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.

God Makes Boys, Mothers Make Men

They say it’s the squeaky wheel that gets greased and we men do a lot of squeaking.

I've written about my father before.  First medical man in the family; hero to the poor and sick of Camden, New Jersey. The driving force behind my career practicing medicine across the globe.   I've realized recently that I'd been remiss by not writing about the influence behind the influences;  the greasers of the squeaky wheels;  the persons responsible for keeping all the plates spinning while the rest of us  pretend that it happens all by itself:  the Mothers.  More specifically, my mother:  Rochelle June, of Brooklyn, New York.

My family comes from a long line of tough Ukrainians, especially the women.  The first to step foot on American soil was my great-grandmother Fagel Ellman from Odessa, Ukraine. At thirteen years of age Fagel landed in  Ellis Island, the port of immigration in New York City.  She and a cousin boarded a slow boat bound for America  in 1900.  After arrival and documentation, she stayed with cousins who were living in the Jewish ghetto of Brooklyn.  Her parents were already dead, but we never knew how or why it happened.  Fagel would never speak about it even to the day of her death.  All we knew was that it was terrible and occurred at the time of massive purging in late nineteenth century Russia. Though she was intelligent, she was not given the opportunity to  attend school or learn to read and write English. She began working in a small local dress shop and stayed there for years earning enough money to live on her own.  As a young woman she married a local laborer named Pinya Cohen, also originally from Ukraine.  He died just before I was born.  Eventually Fagel learned to be a midwife and was  responsible for the births of the pregnant women in the ghetto who could not afford to visit a hospital.  She and her husband bought a small brown-stone building in the Flatbush section of Brooklyn.  It was there that my earliest and fondest memories of my family were forged.  It was like Odessa in Brooklyn and always smelled of  Borscht and freshly baked Challah bread. Fagel was a brave, self-made woman   and though she’d experienced horrific hardships, the only thing she ever complained about was her arthritis (de rigueur for any Jewish grandmother).

Of all Rochelle's jobs, this is her favorite.

Her daughter, my grandmother, was Betty Zeig.  She was born, raised and spent ninety-eight percent of her life in Brooklyn, New York.  She contracted Polio as a two year old and nearly died.  Polio left her with a bad and permanent deformity of her right leg for which she would wear a brace her entire life.  While in her sixties she fell and broke the disabled leg twice.  Each time she just pushed forward with a smile saying "What can you do?" As children we'd listen excitedly for the creaking and clanking of the brace to know when she was coming to the house.  Each visit promised a chance to rifle through her purse where hard, colored candies and square sweet Toffies lay in abundance.   She worked full time and, like her mother, didn't complained for a moment.  The thing I remember most about Betty Zeig was that she never had a bad word to say about anyone.  Even  those who had it coming to them.  When the talk  turned negative and gossipy she would change the topic by shocking the listeners with an off-color, racy joke that had no business coming from the mouth of a grandmother.  She was another intelligent, confident, strong lady and  the most loving woman I've ever met.

This brings me to the point of this story: my mother, Rochelle June.  She is the glue that holds the machine together.  Without her tireless attention to detail, devotion and love we would have been deprived of a father for at least the last ten years.  And if he is a great man, it is because she was there to make it possible.  But this is only the end of the story……………………………

My parents combined education included attendance in every city college and university in New York City.  Statistics showed that Rochelle June was the brainier of the two and was heading on a direct course towards a career in medicine.  Edward meandered between teaching, accounting and  gigs as a piano player before deciding to become a doctor at age 32.  As children, Grandma Betty Zeig would remind us constantly that Rochelle only ever got one grade less than A in her entire scholastic history.  This was a fact that created endless anxiety when  report cards came around.

Where it all started

Both Edward and Rochelle were headed for a career in medicine at the same time, but the money was tight. They grew up in post-Depression New York in homes that were only one generation separated from poverty. They knew the value of working hard, saving what you can and spending what you must to survive.  Admittedly, mom was better at this concept.  There’s a famous family story about the day they were down to their last fifty cents for the week. My father grabbed it from the kitchen counter and used it for cigarettes.  

Mom remained ever vigilant and conscious of spending.  She made money by working in an animal research lab at the medical school attended by my father in Kirksville, Missouri. On weekends she’d take the rabbit  clippers home and use them to give my brother and I haircuts.

