Doctor Down

There comes a time in an aging man's life where he finds himself looking an  adversary (that he has been actively ducking for at least10 years) straight in the eye.  In my recent experience my oppressor was a small Chinese Singaporian man. His weapon of dread was a 165 centimeter (almost four and a half feet!) shiny black colonoscope intended for the deep exploration of my nether regions.  And I was begging him to do it.


This story and what will follow is not for the faint hearted.  It was as embarrassing to me as it was uncomfortable. But for the greater good of humanity it needs to be told.  If even one person, male or female, heeds the call to the "scope" after reading this, my pain and discomfort will be justified.  On a positive note, after this difficult week, I can think of little else in the world that will ever embarrass me again in the long years and predictable medical violations I expect to survive after last week's "scoping."

On the job

My stories usually--no, always-- have the common thread of travel and medicine built into each one of them.  What could possibly be worth writing about an uncomfortable medical procedure that literally thousands of people have quietly each and every day in nearly every country in the world?  I am not without an angle here.  Were I still back in the suburban sprawl of my native Southern New Jersey, I would have driven to West Jersey Hospital at the onset of concerning intestinal symptoms. I'd have been under the scope in less than twenty-four hours and five  miles of well-paved road.  My own colon took a much more lengthy and twisted path to exploration which brought it through three countries, five cities and three separate forms of transportation over  seven, long, disturbing, anxiety-ridden days.  This is my story.


For the past seven years I've been  an Emergency Medical Evacuation specialist.  If you are traveling outside of what you consider to be the civilized world and have a medical emergency greater than Travelers Diarrhea, I know what to do.  I know who, what, where and the fastest way to get you to a competent physician and hospital that will put your mind and body at ease. Sometimes I will even take you there myself.  I've been part of successful medical extractions in Iraq, Peru, Kazakhstan, Congo, Cambodia, Ukraine, Papua New Guinea, Laos, Haiti, Nigeria and dozens of other countries. In these difficult places my clients all had one common hope:  Getting to a hospital where the medicine is real, the scalpels are sharp and the doctors are  adept.  It takes a highly trained and cooperative crew of people to make this happen successfully even in the simplest of international circumstances.  Much like Hillary Clinton's view of The Family, it takes a village.

Your ticket to clean sheets, sharp scalpels and real medicine
(mention of the company name is complete unintentional)

I'm lucky enough to work for arguably the best company in the world for Medical Evacuations.  These guys are experienced, consummate pro's.  I'd mention their name, but I'm once burnt and twice shy.  Recently one of my previous "associated persons" demanded that any writing that included the company's name needed to be cleared by the bureaucratic powers that be in HQ. (I guess I should be a little flattered that they think my blog will have enough readers to make it worth the ink on their letter.) I'd written an account of work in a remote village where, under emergency conditions, I ended up saving the life of a newborn by doing an emergency C-section where no other medical person could do one.  Furthermore, the mother died briefly on the table from a bad reaction to anesthesia.  I resuscitated her and brought her back to life.  In my story I made mention that during this emergency surgery, the doctor in this remote village tied the woman's tubes because her uterus had ripped. He felt that she would likely die if she got pregnant again-- especially since she lived in a place even more remote than our remote medical outpost.  This is not a decision I would have made, nor did I have any part in the decision or the tube tying, but this is what happens sometimes in poor countries where emergency decisions and available resources do not match those of the privileged, second-guessing, fully internetted West.  A few angry feminists took exception to this doctor's sterilization decision and unleashed an attack on my blog as though I was Dr. Mengele  himself.  They wrote to my former "associated persons", my former "associated persons" wrote to me and I removed the blog.  In my former "associated persons" eyes, writing about the remote practices of one doctor (who was not part of their company) outweighs the good of writing about an employee saving a mother and child by performing an emergency surgery (their concern was that I was not supposed to be directly treating patients).  Still, extreme situations require extreme actions and I'll always vote for saving a life over saving face.  I would do it again.  Some people can't handle the truth or the ragged edges that come with it.


But enough of those sour grapes.  Back to my intestines:


I was on a scheduled leave leave from my jungle clinic and enjoying the culinary and infrastructural greatness that IS the civilized world.  I had been in the remote jungle for five months and, finally, I was back in the mix.  I was in New York, New Jersey and Los Angeles filling my face with all the delicacies that I would not see again after my return to remote Indonesia for another 3-5 month encampment.  In Indonesia I am at least an hour's flight on a single engine plane from the closest Starbucks or McDonalds.  To be even more clear, our idea of an upper class restaurant here is one in which wearing shoes is not optional.  In America I attacked these restaurants and fast-food emporiums with complete abandon like a guy who was seeing them for the last time in his life. It was glorious:  cheesesteaks, heaping plates of sushi, chicken parmigiana, popcorn shrimp, Mexican, Chinese, Italian, Japanese, Thai and Lebanese food.  I didn't miss a country.  I'm a little guy, but I can put it away when I want to.  It wasn't until I was on the plane heading home, through Bangkok, that I knew something was wrong.


