Tuesday, January 13, 2015

Fear and Loathing in the Ebola Unit

I was sitting in my tent in a small northern Liberian town called Zorzor when the fever hit. 

My cheeks felt hot like fresh sunburn though it was still a mountainous morning cool in this town near the borders of both Guinea and Sierra Leone.  I’d felt tired and cranky for the previous two days, but attributed it to sleeping on too many floors and too much hard travel through Liberia in the past month.   I’d only taken one day off in the past thirty.  We were moving through the country opening up new Ebola Treatment Units (called ETU’s) and training hundreds of Liberians to run and staff them.  I put my phone camera in selfie mode to look at my face.  My cheeks and nose were bright red and the whites of my eye were sick and glassy.  I looked as old and tired as I felt.  Wow, I thought as calmly as possible:  this is really happening.

I called my friend “Sumo” who’d been hired as the camp manager for the Zorzor Ebola Unit. I’ve known Sumo for nearly ten years as a trusted friend and a skilled paramedic.  I asked him to grab one of the thermometers packed in the storage containers and bring it to me.  I suppose he heard the concern in my voice and asked what’s up.  Just bring it to my tent I said.  He came by five minutes later.  He opened the zipper to the door of my tent and started to step inside.

“Stop.  Just wait at the door, dude.  Don’t come in.  Did anyone see you bringing this?”

“No.  What’s wrong?” he said

“Just toss me the thermometer.”

Don't shoot!
I ripped the box open and took out the Thermoscan.  These are the gun-like thermometers used outside every establishment in Liberia, Sierra Leone and Guinea to check the body temperature without having to touch another person.  Medically these are not the most reliable devices to check a temperature as they sometimes under-read the actual temperature. They are certainly the safest though during an Ebola epidemic.  I fumbled with the batteries, checked the calibration and pointed the gun to my forehead.  I pulled the trigger and held it down.  One beep says no fever - you are clear to enter.  A string of beeps says you have a  fever and you risk quarantine in an Ebola Treatment Unit.  I got the menacing string of beeps. I looked at the screen on the back of the device.  It read 39 degrees Celsius (102.5 degrees Fahrenheit).

“Dude, I have a fever.  I’ve been working in Ebola Units and I have a fever.  I gotta figure this out.”

“Take it easy,” Sumo said, “don’t let your imagination run away with you.”

“It wasn’t until you said that.”

Critical glove check
I’d been providing medical care and training in over twenty countries in Africa and Asia and Europe for the last fifteen years.  I’ve worked through all kind of epidemics including big hitters like HIV, Hepatitis, Tuberculosis and dysentery.  There’s been fears and issues along the way, but never like this.  I had to calm down and work through this logically. The ripple effect if I had Ebola was going to be huge.  My first concern was for the people I’d interacted with in our makeshift tent city camp during the last twenty-four hours.  We lived elbow to elbow.  The number would be in the hundreds. I was going to be the Typhoid/Ebola Mary of camp Zorzor - trigger immediate pangs of guilt.   Ebola can only be spread when an infected person shows symptoms.  I figured, at the latest, my symptoms really started two days before.  Next I would have to sort out my evacuation options.  We’d flown to Northern Liberia on a Russian M8 transport helicopter—a veritable city bus of a helicopter that can carry twenty people and tons of supplies.  To evacuate me from Zorzor to the Monrovia Medical Unit—an Ebola Unit designed specifically for health workers who’ve caught Ebola on the job—would require a monster effort of personal protection, decontamination and would take this vital helicopter out of service for a long time during a lengthy decontamination process.  Last, but certainly not least, would be a difficult conversation with my wife whom I convinced at great length that there was nothing to worry about when I took this job.  I’d told her it was relatively safe and as one of the directors of the project I’d barely have patient contact--which wasn’t exactly true. 

I was still calm.  Ebola, while horribly lethal and easily spread, follows certain rules.  I’ve been teaching these rules to nearly five hundred international health workers over the last month all over Liberia.  To catch Ebola there has to be an exposure beyond the constraints of one’s Personal Protective Equipment or PPE—the biohazard suits, boots, multiple masks, gloves and aprons and goggles that have defined the media’s symbolism of the Ebola worker.  

I’d had one such episode.

