Rule Number Two Read online

  Long before dawn, I slid into a vivid dream of driving in an open Humvee on base with Jason and Tom, our surgical company’s OB-GYN. The azure sky was clear, and the sun felt balmy. I turned my face upward to enjoy the sensations. As we drove, the Eye in the Sky hovered nearby. We drove close to the small zeppelin, looking up at it and singing our ridiculous song.

  As we drove past its tether point, a huge black machine gun — old-fashioned, with cylindrical barrels — emerged from the Eye in the Sky and started shooting at us.

  Tom, who was driving, immediately began to swerve violently and sped up to get us out of harm’s way. I searched in vain for my helmet (which in reality I would be wearing in a Humvee), finally resorting to covering my head with my arms, screaming in fear as we zigzagged away.

  I awoke with a start, sitting straight up and swinging my legs over the side of my cot almost reflexively. My breath caught in my throat and my heart raced.

  I reached for my watch on the floor next to my cot: 0345. The night was deathly silent, in contrast to the howling winds of the day before. I peeked out my window through the sandbags and saw stars in the black sky for the first time in days. The sandstorm had passed. We could go back to the gym. I decided I might as well stay awake for the next half hour before I met Bill. I strapped on my headlamp and wrote in my journal about the dream.

  Since the storms had passed and the winds subsided, Bill and I expected to see the Eye in the Sky the next day as we walked back from our workout. When it didn’t reappear, the rumors immediately began to circulate. My favorite involved the Eye being left up too long and blowing away in a gust of wind, getting stuck on the rooftop of a home in the friendly town right outside our base. The story went on to say that a Marine major had gone into this town looking for the Eye, and when he found it, he paid a couple of Iraqi guys twenty U.S. dollars to guard it for him while he went to get a truck. When he returned, the two guys were still standing there, watching it. Another rumor stated that other people needed the Eye more than we did at that moment.

  We would never know. We did know that in the next few days, rockets rained on our base again.

  Jason and I spent a great deal of time together. We ate breakfast and lunch together almost every day and talked in the clinic between patients. In the short time we had been together in Iraq, I came to consider him a friend and confidant. He offered clinical insight about my patients that was refreshing and usually very helpful. Most important, I felt safe expressing my own vulnerability and fear to him. So our conversations about patients and the most effective ways to proceed in their treatment often ended in discussion about how the cases affected us and how our own feelings affected our abilities as providers. Freud called this countertransference, and he believed it was a major factor in therapy. Jason believed in Freud.

  One of the best aspects of being partners with a psychiatrist who had a Freudian perspective was his comfort with classical dream analysis, something far beyond the purview of my own cognitive-behavioral training. We talked at length about my Eye in the Sky dream, and I learned from Jason that the emotion that woke me out of the defensive cover of sleep was, of course, fear. Fear that the protector could become the enemy.

  Or, perhaps more likely, fear of exactly what ended up being true. Fear that the illusion of safety was just that — an illusion, and nothing more.

  Karen’s Boots

  Sunday was the only day I slept in at all, usually until just before Mass, at 0900. One Sunday morning, though, when Karen knocked at 0730, I was wide awake, attempting to unstick my sweaty legs from the top of my vinyl sleeping bag. I yelled for her to come in. She sat on the edge of my cot near my feet as I folded my thin pillow into thirds and propped myself up to look at her.

  Her tanned face appeared unusually pale.

  “How was last night?” I asked, clearing my throat and tucking a strand of sweaty hair behind my ear.

  She did not speak for a long moment, looking away from me as if entranced by something. I waited.

  “Pretty brutal,” she said finally. “We had two come in from Al Qa’im at about 0300. One was critical.”

  “What happened?”

  She inhaled deeply. “He had a pretty serious abdominal wound and lots of extremity damage. His pressure was bottoming out, and he was bleeding all over the deck of the SST.”

  We referred to the people of our Shock Stabilization Team and to the trauma bay in which they worked as the SST. The blood of our injured patients was not foreign to the deck of the SST.

