Tenth Chapter

Tenth Chapter

Cate

In which our neophyte reaches competence, and we learn about trauma

   University Hospital, the employer of our subjects, is a Level I trauma center. Trauma is the leading cause of death for people ages 1 – 44. The leading causes of trauma in rank order are MVA’s (motor vehicle accidents), falls and assaults. Trauma is a surgical condition by definition. Trauma Centers vary in their capabilities, and are rated level I,II and III, with level I being the most capable. To be a level I center, a hospital must have highly trained and specialized surgeons, nurses and technicians on duty 24/7, as well as the equipment and facilities. It is very, very expensive. The metropolitan area served by University Hospital originally had three Level I centers, after two years only University Hospital had the resources to maintain Level I status. For the trauma victim, being treated at a Level I facility can raise the chances of survival by 25% or more. For those that reach a Level I center within an hour of injury, the odds go up even further.

   The trauma area is adjacent to the ER. There is an ambulance ramp that goes right up to the doors of the trauma area, and directly across the ramp is a helicopter landing pad.  Inside the doors are four stabilization/evaluation bays, and directly behind the bays are two trauma ORs. There is one trauma team in the center at all times, with a second team available in the hospital. A trauma team is made up of an Anesthesiologist, a Trauma Surgeon, a Trauma Resident, two ER nurses, and two OR nurses.

   A patient arrives, by ambulance or chopper, and enters into one of the bays. The most severely injured go right back to one of the ORs. Lines are placed, blood samples drawn, IV fluids and O negative blood administered as needed, the airway assessed and stabilized. O negative blood is used as it is the Universal Donor, and can be given without the time consuming need to type and cross match the patient’s blood. Even with a medical bracelet or “file of life” with blood type information on a patient, the O negative blood is used, as the teams have learned the hard way not to trust such sources of information.  A Foley catheter is placed into the bladder. These steps are the provenance of the anesthesiologist and the two ER nurses. While this is going on, X-rays are taken as needed. The Trauma surgeon acts as captain of the team, and directs the activities of the team as a whole. The OR nurses assess the patient injuries and prepare the appropriate instruments and equipment on the OR, the patient moves into the OR and surgery begins. In more extreme situations the patient skips the bays, goes right into the OR, and all this happens at once. 

   It has been almost two years since we first heard Cates story as a beginning nurse in the OR. Things have “clicked" for Cate, and she has earned the trust and respect of the other nurses and surgeons. It has not been easy. Dr. Syriani, famed surgeon to the deceased, had been particularly hard on Cate. Syriani was known for his lack of tolerance of beginners, taunting and ridiculing them. He had one day gotten Cate to the point of tears, and then crowed to the assembled team “Look! I made her cry!”, as if he had scored some kind of goal. Cate sucked it in and finished the case. She had learned not to give in to frustration and anger. And Syriani never bothered her again. He zeroed in on the scent of fear. That was the day things started to go better for her in the OR. When you get to the bottom, it all looks like up.

   Cate has just completed sixteen hours of classes and passed an exam so that she can take turns  covering the trauma center for the OR. She has had to learn the ABCDE of trauma. A= airway, B= breathing, C= circulation, D= disability, and E= exposure. Always in that order. B is no good if you do not have A, etc. There are detailed algorithms for each of these letters that Cate has memorized. She has practiced the techniques and interventions for each step. Airway is getting the air to the lungs. This could be by inserting an ET (endotracheal tube), tracheotomy, or cricothyrotomy (A large bore needle placed into the trachea just below the cricoid cartilage, and then air or oxygen blown in under pressure). Breathing is the chest and diaphragm, getting oxygen into the blood. This is done manually by an ambu bag (a cylindrical rubber balloon that attached directly to a mask, ET tube or tracheotomy tube), or mechanically with a ventilator. Circulation is the heart and vasculature, getting the oxygen to the organs of the body. There were several avenues of attack here: 1) Replacing fluids by crystalloids (saline, or other IV fluids) or blood products such as whole blood, plasma, etc. 2) plugging the leaks (control bleeding). 3) Reduce the volume to be filled. This last could be accomplished by the use of MAST (Military Anti-Shock Trousers), inflatable pants with three chambers, one for each leg and one for the lower abdomen.

