Ana remembered glimpsing a fist, a bleeding nose, then she went down. She woke handcuffed, her mouth full of dirt, as they loaded her into a van with half a dozen injured people. A cop slammed the door, then sat facing them with his rubber truncheon.
“You’re a brother,” she said. “How can you do this?”
His shoulders sagged, his face remained resolved.
“Auwē. Auwē,” an old woman cried. “Our own boys, trying to kill us …”
Ana bent down to her and held her hands, so full of rage her body shook. As they sped down the road she looked back at the valley, bombs still exploding in the mountains. Again, she felt the suffering of Mākua, felt the land imploring her.
KA HĀ O KONA WAHA
The Ritual of Hā
THE YEARS OF MED SCHOOL SEEMED A BLUR, A LONG BAD DREAM OF scutwork at the teaching hospital—running blood samples back and forth to labs, trotting up and down for X-rays. Most of the doctors were white or Asian males with a continuing disdain for female physicians, but Ana stood up to them, challenging them in lectures. When her diagnoses were questioned, she defended them aggressively, confirming her reputation as a “toughie” from the Wai‘anae Coast.
Observing procedures, she constantly elbowed her way ahead of male students so that during an emergency thoracotomy she leaned in so close the chief resident asked her to step back. Instead she leaned in closer as he inserted a metal spreader between the patient’s ribs. When they were far enough apart, he dipped both hands into the chest cavity and squeezed the heart. Blood shot out of the patient’s chest, spraying Ana’s face. Afterwards, she calmly walked down the hall and threw up in a bedpan.
But during clinical rotations, she found she was not drawn to cardiology, anesthesiology, obstetrics. Internal medicine only partially engaged her. Ward rounds were a bore. Mostly she came alive in the “pit,” the hospital’s Emergency Room, liking the pressure, the way doctors made split-second decisions, the way they relied on intuition. By her fourth year as a subintern, certain procedures came easily. She seemed to have a knack for finding veins, intubating, and inserting central IV lines. The one procedure she dreaded was giving an intracardiac injection: sticking a needle directly into another human’s heart.
The first time she attempted it, the chief resident bullied her. “Come on. You did it with cadavers.”
“This man is alive,” she whispered. “I can’t see his heart.”
“Doctor, this is ER. You hesitate, the patient dies. Aim blind, and do it.”
After a while she began approaching patients as if they were victims. I am learning on your body. I will cause you pain. I may even harm you. A woman went into seizures when she injected the wrong medicine.
“You have to hurt them,” the resident said. “That’s how you learn to do it right. Then somewhere down the line, you’ll save a life.”
In time, most procedures became second nature to her and Ana was able to step back, get a broader picture of the ER, a subculture with its own argot and cryptic codes. A place that sometimes seemed staffed by misfits, borderline personalities. The receiving room was a cross section of humans that only accidents, semi-suicides, or crimes of passion could provide. Hawaiians, Samoans, Filipinos, whites—all holding together their body parts, bullied by big, taciturn triage nurses slapping down junkies petitioning for drugs.
She began to understand that no professional who survived ER would be the same as they were before. Its madness was the alkaloid that transubstantiated them. One entered it a rube, an innocent, and came out a husk. Eyes on a stalk. In between fractures and infarcs, ODs and hemorrhages, patients were grossly misdiagnosed, even mislaid. And then, the real nightmares. A child attacked by a pit bull was missing half his face. What would his life be after this?
In that year, six people in her class dropped out. Each day Ana feared she had caught a different disease. Patients spat and bled on her. They vomited and urinated. She scrubbed her hands until they were red and cracked. She wore surgeon’s gloves, carrying her papers and books in plastic bags. Some days she wore surgical masks, seeing patients as the enemy. The thing to avoid, not heal.
“I feel no compassion at all. I’m becoming conscience deficient.”
“Get out of ER,” Rosie advised. “It sounds like a war zone.”
Yet, day after day, she watched fascinated as the chief resident performed CPR on a patient while simultaneously orchestrating the expertise of interns, residents, med students, clerks, nurses, even a priest. This was what she wanted. Not to play God, but to mobilize random professionals into a single healing machine.
