Of Helicopter Rides and Bacterial Meningitis... (Part one)
By Rick Fischer
"Do you mind if I smoke?" said Sanchez laying stretched out on the bed with her by his side. "No, I could use one as well" she answered with ease, as she cuddled to his left side. He felt relieved as the wave of post orgasmic nicotine washed trough him. It had been some time since the last time. The smell of cheap tobacco made a fine addition to her sweet perfume, his cheap cologne and the hot humid air. The lamplight coming from her night stand allowed him to see her curly brown hair, her white skin and her petite, yet curvy, body. He tried to start a conversation, but soon the head nurse started talking about work. His cue to leave. He felt both empty and relieved to know she wasn't the only one being used. He excused himself and got dressed. After all it was almost three am in the morning. He had clinic duty at eight o'clock and the base was 20 minutes outside town into the dirt-trail.
He felt nostalgic as he climbed on to the dirt bike some NCO from the base had lent him. His old BMW F 800 R was in a depo store in Santa Fé. He didn't bring her here. This unpaved trails would only damage his dearest. He drove carefully trough the dirt-trails with the bike's front-light as his only reference. He shouldn't forget he was the battalion’s physician. If he fucked up and fell who was going to look after him? He started recounting his reasons for getting his commission. He had grown up listening to his father's army stories: from enlisting, to getting a commission, to dishonorable discharge. After he got his medical license that nostalgia had gotten the best of him. He felt quickly disappointed in the army but was in denial of it. At least most of the time. This wasn't his father's army anymore, things had changed. Surprise brought him back from his ruminations as he saw the lights of the battalion’s ambulance on the opposite side of the dirt-trail.
He got in range of the ambulance's lights. The army of this tropical republic was frozen in time regarding equipment and doctrine somewhere between the Korea war and the Six days war. The ambulance, he had judged, was probably Korea war surplus. Once the ambulance driver recognized him he stopped. "Doc, Thank God! We were headed for the town's hospital" said Sergeant Alcazar poking his head through the window. "This boy is in very bad shape" added the combat nurse, with his north eastern accent, as he opened the door. Sanchez climbed in the ambulance. He smelled something fetid. He saw a six foot muscular recruit laying on a gurney. Breathing with effort and grunting incoherently. In the dark was hard to see but his skin was clammy and blotted. The boy was covered in sweat. He ordered the driver to take the bike back to the base, and Alcazar to get the wheel. Sanchez got some latex gloves and got a peripheral venous access. As he was taking his vitals he felt his stomach turn in fear as he realized the boy systolic blood pressure was way below 90mmHg. The boy was in shock. But the crammed space of the back of this 1950's ambulance with no light were not the conditions for a physical examination. He started pumping the boy full of fluids as Alcazar drove towards the town's Hospital.
They arrived in the ER's parking lot and unloaded the patient. The boy was muscular. He must have been at least 90kg. Sanchez could feel his heart pumping in his throat. Regardless of his experience, a critical patient always got the blood flowing. The nursing assistant called the hospital's physician and the head nurse. Dr. Sanchez finally had the opportunity to start examining his patient with the light of the ER. He and Alcazar got him monitorized. BP 60/40 pulse rate 180. He is in shock all right. But why? "Any idea as what happened to him, Alcazar?" Said Sanchez trying not to look too scared. "No idea Doc, the other recruits from his instruction company brought him like that. May be a snake bite?". “That guess is as good as any" thought Sanchez. "Do the ABCDE and you'll always make it to a diagnosis" he remembered on the voice of one of the Emergency Medicine residents from one of his ER rotations. Airway: he neither saw nor heard any obstruction in the boy's mouth, and neck. Breathing: No signs of tension pneumothorax or something strange in the boy’s thorax. Circulation: He was in shock but no signs of bleeding. The clammy skin was a sign of cardiovascular shock but gave no indication of its cause. The abdomen didn't look distended. The blotted skin was a lead to the diagnosis but Sanchez just associated it to the shock. While he was thinking, he and Alcazar where pushing IV fluids into the boy. After 2000cc of Ringer's lactate his BP had risen to 100/50 and his heart rated was down to 130. His heart was young, it could take a lot. "We've already pushed 2000cc of fluids into him. I need you to push another 2000cc. OK?" Said Sanchez, looking at the head nurse, she had just arrived. It was Paula from last night, still in her pajamas. She had gotten the crash car. "Right on it, Doc" She answered. "His heart might be young and fit, but he's going to need some pressor or he won't make it" thought Sanchez. "Paula, do we have dopamine?" He said forgetting he wasn't supposed to know her name. "No, we haven't got any, Doctor." She answered while pushing IV fluids and ignoring his mistake. "OK where was I?" He thought. "D", Neurological Deficit. "Well, he's making incomprehensible sounds. His eyes are open, though. But his motor response appears to be in abnormal flexion. Glasgow coma score 9/15. Of course he has a neurological deficit. “Well, shit I actually have to intubate this boy. In this state, he can't defend his airway. But it all could be secondary to the shock, and shock secondary to what?" Thought Sanchez, as the hospital's on call physician a young lady, Dr. Lemus arrived. She was skinny, with a perfect smile and long straight deep-black hair. Her cinnamon skin was very soft looking. Her bosom was rather large for such a skinny woman, probably breast implants. She would have been quite the eye candy, if Sanchez wasn't in such a mess, and if she wasn't so absolutely terrified. "As a physician, she would make an excellent model" thought Sanchez, starting to feel frustrated. Later, he would find out she was in the first week of her social service year fresh-out of med school. She wasn't useless, though. "Doctor, I need you to get on the phone and notify the Emergencies Regulatory Center. Can you do that for me, please?" Said Sanchez, thinking, at least that's one less thing he'll have to do. "Of course, Doctor" She said, just glad to be getting out of the way. "Under which diagnosis should I present him, Doctor?" She said, on her way out of the crash room. "Shock, probably secondary to a viper attack" Said Sanchez, thinking in frustration, that a snake bite was as good a guess as any.
