Chapter 4

28 May, 6:00, Central Africa Time Zone

Kibogora Hospital, Kirambo, Rwanda

John woke up abruptly, well before his 7 AM alarm, his breath coming in rapid pants and his heart racing. A cold sweat covered his skin like dew, but the temperature in his room was comfortable. He sat up quickly in bed scanning the room for what might have awoken him. And then the dream came rushing back. Sometimes his dreams were vivid and heartbreakingly real. On those nights he would be awoken by his own tears dampening the pillow. Other times, like this one, they would be more flashes of memory – impressions of people, incidents, emotions. These were the ones that triggered his "fight-or-flight" reaction – his breath caught in his chest and muscles tighter than a bow string.

He lay back down again, willing his heart to return to a normal pace. He closed his eyes and tried to sleep, or at least doze until his alarm forced him out of bed. But sleep would not come. Ten minutes later he pushed the mosquito net aside and reached for the black and white marbled composition notebook stashed in his bedside cupboard. When he had retired from active duty, his mandated psychologist had suggested keeping a dream journal to help process and work through his dreams (John refused to call them nightmares, a term he felt gave them more gravitas than they merited). He struggled with the dreams, both in that they interrupted his sleep, but he also couldn't help feel like they were a sign of weakness. But there was nothing he could do to stop them. In addition to the psychotherapy he had also tried hypnotism, pre-bedtime meditation, and medication, all to no avail. The journal at least allowed him to get the dream out of his head and on to paper where it couldn't follow him around all day.

He allowed his mind to drift, grasping at the impressions still remaining now that the haze of sleep had passed. The coppery smell of blood (his? or someone else's?), the warmth of it pouring over his fingers. Shouting voices ("more incoming wounded! Major Watson! There are more casualties coming in!") and the feeling of rising panic. The dry heat of the desert and the squish of blood soaked sand under his boots.

Most of the time these dreams were all the same – the same impressions, voices, sensations. Occasionally though, there was something new. Those times, he would turn the new detail over and over in his mind, massaging it and it would appear in his next dream, well formed in detail. John knew that he was fortunate, in the general sense of things. He had known other soldiers with PTSD in varying degrees of severity. His was manifested through these nighttime dreams and nocturnal panic attacks. Occasionally he would have the odd day where his memories from Afghanistan were at the forefront of his thoughts and there was nothing he could do to banish them. On those days, and they were infrequent, he struggled to push through the fog and go about his life, but the veneer of sadness haunted him.

He finished jotting down his account of this latest dream and replaced the notebook in the cupboard. Sleep was out of the question at this point, he knew. He might as well head over to the hospital and begin his day. Sighing, he swung his legs over the side of the bed, pulling aside the mosquito netting. Thirty minutes later, John was dressed and in the hospital canteen, pouring himself a cup of tea and adding milk. His toast popped up in the toaster next to him and he grabbed it, along with a banana, and headed to the nurses station to check the board. Adelaide had finished her shift and had been replaced by another nurse, Jenny – a formidable and no nonsense Scottish woman. Jenny was currently trying to sort out a scrum of people that had crowded around the desk. As he came up closer to the desk, he recognized a face in the group.

"Mike! Mike Stamford?" The round-faced and balding man turned and saw John, a big grin breaking out. Mike Stamford had been a casual mate of John's when they were in medical school, often studying in the same group. John hadn't seen Mike since they had finished their foundation training. John had spent two more years at St. Pancras hospital training as a trauma surgeon before signing up for the Royal Army Medical Corps 254th Medical Unit.

"John Watson! Of all the gin joints in the world, eh?" Mike broke away from the group and came over to John, shaking his hand. "How are you, mate?"

"Brilliant, Mike, thanks. You just arrived?"

"Yeah," he gestured with his thumb to the small group behind him. "We're the new recruits."

"Well, welcome," said John. "Jenny here will get you all sorted. Come find me later and we can catch up?" They shook hands again and John circled around the desk to look at the board and start his rounds.

The morning passed quickly – they had five new cases of Cholera walk in before lunchtime, and before the day was done, John had set a broken arm, treated a second degree burn, sutured a few minor lacerations, and performed a tonsillectomy on a twelve year old boy with an extremely inflamed pair of tonsils. John was scrubbing out after seeing the patient transferred to the after-care unit. The blood in his veins was buzzing and his every muscle felt jumpy with adrenaline. He missed surgery, and even something as simple and minor as a tonsillectomy gave him the same rush as a more complicated case like repairing a pneumothorax. The facilities at Kibogora were minimal and only suited for the most minor of surgeries. Patients requiring more complex procedures had to be transported to Kigali. John knew that the aid he was able to give here was important, especially for the communities who had gone so long with an understaffed hospital. But damn, he missed surgery.

