Sunday, July 8, 2012

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.”

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