Mule

Work hard and keep your head down. And watch out.

This kid came in with baggage. We all have it. Sometimes it has what you need.

The ambulance from up on the prairie radioed they had a five-year-old and his dad. The radio described a stable little kid with a head injury. Talking, bleeding, vitals stable.

Sid got ready down in the canyon. He was doing another weekend shift to pay off the med school loans. And to gain experience. He liked doing the work down here. It could be stressful. But he felt he could manage it. His wife was so generous to let him do these shifts. She carried the home burden. Little kids can be a real pain.

Sid would now get a little kid with a head injury. No CT scanner here. Sid started thinking about the transport option, how long it would take, the helicopter time. Find an attending to accept him. The hospital had a helipad just outside those big windows looking down on the river. He’d called them many times.

He’d walked out to the chopper beside the gurney with the heart attack, the gunshot, the pregnant lady bleeding. It was his last resort, but you had to handle what came through the door, unless you couldn’t and then you made the call.

Sally was his ER nurse today. It was late on a Friday summer evening. Sid had just gotten there, changed into the scrubs they let him wear, and had a late dinner. The cooks always sent him up a tray. The nurses had to bring their own food, or order pizza. But he, the doc, was special.

Sally had done this a lot, and she knew most the folks that came in, though not all. If she didn’t know them, she had probably heard of them. This was a very small, very remote place, the canyon. The folks up on the prairie were often referred to with a sideways glance by the folks down here. Isn’t that true everywhere?

They radioed in again before they dropped down the grade. Said everything was fine. We wouldn’t hear from them again until they were just right out of town.

Sid imagined what would be happening if these volunteers weren’t there to drive the EMS rig down the grade.

He had seen that once. It was at a different little hospital on a different little prairie in this place with rivers and canyons and prairies and mountains.

The dad had come through the doors with his 12-year-old daughter almost dead in his arms. He’d driven her all the way from their remote homestead. No cell service, no land line, so when she started having trouble breathing, he’d scooped her up, laid her on the bench seat of the pickup and drove like hell. He said he kept shaking her as she faded in and out. Then scooped her out of the seat and brought her through our doors to us. We saved her. Sid had never seen such anaphylaxis. Her nose, her mouth, her eyes dripping mucous. She was barely passing air.

But he’d read about the steps, the treatment. No helicopter, just his wits and steady hand. And the dad who took the steps, driving like hell. She survived.

These things taught him. He cherished them.

Sally was bustling in the ER bay. Sid loved the familiar grey green tiles up to the ceiling. Like when they built it, they knew they’d be flushing down blood spatter.

These people up on the prairie, Sally tsked, like she knew who they were.

Do you know this family?

No, but I can imagine. Letting their child get hurt like this.

Sid went to the coffee room and brewed his first cup of the weekend.

Ten minutes later he could see the twirling lights through the big windows of the family room, down across the river. The few June chinook left were past here by now. The downriver dams had decimated them. It was hard to get by here unless you got a government job. The salmon couldn’t get home around the government concrete walls.

Sid watched the red circling lights turn onto the bridge and then head his way. He sipped the strong coffee. There was no rush. He had learned this. Take your time. They still got to come through town and climb up to the hospital on this bench. He didn’t have to be there right now. He gazed at the light reflections on the still full river, flowing strong as the snow melted. It would run down river for another forty miles until it met the slack water of the uppermost dam. It carried barges and irrigated fields and generated kilowatts but blocked the fish. You can only get so much energy out of a system. You can’t have it all.

The white ambulance climbed the hill below him and the red lights lit up the pine needles like fancy Christmas tinsel. But it was June, and the sun had dropped down below the ridge. It was darkening here, but the sky would be light blue for another couple hours. The colors were transcendent.

Sid and Sally were there as they came in. Just two prairie EMS folks wheeling the gurney with the little guy, his head wrapped in a big white bundle. The kid was dirty. So was his dad.

But the kid wasn’t screaming. Sid liked that. Little kids can be tough. The dad was glaring. Sid didn’t like that.

The dad had on bib overalls with a t-shirt under. He had a big, long auburn beard beneath his darkly tanned creased face. Mind you, this was way before these big beards became fashionable for the in-your-face right wingers and holy rollers. Maybe this guy was a trend setter, back before you could be an influencer. The ponytail he hung told Sid something, as does the shaved head of today’s bearded brethren. Styles tell us something.

Hello, I’m Doctor Hawthorn. Are you this boy’s father?

Just a nervous nod.

Can you tell me what happened? I will look at his injury in just a minute. Sid heard Sally scooting the alert little boy across to the ER gurney behind him.

