The Best American Essays 2013
Page 17
Walter? Homeless? Crushed?
I called his brother and left a message, but Frank didn’t return my call. I Googled Walter and found a record of his arrest for attempted robbery in Queens, New York, in 1980, when we would have been twenty-four. But that created more mysteries than it solved. The records indicated that Walter had served two years of his sentence before being released “to another agency.” Had anyone helped him kick his habit? Treated him for mental illness? How and why had he moved to Texas?
I called the paper in Corpus Christi (I realized as I dialed that the name means body of Christ), and the editor sent me Walter’s obit. I hoped there would be a photo so I could see what the handsome, redheaded boy on whom I’d had a crush looked like as a man, but the only photo showed a body in a bag being handed down from a trash compactor.
According to the story, on December 22, 1986, Walter had crawled inside that dumpster behind Incarnate Word Junior High, trying to keep warm and sleep. The next morning the sanitation workers hooked the dumpster to their truck and tipped it back. A groundskeeper at Incarnate Word saw a man trying to scramble out of the dumpster and screamed for the workers to stop, but the roar of the engine prevented his warning from being heard. The lid came down on Walter’s neck. The fire department needed an hour to remove his body. When they did, they saw that he was barefoot and wearing rags. They were able to figure out who the man was only because he was wearing a hospital ID around his wrist. Apparently Walter had visited the ER the night before to have a swollen ankle x-rayed. There was a bottle of antibiotics in his pocket. He hadn’t been in town very long. A few days earlier he had been arrested for refusing to give his name, but he had listed his address as the Search for Truth Mission. Not that anyone there remembered him.
An article published on Christmas Day (“Officials close the book on man’s grisly death”) added only that Walter Rustic had been a “native of Liberty, N.Y., a town of 4,293 near the Catskill Mountains,” and neither his mother nor his brother could be reached for comment. And so, the reporter wrote, “The sad case of the man who died in a dumpster is closed.” Except the sad case had a happier coda. In 1988 a shelter for homeless men was opened in Walter’s honor not far from where he died. The Rustic House for Men offers a hot meal and a place to sleep for vagrants, although most people probably assume that the name is intended to connote a rural retreat rather than to honor the ragged, barefoot man who died in a dumpster a few blocks away.
I figured I had the facts. But I still seemed to be missing something. I dialed Walter’s brother one last time. An elderly woman answered and told me that she was Walter’s brother’s mother. Which meant she was Walter’s mother too.
“You knew Walter in sixth grade?” she said. “He’s been in your mind all these years?”
I wanted to lie and say I had been thinking about her son for forty years and was very, very sorry he had been beaten up on my account. Instead, I asked if Walter ever talked about Mr. F. But his mother said Walter never talked about school at all. He made it to junior year before he dropped out. I wanted to ask her why, but it’s hard to press a dead friend’s mother as to whether he had been mentally ill or addicted to drugs. All she would say was that Walter had loved to travel. He had traveled from state to state to state, calling her now and then to say hello and ask her to send him money so he could get something to eat. His favorite place had been Tupelo, Mississippi, where he visited Elvis Presley’s birthplace. Another time he called her on New Year’s Eve and told her that he had been picked up as a vagrant, and the police liked him so much they invited him to join their party and share their pizza.
Then, on Christmas Eve 1986, she was sitting in her house in North Carolina—she had moved there a few years earlier—wrapping a present for Walter when she got “the horrible phone call” telling her that he had died. She hadn’t even known he was in Texas, but she flew to Corpus Christi and spoke to the sisters at Incarnate Word, who told her that her son had died in the arms of two nuns, and she got some comfort in hearing that, as she still derives comfort from knowing that the Rustic House for Men takes in vagrants like her son “and gives them a hot meal and a warm clean place to sleep and keeps them there a while until they’re ready to get a job or go out on the road again.”
I have no doubt that Walter would have ended up homeless or dead even if he had been blessed with a more caring sixth-grade teacher. I was only twelve years old. I don’t hold myself responsible for the beating that Walter received that day. But being thrown against a wall doesn’t do anyone any good. It isn’t much fun to occupy any of the circles of hell to which all but the most popular and well-adjusted students find themselves consigned. But schools fail different children in different ways. Kids like Pablo grow up unable to read and write, with no way to earn a living. Kids like Walter Rustic grow up to be dead.
And kids like me? We make it through. We end up who we were meant to be. Sometimes we end up someone better. Despite Mrs. Neff’s refusal to allow me to work in my workbook, despite Mr. Spiro’s decision that I wasn’t ready to skip a grade, despite a similar decision the following year to advance the two smartest boys while leaving me behind because—as the principal claimed—girls don’t finish courses in science or math, I studied those courses on my own and got accepted to Yale, where I earned a degree in physics. I was too far behind my classmates, too angry and confused and lacking in confidence to go on to physics grad school. But I’m not sure how much I care. What gadget might I have invented, what small theorem might I have proved, that could have mattered half as much as my being forced to learn compassion? I gave up the chance to spend my life multiplying and dividing so I could become an authoress and tell the stories of all those poor pigeons who didn’t make it out of school alive, who survived childhood but not adulthood, who are missing from our community. Although how can we measure what we have lost? To what can we compare their absence?
