by Sheri Fink
Making friends with the soldiers has its downside, though, because soldiers tend to die. In October, Nedret’s friend, the brave and wily Akif Ustić, the man who had visited Ilijaz’s fighters at the start of the war and led an action, was caught in an ambush. Legend has it that as he lay wounded, he shot at the Chetniks with all the bullets he had. All save one, in fact, which he’d used on himself. He had been on his way to Sase to fetch hay for the livestock he cultivated for the army.
Perhaps Nedret’s involvement in the military stemmed, in part, from the helplessness he felt in the hospital. Since the convoys, things have changed. The patients in his operating room sing, lost in psychedelic dreams, feeling no pain. The greatest gift the convoys have brought Nedret comes as a clear liquid in a misleadingly plain vial: ketamine. Even its pharmaceutical brand names seem to hint at this drug’s mysterious effects—it’s known as “Calypsol” in the Bahamas, “Soon-Soon” in Taiwan. Street users call it Special K or Vitamin K and take it alone or cut with Ecstasy.
Ketamine’s history is enmeshed with the histories of both general anesthesia and drugs of abuse. As opposed to local anesthetics, which numb just the nerves or the region where they are injected, general anesthetics induce unconsciousness and a lack of response to painful stimuli. With patients anesthetized and their muscles relaxed, surgeons perform long, complicated operations that would never be possible on conscious, sentient patients.
General anesthetics, introduced in 1846, first auditioned for wartime during the Mexican and Crimean wars. Their widespread employment, however, came with the American Civil War. Roughly 80,000 times, in places such as Mission Ridge, Tennessee, under cover of pine forests, men whose legs and arms were injured by the famous Civil War rifle bullets, such as the heavy and deforming Minié, were laid out on crude operating tables. Just before the surgeon raised his blade to amputate, someone placed a funnel-shaped “bonnet” lined with raw, chloroform-saturated cotton over the patient’s nose and mouth. He slipped into blissful unconsciousness. The race to make better and better anesthetics began.
In the late 1950s, more than 100 years after the birth of general anesthesia, a scientist named V. H. Maddox and colleagues produced a compound named phencyclidine. Surgeons started using it to put patients to sleep during surgery, but soon found it caused hallucinations and delirium as patients awoke. So PCP promptly left the operating room and migrated to the street where, as angel dust, zombie, whack, supergrass, killer weed, embalming fluid, peace pill, and rocket fuel, it gave its users feelings of strength, power, invulnerability, numbness, out-of-body experiences, and an inordinate quantity of bad trips.
In an effort to capitalize on the anesthetic properties of PCP while minimizing its psychological effects, scientists synthesized at least 200 derivatives of the chemical and found one—double ring-shaped C13H16ClNO—that worked best on laboratory animals. Named keta mine in the late 1960s, it soon became clear this PCP relative also caused dramatic psychic reactions on emergence from anesthesia. Patients experienced everything from vivid imagery and pleasant dreams to delirium and disturbing hallucinations. Again, the drug traveled to the street. This time it stayed in the operating room, too, for several specific uses—trauma victims with blood loss, patients suffering septic shock from infection, and those at poor risk for other forms of anesthesia.
In technically advanced operating rooms, anesthesiologists employ a complicated array of drugs—both injected and inhaled—and use sophisticated electronic monitoring devices to administer anesthesia. Mechanized ventilators breathe for patients whose own airway reflexes are dampened by anesthetics or thwarted by paralytic agents. But where trauma patients need urgent surgery in an environment without trained anesthetists or a stable source of electricity to deliver gases, monitor vital signs, and ventilate lungs, most of the typical anesthetics won’t do. In conditions like the ones Nedret faces in Srebrenica, in spite of its bizarre psychological effects, ketamine is the drug of choice.
Tiny and easily dissolved in fat, it slips through the tight spaces and lipid-filled membranes of the blood-brain barrier. Within thirty seconds of a nurse injecting the drug, a patient is completely unconscious and ready to undergo surgery, airway reflexes intact, breathing spontaneously without need for a ventilator. Unlike many other anesthetics, ketamine does not depress the heart and respiratory systems. It wears off quickly, too. Within five to ten minutes, unless more drug is injected, it distributes to other, less perfused body areas. Within fifteen to thirty minutes, patients are awake and oriented to person, place, and time.
