13. Golden Hour
…In trouble; in it deep…
April 26, 2007
Wazir Akbar Khan Hospital
"……Yes, general… Yes, general…. Special Forces? …Yes, I understand… They're in transit? OK, then-… Helos……Yes, we can be ready in about fifteen minutes… …Yes, general…. …We'll do our best, sir."
The doctor gently placed the club phone on its wall mount. Clicking it into the cradle stirred up a puff of light brown dust, dust seemed to filter into everything. Even though it was practically brand new by Afghani standards, the thirty-five-year-old hospital was showing its age. Full of anachronisms. Modern medical equipment, best the U.S. Army could buy, commonly resided against walls that were only half-tiled. The fluorescent lighting above him in the narrow side hallway flickered as things moved on the floor above. In a main corridor, a code red thundered by, an IED victim on the gurney.
Shaking his head, he strode to a nearby scrub sink and began washing his hands. He wore a teal green surgical apron, filthy with bodily fluid from previous procedures, over his pixilated army combat uniform. His square, flesh-out brown leather combat boots were impregnated with dust; splotched and stained with dark red spatters. Slipping out of his sullied apron, he hung it on a peg with others over a sign reading in English and Arabic, "For disinfectant." That done, he cleansed his hands again.
Cleaning the previous operation's final lingering traces of dried blood from under his fingernails with a small brush, he glanced up wearily at a small, spotted mirror.
A short man, maybe 125 pounds, looked back at him through small, round spectacles. He was thin; he preferred wiry. Close, untidy black hair contrasted a roundish, very pale face. What made him stand out, though, what made people take a second glance at him, were his eyes – pale gray irises. A cold, penetrating, calculating color. His friends said he took on an almost reptilian appearance under high stress.
Stephen Maturin read his nametag, backwards in the reflection. He worked as head surgeon as part of a joint Army/NATO medical team in Afghanistan, running one of the largest hospitals in Kabul. Primarily treating soldiers, they saw their fair share of children and civilians injured by IEDs, crossfire, and land mines. Now in his lower sixties, in youth he had served with distinction as a surgeon in the British Royal Navy.
In youth. He shivered a little at the words, at the memories they hauled up. In his twenties, he had been a British medical intern in Vietnam, warily serving as a medical advisor during the U.S. buildup. When war finally exploded, he decided his safest chances lay where the heavy artillery was, and he volunteered with a MASH unit. He'd never forget it. He still had flashbacks.
Stephen glared at the mirror as he curled his hands under the tepid stream of water. The flashbacks. How he hated them, although he counted himself lucky, in a way. They weren't physically painful and had never interfered with his performance as a doctor. The operation flashbacks even helped him, in a cosmic way, because when he came to from his nightmare, he often found himself dealing with the same kind of case; the flashback had refreshed him on what to do.
But it infuriated him that he didn't know how to control them. He was helpless to their onslaughts, and that fact terrified him. They needed very simple triggers – a jungle smell, a Medevac helo roaring over, a young boy screaming as he died, a certain type of wound. And without warning, he would transition seamlessly into a flashback. It was as if stock footage, jerky, rough, and grainy, had been plastered over his eyes, and he was powerless to rip it away. Throughout the flashback, his body apparently functioned without him, automatically pushing a gurney or tying a bandage. Then, just as suddenly as it had come, the flashback would vanish in a blink or flash, and he'd find himself standing in front of the operating table, about to begin, knowing what he was about to do but not knowing exactly how he'd gotten there.
Snapping out of his reverie, he shut off the tap and toweled his hands with a sterilized cloth. Glancing at his watch, he snatched a clean apron off an adjacent rack and wriggled into it; the total disinfect would come just before surgery. He heard footsteps behind him.
"Who was on the line, Maturin?" asked Claire, a senior nurse, standing a few feet away, arms crossed over her surgical robe.
"Central command. We've got a spec. ops. team coming in hot. Ten, twelve minutes out. Shot up pretty bad, from what I was told."
Maturin pulled the club phone out again and rang it for the operating room. "Maturin here. We got incoming. What's available?" He waited a minute as he got the answer, then said, "Okay. Finish up that lap in OR two and clear it now. Keep three and five open. They should be hitting the doors in ten minutes or less."
