Sunday, July 8, 2012

A sample - Chapters 1 to 4




   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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Chapter One


Chapter One
  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 songs to his MP3 player, a change from the music of the seventies and eighties that were Uli’s usual fare. 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 the seatbelt. His car hit the curb, throwing him back into the door to his left which had deformed inward, and just as the impact registered in his mind, the car began the sickening roll over with a speed and force reducing his body to the limpness of a rag doll, all the way over, smashing into the tree just as it came upright again. Once more Uli was flung to the left. Suddenly, everything was still again, and Uli was stunned into immobility, his brain brought to a stall by the speed of events. His vision began to be taken over by the small multicolored sparkles that obscured his view of the broken windshield that his brain had only just started to process. Uli entered a state something like when he was just edging into consciousness after a sound sleep. Neither awake nor asleep, he saw mists and fogs, but he could hear a singing voice high pitched and sustained, no, it was two voices, vibrating with harmony, then pulsing rapidly, then rising back to the impossibly long sustained notes. Uli wanted to hang on to the sound of those voices, but the mists rose again, drowning the sound in a blanket of fog. His last thought was of the flashing bright red and blue lights glowing through the fog.
********
   Joyce Circe and her Fireman EMT partner Jack Gordon arrived and went straight to Uli’s car. Uli was very nearly upright in the driver’s seat. Joyce began her initial evaluation. Reaching in through the shattered driver’s side window, she immobilized Uli’s head and felt for a carotid pulse, while simultaneously placing her ear over Uli’s face to listen and feel for signs of breath. Getting positive signs, she then spoke to Uli, her voice pitched low and clear, keeping her face in front of his so that if he responded, he would not feel the need to move his head. Until they knew otherwise, they would assume that he had neck injuries. Uli moaned in response, so Joyce tried again, but she could not get anything she could call a purposeful response, an indication of a lack of consciousness. “Positive for pulse and respirations, not responsive to voice, not able to follow commands” she reported to Jack. She focused her penlight on each of Uli’s eyes in turn. “Pupils equal, reactive to light” she further said. This was an indication that there were no serious injuries to the brain. Jack tried the door, but it was jammed tight. 
   “I smell gasoline” Jack observed, “I’m going to disconnect the battery.” They wanted no source of sparks before they started the business of extricating Uli. Joyce affirmed his comment and turned to immobilizing Uli’s 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 so that there would be no possibility of electrical sparks. He returned to Joyce, who had immobilized 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” Joyce said. She got a big hammer from the tool kit, went to the rear of the car and smashed in what remained of the rear window and crawled in, trailing her medical kitbag.
   Reaching Uli, Joyce paced a BP cuff on his right arm, and clipped an oxygen saturation monitor to his right ear, 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 O2 saturation is only 88” Joyce called out. She got a stethoscope out of the kit and listened to each side of his chest as best she could. “I can’t get any breath sounds on the left” she called out to Jack, and placed a rebreathing oxygen mask on Uli’s face. Joyce opened up the valve on the oxygen bottle in her kit all the way, heard a reassuring hiss, and connected the tubing from the mask. On the monitor, the numbers for Uli’s O2 saturation climbed to 92%. Joyce was satisfied with any number over 90% and would have loved to see something over 95%, but she was still worried about the lack of breath sounds on the left side of Uli’s chest. 
   The door to Uli’s side was deformed well into the drivers’ space, causing her 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 door frame. The device, similar to a hydraulic jack used to lift cars for changing tires, could be operated electrically or manually. He deselected the electrical option for operation and selected the manual mode, no sparks wanted. Jack fitted the handle and began to pump the jack. The tortured metal began to groan as he pumped, the seam growing wider, the metal then squealed as he continued to pump, and finally gave way with a crack. Jack opened the door the rest of the way. Joyce said “O2 sat is up to 92, put his pulse is rising and BP decreasing (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 vehicle 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, heard the rushing sound of waves washing in and out. He found himself on a cold, wet beach in the dark of night. His head was cradled in the lap of a woman. In the dim starlight of the moonless night he could not make out much of her features. “Don’t move” 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, and then the uneven jostling of the litter being 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 back. Uli could not make out much of the passing landscape; his impression was of a tropical seashore area. His rescuer walking alongside 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 gate formed of two square stone columns and twin gates of wrought iron with the figure of a long haired, bearded man with a crown wielding a trident mounted on a leaping dolphin. They proceeded up a long curving drive, and Uli had the impression of carefully manicured gardens to 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 upwards to palace. He thought that his rescuer must be a person of great power and wealth. They entered a portico the depth of a great room, with gleaming figured bronze doors a full story high, and two liveried doormen opened the doors into a great marbled foyer with sweeping curved staircases leading upward on either side. His rescuer issued some quiet instructions to one of the doormen, and departed through a doorway to the left, Uli glimpsing a large room filled with floor to ceiling book cases and a massive ornate desk before the door was closed by the other doorman.
