Authors: Pamela Grim
The events described in this book happened, but some of the names and identifying details about persons and entities depicted in this book have been modified or presented in composite form.
Copyright © 2000 by Dr. Pamela Grim
All rights reserved.
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Originally published in hardcover by Warner Books, an imprint of Warner Books, Inc.
First eBook Edition: January 2002
Warner Books and the “W” logo are trademarks of Hachette Book Group. or an affiliated company. Used under license by Hachette Book Group, which is not affiliated with Time Warner Inc.
ACCLAIM FOR JUST HERE TRYING TO SAVE A FEW LIVES
“Spellbinding…gritty…after a few chapters, TV's so-called slices of emergency-room life begin to look like a tea party.”
“Descriptive language and a vivid narrative style…fascinating reading.…Her colorful descriptions are worthwhile reading for all.”
—from a review by Linda A. Khym, M.A., in the
New England Journal of Medicine
“While the medical know-how is impressive in these dramas…even more so is Grim's humanity.…An acute observer and a compassionate doctor [who] pulls no punches…brutally realistic.…Readers can only hope she doesn't stop writing.”
“Reads like dispatches from the front.…Pamela Grim has peered into our contemporary heart of darkness and in so doing has illuminated us and herself as well.”
—Marc Flitter, M.D., author of
“Transcends reality TV…a fascinating tour.…Grim's pacing is sure, and her writing is deft and often lyrical…introduces us to characters and scenes we can see vividly.”
“Excellent.…If you enjoy shows like
then you will really enjoy Dr. Grim's confessional…will not only make you feel for the patients but the doctors and nurses who care for them.”
“Compelling, taut, and well told.”
“A gripping real-life book…heartbreaking…insightful, humorous…maddening, touching, and inspiring.…Do the rewards outweigh the costs? I urge you to read and find out.”
“Fans of the popular TV show
are sure to like this book. Those who wonder how difficult it is to be on the front lines of medicine will come closer to an understanding after reading this book.”
—Salt Lake City Deseret News
“Impressive.…Grim captures the drama, conflicts, and life-and-death scenarios that happen daily behind the scenes.”
“Gripping detail [and] bold simplicity…told with clarity and intensity.…The images Grim creates are stunning and authentic.”
—Sarasota Herald Tribune
To Al, Barb and the other Pam.
T'S TEN AT NIGHT
and I am making a run back to the hospital to check on a patient. Two new roadblocks have been set up since the night before. They don't even seem like roadblocks, really; it's just the lights shining in our eyes that make us stop. It could be anyone behind those flashlights—we can't tell even when we pull up. Only by straining can we see the soldiers. Our driver rolls his window down and waves our paperwork. There is a long exchange in Hausa, and finally a black face, washed out by the glare of the light, says,
“ Médecins sans Frontières.
Oh, oh, well, okay.” He waves us on.
I am in Nigeria with Doctors without Borders, an international humanitarian organization widely respected as a provider of medical care to various third and fourth-world countries, often under hazardous circumstances. We are here doing crisis medicine, handling a meningitis outbreak in the heart of the sub-Sahara. The outbreak is killing thousands and thousands of people, and we have come because the Nigerian government is unable (read too inefficient, corrupt and useless) to muster anything near the resources needed to fight back. There are about thirty of us expatriates in Kano, five doctors, ten nurses and the rest “administrative.” Unfortunately, there were not enough of us to begin with, even before the cholera cases started.
I am an emergency medicine physician; I have been for over ten years, a long enough period of time, I have discovered, to forget why I went into the field to begin with. Over those ten years 1 have played trauma doctor, social worker, breaker of bad news, heart failure doctor, Band-Aid placer, substance abuse counselor, frontline medic, post-traumatic-stress victim and a thousand other roles. The result was not surprising: I needed a change. I needed a new perspective. Hence Africa.
To be honest, before I came here I had imagined an experience I thought to be very Albert Schweitzer-like. This image had me working in a jungle camp of friendly natives where I serenely administered vaccinations under a tented canopy of brilliant green leaves. The truth: it is a squalid disaster here. We are understaffed and underequipped. The hospital we use had been closed for fifty years. Our staff is made up largely of Nigerian nursing students, most of whom have never even seen an IV before, much less started one. There is no sanitation, no windows, dirt floors, a single hand pump for water, and flies everywhere. Overall we have at least two hundred patients at any one time, but that is just a fraction of the total number of victims. The mortality rate averages about 20 percent.
But it would have been 100 percent without us.
The meningitis outbreak is not a pandemic, not quite on the scale of the cholera outbreak for Rwandan refugees in Zaire, but even so, every morning I have to clear away the dead or the near dead from the front porch of the emergency clinic to make room for the dying. I am currently in charge of the meningitis “emergency room,” formerly a one-room post office. I examine everyone on a bare wooden table, where I also diagnose, treat (chloramphenicol and/or ampicillin) and arrange for a “bed.” (Usually a bed is a piece of swept earth. The few beds we have sport only bare wire springs, no mattresses.) When I first arrive in the morning, it is so busy that if someone dies inside the clinic we put him or her on the floor and just step over the body until the relatives come to take it away. The atmosphere is that of complete chaos, but we have saved lives here, in this small room and throughout the hospital. We will save more, if the government allows us to stay on.
