EVAC!

                                      
I had big plans last weekend.  Actually anywhere else in civilization they would be considered normal plans, but here in the Indonesian jungle they were huge plans.

It was the weekend of Australia Day.  As we are inundated with our Australian brethren here (as is much of Indonesia) it was not unexpected that an American brother would show solidarity.  Also it was the only thing happening in town.  This would be the social weekend of the year.  There would be an Australia Day Hash Run   (For those uninformed, Hash Running is a drinking club with a running problem) and Games to follow. At night there would be a party with a local Indonesian cover band at one of our three possible basic local beach pubs.  The next day would be an Aussie Day Meal at our only campsite pub, The Base Ate (pronounced Bah-say  Ah-Tay, but  more commonly referred to as The Busted Arse). I could almost smell the meat pies and Vegemite on the horizon.

Things did not go as expected.

Finely tuned athletes
on a Hash Run.

I left early Saturday morning for my clinic.  When you are on-call 24/7 for three months at a time there are no true weekends.  They say at this mining camp, if you don't go to work on Saturday, don't even bother showing up for work on Sunday.  My wife and sons were still asleep when I left.  Work was light and I headed home at noon.  Let the weekend commence.  When I arrived home I found my wife with a troubled look and my one year old, young Jonah, in tears with blue fever reliever patch on his forehead.

"He was crying allllllll night," she said, "and has a high fever.  And diarrhea seven times. And he has a big lump on his butt."

The Baby Trifecta of Terror:  fever, diarrhea and a big lump on the ass.  I quickly removed my father hat and changed to my doctor hat.  Let's have a look at this.  I examined him and sure enough there was a horrible, enlarging red lump (nonclinical people forgive me for this description) directly next to his anus.  When I touched it he screamed and looked at me with baby daggers.  He had a fever of 104 degrees (40 degrees Celsius). I diagnosed the little guy with a serious infection and abscess of his bottom that could likely be affecting his large intestines.  Infections like this can grow in the skin and eventually tunnel directly into the large intestine.  With this kind of fever the infection had likely already entered his bloodstream. Untreated it could result in Septic Shock.   It was time to move this situation to Defcon 3.

Were this your child you would bundle him up and drive to the local emergency room.  A doctor, like me, would examine him, monitor him and call in the Pediatric surgical specialist to save the day. My emergency room is only a three minute drive through the jungle, but the Pediatric surgeon I needed was three hours, two flights and one country away in Singapore. Further complicating this scenario, the first flight must be via single engine Seaplane.  Our only Seaplane had been grounded all week due to bad weather and big waves hampering take-off from the ocean.   Either of these factors can put the small eight seat aircraft quickly into the side of the surrounding mountains.

This was one hundred percent going to be a Medivac.  I've arranged Medivacs like this hundreds of times in the last ten years with my company, International SOS.  We are arguably the best in the world at it.  On the scale of severe cases this was not the most serious on the list, but when the patient is a sick baby the stakes are always higher. Kids turn bad quickly.  My great personal struggle was now playing doctor and telling my inner-Father to shut the fuck up for the sake of efficiency and sanity. Many things had to be done quickly. Daylight was burning.  No plane, nor helicopter, nor boat can leave our island after sundown.  If we missed that window of time it was going to be a long, hard night in my ER.  Essentially I did not want to be doing emergency surgery on my own son's ass.  The s reasons that doctors don't treat their own children is obvious:  clarity, emotional attachment, altered judgement.  But here in our remote jungle I'm the only Western doctor.  I don't have the luxury of choice.