   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 canopied and curtained 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 and butter and a tall glass of milk. Uli ate with the hunger born of a man who has been battered and tossed in the sea, expecting to die, and then unexpectedly reprieved and placed into the lap of luxury. Then he was given a cup of fragrant tea. The maid serving it told him that it would make him sleep. The lights were extinguished and Uli fell into a deep sleep.
********
   Murph (Dr. Peter Murphy, trauma surgeon) 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, gentle and warm to the ear. He turned to the Trauma team; Karl and Karen, RNs from the OR, Chloe and Nan, RNs from the ER and Kurt Anderson MD, anesthesiologist, regarded as the best in trauma. “We have a 40 – 50 year old male, MVA (motor vehicle accident) with T-Bone collision, rollover and collision with a tree. He is shocky, but stable, no breath sounds on the left side of the chest, and I had the EMT place a Heimlich valve as the O2 sat was declining even with a rebreather mask on full. The sat has improved. The Drivers side took a direct hit and was deformed well into the driver’s space. When we get the patient, I want a FAST scan of the abdomen. Kurt, we have no c-spine (neck) clearance, so I want a fiber optic nasal intubation. And let’s get the Heimlich valve replaced with a chest tube and pleurevac. 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). Karl went to the phone and placed calls to ultrasound, and CAT scan.
   Karl and Karen were Murph’s 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 neuro case with Dr. North. Dee came into the room 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, 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. When he arrived at the office door he 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.
  Chicky was standing behind her desk, looking a bit pale. “Dr. Murphy 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 in the trauma center, stat”. Minutes later Karl and Karen were in the trauma center, humping the two large olive green bags. Murph waved them into an ambulance that was idling just outside the trauma entrance. They clambered into the ambulance, which motored away from the hospital. 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 tem to the lobby of a bank. He introduced himself “I am Frank Orpheus, I will be your liaison with the command center. This is your staging area; hang in there till we get further instructions.” Frank then turned his face out of the wind to listen to the two-way radio pressed to his ear. The three medicos entered the lobby and claimed three chairs in one of the corners amid the faux marble, mahogany 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 Karl. Murph reached into his breast pocket and pulled out a partially crumpled 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. Karl and Karen both declined. 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 in Desert Storm last year?”Murph and Karl both shook their heads, surprised expressions on their faces, as they knew Karen had never really talked about the experience, and had brushed off all enquiries with banal generalities.
********
  Karen was a brunette pageboy haired mother of two boys, eight and ten years old. She kept fit by keeping up with her boys, and her husband, a tennis and golf pro. Karen’s National Guard unit had flown in to Saudi Arabia aboard a turbo prop C-130 Hercules from an airbase in Germany. That was following a flight from Dover Air force Base in Delaware on a C-147 Nightingale, a jet airplane specially outfitted as a flying intensive care unit. 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 (Meals Ready to Eat), 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 of cargo were loaded onto trucks, the personnel into a couple of conscripted commuter buses, decorated in colorful Arabic script with graphics of green palm trees and blazing orange sunsets, and all and sundry rushed off into the featureless desert landscape. Several hours later they were 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 the first night that desperate measures were in order. The only thing that had kept Karen going was the whiskey, forbidden to the citizen soldiers by the Saudi’s; Alcohol was forbidden by the Koran. Karl had sent it to Karen in mouthwash bottles that he had carefully drained and refilled without disturbing the shrink-wrap seals around the caps. He had purposefully chosen a brand known for its amber color. These in turn were put in a box with some food items, personal care items and with the other essential for the Arabian Desert, packages of baby wipes. Karen had nearly choked when she cracked open the seal on a bottle 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 an interstate back home, offering food, fuel, and refreshment and most importantly, 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 the telltale plywood boxes containing squad tents, 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 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. Karl and Murph chuckled appreciatively. “Good on you!” Karl 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, and 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 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 Daniels, the Wing Commander, and absolute potentate over three bases that comprised the 47th 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 Karl roared with laughter.
  At that moment Frank, guide to the underworld, accompanied by his 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 entrapped 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. Our quartet 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 mellowed by 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 of columns of 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 and cutting torches. 
