I left my ICU shoes in Sulaymaniyah….

…which I feel a little guilty about because they were a gift from our friend Aqeel in Nasiriyah (that whole, third-party-buy-now-pay-someone-else-later thing…turns out it doesn’t actually work). 

They were cute…sort of a funky Middle Eastern take on Crocs…blue plastic with a latticework of round ventilation holes…and they had little plastic flowers on them.  Very cute. 

Sulaymaniyah had the same sort of swap-your-shoes-at-the-door routine that we had in Nasiriyah.   Outside shoes are dirty you know…don’t worry too much about washing your hands but be sure to change your shoes (please forgive the sarcasm…I can’t help it). 

When I walked out of the ICU for the last time the other night, I decided to leave my shoes at the door.  I think someone will use them (occasionally, shoes will get borrowed by local staff to the great distress of some of our team members).  I hope someone will use them. 

Like I said, I felt a little sorry to just be discarding them…but it wasn’t exactly that unceremonious though…I put them down and took a photo of the on the floor.  I wanted to document that action for some reason. 

And then I walked out. 

This month in Iraq was very challenging on many levels.  Physically.  Intellectually.  Emotionally.  I don’t think I have ever worked so hard, for so many days, within so many impossibly difficult clinical situations…no, actually, I know I never have.  I have also never had to face so many deaths…deaths that the whole team worked so passionately to prevent.  But, I am very glad to say, I feel like I was able to rise to the occasion, time after time. 

By my last day, I was done.  Done.  I couldn’t do it anymore.  I was frustrated and bitchy and so broken hearted by the fear of  loosing another patient after we left…

But then leaving was so abrupt.  I gave report to the night shift ICU team…and said goodbye.  I went out to dinner with part of the team, and simply said good bye again.  I stayed up late with a handful of folks until the wee hours of the morning…and then a few of us left for the airport…then one by one, we all went our separate ways, off to our own individual destinations.  Headed home.  Back to our lives. 

(Well, except for me.  Silly girl.  I am just leaving on the next crazy adventure… flying from Sulaymaniyah to Amman to London to Seattle to Spokane, then being driven by a friend to Nelson, B.C. and THEN (hopefully after sleeping) getting on a helicopter and flying to some remote ski lodge in interior B.C.  Like I said, silly girl.)

I knew that this sudden extraction from this experience in Iraq would feel weird...that it would not feel satisfying in anyway…just a predictable succession of hurried goodbye’s.  That’s how it felt when I left Siberia…and Nasiriyah too.  Empty in a way.   

And honestly, I felt like I needed a little more closure than that.  Even if it was solely just for me…to carve out some peace in this experience. 

I needed a way to step away, to put this behind me so that I can more forward now.   I need an end point in time…

So I left my shoes at the door. 

This has been hard.

Siberia was different.  A challenge to be sure, but so much farther along in their management ability.  And we had interpreters.   And all of our patients did very well.  Everything went smoothly. 

Here in Iraq I feel as though we are entrenched in a way.  Limited resources.  Staff that needs so much direction and teaching.  And a multitude of complicated defects begging to be repaired.  Sick, sick children in the ICU. 

Chaos?

They told us that something like 350 people showed up at the hospital the first day in Nasiriyah…have I shared that detail yet?  It still blows me away.  And the surgical waiting list in Sulaymaniyah seems to be miles long…

I think it is hard to feel like this endeavor is little more than a gesture.  I suppose that there is a legitimate criticism to be made there.  But at it’s worst, I also believe that it is a gesture of compassion.  Of effort, regardless of the ultimate outcome.  We all do our best with what we have.  Today.

And while there may not be time now, maybe not today, I think we will be back. 

Someone had asked me while in Sulaymaniyah if I would come back to Iraq with ICHF….

…and I said “of course.”  Which is true.

They also asked where I would go after working in both sites.  The question was easy to answer but hard to explain: Nasiriyah?

This sort of threw everyone at the table during the discussion because I have spent most of the current trip relating horror stories accrued during my first two weeks in Iraq.  And really, nothing so far has been as bad here.  Even when we lost that kid the other night believe it or not. 

At first I couldn’t explain my rationale.  Why do I want to go back to ICU Hell?  Am I crazy? 

