Noora Afif Abdulhameed sits quietly next to her papa in a waiting room at Maine Medical Center, waiting to be called in for her first pre-operative test.
She'd slept in until 7 on this Tuesday morning in July, so breakfast was just a little milk from the hospital cafeteria. Now she's waiting for some cream applied to the backs of her hands to numb her skin so that a routine IV may be inserted.
The 6-year-old was scheduled for a CT scan at 8:30 a.m. to give doctors a better picture of damage to her skull, which was partially shattered by an American sniper's bullet on Oct. 23, 2006, in her hometown of Heet, Iraq.
Noora seems cheerful – she had spoken to other members of her family in Iraq on the phone the night before – but a bit nervous.
"It's stirring up old memories for her, I think, but Afif convinced her it's not an operation," says Susi Eggenberger. The Arundel resident and her husband helped bring Noora and her father, Afif Abdulhameed Otaiwi, to Portland for surgery to repair Noora's head, and are guiding them through their stay.
Otaiwi said his daughter once endured 165 needle sticks for a single operation in her home country. It was "very, very painful."
"She is scared when she remembers," says Otaiwi, a 42-year-old history teacher. "I told her (the CT scan will be) just a picture."
As they wait, Noora practices some of her new English words. She points to the pattern on her dress and says, "flower." She counts to 10. She says, "How are you?" to a visitor and "I love you" to Eggenberger, her patty-cake partner.
When they are called in to radiology, Otaiwi lifts his daughter onto a stretcher, removes her sandals and covers her with a white blanket. Diane Gray, a registered nurse, wipes the numbing cream from Noora's hands, which entails removing a clear bandage.
"It's going to pull a little bit," she tells Noora. "There we go. You have a pretty dress on. Pretty flowers."
Next come tourniquets on both arms so Gray can find a vein. Noora begins to whimper. Michel Ohayon, another nurse, holds her left arm while Gray tries to insert the IV.
Soft crying turns to sobs. Otaiwi, speaking softly to her in Arabic, tries to comfort his daughter by kissing her on her forehead, wiping her tears and rubbing her chin with his finger. Eggenberger stands at the end of the stretcher, rubbing Noora's feet through the blanket.
No luck on the left side. The nurses give Noora a small stuffed otter and tell her to squeeze it with her right hand. Again, no usable vein.
"It's heartbreaking," Ohayon says. "They've done so many (IVs) in her home country that there's scar tissue. You put it in, and there's nothing to thread it through. And then on top of it, she has very small veins."
The staff decides to give it one more try and calls in Dr. Richard Evans, a pediatric anesthesiologist, and Laura Mamchur, a nurse anesthetist.
When they arrive, Gray tells Mamchur, "I think there's one spot left on the left hand that might be good for you."
Otaiwi explains to Mamchur that Noora is afraid of needles. Mamchur tells her, "I'm just going to put a rubber band around your arm, and we're just going to look."
An unusually mature look of determination comes across Noora's face. She suddenly thrusts both her arms out in front of her, veins up, offering them to the strangers.
"Oh, you're so brave," Mamchur murmurs. "You're so brave."
Both Evans and Mamchur start searching for a vein. Noora knows what's coming, and begins to sob again.
"It's OK, it's OK," Mamchur says.
After one more search, this time on her feet, Evans recommends stopping.
"It's just not going to happen," he tells Otaiwi, noting it's "not worth the upset" to Noora to continue.
"Tomorrow we'll give her a mask, she'll go to sleep," he says. "It will be better for her, OK?"
Evans looks over at Noora.
"You win this round."
PAIR DEVELOP PORTLAND ROUTINE
Noora and her family were returning home from a family holiday celebration when, according to eyewitness reports, an American soldier started shooting toward their car.
The first shot hit Otaiwi in his left jaw. The second hit Noora, destroying part of her skull and rupturing her cerebral membrane. The family rushed her to the local hospital, where she was unconscious for 10 days.
Doctors in Iraq performed several operations to save Noora's life, but there was only so much they could do with the medical equipment and supplies on hand. So an American nonprofit group called No More Victims stepped in and flew Noora and her father to the United States for major surgery.
They arrived in Portland on July 10. Left behind in Heet were Noora's brother, Mustafa, 11; her two sisters, Laura, 10, and Haba, 7; and her mother, Afrah, who is expecting her and Otaiwi's fifth child in December.
