Paramédico

Seconds after stabbing it in, without further ado, we are out the door.

Valium, valium, valium. Half the briefcase is full of the stuff. At a guess there’d be at least twenty ampoules in there and even that is not enough some nights. Morphine supplies may be out of stock, while some doctors buy aspirin for heart patients with their own money. But the Valium never dries up. This surprises me as the drug is dispensed like candy. So popular is Valium in this city that it is common for ambulance crews to administer ‘one for the patient and one for the relative’. Balkan funerals are the worst. At these there can be fifty, even a hundred, distressed mourners demanding a shot.

Our next job – or ‘invitation’ as the medics endearingly call them – is to a woman with high blood pressure and a headache. Again, along with a prescription for Monopril and a beta-blocker comes intramuscular Valium.

‘We take the Pimp Juice, they take the Valium,’ laughs Dr Aquarius afterwards. ‘That is how the world goes round!’

An hour later everyone is thrilled to have discovered an apartment block with an elevator, none happier than our smoking asthmatic nurse. On the top floor a man has been vomiting for a week. Exciting stuff, I think to myself.

The apartment is painted a deep red and decorated with kitsch throne-like furniture more suited to a medieval castle than a tiny bachelor pad. Gold candelabras rest on a narrow black table in the centre of the room along with a giant porcelain tiger and a vase of plastic irises. Macedonians have less money now than they did in the communist era yet give the impression they are enjoying the spoils of capitalism. All over former Yugoslavia one can find this same quasi-bourgeois aesthetic. If you want to know how a two-dollar shop can make you look rich, just ask a Macedonian.

When Snezhana Spazovska removes a hideous oil painting of a teary-eyed clown from above the lounge where our patient is lying I am momentarily relieved. Unfortunately she has not taken it down to improve the appearance of the man’s apartment but to hang an IV drip on the hook in its place.

The moment she has done this, we leave.

Not one of the three jobs we have knocked over before sundown has had us on scene for more than five minutes and not one patient has been transported to hospital. Only yesterday, a Skopje steelworks employee with a bleeding nose, a case I would normally spend ten minutes or so treating with manual pressure alone, was handled completely differently. Pharmacology was the mainstay and the patient was fixed in half the time. There were jabs of Valium and Frusemide and a cotton ball soaked in adrenalin shoved up the nostril. Again less than five minutes on scene and no transport. Although it could be argued that a certain thoroughness and continuum of care may be lacking here, the Franco-German model of pre-hospital intervention is so far proving highly efficient. In most other countries where I’ve worked, all these patients would by now be clogging up emergency departments. As for the man with vomiting and dehydration lying there on his over-ornate lounge with a drip in his arm, what happens when the solution has run through?

‘We give instruction on how to remove it,’ says Spazovska, ‘How to stop his vein from bleeding. We explain him procedure, don’t worry.’

To a paramedic from a system without physicians such a practice seems daring. Not every patient is bright enough or possessed of the nerves to remove their own cannula and stem a bleed. But these, it seems, are considered worthwhile risks to save a tenuous hospital system from being overburdened.

Our assigned station for the night lies in the somewhat forlorn suburb of Chaiar, not far from Shutka. After a couple of home visits in the Albanian quarter issuing Tramadol to cancer patients, our driver, Sammy, passes the house of Johann the Killer, the commander of a police unit responsible for war crimes against an Albanian village and currently awaiting trial in The Hague. It’s a purple and mauve monstrosity hung with wagon wheels and cowboy paraphernalia, complete with a ten-foot medieval gate. Sammy is also Albanian and finds it incredible the house remains untouched. As we head to Chaiar he tells me how last month a patient refused to get into an ambulance driven by an Albanian and subsequently threatened the crew with a steak knife.

Ethnic tensions run deep in Macedonia. My friends here, even the young and university educated, frequently shock me with their overt racism towards Albanian Muslims. No one even bothers beginning with the customary ‘I’m not racist, but …’ preface as racists in Australia often do. Perhaps this tension is understandable when the last skirmish of gunfire exchanged between Macedonian forces and Albanian insurgents occurred as recently as 2001. And it is only since 2007 that Macedonians dare to walk through the Old City dominated by mosques and ancient bath-houses separated by the worn cobble streets winding to a Turkish bazaar.