There was not enough money or loans for both of them to go to medical school at the same time.  The plan was for Edward to go first and Rochelle would follow.  Then along came my older brother.  Then me.  Then my sister- all  within five years.  Plans changed and money got tighter.  Mom’s dreams of becoming a Pediatrician changed to the reality of being a mother.  She swears to this day that she is happy with the way it worked out and says she wouldn't have changed a thing.  If it bothered her (and I don't see how it wouldn't), she would ever let us know.  She did become our Pediatrician though.  For as the shoemakers son goes barefoot, so does the doctor’s child occasionally remain sick-- if not for the shoemakers wife of course.  Mom’s diagnostic and prescribing skills were epic and if not for the days we were faked illness, we would have rarely missed a day of school. Even neighbors brought their kids by for her evaluation.  We all knew she would have made a world class Pediatrician.

She was, and is, surrounded by the men in her life living what should have been her  career dream.  Her brother, her husband and her two sons were all doctors, all with successful, interesting careers. I know it must have been hard for her to give up her dream, but as with the other strong women in our family, she never complained.  Twenty years ago she decided to immerse herself in the study of “alternative” medicine. This choice was often subjected to  chagrin and ridicule by members of her family who remain  deeply embedded in Western medical science.  By chance she met a  talented “Chi Gong” and Chinese Medicine master  and helped him establish a hugely successful American practice. Ultimately his practice catered to some of Hollywood’s biggest celebrities and a few famous Fortune 500 executives.  Mom studied with him and soon enough all the antibiotics in the house were replaced with organic Silver compounds and horrible smelling potions, powders and teas.  When my father was diagnosed with advanced, Stage Four prostate cancer she began treating him with with daily tiny “bird peppers” instead of chemotherapy, radiation or hormone treatments.  Amazingly the cancer was diagnosed as Stage Four over fifteen years ago and has never progressed.  Thus her informal practice began to grow and those seeking medical advice from our family only turned to those of us with Western medical degrees when mom couldn't handle it.  She solidified her position in alternative medicine by going through the rigorous ten week training to become a certified Bikram Yoga teacher at the age of sixty-three and still teaches well into her seventies. But this was reallyanything new for Rochelle.  She was the founding member of the Yoga Research Society in Philadelphia in the mid-1970’s which was the first of its kind to investigate the documentable scientific health benefits of yoga.  She was a pioneer.   She may not have held a Western medical degree, but she had no shortage of patients.

Real Ukrainian women don't fear tigers!

I’m an open-minded doctor and have practiced alternative medicine as well in my career, but even I scoffed at some of her theories now and again-- only to be corrected.  Once, while skiing, she took a bad fall and broke three major ligaments in her knee.  An MRI of her leg showed complete disruption of the ligaments as though they’d been cut completely by a knife.  I saw the MRI with my own eyes. All the learned doctors in her life told her to go for surgery as it was the ONLY  means of treatment.    When she said she’d rather try alternative medicine first we all angrily ridiculed her.  I told her it was like cutting a rope in two and waiting for the good will of mankind to piece it back together.  I implored her again and again to get it fixed, but the stubborn Ukrainian part of her said no.  She’d do it her way.  She went for weekly Chi Gong treatments from her friend and did her own exercises and meditation at home.  She received acupuncture and drank teas and potions that smelled like boiling garbage and must have tasted even worse.  Six weeks later she had another  MRI and the ligaments were completely healed. She was back doing yoga in seven weeks.  I don’t think any of we learned medical men admitted we were wrong (doctors don’t generally go down that dead end path), but we knew we were.

For keeping my father alive and with us for so many extra years we, her children and friends, can never thank her enough.  If not for her moment to moment care after his heart attacks, kidney failure, dialysis, prostate cancer, bladder cancer and heart failure he would not be here today.  This is  not the first time she’s done such loving care.  When Grandma Betty Zeig developed terminal breast cancer in her eighties, mom moved her into the house and cared for her until the day she died.  Rochelle will just tell you that it was just the right thing to do.

The extraordinary adventures of Rochelle June could fill volumes of books and still would not do her justice.  It wasn't until I had my own family that I truly appreciated what she’d done for us-- how she’d sacrificed and  thrown herself into our well-being without regret or complaint. I see my own wife doing the same thing now. As a man it baffles me and makes me comfortable at the same time.

Men make adventures and women make families.  I've recently changed my mind regarding which is more important. 

God makes boys.  Mothers make Men.