Fifth Chapter

Fifth Chapter

Carol

In which we have a look behind the curtain where broken hearts are mended

   Carol is a CRNA, a Certified Registered Nurse Anesthetist, an advanced practice RN who has a Masters degree and certification in anesthesia. She worked as an OR nurse for two years out of nursing school, then for five years in a Surgical Intensive Care Unit before entering her two years of schooling for anesthesia. Carol describes the delivery of anesthesia as “Controlled Poisoning”. She is not far from the truth in this assessment, as all the drugs used in anesthesia could have been used by the Borgias for their deadly purposes. The original anesthetic was Ether, first used by Dr. Crawford Long in the eighteen forties. A persistent legend has it that the discovery was the result of an ether party, a popular pastime of medical students of the day. Currently, anesthesia is induced with an IV injection, maintained by an inhalant, and supplemented with paralysis as needed. The injection compounds are all descended from the barbiturate family and have included sodium pentothal, beloved of thriller stories as “truth serum”. As anyone who has actually seen it used in the OR will tell you,  it’s use as a truth drug belongs to the same mythology as the karate chop to the back of the neck producing unconsciousness. Propofol, of Michael Jackson fame, is now the IV agent of choice. As mentioned previously, ether was the original inhaled agent, now supplanted by Sevoflurane and Desflurane. Nitrous Oxide, popularly known as laughing gas, is still in use. Curare, the Amazonian arrow poison, was the original paralytic agent, and is now supplanted by Vancuronium and Pancuronium.

   At the moment, she is studying for her yearly recertification in ACLS (advanced cardiac life support). All the OR surgeons, anesthesia personnel and nurses must recertify every year. There are changes in ACLS almost every year as new drugs come out or as research refines the process. Algorithms are used extensively in ACLS to define the steps to be taken for all sorts of events and contingencies that can occur in the course of treating cardiac arrest. Below is a tounge-in-cheek algorithm Molly wrote once after the ordeal of renewing her ACLS:

   Carol worked with the Open Heart team, and was proud of the fact that she was the only nurse anesthetist on the team. There were two Anesthesiologists on the team, as well as three surgeons, one fellow, one resident, two perfusionists (who operated the heart lung machines), and six RNs. The King of Hearts was Dr. Hector Charles MacIntyre, a dour Scottish-American of exacting standards, volcanic temper, and magical hands. Standing a Napoleonic five feet three inches, he was an alpha male to the core. He was addressed as “Sir” by all the members of the team, including his two junior partners, Drs. Haley and Thompson. Behind his back, everyone called him Hector. He was renowned for tearing up residents and fellows, reducing RNs to tears, and favoring everyone else with his biting sarcasm. Hector did not suffer fools. He commanded enormous respect due to his consummate skill as a cardiac surgeon. Carol had once watched awestricken as he sutured up a small tear in an artery on the back side of the heart. His only view of the tear was in a dental mirror about an inch and a half in diameter, so he had to do each stitch backwards and backhanded from what he was seeing in the tiny mirror. He was using a 7/0 prolene suture which is about as thick in diameter as an eyelash, on a curved needle about the size of this capital letter “C”.  

   His temper was legendary. There were few restraints on the behavior of surgeons; without them there would be no patients, and without patients there would be no income, and without income there would be no mahogany in mahogany row. Once when Dr. Alberts, an anesthesiologist, cancelled one of Hector’s cases because he felt that the patient was an unacceptable risk for anesthesia, Hector kicked a trash can standing next to the scrub sink into many pieces. His rage and cursing could be heard throughout the OR suite, most people just giving each other a knowing look and getting on with their work. Jim, one of the perfusionists, went online and printed out a clipart of a trash can which he taped up in the substerile room between the two heart ORs. It was alongside of a caricature of a Bovie machine that Hector had demolished on another occasion, and several cut outs of cartoon figures of a persons in surgical attire, which represented residents Hector had kicked out of his ORs.

   There has been research into the influence of music in the OR. Basically, the findings are that music chosen by the surgeon is beneficial to his performance. Music not chosen by the surgeon degrades his performance. The type of music does not seem to be relevant, be it heavy metal rock or Mozart, what matters is the surgeon’s partiality. Hector did not allow any music at all. The conduct of every member of the team was rigidly defined, and each could have had algorithms defining their practice. The only member of the team with flexibility was of course, Hector. Conversation was limited to only what was necessary for the procedure.

   The usual day began in the first of the two heart Ors. Dr. Haley or Dr. Thompson would begin the procedure, the fellow or resident would assist the junior partner, or harvest vein graft from the patient’s leg as needed, and things would be much looser in terms of conversation, etc. When the critical point of the procedure, such as going on bypass, was reached, Hector would be summoned. Things became tighter. Hector mostly placed the grafts or valves himself, or directed the junior partner as they performed the critical part. When the critical point was passed, he would move onto the second room where the other junior partner would have things ready for Hector on the second patient. In this manner four to six surgeries made up the normal working day. Throw in the not normal days and the team members usually put in sixty to eighty hours per week. In the substerile room, there was a poster that showed a bedraggled nurse sitting on the side of a bed with the caption “When you are sitting on the side of the bed with one shoe on and one shoe off, and you can’t remember if you are getting up or going to bed, you do know that you are a member of this team”. The team was subject to recall at all hours of the day or night as needed.

