In Case You Were Wondering (or, In Case of Emergency) (Blogging Emergency)

Where I'd gone, I'm currently on my running blog, positivelysplit.blogspot.com.  Come and see what all the excit... oh, who am I kidding, come and read me on the iPad whilst on the loo!

In between editing the 100-plus page of prehospital emergency protocols that were written in, admittedly, impressive, but not close to perfect, English, on the long, long flight from Tel Aviv to Newark, I managed to watch all of the Jason Bourne CIA assassin movies. Watching all three in a row made for a nice distraction from repeated exhortations to place cervical colors on all patients, and naturally, I began to compare in what ways we were similar. Over the past few years I’ve been to some of the same jet-setting places, Munich, Switzerland, India, Moscow… getting in bloodletting fights (mostly with administrators for me) leaves my hands shaking and knuckles… I even have two passports, both issued by the federal government. So I’d be feeling like a globe-trotting super-spy if it hadn’t have been for the humiliation I’d received at Tel Aviv’s airport.

It began even before I got to the airport itself; a soldier, who looked about 17, pulled our vehicle aside for extra screening. Shuffling their feet out in the cold, Ishaq and Abed commented, “it’s because we have East Jerusalem IDs,” wry smiles of apology on their faces. The teenage soldier escorts me to one of those nondescript rooms with x-ray equipment and another bored kid wipes my belongings down with a wand to detect explosives. When the soldier finds out what time my flight is, his eyebrows arch for a second, and then he says, almost, but not quite apologetically, “I will give you a pamphlet that you can show the security inside the airport to help expedite you.” He drops one of the driver’s phones when handing them back, no apology.

Since I am a lone male traveler, in the airport I am labeled the highest security risk, a level 6, and receive what is essentially the most invasive security examination. “Where did you stay while you were in Israel, what did you do, you were in the West Bank, did you go to Gaza?” One snort can’t convey how ridiculous that suggestion is – I may be stupid but I’m not crazy enough to go to Gaza. The screening personnel are always unfailingly polite, please, sir, open your bag, have a seat here, feeble attempts at maintaining the illusion that your dignity is preserved while they make you do a slow, security strip-tease, wristwatch removed, shoes doffed, pockets emptied, even my wedding ring needs to come off before I walk slowly through the metal detector for them. Putting my belt back through the loops of my pants after the security never fails to make me feel cheap, sorry I gotta run off with my metal detector, I got business. Security at that airport is like rape only without the foreplay.

All of this treatment despite the fact that (or, menacingly, because) I’m a citizen of America, Israel’s unfailing ally, provider of all of the weapons that I see slung around the necks of their barely-adult soldiers standing around the checkpoints. I wonder how much more difficult it must be for those other aliens standing around the airport, heads covered, presumed guilty before proof of innocence by submission to the airport security protocols. Making people out to be “others” and not human is what let the Holocaust happen in a place that had been known for blandly pleasant clockmakers; humanizing empathy apparently costs too much.

It’s funny, what the straw for me was: a headphone earpiece. A triviality. Remember: I am a nerd, a compulsive one, and being able to pack all of my electronica with safe efficiency isn’t just something I take pride in, it organizes my psyche. When the security officer escorted me back to the screening area where the clever workers had pulled out every single piece of my gear out on to a table for all to mangle, he said, as though it were a gesture of magnanimity, “see, they have already re-packed your bag.” I began to fume. Quietly seething, I unpacked the uncaringly jumbled mess and began to rewind cords, re-sort compartments, trying to get their psychic urine off my belongings, because that’s what it was, they had pissed all over my stuff. It was then that I discovered that one of the earpieces of my headphones had popped off and was missing. Not the most expensive, but not the cheap ones that come in a plastic baggy with your airplane peanuts, I had traveled hither, thither and yon with these headphones without having lost one of the little earpieces that ensured a proper fit, and some bored teenaged kid had managed to do it while mishandling my gear.

And then imagine, it isn’t a headset, it’s your pregnant wife, your gasping father, your cold, blue child, and you’re forced to sit on the ground and wait at gunpoint because of disagreements that people you don’t know and care nothing of have had. Or if you had watched your sister, mother, aunts, separated from you into another boxcar heading for another place that smoke comes from. Forcing open a clenched fist makes for a pretty crappy handshake, and you wonder to yourself when it’ll get better, and think that it’s going to take a measure of self-dignity that extends far, far beyond the loss of a rubber earpiece.

Maybe I can see if I’m more like Jack Bauer.