It’s hard to kill someone with ketamine. Even if a doctor or nurse mistakenly administers ten times the therapeutic dose, the patient usually just has a good, long sleep.
* * *
A PATIENT SINGS DURING HIS OPERATION, and Nedret remembers that the instructions for ketamine warned of “psychomotor effects.” He hadn’t known what that meant. After the patient wakes up, Nedret asks him about his experiences. He says he didn’t feel the operation and had a pleasant dream, although he can’t remember it.
Each time he administers ketamine, Nedret monitors his patients’ responses, fascinated. Some stay calm throughout surgery and others thrash and appear agitated. Nedret experiments with adding a relaxant, Valium, and finds that high doses in combination with ketamine help to keep his patients calm. But not always.
One day he performs a difficult double amputation. The patient, a muscular man in his late thirties, has sustained severe injuries to his right arm and leg in a mine explosion. Ketamine and Valium are administered and the nurses and doctors arrange the patient on the operating table, securing his left arm and leg to the table with bandages.
They anticipate a difficult operation, and tension pervades the operating room. Nedret knows he has to work quickly in order to minimize blood loss. Instruments fly from hand to hand. Voices rise. The patient grimaces and, with an aggressive expression, starts to lift himself from the table like Frankenstein’s monster. The bandage holding his left arm snaps.
Nedret shouts, and immediately the patient’s movements become more exaggerated, causing short-tempered Nedret to shout even louder. A handful of men have to hold the patient down. Nedret leans over, using his elbow to pin the man’s right leg as he ties off bleeding blood vessels with lengths of suture.
After he finishes, Nedret theorizes that the agitation of the medical staff influenced the behavior of the patient. During the next operation, he tries an experiment. He speaks loudly. The patient becomes aggressive. When he hushes the staff for several minutes, the patient becomes calm.
These experiences intrigue Nedret. He is probably using too little drug, resulting in a partially awake patient. But some of the patients’ movements are due to the so-called dissociative effects of the drug. Unlike other types of anesthesia that resemble normal sleep, ketamine produces a state similar to schizophrenic catalepsy, in which a rigid, insensate patient loses contact with the environment while keeping his eyes open and maintaining many reflexes. The patient often makes coordinated but purposeless movements.
Why does this happen? From what scientists have been able to gather, ketamine plays with the brain, turning off some areas and exciting others, wreaking disorganization. It also appears to block the transmission of pain information as it travels toward brain areas responsible for the emotional aspects of pain sensation and it affects the same brain-cell receptors as morphine does.
Unlike most agents used to induce anesthesia, ketamine has significant painkilling effects that outlast a patient’s period of unconsciousness. That effect is welcomed in Srebrenica. For the first time in months, hope fills the hospital, as sweet, deceptive, and ephemeral as a good shot of ketamine.
13
HOLIDAYS IN HELL
ALL THE NEW MEDICINES and supplies in the world can’t change the fact that there are only seven doctors to care for the perhaps 70,000 non-Serbs corralled into this part of eastern Bosnia. A ratio of one physician to 10,000 patients is more th
an fifteen times lower than the peacetime norm in Bosnia and twenty-five times lower than in the United States. For a population caught in a war zone, it is unthinkably low, particularly because none of Srebrenica’s doctors are trained surgeons and only two have completed a residency in any sort of medical specialty. Nedret, Ilijaz, Fatima, Ejub, and Branka have become war doctors practically straight out of medical school.
Those who suffer from medical illnesses steer clear of the hospital, which is filled to capacity with injured soldiers and civilians. Dr. Nijaz Džanić, the dark-haired internist who had a heart attack before the war and stayed in Srebrenica to care for his ailing parents, treats the civilian sick on the other side of town, in a house attached to an old mosque with a wooden minaret. He established the clinic, on a hill near the Hotel Domavija, after the other doctors returned to reopen Srebrenica’s hospital last July. The forty-two-year-old doctor works with one young, curly-haired nurse and manages to keep the clinic open twelve hours a day, seven days a week. Srebrenica’s civilians keep him busy changing their wound dressings, measuring their blood pressure, and treating their sick children. Nijaz never turns them away. When supplies and medicines ran dry before last month’s convoys, he sent locals to pick herbs such as nana (mint) for stomachaches and zhara for anemia and to collect pine tree resin for rheumatism. The compassionate and reassuring way he prescribed them seemed to make them work almost as well as modern medicines.
