Twenty-Nine

I kept a running tally, and when everything settled down, I confirmed my count: my surgical attending, an emergency medicine attending, two triage nurses, multiple EMTs, other junior surgical residents, two physician assistants, a recorder, more bedside nurses, an emergency medicine resident at the head of the bed, a medical student, the X-ray technologist, and others, including myself, a senior surgical resident to the patient’s left.

A young man had been shot in the leg. The headline might have read something to the effect of Another Victim of Gun Violence in Cleveland. He was bleeding but not catastrophically. His vitals were normal, his pulses intact, but his thigh was swollen and slightly deformed. He was anxious, naturally, and sweating profusely. The pain must have been unbearable judging by the creative strings of profanity he shouted through gritted teeth. Scout films confirmed a broken femur. Our orthopedic surgery colleagues joined us in the trauma bay and soon after booked him for surgery.

In the moments leading up to this trauma activation, I was glued to my phone, my main source of news from the front and sometimes the quickest way for me to learn about relatives and familiar neighborhoods. Fourteen killed in an airstrike, I’ll read. An entire building demolished. Two children missing, still buried in the rubble, presumed dead. And now another Israeli airstrike. This time the courtyard of a hospital. The casualty count can’t be confirmed; bodies are strewn everywhere. Are they dead or dying? Were they already here for medical care, only to become victims again? Who does this limb belong to?

Thousands of miles away from family in Gaza City, I move like a pendulum between two states: immense grief and immense guilt. I am quieter and I prefer to be alone. It is becoming harder to smile. One attending recently noticed me lose my light one morning after rounds. I was distracted, my eyes looking through things instead of at them. I had just learned about Hind, the child who watched her family members die as a tank fired rounds into their car. She was trapped among lifeless bodies, pinned down by the tank. Paramedics were dispatched to the scene but contact was lost.*

Compartmentalization is a skill that has served me well in my medical training and work. Flawed and to my personal detriment as it may sometimes be, I take seriously the rule that we must leave our baggage at the patient’s door. It keeps me sharp, it allows me to deftly maneuver between emergencies, injuries, and complex clinical problems, and it spares patients from bearing burdens that aren’t their own.

But I have also been conditioned to compartmentalize. I have been called a sympathizer or an outright terrorist by classmates and colleagues, sadistically questioned by supervising attendings, asked to remove mention of Palestine from personal statements, CVs, anything that might be tied to my professional identity. More than once it has been greasily suggested to me that my presence might make others uncomfortable. Would I mind not referring to my heritage? Or at least consider saying I’m from elsewhere?

I have learned, like so many Palestinians with professional responsibilities or people depending on them, to maintain a durable and impenetrable exterior. Because I know better than to expect sympathy and because our grief is mocked or met with vitriol, I can learn of a family home demolished in an Israeli airstrike or a cousin severely burned by American-manufactured munitions and no one around me – patients, classmates, co-residents, attendings, even friends – would ever know.

My shield cracked one Tuesday afternoon. At the conclusion of our second case of the day, I found my phone with tens of missed notifications. Have I heard? What’s the latest on the family?

A large hospital in the city of Khan Younis had taken a direct hit. Many of my family members had sought shelter on the hospital grounds, believing at the time that it was a protected zone. There was no way of knowing who was alive and who wasn’t. I excused myself and made a few phone calls. I’m not sure what I wanted to hear, but these days I selfishly prefer to know a loved one is no longer suffering than to wonder about their whereabouts. Death is definitive. Hope tortures.

I returned to the operating room for the next case, clearly shaken, eyes darting off the surgical field to keep them from welling. My attending, who had perceptively caught on, questioned and almost interrogated me on the anatomical anomalies of the thyroid gland and how I would adjust my operative technique. His questions were meant to distract and reengage me, he later admitted, and to rebuild my composure. Fair. The operating room is a dimension of its own, closed off and removed from the outside world, I always thought. The patient under the knife deserves all of me, even the distraught bits.

As I write this, over 28,000 Palestinians in Gaza have been confirmed killed. Thousands more remain missing — hidden in rubble and strewn across inaccessible roads — and presumed dead. My parents’ memories have been reduced to ash. My relatives are scattered, their conditions unknown for weeks at a time. Over 70% of the population is displaced and only a few thousand have homes to return to. Every medical facility in the Gaza Strip has been partially or completely destroyed. Semi-functional hospitals have run out of oxygen. People are dying from lack of dialysis access, and medication refills are a luxury of a past life. Mothers and newborns share their first moments under heavy bombardment and are quickly whisked away to make room for the next wave of injured patients. Entire operations — amputations, facial reconstructions, fracture reductions and fixations — are completed without even local anesthetic.

For the young man with the traumatic injury to the thigh, twenty-nine is a beautiful number because it represents the number of people who responded to his arrival. The system is designed for this; it is designed to rapidly and efficiently coalesce expertise and the most critical technical and physical resources into one 20 ft. by 30 ft. room, prepared to assess and treat any patient with any injury that is brought though our sliding doors.

For me, the number twenty-nine is heavy, laden with guilt. For virtually any injured Palestinian in Gaza over the past few months, to be evaluated by just one of the remaining physicians or nurses is a miracle. I am convinced that Palestinians in Gaza, who have had to establish and reestablish entire functional medical systems under a brutal Israeli occupation and siege, are experts on caring for injured patients in austere conditions. They have much to teach the outside world. But their medical system, as hardy as it is, has been cruelly and systematically broken down, and I am reminded of this every time I join a massive team prepared to preserve life and limb here in the United States.

So when it all settles down and I have a moment to confirm my tally, I realize how redundant I might be in a pool of twenty-nine. The guilt sets in again. Oh how I wish to be useful, to be among my own providing even a small dose of relief to someone in Gaza who never once had a chance at a normal life.

* Six-year-old Hind Rajab was in a car with family members when an Israeli tank opened fire on their vehicle. Her teenage cousin, Layan Hamadeh, called the Palestinian Red Crescent Society (PRCS) for help. An audio recording of the phone call was made public. A burst of gunfire is heard, followed by screams, and then silence. Hind either remained on the line or called back, and she pleaded for help for hours with a dispatcher who tried to keep her calm.

Two paramedics, Yusuf Al-Zeino and Ahmed Al-Madhoun, were dispatched to the scene after the PRCS, in conjunction with the Ministry of Health, finally received permission from the Israeli military to proceed. Communication with the squad was lost shortly after a blast was heard.

Twelve days later, their ambulance was found meters away from Hind and the vehicle she was trapped in. Circulating footage reveals the ambulance had been shelled and Hind’s family’s car had been hit by heavy fire, both vehicles partially flattened.