Without getting too graphic and descriptive, everything inside stopped.  For me, whose colonic regularity was something I could usually set my watch by, this was distressing.  Still, it happens to the best of us so I figured it, like all things, would pass.  I was in Bangkok.  Arguably one of the top five cities in the world to be for a man on a fine food tear.  There was Kwiteow and Phad Kapow to be consumed.  There was Tom Yum soup so hot and delicious that it would leave you in a frenzied craving for more even an hour later while your tongue blistered from the spices.   And there was beer.  Real beer in real pubs with over 30 brands at my fingertips.  I ate, I drank........................and then I bled. Everything inside me ground to a dead halt.  Something was terribly wrong.


Now I had a dilemma.  Bangkok has good, if not sometimes great, medical care.  It is a world hub of medical tourism and the hospitals more closely resemble the Peninsula Hotel than a scary, filthy Southeast Asian medical center.  My son was born in a Bangkok hospital and my wife had a Cesarean section done so beautifully that it could be considered a work of art.  This was definitely the last stop on the bus for medical competence on my road home. The problem was  the Jungle Clinic.  I was on a schedule.  My replacement doctor was nearly on his way off the rock and I would not leave my post without medical coverage.  I'm not sure I took that oath directly, but I felt responsible.  My gut would either get better or it wouldn't.  I'd  sort out everything at the clinic and then deal with my own problems afterwards.  Maybe this wasn't the best plan, but sometimes- most of the time in Indonesia- there is no perfect solution.

Erik Travels:  Blocked up and
 tore up from the floor up

By now I had talked myself into colon cancer.  It made sense.  Complete blockage and copious bleeding plus feeling like shit equals colon cancer (in the paranoid mind of a doctor).  I was going in between lucid states of practical fear (haven't completed my will, fear of a cancer disclosure on my next job application)  and general horrific anxiety. From Bangkok we made it to Bali, but were delayed for thirty-six more hours due to terrible weather.  The only way of getting to the island of Sumbawa is a single engine sea-plane or a long, long day in a very slow and bumpy boat.  It was almost monsoon conditions in Bali and the sea-plane was not going to chance ditching into the ocean .  At one point there was a short break in the weather. We scrambled onto the plane and made it out to the tarmac. Half way down down the runway the storm closed up the sky as quickly as it had opened.  The pilot turned the plane back to the terminal.


Finally, eventually, I made it back to Sumbawa Island.  I was jet-lagged, underslept and had stopped eating three days earlier for fear of exploding.  I had lost nearly eight pounds of hard fought vacation overeating and the bags under my eyes were big, puffy and black.  I looked like shit and felt even worse.  I spent a day getting my family settled back in and catching up on the urgent loose ends and emergencies in the clinic. Fortunately it was quiet over the holidays. Now it was time to call in the cavalry.


I called in to our Alarm Center and reported the need for a medical evacuation.  They asked me who.  I said, me.  They asked me to repeat that twice.  They were not initially aware that our remote site doctors are permitted to be sick (though it is specified in my contract).  They contacted our Asian regional medical directors and they responded like the God's of men that they are.  From remote Sumbawa Island there are two options for the closest centers of medical excellence:  Australia and Singapore.  Both have excellent hospitals and doctors, but specifically they had clinicians adept in the use of the dreaded, yet unavoidable, colonoscope.  I chose Singapore.  If I was going for a beer and a steak, I'd have chosen Australia. For pure efficiency and service there is no place on Earth like Singapore. Within an hour the pro's at my company had the hospital and doctor (a renowned Singaporean MD who had done a fellowship at Duke Medical Center in the America) arranged.  They found a quick replacement for me at the Jungle Clinic.  He would head out from Jakarta.  All I had to do was get to Singapore.

Great weather for a duck, not a Seaplane

Getting off this rock is just as hard as getting on it.  The only way I was going to make a flight to Singapore was if I could get to Bali by noon the next day.  The seaplane was my only option, but it was already fully booked. Someone would have to be bumped off the eight seater flight and they would be pissed. Also the same storm that delayed my return to Sumbawa was still raging off the coast. We are smack in the middle of raining and monsoon season in Indonesia. There was every reason to believe that no one was getting off the island until the storm passed.


I barely slept that night worrying about the things I could not control.  The thought of delaying medical care for at least another day was making me crazy.  I had all the signs of cancer.  All that yoga and fiber for years hadn't done jack shit for me.  At five-thirty AM I lay awake and watched the sun barely come up through the constant clouds and drizzle.  At seven AM I called the mining site manager to find out if the planes were going to be flying through the storm.  He's a friend of mine and I explained the situation to him.


"Hell, why didn't you say so?" he said.  "We'll arrange the chopper to take you to Bali.  You can take the Squirrel."


