A Novel

            Taxis and horse-drawn carts pulled up daily in front of the Afghan Women’s Hospital depositing their burqa-clad women. The waiting room was always crowded with women who reflexively covered their faces when Robert entered, then just as quickly dropped their veils when they learned he was the Western doctor. The Afghan physicians saw at least a hundred patients a day, and Robert found himself consulting on conditions he rarely saw in the United States--severe fistulas, abnormal communications between vagina and rectum or vagina and bladder due to tears during delivery and obstructed or prolonged labors; fungating cancers of the cervix and vulva; women with blood counts so low he couldn’t understand how they managed to remain upright. For the first time he had a patient with an abdominal pregnancy, the result of a ruptured Fallopian tube that originally contained the pregnancy. The fetus had continued to grow and the placenta was now attached to other organs in the woman’s abdomen. He and Doctor Mathir always referred these difficult cases to Peshawar’s main hospital.
            During his first week at the Afghan Women’s Hospital Robert met Doctor Salim, the Pakistani anesthesiologist. He arrived on a morning when they had two hysterectomies scheduled. Doctor Mathir, by virtue of her seniority, always acted as Robert’s first assistant, while the other physicians took turns as second assistant. It was only after Mathir felt totally at ease doing a procedure, as had happened with cesarean sections before Robert’s coming to the hospital, that she permitted the other doctors to operate under her guidance. Robert felt reasonably comfortable allowing Mathir to do most of a procedure if they had an abdominal case, but she was much less confident with vaginal surgery. He patiently guided her through those cases. Zaida, the scrub nurse, did not need any guidance. She was as good as Sean had told him she’d be. Robert thought she was the best OR instrument nurse he’d ever worked with.
      “What new catastrophes, Robert?” Sean invariably asked at dinner. The question was asked jokingly, but Robert knew Sean paid close attention to whatever he related. If there were problems at the hospital, Sean would do everything in his power to rectify them.
            Samantha had her own horror stories. “Do you know what I learned today?” she almost shouted at one of their dinners. “Qasi, that creep we hired to oversee food deliveries to the orphanage, has been selling children to the Afridis. He tells the orphanage he’s located relatives and delivers the child to the purchaser. Most of them are girls being sold into prostitution. Sean, I’m going to shoot that fucking bastard, excuse my French, Robert. Just when I think things can’t get any worse, they do.”
            The more Robert learned about Samantha, the more he admired her. Like Sean and himself, she had grown up in a city, in her case Birmingham, England. The oldest of five siblings, she became responsible for their care after her mother died from pleurisy at the age of thirty-two. Her father worked in a factory. “That’s why I never wanted kids of my own,” she told Robert. “I’ve already raised a family.”
            Her father took to drinking heavily after her mother’s death, often hitting the children when he was at home.
            “It was only when James, the youngest, was finally out of the house that I was able to leave Birmingham for London. It was inevitable, I suppose, that I’d work for an organization like Save the Children.”
            One night a foot messenger from the hospital interrupted them during dinner. Robert recognized the man as one of the hospital’s chowkidars.
            “Please, sir,” he said to Robert, “they need you at the hospital immediately.”
            “Do you know what’s wrong?” Robert asked as he walked quickly alongside the man.
            “A patient operated on this morning is very sick. Doctor Mathir is with her.”
            Two Afghan men stood in the shadows outside the hospital entrance, one of them smoking a cigarette. They stared at Robert as he approached.
            “Husband and son of patient,” whispered the chowkidar.
            Robert was surprised to find Zaida anxiously waiting for him just within the door, out of sight of the two men.
            “The vaginal hysterectomy patient from this morning is in shock,” she told him. “Doctor Mathir is with her and has already called for Doctor Salim.”
            Robert entered the patient’s room and found a worried-looking Doctor Mathir taking the blood pressure of an ashen-faced sixty-year-old they’d operated on ten hours earlier. Doctor Mathir, under Robert’s direction, had performed the vaginal hysterectomy. Robert knew how badly she must feel because of this unexpected complication. He pulled back the blanket covering the woman and found the sheet saturated with blood. Her abdomen was markedly distended and she was gasping for breath. Robert lifted the woman’s wrist. Her pulse was thready. “Can you get a pressure?” he asked Mathir.
            “Nothing,” Mathir said.
            “She’s bleeding from somewhere. We’ve got to open her up. Let’s get her to the operating room. Do we have any blood?”
            “Doctor Salim just arrived,” said Zaida, sticking her head into the room.
            “The woman’s husband and son are waiting outside the hospital,” Doctor Mathir said. “We can ask them to give blood.”