John's stomach gave a loud rumble, reminding him that it was nearly 5 PM and his cup of tea and toast had been many, many hours ago. He finished washing up and headed over to after-care to check on his young patient. After assuring himself that the boy was sleeping peacefully, he went in search of Mike to see if he was up for some dinner. John found him in one of the main wards, assisting a nurse with the settling a cholera patient into bed and starting an IV line for fluids. He caught Mike's eye and gestured his head towards the nurses station just outside the door. Mike nodded and John left to make a few chart notes.

A few minutes later Mike joined him at the desk. "You free for a bite of dinner?"

"Absolutely famished," said John. "Jenny, we're headed down to the canteen for a bit. Send someone down if you need us."

"Sure thing, doc," she said, waving them off.

The canteen wasn't set up to serve hot meals all day long, but a few of the women from the nearby village prepared dinner for the hospital staff every evening. The food didn't vary much from day to day, but it was always delicious. Throughout the rest of the day, there was hot coffee and tea, as well as a small assortment of fruit, dried nuts, basics like bread, peanut butter, and tins of beans and fish. Every few weeks the WHO shipped in non-perishable food items for the staff, since they couldn't exactly nip down to Tesco.

Tonight's dinner was the ever-present ugali, a starchy paste made from maize and water. There was also a bean stew flavored with berbere spice, cabbage, and fried plantains. John and Mike filled their plates, and sat at one of the tables, tucking into their dinner. They ate in silence for a couple minutes, enjoying the hot meal after a long day. Eventually John broke the silence.

"So how long have you been with the WHO? The last I heard, you were set up in a posh private practice in Sheffield." Mike laughed.

"I was starting to feel guilty. Also, one of my partners at the practice went legit, back to full time locum work."

"What, does orthopedics not pay as well as it used to?" John joked.

"I suppose it does. A year ago the remaining partner in our practice offered to buy me out, and I took him up on it. I don't think I was happy there anymore. I found myself wishing for a more self-effacing form of medicine."

"Well, I suppose you found it. This sort of work is nothing if not humbling, that's for bloody sure."

"Yeah, I'm realising that. So I signed up a year ago and since then have been mostly working in Croatia, Turkey, and a few other places over there. This is my first posting in Africa."

"You had a stopover in Kigali?"

"Yeah – a week to do some training, get my papers sorted, et cetera."

"Well Kibogora is quaint enough. We're mostly seeing cases of cholera these days, with the odd cuts and broken bones. We're the only hospital for seventy kilometers, so we get most of the traffic around here. It's mostly triage work, aside from the cholera. We also get the occasional case of yellow fever. Our operating theater is very basic, so the tonsillectomy I did this afternoon will be about the most interesting thing we can do here."

"Well I'm here and happy to help with whatever is needed."

"Cheers, then." They ate for a few more minutes in silence.

"So how did you end up here? You were in and out Afghanistan for, what, five years?"

"Yeah, five years, three months, seventeen days, and four hours."

"Not that you were counting, of course."

"Oh I was counting every second I was in that sodding desert."

"If you hated it so much, why did you keep signing up?"

"I hated it, but I also loved it," John thought for a moment, trying to formulate his thoughts into words. "It was like a drug, working over there. I loved the work – fast paced, the surgeries and the most rudimentary of medical work. The adrenaline rush was a high that I was chasing every hour of every day. When I finished a tour and went home, I would find myself bored and listless. Each break, I would think about calling it quits and finding work somewhere in England. But I was miserable. All I could think about was my next hit. And so I kept signing up for more tours. I didn't know how to live among civilians and I couldn't imagine working with them." He shrugged. "But I also hated it. It's not like back home, or even here, where a patient comes in and the chances of them walking out again are higher than their chances of going down to the morgue. On the front, you were seeing the worst of it, and more often than not, there was very little we could do for them. The facilities weren't always great, so it sometimes felt like we were set up for failure. I lost so many mates and people I knew and had worked with before. In normal medical work, you're working on strangers. Over there, you're trying to save your mates."

Mike was shaking his head sympathetically. "I don't know how you did it, John. I mean, I thank you for it. But I don't know how you managed it for so long."

John let out a dry, humorless, laugh. "Neither do I."

