New Nonfiction by Krista Puttler: “Traversing the Gate of Tears”

Dubai is one gigantic, grey strip mall.

“Does anyone know why they call this place Dubai?”

I look away from my bus window. The tour guide sits on the edge of her seat in the front row, leaning into the aisle, microphone in hand.

“Come on,” her eyes wide, “Anyone want to guess? ‘Do’ and ‘Buy’! Dubai! Because everyone comes here to shop…”

I look back out the window. Like the last port visit, Bahrain, this port visit is one solid color. But instead of brown, this place is gray. We are on a wide highway. Cement buildings flicker past. We drive up and over a bridge, take the next exit off the highway, and wind back down and under the bridge. A pair of palm trees stand a little way ahead like two green phalanxes guarding the terracotta-roofed buildings behind them.

“…and up ahead is the Trump hotel,” the tour guide says.

Everyone continues to look out the windows. Trump became president the first month of our deployment. I wonder if the tour guide expected a different reaction.

“We’ll drive around the back and get out so everyone can get a good picture.”

The narrow street is lined with plots of manicured grass and palm trees. All the palm trees are exactly the same height.

The hotel looks like the palace at the end of the Candy Land board game.

We pull off to the side of the road. I look away from the hotel and out my window. The expanse of calm, turquoise water merges with the sky in an exact horizontal line. There are no waves. There are no dolphins. There are no seabirds.

I step out of the bus and walk over to the sea wall. It is a little higher than my waist. I lean over the top and look down. There is no sand, just turquoise water. It is as clear as drinking water. There are no clumps of algae, no seaweed, no barnacles in the nooks of the seawall. It is as if everything has been sterilized.

I look back at the hotel. A lot of money has made this a picturesque seaside destination. The bushes are trimmed into perfect geometric shapes; there are no cracks in the paved road. Everyone holds up their phones, their faces masked in the hotel’s shadow. I turn back to the water. I search for a ripple on the surface, anything that shows a scar, an imperfection, a smudge, anything that will tell me this place is alive.

“Ok, everyone!”

The tour guide claps her hands, gives a broad smile. She moved here from the Philippines to work as a promoter of this country. That is what a tour guide does, right? Represents this place in such a way as to get tourists to spend a lot of money, tell people about it, then return sometime in the future to do it again. I wonder if she knew this was going to be her job when she left her family behind. I have to believe there is something here that she has found, something more than money, that keeps her here. Has she found a real, living place here?

“Next stop, the Carpet Factory!”

If so, I don’t think we will be shown that place today.

 

 

“Surgeon, how was your tour?”

I look up from the liberty log. The Physician Assistant (PA) leans on the bulkhead in the lobby of Main Medical. Over the last five months of deployment, he has assisted me in taking care of patients and has been a workout companion during group cross-fit classes. He always listens when the sadness gets too great, and I need to tell someone I am missing my husband and two young daughters.

“The trip? Depressing.”

“How so?”

“Everything seems sanitized…”

He wrinkles his forehead.

“Or covered in sand.”

He nods, “Yes, that is everywhere.”

I put the pen down. “Any updates on the patient we transferred off the ship yesterday?”

“The pelvis abscess patient?” the PA asks.

I nod.

He looks behind him then says, “He had surgery, but I think he did ok. They took out his appendix and drained the abscess.”

I exhale. I was afraid of that. I was up all night worrying I did not adequately convey to the transfer service the potential difficulty of operating on this patient. Not being able to directly dictate a patient’s care, or even just talk to the surgeon taking care of the patient is a very frustrating part about being deployed in a part of the world where I know no one and know less about their medical systems. But often, it is not safe to operate on the ship. The safest thing to do for a patient is get them off the ship. And for me to give up control. I hate that. I had hoped the patient would have gotten an interventional radiology drain, that pelvis would have been a disaster to operate in. I have the equipment to drain a pelvis abscess, but he was at risk for getting very sick postoperatively. We have no blood bank, we are not equipped to take care of a sick post-surgical patient for very long, and he is in for a long recovery. Even though I love operating, the right thing to do was get him to a local hospital.

