Wednesday, July 5, 2017

Snake bite! (from February 2017)

I’m curled up in a ball on a cold hard floor in the middle of the night in a hospital in Pietermaritzburg, South Africa. It must be somewhere between 4 and 5 AM. Six other men occupy the “male ward” I am hunkered down in. A nurse (or “sister”) grabs my foot and shakes it saying, “Ma, you cannot be here”. “Where will I go?” I ask her. “Home”, she says, clearly not understanding that is thousands of miles away.

The circumstances that bring me to this place are the worst I have faced on any study away program to date (and this is the sixth Southern Africa semester program I’ve directed, along with three May Experience trips to Botswana, and participation on a trip to Cuba bringing the grand total to 10 study away programs).

It all begins when I get a knock on my chalet door (similar to a cottage) at Giant’s Castle from a couple of students who have received a text message from the top of the Drakensburg’s Mountains from one of our groups of hiking students that there’s been a snake bite. We don’t have many details except the victim can walk and they are on their way back down. Our attempts to reconnect with them are futile.

My head spins…what do I do? Don’t panic. If he can hike down, perhaps it wasn’t a poisonous snake. But as my brain typically does, I go to worst case scenario and begin to make a plan. What is the camp manager’s number? Is there medical evacuation? Where are the details for our travel insurance policy? What the contact numbers to call Furman on a Sunday? With these pieces of information in place…I wait. In retrospect, I should have packed my bag or at least an overnight bag, including my necessary medications for my own medical issues! But hindsight is 20/20…

The next knock I receive, several hours later, announces that the group has made it back to base camp. I rush to go have a look for myself. The student is stable, two dark purple dots provide proof positive of fang marks, and his foot, ankle and leg are quite swollen. When I ask for a description of the snake (fat, gray brown pattern), I know it is time to move and we spring into action. The only snake I know that looks like that is a puff adder and it’s not a good one.

The camp manager arrives shortly after my call and after she sees what I’ve seen and hears the description of snake, she confirms we must go immediately. We begin what turns into a multi-hour effort to get to decent medical care. We (camp manager, myself, snake bite victim, another student coming along for moral support, our tour facilitator and his driver) pile into two cars, and after a 45 minute ride in the pouring rain we arrive at a rural health clinic.

One of the courses the students take on this study away trip is my “Global Health Inequalities” course and this clinic is a perfect object lesson. It is small, understaffed (only a couple of nurses are working), and currently without a working phone line. We describe our situation and after taking the vital signs of the victim, conclude he is stable and must move on to the provincial hospital in Escort.

We pile back in the cars, it’s getting harder and harder for the victim to mobilize (transfer from wheel chair to car). We race, again in the pouring rain, for another hour or more to a larger medical facility. Upon arrival we enter a crowded waiting area tightly packed with plastic lawn chairs. We’re moved back to a dimly lit dank area with a dozen gurneys or so, many of them occupied. A nurse checks the victim’s vitals, takes some blood and hangs an IV. There is no doctor on the premise and we will have to wait another hour or so until he arrives. Unfortunately, I have to go fill out paperwork for admission so I miss the initial stages and don’t know what he’s been given. He almost immediately gets very sleepy and cold and fades in and out of consciousness.

Seeing the condition of the hospital I immediately begin the long and arduous process of negotiating with the insurance company to get him transferred to a private hospital. The closest one is in Pietermaritzburg another hour or so away. When the doctor arrives, he assures me that they have stabilized him, and when I ask if we should transfer to a private hospital he agrees that is a good idea as the lab in not working at the hospital because there is no electricity and there really isn’t much they can do for him there.

The next several hours are a frustrating blur. The only place I can get a cell signal is in the parking lot, in the pouring rain. The insurance company keeps promising to call me back in 5-10 minutes and they don’t, so I have to call them again (hoping I don’t run out of cell time). We’re mired in insurance negotiations and at one point when they ask me again if the transfer is “medically necessary”, I “throw my toys out of the cart” (a great Southern African phrase to indicate I lose it) and scream, “Yes, it is medically necessary! There’s no electricity for the lab to run the blood work, there’s blood on the floor and a hypodermic needle sticking out of the gurney next to him! We must go NOW.”

They finally concede that a transfer is appropriate and we begin again to negotiate how to make this happen. They put me in touch with a “local coordinator” who will arrange the ambulance transfer. He’s not particularly helpful in that he has a local number that I can’t call back (when I try to call, it is a dead number). I wait. Time is passing. People coming and going in the emergency room. A man arrives writhing in pain. He can barely walk to the waiting room without his friends supporting him. Sometime later he leaves the “casualty” (ER) grabbing his stomach in pain loudly complaining about the incompetence of the facility. His family tries to convince him to return but he refuses. This goes on a long time. A female member of the group, likely overhearing my conversations with the insurance, comes to tell me I really should move the snake bite victim as soon as I can. “This hospital is not good! He will die here,” she cautions.

When I’ve finally given up on the insurance company to coordinate an ambulance, I call a private ambulance company myself to try to arrange transport. I hit a road block when they want money wired into their account before they’ll come get us (I am nowhere near a computer to wire money). I offer a credit card, cash, nope…only a wire transfer will do. As we’re trying to figure out how to arrange payment, an ambulance shows up to get us.

