THE MAYHEM STARTED JUST BEFORE MIDNIGHT WITH A VOICE ON THE RADIO. MASS CASUALTY call. The ward secretaries called in extra people. The chief of surgery showed up, began to move people out of the surgical ICU, and cooled the rooms, readying the place for burn victims.
A nightclub in West Warwick was on fire with a couple of hundred people trapped inside.
The ambulances rolled in unannounced, one after another, a third and a fourth after the second. Soon they were coming in waves, the firefighters and EMTs covered in soot, wan and trembling.
Levin heard the radio traffic, half listening to the scanner at the desk as he walked from place to place, so he had a sense of what was headed their way. He was in the main ED with an MVA when the first victim hit Trauma 2.
The first victim was a woman who was naked except for her shoes. Her hair was burned off and her scalp was black, her eyebrows gone, her face blistered; the skin on her arms and back hung loose like melted cheese, and she was grunting, unconscious but still struggling to get air down her ruined, blackened, edematous trachea. Some second-year was asking questions, and Johnny G, the good trauma nurse who had been a medic in Iraq v1, was sticking the patient for a line.
“Do you take any …”
“Give me a tube,” Levin said. He angled the resident out of the way and stood at the head of the bed. “We’re going to knock you out, sweetheart, so we can get these burns fixed. You do the line,” Levin said to the resident. “Johnny, hand me an intubation kit. Somebody get surgery here. Get Versed ready. Or Valium, if that’s what’s nearby. We need to snow her, so I can get her tubed. Let’s move, people. You know you have pulmonary compromise when there is this much eschar. She was inside, in a room filled with hot gases. Let’s get her tubed now and ask questions later. Get respiratory. She’s going on a vent.”
Levin snapped a laryngoscope open and turned its blade so he could see that it was lit. He opened the woman’s mouth with his thumb and forefingers and leaned over so he could see inside. He lifted the laryngoscope with his left hand and leaned over the woman so he could see into her mouth. The tissues were all charred, but he could see what he needed to see. He slid the laryngoscope deep into the woman’s mouth, lifting her upper face with his left hand as he reached for an endotracheal tube with his right.
“Seven up,” Johnny said, and he unwrapped an endotracheal tube from its sterile paper and plastic envelope.
“Seven will do. She’s not too big,” Levin said. He threaded the tube into the woman’s throat, following the light and the curve of the laryngoscope blade. He advanced the tube and closed his eyes as he felt for the smooth moment when an endotracheal tube slips into the trachea without resistance.
But the tube didn’t pass. He opened his eyes, pulled the tube back a few inches, and then reinserted it. This time the tube passed. “Balloon,” Levin said. He held the tube in place with one hand and withdrew the laryngoscope with the other.
Johnny attached a fluid-filled syringe to the small valve that hung from thin plastic tubing and pushed the plunger. Levin grabbed a green Ambu bag from the tray and attached it to the endotracheal tube and squeezed. There was a rush of air, and the patient’s chest rose.
“Check breath sounds,” Levin said, and he squeezed the Ambu bag again. “What’s your name?” he said to the resident.
“Stacy.”
The resident listened to the patient’s chest left and right as Levin squeezed the bag a second and a third time.
“Good breath sounds left and right,” the resident said.
“Ventilate, Stacy, until respiratory gets here with a portable vent,” Levin said. Jacky Montequila, a friend and a surgeon who knew what she was doing, came into the room.
“Jacky, she’s yours,” Levin said. “Let’s get her upstairs to your ICU, and you can make OR decisions later. We’re going to need all the trauma rooms and every open ED bay we’ve got.”
“I’m good,” Jacky said. “Let’s rock and roll. Bill’s clearing out the SICU and getting all the ORs staffed. You keep them coming.”
“It’s going to be a long night. Listen,” Levin said to the resident and the rest of the team and to a couple of medical students who had appeared and were standing at the edges of the room, “in a mass trauma you take your own pulse first. There’s nothing to get excited about. Keep your wits about you. Listen and learn. Keep track of the numbers of victims and know your resources. Manage them. Triage saves lives. Tonight we have burns. Remember the rule of nines. Estimate total body surface area burn using multiples of nine. Nine percent for each arm. Nine percent for the front of each leg and the back of each leg and so on. We need the body surface area estimate for triage. So let’s do one for every burn victim we see tonight. Any significant burn means the patient was inside that nightclub. So tube first, and ask questions later. Tube for any time inside, tube for likely inhalation trauma. Tube for any shortness of breath. Tube for hypotension. Jacky, sound right?”
“On the money. You tube. We debride. The raw excitement of the healing arts.”
And then Levin went to Trauma 3, where there was a man whose skin was still wet from the water the fire guys had used to put out his shirt and pants, and he repeated the sequence. Tube ‘em and move ‘em.
Before long, fire victims overflowed the trauma rooms and filled into the big room of the main ED. Levin tubed seven. The big room stank. Levin and everyone else who worked that night all stank as well. The chairs, the gurneys, the curtains, the counters, the ceilings, and the lights all smelled of burnt hair, burned plastic, and charred flesh.