Then there is the issue of Vodno, the steep mountain high above Skopje where Macedonians have installed the Millennium Cross, the largest crucifix in the world, sixty-six metres tall. Without a hint of shame my friends admit the cross was placed as a mark of territory rather than a symbol of Christ’s grace and tolerance; ethnic Albanians should be constantly reminded who the rightful owners of the city are. Even by night, from the window of the ambulance when everything is black, the cross on Vodno hovers, brightly lit and imposing against the night sky. It may be a thing of beauty but for me it’s a beauty tainted by the country’s godless divisiveness.

At Chaiar Station, a sweet Albanian nurse with near-perfect English is manning the radio and scissoring small squares of gauze from a giant sheet for sterilisation. Her name is Drenusha Arneri and in our earlier conversations she admitted it took her a year to feel accepted by her colleagues. Now, despite being a Muslim, she celebrates Easter with them, helps colour eggs at the ambulance station and even brings along a plate of homemade baklava. Under Dr Maja Poposka the service has come a long way in creating a positive environment. Whenever she can spare one, Poposka even sends an ambulance to Mecca with a team of Albanian medics onboard to help out.

For Dr Maja Poposka nature helps her deal with stress and that is why in the middle of her office at Bucharest Hospital she keeps a giant indoor tree growing in a pot with branches reaching out around the room and leaning like a friend across her desk. By all appearances this chain-smoking doctor is more Russian supermodel than ambulance service director. Before taking up her position two years ago she had already worked fifteen years on ambulances in Skopje, roughly the same time I have worked on them in Australia.

‘Everything I have seen,’ she says matter-of-factly.

We begin a discussion on the improvements made to Macedonia’s ambulances since she became director. New ambulances donated from around Europe, white uniforms for the medical staff, better training and equipment. It is hard to believe, but up until 2006 none of Skopje’s ambulances had defibrillators on board. Response times were notoriously dismal and the ambulance doctors had a countrywide reputation for being mean and rude.

To some extent, from my random canvassing of locals I have met here, public perception of Skopje 194 is still rather poor. At a taxi stand in town not a single driver could recite the emergency number and an informal survey I conducted at a Bob Marley tribute party in a city park revealed the widespread opinion that ambulances still take forever to arrive and are staffed by ‘bitches’ anyway. Neither of these perceptions is at all fair, as I’ve discovered first hand, and I ask Dr Poposka why the service has not done a better job of public relations since she took office.

‘Problem is we cannot advertise our improvements,’ she replies. ‘It is better for us to go about our work quietly and rely on word of mouth. You see, we are still under-resourced and only just manage to meet the eight minutes response time standard for 90 per cent of top priority cases. What will happen if we tell the world how good we are now, how quick and polite and professional we have become?’

It’s true that public ambulance services do not generally benefit from advertising. The better a service looks the more people will call, leading to a higher demand that will negatively impact on response times. The only publicity campaigns an ambulance service should probably entertain are those that concern prevention and discourage calling for inappropriate reasons. This is a vastly more difficult campaign for a service with general practitioners on every ambulance and a public that knows it.

Maja Poposka’s frustrations working on the road prompted her to apply for the top job when the former boss retired. Four old Russian-built Lada station wagons are still parked in the basement of the ambulance headquarters, cobwebbed and rusty. Only a few years ago they were all the city had.

‘You can imagine our reputation, driving around Skopje in these things,’ said Dr Poposka when she took me to see them. ‘We were always late and even then we couldn’t do much for the really sick ones. See, look how low the roof is. None of us ever did CPR in these cars, impossible.’

‘So what did you do in cardiac arrests?’

‘Drive fast.’

Hearing this I understand completely her reasons for leading the service. Watching people die from a lack of space would be maddening for any ambulance worker, let alone a medical doctor.

Behind her office lies a larger ambulance graveyard containing numerous donated vehicles from around Europe, all hand-me-downs still bearing the logos of their former masters. Here I saw a Johanniter Mercedes from the Germans, a 118 van from Rome and a French Renault from the SAMU. Up until recently Skopje 194 used these vehicles as they were. On any one day it was common to see ambulances from various European nations all screaming through Skopje at the same time. This reminded me of a friend who had visited Fiji and happened upon the same ambulance he had driven around Sydney for years being used there since its donation to the country a year earlier.

