Chapter 1

2017 Asmara

I stopped by the maternity ward to do my morning round with the three medical students and a resident. The women lay under white sheets in two rows along either side of the room, with light blue curtains, now wide open, separating each patient. When we reached Miriam's bed, I watched as they presented her. She had been in the hospital for two weeks, but today she seemed flushed; her hands and face appeared more swollen. 

I asked Miriam how she felt. 

"I am fine, I think. Although, I do have some cramps," she said, hands running over her belly. 

I bent to examine her. "Are you having pain now?" 

"No, just last night." 

"You are twenty-eight weeks pregnant today." 

She smiled. "Yes, I didn't think I would last this long." 

"Well, you did. You are still too early, but we are getting there. We will do blood work this morning." After writing the orders, I left the maternity ward and proceeded down the long white hallway to the operating room. 

Mondays and Fridays are busy, and today was starting to be a typical Friday. I had a hysterectomy scheduled and headed to the pre-op area, where the patients waited for surgery. I changed into my surgery scrubs in the locker room, grabbed my white coat, and went to see my patient as I greeted the nurses and other hospital staff. My patient was a high school teacher. 

After the usual greetings, she said, "You are taking out my womb completely? Because I don't need it with all those five children you delivered. It has only caused me grief lately." 

"Yes, I am. No more bleeding." 

"Thank God." 

"People are usually reluctant to part with their uterus. Why are you not concerned?" 

"I trust you. I know you will take good care of me." 

"Yes, of course." 

"Besides, my sister is a nurse in Washington, DC. She had the hys-tir-tomy, right?" 

"Yes, hys-te-rec-tomy," I said, breaking it down for her.

"Yes, she had that surgery, and they took her womb, and she is much happier." 

As I scrubbed my hands in the OR, the resident came to join me along with a medical student. We proceeded into the operating room to gown. 

Once we positioned ourselves in the hierarchical order around the operating table, I instructed the resident to make a generous incision on the belly. We exteriorized the abnormally large uterus. 

"Wow, her fibroids are huge," exclaimed the resident. 

I looked up at the medical student above the mask. "Tell us what you know about fibroids." 

"It is a benign growth in the uterus which can cause abdominal pain and heavy periods," he said. 

"And what are her surgical risks?" I asked.

"Damage to the surrounding organs and bleeding."

"Yes, and usually, the bigger the fibroid, the riskier the surgery," I said as I watched the resident, distracted by how he was operating.

"How many hysterectomies have you done?" I asked.

The resident's head snapped up. "Um, this is my third one." 

I reached for the instrument he held in his hand. "Okay, I will start on my side first, then you can do the same on your side." 

Fifteen minutes into the surgery, a nurse flung open the OR door. "Doctor Segen, there is an emergency. They need you at the maternity ward, STAT." 

"What kind of emergency?" 

Another nurse from the maternity ward barged in. "Miriam is bleeding." 

"How much? How is the baby?" 

"The baby's heartbeat was down, but now it is back up, but she is hemorrhaging." 

I looked at the resident. "Can you handle this?" 

"Ah, ah.." 

"Doctor, Ato Aaron is there. He is demanding you come at once, doctor." 

I ignored the nurse's last comment and instructed her to get another IV line, transfuse blood, and give a fluid bolus. I rattled some other instructions, and the labor and delivery nurse ran out. 

I turned to the OR nurse as I removed my gown. "Get Dr. Ephrem or any other surgeon to assist the resident at once." 

"Doctor, they are all in surgery." 

I opened the door and sprinted down the hall to the maternity ward. 

Upon opening the door of the labor and delivery suite, I could see blood on the floor dripping from Miriam's bed, with the nurses hastily working around her, sidestepping Aaron. There was a muted murmur of prayers from the other pregnant patients. 

"Where is she? I demand she come here at once." Aaron shouted, hands on his head.

"I am here. I am here." 

I looked at her vitals. Her blood pressure was lower than usual, but her pulse was high, a sign she lost a lot of blood. She was writhing on the bed, her belly rock hard. "Doctor, doctor, I am in pain. Please help me, doctor." 