It happened on my first day in a busy Monrovia Ebola Unit with my first Ebola patient ever.  I’d donned my protective gear and entered the “Suspect Ward” where new cases waited for confirmatory blood tests.  It was a hot mid-day in Monrovia, sweltering in the Ebola treatment tent and ten degrees hotter still inside my biohazard suit.  I was drenched in sweat, my goggles fogged over completely.  My N-95 face mask pushed painfully into my nose to the point where I could only breathe through my mouth.  My first Ebola patient ever sat on the side of his bare green army cot.  I leaned down to speak to him and had to yell through the thick mask for him to hear me and understand my American accent.  I asked how he was doing.  He said he felt well.  He was having no more fevers and was not having any diarrhea or vomiting – the hallmark sings of a new Ebola infection.  I examined him as best as possible in the clunky biohazard suit, wrote in his chart and moved to wash my hands before the next patient. 

Suddenly, THUD!  I turn back and he was having a full blown seizure. He thrashed violently on the small unstable cot.  He’d bitten through his tongue and bloody saliva flowed from the side of his mouth.  He’d also pulled out his intravenous line and blood ran from the hole in the back of his hand and dripped and splattered on the floor.   I called the doctor working with me to help and we struggled to turn his head to the side.  He was in danger of choking on his bloody tongue or drowning in his own secretions.  All this time we had to be careful not to rip our suits or gloves and risk exposure to the surely contaminated fluids now filling his bed.  The nurse went to the nurse’s station to find an injection of Diazepam (Valium).  Hopefully that would break the seizure.  We charged the experienced nurse to  give the injection.  Now there were more fears.  I worried when this big man felt a sharp needle pierce his skin, he was going to react and grab one of us or start swinging.  I positioned the team out of his reach and told the nurse to proceed with the injection, but to do it quickly.  He jabbed the needle into the man’s right shoulder, injected in one move and we all backed away.  The seizure eventually stopped and the man looked at me disoriented from the seizure and the Valium.  I looked briefly into his eyes through the fog in my goggles and saw a look of desperation that I’d never seen even in the Tuberculosis and AIDS dying wards throughout Africa in the late 1990’s.  If there’s a devil, I thought, this is his disease.

Uptown Zorzor
My apron and gloves were covered with infected blood.  Protocol says to clean them with 0.5% Chlorine solution which kills the Ebola virus.  I sprayed down my contaminated suit, washed the blood from my outer second pair of gloves and then decided to throw them away and get a new pair.  I carefully removed the gloves to avoid any fluid splashing  and dropped them gently in the waste container.  Only one box of gloves was left on the nurses table, but they were too small.  They would have to do.  As I struggled to put them on, POP.  My hand poked through my only remaining glove.  There it sat unprotected, exposed to the air on my first day ever in an Ebola unit with the most deadly infectious patient I’d ever seen in a long career of deadly infections.  I called out as calmly as possible, “BREACH!”  The nurse instructed me to clean my hand as thoroughly as possible with chlorine and to put on two fresh pairs of gloves.  As I ran the stream of chlorine water over my bare hand all I thought was: I have two small children and a wife.  What the hell am I doing here?  After a good five minute wash I left the unit, decontaminated the rest of my suit and threw it away to be burned.  I moved into the “Green” uninfected zone of the Unit.  I tried not to show it, but I was shaken.

Tent City, Downtown Zorzor
So there I sat febrile in my tent in Zorzor replaying every moment as vividly as if it happened yesterday.  But it did NOT happened yesterday and here is where the rules of Ebola brought reason to my fear.  Ninety-nine percent of Ebola infections occur within twenty-one days after exposure to the virus.  In my head I counted backward to that day in the Monrovian Ebola Unit.   Twenty-five, twenty-six, twenty-seven…twenty-eight days!  Time was on my side.  I wasn’t showing any of the other signs of Ebola that define the infection…not yet anyway.  I told Sumo that this had to be Malaria.  I was convincing myself as much as him.  I’d been taking Malaria prevention tablets, but it is never one hundred percent effective.  I’d had this before.  This definitely felt like Malaria.

“Sumo, can you grab me a pack of Coartem?” I asked.  Coartem is our effective three day Malaria cure.

“Sure.  Why don’t you just rest and chill out though.”

