Just Here Trying to Save a Few Lives

by Pamela Grim

“You walk her to the border,” I told him and sat down abruptly. My hands were shaking.

  I had only sat there for a moment when suddenly there was a murmur from the crowd and a sense of movement. Everyone was shifting restlessly, and somewhere at the near side of the Macedonian side of the border there was a shout. Soon the shout was taken up by the crowd immediately behind it and then deeper and deeper into no-man's-land until it swept by us and passed on into the darkness behind us.

  “Get up, get up!” Bafti called over to me. “The Macedonians are opening the border.”

  “Do you know who they'll let through?”

  “Everyone in no-man's-land. That's what the shout says.”

  I dropped my face down into my hands. “Thank God. Thank God.”

  We walked on but stopped when someone shouted Bafti's name. “I know him,” Bafti said. “He's from my town.” He ran over to a shabby-looking man who was painfully thin. By the time I caught up, they were deep in animated conversation. Now that I was closer, I could see that the man was not just thin, he was emaciated—he must have been hungry for months. He looked like some of the “prisoners” we had gotten recently in the refugee camps from Kosovo. These were men who had been pulled off convoys or found hiding and taken into “custody” by the Serbs. Thousands of them had been held under concentration-camp conditions in makeshift prisons throughout Kosovo. Most had been there at least a couple of months and then were released as some kind of goodwill gesture by the Serbs. They were shattered men. They had been two months starved at least and beaten daily. Each one was nursing spectacular bruises and at least a couple of broken bones. Some had to be carried to the tents. They all told their stories in the hospital tent at night while they waited for food and first aid. The practice for the prison guards was to pick out some feature—some incidental—that would mark someone out as an individual and then beat him for it. One man was captured in a jogging suit. The Serb soldier would say, “Oh, so you're athletic, huh? We'll see how athletic you are.” And then would beat him. And someone else— “Oh, so you like baseball,” because he had on a baseball T-shirt, and they would beat him. One man had a harsh, throaty pitch to his voice from surgery on his larynx. The solider would taunt him. “Can't you talk? What's the matter? Can't talk?” And when he would finally be provoked to say something, they beat his face in. By the time I saw him, he had all of his teeth knocked out, a mandible and an orbital fracture.

  I had been dealing with pain and suffering as a doctor for a decade, and in that time I had unconsciously developed psychological tricks to get me through the day; little emotional shock absorbers that involved the gamut of simple human defense mechanisms—humor, denial, boundary setting. None of these worked here. Each man I saw unloaded from the bus, as we tried to triage the sickest ones to the medical tent and get the walking wounded some food, each one, no matter what I said to try to comfort him, would shake his head and say, “You don't know how it was.” Simply that. I would try to connect with each one, talk with him, joke with him, and each one would look at me and say, “You don't know…you can never know. Thanks be to God you will never know how this was.”

  None of this, none of these walking casualties were about war. Killing was not the point here; winning a battle was not the point. This was not just about war—this was about degradation, desecration, annihilation—annihilation not of the body, but of the soul. And there is a psychology to this, a list of ways to kill without killing; to leave your mark forever on a human soul. Rape, torture, wanton destruction.

  Dini finally told me, one night, after many shots of local brandy, the story of his family's attempt to escape to Albania during the war. They lived in Dakovica. Statistics would later chillingly confirm that ethnic Albanians had the highest mortality rate in Dakovica of any city in Kosovo. After the bombing started, Dini, his mother and his father gathered a few belongings into their little Lada and headed for Albania. They were stopped by Serb military about two kilometers shy of the border. The soldiers made Dini and his parents get out of the car and told Dini's mother they wanted ten thousand deutsche marks. “Ten thousand deutsche marks or we kill your son.” Dini's mother had 3,000 DM—this was all the money the family had in the world. She gave it to one of the soldiers and he threw it on the ground, saying, “Three thousand is not enough. I want ten thousand!” Dini's father then got down on his knees. “Please,” he said, “kill me, kill me, just do not kill my son. Don't hurt my son.” Dini flicked his cigarette in the ashtray in front of him as he told this story. He told it deadpan, with not a whiff of emotion except for a slight smile that twitched, tic-like, as he toyed with his cigarette. He was alive, he said, shrugging. He was there with us. Whatever that was worth.