“They started him on a diet today,” the PA continues.

“Wow, that’s quick.” I pride myself in being somewhat aggressive when it comes to feeding a postoperative patient, but if I had been staring at a pelvis full of pus, I probably would have held off feeding him for at least a day or two. His intestines won’t work normally for a while.

“SMO (the Senior Medical Officer, pronounced Smoh) wants to see if he can be discharged in time to get back on the ship before we leave port tomorrow.”

I shake my head.

“Well, that might be ok, right?”

“No. He should not come back to this ship. Besides, he won’t be ready to be discharged in a week let alone tomorrow…”

“But his surgery went ok…”

“No,” I say again, “He won’t be ready. His guts are going to freeze up and not work. That’s why all you try to do with a pelvis abscess is drain the abscess, not operate on him. That’s what I tried to convey yesterday over the phone anyway.”

“Well,” the PA says, “We are in port, you couldn’t have operated on him anyway.”

“That’s not the point!”

The PA takes a step back.

I exhale. I can’t explain to him how frustrating it is when no one seems to listen; when no one seems to understand how sick this patient is still going to get. Instead, I say, “I’m sorry. I just really miss my family.”

He nods. “I know.”

“I’ll see you at dinner.” I walk past the PA, step over the hatch to the lobby, and into the cross-department passageway.

The patient was in septic shock. If I am honest with myself, I was afraid to operate on him, I was glad we were in port. If we were out to sea, I would have had no choice, he would have been too sick for a Medevac flight. And his surgery would have been close to impossible to perform without another set of knowledgeable hands, Surgeon hands. And there is no other Surgeon. There is just me. And as the lone general surgeon I have gotten into the habit of thinking of the worst outcomes. If the worst had happened – me not being able to get him off the OR table alive – I would not be able to walk into that operating room again. Then what would happen for the rest of deployment? There is no one else to take my place.

I walk into my office and turn on the light. There is a large box marked Priority Mail sitting on my desk. It’s from my mom.

I open the box, pick up the pink envelope on top and open it. It is a Mother’s Day card. Underneath the card there are four pounds of whole bean coffee. “Thanks, Mom.” I stow the coffee under my patient exam table then look back into the box. I pull out a large pack of Red Vines.

“Ha! Well, at least they aren’t Twizzlers,” I say, remembering the sea story I had heard on my first day out to sea. On the ship’s last deployment, the supply ordering had gotten mixed up and the only things that were sent to the ship were pallets of Twizzlers. The joke was that there were surely still boxes of Twizzlers oozing red crust into the bowels of a ship storeroom somewhere. Ah, so that’s where the cockroaches are coming from, I had remarked, putting in my two cents like I always do. But I worried I had upset the storyteller. Instead, my comment was incorporated into future retellings, and will probably continue to be a part of this ship’s lore for longer than I will.

There is one last thing in the box, wrapped in floral paper. I pick it up and tear open the wrapping. It is a folded pink T-shirt. I hold it up and the shirt unfurls under the fluorescent lighting, its silver looped script sparkles: I am a mother and therefore blessed.

This is not what I need to hear today. I am about as far away from being a mother as I have ever been, even before I had children. I can’t ask my daughters about their day, I can’t tell them about mine, I can’t give them a hug. I have left their day-to-day care to a nanny – a very capable, loving nanny – but what mother leaves their five- and two-year-old children? For a career? For a duty? For medicine? I realize I am not the only mother who has deployed. I realize mothers will continue working, striving, and loving their children all at the same time. But it is hard to do everything all at once. Especially when I physically cannot right now. Being reminded of that impossibility is not what is going to help me feel better about being here. I refold the shirt with the words on the inside and toss it into the trashcan.

 

 

Just before Memorial Day, the ship re-enters the Gulf of Aden.

“Is it hot in here or what?” I ask the Radiation Health Officer (RHO), a member of the medical department in charge of monitoring shipboard dosimeters. Condensation drips down the bulkheads. Sweat drips down the side of my face. So much for taking a shower this morning.

