On my fifth day in theater, I stand in the OR at Bagram Air Base, Afghanistan, after another IED explosion. Two patients are laid out on surgical tables, each with a wound that gapes and gray skin tattooed by shrapnel. All the seared flesh smells like barbeque, and if I wasn’t already sick as hell, my mouth would water. Anesthesia drapes hide both patients’ faces, so all I see are two headless bodies. It’s the perfect scenario for a frigid meathead who only cares about bones.
Well-worn surgical drills and screws line the tables next to each patient. I don’t care that I used better equipment to dissect my cadaver in medical school; I’d be satisfied with a Dewalt drill and my grandmother’s sewing needle, which might actually work better. Anxious to feel the weight of the tools in my hand, I scramble into my sterile gown.
“Ready, Dawn,” says Patty, my scrub tech. I know as much about her as I know about the surgical drape: both are monochromatic and flat. I adore them.
I pull the tips of my gloves, smoothing wrinkles that might interfere with sensation. My ring finger is naked and uninhibited, the simple gold band tucked in a drawer back in Mississippi. I told my husband I was afraid it might get stolen if I left it in my living quarters. He chose to see this as a measure of preservation. Life was on hold until my return. We all make choices.
“I’ll keep it next to me while I sleep,” he said and nestled it with the one he pulled from his own finger. The heaviness I felt did not come when he took his ring off but when he anchored it on top of mine.
Vick is a surgeon too, so he understands that rings harbor bacteria and don’t belong in operating rooms. We met in the OR in medical school, scrubbing our hands beside each other before a case. The intensity of the first cut, the merest sliver of skin that peeked out of our sterile garb: foreplay. We kept ripping after we tore the disposable gowns off our bodies. And when it was just Vick and me and surgery, life was grand.
When Vick and I Skype in the mornings—evenings in his part of the world—I don’t mention the hole in the ceiling of the OR where a rocket once exploded or the flies that roam in as they please, making a wedding ring on a finger seem damn near sterile. He operates in a sparkling, climate-controlled, state-of-the-art facility and wouldn’t understand.
I also don’t tell him about the mass of cells multiplying in my uterus. I don’t tell anyone. Right now, merely weeks in, it’s more like a lower vertebrate than a human. Gills don’t bother me. In fact, I’m more comfortable growing an amphibian than a baby. Women who breed frogs aren’t asked with sideways glances from their colleagues how many tadpoles they plan to have.
I nod at Patty.
“Trauma Male 1-3-5-9-3,” says Patty, naming the patient on the table. “Near-amputation of the right hand.”
I’m grateful Patty adds no commentary. We all know that, by virtue of his injury and ethnicity, my patient may have been the bomber. He also may have been defusing it. These possibilities make no difference to me. I intend to make something beautiful from the mess spilled in front of me. Here, in a land of explosive devices improvised to rip flesh from bone, I find my land of opportunity: troves of complicated fractures and blast injuries, a feast for a starving surgeon. One day, my patient will open doorknobs and cut meat for his children. His life will be different because of the surgery I do.
On my first night at Bagram, a siren woke me from half-sleep in my 8×8- foot plywood-walled room. It shrilled like a train approaching a crossing. Then: Incoming! Incoming! Incoming! blared over the loudspeaker. With my inexperienced hands, it took several minutes to throw on my body armor, my Kevlar helmet, and my eye protection, after which I scrambled through the hallways. Outside the door, sandbags crouched three layers deep, the last line of defense against enemy fire. All around, concrete blast barriers chopped outdoor spaces into small courtyards. I started to run to the hospital, anxious to get to work on any mangled extremities, but a member of the QRF—Quick Reaction Force—waved the tip of his machine gun at me, directing me behind more sandbags and into a concrete bunker. As a Major, I tried to appeal to his military inclinations. “It’s my duty,” I said with false conviction. He didn’t care to hear about the way I was needed in the OR. He, too, had a job to do. With fourteen others, I crammed into a space like a concrete tomb, ten feet long, three feet high, five feet across. It was easy to pick out who had been in theater awhile by the way they stretched their limbs in front of them, quick to claim space. I ended up with my knees to my chin for three hours while the QRF secured the base.