The pressure of the MAST diverts blood from the legs and lower abdomen to the chest and head. Disability is the level of function of the brain and nervous systems. Exposure is getting the patient exposed and controlling his body temperature. Trauma victims are by definition thermally compromised. Clothing has to be removed quickly, using scissors that look cheaply stamped out of metal, but their serrated edges and large leverage granting handles can cut a copper penny in half easily. The nurses refer to these as “Rambo” scissors after the Sylvester Stallone movie character. Karen once got a complete set of leathers off a motor cyclist in about a minute. There are two basic means of warming the victims, by IV infusion of warmed fluids utilizing the Level 1 warmer/infuser, and the use of a Bear Hugger. The Bear Hugger is a sort of plastic and paper blanket that circulates warm air around a body. The Level 1 is a piece of equipment that can push a liter of fluid or blood into an IV line in less than a minute, and at body temperature to boot. Both were absolute necessities for the trauma rooms.

   Cate was in a state of adrenaline infused impatience, as this was her first solo in the trauma room, without a preceptor to back her up. Mercifully, the phone rang and Dr. Murphy, the trauma surgeon for the shift picked up the phone and listened. He hung up the phone and announced to the team, “We have a penetrating injury to the neck, an older male, John Doe, trauma scale 4 coming in. He was found unconscious on the sidewalk, no witnesses.The EMT's scooped him up and are coming straight here.” Trauma scale 4 meant unresponsive, very low blood pressure, low respiratory rate, very low pulse. The key thing here was the very low pulse. This told the team that the victim was in the last stages of shock. In the early to middle stages of shock the pulse becomes very rapid, the body’s attempt to make up for loss of circulating volume and pressure. As shock progressed, this compensatory mechanism also fails.  A score of 4 was the worst score in the scale, an indication that the chances of survival were poor. John Doe meant that his identity was unknown. This one was obviously a problem to be addressed in the first of the ABCDE, airway. The team leaped up and prepared the A list items, for placement of ET tube (also known as a breathing tube, to be inserted through the mouth), tracheotomy, or cricothyrotomy,(means of making openings into the windpipe) as well as peripheral and central lines, O negative blood and Normal Saline IV fluid. The other thought that occurred to everyone on the team was that the score of 4 plus a penetrating neck injury probably also meant hemorrhage of a significant portion of the victims blood, so Cate grabbed and opened the tray with vascular instruments, as well as the tray of basic instruments. Once an airway was established and ventilation accomplished, the next likely thing was going to be control of bleeding. 

   With a screech of brakes, the ambulance arrived at the door. The doors of the ambulance flew open and the EMT’s ran the stretcher into the trauma area. Murph waved them past the stabilization bays directly into the trauma OR. Cate took in the MAST trousers, and the victim covered in blood from the eyes all the way down the chest. One of the EMT’s was pressing a wad of towels against the victim's neck. The towels were saturated with blood and the EMT was covered in blood. Several things happened simultaneously: Kurt, the anesthesiologist, got a laryngoscope in the victim’s mouth and was suctioning large amounts of blood, saying “I can’t see a damn thing!” Chloe, one of the ER nurses was hooking the Level 1 to the IV line the EMT’s had placed. She cursed in turn as she saw that the line was running Lactated Ringer’s solution. This meant that blood could not be pushed through the line as it would instantly coagulate, the coagulation triggered by the calcium in the Lactated Ringer’s deactivating the anti coagulant in the bank blood. Only Saline should have been used. Blood would have been the best thing that could be given at the moment, because it could also carry oxygen as well as increase circulating volume. Crystalloids such as Saline and Lactated Ringer’s expanded volume but could not carry oxygen. She started the Level 1 pumping with saline.  Nan, the Other ER nurse was struggling to place another IV line in the other arm, hindered by the omnipresent blood which obscured visualization of the veins, and which also made everything slippery. Cate was mopping at the neck trying to clear the blood, so that she could see the wound and prep it with iodine solution. She couldn’t find a wound. Murph joined her in wiping at the neck with an artery clamp in hand, ready to clip a vessel. The blood was all dark, indicating a venous source as opposed to an arterial one. There was no wound!

