Paramédico

‘Okay, tayo marinig ng ibang song!’ Another Filipino hit is announced on a little transistor radio. It’s all we listen to. A World War II ceiling fan and cheesy music, neither of which is ever switched off – the ceiling fan for obvious reasons and the radio because, in its truest definition relating to ambulance work, we are listening out for jobs. There is still no central emergency number in The Philippines, no control room or ambulance dispatch. So we wait, as we do most days and nights, monitoring the half-hour news bulletins on ordinary FM radio and the occasional updates between Pinoy rock classics by Sugar Hiccup and Tropical Depression. Occasionally, maybe once a week, a member of the public will arrive breathless at the ambulance station, pointing in the general direction of some traffic collision nearby. But mostly we wait for a radio announcement – sometimes for weeks on end – about a pile-up on one of the many highways and skyways crossing Manila. Last month, both ambulance crews took it upon themselves to respond to a train derailment after hearing a report on the radio, but have since done little else.

The air is thick with humidity and the smell of green mangoes. I look around the room and see I’m the last one awake. Having no comprehension of Tagalog, the 1 am news means nothing to me. Half of Manila may have gone up in flames and I wouldn’t know. Nor would my colleagues stir from their slumber. There is nothing to do but stretch out on a bench near the door and submit to the urge to close my eyes.

In heat like this my dreams are always bizarre. The emperor of a mighty country, suddenly inspired into a random act of generosity, orders all hungry tramps in the land to be issued a jar of his finest caviar. But one of the tramps is unhappy and says, ‘Just give me a damn sandwich!’ The tramp says this about the same time I wake up and turn over. While I drift off to sleep again I comprehend the dream may well have been about our two ambulances donated by the United States government. They came with the latest, high-tech equipment, with pulse oximetry, twelve-lead ECG machines and pneumatic ventilators. Like caviar to a tramp are these ambulances to The Philippines’ largest public hospital. Only yesterday we took a patient in from another facility hooked up to our automatic ventilator and found there were no ventilators in the intensive care unit of the hospital. How odd it was to see our state-of-the-art device replaced by a simple bag-valve-mask – a bag manually squeezed every four seconds or so by the patient’s beloved without interruption, sometimes for months. No wonder the bag-valve-mask is known here as as a ‘relative ventilator’. And because the chain of health care is only as strong as its weakest link, there was considerable discussion among the EMTs about why they bothered connecting the ventilator in the first place. More interesting to me was to volunteer in a country where ambulances are better equipped than the hospitals they deliver to. It’s May 1998 and I’m only here for six weeks – half my time ambulance-riding, half island-hopping – far too short a period to help create awareness of a paramedical service among twenty million people in the most densely populated city in the world.

Manolo nudges me with a Philippine breakfast plate of champorado – a combination of sticky chocolate rice served with salty fish, a fish which I detest and usually discreetly dispose of so as not to offend my hosts.

‘We have very important meeting in the evening, Joe,’ grunts Manolo, using the rather annoying nickname I share with every other Western male who bears the slightest resemblance to an American GI. Manolo’s face doesn’t give anything away, even when I know he’s being funny. I’m certain it’s his own type of humour, that he’s one of those straight-faced funny men.

I raise my eyebrows and take the bowl.

‘Chinese Fire Brigade again?’ I ask.

‘You’ll see, Joe,’ he answers.

The two EMTs, Juan and Fermin, are awake. Fermin is brushing his teeth in a sink by the door while Juan runs a comb through his hair over and over again, staring ahead with a drowsy gaze. Neither of them bothers getting into their uniform shirts. They only do this if a job comes in or while escorting me across town to the headquarters of the Chinese Fire Brigade where I lecture in first aid. Three nights ago they also turned out nicely for a dinner with the fire chief whose selection of deep-fried insects and marinated grubs revolved on the centre of the table like a carousel of horrors. With this grisly platter still in mind, I hope this evening’s meeting will be nowhere near Chinatown.

Manolo snaps at Fermin to turn off the tap.

‘All quiet! News bulletin!’ he barks.