While Noora is in Maine, she'll have surgery to replace the missing part of her skull with a prosthetic bone material. A portion of her scalp will be stretched to create new skin that will cover the replacement "bone."
After an initial flurry of medical exams and tests, including two visits each with Dr. James Wilson and Dr. John Attwood – the pediatric neurosurgeon and plastic surgeon, respectively, who have volunteered to repair her head – Noora and her father began adjusting to life in Portland.
They soon settled into something of a routine.
Eggenberger arrives at the Ronald McDonald House, where they are staying, at 9 a.m. every day and walks with them down Brackett Street to Portland West, a social service agency where Otaiwi is taking English lessons.
When they return a couple of hours later, Eggenberger takes Noora for a couple of hours to give her father a break. They go for a walk – to the Reiche School playground down the street, or maybe to a local cafe to get a coffee for Eggenberger and a milk for Noora.
Noora and her father receive a $300-a-month stipend from No More Victims that they use to buy groceries, clothing and anything else they need. Most days, Otaiwi does the cooking.
Although Noora has discovered she likes pizza, she and her father aren't used to American food and the way ingredients are combined here. Otaiwi watched someone at the Ronald McDonald House make a tuna casserole one day and he couldn't understand it.
In Iraq, he said, if you want vegetables, you might make a simple soup. If you want cheese, you eat it with some bread. Same thing with fish. The idea of mixing all those things together with milk made him a little squeamish.
"I can't eat that," he said.
Every day at 1 p.m., Otaiwi sets up his laptop for a Skype videoconference call from his family in Iraq. These daily three-hour visits have become an important ritual for all of them.
They talk about the events of the day, but sometimes Otaiwi just leaves the laptop on a table and sits where his wife can see him so they can just be together. Occasionally, one of Noora's siblings walks into the picture and talks for a moment, or a neighbor or cousin.
Once, after it turned a bit cooler in Portland, Eggenberger picked out some new, warmer dresses for Noora and suggested she model them for Afrah and get her approval.
The videoconferencing has "put (Afrah's) mind at ease a lot," Eggenberger said. "She can see the space and know where they are."
It was difficult for the family to send Noora and her father off to the country that invaded their country. According to Eggenberger, the callers from Iraq are always asking Otaiwi, "What are the people like?"
Otaiwi has been keeping a daily journal in Arabic that will help him answer everyone's questions when he returns home.
Their reception in Maine has, so far, been warm. Otaiwi went to a Rotary Club meeting in York County. They've been invited to the circus, the beach, the lake, out for lunch and boat rides.
Noora has lots of play dates with other girls her age. When she wanted a haircut just like Eggenberger's, a Portland stylist offered to do it for free.
Sometimes, people stop them on the street just to say hello.
One day, on their way to an appointment, a stranger approached them outside the Ronald McDonald House.
"You're our little friend from Iraq?" the man asked Noora. He wished her luck, and looked at the adults standing with her. "Is she doing OK?"
This kind of encounter is typical. There are occasions, however, when Otaiwi will say hello to someone and the person won't look at him or answer him. Otaiwi can tell there's something wrong.
"Maybe he's angry, maybe he's sad. But I feel that," he said.
But that's only happened two or three times. Most people are kind and generous, especially to Noora. "Many people ask her, 'Do you want anything?' " Otaiwi said. "Many people want to help her, and little is anger."
Otaiwi said that when he goes home, he will tell his pupils that Americans do not hate Iraqis and that they are "doing everything they can to help my daughter. That's very important."
"Any place in this world," he said, "you can find bad and good."
HUMOR LEAVENS ENGLISH LESSONS
When Otaiwi stepped off the airplane in Portland in July, he could speak only a few words of English and couldn't understand much that was said to him.
After about five weeks and daily language classes, he no longer needed a translator's help to communicate and could hold his own in a conversation. Eggenberger said that since the English lessons started, she's discovered that Otaiwi has a sense of humor.
One Wednesday morning in August, Otaiwi settles in at a table with two other students at Portland West and waits to hear what he would be studying that day.
"OK, we're going to do grammar," announces Ana Gabor, director of Portland West's English Language Program.
There is a slight pause as she takes in their faces, which look as if they have just smelled something rotten.
Gabor says they will be practicing present- and past-tense verbs with Meaghan Arzberger, a Portland West volunteer. Otaiwi looks at her a bit befuddled.
