No Place to Hide Page 10

  I opened the door, flipped on the light, and rubbed my eyes. Pete stood on the doorstep, his back bent under the weight of three overstuffed duffel bags.

  “What’s up?” I asked, motioning him in.

  Pete dropped his bags on my floor and clapped his hands on my shoulders. A smile split his face, and he reached into his pocket, retrieving a stack of papers. “I got my orders. I’m heading home tonight!”

  His words punched me in the chest. I forced a smile, reminding myself that I should be glad Pete was going home.

  As we talked, Pete dreamed out loud about his reunion with his wife and their boys. His excitement was palpable, visceral, and almost contagious. Almost. I knew that once he left, I would be on my own for a few days, and I had no idea who would be replacing him. Pete had become like a brother to me over the past weeks, and I didn’t want to lose him. My emotions were in conflict — I dreaded losing him, and yet I was happy and excited for him that he would soon be home.

  “I never thought I’d come to the war and find a friend,” Pete said. “I’m going to miss you.”

  We spent an hour praying, crying, and promising to get together if I made it home alive. Finally, fatigue overcame him, and he pulled a blanket onto the floor and fell asleep in his DCUs. I was afraid I’d sleep through the alarm and be responsible for Pete missing his ride home, so I stretched out on my bed and stared into the darkness until it was time to go. I roused him, and we walked to the hospital, where I borrowed a truck to take Pete to the airfield.

  I’ve never been very good at goodbyes, especially when I really don’t want the person to leave. But this wasn’t the time to say, “Why don’t you stay a few more days?” Instead, I put my hand on Pete’s shoulder and said, “Thanks for taking care of me here. I’ll be praying for you.”

  Pete smiled and shook my hand, then pulled me into a hug. He looked in my eyes. “You’ll do fine.”

  Over the next few days I sank into a mental funk, feeling sorry for myself and worrying about everything. The news that Pete had made it home safely made me feel relieved and jealous and sad all at the same time. I resented that, because I’d had to come early, I didn’t get to train with and integrate into the team that would arrive soon — and yet I’d arrived too late to ever fully be a part of Pete’s group. I felt like I was in no-man’s-land. But at least I felt that I’d carved out a place for myself.

  As the replacements began to arrive, I worried: Would the new guys be competent and effective? Would I find a friend, someone to grow close to — a Pete? I felt as if I was losing a family I’d just been accepted into. We had been through mass casualties together, saved and lost lives together, been there for each other. I had overcome my inexperience and proved myself worthy of being one of them, been made welcome in their family.

  After we finished working through the casualties on the last day we all worked together, the Trauma Czar stopped me in the hall and put his hand on my shoulder.

  “Major,” he said, and then leaned closer. “Lee, you’ve learned fast. The new group will be better because of your experience. Good job.”

  That was the only time he ever said my first name.

  CHAPTER 10

  THE IRAQI TODDLER

  EMAIL HOME

  Saturday, January 22, 2005

  Good morning, everyone.

  Yesterday I ran into a lot of new people. Most of the new surgeons are here now (except for my new partner, who is supposed to arrive tomorrow), and it’s funny to see the same fear and excitement that must have filled my eyes twenty-three days ago when I got here. I feel like one of the old guys now, helping people find things and showing them around.

  The people whose replacements haven’t arrived yet seem like they’re holding on for dear life. They don’t smile; they shuffle around doing their jobs, but there’s a pervasive sense of “let’s get this thing done so we can go home.”

  We have letters and artwork from school kids all over America hanging throughout the hospital. It feels very strange the first time you open a letter and it’s addressed to “Dear American Soldier.” I always thought of myself as a doctor who sort of happened to work for the Air Force.

  Now, though, I see clearly that first and foremost I am an American soldier (albeit a noncombatant per Geneva Convention rules). I am, for better or worse, one of the guys the mortars are aimed at. I am a GI, in a foreign country during a war. That’s a far cry from my life as the little cotton-headed kid with the cowlick from Broken Bow, Oklahoma. And it’s a far cry from my comfortable, Starbucks-visiting, BMW-driving, high-tech-surgery-performing life in San Antonio.