Roadworks have begun on a new flyover and taxes will go up for a year to pay for it. Joseph Estrada, one of the country’s most popular film stars, is running for the next election and looks likely to win it. The temperature is 36 degrees Celsius with 98 per cent humidity. Heavy showers are predicted for later in the afternoon. And Silvana cookies – according to a radio promotion – now come in the flavours of coconut and purple yam. That’s all. No bus accidents, ongoing hostage situations, no gangland massacres or people threatening to jump off buildings.

With nothing better to do we mop the ambulance for the tenth time in a week. Considerably more mopping goes on here than any treatment of patients. Mopping detergent with detergent, as Juan always says. Oxygen we check too, and not because it is used for patients short of breath, but for the chance that a slow leak may have dropped the levels. This is the life of a public ambulance service medic in Manila – mopping, cleaning, sleeping …

And waiting for news bulletins.

Our meeting after work, as it turns out, is merely a visit by the rest of the station staff, three of them in all, who, out of pure sympathy for the boredom suffered by their colleagues on shift, have come to bring us a hot dinner. Sunny – a young EMT behind The Philippines Emergency Medical Technician’s Association (PEMTA), which presently boasts a total of seven members – lugs in a small television set and box of cables. He connects them up and tests a microphone with a crackly ‘one, two, two!’ Moments later we are sitting round drinking San Miguel beer, singing karaoke.

‘You have choice,’ says Sunny when it is my turn with the microphone. “New York, New York” or “Barbie World”.

Great! Cringing, I tell Sunny these are not the most interesting songs but see few alternatives in the open catalogue. Reluctantly, I ask him to start the Sinatra.

To my great relief, after just one ‘New York’ into the song, Manolo interrupts.

‘All quiet!’ he yells. ‘News bulletin!’

DR AQUARIUS AND THE GYPSIES

Macedonia

Saints are always good for a holiday. A couple of weeks ago it was Saint George and, now, in the middle of a Balkan summer, it’s Saint Nicholas who really ought to be celebrated at Christmas. But who cares if they want to honour him twice? It’s an excuse for a party and the fact that I’m working all weekend is no obstacle. Not in Macedonia, not among the doctors and nurses and drivers of Skopje 194.

Along the potholed road into the city, looking out from the peeled tinting of the side window, I catch glimpses of grubby youths half-heartedly kicking footballs in overgrown parks under the bleak housing blocks where they live. None of them waves at the ambulance as kids always do back home, hoping for a blast from our siren. On benches, watching them play, stumpy old men sit with motionless wives, saying nothing. At a corner where we pause for a red light a little boy sells eggs from a tray. A gypsy girl does a half-hearted tap dance in front of cars and someone throws her a coin. Homeless dogs scratch themselves in the heat. At a nearby kiosk with torn beach umbrellas outside, a row of bicycles lean against a sun-cracked wall. Behind that, the spire of a mosque rises between apartment blocks where laundry flaps from narrow windows. Here the best suburbs can look like decrepit public housing estates. Like my parents’ photographs from their European travels in the 1970s, everything seems faded and bathed in a vinegary orange light, as if one is moving through an era long passed.

Skopje is littered with the evidence of better times. This city was a base for Alexander the Great, the birthplace of Mother Teresa, the place made beautiful in the Byzantine era and under the Ottomans. It was still beautiful on the day before the earthquake of 1963 when 90 per cent of the city was flattened. Rebuilt by Yugoslavs with a concrete obsession, Skopje became something else and then, when communist rule ended between 1990 and 1992 (and Yugoslavia broke up with Macedonia claiming independence in 1991), the money for public works dried up. Once grand fountains ceased their squirting but still remain as concrete eyesores in every empty plaza. City gardens are knee-high in grass and weeds, pavements are fractured or caved in completely and a whimsical Socialist-era fun park on the edge of town has not changed in forty years. As for the Macedonian dress sense, everyone appears to be clothed in drab and mismatched garments they have quite conceivably selected from suburban charity shops while blindfolded.

