Paradise General (12 page)

“But you have to trust me, if it's better that your leg comes off to save your life, I'm going to do that. For you and for your family. I'm going to take really good care of you. I promise. So let's give you some medicine to take the pain away and help you relax.”

The fear slowly melted off the soldier's face, but as Bill turned, it was devastating to see the price he had paid for speaking the words. Bill knew the leg was finished, and could probably remove what was left with a simple pair of scissors. He was being held prisoner by one of the new medical axioms of this war: lose the limb, save the life. As would be the case with stretchers filled with assaulted extremities this summer, Bill would decide that a young soldier alive with a good prosthetic was better than a young soldier sent home in a coffin. Bill looked like he had aged thirty years in the course of this one conversation, his face a foreshadowing of the horrible decisions we all would be forced to make this summer without time for deep contemplation or thought.

Wiped out from just surveying the carnage, I pitched in and helped out a scrambling Gerry, then walked back to my quarters for a quick nap before my evening shift. As I started to doze, my pager went off.
Shit. What do they need?
The pager simply read: “A controlled detonation will take place in fifteen minutes.” Someone must have found
an unexploded shell on the base, or an IED just outside the wire. The standard procedure for a “controlled det” was to blow it up before it could hurt someone, and it seemed like a good idea to give us all a warning so we wouldn't shit our pants when the base rumbled from the big bang. Now unable to doze, I sat on the edge of my bunk like it was New Year's Eve, watching the countdown tick away the fifteen minutes. Then when the moment came for the climax, there weren't any noisemakers besides the ever-present rumble of the generators and occasional helicopter buzzing the camp. Twenty minutes, thirty minutes, forty minutes—zip zilch nada. Thanks for the warning but how about delivering on the promise? Sleep was now out of the question. I headed over to the DFAC, grabbing a paper plate of dried-out ham-and-cheese sandwiches to provide some energy for the night ahead.

Gerry had done a nice job of clearing the place out, and as I locked away my pistol, he gave me the change-of-shift report.

“We've got an urgent litter with an ETA of twenty mikes. Sounds like an EPW with a GSW to the pelvis.”

“So in English, we've got a bad guy shot in the gut coming in by chopper in about twenty minutes and he ain't walking in on his own two feet. Gerry, why do you insist on trying to fuck with my head?”

“Pure love and affection for a colleague as well as understanding the unique machinations of the military.”

“Shit, Gerry, you love the Army so much, you probably carry pictures of it in your wallet.”

Almost twenty minutes to the second, the doors crashed open with a hurrying bloodstained stretcher whose occupant had skin the color of wax paper. The rolling wheels left bloody tracks on the floor.

“Gunshot wound pelvis. BP 100/48. Pulse 140. Spontaneous respirations 36.”

The flight medic's voice was rapid-fire and businesslike. As our staff went to work to secure IV lines and cut off clothing, he pulled me aside.

“This might be the asshole who planted the IEDs that got our folks this morning. They caught him digging some new holes in the same area and nailed him when he took off.”

The rest of the story dissolved into a distant mishmash of words. The only thing I could hear was the voice from earlier in the day: “God, please don't take my leg.” The echo of that voice mixed with the high-pitched moaning coming from our new patient. The bomber.

It was now our job to save the life of an insurgent who could have been the one who took out three of our GIs this morning, leaving them with mangled limbs and scarred faces. If they were lucky to survive our fast-food surgery, they faced a new life where every morning began with strapping on a fake leg and a look into a mirror that answered with a face that didn't look like the one they had left home with.

I turned and stared at my medics as they cut off clothing and hung IVs. Young kids. Should be home. Going to parties. Gorging on pizza. I tried to picture them in civilian clothes but all I could see was reality.

Sweat dripping into eyes. Nostrils flaring. Shallow panting breaths. They didn't look at who this guy really was—the enemy—they just knew he was a patient and did what they would do with any other patient.

My exam told me the insurgent was in bad shape and going down the tank rapidly; a couple of gunshot wounds to the pelvis and groin put him into the downward spiral of shock. We started pumping blood into him as fast as we could—American blood—then paged Rick and Bernard. They hustled over quickly from the barracks, took one look, and ordered the insurgent wheeled into surgery.