Well, yes, we all know that by now. 

But seriously….

I loved the people; “generosity without borders” as Pavel said.  The culture was so alien…and interesting.  The bizarre juxtaposition of men in traditional Arab dress walking down the same street as men in fancy three piece suits for example.  The funky, striped purple couch in our guest house; watching the news with our security detail…the security guys at the hospital packing their pajamas and sleeping in shifts in the conference room (seriously, they packed their jamies!).  The absurdity of it all…

And clinically…I feel like more of the nurses wanted to learn.  Which is not to say anything negative about the nurses here in Sulay…they really are not that bad…yes, it is hard to get some of them to chart and you have to remind them to give meds, but they know how to do most of the stuff, they just need some help with things like calculating pediatric doses and NOT giving meds through lines that are running pressors (I will say though, that there is one little guy who is awesome and has learned SO much, and there is also one woman who just plain rocks…and she did before we even got there).  But I feel like the handful of nurses in Nasiriyah who wanted to learn, actually really, really cared.  Aside from the aforementioned two exceptional nurses we had here, I don’t think I can say this about the Sulay nurses.

And then there is me. 

I learned so much in Nasiriyah.  Volumes.  I have never had any clinical experience or responsibility like I had there.  I felt like I played such an important role as a member of that team…which is true here as well, but somehow just feels different. 

And as far as explanation, I think that is about as good as I can do for now.  And I know it doesn’t really articulate my sentiments very well.  Maybe I will understand it better myself someday.

But maybe not. 

Did some site seeing…

Nothing glamorous really; Caroline and I followed a group of boisterous school children on a class fieldtrip through the natural history museum (which is one of exactly four destinations listed under tourism for the Sulaymaniyah entry in Wikipedia).  Lots of old clay pots and metal tools in glass display cases…old, old stuff.  Which was pretty cool…

After that we went down the street to find this other museum that we had both heard about: The Amna Suraka Museum, which translates into Kurdish as the "Red Intelligence Museum.”   This is how Wikipedia describes it (also one of the four tourist destinations in Sulaymaniyah by the way):

“…Located in a former Ba'ath intelligence headquarters and prison. This museum showcases the horrific terror of the Ba'ath regime upon the local Kurdish population. Visitors are guided through the prisons and interrogation rooms...”

When we arrived, we were told it was closed.  Damn.  Big disappointment actually considering that we had managed to find the place (and crossed six lanes of highway to get there).  But then, this guy came out and asked us our names; you see, one of the other girls in the group had visited a few days before and met the artist who had made the sculptures that were scattered around the museum depicting different prisoners who were known to have died there.  He had been waiting for us it seemed, and offered to make us a cup of tea and then give us a private, guided tour of the facility.  How often does that happen!?! 

It was haunting to say the least.  The first room he showed us was where the children were imprisoned.  I can’t even imagine what it would have been like to be one of up to 30 children locked in this dark room.  Alone. 

The prison was like a maze by design to prevent it’s historic prisoners from being able to keep their bearings while being moved, blindfolded, from room to room.  It was disorienting.  And cold.  Very cold. 

We walked through the facility, looking at different cells and then I was startled when I looked through a door and saw a white figure standing, taller than me and looking out the tiny, barred window near the ceiling.  It was one of the sculptures (made by our tour guide) of a known prisoner; an apparition in a way.

Many of the dark cells had ragged blankets thrown in their corners which somehow heightened the sense of solitude and despair that must have been present between these walls.

The whole thing was so unsettling…

I knew very little about the details of this particular genocide, and to be honest, I still don’t.  Granted, I know more now…but it seems to be “just” another tale of a disenfranchised people and the violence they suffered at the hands of the “other”…and I have no doubt that somewhere in the world today, people are still suffering in the same way. 

What do we do?

Girl’s night out!

I went out for dinner last night with another nurse from London as well as another lovely female intensivist…this one is from Czech Republic.  We wandered around a little and eventually found this restaurant on the top floor that served local and Mediterranean dishes.  We got a bottle of wine, a bunch of appetizers, had desert and great conversation that centralized around the differences in medical culture around the world.  It was really a treat. 