Three months earlier in Sydney, my paramedic partner and I were called to a woman originally from Macedonia now living in a small flat crammed with imposing floral lounges, a woman who felt the need to phone our emergency ambulance for what she described as a ‘burning tongue’. There is, of course, no documented protocol for such a complaint, but as far as we could gather her tongue was not alight, nor did it look particularly red or swollen or suffering the effects of hot curry or chilli pepper or any other such thing. What we did observe about her, however, was a level of nervous tension that commonly precedes inexplicable symptoms like this and is more often related to mental rather than physical origins.

As a lover of Balkan music I knew a little about the Roma gypsies residing in Eastern Europe, many in the small country of Macedonia, a country of just two million people, landlocked by Greece, Bulgaria, Serbia and Albania. What I didn’t know was that Macedonia is also host to the largest community of gypsies in the world, most of them living in a ghetto – or maalo – known as Shutka.

After the burning tongue I got to thinking about where on earth it might be appropriate to call ambulances for such a complaint. And although people call for some pretty interesting things just about everywhere, my mind persistently returned to Macedonia. Eager to explore not only the blood-and-guts of my industry but the varying cultural peculiarities that affect it, I booked a ticket.

There are two reasons why Macedonian ambulances are always snug in the front seat. Firstly, both doctor and nurse sit beside the driver. That’s three in a row. Secondly, most medics at Skopje 194 have a considerable girth, for which the Macedonian diet is clearly to blame. Here, a meal without yellow cheese is considered inedible, even fresh salad is topped with it. Nevertheless, winters in Skopje can be nasty and the cuddly warmth of a colleague is always welcome.

While all the drivers are male, most of the doctors and nurses are not. Unlike many ambulance services that struggle to attract female recruits, in Macedonia ladies run the entire show. Dr Maja Poposka, the surprisingly young and attractive director of the service is fond of black power suits and high heels, and is a stark contrast to the legion of women she commands who mostly have the attitude and build of lady prison guards. Even in their white scrubs, wooden clogs and dainty black doctor bags, these women could suffocate the toughest male paramedic in their fathomless bosoms. They bark at their patients in voices deepened by Marlboro Reds and give every physical indication that they mean business.

For the weekend of the 2010 Saint Nicholas holiday I have submitted to being the plaything of a lively lady doctor with a black beehive and cherry-red lipstick. She is known simply as Dr Aquarius and she calls me Benja. Dr Aquarius is assisted by a nurse named Snezhana Spazovska who has several sparkling diamantes set in her front teeth and painted fingernails so long she needs five precious minutes to get them into latex gloves. Sammy Rudovski is our driver, has been around a decade or two, and knows the drill. Generally he keeps quiet. Like all the ambulance drivers he is permitted to wear casual clothes, and on this festival night is decked out in a three-piece denim suit. None of them is happy about being on shift while the rest of the country is celebrating.

Like the sound of witches round a cauldron, regular cackles of laughter emanate from the front cabin. The witch analogy is not about evil spells, but rather the wicked sense of humour they share with ambulance workers worldwide.

Just over the river, in the shade of the ancient Kale Fort, we pull up and Dr Aquarius slides back the perspex peep window.

‘Benja, we have a heart problems!’ she shouts.

I appreciate her informing me, as the usual indication I get that we have been given a job is when the ambulance suddenly careens into oncoming traffic with the cry of a siren, throwing me off my seat. Riding in the back like a pet dog is not my idea of a good time. There are few windows and it’s hot, stuffy and claustrophobic.

After a few minutes we move back and forth between apartment buildings; down the driveway of one, reversing up again, going around in circles. Most blocks are identical to one another and confusion is common. When we finally find the address Sammy has picked it by little more than a tiny number scrawled on a wall in white chalk.

Dr Aquarius leads the ascent up a graffiti-sprayed stairwell to the eighth floor carrying her little black doctor’s bag containing a blood pressure cuff, stethoscope, her leopard-skin purse and cigarettes. When I see her do this I lament the many backbreaking years I have lugged every box and piece of equipment to top floor apartments without cause.

By the time we reach the fifth level with three to go, nurse Spazovska is gasping loudly behind me. Like a commando in the jungle, Dr Aquarius motions with her hand for us to stop. We pause a little for Spazovska to catch her breath, and she’s no picture of health. Her heart and lungs are shot by years of relentless fagging, her arteries clogged with Macedonian cheese. Needless to say, performing this job on a regular basis in a city of apartment blocks without elevators ought to keep her in better shape.