  That night, after hearing Dini's story, I kept dreaming—that kind of dream you have when you are half asleep, half awake—of the Skopje clock tower, the time eternally 6:42, the time of the earthquake of 1964, and of Dini's father down on his knees, and of Dini now, an empty carcass of a man.

  We left at four A.M. We were all scheduled back at work in the camp clinic at eight. It was a boiling hot day. We saw the usual: earaches, sore throats, colds, “weak and dizzy” (read: depressed and sick of the camp). At three P.M., though, something a little different. A young Muslim woman in a neat head scarf and a long coat (in that heat!) came in initially complaining of belly pain. I asked her if she might be pregnant and she shrugged, head dipping shyly, and then said, “Maybe—yes.”

  “Let's find out.”

  We sent her out to get us a urine specimen while I rooted around the stock drawer looking for my stash of urine pregnancy tests. I loved doing these—there was a voodoo-like appeal to putting a few drops of urine into a little square of plastic and having the paper marker light up with a “minus” sign (negative) or a “plus” sign (bingo).

  “Do you want to be pregnant?” I asked her when she returned with her urine cup. If she said no, as some women I had seen before had said, I would know why. Life in a refugee camp, with a miserably bleak future—who could ever want to raise a child here? But this woman blushed and nodded her head. “Po,” she said, meekly. “Yes.”

  Three drops of urine. Everyone, the nurses, the translators, the logistician, all gathered around the table to stare down and watch the urine diffuse across the white blotter paper. Slowly the results faded into view, a bright pink positive sign.

  “Congratulations,” I told her as she beamed. Beside me Bafti whispered under his breath, “She's crazy.”

  It was a terrible day—torturously hot and still—not a breath of wind. Once again we saw over a hundred patients in twelve hours and ahead of us was an hour-and-a-half bus ride back to Skopje. We did this only to get up to do it again tomorrow.

  At nine P.M. Dini arrived at the wheel of the battered van. I crawled into the back to go to sleep, and as I closed my eyes I remembered the ride of the morning. On the way we were detoured from the main highway (the only true highway in Macedonia) back into the unalloyed nineteenth century. The road was single-lane and filled with mule carts and horse-drawn wagons. It ran past Muslim townlet after townlet until finally it returned to run adjacent to the main highway. There we saw the cause of the detour, a massive wreck. A mulberry-colored sedan had run head on into a giant semi, one of the huge, underpowered trucks that haul everything from chicken feed to schoolchildren in Macedonia. The accident was a head-on collision. The semi had jack-knifed, the cab now canted sideways. What was left of the sedan was up on the embankment. A body still lay on the ground beyond it. To me, the wreck served as a firm reminder that one of the most dangerous things about the Balkans was the maniac drivers. Sacking out in the back of the van did not buy me much protection, but I figured at least it would allow me to die in my sleep.

  I awoke when the engine started. Someone got in and slammed the door. I heard Bafti's voice saying, “Fourteen more buses. Fourteen.” This meant more refugees. I opened my eyes and turned my head to see one of the buses parked next to us, two small
children and an exhausted mother staring down at me from behind the bus window. Then the van started moving forward and there were more faces staring down through that window, then the next, then another bus with window after window, each like a film frame, jerking forward slowly, a little rectangle of distraught faces and hands pressed up against glass, each frame passing more quickly than the last until the last bus was passed, the film broke and there was nothing but darkness beyond.

  14

  WHY I DO WHAT I DO

  MIDNIGHT SHIFT, Saturday night, shortly before bar rush. Tonight, by some megrim of the scheduler, I have the honor of working with the departmental chairman, Dr. B. Fortunately this is rare—not that we interact all that much even then. As I write this on hospital progress note paper, he is standing way over by the telemetry radio talking into his personal Dictaphone, as far away from the action as you can possibly be and still be in the ER. I contemplate him as he stands there, his white lab coat gleaming in the pale light. Under that white coat he is wearing a golf sweater and a blue shirt with French cuffs and cuff links that also catch the light. Right down to the inevitable penny loafers and crossed-golf-clubs tie tack, he looks like what he is, a country club kind of guy, pretentiously Ivy League and very twee. He really does belong on some golf course somewhere. How ever did he end up here?

