Another Time and Another place
GUNSHOT WOUNDS TO THE CHEST
Lillian Beate Holmen
Gunshot wounds to the chest can be highly lethal. Depending on the injured organ, a large percentage of the patients die before reaching the hospital. There is a big difference between low-velocity and high-velocity weapons. Low velocity injuries are most common in the civilian sector, whereas high-velocity injuries are over-represented in war zones and cause much greater tissue damage. The initial evaluation at the hospital needs to be quick and well-practiced in order to rush the most critical patients to treatment and surgery without delay. All organs in the thoracic cavity may potentially be harmed. Parenchymal lung injury is the most common and the usual form of presentation is hemo- or pneumohemothorax. The most common forms of presentation of cardiac injury are cardiac tamponade and excessive haemorrhage.
However, during military conflict high-velocity injuries, including GSWs are relatively more common. High-velocity GSWs generally have a higher mortality than low-velocity GSWs. A Turkish study from 1998 reviewed 755 patients with penetrating thoracic trauma over a 6 year period. 54,7 % of the patients had gunshot wounds, and 56.2 % of these were high-velocity injuries. The overall mortality due to firearms in this study was 8,95 %. However, the mortality due to low-velocity GSWs was a mere 2.87 % whereas the mortality due to high-velocity GSW’s was 11.6%.
The reason for the relatively low mortality rate due to GSW’s in this series was possibly that most of the patients were relatively stable when admitted., The critically unstable patients died in the field due to lack of a proper transport system that could bring the patients to the hospital quickly.
Gunshot injuries to the chest are associated in 34 % to 36 % with hemato- or hematopneumothorax. A hemothorax is an accumulation of blood in the pleural cavity. The symptoms vary from shortness of breath and chest pain to signs of haemorrhagic shock. Although most are venous in origin and stop spontaneously, bleeding from great vessels or other arteries may occur. In these cases rapid intervention is necessary to control the bleeding and to prevent a tension effect. Clake et al. found that injury to the lung parenchyma was the most common source of bleeding, followed by the internal thoracic or the intercostal vessels (8).
One should always suspect a hemothorax when a patient has a GSW to the chest. The suspicion should be increased by the symptomology and physical findings and can be confirmed by an X-ray, although some use bedside ultrasound to diagnose. A chest X-ray can detect as little as 150 to 200 ml of blood. A bullet, particularly a high velocity one, often destroys the tissue adjacent to its path. Thus the bullet doesn’t necessarily have to pass through the heart to damage it, it can pass nearby and still do harm. Debridement may therefore be necessary as part of the repair of gunshot injuries.
There was nothing in the way of finesse about the way the Russian surgical team approached the methods they would use to keep James Ellis alive. Perhaps some thoracic surgeons at Papworth hospital may have considered the Russian surgeons’ approach to resuscitative surgery, to be somewhat “agricultural.” However, they were operating from an inflatable tent on an austere operating base, with the basics of equipment and they were using tried and tested protocols of battlefield surgery.
They righty suspected that there was an ongoing bleed within James’s chest cavity and they needed to get inside him, aspirate the collecting blood and stop the bleed from the internal thoracic artery. Meanwhile, the base was scoured for personnel with O-Negative blood and they presented at the MTF to donate 350 ml of their Russian blood to keep a British Special Forces trooper alive.
Many paralytic drugs are based on a botanical pharmaceutical called curare. A plant native to South America, it was originally used to paralyze animals during the hunt. By the mid-1940s, curare was being used as an adjunct to anaesthesia. Starting in the 1950s, researchers began creating synthetic paralytic drugs. Paralytic drugs relax the muscles to the point where it is impossible to use most of the muscles of the body. The muscles of the diaphragm, which help the lungs fill with oxygen, are also unable to move, so it is impossible to draw a breath. Once the paralytic medication is given, the ventilator and a breathing tube are necessary. James may have been paralysed, but he felt everything from the tube going down his airway to the aspirator inside his chest. When the debridement and suturing of his artery was commenced, he gave a silent scream, his mind was unable to stand the agony and he went to another place and another time.
He was on the Brecon Beacons. It was raining as it always was. The wind tore at his hair and the collar and hood of his smock slapped his face and neck, as he laboured up to Pen y Fan. James became aware that someone had fallen in step next to him.