   The monitors at the foot of the stretcher alarmed and flatlined. Kurt rammed the ET tube home, suctioned more blood out of it and attempted to ventilate with an ambu bag. The chest rose and fell. The monitor showed no heart activity at all, a condition called asystole. This is not a shockable rhythm, so the use of the defibrillator was out. Cate began cardiac compressions. Chloe took over ventilations with the ambu, synchronizing to Cate’s compressions. Kurt began injection of epinephrine (also called adrenaline) through the chest directly into the heart. A shockable rythm had to be established before the defibrilator could be used. Nan continued to struggle with the IV placement, finally getting it into the antecubital fossa in the inner aspect of the victim’s elbow. She attached it to the Level 1 and started it pumping O negative blood. Murph explored the neck, still finding no wound.

   The team continued their efforts for one minute, the held compressions and ventilation so that it could be determined if a shockable rhythm had been restored. None. The team continued its efforts. After ten minutes Murph called it. Every one backed away from the table looking at each other, their breathing and pulses returning to normal. Kurt ventured an opinion: “The bleeding must be internal, there being no wound. And from the volume of venous blood I suctioned out of the airway, I suspect that what we have here is a case of esophageal varices that eroded and bled.” Esophageal varices are varicose veins of the esophagus, a condition caused by a back up of venous blood from the liver, which in turn is caused by liver disease such as cancer or advanced cirrhosis. He continued, “The victim was expelling all that blood out of his mouth, and the EMT’s could not see that there was no wound, but from the volume of blood expected a vascular injury to the neck.”

   The team turned to removing the clothing from the corpse. Each item was inventoried and recorded. Nan was the one who found his wallet, a few cards and eight dollars in it. There was an ID card. Nan announced " This is no longer John Doe, his name was Harold Morgan. Could we please have a moment of silence in respect for Harold Morgan." Everyone stopped what they were doing for that minute.Then Nan, Chloe and Cate Washed the body and the corpse was respectfully placed in a shroud. An orderly transported the body to the morgue with a bundle of clothing and his meager belongings in a paper bag on top. Paper was used so that the clothing and belongings would dry out and not molder. Then they turned to restoring the OR to a state of readiness. Murph made phone calls; to the police, to the medical examiner, to the 911 dispatcher. He made an attempt to call the number found in Harold's wallet, but there was no answer. Then he began his paper work. To Cate fell the responsibility of filling out the rest of the rest of the records. Murph told them that they had done a fine job, that he could not have expected any better from the team. Everyone looked to the clock willing the hands to speed to the end of the shift. The autopsy report two days later confirmed Kurt's opinion.

Third Chapter

Carl and Karen

In which a journey into the underground uncorks some memories

  Carl was circulating in a neuro case with Dr. North. Dee came into the room quietly and sidled up to Carl. “I’m supposed to get you out. Chicky wants to see you in her office, so give me report on the situation here.” After giving Dee report, Carl headed out of the OR wondering what he was in the doghouse for this time. He could not think of anything he had done or said to any of the surgeons or supervisors that would give offense, that being the usual reason for him to be summoned. When he arrived at the office door he knocked twice and without waiting for a reply, as was his habit, he entered. He was surprised to see Karen there, as Karen was not one of the people Chicky usually brought to her office.

  Chicky was standing behind her desk, looking a bit pale. “Dr. Murphy”, the trauma chief, “just called me. There has been a serious accident in the subway. You two are the best and most experienced I’ve got. I want you to round up the trauma bags and meet Dr. Murphy at the trauma rooms down near the ER, stat”. Minutes later Carl and Karen were in the trauma center, humping the two large olive green bags. Murph (Dr. Murphy) waved them into an ambulance that was idling just outside the trauma entrance. They clambered into the ambulance, and Murph laid out the situation as he knew it. “Somehow, two subway trains have collided near one of the main junctions leading into City Center Station. Early reports are of a large number of casualties, many trapped in wreckage. A surgical team may be needed. I expect we may have to do cut downs to establish IV access, maybe some stabilization of fractures, clear airway obstructions, stop hemorrhage, and whatever we will be doing will most likely involve those who are trapped in wreckage. It will be cold, dark and in very tight quarters. I have the drug bag, and I see you have the bag with our personal gear, and the bag with our supplies and instrument sets. We better get into those jump suits and hardhats.”

