The Children's War

by C. P. Boyko

  And so she lay awake, listening to the distant, echo-swaddled rumble of mortar fire, and methodically evaluated her day. When memories flashed into her mind randomly, she suppressed them, or rather deferred them, restricting herself to a sequential, and therefore dispassionate, review. (She refused, for now, to think about the unexploded grenade; or Hartner’s formal complaint to Major Witte about Latroussaine; or the boy without a face (blunt cranial trauma); or the collapsed lung that had sent the decompression needle flying out of her hand; or the boy who had bled to death (exsanguinating hemorrhage) before they could find his wound; or the self-inflicted foot wound that she had cleaned and dressed, then reported to the military police; and she refused to think about Andrew.) The problem was that by night she could only remember about half of what had happened each day; and it was always the worst moments—the biggest blunders, the goriest injuries—that jumped the queue and forced themselves upon her attention.

  Mostly she lay with her eyes open, because when she closed them the imagery of her thoughts became distressingly vivid—oversized and palpable, as if pressing against her face. Whenever particular images haunted her, she used words as a disinfectant, describing or naming the terrible thing in clinical terms.

  Sometimes, after following long chains of internally consistent and seemingly logical thought, she suddenly stopped herself, realizing that her premise was nonsensical or an analogy corrupt—as when her arm falling asleep under her had seemed a problem of trigonometry, or when she had visualized the dose titration of fentanyl as the revolving door of a hotel she had once stayed in back on the mainland. These lapses terrified her, like omens of insanity, but she reassured herself that she was only tired, and half dreaming.

  That morning she had first gone for a jog; every morning at dawn she ran four times around the compound’s inner perimeter in her combat boots, dodging revetments and pallets but not puddles. Then, sweating and hungry, she had visited the wards, intending only to pause on her way to breakfast and the showers. Nurse Anwar, who was friendly with Latroussaine, refused to write her name on the board before she was on shift. Hillary did not insist. She sought out her patients of the day before, scanning charts for her signature. She was looking for her mistakes, and inevitably found some; but she also found other doctors’ mistakes, and the night staff’s oversights, and unaccountable delays in treatment, and waking soldiers who were thirsty or in pain or hypotensive or simply in need of reassurance; and she dealt with these matters too. Nurses, orderlies, and other doctors circulated as well, but there was always too much to be done. By the time she had completed her first superficial rounds, breakfast was over and her name was on the board.

