THE TRAGEDY OF THE AMERICANS

Ladarat Patalung did not have such conversations about murder every day. It was safe to say that such a conversation was an event and should be treated as such. It should be… marked somehow.

And what better way to mark such an event than with a snack? Just a small something. It was only midmorning. A sweet, perhaps.

No sooner had she reached this gratifying conclusion than her mind began to wander—entirely of its own accord—out the front door of Sriphat Hospital. Down the wide, grand stone steps, it went around the meandering driveway, and to the main entrance on Suthep Road. There, her mind explored the options for a snack that would be appropriate to the occasion.

In giddy anticipation, her hopeful mind wandered along the row of stalls that were reliably arrayed along the west side of Suthep Road. At the first cart there was khao neow ma muang—perhaps the simplest Thai dessert (Khanom)—slices of sweet, overripe mango on top of a small mound of sticky rice and drenched with rich coconut syrup. Or perhaps khanom jark—coconut meat and palm sugar wrapped in a palm leaf and grilled until the coconut and sugar were fused into an intensely sweet toasted candy. Or khao neow dam—black sweet sticky rice smothered in finely shredded coconut. Or…

She had just decided on khao neow dam as being a little more virtuous, when her mind’s wandering was pulled up short by a knock on her office door. Deeply disappointed, her mind hurried back up the hospital driveway, through the grand entry hall, and down to the basement, dragging its heels the whole way.

“Khun Ladarat?”

Oh dear. That was a voice she knew well. A moment later, the door opened and the face to which the voice belonged emerged in the gap, framed against the dark hallway beyond. Ladarat suppressed an instant of annoyance as she realized that her mind’s culinary wanderings had been so abruptly curtailed by her assistant nurse ethicist. She of all people should know that very few things are more urgent than khao neow dam.

Ladarat had just received permission this year to hire an assistant ethicist, and she’d selected Sisithorn Wichasak from more than a hundred applicants. Sisithorn was a new nurse who had just graduated from school two months ago. Young and gangly, she had no discernable social skills whatsoever. She favored big, round glasses; oversize clothes; and wide, open-toed sandals that emphasized her big feet and inelegant toes. Not that Ladarat was qualified to critique anyone’s sense of fashion, but she could think of a few pointers one might offer, if one could find the right moment.

In fairness, though, Sisithorn was exceptionally smart. She graduated at the top of her class at Kuakarun College of Nursing in Bangkok, and then she came here to Chiang Mai because she wanted to learn about ethics.

“Khun Ladarat—Khun Jainukul is here.” Her assistant was breathless with excitement over such an important visitor. “Will you see him now?”

Of course she would see Dr. Suphit Jainukul. The director of the Sriphat ICU was certainly more urgent than khao neo dam, and was not a man to be kept waiting. Nor was he a man who would generally come to visit her in this little basement office. So his appearance was strange indeed.

They greeted each other formally with wais—the traditional Thai greeting. A sort of half bow, with palms pressed together at chest level and brought up to the nose as the head was bent. Much more sanitary, by the way, than the Western tradition of a handshake. More sanitary, and more respectful.

Then the director straightened and took the seat that Khun Wiriya had just vacated.

As he did, Ladarat had an unobstructed view of the door, which was still open, framing the face of her assistant ethicist. Sisithorn looked at her expectantly.

“Khun Ladarat… is this a meeting for which I would be needed?”

“Needed?”

“To take minutes. To record.” She paused hopefully. “To… document important facts?”

Ladarat sighed. She knew she should be pleased to have such an energetic and ambitious assistant. And for the most part she was. But there were times when such motivation should be curbed. Indeed, in Thailand the word “ambition,” tayur tayaan, was often used to mean “overly ambitious.” And it was not generally used as a compliment.

But to be fair, would this be a meeting for which her assistant would be helpful? She glanced at the director, but his eyes were downcast, paying attention only to the iPhone that rested on a broad palm. He was clearly very worried about something. The director’s forehead, she noticed, was wrinkled with concern and lined like a page of sheet music. And his forefinger stabbed at his phone’s screen with an irritable energy that was most unusual for him.

“Perhaps…” Sisithorn persisted, “Khun Jainukul would like tea?”

The director glanced up and turned toward the door. He shook his head distractedly. “No, thank you, Khun.”

“Or a sweet? I can run to get khao tom mud. It will only take a minute…”

Again the director shook his head. “No, Khun. Perhaps another time.”

Oh dear. Whatever the director’s purpose here, it was certainly serious.

Dr. Jainukul always took tea. And anything else—sweet or savory—you’d put in front of him. He was a large man whose ruddy cheeks, shaved head, and plump fingers belied an indomitable strength of purpose and a deep commitment to his patients. In the ten years she’d known him, she’d seen many bureaucrats make the error of underestimating him.