The overalls kind of melted here. The glare fell away and he teared up a bit. We were feeding the sheep. He got too close to the mule. She kicked him.

Did you see it?

No. But my daughter told me she saw it. I just picked him up.

Was he unconscious when you picked him up?

Here the overalls looked at Sid intently. Like he needed to figure something out.

Yeah, maybe. He was kinda limp. God, I feared he was dead. Here Overalls did start to cry.

Sid touched his shoulder. Is this where compassion crosses over to self-interest? Sid needed some information about the incident to decide about the helicopter.

How long do you think your son was limp like that?

Overalls was still sobbing and hadn’t heard.

Sid took a couple deep calming breaths right in front of the guy. He tried again.

Sir, if there is a head injury, the length of unconsciousness can tell us how much injury the brain received. So that’s why I’m asking.

Overalls was coming around. So Sid prompted. Do you think he was limp for a long time? Say a minute?

Oh no. He shook his head. It felt like an hour I was so scared, but it was probably just a couple seconds after I picked him up. He started yowling and I hushed him.

So he knew who you were right away?

Overalls smiled at Sid. Yeah, he knew his Poppa was telling him to hush. He hushed.

Sid liked the guy. Didn’t know his name or what he was about, but he liked him. I’m going to go examine your boy now. I’ll let you know what I find.

The head-wrapped kid was sitting on the gurney, looking around. Hey, what’s your name. You can call me Sid. I’m Doctor Hawthorne.

The grubby boy looked at Sid under the big bundle of gauze and Kerlix wrapped around his head, half covering the left eye. Sid could see the dark dried blood down his neck, onto his chest and staining his light green t-shirt. It was a significant stain.

I’m Isaiah. Sid smiled. Short and sweet.

So you are a prophet. How old are you Mr. Isaiah?

I’m five. His dark eyes pierced Sid.

I need to look at you since you got injured and figure out what we need to do. Can you remember what happened?

I didn’t like riding in that truck. Sid looked at the EMT’s bundling out and they both of them, looked down at the floor and smiled, almost laughed.

Yeah, that’s no fun. But I’m asking about this. Sid softly touched the bandaged head. Do you remember how your head got hurt?

Here the little guy looked away. Like he’d done something wrong. He barely shook his head.

Do you remember your dad picking you up?

Here the Prophet stared at his overalled father and said softly, He told me to hush.

Sid stood there in his blue cotton scrubs. He took a deep breath. Well, I need to look at you carefully, then I’m going to take this bandage off your head and look at that.

Sid did the stethoscope thing, heart and lungs, knowing this was a formality to gain trust and look competent. He even felt the kid’s belly and legs and arms, being a thorough, patient doc. The otoscope came out and Isaiah was not fearful, just solid. Sid lifted the bandage to look in both ears. All good.

Show me your tongue. He did. Teeth OK, no blood back there.

Let’s unwrap this. Isaiah sat quietly as Sid wound off the white webbing over the big pad of gauze 4x4’s.

With the last wrap Sid could see the edges of the cut beyond the 4” pads. Let’s have you lie down for this part. Sally had been watching closely and put a chucks pad on the pillow. She was expecting blood. So was Sid.

The EMT’s had probably put this dressing on 45 minutes ago, so the blood would be congealed to the gauze. When Sid pulled it off, the natural glue would lose its effect, and the blood would flow again.

Sid was careful, peeling it off from the cheek toward the scalp. There was some oozing, but no big gush.

There on the side of Isaiah’s left head, from just above his left eyebrow to the top of his scalp and back down to behind the left ear, was a perfect dirty maroon half circle laceration. It was wrinkled and the edges oozed just enough to make Sid worried about what was underneath.

Sid looked at the EMT’s who were still standing there. Good bandage. You got the flap back up where it needs to be. The woman smiled. The old guy nodded.

Sid got a new pack of 4x4 gauze and pressed it onto Isaiah’s head. Hold this he told Sally. She did. As she applied pressure to the flap, Sid pressed his gloved fingers around the edges, feeling for grating, crepitus. If the skull was fractured, it was time to call the helicopter. Sid knew this sort of check was not what they would do in the big city. The kid would be in a CT scanner before…anything. He pressed slowly and carefully. Isaiah let him.

Sid turned to the overalls Dad who was glaring intently from the north wall. I’m not worried about a serious head injury. I mean, he did get knocked out, but just for a bit. But I will need to clean this wound very carefully. The risk for infection is big. There could be a lot more bleeding, and the scar might be significant. I could get him shipped off to a plastic surgeon; they would do this repair in the OR. What do you want me to do?

Overalls was staring at Sid. For a while. We got no money, no health insurance. Can you fix him doc?