   Having recently read Joseph Wambaugh’s The Choirboys, Carol was inspired to announce “Choir Practice” on select Fridays, whereupon the team minus the King would rendezvous at McSorleys Pub, just near enough and just far enough away, and definitely not a watering hole habituated by hospital personnel. After a drink or two, Carol had a way of retelling the day’s events that put the “choir” into convulsions of laughter. This past Christmas Carol was surprised to receive an envelope from Hector that had “A donation for the Choir” inscribed on the front. Inside were two crisp one hundred dollar bills. Carol would tell of other unexpected acts of generosity by Hector:

   There was Bobby. Bobby was the bottom rung and lowest paid person in the OR. Ever cheerful, he was the one who mopped the floors, dug the bits of suture out of the wheels of all the OR furniture, emptied the suction canisters of their unsavory contents, washed and made up the stretchers, ran the errands, lifted all the heavy objects and patients for the nurses, took out the trash, restocked the linens and solutions. In short, he made the OR the clean and efficient place it needed to be. Perhaps because of his lowly status, he was able to approach Hector with a familiarity that was not dared by others and was certainly not tolerated in anyone else by Hector. Bobby’s passion was the city’s NBA franchise. He would greet Hector with a big smile and share the team’s latest triumph, defeat, escapade, rumor or bit of intelligence concerning trades or draft picks. Hector would respond on the level with Bobby as if there was no difference in their status. He seemed to enjoy the exchange of basketball trivia with Bobby. No one else, not even the junior partners, got that kind of attention from Hector. One day, there was a big change in Bobby. Gone were the smiles and cheerful demeanor. People wondered if Bobby had a death in the family. He wouldn’t talk to people. Reading the sports’ section of the paper, it fell into place. It was announced that there would be an unprecedented hike in the price of tickets for the team’s games. A little calculation revealed that even Bobby’s usual nosebleed section season tickets were now out of his reach. The next day Bobby found a blank envelope taped to is locker door with two courtside season tickets inside.

   Then there was Rhonda, a single Mother, nurse, and not even a member of the heart team. Her son developed a rare metabolic disorder. It turned out that the only physician treating the disorder was in California, three thousand miles away. Hector chartered a plane, and paid for a hotel for Rhonda and her son to make the trip out to California.

   As much as it bothered her, Carol found that patients tended to blend into one another, and unless there was something special or remarkable about one, they were soon forgotten. A name might come up in conversation that would be familiar; but it would require more than just a name or face to retrieve a memory. Given the volume of patients through the heart ORs this was perfectly understandable. There were however two patients that Carol would never forget.

   Frank was one of them. Carol first saw Frank in the ICU. She had gone up with Dr. Miles, an Oral Surgeon, to sedate an upcoming heart patient so that two bad teeth could be removed. This was a not unusual situation. Bad teeth acted as an antibiotic resistant reservoir of bacteria that might cause endocarditis (an infection of the lining of the heart cavity) in an otherwise healthy person, but it was a certain outcome in patients undergoing heart procedures. Reviewing Franks chart, the history and the numbers painted a picture of someone barely hanging onto life. Frank was only forty-four years old. Entering Frank’s room, the first things to strike Carol’s eyes were a number of papers on the walls. They were crayon drawings with legends such as “We Love you Daddy” and “Please get well Daddy”, obviously the work of at least three small children. Carols felt a tight squeeze in her own heart. Frank was already barely conscious, it didn’t take much to sedate him, and the two teeth were quickly removed. Afterward Carol reflected that there must be a great strength inside of Frank to keep him alive at all. The next day Frank arrived in the Heart OR. During the procedure it became apparent that there was extensive damage to his heart, and blockage of the coronary arteries that the stents placed by the cardiologists did little to relieve. Never the less, he made it out of the OR to the ICU. Over the course of the next couple of days, Carol quizzed the junior partners on Frank’s progress. They reported astonishment at the speed and strength of his recovery, and he was discharged to cardiac rehab in near record time. At the last report, he was home and back to work.

   The second was David. At twenty-nine, he was the youngest patient Carol ever had in the Heart OR. David had Marfan’s Syndrome, a genetic disorder of the connective tissue, which forms the structure  and support of tendons, ligaments, blood vessel walls, cartilage, and many other structures. People with Marfan’s Syndrome are often tall and thin, particularly long in arms, legs, fingers and toes. Eye problems are common. Often it is said that Marfan’s Syndrome victims look like Abraham Lincoln, and there has been much speculation as to whether Lincoln had Marfan’s. In the most severe cases, the heart valves are affected. The aortic valve does not fully seal, blood back flows into the heart, causing it to enlarge, and increases the hearts workload. The Mitral valve prolapses, a less significant problem, but contributing to poor oxygenation of the blood and poor circulation.

   David had already had repairs to both of his aortic and mitral valves, and when the repairs broke down, replacements of both valves with artificial ones. Now the artificial valves were dehiscing (separating) from the heart. Because of the difficulty of the situation, a minimally invasive procedure would not be possible as was done previously. This would be old school, involving splitting the sternum and opening the chest wide.