“Come on, Ellis. Push on, push on,” said Sergeant Sagar, which was odd because James could have sworn that Sergeant Sagar had been killed in a parachuting accident, five years previously.
Up ahead at the top of the mountain, the checkpoint loomed out of the rain and low cloud, “Good lad, Ellis! Keep going and dig in, lad. Ten clicks to the next one!” said Corporal Ives, which was very peculiar. Corporal Ives had been killed in Helmand back in 2015.
The next leg was one of the most treacherous, along the knife-edge ridge to Abercynafon and down to skirt Talybont Reservoir. Then he would head south to Trefill. As he headed down to Abercynafon, following a stream the ground became more difficult and he had no wish to sprain or break his ankles. Once he was on the road he began to run, the SLR heavy in his arms. A half-caste girl stepped out of the trees at the side of the road and waved and smiled at him.
“Sis? Sis, what the hell are you doing here? Oh God, not you as well.”
“I’m afraid so, James,” she showed him the infected sores and needle tracks on her arms, “You were right. It did kill me in the end.”
“You were the only family I had,” he sobbed.
“Stay alive, James. Only you can do that bit now.”
I must be going mad, James concluded. He had had enough of being with the dead and decided to return to the operating theatre and the pain.
Four hours later the exhausted surgical team stepped back from the table and anxiously watched the machine monitoring his vital signs and the quiet hiss of the ventilator. His own heart had taken over from the machines and they prayed the sutures would hold.
“There’s nothing more we can do. He is in the hands of God now.”
They wheeled James into the single-bed ICU unit, where the two nurses would monitor him every thirty minutes, waiting for his body to produce urine. Above the silent and absent James Ellis, a reproduction icon of a Madonna and Child stared sadly and mournfully down at him. James wasn’t there. He was lying in a summer meadow at the side of a peaceful river, his head resting on Afarin Khan’s breasts. He would live for her.
Prince Hussein Air Base Jordan – 25th February 2018
Ripley seemed to have gravitated towards Cécile Hammond over the past couple of days. It was mutual and symbiotic relationship and they needed each other. The troopers had a totally different way of dealing with the anxiety and sadness of losing James. Although they wished him well and prayed for his recovery, they couldn’t seem to be mawkish. Casualties were a fact of life and after what they had been through during the past four months, one casualty was miraculous,
The difficulty was getting information about James’s progress or prognosis. There was no way now of directly communicating with the airbase at Ad Dumayr and all Halward could relay was contained in the afternoon sitreps from London.
“Look Ripley, he’s still alive. They’ve operated on him and as soon as he’s stable enough, the Crab medics can fly him home.
But of course she wanted and needed far more and only Cécile seemed to understand. They were sitting in the corner of a Rubb hangar on the Jordanian airbase. The Chinook aircrew and the communications technicians had already been flown home by C130, because they were needed elsewhere and were special. The Blades would go once Daffi Hashmi’s interrogations were finished and he and Cécile with Phillips would fly back to the UK by Falcon jet. With the C17 would come the RAF technicians, who would dissemble the Chinooks for air transportation. Ripley was glad to be rid of the communications equipment and her body and her innermost thoughts were hers alone. It was also good to be able to clean her teeth and floss again.
They were watching the troopers playing sitting volley ball, a game which seemed to be providing them with much amusement. Phillips was a discrete distance away, reading a book. Cécile was becoming a little exasperated with his constant presence, “Look, Mr Phillips, we’re on friendly ground now and you don’t have to be glued to me all of the time.”
“We were on friendly ground in Islamabad weren’t we? Once we’re back at Northolt we can have a divorce party, until then, I remain your close protection, Ma’am.”
It was amusing to Ripley who couldn’t for the life of her, understand why Cécile couldn’t see what was blindingly obvious to her. Cécile and Ripley were talking about the ongoing interrogation of Hashmi.
“The trouble is, what they are doing is little short of torture and I think it’s counter-productive on several levels. Those thugs from the General Intelligence Directorate (Jordan) (GID) are far too predictable and I think Hashmi is just retreating into somewhere, knowing they can’t kill him and eventually he will be back in Britain in a court of law. I think he wants his day in court and will use the whole process for grandstanding his Jihadist credentials.
“Which brings us to the ethical dimensions. If it gets out what has happened to him here, despite whatever crimes he is supposed to have committed, any jury will automatically view him as the victim. I just can’t believe that British politicians would countenance this barbarity, or be so stupid.”
