CHANGE OF SHIFT
“First Aid? Please? First Aid?” Anand Selvam, MD* *Corresponding Author. E-mail: [email protected], Twitter: @TeahouseTrekker. 0196-0644/$-see front matter Copyright © 2015 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.08.016
[Ann Emerg Med. 2015;65:337-338.] “First aid? Please? First aid?” The cab driver grabs me and starts running in a zigzag pattern through the crowd. “Follow me!” he shouts behind. A crushing wave of people surrounds me, and hawkers strike from all sides, yelling, “Mzungu, Mzungu!” In many parts of East Africa, this idiom designates a foreigner or outsider. As we approach the bus, a crowd begins to surround me and the ticket agent. The cab driver grabs my money, thrusts it on the ticket agent, and pushes me onto the bus. “There are no more seats left. Do not lose this ticket or they will kick you off the bus. Do not buy anything. Do not eat anything. Do not talk to anybody!” Despite the earnestness in his voice, I can’t help but remark the dry comedy of the situation; looks like they saved the last seat for the mzungu. The taxi driver turns to leave. I yell after him, “Wait! What’s your name?” He looks back, puzzled. “My name is John,” he replies. I smile. “Asante sana, John.” He nods at me in tacit understanding and rushes off. Through the years, I have realized that I often have to trust many of the people whom I meet in my travels unconditionally. And yet, I never cease to be amazed by the kindness that entire strangers have shown me, often going out of their way to help and even protect me. I am heading to Tanzania, an incredibly beautiful country, but one that, like much of East Africa, is extremely resource limited. Traveling from Cincinnati to Nairobi through Paris takes 24 hours. From here I opt to take a local bus for $10 to rural Tanzania for my global health elective. In addition to the considerable cost savings, the cross-country bus is the bona fide test for any intrepid foreign traveler. As I begin to walk toward the back of the bus, I am intensely aware of everyone staring at me. My trekking pack does not fit in the narrow aisle, so I lift it above my head and scramble over various packages, bundles of produce, and several errant children. I squeeze into the last open space on the bench at the back of the bus among 7 other people. The windows are shut; the heat is stifling; and I am quite literally sticking to the 2 individuals beside me. I feel at home. The bus ride is slated to take 10 hours from Nairobi to the Kenya-Tanzania border. From there I will take dirt roads by jeep to reach the remote village of Shirati in Tanzania. Soon after departure, someone gets up and starts speaking to the passengers in Swahili. He carries on and on, getting louder and louder by
Volume 65, no. 3 : March 2015
the minute until he is screaming. Soon he has the entire bus in a frenzy. I finally realize that he is preaching. This continues for over an hour until his voice is hoarse and sweat drips profusely from his brow. Everyone is in a trance, and even the little children have their arms raised. Bits of English occasionally filter through: “Today will be the start of a new life!” “This is a new beginning!” This is indeed to be a fateful day. In the midst of the sermon, a loud crash erupts ahead of us, and the bus comes to a screeching halt. Everyone stands up at once. I hear murmurs at first, followed by screams as the bus empties. I scramble out into the midday Kenyan sun. Directly in front of our bus, a motorcycle has had a head-on collision with a matatu. Matatus are a type of minibus taxi known by various names and seen across sub-Saharan Africa. I have been traveling for nearly 48 hours straight and am bordering on delirium from dehydration. It feels like I have stepped into a dream. Despite the glare of the sun, I can make out a body lying spread eagle in the middle of the road. It is the motorcyclist and he is clearly dead, presumably killed on impact. His blood and brain matter are scattered everywhere. I drag his body to the side of the road while trying to avoid oncoming traffic. Then I run to the other side of the road. At first I can’t find the matatu. Then it occurs to me what has happened. It struck the motorcyclist, swerved, and tumbled off into the ravine adjacent to the road. I am horrified. I have ridden in such vehicles innumerable times in the past across several countries. They are generally stuffed to the brim with people, as many as 20 at a time. While usually uneasy when traveling in one (the drivers tend to be erratic and have a penchant for high speeds), I routinely do so because it is cheap and is the mode of transportation for the common man. On approaching the edge of the ravine, I spot the matatu. It is lying 30 to 40 vertical feet down at the bottom, upside down. As I get closer, I can hear the wails of women on the side of the road, crying in despair. I push through the crowd that is quickly forming and start climbing down. Women who have been working in the fields start cutting a path with their machetes for the men. As I and some of the other bystanders make our way down, the scene turns even more grim. There are additional fatalities and bodies are strewn everywhere. We begin to carry them, each one bloodied and mangled, up toward the road. In addition to the dead, there are several passengers who are critically ill. In my mind, I quickly begin to triage: several “black” tags already, and several “green” tags as well. One man has open Annals of Emergency Medicine 337
Change of Shift fractures of both lower extremities. He calmly looks at me, but his eyes are pleading and he asks, “First aid? Please? First aid?” I put my hand on his shoulder and can only muster, “Please wait. Help will come.” In reality, I do not know if any help will come. Out-of-hospital care is almost nonexistent in this part of the world, and only a tiny fraction of injured victims are transported to the hospital by ambulance. Most people use vehicles, whether private or commercial, carts, or bicycles if need be. To make matters worse, the nearest hospital might be hours away. I move on to the “red” tags: critically ill people who have a chance to survive, with appropriate intervention. There are several people who are minimally responsive, but others are altogether unresponsive, likely with severe TBIs or intrathoracic injuries. For patients with blood pouring from scalp and other wounds, I quickly have bystanders hold pressure. Another man gasps for air as blood pours from his mouth. He likely has a pneumothorax or hemothorax. I do not have a stethoscope. I do not have an oxygen mask either, nor do I have any intravenous or intubation supplies. I have no supplies whatsoever. The man with the pneumothorax needs a needle decompression or finger thoracostomy with chest tubes. Despite blunt trauma, with witnessed arrest, the motorcyclist could benefit from a thoracotomy. Many of these patients would be helicoptered to Level I trauma centers in the United States. Instead, all they have is me, and I am reduced to assigning GCS scores. My years of education and medical training are useless here. I feel completely and utterly helpless.