It was what Sid expected. Sid didn’t really want to sew up a 15 cm laceration on a little kid’s head with all the dirt and risks. But what the hell. He knew he could. Maybe not as good as the best, but as good as most.

Here walked in the Madonna. Mom with three more kids, one at her breast and the oldest going straight to Isaiah. She looked at Overalls. They talked a bit, Sid standing there, then she looked at Sid with wolverine eyes. You fix him up.

So he set about doing it.

Local anesthesia. It hurts going in. You hurt a five-year-old when you have told him you will help him, it can piss them off.

I’m going to use a combination of lidocaine and Marcaine, because this could take a while, Sid said to Sally. Do you guys have Marcaine down here? Or do we need to call pharmacy? She nodded and found the vials in a drawer.

See if you can get his skin kinda clean before I inject, he told Sally. Isaiah, we’re going to wash you off there where you got kicked.

He just nodded. Little trooper. Then I need to get the area numb, so you won’t feel what we’re doing. The numbing medicine stings a bit if I go too fast, so I will need you to tell me if I’m going too fast. Sid said all this while he was opening up the big suture tray on the stand by the gurney. He unpeeled come dexon and ethilon sutures. Madonna had moved over next to Isaiah. She still had the babe at her breast, but it was sleeping. Sally washed, scrubbed the kids grubby face and up into the scalp. It was a big flap.

Sid knew the anatomy. He knew what was under there. And he expected it to be pretty dirty. So he kept up the banter.

After this wash of the outside we’ll get you numb so you can’t feel anything. Then we need to wash out the cut, so you don’t get an infection. That’s when germs grow in your body where they shouldn’t. Germs aren’t bad, they just need to be in places where our body can deal with them. Our skin keeps them out pretty well, but your skin got cut, so there could be germs down under your skin.

Sid got out the sterile gloves and dropped them onto the tray. It was all set. He drew up the two syringes of local anesthetic. He turned to the patient.

Let’s get you comfortable. Sid fluffed the pillow and had Isaiah lie on his side so he could look at his mom. She was staring at the plastered down flap. Sally had the skin pretty clean. Sid hoped what was underneath wouldn’t be too bad. But a mule hoof is not clean.

Sid slowly injected the local. Isaiah only complained a couple times when Sid rushed it, but dad told him to hush, and mom patted his arm and he calmed down. Sid had done this on so many screaming kids whose parents were just as afraid as they were. This kid was great. It took Sid about fifteen minutes to get it all injected.

Sally, can you get me some sterile saline to wash this out?

Sid lifted the flap.

There it was, the pulsing temporal artery. Sid knew it hadn’t been cut. The dressing would have been soaked, inadequate. There were little bleeders here and there that he could sponge. And there was dirt.

This little kid had a flap bigger than his hand on the side of his face and scalp from a mule kick, and he would live to tell about it.

Sid looked up at the Madonna. It’s not too bad. We’ll clean it up and close it.

She frowned at Sid. Will he have a scar?

Oh yes. One he can be quite proud of. Impress the girls. He smiled at her, there holding the sleeping babe. She was still worried and looked over her shoulder to the overalls. Then she calmed.

Sid spent twenty minutes irrigating, picking out debris, cleaning the wound. Isaiah actually fell asleep. Then Sid closed it. He put just a couple deep sutures to hold the skin down, then a lot of nylon sutures around the edge. He needed three packs of 4-0 ethilon. Then the dressing, almost the same as the EMT’s had applied.

You can take him home. Take the dressing off tomorrow to look at it but then put it back on until Monday. Come back in a week or so for us to take out the stitches.

They loaded out. The prophet was asleep on his dad’s shoulder.

Sally was bustling, cleaning up. Sid removed all the needles from the tray. Five suture sets had gone into that, and the two 5cc syringes of local.

Sally tsked. A mule. They let their boy near a mule. I can’t imagine.

The windows were clear and Sid could see the river, He thought of the big chinook coming up to spawn, the few that could get past the dams. He thought of the reds, where they went to lay their eggs, The streams off the sides, up in the canyons where the clear water flows.

Sally came in. We got another kid with an earache. Sid smiled.

Hey Sally, you ever been kicked by a mule?

She laughed. Naw, Doc, I know better. You?

Sid paused. Not a mule, but a horse. Knocked me down.

Sally shook her head. That little boy was lucky.

Yeah, he had something on his side.

They went to the ER together.

It was still light when Sid headed home on the Sunday evening. The drunks, the crying babies, the sad whiners he left behind. He drove down the canyon, as the river flowed next to him. He thought of the big salmon coming up. They had a place to go to. As did Sid. Then they would die.

Not Sid.

Not yet.