I took the cure and my fever resolved later that day.  I watched closely for any other symptoms, but none came.  That was 4 days ago. I’m starting to feel better.  I’m fatigued, but I can still work and teach.  I'm trying to rest a bit more,and put back lost weight. I'm still working.  There's too much to be done.

Ebola has changed so many of the ways we in the medical field think about things.  Never in my life did I imagine I would think this:   Thank God I have Malaria.

Goooooood Morrrrrrrning West Africa!

Friday, May 16, 2014


My father was dying.

Essentially, he had been “dying” for years.  He had a litany of medical problems that seemed incompatible with life—kidney failure, dialysis, prostate cancer, bladder cancer, lung cancer, skin cancer, five heart attacks, two strokes, atrial fibrillation, hypertension and high cholesterol.  You would think a man with all these problems would have been wasting away in a hospital bed, but he was still an active, functional, feisty son-of-a-bitch until about a year ago. 

I got the call from my mother while on vacation with my family in Bangkok.  She said that my father was dwindling.  He could barely muster the strength to get out of bed twice a day, eat a meal and then fall asleep at the kitchen table.  He was relying on nightly kidney dialysis. This was keeping fluid from building up in his body and filling his heart and lungs with so much water that they would certainly stop.  He’d been on home dialysis for nearly five years.  He had a portable electric machine by his bed that attached to a tube in his belly while he slept.It was disconnected every morning.   Every night two liters of fluid would flow into his body, suck out deadly toxins by the morning .With this he could function, think clearly, keep active, drive and live a normal life. He even traveled with his dialysis machine on vacations.  Now the dialysis had stopped working.

He had gone as far as a tough old Brooklyn Jew could go. Now it was really happening.  He was dying.

The adorable couple
He and my mother had been married for fifty-seven years.  She cared for him with the passion of an Intensive Care Unit nurse. In the past ten years his life had become my mother’s life.  He had nearly died more times than I can remember.  It was only the quick interventions of my mother in these times that brought him back to a reasonable quality of life.  She couldn't let him go. I came home from Asia three times to say my final good-bye to him--sure that each would be the last time I’d see him alive.  God didn't want him yet.

My mother’s voice was shaky and forced. She was sleep deprived.  She’d not had more than 5 hours  straight sleep in the last two years.  She spoke like someone who did not want to believe her own reasoning.  While she didn't want him to suffer, she also didn't want him to go.  Though he could be a major pain in the ass at times, they’d been together a lifetime. Three children, six grandchildren and him – a package deal.Now that fate was asking her to change all of this she could not make that decision.  She asked for my help.

The process of dying was nothing new to me.  Since 1989 I’d been doing work almost exclusively with victims of cancer and AIDS.    My specialty inadvertently became “palliation”--helping people die with as little suffering and as much dignity as possible.  It was a horrible and exquisite view of life’s last breath that only few get to see.  I’d seen so many patients pass away that the act of dying became a relatively predictive medical process.  The fact that I can think of it this way personally and morbidly disturbs me.  It makes me question my own damaged emotional walls and boundaries—the separation between job and life.  I  admit that this part of my job has led to a few extra stress-drinks and a few extra stress-cigars at times.  As I was the reluctant expert in this process, my mother wanted my verification that it was time to let go.  She was too close to the situation.  She’d kept him alive for so long that she couldn't make the decision to stop.  This was a family decision. If we did make the decision, she wanted me to be the one to make sure it was done right.  It was going to be a calculated decision to make as a doctor and a terrible one to make as a son.  It was going to get intense,but I owed it to him.  He’d been a good father.

I headed to the airport to start the twenty-four hour trip home.  At the airport I called my father’s doctor, Dr. Mark. He would give me the real clinical scoop on dad’s condition.  Dr. Mark and I had been classmates in medical school and had been friends for thirty years.  He’s not only one of the best doctors I know, but also has one of the biggest hearts known to man.  He’d usually make a housecall to see my father after ten hours of seeing patients in his own office.  Also, two months earlier he’d buried his own father in similar fashion.
Mark confirmed that dad was suffering.  His quality of life - except for watching daytime New Jersey TV - was nil.  His kidney failure was progressing and leaving him confused and disoriented much of the time.  Mom was suffering too.  She was stressed, sleep deprived and not looking after her own health. I’d heard enough to make up my mind before landing in New York. Soon enough I’d see for myself.