"E" was the last letter: expose the patient. "Take all his clothes" He ordered, as he took a pair of trauma scissors and started cutting through the boy's uniform. He felt the rancid smell intensify, as they moved him to check his back. The boy had crapped his pants. He inspected him from head to toe and yet found no snake bite. "Fuck!" He thought. He still didn't have a diagnosis. But he decided to focus his effort on keeping the patient alive. There wasn't any vasopressors in the little town hospital and he knew fluids would only go so far. "He needs to be intubated. Do we have medications for a fast intubation sequence?" He asked looking at Paula. "Not really, we only have Diazepam" answered the nurse, preoccupied. "Diazepam will drop his BP even more" he thought. He was already at the patient's head with the laryngoscope. The boy, though disoriented, was conscious. He was clenching his jaw. His neck was rigid. There was no way to intubate him without proper medication. He needed at least a sedative and a muscle relaxant. "Ketamine? Vecuronium? Succinylcholine?" He inquired with frustration. "None, Doctor" answered Paula starting to be "infected" by his frustration as well. "Fuck, I can't do shit for this boy here!" He thought. In his dispensary in the base there was even less material to work with. He had to be taken to San José. The city was a two-hour ambulance ride away. The patient's O2 saturation started dropping. "Acute respiratory distress syndrome or shock's lung as the eldest among the professors would call it", thought Sanchez. Disseminated infection through the body was causing a severe response in the blood vessels; said response was causing the lungs to fill with fluid and the boy was drowning. "Well, shit! Crucial part of the management is intubation, but I can't do it. Vasopressors would help, but I don't have any, do I?" he thought. He did have one, and he had just realized it. It was less than ideal, but if he didn't get the boy's blood vessels to increase pressure he would soon drawn in all the liquids he had pushed into him. "Paula, give him 0.5mg epinephrine intramuscular, right now" he said. "Epinephrine? Intramuscular? Like an Epipen?" she replied. "Yes, that's the best we can offer him here," he said. "It will help him regain some vascular tone. Yes, he can have a lethal arrhythmia if I use too much, but it will buy him some time", he was thinking, as the nurse followed his order. The raise in BP and oxygen saturation proved him right. He also had to start mask-bagging him. He timed the mask ventilations with the boy's breathing. The positive pressure of the mask-bag would help pushing out the fluids from the airway. Intubation was the ideal but with the bag mask system he managed to keep O2 saturation around 90%. That was as stable as he would get him, with what he had there.
"There is nothing more we can do for him here, prepare the ambulance, please." the one belonging to the town's hospital, not the one from the Korea war. "He'll never make it to San José, Doctor" Said Paula, lowering her voice. "I know, but if he stays here he's dead as well" replied Sanchez, his frustration turning into determination. "At least I will give him the chance to make it!" Said Sanchez, as he turned around. Only to be faced immediately by Lieutenant Espitia.
"No, don't take him to the road. The colonel is getting a helicopter", he had just walked into the ER room. He had a radio in his hand. On the other side Sanchez could hear the battalion’s commander, Colonel Buitrago. "We're getting a Med-Evac chopper?" Said Sanchez with some hope. "No, that would need approval from army command and air force command in Santa Fé", said Espitia with resignation. "The concepts of: combined arms operations, dedicated air support, operational independence, and such. Concepts which I have heard of in fucking videogames and Wikipedia articles, are still a complete mystery to the military doctrine of the country. No wonder you haven't ended the longest internal conflict in the western fucking hemisphere." thought Sanchez, as he grimaced his face. "The colonel is trying to get COLPETCO to lend us one of theirs" he said, hesitantly. "Oh, OK" said Sanchez, rather surprised. "The national oil company is lending us one of their helicopters that happened to be around the area. That's some alms based medicine right there. Holy shit!" He thought. But, if it was what it took to save the boy's live, he didn't really care. Besides, this would be his first helicopter ride after all, and his first air ambulance transport.