  “We took him to the OR, and we stabilized him for a little while, but then he started bleeding out . . . the exit wound was huge. We couldn’t give him blood fast enough. We went through a lot of units. We couldn’t get a pulse or a pressure for what seemed like forever. Finally, Commander V. called it.

  “Everybody was wasted. It seemed like everyone wanted to cry, but no one could.” I nodded in empathy.

  “There was blood all over the OR, and we needed to take a break before we even thought about cleaning it up. So they all left, except me. I sat there for a while, holding his hand, and for some reason I started thinking about his mom, and how sometime today in the States, a Marine would be coming to her door to tell her. I thought of my mom, I just kept seeing her face, and for some reason I started thinking about a Navy chaplain coming to our family’s door to tell her. I sat there and cried for a while by myself. Then one of my corpsmen popped his head in, and said, ‘Ma’am, the other Marine . . . he’s asking for you.’

  “I went in to see him. He was still lying there in the SST, about to be moved to the ward.”

  Karen looked up, still avoiding my eyes, her lips trembling a little. I placed my hand on top of hers.

  “He saw me and he said, ‘Ma’am, I’m just wondering if you could tell me how my buddy is doing.’ ” Her voice shuddered.

  “I didn’t know what to do, so I decided to tell him the truth. I walked over to him, I took his hand, and I shook my head. I told him that his friend wasn’t going to be okay. I told him we really tried.

  “He started crying then, and I held his hand and we cried together for a little while. I tried to stand at an angle where he couldn’t see my boots, but he did. He said, ‘Ma’am, is that my friend’s blood on your boots?’ I thought about lying, but I couldn’t. I just nodded yes.

  “All he said was, ‘Thank you, ma’am, for taking care of my Marine.’ ”

  Karen shut her eyes then. One big tear escaped down her cheek and she raised her forearm to swipe it away. I squeezed her other hand.

  She sighed, lowered her head, and said, “So . . . do you know how to get blood off of boots?”

  “I’ve heard hydrogen peroxide works.” I swung my legs over the side of my cot. “Come on, I’ll help you.”

  HOME

  My father’s daily messages continued to fill my e-mail in-box. During my time at the Internet café, I allowed myself a rare indulgence through his words: brief immersion into images of my children’s lives. It lasted — at the very most — thirty minutes, at the end of which the Marines who monitored computer use bellowed the words, “Kraft! Your time is up.”

  It’s now 11 pm, and I hear the faint murmurs of our sick babies. It has been a long day. I went to get Pedialyte very early and Meg has kept it down most of the day, but little else. She spent most of the day in your mom’s arms. Whenever she cries, I do my best to keep her distracted — I dance, and point to stars, or trees, or birds or planes, or ants. It works for a while.

  Brian also woke up with a fever. We gave him Motrin and rocked him, until he went down for a nap at 0930 and slept for four hours. The afternoon was better, but he still seemed sluggish, and not at all himself. Then Mike came home, and both babies could not have been happier. They even waved bye-bye to us as he put them to bed.

  I’d best put my head down now, since we have to be ready to assume our duties again early when Mike leaves for work. And I’m tired.

  My heart tumbled in my chest. It i
s really difficult to care for sick children. I felt genuine empathy for Mike and for my parents. I knew I needed to call, to summon the internal strength to provide support for them. I never used to hesitate when someone I loved needed me. Somehow, before Iraq, I was able to be there for my patients and my family and friends, if necessary, with emotional muscle to spare. Today, concrete encased my boots as I stood up and trudged ahead, moving by sheer will into the line for the phone.

  “Hi! How is everyone doing?” I tried to sound cheerful.

  “Hi.” Mike sounded frustrated. “They’re both sick, again.”

  “Yes, I saw my dad’s e-mail. I’m so sorry . . . this must be so hard on you.” There was a significant delay on our phone connections, so I waited in case he was about to speak. He wasn’t. His exhaustion was palpable.

  “I suppose it’s to be expected,” I went on, trying to fill the silence. “Since they’ve only just started day care a few months ago, they’re suddenly being exposed to everything.”

  “I know.” Even across the world, I could sense his stress.