It was noon when I arrived at dad’s house. He was sitting at the kitchen table over a full bowl of lentil soup.  He was slowly and purposefully negotiating the spoon from the bowl to his mouth,controlling the shaking in his hand as best as possible to avoid spilling the soup.  My mother had tucked a thin white towel into his shirt to catch the drips.  He was dressed in white long-johns and a white thermal long sleeved shirt.  He had a thick red fleece robe wrapped around him, secured with a red fleece belt.  He had lost nearly fifty pounds and had become so anemic that he never felt warm enough anymore.  His hands, once the beautiful, delicate hands of a doctor, had shrunken and withered and become darkened with brown spots of aging.  His face had become long and expressionless, but his eyes still glowed.  He still had dark, buoyant eyes that had instilled confidence in thousands of patients during his forty-some years as a doctor.  I stood and watched him from the living room for five minutes before entering the room.  I wondered if I’d cry, but no tears came.
Finally I stepped into the kitchen and caught his eye.  It took a few seconds for him to put it together and then he smiled.  I leaned down and hugged him.  He put his arms around me and squeezed gently.

‘How are you feeling?’ I asked. 
His voice strained to push out sentences in a whisper. “I’m...still…here.  Where’s the…kids?”
“Couldn't make it this trip, Dad. Next time.”

Then he just stared at me for the longest time and smiled--like he was taking in every second possible before they ticked away.  I've looked at my boys this way, though I've never considered what it would feel like for the very last time. 

A lovely Jamaican woman named Lyn had moved into the house to help mom care for dad.  She’d only known him for a couple of months, but cared for him like patient daughter.  She looked at him with love and respect, smiled at him and helped him with his soup.  Dad was like that with people.  When you met him, you just wanted to love the guy.  He’d piss you off, but you never stopped loving him.

Mom and I de-stressing as best we could.
That night we sat down and had “the talk.”  Mom and I discussed the inevitable.  Dad was a vibrant guy who treasured life.  He loved to travel and see new things and embraced adventure.  He never wanted to be the guy withering away while the hospital equipment piled up around his bedside.  He’d told me several times over the past six months that he had no life and just wished he could die. But he was a character so full of life that when he actually got to that crossroad, he could not look down the lane any further.  I understood this.  We all say we are ready to die when it’s our time, but what will we say when that time comes along?  In a conversation that I pray I will never again have, we spoke to each other—my mother, myself and my brother and sister on the phone.  We spoke to Dr. Mark.  And finally we spoke to dad.  It was decided.  I wondered again if I would cry, but still no tears.

We stopped the treatments that night and decided to keep only those things that would make dad comfortable—oxygen, pain medicine, anti-anxiety medicine and medicine to slow down his pulse if his fast heartbeat was making him uncomfortable.  The dialysis machine sat on a cart by his bedside like a monolith with a full sterile bag of fluid on top, ready to be infused.  I switched it off and pulled out the electric plug to keep the flashing lights from keeping dad awake at night.  Kidney disease isnot the worst way to die.  As the kidneys fail, toxins fill the body and the brain.  In the early stages disorientation and confusion occur and then the brain essentially goes to sleep slowly and passively.   No one can predict how long it would take, but with barely any inherent kidney function left in dad, I guessed it wouldn't take long.  Then we all went to bed with anxiety, anticipation and a lot of self-questioning.  When you do the right thing, you expect a green light to shine as a sign of confirmation.  But the green light never comes.
Dad had never missed a night of dialysis in five years.  He awoke the next day groggy and weak and asked for help sitting up in bed. As I lifted him I took his arm in my hand and surreptitiously felt his pulse.  It was strong and fast.  He had the heart of a warrior.  It was becoming clear that he was not leaving--as anybody knows who ever waited for him--until he was damn well ready. His right big toe had become red and painful in early stages of gangrene.  I accidentally bumped it. He took a swing at me and looked at me with daggers.