My life here has developed a routine, a rhythm. Every morning I wake up at 6:15, stumble into the large hotel suite's drafty common area, turn on the little space heater and begin to read and answer the e-mail that's accumulated overnight for me, throughout the day at home. I call my wife and we chat for a bit, at the end and beginning of our day, respectively. After a while I prepare for the day at work and walk out to say hello to the same front desk man and wait for the elevator to take me to breakfast, the same copy of the New Yorker, half-read, folded in my hand. I'm usually the first one to arrive in the hotel restaurant, 10 or 15 minutes before breakfast is scheduled to begin, so I greet the wait staff as they bring in the same plates of buffet food, warm pita, hummus, yoghurt, two kinds of cheese, one flat and a little like Swiss, the other creamier triangle wedges, sliced cucumbers, wedges of tomatoes, a bowl of hard-boiled eggs, a plate of beef sausages, the same coffee that spills out of the urn and on to the floor if you try and pour it when it has finished percolating and is full, tepid milk for the coffee or the breakfast cereal if you prefer, a sliced loaf of chocolate bread, every morning the same. There is a young, single man who wanders in a little after the food is put down who always wears the same zippered, high neck sweater, blonde hair disheveled, who will eventually slouch in his booth while talking to the older single man, laughing about what they've discovered in Jerusalem that weekend; I imagine they, like me, are here on some sort of work, and it seems that they've met in the restaurant. For the past few days there's been a young, single Taiwanese man who's made a friend with a bald, burly looking guy; the Asian man's name is Lee, I know this because one morning the waiter calls over to our table, "Mr. Lee, telephone call for you, Mr. Lee," I didn't know he was addressing the back of my head, and the person sitting opposite of me looked at him and said, "that's Mr. Kim." Every morning, about 10 minutes after the plates are set on the banquet table, the same older, say, the other side of middle-aged, couple arrive, they look European, and I smile at them and say good morning, and they do the same back, and when they do the somewhat guarded looks on their faces melt off, "good morning, sir," says the one whom I presume to be the husband, his voice low and gruff, but pleasant, and these are the words we exchange. Shortly thereafter the other members of my party arrive, and we exchange pleasantries while we plow through our breakfasts, having been given only fifteen minutes or so before our transportation arrives. There is always cigarette smoke in the restaurant.

Every morning we arrive at the medical complex and semi-consciously do a brief walk-around because one entrance that was open the day before is now closed and we try to find which door is open now, we see where the registration desk has been moved overnight, what new puddles of rainwater have formed on the floor from the storm, the semi-present looks on the faces of the physicians and nurses who are just arriving for the new day. While we try to see if our office is still our office or the "doctors' rest-room" again, whether the piss-smelling bathroom next to it has been cleaned or not, what administrative curveball the minister has sent, whether it's to open the children's hospital next Monday despite the fact that there is no staff and no heat and water continues to leak everywhere. Every morning we settle in to hear about the night shift and how there were only three nurses and two physicians and how their multitude of calls to administrators overnight went unanswered, except their final, desperate, pointless call to me, the outsider, the consultant, at 10 PM, with the hope that I might tell someone about it, that I might write it in my report, my assessment and recommendations. Every morning it is the same, an older looking woman with a head covering and a velvety looking dress waiting for her hip x-ray, a middle-aged appearing man with a leather jacket that has shoulder tabs and a shirt with horizontal stripes holding a weeping toddler wearing spotless white tights on her chubby legs or standing at the bedside of an elderly parent who appears for all the world, dead, until they draw another quick breath. Every morning there is a new deficit, a new settlement, another building razed, and although the city is quiet now, and seems to be at peace, there were the sirens overnight, the same frustrations, only growing...

Life here is, all in all, pretty easy (don't tell the bosses back home), and it's surprising how Western the place is; I imagine some countries in the region, like Saudi Arabia, would be more foreign-seeming, and I can attest to the fact that Afghanistan was definitely more exotic, but given the fact that almost everyone here, in the city at any rate, speaks at least a little English, and the food is safe and pretty good, makes one's day here not too alien. However, every so often you run into what would otherwise be a familiar, every-day item, such as the 12 month calendar below, that is pretty much absolutely unlike what you'd have at home:

I wonder what bank this calendar came from...

There are a lot of impolite assaults on one's senses when one is abroad, certain stimuli that have largely been scrubbed away from the sterile Western world, the acrid, tear-stinging smoke of burning trash that finds you even on the 9th floor swanky bar of the hotel, the rank and yet somehow nauseatingly familiar reek of sewage that wafts by you on the street. But every so often you get the unfiltered beauty of the physical world, the lovely bone-cutting chill and damp of the winter rain here in the Middle East, the sweet, cloying smoke of the water pipes that stick to your clothes for hours afterwards, the brilliant colors of a coffee cup left, unexplained, on an electrical junction box:

I couldn't find my camera in time for this trip, so this photo was taken with the Best Camera (that is, the one that you have with you), my iPhone, with the Jewel filter.