That night, while my hamstrings cramped and I mouth-breathed against the product of sub-par shower facilities, an Airman was delivered to the Bagram ER. A rocket had exploded on the unlucky side of the concrete blast barrier. Shrapnel shimmied between sandbags, piercing the plywood walls of his sleeping quarters, swan-diving into his liver. Wizened doctors dashed past the concrete bunker before the QRF siphoned them in. They ran to the hospital, where they cracked the Airman’s chest and tied off vessels and shot him full of plasma and platelets. They fought for his life while I squatted in the bunker swatting flies the size of my fist. Eventually, the QRF located the rocket launcher hidden in the mountains that cradled Bagram and blew it to bits with precision missiles.
The next night, I slept with my body armor on and leapt out of bed when the alarm sounded, as it has every night since my arrival.
The OR is cluttered with all the things we need in a war zone— gauze, tourniquets, bags of packed red blood cells, boxes of sutures, IV catheters—sitting in piles and boxes. The only missing items are the M9s, which stay in the gun rack just outside the entrance. The OR is the only place we’re not required to keep them on person. I tucked mine into a slot before I scrubbed underneath my nails and between my fingers and backed myself through the swinging doors of the OR, butt first so I wouldn’t contaminate myself. I loathe violence and unnecessary death but my M9 is a key card, the going price of admittance. I’m grateful I have one to pull from my pants and put in its slot when required.
There are no pregnant women allowed in a war zone. I submitted to a test before deployment, before the being was advanced enough for detection. I suspected even then but was pleased to see NEGATIVE printed below URINE HCG. The test result earned me the M9. “My penis,” I said to the Airman who handed it over. He didn’t smile at my joke, but I didn’t care. It was my turn to ship out.
“Ancef?” I ask Patty about the prophylactic antibiotics. I don’t want this guy to lose his arm from infection after I get him back together.
“Injected into right thigh.”
“All tools pulled and ready?”
Patty nods. “Except the bone saw. Just finishing the sterilization cycle now.”
I pause at her words, annoyed that our preoperative dance is sullied.
“We don’t need the bone saw,” I say. “We’re not amputating. We’re reattaching.” Patty’s eyebrows rise just a hint and return to neutral so quickly I wonder if I imagined it.
Lieutenant Colonel Peabutcher, the OR Charge Nurse, hurries over. In a civilian OR, I would be in charge. But she is an O-5 and I, a Major, am just an O-4. She outranks me in a military hierarchy that skews the logical order of medical decision-making. Her tight curls fight against the constraints of her scrub cap. A few tendrils escape the bottom and angle themselves toward me. Very feminine and unprofessional. I think about my own neck and am pleased to feel no tickle of errant hair. I have thought about chopping it off, but it is actually easier to keep out of the way wrapped tightly in a bun under my cap.
“Dawn,” she says to me. “This patient’s hand is hanging by a thread.” I look down at my field and examine the wound in an effort to delay eye contact.
“Reattachment is a complicated, multi-stage procedure,” she says.
“My job is to keep this OR running efficiently and in good order. Lives depend on it.”
Now I raise my eyes. I stare into hers without flinching. I have practiced this look in the mirror. It is important to blink slowly and not purse your lips, lest you seem arrogant and aggressive. It is more difficult to achieve the desired goal with a surgical mask in place and more difficult still when facing another woman.
I might choose to remind her that I am the one with MD behind my name, that I trained for five years in residency after medical school, that I am the only individual in the room qualified to make decisions about surgical indications. A man who failed to point this out would seem weak, but there are names for assertive women in positions of power.
“He is my patient,” I tell her. “And I have 173 days to finish.” I fudge on the number a bit, knowing trim bodies, like mine, show faster.
I duck at the sudden roar of an F-16 taking off from the airstrip half a mile across the base. Surgical instruments rattle on tables. The quiver that starts in my earlobe spreads to my entire body. This happens often, every half hour, but my body still bucks.
The pyloric valve in my stomach clamps shut. Reluctantly consumed food roils. It’s not just vibrations from the aircraft’s flight that make it churn. The DFAC—Dining Facility—sits one layer of blast barriers away from the airstrip. The sound that thunders from the F-16 liftoffs is synonymous with the Grade D meat served on this base, and my gut has become like one of Pavlov’s dogs. It threatens to reverse gears every time an F-16 lifts off. In the DFAC, we stand in line alongside stacked boxes that read For Prison and Military Use ONLY. I gnaw on my allocated meat and swallow my malaria prophylaxis. This morning, it all stayed down, even more miraculous given my condition. My stomach gurgles again, warning me that there is no fixed arrangement. Not eating isn’t an option either. I tried it on day two and only hurled faster. Still, I am not deterred by these discomforts.