It’s almost impossible to fathom what it would be like if one of the town’s overworked doctors were lost. But moving back and forth between home and workplace exposes them to risk, and they all experience close calls. One night, as shells fell during his walk home from the hospital, Ilijaz clambered into the covered part of the dirty, stinking river that runs parallel to Srebrenica’s main street, known as “the collector,” because of its tendency to collect garbage. Once last summer, he heard the buzz of a plane and had just a moment to turn toward the entrance of his building before, with a sudden crescendo, the Russian MiG dove and rocket explosions blasted him into the corridor against the staircase. Nedret, lightly wounded several times, has removed pieces of shrapnel from himself.
There is an urgent need for more doctors, especially as Nedret, Ilijaz, and the others begin to burn out under the flame of constant responsibility. Ham radio operators continue to transmit requests to Tuzla for relief. Then, a few days after the last aid convoy and the offensive toward the Drina, thirty-six injured and frostbitten men stumble into town, some carrying others. They are remnants of a group of 102 who set out for Srebrenica from Tuzla, bent beneath American-made rucksacks filled with fifty to one hundred pounds of German medicines and munitions bought in Croatia by refugees from eastern Bosnia. Serb soldiers laid an ambush. Some of the Muslims managed to get away. Lost in the snowy hills, they trekked for twenty-one days in sub-zero weather, running out of food.
Most of those who embarked on the trip were soldiers, but not all. Two experienced internal medicine specialists and three nurses volunteered to return to Srebrenica and help ease the crushing load on the medical staff. They refused on humanitarian principle to carry guns and munitions, and the men who reach Srebrenica haven’t seen or heard from the medical workers since the ambush.
The survivors are hospitalized, put on the intravenous drips they carried with themselves, fed, warmed by the heat of the hospital’s wood stoves, and given pain medication. One dies. Others need their toes amputated. Meanwhile, everyone hopes against hope that the medical workers who set out on the trip are still alive and will make it to Srebrenica.
* * *
AS THE NEW YEAR OF 1993 DAWNS, the concerns of Ejub, the still-chubby pediatrics resident from the village near Ilijaz’s parents’ home, center on missing his wife and son and missing cigarettes. He pines in public for his beautiful Mubina and pens two poems for her, between gulps of plum brandy, on New Year’s Eve.
“Others say they left their wives. I left my heart,” he tells his colleagues again and again.
One cold, wintry day he trudges back to the house where he sheltered the first night of the war and rediscovers dozens of half-smoked cigarettes, the ones he thoughtlessly discarded during his first experience with shelling. Now, on his hands and knees, he gathers up every last one. Treasures.
Ilijaz also scrounges for something to smoke, puffing on whatever leaves he can find or his patients give him. First he wraps them in some blank, white paper left in his apartment by the previous tenants. When that’s gone, he cuts around the edges of their personal documents for cigarette paper, and finally, when nothing else is left, he smokes the entire documents.
Ilijaz finds little time for romance with Fatima. He looks out for her, though, taking her place in the field when organized actions occur, trying to keep her out of danger. Their shared life ended in September when she moved out of his apartment to join her newly arrived mother and brother in a three-room flat granted by municipal authorities. As other displaced relatives moved into town, the occupancy of her woodsmoke-choked abode grew to ten people. Then forty.
New Year’s Eve has always been Fatima’s favorite holiday. The couple sits in Ilijaz’s dark apartment with friends, trying to wrest some sort of New Year’s cheer from the wartime gloom. This year they do not talk about the future.
* * *
WITH AID CONVOYS ON HOLD and Serb forces engaging in a strong counterattack, supplies peter out. The doctors hoard the remaining medicines. Almost a month after the last convoy, food is again in desperately short supply. Srebrenica’s soldiers plan an offensive on Serb villages, calculating the expected weight and types of goods that might be captured in different places. They choose January 7, Serb Orthodox Christmas, the second time they have launched an attack on an Orthodox holiday. And they choose Kravica, a historic center for Serb nationalism whose inhabitants fought against the Ottoman Empire in the late nineteenth and early twentieth centuries and armed and trained local Serbs for this war.