I started pulling the bed. "We have to go, stat!" We ran, wheeling the bed out of the maternity ward, down the hall, to the OR. 

Aaron ran beside me. "What's going on?" 

"I can't talk much, but she is bleeding, and the baby and Miriam are in trouble. I must take her to the operating room and deliver the baby STAT." 

He stopped running, fear chiseled in his face, the same fear I saw years ago as he held me in his arms. 

Then, Miriam touched my hand, trying to lift her head from the bed, as we continued running, leaving Aaron behind. 

"This is the way my mother died," she whispered. "I finally get to see her in heaven." Then, she sank back into the pillow. I wanted to reassure her, but it didn't seem like she was looking for reassurance. 

Once in the OR, we ushered the bed inside and put her on the surgery table. I gowned while the nurse anesthetist put her to sleep, shouting he needed the anesthesiologist in the room. 

"I can't intubate her!" He looked at me from above the patient's head, with eyes wide open. "Her throat is swollen. I can't!" 

"Call the anesthesiologist now," I yelled. "Also, call Dr. Ephrem or whoever is available to assist." As I shouted the last command, I knew all the help I could get was already in the room. It was the worst time to have this emergency. 

I stood with the scalpel in my right hand, inches from her glistening, unblemished, brown belly, tight as a watermelon. I felt the heaviness of the blade as I struggled to keep from making that incision that could mean life for her unborn child but utter pain for Miriam if not intubated. The blood hung, dripping into the IV tube, and the room was full of nurses and a pediatrician ready to care for the baby once delivered. But we stood waiting, knowing that each second we waited was an inch closer to death for both the mother and baby. 

Then, the anesthesiologist, Dr. Simon, ran in and was able to intubate after several attempts. As soon as I heard the "go" from the head of the table, I started fighting time, slicing through the skin, the subcutaneous layer, past the fascia and muscle to get to the uterus. Upon cutting the uterus, I nicked the membrane, which enclosed the baby swimming in amniotic fluid. The water in the womb, usually clear, was now bloody.

I pulled the baby out by the legs, clamped and cut the umbilical cord, and handed the pediatrician a limp, scrawny baby, slightly larger than my palm. The pediatrician hurried away with the baby, and I turned my attention to the bleeding uterus. 

I could hear the commotion outside the operating room, but I kept stitching with haste, trying to control the blood flowing like water from multiple hoses without a valve. Finally, after almost three hours hunched over Miriam's body, I had done all I could for her. I closed her up, straightened my now stiff body, and un-gowned. 

I washed my hand and looked up at the people around me. 

"The baby didn't make it," whispered Elsa. 

"Does Aaron know?" 

"Yes." 

I nodded, wrote a few orders, and headed outside the OR to speak to him. Before traveling far, I ran into Ephrem, a general surgeon, in the hall. 

"The hysterectomy bled, so the resident has stopped operating. I know you are tired, but they are waiting for you. I just finished a case myself. I will talk to Aaron. You go do what you have to." 

"Are you sure?" I asked. 

"Yes, it was a placental abruption due to preeclampsia?" 

I nodded. "A bad one."

"Do you think she will make it?" 

"I don't know," I whispered. 

He gently pushed me toward the OR. "Go; I will take care of this." 

I walked back down the hall, back to the OR, scrubbed, and gowned. In silence, I finished the hysterectomy, ungowned, wrote the orders, washed up, and left to speak to her family with the resident by my side. 

It was now late afternoon. I went to the physician's lounge, with a few chairs around a couple of round tables and a sink. Unlike the old days, it was now usually empty. Ephrem had food ready. 

"Come, eat first." 

I looked at the food before me as I sank into the chair, then stared in a daze out the window across the room through the palm trees. "I just want to rest my eyes for a minute," I mumbled as I closed my eyes.

I could hear him chewing while I laid back. My mind was empty, too tired to think. Finally, I felt strong enough to sit up and eat the pasta and salad. "Ummm, it's delicious." 

"Azeb brought it from home." 

"You are so lucky." 

"Yes, I am." 

After finishing my food and gulping a cup of water, I turned to look at Ephrem. "How was he, Aaron?" 