“Oh I can. It’s been going on since the Blair years. Extraordinary rendition flights to places like this, or Egypt or even the Stans,” Ripley told her, “There are a number of prominent, shameless politicians who have blood on their hands.”
Cécile watched Manny Cohen shuffling on his backside to reach a ball that had been lofted high into his court, “I wish you could interrogate him. You and me. I think that would be more productive than beating the living shit out of him.”
Ripley lit a cigarette. After the initial bout of almost chain smoking after James was shot, her intake was more moderate, “I have been warned by Major Halward that Daffi Hashmi is no concern of mine. He has received his instructions from London. Bunch of ungrateful bastards if you ask me.”
“I spoke with Hashmi twice whilst I was in Ad Dumayr and there’s one thing you should know. He isn’t the same mad jihadist who went to Syria from England. He isn’t even the same psychopath who was involved with the torture and murder of the Tornado crew. He is even more dangerous now. All the beatings, shocks and waterboarding in the world aren’t going to stop him. He will relish the attention a court case will bring him and you can be sure every crackpot, terrorist appeaser and bleeding hearted liberal will be jumping on the bandwagon.
“But he has a weakness and it’s his own sense of importance, righteousness and depravity. If it hadn’t been jihad, it would have been politics, trade unionism, the Eco-Green movement, whatever. Now don’t misunderstand, I’m not saying that all politicians, union members and eco loons are raging terrorists. But there is a certain mind set within aspects of all organisations that believe beyond doubt in the absolute infallibility of their principles, a blinkered fascism that accept as a truism, that their opinions are the only ones that matter. You only have to look at the total lack of scientific reason among the climate changists or the unhinged reaction to a democratic decision to leave the EU, and Hashmi’s mind set is very much like theirs. That’s his weakness.”
“And how do I exploit this?”
“I dunno. You’re the bloody lawyer.”
They both giggled, “When are you next on?”
Cécile looked at her watch, “11:00.”
“Pull out a fingernail for me.”
There is nothing edifying in watching a man being water boarded to within an inch of his life, but Cécile was prepared to make an exception in Daffi Hashmi’s case. As well as the two GID operatives, she and Phillips were in the room and of course, Hashmi. It was a miserable concrete cell with a steel framed chair, Hashmi strapped to a plank raised at the feet, a tap in the wall and a cloth, hosepipe with lots of water. She could tell that Phillips found this nauseating and ordinarily so would she. But these weren’t ordinary times and the scenes on that video file had been seared into her memory.
“Whose idea was it to murder Flight Lieutenant Halling by drowning her, Hashmi?” Cécile asked, knowing she would be called an uncle fucking whore, yet again.
One thing was perfectly clear. Despite his seemingly helpless situation, it was Daffi Hashmi who was running this show. And it went on and on and on and they managed to get absolutely nothing out of him. Her talk with Ripley had given her a new resolve and she knew that she would have to act today, or never.
They left the prisoner hanging from a hook in the ceiling by his arms, which had been tied behind his back in order to partially dislocate his shoulders and went outside for a rest. The two Jordanians were smoking and Cécile went over to one of them.
“Inspector Suleiman, would you please allow me to go in there and speak to him alone?” The Jordanian policeman laughed, “Inspector, I’m being deadly serious. I will be safe if you cable tie his arms behind his back and sit him hard against the walls in the corner of the room, so he can’t get up quickly. Besides, I will have this.”
Cécile took off her smock and was only wearing a tight, black t-shirt under it and nothing else on top. This was a carefully orchestrated part of the prisoner’s humiliation, a trick she had learned from Ripley. The Jordanian secret policemen gaped at her as she un-holstered her Sig, cocked it and re-holstered it. She looked at Phillips who was wearing a strange expression as he returned her glance. Was it disappointment with her? It never occurred to her that it could be something else quite different.
“You will be just outside the door. I won’t go anywhere near him so he won’t be able to grab my gun. You have been asked to fully cooperate with us haven’t you?”
Suleiman thought about it, “Very well, no longer than five minutes.”
“And I will have to go in with you,” insisted Phillips.
“No, Mr Phillips. For the first time I’m going to pull rank on you. We have been abusing Hashmi for hours and all we have succeeded in doing is making him more determined and resolute. As I said to the Inspector, you will be just outside the door.”
