Mash (25 page)

With that they jumped into their jeep and disappeared for what turned out to be another three days. This time their colonel realized that, for the good of the organization if for no other reason, he would have to curtail the extracurricular excursions of his two transients. At the same time he realized that, as the two sweated out the termination of their enlistments and grew more itchy by the day, he needed some means of keeping them busier, and thus happier, in their home away from home. He might have prayed for an increase in battle casualties, but he was too fine a human being for that, so he prayed for any other answer, and the next morning it appeared in two parts, named Captains Emerson Pinkham and Leverett Russell.

Captains Pinkham and Russell were replacements for two of Henry’s surgeons who, having been nursed along to the point of being able to accept major responsibility, had unaccountably but not unexpectedly been whisked away. Henry greeted them, oriented them and then invited them to meet him and various members of his staff late that afternoon, for cocktails at the so-called Officers’ Club.

It was a pleasant, but in some ways disturbing, social occasion and confrontation. Trapper John, Spearchucker, Ugly John and the others who were not on duty found Captains Pinkham and Russell highly presentable. They were intelligent, polite, seemed to possess normal senses of humor and on the subject of surgery talked impressively. This last should not have surprised nor disturbed the veterans, for the surgical world changes rapidly and almost all surgical residents talk well, but the veterans had been so far removed from the mainstream of their profession for so long that, as the recruits expounded on new approaches and new techniques, at least several of the listeners wondered if, when they did get home, they would have to start all over again,

“Well,” Henry said, as he, Trapper John and Spearchucker headed toward the mess hall at the party’s end, “they seem all right. Good men.”

“I think so,” Spearchucker said, “for Ivy League types.”

“I guess so,” Trapper John said, “but we’ll see what the Hawk and the Duke think, if they ever get back.”

“Oh, they’ll be back,” Henry said, “and that gives me an idea.”

Two days later, when Hawkeye and the Duke returned, Henry read them the Old Familiar. While the strains of that were still sounding in their ears, he launched into his project for the preservation of what remained of the sanity of Hawkeye and the Duke, and the perpetuation of the efficiency of his organization.

“Now, while you two clowns were gone,” he told them, “we picked up two new men. Their names are Emerson Pinkham and Leverett Russell.”

“Sound like Ivy League types,” Duke said.

“That’s right,” Henry said. “They are, but they’re good men. They’re intelligent, they’ve had excellent training, and they’re abreast of certain new concepts of surgery that you and I have never even heard about.”

“Good,” Hawkeye said. “Then let them do all the work.”

“No, goddammit,” Henry said, the red rising to his hairline again. “Not for one minute. That’s been the trouble with this organization. When we’ve been busy, there hasn’t been time to teach the new men the kind of hurry-up, short-cut or call-it-what-you-will surgery that you have to do in a place like this. When we’ve had time, you people have goofed off, which is my fault, and as a result anybody who learned anything here just picked it up by accident. Well, that’s gonna stop, and it’s gonna stop right now. These new men are going to be taught everything they can be taught, and you two are gonna teach them!”

“Yes, sir,” Duke said.

“OK,” Hawkeye said. “I guess you’re right.”

At lunch that day, Henry introduced Hawkeye and Duke to Captains Emerson Pinkham and Leverett Russell, and the two veterans invited the two recruits to join them, Trapper John and Spearchucker at The Swamp for cocktails at four o’clock. At four o’clock the two appeared and were served libations. As before, they shaped up well in all the requisite areas. Since their arrival they had observed a number of operations and had performed two themselves, and this, of course, quite naturally invited a comparison between the methods being employed at the MASH and the techniques taught in the high-level stateside training hospitals.

“I think I can speak for Lev as well as myself,” Captain Pinkham said at one point, “when I say that we are not, for a moment, regretting our presence here. There’s a job to be done, and some men are giving their lives so, at the very least, we can give our time and our talents, such as they may be. At the same time, any surgeon, aware of everything that’s going on in his field back home, has to regret it when he’s sent to a place like this, where about all he ever gets to do is meatball surgery. No offense, of course.”

Hawkeye looked at Duke, Duke looked at Hawkeye, Trapper John and Spearchucker looked at their colleagues. The term was one that was used often in The Swamp, but now it had just been used by someone else, and a recruit.

“No offense,” Hawkeye said. “Have another drink.”

As it happened, the Double Natural was moderately busy at this time, and Henry had paired Captains Pinkham and Russell with Captains Pierce and Forrest on the night shift. On this very first night, in fact, there was even a six o’clock chopper, so after they had bolted down a quick meal, the two veterans escorted the two recruits over to view the passengers.

The chopper had brought two 4077th MASH Specials: both had belly and extremity wounds, and one had a minor chest wound. Hawkeye and Duke stood back while Captains Pinkham and Russell made their examinations, then informed the recruits that they would be ready and willing to assist when the patients had been prepared and moved into the OR. After that the two Swampmen retired to the lab where, a few minutes later, Captain Bridget McCarthy found them avidly engaged in questioning Radar O’Reilly who had recently been in communication with Jupiter,

“All right, you two!” Captain McCarthy ordered. “Get out of here!”

“What’s your maladjustment tonight, Knocko?” asked Hawkeye.

“Listen,” she said. “Your two Cub Scouts want to operate on those patients right away, and they’re not ready to be operated on.”

“Now just a minute, ma’am,” Duke said. “Just where did y’all …”

“Attend medical school?” Knocko asked. “Right here.”

“Yes, ma’am,” Duke said. “We’ll go help.” In the preoperative ward the two graduates of the ivory tower surgical training programs were showing their inexperience. The two cases that confronted them were well within the ability of the Double Natural, or any other MASH, to handle. Both patients were in moderate shock, but had no continuing blood loss. Both required preoperative resuscitation by a process well known even to the corpsmen and Korean helpers.

Captain Pinkham had the boy with the minor but significant chest wound. When Hawkeye and Duke wandered in, he was fussing around the patient, rapping on the chest and listening to it with a stethoscope. He was behaving, in other words, like a doctor and not a meatball surgeon, so Hawkeye took a look at the X-ray, assessed the situation and spoke.

“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.”