"So why did you finally stop? What made you decide your last tour was really your last?"

Three years prior

Camp Bastion, Helmand Province, Afghanistan

John was sitting on his bunk in the room he shared with Jim and Reese, two other doctors in the RAMC 254th. He had just gotten off a thirteen hour shift in the trauma center. There had been three patients to come in during that time and all were resting in the ICU after coming through their surgeries. John had scrubbed into a laparotomy to repair some damage after a young private had taken a bullet to the abdomen. They had been able to save the one kidney, but the other had been well ripped to shreds. He had also gone on a transport, an incoming patient had been in bad condition and the trauma czar had wanted a surgeon to go along in case they needed to stabilize him before transporting him back to the hospital at Camp Bastion. It had been a successful shift, but John was ready for the break. He scrubbed at his dry and tired eyes. His scrubs felt sweaty and dirty, and he could use a shower. He sniffed under the neck of the t shirt under his scrub top. Ugh. Definitely a shower.

The incoming trauma alarm sounded across the compound. John wasn't on duty though, so he ignored it and stood, heading towards the shower. He was just pulling off his scrub top, when there was a loud pounding on his door.

"Major Watson! Major Watson!" the voice shouted urgently.

John strode to the door and pulled it open to reveal a winded lieutenant. "What is it," he barked.

"Incoming trauma, sir."

"I'm not on duty, lieutenant. Go and find Captain Reeves."

"Sir, you'll want to come for this. It's Squadron Leader Woods, sir. He's been injured."

Mattie. John's stomach dropped and his heart seized. "I'll be right there." He grabbed a fresh scrub top from his cupboard and pulled it over his head as he left the room.

The transport had already left to retrieve Matt from the airbase. John paced in the reception bay, awaiting the ambulance that would bring Matt to the hospital. He didn't know anything about his condition or what had happened. They should be here by now thought John, frantically trying to keep himself from flying out of his skin.

Matthew Woods was John's best mate – they had grown up next door to each other and had gone through school together. As young boys they had played together every day after school and most of the weekend. They were friends, brothers, and on some level, soul mates. They had always shared everything: homework, punishments, a set of walkie talkies, a sleeping bag on camping trips, even a pet newt. Matt had enlisted in the RAF as soon as he was able, leaving John behind in medical school. They had made a blood oath the night before Matt left for recruit training, that John would join him as soon as he had finished school and his training.

Matt knew every inch of John's soul and John knew every single corner of Matt's. John loved Mattie more than he loved his own mother or sister. They had both known that serving in Afghanistan held a certain amount of risk. Each time that John had mentioned to Matt that he, John, might be done with the military life, Matt had talked him into one more tour.

"Johnny, I still feel like I have work to do here. As long as I can feel useful, as long as I'm still able to offer all that I can, I need to keep doing this," he had implored one night over pints back home. It was a rare occurrence that they were on leave at the same time. There was a month a year ago when their time at home had overlapped. John was beginning to grow weary of the back to back tours. He thought maybe he'd like to find someone nice, settle down, maybe start a family and practice in local hospital where he would see more than just blown off limbs and gunshot wounds. But he knew that he couldn't leave the military if Mattie was still fighting in Afghanistan. He had finally steeled himself to ask Matt about it. He thought maybe he could convince him that they had done their duty, served their time, and it was time to try and start a new life. But Matt wasn't done and didn't want a new life. John had always suspected that Matt was afraid of what he would do without the military. It was the only life that he knew, and life on the outside was full of unknowns.

So they had stayed in and signed up for another tour. John knew, in the back of his mind, that waiting for Matt to say "when" might possibly mean that they were consigning their lives to the military until they were forced to leave: by age, being wounded, or death. As John stood in the ambulance bay at Camp Bastion Hospital, he knew that there was a chance that today might be the beginning of the end of John's military career.

The doors flew open as several gurneys were wheeled into the hospital.

"Talk to me!" shouted Dr. Alan Robbins, the trauma czar on duty, as he strode into the room.

"Three wounded, sir," called the medic wheeling the last gurney in. "Their transport chopper was shot down as it was trying to take off. Two casualties, KIA."

"All right. Bay one, two, and three," Robbins pointed at the gurneys in turn, directing them to their respective triage bays. John inspected each as they rolled by. Matt was lying in the last one and he rushed over to it.

"Mattie," John breathed, clinging to the side rails of the gurney. He followed the medic and doctors into the triage bay.

