no surprise to Penny, who had long ago noticed the difference in the reactions of men. Her long auburn hair with its natural curls and her curvy figure certainly drew lots of attention.

In his dream his hand stroked down her shoulder to her hand, and he took her in his arms. His body responded to the touch of her. But the capricious nature of dreams dissolved the image, and he was left with a great longing. It is the nature of dreams to make rapid changes and shifts in places and time. Uli dreamed he was in his car as it was slammed and rolled; suddenly he was in the stormy seas battered by the waves… He awoke suddenly in the quiet of the night in the large canopied bed. He was drenched in sweat and shaking at the strength of his dream. He settled back into the cushions and his heart slowed, his breathing steadied and he gradually slipped back into a dreamless slumber.





Chapter Two: The Trauma Team and a Journey to The Underground

Dr. Peter Murphy, trauma surgeon, known throughout the hospital as “Murph”, hung up the phone on which he had been in contact with the EMTs bringing Uli into the trauma center. He was a lanky six foot three with the accent of his native Virginia piedmont, gentile and warm to the ear. He turned to his trauma team: Karl and Karen, RNs from the OR; Chloe and Nan, RNs from the ER and Kurt Anderson MD, regarded as the best anesthesiologist for trauma. “We have a 40-50 year old male, MVA T-Bone collision with rollover. He is shocky, no breath sounds on the left side of the chest, and a Heimlich valve has been placed. The driver’s side door took a direct hit and was deformed well into the driver’s space. When we get him, I want a FAST scan of the abdomen. Kurt, there is no C-Spine clearance, so let’s go with a fiberoptic nasal intubation. I want a chest tube and pleurevac to replace the Heimlich valve. We will keep him on the back board and get him to a full body CAT scan as soon as we get him stabilized here. We will use O negative blood if we need a rapid transfusion”. O negative is the universal donor, having none of the antigens that could cause a transfusion reaction. O negative blood is used in those situations where there is no time to test a patient’s blood to determine its type and antibodies. Karl went to the phone and placed calls to ultrasound and CAT scan.

Karl and Karen were Murphs favorite OR team for trauma. To himself, he thought of the pair as K squared. His bond to K squared was the result of an extraordinary journey into the underground. It happened like this:



********

Karl was circulating in a neurosurgical case with Dr. Davies, the chief of Neurosurgery. Dee, another RN, came into the OR quietly and sidled up to Karl. “I’m supposed to get you out. Chicky (Janet Henway RN, Director of Surgical Services) wants to see you in her office stat, so give me report on the situation here”. After giving Dee report, Karl headed out of the OR wondering what he was in the doghouse for this time. He could not think of anything he had done or said to any of the surgeons or supervisors that would give offense, that being the usual reason for him to be summoned. Karl had a habit of saying whatever was on his mind, which some authority figures, especially those with insecurity issues, had a hard time with. Karl felt that life was too short to bottle things up merely to defer to someone else’s ego. Other authority figures more secure and experienced actually enjoyed Karl’s forthright nature.

When he arrived at the office door, Karl knocked twice and entered without waiting for a reply as was his habit. He was surprised to see Karen there, as Karen was not one of the people Chicky usually had brought to her office as Karl was. Chicky was standing behind hear desk looking a bit pale. “Dr. Murphy just called me. There has been a serious accident in the subway. He wants my two best nurses. I want you to round up the trauma bags and meet Dr. Murphy in the Trauma Center stat”.

Minutes later Karl and Karen were in the Trauma Center, lugging the two large nylon canvas bags in the hospital’s blue and white colors that displayed the hospital’s logo. Murph waved them into a waiting ambulance that was idling just outside the Trauma Center entrance. They clambered into the back of the ambulance, which motored away just as soon as the rear doors were shut. Murph laid out the situation as he knew it:

“Somehow two subway trains have collided near one of the main junctions leading into City Center Station. Early reports are of a large number of casualties, many entrapped in the wreckage. A surgical team has been requested, and whatever we will be doing will most likely involve those who are entrapped. It will be cold, dark and in very tight quarters. I have the drug bag and I see you have the bags with the personal gear and the instruments and supplies. We better get into the jumpsuits and hardhats”.

The ambulance was waved through a police barricade, and a fireman directed them to the curb near a subway entrance. As they climbed out of the ambulance, the fireman further directed them to the lobby of a bank on the corner next to the subway entrance. They noticed that his helmet was white instead of the yellow of the rest of the firemen they could see, and closer examination led them to see the legend “Lieutenant” on the white helmet.

The Lieutenant introduced himself: “You can call me Frank; I’m your liaison with the command center. This is your staging area; hang in there until I get further instructions for you”. Lieutenant Frank then turned his face out of the wind to listen to the two-way radio he pressed to his ear. The three medicos entered the lobby of the bank and claimed three chairs in one of the corners amid the marble, mahogany and rented planters. These planters made our team feel something like at home as they were the same as the ones the Rent-Some-Greenery-Company supplied to the hospital. All that was missing was the waterfall with goldfish pond, like the main lobby of the hospital.

Murph reached into his pocket and pulled out a partially crumpled pack of cigarettes. “Hey Murph” Karen grinned “I thought you gave those up last year!” Murph had won an epic battle with the nasty habit that had been followed by many of the staff at the hospital, and had been given a surprise celebration when he had been off the smokes for six months. “I commandeered these from one of the housekeeping staff. I am making an exception for today. Anybody want one?” During his struggle, Murph had been notorious for quoting Mark Twain on quitting tobacco: “Quitting smoking is easy. I have done it hundreds of times”. Both Karl and Karen declined the invitation.