"It's going to get easier," Gabor assures him. "OK, ready?"
"No," Otaiwi replies. "I'm not ready, because I hate grammar in Arabic."
Over the next couple of hours, they work through a bright pink sheet filled with irregular past verbs. They start with "was/were." This one is easy. Otaiwi gestures behind him and says, "Yesterday."
"So I buy groceries," Arzberger explains. "Yesterday, I bought groceries."
"OK," Otaiwi says, followed by a deep sigh.
While Otaiwi takes his lesson, Noora plays Mr. Potato Head with Eggenberger and a young daughter of one of the other students, then goes outside to play ball.
Noora does some learning at Portland West, too, working on colors, letters and counting. She knows the names of all the other children who come with their parents, and she's become especially close to two Somali children.
Noora's English is not yet as good as her father's, but Eggenberger has noticed that she is now talking to herself in English. "I did not know" is one of her catch phrases. She also says, "See you tomorrow" with an inflection that makes her sound a little Italian.
Continuing his lesson, Otaiwi plows through "choose/chose," "draw/drew" and other pairings, using the words correctly in sentences. Then he gets to "eat/ate."
"I am eat," he starts to say, but Gabor overhears and corrects him: "No 'I am' with eat."
This is one of his stumbling blocks, and it appears throughout the lesson: "I am forget to bring a book" and "I am left my home."
But then comes "make/made," and Otaiwi's sense of humor shows itself again. He picks up his notebook, turns it over and points to three tiny words on the back:
"Made in China."
FATHER APPRECIATES SUPPORT
About 6 a.m. on Aug. 22, Noora and her father quietly make their way down the stairs of the Ronald McDonald House. They are the first to stir in the house.
Noora immediately finds a little scooter to ride in the courtyard while she and Otaiwi wait for Eggenberger and her husband, Doug Rogers, to arrive. This was the day of her first procedure, a bit of plastic surgery that will ensure she has enough skin and hair to cover the artificial bone that Dr. Wilson will affix to her skull in major surgery that's still weeks down the road.
Asked if he is fearful about the upcoming procedure, Otaiwi brushes off the question, saying it's "easy" here compared with the multiple surgeries Noora had in Iraq, where she was "in pain and weep all the time. I remember just Noora without my family, and my family without me."
When Noora had surgery in Mosul, she was in the hospital for three weeks, sharing a room with anywhere from six to 15 patients. There was one bathroom for 20 to 25 people. Her father stayed with her the whole time, sleeping on the floor. He had no shower or hot water for the entire three weeks.
Here, Otaiwi said, not only are things obviously physically easier, but there are also people around him who share the emotional burden and "love my daughter all the time."
"Doug and Susi (are) like my brother, and help me all the time," he says.
When the couple arrives, they all walk the four blocks to Maine Medical Center together. The surgery begins at 7:30 a.m. and lasts about two hours.
Dr. Attwood, 55, a plastic surgeon from South Portland, said he's seen injuries like Noora's before, but usually they're caused by car accidents, infections or tumors.
After Noora's skull was shattered, Iraqi doctors removed the broken pieces of bone and took skin from her thighs to graft over her exposed brain. Attwood said when he first saw Noora's wounds, they weren't as bad as he had anticipated. They were all "nicely closed."
"I think the doctors who cared for her prior to being sent to the United States have done an admirable job of taking care of a real life-threatening problem," he said, "and have converted a life-threatening problem into something that can be treated electively. So from that standpoint, I was pleasantly surprised and pleased."
But Noora won't be safe until that soft part of her head is covered with artificial bone – it's actually a moldable cement product – during her major surgery, scheduled for later this fall.
"It's a big enough area that if she were to get hit directly in that spot with something that's hard and smaller than the defect itself, it could penetrate that and cause some significant brain injury," Attwood said. "So it's really important that we try to get this thing covered."
In the Aug. 22 procedure, Attwood created a pocket between Noora's scalp and underlying bone, then placed an expandable balloon inside the pocket. He injected a little saline solution into the balloon. Starting about two weeks after the procedure, after the wound had some time to heal, more saline solution would be injected every few days to expand the tissue.
The injections gradually stretch the scalp so that the doctors will have enough skin to cover her new patch of skull. By the time Wilson and Attwood do the second surgery, Noora should have a bump on her head about the size of a softball. Attwood said most people who go through this take to wearing hats.