However, when we set out that evening, we had started with the plan of crossing the street (always a harrowing experience here with the four lanes of swift traffic and no guarantees that anyone will stop for you).  Our planned destination was what appeared to be a bar and hookah joint.  I was really curious about smoking some fancy tobacco out of one of these things since we have seen similar such establishments all over town.  Seems like a pretty authentic cultural experience and I wanted to jump on the opportunity to check it out.  When in Rome right?  Or…Kurdistan….whatever. 

Anyway, the three of us walk up to the door and the “bouncer” (although, he might have actually been just some dude) told us emphatically “NO WOMEN.”

Damn.  Really?  Even here? 

In Nasiriyah that sort of thing was expected.  Most of the women wore abaya and I didn’t see a single woman with fitted clothing or even her hair uncovered.  It is a totally different story here in Northern Iraq.  Yes, many women are very covered, some even truck around in abaya.  But there are also pretty modernly dressed women running around as well…fitted jeans, fancy high heals, stylish blouses, etc. 

Caroline, the British nurse I mentioned, and I had gone out for some site seeing earlier that day.  We got some looks, sure (“Is it really that obvious that we are foreign?” I asked her; “Yep.”) but nothing like the way I was starred at in Nasiriyah…I felt like I was running around with two heads in that city of 4 million people. 

But not being admitted to the “boys club” was still sort of a surprise.  Maybe not conceptually, but still. 

Over breakfast this morning, one of the night shift nurses (Jennie from Philadelphia) was relating her experience through the night with an eight year old boy we have had in the ICU most of the week.  He is sort of a brat.  I know, I know, I shouldn’t talk about these kids this way, he is sick and all, but we have had some legitimate issues with children who will defiantly not cooperate and will go so far as to hit their own mothers (they try to hit us sometimes too, but we are evidently more adept when it comes to restraining small children during their temper tantrums).  Anyway, she was telling me that she actually made some progress with the kiddo…she kicked him out of bed, sat him up in a chair, put on a movie for him (someone had conveniently left their iPad lying around, with movies on it…and evidently Shrek is amusing even if you don’t understand English), gave him a soda and he was very cooperative and contently sat there, watching his movie, drinking his soda.  Then his mom came in…total turn around.  He started whining, slumping down in the chair, wanted to go back to bed (Jennie would not allow it…someone has to set some freaking boundaries!)…the compromise for not getting back into the bed was that he could put his feet up on another chair.  But then the father wanted to sit in said chair…so the mother sat on the floor in front of her son and put his feet up her shoulders; “She was a human f***king foot rest!” Jennie related…horrified. 

Huh.  Wow. 

The things we as women take for granted in Western countries…

Retraction: It’s the “gas man” not an ice cream truck.

I received this information from one of the darling Preemptive Love Coalition folks:

“Oh, and by the way - the ice cream truck jingle? It's actually the gas man. Yep, trucks roam the streets everyday selling propane gas can refills. They used to bang the cans with a metal stick until the city got tired of that, and now they use the "ice cream truck" jingle.”

Oh.  I see.  Definitely an improvement. Big time. 

Thank you for the clarification Michelle!

An ice cream truck just drove by the hotel....

….same music chiming along that is so familiar back in the states.  But it’s 50 degrees Fahrenheit out there.  And raining.  And it’s 7:30 in the morning. 

Weird. 

(Pavel keeps telling me that Americans always say this word, “weird” a lot.  I think he thinks that  is weird.)

Anyway, that is neither here nor there, just sort of a funny tidbit that I wanted to share cause homey drove by just as I sat down to write. 

So. Sulaymaniyah update.  And Egypt update while I am at it:

Our darling surgeon, though I wouldn’t describe him as exactly the picture of health (what with the cigars, the scotch, the lack of exercise, and the fact that I don’t think he ever sleeps for more than three hours at a time) is having some health issues and we have finally managed to talk him into going home early.  I think.  Unfortunately, flights to the U.S. only leave every other day, so the logistics are thus far as yet to be determined, but at least he has agreed to go. 

But still, I am glad that he is acknowledging that he needs rest.  I think he has been burning the candle at both ends…like for 15 years.  He has managed to accomplish amazing things though…I think he might be my hero in fact, as cheeseball as that sounds.  But seriously…not only the kids that he has operated on, but all the kids that were also saved because of the teaching that he and the other ICHF teams have done with local teams around the world…that is where the real impact occurs. 