Murph drew a cigarette from the pack and then the book of paper matches that had been wedged in between the cellophane wrapper and the pack. To his consternation he discovered that the matchbook was empty. Karl and Karen laughed. “Saved” Karen exclaimed as Murph tossed the crumpled pack into one of the planters. Karl gestured expansively with his hands, “So here we are, hurry up and wait.” “Yeah” added Karen “Just like the Army. Did I ever tell you guys about our welcome into Saudi Arabia during Desert Storm last year?” Murph and Karl both shook their heads. They were a bit taken aback as Karen had never really talked about her experiences in Iraq and had deflected questions with banal generalities.

********

Karen was a brunette with a pageboy hairdo, mother of two boys, eight and ten years old. She maintained her fitness by keeping up with “her boys” who included her husband, a tennis and golf pro at the Country Club. Karen was also a member of the National Guard, the extra income which it provided paying the tuition for the boy’s private school.

Karen had been activated for the Desert Storm campaign against Iraq following the invasion of Kuwait. Her unit, a field hospital, had flown into Saudi Arabia aboard a turbo prop C-130 Hercules from an airbase in Germany. That was after a flight from Dover Air Force base in Delaware on a C-141 Nightingale, a jet airplane specially configured as a state of the art medical evacuation and intensive care facility. Unlike the C-141 Nightingale, the accommodations on the C-130, or in GI patois, a Herky Bird, were Spartan at best. The interior of the plane was one large unheated, unpressurized space, with benches along the sides and pallets of cargo down the center. The pallets were covered with plastic sheeting and were secured to the floor by nylon web nets. Individuals sprawled on top of the cargo or on the benches bundled in layers of clothing and flight jumpsuits against the cold.

Some of the weekend warriors, as Guard members were referred to, ate MREs (Meals Ready to Eat) the food replacing the infamous C Rations which had been the mainstay of field cuisine since World War Two, and only supplanted by MREs a couple of years ago. While you could not say that MREs were popular, they certainly were an improvement over their predecessor. One of the most detested of the C-Rations was the infamous “Ham and Eggs”, a can that when opened revealed an unappetizing greenish-yellow cylinder that did have recognizable cubes of ham imbedded. On the other hand, there was “Steak and Potatoes” which many troops wished they could get back at home; such was the esteem it engendered. Still, the troops maintained that MRE stood for “Meals Rejected by Ethiopians”.

As quickly as the Herky Bird landed, the pallets of cargo were rolled out of the airplane thanks to tracks of rollers in the floor, then were fork lifted onto waiting trucks. The personnel were directed into a couple of conscripted commuter busses, decorated in sweeping Arabic script with graphics of green palm trees and blazing orange sunsets (Or were they sunrises? Hard to tell). All and sundry were then rushed off into the featureless desert landscape. Several hours later they were unceremoniously deposited in a place of rocks and sand indistinguishable from the rest of the territory they had travelled through.



The unit was well drilled in setting up their field hospital, a task that had been practiced on many reserve duty weekends. By sunset the hospital was set up and functional, with one not so minor problem. The pallets with the tents that would serve as living quarters for the staff were AWOL (absent without leave). The desert being roasting hot during the day and freezing cold at night, a determination was made after the first night that desperate measures were in order.

Those first days the only thing that kept Karen going was the whiskey, forbidden to the citizen-soldiers by the Law of the Land of the Saudis: Alcohol was strictly forbidden by the Koran. Karl had sent it to Karen in mouthwash bottles that he had carefully drained and refilled through a small hole he had made in the bottom of the bottle and then resealed. Thus the shrink wrap seals around the caps were intact. Furthermore, he had selected a brand of mouthwash known for its amber color. The doctored bottles were placed in a parcel with some food and personal care items and with the one other essential for life in the desert: baby wipes. Karen had nearly choked in surprise when she cracked open the seals and took a swig after brushing her teeth.

Karen and one of her sergeants hitched a ride to a depot along the road south towards the airstrips and what passed for civilization. The depot was like unto a truck stop along the interstate back home, offering food, fuel, refreshment and most importantly, toilet facilities for the drivers and transitory personnel headed north towards the Iraqi frontier. The intrepid duo hung out until they spotted a large flatbed truck loaded with the telltale plywood cases containing squad tents along with lumber, canvas and other construction materials. They watched as the driver and his companion entered the toilet area. Karen nodded to her sergeant, who mounted the cab of the truck, and then drove off northward. Combat vehicles do not have keys as they would surely be unavailable in states of emergency.

Karen waited outside the toilet area, and when they emerged, she detained the hapless crew of the truck, asking questions about where they were from and otherwise diverting their attention for a good half hour. GIs far from home were always an easy mark for the charms of the fairer sex. Karen gave them some ration coupons for some hot chow from the kitchen of the depot, a welcome change from MREs. Exclaiming that her transport had arrived, she climbed onto a north bound bus. The two GIs never noticed her lack of luggage. Murph and Karl chuckled appreciatively.

Murph opened up. “You hardened war vets may not know it to look at me, but I haven’t always been a civilian. I was in the Air Force for two years, but during peace time”. Karen observed that “You surprise me; you do not have a GI issue halo floating above your head.” “I traded mine for a cup of coffee and a doughnut” retorted Murph. “My best buddy on the base was an OB-Gyn named Esposito, but he went by the nickname “Skip”….

********

Skip stumbled out of the base hospital into the bright sunlight of an absolutely gorgeous morning. The brilliant sun was low on the horizon, stabbing into Skip’s bleary eyes between buildings. Skip had been on the go for thirty-seven hours in a row, representing ten hours of scheduled surgery, four vaginal deliveries and two emergency C-Sections. Military bases were notoriously tough duty for OB-Gyns as they had a population, active duty and dependants that were almost entirely of peak child bearing age. Skip often remarked that he would like to have a bronzed insufflator mounted on a pedestal in front of the hospital.

