Mark Ormrod (3)
MARK ORMROD’S EXTUBATION and his recovery from the acute phase of his care were, he would probably be surprised to hear, considered to be pretty straightforward. The first surviving triple on the ward in Birmingham, he also had a bad burns injury from the heat of the explosions, in addition to the very many rips and tears in what was left of his body from shrapnel. As he became gradually aware of his condition, he worried about his tattoo – a huge abstract pattern that went from the base of his spine and flared out towards his shoulders. His girlfriend had to take a photograph to show him that the tattoo was entirely intact. The photo also showed how little of the rest of him was intact. There were deep gouges along his side, debrided into teardrop shapes by the surgeons, and a nasty-looking set of scabs and scars under his arm running into the dressing over the limb stump. He’d not been aware of the first bouts of surgery, but the family round his bedside were, and the news got worse every time he disappeared from the ward. By now they knew that his left leg was gone as well as his right knee, but, as someone told them, the amputation of the left leg was done through the knee and this was a good thing because if the joint could be saved, then walking was going to be so much easier.
Except that a bone fragment had lodged deep in the thick thigh muscle of his left leg stump and it was infected. Back to theatre. They couldn’t remove the fragment and stop the infection with minimal debridement, so they had to cut away the entire portion of muscle. There was no more muscle to support what was left of the left knee joint, so the leg had to be shortened to match by four centimetres, so the joint was gone and Mark was the newest member of an exclusive club: a bilateral (both legs), transfemoral (across the thigh bone) amputee.1 His left arm was safe, but his right arm, which in its dressings looked intact all the way down to the elbow, was also not healing properly, so back into theatre for shortening, almost up to the shoulder. It was suddenly seeing this arm stump that made him realise what was missing: no forearm – further down – no hand – further down – no fingers. And he cried out, thinking it was a nightmare, that he was asleep, but a nurse came over and explained that he was awake, and what he had lost. In the midst of the hallucinations and pain medication he dozed off again, but then each time he woke, there it was, or wasn’t, all over again. And what was left looked horrifying. There was a drainage tube sticking out of a green Brillo-pad-type dressing at the end, and Mark did his best to hide it under the sheets whenever the family came. But they’d sat at his bedside in his acute care phase, and they had seen his struggle back from the edge, so they hardly noticed the dressing and its ugly tubing.
It wasn’t surprising that Mark reacted so strongly to seeing that his hand was missing. Think about how often you look down and see your hand: even if only out of the corner of your eye, it’s in your line of sight most of the day. Huge areas of the brain are dedicated to controlling hands and processing the sensory information sent to it by the fingers, far more than are used for the feet. These areas activate just when you look at your hands, before you’ve even thought about using them for something, and they activate whether or not your eyes actually find a hand when they look. Mark was experiencing sensory deprivation: agonising, a shock-scream inside the brain every time the eyes look down and send it information that doesn’t make sense. And perhaps there are parts of soldiers’ brains that are tied to their hands even more closely than everyone else’s. Think about saluting.2 Everyone thinks they know how to do it, but to do it right is difficult; it takes precision. The hand at the end of the arm describes a wide arc and then a slight wrist swivel so the fingertips hit the eyebrow at just the right place, thumb down. The downward movement to put the arm back in place is much shorter, snapping a line down the front of the body, thumb tucked in. No room for variation; it has to be done properly every time. It’s an extraordinarily significant, single, small military act. (Just one of the reasons why the hand surgeon at Bastion fought so hard for every hand he could save.)
