18 NOV 2007 Just keep swimming
I got a good start to the day. Sunday is our one different day. We don't have our usual morning clinical openers, and we start the day's operations an hour later. I got up early to run five miles with Gastroenterologist B. He keeps a pretty good pace, but I was able to huff and puff along well enough to keep up. It is so much better to run with someone else! In my world, successful running is all about distraction, not focus. The more I can be distracted from the road, my joints, my muscles, the air, the better. Most of all, I need to be distracted from the most obvious question of all, "Why am I running?" Running on a track starts to get painful, and with every successive loop past the exit, I am more prone to come to my senses and walk off. A treadmill is right out. Even headphones can only distract me momentarily from the glaring fact that I am going nowhere. So a good outdoor run with sights thumping slowly by and spectators in cars for whom to perform is acceptable, but chit chat with a running partner is best of all. I know that there are runners out there who focus, count heartbeats, and beep their stopwatches on at the start of the run. They live for the run and want to immerse themselves in the sensation of running, eager to beat a personal best. I just want to get to the finish with a strong enough stride left to be proud and no one left behind. I would annoy the heck out of you with my chatter, if you were an intense runner.
Got to work and I had two cases to tackle. Washing out a man's leg, after he had been bitten by a dog, and washing out another man's leg that had been shot by with an AK-47. It was pretty much the same operation twice. With due deference to those who love their doggy kisses, the bullets were cleaner than the dog's mouth, unless of course the shooter was using his AK rounds to clean his anus. Due to this difference, I planned to staple closed the wound for the man who was shot and to leave the dog bite open so I wouldn't be trapping mouth and snout bacteria under the skin. Then we could continue to wash it every day.
Before I had a chance to start, a trauma code was called. I kept the OR ready in case this new patient needed an operation. He did. He was an insurgent who had taken M4 rounds to the chest and the belly. The hole is his belly would spout blood in a fountain the width of my index finger about four inches high whenever the dressing was removed. He was trucked on into the operating room double-time as soon as a breathing tube was in his throat. Two of my partners scrubbed to open him up while I flitted around the operating table making some final preparations. I helped one of our medics get a tube into his right chest. As soon as the tube was pushed through the muscle holding two adjacent ribs together, about a liter of blood jumped out of his chest and onto the floor. I got his arms out at right angles to his body on boards and splashed a bottle of antiseptic iodine over his body from the chin to the knees. I tipped his operating table head down to help the little blood he had remaining in his veins to rush to his brain to keep it alive. My partners rapidly sliced a wide incision to open him up and pack his belly full of bulky white gauze to try and stop the bleeding with pressure. In the time it took for me to scrub in and join them, they had already opened the chest to find even more blood. By this time his heart had stopped because it was so empty it had nothing left to pump. He had already received several bags of donated blood pushed into the large IV's in his neck and his chest, but it was rushing out of the holes in his large blood vessels as quickly as it went in. We had called for a whole blood drive and donors were lining up. We pumped his heart using our hands directly. I placed one hand under his heart and one over it, holding my hands like I was praying, but sideways, with his heart between. I squeezed and released in a quick rhythm as the anesthesiologists pumped oxygen into his injured lungs and loaded him up with blood and powerful stimulants. The muscle of his heart began to quiver in an ineffective shimmy of disorganized action. We used electric paddles that looked like serving spoons to shock all of the muscle cells into the same cadence. Even after shocking his heart multiple times and pumping in quarts of blood, we could not get his heart to beat. We let him go.
Whatever this man was doing, it caused our troops to take him down hard. The second these well-trained professional troops had incapacitated him with well placed rifle wounds intended to kill, they immediately initiated efforts to save his life. They brought him to us. From the moment this man was unloaded on the helipad to the moment of his death in the OR with a puddle of blood all around, our crew worked as hard to save him as if he had been one of our own. It was a bad, bad way to start the day. We closed the long incisions on his chest and belly with thick nylon stitches. I couldn't decipher the Arabic character tattoos on his shoulder and forearm, but it must have been a statement of someone or something he believed in. Maybe it referenced a woman, or was a religious statement of belief. Perhaps it was the insignia of his organization. We lifted his thin body into a zippered black bag.
After the blood was mopped up, we proceeded with my two leg operations. They went well. I was in my hooch getting dressed to go workout, when I got the page from Colorectal surgeon J. to report to the ER. We had received a new casualty, an Iraqi Army officer. An IED had blown off his left arm and sent shrapnel throughout his body. He was blown up head to toe. First he was taken to an Iraqi aid station. They applied a tourniquet to his arm and sent him to one of our other combat support hospitals to the north. They opened his chest and belly, controlled his bleeding, and then sent him on to us for further care. When we received him, he was only five hours out from his injury and had already undergone an operation. After ensuring that his vital signs were stable, we used the CT scan to check his entire body for any remaining injuries. The CT scanner showed us that he had a nail in his brain and another in his large intestine. So just two hours after his last operation, he went back under the knife. I washed him head to toe with hydrogen peroxide to remove the dried blood and dirt from hundreds of small scrapes and punctures on all three of his remaining limbs. While Ophthalmologist B. removed his eye that had been pulverized by flying debris, Surgical oncologist J. and I reopened his belly. Things looked good in there. Healthy pink intestines without any leakage or unhealthy swelling lay nestled in a fatty padding. It took two full courses of running our fingers the entire seven feet of his large and small intestine to finally find the nail. The nail was a short roofing nail with a broad head. It had entered the colon point first, plugging it shut like a nail you might run over with your tire. The nail head was hidden in a little tuft of fat and no bowel movement had leaked out of the colon. We removed the nail, cleaned the wound of dead tissue, and closed it securely. It was very rewarding to find and fix that injury. A wound like that untreated would begin to leak stool and might have become a widespread or lethal infection. The officer is strong and recovering in our intensive care unit.
It might not seem immediately obvious how a nail got stuck in his colon. The bombs used by the insurgents against human targets are packed with nails, nuts, bolts, ball bearings, scrap metal, marbles, glass and anything else that might cause some damage. When the explosive detonates, it sends a spray of these lethal missiles into anyone unlucky enough to be nearby, soldier, civilian, or child. In suicide bombings, parts of the suicide bomber can become projectiles. I've removed bits of exploded suicide bomber arm and leg bone from the wounds of those injured in an attack. I’ve met an Israeli surgeon who removed a suicide bomber's tooth from the neck of a young lady. He also has seen cases where the bomber’s hepatitis or HIV infection was transmitted to a victim. They are a crude but devastating tool of violence.
So now I wipe the blood from my sneakers, breath deeply a lungful of Balad dust and eau de burn pit, and leave the hospital to work out. I think I'll go to the recreation center to see the salsa lessons. Maybe that will distract me enough so I can just keep swimming, just keep swimming. I hope I haven't annoyed you with my chatter.