  Here our suctions operate on a pump, and we have to turn them off during surgery because they are so loud we can’t hear the anesthesia guys talking to us. I’m operating on guys who hate me, saving their lives so that we can send them home to the desert, and I’ll never know if they get adequate follow-up care. This couldn’t be more different from my life in the States. We’re all adjusting, but this experience will definitely change my perspective on the things I thought were problems at home. None of them seem so important now.

  I love you all and hope to hear from you.

  Lee

  EMAIL HOME

  Sunday, January 23, 2005

  Good morning from the frozen wetlands!

  Yesterday’s weather was absolutely atrocious. It rained all day and all night, and it’s freezing and very windy. There is standing water in the hospital, and a huge lake out in front that I had to walk across to go back to my trailer last night. Everywhere that isn’t covered in water is covered in mud — a very thick clay.

  Yesterday started with a simulated multi-patient disaster. All hospital personnel were called in and had to pretend to examine, transport, operate on, and care for a huge group of fake patients that all arrived at once. It was chaotic, but it was also a great way to get all the new folks oriented to the process. It was actually a little worse than the real mass casualties I have worked since I’ve been here, but I think that’s only because there were twice as many people as there would be in a real situation. All the last group of doctors are gone, but the techs and nurses stayed a few extra days to train their replacements, so hopefully the transition will go smoothly. I’ve been through a couple of real mass-casualty situations, and I feel confident that we can do it when it happens again. Unfortunately, it will.

  Keep praying.

  Lee

  Just as I thought my day was about to end, my beeper went off.

  I looked down at the pager. Its “911” message ended my plans to go to the gym. Back to the emergency room for me.

  The tech manning the radio in the ER looked up from her desk as I ran in.

  “Black Hawk’s five minutes out. They’ve got a two-year-old Iraqi boy with a head injury from a car accident. He’s not moving.”

  Perfect, I thought. Pete’s back in Ohio, and I’ve got a baby coming in with a brain injury. My new partner was probably having a coffee at Al Udeid, and nobody else in the hospital had even scrubbed into a case here yet. I said a quick prayer that the new anesthesia people and nurses were good at their jobs and grabbed the phone to call the radiology tech.

  A voice I’d never heard before answered. “X-ray, Airman Hernandez.”

  “It’s Warren, the neurosurgeon. We may have a case. Get the CT scanner ready and tell the OR to stand by to do a craniotomy.”

  It was a cold, cloudy day, and the chopper came in hot, no turn into the wind and no easy flare like the pilots did when they knew we were watching. I’ve noticed over the years that even in civilian hospitals everyone seems to move a little faster when a child’s life is in jeopardy. The medics jumped from the Black Hawk even before the skids completely hit the helipad. I sprinted across the Tarmac with a nurse and two techs pushing a gurney.

  The gunner yelled over the noise: “Car wreck near Tikrit seven hours ago. Baby’s not moving purposefully.”

  The medics set the litter onto the gurney, and I looked down a
t the smallest person I’d seen in the war. He was zipped into a body bag, with only his little face protruding. The medics had inserted a breathing tube during the flight, and one of them squeezed the tiny blue breathing bag every couple of seconds. Someone had figured out that putting people into body bags kept them warm during transport, improving people’s outcomes after major trauma. I still wasn’t used to seeing living people wrapped in the shrouds of the dead, but it worked. Seeing a two-year-old in a body bag, however, was another thing altogether.

  We got him into the ER and unzipped the bag. Other than the bloody gauze on his head, he was a perfect, healthy-looking baby. I’d seen plenty of patients, even babies, with brain injuries from motor vehicle crashes, so I was expecting a big scalp laceration or maybe a depressed skull fracture. But when I removed the boy’s head wrap, I saw that his injury had not come from a car wreck.

  He’d been shot in the head.

  His pupils were nonreactive, indicating that the pressure inside his head was far too high and his brain was not receiving enough blood flow. The CT scan showed a huge and expanding blood clot between the skull and the brain, known as a subdural hematoma. Without immediate surgery, he would die. He’d arrived for help so long after his injury because bad weather had delayed the flight. Because of his dilated and nonreactive pupils, and because so many hours had gone by since his injury, his chances of survival and recovery were slim.

