Authors: Mary Roach
The corpsman trainee working on Caezar is having difficulty with the tourniquet. Like Baker, he’s a fine, fumbling example of the downside of an adrenaline rush. An instructor puts his head through the doorway. “What are we doing in here, fuckin’ organ transplant? Let’s go!”
If the scenario were real, Caezar would be dead by now. With a large artery bleed, it can take less than two minutes for the human heart—and, no coincidence, the Strategic Operations Blood Pumping System—to hemorrhage three liters: a fatal loss. The human body holds five liters of blood, but with three gone, electrolyte balance falls gravely out of whack, and there’s not enough circulating oxygen to keep vital organs up and running. Hemorrhagic shock—“bleeding out”—is the most common cause of death in combat.
This is the grim calculus of emergency trauma care. The more devastating the wounds, the less time there is to stabilize the patient. The less time there is and the graver the consequences, the more pressure medics are under—and the more likely they are to make mistakes. In a 2009 review of twenty-two studies on the effects of “stressful crises” in the operating room, surgeons’ performance was reliably compromised: not only their technical skills but their ability to make good decisions and communicate effectively. And the stressful crises of the operating room—defined in this study as bleeding, equipment malfunctions, distractions, and time pressure—are business as usual in a theater of war.
Caezar exits the scene in a fireman carry, draped around a trainee’s neck like a heavy mink stole. Baker follows behind with the stretcher. He’s struggling because his palms are sweaty. He sets down his end in order to wipe his hands on his pants—again, without alerting the guy holding the other end.
“
Really,
Baker?” Palm sweat is a feature of fight-or-flight thought to have evolved to improve one’s grip, but too much of it obviously has the opposite effect. “Put your fuckin’ little girl gloves on if you have to.”
The instructors are mean for a reason. They aim to subject the trainees to as much fear and stress as they can without actually shooting at them. The entire experience—the mock injuries, the gunfire and explosion sounds, the anguish of being called a little girl in front of everyone—is meant to function as a sort of emotional vaccine. Combat training for all troops, not just medics, has traditionally included exposure to some kind of simulated gore and mayhem. For years, writes Colonel Ricardo Love in his 2011 paper “Psychological Resilience: Preparing Our Soldiers for War,” commanders have shown their charges photos and videos of gruesome injuries, or brought in veterans to talk about “the horrors they experienced.” To help prepare future corpsmen, the Naval Health Research Center hands out copies of
The Docs
, a 200-page comic book with lurid drawings of blast and gunshot injuries—a graphic graphic novel.
The pyrotechnics and battle soundtrack not only add realism but also kick-start the fight-or-flight reaction. Sudden loud noise triggers a cluster of split-second protective reflexes known as the startle pattern. You blink to protect your eyes, while your upper body swivels toward the sound to assess the threat. The arms bend and retract to the chest, the shoulders hunch, and the knees bend, all of which combine to make you a smaller, less noticeable target. Snapping the limbs in tight to the torso may also serve to protect your vital innards.
‡
You are your own human shield. Siddle says hunching may have evolved to protect the neck: a holdover from caveman days. “A big cat stalking prey will jump the last twenty feet and come down on the back and shoulders and bite through the neck.”
This may lead you to wonder, do impalas and zebras exhibit the startle pattern? And you would not be first in wondering. In 1938, psychologist Carney Landis spent some time at the Bronx Zoological Park, testing the evolutionary reach of the startle pattern, and the patience of zoo staff. In exhibit after exhibit, Landis could be seen setting up his movie camera and firing a .32-caliber revolver into the air. Less unsettling for zoo visitors—and more entertaining—would have been the experimental technique of fellow startle response researcher Joshua Rosett, who snuck up behind his (human) subjects and flicked the outer edge of their ear with his index finger. I imagine it was a trying time for the Rosett family.
The Bronx Zoo had no impalas, but they did have a goatlike Himalayan tahr, and it was duly startled. As was the two-toed sloth, the honey badger, the kinkajou, the dingo, the Tibetan bear, the jackal, and every other mammal that endured the scientific obnoxiousness of Carney Landis.
You will not be startled to learn that Landis’s book-length treatment of the topic,
The Startle Pattern,
fell somewhat shy of runaway success.
