Thursday, March 21, 2013

Snake Bite Sunday

Here on The Rock we serve our snake straight up in jars

Sunday  only comes  once a week and don't think this little fact gets by me.  I love Sunday.  Sunday is my only day off here on this remote island called “The Rock.”  It's the day I nurse the illusion of free time away from my Jungle Clinic.  In practice I get called in for an emergency of varying degree  during seventy-five percent of my Sundays, but it’s nice knowing that it could be a day off.  This is the nature of the beast on The Rock.  I took this job knowing this beast so there will be no gratuitous pissing and moaning here.  Emergency calls on Sundays vary, but some of them are extraordinary.  The most extreme of recent note was a helicopter crash deep in the jungle that had me doing search and rescue  still wearing  my board shorts and sandals. Two good men were lost to us that Sunday. I've written about this before.  That was not the last disastrous Sunday of record.

Sumbawa Island is not exactly a deserted island, but you can see one from here.  Outside of Indonesia this island is best known for two things:  the large gold and copper reserves dug deeply into the mountainous core and the world heritage rated surfing  beaches. I'm no surfer, unfortunately (as this story will reveal). Sumbawa's vicious swells are no place for a beginner. I’ve sewn up a handful of coral-gashed surfers already this year who found this out the hard way.  And  these injuries typically  happen on Sunday.

Tropical Beach, Sumbawa:  Surfy Heaven
My good friend Rob decided that it was wasteful and ridiculous that I'm not surfing when a surfer's mecca is a mere five minutes up the road.  It's like knowing there's all this gold buried here and not going after it.  Peer pressure got the best of me one Sunday and we headed to Tropical Beach to do battle with the waves. To be honest  this wasn't my first time on a surfboard. I'd mastered the tourist traps of Waikiki and Australia's Byron Bay back in my youth.  Both of these surf breaks were kind and gentle requiring the minimum effort one needs to put into surfing and feel successful.   Tropical beach is not kind and gentle.   To get to the tidal breaks at "Troppie" you need to paddle incessantly for a good two hundred fifty feet through a mixed current and three to four foot breaking waves.  I should also mention that waves pulling to the left tend to dump you onto a two foot shallow of  razor-sharp coral plates.  This coral bed covers an area similar to the size of a small shopping complex.  Knowing all this I grabbed a huge blue "trainer" longboard and followed Rob into the surf. 

The rideable waves break far, far from shore.  It felt like I was almost in Malaysia by the time I reached them.  My shoulders ached from paddling and my nipples were uncomfortably chafed from rubbing against the surface of the board.  Things didn't go well at that point.  The gentle, soft surf of Waikiki with a close shore break was more my speed.  I had four good wipeouts, the last leaving me stranded on the massive, sharp coral garden.  I trudged painfully across the coral bed and dragged the beginner board along until the water was deep enough to paddle to the beach.  The tide was  going out so getting to shore was another rough struggle.  When I finally breached the coarse white sand of Tropical Beach  I'd drew a small crowd of observers who were pointing and laughing.    At least someone was enjoying this. I threw the big board down and dropped to the sand hyperventilating. I couldn't decide which hurt worse:  my burning lungs, my aching shoulders or the tens of coral induced paper cuts on my feet.  I pushed the board up on the sand and collapsed on my back in a small wooden pagoda at the edge of the beach.  My friend Pete was sitting there with my wife and son.
Surfy Rob, the instigator

"Kowabunga, dude," he said. 
"You saw that, huh?"
"Oh yeah. Nicely done.  If I were you I'd stick to yoga."
"No shit."

I closed my eyes  enjoying the heat of the Indonesian sun was on my face.  The burning in my lungs began to fade.  When  I started to fall asleep, my phone rang.  It was one of the Australian managers of the mine.

"Doc, G'day. Patrick here. I think I have a little bit of a problem."
I thought:  if you need me to move anywhere off my back right now, you have a bigger problem than you know.
"What's up?"
"Well I'm up on the hiking trails in the jungle behind camp.  I brushed by a tree and a bright green snake bit me on me arm.  Just happened about two minutes ago.  Whadya reckon?"
"He didn't have a pretty little red streak on his tail did he?"
"Well, I didn't get that friendly with him, but yeah I think he did."

Green Tree Viper.   Very pretty, very poisonous. We don't see them out in the open much, but they are all over our jungle and even in our gardens.  Sunday officially canceled. 