            She accompanied him to where the two men were standing. They gawked at the Afghan doctor’s bare face as if they’d never seen a woman’s face before.
            “Tell them their mother is hemorrhaging and needs blood,” said Robert.
            Mathir listened impatiently as the two men spoke to one another, then turned to her. The younger man gesticulated wildly. She snapped angrily at him and turned to Robert.
            “They won’t give blood,” she said. “They are afraid. They say you can point a gun at them and kill them, but they won’t give blood.”
            “His wife, his mother?” Robert pointed at each of them. “Not even for her?”
            She shook her head. “They will run to the bazaar and buy some. I told them the type.”
            “How do we know the blood is good?”
            She shrugged her shoulders.
            “We don’t have much choice. Tell them to hurry.”
            He dashed back inside and began scrubbing while Doctor Salim covered the patient’s face with a mask and gave her oxygen. Zaida was already in position at the table, her instrument tray ready.
            Robert drew his scalpel vertically down the woman’s wrinkled abdomen while Mathir was still at the sink. Zaida assisted him, blotting the blood that followed the path of the blade. She stretched the thin abdominal wall to provide exposure and in seconds, Robert had entered the woman’s abdomen, which was filled with dark blood and clots.
            “Jesus,” he muttered, scooping out clots with his hands, then suctioning. “She’s bleeding from everywhere.”
            Rather than the one bleeding vessel he’d expected to find, blood oozed from every pedicle they’d tied off that morning. The ligatures were all intact. She was also bleeding from every place they’d sutured in the peritoneal lining and fascia. He looked up at Doctor Mathir as she entered the room. “Either she’s got a clotting problem or her tissues are very poor from malnutrition,” he told her. “There’s no loose vessel I can see. We’ll just re-suture every place that’s oozing and apply pressure.” While they were working, another nurse entered. She held out two plastic bags of blood. Doctor Salim jumped up from his stool at the head of the table and took them from her. He hooked the first bag to her IV and squeezed it. The intravenous tubing turned a solid crimson as the blood flowed through it.
            I hope to hell that it’s the right type, Robert thought.
            “How’s she doing?” he asked as he sutured.
            “Her blood pressure is coming up and her pulse is better,” said Salim.
            “Hook up the second unit as soon as this one’s in,” said Robert.
            After re-suturing every oozing pedicle and closure line, Robert applied pressure with wet laparotomy pads. He watched the clock for five minutes, then slowly lifted each pad. The bleeding was controlled.
            “She’s dry now but we’ll have to watch her carefully tonight,” he told Mathir. “Check her vitals and hematocrits frequently. You’d better tell those two--” He restrained himself. “Those two gentlemen outside to get another two units of blood. I’m sure she’ll need them. If anything comes up tonight, send someone to my room.”
            Robert thanked them all for their assistance. He looked at his watch. It was too late to go back to Sean’s. Except for a brief glance, he ignored the two men waiting outside the hospital. They sat with their backs against the fence, their partouks wrapped around them. He walked wearily through the quiet streets back to his room. The usual light show was in progress in the skies over Torkham, flares bursting like a Fourth of July celebration in progress. But the night was quiet, not even a sporadic gunshot. He thought of how enigmatic the Afghans were. Fearless as warriors, yet too terrified to donate blood; eager for large families, yet unwilling to provide semen for sperm counts; and terrified of betrayal by women.
            “Hard to understand,” he said aloud as he entered his room. He peeled off his clothes and moments later was fast asleep.
            The following morning, Friday, the hospital waiting room was empty. Zaida was sitting with the patient he’d operated on during the night.
            “Don’t you ever go home?” he smiled.
            “I slept in the room with her. She’s much better.”
            The patient, who looked twenty years older than sixty, smiled toothlessly, her gums showing. Robert checked her vital signs and palpated her abdomen. It was soft, all the distention of the night before gone. He nodded approvingly.
            “Tell her she’s doing fine,” he said to Zaida. “Do we have a blood count from this morning?”
            Robert looked at the chart she handed him. Doctor Mathir had checked her hematocrit at four. It was better than he anticipated but she still needed more blood.
            “Do we have any more blood for her?”
            “We have two units in the refrigerator.”
            “Let’s transfuse them today and check her hematocrit after the second one. You should go home and let one of the other nurses take care of her.”
            “The hospital is my home. The room where I live is too quiet, too dark.”
            “I understand your husband is in the United States.”
            “Yes, he is in New York City. He works in an Afghan restaurant.”
            “He’ll bring you to America?”
            “Yes, inshallah. He is working on it. Maybe before the end of this year.”
            How will this hospital ever replace her? Robert wondered.