   They were led into the maze of wreckage, and 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 section 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. Frank gave her a boost to help her enter through a window with its glass missing. 
   Without comment, Karl 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 Karl. 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. Karl prepared the Gigli saw, a thin wire about a foot long 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, into the internal jugular vein, a good choice as it could tolerate large amounts of fluid delivered nearly directly into the heart. 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 advanced 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 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 lightly 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. She then began squeezing the IV solution bag to get as much fluid into the woman a quickly as possible. As soon as the bag emptied she pulled it off the line, spiked another bag and began to squeeze again. By increasing the volume of circulating fluid Karen would get the blood pressure as high as it would go, keeping the vital organs perfused and countering the effects of shock.
  Outside, Frank held two work lamps over the heads of Murph and Karl, 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 to expose the depth of the incision to Murphs’ view. With his other hand he swabbed the incision with the sponges to clear the incision of blood. Murph repeated the encircling motion with the scalpel cutting right down to the femur (thigh bone). Karl 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 speed which 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 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 met with steaming cups of coffee.
  Frank extended a fist towards Karl, 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 half 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” Karl said to Frank, referring to the Hundred and first Airborne Division. “Company E, first battalion, 506th PIR” said Frank. “45th Medical Company Medivac” replied Karl. 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, Karl” Karen said. “Let me tell you about Dustoffs” Karl replied…..
********
   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 or Dennis Weaver. When Karl reported to the 45th Medical Company, Air Ambulance Detachment, there was a celebration going on. Karl had been met by Tommy Jones, the crew chief of the chopper Karl was assigned to. Everybody called Tommy “Gremlin”. Tommy’s distinguishing feature was a pair of prominent ears accented by the GI hair cut. 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, similar to Tommy’s, hence his nick name.
  Gremlin introduced Karl around as his new “band aid”. A medivac chopper had a permanent crew of a crew chief and a 91-B, the occupational 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 than the “B”. 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, and the lack of lift caused them to be exposed longer to hostile fire. The Hueys could also use a hoist to lower a sling, litter or jungle penetrator, a method which exposed the hovering chopper to hostile fire, 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, and while they may not engage in direct combat, they are expected to defend their patients as necessary. In other words, if they were being shot at, there was nothing they could do by the treaty. However, if they had patients under their 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 was also armed. The pilot and copilot carried .45s and CAR-15s, a short barreled, short stock carbine version of the M-16, which were clipped onto 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, Karl, 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. Some crackers and cheese from a C-ration box made the rounds. 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. There had been incidents where the opposition known as “Charlie” had lured a medivac chopper into ambush with captured smoke grenades. So now the SOP (standard operating procedure) was to use a different color each day and confirm sightings with the ground forces. 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 purple smoke 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 blindingly white flame. Matt and Sonny were out of the chopper and had taken up positions facing outward, weapons at the ready.    
   As Bandaid and Gremlin reached the pilots all four of the chopper’s crew 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, placed his foot in Gremlin’s armpit, took a grip on his wrist and pulled hard as Gremlin screamed. The dislocation was reduced. Bandaid took a triangular olive green bandage from his kit and immobilized the arm. Then he busied himself with the wounded. The second half of the longest day of Bandaid’s life had begun: He immediately had two more patients as well as the two they had come for. Later that afternoon Hueys with gunship escorts evacuated the four medivac crewmen and four additional wounded Gis. The two critical wounded they had been called in for had died, despite Bandaid’s best efforts. Their olive drab poncho wrapped bodies were reverently placed on the floor of one of the Hueys. Bandaid was reduced to a limpness of fatigue and delayed shock next to his patients in the other Huey.
********
  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.

Chapter Two
  Murph turned from the phone and addressed his team: “We have a 40 – 50 year old male, MVA with T-Bone collision, rollover and collision with a tree. He is shocky, but stable, no breath sounds on the left side of the chest, and I had the EMT place a Heimlich valve as the O2 sat was declining even with a rebreather mask on full. The sat has improved. The Drivers side took a direct hit and was deformed well into the driver’s space. EMTs give the victim a Glasgow coma scale of twelve. When we get the patient, I want a FAST scan of the abdomen. Kurt, we have no c-spine clearance, so a fiber optic nasal intubation. And let’s get the Heimlich valve replaced with a chest tube and pleurevac. We will transfuse with O negative blood as needed. 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”. Karl went to the phone and placed calls to ultrasound, and CAT scan.