  Slimmer too, I thought, because I was alone. I’m not a pediatric neurosurgeon, and although all brain surgeons are trained to work on kids, there are major differences in how we care for babies as compared to adults. I hadn’t operated on such a small person in a couple of years, and I was nervous. Especially since there was nobody there who could bail me out if I got into trouble during the surgery.

  “Let’s move, people. This little guy’s out of time,” I said.

  Three minutes later, we were in the operating room, and I was shaving the baby’s head. A nurse poured brownish-red iodine solution on the boy’s scalp and scrubbed the skin. I watched as the fluid mixed with his blood and soap bubbles ran onto his chest, where I noticed that someone had written 2013.

  “Knife!” I yelled over the roar of the suction pumps.

  I was comforted by the familiar slap of metal on my palm, and I looked up into the only face I recognized. Nate was scrubbed in with me, the only other person in the entire hospital who had ever previously scrubbed into a case here.

  I pulled the knife through the paper-thin scalp, making a question-mark-shaped incision that began just in front of his ear, curving backward and then upward, ending just behind the hairline in the middle of his forehead. I peeled back his scalp and the underlying muscle and saw the stark white of his temporal, parietal, and frontal bones.

  The scalp was maybe four or five millimeters thick, less than a quarter inch. Every time I placed forceps on his skin, they left an imprint. I remembered my pediatric neurosurgery professor, Dr. John Myseros, teaching me how delicately the infant scalp must be handled, or the injured skin may fail to heal. I had to be extra careful, since all my instruments were designed for use on adults.

  Every drop of blood counts in surgery. Adults have about six liters of blood in their bodies. Babies the size of 2013 have less than a liter, and he had already lost some. I tried to stop the scalp bleeding with Rainey clips, but they simply fell off. Again, no one had thought to include pediatric Raineys in the instrument sets. I used the cautery to cook a big scalp artery that was costing him a lot of blood, but worried about his little scalp healing if I compromised the blood flow.

  “Pressure’s pretty low, Doc,” said the anesthetist, whose name I did not yet know.

  “Give him more saline and type his blood.”

  I got control of the scalp, and it was time to open his skull. His blood pressure and my worries about his scalp would be irrelevant if I didn’t get that clot out in time.

  From the corner of my eye I saw movement. I turned to see a tall, extremely thin man being gowned by the scrub tech. Someone was scrubbing into my case.

  He stepped up to the table and said, “I heard you had a baby in here. Mind if I help, Lee?”

  I looked into his eyes, since the rest of his face was masked, and recognized Chris, a pediatric surgeon with an office a few doors down from mine at Wilford Hall. We had worked together on a few cases, but never operated together before. I hardly knew him. What was he doing here?

  Chris must have seen the wonder in my eyes. “I got deployed as a general surgeon, just arrived today. I’ve never done a craniotomy before, but I can help you with the post-op care.”

  The kid’s prospects for survival had just improved dramatically. “Glad to have you. Drill.”

  Nate handed me the drill, a one-hundred-thousand-rpm, nitrogen-powered, precision instrument with a bone-cutting bur 1.5 millimeters thick. I removed a large piece of his skull, revealing the thick, leathery covering over his brain known as the dura.

  The dura bulged out of the head menacingly, red and angry and, worst of all, not pulsating. Normally the heartbeat is transmitted through the dura, and it pulses gently in and out of the edges of the skull. 2013’s dura was rigid and still. Not a good sign.

  Nate handed me a very small scalpel, and I sliced through the dura. Immediately, thick, clotted red blood began to squeeze through the opening. I thought of my mentor Dr. Baghai and his coolness in this situation. I thought, Control this, Lee — do not let this kid die. With scissors, I extended the dural opening, and a congealed, formed clot slid through and fell out of the baby’s head. It looked like a piece of liver, and once it fell out I could see the swollen brain.