For Mark, some good news, finally. He’d had a CT scan of his head, and it showed no traumatic brain injury. The hallucinations were just from the drugs; what everyone could see of him was what he would be from now on, with the same capacity to cope and rebuild. On 2 January Mark finally moved out of Critical Care and into his own room on the Burns and Plastics ward. He was getting to know the plastic surgeons and the physios who were planning his rehabilitation, but most of all he was getting to know his new body, only two-thirds the size it had been before the explosion, and the endless new consequences for his new frame. He was awake for the whole day and trying to sleep at night, something like normal, but it was boiling hot in his room, for no good reason other than useless hospital ventilation, no openable windows as usual, and his body was covered in sweat, on no sleep, hour after hour, night after night, so he was grumpy with his nurses and family. His truncated body tried and failed to cool itself – no soles of feet, no palms of hands, leg surface area mostly gone so no way to vent the heat, but with the same amount of blood pumping round half the area, heat keeps coming. Heat made worse because Mark had multiple burns and new graft sites from the multiple surgeries needed to keep his wounds clean and make viable stumps for him. So the wounds were hot, and the donor sites, where the flaps had come from, were hot and bruised and electrified with pain to the touch.
And he had an infection. The smallest thing on the wards in Birmingham, but by far the most deadly, feared as killers as they had been on the Western Front; we’re better at controlling them now, but not perfect. The hectic in the blood.3 Debridement after debridement and still casualties had contamination blasted deep into their tissues that no one could find or get at. And the surgeons can’t take infinite amounts of tissue away, because something has to remain as a bed for grafting, so very broad-spectrum antibiotics are part of the complex of lines running into the patients as they are admitted to Birmingham.
Bacteria run rampant on a human body with uncontrolled tissue damage, weakened by blood loss.4 They grow on the spot, and then they spread deep inside the human body, infecting the whole system, and they do it fast. They cause a system to go septic – sepsis, dreaded in operating wards. Infections produce toxins, which damage small blood vessels and can cause them to leak fluid, causing blood pressure to drop, blood flow to slow, oxygen and energy to diminish. Infections can be lightning-quick or take their time. They turn a simple leg wound into a three-month stay in Birmingham, with five operations to sort out one rotten artery, and they damage just like shrapnel or bullet – tendons and muscles weakened or ruined, curled toes, months of physio.
Bacteria are everywhere – from the colonies already present on human skin, densest on soldiers from patrol groups who haven’t been able to wash much – bacteria that transform in the instant of wounding from domestic nuisance to killer. And then there are the bacteria in the environment in which wars are fought. On the Western Front a millennium of manured farmland ensured that the soil men fell in was rich and dense with every kind of rot bug, and nothing much to fight them with, and in the field hospitals surgeons cut away more and more necrotic flesh, with thoughts of stumps and prosthetics long gone, just trying to save a life, and still the smell of death returned and death itself soon after. Alexander Fleming spent his war in a mobile microbiology lab on the Western Front desperate to solve the problem of the wards that reeked, and the men who rotted away. Afghanistan has its own range of bacteria, either in the desert or in the fertile green zone where the farming is done, and it too got blasted into a casualty on the back of the shrapnel and bomb fragments. Sometimes the soldiers took shelter in a ditch that turned out to be a sewage drain. Blast injury also blew holes in everyone within range, and blew bits of everyone into each other. Someone else’s skin bacteria inside them, someone else’s bone fragments, their flora-rich intestine, even if whoever is blown up is blown away – gone in a flash – into ‘pink mist’ – still the bacteria cling to the particle-fines of humanity and look for larger ones to seed.5 And in a horrifying miniature echo of the Western Front a century before, combatants sometimes smeared excrement and manure on their ammunition and into IEDs so those bacteria buried themselves around bullets and shrapnel in the bodies of their targets.6 There are lots of fungi in the soil of the green zone, which were particularly problematic for the plastic surgeon, who never forgot about the possibility of fungal infections because they were particularly threatening to the viability of free flaps, and if the Critical Care staff couldn’t get them under control with anti-fungals, they reduced the already limited areas that could provide donor tissue.7
Not just fungi. Viruses and blood-borne diseases are ever-present in Afghanistan. The malaria season runs from March to the end of October, and soldiers are bad at taking their anti-malarials, so anyone admitted to Bastion and Birmingham during this period was assumed to be at risk, and medication was added to the lines on their body in Critical Care.8 And then there are those fragments from other bodies that might have been carrying diseases as well as bacteria – hepatitis and HIV in particular. And not just in Afghanistan. In the London bombings of 2007 there were twelve cases where ‘biological material implantation’ was found to have happened among the casualties, which required complicating testing and treatment at a time when lives hung in the balance.9 Hospitals too have their own little colonies of bacteria, such as Acinetobacter, hanging around, difficult to totally root out, waiting for intubated Critical Care patients because it likes to roost in their secretions.10 Use that hand gel the next time you visit a hospital, please, because although there are other reasons why bugs like hospitals, it’s the unsanitary practices of visitors that are the worst culprits.