Yet he did love his food, and especially sweets. And simple khao tom mud was his favorite. The national dessert of Thailand, it consisted of small packets of sticky rice and coconut milk and syrup, neatly wrapped in a triangular banana leaf. Ladarat had witnessed the director consume a half dozen with an expansive enjoyment that was contagious, and which reminded her just a little of her late husband, Somboon.

Not today, though. As this large, exuberant man refused Sisithorn’s offer without any interest, Ladarat knew something was very, very wrong.

She shook her head at Sisithorn, who also looked suitably concerned. To her credit, she, too, was alarmed by the director’s refusal of khao tom mud and accorded it the significance it deserved. Without another word, she backed out through the door, closing it gently behind her.

In the moment of silence after the director glanced up again, Ladarat drew her conclusions quickly: The director is here to ask for my help.

And: This request for help is making the director very, very uncomfortable.

“You have heard,” the director asked hesitantly, “about the tragedy of the Americans?”

He offered a weak smile and the rattling skeleton of a laugh that would have been inappropriate anywhere else. But in Thailand, a laugh is provoked almost as often by embarrassment or sadness or anger as it is by humor. Over the years Ladarat had had many opportunities to wonder at her strange culture that could produce such an anomaly.

Ladarat positioned her yellow pad in front of her, turning to a fresh page and hoping fervently that this page would not be as interesting as the last. She wrote today’s date. Then: “Americans. ICU.”

Then, the most important word she would write today: “Elephant.”

She nodded. Of course she had heard about the sad story of the Americans. A young man and his wife. They’d just been married down in the Gulf of Thailand, at a fancy resort on the island of Koh Samui. Then they’d taken their honeymoon by going trekking with elephants in the Golden Triangle, northwest of Chiang Mai.

On their first day in the forest, the elephant on which they’d both been riding just a few minutes earlier turned violent. It trampled the man, damaging his spine and badly damaging his brain. His new wife had been hurt, too, with a fractured pelvis and other serious injuries. Hoping to avoid a tourism debacle, the Thai Air Force had intervened, sending a helicopter into the deep forest to airlift them both back to the best hospital in northern Thailand—hers.

They’d arrived here two days ago, on Saturday. Since then, the wife had woken up, but the man had not. Ladarat had heard, in fact, that there was too much brain damage, and that he was brain-dead. Or close to it. So sad.

She wrote: “Husband? Wife?”

“The man,” Khun Suphit said. “He will not be waking up.” He shook he head sadly.

“Ever?”

“Ever.”

They both thought about this for a moment. It was Ladarat who broke the silence.

“How is the wife?” she asked.

Khun Suphit brightened, just a little. “She is doing better, I’m happy to report.” Although truth be told, he didn’t look at all happy.

“But emotionally, how is she doing? The knowledge of her husband’s condition must be a terrible shock, no?”

Ladarat had always believed that how you feel determines, in large part, how well you do medically. And she was convinced that doctors and nurses needed to attend to a patient’s emotional health at least as much as they attend to his physical health. The good Professor Dalrymple offered wise counsel on this topic, which she credited to an American physician named Dr. F. W. Peabody: “In order to care for a patient,” she admonished, “you must care about the patient.”

Ladarat looked up from her notes at the director, who, she noticed, had become strangely silent. He gave a short laugh that reminded her of the sound that a very old and faithful bicycle tire makes when it is deflated for the last time.

It was then that she knew why Khun Suphit was sitting in her office now. She knew why this important man had honored her by coming to her little office in the hospital’s basement. And why he looked so uncomfortable.

“You see,” he said slowly, “I’m not sure she knows about her husband.”

“You’re not sure? Ah, Khun Suphit, so you mean you’re not sure she understands what you’ve told her?” Ladarat was almost certain this was not what the director meant.

“Well…” Again the sad laugh.

“Yes?”

“You see, we have not told her yet.”

“Indeed?”

“Indeed.”

So the director did not want to tell the woman. He did not want to be the bearer of bad news, and above all, he did not want to cause distress. So very Thai. And yet so very wrong. Did he not have an obligation to share this news honestly? He most certainly did.

“Ah, I see,” she said. “And so… when you do tell her, you are worried that she will be upset. Of course I understand. When you tell her, we should invite one of the monks from Wat Sai Moon.” That was the monastery across the road from the hospital. “Would that be helpful?”

He shook his head. “No… I mean, yes, it would be helpful. But it’s just that we… I… thought that it might be better if you tell her.”

Oh dear.

“I see,” she said. “But why would that be?”

