Wednesday, June 15, 2011

Third Chapter

Carl and Karen
In which a journey into the underground uncorks some memories
  Carl was circulating in a neuro case with Dr. North. Dee came into the room quietly and sidled up to Carl. “I’m supposed to get you out. Chicky wants to see you in her office, so give me report on the situation here.” After giving Dee report, Carl 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. When he arrived at the office door he knocked twice and without waiting for a reply, as was his habit, he entered. He was surprised to see Karen there, as Karen was not one of the people Chicky usually brought to her office.

  Chicky was standing behind her desk, looking a bit pale. “Dr. Murphy”, the trauma chief, “just called me. There has been a serious accident in the subway. You two are the best and most experienced I’ve got. I want you to round up the trauma bags and meet Dr. Murphy at the trauma rooms down near the ER, stat”. Minutes later Carl and Karen were in the trauma center, humping the two large olive green bags. Murph (Dr. Murphy) waved them into an ambulance that was idling just outside the trauma entrance. They clambered into the ambulance, and 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 trapped in wreckage. A surgical team may be needed. I expect we may have to do cut downs to establish IV access, maybe some stabilization of fractures, clear airway obstructions, stop hemorrhage, and whatever we will be doing will most likely involve those who are trapped in wreckage. It will be cold, dark and in very tight quarters. I have the drug bag, and I see you have the bag with our personal gear, and the bag with our supplies and instrument sets. We better get into those jump suits 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. He introduced himself “I am Frank Orpheus, I will be your liaison with the command center. That is your staging area; hang in there till we get further instructions.” Frank then turned his face out of the wind to listen to his two way radio. The three medicos entered the lobby and claimed three chairs in one of the corners, amid the faux marble and rented planters. These planters made our team feel at home as they were the same as the ones the Rent-Some-Greenery company supplied to the hospital. “All that is missing are the aquariums that the hospital gets for the patient rooms from the same outfit” observed Carl. Murph reached into his breast pocket and pulled out a pack of cigarettes. “Hey Murph” Karen grinned “I thought you gave those up last year!” “I’m making an exception for today. Anybody want one?” Murph gestured with the pack. Carl and Karen both declined. Carl 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 in Desert Storm last year?”Murph and Carl both shook their heads, surprised expressions on their faces, as they knew Karen had never talked about the experience, and had brushed off all enquiries with banal generalities.

  Karen’s unit had flown in to Saudi Arabia aboard a C-130 Hercules from an airbase in Germany. That was following a flight from Dover Air force Base in Delaware. The accommodations in the C-130, also called a Hercules, or in GI speak, a Herky-Bird, were Spartan at best. The interior of the plane was one large unheated space, with benches along the sides and pallets of cargo covered in plastic sheeting and anchored with Nylon web nets to the floor of the aircraft. Individuals sprawled on the benches and on top of the cargo, bundled up in layers of clothing and flight jumpsuits against the cold. Some ate MRE’s, the food which had supplanted the infamous C-rations which had been the mainstay of field cuisine since WWII, right up until a couple of years ago. While you could not say they were popular, they certainly were an improvement over their predecessor. Still the troops maintained that MRE stood for “Meals Rejected by Ethiopians”. As quickly as the Herky-Bird landed, the palates were loaded onto trucks, the personnel into trucks and a couple of conscripted commuter buses, decorated in colorful Arabic script and graphics of green palm trees, and rushed off into the featureless desert landscape. Several hours later all was unceremoniously deposited in a place indistinguishable from any of 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 minor problem. The pallets with the tents that would serve as living quarters were AWOL. The desert being roasting hot during the day and freezing cold at night, a determination was made after two nights that desperate measures were in order. The only thing that had kept Karen going was the whiskey, forbidden to the service people by the Saudi’s.  Carl had sent the whiskey to Karen in a care pakage. He had gone to the store, chosen two quart bottles of mouthwash of an appropriate amber color. Carl drained the mouthwash out through small holes he made in the bottom of the plastic bottles, washed them out, filled them with Jack Daniels, and resealed the holes. The shrink wrap seals around the caps were thus intact. Karen nearly choked when she 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 an interstate back home, offering fuel, refreshment and toilet facilities for the drivers and transitory personnel mostly headed north toward the Iraqi frontier. The intrepid duo hung out until they spotted a large flatbed truck loaded with lumber 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 drove off north ward. Karen waited outside the toilet area and detained the hapless crew of the truck, asking questions about where they were from and otherwise diverting their attention for a good half hour, GI’s always being an easy mark for the charms of the  fairer sex. Karen gave them some ration coupons and encouraged them to get some chow, and exclaiming that her transport had arrived, climbed onto a departing north bound bus. The two GIs never noticed her lack of luggage. Carl and Murph chuckled appreciatively. “Good on you!” Carl exclaimed.