The insufflator is an essential piece of equipment for performing laparoscopic tubal ligations. Think of the abdomen as a plastic bag containing a few groceries sitting on a table. The insufflator inflates the grocery bag with carbon dioxide, creating room for a view through a telescope and for maneuver by instruments. Each tubal ligation reduced Skip’s late night hours appreciatively.

Given this ordeal, Skip’s uniform was in an advanced state of disarray, jacket over his shoulder, shirt tail halfway out; tie untied, sleeves rolled up, dark unshaved stubble on his cheeks and chin. Just at that moment as Skip was taking his bearings, an Air Force Blue Staff Car with flags flying from the front fenders pulled up to the curb. Skip watched in unfocused wonder as the driver energetically leaped out of the staff car, and with a flourish opened the rear passenger compartment door. A crisply uniformed man emerged along with a clipboard bearing minion. Skip’s eyes registered the three sparkling stars on the shoulder boards, and something deep within his consciousness screamed an alarmed “Oh Shit!” His lanky frame drew itself to attention; his arm arose in the crispest salute of his entire military career, the jacket that had been over his shoulder falling to the ground. Three stars could only be General Daniels, the Wing Commander, and absolute potentate over the 47th Tactical Fighter Wing.

The General advanced slowly, his gaze fastened on Skip as if epoxy glued. He stopped a pace away and directly in front of Skip. One, two, three beats passed and then the torrent started with “the kind of example you are setting” building to “what a disgrace you are to the uniform” rising in pitch and fervor to “just giving in to the commies and hippies” on to “the beginning of the end of western civilization” and concluding with “what have you got to say for yourself?” Skip deliberately and calmly reached into his rear pants pocket and withdrew his wallet. He raised the wallet to his face as he flipped it open. “Scotty, beam me up” he spoke into the wallet, then flipped it shut, replacing it into his pants pocket. Then he walked away, dignity intact, leaving the General locked in place, frozen by disbelief at what he had just witnessed.

********

At that moment Frank, guide to the underworld accompanied by his crackling radio approached. “Time to move out” he said “I’ll fill you in on the way”. The situation as he outlined it was that there was an older woman trapped in the wreckage. The EMTs thought that she might be going out faster than the progress of freeing her, and that a speedy amputation of her entrapped leg might be the only way to save her life. The team crossed the street and into the entrance to the subway, descending the stairs to the passenger platform which was crowded with firemen and EMTs taking advantage of the bright lighting and space to sort their gear and prepare to move out. Our quartet jumped down from the platform to the tracks below which seemed felted with a thick even coating of greasy black dust. Jogging on the tracks they made their way into the darkening tunnel lit at intervals by naked light bulbs mellowed by their own coating of the omnipresent thick grime. In contrast to the rest of the surroundings, the rails gleamed with a brilliant shine. Following Frank, they became aware of the narrow tunnel emerging into a larger space, the grime frosted bulbs making islands of light in the intervals between the seas of blackness. “This is where the subway and commuter train tunnels are beginning to converge upon City Center Station” Frank offered by way of explanation.

Silhouettes of steel columns that supported the ceiling and of toppled and wrecked cars began to be visible, spot lit in places by work lights and the arcs of sparks from the metal cutting saws and torches. They were led into a maze of wreckage and to the side of what could be recognized as a commuter train car. Two firemen lit up by work lights were working with a circular saw creating a comet tail of golden sparks, finishing an opening in the stainless steel side of the car. A section of the metal about a foot and a half square hit the tracks below with a ringing clang. A woman’s knee was visible framed in the opening. Murph directed Karen to get into the car to monitor the woman and to administer a fast acting anesthetic and narcotic. Karen took a smaller package from the trauma bags and followed their guide around the wreckage to enter the car. Frank gave her a boost to help her enter through a window with its glass missing.

Frank returned to where Murph and Karl were working at the side of the car and adjusted the work lights to better illuminate their efforts. Without comment, Karl sorted through the bags and assembled a Gigli saw, betadine antiseptic, an Esmark rubber bandage, packets of sterile surgical towels, sponges and lastly a large number twenty-one scalpel. He quickly doused the exposed knee with the betadine (a potent solution of alcohol and iodine) and opened the packages to make a small makeshift sterile field. Murph donned sterile rubber gloves and handed another pair to Karl. Murph drew the Esmark bandage, a roll of rubber about four inches wide and four feet long, above the knee, being careful not to get snagged on the sharp metal edges of the opening into the car. Then he tightened the tourniquet he had fashioned from the Esmark and secured it with a Kelly clamp. Karl prepared the Gigli Saw, a thin wire about a foot long with serrated teeth along its length, by attaching small handles at either end.

Inside the car, Karen rapidly placed the probe of a pulse oximeter on the woman’s earlobe. Only the woman’s head and shoulders were visible from the confining mass of twisted seats and other wreckage. Karen tried speaking to the woman and shaking her shoulder but there was no response, the woman was mercifully unconscious. Karen noted with satisfaction that the EMTs had managed to get a Blood Pressure cuff around one upper arm, and had got a large bore IV into the woman’s neck. It was in fact into the internal jugular vein, a great choice as it could tolerate large rapid infusions of blood or fluid delivered nearly directly into the heart.

The readout of the pulse oximeter showed Karen a rapid pulse, a high rate of shallow respirations and an alarmingly low blood pressure, classic signs of an advanced state of shock. No doubt about it, this woman was “circling the drain” as the medics not too delicately put it. She called out the vital signs to Murph who made the tough decision: Do it now, do it quick. He gave the order to Karen to administer Propofol and Fentanyl. Anticipating his order, Karen had removed the syringes from her kit. She opened up the IV drip wide and injected the Fentanyl (a powerful synthetic narcotic analgesic) and then the Propofol (a rapidly metabolized anesthetic).