Almost makes up for the stink of poo...

I am sitting with Orrine and Noor. "What about Sully?" asks Orrine. "No - his name is Saleh, SAH-leh." "Oh. How about Nadja?" "No - it's Nadira, NAH-deer-ah." "Okay. That Dyah guy was okay too." "Um, it's Diaa, DEE-ah, like the Spanish word for 'day'."

It doesn't let up. Noor starts now. "When is Pak-tahn coming?" For goodness' sake, Noor grew up speaking American English. "It's PAX-ton." "Okay, whatever. Are you ready, Ahrlen?" I can barely keep myself from rolling my eyes and sighing loudly. "Noor, it's Orrine, or-REEN."

For heaven's sake, I'm having to translate English to English for these folks...

A man in a white sedan pulls up to the front of the hotel. He rolls down the window, cranes his neck, and asks, "Dr. Teh-ey?" "Yes!" He knows my name, but why take the chance? "What's your name?" "Fatah." That's not it. "Arafat" he says after a brief pause. That's it. I get in to the front seat.

Familiarity has rubbed some of the exoticness off things around here, at least for me. The fact that almost everyone I've met has spoken at least a little English, even if it's an Arabic-English pidgin, has made life here seem much plainer. I, on the other hand, seem to remain bizarre and alien, telling by the frank and slack-jawed stares some people give me, with the occasional "Nihao!" or "Konichiwa!" I wonder if I can have a race-burqa made...

We are in the offices of the Juzoor foundation, a non-profit organization that does a lot of healthcare education. We've contracted them to do life support education for us, and currently we're arguing about whether to order airway positioning first or CPR, seeing as how the new emphasis on chest compressions has confused everyone. Suddenly, all eyes turn on me: "how about you, Tae? As our representative from America, what is your opinion?" Uh oh - playing the foreign consultant card in an attempt to break the deadlock. "Um, gosh, you're both right, but it's a matter of knowing, culturally, what your people would respond to." Wiggled my way out of that one! I wonder if I can have an awkward-political-pawn burqa made...

The "medical director" of the Emergency Hospital is a politically appointed thoracic surgeon, not an emergency physician. Granted, he got to where he is by virtue of his long-standing commitment to the city of Ramallah and his well-respected clinical care, but he has little administrative experience or skill.

We are sitting in his office, tensely negotiating the future of the Emergency Hospital - "who's going to be the medical director?" "I am." "Even though as a member of the board of directors you have a conflict of interest? Who will be the residency director?" "I will." There's a long, awkward pause.

The director sits back in his chair, and after a moment, leans forward and asks, "have you ever seen the t.v. show, 'E.R.'?" His "R" rrrrrrooooollllllssss off his tongue. Orrine and I look blankly at each other, then turn to face him again - neither of us have watched the show. The grin on his face starts to fade. "How about 'Grey's Anatomy'?" Blank stare. "'Scrubs'?" Nothing. Another long awkward pause.

I didn't realize that there were so many American medical shows broadcast in Palestine. Personally, my favorite medical show was "M*A*S*H".

I listened to more of the lectures for my Intro to Islam class tonight, and considering some of the awful things that have been going on in Afghanistan as of late brought to mind one of my old blog posts from 2004/2005, one of many peaceful memories I have of the place:

It was still chilly and overcast but the rain had stopped when we'd exited Kabul. The plains were broad and green, punctuated by clusters of walled-off mud buildings while they sloped up to the mountains on our left. We could sometimes see their white peaks through the clouds, rugged and imposing.

Many of the rough mud buildings were in ruins, and there were tank-remains that dotted the fields. Ayoob pointed at different, broad stretches of land and in his careful, deliberate English would tell us, "here, from 1993 to 1996 I cleaned of mines."

Geoff suggested that we stop for tea; Ayoob pulled over in a dusty village where we waited for Geoff to catch up. Their vehicle arrived about a half hour later - it turned out that Borhaan, a pediatrician who was returning to his homeland for the first time in over twenty years, had found some old acquaintances and had stopped to talk. After a brief discussion we decided to try and find a more picturesque village for tea, one with fewer limping dogs and men in dusty single-breasted suits riding bicycles.