  Murph opened up. “You might 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 peacetime unlike you combat vets.” Karen observed that “You surprise me; you don’t have a GI issue halo floating above your head.” “I traded mine for a cup of coffee and a dime” 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 a beautiful morning. The brilliant sun was low on the horizon, stabbing into his 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 notorious for tough duty for OB-Gyns as they had a population, active duty and dependants, almost entirely of peak childbearing age. Skip often remarked that he would like to have a bronzed insufflator mounted on a pedestal in front of the hospital, the insufflator an essential device for performing laparoscopic tubal ligations, each of which reduced Skip’s late night hours appreciably. Given his ordeal, Skip’s uniform was in an advanced state of disarray, jacket over his shoulder, shirt tail half out, tie untied, 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 shoulders, and something deep within his consciousness screamed an alarmed “Oh Shit!” His lanky frame drew itself to attention, his arm rose into a crisp salute, the jacket that had been over his shoulder falling to the ground. Three stars could only be General Davis, the Wing Commander, and absolute potentate over three bases that comprised the 48th Tactical Fighter Wing. The General advanced slowly, his gaze fastened on Skip as if he was seeing something so out of place as to be inconceivable. 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 to the uniform”, to “Just giving in to the commies and hippies”, on and on with rising voice up 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, withdrew his wallet, raising it up to his face as he flipped the wallet open. “Scotty, beam me up” he spoke into the wallet, then flipped it shut, replaced it into his rear pocket. Then he walked away, dignity intact, leaving the General locked in place, frozen into disbelief at what he had just witnessed. Karen and Carl roared with laughter.

  At that moment, Frank, guide to the underworld, complete with crackling radio, approached. “Time to move out” he said, “I will fill you in on the way”. The situation he outlined was that there was an older woman trapped in the twisted metal of 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 leg might be the only way to save her life. The team crossed the street and entered a subway entrance, and descended to the passenger platform which was crowded with firemen and EMTs taking advantage of the bright lighting to sort their gear and prepare to move out.

They jumped down from the platform to the tracks below which seemed felted with an even coating of greasy black dust. They made their way into the darkening tunnel lit at intervals by naked light bulbs with their own coating of the omnipresent thick grime. 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 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 girders 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 metal cutting saws. They were led into the maze of wreckage, and led to the side of what could be recognized as a commuter train car. Two firemen were working with a circular saw, just finishing an opening in the stainless steel side of the car.  A square of the metal about a foot and a half square hit the tracks below with a clang. A woman’s knee was visible framed in the opening. Murph directed Karen to get in the car to monitor the woman and administer a fast acting anesthetic and narcotic. Karen took a smaller package from their bags, and followed their guide around the wreck to enter the car. Without comment, Carl sorted through the bags and assembled a Gigli saw, betadine antiseptic, and esmark rubber bandage, a package of sterile surgical towels and sponges, and a large number twenty-one scalpel. He quickly doused the exposed knee with the betadine, opened the packages to make a small makeshift sterile field, Murph donned sterile gloves and handed another pair to Carl. Murph drew the rubber esmark bandage, a roll of rubber about four inches wide and four feet long, around the leg just above the knee, being careful not to get snagged on the sharp metal of the opening into the car. Then he tightened the tourniquet he had fashioned from the esmark and secured it with a Kelly clamp. Carl prepared the Gigli saw, thin wire with serrated teeth along its length, by attaching small handles to either end.

