Balancing Act

It is difficult to hold your son’s hand, after receiving a phone call and flying across country overnight, to look at his misshapen and lacerated face, eyes filmy, conversation disoriented, perseverative, a gurgling cannula sucking blood from his mouth, oxygen in his nose, multiple IVs.

On the other hand, it’s not difficult. It is exactly where you want to be, your every fiber seeking to draw out the pain, heal the tissue, do the right thing. Eighteen hours ago, he was laying on a Tucson street, bicycle broken like matchsticks, hypotensive, airway filling with blood, dying; the victim of a negligent driver. Eighteen hours before he was a joyous teenager, a top of-his-game espoir, bound for European races and national team slots, working ardently at winter training. Prompt EMS, suction and IV saved him, opened his airway and restored circulatory volume. Open reduction surgery with internal fixation by titanium plates and screws would rebind his jaw, fractured in a dozen places, eight teeth knocked out across the top of his mouth, right condyle snapped and dislocated, fractured left subcondyle.

This I balance five weeks post trauma. He’s had a remarkable recovery. His legs are strong, as are his lungs. His power is up, exceptional watts per kilogram. Six hours today on the bike, riding out from our house near Washington, DC. "Let him go, be the wind at his back" -- I tell myself. This I will do, but it is hard. When I was about Nathan’s age, a negligent driver ran a red light and hit me. At the time, January 1977, my own father wrote:

As I stood there in the hallway outside the Emergency Room, I saw Jim standing vibrant, healthy and loving in the family room and cursed myself for not putting my arms around him and persuading him to spend New Year’s Eve at home with us. He was close to doing so – if I had only held him at home. If, if – there were so many ifs to ponder as I waited for the double doors of the operating room to open … The doors finally parted ... [Jim's surgeon] talked briefly but directly. Jim was in grave danger. It would be several more hours before we knew whether the brain’s swelling would reach fatal proportions or stop … They wheeled Jim out. His head was a white turban of bandage. Tubes were in his arm and nose. We tried to touch him as the attendants wheeled him past us on the quiet rubber wheels of the stretcher. I probably called out what I had heard and said dozens of times on the battlefield but seldom believed: “Hang in there. You’ll be all right.”

With this, I work to balance the eerie burden of repeated history. I wasn’t as lucky as my son, my injuries deeper and harder to compensate. Where does a parent draw the line? My two boys began bike racing at ages 10 (Avery) and 13 (Nate). For us, it was the next stage beyond youth soccer, basketball, lacrosse and whatnot pediatric sport mayhem. A phase. But cycling became more, a unifying principle around which our family organized our lives, travels and passions. And the boys became good, very good. Racing around the country and internationally. Cycling is the main thing; both boys wish to become professionals, have guided their college selections towards physiology and sports. Who would have thought? This from a family of scientists, software geeks, lawyers, writers and school teachers?

Cycling is the path that is before my sons, their passion and desire. It is a beautiful thing, their choice. Their hard work and success will bring not just individual victories, but will also lift others seeking joyous and healthy lifestyles. While I urge caution, the Tucson experience is a stronger caution than any can imagine.

Will I feel bad at the next accident? Of course. And we will be there, with every fiber and talent we possess, as we care for those we love, gently enabling their passion, the next podium, the beautiful slice through the sun and air.

SV7-8 -- Chill Sunday, LeAlem Monday, Learning

Site Visit Day 7-8 (Sunday-Monday) -- Took a restful Sunday, pretty well recovered from medical distress that made for sharp Friday. Walked about five miles around Addis, drinks with leader in Addis Ababa Cycling Federation, Dr. Telaye Wube. Did a good bit of writing and reading, picking-up Abraham Verghase's Cutting for Stone, recommended by EHN board member. Verghase's novel tells of romance and graphic detail of (some extraordinary) medical work at an Addis Ababa missionary hospital, during the early years of Emperor Haile Selassie. Gripping and apropos, intellectually large.

Similarly peaceful if routine Monday, with morning and afternoon case study work at LeAlem. A number of compelling stories captured, images below.







I'm increasingly impressed by the business model we've set for EHN/LeAlem. Here's a clip from my current draft: "LeAlem is performing work efficiently. Several notable factors and measures contribute to this finding, including: The clinic is an established, ongoing commercial operation that is not dependent upon charitable funding for successful performance; economic efficiencies that support successful commercial performance carryover to charitable activity supported by EHN; [and] costs for non-profit, charitable patient care is the same or less than costs for commercial activity. (E.g., some commercial patients request/demand additional tests that are not provided to charitable patients, where medical staff deem these tests non-essential.)" So, it seems we're on the right track.

On another interesting contextual note, the African Union 2010 Summit begins later this week, so the hotel is filled with an extraordinary range of diplomats and interest groups. Adds a definite class and mystique. It's pretty cool to sit in the hotel bar and absorb the culture, watching African soccer championships on big screen, sipping beer or such.