The curtains in the ED bays flapped as the ED docs, residents, and medical students hurried from place to place. They shouted orders, cut off clothing, drew blood, ran EKGs, intubated every other victim, talked to patients, and then moved patients upstairs lickety-split, first to the surgical ICU, then to the recovery room, and then to every ICU in the house as they filled every bed and needed more. The phones rang endlessly. The overhead page and their beepers didn’t quit for a moment. People, the burned, screeched or moaned until they got morphinized and intubated.
The addressograph machines, which copied the patient’s name and number from little blue cards onto the order sheets and the progress note sheets, thumped and rattled all night long. The floor was covered with wrappers from IV catheters, the wax paper backing of labels that went on tubes of blood, and the pale blue translucent plastic needle covers were everywhere, like confetti or shell casings.
The stink of burn is lipophilic. It likes fat and gets absorbed through your skin and through your nose and mouth and lungs, because it is in the air you breathe. It burns your eyes. The molecules—all those little roasted organic compounds—come in through your corneas. The stink gets deposited in your fat cells, liver, and brain, and it lives there for months, if not forever. You walk away, perhaps, but the stink of burn and smell of pain and the stench of dying always walks away with you.
Somehow, the ED staff managed to wrap it up by daylight. Sixty-three survivors. Forty-three admitted. Seventeen assessed, treated, and streeted. Three moved north to Boston by helicopter. Something like a hundred dead left on the ground in West Warwick, and then moved straight to the morgue. Hell of a night.
Levin tried sleep—and failed at it.
You don’t really sleep after bad nights in the ED. You don’t think about the dead and dying, but they are there anyway, looking at you. You don’t speak about it either. Judy was long gone to work when Levin got home, which was just as well. You stumble home, make a cup of coffee to try to warm yourself, open the Providence Journal, then fall asleep sitting up. You wake up when your bent neck hurts enough. You stumble off to bed, and then don’t sleep. The phone rings—someone selling something or a wrong number or the oil company calling to see if you want your oil burner cleaned. The bright late winter sunlight, reflecting into the room from the snow on the streets and on the roofs, wakes you. Someone backs up a utility truck, the burning beep beep beep wakes you next—in half sleep, and you think it’s a monitor in the ICU or an IV pump or a beeper you’ve slept through. Then your beeper goes off—some nurse pulled your number off the chart and has no idea who the hell you are, that you are off call and don’t admit to the floor anyway. You get a few hours of this, a half hour of obligatory unconsciousness, followed by some jackass knocking on your door, followed by obligatory unconsciousness again. Then you are sort of awake, your brain barely turning over. It’s 12:45 p.m. You wanted to sleep until 4:00.
I should go to the garage, start Julia’s car and back it up a foot to save the goddamn tires, Levin thought. But not today. Not much is going to happen today. Levin’s body was running but his brain just wasn’t engaged.
Shift starts again tonight at eleven, Levin thought. Repair the world. Ha. Save one life and you save the world. Right. Bring the withdrawn light back to the world. Say what? Heal the wound one stitch at a time. Or not.
What a mess. What a goddamn mess the world was.
What a mess, and too damned much work to do. Levin had to give his yearly talk at the medical school in four days—the role of emergency medicine in a country without a health care system—so there were slides for him to tune up and references to check. They needed the PowerPoint by e-mail in enough time to put it up on the website and make sure it was downloaded on the computer in the lecture hall. There was the Free Clinic executive board meeting at 6:00—no money, staff chaos, no continuity, too many patients, not enough people or time or purpose—but at least the clinic tried to take care of the illegals who no one else would see, and at least it was free. There was the Peace Coalition meeting at 7:30 to plan a demo. Little Georgie Bush was getting ready to invade Iraq again.
Levin felt dead. All work and only work. He sometimes flashed on snippets of another existence, his life before he talked himself into med school. He was in the back of a U-Haul truck with thirty people who were about to occupy an air traffic control building in a desperate attempt to end a war, to stop the bombing of hospitals and the napalming of children. He was marching down the main street of a town in Mississippi, where the sidewalks were lined by angry white people. Sometimes he remembered Sarah before she went off the deep end and the intensity of being with her and talking to her for hours and hours. Sometimes he thought about walking in Muir Woods among the redwoods. Real life was an engaged life. This was sleepwalking. Might as well just keep working. That way Levin didn’t have to think about the failures. Or feel. Or hope. Or remember.
Global health. Revolutionary justice. Repair the world. Use medical care as an organizing tool, creating solidarity through compassion. Build resilient communities. Say what?
Bill Levin was a thin man of sixty-seven who wore thick-lensed glasses and had thinning salt-and-pepper hair that he combed backward. When he talked you saw a prominent forehead and eyes that looked bigger than they were because of the thick lenses. He looked like an owl or a mathematician, and he was the workhorse of the ED, the guy who could treat ‘em and street ‘em and keep coming back for more. No one really understood what he was about or ever listened to his tirades, sitting at the ED desk, and no one even remotely suspected that he was a man with any kind of an inner life. He just showed up at the ED whenever they needed him, worked double shifts to give coworkers time off, and saw more patients than any other doctor. His snarky comments about capitalism, politics, or the hospital administration were easy enough to ignore as long as he kept seeing the patients and emptying the rooms, so that each empty room could be filled again with one more patient, over and over again.
