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by Krista Puttler
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A shrill, persistent ring echoed down the darkened, red-lit passageways. I blinked awake. The lamp over my sink cast a dim light into my stateroom. I swung my legs out of my rack, found my shower shoes, and stood up. The phone rang again. The screen blinked “Medical” in dark green letters.
“Hello?”
“Surgeon?”
Yep, that’s me. The Ship’s Surgeon aboard a US Navy aircraft carrier. When we were out to sea, I took out appendixes, fixed hernias, and drained abscesses. As the sole surgical asset, I also reduced and stabilized broken bones, managed electrical shock and anaphylaxis patients, treated every imaginable cause of groin pain, and stabilized heart attack and stroke patients. I was the de facto orthopedist, urologist, gynecologist, and critical care intensivist for the five thousand sailors and airmen on board. And for the indefinite future I was also the acting Senior Medical Officer, the Medical Department Head, the medical director of the ship’s ward, and the only fully trained physician on the ship. I was not even supposed to be here; I was notified two weeks before the ship left the yards that I was to fill the vacant Ship’s Surgeon position. And now with the previous SMO and family practitioner also unexpectedly off the ship, I was performing multiple roles that I had no training for. With a young Medical Department and all these leadership changes, it was not shocking that the ship’s leadership and crew had no faith in its Medical Department.
“Yes, HM1?” I answered.
“I have a patient with what looks like a large corneal abrasion but I’m not sure. I don’t need a Wood’s lamp to see it. I mean it’s right there. Should I put fluorescein in anyway, to confirm it is a corneal abrasion or should I just start antibiotics?”
I blinked. This was an odd phone call. Typically, corneal abrasions, as the Independent Duty Corpsman said, were not seen with the naked eye. Oh sure, the eye may look red and irritated, but the scratch confirming the abrasion is not seen until fluorescein, a thin strip of yellow dye-impregnated paper, is applied to the eye and then viewed with the Wood’s lamp, a type of black light. When the yellow dye touches the white portion of the eye, the dye fluoresces under the black light, causing any irregularities, such as a corneal abrasion, to turn a bright yellow. This maneuver is a routine part of any eye exam when one suspects a corneal abrasion. The IDC did not need to ask my permission to perform this basic exam. He normally would just have done it. That was why my palms were sweaty. That was why this phone call did not make sense. And I was just a general surgeon; I didn’t do eyeballs. I hated eyeballs.
“What brought the patient into Medical?”
“A wrench to the eye.”
Well, that explained it.
“Hold on the fluorescein,” I said, “And everything else. Have the patient sit quietly with the lights off in the exam room and I’ll be down shortly.”
“Yes ma’am. Thank you!”
I hung up and looked at the clock on the phone, 0315. Less than three hours until reveille, when the ship’s day officially began. I wouldn’t be going back to sleep any time soon. We had been out to sea for the past ten days and I had been called down to see an emergency patient in the middle of the night during every one of those days. If I did not get some help soon, there was no way I was going to be able to keep up this pace for the next two weeks we were out to sea, let alone the next three months before deployment. And I didn’t want to think about what would happen if they did not find a Senior Medical Officer and a family practitioner for the seven-month deployment. But I could not think about that now, I had a patient to see. I pulled on my shipboard coveralls, put my hair back in the uniform regulation bun, and ran out of my stateroom.
Four minutes later I was three decks below in the midships Main Medical Department. The patient was in the AVR. I don’t actually know what that acronym stands for, but I liked to think of it as the Aviation Trauma Room. It was a large exam room across the passageway from the Flight Surgeons’ office, a physician (not a Surgeon) who had only one year of post-graduate training, and next to the Aviation Medical Technician’s office and audio booth. Inside the AVR was the extra OR exam table, all the optometry equipment (the slit lamp, an optometrist’s exam chair, a machine for making lenses), extra oxygen tanks, and an extra cardiac arrest cart.