I turn to Patty, who busies herself organizing the tray of equipment. “I need the microsurgical instruments. I’m going to salvage this man’s hand.” The pitch of my voice wavers. Not enough for anyone to notice, I hope.
Patty says to the circulation nurse, “Bring in Tray 23 for Dawn.” She packs away the unnecessary gear and readies the table for fresh supplies.
During my first private practice interview after residency, the senior partner swiveled in his leather chair, frowning at my curriculum vitae. He flipped through the pages multiple times: my list of scholarly publications, my membership in the medical school honor society, my board scores at the 90th percentile. “Forgive me,” he said when he finally looked up. “But I’m not used to…I mean, we have plenty of female secretaries and nurses, but this is different.” He bent toward me across the desk like an elderly man bending down to speak with a child. “Why orthopedic surgery?” he asked. “As opposed to, say, pediatrics? It seems a lot more family friendly.”
I ran my hands over hair slicked back into a tight bun and smoothed my pantsuit. “I don’t like kids,” I lied.
Later, when I told Vick, he said, “Maybe it’s not what you think. Maybe they just didn’t think you were right for the job.”
I signed papers the next week in an Air Force recruiting office housed in a strip mall. A man in a dress uniform and standard issue haircut told me to pack my things for Commissioned Officer Training.
“Why’d you do this?” asked Vick as I threw three new pairs of camouflage pants into a bag of the same color.
He’d been with me and the other residents at dinner when my male colleagues concluded the gender pay gap existed because women didn’t work as hard as men, always taking time off to have babies and the like. I’d told Vick of the times I had been encouraged to smile more so that my patients would feel more comfortable. The time a friendly patient told me all about his struggle with trigger finger, allowed me to examine him and inject his joint with steroids, and then, walking out the door an hour later, complained he hadn’t seen a doctor all day.
I gripped my military orders, stared at my husband’s generally kind but now confused eyes, and found nothing but silence left in my throat.
To my right, the door thumps open for Dan, my partner orthopedic surgeon. Dan is a captain, an O-3, a rank below me. He just finished residency last year, but no one ever looks at him and asks when the doctor is coming in. No patient ever glances over Dan’s shoulder to ask the male nurse, the male orderly, the male radiology tech for his opinion.
“Your X-rays, Dr. Sadler,” says Peabutcher, handing him the images.
I don’t bother to roll my eyes at the disparity in how she addresses us.
Red tracks circle Dan’s eyes from his military-issued eye protection. We all wear the goggle-like gear outside to defend against the blinding desert dust. Dan sees the open book pelvic fracture on the X-ray and looks down at the body of his patient, a man facing a potentially fatal orthopedic injury. The patient is paler than when I entered the operating room twenty minutes before.
I turn to shoo the flies that buzz around my patient’s open wound. One could argue that flies are annoying, foul little creatures, only good for consuming dead flesh and making more little flies. I hate them mostly because their large number reflects poorly on my work—the more blood shed, the more they are attracted here. I remind myself they are a gauge of Dan’s success as well—or his failure, given the pasty gray cast to his patient’s skin. His patient grows weaker by the second. My patient is a prideful olive-pink. However, I must always be better to be the same. I don’t want to give Peabutcher any reason to shut this case down.
“Best deployment in the whole damn desert. Am I right, D?” says Dan, watching the flies circle back. He has no idea what a luxury sarcasm is.
From the corner of my eye, I see Peabutcher reach for the swatter that hangs from a nail. She and I catch each other’s eyes.
“Patty,” I say and concentrate on my field.
She clicks a button and casts the table in a beam of harsh brightness. We cover the patient with blue sterile drapes until only a mangled extremity lies before us. I bend over the wrist and begin a thorough survey of each structure that will need repair. Tendons, vessels, and nerves spring from the wound like noodles in blood sauce. I run a probe along each one, assessing its integrity. Necessary instruments arranged, Patty stands over me in silence.
“Let’s make a little us,” said Vick one rare evening when both our pagers were off. He’d just come in from clinic and was loosening his tie. He sat down at the kitchen counter and poured a bottle of Samuel Adams into a glass while I dumped dried pasta into a pot. “We’ll buy a Diaper Genie and a minivan and send out Christmas cards with our family picture on them.”