There was some serious multitasking to be done.  I told my wife to pack a bag for her and the baby right away.  Then I   put the wheels in motion for the medical evacuation.  I needed flights that were as direct as possible with as little transit time as possible.  I needed transports between the flights and I needed a proper Pediatric specialist in Singapore.  I packed a cursory bag of clothes for myself while I spoke to my office.  I still had another son at home to consider.  He would stay with his grandmother who was fortunately visiting at the time.  My wife and I rushed to the local shop at our camp to make sure we had food at home for them. Raining season has been a bad one this year and we didn't want them stuck at home without food. I received a call while we shopped.  The Seaplane was available, but wheels up was in forty-five minutes.  The only flight available today.  If we headed to the port now it gave us fifteen minutes to spare.  I'd worry about the next flight once we were in the air.  Right now we just needed to get off the Rock.

Besides the obvious there was one more issue.  Either myself or another Western doctor are contracted to be physically available on The Rock at all times.  There is no end to the serious injuries, diseases, traumas, fractures, pregnancies and, of course, sick children that roll up to the clinic daily.  I take this responsibility seriously.  The place is small.  Most of the patients are my friends.  If I wasn't here during an emergency for one of them or their children I don't think I'd be able to forgive myself.  I've never left a medical post in my life--not during hard weather, disaster or impending violence.  But this was  about my youngest son.  Where he goes, I go.  No matter what.

We packed up the car and bundled up the baby.  The access road to the port was gravel and dirt and had been badly gouged by heavy equipment and heavy rains.  I sped to the port, winding and dodging crater-sized potholes.  I stuck the magnetic blue rotating emergency light on my vehicle and passed around the slower cars and trucks.  For some reason the thought of missing freshly baked Australian meat pies flashed into my brain.  I shook it off.  I was  stressed and needed to focus.  On the way to the aiport my office called with the rest of the flight options.  There was a flight to Singapore from Bali in ninety minutes.  If we missed that we would have to wait another five hours.

At the port they were starting to load the plane.  My son was crying and uncomfortable and as timing would have it he had shit himself again.  I walked to the plane and got the pilot's attention.  This is a small town.  I know all the pilots.  They do all my other  evacs.

"Mate, not to put any pressure on you, but my boy is sick and needs a surgeon.  In ninety minutes we need to be on a plane headed to Singapore."
"Right O," was all he said.

The flight to Bali's airport is only forty-five minutes, but we had to stop at the next island first to drop off some scheduled passengers.  We stopped at Lombok International Airport and every passenger except us left the plane.  I stared at my watch hoping it would magically slow down.   It was going to be tight. The ground staff was painfully slow unloading the plane and giving the pilot more information.  He told them in no uncertain terms to get their asses moving.  We had a sick child to be moved.  He started up the plane and headed to the runway.  He said, "Mate, we'll do our best."

Thirty minutes later we were on the tarmac of Ngurah Rai Airport in Bali. During flight I called and requested that an airport official meet us at the plane to help smooth a faster  transit to the international terminal. The terminals were far apart and there would be throngs of people to wade through.  We had forty minutes to make it on the plane and tickets had not yet been purchased.  I ran ahead with the agent and our bags. There was a Garuda Airlines flight with open seats.  My heart sunk a little.  Why did it have to be Garuda? Anyone, but Garuda! I've never had a good or even reasonable experience with Garuda, Indonesia's national airline. Their lack of competence is only exceeded by their complacency. They tend to maintain their number one status because numbers two and three tend to keep crashing.  But this was all we had and it looked like it was going to work. Then Garuda Customer Dis-Service got involved.

The baby had spiked another fever so I asked my wife to give him some more Ibuprofen.  She sat down in front of the ticket counter to get the medicine from her bag.  Enter one of Garuda Airline's highly trained staff.

"Sir, this is your baby."
"Yes."
"He is sick."
"Yes, thank you for that.  I know he's sick.  I'm bringing him to Singapore for treatment.  It's okay.  He only has a fever.  It's safe for him to fly"
"Sir, he is too sick to fly.  How do you know it is safe?"
(Vital seconds ticking away until the flight will leave)
"Because I am his doctor.  I'm his Medical Escort to Singapore."
"Ah, but you said he is your son."
"Yes he is my son."
"And this is your wife.  But you are his doctor."
"Yes."  (Calmly biting tongue.)
"But this cannot be.  Who is his doctor?"
"I am."
"You said you are his father."
"Yes I did.  I am his father and I am his doctor.  Can we get this thing moving along.  We are running out of time."
"Sir.  I cannot let this baby fly.  He is too sick."