"Angry, scared. He is in the ICU, by her side." 

I pushed back my chair and left. 

 

 

 

 

 

 

 

 

 

Assignment I-

I. Act of Story Statement

After Eritrea's independence from Ethiopia, Segen, a young revolutionary turned OBGYN, struggles to provide medical care to her patients while living under a dictatorship.

 

II. Antagonistic Forces

The primary antagonistic force is a dictatorship:

The desire for freedom governs most of the story's events- war, migration, and fractured families. When Segen's father is taken by the occupying Ethiopian Military Police, she leaves her sister and mother behind and joins the revolution, where a third of the combatants are women. In these mountains, where self-sufficient underdogs fight the superpower-backed Ethiopia, Segen takes up arms, serves as a medic, and ends up in a love triangle.

After independence, however, Segen watches the democracy and freedom she and her comrades fought and died for slip away. She sees history repeat as the Eritrean youth and colleagues escape yet another dictator and fellow veterans are ushered to prison.

 

The secondary antagonistic forces are betrayal and sexism:

Despite being a female freedom fighter, Segen battles betrayal and sexism after independence as she tries to reintegrate into Eritrea's patriarchal society. First, she is betrayed by her fellow veterans who govern the country. Then, her husband betrays her by leaving her after multiple miscarriages due to the decision she and her husband, a fellow fighter, made as young revolutionaries. He marries a younger woman. But circumstances force her husband, now a top government official, and his new wife to seek Segen's medical care. And here again, Segen confronts sexism while caring for her patient, even if it may cost her dearly.

Her husband, Aaron, is also an antagonistic force–He breaks up a budding relationship between the protagonist and his best friend, thereby changing the course of Segen's life. He then divorces her, and marries a much younger woman, thereby inciting a core wound- betrayal. Later, he is responsible for causing trauma to the protagonist due to what happens to his wife when he and his second wife seek Segen's medical expertise.

 

III. BREAKOUT TITLE OPTIONS

Sandals in the Mountains

The Inferno Surrounding Me

 

IV. Genre/ Comparables:

Genre: Literary fiction

Comparables:

1. Cutting for Stone by Abraham Verghese, published in 2009–Like Cutting For Stone, takes place in Ethiopia and the United States, but also because it is romantic literary fiction with medical drama.
2. The Nightingale by Kristin Hanna–similar to my book, this historical fiction deals with war and the aftermath. Although my book may not be considered historical fiction due to the timeline not being as far back in history, it is still researched and accurate in the historical context.
3. When Breath Becomes Air, by Paul Kalanithi (memoir)--medical drama, dying, love, delayed gratification, and saying goodbye to the medical profession.

 

V. Logline

After winning Eritrea's independence from Ethiopia's harsh dictator in 1992, a young combatant turned OBGYN is betrayed by fellow revolutionaries as she watches the country she fought and exchanged her fertility for slip into a dictatorship to be known as the North Korea of Africa. One of only a few doctors left behind, she struggles to provide medical care and reintegrate into a patriarchal society that ascribes women as primary procreators. 

 

VI. Inner Conflict:

Segen, seeing her colleague escape, battles the desire to leave. She ponders if life in a foreign land, as a secondary citizen, is worth the risk of migration. What does she owe her country? Who will be left for Eritrea?

Also, despite being a female freedom fighter and an OBGYN, Segen has an inner conflict about self-worth in a society that ascribes women primarily as procreators. She is single, with no children, and envies the traditional family structure that she sacrificed as a combatant.

 

VII. Setting

The primary setting is Eritrea, a mysterious country in the horn of Africa labeled by some as the North Korea of Africa. Part of the setting is in the harsh northern mountains of Eritrea, where the revolution takes place and self-sufficient underdogs, with thirty-plus percent of combatants being women, become a shadow government to the areas they liberate. The other setting is in Asmara, the capital of Eritrea, a beautiful metropolis once occupied by the Italians. Thus, with palm trees and pastel-colored buildings with art deco architecture of the 1920s, Asmara has a distinctly European and African vibe with a highly social society.