I smiled and nodded and wondered how he might feel if he had to toggle between the disapproving stares of his partners, concerned with coverage during maternity leave, and the judgment of other mothers, aghast that one might consider shortening leave to four weeks.
“There must be a way,” he said. “Other women figure it out. It’s the year 2010. You don’t have to choose anymore.”
Who does he imagine will be the one to leave their patients with bowels hanging out or bones partially mended when our child vomits all over the lunchroom? Or when her eye becomes red and goopy? Or when she falls from the monkey bars one day?
“We’ll figure it out,” he said.
I hear Dan’s breath in my ear, the haaa-whaaa of air forced around a generously sized adenoid. I turn to find him staring at my operative field.
“Whatcha got?” He bends closer. “Whoa. You’re gonna have to watch that radial artery. This kid’s gonna bleed out if you don’t lock that thing down.”
“She’s reattaching,” says Colonel Peabutcher.
“Yeah?” he says to me.
“Yes, that’s my plan,” I say and immediately wonder why I didn’t stop
Peabutcher raises her eyebrows at him.
“For this shithead?” He holds his hands before him. “I’d chop it off myself. Not think twice.”
Peabutcher nods. “Mm-hmm.”
I make myself stand to the full potential of my five-foot, two-inch frame. “I can do this. It’s the right thing to do.”
Dan nods. “You were a teacher’s pet, growing up, weren’t you?” His cheeks press against the bounds of his surgical mask as they round into a smile.
I nod as though I’m not the same person who snuck pills for ten months while my husband tracked my period, circling and planning for ovulation.
I called my OB-GYN’s office and explained to the nurse that I needed pills but didn’t want a trail. No bills to my insurance.
“Okay, but don’t wait too long to have your babies,” she said. “Advanced maternal age starts at thirty-five.”
“I’m trying to build a career.”
“Honey, isn’t your husband a surgeon?” she said.
The scrub tech calls from the other table. “Dr. Sadler, your patient’s tanking.”
A buzz rises around Table Two. Peabutcher, the anesthesiologist, and the tech all scurry around the patient. A bustle commences. Sterile instruments are opened and large bore IV catheters are inserted. Saline rushes in and blood transfuses. Dan winks at me before strolling to his table. “Well, let’s close this pelvis on up,” he says.
I turn away and stand before the starting line, the blank canvas, the mound of clay. “Drill.”
“Drill.” Patty slaps the instrument into my palm.
I start with the two forearm bones. In uninjured form, they dance around each other in a delicate but powerful maneuver to rotate the extremity. Several inches of each bone are pulverized and, in a few months, will need to be replaced with a bone graft. For now, I fix both ends with a locking plate and screws to span the defect. When I finish this step, I allow myself a moment of triumph. My palm encircles my patient’s in a handshake, and I twist his wrist to the right, then left, feeling the smoothness of the movement, the purity of a function perfected through evolution.
The thing is, I am not opposed to the idea of having children, of pouring myself into the care of another person and discovering what solidifies, of carving a masterpiece from love instead of bone graft, rules instead of a drill. Maybe it is the pregnancy hormones, all the estrogen and human chorionic gonadotropin storming through my veins, but sometimes when I sniff the air, I smell the sweet tang of a baby’s hair instead of the formaldehyde scent of my mask. The problem is, one scent always overpowers the other.
It is the quiet that catches my attention. There is no umpire commentary from Dan with each bang of the mallet against a femoral nail (“Stee- rike one!”). No excited laughter. No one checking over my shoulder to monitor my estrogen-laced mistakes. When I look behind me, I see Peabutcher and Dan bent steeply over the table, voices hushed for once.
“What’s going on over there?” I say.
Patty looks to Table Two. “It’s not going well.”
“Hmm.” I shrug it off and step back to recalibrate my task. The bones are back in anatomic position, albeit with a large slab missing from the middle of each. I move on to fixing the soft-tissue structures that spring from the wound. The radial artery is torn like a piece of well-done asparagus, with threads tracking all the way along its length. I remove the tourniquet and, immediately, blood floods my view. The patient’s fingertips are cold and white. I touch them with my glove, leaving crimson prints, trying to massage away the gangrene that settles there even now.