Levin was a ’60s leftover who washed up in Providence in 1979, after years of drifting from one demonstration to another, from one concert to the next, blown from place to place by pot smoke and unachievable dreams. He spent ten years in the International Socialist Organization, which sent its well-educated members into factories and warehouses to organize the revolution. Levin dug the work, the cab driving, the assembly line at a wire and cable factory, but he dug the people more—the hard-bitten, burned-out French Canadian dopers and the Azorean immigrant women who didn’t talk much but sewed all day long so they could be with their kids at night, and the crazy Italian shop steward from West Warwick who was as corrupt as the day is long, who loved cars and beer more than women and wasn’t shy about who he was, not ever. When the organizing yielded nothing—no class consciousness, no new unions, and no revolution, Levin finished college in Rhode Island and talked himself into medical school. That way he could still repair the world. Stitch up its wounds and open its airways.
Levin woke. It was 12:45. Computer time. He worked on his paper about emergency medicine in the developing world. He answered e-mails. Weekly e-mail from Julia. Pictures of clinics in the mountains. No electricity or piped in water. Smiling kids. Julia was in Africa doing real medicine. No CT scans. No MRIs. No consultants. She was in a place where they had real diseases—TB and HIV, meningitis, typhoid, malaria, rheumatic fever, and goddamn infant diarrhea; diseases that killed people in Africa by the hundreds. By the thousands. By the millions. Most of Levin’s work was unnecessary, silly, or corrupt. His patients came in complaining of neck pain after a meaningless fender bender or back pain after carrying a dresser down a flight of stairs. Sometimes all they wanted was a record so the car insurance would pay them better or they could get worker’s comp. Sometimes all they wanted was Vics or Oxys to sell on the street.
At 3:00 Levin went for a run. The sun had come back, early spring sun, bright but not strong. There was still snow on the ground but the air smelled of the sap that was moving in the maples that lined the streets. The light carried the hope that winter was finally over.
You have to run in the street, because no one ever shovels their walks anymore, so he stayed to side streets where there weren’t many cars. He ran on Lafayette at first, up the hill to East, then right on Roberta. Left on Alfred Stone to the cemetery where they always plow the roads. A good mile around the cemetery, then down to the river, to hear the seabirds and look out over the marshland.
Levin imagined this place as it was in the time before people, when it was a high bluff over a beautiful river and estuary; the lime green grass and cattails waving in the breeze blowing north from Narragansett Bay. The river was beautiful, even in winter, even despite the squat brick buildings in the industrial park across the river in East Providence. Levin imagined this place again as a virgin estuary under a blue sky, the river teeming with fish, the deer, the beaver, and the fox coming to the river to drink at sunset.
Then Levin ran uphill, out on Pleasant, left on Ridge, left on Swan, then home again, pretending that the constant roar of traffic and the grinding of the trucks on Route I-95 just three blocks down the hill was also part of another world. About three miles altogether, maybe four, just enough to break a sweat and make you feel your skin and lungs but not so much as to put you down for the rest of the day.
He threw in a wash and made a salad for dinner.
Judy got in a few minutes after 6:00. They had been together for fifteen years. She had been abused when he met her, and he had talked her into a safe house, staying with it until she went. Now she worked in an abortion clinic counseling the kids. Good work. She talked, he listened. She was one life saved, which was a good thing. She liked to watch television. Levin spent his days and nights worrying about justice. You find out later that a saved life isn’t the same thing as passionate company.
They ate in a hurry, and then he left for the first meeting in South Providence. The second meeting was at the Beneficent Church downtown. The Peace Coalition was planning the same demo that they’d been having for the last thirty-five years. Same groups. Same speakers. Same self-righteous and inclusive gobbledygook—rainbow this, peace and justice that, community this, environment that, but no focus, no program, and no impact. If Republicans had been running it, they would have been in and out in forty-five minutes. All these Peace Coalition types ever did was whine about what they couldn’t change, concede defeat, and sit back to watch the bombs fall. Everyone knew that this invasion, like the shock and awe bombing of Baghdad, was already a done deal. More U.S. exceptionalism. Our version of the golden rule. He who has the gold makes the rules.
His shift started after the meeting. He walked out to the parking lot.
What Levin saw in the church parking lot didn’t make sense. His car door was open. There were CDs and CD cases on the pavement, and a pair of legs hung out of an open door. For a few moments Levin was confused. That was his green Subaru wagon. It didn’t make sense that someone’s feet were hanging out of his car at 9:45 at night.
“Hey,” Levin said.
A thin black man wearing sweatpants and a hooded sweatshirt wriggled out from under the steering wheel into a runner’s crouch. There was a flat black box under his arm. A laptop. Levin’s laptop. Just a kid, eighteen or nineteen. Dark skin. Bright eyes. Big forehead. Tiny ears. With a white coat, he could have been one of the hospital workers or community health center nurses Julia sent pictures of.
The thin black guy paused just long enough to decide Levin wasn’t a cop. Then he threw something at Levin.
Levin, always quick with his hands, caught what the guy threw in midair. A screwdriver. He threw it back, hard as he could. There was a thud. Metal hit flesh and bone. A hand flew up to a skinny black head.
“Fock you,” the thief said. Some kind of accent, maybe Jamaican. Then he was gone, running down Chester Street, Levin’s goddamn laptop under his right arm.
Then Levin was running after him.
“Stop him!” Levin yelled. But there was no one on the street to hear him.