It sounds like the plan is for the rest of the team is to remain here and operate with the local team only.  So low complexity cases, fewer cases, and likely cases that do not require cardiac bypass.  We will see how it goes.  This is what we did yesterday in fact, which is nice because the ICU isn’t plunged into utter chaos as a result.  And when you remove the chaos induced by having exquisitely ill post-op open heart patients populating your ICU, we actually have time to teach.  Which means, that while we are not going to be able to “save” as many kids this trip, we can still work toward our ultimate goal.

Oh, and Egypt…not going.  Regional strife or something.  I guess the nurses are striking (they want better wages, benefits, everything we take for granted in the States, blah, blah, blah)…but actually, it is reassuring to know that we (the crazy folks at ICHF) really won’t be going places that are immersed in political turmoil.

Shucks. 

No excitement in the ICU today…

…and I am so thankful for that.  Two shifts in a row without any major disasters. 

What a relief. 

Subsequently, I don’t have that much to say.  And I am pretty exhausted.  So I am just posting this photo for today. 

So, I am becoming pretty competent at coding….

…which is good from a professional standpoint, but it sucks. 

We have done some very difficult cases; both trips.  We have had a few, worst case scenarios pan out as…just that. 

Mostly just plain, old fashioned, bad luck. 

I have been privileged to play such a part in these situations with a team of remarkable doctors, surgeons, and nurses, from literally around the world.  I have been directly and very actively involved in more life and death situations in the last three weeks than I have in my last three years as a nurse.  I have learned volumes.  And I am so grateful for this. 

But it gets very disheartening.  You compress the heart, you bag, you defibrillate, you give epinephrine, you give calcium, you give bicarbonate, you push blood and volume.  And sometimes it works…

…and sometimes it doesn’t. 

It’s hard when the bad ones start to pile up; unfairly, they matter to your own heart more than the saves ever will. 

Yesterday morning I was numb. 

Today, I got to read the following entry from the Preemptive Love Coalition Blog; I have gotten to meet Jeremy and work with him both here and in Nasiriyah.  He is a wonderful and devoted young man who illustrates, along with his equally remarkable counterpart Cody Fisher, just how much two people can accomplish with a little motivation and passion. 

I needed to read his words.  I didn’t know it until I did. 

Thank you for this heartening perspective Jeremy.

Yahya passed away early this morning after an all-night surgery. It was a surprise to everyone. When he was admitted to the ICU there seemed to be plenty of confidence that he would be just fine. But within just 30 minutes of admission his heart gave out and all efforts to revive him failed.

I still remember the first time I was introduced to Yahya. It was over a year ago. His uncle called my cell phone and said, “I’m at your office, I need to talk to you about a sick kid.”

It was after hours and I was already at home. But I could hear the urgency in his voice so I invited him to my home for tea. He arrived and made an impassioned plea for Yahya – his brother’s son. I was leery of helping Yahya after reading his reports – we had seen some children with complex heart defects like him die abroad and I couldn’t stand to put a family through that drama again. I did my best to avoid commitment and send Yahya’s uncle into the night without any solid hope for his nephew.

The following weeks were filled with phone calls and followup from the family, “Please help our boy!”

Finally, I met Yahya’s mom and dad and the little cutie himself. As they sat in my office they pled with humble urgency. They weren’t forceful. They weren’t rude. But they applied enough pressure on me that I couldn’t say “no” any longer. They made it abundantly clear that they understood the risk of his surgery and that they wanted it badly enough to endure whatever might come.

One of our core values as an organization is that we give “hope to the hopeless.” What that means is that we try to balance our impulse to be “last chance” people with our instinct to be “long-term” people. We held back on Yahya wondering if it would give him long-term viability. But we ultimately dove in with Yahya’s family because we were their last chance. No one else would take on the risk.

We solidified this core value in November 2009 when we asked you what to do about a little boy named Ramyar. We asked you if you wanted us to apply your money in a high risk surgery or save it for a “sure thing.” You overwhelming said, “We want this Coalition to be about hope for the hopeless.”

We haven’t looked back since. We are the Last Chancers.