———
BY HER SECOND YEAR OF INTERNSHIP, ANA HAD LEARNED TO REGARD death as a nebulous thing. Sometimes they pronounced a patient dead who still had heart activity, electrical activity. She began to wonder, When precisely does the last cell die, and is the soul intact till then? And when exactly does the soul depart and the body become just a container?
One night a team stood over the corpse of a man with a crushed chest. When they tried to get at his heart, blood sprayed on monitors, instrument trays, the walls. It poured out of the body so copiously it lay congealed on the floor in black lacquered clumps. After someone called time of death, and everyone cleared out, Ana pulled off her bloody gloves and mask, and gazed down at the body. She turned to a rubber-gloved man with bucket and mop who had entered the room.
“Juan. Do you believe humans have a soul?”
He was slender, quiet, and efficient. He paused in mopping up the carnage. “A soul? Yes, sure I do.”
“Well, when do you think it leaves the body?”
He looked down at his mop. “When I come in.”
Sometimes she couldn’t let the bodies go. Suppose Juan was wrong? She walked beside them as aides pushed them down the hall toward the morgue. On the down elevator, she chatted with the aide, but she was really talking to the corpse.
“Well, the crappy part is over. Now it’s just the long, long sleep.”
Still, she was not satisfied. If we really possess a soul, how does it feel when the newly dead body is violated?
One night the EMS team brought in a suicide, a woman dead from overdose. As soon as the attending declared her dead, they physically ripped her apart. The resident sliced her chest open, using a vise to spread her ribs so students could practice heart massage.
Ana heard the ribs crack. She watched them toss around the heart. They performed half a dozen procedures, injecting her, intubating her, reintubating, over and over. All this on a woman so unhappy she had taken her own life. Wasn’t this violation a second death? How did a soul survive this?
Later she stood outside ER, smoking a cigarette. Another intern joined her.
“Brutal, huh? They couldn’t even wait till she was cold.”
His name was Will Chong, from Kailua on the island’s east coast. “I kept wondering how they’d clean her up for viewing. Her family’s going to ask what happened to her chest—that huge, ugly scar where they sewed her up.”
Ana shrugged. “They’ll lie. Say they tried everything to save her.”
“Well, don’t let them get to you. They always try to break down female interns first.”
He was tall, boyish-looking with lovely golden-yellow skin. His father was a neurological surgeon who wanted him to follow in his footsteps. Will said when he chose Emergency as a specialty, his father stopped supporting him.
“He calls it the loser’s specialty of medicine. I don’t care. When I’m attending physician in ER, I’ll do my twelve hours on, twelve hours off, and have a life. No one tracking me on a beeper.”
They had been interning at Queens, the largest, and best-equipped hospital in Honolulu. Even into her second year, Ana was still trying to adjust to the grueling schedule. On-call round the clock for thirty-six-hour stretches, then a few hours’ rest in between, she lost all track of days and weeks. Her skin broke out, she grew depressed.
Sometimes she came off duty so wired, she could not
sit still. Will saw her dancing round the canteen and brought her coffee. She drank three cups and deflated; her eyes flickered and slowly closed. Sometimes she fell asleep at the table, leaning on her elbows while he watched. He began to find it soothing, and rather intimate, watching her sleep.
He did not find Ana conventionally pretty, though she should have been. Black, curly hair pulled back in a twist, a natural tan as if she were tinted from the sun. The full Hawaiian nose and lips. Her slightly slanted eyes were pale above wide cheekbones, she even had a dimpled chin. But she possessed a penetrating no-nonsense gaze that made her face seem hard, as if she were taking someone’s measure.
Her body was nice, he thought, long legs, small breasts—full-bodied though, not slender. He imagined rainwater following the line of her hips. But what had first caught his attention was her height. That is, she was average height, but seemed much taller because of her beautiful wide shoulders, the proud way she carried herself. He looked down at her big, lū‘au, “townie” feet and smiled. All in all, he found her rather beautiful, but in a scary way.