“Car thief!” Levin yelled next. A few people walked out of a wine bar two blocks away. They hurried to their own cars.
The thin black guy was quicker than he was. Levin was in shape, but he was not a sprinter. He was twenty yards behind and probably fifty years older. Levin pushed himself, gained a little, and then looked back to see if the people coming out of the wine bar were still there. They were gone.
The running man flew across Pine and then went under the I-195 overpass, where it was dark and deserted. Levin listened as he lunged forward. No sirens. The guy darted left toward the river, running as fast as Levin had ever seen anyone run. Levin pushed harder, but the car thief pulled away into the gloom.
And then Levin’s breath failed him. He stopped, bent over, winded, and the car thief’s footsteps pounded off toward the deserted river. That boy is going to have one impressive black eye in the morning, Levin thought. The laptop’s gone, but turnabout is fair play. An eye for an eye, actually and metaphorically. Maybe some justice was done.
There were no people anywhere. Levin was old and slow. The thief was young and quick. What had Levin been thinking? It was just a laptop, just a thing, and it was pretty well backed up. He lost some PowerPoints and the drafts of a couple of papers, but no startling new ideas. What would have happened if he had caught the guy? Just not worth the risk.
Levin was halfway between Pine and Weybosset, almost back to his deeply disrespected automobile when he heard the sirens at last. At least somebody had called it in.
The lock on the driver’s side door had been ripped out, so there was no way to close the car door. But it was just a couple of blocks to work. Why God invented duct tape. Levin found a roll under the pile of papers in the trunk. Chance favors the prepared mind.
He was duct taping the door closed when the cops showed. They looked into the car with a flashlight and offered to call an ambulance. Police report available in five days at headquarters. No illusions about pursuing the perpetrator. Justice, such as it is now, would be found in an insurance settlement.
His goddamned car. And his goddamned laptop. Maybe this was some kind of a message from God. Perhaps Levin had just been repurified. Maybe. Levin had politics that didn’t work, ideology that no one cared about, an emotional life that was a train wreck, and now, no laptop and a car with a door that was missing a lock and a steering column that was messed up. You bang you head against the wall enough and your head splits open. Maybe it was time to just start fuckin’ over. Give up. Go to Cuba, sit on a beach, and look at the women.
Levin had a decent night. No drama. Just drunks and ODs. A bunch of people short of breath and a couple of schizophrenics out of control, the aftermath of the Station disaster, which got people who were already on the edge unhinged. Just dribs and drabs. A patient or two an hour. No beeping. No clamor. No ringing phones. At 2:00 in the morning, the nurses turned off the lights at the back end of the ED and pulled the curtains around a couple of the bays to let some of the drunks sleep. Sometimes you catch a break working the overnight. Huge change from the night before.
But then they needed him to pick up an extra shift. Betty Kidd, who was days, had a cousin who had died in the fire and needed to miss her shift for the funeral. They needed him until noon. Extra shifts suck, particularly after an overnight. Extra shifts after no sleep the day before suck double or triple.
He’d be done at noon. By 11:30 Levin was already in a landing pattern. He got a cup of hot coffee to warm his cold bones. He hit the head, relaxed his innards, and threw some cold water on his face and on the back of his neck. Then his brain started shutting down. No new thoughts. He imagined his bed. His warm bed. In his mind, he was already in his bed when Johnny G stuck a clipboard with one more chart in front of him.
Damn.
At least the guy in Bay 34 had a simple problem. A twenty-year-old with facial laceration. Just stitching. Great last patient. No previous medical history. Walked into a door. Pretty straight forward. Levin looked at the chart and the facial films before seeing the kid, ordered up a tetanus shot, and asked Johnny to put a suture tray together so he could breeze in, do the deed, and be gone. And then home to a nice warm bed.
Levin loved sewing. It was simple manual labor. He could sew in his sleep, which was a good thing because his brain was of questionable value after working for twelve hours straight. He’d offer the kid plastics but he hoped the kid would say just go ahead and do it, so Levin could finish his shift with something simple, and then get the hell out of there.
He blew through the curtain, headed for the packet of sterile white imitation latex surgical gloves, which were open on the procedure tray and lay awaiting his hands.
Thin dark-skinned black kid. Serious shiner about the right eye. Three-centimeter lac.
Something familiar. Levin woke up. What was it? Who was it?
The thief. The goddamn car thief. Laying there in Levin’s ER. Turnabout is fair play.
“Hey,” Levin said, as he turned away from the procedure tray. He expected the kid to bolt. But there wasn’t even a hint of recognition on the kid’s face. The kid just eyed him, some white guy in scrubs.
Levin waited. The kid did not have a clue. “I’m Dr. Levin,” he said and extended his hand.
The kid took Levin’s hand. He had a warm, formless hand, and it took all the energy Levin had left not to twist the bastard’s hand and arm behind his back and push the arm up until the idiot cried for mercy. But Levin was a doctor, and you can’t beat up on patients, even the ones who screw you, even the ones who fuck up your car and steal your blinking laptop.
“Ran into a door, huh?” Levin said, still one tiny wrong move away from jamming the kid’s arm behind his back or calling a cop.