He slammed the phone unit back on its wall mount and turned to Claire.
"Get the OR teams ready. I'll alert the ED."
"Yes, sir," she said. Turning, she dashed down the hall, yelling for other nurses as she went.
Maturin pushed an intercom on the wall. "Would trauma teams one and two please report to emergency," he said, listening to his own voice drift from the scratchy overhead speakers, "And please send baby arms to the H."
"Baby arms" was the term for patient receiving equipment, easing the transition from transport to theater as if gently catching a baby.
Maturin turned swiftly and ran towards the stairs. In five seconds he made it down, arriving in the Emergency Department in five more. He found the MOD (medical officer of the day) kicked back in a swivel chair, pouring over a list of the week's radio codes as he waited by the radio desk. The MOD's eyebrows perked as he saw the doctor's taut mouth.
"We got incoming," the gray-eyed doctor snapped.
"How many?" asked the MOD, tossing the list onto the counter.
"Sounds like five to six."
The MOD coolly lowered his boots off the desk and, now businesslike, straightened up in the chair. "What do we have?"
"Don't know yet. Central command didn't have specifics. But he was pretty insistent we give these guys extra special care, whoever they are. Any word on the horn yet?"
As if in answer, the radio crackled to life. "Mama Echo 21 calling Charlie Base hospital. Mama Echo 21 calling Charlie Base, over. ETA is eight minutes."
"Echo 21? That's them," Stephen said grimly.
With practiced fluidity, the MOD crabbed his chair sideways, coasted precisely to a stop, and grabbed the mike handset. "This is Charlie Base. What you got, Mike? Over."
"Hey, Will. We have six, repeat six severe traumas. All surgical cases, over. Each crew is gathering patient histories; they should all be in your inboxes by the time we land."
"Thanks; we'll check email." The MOD lifted a pen from his breast pocket and slid a notepad forward. "Give me the lowdown, Mike. Over."
"Oh-kay, first case. American, 22 year old white male, six AK rounds to the chest. Blood pressure 60 over 38, heart rate 176, losing a lot of blood. We have him intubated and on the ambu bag. He's got a pneumo. Two large bore IV's, pouring in saline. Don't know if he'll make it, over."
About this time the trauma teams assembled, four trauma surgeons under Maturin's command along with five residents, eight nurses, and seven senior interns. They filed into the ED and gathered around as the MOD jotted notes.
"Harris," Maturin barked to the first surgeon, a black American, "Take that first Yank. If he's gone by the time they arrive, take whatever you can find."
The radio sputtered again. "…Second case. Al-Qaeda. Apparently, the brass want these guys alive so they can talk. 28 years old, BP 162 over 90. Heart rate 134, respiratory rate 28. Conscious at this time. Multiple trauma wounds secondary to mortar rounds. One has penetrated his right lower chest. No evidence of pneumo at present. He's breathing on his own. Good lungs sounds in all fields. Two other fragments hit him in the epigastrium and left lower quadrant. Significant blood loss. Two wide bores, sixteen gauge in both arms. Saline going in. Morphine 10 mg given, over."
Stephen glanced at a lanky, ash-blond Canadian surgeon. "Melbourne, take that one."
The MOD readjusted the mike to clamp it between his shoulder and cheek. "Okay Mike, what's next, over."
"Third case. Al-Qaeda. 36 years old, multiple trauma wounds to abdomen. Four M-16 rounds. He's a mess, Doc. BP 90 over 42. Heart rate 165 and thready. Belly's wide open. We swabbed it with betadine and wrapped it up as best we can, but his guts are all torn up. He's been sedated with Morphine 20 mg. and Midazolam. He's intubated and on the ambu, too. We had to give him some succinylcholine to keep him from fighting us. ETA now six minutes, over."
"Jackson," said Maturin to another American, "That one's yours."
The medevac chopper pilot kept going, "Older woman, age unkown, appears to be in her late thirties. She's a goddamn horror story, Will. Face all torn apart. The ops told me she took shrapnel to the eye. We've got her backboarded to keep fragments from moving; I'm worried about her brain. BP 70 over 40. Heart rate 152. Respirations 30. Unconscious."
Maturin turned around to face his South Korean ophthalmologist, Dr. Brenniger. Without waiting for the order, the Asian removed his glasses, gave them a quick clean on his coat, and slid them back onto the bridge of his thin nose. "Certainly."