Propofol is metabolized so rapidly that it must be titrated, meaning that it is given in a continuous trickle after anesthesia has been established. Karen lightly flicked the woman’s eyelashes and noted the lack of protective reflex response (an eye blink) an indication that the required state of anesthesia had been established. “Go!” she shouted. She then began squeezing the IV bag to get as much fluid into the woman as rapidly as possible. When the bag was empty she pulled it off, tossed it aside and spiked another bag which she squeezed again. By increasing the volume of circulating fluid in the blood stream she would get the blood pressure as high as it would go, keeping the vital organs perfused and countering the effects of shock. She pushed another bolus of Propofol into the IV. She spiked another bag of fluid.

Outside, Frank held two work lamps over the heads of Karl and Murph, one in each hand, lighting the narrow opening and the woman’s leg with brilliant light. Murph cut deep with the scalpel just above the knee, making an encircling incision around the leg. Karl worked with a clamp and retractor in one hand and a sponge in the other to expose the depth of the incision to Murphs view and to clear away the blood that flowed into the wound, greatly reduced because of the tourniquet. Murph repeated the encircling motion with the scalpel, this time cutting right down to the femur (thigh bone). Karl spotted the exposed tubular end of a large vessel and clamped it with a Kelly clamp, sealing it. Murph passed the end of the Gigli saw around the exposed bone, grasped the handles, one in each of his hands, and began sawing back and forth. Frank was astonished at the speed which the Gigli saw made through the bone, four times back and forth and the bone parted. “Go!” Murph shouted.

Inside the car, Karen had moved aside and two EMTs heaved on the woman’s shoulders while supporting her head and neck, dragging her onto a stretcher. Grasping the handles of the stretcher they exited the ruined car, where a third EMT slapped sterile gauze over the stump and held it in place as they made for the exit and a waiting ambulance, “Go with God” Murph intoned, Karen reflexively applying the “amen” while crossing herself. “Dustoff accomplished” said Karl. Frank gave Karl a long look and after listening to a static filled exchange on his radio, led them back through the maze to the refuge of the passenger platform, where they were given steaming cups of black coffee. They sat on the floor of the crowded platform.

Frank extended a hand towards Karl, who met it in a handshake, which then was followed by a complicated series of grips, slaps, slides and a knuckle bump that had Karen and Murph staring for the half minute that it took to complete. What they were witnessing was a “Dap”, a ritualized greeting practiced by enlisted troops during the Viet Nam war. It was actually possible for the initiated to recognize the specific unit of another from a dap. “You were a Screaming Eagle” Karl said to Frank, referring to the 101st Airborne Division. “Company E, first battalion, 506th PIR” replied Frank. “45th Medical Air Evac” said Karl. Murph and Karen regarded the two vets with a quiet respect, as they sat among the coils of electrical cords, work lights and boxes of rescue gear. Steam rose from the paper cups of black coffee as they sipped the welcome warmth. “I didn’t know that you flew Dustoffs Karl” Karen said. “Let me tell you about Dustoffs” Karl replied…..





Chapter 3: The Story of Bandaid and Gremlin

Karl was just twenty years old, with a fuzzy head of light brown crew cut hair and a mustache to match, with an accent from western Pennsylvania that reminded people of Jimmy Stewart, another western Pennsylvania native. When Karl reported to the 45th Medical Air Evac Detachment there was a celebration going on. Karl had been met by Tommy Jones, the crew chief of the helicopter Karl was assigned to. Everybody called Tommy “Gremlin”. Tommy’s distinguishing feature was a prominent set of ears made even more so by the short GI haircut. In fact he bore a strong resemblance to a character in a Bugs Bunny cartoon from the forties. Bugs is up in the air in a WWII bomber with a gremlin doing his best to disable the aircraft. The gremlin had an oversize pair of ears that looked like the tail fins of an airplane, similar to Tommy’s, hence his nickname.

Gremlin introduced Karl around as his new “band aid”. A medivac chopper had a permanently assigned crew chief and a 91-B, the occupational code for a corpsman, which generically became a “band aid” in GI patois. The Crew Chief basically owned the chopper, being responsible for its upkeep and maintenance. The pilot and copilot that completed the crew rotated to different choppers every day. The pilot functioned as the mission commander, making the decisions and giving the orders. He also handled the radio communications and navigation. The copilot actually flew the chopper.

The reason for the celebration was that the unit had received new choppers; UH-1H models to replace their UH-1Bs. The proper designation for the UH series was Iroquois, but everybody called them Hueys. The 1H model had a longer body with a bigger cabin than the1B model. It could accommodate six patients, three on litters and three sitting as opposed to two, maybe three total in the 1B model. Most importantly, the 1H model had longer blades and a more powerful engine. This gave it a lot more lift which was what pleased the crews so much, enabling them to get in and get out much more quickly. The first crews in country had been alarmed to find that the high ambient temperatures of the Vietnamese climate caused the air to act as if it was thinner, as would be found in a high altitude situation, resulting in greatly reduced lift. The quick in and out or “dustoff” was the preferred method of operation, and the lack of lift caused them to be more exposed to hostile fire.

The Hueys could also use a hoist to lower a sling, litter or jungle penetrator, a method that exposed the hovering chopper to enemy fire, making them an easy target. The hoists were also very heavy and tended to make the choppers slightly off balance to the side they were mounted on. If the crew had their way, the hoists would be removed and replaced by an M-60 machine gun. It may come as a surprise to many readers who expect that medics are unarmed non-combatants, but it is a fact that by the Geneva Convention that medics in combat situations are routinely armed, and while they may not be engaged in direct combat, they are expected to defend their patients as necessary. In other words, if they are being shot at, they could do nothing to defend themselves by the treaty. However, if they had patients under heir care, it was ‘fire at will”. Karl was qualified with the M-16 rifle, .45 automatic pistol and M-60 machine gun. He always carried the .45 on his hip. There were two M-16s in brackets in the cabin of the chopper along with bandoliers of ammunition. The crew chief and the pilot and copilot were also armed.