“Sorry dad, it was an accident.  Do you want a pain pill?”
“What are you trying to do?  Dope me up?  I’ll go when I’m ready!  Now get me my blue shirt and black tie.”
Classy until the very end.
“Okay, in a second,” I humored him, and we kept at our custodial care of him. We stacked pillows behind his back and around his body to keep him upright.  Mom cleaned his face. He waited twenty seconds.
“Why the fuck is it taking so long?  Did you hear me?  I want my blue shirt and black tie.”  I looked at mom. 
“Best do what he says, mom.”  My mother went into the closet.  She knew which one he wanted.  She brought out a soft, light blue button down oxford and a jet black tie already knotted.  My father kept all his ties this way.  He despised retying them.  As we put the shirt and tie on over his long johns, mom asked him what he was getting dressed up for.

“I’m heading to the Iranian embassy to meet the representatives,” he said to us--like we were idiots.  With the shirt and tie in place he looked as alive as ever.  Then, dressed for success, he asked to be helped back into bed and fell asleep.

Mom and I went outside to the porch to smoke.  She lit a cigarette and I lit a cigar.  I took a deep draw, turned my face up to the spring sun and closed my eyes.  We talked about the future and a hundred what-if’s.  She couldn't bring herself to think of the day after dad would die until that day.  She was exhausted physically and now facing the emotions of losing her partner of fifty-seven years in, at most, a matter of a few days.  She was struggling with herself.

“I don’t know what God wants,” she said, “but I hope this is right.”
“I think it is, mom.” I said, “What would you want if it were you?”
“I know, I know.”

By this time my sister had arrived from Australia.  She crawled into bed with dad, hugged him and cried.  In the late afternoon he woke up and was hungry.  One thing about my father:  come Hell or high water, he never missed a meal.  I helped him sit up in bed and he motioned me to come closer to hear him.  He whispered that he wanted a Philly cheesesteak.  I told him I could make that happen.  We put his red bathrobe on him, put him in a wheelchair and moved him to the kitchen.   This was the last time he would ever get out of bed.

The next morning I awoke and went to his bedroom.  He was lying still propped up on several pillows to make his breathing easier.  He was breathing shallowly through an open-- a sign in medicine we callously refer to as the “O” sign.  It usually means the end is not far away.  I turned to walk out of the room, but he woke up.  He asked me to come closer to hear him.  I brought my face close to his and could smell the ketotic odor on his breath from the toxins building up in his body.  He whispered that he wanted to sit up.  I called my mother and sister in to help.  With my sister on one side and me on the other we lifted him by the shoulders.  His muscles had become stiff and inflexible.  His arms, once those of a bodybuilder, had become thin and boney and shook as he tried to use them to sit up.  Once at the edge of the bed my mother pushed pillows all around to support his weight.  He grimaced and moaned no matter how gently we tried to move him.  He was out of breath as though he’d just run a marathon.  The extra fluid in his body was beginning to build up in his lungs and heart.   I desperately wanted to make sure he did not go into painful cardiac failure or suffocating lung failure.   I sat down in front of him.

“Dad, I want you to take some pain medicine. We’re not trying to dope you up. The medicine will help you breathe easier.  It can dilate the blood vessels in your lungs and slow down your heart. It can make it more comfortable to breathe.”
“What’s the name of the drug?” he asked me.
“Dilaudid 2 milligrams.”
“What’s the generic name?” he asked.
“Hydromorphone.”  He stopped to consider this for a few seconds.
“Does mom agree with you?”
“Yes she does, dad.”
“Okay, I’ll take it.”
He, much like I probably will when my time comes, needed to hear it like a doctor.

That Saturday was the first time in five years that my brother, sister and I were in the same country at the same time.Old friends and cousins flocked to the house to see us together as a family.  Everyone wanted to see dad before he left.  I had called a home hospice agency to see if we could get some extra help in the house for my mother.  The nurse arrived at the house and sat at the dining room table with us getting information and signing papers.  She said they’d send a hospice package over with the medications and supportive items that dad might need.  Then she asked if she could visit with dad.

When we walked into the room dad was talking to himself and becoming agitated.  He was reaching forward like he was beginning to panic and desperately trying to sit up.  He had pulled his oxygen cannula from his nose and threw it off the bed.  My sister and brother went to the bed to help him.  I took a half milligram of Xanax, crushed it quickly, put it in water and loaded it into a syringe.  My brother pushed the liquid into my father’s mouth.  Dad tried to turn to the left, then to the right—like he was trying to get away from something.  Then he gasped once and lay back down.  His mouth was open.He was no longer breathing.  I reached down, took his hand and checked his pulse.  It had stopped.  My instinct as a doctor was to “do something”, but there was nothing left to do.  I looked over at my mother.