So there are solid, life-saving reasons why the military patients in the Critical Care unit had those endless tests and screens and swabs on anything that leaked out of their body, and their blood and spinal fluid, and tissue samples from debridement surgery, with path labs working flat out, very broad-spectrum antibiotic, anti-fungals all round, and everyone hoping the strains found by the labs weren’t resistant. There is a lab in the university next door to the hospital, and there a microbiologist leads teams of researchers trying to push back against the day that all the bugs that can infect a wounded soldier and all the other patients no longer respond to the very broad spectrum they are given on the Critical Care unit. Because that’s the day we are back in the foetid tents of the First World War’s field hospitals watching the dying, unable to do anything.
Mark Ormrod had a hefty dose of Acinetobacter, and it made him even hotter and more uncomfortable, and it meant that the family who had been able to hold his hand and help him turn over in bed could no longer touch him for fear that they would catch it and spread it around the hospital. So they sat around his bed, hands clasped in their laps, as they were being constantly reminded by the nurses back in their plastic full-length aprons and gloves, and they looked at their son, and he looked back and everyone did a lot of crying, for hours. Once, alone, Mark tried to move himself, for the first time, to roll on to his side without his wounds being scraped as he did so. He had two fingers working on his remaining hand, and so he gripped the bed rail with them and started to pull, and rocked back and forth a little, tensing his weakened stomach muscles to pull himself over, slowly, a little more and a little more, until he could finally lie on his side. He unclawed his fingers from the bed rail and laid his hand carefully down on what was now a rumpled and sweat-sodden bed sheet, the effort utterly exhausting.
Several days later, when he was declared free of the Acinetobacter, his family were allowed to gather close to him, and his father gave him his first shave, so very carefully, from one side of the bed and then across to the other; and as he worked he cried, trying to hide it at first, but then giving in to tears, but keeping his hand with the razor in it always steady. And Mark cried too, and kept his face still until his father was finished, and he told him that soon he’d be shaving himself, he’d see. But every time he closed his eyes for some low-quality sleep, when he woke up all he saw were stumps; no matter how many times he opened his eyes, still stumps. He was not going to wake up and find it was all a bad dream, ever.11 Mark’s own words, own memories. And those of his family too, all of them with the extra second in the chronometry of their lives, the second before waking memory, no going back. They are a strong family, the Ormrods. They seemed instinctively to know what was best for each other. Later, other families would have to be more carefully managed at the bedside. It was too easy to slip into old patterns of parenting, so nurses drew mothers aside and explained that their child was still an adult, even if they were taller than him again, and although they would now have a new life, it would, as far as possible, be an independent one. No matter how hard it was for them to adjust to, they should try. They need not worry about where he was going to sleep from now on or whether they needed to build a wet room. People were going to come and teach their son how to do the things he could not yet quite do on his own, and they should give them some space and let everyone get on with it.
So, gradually, Mark began to look up and see his new road ahead. He knew that his next operation would be his last for that stay (he ate fried chicken and takeaway pizza afterwards to celebrate), and his friends were visiting in numbers. One of them had been a hospital porter and knew his way round all the buildings, and as he chatted, he looked out of Mark’s window and realised exactly where they were. He complimented Mark on his inspirational view – of the hospital’s morgue. By now Mark could pull himself up enough to look out, and sure enough, just as he did so, an ambulance rolled up and a body was delivered, wrapped in its black plastic shroud.12 Everyone else in the room laughed, because what else could they do, and Mark watched as the body was wheeled in, until the doors closed behind it and the ambulance pulled away. That was the alternative, a short journey. And now he knew that he preferred the other option, the long journey, the one where he didn’t die, with all its pain to be endured, tracking back to life, doors opening, not slamming shut into darkness.