  Inside the car, Karen rapidly placed the probe of a pulse oximeter on the woman’s ear lobe. Only the woman’s head and shoulders were visible from the confining mass of twisted seats and other wreckage. She 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. The woman seemed delirious and did not respond to Karen’s ministrations. The readout of the pulse oximeter showed Karen a very rapid pulse, a high rate of respirations and the BP cuff an alarmingly low pressure, the classic signs of shock. 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 this order, Karen had removed the syringes from her kit. She opened the IV drip wide and injected the Fentanyl, a powerful 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 flicked the woman’s eyelashes and noted the lack of a protective reflex response (an eye blink), a sign that anesthesia had been established. “GO!”  She called out.

  Outside, Frank held two work lamps over the heads of Murph and Carl, 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. Carl worked with a clamp and retractor to expose the depth of the incision to Murphs’ view. Murph repeated the encircling motion with the scalpel cutting right down to the femur (thigh bone). Carl spotted the exposed tubular end of a large vessel and snapped on a Kelly clamp, sealing it. Murph passed the end of the Gigli saw around the exposed bone, grasped the handles and began sawing back and forth. Frank was astonished at the sped the Gigli saw made through the bone, eight back and forth’s 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 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”. “Dustoff Complete” said Carl. Frank gave Carl 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 met with steaming cups of coffee.
  Frank extended a fist towards Carl, who met it with a knuckle bump, followed by a complicated series of shakes, slaps, bumps, snaps and slides that had Karen and Murph staring in fascination for the nearly one minute it took to complete. What they were witnessing was a “Dap”, a ritualized greeting practiced by enlisted troops during the Vietnam War. It was actually possible for the initiated to recognize the specific unit of another from a dap. “You were a screaming eagle” Carl said to Frank, referring to the Hundred and first Airborne Division. “Company E, first battalion, 506th PIR” said Frank. “45th Medical Company Medivac” replied Carl. Murph and Karen regarded the two Vietnam vets with a quiet respect, as they all sat down among the coils of electric cord, work lights and boxes of rescue gear. Steam rose from the paper cups of coffee. “I didn’t know you flew Dustoffs, Carl” Karen said. “Let me tell you about dustoffs” Carl replied…..

   When Carl reported to the 45th Medical Company, Air Ambulance Detachment, there was a celebration going on. Carl had been met by Tommy Jones, the crew chief of the chopper Carl was assigned to. Everybody called Tommy “Gremlin”. Tommy’s distinguishing feature was a pair of prominent ears. 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 era airplane with a gremlin doing his best to disable the aircraft. The gremlin had a pair of ears that looked like the tail fins of the airplane, and identical to Tommy’s, hence his nick name.

  Gremlin introduced Carl around as his new “band aid”. A medivac chopper had a permanent crew of a crew chief and a 91-B, the occupation code for a medic, 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 a 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-1B models. The proper designation for the UH series was the Iroquois, but everybody called them Hueys. The “H” model had a longer body with a bigger cabin. It could accommodate six patients, three on litters, and three sitting as opposed to two, maybe three in the “B” model. The “H” also had longer blades and a much 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 temperatures of the Vietnamese climate caused the air to act as if it was thinner, as in a high altitude situation, resulting in greatly reduced lift. The quick in and out or “dustoff” was the preferred method of operation. The Hueys could also use the hoist to lower a sling, litter or jungle penetrator, a method which exposed the hovering chopper, making them an easy target. The hoists also were heavy and tended to make the chopper slightly off balance to the side they were mounted on. If the crews had their way, the hoists would be removed and replaced with an M-60 machine gun. It may come as a surprise to many readers who expect medics to be unarmed non-combatants, but it is a fact by the Geneva Convention that medics are routinely armed, as while they may not engage in direct combat, they are expected to defend their patients as necessary. Carl was qualified with the M-16 rifle, .45 automatic pistol and M-60 machine gun. He always carried the .45. There were two M-16s in brackets in the cabin of the chopper along with bandoliers of ammunition. The crew chief was also armed. The pilot and copilot carried .45s and CAR-15s, a short barreled, short stocked carbine version of the M-16, were on the bulkhead that separated the cockpit from the cabin of the chopper.

