Brother's Keeper

  For the third day in a row, Nick is trying to convince Akbar to take them on his next hunt. They need fresh air, which is to say they need a break from the damp walls, the cramped quarters – and the growing tension not just between captors and prisoners but also between each man and the other three. They have another reason as well, one they have no intention of sharing: they want to get the lay of the land. It’s becoming clear that sooner or later they will have to escape. They have no plan as yet, but with each passing day a successful ransom has begun to seem less likely.

  Akbar makes the same arguments he made yesterday and the day before that. The third time around Burkett can almost get by without translation: hunting requires silence and deep concentration. It is a soli­tary endeavor, a form of prayer. The Americans would block prayer with their sacrilegious conversation, and even if they were able to keep quiet, their stench alone would warn away any game.

  Akbar’s face discourages anyone from taking his last point for a joke. And it’s probably true that the Americans must bear a greater portion of blame for the odor, that rank combination of mold, dampness, and stale sweat. Part of the problem is their continued insistence on daily exercise even in the mud and rain. Every afternoon they bathe in the stream, but weeks have passed since their last bar of soap ran out.

  Sajiv, who typically remains silent during Akbar’s arguments on hunting, suggests that the smell of the Americans might serve as an advantage. The animals might mistake them for potential mates.

  ‘Why not take them with you?’ Sajiv asks.

  ‘Do you not appreciate having meat in your stomach?’ Akbar says.

  ‘Of course I appreciate the meat.’

  ‘If you want so badly for them to experience hunting, why don’t you be the one to take them? You can bear responsibility for them in the wilderness.’

  ‘I have no interest in spending all day in this downpour.’

  ‘What if Tarik came and found no one in the compound but you?’

  Akbar falls silent and looks at Nick as if suddenly aware of the ongoing interpretation. It occurs to Burkett that Nick’s knowledge of Arabic prob­ably adds to the stress of the crowded conditions – at least for Sajiv and Akbar. For four men sharing fifty square feet – and much of that space taken up by the fire pit – a language barrier might have offered a modicum of privacy.

  But when Akbar speaks again, his voice is louder, his words slower, as if he were attending to the need for interpretation – as if he wanted the Americans to understand.

  ‘Suddenly your real motive is clear,’ he says.

  ‘And what might that be?’ asks Sajiv.

  ‘You want to be left alone with your pornographic magazine.’

  Here Sajiv looks at the Americans and says, ‘I have no such magazine.’

  ‘You would multiply your sin by lying about it?’

  ‘You’re the one who is lying.’

  Sajiv goes outside and walks through the rain to the woodshed and returns with a plastic bag. He pulls out a glossy magazine entitled Holly­wood Extra! , the text a mixture of Arabic and English.

  ‘Is this the magazine you call pornography?’

  Akbar gasps at the cover, which shows the actress Jennifer Aniston in a bikini and Angelina Jolie and Scarlett Johansson at some movie premiere. After staring for a moment, he averts his eyes, spits in the fire, and says, ‘Filth.’

  Sajiv displays the magazine not for Akbar, but for the Americans. He flips through the pages, offering glimpses of actors on red carpets, stills from popular movies. He gives an uncomprehending shrug, as if to ask, Does this look to anyone like pornography? Unlike the newspapers reviewed by Akbar, none of the photographs in the magazine have been defaced.

  Women in gowns and bathing suits: is it pornography or not? Both Akbar and Sajiv seem now to await a verdict from the Americans, as if they were experts on the subject. Clearly it isn’t, not by Burkett’s stand­ards, but the challenge faced by Nick is how to phrase it without causing offense.

  ‘Best not to say one way or the other,’ Burkett says.

  Nick thinks for a time before diplomatically suggesting that many of the women are in fact dressed in revealing outfits.

  But this isn’t enough for Akbar, whose eyes twitch side to side as if searching for some means of expressing his outrage.

  ‘What if Tarik saw this vile material?’ Akbar asks.

  ‘That name again,’ says Burkett. ‘Who is Tarik?’

  ‘No idea,’ Nick says.