By the time we reach the patient’s door, Snezhana Spazovska seems close to respiratory arrest. Our patient, on the other hand, is calmly sipping a cup of tea. There must have been a mix-up, he says. He made it very clear to the call-taker that what he had done was slam his finger in a door. There’s no question that slamming a finger in a door is painful, but calling an emergency doctor and nurse to apply an ice pack hardly seems reasonable.

It surprises me this one has slipped past the control room at Budapest Hospital. When I sat with them a week ago I’d become convinced that only the meanest nurses were assigned to work there. Every second emergency call received would have them abusing the caller for not being sick or injured enough to warrant an ambulance. Phones were continuously slammed down in the ears of helpless victims as services were refused outright.

Nurse Spazovska is pale and sweaty and can barely speak. She leans over the patient’s glass coffee table while Dr Aquarius – who no doubt has seen this all before – rubs her back. Just for a moment I wonder whether I’m witnessing some drama created to give the man with his bruised finger a demonstration of what a real sick person looks like.

‘I … my … is … tachycardia,’ Spazovska splutters.

It’s bad news when someone with shortness of breath speaks like this, catching air between each word.

Her heart is doing double-time when I take her pulse, convincing me she’s genuine enough. Meanwhile the guy with the finger looks on with confusion. Despite our offers, Spazovska refuses medication and we patiently wait ten minutes for her to regain her composure. A recovery of sorts is made but it’s no way to be starting a night shift.

Macedonia is a guarded nation with a great suspicion of outsiders and not many places have had me feeling more like a foreign agent than Skopje. No one gives much away here. Few people are open or candid. Faces are stony, scrutinising you with narrowed eyes. This is understandable considering the country’s communist history, not to mention that ‘a writer is something of a spy’ as Graham Greene once wrote in Stamboul Train. Thanks to a shared block of Schogetten Stracciatella chocolate, the ambulance team now considers me a true colleague and that respect is unreserved.

Zoran Kostovski, the Australian Honorary Consul in Skopje, is a man with incredible personal energy and vibrant enthusiasm. He is also connected at every level of government thanks to the success of his private company, Motiva, which he started after reading Body Language by Australian author Allan Pease. The objective of Motiva is to provide its clients with training in superior communication techniques – particularly of the non-verbal variety – and it is through his delivery of these workshops to politicians that Zoran has not only befriended Nikola Gruevski, Macedonia’s current prime minister but, to my great fortune, the current health minister, Dr Bujar Osmani.

When I first shared a bottle of Macedonian wine with Zoran he revealed there were only ever ten or fifteen Australians with no family connection to Macedonia visiting the country at any one time and that despite this minuscule number, they managed to keep him busy round the clock. This may have sounded like a complaint had Zoran not reassured me that he thoroughly enjoyed the entertainment his position afforded him. There was a poet who fell off his chair and fractured his hip. ‘Dangerous work, poetry,’ he said. Not long after, he was called to the police station for a female with schizophrenia found wandering the streets of Skopje in a state of undress. She had run out of medication while on holiday. Then there was the man who got so depressed after arriving in the drab city he promptly threw himself out of the second-storey window of his hotel. As anyone in ambulance work knows, the second storey is a half-arsed attempt at suicide. Once, I tell Zoran, I went to a man threatening to jump off the first level of a high-rise parking station. Ridiculous. Most interesting of all, says Zoran, was the man from Melbourne who arrived in Skopje at the time of the Victorian bushfires wearing little more than shorts and a T-shirt, carrying a handful of possessions in a small plastic bag. Apparently he wanted to get as far away from the fire as he could.

My request to meet the health minister, in order to acquire permission to join ambulance crews in Skopje, was a comparatively easy one, Zoran assures me. ‘And he’s an outstanding guy, in the toughest job, trying to do his best to bring reform.’