338 Annals of Emergency Medicine
Selvam In the midst of my despair, the situation somehow worsens. The crowd surrounding us enlarges and is growing angry. They are trying to stop vehicles and buses to help transport the victims as they know that no ambulance is going to come to their aid. They start banging on cars, and windows and windshields begin to shatter when people refuse to stop. Our bus driver, fearing the growing mob, begins to drive away. All the passengers who are milling about start running after the bus. Suddenly I find myself faced with a horrifying split-second decision: do I stay or do I go? In my haste to get to the accident scene, I have left everything on the bus. I do not have money, my passport, or a phone. In addition, I only have a very vague idea where I am (some 4 hours away from Nairobi and still 6 hours away from the Tanzania border). .There are again stares as I walk to the back of the bus, but this time it is because there is still fresh blood dripping from my hands and clothing. I slowly return to my spot on the bench, with a sinking feeling in the pit of my stomach. I look out the back window and can still see the bloodstain in the middle of the road from the motorcyclist. I can also see the victims I am leaving behind, perhaps to die. Waves of nausea strike me and all I can do is clutch my face in my hands. Today I failed as a physician. Hopefully, tomorrow I will do better. Author affiliations: From the Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH.
Volume 65, no. 3 : March 2015
“First Aid? Please? First Aid?” Anand Selvam, MD* *Corresponding Author. E-mail: [email protected], Twitter: @TeahouseTrekker. 0196-0644/$-see front matter Copyright © 2015 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.08.016
[Ann Emerg Med. 2015;65:337-338.] “First aid? Please? First aid?” The cab driver grabs me and starts running in a zigzag pattern through the crowd. “Follow me!” he shouts behind. A crushing wave of people surrounds me, and hawkers strike from all sides, yelling, “Mzungu, Mzungu!” In many parts of East Africa, this idiom designates a foreigner or outsider. As we approach the bus, a crowd begins to surround me and the ticket agent. The cab driver grabs my money, thrusts it on the ticket agent, and pushes me onto the bus. “There are no more seats left. Do not lose this ticket or they will kick you off the bus. Do not buy anything. Do not eat anything. Do not talk to anybody!” Despite the earnestness in his voice, I can’t help but remark the dry comedy of the situation; looks like they saved the last seat for the mzungu. The taxi driver turns to leave. I yell after him, “Wait! What’s your name?” He looks back, puzzled. “My name is John,” he replies. I smile. “Asante sana, John.” He nods at me in tacit understanding and rushes off. Through the years, I have realized that I often have to trust many of the people whom I meet in my travels unconditionally. And yet, I never cease to be amazed by the kindness that entire strangers have shown me, often going out of their way to help and even protect me. I am heading to Tanzania, an incredibly beautiful country, but one that, like much of East Africa, is extremely resource limited. Traveling from Cincinnati to Nairobi through Paris takes 24 hours. From here I opt to take a local bus for $10 to rural Tanzania for my global health elective. In addition to the considerable cost savings, the cross-country bus is the bona fide test for any intrepid foreign traveler. As I begin to walk toward the back of the bus, I am intensely aware of everyone staring at me. My trekking pack does not fit in the narrow aisle, so I lift it above my head and scramble over various packages, bundles of produce, and several errant children. I squeeze into the last open space on the bench at the back of the bus among 7 other people. The windows are shut; the heat is stifling; and I am quite literally sticking to the 2 individuals beside me. I feel at home. The bus ride is slated to take 10 hours from Nairobi to the Kenya-Tanzania border. From there I will take dirt roads by jeep to reach the remote village of Shirati in Tanzania. Soon after departure, someone gets up and starts speaking to the passengers in Swahili. He carries on and on, getting louder and louder by
Volume 65, no. 3 : March 2015
the minute until he is screaming. Soon he has the entire bus in a frenzy. I finally realize that he is preaching. This continues for over an hour until his voice is hoarse and sweat drips profusely from his brow. Everyone is in a trance, and even the little children have their arms raised. Bits of English occasionally filter through: “Today will be the start of a new life!” “This is a new beginning!” This is indeed to be a fateful day. In the midst of the sermon, a loud crash erupts ahead of us, and the bus comes to a screeching halt. Everyone stands up at once. I hear murmurs at first, followed by screams as the bus empties. I scramble out into the midday Kenyan sun. Directly in front of our bus, a motorcycle has had a head-on collision with a matatu. Matatus are a type of minibus taxi known by various