The cabin of the chopper was shaped like a “U” with a fat bottom. The fat bottom of the U was the bulkhead that separated the cockpit from the cabin and the two thin arms of the U stretched rearward, embracing the walls of the mechanical space. There were two seats made of aluminum tubing and a canvas sling, like a lawn chair designed by a cubist artist, facing rearwards from the bulkhead. They faced brackets that secured standard litters, one on the floor, a second one 24 inches above the first and a third 24 inches above the second. A fourth litter could be placed across the seats, unless the seats were used for sitting casualties. Two more bench seats were on the arms of the U facing the doorways on either side of the chopper. The walls and ceiling were covered by quilted pads of “olive drab” the ubiquitous uninspiring color of the army.

The next morning, Karl, who had during the course of the evenings party evolved from being the generic “band aid” to the proper noun “Bandaid”, met with Gremlin and the assigned pilots of the day down on the flight line. The pilot was Chief Warrant Officer Sonny Rodriquez, a quiet spoken, short dark man from Albuquerque, New Mexico. The co-pilot was Warrant Officer Matt Thomas of Altoona, Pennsylvania. If the stereotype of the pilots of fixed wing aircraft was that they were cocky extroverts, the stereotype of chopper pilots was that they were moody introverts. Rodriquez and Thomas certainly fit the bill.

While Gremlin and the pilots completed their preflight checklists, Bandaid checked the medical supplies, weapons and other gear in the cabin, making sure that everything was in its place and properly secured. Then the whole crew retreated to the shady side of the chopper, sat in the open door of the cabin, and passed around a canteen filled with kool-aid. Cigarettes were lit, and some crackers and cheese from a C-ration box made the rounds. The tedium of waiting in the humid tropical heat settled like a thick fog, reducing everyone to a somnambulistic state.

The crackle of static from the radio dissipated the fog in an instant. It was a call to action from mission control and the crew jumped to their places. The chopper lifted straight up about three feet, tilted nose downward, and then leaped into the morning sky. Immediately after leveling off, radio contact on the operational channel was established with the ground unit requesting the dustoff. Coordinates for the landing zone or LZ were established. Switching to the command frequency, Sonny requested gunship escorts. Mission Control replied that there would be no gunships available for about a half hour. Switching back to the operational frequency, Sonny communicated the delay. The infantry commander replied that the LZ was secure and that it was imperative that his casualties get immediate medevac as they were critical. Sonny made the command decision to go in naked, without gunship cover.

The Huey arrived at the LZ, a large area of tall grasses surrounded with trees. The infantry unit tossed a smoke grenade which blossomed purple to one side of the clearing to mark the site and to give the pilots an indication of the wind direction and strength. Sonny spoke into the mike on the front of his flight helmet “I see Goofy Grape”. “Confirm Goofy Grape” replied the infantry commander. There had been incidents of medivac choppers being lured into ambush by “Charlie”, as the enemy was called, utilizing captured smoke grenades. So now SOP (standard operating procedure) was to use a different color every day and to confirm sightings with the ground units.

The Huey nosed up and began its descent to the site, when it took several hits above and behind the crew cabin. Gremlin and Bandaid cowered on the floor and reported the hits over the intercom. The wine of the gas turbine engine continued, but there were crunching and grinding noises coming from above the cabin, and the distinct chop-chop sound of the blades grew quieter. “The transmissions gone” reported the co-pilot, and the chopper began a rapid descent. With the transmission out of action, there was no power to the rotating blades and they were in autorotation, passively turning by force of the choppers forward momentum.

The turbine engine still gave them some thrust to maintain the forward momentum. Choppers do not get their lift from blowing air downward as popularly believed, but from lift generated by air passing over and under the airfoils of the blades, exactly like the lift generated by air passing under and over the airfoils of the wings of a conventional aircraft. So the blades were still generating some lift. The chopper had become essentially a glider. If they had been in hover when they were hit they would have fallen right out of the air, as they would be lacking any forward momentum.

Matt banked the Huey towards the source of the purple smoke figuring that he could be sure of some freindlies there. The Hueys glide path carried them past the smoke into a running landing unlike the gentle vertical settling they were intended to do. The rear edges of the skids hit first, slamming the nose down hard. Fire broke out in the mechanical space. Bandaid helped Gremlin to his feet, as they had both been flung around the cabin by the force of the landing which had collapsed the fragile aluminum tubing of their seats. Gremlin yelped in pain when Bandaid touched his left shoulder. The left arm was dangling uselessly. Bandaid slung the strap of his rucksack full of medical supplies over one shoulder, and the sling of an M-16 over the other. He helped Gremlin out of the chopper to the ground and reached back in for a bandolier of ammunition for the assault rifle.

The magnesium-aluminum alloy skin of the chopper began to burn with its distinctive brilliant white flame. Matt and Sonny were already out of the chopper and had taken up positions facing outward, weapons at the ready. As Bandaid and Gremlin reached the pilots, all four began to race to a small knoll where they took cover in the tall grasses. A squad of GIs came running from the nearby tree line, grabbed the four airmen and raced like greyhounds for the trees. The telltale deep pounding sound and rhythm of a Chinese made fifty caliber heavy machine gun could be heard from the opposite side of the clearing. “That’s the bastard that got us” Sonny said. A firefight raged about them, and then mortar rounds began to explode on the opposite side of the clearing. The Chinese machine gun was silenced.

