The M1 road to Lilongwe in Malawi afforded me some time to think about my first work experience in Africa before my minibus was struck by a train. There was a moment that shrank down to a pinpoint and all too quickly that moment was over.
In June of 1999, one month prior to the crash, I had begun working with 11 of the medical students in my class, helping establish a new orphan project along the M1. No building can possibly hold the number of children orphaned by the diverse problems in Malawai, so instead our orphan project serves children by finding adoptive parents, protecting them from exploitation or abuse, keeping them fed and in school and a part of their community.
We helped build a small library, cleared a field for the children to play in, and organized their stocks of medication. I changed my first diaper, learned some Chichewa, and had several marriage proposals thrown my way by the local women. I stepped on a puff adder, which during winter is less dangerous than it sounds. During our down time, my friends and I laid out on the beach of Lake Malawi, enjoying a fine Malawi gin and tonic, learned cricket from the Afrikaner proprietor of ÂPalm Beach ResortÂ and swam in blood-fluke infested water. Halcyon days, especially when we watched a family of hippos cruise through the waters we had occupied minutes before them. In Africa, hippos kill more people per year than any other animal.
At night, the lake filled with fisherman, trolling nets behind boats carved from tree trunks as they kept large candle burning upon the bow. The darkness was broken by these softly flickering lights that silently crisscrossed the water. After nightfall we hung out at the beach bar, reeking of mosquito repellent and beer. I bought an ounce of most excellent weed for 20 kwacha, or about 15 cents.
When children lose their parents in this region, they often starve to death or barely subsist. As I mentioned, this orphan project does not just keep children alive, as with emergency feeding programs, it strives to keep them part of their community and part of the solution of the HIV epidemic. Eventual HIV educators, peer counselors, entrepreneursÂ not bad for such a small investment of time and effort. There were many fond memories to be had as I packed for home, each bag of my luggage conscientiously holding the maximum of one liter of alcohol, as per customs regulations.
We sat in a state of torpor as our minibus taxi cruised toward the airport. I was thinking, much like everyone else on board, of nothing in particular as I saw a train approaching from the right on tracks that would cross the path of our minibus. In my stupor it slowly dawned upon me that this collision course could be predicted by a high school algebra problem. Or maybe geometry. IÂm a doctor, not a math geek. Either way, the next few seconds passed with my realizations that we would definitely strike the train, there was no way we would make our flight, and I would miss my meeting with a beautiful blonde Canadian volunteer who said she would be on the same flight. You think the strangest things when you are pretty sure you will die.
The actual collision was underwhelming Â I closed my eyes in time to feel a dusting of glass across my face, and I hung onto the seat in front of me. We just slowed down really, really fast. That wasnÂt so bad.
One student exited the bus through a window and helped pry open the door so those of us who were a bit stunned could walk out of the bus. As I moved toward the door, I noticed the Malawian driver, who was wedged between the door and the dashboard in such a way that his right chest and torso could no longer exist. He had not been paying attention to the road. The next sensation was that I was about to pass out thanks to ÂvasovagalÂ. This is a retarded reflex whereby stress causes the heart to slow, and blood pressure to bottom out. Rather than fall in an undignified fashion, I laid down and lost consciousness for what turned out to be only a few seconds. Then, I got up and began taking stock of the situation and my co-passengers. Two obviously dislocated arms, one person whose right eye was not working, one person with neck pain, another one with chest painÂ it was at this moment that I realized I somehow didnÂt know shit about anything, medical or otherwise.
One woman was lying on the ground, and was breathing rapidly. She appeared calm, despite having been thrown out the front of the bus on impact. I looked forward to see the train, an engine and one car, derailed and resting just off the road. The minibus itself had been crumpled like a beer can Â the roof was caved in, the chassis twisted along its axis.
Some of us wanted to Âdo somethingÂ, but had no notion of how exactly this was done. Fortunately, one member of our party was a paramedic, and shot the appropriate orders around. The woman on the ground had back pain, so needed a hard board stretcher. I raced off to the nearest house, and pulled their front door off it hinges. Another woman was found on the ground on the other side of the vehicle, and was breathing shallowly, and was unresponsive. If we get everyone to the nearest clinic, we will be okay.