But the patient is the one with the disease. You got to pull yourself out of the equation whenever you walk into a patient’s room. Medicine is unself-interested advocacy. All the crap that Levin had been saying all those years, everything he kept telling students and interns and residents and colleagues, all that preaching came back to him, right then. You got to put yourself aside. Patient care comes first.
The kid didn’t answer.
“Got any allergies?” Levin said.
The kid didn’t answer.
“You speak English?” Levin said.
“Small-small Inglis,” the kid said.
“Anybody here with you?”
The kid didn’t answer.
“Ma or Pa?” Levin said.
“Ma he,” the kid said. “Ma here.”
Levin nodded, stood, and opened the curtain at the foot of the gurney.
“I need a translator,” he said, in a voice that was louder than speaking but not a shout. “And see if this kid’s mother is in the waiting room, will you?”
The kid’s mother was there in five, a tired looking but well-dressed woman in a tan coat. The translator was a portly Liberian guy in his fifties who worked as a technician in the lab.
“Dr. Levin,” Levin said, when Johnny G brought the mother in, and he extended his hand.
“Yvonne Evans-Smith,” the mother said. She had a strong grip. “This is Terrance Evans-Smith,” the mother said. “He injured himself on a door. He is a recent immigrant from Liberia, and his English isn’t good yet.”
The mother’s English, on the other hand, was perfect; a formal, polite, British English that made Levin wonder what that story was—mother is a well-dressed black woman who talks like the Queen, kid who steals cars and barely knows the language. It wasn’t all making sense yet.
“Thanks,” Levin said to the translator. “I think we’re good.”
“Tell me about the door,” Levin said. “When did you hit this … door?”
Levin pushed the kid’s head back on the pillow. He was rough, even rougher than he intended to be. He held the kid’s jaw between the thumb and forefingers of his right hand. He swung the overhead light around so it lit the kid’s face but also so it went right into the kid’s eyes. He moved the kid’s jaw back and forth in the light, and turned the kid’s head from side to side. The cut was three centimeters long, just over the right eyebrow, pretty clean, with a decent amount of swelling and ecchymosis at its base. The tissues around the wound and around the eye were a dusky purple black.
“Last night, after sundown,” the mother said. “I noticed the wound this morning, when I saw blood on his pillow.”
“Quite a shiner. Pretty dangerous door,” Levin said. “This cut is gonna scar up good unless we sew it.”
About sixteen hours had passed since Levin threw the tool at the kid. At least the kid told his mother the truth about the timing. You need to sew lacerations quickly, otherwise you risk infection. Inside eight hours is best. Sixteen hours is stretching it. Twenty-four is too long.
“Johnny, get me a Betadine soak, will you?” Levin said in a loud voice.
Johnny appeared a few moments later. He brought a bowl of gauze soaking in a brown liquid. Levin laid the gauze on the wound.
“And he needs tetanus,” Levin said, loud, as though the person he was talking to was deaf. “No allergies, right?” he said, almost shouting and then he remembered that the mother spoke English.
“No known allergies, right?” Levin said again, quietly this time.
“No allergies,” the mother said.
“What does he do for a living, besides interacting with doors?” Levin said. “He in school?”
“Look,” Levin said, “It’s a laceration on the face. I’m good at fixing them. I’ve done thousands, maybe two or three a day for the last ten years, but any laceration repair can cause a scar, and people are sensitive about scars on the face. Sixteen hours out, greater than usual risk of infection.”
Levin paused, and looked at the kid and then back at the mother. “I’m supposed to tell you that I can get a plastic surgeon to sew the scar.” Levin stopped. What the hell am I doing? He thought. I have no business treating this kid.
“But I’m not gonna sew this right now,” Levin said. “I am going to stop bullshitting you. Your kid didn’t get the damn laceration from a door. Your kid got the laceration from me. Terrance here got the laceration from a screwdriver I threw at him last night, after Terrance threw it at me when I caught him breaking into my car. My personal car. Terrance is a goddamn car thief, and he fucked up my car and stole my laptop. Forgive my French.”
“Fock you,” Terrance said. He reached up, brushed the packing away from the wound and he jumped up.
Levin turned to the kid. “So what’s the story, Eddie? You got my laptop? You give me my laptop, I fix your face. Capiche?”
“Fock you,” the kid said as he started to push past his mother. There wasn’t enough space between the gurney and the next cubicle for two people. The kid’s mother blocked his escape, her hands on her son’s chest.
“Lay ba dan,” the mother said. “De mon to zip de wou.” Lie back down. Let the man sew the wound.
“Fock you,” the kid said.
Then the mother slapped Terrance’s face, hard enough that the sound of the slap rang out across the big room. People working at the desk and in other cubicles heard the voices and the noise. They turned toward the noise, a response that is natural to people who work in the ED whenever there is the sound of trouble.
The slap stopped the kid’s forward motion. He shrank back, transformed from a thief who was quick on his feet into a misbehaving child.
“Lay ba dan. Quick-quick,” the mother said. Lie back down. Now.
“Lie down. I got to repack the wound,” Levin said.
“He will lie down,” the mother said. “I will speak to him from this point forward. And I will speak for him.”
The kid backed away from his mother and leaned on the edge of the gurney, glowering at Levin. The he laid back. He watched Levin, ready to jump and run.
“Why I am sewing this instead of calling a cop?” Levin said.