   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 on the bulkhead. They faced brackets that secured standard litters, one on the floor, a second 24” higher and a third 24” over the second. A fourth litter could be placed across the canvass sling seats as needed; otherwise they were the seats for Gremlin and Bandaid. Two more bench type seats, one on each side, were on the arms of the U, facing the doors on either side.The walls and ceiling were covered by quilted pads of “olive drab” the ubiquitous uninspiring color of the army. The next morning, Carl, who had during the course of the previous evenings party evolved from being the generic “band aid” to the proper noun “Bandaid”, met with Gremlin and the assigned pilot and copilot 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 copilot was Warrant Officer Matt Thomas of Altoona, Pennsylvania. If the stereotype of airplane pilots was that they were cocky extroverts, the stereotype for 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, and made sure that everything was in its proper place and secured. Then the whole crew retreated to the shady side of the chopper, and sat in the open door to the cabin. A canteen filled with Kool-Aid was passed around. Cigarettes were lit. The tedium of waiting began.

  The radio crackled with a mission from control and the crew jumped to their places and the chopper lifted up, tilted nose down, and took off. Immediately after takeoff, radio contact was established with the ground unit requesting the dustoff. Coordinates for the landing zone or LZ were established. Sonny asked if there would be gunships flying cover. The unit replied that the LZ was secure as they had taken out a sniper. Sonny switched to the command frequency and requested a gunship to cover his mission. He was informed that there would be a thirty minute delay. Switching back to the operational frequency, Sonny explained the delay for a gunship escort. The ground unit commander came back that there were two critically wounded, needing evacuation stat, and repeated that the area was secure. The Huey arrived at the LZ, a large area of tall grasses surrounded with trees. The ground unit tossed a smoke grenade which blossomed purple to mark the site and to show the wind direction and strength. “I see Goofy Grape” Sonny spoke into the radio. “Confirm Goofy Grape” replied the ground unit commander. The Huey nosed up and began the 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 to the pilot over the intercom. The whine of the gas turbine engine continued, with crunching and grinding noises coming from above, and the distinctive chop-chop sound of the blades grew quieter. “The transmissions gone” reported the copilot, and the chopper began a rapid descent. Without power to the blades, the Huey still made some lift from the blades in autorotation. This was due to the fact that they still had some thrust and momentum. Essentially, the Huey had become a glider. If they had been in hover when they were hit they would have fallen right out of the sky. Matt banked the Huey towards the source of the smoke grenade figuring he could be sure of freindlies there. The Huey’s glide path carried them past the purple smoke into a running landing, the nose touching first, then the tail slamming into the ground. Fire broke out in the engine above the crew. Bandaid helped Gremlin to his feet, as they had both been flung out of their seats into the rear bulkhead by the force of the landing. Gremlin screamed in pain when Bandaid touched his left shoulder, the arm dangling uselessly. Bandaid slung the strap of the rucksack containing his medical supplies over his shoulder, helped Gremlin out the door, and grabbed one of the M-16s and a bandolier of magazines for the assault rifle. The magnesium-aluminum alloy of the Hueys skin and frame had started to burn with its distinctive white flame. They ran and took cover on a small knoll among the tall grasses. A squad of GIs came running from the nearby tree line, grabbed the four airmen, and raced hell for leather for the trees. The distinctive deep pounding sound and rhythm of a Chinese .50 caliber could be heard among the other small arms fire. “That’s the bastard that got us” said Sonny. The firefight raged around them, and then mortar rounds began to explode on the opposite side of the LZ. The Chinese .50 caliber was silenced. Bandaid diagnosed Gremlin with a dislocated shoulder, reduced it, and immobilized it. Then he busied himself with the wounded. Later that afternoon Hueys with gunship escorts evacuated the four medivac crewmen and additional wounded. The two critical wounded they had been called in for had died, despite Bandaid's best efforts.

  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. “Sorry to tell you, your lady didn’t make it. She died on the OR table.” Four countenances fell in unison, each internalizing the unwelcome news.


Anonymous said...

I can not wait for the next chapter! Keep up the good work.

orfyn1.0 said...

Thanks for the feedback, it is a real boost to me! Chapter 4 will post mid July, it concerns a very unusual transplant case. Regards, Orfyn