Still, committing to Yahya was full of complications. His surgery in Turkey was cancelled due to an unavailability of an expensive assistant device. In fact, there was even discussion as to whether or not he should be included in our current Remedy Mission. Ultimately, we let the family themselves decide.

Our local cardiologist, along with our American surgeon, explained the risks of surgery, the option of waiting, etc. etc. Yahya’s dad was given a 50/50 chance of survival for little Yahya. Understandably, they wanted to give it a try. The couldn’t stand the risk of feeling like they had an opportunity to try and let it slip through their hands.

What would you have done? I have two kids – 5 and 3 years old. I have no idea what I would have done.

During Yahya’s surgery our Family Services Director, Jessica, sat down in the ward with all the parents whose kids were either in surgery or in critical condition in the ICU – those families whose kids were not “out of the woods” yet. As they asked questions about our organization and how long we’ve been working here, she recounted for them our past of taking children outside the country to significantly nicer hospitals than this Iraqi version in which we currently work. She told them about excellent American-trained Turkish doctors and fancy, pristine protocols abroad. Without fail, every family was so grateful for the chance to receive surgery at home. Let the Turks have their pristine hospital. “What if our child were to die abroad?” That would be a burden far too great to bear.

You gave Yahya’s family a chance that no one else would have. He had been rejected by every other opportunity out there. They are grateful to you. They will rest knowing they gave it their all for their only child.

And this is what we find almost universally – parents who just want a chance. And that’s what Remedy Missions are all about. We could continue to export kids to world class facilities, but who would invest in the future? We could continue to select the easiest children that almost never die, but does that make us any less culpable for the kids we pretend aren’t knocking on our door?

Was this a wasted opportunity? Did we waste the $670 that it cost us to provide Yahya surgery?

I used to feel that way when I child died in Turkey or Jordan or Israel. I don’t feel that way anymore. Yahya’s death – though a terrible loss – was still an opportunity for local doctors to learn an innovative technique that they will be able to apply in future situations. His death was almost certainly unrelated to the particular tactic used in attempting to heal his heart. Educational gains always have significant costs. Before we only had the “we gave this child a chance” platitude. It’s not untrue. But local learning is an equally deep reason why your gift for Yahya made a difference.

Thank you for your willingness to stick with us through life and death. The gains that are needed here will not be made without significant risk and vision. We deeply appreciate your demand that we be the people of the last chance. I think it’s easier to sleep knowing we tried, than knowing we played it safe just so we could publish numbers and blog posts that seem more palatable.

With you,

Jeremy Courtney
Executive Director

Preemptive Love Coalition

Okay, it’s Sulaymaniyah….

…or at least that is what my Iraqi Airlines ticket says.  I have just seen it spelled so many different ways as well as Googled it and gotten similarly different results. 

Anyway. 

[Oh, and FYI, I am posting these about a day behind when they are actually happening…I try to write them, go to sleep, then re read and post.  (But actually, this one is a couple days old.  Sorry.  I had a really bad night last night…got sort of wasted after work…more on that later.  Mabye.).  This loose editorial system can also be credited with whatever grammatical/spelling errors present in “the blog.”  But anyway, that is why the days may seem a little inconsistent.] 

Back on task. 

I worked yesterday and now I will work tonight and the next night.  Which is nice because it means I got a full night of sleep last night and am now about to lay down for a nap…after I finish writing and finish this here glass of wine. 

I was able to go for a little walk today after breakfast with one of the other nurses.  I wanted to procure a hooded sweatshirt since somehow I managed to leave the US without one (I think I had planned on wearing one on the plane so I didn’t pack it…then forgot about this clever plan…and I knew that if I tried to get one in Nasiriyah, there was no way I would be allowed to pay for it.  So yeah…).

It was so nice to walk around without the entourage I had become accustomed to!  I do, however, think that I need to be extra vigilant about not getting hit by a car here in Kurdistan (Mom, I promise that I am being VERY careful when I cross the street).

So yeah, found a sharp new hoody, found some beer, and snapped some photos. 

I noticed this when my flight was landing here, but Northern Iraq (i.e., Iraqi Kurdistan) bears a shocking resemblance to eastern Washington.  Landscape-wise at least.  Not architecture or construction for sure, but physical features of the horizon.  The hills in the distance look like the same rolling, tree-less slopes that I grew up with.  It looks like the view from my parent’s back porch. 