Bandaid diagnosed Gremlin with a dislocated shoulder. Seating Gremlin on the ground in front of himself, he braced his right hand against Gremlin’s back, and with his left hand pulled Gremlins left arm down and posterior, relocating the shoulder with a sharp popping sound. He then secured the arm in a sling made from an olive green triangular bandage from his kit, and immobilized the slinged arm to the chest with another bandage. Then he busied himself with the other wounded. The second half of the longest day of Bandaid's life had begun. His patient population immediately doubled from three (counting Gremlin) to six. Later that afternoon Hueys with gunship escorts arrived to evacuate the wounded and the dead. They were wrapped in their olive green ponchos which had served them in life as rain gear, sleeping covers, shelters, and now as funeral shrouds.

********

The crackle and hiss of Frank’s radio brought them back to the reality of the passenger platform. Frank listened to the transmission and then turned to the team. “I’m sorry to tell you, but your lady didn’t make it. She died on the OR table a few minutes a go.” Four countenances fell in unison and each internalized the deeply unwelcome news in their own way.





Chapter 4: The Trauma Team and Uli’s Hostess

The Trauma Center is on the ground floor of the hospital separate from the Emergency Rooms. It has a drive ramp up to the front door for ambulances, and a helicopter landing pad on the lawn directly across the ambulance ramp from the entrance. Inside, there are stabilization bays where patients can be diagnosed and treated. At the rear are two trauma ORs where surgical procedures can be carried out after stabilization. The most severely injured can be taken directly to these ORs from ambulance or chopper.

In Trauma OR One Murph turned from the phone on which he had been talking directly to EMT Joyce Circe and addressed his team: “We have a 40-50 year old male, MVA with T-Bone with deformation into the driver’s space and rollover into a tree. He is shocky but stable at the moment, no breath sounds in the left chest, a Heimlich valve has been placed improving his sat. Glasgow coma scale of twelve. When he gets here I want a fast scan of the abdomen, a fiber optic nasal intubation, the Heimlich valve replaced with a chest tube and pleurevac. As soon as he has been stabilized we go for a full body CAT scan. Let’s get it on people!” Karl went to the phone and made calls to ultrasound and CAT scan.

To translate for our non-medical readers, the absence of breath sounds in the left chest suggested pnuemothorax or collapse of the lung on that side. A Heimlich valve is a device that is used in the field to permit air and fluid to move out of the chest by the pumping action of breathing, but not back in. It is placed through a stab in the wall of the chest. This allows the lung to re-expand, causing the O2 saturation to rise. A Chest tube and pleurevac is a more sophisticated device to do the same thing, but is more appropriate to the hospital environment, utilizing a water seal and suction to expand the lung by creating negative pressure in the chest cavity. The description of T-Bone collision with deformation and rollover with tree impact gave the team an indication of the severity of the accident and the proportionate level of injuries to be expected. They would be thinking about extremity fractures, internal injuries, possible neck injury, and head trauma.

The FAST scan is a rapid read ultrasound exam that can show the source of internal bleeding and many types of internal injuries. It can be accomplished in three minutes or less. A Glasgow coma scale score indicated the presence of traumatic brain injury and an estimate of severity. A score of twelve was the bottom of the range for a moderate incapacitation. A full body CAT scan would demonstrate just about anything that could be wrong, but it is time consuming, so it would be necessary to get the patient stabilized first.

The stretcher borne by Joyce and Jack burst through the doors; Murph waved them through the stabilization bays to the trauma OR. The team fell to their assigned tasks. Chloe placed EKG leads, a pulse oximeter probe and a BP cuff to get the monitors going for the team, and then drew blood samples for the lab. Nan started a transfusion of O negative blood in the IV line Joyce had started at the scene of the accident. Nan first checked to be sure that the line had been running saline (essentially salty water) as other IV fluids such as Lactated Ringers, Ringers or Albumin contained Calcium which would instantly deactivate the compound put into bank blood that kept it from clotting. You can imagine what a disaster it would be to clog up the only IV line into a patient in this critical situation would be.

Once the transfusion was started, Nan began the tricky business of getting a line into the radial artery in the patient’s right wrist. At the same time, Kurt was placing an endotracheal tube (ET tube) over the flexible licorice stick like wand of a fiber optic laryngoscope, and then with direct vision threaded the laryngoscope through the nasal passages, through the pharynx and throat past the vocal cords into the trachea. He pushed the ET tube down the laryngoscope into the trachea. He removed the laryngoscope and then inflated the balloon cuff of the ET tube to seal the airway, connected his breathing circuit and began to ventilate the patient with pure oxygen. This nasal approach was done instead of the usual placement of the ET tube through the mouth because of the possibility of neck fracture and the need to keep the neck immobile.

Karl cut away Uli’s clothes to expose his chest and abdomen, and then poured Betadine (a solution of iodine and alcohol) over everything thus exposed. Karen, sterilely gowned and gloved, was setting up the sterile field and instruments needed for surgery in the abdomen and chest. These would not be counted as was the usual practice in surgery to save time. The full body CAT scan would reveal if anything was left behind, as any retained object could be removed later when the immediate crisis had passed.

Murph pulled out the Heimlich valve from between the ribs, used a scalpel to slightly enlarge the incision, and pushed in a chest tube that had a sharp metal spike through its hollow center called a trocar. As soon as he felt the trocar push through, Murph pulled the trocar from the tube, and pushed the tube into the chest cavity to the depth that his experience told him would be enough, but not too deep, then connected it to the pleurevac and connected the pleurevac to suction. The pleurevac provided a space for the collection of fluid from the chest cavity and an escape for any air trapped there. A water seal kept air from getting back in, and regulated the force of the suction. It began to bubble in a satisfactory way. Chloe sewed the chest tube to the skin of the chest to be sure that it would not get pulled out accidently.