“He’s gone.”  I said.

The next thing I felt was my legs buckle and my body shake.  My face hit his mattress and I cried harder than I've ever cried in my life.  It was an uncontrollable, uncomfortable cry that came from no place I’d ever experienced.  My sister hugged my father and said ‘I love you daddy.’  Mom took his hand and said good-bye.  She said she’d see him again soon enough.

I left the bedroom to tell our friends that he’d passed.  The room went quiet and those who could handle seeing him lifeless went to say good-bye.  I found a bottle of Avion Tequila on the kitchen counter and poured two glasses for my brother and me.
“To the old man,” I said.  I poured a second one, drank it and went into a corner shaking and crying again. My doctor job was finished - it was time to be one hundred percent a son.

My sister and I stayed around for another week to help mom.  Soon enough we’d have to go back to our families halfway across the world.  Visitors would come to the house every day to bring over food and pay their respects.  In short time we had more food than the local grocery store.  My sister brought it to the local family service office near our house to be given away.  Dad would have liked that.  When the people came in, I generally left the house.  I can handle a man dying.  Apparently I can’t handle the conversations that follow.  

It is nearly four weeks since dad passed and each day is still a bit of a struggle. I go between sad, numb and stuck in neutral. I’m back at work in my Jungle Clinic in Indonesia. Plying my craft seems to lift my spirits or at least defer the feelings for a few hours at a time.  Emergency cases, more than anything, help me to feel normal and engaged—if that makes any sense.  I’m not sleeping well.  Each morning my body wakes up at 4:43 AM.  I think that was around the time on that Saturday, on the other side of the world, that dad passed away.  The body remembers what the brain longs to forget.  There are a lot of unexpected emotions at play.  Everyone says it’s going to take some time.

I have time.
From Boys to Men

Friday, March 14, 2014

Addicted to the Action

We have a witching hour here in our Jungle clinic, but it isn't at night.  That hour is 3:30 PM every day of the week.  After this time anyone coming in for any dire medical emergency is going to be a guest in this remote field hospital until the following morning's first light.  It doesn't matter if the victim is  shot, stabbed, bleeding, giving birth, having a heart attack or even a vicious hangover.  No one gets off the island after dark.  Not by boat, not by plane, not by helicopter.  Most clinics in our situation are military hospitals.  They have decently trained experienced surgeons, mobile intensive care units and operating rooms.  We do not have these things - yet we still do a fantastic job. We have a group of locally trained young doctors,  paramedics and support staff directed by a couple of  weathered older doctors - myself and my Indonesian counterpart, Dr. Anneke.  We've never lost anyone who wasn't already lost.
My clinic has an emergency call system that sends out a  series of endless, deafening chirps and tones when the Emergency Response Team has been called. This siren keeps wailing until it is answered. When this happens all conversations go silent and the nearest paramedic charges to the radio to take the call. Unfortunately this unit is also tied into the phone system on the island and sometimes the calls are wrong numbers intended for the camp mess hall. When this happens we are not annoyed - we are grateful.  The radio gets put back on its latch and we go back to work.  

This afternoon the emergency response sounded.  I was just leaving my office for a  meeting with the managers of this massive mining complex in the middle of the Indonesian jungle.  These are the people that employ us to keep this place safe from injury, biohazzard and any number of medical disorders.  This is the other half of my job - understanding and maintaining the business of medicine - equipment, staffing, functionality, protocol and cost efficiency.  These meetings are less exciting  than an ER emergency, yet just as necessary.  My chief paramedic grabbed the microphone and put the call on speaker.  The voice on the other end crackled and hummed with someone speaking too closely and excitedly into a microphone.  The voice  was speaking Bahasa Indonesia and I'm ashamed to say that after nearly three years here my command of the language is still only basic at best. The paramedic turned his ear in order to hear more clearly.  He quickly jotted down the information as it came.