"Thank you." Stephen leaned next to the radio. "What's next, Mike?"
"32 year old black male. Al-Qaeda. Abdominal trauma for mortar round. Single mortar round wound to lower right quadrant. BP 158 over 86, heart rate 124, respirations 22. Stable, mental status intact. Tried to choke a few of the medics. We had to strap him down pretty good. He's been given 10 mg Morphine, and seems to be holding, but he's an exploratory lap for you, over."
Maturin looked sideways the MOD. "Assess that one and keep him stable. When we can, we'll get him in…."
The ED doc nodded and turned back to the radio. "Okay. Mike, what's the last one? Over."
"19-year-old white female, I repeat, white female......"
Bloody hell… thought Maturin irritably as murmuring erupted from the trauma teams as well. What in hell was some civvie doing out there? Got caught in crossfire, maybe?
"............serious stab wound to upper umbilical, BP 60 over 40, heart rate 162, respiration 32. Discovered unconscious, now on Midazolam. Moderate trauma wound to left thigh and minor trauma on both arms. Whoever gut-stuck this poor kid hit the right place. She's bleeding all over the place. One IV in right arm, only a twenty gauge. Trying to pump in the saline as fast it will take. ETA four minutes, over."
Maturin picked up the mike as the MOD scribbled. "Mike, this is Maturin. Did you say a female? Over."
"That's right, doc. Red blooded American female as any."
"American?" Goddamnit... "Brass never mentioned her!"
"Don't ask me how she got here. The face seems real familiar, but these birds don't have rear-view mirrors and nobody gave out names. The Specs in back are going apeshit over her, though. See you in three, doc. Over and out."
"Charlie Base out, Mike," He turned to the trauma teams. "My team will take that last one." He paused for effect, then clapped loudly and pointed toward across the trauma wing. "Okay boys and girls, let's rock and roll!"
Breezing through the ED complex, commonly and mistakenly known by the Yanks as simply "the ER," he slowed by the glass-walled resuscitation bays. In the operation boxes, orderlies hastily prepped for the new load, swinging bank lights forward, stripping clear plastic wrap from trays of disposable instruments, pulling squashy bags of saline and artificial blood out of drawers and stringing them on IV stands. For the brief moment, the blood pools, bandage wrappers, scissors, clothing shreds, and wrinkled strips of muscle and charred skin were gone, linoleum floors winking brightly in their place. Maturin knew they would revert to stinking pigsties in only a few minutes. Reaching the end of the ward, he strode through the double-wide automatic glass doors, stretching on disposable latex gloves as he went.
Dust swirled across the open helicopter landing area. Before him spread a large field, if small patches of yellowed, dust-choked grass could be called a field. Spray-painted at carefully measured intervals across the expanse were big, circled Hs. Maturin found himself standing with his fellow surgeons, wordlessly squinting toward the high, barren mountains to the south with uneasy anticipation. Orange gurneys shifted on the gravel. IV bags tatted against their metal supports in the light wind. Behind him, the airy, brand new trauma center gleamed in the fresh sunlight. The entire hospital was a hodge-podge of old and new wings, tacked onto one another like patches in an old skirt.
Maturin craned his head backward. He couldn't see them, which was strangely reassuring, but he knew snipers lay ready in the balconies, protecting the valuable medics against a Taliban attack.
"Hey, is that blades?" called a young anesthetist, late 20's, a fit black man with a bald head (the CRNA always shot back that it was "shaved"). He consistently reminded Stephen of that Turk fellow from the American show Scrubs.
The pale MD tilted his head to one side. It *was* helicopter rotors. Floating from the direction of the mountains, they steadily grew louder and louder. From the noise, he estimated there were at least four.
"You bet damn right they are," said Claire in a steely voice, tightening her grip on a gurney.
As the unseen choppers thumped the air, Maturin's experienced eyes picked up a dust plume rising over the ridge, not four miles distant. It meant only one thing. The birds were heavy loaded, flying just above the ground, and moving – fast.
The foreshadowing cloud of dust advanced across the far side of the mountain, rising like an approaching locomotive's smoke. Gradually, heavy bass thuds blotted out all other noise, jackhammering on their ears.