Then I broke.  I was sitting on the floor helping my wife give the boy medicine.  I dropped the medicine and stood up.  I got within inches of the man's face.

"Stop talking and listen to me," I said calmly, but forcefully, "I run a clinic on the island.  This is my patient. This is also my son.  I am his medical escort and I am also his father.  I am his doctor.  I am the one who is going to take him SAFELY to Singapore to see his doctor.  How many more frigging ways do you want to hear it???  Do you need a note?  I'll sign a note.  HE..........IS........FIT..........TO...........FLY!"
"Are you a doctor?"
"Really?  Listen, pal, get me the form, take a copy of my license, whatever!  But he's getting on this damn flight.  You are supposed to be customer service!  Not customer obstruction!"
"Sir!  We are not used to this kind of behavior!  You cannot step to me like this! It is not how we do things here."

I held my tongue.  Whatever I was going to say next was not going to get my son on that plane and was going to land me in the security office.  I just looked him in his eye.  Whatever he saw there made him reconsider, but not without the requisite Saving of Face.

"You will have to sign a form!"
"Make it happen.  We are running out of time."

With tickets in hand we headed to the gate.  I muttered a 'fuck you very much' under my breath as we walked past his office.  Childish, I know, but satisfying.  Our gate was the last one in the wing furthest from the ticket office.  Our tireless airline agent stayed with us through this entire episode  until we boarded the plane.  At least he knew that you never leave your Wingman.

Once on the plane we began to relax.  The flight was fairly empty.  My little guy was miserable.  His fever was slow to resolve.  As a doctor I had this situation under control. He had antibiotics onboard and his fever was being treated.  I was close to completing this mission. As a father, though, it was far from over.  I began to re-suffer the guilt of raising this child in less than the safest of environments.  He was born in Bangkok because there's no birthing capacity here on The Rock.  I brought him to this remote Indonesian island by helicopter when he was six weeks old.  I had to squeezed an oversize pair of protective earphones over his ears during the trip for fear of damaging his eardrums with the noise of the rotors.  I've been on the other end of every vaccine injection he's had and every infant examination for the past year.  Now I've gotten dangerously close to having to perform emergency surgery on  a very difficult and sensitive area of his little body.  If he's looking for issues to talk about in therapy, I'm  front-loading him with plenty.

Post op fatigue.

Two hours later we were in the Utopian Republic of Singapore.  Our transit through the airport and immigration was so smooth and quick that I was tempted to stop in Duty Free for some well earned high end whiskey. The International SOS transportation team was patiently waiting for us just outside of customs.  We jumped into the waiting van and sped off to Mt. Elizabeth Hospital. It was nearly nine PM when we arrived. Magically his surgeon, Dr. Chui, was patiently waiting for us. The sense of competence and civilization and commercial choice in Singapore was dizzying.  I've been in the jungle for so long I nearly forgot it existed.  I felt giddy as though we were bathing in the divine light of choice.  (I should add that my wife, who grew up in rural Thailand, experiences this whenever we enter a New Jersey liquor warehouse.)

The doctor side of me successfully handed off the patient to the surgeon in stable condition.  The father stuck around and worried.

Dr. Chui is a class act.  He had that kind of demeanor that informed and reassured at the same time.  I  hope I come off  the same way to my patients.  Inside my brain the fight between listening like a father and responding like a doctor continued.  He presented the surgical and treatment options.  This infection likely went all the way through to his anus.  He would have to open it up entirely.  I asked him what he would do if it was his child.  He said he'd bring him to a  doctor he trusted.