  The ambulance was waved through a police barricade, and a fireman directed them to the curb near a subway entrance. As they climbed out of the ambulance the fireman further directed them to the lobby of a bank. He introduced himself “I am Frank Orpheus, I will be your liaison with the command center. That is your staging area; hang in there till we get further instructions.” Frank then turned his face out of the wind to listen to his two way radio. The three medicos entered the lobby and claimed three chairs in one of the corners, amid the faux marble and rented planters. These planters made our team feel at home as they were the same as the ones the Rent-Some-Greenery company supplied to the hospital. “All that is missing are the aquariums that the hospital gets for the patient rooms from the same outfit” observed Carl. Murph reached into his breast pocket and pulled out a pack of cigarettes. “Hey Murph” Karen grinned “I thought you gave those up last year!” “I’m making an exception for today. Anybody want one?” Murph gestured with the pack. Carl and Karen both declined. Carl gestured expansively with his hands, “So here we are, hurry up and wait.” Yeah” added Karen, “Just like the Army, “did I ever tell you guys about our welcome into Saudi Arabia in Desert Storm last year?”Murph and Carl both shook their heads, surprised expressions on their faces, as they knew Karen had never talked about the experience, and had brushed off all enquiries with banal generalities.

  Karen’s unit had flown in to Saudi Arabia aboard a C-130 Hercules from an airbase in Germany. That was following a flight from Dover Air force Base in Delaware. The accommodations in the C-130, also called a Hercules, or in GI speak, a Herky-Bird, were Spartan at best. The interior of the plane was one large unheated space, with benches along the sides and pallets of cargo covered in plastic sheeting and anchored with Nylon web nets to the floor of the aircraft. Individuals sprawled on the benches and on top of the cargo, bundled up in layers of clothing and flight jumpsuits against the cold. Some ate MRE’s, the food which had supplanted the infamous C-rations which had been the mainstay of field cuisine since WWII, right up until a couple of years ago. While you could not say they were popular, they certainly were an improvement over their predecessor. Still the troops maintained that MRE stood for “Meals Rejected by Ethiopians”. As quickly as the Herky-Bird landed, the palates were loaded onto trucks, the personnel into trucks and a couple of conscripted commuter buses, decorated in colorful Arabic script and graphics of green palm trees, and rushed off into the featureless desert landscape. Several hours later all was unceremoniously deposited in a place indistinguishable from any of the rest of the territory they had travelled through.

  The Unit was well drilled in setting up their field hospital, a task that had been practiced on many reserve duty weekends. By sunset the hospital was set up and functional, with one minor problem. The pallets with the tents that would serve as living quarters were AWOL. The desert being roasting hot during the day and freezing cold at night, a determination was made after two nights that desperate measures were in order. The only thing that had kept Karen going was the whiskey, forbidden to the service people by the Saudi’s.  Carl had sent the whiskey to Karen in a care pakage. He had gone to the store, chosen two quart bottles of mouthwash of an appropriate amber color. Carl drained the mouthwash out through small holes he made in the bottom of the plastic bottles, washed them out, filled them with Jack Daniels, and resealed the holes. The shrink wrap seals around the caps were thus intact. Karen nearly choked when she took a swig after brushing her teeth.