View from the ER:
Hello jungle.  One table,no waiting.
"Ada apa (What's up)?"  I said to him. (I hoped that he wouldn't take my Indonesian response as a cue to speak back to me in Indonesian.  Fortunately we've worked together long enough that he knows my capabilities.)
"It is a child, doc.  Maybe two years old. She fell from a ladder and hit her head. The report says that she has vomited many times and is not really awake."
I instinctively checked the time - I do this in every emergency.  It was 3:22 PM.  If this was evac worthy - and from the sound of it, it could be - we were already behind schedule.
"Let's go get her."
"Ambulance already on the way, doc."

We didn't say much after this.  We knew the drill.  Dr. Anneke prepared the ER - portable ventilator, intubation tubes, intravenous lines and vials of emergency drugs and syringes.  She lined them up on our Crash Cart like someone setting the table for a formal dinner.  I prepped our doctors and nurses on what might come through the door and how we should respond.  They must think I sound like a broken record during every case, but I tell them the same thing:   preparation, preparation, preparation.  This is the difference between losing control and a good outcome in a difficult situation. I presented the worst case scenarios - she could have a fractured skull or broken face bones.  She could be in a coma with pressure on the brain from swelling.  This could stop her from breathing. She had to be watched closely and meticulously. This was a two year old from the village nearby.  It's always worse with children.  The stakes are higher, the parts are smaller and the emotions run deeper.

While we waited impatiently for the ambulance I received a call from the mining operations manager.  A new vice president of the mining company was visiting the Indonesian site and wanted to see our jungle clinic operations.  I was about to tell him to delay the visit, but I didn't.  The business medicine side of me thought this might be a good opportunity to show our client how we roll here during times of high stress.  Normally, if we are doing our job right, they hear nothing from us.  People get treated - life and work go on as usual.  I thought it might be a good idea for the guys writing the checks to see the bang they were getting for their buck.  This was calculated and risky, but I had confidence in my team.  I calmly told him we had an emergency coming in, but they should come on by anyway.

The ambulance rolled up to the emergency entrance and abruptly shut down the siren.  I gloved up and followed the emergency team outside.  Part of my job here is making them self-sufficient, so I stayed back to watch the captains of the team take control.  If things did not move fast enough I'd jump in.  Vital minutes were passing by and the decision  to evacuate this little girl by helicopter needed to be made in a hurry.  It was raining and the skies were already dark.  When the doors of the ambulance opened I heard the little girl crying.  This was a  good sign.  If she was in a coma this case would be an evac one hundred percent. I stood impatiently behind my emergency crew waiting for them to extract the child.  They were inside the ambulance securing the intravenous lines and oxygen equipment.

"Lets go, lets go, lets go," I said. "this is taking too long."

I pushed past the paramedics and crawled into the ambulance.  The girl's little body took up only one third of the gurney.  The ambulance crew was having difficulty with the locks on the bed, so we took her out by hand. She had her eyes open and was crying. With these good signs the need for evac seemed less likely.  I figured we'd likely be good able to manage her in the clinic, but we still had to do  x-rays and exams to make a decision. The report that she'd vomited four times and may have been unconscious were still ominous signs of a possible brain injury. If her skull was fractured that upped the risks. Until we knew otherwise this is how it would be handled.

Ask yourself - and please tell me - how you would feel at this point.  Scared?  Nervous? Anxious? Because that is probably a normal reaction.  I will admit that I felt little of any of those emotions.  If I had to put my feeling in words,  I'd have to call my immediate feeling  almost giddy. Moments like these are an emergency doctor's Mona Lisa or Stairway To Heaven.  A challenge is set forward with massively horrible odds and consequences - yet the strength of humanness; the magic of human capability usually wins over. In most cases these things work out and everyone goes home at the end of the day.  It's times like this when I stop and look at what it takes to do this job:  a truckload of faith and big cajones.  Experience has taught me that anyone working here is better off  humbly ignorant that they posses either of these.  Any professional in this field will tell you the same thing.

We put the little girl on the ER gurney and wheeled her into ER bay one.  It took every ounce of control I had not to jump in and do everything myself.  But this was my junior doctors' case and this was the kind of case a young doctor needs to cut his or her teeth on to gain confidence.  I hovered close by and gently pushed the paramedics in their proper positions.  The doctor in charge needed one eye on the patient and one eye on the staff when they are young and learning.  An ER case with trauma is a symphony in motion with several moving parts happening at the same time.  And remember:  we were on the clock.  The window of time to evacuate was literally ten minutes away. The little girl was scared and fighting everything out team tried to do. She cried, coughed and vomited.  I started to push things along.