The victim and I load into the back of the ambulance and send our comrades back to the camp to take care of the rest of the group. The EMT checks his vitals and looks quite concerned. I know just enough about medicine from my many hours of observing in hospitals for my courses to make me nervous at what I see too. The EMT calls ahead to get a more highly qualified EMT to swap out with him on the road. It is raining like mad -- thunder, lightning, the work -- just to add to the stress of the situation! We are careening at a dangerously high rate of speed down the road. I am not buckled in (there is no buckle) and I try not to think about the consequences of an accident (especially for my unhealthy neck).

The EMT continues to rub the chest of the victim to make sure we can get a response. The victim is such a nice young man that each time we wake him, he immediately apologizes, “I’m sorry. I’m sorry.” When he stops doing this, I start to get more nervous. My anger towards the insurance company for delaying our transfer seethes. At some point along the way we pull off the side of the road and the EMTs switch out. The new man seems highly competent. I exhale a bit.

We finally make it to the hospital and get transferred into a two bed trauma bay. I get whisked off to fill out more paperwork. The EMT is very kind and not only gets me to the half-asleep administrator who tries to check me in but he stays with me to try to answer the questions that are not designed for patients from out of the country (our address from the USA confuses her greatly so we end up simply telling her that we live in Giant’s Castle). When we’re finally finished with that, the EMT walks me back to the trauma bay (I might still be wandering the halls of the hospital if not for him!).

In my absence the on-call doctor has come to assess the victim and they decide to not call in a specialist because he is stable and instead admit him. Unfortunately, the doctor who assessed him is long gone and I need to call Furman and his parents but don’t have enough information to communicate with them effectively so…I go looking for the doctor. If it’s like most ERs, there’s a room somewhere that doctor is sleeping in. I go looking. Wandering the halls, opening doors and saying, “Doctor?” I finally find him. We have a brief conversation and he confirms that he’s being admitted tonight. It is now about 3 AM.

With nowhere to go, I settle in on the floor of the trauma bay and wait for the transfer. I can see for myself that his vital signs have improved. The bed next to his provides some entertainment. A couple of different patients rotate through. One rather obese woman with nausea is there for a while (which was quite unpleasant, I’d rather deal with a snake bite than vomiting!).

We are finally moved to the male ward which brings you to the start of this entry (on the cold hard floor). When I’m kicked out I reluctantly move to a tiny lounge one floor up. I have promised his parents I wouldn’t leave him but they won’t let me stay, so I have no choice. I grab the pillow and blanket I have taken from an empty patient bed and I curl up on a love seat. It’s one of the longest nights of my life.

Early in the morning I return to the male ward. We’re told a doctor will be rounding soon. It is an African “soon” which means late morning. In the meantime, people start showing up – a doctor (not on the case but checking in to see if he can help), a man in the safari industry who knows some snake specialists (to try to help us assess what type of snake it is), and a woman who basically takes me in for the next several days – literally feeds me, houses me, dresses me in her daughter’s clothes and transports me back and for to the hospital (and ultimately to the airport when we leave). These individuals are contacts through a business network that the parents of the victim are a part of. They are a god send. We get better care, expert evaluation of the type of snake, and for me, some food and sleep!

In Medical Sociology we talk about “social capital”, a term used to describe networks and connections that help improve health outcomes. We clearly benefited from this. Not only were we able to move to a hospital comparable to any US medical facility, but we were able to “work the system” to our advantage.

The long and the short of it is that the snake was a Berg Adder. Both neurotoxic and cytotoxic, the victim suffered some vision problems (double vision and an inability to focus) for a week, he lost his sense of taste temporarily, and had swelling in his foot, ankle and leg for a long time after (he was in a wheelchair for a while, then on crutches and still in a compression sock to reduce swelling even when we return to the States – a couple of months after the incident). We stay three nights in the hospital and then fly to Cape Town to join the group (thanks British Airways for upgrading us inexpensively to First Class and letting us wait in their “lounge” – gourmet food, wine bar, that’s the way to travel!). When he transitioned from the wheelchair to crutches, we ultimately donated his wheelchair to a rural hospital in Namibia in great need of additional resources.

While this is the worst study away experience I’ve had to date, I am thankful for many things. I’m thankful for our stellar South African tour guide and camp manager who made sure we made it to care. I’m thankful for a brave and kind student who weathered not only the bite but the aftermath in good spirits. I’m thankful for his friend who stayed with him in the regional hospital while I argued with the insurance company in the rainy parking lot. I’m thankful for his trusting parents who put the care of their son in my hands (I had the opportunity to meet them on the day of his graduation and his mom gave me one of the most heartfelt hugs I’ve ever received. She cried, then I cried, then grandmas cried. His entire familial clan was so grateful and I was so happy to have the opportunity to meet them all!). I’m thankful to Furman for the clear headedness and support (asking, “what can we do to help?” helped me feel not so alone in an ER in a foreign country in the middle of the night). I’m thankful for an EMT that went above and beyond the call of duty to help me through the admission process. I’m thankful for strangers who showed up at our hospital room to offer help to people who will never be able to repay them. National Geographic Explorer, DereckJoubert once remarked about his friendship with Paul, “Sometimes you meet the nicest people on the hardest roads.” I thought of that statement often in the middle of this experience. This snake bite incident was certainly the hardest road I’ve faced on study away and I certainly met some of the nicest people. 

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