  She flushed with saline and rebandaged a suppurating knee, which its owner kept picking at, then she wasted five minutes failing to convince him that most wounds were best left open, and left alone. She rewrote triage numbers on the foreheads of two gas gangrenes who had sweated the ink off in the night. She sent a land-mine amputation to the operating room to have his remaining femoral artery reapproximated, something that should have been done as soon as he’d stabilized—six or more hours ago, according to his chart. Now he would probably lose the other foot. The mandible fracture had again panicked in the night and snipped the wires holding his jaw shut. “I thought I was going to puke,” he apologized. She reconnected the upper and lower arch bars and put the wire cutters away in a drawer, reminding him to use them only in an emergency. She piggybacked a sedative onto the IV of a crushed trachea whose chin had been sutured to his chest to prevent further injury, and who had been thrashing and shouting in his sleep. She examined and spoke soothingly to a fractured clavicle who feared syphilis. She put a collapsed lung with hyperglycemia on five units per hour of insulin. She cleaned and reattached an ileostomy bag that had been dislodged by gas buildup, pretending not to hear the man’s questions about when the bag could be removed. The answer was never, of course: he was missing a colon and a rectum. She injected a small amount of furosemide into a multiple fragment wound whose urine output was low. She put a heatstroke with low sodium on a free water restriction and added seven hundred milliliters of saline to his IV. She stopped a transfusion on an abdominal through-and-through who was spiking a fever with chills and back pain. Suspecting a blood-type reaction, she injected adrenaline and ordered liver function, clotting time, and complete blood-count tests. The donor unit said O positive, and the patient’s chart and dog tags said A positive, which should have been fine, but there was no record of a crossmatch being done, and the dog tags were often wrong. She supposed it could be septic shock, but his blood pressure was normal and his extremities were cool, showing no sign of vasodilation. She sent him to the NPR for observation and saline from a fresh IV, then filled out a medevac tag for transport to the mainland. Was she saving his life, or wasting the taxpayers’ money? She’d never know; whether right or wrong, she’d never hear about it. She avoided the cranial fracture with blood in his eye, because he was on bed rest and was not allowed to read and would want to talk to her about the reasons for the war. (What the hell was he doing thinking about these things only now? It reminded her of Andrew.) She also avoided the forearm amputation who two days earlier had been accidentally given a subtherapeutic dose of ketamine (Orderly Parungao had used the wrong syringe) and who consequently was convinced that his spirit had left his body. In proof of his newfound immortality, he said that he could still feel the “spirit” of his missing arm. No amount of explanation of the physiology, of the fine nerve fibers in his arm or the interdependent network of neurons in his brain, could convince him otherwise. It was none of her business, anyway. Besides, was she so certain that her understanding of the body—as a delicate, interwoven complexity leaving no room for spirit—was the superior one? To patients who asked her point-blank if they were going to die, she always answered, “Not if I can help it,” even when she could not. And for patients who saw through this bravado and asked what would happen to them after they died, she had no answer at all. This soldier could at least have told his dying comrades that their spirits, equipped with arms, legs, and heads, would survive elsewhere. And how could she know for sure that he was wrong? Perhaps she and the other doctors should give all their anticipatory casualties a shot of ketamine and let them decide for themselves. Finally, she checked on the islander who had refused a blood transfusion the day before. Though he wore no uniform, he was presumably an enemy soldier, and had been handcuffed to the bed till he could be moved to the prisoners’ ward. Now he was too weak to resist, so she started him on fluids, antibiotics, and packed red blood cells. At this moment Hartner appeared at the bedside, tall and groomed and ruddy, healthy and fed and rested. He was with Baltin and Martoskif, his favorites. Although he made no comment, Hillary blushed with shame. Two days earlier he had screamed at Latroussaine for sending a jinkie into his preponderant room when he knew for a fact that there were mainlanders, dying combatants, still waiting to be triaged.

  “Have you eaten, Doctor V.?” When she hesitated, Hartner sent a passing technician for coffee and buttered rolls. “We can’t have you rarting on us, now can we, Doctor?” He was in a good mood. He used the slang term with comfortable clumsiness, like an old man tossing a softball. Hillary smiled at the notion that Hartner could ever be thought a fogey—though she herself did not approve of words like “gork,” “crump,” or “rart,” humorous terms for such unhumorous conditions as coma, deterioration, and death. Martoskif had popularized “rart,” which meant to rapidly assume room temperature—that is, to die, or to be dead. He sometimes wrote it in capital letters on charts or on casualties’ feet. It had even gained currency among the soldiers: she’d overheard someone in the mess call the powdered eggs “completely fucking rarted.”

  “Join us in the anticipatory room, Doctor?” said Hartner. “Let’s see what kind of mess our friend the senior triage officer has left things in, shall we?” He too was looking for yesterday’s mistakes: Latroussaine’s.
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  She ate her rolls with a surgical clip while Hartner went from bed to bed, checking pulses, blood pressures, and pupil dilations. Occasionally he addressed a question, in which the answer was contained, to her or Baltin or Martoskif. Did she manage to reply intelligently? Her mind was forever going blank in Hartner’s presence. Probably she was still awed by him. He was, after all, forceful, handsome, a captain, and a brilliant surgeon in the classic mold: poised, dexterous, unhurried but unhesitating, and domineering. Many nurses and orderlies thought him cold and overbearing, but Hillary found his confidence reassuring, his mere proximity a relief. When he was in charge there was little for her to do but appear attentive and follow orders. Perhaps that was why she sometimes sank into a trance: her mind was taking the opportunity to rest.