"Hayes, you take bay one. Reese, bay two. Dr. White, you're with me in bay three," Robbins gave his directives and the teams set to work over the soldiers. He noticed John standing by the side of the gurney. "Watson. You're off duty. We've got this from here. Go get a shower and some sleep."

"Sir, I...I need to be here. This man is my friend." Friend. As if that simple word that could used to describe Mattie.

"I don't think so, Watson. You can wait outside, that's an order."

"Alan. Please I need to help. Please." John was begging now, a pleading note in his voice. He didn't even care. Robbins must have noticed, because he only paused a half second.

"Fine. You can assist. But I don't want a word out of you and I want you to do as you're ordered. Is that understood?" John nodded, his eyes never leaving Matt's face. He was swaddled in layers of white cotton blankets, staving off the chill of shock and blood loss. Aside from the cuts on his face and trickle of blood from beneath his hairline, John thought he looked like he might have been asleep.

"All right, let's see what we're dealing with here."

With his heart in his throat and tears in his eyes, John acted as nurse, helping remove the blankets, taking Matt's vitals, and handing Robbins gauze pads when he called for them. There was a lot of blood. It took a couple minutes to sort out the source of it. There was obvious abdominal damage, but without scans it was difficult to tell how dire it was. The immediate concern was Matt's left leg. It was crushed – bone fragments protruding from the flesh and blood leaking from severed arteries. It was clear to everyone crowded around the gurney that the leg would have to be amputated.

"Watson, do what you can to stop the bleeding from that femoral artery." John's hands shook as he wrapped the tourniquet cuff around Matt's upper thigh. As the cuff began to inflate, the bleeding slowed dramatically.

"Okay, BP is coming back up. We're still losing blood somewhere though. It's got to be internal. Let's get some scans before we take him into surgery," Robbins barked out the orders and everyone moved to carry them out. "Watson, you can scrub in, but stay out of the way."

John stood at the sink in the scrub area, hands braced on the side of the sink, and the cool metal slick under his sweating palms. His chest was tight with unshed tears and his throat burned. He felt like he was drowning in sorrow, a tide that he could not fight against. A sob escaped and he let a few tears fall. "Matt," he whispered to the quiet room. "You've got to pull through. I need you to pull through. I can't begin to live without you." On the other side of the window, Matt was being wheeled into the surgical theater and a nurse poked her head around the corner into the scrub room.

"He's conscious and asking for you, Dr. Watson,"

"I'll be right there," John wiped away the remaining tears, scrubbed in as fast as he could and rushed into the OR. He knelt by Matt's head, setting his bare hand in his hair.

"Matt," he whispered. "Mattie, I'm here." He brushed Matt's hair back away from his forehead. He had beautiful hair – thick curls in a wild shade of orange. It was so soft under John's hand.

"John," Matt's eyes fluttered open, a glaze of pain and narcotics evident in the green irises. "John, I wrecked the chopper. My CO is going to be so hacked off with me."

"Shhh," John smiled at him. Matt's sense of humor was one of the many things John loved about him. "You may get latrine duty for a few weeks, but you'll be fine. It wouldn't be the first time, would it?"

"No, it wouldn't," he licked his cracked lips. "John, I'm sorry, this is all my fault. We should have gotten out of this hellhole years ago. You were right."

"Listen to me, Matthew Woods. I would follow you anywhere and do it willingly. You didn't do anything. We had...no we have work to do. You're going to be fine, you'll recover, and we'll get back to work." He felt tears building again.

"I think it may be time for us to request a transfer though," Matt tried to smile. "Johnny," he whispered, and John tightened his grip on Matt's hair. He brought his other hand up and gripped Matt's cold one in his own. "Johnny, I'm sorry we never had our time. I love you, y'know? I love you. I'm sorry we never had our chance."

John was aware of the crowd of doctors and nurses listening, but he didn't care. The hand in Matt's hair slid down to cup his cheek. "I know, you stupid git. I know, and I love you too." Matt's eyelids began to flutter again. Above them, an alarm began beeping noisily. "Mattie," John said sternly, squeezing his hand tightly. "Mattie, listen to me. You stay with me, okay? Don't you leave me. We'll fix you up, and then you and I can get out of here. We'll go home and see our mums. Have a pint. You just stay with me, damnit!"

"Dr. Watson, we have to put him under now." Robbins had come to stand behind him. John nodded, squeezed Matt's hand one more time, and stood. "Do you want to assist? Dr. White can do it if you're not up to it."

"No, I'm fine," John said forcefully, looking Robbins directly in the eye.