  Akbar stands and kicks the leather sack that holds Sajiv’s chaupar set. The tokens scatter, at least one bouncing down the stairs and landing with a splash in the basement.

  ‘Didn’t you come here to escape the temptations of the world?’ Akbar asks Sajiv. ‘The internet cafés and whorish American women? What today a man tolerates, tomorrow he accepts and the next day embraces.’

  Sajiv goes down to retrieve his game piece from the ankle-deep water.

  While he’s gone Akbar opens the magazine to a random page and what he sees there, a woman in a bathing suit, prompts him to cast the maga­zine into the fire. When Sajiv returns, he shows no surprise at the sight of the burning pages. Akbar, perhaps feeling guilty for what he’s done, helps him collect the remaining game pieces.

  It is past midnight when the boy, who they now know is called Asadullah, arrives from the neighboring compound. They haven’t seen him or the woman since the rains began. Though out of breath and soaking wet, he shows no interest in drying himself by the fire. The words come in frantic bursts. Burkett catches saa’idni and mareedh. Help me, sick. Nick fills in the details: a baby with vomiting, fever, and bloody stool.

  ‘How old?’ Burkett asks.

  ‘Six months,’ Nick says.

  ‘What color is the vomit?’

  ‘Bilious,’ Nick says. ‘You think it’s volvulus?’

  ‘I don’t know,’ he says. ‘Maybe intussusception. We should go there.’

  Sajiv begins lacing his boots, but Akbar makes no move to leave. He sits there watching, his eyes bouncing from Nick to the boy. He seems to be withholding a decision even though there is nothing to decide. A baby is sick – how could they not help? Perhaps Akbar suspects a conspiracy between the Americans and this teenager. It would be no less plausible than the escape tunnel he occasionally searches for under their bed mats.

  Akbar declares that Burkett must see the baby while Nick stays behind. To treat the child Burkett needs Nick to interpret, but there is no point in arguing: Akbar would never betray such weakness as a change of mind.

  So Nick interrogates the boy, who is clearly impatient to return. The symptoms began mid-afternoon, perhaps twelve hours ago. There were only two episodes of bloody diarrhea, but the abdominal pain and tender­ness seem to have become worse.

  ‘Was the stool watery?’ Burkett asks.

  The boy shakes his head.

  ‘Was it like jam?’ he says.

  ‘Jam?’ Nick asks.

  ‘Just ask him – like cherry jam.’

  The boy nods.

  ‘Does he feel better after throwing up?’

  ‘It’s a she,’ Nick says. ‘She felt better at first, but now she’s inconsolable.’

  ‘And still vomiting.’

  ‘Yes.’

  ‘Did she have a recent infection?’

  ‘No.’

  ‘No diarrhea or vomiting before today? Maybe an upper respiratory infection?’

  ‘No.’

  ‘Why can’t they take the child to a hospital?’

  ‘They tried,’ Nick says. ‘The girl’s parents left this morning, but there was a bridge.’

  ‘The bridge was flooded?’

  ‘I don’t think so,’ says Nick. Again he questions the boy and says, ‘The bridge was destroyed – bombed.’

  ‘Isn’t there anothe
r way?’

  ‘It would take three days by mule cart. The parents thought the best thing was to come home.’

  It is Sajiv who accompanies Burkett to the neighboring compound. Following the boy, they move at a brisk pace despite the rain and mud – a half mile in ten minutes.

  The mud brick walls of the compound have a foundation of piled stone. Burkett and Sajiv stand in the rain while the boy fumbles with the door. Not a sound from inside: the silence is a problem. If there is a sick baby, they should hear it crying, even over the patter of rain.

  In the main room Burkett counts twelve people, standing women and seated men. The crowd would account in part for the warmth – not unpleasant after the rain – and that same ammoniac smell which seems to exude from anyone who spends long enough in these mountains, Burkett himself included, but so much stronger here in this concentration of sweating adults.