Ilijaz slips out of Srebrenica by cover of night to set up a medical field station near the front. At 8 on the icy, snowy morning, patients begin to arrive at his station, their legs and stomachs heavily injured by mine explosions. Ilijaz cuts away dead tissue and dresses the wounds, administers painkillers, and organizes transport to the hospital.
Meanwhile, more than a thousand Muslim troops brave minefields, shoot, and shell their way past a thin line of defense and pour into the Serb-held village of Kravica. According to Serb sources, roughly four dozen Serbs are killed, most of them soldiers. The Muslim side counts about two dozen dead.
By late afternoon, some soldiers are stuffing their mouths full of cakes from the elaborate Christmas dinners left behind by the handful of village women who lived in Kravica. The air fills with the yodels and shouts of thousands of hungry Srebrenicans who follow the soldiers to gather sheep, cows, and oxen from the barns, potatoes and cabbage from the cellars, and anything else they can scrounge. Smoke billows toward the sky from dozens, perhaps hundreds, of houses set alight.
As much as Srebrenica’s hungry civilians regard the attack as a desperate bid for food, Kravica is also a strategic military target linking Srebrenica with the two Muslim-held enclaves of Konjević Polje and Cerska to the northwest. With Kravica, Srebrenica’s soldiers, under commander Naser Orić, now control about 350 square miles of territory, coming close to the front lines with Tuzla. Just five more miles and they will break the siege and link Srebrenica with the bulk of Bosnian government–controlled territory.
“Kravica is ours!!!” an ecstatic medical assistant in Konjević Polje writes in Bosnian in her diary. Since the war started, nurses there have performed amputations by themselves in houses, using plum brandy in place of any anesthetics. Now patients from the village, which has no medical doctors, can be transported by family members to Srebrenica Hospital. Unfortunately, this only adds to the burden on the already overworked Srebrenica doctors. The physicians from Tuzla who tried to join them last month and were ambushed have never
arrived.
* * *
JUST AS EXCITING AS THE WIN IS TO THE SREBRENICANS, it is humiliating, tragic, and highly symbolic to the Serbs. Four days after the offensive, on January 11, at 11 A.M., after morning rounds, the loud buzz of a lowflying airplane shakes the hospital building. Ilijaz knows the sound. Upstairs in the operating room, a nurse cracks that they’d better prepare for casualties.
In his clinic on the other side of Srebrenica, Dr. Nijaz Džanić also hears the airplane. He asks his nurse to go see what kind of plane and how close it is. She goes out through the waiting room and runs back inside a few seconds later.
“It’s very close.”
“What kind of plane is it?” Nijaz asks her.
“God, I don’t know.”
Nijaz goes out to see for himself as the nurse sits back at her desk. Just then, an explosion rocks the room and the glass from the large window blows out and showers her with splinters. She sits for a moment, stunned, and then stands up.
“Nijaz?” she calls.
* * *
IT TAKES ABOUT A HALF HOUR for the injured patients and the bad news to hit the hospital: A bomb exploded on the old wooden minaret and rained shrapnel into the waiting room of Nijaz’s clinic. Two people have been killed. One of them is the doctor.
Ilijaz and the other men attend Nijaz’s dženaza burial prayers. They are gone just briefly; there is little time for ceremony. The supplies from the clinic are quickly transferred to the hospital and Ilijaz and the other five remaining doctors now share the burden of treating the ill in addition to the injured.
* * *
WHILE SERBIAN PRESIDENT Slobodan Milošević tells the world his country is not involved in the Bosnian war, Bosnians near Ilijaz’s birth village have watched Serbian troops regularly cross a bridge from Serbia to the Bosnian town of Skelani. From the same high point, Kragljivoda, where Ilijaz first began treating war patients, they see fire spew from the muzzles of tanks on the asphalt road switchbacking up Tara Mountain in Serbia, six miles away. Sometimes, instead of merely watching missiles fly and awaiting their resounding boom, the villagers become their targets.