Steve, the ultrasound technician began the FAST scan with a probe that had been placed in a sterile plastic cover. Murph watched the screen of the ultrasound machine along with Steve. Starting with the lower left quadrant, Steve worked the probe so as to miss nothing, then moved the probe to the right lower quadrant and then to the right upper, lastly to the upper left quadrant. “There!” he and Murph exclaimed in unison. The scan showed a ruptured spleen and a large collection of blood called a hematoma. Murph quickly stripped off his gloves, applied a disinfectant hand cleaning solution to his hands, worked it in and held out his hands and arms to Karen for gowning and gloving. Chloe and Nan had finished drawing multiple tubes of blood, which Nan took to the stat lab. Chloe turned to assisting Kurt.

Kurt had finished his tasks and started the flow of anesthetic drugs. His monitors showed him the quality of Uli’s vital functions. He looked up to meet Murph’s gaze and gave him the hand motion of slicing with a scalpel. Murph made his initial incision. Kurt fell to his next task: placing a Central Venous Pressure line (CVP) into the jugular vein of Uli’s neck, threading it down until it reached the Vena Cava, the point where the venous system of the body joins the heart. Altogether Kurt’s monitors showed the blood pressure, venous pressure, and arterial pressure, the oxygen saturation of the blood, EKG, and the CO2 level in the blood.

Murph’s hand pressed the scalpel to the flesh just below the Sternum and drew it down to the umbilicus in one smooth slice, exposing the fatty subcutaneous layer and midline fascia below. Blood began to flow from the cutaneous blood vessels at the edges of the skin. /With the Bovie pencil, he zapped each point of bleeding as Karen swabbed with a sponge to show the source of each stream of scarlet precisely. Murph took up the scalpel again as Karen snapped two hemostats on each side of the mid line about an inch apart and lifted. This was so that Murph could cut through the midline and peritoneum without fear of cutting the organs underneath. A small cut made, the scalpel was placed in the small basin on the instrument table, the hemostats were removed, Karen handed Murph a stout pair of scissors as she readied retractors to hold the enlarging opening wide. With her other hand, she readied two suction lines ready to clear away a tide of blood that would be exposed so that they could visualize their target, the spleen.

Less than seven minutes had elapsed since Uli arrived in the Trauma OR.

********

Uli awoke to sunlight streaming in through the floor to ceiling windows. He slowly rose from the bed, every ache and pain announcing itself to the morning. Standing hurt a lot and walking was an impossible agony. He looked at the floor to ceiling windows and the balcony outside. His gaze fell upon a drive of crushed shells gently, sinuously curving through elaborate formal gardens of tropical flowers and shrubs set in a groomed lawn that looked like bright green velvet. There was a knock upon the door to his rooms, which he saw were so large and elaborate as to be better described as chambers. He called out “Come in!”

The door was opened by a liveried servant who ushered in an elderly man with short hair and a medium well trimmed beard, both of a matching salt and pepper color, and both expertly barbered. He had a spry athletic gait that belied his apparent age and the wooden staff he carried. He was dressed in a white toga-like garment with purple binding around the edges. He certainly did not need the staff for support. The staff appeared to be cunningly carved and painted so as to have the effect of a life-like snake winding its way up the rustic wooden branch. On closer examination it actually was a snake climbing the limb. Just then the staff flickered, giving the effect of static as on a television set, and reformed as a sleek gleaming metal staff with two snakes of gold forming a double helix up the chrome staff and a pair of silver wings spread at the top.

The man gave the staff an annoyed look, raised the staff and brought the butt of the staff down sharply, striking it on the floor as if to cause a malfunction to correct itself. There was another burst of static and the staff reformed itself as the rustic wooden one with an actual snake. He looked up at Uli and his annoyed expression turned into one of smiling satisfaction. “I am Aesculapius, a healer. Her Ladyship has asked me to examine you.” The staff flickered and did the burst of static and transformation again. “Confound it!” He exclaimed and struck the staff on the floor again, causing it to revert one more time. “It keeps getting bleed through from your world, where the medical profession has confused my staff with that belonging to Mercury. He as you may know is the messenger of the Gods and is himself the God of Commerce. From what I know of your world, Mercury’s staff may be a more appropriate symbol for the physicians there than my poor staff. In any case, come and sit before me so that I can examine you.”

Uli sat in the chair Aesculapius had placed behind him. Mumbling to himself, Aesculapius removed the bandages and dressings from Uli. He flexed and contracted Uli’s joints as if testing their range of motion. Next he thumped Uli’s chest and back, listening carefully to the sounds produced. He put his ear to Uli’s chest, felt pulses at several places and passed his hands over all the injured areas of Uli’s body. The snake extended himself from the staff, flicking his tongue as if tasting Uli’s aura. Almost immediately Uli began to feel better. Looking at himself he was astonished to see that all his cuts, bruises and scrapes had healed. Aesculapius nodded his satisfaction, and took a small vial from a hidden pocket in his toga and held it out to the snake. The snake put his fangs over the edge of the vial and a pair of deep amber fluid drops collected in the vial. Aesculapius added some clear fluid from another vial, swirled it around and then handed it to Uli. “Take two drops of this every morning with some wine and I will find you again in a week or so”. With that he walked out the door, the staff swinging in time with his spritely gait, trailed by the servant.



Uli saw that his clothing was draped over a valet stand of polished walnut, not only clean and pressed, but looking as if it was brand new. As he dressed he was amazed at the absence of pain that had made getting out of the bed and into the chair before Aesculapius a near torture. He dressed and went out of his room into the hallway where another of the liveried servants was waiting for him. “Please follow me” the servant intoned, and led Uli down the sweeping stairway, through the marbled foyer into a formal dining room and out onto a terrace where breakfast was laid out on a long wrought bronze table with a glass top. Sitting at a smaller matching table to the side was the woman he recognized from the beach the night before. She was wearing simple but elegant sandals, dressed in jeans and a brightly colored blouse, with a heavy looking silver and gold necklace of sea shells, a silver and turquoise concha belt and a jangle of many silver and gold bracelets on both wrists, looking as if she had stepped out of the pages of a fashion magazine’s “casual summer look” photo shoot. “Help yourself, we breakfast informally here, and then come sit with me” she said. Uli realized that he was very hungry and heaped a plate with eggs, bacon and a thick slab of freshly baked bread. There was butter in a stoneware crock and jam in a cut glass jar. He filled a second plate with cantaloupe, strawberries and chunks of pineapple.

