Caring for Jeff from Ruff's War

Ruff's War, just published by the Naval Institute Press, recounts the emotional impact of war on a U.S. Navy nurse serving on the frontlines in Iraq. She and her co-author, tell what it was like to be the only nurse-anesthetist in a surgical team working to save a wounded Marine.

Jeff was brought to Camp Anderson in a helicopter after sustaining a wound to his neck. He was swiftly removed from the chopper and carried to the triage tent on a litter. Prompt evaluation of his wounds revealed the need to establish an airway as quickly as possible because his trachea was already moved off center.

Jeff was awake and alert when he was placed on our table in OR number two. His sparkling blue eyes were filled with pain and fear as he looked up at me. The wound he had sustained was severe, and he was gasping for breath. A hematoma (a mass of clotted blood) had formed around his carotid artery, causing pressure against his trachea and deviating it. He was able to breathe, but the deviation of his trachea was so severe that endotracheal intubation, or the insertion of a tube into his mouth and down into the trachea to provide an open airway for the administration of oxygen and anesthetic, would be difficult if not impossible.

Prior to Jeff's arrival, we had received a brief report of his condition from the triage personnel and were prepared to perform a tracheotomy, an emergency procedure requiring the surgical formation of an opening into the trachea through the neck to allow the passage of air. Commander Fontana, the surgeon in the case, said, "Cheryl, we are getting an airway casualty in, and I plan to trach him (perform a tracheotomy) if you cannot get a tube in."

Jeff was scared, and his fear was intoxicating. He had been informed in the triage area that a tracheotomy might be needed to save his life. I introduced myself and told him, "Jeff, I'm going to put a mask over your face to give you oxygen. I'm going to take real good care of you,"

As soon as I began to cover his nose and mouth with the oxygen mask, he said, "Hold it. Please, please don't cut my throat." Having been informed by one of the physicians in the triage area that a tracheotomy might be needed, he fully understood what might occur, and he was begging me to stop the surgeons from performing that procedure. As I looked into his eyes, I could readily see the fear and anguish on his face, and I felt his fear deep within my soul. I said, "Jeff, I am going to do everything I can to get this airway into you. Just know that I am going to take the best care of you that I can." It was now totally up to me to do all I could to grant his wish of not having the surgeons cut his throat.

Despite years of training, to a certified nurse anesthetist, a patient with a difficult airway is the most humbling and challenging endeavor that our specialty encounters. Unlike a stateside hospital that is well lighted and safe and possesses ready access to the most advanced technological equipment and supplies, our wartime OR number two included nothing but the barest of essentials. This was the time, the final reckoning that would answer the two questions that had haunted me throughout my many days of deployment. Did 1 truly have the knowledge, skill, and expertise needed to provide the best medical care to our wounded troops? Would I find the strength to make the best decision and do the right thing?

After reassuring Jeff, I induced unconsciousness and then administered succinylcholine, a rapid-acting anesthesia agent that produces skeletal muscle paralysis. With this administration, I knew I had crossed the bridge; he was no longer capable of spontaneous breathing. I had to get the endotracheal tube inserted and inserted quickly, or the surgeons would have no choice but to perform the tracheotomy. I closed my eyes and prayed, "God, please help me to do this."

When I looked down into Jeff's throat I could not see an opening, just soft tissue and blood. Relying on my previous clinical experiences, I knew I needed to arc the endotracheal tube a bit more than usual and scoop upward. I just knew the trachea had to be there. God had to be guiding my hand, for when I inserted the tube it miraculously slid down right into his trachea. Jeff now had an established airway in which to administer life-saving oxygen. We would not need to perform a tracheotomy, and his plea "Please don't cut my throat," could and would be honored.

I immediately hooked him up to the breathing circuit and began oxygenating him. His chest rose bilaterally, indicating that oxygen was entering both lungs, and the endotracheal .tube began to fog with his carbon-dioxide exhalation. I never was able to visualize his vocal cords before inserting that tube, but I had no doubt, on the basis of the bilateral rise of his chest and the fogging to the tube, that the tube had been inserted exactly where it was supposed to be. When I looked up at the crew in the OR, they all began cheering. They had been standing back, holding their breaths, watching and praying for my success with the insertion of the tube. Their cheers, combined with the grateful look radiating in their eyes, brought me to tears. All I could do was thank God, for he had definitely come through when I needed him the most. He had answered my prayers and the prayers of all who were a witness to this event.

Because the gunshot had created significant and massive damage so close to the carotid artery (one of two principal vessels supplying blood to the brain), performing surgery under the primitive conditions in which we were surrounded was determined to be too risky. We knew we did not have enough blood should the artery rupture. Jeff could easily bleed to death on the table if such an event occurred.

I steadfastly secured the endotracheal tube and filled syringes with vecuronium (a longer-acting neuromuscular blocking agent), midazolam (used to produce drowsiness and to relieve anxiety), and various narcotics. I sat there continuously squeezing the Ambu bag and breathing for Jeff as we wailed for a chopper to land that would take him farther away from enemy lines to a better-equipped, more sophisticated trauma center.

While I waited, I realized I had formed a deep emotional bond with Jeff and did not want to pass his care off to someone who might not understand how miraculous the insertion of this airway had been or how important it was to keep intact. If this endotracheal tube should become dislodged, I believed there would be no way for it to be successfully inserted again, especially if Jeff was on the helicopter when this happened. Even the possibility of performing a tracheotomy with the rapidly developing hematoma was high risk; the most skilled surgeon could easily cut into the hematoma, and Jeff would then bleed to death. I hated the thought of handing over Jeff's care to another and decided I needed to provide him with anything I had that might foster his chances of survival.

Before I left the States, I had taken a Jackson Reese/Mapleson ventilation unit from NMC, Portsmouth, and carried it with me in my Alice pack. This unit had a latex Ambu bag that was more pliable than the hard rubber construction of the bags we routinely used. It allowed easy adjustment to the flow of oxygen, and positive pressure could be applied to it if necessary to keep a patient's alveoli (tiny sacs in the lungs) open. Less than forty-eight hours into caring for the wounded of this war, I had decided to give up my only special Ambu bag to Jeff without really knowing how many other Jeffs I would need to provide care for. Still, something inside me said, "Give this to Jeff. He needs it," so I decided it would be my special gift to him along with several oxygen cylinders I had prepared to accompany him while he was being transported.

A chopper landed, and along with the corpsmen, I accompanied Jeff as four stretcher bearers took him to the helicopter pad. All throughout this transport process to the chopper, I kept breathing for him by rhythmically and steadily compressing the Jackson Reese/Mapleson bag. The blades of the helicopter continued to rotate . . . I screamed to the receiving corpsman on board, "Keep squeezing the bag! Keep him alive! Keep him alive!" I had written out on a tiny piece of paper when and how often to give Jeff the syringes of vecuronium and midazolam I had drawn up. I tried to yell over the noise of the rotating blades, for I desperately needed to know that the corpsman on board the chopper understood my orders. He gave me the thumbs-up sign. . . .

Turning Jeff's care over to another was an agonizing and highly emotional experience for me. I had no idea where he was going or whether the corpsman on board the helicopter had heard my plea. All I could do was let him go and pray that he would be okay. I had done everything in my power to honor his wishes and to save his life. It would not be until I returned to Kuwait a month and a half later that I would learn of Jeff's fate.

EDITOR'S NOTE: Jeff survived. President George W. Bush pinned a Purple Heart on the young Marine at Bethesda.