One day after a postmortem, they stood scrubbing their hands. “Now for a stealth injection of caffeine! Then, sleep.”
Will glancd at her. “Maybe we should try that together sometime.”
Ana slowly leaned back. “Is that a proposition?”
“Could be. Aren’t interns supposed to be sex maniacs?”
“Not this intern.”
He laughed, half joking. “Ana, can’t you see we’re fated? We’re locked up in here like savages, confused and half-insane. Forced to sleep in our clothes and filthy shoes. We kill more patients than we save. Who else would want us?”
She looked down at their shoes like walking petri dishes of biohazards. She laughed back, attracted to him against her will.
When it eventually happened, it seemed natural and easy because they had learned to like each other first. The first night they slept together, Will collapsed in her arms before he got his pants off. She found it touching, holding him, listening to his snores. It had been so long, just feeling a man’s head against her shoulder was a shock.
Nights when they couldn’t sleep at all, they made love frantically, listening for the pager. Then they lay back, discussing patients, procedures, and mistakes. And unrelenting fear. A man with eruptions over his body had yanked the IV from his arm and jammed it into Ana’s butt. She was put on antibiotics. Will helped resuscitate an overdose who then nearly strangled a nurse to death.
“I’m beginning to see the downside,” he said. “Even nurses say ten years in ER, then burnout.”
One night she woke in a sweat, unable to identify familiar terms. Posturing decerebrate … Peritoneal lavage … Esophageal reflux. Her mind completely blank, as if her brain had died. Will found her shaking, nearly incoherent, and asked for Emergency Time-off. For hours, he walked her up and down the streets of Honolulu, both of them amazed. They had forgotten the sound of healthy humans, the noise of traffic. The feel of soft trade winds on their skin. They stroked the rough bark of a tree, they waded in the ocean.
“Think about this seriously,” he said. “We’ve still got two years of residency ahead. I wonder if by then we’ll still be human. Maybe you should get out of ER, specialize in cardiac, or OB-GYN. You’d be excellent at that.”
She folded her arms and stared at him. “You think Emergency is a man’s domain? That a woman can’t do the job?”
“I think it’s a job for animals. Look at us. We hardly have time to bathe. Half my friends own their own homes. They’ve already been to Europe. I don’t even own a decent watch. I’ve never owned a car. We’ll be old by the time we accomplish these things. We’ll be burned out, and angry. All this sacrifice for people we’ll never see again.”
He took her hand, unable to look her in the eye. “You know, I’ve come to love you, Ana. More than love you. We’ve been like soldiers side by side in battle. I would trust you with my life. I don’t want to see someone like you turned into a … grunt.”
His words touched her so deeply, Ana could not speak. She turned away so that they seemed apart, though their feet touched in the sea.
SOME NIGHTS FOR AN HOUR PEOPLE OUT IN THE CITY STOPPED trying to kill each other. The Emergency Room fell silent, interns and nurses slumped in chairs, asleep on cots. On such a night, Ana stood beside a corpse waiting for the gurney to the morgue. A slender young man thrown from a truck, whose heart had been pierced by a sliver of metal. By now she knew the procedure by rote. They had stabbed him full of needles and tubes, slammed him with defibrillator paddles, then tore him wide open, cracked his ribs and broke into his chest. They passed around his punctured heart, then pronounced him dead. While Ana closed and stitched his chest, the resident pulled off his gloves and called time of death.
“He was DOA, but what the hell. Can’t say we didn’t try.”
Then everyone cleared out, leaving the young man naked, spread out like a crucifixion, the airway still clamped between his teeth, his chest a ragged line of stitches.
Ana stepped closer. “Now we are alone. And where is God? How could he do this to you? How could we?”
First do no harm. Hippocrates. Yet she constantly watched doctors slice into bodies with a kind of vicious glee.
“For students,” they said. “And interns. This is a teaching hospital.”
She didn’t always believe it. She saw the expressions on their faces—victory when they revived a patient, or sour defeat.