He sat down across the table from his hostess. “My name is Ulrich Steiner but please call me Uli. I am at a loss for words to thank you for my rescue and the restoration of my health and clothing. These are not small matters to me and I am very grateful. From a comment that Aesculapius made, I take it that I am in some other world than my own”. Placing the heavy hand blown glass that she had been drinking from down on the table, the woman replied in an accent that sounded cultured but did not have the sense of any place or nationality to it “I am Calypso, and to follow your custom of using informal names, you may call me Callie. This is my island, and indeed you are in, as you said, another world. I have had many visitors here from many different worlds including you own. Usually my visitors have been sent here directly or indirectly by one or another of the gods, and it is the usual thing for me to help them get on with their quests. Once in a while a visitor gets here by random chance, but you do not have the aspect of one of those”. Uli looked her in the eye and replied “I cannot say if I got here by design or by chance but as pleasant as your island is and as gracious as your hospitality is, I would much rather be back in my own world”. Callie gave him an appraising look and said “Then we first must determine what type of hero you are, so that we can then know the nature of your quest. I do not think that it is from the roll of dice by the goddess of chance that you arrived here”.

“In your time and place there are many types of heroes. Tell me, are you an orphan?” Callie asked. “No” replied Uli, “what has that to do with anything?” Callie continued her questioning: “Do you have an arch foe or any extraordinary powers?” “No” answered Uli. With a serious countenance Callie said “Well then you are not a Super Hero. They are almost always orphans and solitary in nature”. Uli laughed “I thought that super heroes were just juvenile fiction. Can you seriously see me running around in a spandex costume complete with a ridiculous cape, performing superhuman feats and then assuming a disguise as a normal unsuper person? I mean really!” Callie eyed Uli with a cool look “I have seen much stranger types here, do not be so sure of your perceptions of the world. If you are not a super hero, then there are many other types. Your world is chock full of superhero stories, so I thought that I would start there”.

“If you are not an orphan, what about your parents? Are they aristocrats, demigods or gods?” Uli answered “No, they are ordinary folk”. Callie continued, “Has your separation from your world been the result of a difficult choice that you made to preserve honor? The honor of your family or yourself? Does this cause you to have great suffering?” “No, no” Uli almost laughed. “All right Callie conceded, “I can see that you are not a classical hero. I get a lot of those here; I had one who hung on here for seven years, boasting about his combat prowess and wooden horses. Such a bore! It was such a relief to finally see the last of him”.

“Perhaps you are a Byronic hero” Callie offered. “What is a Byronic hero?” Uli was obviously not familiar with the term. Callie began to lecture, Uli feeling that she should have a blackboard and that he should be taking notes. “Byronic heroes are very complex. They are always arrogant, very cunning. They are disrespectful of rank and station, distasteful of social norms. Jaded and world weary, they have a troubled past. They exude mystery, have a sexual charisma and are often self destructive”. Uli fought the urge to raise his hand “That sounds a lot like the vampire types in the books my daughter reads. No, I am definitely not one of those”.

“What about Antiheros?” Uli asked. “No, I don’t think so” replied Callie, “although they are very popular in some times and places; you certainly do not fit the type. They are conspicuously in contrast to the heroic. They are supremely selfish, cynical, moody, and prone to violence. They often lack physical prowess, and pursue their motives by breaking or bending laws and customs. For them, the end justifies the means. Their sense of honor is twisted or perverse. Even so, they manage to achieve heroic ends despite themselves”.

Callie continues “Then there is the Picaresque hero. The Picaresque hero is often of lowly estate or class, uneducated in the formal sense but possessed of a high level of intelligence and a keen knowledge of the means by which the world about them operates. They live by their wits in a corrupt society, confounding foes of superior station with clever stratagems to great humorous effect”. “No” said Uli “I do not fit that bill either. That sounds a lot like Huckleberry Finn”. “I know this Huckleberry fellow; he was through here some years back with a ship’s captain named Twain. They were a most amusing and entertaining pair! Such stories they told!” Callie smiled broadly and there was a gleam of affection in her eye at the recollection of the pair. Uli barely contained his amazement.

“Well, that leaves one other major kind of hero” Callie said. “They are relatively new on the scene compared to others. They, like you, are often simply an ordinary person in extraordinary circumstances. The odds always seem to be stacked against them, usually overwhelmingly so. There are two subtypes. Tell me, do you feel that you are the victim of a conspiracy, perhaps directed by a charismatic villain who personifies that which you are most opposed to?” “No” Uli once again insisted “I am not the paranoid type, and I do not have the sense of being victimized”. “Then you are not of the Hitchcockian variety. That leaves only the Capraesque. I am speaking of course of the American hero” Callie explained. “You mean like George Bailey or Mr. Smith? I definitely could see myself as Gary Cooper or Jimmy Stewart” Uli said. “Very well” Callie said with a satisfied smile, the question of Uli’s nature now resolved for her. “Now we know the nature of your quest and your challenge. Your task is to return to your wife and family and you must overcome your obstacles by means of gaining insight into your own nature and the importance to you of your family”. Callie continued “I must warn you, there is a force that would seek to keep you from your quest, that would enslave you to its will if it thought that you could increase it’s power. And others have become used to the comfortable life afforded by my island and have lost all desire to return to their own world. In fact some are also here to find refuge.”

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