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.