She wet a cloth and gently wiped the young man’s face. “I’m sorry there’s no God to comfort you.” She covered the body with a sheet. “I’m sorry we didn’t honor you in death.”
Then she stepped back and looked around. This is it. The life I’m training for. This is probably all there is going to be.
She moved to the intern’s lounge and stood in a bathroom terrified. She looked down at her legs, trembling so badly her knees knocked. Her arms shook uncontrollably. She slid to the floor hugging herself. From deep in her throat strange sounds issued, like a small, sick dog trying to bark. Her whole body sobbed.
That night she clung to Will. “Am I having a breakdown?”
He rocked her gently. “You’re just throwing out emotions you won’t need. You’re becoming a professional.”
WHEN WILL TRANSFERRED TO A CHICAGO HOSPITAL TO DO HIS residency, Ana spent a year of such visceral loneliness she felt someone had removed her vital organs and given them to her to hold. In that year, the first heart transplant was successfully performed in Honolulu, but seventy people died of AIDS. Surgeons stood with human hearts pulsing in their hands, yet actual contact with human blood became an anathema.
Rosie shook her head. “It’s what you wanted, life in the pit.”
By then, Ana had even learned to preempt her sense of smell: the fruity breath of diabetics, the musty scent of liver failures, the ketone odor of anorexics—a faintly rotten smell. Sometimes her mind went blank, her hands froze in the middle of procedures. Little moments of anarchy. She wondered if she had made the wrong career choice. But then, back aching with fatigue, she remembered her Aunt Emma who had passed on to her the healing gift in the Ritual of Hā.
In her second year of residency she dreamed of Emma with disturbing frequency. She woke in the dark remembering how, when she was twelve, the woman had been diagnosed with cancer. Surgery had left her a virtual invalid. Rosie said she was sick in her chest, that doctors had taken off her breast. Ana did not believe her. One day while Emma slept, she had crept into her room and carefully pulled aside her nightgown.
Looking down, Ana’s whole body had trembled, she felt a buzzing in her ears and momentarily lost her vision. They had cut out everything. Not just the woman’s breast, but the lining of the chest muscles and all the chest muscles themselves. They had cut out all of the lymph nodes under the arm that formed a network of adjacent tissues. They had scraped the woman to the bone.
What had been left was a vertical scar almost two in
ches wide that plunged from her left shoulder down to her stomach. It was intersected by an equally wide horizontal scar extending from midchest across to her armpit and down under her arm. As the scar had healed, keloids formed—big knots of fibrous scar tissue adding to her terrible disfigurement. Excruciating pain from the badly healed scar had kept Emma from lowering her arm. For months she had lain with the arm outstretched so that the scar resembled a knotty crucifix hung from her left shoulder.
Ana had stood at her bedside, transfixed, feeling her own body go damp and cold. She smelled the salt and rancid odor of the woman’s flesh and wondered what awful sin she had committed to deserve this. Sinking to her knees, she had crawled from the room and sat in a closet for hours. She never told what she had seen. Months later, Emma died floating inside an oxygen tent like a withered doll propped up in an aquarium. In her last moments they opened the tent and she drew Ana close, expelling her last breath into the girl in the Ritual of Hā.
Now dreams of Emma persisted, so did a nagging pain. During a checkup, a small mass appeared on Ana’s mammogram.
“A macrocalcification,” her gynecologist said. “Which indicates a tumor.”
A biopsy was performed after which Ana lived with the image of Emma; the large, knotted crucifix hanging from her shoulder. Lab results were positive. She sought a second opinion, which confirmed the need for surgery. She was barely twenty-nine years old.
In the past year, Ana had broken an internal rule and gone out with a patient, a plumber who had come into ER complaining of back pains. During her examination, she had noticed small nicks on his cheeks and neck, and that he was clean-shaven. Somehow that touched her, that he had taken the time to shave before coming to Emergency. She had imagined him lowering a razor into soapy water, twisting it clean, then commencing to shave, calmly scraping his cheeks and neck. She imagined him nicking, then circumnavigating troublesome spots round the thyroid mound while wondering how serious his back pains were.
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