   David went under anesthesia and onto bypass with the heart-lung machine without incident. The valves were exposed and removed. Hector measured carefully for the size of the new prosthetic valves, and special horseshoe shaped reinforcements so that the heart would not dehisce from the valves so readily. Hector placed each suture with great care, placing a clamp on the ends, and then clamped to the drapes so that they were arrayed like the rays of the sun instead of tying them down immediately. When all thirty eight sutures for the aortic valve and twenty nine for the mitral valve were in place, they would then be knotted and the ends cult off. This was to ensure that the tension of the sutures would be even. Denise, the scrub nurse, gave alternating green and white sutures to Hector so that each would be tied without mix up with its closely neighboring sutures. Everyone collectively held their breath as Hector knotted the sutures down, praying that the delicate tissues would not tear. At last the valves were in place, and the heart walls closed. Hector called for the internal paddles, placed them on either side of the heart, called out “Hit It!. Kerry, the circulating nurse pushed the discharge button on the defibrillator, and the electric shock was delivered directly to the heart. It didn’t start beating. Hector ordered the voltage increased. “Hit It!”. The heart didn’t beat. “Restart bypass” Hector directed. The roller pumps began spinning again, squeezing blood through the clear plastic tubes. Carol ran down the status of the electrolytes and the levels of oxygen, carbon dioxide, bicarbonate and pH of the blood. She had been sending off tubes of blood for these tests, called “blood gasses” at regular intervals. The numbers were all good. Hector said, “Give it ten minutes on bypass to rest the heart, and then we’ll try it again”. In ten minutes, the process was repeated. No beats. Epinephrine was given directly to the heart. No beats. It was all repeated again and again. After an two hours of every technique and trick he knew, Hector faced the inevitable. David’s heart would not beat on its own. For the first time ever, Carol detected defeat in Hector’s voice. “Turn it off. Time of death..” He looked up at the clock, “Thirteen twenty-six.” Kerry choked back a sob, Denise was frozen into immobility and looked lost. Hector slowly, silently stepped away from the table and stripped off his gown and gloves, pushed through the door, and trudged off to talk to David’s family.

Fourth Chapter

Nancy

In which we learn the circumstances of a most unusual bequest

  All patients coming to the OR are given a score on the ASA Physical Status Scale. The score from this scale correlates very closely with the probability of complications for an individual. The higher the score, the more likely complications will occur, and the more likely the complications will be serious. The Scale goes like this:

ASA 1 – A normal healthy patient with no co-morbidities

ASA 2 – A patient with mild systemic disease, such as diabetes controlled with diet or oral drugs, or an obese patient, or an otherwise healthy patient who smokes, or a patient with well controlled hypertension.

ASA 3 – A patient with severe systemic disease and or co-morbidities, such as poorly controlled diabetes or diabetes with renal impairment, or morbid obesity, or heart disease or angina.

ASA 4 – A patient with severe systemic disease that is a constant threat to life, or combinations of severe systemic diseases such that there is an imminent threat to life.

ASA 5 – A moribund patient who is not expected to survive without the operation.

  ASA 6 - A patient declared brain dead whose organs and or tissues are being removed for donor purposes.

  It began with a call from the warden at the State Penitentiary. A death row prisoner, scheduled for execution in a month, wished to donate a kidney to his mother who had end stage renal failure. The Governor had approved the prisoner’s request. The Chief of Security from the Penitentiary came to look over the Hospital and OR, and to plan the donation with the Hospital staff. They met in Chicky’s office. Included in the meeting were Nancy, the head nurse of the transplant team, and Dr. Mike Moatz, the transplant surgeon. Chicky’s office was in a former supply storage area, just large enough for her desk, four tall filing cabinets and a small table with four chairs. No windows. Each of the filing cabinets was of a different color, the chairs were mismatched, and the desk looked like a survivor of the sixties. The chair behind the desk was new looking and of the quality the office supply catalogs called “Executive”. Four Diplomas hung on the wall, one from a hospital school of nursing, a BS in Nursing from a state university, A Masters in Nursing from a small Catholic University, and an MBA from another state university. On the desk was a new top-of the-line Intel Quad-Core laptop purchased by Chicky personally, with Molly’s advice, to replace a generic and antiquated Pentium III PC provided by the hospital. Chicky had always been amused to note that the computers in the executive suite were always the newest and fastest models while those used by the actual workers throughout the hospital were always a generation or more behind.  Chicky’s Spartan quarters were on a par with other nurse directors/managers and did not compare with other non-nursing department heads well. Those Physicians among the hospitals officers had the most palatial offices of all. It was no coincidence that the staff referred to the area of the executive offices as “Mahogany Row”. Office décor in the hospital was a matter of stroking egos.

  It took little time for the Chief of Security to outline the requirements for the situation. The prisoner had a violent history, and had been involved in several altercations with the guards. A condemned man, he had little or no incentive to be cooperative. He literally had nothing to lose. Solitary confinement, being fed on “The Loaf”, had no observable impact on his demeanor. “The Loaf” was the modern equivalent of bread and water, being a bread-like mass concocted of various food items making up a complete nutritional diet in a monotonous and unappealing cube.

   After much discussion, a plan was formulated that accommodated the sterility and operational needs of the surgical procedure and the restrictions necessary for tight security. Everybody’s thoughts were of a hostage situation or worse. It was obvious that the Chief of Security thought the whole matter a bad exercise of judgment, but you don’t argue with the Governor. The OR staff was focused on the need for the kidney in the knowledge of the scarcity of organs. The average time on the waiting list for a kidney was seven years. Ten years was about as long as a person could go on dialysis, so most transplants were the best match available, often quite short of a perfect match. This meant that the recipient had to be put on large doses of immune-suppressants and steroids to avoid organ rejection. This in turn made them very susceptible to infection and other disease processes, yielding a shorter life span than a really good match.

  Nancy changed out of scrubs in the locker room, and walked to the parking garage. She got on the lift which rose past the levels reserved for physicians, the levels for administrators and arrived at the open season levels next to the roof. She located her well used minivan which bore all the signs of children: toys, food stains, a child seat and cartoon stickers on many of the interior surfaces. On the drive to one of the suburbs of tract homes she had the radio tuned to NPR, but wasn’t hearing it, being lost in thought about the upcoming “harvest”, as an organ donation was known to the surgical community. Nancy had flown to remote hospitals, and been in most of the hospitals in the metropolitan area for organ harvests and had even been to the Medical Examiner’s office down town to recover cadaver skin, bone and corneas. But this harvest was hands down the weirdest of all.