Their next looks were to me, an odd silent exchange. Here we were: American doctors dressed as American soldiers. We wear uniforms, carry weapons, and even salute when we have to. Now we faced the litmus test of our oaths: military versus Hippocrates. Tonight, as Rick and Bernard broke their gazes and strode toward the OR, it was clear Hippocrates won, and though we didn't dwell on
it at the time, so did American values. No flags waving, no rousing speeches, no Fourth of July fireworks—we just did what we had been trained to do.

I think we have an advantage as doctors. We go into auto mode, a skill we begin learning the first days of internship and residency. It's no longer a good guy/bad guy/I don't know what side he's on guy. We see bleeding—we see broken—we see things that need fixing.

That night, Rick and Bernard spent six hours trying to plug the leaks in an enemy pelvis made by American bullets. The X-rays on the OR viewbox didn't list nationality, the scalpel didn't cut differently into flesh that was hostile, and the blood pooling inside the pelvis was just as red as what flowed through our veins.

As Rick and Bernard tried to embroider together a torn-apart body, I worked away in the ER, caring for several guys whose truck had hit a roadside bomb. Their wounds weren't life-threatening, so when word filtered from the OR that my friends needed a quick extra set of hands, I left my American soldiers and scrubbed in for a short time. What kind of doctor walked away from his own GIs to try to save an enemy bomber?

As I pushed open the doors of the OR, I was greeted by the voice of Jimmy Ruffin softly playing in the background, asking what becomes of the brokenhearted?

The tune was accompanied by the steady beat of a heart monitor and the “whoosh-whoosh-whoosh” of the ventilator pushing a rhythmic flow of air into the insurgent's lungs. As I edged my way toward the table, I glanced at the bomber's pale and sickly face. On top of the pastiness sat the slightest wisp of a mustache.

“Where do you want me?” I asked.

Rick positioned me next to Bernard on the far side of the table, my main job being to suction pooled blood out of the depths of the abdomen. Besides the faint music in the background, there were few words heard. It was all business.

“Mayo retractor.”

“Kelly clamp.”

“Curved snips.”

“Metzenbaum.”

“Dave, shift to your left for a second, we got to get down in there. Can't see.”

I pushed a step to the side and bumped into a body that wasn't supposed to be in my way. Before I could open my mouth, I realized it was our chaplain. She was bent over at the head of the OR table, her hand tightly grasping the limp hand of the insurgent. Through her mask, I could see the faint facial movements of her mouthing a prayer. I wondered who she was praying to. The God I believed in? Allah? Some generic Supreme Being? I guess it didn't matter. Our chaplain would come and hold the hand of any critical patient on the table; friend or foe, there was no distinction. She took the same approach as we physicians; it was a human being on the table, one that needed urgent medical or spiritual care. The right, wrong, or morality of it could be argued by others. Others that weren't in the room and standing in our bloody boots.

The case continued.

“Adson forceps.”

“Sponge. No, give me two or three. Quick.”

“More suction. C'mon, Dave, faster.”

“Now tie that bleeder off. Atta boy.”

As I watched Rick and Bernard move in concert, it seemed like they'd worked together for decades. They were maestros in the OR; I, on the other hand, was tone-deaf. But their patience with me was infinite.

After twenty units of American blood and buckets of American sweat, Rick and Bernard closed the abdomen and pelvis. It looked like the IED planter might make it.

As I walked through the blanketed door of the OR, I saw the first peek of dawn. Almost twenty-four hours had passed since I lay in my bunk dreading my first night shift, a shift that turned out much
differently than I expected. Things moved so quickly that instead of fear, my biggest battle was one of ethics. I cleared the remaining soldiers out of the ER and met up with Rick and Bernard at the chow hall for a meal the clock said was breakfast.

They were silent except for occasional spurts of exhausted anxiety. We all hated the guy for what he had done to our soldiers, yet the conversation kept on drifting into a weird doctor-speak of “I hope that oozing stops” and “that left kidney did not look good” followed by “those retroperitoneal tears are a bitch” and “I'll go back and check on him, you go to bed.” I know they replayed the surgery over and over in their heads, just like all good doctors do.