Indeed, on the day I’m meant to meet Dr Osmani, the front page of every newspaper shows hospital doctors walking off the job in protest at their low wages. In Macedonia, public hospital doctors earn little more than 400 euros a month, while nurses get 350 euros. Because the average rent is around 150 euros and electricity in the winter another 100 euros on top of that, most in the medical profession cannot even afford to visit a restaurant or have a drink in a bar. The wages are so low that over time it has become common practice to ask patients for money. Jumping the queue for surgery is achieved with cash alone and those without it may wait for a decade. The poor have enough trouble getting a prescription.

There is probably never a good time for an Australian paramedic to take tea with the health minister of a country burdened by such challenges. Nevertheless, I was invited to do so by Zoran and we sat in the very pleasant company of a softly spoken Osmani as he elaborated on his work.

Most significantly, his effort to stop kickbacks in the form of over-supplied medical materials to hospitals has put many of his public hospital doctors offside. At a Holiday Inn conference in 2008, Zoran introduced Dr Osmani to a patient classification software developed by Australia that keeps track of hospital resources and is known as the Australian Refined Diagnosis Related Groups (AR-DRG) system. Many countries suffering the effects of health service corruption have installed this program with enormous success, including Saudi Arabia, Greece and Romania. On behalf of the prime minister, Zoran negotiated the purchase of the AR-DRG software by Macedonia for a very modest price. Two years later it is ‘still in the process’ of being installed. Across Macedonia, hospital heads have made every effort to block its introduction, revealing just how many people are dependent on medical supplies kickbacks to supplement their incomes. As effective as the AR-DRG system may be, it does not address this root cause of corruption.

As for my placement on ambulances of Skopje, Dr Osmani has no objection and simply warns me not to injure myself. He is unconcerned I might pen something critical about the Macedonian health system. ‘It wouldn’t be news,’ he says. ‘Everyone knows the country is poor. Why should we pretend it to be otherwise?’

At a roadside kiosk Dr Aquarius buys us bottles of Pimp Juice, a local soft drink we sip through straws on the way to the next job. Earlier in the week I saw a billboard for the beverage depicting a smiling gangster with gold teeth. This is what many of the young men look like in Shutka, the capital of gypsies, and I wonder if it’s bottled there.

For my benefit Sammy takes the ambulance past the house of Esma Redzepova, known globally as the Gypsy Queen, a singer whose remarkable voice carries the collective emotions of the Roma, and whose music I have followed for some time. In opposition to those who react angrily to being labelled a gypsy, Redzepova encourages the Roma to be proud of the term and has always used the earnings from her record sales to distribute free medicine to the poor.

A little further on, near Topaana, one of the earliest gypsy maalos, stands the ominous new American embassy. Rumour has it this is not just any embassy. The complex is so vast one would need an hour to walk around it. Much to the dismay of Topaana gypsies it has also taken up every inch of what was once the beloved city park they used for weddings and picnics, forcing them onto a small, cramped traffic island in the embassy’s shadow.

Just off the Krimska Road, a family of rotund Macedonians has had a fierce argument during which the father has shattered a framed photograph of his wife and stormed from the house leaving her and his three adult children in a state of hysteria. The two daughters, both in their mid-thirties, are howling uncontrollably on the lounge while a younger man, probably in his late twenties, kneels at his mother’s feet sobbing. One would think the woman’s husband had passed away, but he has only gone to the pub. Were it not for the fact we attend jobs like this every day in Skopje I would not be so cynical. Nor would I be wondering why so many simple disagreements in this country result in group hyperventilation or all-out brawls.

Dr Aquarius tries to calm the lady, gives it about a minute or so, looks at her watch, then twitches an over-plucked eyebrow at nurse Spazovska and rolls up the sleeves of her lab coat. Spazovska knows the drill and opens a black briefcase she has taken into the house. In it are rows of glittering glass ampoules tinkling like little wind chimes whenever she handles them. It’s pretty much all the nurses ever carry, the drugs – the first line of emergency care in Macedonia. The only other items apart from medications are cotton balls for swabbing, needles and saline, and a bunch of thin candles to light for the dead. With nimble fingers Spazovska removes an ampoule of Valium 10 milligrams, snaps its neck, draws it up and hands it to Dr Aquarius.