Wednesday, July 30, 2014

Humans Are Never Just "Collateral Damage".

Trudy Rubin's July 29th editorial in the Spokesman-Review highlights what Americans and many others often fail to do - to see imperiled people as humanity. They are not "others". Not "news items". Not "collateral damage".

All of us sometimes try to escape responsibility by putting the blame elsewhere, on someone "different" from us. Nowhere is this more obvious than in the present Gazan/Israeli conflict.

It's been sixteen years since I visited Israel, but I can identify with Ms. Rubin's observation that Gazans [and Palestinians living in Israel] are rarely seen as individuals. Rather, they are seen as opponents. Never mind that Israelis build new housing developments in West Bank territory, or blockade Gaza, or bomb Gazan neighborhoods. Hamas, in turn, fires rockets indiscriminately at Israel, and vows to eliminate Israel's existence.

Too many of us support the right to "get even". We idealize freedom, and justly so. But there is a difference between "freedom from" and "freedom to". Both have their place in civilization, but only when our own rights do not exclude the rights of others.

Military force alone is producing no result but mayhem.

Tuesday, July 29, 2014


There are times when I want to get totally away from every-day life and work, to think, or maybe dream, or learn something new. I suppose I could do this on the hillside above my house on a summer Saturday afternoon. But one of my favorite places to be alone is the railroad track outside Sandpoint, Idaho, on a hot summer day.

This isn't just any railroad track. This is THE main line of the Burlington-Northern Santa Fe transcontinental route, the place where the tracks divide. The left-hand track carries trains across northern Montana to St. Paul and Chicago. The right hand track leads them instead to Missoula, Helena, and the cities of the southern half of Montana. And in between the two main tracks is an old rusty siding, no longer used, ending abruptly at a pile of old railroad ties. I can sit there on the ties and smell the hot tar in the sunshine, listen to the whirring grasshoppers, see a hawk wheel slowly overhead. And watch the trains go by. I could sit there all day, if I hadn't promised my wife I'd take her to lunch.

One summer day, I wandered a little farther up the track, idly picking up pieces of scrap iron, rusty railroad spikes and the like and depositing them in neat little piles. When I returned, two men had taken my place at the dividing of the tracks. Seen from a distance, they wore hats that glittered, and they were doing something with fire. After watching them from afar, I reasoned that they were probably not sabotaging the rails at ten in the morning, and I strolled up closer.

The gleaming hats proved to be welder's shields pushed up on their foreheads, and they were merely a couple of bearded railroad repairmen surrounded by tools from a pickup truck parked on the road beside the track. We exchanged howdys. They spotted my notepad tucked in my belt, and asked if I was writing a book. I dismissed that idea with a small laugh, leaving me free to ask what they were doing.

"We take the clickety-clack out of the track," the older of the two told me. The mainline rails are an unending ribbon, free of the joints that used to give background noise to every train trip. I asked why the hot sun didn't cause such a long piece of steel to expand in the heat and bend out of shape. Even quarter-mile-long bridges need room to expand in the heat. I didn't understand his whole answer, but he said it is only an occasional problem. Like now, at this point. The inspection truck—a pickup that rides the rails on iron wheels—had recently been by, and had found a bump at this place as it passed, plus a couple more farther toward Bonners Ferry that they would presently go fix. He showed me a half-inch thick cross section of rail which he and his partner had surgically removed from the track with a large circular emery saw. They had then jury-rigged a small brick crucible around the gap, melted some of the track-side scrap metal with a welder's rig and re-welded the track together, polishing their weld smooth with all the care a dentist might spend on a front tooth filling. These two men were responsible for such repairs from Sandpoint all the way to Libby, Montana, an 85-mile long stretch.

These new methods of railroading fascinate me. After they left, I compared their work with the old unused spur, with rails bolted together every twenty or thirty feet. A date stamped into the rusty side of the rail on the spur said 1920. I moved back to where the main switch determines which route each train will take for the next thousand miles. There is no switchman there anymore. A computer in some city far way, activates the heavy-duty electric motor that moves the rails, and changes the overhead signal lights from red to green. In winter, an automatic propane-fired blower melts any ice that might clog the switch-points. I am told that the bits of scrap-iron I idly put in little piles next to the track might just as well have been left alone—a work train with a large magnet periodically comes along and recovers most of them.

But the job I have always dreamed about—the locomotive engineer—is still filled by a human being. A train is coming now; it had stopped down at Sandpoint station until the signal turned green. Its four diesel engine units throb mightily as it slowly accelerates its l06-car, mile-long load, the triangular pattern of the three headlights visible a mile away, The brilliantly painted orange-and-yellow engines with their Santa Fe logo are moving at thirty miles an hour by the time they reach me.

As he passes, the engineer, high in the cab, waves to me.