The insurgent survived the dawn—due in large part to our ICU nurses—but later that morning started to bleed again. No matter how many units of blood and blood products he got, his body was shutting down. He needed to go to surgery again.

This time I scrubbed in with Rick and Bernard from the start. They had done a helluva job putting together the jigsaw puzzle that was once a functioning abdomen. Yet no matter what, when a person's blood stops clotting, there is nothing more you can do. The insurgent went into cardiac arrest three times on the table, and three times we shocked him back to life. Yet it wasn't enough. There was nothing left to sew, because with every stick of the needled suture, a fresh flow of blood began.

We were witnessing the “rude unhinging of the machinery of life”—a phrase coined during the Civil War to describe the process of a body rapidly going into shock, a condition where blood ceases to clot, blood pressure plummets, and the heart exhausts itself to a standstill. Throughout the ages, countless physicians have stood by helplessly as their patients spiraled down the pathway to death; there was nothing they could do to halt the journey. We reluctantly joined that centuries-old fraternity.

It was time to close up the abdomen and come up with plan B. But we knew plan B didn't exist for this insurgent. He died about thirty
minutes later despite the best care we had to offer.

At the foot of his bed in the ICU, the three of us quietly stood pondering his limp body, shaking our heads slowly as we tried to figure out why he planted the IED in the first place. He probably needed a few bucks for his family—we heard the going rate for shoveling a hole was $20 a dig. I stared at the adolescent attempt at a grown-up mustache.

Our insurgent was just fifteen years old. I know my thoughts drifted toward home—and distant stares told me Rick and Bernard went to theirs, and to our own kids who were once fifteen years old. When the worst they did was get home a few minutes late on a Friday night. They didn't plant bombs. They weren't the enemy. This kid was.

We just walked away, not saying a word. Our steps out of the ICU mirrored those of old men.

I walked to the latrine to shave off a day's growth of stubble. I stared into the mirror, rubbing on a thick lather of Barbasol, not sure whether it was good that a bad person had died or sad that
this
bad person had died.

After what I had done, I wasn't sure I liked the face I saw in the mirror, then, too, neither did I hate it. At least I was able to look and face myself.

I
T WAS A
bustling day in the ER when an unannounced chopper thundered in carrying a young soldier whose vehicle was blown ten feet into the air by a well-hidden IED. His condition was one step past critical by the time he got to me. I had to ignore the raw stumps that minutes before were a complete arm and leg; tourniquets were on snugly and the oozing could wait. There was no time to waste before fixing the more important blood pouring from his neck, as well as trying to figure out why his abdomen was rapidly swelling like a balloon.

To look at his face, though, you would have thought life was fine. There was no sign of damage, just little smudges of dirt on his cheeks and peacefully closed eyes. With short-cropped blond hair and a square jaw, he reminded me of a typical twentysomething I would see in my practice for a winter's sore throat or a sprained ankle from a summer evening softball game. But that's where the resemblance came to an end. From the neck down, this kid was in bad
shape. The force of the blast had ruptured his liver and spleen and I was squirming as I gazed at the small holes burned into his neck by hot chunks of shrapnel. I had no clue where these holes led and what the hot shards of metal had hit as they ripped through the skin and deeper tissues. I shut out images of home and the faces I'd left behind. Forcing myself into medical autopilot, I went to work trying to keep the soldier alive.

It took twenty-eight minutes of medical improv to get him stable enough for surgery. We made up treatments as we went along; pumping in countless units of blood and vials of medications, cautiously peeking under, then changing saturated bandages, and adjusting tubes and dials to force oxygen into his reluctant lungs. I was soaked with his blood by the time we were done, but it would be hours until I could shower and change my uniform. The warm stickiness didn't bother me, though, and even served an important purpose: reminding me there was a young man who belonged to that blood, and now he belonged to me. I was so tired I was weaving on my feet, but there was no way I could abandon this soldier.