The patient was sitting on a chair in the dark, elbows on the exam table, head in his hands, snoring. I slowly opened the door and let in the light from the passageway. He stopped, mid snore, let out a huge exhale, then continued snoring. I walked into the room, turned on a goose neck exam light in the corner, sanitized my hands, and slapped on a pair of gloves. The patient continued to sleep. I sighed, walked over to the patient, and tapped him lightly on the shoulder. He woke with a jerk, the one thing, considering his injury, I was trying to avoid.
“Good morning.”
“Good morning, Ma’am.”
“Is it okay if I turn on the overhead light?”
The patient nodded.
He was young, maybe twenty. His right upper eyelid was swollen and had a bluish tinge. I gently pushed up on the eyebrow and opened the eye. There was no white of his eye; instead, it was a dull pink. And the iris seemed misshapen. I moved to the side and looked at his face in profile. The normal round projection of the eye was gone. The front part of it was flat, like a miniature Half Dome within his socket.
Then I saw it. There was a dark vertical mark, shaped like a crescent, just lateral to the iris. The middle portion throbbed like a pulse point. This was no corneal abrasion. This was an impending open globe laceration.
“Is everything okay, Surgeon?” the patient asked.
I shook my head. I turned off the bright overhead light and pulled up a chair.
“You have a serious injury to that eye.”
He nodded.
“It’s not a full-thickness injury, but it’s close. We need to get you off the ship as soon as possible to get that repaired.”
He looked up at me and blinked. Even in the dim light of the goose neck lamp, I could see that his eyelid did not close completely. The hematoma on the upper lid was getting worse.
“Can’t you fix me, Surgeon?”
I opened my mouth, closed it, and shook my head.
“I have never operated on an eyeball before.”
In the dim light of the room, I saw his Adam’s apple jump. Was he scared because he had a risk of losing eyesight in that eye or because I just told him I was not the miracle worker he hoped I would be?
As the only Surgeon on the ship, I was asked to do a lot of things that I would never be asked to do at a shore-based, fully-staffed hospital. To the outside observer, it seemed I could do anything. But a traumatic injury to the eye was too much. Even if I knew how to fix it, and I didn’t, I wondered if we even had the correct suture in my closet-sized operating room.
“Am I going to go blind?”
I knew I should lie; it would make him feel better and perhaps have confidence in me again, but I couldn’t do that.
“I don’t know.”
He nodded.
I stood up. “I’m going to have the IDC put eye patches on both of your eyes and then sit with you until we can get you off the ship.”
“Yes, Surgeon. Thank you.”
A tear escaped down the left side of his nose. Was the right eye so damaged that it couldn’t make tears anymore? I didn’t know.
I leaned down and took his hand. “We’ll get you taken care of as soon as we can.”
“Yes, Ma’am.”
I walked out of the room. I looked at the clock on the wall, 0400, two hours before reveille. We were just on a training mission, doing circles in the ocean, but I did not know how close those circles were to the shore, and we needed to be close enough to fly this patient off via helo. The other medevac option, the Carrier Onboard Delivery plane, or COD could fly farther than a helicopter, but it required a catapult shot. The force of the catapult would most certainly tear the thin tissue keeping the eyeball intact.
I walked back down the dark passageway and opened my office door. I needed to put on my Senior Medical Officer hat. I needed to wake up my Medical Admin Officer so she could find the closest hospital that could take care of traumatic eye injuries. I had to notify the sailor’s Department Head and the Executive Officer of the ship to let them know he was leaving. I had to call the Strike Officer to see when I could get a Medevac. I had to call the Handler to make sure the flight deck would be safe to transport the patient, and I had to call the Ordinance Handling Officer from the Weapons department to ask if I could use one of their weapons elevators. I also had to call the Captain.
When to notify the Captain was always the tricky part. And the previous SMO didn’t give me any tips on when to do it. I needed to call the Captain relatively quickly in the process so that he did not hear about the medevac from someone else, but I also didn’t want to wake him up and sound like an idiot.
I decided to radio him first and get it over with.