  A large artery was pumping blood, and it squirted up into my face as I tried to gain control of it with cauterizing forceps. Once the bleeding was stopped, I pointed at the brain and said to Chris, “Pressure’s off now. Say a prayer that the brain will start to pulsate. If it doesn’t, we may have been too late.”

  We watched for what seemed like hours, and slowly the brain began to move. With every heartbeat, the brain turned less and less red, eventually achieving the healthier pink color of a normal brain.

  I knew from the CT scan that the bullet had lodged just under the surface of the frontal lobe. Other than tearing the artery, which had caused the near-fatal subdural bleeding, the bullet itself hadn’t done a whole lot of brain damage. I started to let myself believe that this kid could not only survive but maybe recover.

  I dipped my little finger in sterile saline solution to make it slippery, then gently felt inside the hole in the frontal lobe. I could feel the metal bullet fragment there. Using the smallest forceps I could find, I pulled the bullet out and dropped it into a metal pan. When he heard the clinking sound you always hear on TV when doctors remove bullets, Nate laughed out loud. I turned to him to see what was funny.

  “I’ve never heard that sound in real life before. The pans we use in America are plastic.”

  He was right; I’d never heard it either.

  Chris nudged me and pointed at the brain. “What’s that?”

  I looked down and saw where he was pointing. A dark blue vein the size of a small sausage snaked across the surface of the boy’s brain. It looked tense and swollen, as if it might burst.

  “Vein of Labbé,” I said. “It’s the only way out for most of the blood in his brain. If it clots off, he’ll die.”

  “What can we do to prevent that?”

  I shook my head. “Keep his blood pressure up, keep him hydrated, and pray.”

  As I sewed the dura back together, I had a big decision to make. Should I put the bone back in, or leave it out? If I left it out, the baby would have to have another operation later, assuming he survived — a second chance for this dusty, makeshift operating room to expose him to infection, bleeding, and the general perils of brain surgery. But if I put it back in, he would be at risk for high intracranial pressure if his brain swelling worsened.

  I looked at his brain, still pulsing nic
ely and now nearly as pink as a normal brain. When I was a resident and we were discussing theoretical surgical problems, we used to jokingly say, “WWJD” — meaning not “What Would Jesus Do?” but rather “What Would Jack Do?” Jack Wilberger was our department chairman, and he was (and still is) known for his sage wisdom and thoughtful solutions to difficult problems.

  Dr. Wilberger and Dr. Baghai and the rest of my old professors weren’t available to me for questions now, though. I remembered a piece of advice one of my fellow residents had given me: When there isn’t a right answer, brain surgeons have to make a decision and “Just sell it, baby.”

  So I stood there for a few seconds, saying a prayer without hearing an answer, and made my decision. JSIB, I thought.

  “Nate, hand me the bone flap.”

  I taught Chris how to attach the flap back to the rest of the skull, and he taught me a few things about sewing the thin, delicate scalp together. I put in an ICP monitor, and a comforting green 0 showed on the screen.

  We rolled the baby down the hall to the ICU. I wondered who there would help us take care of him. Two soldiers stood in the hall, and one of them spoke as we passed by. “Doc, we heard that his parents tried to run a checkpoint. Marines had to shoot into the car. Both of them died.”

  I looked down at this precious Iraqi baby, 2013, and wondered how a brain-injured orphan would survive the war, and what would happen to him if he did.

  CHAPTER 11

  THIS KID’S GONNA DIE, AND IT’S MY FAULT

  I was standing on the helipad, watching a huge, twin-rotor Chinook fly away from the hospital. Actually, I learned after the war that the helicopters everyone called Chinooks were really CH – 46 Sea Knights, a slightly smaller Marine Corps version of the Army’s CH – 47 Chinooks.

  I’d learned to recognize the difference in the sound of different types of aircraft, so that I could usually tell by the sound whether an approaching helicopter was likely to bring me business. Those we called Chinooks almost never flew in the daytime, probably because they offered such a slow and massive target. This one had landed at the hospital several hours before, after delivering a few banged-up Marines who needed minor care. I had a cup of coffee with the crew, and they let me look around inside the chopper before they took off to get back to their base before sunrise.