And the little boy inside me waves back.

Friday, July 18, 2014

Consistent with Ebola

Mountain peaks twelve hundred meters high brood darkly over the forests and valleys of the Thai-Burma border. On the Thai side, a single paved road snakes northwestward from Kanchanaburi 210 kilometers to the small town of Sangklaburi. It then goes up over Three Pagodas Pass and on into Burma, following the route of the old Japanese “Death Railway.” It is often said that, in World War II, one prisoner of war died for each railroad tie laid down on that temporary, war-time rail link with Burma.

Nowadays, death comes from the forest itself in the form of falciparum malaria, scrub typhus, rat bite fever, and a host of other fevers still unidentified. They are borne in the undernourished bodies of thousands of refugees fleeing the military dictatorship that has held Burma in its grip for forty-six years. The diseases funnel through the refugee camps along the border, where lone doctors provide rustic medical care in thatch-roofed bamboo buildings, funded by such groups as Doctors Without Borders or the Refugee Consortium.

Other than these small outposts, the first line of medical defense is ten kilometers inside Thailand at the small community of Huay Malai, twenty km west of Sangklaburi town. Kwai River Christian Hospital is a twenty-five-bed facility with a couple of doctors and nine Thai nurses, run cooperatively by the Thai Baptist Missionary Fellowship and the Armed Forces Research Institute of Medical Science (AFRIMS), which in turn is a joint project of the Thai and U.S. military. Here AFRIMS maintains a research laboratory to identify the causes of fever in that part of the world. Most of the years I visited there, Dr. Phil McDaniel ran the clinical wards, assisted by a constant trickle of visiting doctors, medical students and the AFRIMS laboratory staff.

I was substitute doctor in Phil’s absence when, one Friday at 5:20 p.m., a child arrived from the refugee camp at Holokani. Carried in his mother’s arms, four-year-old Hon Side was feverish and convulsing. His feet were dark splotchy red from bleeding under the skin. He had an intravenous line in one arm and a letter from the refugee camp doctor, stating he had treated him for two days with quinine, ampicillin, and gentamycin, and was now referring him as a possible case of meningococcic meningitis
Two nurses quickly controlled the child’s seizures with an injection of diazepam and established a second IV line, while our current medical student (Pia Sannaraj, a Thai-American from San Diego) and I examined him. Neck a little stiff, a few rattles in his chest, and the ominous dark-red patches. He certainly might have meningitis, and while we waited for the lab’s first blood report we injected artesunate, an anti-malarial drug safer and more effective than the quinine he had received at the camp. While a male nurse-aide held him, gently but firmly bowing the child’s back, I carefully inserted a needle into his back, drew off spinal fluid and sent it to the lab. An hour or so later, the lab reported a normal white blood cell count, no malaria, normal spinal fluid, but noted the presence of blood in his urine and a very low platelet count, one of the factors that helps blood to clot.

That changed our thinking to Thai hemorrhagic fever, where blood and fluid leak out of the vessels causing a rapid downward spiral into irreversible shock and death. The trouble with that was, having had it for two days before coming in, he should either be recovering or dead by now. Nevertheless, Pia and I pushed IV fluids as much as we dared, trying to keep his blood pressure up while not suffocating him from fluid overload. The AFRIMS staff is not there on weekends.

I am a firm believer in coincidences whenever they appear. Dr. McDaniel would be back from his medical conference the next day, but he had sent his new associate, Dr. Kathy Welch, on ahead to escort a visiting doctor from Congo, Dr. Dan Fountain.

Dan and I go a long way back together as teen-age acquaintances in central New York State, same vintage but different medical schools, after which he went to Africa and I to Asia. He went on ward rounds with Pia and me Saturday morning, when we noted that the little boy, Hon Side, was now vomiting blood, and had a platelet count of 29,000, a level low enough to induce panic in doctors. Moreover, the kid’s baby brother had died with the same symptoms—not six months ago, as the original story went, but just last week. His fever was now 103, his hands were turning red like his feet, and his chest X-ray suggested we had better back off on the IV fluid.

When rounds were over and Pia and I were ready to begin work in the crowded outpatient department, Dan took me quietly aside. “I don’t know much about your Thai hemorrhagic fever,” he said, “But there may be problems for your hospital with that little boy. That looks for all the world like the Ebola virus outbreak at Kikwit, near our hospital in Congo back in ’95. It was just a case now and then in the villages until it hit the hospital, and then it spread like wildfire. They soon had 300 cases and about 240 of them died, including many of the hospital staff. You’d better notify Center for Disease Control.”

CDC, in Atlanta, Georgia, maintains world-wide surveillance of dangerous infectious diseases. Ebola virus is one of the worst, with no effective treatment, no vaccine, and an eighty to ninety per cent mortality rate. It took me a few moments for it to sink in. “It’s Saturday now,” I hesitated, “probably the quickest way to get help is when Dr. Miller comes back to the AFRIMS lab Monday morning. He has the equipment and know-how for this. But I thought Ebola only happened in Africa?”