"Hopefully, it will be a big bulge," he said. "The bigger the bulge, the more tissue I can create by stretching the existing scalp, the better coverage I'm going to have. So it's going to look odd."
It will be at least six weeks between this procedure and her major surgery.
PHYSICAL, EMOTIONAL HEALTH AT RISK
The morning after the Aug. 22 surgery, a Saturday, Noora and her father emerge from the hospital with Eggenberger and Rogers for the short walk back to the Ronald McDonald House.
Otaiwi looks exhausted. Noora's head and neck are covered in white bandages, and her hospital bracelet is still on her ankle. She holds tightly to a large bag full of medical supplies that she insists on carrying herself.
She will be on antibiotics for the next few days. If the wound becomes infected, Attwood will have to take the expander out and wait for everything to heal before trying again. That could take months.
It had been a rough night for Otaiwi. Noora slept for a long time after the surgery, but when she woke up, she began to feel some pain and started crying.
"She say, 'Papa, I need my mother, where my mother?'" Otaiwi says. "I say, 'Your mother very far. She cannot come.' And after that, I felt, 'I am not strong.'
"I'm very tired, you see. I start to weep all the time, because my daughter need her mother, and I can't bring her mother. She began to feel more pain. But what can I do? No choice. You must do the surgery."
There's never been any question about that, and not just because Noora's health and safety demand it. Her emotional well-being is at risk, too.
"In Iraq," Otaiwi says, "very bad kids make fun of Noora. Tell her, 'Go, your head is broken. Your head is without hair.'"
Otaiwi had set up his computer in Noora's hospital room so their family in Iraq could see her after the procedure and know that she was OK. When her mother's image came on the monitor, Noora turned her face away.
A cousin held up some presents he had for Noora – new clothes, a hat – and that helped ease her sadness. Eventually, she began to talk and even laugh, and began to interact with her mother.
Noora's family has sold almost everything they have, and borrowed money, to help her survive. Otaiwi makes $200 a month as a teacher. He would have to work five months just to pay for one CT scan in Iraq. Noora has had many.
Their trip to America represents the end of the road. Otaiwi believes it is their last chance to restore Noora's health.
And her life.
"I want to come home and not have kids make fun of my daughter," he said.
FOR GUIDE, A DELICATE BALANCE
Within a half hour of her return to the Ronald McDonald House, Noora is on a tricycle, pedaling madly down Brackett Street.
She grunts while going over a small hilly spot, and Eggenberger, who's following her like a mother hen, gives her a little push.
"This way?" Noora asks, pointing in one direction. "This way," she answers herself as she rides determinedly down the sidewalk, legs pumping. Eggenberger rushes after her.
"One of the things that she does when she goes out, she'll turn into the street or do something just to see if I'm watching," Eggenberger says later. "She tests me a little bit."
Noora screeches to a halt at a sidewalk yard sale and peruses the jewelry, eventually choosing some purple beads that Rogers quietly pays for with a dollar from his wallet. A neighborhood resident, Alice Mazurie, spies Noora outside and walks over to give her a stuffed penguin.
Carrie Marsh stops by, too, to bring Noora a get-well card and a bouquet of flowers. "How are you, sweetie?" she asks. "This is for you."
"She loves flowers," explains Marsh, one of the many Portlanders who have fallen in love with Noora. "I was walking in the park the first week she came, and she was playing, and I started playing with her. I volunteer now a couple of times a week. I play with her, and I took her to the beach."
Lots of people do their part, but it's Eggenberger who has become something of a mother figure to Noora.
Yet as much as Eggenberger cares for the 6-year-old, she has set some emotional boundaries because she feels Afrah's pain when Noora gets mad at her mother for not being there and acts out.
"This has been a difficult thing because, you know, I wanted to love Noora, and we have a really close relationship," Eggenberger says. "But it's critical to me that Afrah knows that this is her child. That's a really touchy thing. I want her to know that I will love her child while she's here. I think that she worries about that."
Eggenberger said she and Rogers had no idea what they were getting into when they told No More Victims they would help a child. They knew it would be a long-term commitment, but weren't quite sure what to expect.
"Sometimes it's overwhelming to me," she says. "I go to some of this stuff with Noora and "
She begins to weep. " you think about what she's gone through."
"It's probably the most intense, demanding thing I've ever done," she says, "and it's by far the most rewarding thing I've ever done.