“I just don’t know.”
“Staff-sergeant Phillips, I am giving you a direct order. You are to remain outside the door until I leave the cell or call you in. Is that clear?”
“Yes, Ma’am,” he said reluctantly, “But I do so under duress.”
Phillips and the Inspector went into the cell and dragged Hashmi down and dumped him in the corner. Phillips covered him until Cécile went in.
“Remember, we’re just outside the door.”
“Thank you. Don’t fret Mr Phillips. I’m a big girl.”
She closed the cell door and looked down at Hashmi in the corner for a long time. He looked back at her and despite the pain he was in, he grinned.
“And which one are you going to be, Tits? Miss Nice or Miss Nasty? Did you enjoy watching me being tortured, you kuffar whore!”
“As a matter of fact, yes I did. Afarin Khan sends her regards by the way. She did you up like a kipper, didn’t she? And your attack dog, The Bosniak, she did for him as well. Cut his filthy heart out. She’s quite tasty isn’t she?” Cécile could tell by his expression that this hit home, “And here you are, grovelling on the floor like a whipped dog, and here am I, enjoying watching you suffer.”
“No court will manage to put me away for a long time, and you know it. I’ll probably go away for ten to fifteen and out in five to eight. I’ll be living a life of luxury in a prison that me and my brothers run. And when I get out, I’ll come looking for you.”
“I would like to talk about Flight Lieutenant Emma Halling and Flight Lieutenant Finn Waldrum.”
“The RAF Tornado crew? He was tough. She pretended to be, but after a while… Well you get the picture. Oh please don’t hurt me anymore,” he said in a sarcastic sotto voice, “And she was a lousy fuck as well.”
Cécile nodded. She moved to the chair, picked it up and jammed it against the cell door, the back under the ridge of the steel panel. She crouched down in front of Hashmi.
“Do you know something, Daffi. You’re absolutely right. After what you’ve been through, a court and jury will be very reluctant to assume absolute guilt and no Judge would give you the sentence you deserve. I said I wanted to talk about Emma and Finn. You tore his body apart between two trucks. For how long was Emma tortured? Days or weeks and then you drowned her. You didn’t even have the decency to kill her first.”
“I’ll tell you something really funny. I knew Emma very well. She was the most kind, generous and gentle woman you could ever wish to meet. You see, I loved her and she loved me. We were going to move out of the mess and live in our own house, our own home and set up a life together.”
“Oh wow! That’s priceless, you were rug munchers. No wonder she didn’t like cock.”
“And you and your friends brutalised and murdered her. The rest of them are dead and I was there on both occasions. You’re never going to see the inside of a court, Daffi Hashmi. You’re going to die in this cell, killed by a woman. That will be me.”
She drew the Sig, jammed it into his crotch and pulled the trigger. The sound in the enclosed cell was deafening, as were Hashmi’s screams as the hollow point round blew off his penis and left testicle. The flattened bullet ricocheted up off the floor and destroyed his sciatic nerve. Blood and urine pooled under him.
“That’s for Emma Hallet, you bastard and this one’s for Finn Waldrum,” She blew off his left kneecap.
“And the happiness you destroyed!” Bone fragments and blood from his right kneecap sprayed up the cell wall. She could hear shouting and hammering from outside the cell.
“And all the people whose lives you have destroyed!” His right shoulder splashed on the wall behind him, followed by the left. The hammering was frantic and the chair was starting to rock.
She put her face right into his and screamed: “SEE YOU IN HELL YOU FUCKING BASTARD!”
Cécile rammed the muzzle of the Sig into his forehead and butted his head against the corner of the walls. Again she pulled the trigger and Daffi Hashmi’s brains and pieces of his skull sprayed up the wall behind his destroyed head, spattering her face. The chair skated across the floor as the door smashed open. Phillips ran towards her as Cécile put the muzzle of the gun in her mouth.
“NO!” he yelled and kicked the gun out of her mouth as she pulled the trigger. The round ricocheted off two walls and Cécile screamed in anguish. She looked like an evil banshee, showered with Hashmi’s blood and brains.
“YOU BASTARD! YOU SHOULD HAVE LET ME DIE! I WANT TO DIE!”
© Blown Periphery 2020
The Goodnight Vienna Audio file