There's a measles outbreak as well.
We see most of the desperately ill in the morning. They come in early, after curfew lifts, and they sit and wait for me. The first hour is always a disaster. I wade down the hallway doing triage. “This one's sick, get him in now.” “This one's dead, forget it.” “This one's almost dead, just leave him be.” To the families, it must seem as though we are passing judgment from on high: this one lives, this one doesn't. I don't think they have any idea what it is I see in each patient when I pass my sentence. I don't know if they know it has nothing to do with me at all, that I have no special power. Still, they accept what I say. No one argues, or rarely do they; no one pleads with me to change my mind, to take one more look. No one reaches out to hold me back, to convince me. Everyone in this line accepts the judgment I pass on to them, even if it is a death sentence.
In the afternoon I round on my intensive care verandah and three intensive care tents. These are where most of the critical cases are, not that we can do a whole lot of intensive care.
Médecins sans Frontiéres
has shipped down over four tons of supplies, but it is pitiful to see how little four tons of supplies is for those of us who practice Western-style medicine. We have liter bags of normal saline, IVs, IV tubing, and a few drugs: ampicillin, phenobarbital, Valium and paracetamol—a form of injectable Tylenol. The backbone of our therapy is something called oily chloramphenicol, an oil-based slurry of a venerable antibiotic; it is long lasting and dirt cheap. Listing what we have makes it seem like a lot, but simple things go missing. For example, we have no tape to tape the IV catheters down. Fortunately, someone at the start of the mission figured out that you could take the labels off the saline bags and tear them into strips. With these strips you can tack the IVs in place. We also have no gloves—but this may be, partly, a cultural thing. The first day I worked, the first time I went to start an IV, I looked around automatically for the glove box—de rigueur in America. There was nothing like this, so I asked Pierre, our chief logistician and head of supplies, for gloves.
He gave me a funny look. “Gloves?” he asked. “You're just starting an IV. What do you need gloves for?” He shook his head and raised his eyes heavenward. “Americans,” he said, tapping his forehead and walking away.
I started after him.
“ ‘No gloves’ is not an American thing, it's a French thing. You guys are crazy”
He didn't look back; he just raised his hand over his head and waved at me. “Okay, okay,” he shouted back to me.
He found me a box of gloves.
The other French thing is the smoking. I had dinner before I left with another American who had spent six months in Burundi with a French crew. I don't know what his medical experiences were like because all he could talk about was how much the French smoked. “Meetings, dinner, lunch, at work, after work, in the wards, in the
for Christ's sake.”
The first thing the mission director asked me when I arrived was: “You don't have that American thing about smoking, do you?”
I raised my hands. “No, no,” I said, “not at all.”
This apparently was all the mission director wanted to know from me. Afterward I never saw or talked to him again.
Back in the car, we continue on past the roadblock, down a street lit by the shallow beam of our one working headlight. The shops and stores that line the main roadway are all shuttered. This is a street that is packed with hundreds and thousands of people during the day. It's dead quiet now.
Pierre, of the gloves argument, is sitting in the backseat trying to read some shipping labels by starlight. As the chief logistician, he has the unenviable job of trying to maintain some small degree of order in a whole sea of African chaos. He is returning tonight to bring in a fresh supply of oily chloramphenicol. I am going back to see a patient who, with luck, might still be alive. I admitted her just before I went home. A little girl. I had been starting an IV on an older woman, deathly ill from meningitis (she died about twenty minutes later), when I looked up and saw a young couple scurry across the open field in front of the ICU tents. I waved them over and they stopped breathlessly before me. The man handed me the bundle he held in his arms. It was a baby, maybe eight months old, and the baby was seizing. Great spasms, with arms extended, joints locked and legs twitching. She could have been seizing from anything, malaria, meningitis, cysticercosis, even a simple febrile seizure. What to do?
In the U.S. the workup would begin now: hundred of dollars of laboratory tests, x-rays, IVs. The poorest child in America would have a bed covered with a spotless sheet and a half dozen people crowded around it, trying to save someone's precious baby. But
baby, now, was examined on a mat on the ground with flies everywhere. The only diagnostic tool I had was my stethoscope. I couldn't look in the child's blood for signs of malaria. I couldn't tap the spinal fluid to make certain of a diagnosis of meningitis. (After the first week, when the epidemic was confirmed, we never tapped anyone. There wasn't time or equipment. If the patients were sick, you treated them for meningitis. If they didn't have meningitis, they would die.)
I squatted down by the child and pulled down on one arm while Simon, my nursing assistant, knelt down over the other. We had to use old IV tubing as tourniquets; there wasn't anything else. Simon and I squatted there, tap, tap, tapping the arm, up and down, looking for a vein to administer the IV. Babies this age are the hardest, even when they are not seizing. Their veins are thread-like and deep under the skin. This time I got one in before Simon. Usually he's a much better shot.