RHO opens his mouth, raises a finger, but I cut him off. “Never mind. I’m going to breakfast; would you like to join me?”

“Sorry, I have a rad health physical with SMO in a few minutes.”

“Wow. Both of you here? This early in the morning? Is the world ending?”

“Don’t remind me! Plus, I think he said he was going flying later or something.”

“Oh, great. I really am always the last person to know.”

“Ha! I know!” RHO says, “And you are the one who has to cover for him…”

“Don’t remind me,” I echo and walk down the passageway.

I push open the Wardroom door. There are only two occupied tables. I exhale; some days it is preferrable to eat breakfast alone. I decide on a hard-boiled egg and a bowl of oatmeal and walk over to an empty table in the corner. I put my tray down, walk over to get some water, then head back to my spot. An officer who sometimes goes to the same weekly exercise class as I do sits at my previously empty table.

“I hope you don’t mind, Surgeon,” he says as I sit down, “But I hate eating alone.”

I nod because it’s the nice thing to do, roll the hard-boiled egg on the tray until it cracks, then start to peel it. I exhale; I need to make conversation. “How’s your day going?”

“Oh,” he replies, “I just came off duty. Going to get some sleep, then back on duty tonight.”

“Busy schedule on the Bridge?”

He nods, then puts his fork down. “Surgeon, are you ever not on duty? I mean, who covers for you if you get sick?”

“No one.”

“What’s your secret?”

“About working all the time?”

“No, about not getting sick.”

“Oh.” I look down at my oatmeal. It looks like a lumpier version of grade-school paste. “I don’t know.” I push the oatmeal away. “I have two young daughters at home, so my immune system is primed, I guess.”

“Yes, Ma’am.” He takes another huge bite of scrambled egg, swallows, then stands up. “Well, if I have your permission, Ma’am…”

“Yes, please.”

He picks up his tray. “I’m off to get some rest, we’ll be busy going through The BAM tonight.”

“The what?”

“The BAM…something,” he twirls his hand in the air, “Mandeb,” he shrugs, “You know, The Gate of Tears.”

“Oh,” I nod, but I have no idea what he means.

I wait until he leaves the wardroom then I pick up my tray, guiltily turn in my uneaten bowl of oatmeal at the dirty dishes window, and rush back to my office. I open the search engine on my computer, but per normal, the connection is painfully slow. I see sick call, clinic patients, cover for SMO while he goes flying, grab a quick lunch, see a walk-in abscess patient, and look at an X-ray for the PA before I can google, The BAM.

To re-enter the Red Sea from the Gulf of Aden, the ship has to traverse the Bab el-Mandeb, shortened to the BAM, translated as, the Gate of Tears. It is the narrowest part around the Arabian Peninsula, a choke point for container ships because of the minimal room they have to navigate safely around the point. Are aircraft carriers bigger than container ships? I don’t know. When we went through the first time, I did not know to ask that question. I was blissfully unaware; I did not question my own safety. Something has happened to me between the beginning of deployment and now.

I look up at the television screen on the bulkhead in my office. It is on the black and white flight deck camera channel. The sky is a deep grey, the water a dark black. I can’t clearly see the edge of the deck. We are going through this narrow passage at night. I know that I personally try not to do anything at night – I try not to operate at night, I try not to medevac patients at night – everything is riskier at night, right? Or does this mean that it is riskier to traverse this place during the day? I don’t know.

My heart races. I can’t make it slow down.

I want to go home. And I have no control over that desire. I have to trust that our Captain, just like a Surgeon, has tirelessly prepared for all possible contingencies. But I also know that not every part of a surgery can be planned. An anatomic variant, a hesitation from a team member, or just plain old bad luck, can end an operation prematurely. We got around this point the first time without a scratch – I didn’t even know I should have been worried.

I turn off the TV and rush out of my office.

