Quotes from Just Here Trying to Save a Few Lives, by Pamela Grim

- ‘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 fifth 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.’ (2)

- ‘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.’ (2)

- ‘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.’ (3)

- ‘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 here makes it seem like a lot, but simple things go missing. For example, we have no take 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.’ (3-4)

- ‘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 US the workup would begin now: hundred [sic] of dollars of laboratory tests, x-rays, IVs. The poorest child in American 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 this baby, now, was examined on a mat on the ground with flies everywhere.’ (4-5)

- ‘ ‘I shall go to America,’ one tells me dreamily, and I know that feeling – everything has it when they are young – and sometimes I think I’ve never lost it: that feeling that somewhere in the world – not here but somewhere – there is a place one can find oneself…where someone could be who he or she really is. In Nigeria it is America.’ (6-7)

- ‘There are no beds at all in the tents. Each patient has a mat – brought in by the family – that serves as a sickbed. At the foot of each mat a family member sits – or, as now, dozes. The family member serves as the patient’s caretaker – making dinner, feeding, washing. The hospital merely supplies and administers the drugs. If a patient requires any drug beyond that which our meager pharmacy supplies, the patient’s family must get it from an outside pharmacy and bring it for us to administer. I walk cautiously through the tent, past the sleeping figures. Bags of saline are randomly tied to the tent cross beams; we have no IV poles. Tubing snakes down here and there to a patient, who stirs restlessly or lies still as death as my little entourage and I pass by.’ (7)

- ‘I can see the baby’s IV tubing more clearly now and see that it is covered with flies. There are flies almost everywhere you look. During the day the constant fanning of the relatives keeps the tent somewhat clear of them, but now, at night, they range free. The woman on the next mat over, unconscious and with no relatives, has a dozen of them feasting at the edges of her closed eyes.’ (8)

- ‘Why am I in Nigeria? I wonder this for the hundredth time as I look up at the stars. There is the thin arc of a comet up above one of the trees. The answer is simple burnout. I am here so I won’t be there. So I won’t be back at home and in the ER. A crisis of faith brought me here to Nigeria. I had been thinking more and more that I might not want to spend the rest of my medical career wide awake at three AM attending some screaming drunk shackled to the bed while someone in the next bed over vomits copiously into a metal basin. It was beginning to get me in ways I really didn’t understand. Or ways I understood too well. It didn’t take a genius to figure it out. The fact is that I have just seen too many cases of child abuse, sexual abuse, assaults, bad mothers and worse fathers, disastrous car wrecks, people dying who shouldn’t die, people alive only by some whim of God’s. I was turning into someone I didn’t recognize, someone I didn’t particularly like.’ (11)
- ‘The funny thing is, I think, as I wipe the tears out of my eyes, I don’t feel sad. In fact I really don’t feel anything. And that, it occurs to me, is the problem. I never feel anything anymore. The death of a child – I shrug it off. A bad car crash where people come in dying or dead – nothing; it feels like nothing to me. It’s not as if I don’t care. I’m sure I do care or I wouldn’t be here. But I’m not sure anymore what caring really feels like. It doesn’t exist for me as an emotion. In fact, I think, as I turn the bottle cap over and over again, nothing exists for me as an emotion anymore. I try to remember the last time I felt sad or upset, worried or lonely or confused or even happy. The only emotion that seems to have remained a friend is anger. I still know how it is to be angry. All the other emotions just get in the way of being a doctor, of working in the ER, of working in Nigeria.’ (15-16)

- ‘Here I sit, as detached as ever, another tragedy under my belt. My youth is gone, spent haunting hospital corridors at all hours of the night, and now my middle age is spent in some washed-out back corner of a country where I have to come to make decisions about my life and have ended up, once again, awestruck by the suffering God can inflict.’ (16)

- ‘This is the hardest part of the job. Breaking the news. The bad news. As an ER doctor you get to give families the worst news they will ever receive and you get to do this almost every day. It’s your job to say, ‘I’m sorry, but your mother, daughter, brother, husband, [insert name here], has died.’ (24)

- ‘You’ve always had a very special adversarial relationship with God, just like every other practicing physician you know.’ (25)

- ‘I was near the end of my residency, and by now, nothing fazed me. I had become a medical automaton shorn of wasteful emotions, emotions like concern, compassion, surprise.’ (80)

- ‘Most obstetric physicians I had trained under taught us that the vaginal wall at this point during delivery is entirely anesthetized. But most of these doctors were men. Every woman who has so much as felt the cold steel of scissors or scalpel on her skin has gone through the ceiling. This time was no different. The woman screamed and beat the cart railing while I cut into the flesh. The vaginal entrance opened wider and the baby practically popped out into my hands.’ (90)

- ‘Scientists have proved that ER physicians spend 50 percent of their time writing on charts. This is another thing they don’t show on TV.’ (116)
- ‘The Hoover is a simple test. You have the patient lie down, then you place your hand under his left heel. You ask him to raise his right, his weak, leg. Normally if someone has true weakness, he or she will attempt to lift the affected leg by placing pressure on the contralateral, stronger leg. People who are faking weakness usually don’t brace with their other heel.’ (146)
- ‘You never know you’re burned out. When the stress of the job starts destroying mental software, the capacity for personal insight is the first to go.’ (169)