Chaiar Station is little more than a few cold rooms in the wing of a small clinic, lit by a tiny television with bad reception that everyone put in for. Few want to miss the Macedonian version of Wheel of Fortune known here as Wheel of Happiness. For those who know that money does not guarantee happiness, the game show is followed by an addictive Turkish soap opera. As we settle in to watch the next episode of Yabanci Damat, Drenousha helps us get into the spirit of things by serving Turkish coffee.

Ambulance stations of Macedonia become drop-in medical centres after hours and on the weekends. So an additional doctor is always on duty at night and has a separate consultation room. For the festival night of Saint Nicholas, Dr Save Bobonovski is on shift, his first name ensuring great popularity among his patients. At one time he also worked on the ambulances, but that was ten years ago and he quit after attending a nasty accident at Alexander the Great Airport. On 5 March 1993, eighty-three people died when flight crew forgot to de-ice a Macedonian Airlines Fokker prior to departure and it crashed seconds after take-off. Save was first on the scene. As he tells it, bodies and body parts were scattered as far as the eye could see. He decided soon after he was more suited to working indoors.

A second crew comes by on their way to a chest pain and picks up an ECG machine. At present there are not enough to go round and Chaiar ambulances have to share a single ancient Hellige box with its little rubber suckers and wide leather straps that bind to wrists and ankles and around the chest. It must hark from the 1960s or thereabouts and looks more KGB than ECG. We’ve used it plenty of times, and vintage though the Hellige may be, it is still a functional 12-lead cardiograph.

Dr Aquarius scoffs. ‘Our government doesn’t have money for new ECG machines, but they sure have it for bronze lions in public squares. Have you ever seen a bronze lion save a life?’

To boost morale, reinvigorate patriotism and attract tourists, the government of Macedonia has created a controversial building project known as Skopje 2014. By crossing the old stone bridge over the Vardar River in the direction of the central mosque, one can see where work on the multimillion denar project has begun. A highly fanciful preview of what the completed dream may look like is also available on YouTube as a musical montage. Ridiculous oversized monuments are superimposed on city intersections, including a sky-scraping Alexander atop his rearing horse in the main square. Imitation baroque buildings line the banks of the Vardar where a troupe of dancing fountains shoot from the murky rapids.

Continued Greek denial of Macedonian identity is certainly part of what has prompted Skopje 2014. But for unemployed and hungry Macedonians it is all too much.

‘Remember how Ceausescu died in Romania?’ says Dr Aquarius. ‘He built an Arc de Triomphe replica in Bucharest while his people were starving and was executed by firing squad.’

There is a patient with shortness of breath in Shutka, where we spend most of our time each shift. As in the films of Emir Kusturica and their endless parties of drunken gypsies firing pistols into the air, breaking bottles over each other’s heads and tripping over roaming geese, the maalo has an atmosphere of madness even in the absence of wedding receptions. Still, we are rarely called to trauma cases. There is surprisingly little violence in Shutka considering the quantity of the homebrew, rakija, the inhabitants consume. They are not a violent race. Never have the gypsies fought a war or occupied a land.

In contrast to the guarded personalities of many Macedonians, the gypsies are warmer and quicker to smile. Perhaps they feel secure and at peace here. Macedonia may be over-spending public money on bronze lions and flaming crucifixes, but the country has arguably the most compassionate policy towards the Roma anywhere in Europe. By comparison, Italy and France spent much of 2010 gypsy hunting. Although they weren’t shot, as happened under the Nazis in World War II, gypsies were rounded up like cattle and forced back to Romania and Bulgaria. Many were not from these countries in the first place. It’s hard to know what land, if any, a gypsy calls home. Since migrating from India a thousand years ago, they have spread to all corners of the earth and are regularly uprooted and chased away by governments.

Macedonia, however, has allowed gypsies the right to identify as Roma, to live in their own suburb and to have a representative in parliament. With its own mayor, permanent housing and radio stations, it is no wonder Shutka has become host to the largest number of gypsies anywhere.