The passageway is deserted. The ladderwell is deserted. The overhead lights in the hangar bay are off; everything has more shadows tonight. No one is working out in the hangar bay gym. All the Weapons Department office doors are closed. I make it all the way to my stateroom without seeing anyone. I am all alone.

I enter my stateroom. It is dark except for a small light on over the sink. My roommate’s bunk is empty. I take off my boots and lay down on top of my blanket. I don’t take my uniform off. I don’t take my hair out of its bun. Most nights I know I will be woken up in the middle of the night for a medical emergency, but I always change out of my uniform and get into pajamas to at least attempt to have a good night’s sleep. I don’t want to risk it tonight. I don’t want to use up all my luck. Perhaps, if I don’t change out of my uniform, the one thing I have control over tonight, I won’t be needed, I won’t have to get out of bed, and then perhaps we will have enough luck left to eventually get all the way back home.

 

 

“Surgeon?”

One of my Corpsmen stands in my office doorway. “Is it time, HM3?” His rank is Hospital Corpsman, third class.

“Yes, Ma’am,” the Corpsman says, “My flight leaves in an hour.”

I look back at the TV on the bulkhead. The morning after the BAM crossing, I rushed down to my office and turned it on. The waters of the Red Sea looked the same color grey, there was no indication on the screen that we had done anything significant while the TV was off. And this morning, the waters of the Mediterranean also look the same color grey. Perhaps that is the point.

I stand up and walk to the door. “Goodbye, HM3. Good luck at your next duty station.”

“Thank you, Ma’am.”

The Corpsman turns to leave, then stops. “Ma’am?”

“Yes, HM3?”

“When I first heard that you were leaving the Navy, I thought, there goes all the common sense.”

My breath catches in my throat. I don’t know what to say. Am I giving up? That is my greatest fear. And will there be anyone left who will continue?

“Ma’am?”

“Yes, HM3?”

“Can I get a hug?”

My chest aches. I nod and walk over to my Corpsman — my Corpsman who had worked tirelessly on the ward with me, who had carried his Medical Response Team bag to countless medical emergencies, who had cared for mass casualty patients and sailors in his repair locker, a remote location on the ship where sailors stop flooding, put out fires, and repair damage — and I pull him into a hug.

“Goodbye, HM3. Do good things.” And I let him go.

“Yes, Ma’am. Goodbye.”

I sit at my desk and close my eyes.

I shake hands with patients daily. I place a hand on a shoulder when I listen to a heartbeat inside a patient’s chest. My fingers touch tender abdomens. But in actuality, I have very little human contact.

 

 

I leave the department, change into gym clothes, and walk aft through the hangar deck. I catch a sliver of the turquoise sky just above the dark green of the sea. I walk up to the O-3 level, enter the cardio gym, and go for a long run on a treadmill. For the next hour, I forget about the pelvis abscess patient who flew back to the states and had to have another emergency surgery. I forget that my daughters are growing up without me. I ignore the constant questioning thought – What good am I really doing here? – and I just run.

At the end, I stop the treadmill, and clean the console. I exit the gym via the long port-side passageway. My chest burns: my legs are spent. I pass a berthing area, a lounge area, go up two steps, pass through a hatch, then walk by a humid open machinery room. I go through another hatch, go down two steps, and pass single-occupancy staterooms and the radio office. I stop in front of one of the midships knee knockers.

It is like all the other knee knockers — an oval opening for a hatch without the hatch, like the one that caused a large scalp laceration in one of my patients. The bottom metal rim of this knee knocker is immaculately shined. There is not one speck of dirt on it, no smudges, no fingerprints, no faint boot marks. I have never seen one so clean before. It is as reflective as a mirror.

I turn and look down the passageway behind me. I turn and look up the passageway in front of me. I am alone. I lean forward over the metal lip, hoping to see my face upside-down, like in a circus mirror, but all I see is a thin dark shadow.

I stand up, lift my foot over the shined metallic surface, and for a moment, my shoe meets only empty space. Where is the deck on the other side? I look down at the bottom of the oval. Its reflective surface is gone, replaced by one large shadow. I feel as if I am falling into that blurred image; I feel erased.