“Terrance is here illegally. He’s overstayed his visitor’s visa and is working under the table,” the mother said.
“He’s doing more than working under the table,” Levin said.
Then Levin put his hands on the kid’s face again. I get it, Levin thought. Call a cop and the kid gets deported. He gloved and opened a few packages of gauze that were sitting on the tray table next to him, soaked them in the pan of brown liquid, and laid the now brown and wet gauze on the kid’s wound. There’s some kind of war on in Liberia. Or was.
Later he would think, Why did I do that? The whole thing was crazy. He had been up all night, he was tired, his judgment was impaired, and his hands just did what they were trained to do. Your hands work even when your brain is not really there.
“Terrance was in the war in Liberia,” the mother said to Levin.
“How is that my problem?” Levin said. Then he unfolded a paper drape from the treatment table.
“The war gang found him in 1993,” the mother said. “He was ten. School ended for him forever on that day. They took him away to fight for Charles Taylor, our president. Taylor was a warlord then. Taylor’s people put a gun to his head, and then another gun in his hands. They got him high on pills. They taught him how to kill, and they taught him how to maim and how to steal, but they didn’t teach him how to read or think or work. Ten years old. There was no one there to teach him to listen, to know right from wrong.”
“And that makes it okay for him to steal my car?” Levin said.
“A stolen car is nothing,” the mother said. “People here don’t understand the life this boy led. He was part of a pack of boys and girls who roamed the countryside with guns and machetes, involved in activities I don’t care to think about. They killed and they stole and they raped and they maimed. Then they were cut loose and left to fend for themselves, which they did, until their ammunition ran out. Then they were hungry. Those boys came into a market where we used to live. My family found him and sent him here, to me.”
“So I should just sew the cut and leave the police out of it?” Levin said.
“He is on a visitor’s visa. I bought him a good used car so he could find a job, but who will hire him in America with no green card, no skills, no education, and no English? He is a night watchman. He will always be a night watchman, unless he is in jail or until he is deported. I am sorry for your car. I am sorry for your computer. I am sorry for my son, who everyone has abandoned. And I am sorry for my country, which has abandoned decency, and which the world ignores. He hates it here. He wants to be back home and roam the streets again, hopped up on who knows what. Right now, you and I are all that stands between him and that.”
If he were back home, Levin thought, I would be in my bed. What a goddamned stupid place to be. I want my bed. I’ve been up twenty-four hours straight, and I haven’t had a good night’s sleep for three days. I survived through all sorts of carnage the other night, and then the drunks, and now this. My brain isn’t working. I want my bed, and I want my computer back. Maybe she’s right, goddamn it. Maybe this kid didn’t have a chance. Fuckin’ American colonialism. We fucked up Africa. We fucked up Central America. We’re fucking up the Middle East. This kid stole my computer and fucked up my car, and now he wants me to fix his face. Or she wants me to fix his face. Or something. And she imagines that if I can find the energy I need to fix his face, then I won’t call the cops. Why is this my problem? I’m the completely wrong person to sew this lac. But it will take me ten years of explaining to get someone else to do it. Why can’t we ever get anything right? Why can’t we fix one little piece of a broken world? Just one little tiny piece without all these curveballs? Is there not one little place for justice in this mess?
“Alright,” Levin said. “I’m going to sew the goddamn laceration. I’m going to do it fast, and I’m going to do it perfectly, and I don’t want one squeak out of you, kid. You hear me?”
“He hears you,” the mother said.
“From him. I want to hear it from him,” Levin said.
“Sew it,” the kid said. “Please to sew it.”
“That’s better,” Levin said. “Now keep still. Not a word. Not a peep. I’m going to numb it. The numbing will burn for a minute, and then you won’t feel a thing.”
Levin broke open a glass vial and drew the contents into a syringe. He changed the needles on the syringe, and then paused. Second thoughts. Always second thoughts. That’s what they teach you in doctor school. Always second guess yourself. Before someone else does.
“Look, like I was saying, it’s a laceration on the face. Any laceration repair can cause a scar, and people are sensitive about scars on the face. Sixteen hours out means greater than usual risk of infection. Some people would want a plastic surgeon to sew the laceration, and that is perfectly okay. I can call a plastic surgeon to the Emergency Department. It might take a couple more hours, but the plastic surgeon is specially trained to repair lacerations on the face and might be able to produce a better looking scar than …”
Levin paused.
“… and you really don’t want me fixing this cut. Terrance here just fucked up my car. He doesn’t want me standing over his face with a needle in my hand.”
“I want you to do this for us, please,” the kid’s mother said.
“Look lady, would you translate for your son. It’s his face. His decision.”
“Please proceed. It is fine for you to proceed. Better for it to be you,” the mother said. “He will perhaps remember this day the next time he sees a car to snatch.”
Levin waited, his gloved hands suspended in the air.
“Do it,” the kid said, from under the drape. “Please to do it na.” You could hear the bravado in his voice. He thought he was so tough he could stand anything. Which included Levin sewing his face, despite their mutual history. Pretty tough after all, this kid, Levin thought.
“It’s going to sting, to burn,” Levin said. You might feel a pinch. Tell him it’s going to sting. For a minute. Then the stinging will disappear.”