The road became tree-lined and shaded, the fields greener and thicker. Geoff's vehicle came to a halt ahead of us, and still irritated by the last half-hour delay I cracked that Borhaan must have found more friends when he stepped out of the truck and embraced the heavily armed man standing at the passenger's side window - looks like he actually had found more old friends. As it happened, while we were driving Borhaan started to recognize the region as the one his uncle's chauffer, whom he'd last seen 25 years ago, was from. The man's son, who immediately recognized Borhaan, was now the regional security chief, and he escorted us to his father's house.

The vehicles were parked by a school and we walked up a broad dirt path, flanked by men with guns. It was, however, still, quiet and peaceful, the men were polite and deferential. You could hear the children playing in the school down the road, carefree.

Borhaan was finally reunited with his family's former chauffer, who had an enormous goiter. No one cried; Borhaan just had this halfway stunned and pleased look in his face the entire time they chatted in Dari, or was it Farsi? We followed Borhaan and his family's former chauffer to the end of the dirt path which opened to a surprise: they had erected a large concrete tea platform and surrounded it with living birch trees that formed an arbor around the retreat. They had fashioned a canopy over the tea platform by laying cross-branches between these trees, and several vines were entangled on the beams overhead, providing a dappled shade. Rosebushes lined the path and stairs to the tea platform, and while we situated ourselves on the carpets and cushions laid out for us, one of the man's heavily armed sons cut a bouquet of the flowers for Tammi.

Borhaan and the old man caught up while his sons served us tea, candied almonds, bread; here, you could breathe, deep, cool breaths, and look at the snow-covered mountains almost hidden by the clouds. Night was falling when we left for Kabul, a dusty, hazy light on the horizon.

I was trying to decide upon what subject I should blog tonight; I asked my wife on g-mail chat tonight what topic I should choose, and she suggested, tentatively, "food?" But, I protested, I've already written on fries, not just once, but twice!

However, as she often does, my wife got me thinking... food... hmmm... Well, this quarter, I'm taking a distance-learning class, Introduction to Islam, through my grad school, Fuller Theological Seminary. It seemed to be about time; considering the amount of time I've spent traveling through Muslim countries, I still can't tell the difference between my Saalam and my Salman, my Shiite and Shi'a.

I listened to the first lecture last night, and part of the lesson included an explanation about how significant food, and in particular the sharing of food, was in this culture, and how an act as small as sharing tea signifies that you are most welcome, you are accepted, you are one of us. In the West, sharing food and drink is a much more casual event, but in the Middle East this means that you're as good as family. Remembering now all of the times I've been invited to sit down to tea, to hard-boiled eggs, to lavish meals of lamb and rice, by all manner of people in this part of the world, I'm beginning to realize how grateful I really should have been for their hospitality, and how serious my obligations to them are. Even today, sitting in the project's office, plied with coffee, soda, pastries, each offering a message of peace and welcome, symbols of how tied we are to each other.

And yes, I had french fries for dinner again. What - they're good!

CRITICS, PROGRESS, AND THE DANGER OF FRIES

It's raining in Ramallah, seriously pouring, the big kind of drops that seem to fly whip in sideways under umbrellas leaving big splotches on your clothes that wrinkle your supposedly wrinkle-free duds. The critic John Ruskin described what he called the "pathetic fallacy", the human tendency to interpret the condition of the natural world in anthropomorphic terms, so one might say that today's weather was angry or downcast, when in fact the weather doesn't really care one way or another, and I agree - rather than seeming unwelcoming, this weather makes me supremely cheerful, I love this stuff!

In the office, before the morning meeting, Amal greeted me with a smile, calling me her son. Dr. Damianos met me with a hug, "welcome back, welcome home, Dr. Tae!" It's tough to keep things coolly professional when everyone is so warm. Not that every five minutes the office spontaneously stops to hold hands and sing kumbaya, but it's close.

After a briefing we short term technical advisors make a site visit to the Palestinian Medical Complex where I am pleasantly surprised. Okay, that's to put it mildly, I'm actually cheerily gobsmacked to discover that many of the changes we'd suggested in our technical reports from my last visit were put in place, or at least initiated. One entrance was converted to "ambulance only", the other to ambulatory patients, with registration and triage areas. They'd instituted a fast track, a tiny one, but a fast track for nonurgent patients. They'd took patient rooms that had been turned in to administrative offices back in to patient rooms, and the administrator who lost his space met me with a cheerful handshake rather than the fury of the evicted. Most stunning, we learned that three weeks ago the PMC had decided to recognize emergency medicine as a specialty. (For a brief history of emergency medicine residency training in the States, click here.)