  That night, after the children were bedded down, and before Nancy’s husband Steve headed out for his night shift with the police department, Nancy asked if he knew anything about the unusual organ donor. “He’s a real bad one” Steve answered, “He shot and killed two men in a drug deal that went bad, went home and to top it off, beat his girlfriend to death with a chair. In my view, death by lethal injection is too good for him. You guys should take his kidney and then not bother to wake him up.” He hugged and kissed her, went out to his police cruiser and headed off to the station. In the days leading up to the harvest there was much discussion among the OR staff, and Steve’s opinion seemed to be shared by many. Most organ donations were from cadavers, brain dead from one cause or another. A nearby state did not have a helmet law for motor cycles, providing a steady stream of donors such that Nancy’s team mates began to refer to the machines as “donorcycles”. The first time Nancy had seen the respirator and monitors turned off with the brain dead donor still on the OR table, all the monitor tracings going flat, it creeped her out. Nancy had participated in live donations before, with the donor a close relative of the recipient, and the two surgical procedures being carried out simultaneously in adjacent ORs. This time, the recipient would be in another hospital about an hour’s journey away from the donor.

   The night before the harvest, Nancy tossed and turned. There were so many implications of the harvest that were troubling, not the least of which was a report in the news of organs from executed prisoners being marketed in China. News of the harvest had also leaked to the media the day before. The botoxed anchor of the local TV news and his generic surgically enhanced blonde sidekick, half his age, reported with earnest, serious expressions that the prisoner had refused all appeals, and wished to die rather than spend life behind bars. The leak also created a fear of a media circus descending on the hospital. Nancy had a mental image of a large crowd with signs and banners on the front lawn being led in protest songs by a banjo playing Pete Seeger. Opposite was Rush Limbaugh leading a crowd with “Roast in hell” and “Bring back public hangings” signs. Due to security concerns, changes had been made in the plans for transport of the prisoner, security around the hospital increased and a public relations campaign planned.

   On the morning of the harvest, Nancy arrived at work as usual. There were no TV vans with satellite dishes, and no Pete Seeger, which calmed one of the anxieties fluttering in Nancy’s stomach. She changed into scrubs, checked the schedule board, noted that the harvest was on first as she had expected.

Donning her surgical mask, Nancy went to the OR and began arranging the equipment, checking that all was in proper working order. Then she went through the small substerile room that was shared by the two adjacent ORs. The substerile room was an area containing a sink, an autoclave for sterilizing items, and a warming cabinet for keeping blankets and fluids slightly above body temperature. Some linen and other supplies were stored there as well. Nancy made sure that the area was clear to allow free passage through the substerile room. Security dictated that no instruments or any objects that could be used as weapons could be in the OR with the prisoner until he was under anesthesia and unconscious. So Nancy and her scrub tech Tim would have to open up their sets and supplies to set up their sterile table in the adjacent OR and then move it through the substerile room when they got the signal. Tim was already in the next OR, and had gathered all the needed sterile sets and packs. He left the OR to scrub up, and Nancy opened all the sterile items. When Tim returned with his hands raised in front of him in the manner familiar to all who have seen Medical shows on TV. Unlike The TV shows, masks are always worn while scrubbing, and by anyone around someone scrubbing, and always in the OR. It was a favorite pastime of the nurses and techs to spot all the breaks in sterile technique by the actors posing as surgeons and nurses, and there were always plenty of them. The intimate conversations of the TV nurses and surgeons complete with voiceovers while in the OR were also a source of mocking amusement. Nancy tied up Tim’s gown after he had donned the gown and gloves. She left Tim to do the sterile set up, and went to the pre-op area to see the patient.

 The prisoner was in the isolation room, separate from the common area of pre-op, usually reserved for those patients coming to the OR with an infection or contagious condition. Upon entering the isolation room Nancy immediately saw the heavy shackles on the patients’ hands and feet, firmly binding him to the gurney. She advanced to the gurney, pulling up a chair so that she would be at eye level with the prisoner/patient. Nancy had given much thought as to how she would approach this patient interview. First of all, she had decided that she must think of him as Mike ______, not as the prisoner, or as the patient. Before she could initiate a greeting, Mike spoke up “Sorry about all the chains, I can see they spook you. The hell of it is, I would do things in other situations, but not now – I don’t want to f***k things up for my Ma. Life has been a real s**tstorm for her, being sick and all, so this is the thing I can do for her.” Nancy replied “Thank you for that Mike, my name is Nancy. I’ll be your nurse in the OR. Right now I need to confirm some of the information I got from your chart, and then ask you some questions.”

  Nancy started down her check list of innocuous seeming questions, almost all of which the patient would have been asked before. The repetition of the questions while annoying to the patient, was intentional. Nancy could not count the times that patients suddenly remembered something important when asked the same question for the fourth time. And as routine as the questions sounded, they all reflected matters that were matters of safety and even life or death. For example; “When was the last time you had something to eat or drink?” With the induction of anesthesia there was a very real risk of patients suddenly vomiting, which if any of the vomitus was aspirated, posed a very possibly lethal situation. Jimi Hendrix died from aspiration when he overdosed, a situation very much like the induction of anesthesia. Another routine question was “are you wearing contact lenses?” Anesthesia knocked out normal protective reflexes, so contact lenses left in the eyes during surgery could result in damage to the cornea, as there would be no eye blinks, or movement of the eyeball as in normal sleep or in an conscious state. Another question always asked was “Have you ever had anesthesia or any problems with anesthesia, or has anyone in your family ever had a problem with anesthesia?” This is because of Malignant Hyperthermia, an inherited defect of calcium metabolism which can be triggered by exposure to many of the most common anesthetic agents. There is no straightforward test or practical screening procedure for the condition. It occurs once in every fifty thousand to one hundred thousand cases. It is associated with a five to ten percent mortality rate. Nancy had seen it once in her career and never wanted to see it again.