Then Levin took a breath, shrugged, and inserted the needle into the tissue underneath the torn skin and injected local anesthetic into the tissue. Then he pushed the needle deeper, and advanced the needle again. He pushed a little, advanced a little, pushed a little, advanced a little, injecting deeper or in a slightly different direction each time until the flesh beneath the wound was tense with local anesthetic.
The kid squirmed under the sheet. The mother put her hand on his shoulder under the sheet, and the kid quieted.
“Not a peep,” Levin said. “I’m really good at this. You won’t feel a thing from now on. Breathe normally. Just don’t move.” Then Levin leaned over the kid’s face and the sterile field that covered it, and he began to sew.
You leave the world when you sew. Or the world becomes the wound and the wound becomes the world. The first stitch, in the middle of the wound, is the most important stitch because it brings the edges of the wound together. So the needle has to be exactly the same distance from the wound edge on both sides, which means you have to align the edges perfectly in your own mind. You have to visualize that wound with three-dimensional geometric precision, penetrate the skin with the needle in exactly the right place, twist the needle holder with exactly the right degree of torque and at exactly the right angle, find the underside of the opposing side in just the right place, feel your way through the tissue, and then penetrate the skin so the needle emerges on the other side of the wound, exactly the same distance from the edge on the opposing side as it is on the near side. Then you grab the needle just below the point with forceps, hold it in place as you squeeze the needle holder to release the needle and you pull it through the tissue, leaving enough suture so that you can tie a closing knot and bring the wound ends together.
“I know somebody in Liberia,” Levin said, after the first stitch was placed. It ended up exactly where it needed to be.
“In Monrovia?” the kid’s mother said.
“Some place else. I don’t remember the name of the place. How big is Liberia, anyway?” Levin said. He was sewing, and he kept his mind on his work.
“Big, but not too big. Liberia is about the size of Tennessee,” the kid’s mother said.
“Bigger than Rhode Island. Which means my friend could be anywhere.”
“What work does your friend do?” said the kid’s mother.
“She’s a doctor. She works in a little hospital and goes around to a bunch of health clinics in the countryside.”
“My people are in Saint John’s River,” the kid’s mother said. “Near a small city called Buchanan, which is a three- or four-hour drive from Monrovia, the capital. Liberia is not a safe place now, not for Liberians or Americans or anyone else. Your friend is a brave woman. Or a stupid one.”
“Hey, I’m the guy with the needle in my hand, remember? Brave. And headstrong. Not stupid. It could be Buchanan, I’m not sure. What’s the war about?” Levin said, as he placed one more stitch.
“What is any war about?” the mother said. “Greedy men who want more than they need. And poor people doing what they are told to do, who are slaughtered for their trouble.”
“Which makes it okay for your kid to steal my laptop?” Levin said.
“I am ashamed about what happened, if you are correct and it was my son who broke into your car. I’m ashamed for my son. I’m ashamed for myself. And I’m ashamed for my country,” the boy’s mother said.
“Sounds like a different kind of place,” Levin said.
“Different, yes, but also the same. In Liberia, there is nothing. Most people don’t have electricity or running water. But we have children anyway, like you do.”
The kid shifted under the drape, and Levin held his hands still. The kid’s mother moved her hand under the drape.
“Okay?” Levin said. Then the kid settled, the drape rose and fell as he breathed in and out. Levin began another stitch.
She is a decent sort, this kid’s mother, Levin thought. Been through a lot. Dignified. “Which means?” Levin said, as he was stitching.
“Which means life goes on despite the wars. Which means we have to feed ourselves and care for our children any way we can. Which means we have to live with people who have done terrible things. Which means we have to pretend to forget what no one should have to remember, but we remember anyway. Which means we put our faith in God, never in man. We believe in hope, and we believe in God, but we fear one another.”
“Are we so different, here?” Levin said. “We’ve done some pretty terrible things to black people and Native Americans, and we pretend to forget those things.”
“You can’t be serious,” the kid’s mother said. “Don’t you understand what you have? You all have enough to eat. Warm houses in the winter. Cool houses in the summer. Cars to drive in, and streets that are paved to drive those cars on. Schools for the children. Hospitals for the sick. Too many guns, yes, but no gunfire in the streets and no explosions in the night. Except in some places where people who look like me live. Your history is also difficult, yes. But you have a life and the time and space to try to make amends for the past. Each of you can hope to build a better life for yourself. Everyone in the rest of the world wants only to live like you live.”
Levin was down to the last stitch.
She wants me to let the kid off the hook, Levin thought. She wants me to let everyone off the hook. It’s okay now. The sun is out, and no one is dying in the street, and that is justice? History composed by the victors. Rules made by people with money to suit themselves. Okay, she loves her kid, and he is no angel. But you can’t just pretend it’s all okay when it isn’t. Property is theft, Levin thought. I know that. One little laptop doesn’t count for a hill of beans in this world. So why am I so ticked off?
Levin pulled the paper drape off the kid’s face, bunched the paper into a ball, his right hand high and steadied by his left hand as if he were shooting a basket, and threw the balled paper into a wastepaper basket. Then he looked closely at the wound repair, seeing only the new suture line and not looking at the kid’s actual face at all.
“Two points,” he said. “Nailed it. We got us a perfect sculptural closure, with perfectly matched wound edge opposition, resorbable suture, and not a single unnecessary stitch. The Michelangelo of suture repair, if I don’t say so myself.”