I had put in hours of desk time writing those reports which felt like so much busy work that I imagined the bureaucrats of the Palestinian Authority would politely ignore, and my advisory documents would be filed away to slowly decompose. One reason I was so surprised was because everything I'd heard about the progress at the PMC when I'd returned to the States made it seem that things were actually going backward - the nurses had gone on strike twice, the housekeeping contract had been lost and replaced with a decidedly inferior one, etc. Of course, the truth of the matter isn't that my technical reports had been so lyrical, so moving that the readers had been compelled to obey them, like international development scriptures, but rather that the local people who worked on the project had been diligently chipping away and making real progress. (Although, to confess, I was surprised at how many people casually mentioned that they had read the reports.)

While at the site visit, however, we learned something rather distressing: at the morning meeting we were told that the cousin of one of the project's employee's had died recently, and then subsequently discovered during our tour that he had died because of something that had happened at the PMC, at the very emergency department we've been trying so hard to improve. It's getting personal now...

Tonight's the second consecutive night here in the Holy Land that I'm having dinner with french fries. The food critic Jonathan Gold writes that to him, fried potatoes are proof of the continued existence of a loving god. I notice that the menu makes no mention that these fries are free of trans-fats or other dietary malices. It seems that in the Middle East the people are unfraid of death, at least by coronary...

RAMALLAH REDUX

Aaaannddd... we're back! I've just settled in to my hotel room for round two of the rumble in Ramallah, and I'm only the tiniest bit dizzy from not having slept for two days - dreams! Who needs them! I've got just enough energy to write and spell check through a few unconnected observations.

Just to refresh your memory, your faithful correspondent is in the Holy Land as a US Agency for International Development technical consultant in emergency medicine, and not just for the fantastic kebab, shawerma, shish tawouk, falafel, hummus, shashlik, clay pot dish... but of course, for dinner tonight instead of those delicious local dishes I somehow managed to order myself a chicken sandwich. With french fries. And extra ketchup.

As mentioned, the flight was super-long and painful, but I think I might be getting used to sitting in the plane for those long stretches - perhaps I'm developing butt calluses...

Traveling alone unfortunately gives you the temptation to do all sorts of awful, tawdry, shameful things, things you wouldn't normally do in the presence of your peers... on that long flight over I cheapened myself by watching "City of Ember", "Max Payne", and "Love Happens". Okay, I didn't watch "Love Happens", but I'm still having trouble looking at myself in the mirror...

Well, actually, I didn't travel alone (but the joke was so much more effective that way), but rather with a really terrific human being, Orrine, who's a nurse. We've known each other for a while now but recently I realized that the first formed memory I have of her speaks volumes about her nature. Now, if you're squeamish you may want to skip this story - working in health care, particularly emergency care, means that all sense of propriety has left your soul and you no longer intuit what's appropriate to share with a mixed audience - but if you're like the 99.9% of the world that relishes a gruesome story: a nurse rushes up to the doc's desk and asks, a bit flustered, "hey, are you all busy? Can somebody come and see this guy?" As the new kid trying to ingratiate myself, sure, I volunteer myself and walk over. So, the background story is something you have to know: the patient, a man, said that he had tried to vault a barbed wire fence a week ago but had somehow gotten his (you can cringeingly see where this is going) "delicate bits" caught on the pointy barbs, and had let the wound(s) fester for a week before finally deciding that, hey, an abscessed, bleeding penis is probably a health problem.

Now, having had some of the new rubbed off me since then I now realize that what I had naively assumed was the truth was probably, well, let's say part of a broader narrative that I may not have entirely uncovered, but the points to remember are 1)blood, 2)pus, and 3) this man's "junks". I walked in to the room to see Orrine, who was the triage nurse that day, finally figure in to my meandering retelling, because she had done exactly what you do with uncontrolled bleeding, applying direct pressure to the area, and in this case, the area was one typically covered by one's bathing suit, and there she was, death grip on this gentleman's exsanguinating willy, but doing so with total composure, calm, even aplomb, and still somehow also compassionate, all while trying to prevent death, or at least loss of gender identity, and I thought to myself, wow, what a cool customer, this Orrine, someone who epitomizes what ER nurses do every single day. I mean the calm, compassionate, critical care stuff, and not the handling-of-a-guy's-you-know-what-that'd-been-injured-while-leaping-over-barbed-wire part. Anyway, she's well-equipped for this USAID project.

We were met at the airport in Tel Aviv by Waleed, one of the project's drivers. We shake hands warmly and I ask, "what's new?" and he says with half a grin, "nothing, nothing's new!"

Which, I suppose around here, is actually sometimes a pretty good thing...