He hears voices behind him — whispery, indistinct — and pays them no mind. Then he hears two loud cracks in the air. Gunshots. And before he can react, he feels an overwhelming force, a heat that knocks him forward onto his knees. And then, sounds stop altogether: all he hears now is a high pitch deep within his ear, a cochlear emergency tone. A warmth spreads over him, like he’s being doused in Mentholatum. Brightness creeps into his peripheral vision. Daylight’s burning, his father says. So soon? Look: past the boots surrounding him, the sky is still obviously dark. Any fool can see. He keeps his eyes fixed on the horizon, too numb to react. The warmth enveloping him is too much to bear. Hands pull the sack off his shoulder and pat down his pockets. It can’t be dawn yet, but there’s the sun, blinding. Daylight’s burning. Come on. Let’s go.
PRIORITY PATIENTS
— Priority patient, the nurse announces. — Priority patient coming in!
What the term really means is that a white person has hurt himself.
Médecins Sans Frontières has set up modular field hospitals, six surgical tents, side by side. The initial four Trigano tents used for surgery are still operational, but patients want to be treated in the newer tents.
MSF has also doubled the number of patient tents, all of which have filled to capacity. Sunlight illuminates the tents during the day, the translucent plastic glowing like an incandescent bulb. All injuries are visible. But at night, the soldiers dim the overhead lights so that the tents are trapped in eternal twilight. Electrical power, though restored, is intermittent. The temperature reaches a few degrees above zero Celsius, and the injuries become shadows, darkened murmurs that occasionally break through the painkillers.
Two paths lead from the surgical tents, both well trod, the ground sunken and compacted. The first leads to the patient tents. The other leads to where bodies are stacked to be buried or incinerated.
Dev has seen two priority patients so far. The first was a Frenchman, who twisted his ankle constructing temporary housing. By the time he reached Dev, his ankle was black, and his foot had swollen to the size of a melon. Dev cut his boot off with surgical shears. The man was medevaced out, a waste of resources.
The second was a young American woman, a college student. She was having a panic attack, inconsolable, alternating between screaming and sobbing. She could not describe what had prompted the attack; she hugged herself while crying and pulled her hair while screaming. This continued for hours. None of the other patients, the “nonpriority” ones, could sleep. Eventually, Dr. Ferrell, the other doctor in the tent, also American, held her down, and Dev gave her an injection of phenobarbital sodium. She, too, was evacuated.
The only painkillers available are aspirin and morphine. No middle ground: no tramadol, no meperidine. Dev distributes aspirin like a garnish. A single soldier guards the morphine in an air-conditioned trailer. Only medical personnel know which tarp hides it. When Dev opens a box, the cardboard is so cold that his hands shake as he tears through the plastic wrap. The vials shake and tinkle like chimes.
If it weren’t for morphine, no one would get any sleep at all.
A nurse parts the flap of Dev’s tent. — Priority patient, she says. — An emergency.
— I heard. Bring him in.
The nurse ties back the tent flaps.
— Some action at last, says Dr. Ferrell.
Dev shrugs. Dev heard about, but didn’t see, the priority patient who was slashed in the face with a machete.
The need for surgeons has shifted from emergency to orthopedic. Even in the best of conditions, medicine is not an exact science. Limbs set in haste are now as lumpy as poorly mixed dough. Many makeshift splints — wooden planks, bamboo poles, metal tubes — have not been replaced. Dev sees them and thinks, That was mine; that was mine. What he had done now needs correction.
Last night, an elderly woman with two skull fractures tried to rip the bandage off her head. After the first few layers, the gauze adhered to the dried blood and lymph, but before she caused herself serious damage, a nurse restrained her. Dev has heard the woman’s story: during the earthquake, she had rushed inside the house for her grandchildren, but — all gone, all gone. Why is she alive? she demands. For hours, she fingers the edge of the bandage, like she wants to rip open her own head.
Dev, on arrival, worked over sixty hours continuously before resting. Then, a flood of foreign doctors, coming to take pity. One mistook Dev for a translator. What is that man saying? he asked. Can you tell him that I’m here to help?
Tell him yourself, Dev said.
People always take advantage of one’s generosity.
With this surfeit of doctors, mobile medical teams rove the outlying villages. Things seem well taken care of. In a day or so, Dev will leave. He is finished here.