The rough phupah crescendoed to a thunder, pounding vibrations through Maturin's feet and ribcage.
As it climaxed, a convoy of four helicopters exploded over the ridge.
And Stephen Maturin was instantly transported back to Vietnam.
Mountains in the distance and the ground before him were still bare, unusual for the thick tropical forests of 'Nam, but he knew why. He was standing on Hill 937, more famously known as Hamburger Hill. Vegetation had been picked clean by firefights, massive artillery strikes, and thousands of gallons of napalm.
A contingent of olive-drab UH-1H Hueys barked toward them, a few yards over the ground, full throttle, hard-charging, pouring on the coal.
Olive drab. How Maturin loathed the color olive drab. As the machines came into focus, he could see big red crosses plastered over their noses and sliding doors.
Crosses. Perfect, Stephen thought bitterly. The best goddamn targets in the sky… The VC get paid double when they take down a dustoff…
Flying a perfect Finger Four, they banked as one in a wide circle over their heads, bleeding speed. As they turned, Stephen could see a maroon streak, like a ragged racing stripe, tracing up the side of one Huey. It started thick and dark directly beneath the closed bay door. It narrowed as it followed the curve of the tail, sucked up and back by the tail rotor. Once on the boom, it became a delicate red line, flowing backwards until the rotor blast flung it from the metal skin.
Stephen's lips curled backward as he noted its length. He knew what this was; he'd seen it many times before. It wasn't paint.
It was blood.
Some poor guy, or more, in there was mortally wounded, bleeding dry. Nothing they could do, of course, but that didn't stop him from spraying five liters of the stuff across the cabin and floor.
The choppers touched down in a staggered line, only yards to spare between the blurred main rotors. Dust sprayed. Yelling. Screams. The trauma teams charged forward. The helicopter's sliding doors rolled open as they came. Stephen ran toward the nearest helicopter, the one dripping blood. Everything moved in slow motion. Nicole and Christy, nurses from his platoon, followed him. Ducking under the blades. Felt his drab BDUs ripple in the strong wash. The Lycoming 1400-hp turbine roared in his ears. The cargo door rumbled open as he stretched his hand forward.
Out spilled a wash of crimson blood. The small waterfall cascaded over the lip and splattered over the ground, pelting the lower legs of his pants. The metallic, coppery reek of it hit him square in the face. Inside the helo was a nightmare. Dark, cramped, hot, smelly, wires and blood everywhere. A medic performed CPR to a body on a stretcher, his yells unheard over the engine noise. The soldier in question jerked sickeningly, lifelessly, as the compressions pounded on his chest. The medic wore elbow-length rubber gloves. The rubber up to his elbows shone crimson.
Live combatants turned to look at Maturin as he opened the door. Wide-eyed. Shouting in slow motion, unheard in the doctor's intense concentration. Clambering out of the chopper, struggling to lug their buddies out with them. Maturin and a nurse grabbed a patient and yanked him headfirst onto a waiting stretcher. The saline bag trailed. He grabbed it and snapped it onto the IV pole.
In one of those seconds that seem to go on forever, Maturin glanced down at the casualty he was loading. A translucent green oxygen mask strapped over his face. Large, round eyes closed. Very pale.
But… something was wrong. Maturin leaned closer, trying to figure out what.
Hold up… It's not regulation to have shoulder-length red hair... he thought dimly. He looked farther down the body, which was inexplicably dressed in a black top. Oooor a... chest...
He blinked. No usual lurch or bright flash of light. The scene didn't change. He continued to gaze at a very pretty face, one with a cute pointed nose and full lips.
The realization hit him so hard he recoiled. This was no Vietnam flashback. There never had been a Vietnam flashback. This was the real deal. And he must be staring down at the one they called Kim Possible.
Like a sports car in the middle of a gear change, he clutched for a moment. Then everything fell in, locked down, and floored it. He was back in control.
He heard Harris yell something over the roar of the Black Hawk's engine. "What?!"
"I said, my guy's gone, Stephen!"
"Okay, relieve the MOD!"
Confusion reined as less severe casualties stumbled out of the medevac bays areas and began wandering around in shock. Melbourne's team reached their patient and hurriedly loaded him on the stretcher. The saline bags flashed onto the poles and Melbourne quickly assessed him. An intern strapped a BP cuff around the terrorist's arm and a steady sinus tachycardia rhythm appeared on the monitor. The soldier himself was barely conscious, gritting his teeth from the pain, but made no sound.