I proceeded to steal a part of someoneÂs bed to make another hard board for the second woman, as one of our group bribed three men in trucks to transport us away quickly. Just a few more minutes, and we would be in the hands of professionals. I kept daydreaming about gin and tonics. It still hadnÂt sunk in that this accident was bad, just that we were about to miss our flight out of Lilongwe. As we arrived at the clinic, I sank into a chair, and the staff began to sort us out. The two women on hard boards were placed on gurneys, and I started drifting, wondering what minimal task I could do next.
ÂSheÂs not breathing.Â
I looked about and noticed for the first time that the staff was standing in the wrong places. Superficial cuts were being indifferently wiped, nurses talking amongst themselves, and they were looking in drawers for equipment, slowlyÂ
too slowly. Panic rushed to the fore as I realized that I was one of the most qualified people in the room. I jumped to the side of one of the women laying on a gurney, to discover she wasnÂt breathing. This was my first time witnessing this event. Her eyes were glassy and half-open as blood trickled out of the corner of her mouth. Her CV coursed through my mind like a voice in my ear:
Spent the last two years working with heroin addicts in New York. Volunteered with HIV clinics. Lived for six months as a homeless person in abandoned buildings, watching, learning, and beginning to understand the deepness of addiction. Planned to eventually graduate from medical school and work with HIV patients and international health.
I had no idea what to do Â CPR is usually a good place to start, so I helped with starting an IV, fluids going, beginning respirations. I breathed into and was shortly covered with her bloody vomit for my troubles. I kept trying, she kept vomiting. I did not understand that intubation was necessary to protect the lungs. Her eyes were not moving. One of the students knew how to intubate, as she once intubated a dog in a research lab. Once the tube was in place, I proceeded to squeeze the ÂbagÂ and deliver full breaths to her blood and vomit filled lungs. Fuck me, this is really happening. Straddling her while delivering chest compressions, we were wheeled down the hall to a waiting truck to drive us to a bigger, better hospital in Blantyre, where there was some hope of keeping her alive.
The drive was three hours.
Somehow, the drive was quiet. There was only the rhythmic squeeze of the ventilation bag, the ÂpppbbtttÂ of the air passing through its valve, repeat. I kept the chest compressions going for nearly the whole journey. A wound in her shoulder eventually stopped its slow trickle of blood. Her skin was ice cold. The physician at Queens Hospital in Blantyre assured me my friend was dead. I knew that. After all, I had medical training, didnÂt I? Those of us who could walk numbly drifted amongst those who could not. We waited for a few more hours for our medical evacuation. The time was passed by feeble reassurances amongst each other and trying not to think about anything.
The Royal Air Force provided an airlift to Milpark Hospital in South Africa, one of the finest trauma hospitals in the world. They stabilized all of us, identifying a broken neck and pulmonary contusion that would have been fatal had the Brits not been so quick about moving us. Eventually we were placed on a very comfortable South African Airways flight back to the United States, a return we all dreaded. During this time, we had each other, and could rest in silence, which was some comfort. Upon our return, we would have to talk to anxious family members and answer a lot of questions. None of us were thinking, instead our minds were racing with the driveshaft disengaged.
After an initially uneventful return, the slow creep of those thoughts began in me. Portions of the accident returned, as the brain started piecing the incident together, and an unwanted analysis began. Foremost fact: I was the only person on that bus who was not injured, not even a scratch. At times like this you start to bargain with fate, hoping to exchange an arm, a gaping abdominal wound, or your life for someone who you barely knew. Of course, this is the feeble bandage for guilt that one provides. There is no way to fix that memory, and the post-game analysis is unkind for a very long time. You start to realize there were moments before the actual impact when some intervention would have made all the difference. For me, there were about six seconds between seeing the train on a collision course with our minibus taxi and the crash. Consider for a moment how agonizingly long this is, and time yourself doing stuff for six seconds. I can run nearly a city block in that time period.
If you want a moral to this story, I suppose this is it: time is of the essence. As medical professionals, we spend our entire lives preparing for that time Â all six seconds of it, in this case. For every person there comes a window upon which an entire lifetime may depend. Usually, it happens only once. When that moment arrives, not everyone is equal to the task. And then the moment is gone. Afterwards, there is ample leisure time to wonder when – or if – another moment will come like it again.