  But then B. is not really happy as an ER doctor. He doesn't like drunks, he doesn't like the psychiatric patients, he doesn't like street people and he doesn't like doctors like me. I may be a good clinician but I am bad with charts. I don't document well. (Doctors never write; they document). This makes me, according to him, a medical legal risk. “Look here,” he said to me the other day, “you didn't document the patient's condition on discharge.” “That patient was dead,” I told him in return. “Well, you need

  to document that.” Fortunately, as he said this he was standing in front of me, not looking at me. He didn't see me roll my eyes at him. But I am always rolling my eyes. Every time we talk I am reminded of the awful destructive power of mediocrity. I look at him sometimes and think: Born to Do Hospital Administration.

  So B. and I are together tonight. As I sit here tonight, still gazing at him, I idly consider the differences between his lab coat and my own. His is pristine white—there is an ironed crease running down each arm. I, on the other hand, can trace a complete history of this previous week's shifts based on my lab coat stains. There was the patient from two days ago, victim of a motor vehicle accident, drunk and out of control, who bled all over me. Here the little kid from Wednesday who vomited pink Kool-Aid on my sleeve. The black blotches on the front were spray painted by a suicidal sixteen-year-old girl who kept spitting up charcoal as fast as we poured it in. All this, of course, is overlaid with the trail of coffee stains I have spilled on myself over the course of the week. I contemplate these stains, thinking: I was born to wallow in this sea of bodily fluids. B. definitely was not.

  Born to this or no, tonight I'm in survival mode, sitting in the nurses' station in my favorite chair, head down, feet up on the desk, an unread New England Journal of Medicine in my lap, coffee cup half filled with stale coffee in my hand. Next to me, facedown on the counter, is the medical thriller B. is reading. There's a picture of the handsome doctor-author on the back, stethoscope draped casually over his neck (but he's an ophthalmologist).

  B. is writing his own medical thriller so he can be a doctor-author too. In other words, he is desperate to leave medicine, as is almost everyone else who works down here. This is it, the most “exciting” medical specialty there is, and we all would do anything to get out, quit the constant headaches, the pressure, the nights, the weekends, the drunks, the strung-out, end-stage addicts. We don't have many plausible options available though; almost all of us have invested a lifetime in education to get to this place. The only ways out seem to be either to hit the jackpot (same chance as everyone else standing in line waiting to buy a couple of lottery tickets and a carton of cigarettes at the quick-stop store) or write a bestselling medical thriller. Both are about as likely. B. is serious about his book, though. He has produced a 420-page manuscript that he is pretty sure could be a major bestseller. I've read a couple of chapters. The story involves your typical multinational terrorist organization that hijacks the last living sample of the smallpox virus and threatens to cause a worldwide pandemic. I note the genre differences. If the forces of truth, justice and public health prevail it's a thriller; if the virus is set loose and ravages the world, it's science fiction. B. apparently plans to stick to the thriller side of things. There is the beautiful young emergency room doctor as the heroine. The hero is a brilliant young scientist from the Centers for Disease Control. I point out to B. that CDC employees are actually federal agents who have the power to arrest private citizens. To me that seems more comical than anything, but B. loves it. “Great,” he says. “I can use that.” Meanwhile the real world of medicine stumbles on around us.

  What is the real world of medicine? What is the everyday stuff that never makes it into mystery thrillers? Well—I'm looking around at the detritus in front of me—a great deal of it is simple advertising. A fact of modern medicine; it's everywhere you look. The magazine on my lap features an advertisement where a young woman windsurfs through a field of flowering alfalfa to advertise an allergy medication. On another page an exuberant woman romps with a beaming young child to celebrate some antidepressants. Scattered on the desk is the usual: a pad of Post-It notes featuring an ad for Zapnia, an antibiotic (“Go for Freedom!!”). A coffee cup features a sunrise over mountains and the words: “It's Going to be a Noxenal Day!” (an antidepressant). My pens: the one I am writing with advertises an antihypertensive on the clip (“Defuse the High Pressure Time Bomb!”). The one in my pocket features a drug for reducing cholesterol—no slogan, just the name. All these courtesy of the various drug representatives, the “drug reps.”