“Captain. Surgeon.”
“Go ahead, Surgeon.”
“Sir, I know it is early [Never apologize for waking the Captain. If you need to apologize when waking the Captain, then don’t wake him in the first place.], but I have a patient in Medical who is in danger of losing vision in his right eye. The patient needs to fly off as soon as possible by helicopter. When I know more details, I will call you back.”
“I understand. Thank you, Surgeon, for letting me know.”
“Yes, sir.”
My radio clicked off. I wiped my palms on my coveralls. This was it. I was either doing the right thing, had diagnosed the patient correctly and had spun up an entire helicopter crew and changed the ship’s course to help this one shipmate, or I had put an entire helicopter crew at risk for flying before sunrise just for a corneal abrasion. I pushed the panic down and prayed I was right. There was no one here to listen to my doubts, no one to share the blame. All the responsibility would be mine.
***
“Surgeon. MAO.”
I unhooked my radio from my belt.
“Go ahead, MAO.”
“I have an accepting physician from the closest Level 1 Trauma Center on the phone in my office.”
“Be right there.”
My radio clicked off and I walked back around to the medical admin spaces.
The Medical Admin Officer held out the telephone.
“Thank you, MAO.” I took the receiver and sat down. “Hello?” The emptiness of the POTS (Plain Old Telephone Service) line filled my ear. There was a terrible delay. There was always a terrible delay.
“Yes?” the voice in the receiver said, “You have a patient to transfer to us?”
“Yes!” I yelled a little too loudly, “I am the general surgeon on an aircraft carrier, and I have a patient that I am concerned may have an impending open globe from taking a wrench to the eye.”
Static. Then silence. When this happened, I hoped it was because of the delay on the line, but as the silence continued, I wondered if the physician on the other end was having a hard time understanding my phone call.
Is the line still through? I mouthed to the MAO.
She shrugged.
Or perhaps, this prolonged pause meant the physician did not believe me and he was trying to figure out how to tell me gently that I did not need to transfer a corneal abrasion.
If I could not convince this physician, my patient would not be able to leave the ship, and he would most certainly lose that eye. But worse than losing sight, would be losing the trust of this sailor. I had said I would get him to appropriate care. I did not have a lot of resources on this ship, but I did have my word. If my word meant nothing, how was I ever supposed to convince the ship that its medical department would always take the best care of them that we could? How could an airman work on the flight deck, the most dangerous working environment on earth, knowing that his medical department would not help him if he got injured?
Finally, a sigh came over the line. “Why do you think you have a possible open globe and not just a corneal abrasion or ulcer?”
My panic transformed into anger. I wanted to scream that even though I am just a general surgeon and I’m not working at a fancy hospital I am not an idiot. But I took a deep breath and tried my best to calm the rising indignation. I needed to convince him so my patient could get off the ship.
“I see a wide, dark line on the side of the globe. It is not currently leaking any fluid, but when I look at the globe from the side, the cornea and iris appear flattened, almost as if they are sinking in.”
I heard a quick inhale from across the chasm of the static. Somehow, I had convinced him.
“Okay,” the voice said, “Send the patient as soon as possible.”
“Thank you very much!”
I handed the phone back to MAO and walked back to the AVR. The patient was in the wheelchair. The Search and Rescue Corpsman and the Flight Surgeon were ready to go. The Weapons elevator was ready. The helicopter blades were spinning.
“We are all set, Surgeon,” the SAR Corpsman said.
“Just waiting for your final word,” the Flight Surgeon added.
I nodded, walked to a corner of the AVR, and radioed the Captain.
“Sir, we are ready in Medical. Heading up to the roof, now.”
“I understand, Surgeon, thank you for letting me know and getting everything ready so quickly.”
“Yes, sir.”
My radio clicked off and I turned to face the room. “Let’s go.”
The SAR Corpsman pushed the wheelchair ahead of him and the rest of the team followed the patient out of the department. As I helped to load the patient into the Weapons elevator, he searched for my arm, then gripped it.