Here's a tree-full of bad news:  a Green Viper Mating Ball
"Patrick, sounds like you got bit by a Viper.  How big was he and how badly did he get you?"

(Insert typical Aussie, Crocodile Dundee comment of disaster underestimation here............wait for it.....) 
"Awwwwwww, he was just  a little fella, Doc.  Maybe a meter long. He's got me good though.  He was hanging off me arm.  I had to shake him off."
"How are you feeling right now?"
"A bit nackered from the walk.  Bit  hungover from the pub last night.  Otherwise not too bad."
"Okay.  Here's what I want you to do:  Stop moving around.  Take your shirt and wrap it around your arm snugly, but not so tight that it cuts off the circulation. Here's the thing:  If you start moving or walking its going to push the venom into your circulation. Lie down and keep the phone by you.    We'll come to you. I repeat, we will come to you.  Which kilometer marker are you near on the trail?"
"Bout half-way, Doc."
"Okay.  Call you right back."

I looked up at Pete.

"We got a Viper bite."

Displaying Compress IMG_0604.JPG
Sumbawa local.
Things needed to be done quickly and Patrick was far from the clinic where he needed to be quickly.  Pete called the  Emergency Rescue Team. I called the Jungle Clinic to rally the rest of the doctors and paramedics from the beach and whatever restful Sunday afternoon activity they were pursuing.  We try not to get too attached to a day off here.  I asked Rob to grab the trainer board and I hobbled to my car.

The clinic was only five minutes away, but raining season had made the dirt access road  muddy, uneven and full of holes.  I drove as fast as I could swerving around divots in the road as big as buffaloes.  My vehicle is a not-made-for-off-road Toyota Kijang family-van.   It swerved badly through the muck and gravel.  When I got to the gates of our village I laid on the horn and stuck my head out the window.  The security guards must have wondered what is wrong with this screaming white boy.  I told them, with my inept command of Indonesian language, that there was an emergency at the clinic.  They shook their heads and opened the steel gates to the townsite.

Imported from Thailand:
Tom Yum Antivenom
The doctors and nurses had already arrived at the clinic. I  barked ER preparation orders. I realized that I was still in my swim shorts, tank top and sandals.   I was getting clumps of sand on the ER floor.  Welcome to casual Sunday at the Jungle Clinic.  The paramedics set up the ER bay for a possible emergency resuscitation.  I checked the refrigerator for Anti-venom.  A year earlier I had hand-carried six bottles of Green Viper Anti-venom into Indonesia from Thailand. It was not available here.  I sweated during immigration and customs check in Jakarta.  My concerned was for detection of this product in my carry-on bag initiating a body cavity search in a hot back room.  As luck would have it I didn't get caught. (I also managed to get in two extra bottles of booze over the customs limit that trip.)  

I pulled out the package insert from the Anti-venom box.  Luckily it was in English.  This would be, if necessary, my first time administering anti-venom to a patient.  Back in Beverly Hills  the chances of treating a poisonous snake bite victim were few and far between.  Contrary to what you've seen on medical TV shows,  you don't just whack in Anti-venom  willy-nilly and send the patient on his way. Nearly ten percent of people who get Anti-venom are severely allergic to it.  Giving the drug can result in full  anaphylactic shock and death in those sensitive people.  Ideally Anti-venom is only supposed to be given in an Intensive Care Unit where a full resuscitation team can be scrambled.  We have none of these luxuries. We are in the middle of a remote jungle. We have a basic clinic with a basic ER. It is a one hour helicopter flight from the closest ICU if we can get there.  No flights happen at night.   Nobody gets off The Rock until daybreak.  Patrick was still out there in the jungle and it was closing in on three PM. If we couldn't get him off the island by four, it wasn't going to happen.  We were officially battling the clock.

Suddenly, we couldn't reach Patick.

I called his mobile phone five times with no answer.  Search and Rescue were already mobilized, but no word from them.  I was about to call Pete to see if he'd heard anything when his truck pulled up to the ER entrance.  Patrick was in the passenger seat.

Pete said, "If you want something done right, do it yourself."

It turns out that Patrick became bored and decided to walk the last kilometer on his own.  Pete found him sitting at the edge of the jungle.    I asked him which part of "don't move" was unclear.  He said:

"Awwwww, doc, it's just a little love bite on me hand! This was just a short stroll."