T
ODAY’S SECOND
scenario is a simulation of the aftermath of an explosion on a Navy destroyer. I have a symptom this time: smoke inhalation burns, which entitles me to some lines and a perioral dusting of soot. The set comprises a room of sailors’ bunks, or “racks,” and a sick bay down the hall. Catwalks overhead allow instructors to observe the trainees and hurl down invective.
The sight of smoke from a smoke machine is our cue to action. Five of us lie on racks in the dark, emoting amateurishly. I tell the trainee who comes to my aid that it hurts to breathe. He helps me out of my rack and steers me out to the hall. “Right this way, ma’am,” he keeps saying, as though my table awaits. He shouts ahead that I’m going to be the priority. “Ma’am, we’re going to have to crike you. Do you know that that means? We’re going to make a small incision right here.” He touches the front of my neck. Crike is short for cricothyrotomy. They’re going to pretend to cut an emergency airway for me to breathe through.
“You are?” My symptoms only call for oxygen.
“Yes, we are. Because you can’t breathe.” I’m lifted onto the sick bay exam table.
“Well, it’s more that it
hurts
to breathe.” I’m trying to give a hint. “It
burns
.”
The trainee picks up a scalpel. A voice sounds from above, like God calling to Abraham. “Stop!” It’s one of the instructors. “She’s talking to you, right? Then she’s breathing. She doesn’t need that.”
Someone else yells, “Blood sweeps!” A corpsman trainee reaches under my back and slides both hands from shoulders to hips. He looks at his hands, checking for blood, for a wound that might have been overlooked. If you don’t happen to be wounded, blood sweeps feel lovely.
My massage is short-lived. I’m carried back out to the hallway and set down beside another amputee actor, Megan Lockett. I saw Megan in the makeup room earlier. The special effects gore was still wet on her stump. She sat with her legs crossed, idly scrolling on her phone. It was like lions had come and gnawed off her foot while she checked Facebook.
The floor is slick with blood. Megan is having a bleeder malfunction. A pair of trainees skid and slip, trying not to drop the latest priority victim, a man wearing a tourniquet on his lower leg where a sock garter, in more civilized circumstances, might go. They plop him down on the exam table.
“And why is this guy so important?” yells God from on high.
“Open fracture!” someone tries.
“Is he dying? No, he’s not!” More loudly now: “Who’s dying, people? Who is the most likely to die?” No answer. God’s hand points at Megan. Megan raises her stump.
Hello, boys!
“What does this patient look like she has?”
Two trainees rush over to get Megan, while Open Fracture joins me in the hallway of survivable maladies. I try to make some room, but my pants are sticking to the floor. I learn later that Karo syrup is the main ingredient in special effects blood. This makes life safer and more pleasant for actors whose role calls for them to cough up blood, but if it dries while you sit or stand in it, you will fuse to the floor like a candy apple on a baking tray.
When it’s all over, the trainees are called to a debriefing on the pavement outside the set. An instructor named Cheech starts it off.
“That was godawful. You lost your minds. A woman who’s missing a leg should have been the number one priority.”
Excuses are offered. It was dark. Smoky. She was down on the floor.
“There was one patient standing in the middle of the room,” Cheech says. “
Standing in the middle of the room.
And no one paid any attention to him. You need to make your bubble bigger. Don’t get fuckin’ tunnel vision.”
The technical term for fuckin’ tunnel vision is attentional narrowing. It’s another prehistorically helpful but now potentially disastrous feature of the survival stress response. One focuses on the threat to the exclusion of almost everything else. Bruce Siddle tells a story about a doctor who had some fun with an anxious intern. He sent him across the emergency room to sew up a car crash victim’s lacerations. The intern was so intent on his stitching that he failed to notice his patient was dead.
I
T IS
easy to get lost on the way to the Strategic Operations bathroom, and very entertaining. You might pass a rack of freshly painted excretory systems hanging in the sun to dry, or a man seated at a workbench, trimming the seams of a molded silicone Cut Suit penis.
§
You might overhear a person say to another person, “If you use different blood, it voids the warranty.” At one point I take a wrong turn and find myself in a storage area. A filing cabinet drawer is labeled “Spleens.” “Aortas,” another says. On the top of the cabinet, Cut Suit skins are folded like blankets. When I finally find the bathroom, the sign on the door, which uses the military slang “HEAD,” confuses me in a way it would ordinarily not have.