Also today, had a bit of a medical "Whoops!" I'm trained as an Emergency Medical Technician, and I've seen pretty much, from ER/ICU/brain surgery, to nasty bone, blood and shock trauma. I'm trained in scene safety and personal protection. But Africa is different. I probably need to assume many things are contagious, more than I'm used to. Today a very appealing child came in, and I lifted him high in my arms, offering comfort. Well, the little guy was recovering from Typhus, which is fatal (if untreated) 10-60% of the time. The translation was uneven, so I heard Typhoid, for which I'm inoculated. On return to hotel I read about Typhus. I quickly re-upped my Purell (alcohol gel) scrub and hopped in the tub for a thorough wash; I'm already on Cipro ... Well, it's to learn. This trip is definitely stretching my envelope.

LeAlem 2010 Picture Library
EHN Blogs

To Addis

Been hectic here. Next Friday I go to Addis. Leave 9:30 AM, arrive 8:30 AM Saturday, refueling in Rome. It's a nice flight, time to sleep and read. I've vaccinated and medicined up -- yellow fever, typhoid, rabies, hepatitis A/B, DPT, anti-malarial, Cipro, lomotil and such. I lost part of my EMT kit this summer at a bike race, so I restocked -- new stethoscope, CPR mask, airways, saline, wound care, PPE, glucose, splints, occlusives, etc. I'm not sure, but I may have some EMT work during the site visit. We will be looking at some unsupported locations, folks who need care. It will be sad in some ways, hopeful in others.

I'm traveling as a volunteer for a 501(c)3 non-profit I helped start in December 2008, Ethiopia Healthcare Network (EHN). When my mother died cruelly from ALS in 2005, my father reflected that while he had personal monuments -- books, stories, a play about his work, -- there was not a memorial that represented Joan, though she did wonderful things. We asked her pastor and he guided us to support a clinic construction project in Dukem, about an hour south of Addis Ababa. Impressed with the mission and church, I signed on, helping to raise and contributing a goodly sum. Fortunately, in a way, before we sank funds into construction, we lost title to the rural land (due to a reportedly corrupt act). I helped refactor the program as a non-profit corporation focused not on real estate construction but on efficiently providing care to needful patients, disadvantaged women and children. In November 2007, we conducted a survey in Addis, including visits to several clinics. I was very impressed by one facility and its medical director, LeAlem Higher Clinic and Dr. Alemayehu Gebrehiwot. After the land problem, we reached out to LeAlem and requested a proposal.

With EHN support, starting in October 2009, LeAlem hired a part-time doctor, social worker and nurse to provide healthcare to disadvantaged women and children. Results have been promising. Here's a summary from November 2009: "LeAlem exceeded numerical benchmarks set by the grant, caring for 103 patients. Ninety-two percent (92%) of the patients had annual income below $100 US per year; the balance had annual income of $100-200 per year. Ninety-seven percent (97%) of post-school age patients were female. Without EHN support, all patients would not have had access to professional healthcare. Patient outcomes were largely positive, alleviating suffering, treating disease, and supporting improved pre-natal and infant health. Patients were treated for a diverse range of diagnoses, including pneumonia, head injury, reproductive complications, pregnancy, diarrhea/intestinal disorder, gangrene, hemiparesis, urinary tract infection, seizure, candidiasis, asthma, metastatic cancer, adverse reaction to anti-retroviral therapy (ART), and Parkinson's disease."

We cared for 168 patients in December and my sense is that patients and service capability will continue to increase, partly owing to this month's trip. Interest and activity is burgeoning. I've several letters and resumes from medical school students who want to work in Addis as summer volunteers. Individuals with high net worth are looking into the program, we're organizing a fundraiser at the Ethiopian Embassy in DC, and more.

The purpose of my trip this month is to review grant progress, develop case study material, understand how we can best help, and develop relationships and ideas for future work. With EHN's Board, I wrote a 30-page site visit plan, providing background, articulating survey questions, and identifying contacts, from US embassy staff, to NGOs, social service providers and other clinics and doctors. The plan will help make the trip productive and facilitate writing an assessment and additional media.



The situation in Ethiopia is grim. Famine is projected by monitoring organizations. [USAID] Four million children are orphans, 500,000 from AIDS. Under-5 mortality rates are high. Less than 6% of women have medical care when they give birth. Average per capita income is $630 US. [WHO]

What EHN and LeAlem are doing is a small initial step. Our vision, though, is broad and resources sound. As noted by the plan, EHN is fortunate to be headquartered in Foggy Bottom, Washington, DC, blocks from the State Department, international development organizations, and a major university and medical school. EHN's Board is an exceptional team of medical doctors, individuals born in Ethiopia, well-connected professionals, and individuals with long-term experience with innovative charities. We envision drawing upon resources in Washington and helping them deliver value, and we envision EHN clinics and projects across Ethiopia networking together and with regional resources, NGOs, government and other organizations to provide care, alleviate suffering and improve outcomes.