Not everyone in Shutka is satisfied. Many are disappointed the government is not doing more to help them. Social security is only available to those Roma registered as residents of Macedonia and even then it is a paltry 50 euros a month. With some notable exceptions, including a handful of doctors and lawyers, the Roma are not much interested in education and few end up qualified for decent work. This forces many to rely on the garbage collection, the begging and the thievery for which they are known. Attending a school or a job to become a cog in society holds little appeal. More thrilling are horses and music and fire, all things wild and free, living each day as if it were the last.

Finding an address in Shutka can take a while. Some of the streets are cracked and deeply gouged with potholes and the eccentric little homes rendered in lurid colours have all kinds of madcap decorations hanging on their outside walls, from obscure coats-of-arms to enormous cuckoo clocks. But street numbers on letterboxes are scarce. We stop and ask a group of men sharing a foot-long salami and rakija if they know where our patient lives. After some lengthy argument they point toward the bazaar. Sometimes, even in serious emergencies, we drive around the maalo in dizzy confusion, following several opposing directions. Thankfully, the streets are easy to remember. Without a shred of irony the Roma have given them names like Washington Square Boulevard, John F Kennedy Parade and Disneyland. Shoddily constructed miniature palaces of concrete can be found here. Poorer homes, in many cases, shanty-style shacks are more likely found along Che Guevara Drive, Shakespeare Avenue and Garcia Lorca Lane. At the bottom of the hill there is a quarter of Shutka I have visited that looks no different to a Bombay slum, complete with muddy passages, huts constructed from junk and United Nations water pumps.

Past the smugglers’ bazaar where toothless old men sell lacy bras hanging in rows along rusty fences, where bootleg perfumes and pointless porcelain pigs go for a steal, we pull up at a partially collapsed building and enter a 2-metre-square room, home to a family of seven. Our patient is a forty-year-old woman with six children and a husband in jail. Only a gypsy can peel potatoes while suffering severe respiratory distress, I think to myself. Her mouth is snapping with every breath, as if biting for air.

Everyone seems to have breathing problems in Shutka. It’s either asthma or emphysema or bronchitis or all of these at once. Temperatures in winter can drop to minus 20 degrees. If there is rain the streets of Shutka become rivers of freezing mud and many of the children do not have boots. Chest infections are common. Adults sit all day and night in crowded rooms, chain-smoking the contraband Marlboro their children passively inhale.

Dr Aquarius and Snezhana Spazovska don’t mess about. They promptly administer an injection of Amyphyline and Dexamethasone during which the woman only momentarily ceases her potato peeling. It surprises me that oxygen is rarely given to patients the crew intends on leaving at home, especially those with breathing problems. On this occasion Dr Aquarius is feeling generous and runs the patient on a low rate through nasal prongs for several minutes, though staying on scene too long in the maalo is unwise. News of an ambulance entering the ghetto quickly gets around and it’s only a matter of time – often less than fifteen minutes – before every sick person with the slightest complaint surfaces for treatment. Suddenly the ambulance becomes a mobile clinic and is trapped indefinitely. Many gypsies are not registered citizens and have no entitlement to hospital treatment. For them, the only hope of getting medical help is to bail up ambulances whenever they see them and appeal to the compassion of the doctor on board to get a free consultation.

The sun has dropped below the snow-capped Shari Mountain Range when we pull up at a small house so crooked it could have been built by a child. It is dark as a cave inside and the floor is covered in the shapes of countless bodies wetly snoring under thick floral blankets. A woman who does not bother brushing the hair from her face rolls over and pulls down an edge of her grimy tracksuit pants, exposing a buttock.

Dr Aquarius sighs and nods at nurse Spazovska who flicks open her black briefcase again, cracks a few ampoules, draws them up and stabs them in. The woman pulls the blanket over her head, falls back to sleep and we are out the door.

Two minutes and thirty-five seconds and not a word exchanged between medic and patient.

‘Did you know her?’ I ask, perplexed.

‘Not personally,’ says Dr Aquarius, climbing back into the ambulance.

‘How did you guess what was wrong with her? Or what to give her?’

‘You should understand by now. When they want an injection straight up it’s the same thing every time. Vitamin B1, B6, B12 and C for good measure.’

