“Doctor,” he said, “this guy obviously has holes in his bowel and his femur is broken. It’s not a bad fracture, but he’s probably dropped a pint here. There’s at least a pint in his belly and maybe a pint in his chest. Agreed?”
“Agreed,” Captain Pinkham said.
From there Hawkeye went on to explain that the patient also had a pneumothorax, meaning that there was air in his pleural, or chest, cavity because his lung was leaking air and had collapsed. In addition, he suggested, the shock from the blood loss was probably augmented by contamination of the peritoneum, or abdominal, cavity by bowel contents.
“So what he needs,” he said, “before you lug him in there and hit him with the Pentothal and curare and put a tube in his trachea, is expansion of his lung, two or three pints of blood and an antibiotic to minimize the peritoneal infection.”
“I see,” Captain Pinkham said, beginning to see a little light, “but we’ll still have to open his chest as well as his belly.”
“No, we won’t,” said Hawkeye. “The chest wound doesn’t amount to a damn. Stick a Foley catheter between his second and third ribs and hook it to underwater drainage, and his lung will re-expand. If he were going to do any interesting bleeding from his lung, he’d probably have done it by now. We can tap it after we get the air out and his general condition improves. Right now we just want to get this kid out of shock and into the OR in shape to have his belly cut and his thigh debrided.”
Two corpsmen brought what at the Double Nature passed for an adequate closed thoracotomy kit. It contained the bare essentials for insertion of a tube in a chest, and after Hawkeye had watched Captain Pinkham fiddle around with it for awhile, he spoke again.
“Look,” he said. “All that’s great, but there will be times when you won’t have the time to do it right. Lemme show you how to do it wrong.”
Hawkeye donned a pair of gloves, accepted a syringe of Novocain from a corpsman, infiltrated the skin and the space between the ribs and shoved the needle into the pleural cavity. Pulling back on the plunger he got air, knew he was in the right place, noted the angle of the needle, withdrew it, took a scalpel, incised the skin for one-half inch and plunged the scalpel into the pleural cavity. Bubbles of air appeared at the incision. Then he grasped the tip of a Foley catheter with a Kelly clamp and shoved the tube through the hole. A nurse attached the other end to the drainage bottle on the floor, a corpsman blew up the balloon on the catheter and now bubbles began to rise to the surface of the water in the bottle. Hawkeye dropped to his knees on the sand floor and, as he began to suck on the rubber tube attached to the shorter of the two tubes in the bottle, the upward flow of bubbles increased as the lung was, indeed, expanding.
“Crude, ain’t it?” said Hawkeye.
“Yes,” said Captain Pinkham.
“How long did it take?”
“Not long,” admitted Captain Pinkham, who couldn’t help noticing that the patient’s breathing had already improved.
Duke, meanwhile, watched Captain Russell apply his surgical resident’s approach to the other soldier who, waiting for blood, was still in shock. Captain Russell, afraid that he’d miss something, was examining the patient centimeter by centimeter, fore and aft, while the corpsmen waited impatiently to start the transfusion.
“Excuse me,” Duke said after a while, “but all you’re doin’ now is holdin’ up progress. Why don’t y’all let these folks get to work?”
“But don’t you think …” Captain Russell started to say.
“What I think,” Duke said to the corpsmen, “is that we better start the blood.”
Having taken the recruits that far, the two veterans headed for the game in the Painless Polish Poker and Dental Clinic to pass the two hours until the patients would be ready for surgery. When they figured that the patients had been sufficiently transfused and adequately resuscitated, they headed back to the OR, scrubbed and joined their junior partners.
Duke and Captain Russell had a boy whose small bowel was somewhat perforated, requiring removal of two different areas and closure of several individual holes. This sort of work is done ritualistically in most surgical training programs, because it is basic to belly surgery and should never be learned incorrectly, and as a result, the surgical residents in their third and fourth years of training, particularly in good teaching hospitals, may still be at the ritualistic stage. Captain Russell surely was.
Duke having determined that all they had to do was fix the small bowel and that time, up to a point, was not going to be a factor, decided to sweat it out. For two hours he stood there amusing himself by mildly insulting Knocko McCarthy, who wouldn’t hurt him while he was scrubbed, and assisting in wonder as Captain Russell performed a small bowel resection as performed by the residents in a large university hospital.
“Do y’all mind if I do this one?” he asked, as Captain Russell finally advanced on the second area needing repair. “I lost twenty bucks in that poker game, and I’ll never get even at this rate.”
He didn’t wait for an answer. In twenty minutes he removed the damaged segment of bowel and sewed the two ends together.
“Y’all probably noticed,” he explained to Captain Russell as they were closing, “that when clamping and cutting the mesentery, I wasn’t quite as dainty as y’all were. Y’all will recall that I didn’t do the anastomosis with three layers of interrupted silk, like y’all did. I used an inner layer of continuous catgut and interrupted silk in the serosa. Where y’all put twelve sutures on the anterior side of yours, I put four. Y’all observed that the lumen in my anastomosis is as big as yours, I’ve got mucosa to mucosa, submucosa more or less to submucosa, muscularis pretty much to muscularis and serosa to serosa, and there ain’t any place where it’s gonna leak. It took y’all two hours, and it took me twenty minutes. Your way is fine, but y’all can’t get away with it around here. Y’all will kill people with it, because a lot of these kids who can stand two hours of surgery can’t stand six hours of it.”
“But …” Captain Russell started to say.
“That’s right,” Duke said, “and if I’m really in a hurry I’ll ride with just the continuous catgut through all the layers.”
So it went, for several weeks. The recruits, being polite, listened and, being intelligent, learned. They had both, however, been born and bred, as well as formally educated, to be fastidious, so the shucking of old habits did not come easily. Captain Pinkham, in particular, still tended to get bogged down in detail. He would become completely absorbed in repairing damage to a hand and ignore or sublimate the obvious fact that the patient could die of his abdominal wounds. Once, in fact, on a busy night while Hawkeye was occupied elsewhere, he spent six hours on a case that should not have taken more than two hours and managed to miss a hole in the upper part of the stomach. The patient almost died, early, from too much surgery and, later, from the missed hole. Hawkeye took that one back to the table and, two days later, with the patient well on the way to recovery, he was able to make this the case in point.
“Now I’ll offer you some thoughts,” he told the much relieved Captain Pinkham. “This is certainly meatball surgery we do around here, but I think you can see now that meatball surgery is a specialty in itself. We are not concerned with the ultimate reconstruction of the patient. We are concerned only with getting the kid out of here alive enough for someone else to reconstruct him. Up to a point we are concerned with fingers, hands, arms and legs, but sometimes we deliberately sacrifice a leg in order to save a life, if the other wounds are more important. In fact, now and then we may lose a leg because, if we spent an extra hour trying to save it, another guy in the preop ward could die from being operated on too late.”