  Then again, she thought, munching in memory her stale bread, maybe she was not sleep-deprived so much as malnourished. Maybe she was not getting enough protein? She quashed that hypothesis. Granted, she often skipped meals, but when she ate she ate heartily enough. Besides, she knew there was enough protein in even the potatoes, rice, and chocolate bars that were her staples; indeed, there was probably a day’s worth of protein in the bread she now ate, the butter, the cream in her coffee. So where did such worries come from? A lifetime of vegetarian guilt; years and years of friends, family, and colleagues (even doctors!) showing solicitude for her health.

  “Let’s get another pillow under this handsome exophthalmic head of yours, private. There we are. A simple thing, but surprisingly effective, eh? Check back in an hour, doctors, and see if his ICP hasn’t gone down. A little trick we might all keep in mind.”

  She sipped her coffee with distaste—she would not herself have added cream—and thought of the cow she had adopted in high school. Hillary’s sponsorship had rescued Millicent from a factory farm and transplanted her to an animal sanctuary nestled among rolling, verdant hills. But even this recollection carried guilt, for in her first year of medical school the sanctuary had suddenly doubled its fees, citing the rising cost of feed, and Hillary, who had barely enough money for textbooks, had been forced to withdraw from the program. Dolly, her cynical roommate, tried to cheer her with the suggestion that there never had been any such cow as Millicent, that it was all a scam. But Hillary knew better; she had seen pictures.

  For a vertiginous moment, she could not remember what ICP stood for.

  Of course, the chocolate bars she ate had milk in them.

  Even if she was malnourished, she was still healthier than eight-tenths of the world’s population. Indeed, it was as shameful today to be well fed as to be rich. (Andrew’s family’s lack of embarrassment had always amazed her.) Most of the islanders, certainly, both combatants and civilians, were underfed. Outwardly they were a tough, wiry people, but she saw signs of malnutrition every time she opened one of them up. Spongy bones, jellylike marrow, shrunken livers, inflamed bowels, soft tissue that bruised and bled easily. Last week she had tried to repair a torn colon in a pelvic fracture, and the sutures had cut through the intestine like cheese. The mainland forces’ bullets, too, whether by design or shoddy manufacture, seemed to have a greater tendency to fragment, ripping tortuous and jagged holes through the locals’ softer bodies—wounds that were almost impossible to trace and debride fully, and thus were particularly susceptible to gas gangrene. As a result, and because they were triaged last, most islanders were sent directly to the anticipatory room (where casualties were anticipated to expire). Often there were more islanders in the AR than mainlanders. There certainly were now. Hartner ignored them.

  The nurses and orderlies who dreaded working with him had to acknowledge that, unlike many brilliant surgeons, Hartner had an excellent bedside manner. Baltin and Caltavos and others, who were general practitioners, said that he should have been a general practitioner. Even here in the anticipatory room, where one’s tact and empathy might be expected to lapse, Hartner was at his warmest and most personable. He spoke directly to any casualty who was conscious; he asked them how they felt and what they had been through and whether there was anything he could do for them; he placed a gloved hand on their forehead or shoulder while they spoke, and he never appeared impatient with their replies. When he looked at their chart, he held it in their view, treating them, in effect, like a consultant on their own case—although, had they been able to decipher the notations on that chart, they would have discovered that they were expected not to survive, and were only being made comfortable while they fulfilled that expectation. When Hartner discussed the real prognosis or the true extent of the casualty’s injuries with his entourage, he employed the usual medical euphemisms and abbreviations, but he spoke so loudly, openly, and cheerfully that no casualty could doubt they were convalescing. None of them ever had to ask Hartner if they were going to die, or what would happen to them afterwards. His manner was like clean and sterile sunlight, neutralizing fear.