JON KERSTETTER
Triage
FROM River Teeth
OCTOBER 2003, BAGHDAD, IRAQ. Major General Jon Gallinetti, U.S. Marine Corps, chief of staff of CJTF7, the operational command unit of coalition forces in Iraq, accompanied me on late-night clinical rounds in a combat surgical hospital. We visited soldiers who were injured in multiple IED attacks throughout Baghdad just hours earlier. I made this mental note: Soldier died tonight. IED explosion. Held him. Prayed. Told his commander to stay focused.
In the hospital, the numbers of wounded that survived the attacks created a backlog of patients who required immediate surgery. Surgeons, nurses, medics, and hospital staff moved from patient to patient at an exhausting pace. When one surgery was finished, another began immediately. Several operating rooms were used simultaneously. Medical techs shuttled post-op patients from surgery to the second-floor ICU, where the numbers of beds quickly became inadequate. Nurses adjusted their care plans to accommodate the rapid influx. A few less critical patient beds lined the halls just outside the ICU.
The general wanted to visit the hospital to encourage the patients and the medical staff. We made a one-mile trip to the hospital compound late at night, unannounced, with none of the fanfare that usually accompanies a visit by a general officer in the military. After visiting the patients in the ICU, we walked down the hallway to the triage room.
One patient occupied the triage room: a young soldier, private first class. He had a ballistic head injury. His elbows flexed tightly in spastic tension, drawing his forearms to his chest; his hands made stonelike fists; his fingers coiled together as if grabbing an imaginary rope attached to his sternum. His breathing was slow and sporadic. He had no oxygen mask. An intravenous line fed a slow drip of saline and painkiller. He was what is known in military medicine as expectant.
Some of his fellow soldiers gathered at the foot of his bed. A few of them had been injured in the same attack and had already been treated and bandaged in the emergency room. These fellow soldiers stood watch over the expectant patient. The general and I stood watch o
ver them. One soldier had a white fractal of body salt edging the collar of his uniform. One wept. One prayed. Another quietly said “Jesus” over and over and kept shaking his head from side to side. And another had no expression at all: he simply stared a blank stare into the empty space above the expectant patient’s head. A young sergeant, hands shaking, stammered as he tried to explain what had happened. The captain in charge of the expectant soldier’s unit told the general and me that this was their first soldier to be killed—then he corrected himself and said this was the first soldier in their unit to be assigned to triage. He told us that the soldier was a good soldier. The general nodded in agreement and the room was suddenly quiet.
The general laid his hand on the expectant soldier’s leg—the leg whose strength I imagined was drifting like a shape-shifting cloud moving against a dark umber sky—strength retreating into a time before it carried a soldier. And I watched the drifting of a man back into the womb of his mother, toward a time when a leg was not a leg, a body not a body, toward a time when a soldier was only the laughing between two young lovers—a man and a woman who could never imagine that a leg-body-man-soldier would one day lie expectant and that that soldier would be their son.
As I watched the soldiers at the foot of the bed, I noted their sanded faces, their trembling mouths, their hollow-stare eyes. I watched them watch the shallow breathing and the intermittent spasm of seizured limbs and the pale gray color of expectant skin. I took clinical notes in my mind. I noted the soldiers—noted the patient. I noted all the things that needed to be noted: the size of the triage room, the frame of the bed, the tiles of the ceiling, and the dullness of the overhead light. I noted the taut draw of the white linen sheets and the shiny polished metal of the hospital fixtures. A single ceiling fan rotated slowly. The walls were off-white. There were no windows. The floor was spotless, the smell antiseptic. A drab-green wool army blanket covered each bed. Three beds lay empty. I noted the absence of noise and chaos, the absence of nurses rushing to prepare surgical instruments, and the absence of teams of doctors urgently exploring wounds and calling out orders. There was an absence of the hurried sounds and the hustle of soldiers in the combat emergency room one floor down. Nobody yelled “medic” or “doc.” Nobody called for the chaplain. Medics did not cut off clothing or gather dressings. Ambulances and medevac helicopters did not arrive with bleeding soldiers.
The American Heritage Dictionary defines triage as “a process for sorting injured people into groups based on their need for or likely benefit from immediate medical treatment. Triage is used in hospital emergency rooms, on battlefields, and at disaster sites when limited medical resources must be allocated.” All dictionary definitions refer to the origin of the word triage as deriving from the French verb trier, to sort. The essence of the meaning is in the sorting. In the context of battle, a soldier placed in a triage room as expectant has been literally sorted from a group of other injured soldiers whose probability of survival was deduced by a sort of battlefield calculus implemented by a medical officer or a triage officer. The sorting occurs rather quickly—usually with minimal, if any, deliberation.
A military physician trains for triage situations. I trained to make combat medical decisions based on the developing battlefield situation and limited medical resources. I read about triage. I role-played it in combat exercises. When I first learned about the role of triage in combat, I reasoned, Of course, triage is necessary. It’s part of war. You do it as part of the job of a medical officer.