"OR two, now!" yelled Melbourne, "He's stable enough. Get four units of blood stat, type O negative. Transfuse now. Type and cross four to six more units. Start Ringers at 250 cc an hour. Get a central line kit in the operating room and have the anesthetist put in a jugular line. I don't want it in the subclavian. Let's go!"
The team immediately moved off, headed for the ED doors.
In the meantime, Jackson moved his patient onto his stretcher as Harris ran over to the fourth chopper with his team. The other gut wounded terrorist was in a great deal of pain but was able to move with some help. Harris's team transferred him to a stretcher, and he grimaced from the bumps as the team dashed his stretcher over the rough ground for the hospital.
Jackson's patient was intubated and sedated. The ambu bag ventilator – a squeezable plastic pouch used to maintain respiration – was handed off by the medic to one of the interns who continued the regular respiration. The IV bags were hung on the poles and Jackson's team ran their patient to OR.
"How bad, Jackson?" shouted Maturin.
"God awful, Stephen!" he yelled back, "He'll be lucky if he doesn't end up with short gut syndrome!"
Maturin just nodded as he prepared to move his casualty.
"Go, Go, GO!" he yelled, helping Claire drag the stretcher out from under the air wash and ran with it toward the ED. As he jogged, he did a quick analysis of her condition. Multiple lacerations over the face and arms. Penetration trauma to the left thigh. No limbs missing. A knife handle, wrapped in disinfectant-soaked cloths, stuck up from the mass of reddening bandages around her middle like a fork in ice cream. He winced. Ouch… likely penetration of the stomach, so it'll be a dirty wound. Probable small intestine lacerations that will need oversewing. Pancreas might have been hit. God, I hope it didn't hit the aorta or celiac artery. No way to know until I get in there....
They burst through the sliding glass doors.
"Claire, what's her vitals?"
"BP is 60 over 40… Pulse is 146..."
"About a liter and a quarter, sir. The medic in charge of her told me the spec ops packed her guts full of QuikClot, so at least she didn't exsanguinate."
"Damn, that'll be a bitch to clean up… How long has she been on oxygen?"
"That rules out Oxycyte for now… Get her into OR 5 and hook her up to a liter of Ringer's. Then type O-negative for immediate transfusion, stat. Make sure John got her patient history, too."
As Claire shouted commands, he broke away from the cart for a moment to watch the ordered chaos swirl around him. Yelling, calls for bandages, a scalpel, ten milligrams of morphine. A calm panic.
"Hey!" he called loudly over the wheeze of breathing machines and whine of EKGs, "Get these people stabilized; I want them on this evening's transport to Landstuhl!"
Claire tapped him on the shoulder. "Sir…"
"Two casualties, the young lady and a woman, can't wait for Lands. We have to open them up now."
"The lady has acute intestinal trauma, and the woman…?"
"A blowout fracture of the right orbit secondary to trauma to the eye. Dr. Brenniger is working on her now."
"Let's get to work on the redhead, then." He felt himself slipping into an oiled, professional serenity. Claire saw his face tightening. The reptile.
They ran the stretcher down the hall to the OR suites. Assistants slit away her clothes, simultaneously covering her bared body with teal surgical drape. Bright xenon light danced off her pale skin. An EKG screeched.
The anesthesiologist pushed a dose of succinylcholine into the IV on her right arm and monitored her vitals as she quickly went limp. Finding a large vein in her upper left arm, he inserted another IV line and began pumping frigid saline solution into her body; the forced hypothermia would drastically slow tissue damage.
While the anesthesiologist double-checked his IV lines, a respiratory technician finished prepping the ventilator and replaced the ambu bag with ventilator hose, freeing up an intern to help uncover the surgical instruments.
"How 'bout that… Kim Possible, eh, John?" murmured the respiratory tech as he urged the breathing tube a little farther down the teen's throat.
"Hmm…" John muttered distractedly as he sewed the lines in. "Wonder how she got out here. And Pale Face thought she was some puking civvie… 'Scuse me."