  The poor drug reps. We get a visitation every day. Once upon a time they were unsmiling men dressed in cut-rate brown suits, carrying stodgy sample satchels. Now they are attractive young women, well dressed and elaborately coiffured, the clip, clip, clip of their high heels a marked contrast to the soft padding sound of the usual ward sneakers. They come bearing gifts: drugs—often hundreds of dollars' worth of samples—for the doctors to pass on to their patients, friends and family. Then the added inducements: notepads, calendars, expensive pens, refrigerator magnets, ice cream scoops, flashlights, clinical guides, business card holders, boxes of tissues, timers, T-shirts, canvas bags, key rings, decks of cards.

  The problem is, of course, that in order to dispense these gifts, those well-dressed, well-heeled young women have to actually come into the ER and see this life firsthand. Yesterday, for example, the pleasant, terminally blond Abbott drug rep stood giving her usual speech (“This drug extends the spectrum of coverage to include Varicella and Yersinia pestis”) while opposite her in room 10 a pathetically manic woman, who an hour before had set fire to her hair, sat up on the gurney screaming at her: “Fuck me, fuck me, fuck me, you Teutonic goddess.”

  This is the real world of the ER. And tonight it's all around, evanescent yet eternal, lit only by cold fluorescent light, the sole illumination for this nightless place.

  I glance at my watch. Ten after two; the trauma phone should be going off shortly for our first drunk-driving accident of the evening. Meanwhile there are a stack of charts in front of me that need to be dictated, another stack that needs to be signed, yet I just sit here, not reading the magazine in my lap. I should really be thinking about my future, my life post-emergency medicine. After all, I've done this now for over ten years. Isn't it time to stop spending my life hunkered down over screaming, manic burn patients and start thinking about a career? But try as I might, I can't imagine life without this place—the crazy hours, the screaming babies, angry mothers, the bizarre drunk William Burroughs look-alikes, the respectable businessmen wearing nylon stockings and panties under their suits, the psychotic r
ap poetry issuing from an out-of-control schizophrenic tied down in the psych cubicle. I could leave them all behind and return to the world of the living, a world where no one could ever imagine that this other world, almost an anti-world, existed.

  Over the years I have tried to tell people about what life is like in these little rooms. The best I have done is to come up with this analogy. Imagine you are standing in a field somewhere, a brightly sunlit field with flowers, trees and birds. There is also a rock at your feet. You bend down and pick the rock up to look at the ground underneath it. There you see worms and bugs and slimy slugs and things that scurry to get out of the light.

  That's what life is like in the ER. Every day at work is like picking up a rock just to see what's underneath. And whatever it is, it's pretty much guaranteed not to be a pretty sight.

  Two weeks ago I was asked to appear on a panel, a presentation about emergency medicine for a medical student “Career Day.” There were five of us official emergency medicine physicians sitting in a row at a table in the front of a lecture hall. Three dozen students gazed down at us as we each gave a little rundown on our lives and our “lifestyles.” Most of it was party-line stuff. During the question-and-answer period, though, one of the students startled a panelist into an honest answer. “Why did you” he said, looking at the doctor sitting next to me, “go into ER?”

  My colleague thoughtfully searched the ceiling. Everyone sat very still; even we panelists wondered what he would say. Wasn't this the most important question?

  “Because I have a very short attention span,” he said, scratching the back of his head and smiling.

  There was silence and then a number of students started coughing. Nobody laughed. Remember—this was a group obsessed about their future. Then the question was passed down the line of panelists. The woman to the left, a director of a large suburban emergency room, said she got into ER in order to get out of an impossible surgery residency. An academic physician next to her said he liked the trauma and liked the research questions that could be asked about trauma.