We stayed at the hospital and the little guy went to surgery the next morning.  My wife cleaned him up and dressed him in the over-sized gown they'd left by the bedside. For anyone else's child I would rest assured it was a relatively simple procedure. They let  my wife take him into the operating room and hold him until the anesthesia took effect. The surgeon told me up front that he didn't let fathers into the operating room even when they are doctors.  I told him he didn't have to worry about me asking to be there. My boy was out of surgery in less than an hour.  He had an intravenous catheter in his hand.  They had wrapped it safely in five layers of bandage and put an arm board in to keep him from pulling it out.  He hated it.  He would get antibiotics though this until his fever stopped.  He still had the dangers of bacteria present in his blood.  Then we were trained in the not so pretty aspect of his post-operative care:  every time the little guy moved his bowels we were instructed to fill three large syringes with water. We then had to put the tip of each syringe as far as possible into the wound at his anus and spray the water hard to clean out the deep part of the wound.  None of us were a fan of this process.  He screamed bloody murder and looked at me with an angelic face questioning why I would ever do this to him if I truly loved him.  He wouldn't look at me for twenty minutes afterwards. It was rough and it was messy, but had to be done.

The worst was over, but there was drama occurring on another playing field.  My replacement, Dr. Mike, was mobilized immediately to cover my clinic.  Only an hour after he arrived on the island a man was nearly crushed under a two ton  machine and sustained multiple serious fractures and internal injuries.  Dr. Mike and my Indonesian counterpart, Dr. Anneke, like all our field doctors in International SOS, were cool and competent. They worked well under pressure and applied the emergency life-saving procedures.  Along with our medical team they stabilized this man's injuries and immediately evacuated him safely to an emergency surgical team in Bali. They saved a life.  I could not help feeling a little guilty that I wasn't present during this trauma--not just because I know I could help the man, but oddly enough because I  hate missing the action. Its the measure of the job.

I stayed in Singapore for another two days until my son was stable and the fevers were gone. He was in good and competent hands.  My wife would remain in Singapore with him for a few more days of observation.  I reluctantly started the long trip back to The Rock.  The fastest way to get me there was from Singapore to Jakarta to Lombok and finally Sumbawa.  The trip took two days total.  Civilization seemed to diminished with each stop.  I arrived in the morning and took over  from Dr. Mike.  I thanked him and Dr. Anneke  for their heroics in my absence. They are stars. There was no rest for the weary. It was a busy day at the clinic and I hit the ground running.  At the end of the day I visited my neighbor, Pete.  He opened a bottle of Jack Daniels Gold Select to celebrate.  He said I looked like shit. I told him I felt like shit.  I don't ever remember being that tired.

If you  bring a small and fragile baby into the jungle you tempt the fates.  There's no way around that.  I suppose one of the reasons I'm here is to mitigate that risk a little.  Its not possible to remove it entirely. The company wants those living here with families to feel safe.  It lets them keep their minds on the job and not on the fears and hazards of the dangerous paradise in which we live.  I know that I can handle most things that come into my clinic.  And I know what I can't handle.  That's just as important. When its time to evac, we do it quickly.  We are  damn good at it.  Time is everything in these cases.  There were a hundred "what if's" going through my mind that day.  What if this happened after dark.  Or if the storm  from the previous day had grounded the plane.  Or if that asshole at Garuda has really prevented us from taking that flight.  In my mind I had contingencies.  I'm paranoid by nature so I always have contingencies.  A friend of mine many years ago told me that the secret to happiness is to have alternatives.  I didn't know what he meant back then.  If we didn't make it out of here I would have done the surgery.  I would have rounded up my young crew here, given the anesthesia and removed the abscess.  I would have stuck a difficult, painful intravenous in my fragile little boy and given him.antibiotics.  I wouldn't have done it as well as a Singaporean surgeon, but I would have made it work.  And I would have a hundred more tense and stressful memories floating around my brain that I don't need as a father. I'm growing weary. The question is no longer whether I can do something.  The question is whether I should have to.

Trust me.  I'm a doctor.  On an island.