"Doc, what do we have?"
"Vital signs are good, doc.  No bleeding.  No laceration, but a big lump on the side of the head.  The skull feels okay.  I'm not sure if its fractured though.  We don't know about the neck so we put on a collar."
"Let's get her to x-ray.  We need a decision."
"Okay, doc."

One picture holds all the answers.
The mining managers came through the ER door with the new Vice President of Operations while the child was being wheeled into x-ray.  An entourage of doctors and paramedics followed the child. He asked if he should come back another time. I told him we had a few minutes while x-rays were being done.  I switched gears and gave him the selling points of our clinic: how we function, what we do, the company behind us and how we successfully restore medical order in this harsh and wild jungle. I kept glancing at the x-ray room door while we spoke - it was taking too long.  I excused myself when the red x-ray warning light turned off.

The x-ray images came up on the computer screen and I scrutinized them with my junior doctor.  I was thanking God that we had digital x-ray installed here after a year of begging the client to buy it.  I was able to digitally manipulate the images to see the vital areas on her little head and neck.  If I was going to clear her from injury I needed to be absolutely sure I wasn't missing anything serious like a hairline crack in her skull or neck.  Any doubt leads to an unnecessary medical evacuation.  Not on my watch.   Fortunately there was no fracture of her skull, neck or face.  She absolutely had a severe concussion and needed to be watched, but we could manage that here.

Back in the ER the little girl had fallen asleep.  I told the staff to try to keep her awake - make sure she was easily arousable.  If not it meant the brain injury was worsening.  The latest hour for air evacuation had already come and gone.  The paramedic squeezed the little girl's arm and tickled her foot.  When she opened her eyes she saw my face and began screaming and crying. She yelled something in Indonesian about seeing a ghost.  This was probably the closest she'd ever gotten to a scary "Buhle" (white) face.  I left the room to let her calm her down and told the paramedics to check her vital signs every fifteen minutes.  She was going to be okay.

I cherish these cases more than ever - the ones that go well.  My time  in this jungle clinic may well be winding to a close as my contract comes to it's end.  At the end of the day this is a job and an adventure.  We - my wife and my sons - will likely end up in a more civilized urban or suburban environment.  I'm going to miss the action.  It is going to be a difficult transition. I already know this. For the past five years I've been promising my wife stability for her and the boys.  She wants the things most people want for their families:  a house, a neighborhood with more people than wild animals, maybe a Starbucks or 7-11 closer than an hour helicopter flight away.  To be honest I want these things too, but I want the action more.  For better or worse it has become that which defines my reason for getting out of bed every day. This is something I watched my father go through.  His world seemed to implode when he stopped seeing patients.  He had the look of a man who was no longer in the game and hated the sidelines.  I promised this would never happen to me.  I'm in my fifties now and should probably be winding down and handing the difficult cases to those younger and hungrier than me.  But I can't do it.  I feel that all these difficult experiences have really made me hit my stride.  I'm smarter, sharper and more competent in an emergency than I've ever been.

Someone asked me recently if I was an Adrenalin Junkie and I said, no.  Adrenalin Junkies put themselves in dangerous and difficult situations as a hobby.  This is no hobby.  This is how I make my living.  I know a handful of other doctors and paramedics in the same boat.  The motivation is hard to understand.  The pay is not great.  The living is hard and we are guaranteed painful time away from our families.  I suppose I do it because it is the only thing that makes me feel like my days really matter.  And it will be difficult to go backwards to a nice comfortable doctor day job. To go forward will mean I'm going to have to up the ante - more dangerous areas, more difficult diseases and likely places with more potential for violence.  I will keep my family out of harm's way, but I won't promise that for myself.  It wouldn't feel right.  Not yet. Meanwhile I'm going to go home and tell my wife about this child in my ER and how well my team handled this case.  Then I'm going to spin the story to the idea that this is good work- worthy work that should continue.  I'm going to try to convince her that we still have a couple of years on the wild exotic road before we have to settle down in a boring suburban sprawl for the sake of the kids.  She will get angry, but she won't show it.  She'll tell me I've said that every year for the last five years.  I'll tell her, again, this time it's different.

The long walk to the clinic.