   When she reached the end of her checklist she asked Mike if he had any questions as she always did. Mike’s question took her by surprise. Mike asked “What’s it like, going to sleep like that? I figure this is sort of a dress rehearsal for me.” Nancy paused for a moment, then looked him straight in the eye and said “I had anesthesia once. The anesthesiologist told me to pick out a good dream, I felt some cold moving up my arm from the IV and it was as if a switch was turned off. I woke up when it was over and there was just nothing in-between. The time I was out just didn’t exist for me. You are probably right about it being a dress rehearsal. I expect it will be almost exactly the same except that there will be no waking up.” Mike said matter-of-factly, “That’s about what I expected. Just nothing.” He seemed to appreciate the directness of Nancy’s answer to his question. Still looking him directly in the eye, Nancy said “I will be standing next to you during the induction of anesthesia. We will take good care of you while you are here.” Mike nodded. Nancy got up and left to return to the OR.

   Tim had completed setting up the sterile table. Nancy got the count sheets and the pair began counting the table. Sharps, such as blades, hypodermic needles and suture needles were counted in one category. Sponges and towels were counted in a second category. Then all the instruments were counted by type and name. Lastly all the small accessory items were counted. All would be counted again as the abdomen was closed, and a third time as the skin was stitched or as more commonly now, stapled. The point was to make sure that none of these items remained inside of the patient. A retained object was one of those things that was indefensible, an instant judgment against the surgeon and OR nurses. The legal term is “Ipso Facto”, meaning “by the fact itself” negligence has occurred. In cases of extreme urgency, when there is no time to count, X-rays are taken before leaving the OR. All the objects used in surgery are radiopaque, which means they show up on an x-ray. So even in those situations there is no defense. The counting complete, Nancy walked through the substerile room to the other OR, leaving Tim to mind the sterile table. Sterile tables are never left unattended, lest they be unknowingly contaminated.

   Nancy arrived just as Mike was brought in to the OR, still manacled to the gurney. Two prison guards accompanied him, and would be in the OR until he was unconscious, then they would remain just outside the doors until it was time to wake Mike up. The gurney was pulled up even with the OR table, the guards unlocked the shackles, Mile slid across to the OR table, and was once again shackled, this time to the table. The guards moved back, and Nancy took her place to the right of Mike’s head. Dr. Nelson, the anesthesiologist talked Mike through the steps in preparation for induction. Nancy helped to place the monitoring leads, and when all was complete, held the oxygen mask to Mike’s face to pre-oxygenate his blood, the last step before injection of Propofol, the induction agent. Nancy said to Mike “ Would you like me to hold your hand as you go off to sleep?” Mike swallowed hard and nodded to Nancy. She took his hand. Dr. Nelson said “OK, I’m injecting now, you may feel the drug gong up you arm. Some say its cold, some say it burns, but it will only last a couple of seconds.” Mike nodded again and Dr. Nelson injected the milky drug. In seconds Mike’s body visibly relaxed, and his eyes lost focus. Dr. Nelson squeezed the rubber bag a couple of times in quick succession, and removed the mask, tilted the head back, unfolded his laryngoscope and with a deft motion, placed in Mike’s mouth and down his throat. While he was doing this, Nancy drew the clear plastic endotracheal (ET) tube from its wrapper, attached a 10cc syringe filled with air to the small inflation line on the side of the ET tube, and held it in readiness. She felt just below Mike’s adamsapple for the cricoid cartilage, applying a gentile pressure. This caused the rigid cartilage to compress the esophagus, keeping the trachea open and the esophagus closed a precaution against aspiration and lessening the chance of a misplacement of the ET tube. When Dr. Nelson got a good view of the vocal cords, he held up his hand and Nancy placed the ET tube in his hand, properly oriented for insertion. With a skilled and practiced motion, Dr. Nelson pushed the ET tube through the vocal chords and into the trachea. Nancy gently but firmly pushed the plunger of the air filled syringe, inflating the balloon-like cuff at the end of the ET tube. The trachea was now sealed off from the esophagus, preventing any chance of aspiration. Dr. Nelson gave a squeeze again on the rubber bag, observed the rise of the chest, and as pressure was released, the condensation that appeared in the transparent ET tube. These confirmed to Dr. Nelson and Nancy that the tube was correctly placed in the trachea and not in the esophagus.

   Nancy held the doors so that Tim could bring the sterile table through the substerile room into the OR. The guard removed the shackles from Mike. Nancy placed a foley catheter into Mikes bladder, so that the urine output could be monitored. This was important because the first observable sign of hemodynamic instability (the interaction of blood volume and pressure) would be a decrease in urinary output. It would also be a direct indication of Mike’s kidney function. Nancy also placed SCD (sequential compression device) sleeves on Mike’s legs to prevent the formation of clots. If Mike formed clots in his legs, the least serious complication would be a DVT (deep vein thrombosis) which would require him to be on anticoagulants until the clots cleared, which could cause post-operative bleeding. More seriously, if clots formed and broke loose, Mike could suffer a PE (pulmonary embolism) a potentially fatal complication. Then she placed a grounding pad for the elctrocautery, more commonly called a Bovie, which would protect Mike from electrical burns from the electrocautery. Lastly she painted Mike’s abdomen with gluteraldehyde solution to disinfect the skin. While Nancy was occupied, Tim gowned and gloved Dr. Moatz, and his transplant fellow, Dr. Ted Farrand. The trio of sterilely gowned and gloved team members then draped Mike. Tables were moved into position, Tim Passed the scalpel to Dr. Moatz, and the incision was made.