  At last he found what he was looking for: a casualty whose prognosis appeared incongruously favorable. Private Reingold had arrived at the triage tent yesterday morning in the middle of a spate of mass casualties, all from the same platoon, suffering from mortar-fragment, land-mine, and blast injuries. Reingold had been mistaken for one of them, though in fact he was from a different battalion altogether. His medevac helicopter had been diverted for the emergency; in the confusion his chart was misplaced, and the evac tag on his wrist went unnoticed. Apparently unconscious, with an arched back and rigid arms and legs, and covered in someone else’s blood, Reingold had been sent to the AR as brain damaged (decerebrate). Today, however, he was awake, and showing no signs of brain damage, or indeed injury. Hartner guided him patiently through the reflex, balance, and attention tests. Reingold was able to tell him that he had not been in any firefight, but had been sent to the rear with a fever and headache. Light and noise bothered him, too, and his jaw and fists kept clenching of their own accord. —“Any cuts or scrapes in the last week or two?” —“Just my right foot. Damn blisters keep opening up on the rivets in my boots.” —Hartner looked to Baltin, who asked Reingold if he’d ever been immunized against tetanus. —“When I was a kid, I guess.” —Baltin ordered the blood tests, Hartner requested diazepam for the muscle spasms, Hillary gave separate injections of tetanus toxoid and immune globulin, while Martoskif, with dictation from Hartner, updated Reingold’s chart, drawing a large quarantining box around the old incorrect diagnosis. All four doctors signed. —“We’ll put you in the officers’ tent,” said Hartner. “It’s quieter.” It was an unusual journey for any casualty to make. The clerk had to be called from across the room to mark his entry, and was duly amazed. —“Miracle cure, huh?” —Hartner chuckled. “Sure. Sometimes Latroussaine makes us look good, too.”

  Passing through the PR, they were hailed by Caltavos, who wanted a second opinion. A casualty who had come in three days earlier with apparent influenza had returned in much worse condition. Hillary peered at the chart over Hartner’s shoulder and was relieved to see only Caltavos’s name on it. —“She came into the NPR pallid, diaphoretic, emetic—” —“She’s a combatant?” asked Hartner. —“Private with the Seventh Rifles.” —“What was the triage assessment?” —“Oh, the same: probable flu. So I put her on antibiotics and kept her hydrated and the next day she was feeling better so I sent her back to her company.” —“And now?” —“Crumping like crazy. Puking again, pain in her upper right quadrant, low urine output, jaundiced . . . Christ, you name it: low sugar, lactic acidosis, bleeding gums, bruising. Haven’t got the clotting times back but, well, to the unaided eye she’s not clotting so good. I’m afraid to take more blood for tests.” —“So what’s your impression, doctor?” —“Well, her liver’s fucked. I mean, her hepatic vein and artery are sticking out an inch.” —“Is she a drinker?” —“She says not. But I can’t hardly do a biopsy with her blood this watery.” —“No. How else could we rule out cirrhosis? Doctor V.?” —She felt a pang of gratitude that the question was easy.
“An ultrasound might show edema.” —“Sure,” said Caltavos, “but what I’m wondering is, what’s left to rule in?” —“Oh, it could be just about anything,” said Hartner. “Hepatitis, Wilson’s disease, Budd-Chiari.” —“Sure. But we’re not exactly equipped to test for any of that.” —“We’ll do what we can. Is she awake?” —“Some hebetude. Keeps forgetting where she is.” —“Okay. Let’s talk to her.”

  Hillary stood as far from Private Shibiatisu’s bed as possible without drawing attention to herself. The girl’s face was a grayish yellow. Droplets of sweat stood out like plastic beads on her forehead. Hartner squeezed her shoulder. She smiled up at him weakly but as if with full recognition. —“Hiya, doc.” —“Hello there, private. How are you feeling?” —“Not too good, I guess.” Hillary could smell the sweet, fruity odor of the girl’s breath from where she stood. Her blood was already saturated with ammonia. (She reminded Hillary of Andrew. But why?)