I am going to die.

I am going to die here, on this boat, and my family won’t ever know what happened.

I am going to die.

And I am all alone.

A rushing sound fills my ears. The bulkheads seem to vibrate.

Then, my daughter’s voice calls to me from across the void.

You aren’t going to die, Mama, just the part of you that you don’t need anymore. Everything is going to be ok.

I blink.

The rushing and vibrations stop.

I look back up and down the passageway. I am still alone. I am still going to die. Just maybe not today.

I lean forward, put my running shoe down on the solid deck, and continue walking down the passageway.

 

 

“Good run?” the RHO asks.

I nod. I open my mouth to ask if he ever felt like he was going to die. Now. Today. Or if he has ever heard his daughter’s voice in his head as clear as I hear his voice right now, calling him back from an abyss. But something tells me to shut my mouth. I can’t tell anyone about that shadow in the knee knocker, that void, that nothingness. But that also means that I can’t share my relief when I heard my oldest daughter, Evelyn’s voice.

Not that it matters. No one will believe me anyway.

Perhaps, I am just hungry. “Dinner?”

“Yes! I’m…”

“Medical Emergency! Medical Emergency! Medical Emergency in…”

The RHO looks at me. There is fear behind his eyes. “That is deep trunk extraction territory.”

In certain areas of the ship, particularly some Engineering spaces or Reactor spaces or Weapons spaces or Supply department storerooms, the only way to get in or out is up a long, narrow, vertical ladder. If a medical emergency occurs in any of these spaces, the Medical Response Team cannot carry the patient out on a stretcher. The only way to get out a non-ambulatory or unresponsive patient is by hooking them into a stretcher and hauling them up as quickly as possible by a big cable and pulley system.

“Surgeon!”

I unclip my radio. “This is Surgeon. Go ahead.”

“Surgeon. This is SMO. A sailor was found down, not sure if he’s breathing, not sure if he fell, either way, non-ambulatory. Senior Chief and HM1 are heading down there now.”

“A deep trunk extraction?”

“Yes. I already called CHENG.” CHENG is short for Chief Engineer. A team from the Engineering department manages the cable and pulley system.

I grab my go-bag from the bottom drawer of my desk. I push the talk button. “SMO. This is Surgeon. Where is the extraction point?”

“The aft mess decks. I’m on my way there, now.” My radio clicks off.

I look up at RHO. Do I ask him about that voice anyway?

I shake my head and run out of the department.

I jog down to the aft mess decks. If the patient fell, a closed head injury or a high cervical spine injury could cause airway compromise. But why did he fall? Sailors go up and down these ladder wells all the time, many times a day. Dehydration? Exhaustion? Did he have a heart attack? A stroke? Did he take too much Benadryl? Did he take too much of something else? Did he want to fall or was he just ok with not being able to re-grab a rung?

To erase one’s life, to take it away, means we all have failed that one person, our shipmate. It means there is no purpose in the mission anymore. And I am not talking about the dropping-bombs-on-bad-guys mission. I’m talking about the working together for something bigger mission. Freedom. Hope. Justice. Big lofty, naive ideals. Ideals I have had to hold close in the middle of the night. Tightly. If I did not naively believe, well, how would I have been able to treat patients with my limited supplies and personnel? How would I have been able to look a transfer patient in the eye and tell him he will be ok, he will be given better care at the host nation medical facility than with me on the ship, even though I fear I am lying? How would I have been able to hope that my daughters will someday understand why I had to leave?

And when those ideals fail us, it doesn’t matter how tightly you hold on. Like knowing the potential consequences of traversing the BAM in daylight. Like deciding, despite all the work it took to get to where I am, The Ship’s Surgeon, I cannot do it anymore.

The bulkhead closes in, the fluorescent lights buzz down, my vision flickers. I have to stop thinking about my decisions. I need to focus on helping this sailor. This is why I am here. And there is no one else.

Up ahead, a group of dark blue shapes bends and twists. I blink and my vision clears. There are so many people working to save this one sailor. Working, not for the mission of the ship, but for our shipmate.

