The Shrine at Altamira

by John L'Heureux

  This was his job and he lost himself in it: saving what could be saved, repairing what could be repaired, cooling, cleaning, rescuing. He made sure he felt nothing.

  He worked quickly and methodically, oblivious to everything except the job before him. Finally he straightened up and looked around at the rest of the team, three doctors, three nurses. They had been at work for more than three hours now, and the boy was still alive. It was a good sign. If they could keep him breathing, and keep infection out, he might yet make it.

  When they left the emergency room, Peggy was thinking, The boy has no face, it’s gone, it’s melted. And to Dr. Clark, she whispered, “He won’t live, will he.” It was not a question.

  “Fifty-fifty,” the doctor said.

  “It might be better if he didn’t,” she said.

  “But we don’t know what’s better, do we,” he said. “We’re not God.” And he thought, We’re not so cruel as God.

  They smiled a little and went off in their different directions, a doctor and a nurse, having done their job, or at least begun it.

  John was playing on the beach, and the sun was very hot. It was so hot he didn’t want to play anymore, and he asked his mother for a drink of water, but she only laughed and spread her arms and said, There’s water everywhere, why don’t you go swimming? He ran down the beach to where the wet sand began, but even the wet sand was hot, and the water kept pulling away from him until there was only sand, and the sun so hot, and nobody would give him a drink. He needed water, he thought he would burn up if he didn’t have a drink of water, but then he remembered he couldn’t have a drink of water because he had been a bad boy. He couldn’t remember how he’d been a bad boy. He promised he would never be bad again if only they would give him some water, just one gulp, one sip only. But they wouldn’t give him water. And the sun was so hot. And the sun was so hot.

  Dr. Clark lay in bed, unable to sleep, thinking of that boy. He would never have a child himself. They were too fragile, they broke, they burned. They died.

  John, however, was not going to die. He was going to live, knock on wood, and so Dr. Clark forced himself to think ahead to the necessary operations: he’d need two to three surgeons for each one, Peggy and two other nurses to assist. And they’d have to be quick. The boy’s condition would allow no more than three hours in the operating room at any one time, no more than eight to ten units loss of blood. It would take time, maybe years, to finish the job. And how many operations? A hundred? More?

  At last he drifted into sleep.

  He dreamed he was walking with Peggy in a strange city. There were no people in the street, no cars; there was not a sound. We shouldn’t be here, he thought. He laughed softly, a nervous laugh, and Peggy turned to him and said, I know, but they kept on walking. Suddenly they heard crying and the screams of children. A fire, Peggy said, and pointed. He could see flames in the upper windows. The windows burst and flames poured out into the street, and there were children inside. Come on, he said, and together they ran to the building and up the stairs, but the stairs kept winding on and on, with no landing and no doors, so where were the children? They stopped. They could go on no longer. A door opened and a little girl stood there, on fire. He tore his coat off and wrapped her in it, smothering the flames, and then he ran down the endless stairs into the street. Then back again—he had no time to think of Peggy—and the stairs wound up and up and he couldn’t go on, but of course he had to. Another little girl, her dress on fire. He put the fire out, then down the stairs and out into the street. Then up, another child, a little boy with no nose and no ears, then down, then up, then down, and so all night.

  He woke, thinking of John. He would do what he could for him. He thanked God he had never had a child.

  “Well, he’s still alive,” Peggy said.

  “Knock on wood,” Dr. Clark said.

  “He must be terribly strong for such a little kid.”

  Dr. Clark said nothing.

  Later Peggy said, “He must be a fighter. You can never tell who’s a fighter just by looking at them. At least I can’t.”

  And still later she said, “He is going to make it, don’t you think?”

  “I try not to think,” Dr. Clark said.

  . . . . .

  Peggy had gathered the family for preliminary counseling. The social worker had warned her it was not going to be easy.

  The mother was hysterical, blaming herself and cursing her husband, who—incredibly—had set the child on fire. She must not be allowed to see the boy just yet. The social worker was adamant on this point.

  The grandmother was stoic. She spoke little English, but her attitude was hopeful and accepting, so she would be a big help when it came to family counseling, providing there was an interpreter at hand.

  Peggy noted these things for future reference. No matter how brilliant the physician, no matter how successful the surgery, it was the family’s support the patient depended on.

  And John, with no face, would need all the support he could get.

  On the third day, Dr. Clark decided John’s left hand and arm and leg were ripe for grafting. They had sustained only second-degree burns, and the dead flesh could be cut away without much difficulty. He would do the hand immediately, the arm on the fourth day, the leg on the fifth. The third-degree burns on shoulders, neck, and face would have to wait until later.

  To take the grafts Dr. Clark preferred the Brown dermatome because it was adjustable and it was fast, and what he needed now, quickly, were grafts of varying degrees of thinness. John’s right thigh had been prepared as the donor site, and the lowest part had been lubricated with sterile mineral oil. After the first few cuts, the oil would not be necessary since the blood itself would lubricate both the skin and the instrument.