   About an hour and a half later, Dr. Moatz took the kidney to the sterile table, flushed it with Wisconsin University Solution, a mix of nutrients and electrolytes, placed it into a sterile plastic bag, and then into a sterile plastic jar. He handed it off to Nancy, who placed it into a Styrofoam container full of ice, which in turn went into a foil lined corrugated box. She attached all the relevant records and certifications that she had completed in a pocket on the side of the corrugated box, and a duplicate set inside. Until recently swing top Playmate coolers had been the transport container of choice. Thus packaged, there was about an eight hour window for transplant of the kidney, but the sooner the transplant, the better. Dr. Moatz checked to see that all was well with the closure which he left to Dr. Farrand, stepped back from the sterile field, and pulled off his gown and gloves. He took the precious package and left the OR, already on his cell phone to alert the waiting team with Mike’s mother that he was en route with the kidney.

   The closure of the wound was uneventful, Nancy and Tim completed their counts which were correct, and mike was moved from the OR table to the gurney while still asleep and entubated, a departure from the normal procedure which was to wake a patient up and extubate (remove the ET tube) while still on the OR table. In this case, the move was made first to enable the guard to shackle Mike before he awoke. As Mike began to stir, the extubation was smoothly accomplished. Shortly mike became conscious, looked about and grunted “S***t, I’m still here”. In his groggy half alert state he was taken to the PACU, and Nancy and Tim paged for housekeeping and began the process of turning the room over for their next case, a routine Inguinal Hernia Repair. The excitement was over, and they were instantly plunged back into the routine of a busy day.

   About two in the afternoon, another nurse came into the OR and relived Nancy, with instructions for Nancy to go to Chicky’s office. Nancy gave her report and went to the office expecting that it had something to do with the harvest. Entering the office, she saw a uniformed officer and then the pale look on Chicky’s face. Her knees felt suddenly weak. The officer grabbed her and eased her into a chair. “I am very sorry to tell you this” he said, “but your husband was struck by a car while he was making a traffic stop. He was killed instantly.” The officer and Chicky allowed Nancy a moment for the news to sink in. Chicky asked if there was anyone she could call for Nancy. She shook her head side to side. The officer said “We are here to take you home, another officer will take care of your car. The chaplain will be at your home by the time we get there.” He helped Nancy to stand a tenderly took her arm and led her from the office.

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.

Second Chapter

Molly

In which we visit the tree of knowledge and perhaps taste the fruit

  Molly has been around the OR for a long time. To give you an idea of her tenure, consider suture. Nowadays suture is mostly synthetic, at least a dozen different materials, dissolvable or not, monofilament or braided and comes with a bewildering number and types of needles attached. Some needles are permanently attached and others come loose with a sharp tug, called “control release” by the manufacturer. When Molly started in the OR there were only six types of suture material and all the needles were “free”, meaning that they had to be threaded just like your needles at home. There were two choices of dissolvable suture, cat gut and chromic. Chromic was cat gut treated with chromium salts to make it dissolve more slowly. Cat gut was actually made from collagen and fiber derived from slaughter house cattle. There was also the ubiquitous silk, a braided non dissolvable thread. Lastly, there was Nylon, just like that used for fishing line. Occasionally stainless steel wire was used. Once in a while you encountered a surgeon who used cotton suture, a holdover from the WWII era when supplies of silk were very short. Now there is an enormous variety of types of suture available, each with very specialized properties. Every OR nurse used to carry a needle book in her scrubs pocket, made from a piece of surgical towel, and stocked with about 2 dozen needles of various types and sizes. This needle book would be autoclaved (a high pressure steam cooker) to sterilize it whenever that nurse would scrub in on a case. The nurse would replace her inventory as the needles became dull or bent. Free needles are still used on occasion, but they come sterile packaged. Suture is also characterized by its diameter, starting at #5 (like unto kitchen string) descending to #0. Then it further decreases by the number of zeros, 00,000,etc., actually pronounced two-oh, three-oh and so on all the way down to twelve-oh which is smaller in diameter than a baby’s hair and used under a microscope.

  All this information about suture and more is basic knowledge for the OR nurse or tech. Molly excels at imparting all of this extensive body of knowledge to neophytes in the OR. She has trained, or as the profession refers to the process, precepted almost everyone gathered in The Recovery Room tonight.

  In the late seventies two brothers, Stuart and Hubert Dreyfus, researchers at UC Berkley, under contract from the US Air Force, studied how pilots were trained and how they developed over the course of their careers. They identified five stages in the course of development:

1.       The Novice, characterized by a rigid adherence to taught rules or plans, and an inability to exercise discretionary judgment. Molly would say that “they practice cookbook nursing; they need a recipe because they don’t know how things will turn out”.

2.       The Advanced Beginner. This stage begins limited situational perception, with more flexible application of the rules, but all aspects of the tasks presented are treated equally, with an inability to appropriately prioritize tasks. In Molly speak, “they can adjust the recipe, but still don’t get the whole enchilada”.

3.       Competent. The individual in this stage is able to cope with multiple activities and the accumulation of information, and is beginning to see how their own actions influence larger goals. They make their own rules in reaction to situations that do not fit the taught rules. Molly says “these guys can pick the right recipe for the occasion and change it up if it is not turning out right”.