If they’re agitated, Valium is part of the cocktail too. And gypsies are notoriously prone to agitation. Should the Valium run out, the doctor will resort to aqua injections – plain water or normal saline. Few patients know any better. It is not about the drug anyway but about the spritz. With the exception of heroin addicts I’ve never met a patient enthusiastic about injections. Many Roma, however, can’t get enough. This is because they have what Dr Aquarius calls ‘injection jealousy’. Should a gypsy observe her neighbour receiving two vitamin injections from an ambulance crew, she will later call up and try to outdo her rival by asking for three. Roma are very jealous people. Angry scenes occur if ambulance crews don’t give the maximum number of injections, regardless of whether the patient needs them or not.

‘Once, in Shutka alone, I gave one hundred and thirty injections over a single week,’ boasts Snezhana Spazovska through the slide window.

Seems to me a bad precedent has been set. A community expectation has been established from which these medics find it difficult to escape.

‘Most of the time the Rom are very peaceful,’ says Dr Aquarius. ‘But, well, we give as many injections of Valium or vitamins or aqua as it takes us to get out of there quickly. It is not only Rom. Other Macedonians are like this too. No patient in our country is satisfied without a spritz.’

Injections are a matter of service efficiency rather than pandering. If a crew decides to leave without giving a jab, the patient is likely to wait fifteen minutes or so then call again. Indeed, they will call and call until they get an ambulance crew willing to give them one. Repeat callers are not unique to Macedonia and are a problem anywhere, in any country. Some callers in Australia are known to have our easy-to-remember three-digit emergency number on speed dial. In exasperation, some paramedics manage this problem by transporting the patient to hospital to remove them from their home phones so they won’t call again. Of course, this simply shifts the problem. Treating patients in the field is more desirable, but whether it is ethical to inject a patient for the sake of operational efficiency alone is an interesting question. Maybe a little bending of the rules is justified for the greater good, allowing ambulances to be more readily available for life-threatening cases. I can’t help thinking, however, that if injection-jealous gypsies knew that the party was over, the call volume would drop and the burden would ease naturally.

Girls with gold hoop earrings smile and wave and kick up bright floral dresses as we pass them trailing a mob of grubby children. Their look is a welcome flashback to the gypsy aesthetic of old in a township where most of the women have long ago discovered Adidas and cheap bling.

We pull up outside a peppermint-green house with a waterfall feature built against the front wall. Inside a middle-aged woman lies theatrically collapsed on the hallway carpet, hyperventilating. A dozen family members and relatives shuffle in behind us to have a look.

Dr Aquarius asks the woman a few questions, which she answers with excessive gasping and groaning and rolling about. Spazovska is next to me and whispers, ‘Pain all over.’

Right. Pain all over. As if I couldn’t have picked it, that classic ailment of the chronic neurotic. How it makes us laugh when we hear it! Not in front of the patient – never in front of the patient. Oh, but how we laugh. From what I can tell, Dr Aquarius is examining the patient in the same manner I do in such cases. Slowly she palpates every region of the woman’s body. What about here? And what about here? And here? And every time the woman groans or winces or pulls away, even when Dr Aquarius has reached and squeezed the tip of her pinky finger. What drives an unusually thorough examination like this is a hope that our looks of confusion in response to the patient’s unspecific complaints will be a hint to her and her relatives that we are not convinced and that perhaps, to avoid embarrassment, someone should put an end to the entertainment before we are forced to do so in the back of the ambulance.

‘She requesting something special,’ Spazovska says.

Gypsies love a bit of drama. This I can appreciate – life is great when it’s thrilling. Less forgivable are the patients who have an ambulance called for the sake of attracting attention. Attention-seeking exists in every country and in every cultural group, and is particularly prevalent in very large families. A person feeling left out or snubbed for some reason may decide that by feigning a medical emergency they will get what they crave. The strategy usually works well and they soon find their extended family standing around them saying pointless things like, ‘Oh my God! Oh my God! Oh my God!’ and rushing wet towels from the bathroom. Perfect! So long as their symptoms are as ambiguous as ‘pain all over’ and appear severe enough, the little fakers may even get a ride to hospital. Of course, on arrival they will make a miraculous recovery and discharge themselves before a doctor has even seen them.