The ground is wet from passed-on rain; sporadically little drops sting my upturned face, sudden remembrances of a rainy day now at dusk. Chill spreads up my legs and into the small of my back but I am focused on the Lodge Pole Pines that stretch black into a yellow-pus sky. I am struck by the stark colors, black against creamy yellow, how they hold my eye like a car accident. It will be dark soon, and colder. I pull my rain jacket down past my navel and am shocked, for a moment, when my fingers emerge from the folds of clothes covered in black-red stains. I am bleeding. Some forty feet away I can see someone lying against a boulder, eyes closed, gooey brain matter and blood oozing from a crack in their forehead. The woods are quiet but for the distant swoosh of the creek away down the hill. I look at my fingers again and notice the darkened tips have disappeared, camouflaged in the open wound of sky. A tremor ripples through me, from the slow-spreading cold, but also because I am imagining that my plane has just fallen out of the sky, that I am bleeding profusely, without help in a darkening wilderness. I am imagining I am going to die. But not yet. Not alone.

A male voice scatters the silence, bellows,
“Alright guys, go!”

And the woods are ruptured with screams.

The screams are feigned, but echoing through the murky trees they sound real and terrible. We who cry out are simulacrums of the dead, dying, and wounded, and we must make this experience as accurate as possible. I, and everyone else scattered in the darkness, have volunteered to be patients for a Wilderness First Responder class. The WFR certification is a ten-day class where students learn how to recognize and treat a wide range of traumatic injuries and medical issues in a wilderness setting. At the end of the course, students are expected to be able to stop life-threatening bleeds, set broken bones, reduce dislocated joints, perform CPR and rescue-breathing, recognize and treat various medical conditions like diabetes, and know how and when to evacuate their patients, and all in a backcountry setting with little to no medical equipment. The learning curve is intense and many WFR students go on to guide positions where traumatic injuries and illnesses do happen. To prepare students for what they may face, the WFR class tests students in the ultimate simulator: an extended training scenario wherein students must work together as teams to locate, care for, and evacuate up to ten patients from a wilderness setting at night. The patients are volunteers and their injuries run the gamut from annoying to life-threatening. In most scenarios, a one or two patients are slated to die from their injuries.

For tonight’s scenario, there are nine patients, myself included. Preparing for the scenario is not unlike rehearsing for a play. We are given cards which describe the scenario in depth—in this case it is a plane crash—and what our injuries are. We memorize sets of changing vitals, patient histories, improvise our conditions based on what treatments are administered, and perform as realistically as possible our characters. Some patients are instructed to be belligerent, unreliable, or so hysterical that they don’t follow rescuer instructions or give accurate information. One patient during this scenario is told to, “Scream a lot. Like, you want to distract everyone and make it difficult for rescuers to hear anything else.” Because realism is the goal, make-up and prosthetic wounds are meticulously applied. One patient is assigned an amputated hand. Her hand is taped closed and a latex bloodied stump with a protruding bone end is glued over. In her taped palm is a small pump which spurts blood out of the stump when she squeezes it. The instructor has brought along a two-liter bottle of fake blood, and gives each patient a generous dousing before the scenario begins. Getting assigned a really gory injury or a character that requires a lot of acting chops is fun, like a performance. But under all the pageantry and fabrication lurks a tacit understanding: this is training for real events. We are pretending to be hurt so that rescuers can train to help real people who are hurt, people who will suffer, and may die. I wonder who it was that died to supply the medical information on my character card.

For perhaps a minute or more cries and moans ricochet around me. I don’t yell; my injuries have compromised my diaphragm and abdominal muscles. Out of the inimical black two bobbing lights appear. They’re moving fast towards the noise, which rises up to meet them. Everyone is calling to them at once: Hey! Over here! Help! Help me! Oh my God I’m bleeding! Pleas flood in from all directions suspending the rescuers as if in a spider web; how do you choose who to help when everyone needs you? This is triage, the team charged with identifying and tagging patients. Triage only treat immediate life threats, blocked airways, hemorrhagic bleeds, and tag patients with green, yellow, red, or black triage tags.