“Suture.” Patty hands me a needle driver loaded with thread barely visible to the naked eye and suctions the surgical field. The patient’s loss of blood is staggering. I clip the end of the radial artery to stop the flow, but collateral vessels too small to fix continue to bleed.
I consider amputation. I must do what is best for the patient and exsanguination is not it. But there is something about the way the blood surges over my fingers, relentless in its quest to bring oxygen and life to its severed cousin. His blood believes and I believe. I take a deep breath and settle my eyes behind the viewfinder of my surgical microscope. I sew the first threads of the radial artery back together. I slowly make my way around the circumference of the artery, anastomosing the two open ends of vessel, like fitting two jagged straws together.
I have nearly completed my work on the vessel when I hear “Whoa.” It is a breathy exclamation from the next table, not very loud, but it pulls at my attention the way the click of a lock can wake a person from deep sleep. It is an awe-filled preamble to “I think we found where he’s losing all his blood.” Dan’s tech suctions, and the collection system immediately fills with purple-red fluid. It overflows before the circulation nurse can replace the system.
“Hey, D?” Dan says from behind me. “You got a sec?”
My fingers have found the rhythm of my patient’s heartbeat. I need five more minutes. Five more minutes and blood will flow into my patient’s fingers again. I am so close.
A siren blares. Incoming! Incoming! Incoming!
Soon, more patients will be hustled in by medevac crews, the ORs cleared for an Airman with a sucking chest wound or a Staff Sergeant with shrapnel to the neck.
“Dawn,” says Peabutcher. “Put the tourniquet back on your patient. You can amputate later. Dr. Sadler’s patient is exsanguinating and he needs you to assist.”
I squeeze the gray fingers in front of me. I imagine watching each joint flex around my own fingers, squeezing mine back. I imagine knowing I made it happen.
“Dawn, Dr. Sadler’s patient is dying.”
I look over at Dan’s table and see the patient’s blood pressure too low to register on the monitor, his heart rate of 50 beats per minute.
She points at my surgical field. “No one needs a hand to live.”
I look at her eyes blinking slowly, her unflinching stare, the strength we call masculine just out of reach. I wonder if, below her surgical mask, her lips fight off their instinct to purse.
I shift my attention across the aisle. There is blood all over the rotting
floorboards, mixing with the silt that tracks in from the desert. Rivers of blood crisscross through the valleys of sand. Pink-red arterial blood flows from my patient and mixes with the blue-red liquid rolling from Dan’s patient until it all looks the same.
I step away from my patient. A fly circles in, buzzing back and forth between us. It zooms around my head, taunting me, and lands on my thigh, blending with the blood that soaks my scrubs. I smash my left hand against my leg. The fly drops to the floor.
Dan stands over me while I repair his patient’s iliac artery, a larger version of the radial artery I just abandoned. The bleeding stops, and Dan hustles to the ER to evaluate the latest casualties. I return to my patient.
The soft tissues have given up during my absence. The flesh is purple and mottled from lack of blood flow. I saw away the bones on my patient’s wrist. I wrap skin over the stump of flesh and sew it shut. When I finish, I wrench my gown from my body. Anesthesia removes my patient’s drape and I see his face for the first time. He is barely a man. Burned flesh dots his cheeks and eyelids where shrapnel scattered.
I wonder if I could have made it long enough to finish his bone graft. I wonder how many surgeries my uniform and scrub gown will cover me. When I’m discovered, I’ll be pulled from the OR, shipped back to the US, replaced by another surgeon. Back home, I’ll grow to unrecognizability, foreign DNA surging through my vessels, a parasitic being sucking nutrients from my bones. Finally, I’ll push until blood and stool and progeny cascade out of my orifices while someone else, the physician, delivers the baby. My husband will be thrilled. He’ll kiss me in the morning, lips sliding from mine to the infant without noticing the distinction. He will smile and leave for work, every wish fulfilled. After a long day in the operating room, scooping out infected appendices and pancreatic tumors, he’ll come home to find me searching for what is buried beneath my stretch-marked belly and dripping breasts.
Peabutcher waits for me near the gun rack. Her weapon is already tucked against her leg when her eyes fall to my empty holster. She grasps my M9, letting her fingers encircle its girth, and pulls it from its slot. I hold out my hand and she slaps it into my palm like a surgical instrument. I accept it, my ticket back in, for now.