Here's why we don't want snake bite victims running around.  Keep this in mind the next time you are running around in a hot, remote jungle:  The only reason that people don't die immediately is the route that the venom chooses to take in the body.  Venom spreads through the lymphatic system.  The lymphatic system has no direct pump like the arteries or veins. It uses the motion of the surrounding muscles to massage and mobilize anything that gets into the system towards the heart.  Thus my advice to lie down and be still---even in the middle of the jungle. Wrapping the bitten area snugly can further delay the movement of the venom in the body.  So what is the worst thing that Patrick could have done?  Take a nice vigorous walk in the jungle in the height of the Indonesian heat at a time when we will likely be unable to get a helicopter to evacuate him from the island.  Suddenly the clock ticked faster.

Fortunately statistics were on Patrick's side.  Green Vipers only pump in enough venom to do serious damage (generally resulting in uncontrollable internal bleeding) about ten percent of the time.  Vipers are territorial and Patrick had gotten too close.   Hopefully this was just a “love bite” from a snake protecting his little piece of turf.   Keeping the venom out of circulation is important, but if so patients are still not out of the woods.  Viper venom can be locally destructive to the muscles and nerves especially when it happens near small vital structures.  There’s high risk of losing fingers and toes weeks later from severe Viper bites.

If you are seeing this,
there's a long night ahead of you
I hooked   up an IV and ran some blood tests that would suggest whether venom was already in his system.  They were normal---for now.  His arm was already painfully swollen twice its size.  This suggested that the venom had begun to work its way towards his heart.  We would  keep checking these tests throughout the night.  If the tests didn’t change for the next twelve hours it meant that he wouldn't need to risk potential anaphylactic shock from our Anti-venom--or that he’d bleed to death in my ER.  I’ve never had to give Anti-venom  and I didn’t want to start now in the middle of the night in a remote clinic in the jungle.

Five hours after Patrick’s arrival I decided he was stable enough to leave him with my junior doctor for a while.  I wanted to shower and change out of my wet, sandy beach clothes.   I was starving and hadn’t eaten since breakfast.  Outside the tenseness of the ER, the night was cool and silent in the village.  Just like every Sunday night.  My paranoia about snakes was at a new high.  I carefully shined a flashlight ahead on the dark  path  to my house and stomped my feet every few feet to scare away any invisible predators.  As soon as I kicked off my muddy sandals and walked into the house I got a text message. 

“Call me right away.  Bad news.  Curtis.”

“Now what?’ I said out loud to no one.

My friend Curtis was back in Philadelphia.  I stood in the middle of the room afraid to sit down and get sand on the furniture.  This call didn't sound like something I wanted to put off until I'd showered.  

“Curtis, hey what’s up?  I got your message.”
“Yeah, thanks for calling back.  I don’t know how to say this.  Jimmy’s wife just died.  I mean she killed herself.  I knew you'd want to know.”

Jimmy was a close, mutual friend of ours.  He was, and will always be, like our brother.  This made his wife Christine our younger sister and that was how she was regarded since we'd all met nearly fifteen years ago.  Christine was the party in every room she entered.  She was beautiful. She was funny without trying to be.  She was one of a kind and you couldn't help but want to be around her.  I’d seen her just six months previously on my last trip  to America.  She was, as always, Christine--happy, laughing, cracking me up.  I couldn't imagine going back to America and not see these two together.  It was always the highlight of my infrequent trips back home.  I couldn't believe what I was hearing.  Everyone who got this news, like me, died a little too. 

“What the fuck?  I mean how?  Why?”
“We don’t know yet.  Bunch of reasons, but its going to take a while to piece it all together.  Doesn't really matter now though.  Jimmy is in pieces.  He's not doing well.  When he wakes up tomorrow without her its going to be worse.  I’m going to stay with him for a while.  Its really not good.  When we start unwrapping the reasons she did it, its probably going to get worse.”

“I can’t get my head around this.  I don’t know what to say.  Is there anything I can do?”  I’m ten thousand miles away on the other side of the world. There’s obviously not fuck-all I can do for anyone back home.  There’s never a good night for a friend’s suicide, but there’s definitely some nights worse than others.
This is just fucking terrible.  Thanks for letting me know.  I’ll check in with you tomorrow and try to call him.”