  The women wear burqas, but not Asadullah’s sister, the mother of the sick child, who wears a headscarf and a loose fitting shift over what looks at the ankles and wrists to be a bright red sweat suit. Burkett sees at once what he couldn’t have seen on her visits to their compound – that she is attractive, perhaps even beautiful. Or is this merely an effect of her eyes in the firelight, the glow of her tears? Whatever the case, he should stop staring, even if this is the first female face he’s seen in over three months. A moment passes before he even notices the baby, her daughter, lying in a crib.

  Sajiv joins the four men who sit on a rug as far as possible from the crib and its feminine penumbra. The men are puffing on the rubber tubes of a hookah.

  Burkett washes his hands with a rag in a bowl of warm water. No one speaks as he nears the crib. He looks at the mother, who nods her consent.

  The baby is dying. He suspects intussusception, a condition where the walls of the bowel roll inward to form an obstruction. He feels the racing pulse and taut abdomen. The child is dehydrated and possibly septic as well. He bends close to the skin of the child’s belly and draws its scent into his nose. In an extreme case of bowel necrosis he might detect a faint odor of putrescence – it would imply a dire prognosis – but here he smells nothing of the sort.

  One of the women hands him a white plastic box, a first aid kit. Inside he finds a cracked tube of Neosporin, a stack of gauze, several bandaids, and a syringe of epinephrine. None of this can serve him here. He might have come up with a creative use for the epinephrine if it weren’t expired by over a year.

  The fire pit has a wall to contain the cinders. Smoke escapes by means of a metal pipe, a kind of makeshift chimney attached by brackets to the mud brick wall. One of the women stokes the fire with an old-fashioned wooden bellows.

  The bellows give him an idea, perhaps ridiculous and even irrespon­sible. And yet he can’t help but wonder: could he reverse the obstruction by pumping air into the child’s colon, the very method used by surgeons in any American children’s hospital? Those surgeons of course have the advantage of imaging guidance and pressure control. Burkett couldn’t hope for a bellows with a check valve or pressure gauge – he might as well ask for a fluoroscope. And he can tell by just looking that the wooden spout would be too large for the child’s anus.

  But some kind of lubricant could make the difference – animal lard or soap, perhaps. Worst case, he could use water. He reckons that a mere anal fissure would be an acceptable risk, a small price to pay.

  He picks up the bellows, drawing curious looks from those faces he can see. An air enema. Of course it also carries a risk of perforation – a significant risk, given the lack of pressure control – but the child will most certainly die if Burkett does nothing at all.

  He wishes Nick were here to interpret. He looks at the child’s mother and tries to explain the problem of bowel obstruction. The typical met­aphor for intussusception is ‘telescoping bowel’. He stands in the space between the men and the women. With his hands he tries to pantomime the enfolding colon, increasingly aware of an unbridgeable gap between hand gestures and bowel anatomy, and when the mother lifts one of the baby’s hands and gives him a questioning look, it occurs to him that she thinks he’s trying to describe some defect in the child’s fingers.

  An old man, the grandfather or great-grandfather, says something, and others flash skeptical glances. Sitting beside him, Sajiv looks for a moment like he might come to Burkett’s defense but instead wraps his lips around one of the tubes of the hookah.

  ‘It’s a matter of plumbing,’ Burkett says, but of course none of them understand. He speaks from habit, a rote metaphor to explain problems of stool, urine, and blood.

  A matter of plumbing. It suddenly strikes him as odd how much of human physiology can be reduced to substances moving in tubes.

  He tries for a simpler pantomime, the motion of writing, the fingers of one hand scribbling against the palm of the other. This prompts obvious confusion and even vexation among the family members, until one of the women produces a leather-bound book and ballpoint pen. He can tell from her arthritic hands that she is old. The book is a diary of some sort, with pages of calligraphic script running right to left.

  Three women in burqas face him like a row of pawns on a chessboard. Only moments have passed, but he couldn’t even say which of them gave him the diary – the one in the middle? He flips to a blank page at the end and begins drawing. He kneels to rest the pages against his thigh. For his rune-like infant, composed of lines and circles, he receives quiet nods of understanding. He adds a coil of intestine and points to his own abdomen and says, ‘Bowel.’ Lower on the page he draws the sinuous ileum merging with the larger, sack-like colon.