Then Levin retrieved a small foil envelope from the suture tray, opened it, and squeezed a thick line of antibiotic ooze over the wound, covered it with gauze, and taped the gauze to the kid’s skin with white surgical tape.
“The usual discharge instructions,” Levin said. “Keep it clean and dry. Return for redness, tenderness, fever, or bleeding. Wound check in three days. I’ll write you a script for Bactrim, which is maybe a little overkill, because we waited sixteen hours before sewing the wound. Suture removal in a week. Follow-up with a primary care physician in two weeks. They’ll give you a list of community health centers and primary care doctors taking new patients at checkout.”
“But what the hell,” Levin said, as he stepped back from the gurney. “I’m not discharging you. I’m going to get a cop, and I’m gonna get my car fixed and my laptop back.”
“And you are going to send my son back to Liberia where he will die in the next war?” the kid’s mother said.
“I’m not sending this kid anywhere. The war in Liberia ain’t my problem. I didn’t break into a car. He did.”
“And you have witnesses to this break in?” the kid’s mother said.
“Lady, I don’t need witnesses. I saw this with my own eyes. You have a lawyer?”
“I can get a lawyer.”
“Oh come on. Are you trying to say your son didn’t break into my car? I just fixed this kid’s face.”
“Dat ca shi. Da laptop shi,” the kid, Terrance, said. The car is shit. The laptop is shit.
“Move yo mouh” the kid’s mother said. Stop talking.
The kid jumped off the gurney and stood between his mother and the large open room. Then he was gone.
“Yo, security,” Levin said, his voice loud enough that the whole room could hear. “I’m sorry for your trouble, lady, but this just isn’t my fight.”
It took half an hour for the cops to show, and by then the kid was long gone.
After security came and went, Levin went to the ED crash room to wash his face, stash his stethoscope in his locker, and get his coat. They weren’t going to find the kid, at least not right away. There would be a police report ready in five days at the new Public Safety Complex on Washington Street. Which didn’t matter for shit, because there already was a police report sitting there from when good old Terrance broke into the car in the first place. His car would cost more to fix than it was worth. No cop ever chases a car thief. They write it down and let you file for insurance. No one was ever going to Pawtucket to look for this kid. Let’s be real.
Levin had no business repairing that lac. What had he been thinking? There was no way he could have been free of bias. If the tables were turned and a colleague or resident had asked him about doing the repair, Levin would have said, huge conflict of interest, patient with whom you’ve had an altercation—you recuse yourself right then and there and find someone else to be the suture jockey.
Working twelve hours without a break keeps you from thinking straight. Dealing with the kid at all was a huge mistake, and if anything had gone wrong Levin knew that the Medical Board would take his license away. Hell, should take his license away. But the lac repair went smooth as glass. God protects children and fools. And ER docs coming off call.
Levin walked out through the waiting room. He needed a shower and a night’s sleep. The mother was standing near the main ED door.
“Sorry about all the fracas,” Levin said.
“I am sorry for your trouble with the car,” the mother said. “I’m Yvonne Evans-Smith.”
“You told me,” Levin said. “And you have a son named Terrance.” They stood together. “And I bet your son Terrance took the car and left you stranded,” Levin said, after his brain told him why the woman was standing there almost an hour after her son had fled.
“The car is here. He took the keys. It’s his car. The keys were in his pocket,” the woman said.
“He have a license? He’s on a visitor’s visa, right? So he’s undocumented. And no license,” Levin said. “But what does it matter. He’s someplace else with the keys. And you’re stuck here.”
“I’m waiting for a cab,” the woman said.
“What the hell, I’m headed out. I’ll run you home,” Levin said. “As long as you don’t mind riding in a car that you have to start with a screw driver, that has a fucked-up steering column and a door held on by duct tape.”
Where the hell did that come from? Levin thought. Talk about no boundaries. Why the hell do I always have to try to fix everything myself? Another dumb idea on the long list of dumb ideas. Will I never learn? Levin thought.
“I’m fine with a cab,” the kid’s mother said.
“The hell with the cab, Ms. Evans-Smith. Yvonne, right? This is Providence, Rhode Island. Deep in the middle of nowhere. You could wait an hour for a cab around here. I live up on the East Side, right on the border with Pawtucket. And you live where?”
“In Pawtucket, as well, just off Mineral Spring.”
“Hell, that’s one exit up 95 from me. And who knows, maybe we find your kid, and maybe I get my laptop back.”
“I don’t know what happened to your car or your laptop,” Yvonne said.
“Lady, you can bullshit me all you want but don’t bullshit yourself,” Levin said. “It was your kid. But that’s okay. It was your kid, but it wasn’t you. Let’s forget about the car and the laptop for a little while. Just let me run you home, so I can get out of this place and go home and get some sleep.”
“Thank you, then,” Yvonne said. “Very kind, considering what we have just put you through. I can’t make any promises about the laptop, though. We can only hope.”
“Let’s do a little more than hope,” Levin said. “This way you’ll know where and how to find me. In case the laptop happens to magically appear. Just in case.”
It was cold on the other side of the revolving door. There had been a little bit of snow overnight, which remained on the ground as an icy crust. Still, the sun was back, and it was worth all the money in the world, even though the air was still cold. Spring was coming.