  “I’m just so sorry.” I didn’t know what else to say, so I stopped talking, figuring he needed to vent.

  I pursed my lips when they trembled. I didn’t want Mike to know how difficult it was for me to hear about his exasperation and my children’s illness when I was helpless to intervene. I sunk deeper and deeper into my grief. I knew he was sinking too.

  “Kraft! Time’s up.”

  Dunham

  Mass casualty. The two words hammered away at us, beginning that first day when we sat together on bleachers at Camp Pendleton, holding our empty seabags in our arms. Mass casualty. The words assaulted us after dark during those seven months in the desert. They shattered the nights of silence after we had collapsed onto our hard cots. We wondered each night if sleep would be interrupted by the echo of those two words yelled down the concrete corridors of our barracks. When they came, they catapulted us into strange, trancelike nights that blurred the boundaries between nightmare and reality, helicopters whirring overhead and voices piercing the blackness. The two words even greeted us in the morning as we debriefed the evening’s experiences at staff meetings and medical rounds. We talked about the mass casualty, planned for it, ran drills pretending it was happening, and set up elaborate scenarios to make sure we would be able to function when we were totally overwhelmed. With two operating rooms, it did not take much. Any more than two surgical cases exceeded our limited field capacity.

  One day in mid-April, nightmare became reality. Although our experiences to date with multiple patients at once had been called mass casualties, the term was redefined that day.

  Right before lunch, I stood in front of the hospital in my flak jacket and helmet, taking a picture of one of my colleagues next to the sandbags and the ALPHA SURGICAL COMPANY red Marine Corps guidon. Chief Edmonson walked outside and approached me as I tucked the camera into the large cargo pocket in my pants. She whispered in my ear, “Don’t leave, Doc,” as she eyed unsuspecting Marines walking up to the hospital for routine medical or dental care.

  “You mean for lunch?” I asked, surprised.

  She nodded. “This isn’t for sure yet, but we may be getting fourteen from Al Qa’im.”

  I followed her inside. No sooner had I taken off my helmet than the distant thumping of a Black Hawk’s blades beat the desert air, audible even when they were several miles from the hospital. I swallowed and found the back of my throat had risen to form a hard lump.

  Minutes later, the helicopters landed on our makeshift pad, one after the other, in a surreal moving image of black fuselage paint and blood red crosses, setting down within huge tornadoes of tan dust. We waited inside, watching through the dirty glass doors, as medical corpsmen and Marines formed into groups of six to carry gurneys.

  Dave, our OR nurse and a former Army Special Forces medic, coordinated litter bearers. His voice was low and raspy from too many years of smoking, and as he called their numbers, the teams ducked their heads and ran out to the birds. One by one, each group of six men and women grasped the handles of the gurney, slid it out of the hatch of the Black Hawk, pivoted slowly, and brought the heavy, bandaged, and bleeding patient back inside our hospital.

  KATIE FOSTER SAYBOLT

  The corporal was brought in first. I drew in my breath as I saw him. The tube down his throat protruded awkwardly from his mouth. At his brief visit to a forward resuscitative surgical suite before he came to us, other medical personnel had placed this lifesaving artificial airway and applied what was now a blood-soaked bandage around his head. His eyes were shut, bulging from his face and giving his eyelids the appearance of swollen, bruised globes. His name, written in black ink on his bare chest, was Dunham.

  His litter team took him to the SST first, and behind him other teams carried thirteen other patients through the doors according to their triage priority. They formed a crooked line of gurneys resting on the dusty tile floor, each with its litter bearers waiting to pick up their patients again and move them forward in line. Jess, a pediatric cardiologist, and his team of corpsmen worked fast on Corporal Dunham, who had two obvious entrance wounds to the frontal lobes of his brain. The Marine made no meaningful movement, and Jess gave the order that he be moved to the expectant ward. This is the combat medical term for the triage area where casualties who are too critically injured to be saved are placed. Most American doctors, even those with wartime experience, never become used to giving that order. I am not sure Jess ever truly recovered from it.

