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  “This is the operation for Grand Bassa County, sir,” the female marine said. She stood, and the second marine stood as well and came closer to Carl.

  “Who is this Dr. Richmond?” the second marine said.

  “Dr. Richmond is a pediatrician working for a British organization called Merlin, who was posted to the Liberian hospital in Buchanan. She’s an American citizen. She was abducted yesterday, at about 1300 hours. Her driver and her guard were killed. She’s out in Grand Bassa County somewhere. Taylor or one of his goddamn militias has her. You need to go and find her. Like yesterday.”

  The male marine looked at his desk and began to shuffle through a file folder.

  “I don’t have any information about Dr. Richmond, sir,” the male marine said.

  “Look, the duty officer at the State Department last night said we have really good intel about who is on the ground and where they are,” Carl said. “You know where she is. You have to know. You have to send out a squad and find her. She’s an American. She’s a goddamn American citizen.”

  “I just don’t have any information about a Dr. Richmond, sir.”

  “You are going to leave an American civilian on the ground in the middle of this mess?” Carl said.

  “I don’t have any information about Dr. Richmond, sir,” the man said. “All Americans were moved to the beach and transported here. All present and accounted for.”

  “The mission is complete, sir,” the woman said. “We have successfully evacuated the American citizens on the ground in Grand Bassa County, Liberia.”

  “You haven’t evacuated every American citizen. Go back in and get Dr. Richmond,” Carl said, his voice loud and his back stiffening. “You have a commanding officer?” Carl said.

  Carl’s voice carried across the room. People stared. Some began to drift in from the table of coffee and donuts.

  “Come with me,” the man said.

  “I have a satellite phone,” Carl said.

  “I have a commanding officer,” the man said. “I also have a brig, sir. The operation is complete. I’m sorry. We’re not going back in.”

  “You damn well better go back in. You have an American citizen that you have left stranded in the bush. I’m going to need both your commanding officer and your brig if you don’t go back,” Carl said. “Because I’m one step away from getting in that damn helicopter and going back myself. And I don’t have a clue about how to fly the thing.”

  “Exactly why we have a brig. And a master-at-arms,” the man said. “Understand your concern, sir, and happy to accommodate you in the brig if you can’t take no for an answer.”

  “I can’t take no for an answer,” Carl said. “I can’t believe somebody forgot to tell somebody else. You left her file on a desk somewhere. She’s out there. You can’t sail and leave her.”

  “The mission is complete, sir,” the man said again. “We’ve successfully evacuated the American citizens on the ground in Grand Bassa County, Liberia.”

  “You have an American citizen on the ground in Liberia in the middle of a goddamned civil war,” Carl said. His voice got louder, and more people began to move toward them.

  “At the end of a civil war, sir,” the man said. “Our information is that this war is over.”

  “You have an U.S. citizen missing,” Carl said. “Her driver and her bodyguard were both killed and were left lying in the dirt. Her truck was set on fire. She could be anywhere, and she is in grave danger. And you are telling me the operation is complete?”

  Now there was a crowd of people around them. Four men in uniform began to move through the crowd.

  “Mission accomplished, sir,” the woman said.

  “We’ve heard that one before. I’m going to start dialing this satellite telephone. I’m going to call every senator and congressman in the Washington until you get on the phone and get someone back in there to get Dr. Richmond …”

  A man in his late forties with graying hair and wearing a different uniform now stood in front of Carl, and four other men in uniform stood next to him.

  “I understand you concern, sir,” said the older man. “Feel free to make all the telephone calls you wish. But why don’t you come with us now? We’re going to take you to a place that is a little more private.” Four sets of hands wrapped themselves around Carl’s arms.

  The brig of the USS Iwo Jima is a little room with barred windows in the door. They usually make you take off your shoes and belt. Carl was a civilian, so he got to keep his satellite phone. He worked the phone until the battery ran out.

  In Monrovia, after the shelling started, people thought the Americans would come and save them all. Liberians stacked Liberian bodies in front of the American embassy, hoping that they would stimulate some thought, or guilt, or action. The helicopters came in and pulled the expats out. Just the expats. Americans saved Americans and Europeans. Liberians were left to save themselves.

  Chapter Three

  William Levin. Providence, Rhode Island. February 20 and 21, 2003

  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 co
uld 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.