“Thank you, Surgeon. I will never forget this.”
“You are welcome. Now let’s get you better.”
As the gate to the elevator closed, I turned and ran up the five ladder wells to the Handler’s office. It was in the front part of the Island, the superstructure that sat on the starboard side of the flight deck. I knocked and entered.
“Good morning, Handler. Do you mind if I look out your window?”
“Oh, no, Surgeon. Go ahead.”
I walked around the plexiglass mock-up of the flight deck. Like a three-dimensional puzzle, it showed the current location of every plane, helicopter, person, and piece of machinery that was on the deck. Currently, there was a single disk in the center of the plexiglass symbolizing a spinning helo.
I looked out the window. The medevac helicopter blades were turning. A member of the flight crew was standing just outside one of the open side doors. A large hatch in the flight deck itself flipped open like a slow-motion jack-in-the-box lid. The elevator made it to the top and then the patient, the Flight Surgeon, and the SAR Corpsman walked onto the deck and into the helicopter.
The Handler coughed, “Is his eye going to be okay?”
The helicopter door closed. The Weapons sailor ran back to the open elevator, walked into the center of it, and disappeared underneath the flight deck. The hatch closed over top. The helicopter lifted off the deck, flew off the port side, and headed back to shore.
I looked back at the Handler. I had told him we had an emergency medevac, but not the details of the injury. I was always amazed at how quickly stories traveled around the ship, like fallen leaves blown up in a sudden gust of wind, spiraling and scattering far beyond where they had first started.
“I hope so,” I replied, then walked out of the office and back down the five decks to Main Medical.
***
A shrill ring pierced the quiet.
I looked up from the article on my computer screen, “10 Surgical Pearls for Open Globe Repair” from the American Academy of Ophthalmology by Elizabeth Yeu, M.D. If I had only learned one thing in surgical residency, it was to read as much as I could about my patients, particularly the ones with injuries that I had never treated before. If I ever had another globe injury, I was going to know how to fix it.
The phone in the MAO’s office rang again.
It was late, after dinner. Everyone was gone from the department except the duty Corpsmen, the night IDC, and me, having just finished setting and splinting a smashed finger.
The phone rang a third time.
I wondered if the duty Corpsman could hear the phone from the front desk. I turned back to the article on the screen.
Ring! Ring!
Nope. I sighed, rushed out of my office, and ran around to the MAO’s desk. I picked up the phone, “Hello?” Static. Then the dial tone. I replaced the phone in its cradle.
Ring!
“Hello?”
“Um, yes, is this the aircraft carrier that sent a patient off with an eye injury this morning?”
“Yes, it is.”
“I am the ophthalmologist who took care of the patient, can I please talk to the Ship’s Surgeon?”
I swallowed. Here it was, the chewing out that I had been dreading all day. On one hand, I hoped I had been right in my diagnosis to justify the medevac and the subsequent disruption of everyone else’s day, but on the other, I really hoped the patient did not lose eyesight in the injured eye.
“This is the Ship’s Surgeon.”
“Oh great! Excellent job!” the voice on the other end said, “I just wanted to tell you that your diagnosis was correct. I operated on the patient as soon as he arrived, and everything is going well. With your quick diagnosis and fast evacuation, you gave the patient the best shot possible of retaining vision in the affected eye.”
I sat down. I blinked away a tear. We had done it. Even though we had a small team, we worked together and got the patient the best care we could. Perhaps we even proved ourselves as deserving of being the ship’s Medical Department. Time would tell. But the one thing I knew for sure, as soon as I hung up the phone, the story would circulate, and soon, the entire ship would know that even with a potential catastrophic injury, their Medical Department would take great care of them.
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Krista Puttler was a general surgeon in the US Navy. She is working on her first book, a memoir of her last year on active duty as a Ship’s Surgeon on a deployed aircraft carrier. This essay is about one of the patients she took care of while on the ship. She lives in Norfolk, VA with her husband and three daughters.
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