  The men in the corner have gotten to their feet, leaving Sajiv alone with the dubious grandfather. The boy, Asadullah, watches in silence as Burkett again draws the same segment of bowel, the ileocecal junction, but the ileum, now massively distended, protrudes into the colon and tapers to a point.

  Burkett shows what he’s drawn to the baby’s mother. She turns to Asadullah, who takes the book and begins explaining. Burkett can tell from the way the men nod and whisper among themselves that the boy is known in the family for his superior intelligence. The boy displays the book for the others, his finger tracing the intestines. He holds his breath and inflates his cheeks. Burkett might have doubted the boy’s interpreta­tion, but he sees the puffed cheeks as a hopeful sign, perhaps an analogy for obstruction: the distention that results from downstream blockage.

  When the boy finishes, he turns to Burkett with a look that seems to ask, Now what?

  Burkett stands over the crib with the bellows and tries to convey the idea of an enema, gesturing between the spout and the baby.

  ‘Do you understand?’ he asks the boy.

  He sees he doesn’t, so he takes the notepad and flips back to his first drawing. Between the stick legs he jots a triangle for the bellows and an arrow for the direction of air.

  The boy studies the illustration and with a nod turns to address the others. Burkett has no way of knowing how much he actually under­stands. But then one of the women retrieves a clay jar from another room – a lubricant of some kind, similar to petroleum jelly. The concept of lubricant far exceeds what Burkett could draw or sign, but somehow this woman recognized his need for it. He nods his thanks toward the screen of her burqa. Ever so slightly the burqa tilts: a nod in return, or perhaps he imagined it.

  The boy smears jelly on the spout of the bellows. Burkett takes one of the infant’s flaccid wrists and feels for the pulse, but it is so weak he has to palpate the neck instead. The heart rate is well over a hundred beats per minute. Babies tend to have elevated heart rates at baseline, and Burkett is no pediatrician, but what could this be if not septic shock?

  He turns over the child. The mother shifts the head from left to right. To face Mecca, Burkett realizes: a Muslim should face Mecca when she dies.

  He spreads the buttocks and studies the anus, the
tiniest hole, smaller than he expected. Even with lubricant, the spout of the bellows is just too large. The damage would be far worse than a fissure.

  The hardest decision for a surgeon, the decision to do nothing: but now that bacteria have infested the blood, now that the child is sure to die, why subject her to the trauma of the bellows? Why risk a painful treatment for a condition she might not even have? There is no question of bowel obstruction – but caused by what? He can’t be certain of intussusception. She could have some kind of mass or, as Nick suggested, a volvulus, a twisting of the bowel.

  Intussusception. Perhaps he was too easily convinced by the jam-like stools – words he himself proposed. Perhaps he’s committed the error of molding the evidence to fit the diagnosis. He heard only what he wanted to hear. Even the bellows, so appealing for their novelty, seem to have reinforced his diagnosis of choice.

  Asadullah is kneeling between Sajiv and the old man. The old man listens, nods, and with a curved dagger slices one of the rubber tubes from the hookah.

  It is a good idea. There is no reason the length of hose couldn’t be used for an enema. The boy tugs on the rubber segment to prove its strength and elasticity. The relatives mumble their approval, clearly impressed by the boy but uncertain why Burkett isn’t convinced, as if the doubt in his face were connected solely to this particular piece of tubing and not the entire course of treatment.

  He wishes the boy would forget the bellows and the rubber tube. A harebrained treatment, he thinks: more likely to perforate the colon than bring any relief to the child. By adding pressure to an already distended system, Burkett risks killing the baby faster and more painfully. But the enthusiasm of Asadullah only kindles the general sense of hope, the notion that Burkett has the power to make things better. Before his arrival, most if not all of the relatives had accepted the futility of the case, prob­ably even the mother, but now they have the bellows and tubing, tangible objects to which their hopes can attach. They have intestinal doodles and ideas of plumbing.