4.       Proficient. The total pro, this person has a holistic view of situations, is able to correctly prioritize the actions to be taken, especially in those situations that depart from the norm. He or She uses maxims for guidance, with meanings that adapt to the situation at hand. According to Molly “you can throw this type into alligators waist deep, and they can still drain the swamp”.

5.       Expert. This Zen master-like individual transcends reliance on rules and guidelines, has an intuitive grasp of the problems faced, has a clear vision of what is possible, and uses an analytical approach in new situations. Molly is famous even among the surgeons for being able to predict when and what complications are going to happen, and make appropriate preparations. The surgeons all tell the residents to ignore Molly at their own peril. While this ability may seem magical, it is actually a result of recognizing certain signs and patterns and applying them to a vast store of experience. Typical of practitioners at this level, Molly is not able to clearly articulate how she knew, but will say “He looked funny to me” or “I just knew”.

    More importantly, the Brothers Dreyfus recognized that there was a progression in the source of knowledge and skill from stage one to stage five. In the first stage, it all comes externally, from the teacher. By stage five, it all comes from within the individual, with a changing mix of external and internal sources in the mid stages. Experts can’t be taught, but they can be nurtured.

     She often speaks of the nurse she knew with ten years experience: “Unfortunately she had the same experience for ten years”. She also tells the neophytes not to get too worried about not getting it. “One day when you have been here about a year, something will click, and you will just get it”. The level of competence has then been reached. It generally takes three to four years for an individual to develop to the Proficient level, at which time Molly bestows the title of “A Good Nurse (or Tech)”. Molly is one of the very few who have made it to the Expert level, a fact that all at The Recovery Room would agree about.

  And herein lies the tale of Lisa, as told by Molly at The Recovery Room:

“At first we all took a shine to Lisa – she had a sunny, happy personality, and was much attuned to others. She would bring in cookies she baked to the classes. A regular little beam of sunshine. Then I noticed she couldn’t tell her right from her left. I had to write R and L on the toes of her shoes with a marker”. Giggles came from around the table. Carl interjected, “I knew a guy like that in basic training in the army. The Drill Sergeant bent over and picked up a small pebble and put it in the guy’s right hand. Then he bends over and picked up a leaf off the ground, and puts it in the guy’s left hand. Then he marches him all around yelling “Rock, Leaf, Rock, Leaf”, and slowly changed it to “Right, Left, Right, Left”. The giggles grew into guffaws.

  Unruffled, Molly continues “As you can imagine teaching Lisa the art of sterile technique was a real joy. Lisa just could not get the rules of keeping a field sterile. Doing practice set ups she would break every rule in a minute or less, contaminating the whole shebang. I had to start putting a cotton ball on everything she would contaminate. Her set ups would look like there was a snow storm. But, slowly she got it, and kept up that happy, chirpy disposition throughout. It took a lot longer than anyone else I ever taught.”

  “Now in those days we had an OR supervisor who was one of the last of the old breed, probably a lot like your Drill Sergeant Carl. Her name was Miss Perdue, everybody called her “Chicky” but not to her face, that’s for sure. Well, I began to wonder why Chicky hired Lisa, as Chicky certainly did not tolerate fools. I went to her and explained about Lisa and suggested that perhaps the OR was not a good choice of practice for Lisa. Chicky gave me a three count stare and told me that she wanted Lisa to succeed in the OR, and that of course she was fully confident that I could make it happen. I began to wonder what lay behind the hiring of Lisa, and what Chicky was saying between the lines.”

  Lisa began to make some progress, and left the shelter of Molly’s lessons into the real world, assigned to be with some of the more experienced nurses. Each day the nurse assigned to Lisa would come back to Molly and report on Lisa’s lack of progress. Most of them requested to be relieved of the burden of the neophyte after a day or two. One told Molly who Lisa’s father was: A big contributor to the hospital and friend of many of the hospital’s board of directors. That answered the question of Chicky’s hiring decision, or more accurately the lack of one. Another of Lisa’s partners compared her to the main character in the movie Fifty First Dates, where a woman had a brain injury that prevented the transfer of short term memory to long term memory, with the result that every morning she began at the day just prior to her injury, and the memory of all events subsequent to her injury were lost. “It’s like she is starting from zero every day, she remembers nothing from the day before”. Lisa began to be referred to as Fifty First Dates, which rapidly became shortened to First Date. A nick name was born, and spread through the OR at a pace only a delicious rumor can compete with. Lisa was utterly oblivious as to the meaning of her nick name, but took it as a sign of acceptance.

   Molly and her husband Ed were childless. Adopting from another country didn’t sit right with them, as there seemed to be no shortage of children needing homes here in the USA. They had tried fostering twice. The first time was an 11 year old boy with such severe behavioral problems that their efforts were entirely in vain, and they breathed a defeated sigh of relief when the courts removed the boy from their care. The second time was a lovely eight year old girl from a home where both parents were in prison, the mother for drug dealing and the father for murder. Despite such a calamitous environment, the girl was a gem, and Molly and Ed lost their hearts to the little girl. After two years, Molly and Ed began to explore the possibility of adopting the child, but the mother was released from prison, and wanted custody of the child. After that heartbreaking experience, they gave up on fostering.

   Instead, Ed had his woodworking, and Molly had her computers. Presently Ed was making a coffee table from a gorgeous slab of walnut cut straight through the center of a log, with the bark intact on both edges. His design was both rustic and sophisticated at the same time, an effect that took all of his great skill to pull off. Molly was working on a program she had written herself to aid in educating nurses and techs to the intricacies of different surgical specialties. The program presented information, asked some questions about the material presented, and if the questions were answered correctly, a reward display appeared to the user. The reward displays were incremental, and became more complex as the student progressed, involving full multimedia capabilities of the computer. Molly had built the computer she was working on herself from the latest and hottest components that she could find on the internet.