  Dr. Clark nodded, ready to begin. The secret was to get tenseness of the skin from both ends of the donor site, and to work from the back of the thigh upward, so that blood wouldn’t obscure his view and so the graft wouldn’t fall in front of his advancing knife. He was an expert at his job. His assistant adjusted the skin tension while Dr. Clark pressed firmly on the dermatome. A thin, thin layer of skin rose from the boy’s thigh in a perfect narrow strip. Dr. Clark laid it, raw side up, on a square of moist gauze and then returned to the thigh to excise another strip of skin. In less than an hour he was ready to begin the preliminary work for grafting.

  To prepare the hand for the new tissue, he had opted for tangential excision of the old dead skin. This would allow him to remove the devitalized tissue slowly, layer after layer, until he reached a viable base, living flesh, where blood appeared. During the previous day, Peggy had applied an ointment to the wound every eight hours and by now the charred skin had been toughened and the wound was translucent. As the excision progressed, Dr. Clark would be able to judge the viability of the skin beneath his knife.

  He located the central zone of coagulation and, using a Humby knife now, he bore down lightly on the devitalized tissue. It was like slicing corned beef, the blackened eschar curling through the knife, crumbling, the smell of smoke still there in the dead flesh. He removed another strip. And then another. He kept on pressing deeper into the dead tissue until at last he reached a good base of living flesh, and there was vigorous bleeding. Peggy applied warm moist packs, and then he cut again, deeper, taking enormous care not to injure nerves and tendons of the fingers. Now the grafting proper could begin.

  He applied meshed split-thickness grafts, 12/1000 of an inch, stapling them into place to cut down on operating time. He cut a strip of graft twice the size of the index finger. He made transverse cuts, a few millimeters apart, around the periphery of the graft to about a quarter of the width of the strip. He placed the skin on the exposed finger so that the graft lay naturally against it, taking on its contours and irregularities, as if the skin were a glove. Then he moved on to the middle finger, and the next and the next. He left the thumb for last, and the scarcely burned palm. When he was done, he dressed all f
our fingers in a layer of wet wool, and then applied a layer of ribbon gauze, dry wool, a crepe bandage, and—at last—a plastic splint to keep the hand in correct position.

  If everything went perfectly, the graft would adhere in four days or so, and Dr. Clark would remove the dressing and inspect the wound. With the splint off, he’d encourage John to move his hand a little, opening it, closing it, so that beneath the bandage the skin would regain flexibility and become his own again. In six months the mesh pattern on his skin would begin to fade, but it would always be there, a reminder.

  And that was his hand, one percent of his body, not critically burned.

  Now, with the help of the two other physicians and the three nurses, Dr. Clark could move on to the arm. Later they would do the leg. And then the shoulders, the neck, the face.

  All that would take time, of course, and healing, and many separate operations.

  At the preliminary hearing the judge remanded Russell to a week of psychiatric examination to determine his competency to stand trial. Like everybody else, the judge presumed he must be a lunatic to set fire to his own son. When the team of psychiatrists determined that Russell was sane, the judge only shook his head. He appointed a court lawyer for Russell’s defense and ordered him to be held without bail until trial.

  Privately, the judge was relieved. Crazy or not, he wanted the bastard to fry.

  Peggy finished cleaning around the hole where John’s nose had been and checked to see if his breathing was okay, and then she sat down beside his bed. It was late afternoon, the first time she’d been alone with him today.

  “You’re going to be all right,” she said, leaning close and whispering. “I know it hurts, terribly, and you wish the pain would stop, but it will stop, and you’ll feel better again. Not right now, but in a while. Okay? I want you to know that.” She laid her hand on the sheet close to him and pressed down a little.

  “I can’t touch you, John, because it hurts too much, but I want you to know something. Whenever I press down on the bed like this—see?—it means I want to give you a hug, and this is the best I can do. I’m giving you a nice hug now. Can you feel that? And there’s no pain with it. It’s just very nice, because I love you and we all love you here. We all want to give you hugs.”

  She sat beside his bed for ten minutes, and then fifteen, pressing lightly on the sheet and letting up, each pressure a new hug. At five o’clock she left him and went off duty.

  It was Friday, dance night, and she and her friend Rebecca were going up to the city for a nice dinner at Fisherman’s Wharf.

  Unlike Rebecca, Peggy never worried about her weight. She’d been overweight all her life and had always been able to get any man she wanted. She wanted one tonight.

  After dinner at the Wharf, she and Rebecca were going to hit the discos and—who could tell?—she might get lucky and hook up with some sexy carpenter and they could hammer away at each other all night long. She was up for it. Cha-cha-cha. Rock ‘n’ roll.

  . . . . .

  Maria worked late whenever she could, even typing routine letters and documents she would ordinarily have passed on to one of the secretaries. Mr. Ackerman had offered her time off, at full pay, but she insisted that she wanted to work because it helped her to forget. Forget the horrible things, she explained, not forget her son.