Making my way back, I pass a Cut Suit training tutorial and decide to sit in. A woman with creamy tanned skin and variegated blonde hair stands at a table with the suit’s various components, which she is demonstrating, like Tupperware, to two Marines from Camp Pendleton. (The Marine Corps had just purchased one of the suits, and the two Marines, Ali and Michelle, were training to be Cut Suit Operators.) The teacher, Jenny, shows them how to unsnap the “visceral lining” to access the abdominal organs. “You can do an evisceration,” she says pleasantly, and notes that a slashed latex lining can be simply discarded and replaced.
¶
Visceral Linings are available for purchase in packages of two hundred. It seems like a crazy amount of evisceration.
Jenny picks up a loose intestine and tells Ali and Michelle that they could, if they wished, fill it with simulated feces that they could make themselves, using oatmeal dyed brown and scented with a party novelty called Liquid Ass. The Cut Suit training coordinator, Jaime de la Parra, used to travel to conferences with Liquid Ass in his luggage, for demonstrations. Other employees, including Jenny, do not, and recently Jaime asked her why. “I told him: ‘Because no one will come to our booth.’”
Segall, the Cut Suit’s inventor, is proud of its realism, and justly so. Still, no matter how rank the intestines smell or how realistically the amputee’s stump is bleeding, students must know it’s not real. No one hacks off a limb to train a group of medics.
Or not a human limb, anyway.
A
S FAR
back as the 1960s, students of combat trauma medicine have practiced life-saving procedures on anesthetized pigs and goats. There would be no issue here, except for the fact that barnyard animals don’t naturally wind up in situations where they’re shot or stabbed or blown up by an IED. So the only way to train students on them is to hire a company to do the shooting or stabbing or leg-removing. There’s one of those companies not far from here.
Live tissue training is the topic of conversation at lunch today, on the back deck of Stu Segall’s diner. Stu and I are joined by Kit Lavell, the company’s executive vice president. Lavell fills me in on legislation that would require the Department of Defense to reduce the number of animals used for live tissue training from the 2015 level—about eighty-five hundred per year—to somewhere between three and five thousand. An animal rights organization called Physicians Committee for Responsible Medicine is behind the push. Advances in patient simulators—and high-drama Cut Suit demos before members of Congress—have made it harder for defenders of live tissue training to make their case.
Unfortunately for pigs, the layout and size of their viscera approximate ours, as do their blood pressure and the rate at which they bleed. Goats are better for practicing emergency airway procedures, as there’s not four inches of neck fat to slice through.
I watched a YouTube clip purporting to be part of a live tissue training class that someone surreptitiously filmed. A group of men stand around a folding table on a rainy day. A makeshift roof with a tarp drips overhead. Two or three men at a time lean over an inert pig laid out on the table. Their backs are to the camera. They chat quietly. They look like pit masters at a whole-hog barbecue. A veterinarian is there, and you can hear someone ask him to give the animal a bump, meaning more anesthesia. The leg amputation happens off-camera, but you can see the instrument the instructor uses: a set of long-handled shears of the sort one might use to cut through chain link. It sounds ghastly but gets the job done quickly. Assuming the anesthetic was competently administered, the proceedings struck me as no more upsetting than what goes on in slaughterhouses every day in the name of bacon and chops and short rib ragu.
For that very reason, Siddle feels, it’s an incomplete “stress inoculation.” “While it’s a good experience to work on something live, something that pumps, it’s not a human. It’s not screaming.” To gain experience with actual screaming humans, Camp Pendleton’s corpsman trainees may spend time observing and helping out in an emergency room in a gang-saturated Los Angeles neighborhood. “That’s our equivalent of Iraq or Afghanistan,” Ali said earlier. “Gunshots, strafings, stabbings.”
Michelle, the other Cut Suit Operator-in training, experienced both live tissue training and a stint in an emergency room. She found them helpful in different ways. Live tissue training provides a controlled teaching environment. Students can try things out, grab a slippery artery between two fingers to stanch a bleed. “You’re not,” she said, “going to be doing that with a patient in an emergency room.”