   Molly was also deep in thought about Lisa. There had been many complaints about Lisa in the past week. She could not keep drugs of similar names straight, such as Pitocin/Oxytocin, Epinephrine/Ephedrine, and so on. Lisa had thrown out an important specimen, which fortunately was retrieved from the trash, a very messy and unpleasant task.  Her counts of sponges, instruments and sharps were frequently incorrect, leading to delays in surgical procedures while the counts were reconciled. On two occasions abdominal flat plate X-rays had to be taken to rule out retained objects inside patients. And she still regularly contaminated sterile fields. Many of the staff refused to be assigned with Lisa. Molly was beginning to have that hollow feeling of failure and defeat concerning Lisa. Lisa was impermeable to all of the controversy swirling about her, her sunny and cheerful disposition undimmed.

   On Monday morning, Molly arrived at work with a sense of dread. She felt that she had to tell Chicky that Lisa was a hopeless fit in the OR and must be moved on. Molly’s first stop in the OR suite was to check the assignment board. Lisa was assigned to the preop area, where patients arrived to the OR just prior to their surgery, and a last check was made of all their paper work, vital signs and over all condition assessed, verification of identity and surgical procedure and laterality (if applicable) were checked. Family members were talked to and both patients and family members given chances to express concerns and ask questions. Surgeons and anesthesia providers also talked to the patients and their families. These were all important considerations, and were the hospitals first line of defense against mistaken identity, wrong procedures and wrong side procedures. The nurses in the preop area also served as family liaisons, getting messages from the OR to the families. Molly thought about it, and decided to see how this would go before she talked to Chicky. Lisa’s personable disposition might be a real asset in this role.

   At the end of the week, Chicky had received several letters by way of the hospital administration from patients and family members praising the care and concern they had received. Comparing patient records to the letters demonstrated that Lisa had been the nurse involved. Molly thought “Chicky sure knows how to make lemonade”.

First chapter

THE END OF SHIFT REPORT

The Recovery Room

A prolog in which we meet our dramatis personae

  If you leave University Hospital by the back door, which is down a dark hallway never used by the public, and then cross the alleyway, you reach The Recovery Room. Now, if it had been adjacent to a golf course it would have been called The 19^th Hole. If it had been downtown among the financial district, it would have been The Office. Out in the burbs it would be The Alibi. But next to a hospital it could only be The Recovery Room. Inside the hospital, the area next to the OR is no longer called the recovery room, but the PACU, which stands for Post Anesthesia Care Unit. They still call the Operating Rooms the OR.

  The Recovery Room is frequented by many people of many walks of life, and is often patronized by various employees and resident physicians of the hospital, but almost never by the Attending Physicians. The Recovery Room is perhaps not sufficiently upscale enough for the Attendings. In the full light of day it looks pretty shabby, but into the evening when the sun gets lower and the tinted lights come on, it doesn’t look so bad. Some of the Administrative personnel from the hospital come here at times, but only when their numbers are sufficient to give them the security of their herd. In ones and twos they get the nervous feeling of herbivores in the presence of carnivores.

  Tonight there are a group of OR nurses, technicians and nurse anesthetists gathering in The Recovery Room, after they give their end of shift reports to the nurses, techs and anesthetists relieving them. The occasion is a farewell to one of the nurses who is leaving for a job in a sunnier climate. The departing one is Carl, a nurse of unusual background, a figure looked up to by the OR staff and many of the surgeons as well. He is less well liked by the managers and administrators, who, while they might not be happy that Carl is leaving, share a certain sense of relief that he is going.

  Carl is unusual as a nurse for a number of reasons. First of all he is male. Secondly, he is somewhat older than his peers. He is in fact a second career nurse, not that unusual these days, as there are more than a few. What is unusual is in the area of his first career, not that he ever talks about it much and then only with his fellow Vietnam veterans. This perhaps explains his dislike for those who are paid to ride desks, go to meetings, come in late, have long lunches and go home early; administrators if you give them a name. Carl calls them REMFs. The R and E stand for Rear Echelon, the M and F we will leave to your imagination. Karen, another OR nurse and a veteran of Operation Desert Storm, is one of the very few he has swapped war stories with.

  Also there is Tim: OR technician and one of the only other men on the OR staff. Tim, he of the million dollar idea, is also a second careerist, having been a carpenter prior to working in the OR. Anne is the looker, the one who induces sudden attention deficit disorder in men on the street, with the resulting collisions with parking meters and other sidewalk obstructions. There is a spirit like a samurai sword, combining great strength and flexibility with the ability to cut to the core, sheathed in Anne.  Nancy is the young widow, single parent, and the nurse who knows how to count. She is also the leader of the Transplant Team. Carol is a Nurse Anesthetist, former OR and ICU nurse, talented story teller, and the pacemaker of the open-heart team.

  To round out the ensemble, there is Molly, longest surviving nurse in the OR, a teacher or sensei to nearly all who have followed her, and as an exception to people of her age bracket, an expert at the digital world, having bought her first computer in 1979, an apple clone. Lately, she has taken to building her own PCs, being unsatisfied with the offerings of the market place. To be the Yin to Molly’s Yang, there is Caitlyn, our story’s neophyte. Caitlyn, who prefers to be called Cate in reaction to her parent’s trendiness in naming her, says “At least they didn’t name me Brittany, Ashley or Courtney”.

  So, let the first round be served, your humble narrator urges you to sit back, and let the stories begin.