The anesthesiologist shuffled over to Kim's neck, displacing the respiratory tech, and swabbed her throat with alcohol. Bending down, he pulled out a small plastic box from an under-table locker and ripped the paper off the top, exposing IV kit material. After donning sterile gloves, he took a small amount of lidocaine and numbed the small "V" beside her right sternocleidomastoid muscle, which started below her ear and ran down the side of her neck. Lifting an empty syringe with a twenty-gauge needle, he eased it into her neck. Two centimeters down, a sudden squirt of dark-red blood indicated he had hit the internal jugular vein. With practiced skill, he threaded a small wire through the needle into the vein and down to the girl's heart, looking over to the EKG monitor as he did so. He was rewarded with a couple of irregular blips as the metal wire caused minor short-circuits in her heart, meaning the wire was in the correct vein. John withdrew the needle and jammed a small plastic tube in its place, which went over the guide wire and into the vein to create a tunnel for the catheter.
Retrieving a large three-lumen catheter tube from the plastic kit box, he pushed it down until the stopper hub pressed against her skin, five inches of catheter tube now stuck inside her jugular vein and superior vena cava, the tip just above the heart's right atrium. He quickly used another syringe to test back-flow in each of the three lumen compartments, then flushed them with saline before stitching down the central line to prevent it from pulling out. As he finished, the Type O-negative blood arrived and he immediately hung up the first bag.
Stephen watched from just outside the door as they prepped the patient. Stripping off the contaminated latex gloves, he stepped on the foot control of the scrub sink and began a final hand-washing. After his digits became sterile, he held up his dripping hands to dry them without touching a surface and to signal he was about to operate. A nurse dried them completely with a small sterile towel and then slid fresh gloves onto his hands, being careful not to touch the finger rubber. Backing into the OR, using his shoulders to open the door as so not to soil his hands, he met Claire, already gowned and sterile.
From a table marked "Sterile," an assistant calmly fitted a puffy surgical cap on his head, tied up a mouth protector, and carefully slipped his operating goggles behind his ears.
"Thank you…" He turned to Claire. "Vitals?"
"Heart rate 144, BP 58 over 30, respirations on the vent 20."
"Flowing. Intubated at 100 percent."
"Saline is wide open in the arm. But that one's not very good. Rate's only about 80 or so. The blood's going in the central line."
"Start another saline wide open in the central line."
"Already on it, Stephen," answered the anesthesiologist.
Valves opened; fluids flowed. Kim's condition leveled out somewhat.
Maturin turned to his head nurse. "Claire, draw labs. CBC, CMP, PT, PTT, blood cultures times two. Get a d-dimer and fibrinogen while you're at it."
"What are her vent settings?"
The respiratory tech answered, "Vital capacity 600 cc. Rate 20. FiO2 1.0, PEEP of 5."
"Need ABGs now."
"Already done, sir," replied the respiratory tech proudly.
"Good work," answered Maturin, "And…?"
"pH 7.28, pO2 325, pCO2 28, bicarb 26."
"Okay, cut her FiO2 to 50%, and repeat ABGs in five minutes."
"She'll probably benefit from an arterial line for that."
Maturin glanced at John. "Do it."
The anesthesiologist grabbed an arterial line kit from the bottom of the anesthesia machine and walked around to the girl's right side. Swiftly he ducked underneath the sterile drape so as not to violate the sterile field and exposed her right inner thigh. One of the other nurses prepared the art-line monitor unit and slid it into place with its brothers on the display rack. Using a similar wire technique, the anesthesiologist put an arterial monitoring line into the girl's right femoral artery and soon had it hooked up to the module. The monitor screen soon showed the pulsating pressure waves of arterial blood flow that indicated how well blood was circulating throughout the body. It also was much more accurate in showing true blood pressure, which unfortunately showed it to be a little lower than with the external cuff, running about 52 over 26.
"Damn it!" muttered Maturin, "Have we got the dopamine ready?"
"Hanging now, doctor," said Claire.
"Start her at 20 mikes. And get some neosynephrine ready too. I feel we're going to need it as well."
"Blood pressure's up at little. 72 over 40."
"That's better, John. The dopamine's working some."
"How high do you want it before you go in?"
"I don't think I can wait."
Claire returned with the blood lab data and handed the cleanroom papers to John. "Thank you…" He skimmed through the results, making notes on a clipboard beside the anesthesia machine.