More than twenty years ago, when I was a newly minted captain, I attended the two-week Combat Casualty Care Course at Camp Bullis, Texas. The course was designed to teach medical officers combat trauma care and field triage techniques. The capstone exercise included a half-day mass casualty scenario complete with percussion grenades, smoke bombs, and simulated enemy forces closing on the casualty collection point. The objective was to give medical officers a realistic setting in which to perform triage decisions and to initiate medevac protocols according to standard operating procedures. About twenty moulaged patients mimicked battlefield casualties ranging from the minimally injured to those requiring immediate surgery. Each medical officer in training was given five minutes to perform the triage exercise and to prepare an appropriate medevac request. Providing treatment was not an option: the exercise focused exclusively on making triage decisions.
All the participants could have easily completed the role-play within the time limit. Nothing, of course, is that straightforward in army training. There is always some built-in element of surprise to test how well trainees cope with chaos. In this case, the element of the “unexpected” was a simulated psychiatric patient who was brandishing an M16 rifle and holding a medic hostage while threatening to commit suicide. In order to maintain the element of surprise, the doctors who had finished their turn were whisked out the back of the triage tent, not to be seen again until the after-action review some hours later.
My turn. I entered the tent at the shove of my evaluator. The mock psych patient was screaming and threatening to kill a nearby medic. Other medics were pleading with the disturbed patient to lay his weapon down and let the wounded get on a helicopter. I was to take charge and get control. I did. I approached the screaming patient with quick, confident steps. I got about halfway through the triage tent when he pointed his rifle directly at his hostage medic and yelled, “One more step and the medic is dead.” I backed off slowly, turned sideways, and quietly pulled my pistol. In an abrupt and instantaneous movement, I reeled around and shot the psych patient with my blank ammunition. “Bang—you’re dead!” I yelled. A nearby evaluator took his weapon and made him play dead. One out-of-control psycho eliminated. I finished the triage exercise within the five-minute time limit. My evaluator laughed. “Damn,” he said.
I felt great. I had control.
In the after-action review, I was asked about my decision to shoot. “Time,” I answered. “I only had five minutes, so I maximized my effectiveness by eliminating a threat. It’s combat,” I argued.
One fellow doc asked if I would really shoot a patient in combat. A debate ensued as to the ethics of my decision. Nobody else had shot the psych case. Nobody else finished the exercise in the allotted time. Some trainees had considered shooting the crazed soldier but had failed to act. Some managed to talk the psych patient into giving up his weapon. Those physicians had taken nearly fifteen minutes to complete the exercise—minutes in which some of the simulated patients died a simulated death. In the end, it was decided that my decision to shoot, while potentially serving a greater need, may have been a bit aggressive, but that it was in fact my decision, and my decision met the needs of the mission. All ethical considerations aside, I felt that I understood the necessity and the theory of triage. I understood it as part of my job.
Military triage classifications are based on NATO guidelines and are published in numerous websites and Department of Defense publications. The triage categories in the third edition of Emergency War Surgery, the Department of Defense bible of military medicine, are listed below:
Immediate: This group includes those soldiers requiring lifesaving surgery. The surgical procedures in this category should not be time consuming and should concern only those patients with high chances of survival.
Delayed: This group includes those wounded who are badly in need of time-consuming surgery but whose general condition permits delay in surgical treatment without unduly endangering life. Sustaining treatment will be required.
Minimal: These casualties have relatively minor injuries . . . and can effectively care for themselves or can be helped by nonmedical personnel.
Expectant: Casualties in this category have wounds that are so extensive that even if they were the sole casualty and had the benefit of optimal medical resource application, their survival would be unlikely. The expectant casualty should not be abandoned, but should be separated from the view of other casualties . . . Using a minimal but competent staff, pro
vide comfort measures for these casualties.
The text of Emergency War Surgery further notes, “The decision to withhold care from a wounded soldier, who in another less overwhelming situation might be salvaged, is difficult for any surgeon or medic. Decisions of this nature are infrequent, even in mass casualty situations. Nonetheless, this is the essence of military triage.” Triage requires assigning patients to those various categories based upon a rather quick and semi-objective assessment of a patient’s injuries. If the triage officer calculates that a patient falls into the expectant category, treatment is withheld in order to allow medical teams to concentrate more efficiently on those soldiers with potentially survivable injuries. Preserving the fighting force is the central tenet of the process.
I have read and reread the official triage definition. I suppose I might have used it in a classroom of medics that I instructed. I am intimately familiar with the words that describe each category and with the professional commentary about the mechanics and ethics of sorting injured patients, yet I repeatedly come back to those words that try to clarify exactly what might be involved in the process of triage. I find the words weak and innocuous. They undercut the gravity and scope of a real-time triage experience. Here’s the rub: the official commentary about the decision process focuses on the essence of triage as being the difficulty of making that decision. The difficulty is a given, but I think there is more. I think the essence of military triage is the necessity of making the decision when the combat situation demands it. It is the necessity of triage that requires medical staff to assign expectant soldiers to their death in order to provide an accommodation to a calculated greater good—a cause measured by the number of combat survivors. It is an accommodation that has not changed since the trench warfare of World War I.