  John was on her mind, she said, every minute of every day. He was on the critical list, and he’d remain there until all the grafting was done, because with each graft there was new danger of infection. That’s why almost nobody was allowed in to see him. She had seen him of course, for a minute, on the day after he was admitted. He looked terrible then, not like a human being at all, but the nurse had told her not to worry too much, they do miracles today, they’d give him back his face. So when she thought about him, she just concentrated on how he used to look and told herself he’d look like that again.

  She thought about John all the time, she said, but that was not really true. Most of the time she thought about Russell. To go this far, to do this terrible thing to their son, he must have been crazy in love with her, he must have been in terrible pain. The newspapers said it was incomprehensible, and the television said so too, and her friends at work, but Maria understood at once. She possessed him finally. He loved her more than she loved him.

  He loved her and she did not love him at all.

  . . . . .

  The psychiatrists who examined Russell gave him a battery of written tests and then conducted personal interviews. The written tests were contradictory, indicating both huge reserves of rage and bitterness and, at the same time, a healthy adjustment to society and to life. The personal interviews were more rewarding. Face to face, Russell answered whatever was asked, simply but fully. His manner was not hostile or paranoid or psychotic. He accepted blame for what he had done, and he expected to be punished. All three psychiatrists agreed that he was clinically depressed, possibly an alcoholic, and most likely an abused child. They pronounced him sane and competent to stand trial.

  John woke up and it was night again. He had been having that dream. He felt hot and wet and he tried to wipe his forehead, but his right hand was tied to the bedrail. They had kept him like this for a long time now: with his neck in a brace so that he couldn’t move his head, and his left arm held straight out in a splint, and his right hand tied down. They were afraid he’d touch the sore parts, the nurse said, so they tied his good hand to the bed, loosely.

  He wanted to blow his nose. He wanted to wipe his forehead.

  He had been having that dream again, but he couldn’t remember what it was. It scared him, and he woke up.

  He was in a hospital with a lot of other sick people and they had all been burned, some even worse than him. Peggy had told him that. She pressed on the bed to let him know she was hugging him, but he wished she would just hug him instead. He wanted to hug her. She was a nurse, and she was very nice, but he wanted his mommy and his grandma. And his daddy.

  His hand and his arm were itchy, the burned ones, and his leg was itchy. His neck and face didn’t hurt at all, even though that’s where he was burned worse. He knew this from hearing the doctors and the nurses talking. Dr. Clark was the worst. He was the one who always came to see him before the operations. And then they’d wheel him into that room and tell him to breathe deeply and everything would go dark green, and sometimes dark brown, and then the dream would start. He didn’t want to dream ever again. He wanted to stay awake and go to school every morning and run on the grass with all the kids.

  Somebody was groaning somewhere. Or crying. Everybody here was a sick person. And he was sick too, with burns. “His father did it,” they said. “Can you believe it?” But he knew his daddy didn’t burn him. He knew he had been a bad boy. He loved his daddy. His mommy always said he should.

  He was awake, and then he was falling asleep. He could tell he was about to dream, and he tried not to, but he was too tired and the dream began. There was a light brown square up at the top of the room and he had to keep it from falling, so he concentrated hard and moved it slowly slowly slowly across the wall, but then it started to crumble, and pieces were falling, and he wanted to wipe his forehead and it was so hot and he just wanted a drink of water and he wanted it all to stop. Now.

  So it had stopped. It was over. He could just sleep now and not dream.

  But up at the ceiling in the corner of the room there was a dark brown square and he had to keep it from falling. He kept staring at it. He had to concentrate.

  The grafts were taking very well, all of them. The neck, of course, was the most difficult, because no matter how careful the grafting, no matter how perfectly fitted the neck collar, there was always the possibility of contracture. The limbs could be exercised, the fingers could be forced apart with splints, but the neck—with burns this bad—was a special problem. The chin just naturally seemed to affix itself to the chest.

  Dr. Clark had seen contractures so extreme that, to separate the chin from th
e sternum, there was no other option but to make a horizontal incision on the neck, cutting nearly from ear to ear. This incision, a gentle slitting of the throat, released the scar tissue and opened a huge defect involving most of the front and sides of the neck. Split-thickness grafts could then be applied and the healing started all over again. In some cases the operation had to be repeated two and three times.

  John’s case was very bad, but the neck grafts were taking well nonetheless. Dr. Clark had not allowed him a pillow, since it might tip the head up and push the chin forward. Furthermore, he had insisted on a plastic splint, U-shaped to fit the neck and designed to force the head backward, stretching and exercising the grafted skin. The splint had to be adjusted each week to maintain pressure, and John would have to wear it for six months at least, maybe for a year, but these measures seemed to be working well. Dr. Clark hoped to get away without—he hated the term—having to slit the boy’s throat again.

  He stood beside John’s bed and smiled at him.

  “How ya doing, young fella?”

  “Fine,” John said, and his facial muscles twitched as if he might be trying to smile. He couldn’t do it, of course, but he kept on trying.

  Dr. Clark had spent a long day in the operating room, and he had lost an elderly burn patient who died right on the table, and now here was this little kid, in agony, trying to smile at him. It was too much. “You’re a brave boy,” he said, and turned away quickly, because he thought he might cry.