Stephen limbered his fingers. "Ready to put her under?"
"Any time you are."
"Good. Begin." As John opened the valves and monitored the sevoflurane flow rate, Maturin turned as a nurse rapped her knuckles on the open OR door.
"Doctor Maturin, sorry to interrupt, but we have the okay from the 651st Medical Company. They'll take the less severe casualties."
"Good," he replied, "Anything else?"
He turned to check the vitals monitor again, continuing the conversation over his shoulder. "…Okay, thanks for your help. Let's get those lesser casualties......–"
"…Kim! …KIM!" The strangled cry rang through the department. A blonde young man, similar to the girl in age, was attempting to break free of the medical assistants trying to hustle him around the edges of the ED, using their bodies to block the surgery from view. In a surprising show of flexibility, he broke their grasp and dashed to the transparent partition, staring, horrified, at the girl on the operating table. He reached out a hand, as if to touch her through the glass, ignoring his own cuts and bandages. The orderlies finally caught up with him and flattened him against the wall like cops. Writhing free, he pushed through the doorway.
He rushed forward but was blocked by two of the surgical techs.
"Don't touch her!" Maturin barked without turning around, "She's sterile!"
The young man looked up briefly as he lurched to a stop, face ripped with anguish.
"Kim! Don't leave! Hang on for me, OK! Hang on…! I still need to get you that soda…!"
The surgical techs managed to keep him restrained.
Maturin turned around and eyed him calmly. Ron looked up, staring at him with fear in his eyes. His pupils flickered between the doctor's face and his girlfriend on the table.
"Son, listen to me. She has a severe abdominal wound and is bleeding heavily. I have to operate. I can't have any interruptions. But we'll do everything we can, son. Stay calm for me. Can you do that?"
Ron nodded, tears streaming down his blood-streaked face.
"Nicole," said the surgeon softly, "Make sure Mr. Stoppable – I think that's his name– gets the minor surgery clinic to look at his arm… And see if you can get the folks there to calm him down as well."
"Yessir." The attractive black-haired nurse nodded to the burly medical assistants. Ron went limp and went quietly with them back to the ED.
Maturin watched a moment as he vanished into the chaos of the emergency floor, then returned to the operating field.
"Heart rate still 146, BP 65 over 40. Respirations 20."
"Damn. Can we get another large bore in her?"
"I'm on it," said the anesthetist. He went around to the left side and managed to sneak in under the sterile drape once more. Within five minutes he had a sixteen gauge in the left femoral vein. He hooked it up to another bag of normal saline.
"Open it wide."
Looking at the girl's belly, the knife stuck into the upper umbilical section of the abdomen. Blood slowly trickled out from the wound.
"Blood pressure?" he asked again.
"70 over 40."
"Okay, let's go. Keep the crash cart nearby. ...Scalpel."
He immediately felt the handle slap into his palm. He didn't even have to look; OR nurses were trained to place whatever he asked for in his hands instantly and exactly positioned for the purpose.
He made a quick incision down to the navel. Once he was through the skin, he used a sponge to mop up and control the bleeding. He handed the scalpel back.
This was a tool that cut like a scalpel, but used electric current as a cautery. It could cut and stop bleeding at the same time. Thankfully, there was virtually no abdominal fat to go through. Only hard, toned muscle.
He was soon down to the midline connective tissue. Using the bovie he sliced a line right through the linea alba, a tough midline tendon through the center of the abdominal muscles, and reached the peritoneum. This thin layer of tissue covering the abdominal organs easily fell apart to the sides.
He was handed the device by the nurse. Slipping its tongs into the surgical wound, he ratcheted the mechanism to spread the skin and muscle sections apart to reveal the abdominal organs. Now he was able to see the first hand effects of the injury, the first being the massive amount of blood in the abdominal cavity and an ungodly mess of QuikClot granules.
A suction catheter was connected by the nurse and handed to him. He then stuck the tube down into the abdomen and started to suck out the blood and fluids. The tube cracked hollowly as large, syrupy globs of QuikClot were carried away. It took him thirty seconds to get enough blood and gore out to see what was going on.
"How much did I get out?"
"Okay. Give her another two units of blood, stat. Hose."