Green patients are those who are ambulatory. They are walking wounded who can evacuate themselves to the designated safe area. Yellow patients are non-ambulatory, but they are not dying right now, and can wait for treatment. Red patients are dying right now and require immediate care. Red patients are most difficult for rescuers, not only because of the extensive nature of their injuries, but because each requires the rescuer to assess the chance of survival. Patients who are alive but require an inordinate amount of resources may be deemed too costly to save. These patients will receive a red “expectant” tag, meaning that they will have to wait to receive treatment behind the red “immediate” tags, those estimated to have a higher chance of survival given the resources available. Red “expectant” patients often will die while awaiting treatment. Black patients are those without a viable pulse or who are not breathing even after the airway has been cleared and rescue breaths administered. The worst fate, it seems, it not to watch the world end, but to have to decide for whom it ends.

Triage heads for the first patient they see because he has run up to them, a walking wounded. He grabs them each by an arm, clinging to them like a drowning man.
“My face!” He says over and over.
He has a large gash across his cheek. They try to follow their training, but the patient is holding them, begging, creating a distraction that could prove fatal for other patients. Losing patience and time, they shake loose of his grip and drop a green glow-stick at his feet. Their headlamps sweep over the astonishment on his face and leave him in the dark. When they find me, I am given a hasty occlusive dressing over my abdomen and a red tag and they are gone. Triage does everything correctly but it still feels like a betrayal, to be categorized and left behind when I most want to be seen.

It’s pitch black around me and I am alone again. Clouds curtain the stars and moon and the vacuous pits of trees absorb any lunar light that tries to break through. Triage has come and gone and now patients must wait in the agonal dark while the resources are assessed and assigned. Faint suffering sounds like snatches of birdsong still tarry. I wonder what the other patients are thinking to themselves as they wait for the rescuers to arrive on scene. Are they obediently reviewing their vitals trends and medical histories? Or, like me, are they trying to grasp the thread that connects the inner experience of suffering with its outward effects. How does someone with an open femur fracture exist? Do they scream away the pain like an unyielding siren? Do we suffer like animals, stoically, terminally? Or does that most human impulse persist: that which begs feel what I am feeling.

Suddenly white beams of light are cutting up the darkness, the rescuer’s headlamps, and I am surrounded by strangers. Of the four people attending me, I catch the name of one, Dylan. He’s young, pale-skinned with blond hair and a nearly white-blond beard. He asks my name. I tell him “Becky” but he hears Maggie and I don’t correct him. We are told to use our real names during the scenario, but am I always uneasy doing so, as if my true self will break through the memorized stats and spurious injuries and the horrible truth of what we are doing here together will seize us all like adders. They assess life threats and complete a head-to-toe exam. There they find my belly ripped open and glistening, slippery chords of intestines dangling onto the ground (To create this wound, long red balloons of the type usually used to make balloon animals were filled with mud, glued to my stomach, and then covered in corn-syrup blood). A dressing of gauze and plastic is taped over as best as can be managed in an attempt to shield the innards from the outward world. In the field and with their training, this is all they can do. I can see in their faces that they know it’s not enough.

I am panting fast and shallow, my face cut through with terror. I whisper to Dylan a premonitory warning, “I’m going to die.” Patients with grave injuries often aren’t as oblivious as we’d hope them to be; some know when their circumstances are hopeless. In these moments it is not medical care they want but simply someone to acknowledge their humanity before it is lost. Dylan dashes himself against my proclamation, looks right at me, says,
“No, no, you’re not, because we have people coming to help you and get you out of here.” In my head I wonder if he truly believes this or he’s trying to keep me calm despite the inevitable. A medical instructor told me to never promise a patient’s survival. It’s a promise you can’t always keep.