The trip will be one positive step followed, I hope, by many.

EMT Training

This was my second rotation at the Inova Fairfax Emergency Department. My prior study at Inova consisted of about 12 case observations, ranging from care for patients with significant hypertension, respiratory difficulty, wound care, substance abuse, cancer-related medical disability, syncope, and psychogenic issues; as well as procedures such as male patient personal care, cleaning medical equipment, electrocardiograms, ultrasound, and computerized axial tomography (CAT). My preceptor gave me high marks, but apologized that the round was “not very exciting.”

For my second study, I arrived at 6:40 AM, and was assigned to ER triage. The initial observed cases included leg joint swelling, abdominal pain (suspected early pregnancy), severed finger (construction accident), severe hypertension (BP 294/179) with acute abdomen, and a cancer patient with tachycardia (P 200). At about 9:00, we were notified of incoming code yellow and code blue vehicular trauma patients, transported by ambulance and air, respectively.

My preceptor assigned me to stand in a doorway between the two large ER patient care bays. Patient 1, the code yellow, arrived first, and was transferred to an ER bed in bay 1. S/he was alert, responsive and in severe pain. ER staff performed a rapid trauma assessment and identified probable pelvic fractures and lower abdominal injuries. The patient received x-rays in the bay, and was to advance to CAT scan. Cervical spine immobilization and backboard techniques were used throughout patient care.

Patient 2, code blue, arrived and was transferred to a ER bed in bay 2. Patient 2 received a Glasgow Coma Scale rating of 4 at the accident scene and 3 in the ER. (GCS scores range from 3 to 15, with 3 being most severe.) Prior to arrival, the patient was intubated by EMT personnel. The unresponsive patient was catheterized, given intravenous fluids and medications. Rapid trauma assessment indicated no obvious trauma beyond ecchymosis (bruising) and swelling about the left eye, and slowly reactive pupils. I helped transport the patient to CAT scan. I considerately asked a few questions. A medical resident, previously an EMT-paramedic, instructed me to ‘follow [and observe] this patient all day.’ Imaging showed approximately 2 cm midline deviation of the cerebrum. This indicated cerebral hemorrhaging and swelling. The patient and trauma team returned to the ER bay and further medications were administered. The patient received various assessments, including deep foot stimulation, for which s/he was unresponsive. The patient showed seizure activity in the arms. Subsequently, we took the patient to the Trauma Intensive Care Unit (TICU). The patient was evaluated by a neurosurgeon. An intracranial pressure (ICP) monitor was inserted by drilling a hole in the patient’s skull above the right ventricle and inserting a fiber optic measurement device. Patient position was managed, from Trendellenberg (feet elevated) to reverse Trendellenberg to observe ICP. ICP ranged as high as 85; normal is less than 15 mm Hg. Medications, including mannitol (an osmotic diuretic to reduce intraocular and intracranial pressures), were administered. The patient appeared to be roused, moving all four limbs, and a doctor worked to evoke a patient response by loudly calling the patient’s name, asking the patient to show two fingers, slapping the patient’s chest and squeezing the patient’s hand and arm. The patient did not respond to the stimulation.

ICP remained high. Medical staff inserted main line IV routes for high-volume administration of medications in the patient’s chest and arm(s). I maintained traction on the patient's right arm, to help manage swelling caused by the new line. Doctors indicated that surgery was required. We took the patient for a further CAT scan in order to image the current positioning of the brain. The patient was taken to an operating room (OR). Because I was not wearing surgical garb, I remained in an outer hallway. The patient was prepped for surgery, head shaved and orientation lines marked on the patient’s head (with lines indicating a left-superior cranial incision arc, from the top of the head to above the left ear). My preceptor returned from the OR and saw that I was outfitted in surgical garb — hat, mask, shirt, pants and booties. I put on gloves in the OR. There were approximately 12 medical personal in the OR, including the neurosurgeon and resident. I stood out of the way, about six to twelve feet from the patient, observing medical procedure and asking infrequent questions. The surgeon cut a rounded triangular skin and tissue flap (approx. 10x15 cm.) from the patient’s left superior cranium, and lifted this flap back to expose the skull (cauterizing vessels/tissues in the process). The surgeon drilled approximately six burr holes on the perimeter of the exposed skull area. (This procedure is termed craniotomy.) When the surgeon(s) subsequently pierced the dura mater beneath the skull, cerebrospinal fluid and blood gushed from the opening(s). The burr holes were connected by the surgical drilling/cutting instrument and the patient’s skull segment removed. (This procedure is termed craniectomy.) Incisions were made into the dura mater. Upon broad opening of the dura mater, the brain herniated about 2-3 centimeters from the plane of the skull. This was dramatic. It looked like patient’s brain leapt from its container. Several medical staff commented: “Did you see that? ... That’s not good.”