I’ve been gone from America for a while and had no idea she was in such a bad place.  He never told anyone she was having a rough time and, understandably, didn't anyone to know.  I felt dizzy and stood  in the middle of the room.  I didn’t want to breathe, didn’t want to shower and I definitely didn’t want to go back to the situation in the ER.   Not tonight.  Not on this night.  What I wanted to do was rally around the good friends I still have. And be supportive.  And grieve like a normal person.  And be back in Philly where I felt like I could be marginally useful to my good friend--as he had been to me many times.  As fucked as I felt, I knew I couldn't fathom what he was feeling.  And I hated it.  I walked into my bedroom to get ready to shower.  My wife and son were on the bed laughing playing a game on the Ipad.  She asked me what was wrong.  I said, "Everything."

I took a cold shower and let the water run over my head for five minutes.  I felt  slightly getting dried seawater off my skin and sand out of my hair.  I was sad and disoriented, but life goes on.  Nothing I could do about Jimmy and his family.  Best tend to the living, I thought.  A mile away from here  in my emergency room there was  a serious situation going on.  I had to get my head back in the game.  I grabbed a pack of Tom Yum Goong noodles   smuggled in from Thailand (with the Antivenom). I’d eat at the clinic.  After this phone call  I wasn't hungry, but figured I better put something in my stomach.   It was going to be a long night.

Bad News Viper Bite
Back in the ER Patrick was beginning to sweat profusely. He complained about a severe headache. His blood tests were elevating, but remained normal.  I carefully examined his nervous system. Central nerve symptoms are the earliest sign of big trouble.  His arm began to ache and throb.  This was either the effects of the venom or pain from not moving it for six hours.  I loosened the ace bandage I’d put on him earlier.  Sure enough there were two distinct fang marks and the area surround them was bruised and purple.  This meant that there was definitely some venom injected.  There was no way of knowing how much.  We were getting closer to the point that he would need the Anti-venom.  I gave him a dose of intravenous Cortisone in preparation.  If he was one of the unlucky people who needed anti-venom and was allergic to it, the cortisone might be enough to save him from anaphylactic shock and death.  I carefully set up the Anti-venom, dilution water and IV supplies along the counter next to his gurney.  Fifty percent of battle of emergency response is preparation.  The other fifty percent is a clear head and a lengthy panic threshold.  There was seven hours left before daybreak and the opportunity to get him off the island.  If there was going to be a problem it would happen in the next four hours.

The junior doctor and I took shifts in the ER that night.  It was all about watching the monitors, checking the physical signs and doing the blood tests. When it was his shift I went to my office and wrote an email to Curtis.  I wanted to see if there was anything I could do for Jimmy, but mostly I just wanted to vent my feelings and frustrations.  Nothing made sense.  One guy in the next room was facing death and doing everything to stay alive.  Across the ocean a beautiful, lively young girl took her own life in a few seconds of a bad decision on a very dark day.  All the love I had for her--for them--turned into pain today.  Going home was never going to be the same.  It could never be.

Cobra Under Glass:
Popular favorite.
Morning came not quickly enough.  Patrick remained stable.  His blood tests  showed no  signs of systemic envenomation.  At sun up I took out his IV line.  He had been lying in bed in a puddle of sweat and mud for sixteen hours. He could no longer stand his own smell.   The clinic driver had not yet come to work so I drove Patrick home in my car. I asked him to come back to the clinic after he’d showered.  I’d be doing the same.  That's how we do it here in the small village in the middle of this island in the middle of nowhere.  We all work and play and socialize together.  There's rarely a patient who is not a friend or a child of a friend.  There's every  chance that an emergency will turn horribly personal.

When I got home my wife and son were awake.   She was cooking him breakfast before school.  She told me I looked terrible.  I told her about Christine, but I didn't have time to talk about it.   I had to drive my son to school and go back to work.  Just like every other day.  I was exhausted and only then did I notice how sore my back and chest were from my failed surfing endeavor.  That surfing session seemed like it was a  week ago, yet twenty four hours had not yet passed.  If this was my day off, I’d prefer to be at work.   Days like this make you older, I thought.  I don’t want to be that old.  There were six more days until next Sunday.  Maybe the next one will be a real day off.  It had to be better.

1 comment:

  1. Sorry for the loss of your friend, glad the Aussie lived to see another day, the viper mating ball is going to give me nightmares, and as usual, love reading about your life on The Rock. Peace out Erik, Jami