Almost immediately the first set of vitals are collected. Rescuers take the actual vitals and then the patient adjusts them as necessary to fit. A rescuer who has been bent over me, feeling my pulse and watching my chest for breaths announces to the group,
“Heart rate one hundred. Respiratory rate thirty,” then he looks at me, making eye contact for the first time since he’s arrived.
“Heart rate one-ninety. Respiratory rate true,” I say flatly and then submerge back into my showy husk of suffering. I see Dylan write these down on some athletic tape he’s stuck to his pants to use as an improvised notepad. The team learns my pupils are sluggish to react to light and my skin is pale, cool, and clammy to the touch.
“Shit. She needs to evac like right now!” Dylan says then he is on the radio, “Twenty-eight year old female with evisceration to the lower abdomen. Intestines visible with a suspected abdominal hemorrhage. Requesting immediate evac,” he chants. For a moment we are all frozen waiting for the radio response. I knew what the response would be; when it comes it still cuts to see it register on my rescuer’s faces. The static crinkles and a male voice, too calm, says, “Evac denied. Resources needed elsewhere. Two rescuers, please dispatch to team 2.”

They know now that my red tag was not immediate. Triage deemed me too costly to save. Dylan opened his mouth and closed it. He had things to say, hatred to pour out over the heartlessness of a system that forced him to care for a patient that no one intended to save, but he could not say them. I realize then that he really did believe I would be saved; he thought he could promise me my life. It is a mistake that I’m glad he’ll learn tonight, before he meets his first real patients.

Two of the four-person team stands up. One of the men turns away from me and calls into the dark,
“Yo! Team 2, where are ya?” A call from perhaps thirty feet away comes in answer,
“Over here! Need more hands!” and two of the four are gone.

WFR students and certified WFR’s can be taken by bravado. Their skills are practiced in high-pressure scenarios the scope of which many professional first responders rarely see in real-life. The confidence that comes of assuming you’ve seen it all can make WFRs cocky and aloof. During night scenarios teams often rush to find the most messed up patients, where the action is, and rescuers will try to jump teams to get in on a more seriously injured patient. The bombast, like the patients themselves, is often fabricated, part of the theatre of the WFR. The dramatics are a double-edged sword, at one end providing realistic skills practice in the field, but on the other end, the simulated gore and suffering are a constant reminder to students that what they are doing is not real, cannot be real. The consequence of real suffering and death simply cannot be articulated nor would any instructor invite such vulnerability into a standardized classroom setting. Every real-life first responder or medical practitioner carries the burden of empathy and the trauma of unalleviated suffering with them. It isn’t taught, nor can it be anticipated, when a patient will become a person for a newly certified WFR. All the posturing and competitiveness among WFR students falls away once the stage is dismantled. I have never known a WFR-trained guide or a first responder when responding to a real medical emergency to wish for more suffering, to want more screaming, to want to watch someone die.

Dylan squats beside me, his warm hand pressed over the bandage on my wound. His remaining partner stands rocking on his feet, perhaps thinking of defecting to a different team, one with a patient that perhaps could be saved. Around us the night is alive with voices and movement but within our small circle of light the stillness of immanent sorrow holds us steady and braces our backs. Still, Dylan is not giving up.
“OK, shock is going to be an issue. She needs to be warmer. And get another set of vitals.” Still holding pressure on my stomach, with his free hand he pulls a sleeping bag from his pack and drapes it over me and tucks the edges around me. He asks me how I’m doing, but my level of consciousness is now too low for me to respond coherently. “We’re going to wait this out together,” he tells me, “stay with me and I’ll stay with you. OK?” I know without a doubt he won’t leave me. It is the last thing I am sure of. Moments later, as my card instructed, I lose consciousness and soon after, my pulse stops.