Dev washes his hands with water from a collapsible water jug and dons gloves with a snap. The latex pulls at hairs on his hands and wrists.
At New Delhi General, a priority patient means an ill dignitary or a Bollywood star having a “procedure,” but here, in Bhuj, it suggests a hierarchy. Dev challenges any doctor to look a patient in the eye and tell her that she is not a priority.
They play a dangerous game, coming to “save” India.
— This way, this way, the nurse calls. Both Dev and Dr. Ferrell are prepped, though neither has been apprised of the incoming injuries. Another waste of resources: these gloves, this face mask, their time. MSF took control of the medical cluster to avoid duplicating efforts, but no one seems concerned about waste. Dev can think of ten efficiency measures off the top of his head. But he’s only here to help.
Two soldiers appear, carrying an improvised stretcher, a blanket secured over two wooden planks. The priority patient has arrived.
Unknown subject, Caucasian male, approximately twenty-five years of age. Brought to field hospital at 9:11 a.m. Attending physicians, Drs. Khanna and Ferrell; assisting, nurses Sharma and Zinta. UnSub pale from blood loss, barely detectable pulse. Unconscious from shock, unresponsive to verbal commands. Intravenous morphine. Two gunshot wounds (caliber unknown) to lower and midabdomen, most likely 9 mm small arm. N. Sharma shears clothing, and N. Zinta inserts tube for stomach decompression. Exit wounds suggest left kidney and liver in danger. First unit of blood administered. N. Sharma sterilizes area with iodine. D. Khanna incises from bottom of sternum to navel. N. Sharma prepares portable battery-operated suction. After six-centimeter incision in peritoneum, N. Sharma inserts suction line. Tube occludes with blood clots but clears. Peritoneum set back and secured with plastic microvascular clips. Blood flooding cavity, more than mechanical unit can handle. Second unit of blood. D. Khanna requests N. Zinta to apply additional hand suctioning with Jackson-Pratt drain. Damaged liver apparent. Bile in cavity. Bowel also perforated, leaking contents. D. Khanna to concentrate on wound to upper and midtranspyloric plane; D. Ferrell to concentrate on lower. Third unit of blood. D. Khanna places swab beneath liver. D. Ferrell wraps gauze compress around bowel. Cavity rinsed with saline to improve visibility. Urine in catheter bag shows blood, suggests damage to left kidney. D. Ferrell repairs bowel while D. Khanna examines second bullet track. Fourth unit of blood. Pulse extremely weak. Damage to liver extensive. Momentary displacement of liver shows gallbladder also perforated. Forceps used to clamp hole in gallbladder. N. Zinta’s bulb full; replaced to resume suction. Gauze beneath liver saturated, replaced. Fifth unit. Undersurface of liver has large, bleeding laceration. Attempt to close fissure with metal clamp results in crushing. Wide stitching used instead. Surface begins to clot. Lack of bile in cavity suggests biliary ducts intact, bile leakage from gallbladder alone. D. Ferrell examines intestines for additional holes, sutures as necessary. Heavily damaged sections (bruised, torn) will require bypass. Interior bleeding continues unabated; blood pressure near undetectable. Sixth unit. Further examination shows second bullet track continuing past liver and into biliary system, possibly breaching inferior vena cava or portal/hepatic veins. Amount of blood lost greater than amount intravenously introduced. N. Sharma indicates UnSub declining precipitously. D. Ferrell pronounces left kidney unsalvageable, must be excised. Second gauze compress beneath liver removed, replaced. D. Khanna conducts examination of veins from lower transpyloric plane upward. Seventh unit. Inferior vena cava from renal vein onward appears intact. Possibility of bullet ricocheting off a rib and traveling transverse. Blood escaping at constant drip. D. Ferrell momentarily assumes J-P drain; N. Zinta to retrieve additional units of blood. Portal vein appears intact from superior mesenteric onward. N. Sharma announces UnSub crashing. Examination of hepatic veins shows that two have been completely severed by bullet; third under significant, possibly unsustainable strain. Blood pressure drops to zero. UnSub enters cardiac arrest. D. Ferrell suggests manual coronary palpitation. D. Khanna declines. Given current operating conditions, performing bypass procedure impossible. D. Khanna declares patient dead. 9:48 a.m., February 2, 2001. N. Zinta instructed to return eighth unit of blood to storage.