  Our expectant ward appeared to have once been an old laundry room. Its cracking tiled floor surrounded a drain in the center of the room. Even a nonmedical person could figure out why we used that space. Here a patient could be moved away from the chaos of other casualties. Here he could receive pain medication and supportive care until he died.

  Our mass casualty plan assigned dentists and dental technicians to monitor the expectant ward. When I arrived, they were taking care of Dunham. I entered the room and spent a few minutes with them as they touched the corporal gently and spoke to him in soft voices. His litter rested on the floor, and they sat around him on the tile. Their legs were folded in uncomfortable positions and they shifted often to maintain circulation. At one point, one of our senior dental technicians, DT1 Graham, rose to change the bag of fluids and asked me to take the Marine’s hand that he had been holding.

  I was immediately drawn to Corporal Dunham; I was unable to leave him. We told him that we were proud of him and that the Marine Corps was proud of him. The chaplain came in and we all bowed our heads as he prayed out loud, asking God to take this brave Marine into His arms. DT1 Graham went through the front pocket of the Marine’s desert utility blouse, which had been cut off and was stuffed behind his head on the gurney. We found the Rules of Engagement card for Operation Iraqi Freedom, which included some basic Arabic words for phrases like Stop and I am an American. He also carried a small, laminated map of Iraq. His dog tag no longer hung around his neck, likely a result of the blast that injured him. But as regulations required of all of us, his second tag was laced into his boot.

  We learned his first two initials were J.L. and that he was Methodist. We guessed his first name might be John, or Justin, or Jason. He was not wearing a wedding ring. In combat, that did not mean much, but we pretended it did.

  We called him Corporal Dunham as much as possible. We told him he was doing great. We waited, anticipating that his breathing would become labored and his heart rate would become irregular.

  They never did. His breathing remained steady and slow, and his heart beat on. Sometimes I swore I could see it moving under the muscles of his chest.

  Many long minutes later, I moved his arm. It had looked uncomfortable to me. He was a tall, muscular young man, and his elbow hung off the edge of the cot. I told him what we were doing, and together DT1 Graham and I picked up his arm and moved it closer to him, adjusting the straps that kept him balanced there. I continued to h
old his hand, and as we moved his arm, I felt a distinct squeeze. He had squeezed a few times before, but only in short, reflexive twitches. This was different. His whole biceps muscle flexed as he squeezed. I looked at my colleagues. We didn’t breathe. He squeezed again, so hard that he pulled me toward him.

  “Corporal Dunham,” I said urgently in his ear. “Can you hear me? If you can hear me, squeeze my hand again — now.”

  He did.

  I looked up, making eye contact with DT1 Graham, DT3 Stirling, who was sitting across from me, and James, one of our dentists, who was standing in the corner. Everyone’s eyes looked the same: huge and hopeful. I looked at our company commander, who was lingering by the door. She ran for help.

  The five physicians of the company arrived at the expectant ward in about one minute flat. Two stethoscopes were placed on his chest, and Mike, a family medicine doctor, looked up and said, “I’ve got seventy-two beats per minute . . . sounds good to me.” Jess held open the Marine’s eyelid and flipped a light back and forth. Dunham moved his head in response and squeezed my hand again. Several of us cheered. “Get him out of here” came a shout from somewhere in the room.

  Everything sprang into motion. Voices yelled for a litter team, and within moments their boots pounded down the passageway. They lifted the gurney and moved it into the intensive care unit while the admin clerk called for an urgent surgical medevac. Karen, one of two nurses in the ICU that day, knew that he had been responding to my voice, and in a gesture of friendship I will never forget, she handed me surgical gloves and asked me to continue to hold his hand. He squeezed frequently then, maintaining a strong grip, especially when I told him he was going in a helicopter. I told him my friend Steve, one of our physician assistants and a former helicopter air crewman, would be going with him. I laughed out loud each time he squeezed. He moved his head and feet on command. The energy in the room was electric, and we could not help grinning hopefully at each other. The chaplain wandered back in, looking confused. I told him, laughing, that I thought this young man might need a different prayer.