"All right then. Let's get to work"

The first hour of surgery passed in a blur. The orthopaedic surgeon came in, and John watched in horror as Matt's leg was amputated. That strong, muscular leg that he had used to climb trees, run races, and catch John in a leglock when they were wrestling. John was nearly sick as the surgeon cauterized the blood vessels. The smell of Matt's burning flesh was acrid in the air. With that source of bleeding staunched, Robbins set to opening Matt's abdomen to repair the internal damage. He and John worked fast, mopping up blood, taking stock of the damage and making a plan.

"That kidney will have to go. The spleen is bleeding, but we may be able to repair it. Damnit," Robbins swore. "Where is all this blood coming from?"

John had started to sweat under his cap. His hands were shaking with repressed emotion, and the muscles in his back were starting to seize from the tension. Disassociate! Disassociate! John tried to separate his love for the man that lay on the table before him from the abdominal cavity his hands were currently deep inside.

"Fuck, fuck, fuck!" Alarms were going off from monitors all around him. Robbins tossed blood soaked laparotomy pads to the floor at his feet.

"His blood pressure is dropping."

"Watson, have you found that bleeder yet?"

"Hanging another two units of blood."

"Not yet. Come on, come on!"

"Damnit. Forceps please. I need sutures here."

"I got it. Right here, under the spleen."

"Can you get it under control?"

"There's too much blood, I can't see anything!"

"Let's get some suction in here."

"Pulse ox is crashing. BP is 60 over 40."

"There has got to be some other leak in here. Where is all this damn blood coming from?"

"Here! The right gastric artery is shot to hell."

"Can you repair it?"

Before he could answer, the sound that every surgeon dreads, the sound that haunts every surgeon's nightmares, rang out, piercing John's heart.

"He's flatlined!"

"Charge the paddles."

John had backed away from Matt's body. He was covered in his blood. He felt like he was floating above himself, up near the ceiling, looking down on the scene. Robbins was issuing orders, using the defibrillator, attempting to revive Matt. John went to the end of the gurney, stripping off his latex gloves, tossing them on the floor. Once again he dropped down to a crouch, bringing himself face to face with Matt. He reached out a finger and caressed Matt's lips. They had turned pale, so different from their normal warm red. John loved Matt's smile – it started at his mouth and reached all the way up to his mossy green eyes.

"Mattie," John whispered. "Please don't go. Please don't leave me." Tears began to slip down John's face catching on his chin before falling to the floor, mixing with the blood.

Robbins continued to speak emphatically above him, alarms sounding, and nurses rushing around.

Then quiet fell. The tone of the alarm changed, everyone had gone quiet.

"Fuck. Fuck!" Robbins threw down his forceps and they clattered to the floor. John caressed Matt's pale cheek, his hand drifting upwards into his soft hair. Then he stood and grasped the cold hand laying on the gurney, giving it a squeeze. He looked up at the clock on the wall.

"Time of death," his voice caught on a sob in his throat. "23:37."

The next couple of months were a blur to John. His coworkers didn't know what to do with him or what words of comfort to offer him. He supposed that he must have worked, but he wasn't aware of getting up for shifts, scrubbing into surgeries, or checking on patients. He may have grieved, in between those surgeries and patient rounds. Two days after Matt's death, his commanding officer had ordered John to speak with one of the psychologists in the hospital. He sat there, in the woman's office, for the obligatory hour. He knew what he was suffering from had no diagnosis code, nothing she could put in his chart. A broken heart was not a medical condition or something that could be treated.

Matt's body was transported out later that week, sent home to his mother. John had refused to watch as they loaded the body onto the plane. He had gone down to the morgue once, the afternoon after. He had been hoping that seeing Matt's body would help him to grieve. But the body on the slab down there was not Matt's. There was no laughter in those eyes, no quirk in the lips, no warmth in the limbs. That body belonged to a stranger, and John never wanted to see it again. He had considered asking for leave to return home for the funeral, but all he wanted to do was finish up the two months left of his tour and get the hell out of Afghanistan.

Finally, John boarded his own transport airplane out of Camp Bastion. He was alive. He was leaving alive and never coming back. He only wished that he had something to look forward to back in England.

Present day

"John? Hey! John!"

"Huh? Oh! Sorry, I guess I was out woolgathering," John shook his head to clear his thoughts. "Sorry, what did you ask me?"

"I was just curious what made you finally give it up?"

"Just finally one too many casualties, I suppose." He shrugged, and Mike, perhaps sensing that there was more to it than John was revealing, let the subject drop.