   To translate for our non-medical readers, the absence of breath sounds on the left side of the chest suggested pnuemothorax or collapse of the lung on that side. A Heimlich valve is a device also called a flutter valve that is used in the field to permit fluid and air to move out of the chest by the pumping action of breathing, but not back in. This allows the lung to re-expand, causing the O2 saturation to rise. A Chest tube and Pleurevac is a more effective device to do the same thing, but appropriate to the hospital environment, utilizing suction and a water seal to expand the lung by creating negative pressure in the chest cavity. The description of T-Bone collision with deformation of the drivers space,  rollover and tree impact put the team on alert for the possibilities of multiple fractures of the limbs, possibly the neck, head trauma, and internal injuries. 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 to four minutes. Before the FAST scan, the method for checking traumatic internal injuries was peritoneal lavage (PL), consisting of inserting a large bore needle into the belly, infusing three to four liters of warmed fluid, and then aspirating through the abdominal wall in all four quadrants of the abdomen to see if there was blood present, and if so, which quadrant had the most blood in the aspirant. Obviously a FAST scan was faster and provided superior information over PL. PL is still used where FAST scan is not available. A full body CAT scan will demonstrate skeletal injuries, other organ injuries and the presence and nature of nay head injuries. Keeping the victim on the back board kept any fractures of the limbs, back or neck stabilized.
   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. Chloe placed EKG leads, a pulse oximeter probe, and BP cuff for monitoring. Nan started a transfusion of O negative blood in the IV line that Joyce had placed, and then started the placement of an Arterial Pressure monitoring line (radial A-line) in the radial artery of the right wrist. Kurt threaded a fiber optic laryngoscope through an endotracheal tube and then with his eye to the eyepiece, began threading it through the Uli’s nose. This technique, while much more difficult than an oral placement, avoided the need to move the neck, as would be the case with placing the tube through the mouth. 
   Karl cut away Uli’s clothes to expose his chest and abdomen, and then poured an iodine solution over all of it. Karen, gowned and gloved was setting up her sterile table with the instruments needed for surgery in the abdomen and chest. The table would not be counted as usual for surgery to save time, and the full body CAT scan would reveal if anything was left behind, as it 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 it, called a trocar. As soon as he felt the trocar through, Murph removed the trocar, pushed the chest tube in to the depth his experience told him would be sufficient, but not too deep, connected it to the pleurevac, and then connected the pleurevac to suction. The pleurevac provided a space for the collection of fluid and air from the chest, and a water seal that kept the suction at a regulated level, and also prevented back flow into the chest if the suction was disconnected or discontinued. It began to bubble. 
   Nan sewed the tube to Uli’s skin with a suture to prevent it from being accidently pulled out. Steve, the ultrasound technician that Karl had summoned 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 left lower quadrant, Steve worked the probe so as to miss nothing, then moved on to the right lower quadrant, then to the right upper quadrant, and finally to the left upper 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 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 the nasal intubation attached his breathing circuit and had began the flow of anesthetics. He indicated a go with the motion of a hand making an incision with a scalpel, and fell to his next task: placing a central line, also called a CVP line, into the jugular vein of Uli’s neck, threading it downward until it met the vena cava, the point where the venous system enters the heart. This would enable the rapid infusion of very large quantities of blood or fluids, and measurements of the venous pressure where it entered the heart. Altogether, Kurt’s monitors showed the venous pressure, the arterial pressure from the radial A-line, the blood pressure updated every minute, the oxygen saturation of the blood and the CO2 level in the blood. Karen and Murph spread sterile drapes across Uli, and the incision was made.
********
   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 to the floor to ceiling windows and the balcony outside. His gaze was 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 of 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 length well trimmed beard, both of a matching salt and pepper color. His spry athletic gait belied his apparent age and the wooden staff he carried. He was dressed in a white toga sort of gown 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 staff and a pair of silver wings spread at the top. The elderly man gave the staff an annoyed look, raised the staff up and brought the butt of the staff down sharply, banging it on the floor as if to cause a malfunction to correct itself. There was another burst of static, and the staff reformed as the rustic wooden one with an actual snake. He looked up at Uli and his annoyed expression turned into one of 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 the staff to once more revert. “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 himself the god of commerce. From what I know of your world, it may be a more appropriate symbol for the physicians there than my staff.”