  Karen and one of her sergeants hitched a ride to a depot along the road south towards the airstrips and what passed for civilization. The depot was like unto a truck stop along an interstate back home, offering fuel, refreshment and toilet facilities for the drivers and transitory personnel mostly headed north toward the Iraqi frontier. The intrepid duo hung out until they spotted a large flatbed truck loaded with lumber and other construction materials. They watched as the driver and his companion entered the toilet area. Karen nodded to her sergeant, who mounted the cab of the truck, and drove off north ward. Karen waited outside the toilet area and detained the hapless crew of the truck, asking questions about where they were from and otherwise diverting their attention for a good half hour, GI’s always being an easy mark for the charms of the  fairer sex. Karen gave them some ration coupons and encouraged them to get some chow, and exclaiming that her transport had arrived, climbed onto a departing north bound bus. The two GIs never noticed her lack of luggage. Carl and Murph chuckled appreciatively. “Good on you!” Carl exclaimed.

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

  Skip stumbled out of the base hospital into the bright sunlight of a beautiful morning. The brilliant sun was low on the horizon, stabbing into his bleary eyes between buildings. Skip had been on the go for thirty seven hours in a row, representing ten hours of scheduled surgery, four vaginal deliveries and two emergency C-Sections. Military bases were notorious for tough duty for OB-Gyns as they had a population, active duty and dependants, almost entirely of peak childbearing age. Skip often remarked that he would like to have a bronzed insufflator mounted on a pedestal in front of the hospital, the insufflator an essential device for performing laparoscopic tubal ligations, each of which reduced Skip’s late night hours appreciably. Given his ordeal, Skip’s uniform was in an advanced state of disarray, jacket over his shoulder, shirt tail half out, tie untied, dark unshaved stubble on his cheeks and chin. Just at that moment, as Skip was taking his bearings, an Air Force Blue Staff Car with flags flying from the front fenders pulled up to the curb. Skip watched in unfocused wonder as the driver energetically leaped out of the staff car, and with a flourish, opened the rear passenger compartment door. A crisply uniformed man emerged, along with a clipboard bearing minion. Skip’s eyes registered the three sparkling stars on the shoulders, and something deep within his consciousness screamed an alarmed “Oh Shit!” His lanky frame drew itself to attention, his arm rose into a crisp salute, the jacket that had been over his shoulder falling to the ground. Three stars could only be General Davis, the Wing Commander, and absolute potentate over three bases that comprised the 48^th Tactical Fighter Wing. The General advanced slowly, his gaze fastened on Skip as if he was seeing something so out of place as to be inconceivable. He stopped a pace away and directly in front of Skip. One, two, three beats passed and then the torrent started, with “the kind of example you are setting”, building to “what a disgrace to the uniform”, to “Just giving in to the commies and hippies”, on and on with rising voice up to “the beginning of the end of western civilization” and concluding with “what have you got to say for yourself?” Skip deliberately and calmly reached into his rear pants pocket, withdrew his wallet, raising it up to his face as he flipped the wallet open. “Scotty, beam me up” he spoke into the wallet, then flipped it shut, replaced it into his rear pocket. Then he walked away, dignity intact, leaving the General locked in place, frozen into disbelief at what he had just witnessed. Karen and Carl roared with laughter.

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

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

  Inside the car, Karen rapidly placed the probe of a pulse oximeter on the woman’s ear lobe. Only the woman’s head and shoulders were visible from the confining mass of twisted seats and other wreckage. She noted with satisfaction that the EMTs had managed to get a blood pressure cuff around one upper arm, and had got a large bore IV into the woman’s neck. The woman seemed delirious and did not respond to Karen’s ministrations. The readout of the pulse oximeter showed Karen a very rapid pulse, a high rate of respirations and the BP cuff an alarmingly low pressure, the classic signs of shock. She called out the vital signs to Murph who made the tough decision: Do it now, do it quick. He gave the order to Karen to administer Propofol and Fentanyl. Anticipating this order, Karen had removed the syringes from her kit. She opened the IV drip wide and injected the Fentanyl, a powerful narcotic analgesic, and then the Propofol, a rapidly metabolized anesthetic. Propofol is metabolized so rapidly that it must be titrated, meaning that it is given in a continuous trickle after anesthesia has been established. Karen flicked the woman’s eyelashes and noted the lack of a protective reflex response (an eye blink), a sign that anesthesia had been established. “GO!”  She called out.

