11.

SPENCER HEARS A LOUD PULSING SOUND behind him. Sirens blare, he can hear machine guns exchanging fire and mortars landing. It’s total chaos. Before him lies a man squirting blood so powerfully it’s almost satirical, a ridiculous movie prop. Three men stand behind him as Spencer tries to decode what’s going on. This body is broken, unconscious, and has a brachial bleed; the arm has been blown off and the long artery down the bicep severed right down the middle. So the nub of an arm is pulsing blood out all over Spencer, but more importantly—or less importantly?—the man does not seem to be breathing. Spencer gets behind the body and puts his hands under the neck, cupping it like he’s ladling water from a pond, easing the chin back so the mouth and nose are facing up. You do that so if there’s something he’s choking on or if he has a kinked airway you’ll unkink it—but of course it’s not kinked; Spencer knows the mechanism of injury, and this guy is obviously not choking. Spencer collects himself. He shimmies back over to the arm and pulls out his tourniquet, sliding the man’s arm through the loop, and the man does not resist, of course, so Spencer manhandles the arm. He’s not worried about breaks and fractures; he’s worried about blood loss, followed by loss of blood pressure, followed by lack of profusion, lack of oxygenated blood to the brain, brain damage, and after that—he doubles the tourniquet over and then pulls it tight enough that he can feel the tissue compressing, like he’s trying to permanently reduce the size of the man’s arm, but that’s good, that’s good—now back up to his head, to address the next pressing problem: is he breathing? His chest is not rising. CPR? No, not yet. First he has to establish an airway. The man is unconscious so . . . Spencer remembers—when you’re unconscious the muscles in your jaw relax and your tongue can fall back and block your breathing, plus with trauma there could be blood clogging the airway. Spencer rifles through his pack for the long surgical-looking tube with the trumpeted end; he drops it, damn it, picks it up, wipes it off, starts fumbling with a pack of lube, tries to tear it open but it slips through his grasp, fuck, he picks that up too, tries to tear it open again but loses his grip and the pack goes flying—fuck, fuck!—and then decides, What the hell, and then he’s got his left hand over the man’s cheekbones, and he’s driving the tube up the man’s nose. Gunfire behind him. He guides the tube with one hand and shoves with the other, threading it up the nose and into his windpipe, all the way down until all that’s visible sticking out of the man’s nose are a few millimeters and the trumpeted end, like a tiny mushroom sprouting from the right nostril. The background noise is no longer there, it’s entirely shut off in fact; suddenly it’s totally silent, and Spencer feels a tap on his shoulder.

“Airman Stone, congratulations. You just gave this man permanent brain damage.”

Spencer takes his hands off and leans back. He wipes sweat off his eyebrow with a forearm. “Don’t I need to make sure he has an airway—”

“You do. But did you notice that our friend here has clear fluid in his ears? What might that clear fluid be, Mr. Stone?”

“Aw, crap.”

“Not quite, Airman Stone. Guess again.”

“Spinal fluid, sir. It could be spinal fluid.” The other members of his team stand back.

“Correct! Spinal fluid. And if our friend has spinal fluid in his ears, what does that tell us?”

“He could have damage to his skull.”

“That’s right! Poor old Rescue Randy here could well have a skull fracture. That tube of yours would have gone right through it. So, to recap: you just walked up to a guy who was already having, if we’re being honest, a pretty bad day to begin with, and you shoved a piece of silicone into his brain. Congratulations, Airman Stone, you just lobotomized your patient.”

And so it was that an inanimate man, a pretend trauma victim, solidified Spencer’s understanding of all emergency medicine’s most counterintuitive notions.

A man might need to breathe, but you can’t just give him an airway.

A man might need to breathe, but if he’s bleeding sometimes you have to deal with that first.

A man might be bleeding out, but you can’t always just stick a tourniquet on.

Spencer learned of the human body as an intricate, beautiful, elaborate system of ways to end itself. Cure this, destroy that. You need a tourniquet to stop someone from bleeding out, but if a tourniquet’s been on too long, you get necrosis—tissue death. That means that by trying to keep a patient from dying of blood loss you can give them an irreparable limb infection.

Or if the injury is at a juncture, like in the armpit or the groin, you can’t very well tourniquet that, because what do you tie it around?

Or, the trickiest of all, what do you do about a wound above the shoulders? A head wound, or a bad cut on the neck. They say “put pressure on the wound to stop the bleeding,” but what are you going to do, ball up a towel, or a T-shirt, and shove it into someone’s neck? You can’t very well put a tourniquet there, because a tourniquet on the neck is the same thing as a noose. So if you’ve got a patient bleeding out of the neck then . . . then he wasn’t really clear on what to do. Surely in combat treating neck wounds must be important, because soldiers wear helmets on their heads and flak jackets across their chests; it’s their necks that are unprotected. So what do you do?

He wondered.

You say a prayer and hope something creative occurs to you.