He was down to the intestines and he could see at least two lacerations. The internal contents were slowly leaking out. These he separated out and put a towel underneath each leak to limit the spread of contaminants. He moved the transverse colon down and was able to see the knife blade going directly through the twists of the small intestine. But there was still significant bleeding coming from behind it. He used the suction to keep the area clean and had collected another 400 cc in less than a minute. Looking closer, he made out the problem. The mesenteric artery had been partially cut and was heavily bleeding.
"Pressure's falling, 68 over 35. Heart rate 156," said the anesthesiologist.
Maturin didn't acknowledge him and just kept working.
He was handed the tool and he quickly placed it across the celiac artery. This cut off blood flow to the liver, spleen and most of the intestines, but as long as he restored blood flow within fifteen minutes or so, chances of damage would be low. It was the only way he could quickly stop the bleeding and repair the artery. He quickly suctioned the cavity out again. Now it stayed uncovered as the bleeding was stopped.
"Ohhhh-kay, let's make this kid feel a lot better." He glanced behind him at one of the unsterile nurses. "Jones, right?"
"Bring a pan over. Careful. Kathy, a towel, please."
The surgeons shuffled apart to open their ring to Jones, and Kathy, a sterile nurse, laid a disinfectant-soaked cloth in Stephen's open palm. Hand protected, he reached forward, carefully wrapped his fingers around the swaddled knife handle, and slowly, gently pulled upward. Covered in blood and muck, the blade glided smoothly out. Maturin stared at the weapon in his hand for a second; its reflection hovered ghostlike in the glinting goggles around him.
Jones gazed at it with revulsion and awe as Stephen gingerly lowered it onto the waiting platter. "One… one of the soldiers told me this was bin Laden's..."
Maturin eyed it with disdain. "Then take it and toss it in the incinerator… Go wash up. Thank you."
Jones moved away and the circle closed again. Maturin looked down, refocusing his thoughts. "3-0 gut."
He was handed the suture. The laceration went halfway through the artery, but he didn't think it would need a patch. Very carefully he began to stitch the wound together. In ten minutes he had the job done and cautiously removed the cross clamp. The artery immediately puffed up with blood flow and began to leak around the stitches. But it was minimal. He dabbed at it with a sponge and stopped the bleeding completely in about five minutes.
"Pressure's still not good, Stephen," John said uneasily.
"Start the neosynephrine."
"Two mikes. Dial up to get a systolic of 90 minimum… Blood pressure?"
"Falling, 60 over 30."
"Damn!" he muttered again.
Abruptly, the life support systems went haywire. A doctor rolled a breathing machine forward. Another stood by with an amp of lidocaine.
"We're losing her! We're – !" Maturin glanced up at the heart monitor, worry etched across his brow. "V-fib!"
One of the nurses outside the sterile field charged over to the side of the OR, grabbed a defibrillator, and brought it to the bedside.
Maturin stepped away for the operating field and let the surgical techs clear the blanket away from the girl's chest. The pads were quickly affixed at the lower left side just under the breast and at the top of the sternum.
The wires were attached.
"Charge to 60 joules."
Three seconds. The machine spooled up to a tinny electrical whine.
Everyone stepped back from the OR table, hands raised.
Kim's body jumped off the table about an inch as the charge convulsed her muscles.
"Still V-Fib! Charge to 120 joules. One mg epinephrine, now!"
One of the nurses reached into the crash cart and pulled the box out. Rapidly she whipped out a syringe and removed the needle. She deftly cannulated it into one of the central line ports and pushed the liquid adrenaline all the way in.
Another shock was given. Again the girl's body writhed.
Maturin looked at the monitor. She had been in rough fibrillation rhythm. Momentarily she went back into sinus tach, but it soon degenerated back into another unstable rhythm.
"One more epi!"
It was given.
"300 joules this time."
The machine charged up.
Once more the girl's body convulsed. They waited anxiously as the monitor vitals came back online.
"Maturin, she's hanging by a thread!"
"Well, don't let her go asystole!" he shouted back, turning to the crash cart, "I don't know if it's possible for her system to take it!"
Behind him, doctors gasped.
As he whipped around, the histrionic EKG fell into one long, loud, flat unbroken scream.
April 26, 2007
Wazir Akbar Khan Hospital
To be continued...