  Outside, Frank held two work lamps over the heads of Murph and Carl, lighting the narrow opening and the woman’s leg with brilliant light. Murph cut deep with the scalpel, just above the knee, making an encircling incision around the leg. Carl worked with a clamp and retractor to expose the depth of the incision to Murphs’ view. Murph repeated the encircling motion with the scalpel cutting right down to the femur (thigh bone). Carl spotted the exposed tubular end of a large vessel and snapped on a Kelly clamp, sealing it. Murph passed the end of the Gigli saw around the exposed bone, grasped the handles and began sawing back and forth. Frank was astonished at the sped the Gigli saw made through the bone, eight back and forth’s and the bone parted. “Go!” Murph shouted.

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

  Frank extended a fist towards Carl, who met it with a knuckle bump, followed by a complicated series of shakes, slaps, bumps, snaps and slides that had Karen and Murph staring in fascination for the nearly one minute it took to complete. What they were witnessing was a “Dap”, a ritualized greeting practiced by enlisted troops during the Vietnam War. It was actually possible for the initiated to recognize the specific unit of another from a dap. “You were a screaming eagle” Carl said to Frank, referring to the Hundred and first Airborne Division. “Company E, first battalion, 506^th PIR” said Frank. “45^th Medical Company Medivac” replied Carl. Murph and Karen regarded the two Vietnam vets with a quiet respect, as they all sat down among the coils of electric cord, work lights and boxes of rescue gear. Steam rose from the paper cups of coffee. “I didn’t know you flew Dustoffs, Carl” Karen said. “Let me tell you about dustoffs” Carl replied…..

   When Carl reported to the 45^th Medical Company, Air Ambulance Detachment, there was a celebration going on. Carl had been met by Tommy Jones, the crew chief of the chopper Carl was assigned to. Everybody called Tommy “Gremlin”. Tommy’s distinguishing feature was a pair of prominent ears. In fact he bore a strong resemblance to a character in a Bugs Bunny cartoon from the forties. Bugs is up in the air in a WWII era airplane with a gremlin doing his best to disable the aircraft. The gremlin had a pair of ears that looked like the tail fins of the airplane, and identical to Tommy’s, hence his nick name.

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

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

   The cabin of the chopper was shaped like a “U” with a fat bottom. The fat bottom of the U was the bulkhead that separated the cockpit from the cabin and the two thin arms of the U stretched rearward, embracing the walls of the mechanical space. There were two seats made of aluminum tubing and a canvas sling, like a lawn chair designed by a cubist artist, facing rearwards on the bulkhead. They faced brackets that secured standard litters, one on the floor, a second 24” higher and a third 24” over the second. A fourth litter could be placed across the canvass sling seats as needed; otherwise they were the seats for Gremlin and Bandaid. Two more bench type seats, one on each side, were on the arms of the U, facing the doors on either side.The walls and ceiling were covered by quilted pads of “olive drab” the ubiquitous uninspiring color of the army. The next morning, Carl, who had during the course of the previous evenings party evolved from being the generic “band aid” to the proper noun “Bandaid”, met with Gremlin and the assigned pilot and copilot of the day down on the flight line. The pilot was Chief Warrant Officer “Sonny” Rodriquez, a quiet spoken, short dark man from Albuquerque, New Mexico. The copilot was Warrant Officer Matt Thomas of Altoona, Pennsylvania. If the stereotype of airplane pilots was that they were cocky extroverts, the stereotype for chopper pilots was that they were moody introverts. Rodriquez and Thomas certainly fit the bill. While Gremlin and the pilots completed their preflight checklists, Bandaid checked the medical supplies, weapons and other gear in the cabin, and made sure that everything was in its proper place and secured. Then the whole crew retreated to the shady side of the chopper, and sat in the open door to the cabin. A canteen filled with Kool-Aid was passed around. Cigarettes were lit. The tedium of waiting began.

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

  The crackle and hiss of Frank’s radio brought them back to the reality of the passenger platform. Frank listened to the transmission, and then turned to the team. “Sorry to tell you, your lady didn’t make it. She died on the OR table.” Four countenances fell in unison, each internalizing the unwelcome news.