- ‘During the worst years it was like getting up in the morning and going into war. Things happened in that small clutch of examining rooms that no one else had ever seen. And if you tried to talk about it, to your spouse or your few friends who did not work in ER, you would get the fisheye – a look of suspicion and disbelief. They didn’t really want to know; they certainly didn’t want to believe and you couldn’t blame them. Even if they were interested, they didn’t have the right mind-set [sic] to understand what all of you working in the pit relearned every shift. The dead end of rage, the sordid stupidity of drunks and addicts; the awesome destructive power of bad luck. Everyone in that other world, the ‘real’ world, lived in a cocoon of safety. You didn’t want to be the one to tell them how much of an illusion that cocoon is. Only cops seems to know these things. There is a secret fraternal order of people on the front lines. Members include the ambulance drivers who scrape up pedestrian victims smeared across a roadway by hit-and-run drivers; orderlies who wheel the dead bodies down to the morgue late at night; strung-out, exhausted nurses; the even more strung-out ER doctors on the tenth shift in a row.’ (170)

- ‘You had forgotten that this is Sunday, heroin withdrawal day. It’s a police thing. They like to bust heroin addicts late Friday afternoon, just after the courts close. Then an addict can’t get bonded out until Monday morning, when the courts and the bail bondsmen open back up for business. An addict will be stuck in jail with no hope for dope all weekend. Friday night, Saturday morning, noon and night. Withdrawal time. By Sunday at noon – after thirty-six hours off the stuff – a hardened career criminal who wouldn’t tell a cop the time of day if he thought the cop wanted to know, was now clinging to the officer’s leg, ratting out his own grandmother, anybody, everybody, just to get out and get another fix. That’s when the cops start asking serious questions.’ (174)

- ‘The sanity issue was germane to us all. We were all more or less in a perpetual state of shell shock. The pressure was everywhere – unrelenting. It crept into every facet, crack and crevice of a person’s psyche. It rotted the woodwork, scarred the metal joists and broke down, without pity, the fragile scaffolding almost all of us use to hold ourselves together.’ (188)

- ‘As I think back, what I remember, more than anyone I knew or anything that happened, is the pervasive sense of exhaustion, of being up for hours and hours, days and days, weeks, months. Exhaustion was like dust, settling over everything. You felt as if you had to swim through the day; the drag coefficient of even the littlest gesture made you ponderously slow. You even though slowly. The whole world seemed darker than you ever remembered it – and the memory of the real light had almost vanished. And with the exhaustion came the phantoms of emotions, monstrous feelings, panic, terror, paranoia. Sudesh, standing by the bed, looked punch drunk, bedazzled by the suction equipment. This was his eighth twelve-hour shift in a row.’ (191)

- ‘The golden hour. In emergency medicine this may be the only chance you get to save a life. Sixty golden minutes, each is an opportunity won or lost, each weighs in with the question Live or die? Live or die? Questions synchronized to the ticking of the clock. Can’t get an IV in? The patient will die? Can’t get the patient intubated? Dead, dead, dead. Can’t find the cause of the hypotension? Don’t make the diagnosis of a ruptured aortic aneurysm? Get the central line in too late? Drop a lung? Don’t recognize within the slobbering, comatose drunk before you the massive intracranial bleed? More than one of these? Then the patient dies. And the pressure is on you, big time. It’s because of you that the game gets won or lost. But the question is, how long can you play the game with stakes like these.’ (195-196)

- ‘There were, in the entire hospital, two Bosnian-controlled stethoscopes, a single ventilator, and a vintage 1948 ECG monitor we used to get electrocardiograms (not that we could to much with the information). The hospital had exactly three ampules of morphine, enough to treat fifteen minutes’ worth of pain, no high-blood-pressure medication, and frequently no electricity or heat. In the ‘intensive care unit’ the nurses would borrow my watch in order to take a patient’s pulse.’ (211)

- ‘I tried to imagine what a world with a hundred diseases just like AIDS – diseases that could savage a whole generation in a heartbeat or two – in which no one had the power to stop them, nothing worked. That was life before vaccines.’ (219)

- ‘We even save a few lives, but only a fraction of the lives that need to be saved. Soon, we will leave and when we leave there will be nothing to take our place. The meningitis epidemic, cholera, measles, typhoid fever, all preventable diseases, will return and continue as before. The only solution is a political solution, national public health programs, responsible corporations who reap only as much as they sow. Shell Oil with a conscience. Nigeria doesn’t need us. What we do here is less than nothing. We take the pressure off the powers that be, making it easier for those who plunder to keep on plundering. This is the humanitarian aid paradox.’ (247)

- ‘When you work in emergency medicine, you are seeing patients who are the least common denominator as far as human beings go; people who are heartbreakingly stupid and dirty and drunk and high and obnoxious – unbelievably obnoxious. These people have all flowed out of the darkest side of life. And when you are finished with them, that’s mostly where they’ll return. So each of you who is thinking you want to go into emergency medicine will have to ask yourself, ‘Do I really want to do this?’…I know the answer for myself – every day I work I’m taking care of someone who is just like my grandfather, someone just like my mother. But everyone in the room needs to ask himself or herself, ‘Do I want to spend the rest of my life with addicts and idiots and drunks and psychotics? Is that what will make me happy?’ ’ (291-292)