*
But what about when the doors did slam, because the patient had not been able to survive, no matter how hard he was fought for? In the twenty-first century nurses continued to make entries in the patient diary even though they knew their patient would never read it. They told of how they washed him, shaved him, tidied him up. What music had played on the ward radio as they worked, and how they had been honoured to give these last moments of service. The diaries became something entirely for the family left behind. This desire to communicate the care given in a loved one’s final hours – to seek somehow to share that process – is nothing new. In 1916, a century before, the first mass conscription armies came to the Western Front, and then followed the first mass conscription deaths in what had become a war of attrition. The medical services were braced for them. Field hospitals with newly dug cemeteries and stacks of plywood coffins, and in between them the moribund wards – what we would today call palliative care (the forerunners of remarkable places like Trinity Hospice) – where soldiers who could not be saved went to die. Just as at Bastion, they were there for only a few hours, but the nurses, who ran the wards entirely on their own, cared for them every moment, feeling as strongly about them as about any patient they would ever have. They made them comfortable with pain medication or sips of water or just their gentle, skilled company in the last moments. These were never rushed, even if hundreds more men likely to die that day waited for a bed.
Nurses couldn’t hold all these moments in their memory, no matter how devoted they were, so they devised a solution (and, unlike at Bastion, we’ll never know who by). Special care, went the official directive, should be taken to safeguard the belongings of dying patients. Messages and wishes should be carefully recorded and a special book kept for this purpose.13 So the belongings were kept in a labelled cotton drawstring bag, and a notebook created – a ward diary – that was taken to each bedside as the patient slipped away or murmured or cried out. For nurses who would have to write as many as sixty ‘break the news’ letters during offensives to come, the diaries were a godsend. From them they could draw the smallest and most exact details of a life at its end, so that the family had not just a blood-stained uniform and a paybook to remember their loved one by, but a record of their last words, and the scraps of comfort from knowing someone stood at their side to hear them. On the very last day of the war a young soldier died, and his nurse wrote home that
He passed away peacefully at 5.52 on Tuesday 12th November […] He talked of going to Blighty to see you and then before he died he thought he was with you all and put out his hands to first one and then the other with such a glad smile, he called you by name and then ‘Ada’ but we could not catch what else he said. He was a very good patient and we did all we could for him and he had everything that was possible.
Another death, of a much loved regimental medical officer, gave similar details of his end from an abdominal wound, recalled by his nurses weeks after the event for his wife. Without the diary none of this would have been possible.
Your husband was quite conscious until about 8.30pm and used to ask the conditions of his pulse etc. After about 8.30pm he was unconscious and died at 9.20pm on 20th. He did not speak of anything except, soon after he was admitted, he asked if it would be possible for you to come out, so the MO told him, not so far up the line as this […] If there is any comfort at all to you, I know your husband did not suffer – in fact he seemed to have no pain at all, only weak and exhausted. I am so very grieved to have to tell you this, because I know just how terrible it all will be to you […] I am sorry I can tell you so little.
And
I was with him until almost the last, and, apparently he did not suffer much pain. He was drowsy from the effects of morphia but was quite conscious and took a keen interest in all his symptoms. I think he knew his critical condition but was quite composed and realised that everything possible was being done for him […] He was anxious to smoke a cigarette which he did about 2 hours before his death. He gradually got weaker from internal haemorrhage and passed peacefully away.14
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The DCCN knew how it was to watch a patient die. In the Critical Care unit at Bastion she had written carefully in their diaries for their families and seen their bodies quietly removed from the ward to the morgue and then home on the aircraft in a flag-draped coffin. She never knew if what she had written had helped, or if it had not helped, or if it had meant nothing. She still doesn’t know, and some day she hopes to, but in the meantime she has a note of the days of their death in her own personal diary, one of those with a small leather flap and a lock on it. Every year, on the anniversary, she sits quietly in her office, unlocks the diary, opens the page and remembers each one of them.