names and seen across sub-Saharan Africa. I have been traveling for nearly 48 hours straight and am bordering on delirium from dehydration. It feels like I have stepped into a dream. Despite the glare of the sun, I can make out a body lying spread eagle in the middle of the road. It is the motorcyclist and he is clearly dead, presumably killed on impact. His blood and brain matter are scattered everywhere. I drag his body to the side of the road while trying to avoid oncoming traffic. Then I run to the other side of the road. At first I can’t find the matatu. Then it occurs to me what has happened. It struck the motorcyclist, swerved, and tumbled off into the ravine adjacent to the road. I am horrified. I have ridden in such vehicles innumerable times in the past across several countries. They are generally stuffed to the brim with people, as many as 20 at a time. While usually uneasy when traveling in one (the drivers tend to be erratic and have a penchant for high speeds), I routinely do so because it is cheap and is the mode of transportation for the common man. On approaching the edge of the ravine, I spot the matatu. It is lying 30 to 40 vertical feet down at the bottom, upside down. As I get closer, I can hear the wails of women on the side of the road, crying in despair. I push through the crowd that is quickly forming and start climbing down. Women who have been working in the fields start cutting a path with their machetes for the men. As I and some of the other bystanders make our way down, the scene turns even more grim. There are additional fatalities and bodies are strewn everywhere. We begin to carry them, each one bloodied and mangled, up toward the road. In addition to the dead, there are several passengers who are critically ill. In my mind, I quickly begin to triage: several “black” tags already, and several “green” tags as well. One man has open Annals of Emergency Medicine 337
Change of Shift fractures of both lower extremities. He calmly looks at me, but his eyes are pleading and he asks, “First aid? Please? First aid?” I put my hand on his shoulder and can only muster, “Please wait. Help will come.” In reality, I do not know if any help will come. Out-of-hospital care is almost nonexistent in this part of the world, and only a tiny fraction of injured victims are transported to the hospital by ambulance. Most people use vehicles, whether private or commercial, carts, or bicycles if need be. To make matters worse, the nearest hospital might be hours away. I move on to the “red” tags: critically ill people who have a chance to survive, with appropriate intervention. There are several people who are minimally responsive, but others are altogether unresponsive, likely with severe TBIs or intrathoracic injuries. For patients with blood pouring from scalp and other wounds, I quickly have bystanders hold pressure. Another man gasps for air as blood pours from his mouth. He likely has a pneumothorax or hemothorax. I do not have a stethoscope. I do not have an oxygen mask either, nor do I have any intravenous or intubation supplies. I have no supplies whatsoever. The man with the pneumothorax needs a needle decompression or finger thoracostomy with chest tubes. Despite blunt trauma, with witnessed arrest, the motorcyclist could benefit from a thoracotomy. Many of these patients would be helicoptered to Level I trauma centers in the United States. Instead, all they have is me, and I am reduced to assigning GCS scores. My years of education and medical training are useless here. I feel completely and utterly helpless.
338 Annals of Emergency Medicine
Selvam In the midst of my despair, the situation somehow worsens. The crowd surrounding us enlarges and is growing angry. They are trying to stop vehicles and buses to help transport the victims as they know that no ambulance is going to come to their aid. They start banging on cars, and windows and windshields begin to shatter when people refuse to stop. Our bus driver, fearing the growing mob, begins to drive away. All the passengers who are milling about start running after the bus. Suddenly I find myself faced with a horrifying split-second decision: do I stay or do I go? In my haste to get to the accident scene, I have left everything on the bus. I do not have money, my passport, or a phone. In addition, I only have a very vague idea where I am (some 4 hours away from Nairobi and still 6 hours away from the Tanzania border). .There are again stares as I walk to the back of the bus, but this time it is because there is still fresh blood dripping from my hands and clothing. I slowly return to my spot on the bench, with a sinking feeling in the pit of my stomach. I look out the back window and can still see the bloodstain in the middle of the road from the motorcyclist. I can also see the victims I am leaving behind, perhaps to die. Waves of nausea strike me and all I can do is clutch my face in my hands. Today I failed as a physician. Hopefully, tomorrow I will do better. Author affiliations: From the Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH.
Volume 65, no. 3 : March 2015