I will my tired legs onward.

A group of sailors bends over a large pulley next to a hole in the deck, an open escape hatch. My Surgical Tech is crouched next to the opening, his Medical Response Team bag next to him. The Executive Officer (XO, the second in command of the ship), the Command Master Chief (CMC, the highest-ranking enlisted member on the ship), and the Senior Medical Officer stand off to the side. I nod to SMO. His role is clear – he will oversee, he will support the command, as needed. My role is less clear. I am supposed to do something, swiftly and expertly, if the patient needs it. No one cares if I will be called on to do something I have never done before. I am just supposed to be able to do it. Expertly.

My legs wobble. Even before surgeries I have done so often that I can do them in my sleep, there is always a brief moment before I operate when I doubt my abilities. That moment has gotten longer the longer I have been on this ship. It is hard to know if you are about to do the right thing when you are all alone and have no one to tell you that what you are doing is right.

“Ready?” one of the Engineering sailors yells down into the open hatch.

I cannot hear the response. I open my go-bag and take out two fourteen-gauge needles, the plastic wrapping slippery in my fingers. It is mechanical, my hands reaching for these life-saving devices. I do not think about it. If the sailor is unconscious from a fall, and cannot breathe from collapsed lungs, these needles will save his life. All I have to do is put them in the correct place.

Sound, buzzing, rushing returns to my ears. The clank of the cable against the metal hatch opening, the calls and grunts of the sailors around me.

It will be soon.

The machine clanks, pauses, then clanks again. My Surgical Tech stands up. The orange end of a stretcher peeks up over the hatch in the deck. He grabs the handle on the end as the stretcher emerges.

I cannot tell if the sailor is breathing. I want to rush at the stretcher, assess for signs of life, to work quickly. But I stay where I am. I wait until the stretcher is righted. I wait until it and my Corpsman are away from the gaping hole.

“Surgeon!”

I rush over to the patient. I see fog in the oxygen mask.

I bend down, place my fingers into the hole in front of his cervical collar. I feel a bounding pulse. “Stretcher bearers!” I yell.

I let our shipmates carry the stretcher down the passageway.

I lift my radio and call Main Medical. “We are on our way.”

I turn back to SMO. His face is tense. I nod and he returns it. Then I rush down the passageway.

 

 

“Surgeon, is the patient going to be ok?”

I nod, then hesitate. “I hope so, Nurse.”

I don’t know what it is like to be on the other end of a deep trunk extraction team. I can imagine it is far lonelier than stepping over a knee knocker and thinking there is nothing but blackness, an absence of hope. I can fix a collapsed lung, I can stabilize a broken neck, but I did not have to do any of those things for this patient. All I had to do was listen.

“Nurse, have a good night. Let me know if you need anything.”

“Yes, Surgeon.”

My patient is asleep in his bed on the ward. I nod to the shipmate already at the bedside, I hope my gratitude washes over him, and I walk on.

I walk past the closed OR doors. I don’t feel much like celebrating or raising a fist in the air. We work and we work, and we try to do the right thing. But is what we are doing, right?

I walk into my office and sit down.

How are we all going to be ok so we can continue to do this job until the end? I think that is the question Nurse is asking.

I look over at a drawing on the bulkhead next to my desk. My youngest daughter, Waverly, sent it to me. It has been next to me the whole deployment, retaped several times, the edges curling. It is labeled, My Family. I look at the row of faces with our arms and legs sprouting directly from our heads. That always makes me smile. There is a D beneath the biggest one, and an E and a W below the two smaller ones in the middle. And at the end of the row, beneath the medium-sized smiley face, there is an M. I lean forward. But there is something else. I have never noticed it before. Perhaps the pink construction paper needed to be faded enough for me to see it. Directly in front of the letter M there is a tiny, pink-colored heart scratched into the paper.

Perhaps that is the answer to Nurse’s question. With enough time, as long as it needs to take, we will eventually get to the answers. And hopefully, we will be ok.