Only with densely packed, rectangular buildings between me and that skyline. 

Which is a big surprise.  But also in a way such a comforting relief.    

To quote Kristin Hersh from her recent memoir Rat Girl, “…it is like finding home in a foreign country” (p. 49). 

Day….????

….I am pretty sure it is Wednesday.  My first day in Sulaymaniah (or Sulymaniah or Sulaymaniyah…I really need to figure out how to spell it properly at some point) but I think it is the 3^rd surgical day maybe?  Pavel (a.k.a. Pasha…which is a nickname for Pavel by the way and will continue to be used interchangeably) and I got here late, as you all probably know, but it turns out so did four other people.  I guess there was some in climate weather on the west coast of the US?  People got stranded and delayed for days (this poor nurse from Virginia made it to Turkey by Sunday but they couldn’t fly her to Iraq until Tuesday….and then they lost all of her luggage). 

Among the missing were both intensivists (Pavel being with me) as well as the perfussionist, which severely restricted the team’s options for surgeries the first two days.  They were able to do a few “off pump” (i.e., cardiac bypass) cases but there were pretty much just two of our ICU nurses to manage post op patients.  And it doesn’t sound like things went smoothly. 

But nobody died (yay!).  And everyone actually looks pretty good.

Anyway…I came in this morning expecting a total déjà vu of my previous two plus weeks.  I was pleasantly surprised!  What some of the other nurses saw as random chaos, looked to me to me logically organized and totally navigable (is that a word?  Like “-able” of navigate?).  Better equipment, more of it, TWO sinks (!!!!!), competent nurses (I was told however that this was the “A” team and the rest of the staff wouldn’t be quite as capable, but still).  I was SOOOOOOOOO excited. 

And relieved. 

It was nice (and very helpful for everyone else) that I was already very familiar with local preparations of medications and how to mix everything the way I wanted it, which all came in very handy when we had a run of ventricular tachycardia on our first new case for the day.  And that sort of semi-code scenario actually went really, really well!  Granted, the surgeon accidently squirted the blood he was pushing all over me and our patient (nothing like a proper blood bath during a code to lighten the mood), but other than that everything went very smoothly!

After things quieted down a bit after all the excitement, one of the poor nurses who has been manning the ship solo for the last two days looked at me as said “You love this?  You want to keep doing it?”  I laughed. 

Later, this same nurse made a comment about feeling like she was forgetting something.  “Um, the documentation that you don’t really have to do?”  I replied.  “Yes!” was her excited but slightly disoriented response, followed by “Is that why you like it?”

“Because I get to just do nursing stuff and not spend hours documenting everything in case I get sued?”

Yep.  I get to be “just a nurse.”  That’s why I love it.

Nasiriyah is behind me…

…as is Baghdad.  At least for now.  

I guess I should recap the last few days since I was pretty much too exhausted to write last night.  Well, that’s not entirely true…I was exhausted but I found a treadmill at Saddam’s palace (where I spent the night) and couldn’t resist taking it for a spin after not running for two weeks…and after that, I was too exhausted to write anything. 

Anyway…

…to intone the Grateful Dead: “what a long strange trip it’s been.”

As we were speeding down the deserted highway out of Nasiriyah en route to Baghdad yesterday afternoon, I taught Pavel a new word: absurd.  I used it to describe the circumstances and events of the previous two weeks we had spent together in Nasiriya.  The whole thing was just so weird…being an American in Iraq, hanging at Saddam’s Palace in Baghdad, having the ever-present security detail, right down to the armed guards outside the ICU…the sick patients, the difficult clinical situations, all the stuff I learned how to do…and the fact that we had just driven past a herd of camels by the side of the rode…

He agreed about my usage of his newly acquired English word after I laid out how our experience illustrated it’s meaning.   

And then, one of our rear tires exploded. 

I looked at him and said, “and that would be our tire that just blew out.”  We both broke out into hysterical laughter at the additional absurdity that we with our six man babysitting team were now broken down by the side of the rode in middle of nowhere Iraq. 

Sweet. 

And absolutely ridiculous. 

And somehow, all I can do at this point is laugh about it all.