I told them there was a CPR mannequin behind the boulder at my feet that they should use before adopting the guise of death. Dylan began CPR while the other remaining rescuer performed rescue breaths. At first it was easy to lie there, eyes closed, listening in on the scenario as it continued to unfold around me. Dylan delivered excellent CPR, strong and consistent, but I was dead. My task had been completed. I let my mind wander into the night as the fraught clicking of the CPR mannequin beat ever on. The other rescuer is soon called away to an evac team to help carry patients. Before he leaves he says to Dylan as way of an apology,
“You can probably stop. Pretty sure she’s dead.” But Dylan does not stop the exhausting work of compressing the chest one hundred times per minute.
“I’m not stopping until IC [Incident command] tells me to or she comes back. You can go,” he says, and his recreant partner slinks away. I am proud of Dylan. I make a mental note, when I am alive again, to praise him for sticking with his patient.

Ultimately the Wilderness First Responder class doesn’t teach students how to save people. The skills WFR students learn are not cures or even crutches. Medicine is too complex, the tools required too burdensome and apt to cause damage if used incorrectly, to teach in ten days. WFR student’s main functions are to document, to understand what injuries they are seeing, and to be able to provide support to patients until they can be delivered to definitive medical care.

Periodically Dylan had to check my pulse. He’d press his fingers to my carotid artery and ask hopefully,
“Do I feel a pulse?”

I have to tell him no. He is upset, not just mock upset for the scenario as I have been as a patient. Delivering CPR is grueling and I can see the sweat mingled with frustration on his face. Each time I deny him my pulse he curses softly, as if I am a waylaid baby bird, the kind we all occasionally find as children, who won’t eat the mushed-up bread crumbs he offers. Watching the featherless translucent creature grow weaker until it can’t to hold its knobby, bald head up, I imagine a young Dylan felt despair similar to what he feels now. There are two kinds of people in the world. There is the kind who, after failing to save a baby bird, sheepishly tuck it into a low-hanging branch and leave it to die out of their sight. The other kind, when faced with the same failure, stay, the weakling creature cupped snugly in a small towel in their hands, and wait for the creature to pass in their presence. In the second kind of people there is some instinct that must stay through the end because, while staying will be painful, it is better to know that pain than be haunted by its phantoms.

For me there is nothing to be done but stay, which he does.

He never stops CPR. With each desperate question, do I feel a pulse, I want to come back to life for him. As I lay there I cast about for any acceptable medical scenario in which I could regain a pulse, perhaps consciousness, but there is none, of course. I have died of a massive abdominal hemorrhage. Even a doctor, given the same resources and scenario, wouldn’t have been able to change my outcome. But I want to give him my strong, steady pulse; I want to tell him I’m perfectly alright, it’s just balloons and red dye; I want to tell him he did everything right, that I couldn’t have lived. But he is suffering his own trauma and I can’t save him from it.

The radio crackles. The too-calm voices says, “I’m going to call it. Patient is code black. Please dispatch to team six.” He leans back, sitting on his heels, his head bowed. For a moment I think he might weep. His legs crumble and furl, and he leans heavily against the base of a nearby tree. He closes his eyes; his face goes slack but for flecks of grief. For a moment we switch roles. He looks dead and I, slipped back into life, know he is feeling that obscene truth: when medicine can’t save someone, help becomes bearing their pain.
“I’m sorry I couldn’t save you,” he says to my still body. He stands up, gathers his backpack, waits. He says, “I’m so sorry” once more. Then, before he goes, he sighs. His shoulders rise and fall with the heft of it, a deep, open-mouthed moan accompanies it, and a billow of frozen breath ghosts through the beam of his headlamp. Then he is gone, his light bobbing towards someone else who cries out to him, who lives still.

And I am gone, too. It is almost as if, in the night veracious, we went together.

 

Rebecca Young’s essays and stories have appeared or are forthcoming in Bird’s Thumb Review, Literally Stories, Two Hawks Quarterly, Animal Literary Magazine, and others. She is currently pursuing her MFA in fiction and nonfiction with Vermont College of Fine Arts. She lives in the tiny mountain town of Leadville, Colorado, where she enjoys hiking, skiing, rock climbing, and mountaineering.