Ladarat knew exactly why that would be, but she pressed on. “You know his condition better than I ever could. After all, you’re his doctor, and the director of the ICU. Such information should come with authority. Who better to explain his condition and prognosis?”

“Ah,” he said. “But you… you’ve spent time in America. In Chicago.” He pronounced that city with singsongy Thai vowels that oddly seemed to fit her memories of the city better than the prosaic pronunciation to which she’d become accustomed.

“I thought that since you know Americans, and how they think,” he continued, hurrying, “you’d be better able to explain his condition.”

“And what is his condition?”

Relieved to be back on firmer ground, the director stopped fidgeting and assumed the calm, patient demeanor to which Ladarat was accustomed. He smiled sadly and explained that the man’s condition was very grave indeed. “He has no evidence of brain function. His pupils are not contracting, and he cannot breathe on his own.” He paused. “It is, truly, very bad.”

Ladarat nodded, beginning to see why the director wanted her to convey this information. In the United States, she knew, this man would be brain-dead. His life support would be stopped. That would be very sad for the man’s family, of course. But at least they would be able to close that door behind them.

But here in Thailand there was no such door for them to close. There were no such hard-and-fast rules about what to do. So it would be difficult indeed to explain the man’s situation to his wife. And if his situation were not explained correctly—and perhaps even if it were—she might insist on keeping him “alive” and supported artificially, for weeks or even months.

Their hospital could not afford that. Their ICU was always full, she knew, and there was always a waiting list. As long as the American was there, there would be patients who would not get the ICU care they needed.

Of course she would help. There was no question of that. Wasn’t this why she’d been sent to receive ethics training at the University of Chicago? Wasn’t this why she had braved a year of extreme cold, and rude people, and bland, salty food? Food, in fact, that was so tasteless that eating a meal was no more satisfying than reading a menu. She suffered all of that for a year so she could bring the principle of ethics back to the best hospital in northern Thailand.

So she would have to help. No question. But this was the director’s responsibility as well.

“Then we should meet with her together,” she suggested. “I will need to ask you for the medical details and prognosis, and of course, the importance of your position and status will make the conversation easier.”

A little flattery, Ladarat had always found, worked wonders with doctors. With everyone, actually. But with doctors more than most.

Yet the director did not seem to be overly enthusiastic about this plan. He looked down at his hands. Then up at the tiny mail slot window set high into the wall behind her.

“You are the expert in injuries of this type,” she explained gently. “Everyone knows this. It would seem strange, would it not, if you were absent for such an important discussion?”

This direct appeal to his vanity was her last hope. The director considered for a moment. At last, Khun Suphit seemed to agree that his absence would be strange indeed. He nodded.

“But you will do the talking?”

What could she say? She nodded. “I will do the talking.”

The director stood up, at least partly relieved. This meeting had not gone quite as well as he’d hoped, but it had gone better than he’d feared.

And that, Ladarat had always thought, was the way things usually worked out. One’s hopes are never fully realized. Or almost never. But on the other hand, one’s fears are not usually justified. If she were wise enough to write a book like Professor Dalrymple’s, that would be the sort of advice she would offer.

“Then we should go now,” the director announced.

“Now?” Ladarat’s stomach gave a modest lurch of protest as she realized that there would be no khao neo dam in her immediate future. Nor would she be able to begin her work as a detective. Nor would she be able to prepare for the upcoming inspection.

“Right now,” the director said. “You see, she has been transferred out of the ICU and is in a private ward. And the man’s parents are here. They flew here last night from Alb… Alb…”

“Albuquerque?”

“Yes, that’s it. Al-bu-quer-que. And they want to know what is happening.”

“I’m certain that they do.”

And she was certain, too, that the man’s parents wanted their son to get the best possible care. No doubt they were deeply suspicious that anyone could get the best possible care in Thailand, of all places. If he’d had the good fortune to be in a Bangkok hospital, which everyone knew rivaled the best in the United States. Instead, they were here in Chiang Mai. Little more than a point of departure for tourists and trekkers venturing into the wild forests of the Golden Triangle. At least that was what they thought.

So she would need to reassure them that Sriphat Hospital was the equal of any hospital in Bangkok. Or Albuquerque. Or even Chicago, for that matter. But that, she knew, wasn’t going to be easy.

As Ladarat rose to follow Khun Suphit out of her little office, her gaze rested for a moment on Professor Dalrymple’s wise book. She thought of another wise passage from that very wise book: “One must never tell a patient that there is no hope. There is always hope. It’s just a matter of helping our patients hope for what is reasonable.”

That was good advice indeed. But what could this poor man’s family hope for? And certainly there was no simple aphorism that could offer comfort to his wife. Still, perhaps Ladarat could offer something.