“Monday is too late. Get on the phone now. Pia tells me she has a number for Dr. Miller in Bangkok.”

“You really think this could show up this far from Africa?”

“Who knows how these things show up? Ebola turned up in Reston, Virginia, in the 90’s. The origin was traced back to the Philippines, and nobody knows how it got there.”

We moved Hon Side into an isolation room complete with gloves, gowns and masks, and a bucket of hypochlorite solution to soak everything in. The head nurse reached Dr. Miller and he sent a lab tech to take special blood samples and freeze them. If it is Ebola, the minority of cases who don’t die can take weeks to recover.

“It’s not contagious until you have fever and bleeding,” Dan told us. “Each of you who has had contact with the boy will need to take your temperature twice a day for the next two or three weeks. If you have no fever, you are home free. If you do get fever, take malaria medicine. If you still have fever, turn yourself in at a hospital wherever you are and tell them you may have contacted an Ebola patient. That will get CDC’s attention, I assure you.”

Phil McDaniel had no trouble believing the danger when he got back next day, but we had trouble with the nursing staff, who wore gloves and mask, but would not put on a new isolation gown each time they entered the room, until we agreed to have them check him every four hours instead of every two. And we caught a substitution of Dettol instead of the required hypochlorite disinfectant solution. Danger of one’s own death from a disease never before encountered is hard for anyone to grasp. Americans hadn’t experienced a deadly epidemic in eighty years.

At latest report (by e-mail after I left for America the next day), Hon Side’s platelets had dropped to 14,000, and areas on his hands and feet were turning black.

After I got home two days ago, I thought my fatigue and aching muscles were from jet-lag on the long trip home. But today my throat is sore; I have a fever of 102 and my head is beginning to ache. There is a bruise on my hand; I don’t remember hitting it against anything. But it’s hard to remember anything today; I feel lousy, and just want to crawl into bed and sleep. I wonder what the emergency room doc would say if I tell him I may have Ebola?

How many people here will catch whatever I’ve got?

Tomorrow’s newspaper should be interesting . . .

if I’m around to read it . . . .

(from "After I got home" and onward is fiction.) © Keith Dahlberg, MD

Thursday, July 17, 2014

Honest Workers- JOE

Joe and my wife and I had just finished inspecting our back yard where the new garage was going to go. He had my sketched floor plan in his hand, and changed the dimensions enough to allow space for a couple of pickup trucks to park in there, this being Idaho where a gun-rack in the rear window is important for all but those few of us who prefer 40 miles in a gallon more than two elk carcasses in the back.

Joe's weather-tanned face concentrated on the sketch for about a minute, and then, "Okay, I'll get the permits Monday and we'll get Ron's backhoe in here and start work the next day."

"So, how much advance do you need for materials and all?" I asked.

"By golly, I don't do business dat way. You can pay me when the job is done." His tone allowed no argument. And that was it. No legal contract. I knew Joe and Joe knew me. No blueprints either. The sketch he had marked up would be enough for the County Building Inspectors; they knew Joe's work too, though they would be out to check the concrete and rebar on the foundation, and other items as the work progressed. In the twenty-five years since he had immigrated from Central Europe, Joe had become something of a local institution, and soon had a reputation for honesty and competent work. Always ready for a beer or a cigaret, after work is done for the day, he might also be found up on stage at some local event, pumping out a polka on his accordion, or just enjoying the crowd. The phone message on his answering machine never changed: *I'm not here right now, but leave a message and I'll get back atcha."

Joe doesn't waste time starting a job. When my old garage was leaning over like the Tower of Pisa, he appeared with his crew at 1:30. By 2:30 they had the building down and scraped into a neat pile, using his all-purpose back hoe. They carefully watched the pile of debris burn until 5:00, leaving it to a watchman with a hose. Although they had scraped all the tar paper off the roof boards before torching the pile in accordance with the the fire chief's regulations, I noticed that the pile of tar paper was a little smaller each time I looked out the window, until only enough was left to fill the back of a pickup. Joe is practical above all else.

But on any job, he always has time to talk a bit over a cup of coffee in our kitchen before getting down ro business. We found that we both had ancestors in Bern, Switzerland. We shared reminiscences of housing problems we each had had when moving into the Silver Valley. He spots a mango sitting on my window - it's new to him, and he wants to know all about it, but won't try one now - got to get to work.

He comments on the hummingbird at the feeder by the back door, and then is "back at it" with his surveyor scope and string line, or hammering planks into forms for when the concrete truck will arrive.

That garage Joe built is nineteen years old now, as sturdy as the year he built it.