Surgeons reattached the patient’s skin and tissue flap and conducted various closing and wound care activities. I accompanied the patient back to TICU. The patient’s ICP was reduced, but s/he remained in critical condition. At 3:30 pm, I excused myself, returned my surgical garb, met with my initial preceptor (in ER triage), obtained signoff, and returned home.

[material redacted]

Ride Sally Ride, 6.06.2009

Rode bike out to nice criterium in Sterling, Virginia, hosted by Whole Wheel Velo Club.  (Carolyn drove and brought camera gear ... I drove home, she rode ... symmetry.)  Arrived about noon, in time to catch some master's racing and my son Avery's Cat 4 event along with Cat 3, Women's and 1/2/3 events.  Good light, hazy then a little bright later in the day.  Shot many shots, all manual focus but sometimes using 3-4 shots per second bursts.  Posted 150+ here.

Hung out in basically same place all day, catching riders from 6-20 feet away.  Nice tight corner, might have been better with wide angle, but seemed to do okay with lens at about 100-135 mm focal length (using 70-200 F4L).   A fellow I met at at Crystal City, also working with Canon 5D, used his ISO and shutter speed cranked way up (e.g., ISO 1600+ w/1/3200 shutter), so I tried amping these settings a bit.  Basically, I didn't like the results.  High ISO resulted in loss of fine-grained detail, and increased depth of field so much that backgrounds came into focus and proved distracting.  (In many shots, you can see my friends chillin' in lawn chairs under their canopy or other noise, like building roof antennae and telephone wires.)  Lesson learned.

During my only saunter of the day, a junior crashed after high-speed corner following downhill chute.  Fearing it was my own (I asked, "red and white?" and the official said "yes," making it likely one of the kids I work with ...), I ran to the crash.  It was a high octane junior from another team.  An EMT was on scene, so I put on blue gloves and took C-spine (held his head to immobilize the patient's cervical spine).  The youth's helmet had been blown apart on the left side, so we feared head injury; 6-8 cm laceration on left face, possible jaw/orbital injury.  Hip abrasion and injury.  Transferred C-spine to crew when ambulance arrived.  I've seen a lot of injury, but this one made me nauseous.  Maybe because it was a youth like my own, or empty stomach.

Wilmington Grand Prix, 5.16.2009

Long but pretty good day at Wilmington Grand Prix in Wilmington, Delaware.  Several colleges, art schools and galleries add some exotic background, interesting people.  Town seemed grittier than 2007.  My guess is the recession has led to cut backs.  Pretty overcast in morning, with partly sunny, at best, toward afternoon. Shot most action at ISO 800 @ 1/1000th second.

Did more work than usual shooting using manual focus, this seemed effective at catching close-in fast-action shots.  I think I'll do more manual focus from now on -- my Canon 5D is great for portraits/candid work, but sluggish for sports.

Selected and posted 151 photos here.  Exciting Pro/1 race -- National Race Calendar (NRC) event.  Son Nathan did a lot of hard work leading in Cat 2/3 race at start of day, followed immediately by Junior race.  A lot of crash action; caught some with camera.  Had EMT role for racer in Cat 2/3 event -- face/head injury, blood in trachea impeded breathing, worked C-spine, facial injuries, until back-boarded and transported.

Off to Baltimore tomorrow for Bike Jam.

Tyson's Corner Circuit Race, 04.05.2009

Pretty mellow but long and diverse day at Tyson's Corner Circuit Race.  Carolyn started on site at 6:30 AM and I followed about seven with Avery.  We helped Tom and Judy Kendall and NCVC Junior parents set up food tent, barbecue etc.  Because ambulance was late, I was tasked with serving as EMT so the first 8:00 AM race could get started.  Unfortunately, I was on and off duty all day because ambulances had to run various folks to the hospital, a few with serious injuries.  (I covered while the ambulances were off-site.)  Finished about 6:00 PM, following 1/2/3 race and clean up.

Photos were pretty good, selected posted here.  Weather was sunny and warm (about 65 degrees).  Used favored 70-200 F4L lens on Canon 5D, ISO 400.  During the high-end 1/2/3 race, my friend Myron compelled me to get into the Carrera race lead car. I turned around in the convertible, hung over the back and shot a lot.  Pretty bouncy ride, but a few interesting pictures came through.  Hopped out after three laps, feeling nauseated. 

Had good fortune to spend time with my hero Kevin Dillard, sharing photo thoughts and stories.  Whilst we were at Tyson's, 18-y.o. Nathan was in Philadelphia grabbing third in the prestigious Lemon Hill Criterium Elite race.  All good stuff.