    “In any case, come and sit that I can examine you.” Uli sat in the chair Aesculapius had placed behind him. Mumbling to himself, Aesculapius removed the bandages and dressings. He flexed and contracted Uli’s joints, thumped his chest and back, put his ear to Uli’s chest, felt his pulses at several places and passed his hands over all the injured areas. The snake extended its head and its tongue flicked at Uli. Almost immediately, Uli began to feel better. Looking at himself, he found all his cuts and bruises healed. Aesculapius nodded his satisfaction, and took a small vial which he held out to the snake. The snake put its fangs over the edge of the vial and a few drops of an amber fluid collected in the vial. Aesculapius added some clear fluid from another vial, swirled it around to mix the now cloudy fluid and then handed the vial to Uli. “Take two drops of this every morning with some wine and see me again in a week.” With that he turned and walked out the door, the staff swinging in time to his sprightly gait, trailed by the servant.
   Uli saw that his clothing was draped over a valet stand of polished walnut, not only clean and mended, but looking as if it was brand new. 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 barefoot, dressed in jeans and brightly colored blouse, with a heavy looking silver and gold necklace and wide silver bracelets, looking as if she had stepped out of the pages of a J. Crew catalog. “Help yourself and come sit with me” she said. Uli realized that he was starving, and heaped a plate with eggs, bacon and a thick slab of fresh baked bread. 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 you can call me Uli, and I am extremely grateful for all that you and your servants have done for me. From a comment that Aesculapius made, I take it that I am in some alternate world to my own.” Placing the heavy hand blown glass that she had been drinking from on the table, the woman replied to Uli “I am Calypso, and to follow your world’s custom of using informal names, you can call me Callie. This is my island, and indeed you are in, as you said, an alternate reality. I have had visitors here from many different worlds, including your own. Usually, my visitors have been sent here directly or indirectly by one or another of the gods, and it usually falls to me to help them get on with their quests. Once in a while, a visitor just happens to get here by random chance, but you do not have the aspect of one of those.” Uli looked at her eye to eye and replied “I can’t say whether I came here by design or by chance, but as pleasant as your island and your hospitality are, I would get back to my own world”.  
   Calllie gave him an appraising look, and said “Then we must first determine what type of Hero you are. In your time and place there are many tales of super heroes. Are you an orphan?” “No, but what has that to do with getting back to my world?” “Super heroes are almost always orphans. Tell me, do you have an arch foe or any extraordinary powers?”Callie asked with a serious countenance. “No, no” Laughed Uli. “I always thought that super heroes were just juvenile fiction. Ye gods! Can you really see me prancing around here in tights with a cape, vaporizing things with a stare? Surely they do not actually exist here!” Callie continued to regard Uli with a level gaze. “Well,” she said, “maybe you are a classical hero. Are your parents’ gods, demigods or aristocrats?” Uli laughed even harder. “No, no, no!” Calllie continued “Has your separation from your world been the result of a difficult choice you have made to preserve your honor? Are you suffering?” Uli laughed even harder. “All right” Callie conceded, “I can see that you are not a classical hero.    
   Then perhaps you are a Byronic hero.” Uli regarded Calllie with curiosity “What in the blazes is a Byronic Hero?” “They usually display a combination of the following traits: “Arrogant, Cunning, Disrespectful of rank and station, distasteful of social norms, jaded and world weary, they have a troubled past, are mysterious and charismatic, self destructive, seductive or sexually attractive.” “That sounds like an anti-hero” remarked Uli. “Anti-heroes are altogether different” said Callie “they are conspicuously contrary in character to a hero. They are selfish, cynical, moody, prone to violence, lack physical prowess, but often pursue noble motives by bending or breaking laws and social norms. For them the end justifies the means.” “No I don’t think I am any of those” Uli said. “Then there is the Picaresque Hero” Callie said. “The picaresque hero is often of lowly caste or class who lives by his wits in a corrupt society, confounding his foes of superior station with clever stratagems to humorous effect.” “No,” said Uli, I don’t fit that bill either. That sounds a lot like Huckleberry Finn.” Callie replied “I know this Huckleberry fellow. He passed through here some years back with a ship’s captain named Twain. They were a very entertaining pair.” Uli stared at Callie in amazement.
   “Well, that leaves one other kind” Callie said “They are relatively new on the scene compared to the others. I am talking of course of the American Hero. They are often simply an ordinary person in extraordinary circumstances, who, despite the odds being stacked against them typically prevails in the end. There are two basic types. 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, that sounds paranoid to me” replied Uli. “Then you are not of the Hitchcockian variety, that leaves only the Capraesque” “You mean like George Bailey? Or Mr. Smith? I could see myself as Jimmy Stewart or Gary Cooper” replied Uli. “Very well” said Callie “Now we know the nature of your quest, which is to return to your wife and children, and you must overcome your obstacles by means of gaining a new insight into your own nature and the importance to you of your family.”