I knew the Squirrel.  The Squirrel is the AS350 Eurocopter single engine chopper that I'd used to search for  a downed helicopter a few months ago.  I get douche-chills every time I hear it's name.  It was our best chance of maneuvering around and under a storm.  It would be ready for me by ten AM.


I said goodbye to my wife and son and drove to the port helipad.  It was still pissing down rain.  I was handed a small life vest and told to watch a comforting safety video about the Squirrel that explained what I should do if we ditch into the sea.  The ground crew walked me out to the chopper.  The Squirrel's engines were already primed and deafening.  I couldn't hear myself speak.  I jumped into the co-pilot seat and put on the headphones.  The pilot looked over at me and smiled.


"Hey doc.  Here we are again."
"Always in the best of circumstances.  Are we going to make it through the storm?"
"We're going to try.  Let's go."
We lifted off.  I've still never experienced anything as unnatural as a helicopter lift off.  Like someone's plucked you into the sky as a big joke, with the expectation that you will fall back to earth just as suddenly.

The Sumbawa coast from the "Squirrel"

The Squirrel hovered at five hundred feet, just even with the cloud line to our right.  The pilot kept us parallel to the storm.  As the clouds and wind moved left, we moved left.  When I looked down, from this altitude, onto the island where I lived, it was like seeing it for the first time.  Sumbawa is pristine.  Under the rain the Sumbawa coast is a blanket of glowing jade green running all the way to the ocean.  No roads, no homes, no people.  Only the thickest, most dense jungle you've ever seen.  About one hour and three islands later we started descending to Ngurah Rai Airport in Denpassar.  There was no magic flight path or radar guidance for this flight.  The pilot just looked for the clear spots ahead and flew to them until we made it to Bali.


The rest was the trans-international Asian equivalent to the five minute drive to West Jersey Hospital.  One more airport, a flight on Singapore Airlines SQ942 and arrival in beautiful and efficient Changi Airport where the lines are short, the immigration is quick and everyone says Thank You.  Singapore  gives you the impression that everything is going to work out in the cleanest, most efficient, most polite way possible.  If I were asked to write a National Slogan for Singapore it would be this:


"Welcome to Singapore.  We are still Asia, but shit works here!"

Directions:  Head to the clouds and turn left

My company sent a nurse and a driver to meet me at immigration. They brought me straight to Mt. Elizabeth Hospital and had me admitted. The doctor came in a few hours later.  He was a busy guy and I was happy he'd squeezed my colon into his schedule.  He was a short, serious-looking Chinese man who was all business, but had a quiet confidence about him. I tried to be as much of a patient and as little of a doctor as possible.  I wasn't comfortable or used to being in the opposite seat in a medical conversation.  I will never be. There could a number of things causing my intestines to be blocked and bleeding, but we had to make sure it wasn't cancer.  Whatever it was, the answer was at the end of a four and a half foot scope tomorrow at high noon.  I'd spend the rest of the day and night getting "The Prep."


The Prep is Hell.  Modern medical science has this one down.  Two separate medicines that will tether you to a toilet like an umbilical cord on a baby.  You will go no further than  twenty feet away from a bathroom, depending how fast you can move.  The nursing staff at Mt. Elizabeth hospital is as conscientious as you'd expect a nursing crew to be in Singapore.  They were pretty much in my room every twenty minutes whether I called for them or not.  After a while I stopped being embarrassed with the conversations I was having with them behind the bathroom door.  I trusted they could understand what I was saying between my thick American accent and the other horrific sounds   coming from me.  They speak English in Singapore, but it rarely sounds like it.

Best view in the house

After an exhausting sleepless night and a few changes of bed clothes the moment of truth came and went anticlimactically.  I remember a flash of an intravenous needle stuck painfully into my hand and a squirt of narcotics that shut out the lights.  When next I opened up a heavy set of eyelids the doctor was in front of me saying, "It's okay.  It's all okay."  He had even made me a DVD of the exam which I was happy to pay eight Singapore dollars for and keep for reference.  I was relieved, but hoped I'd still feel the same when the drugs wore off.  The diagnosis was "Diverticulosis," a pesky, but not uncommon ailment that arises from over-activity of the colon. It turns out that all the yoga and fiber did have an effect--a bad one.  I needed to slow things down and ease up on the healthy stuff.  If they let me out of Mt. Elizabeth, I'd bee-line to the McDonalds I passed on Orchard Road.  In my mind I was already working out cheesesteak importation strategies to the island of Sumbawa.


I had traveled one thousand one hundred fifty seven miles of fear and uncertainty, but it took the last four and a half feet to bring me to peace of mind.   I stayed one more day in Singapore for observation and then started the long journey back to the rock I call home.  I had peace and I had clarity and it was as if this clarity had extended to the skies. It was clear sailing and sunny skies all the way back to Bali Ngurah Rai Airport and a smooth, unfettered flight home on the seaplane.  After an hour we descended,  ultimately landing on the calm blue waters off the Sumbawa coast.  Our ambulance driver was waiting for me with my car.  It felt good to be home.