Topang

Every new year’s eve is different, the end of 2012 was all the more so. A trip to Kosrae for a toeny – gathering – Christmas. At four in the morning of old year’s day, our eighteenth wedding anniversary, a night fright trip through desperately pouring rain in a van leaking gas fumes and no air conditioning system. She was admitted and later found to have a high white blood cell count. The location of the pain suggested an appendicitus. Other possibilities included adhesions or an ascending UTI.

Hospital ambulance bay

2013 was ushered in from inside a medical outpost of limited capacity. In the smaller hours of the morning a Nipastu in the next bed over said a new year’s prayer for those in room one and beyond. In the quiet darkness there is a sense of loss of control that illness brings. A fear of what lies ahead. Prayer fills the dark silence with a small voice of hope and a trust that somehow the road ahead will be bearable even if not survivable. One is no longer alone in the dark.

Maybe we are not treating some of the chronic diseases in room one correctly. High blood pressure, high blood sugar, weak cardiovascular systems are not necessarily improved by seven days a week, twenty-four hours a day of bed rest. Would not some physical therapy, some exercise, component be beneficial?

Walking on a treadmill. Light weight strength training. Under supervision with vitals monitored. Diet and exercise seem to me to be key treatments, but in room one there is only lay in bed around the clock. This cannot be good. What is the current research based thinking on the treatment of these chronic diseases when they reach the point of medical admission to hospital?

The smaller things are indeed joyous in the limiting world of room one. Coffee. Hot. In the morning. A hot cup of coffee and the morning sun banishes the terrors of the night.

Visitors. A chance to chat, catch up on events beyond room one.

DSCF6803

The life of a topang is about minimalism. Limited surface area for living, limited options for engaging the brain. A topang can sit in a chair. Perchance sleep on a vacated bed. Gaze through a dust encrusted screen at a window sized slice of the world outside.

The view from the window

There are unending empty hours for the topang, punctuated by the occasional needs of their patient. Sometimes the patient is released and goes home on this island – chronic diseases do not mean that one is released due to being cured. Sometimes the hallway whisperers carry the news that a patient has gone home beyond this island, beyond this life, their last rasping rattle hanging in the dead air. The topang now seated outside of the room, head hung low, tears running down their soft brown face. A topang’s final charge is to faithfully report the details of the passing of their patient, over and over again.

The topang lives in a world where there are only those two outcomes possible. Life. Death. No shades of gray. There are only the two extremes of joy or desolation. All other emotions are amplified to these extremes.

After a term of seven-twenty-four work, a quadruple overload, I had committed to doing absolutely nothing over the break. Goal achieved. Eat. Sleep. Sit. Repeat. Seven-twenty-four. My world is a No Exit life in room one. I could leave, but a topang is duty bound to remain with their patient.

In room one I am junior topang. Rose is senior, taking care of Nipastu. I look up to Rose, she can sit and look out the window for hours without betraying the slightest restlessness. Being Rose, getting my own over active mind to simply zone out for hours, becomes a personal endeavor for me. To be able to do nothing, think nothing. To just exist.

The topang’s topang, however, is Arcie. Arcie remains with her patient, assisting with all the maturity and grace of someone decades older. In evening she comes around and visits many of the chronic longer term patients. She is genuinely interested in their well-being. Her parents ensure that she gets home for showers and meals, but Arcie always insists on returning. She was born to be a care giver. She has a need to care for those in pain and suffering. Her bright smile, her encouragement, and her endless optimism that accompanies youth, lifts everyone’s spirits. If a positive mental attitude helps people recover, then Arcie may be one of the most powerful medicines in the hospital.

Arcie

Night settles back in. My patient appears to be improving, but the night ahead is long. If something is going to go wrong, then it will go wrong in the small dark hours of the morning. The joy of seeing improvement creates the possibility of desolation. One might want to return to the middle, but there is no middle, only recovery or not. Joy or desolation.

A topang is unwatered, unfed, tolerated but technically ignored by the official processes of the hospital organism. The topang ekes out an existence as a symbiont providing care and companionship in exchange for excess food. Blanche DuBois’ kindness of strangers is the life blood of the topang. A family chooses to make dinner for everyone in room one, bringing a sense of celebration of the new year.

New Years Day dinner

With room one again full, the topangs sleep where they have always slept, on the floor between the beds. Nipastu has the wall bed, my patient is in the middle of the three beds along the south wall of room one. Three more beds are arrayed on the north wall. Rose and I sleep on the floor between those we watch over and care for. As I fall asleep on my kiyaka I realize that for my eighteenth wedding anniversary I am sleeping next to a woman who is not my wife.

A massive bang. The hospital plunges into darkness. Then the sound of a generator coming up to speed. Automatic transfer switch. Outside the window the high school is suddenly lit up like Christmas tree. External lighting on every floor is energized. The residents of room one sit in the dark and watch the twinkling lights of the empty high school. A baby cries in the darkness in the children’s ward across the hall. I make a mental note to myself, “If on life support, run a really long extension cord across the road to the high school.”

Nurses with flashlights eventually come around to check on patients. The nurses here really are wonderfully caring, personable, and treat patients as members of their own family. Which many are. Eventually the power returns and the routine of the night returns.

Nurse Yonis is waking me up. Something has gone horribly wrong. She is crying. On duty. “Dana, come help us!” she pleads. Out in the hallway I hear someone shouting “Security! Pang security!” She runs out of room one, and I follow at a run. We run out the front door where too few people are struggling to move a heavyset man on a stretcher out from the back of the ambulance. I immediately grab the stretcher, as does another man who I recognize as a patient in the hospital. As we move the stretcher into room three – nominally the intensive care bay – I am mentally confused. The man on the stretcher is my patient’s doctor, the doctor on duty. My mind is reeling. Why is the doctor on duty on a stretcher? Coming out of an ambulance? And not apparently breathing. Non-responsive. The nurses are clearly operating in a state of shock. Their team leader is the man down. Yet the nurses work quickly and rapidly, taking control of the situation and beginning treatment. I leave the room as another doctor rushes in and return to room one where the news had preceded me.

A patient had passed away this evening. The world of Kosrae is a small place of interlocking family relationships. No one else in the hospital was in a medically critical condition. Most of the patients are dealing with chronic diseases of one form or another. The patient’s home was nearby, thus there was nothing unusual in the doctor accompanying the body of the deceased to his home. A way to honor the patient and reassure the family.

In the small hours of the night essentially only a skeleton crew is on hand. The doctor had helped lift the patient and become winded by the effort. He then accompanied the body. Not more than two minutes from the hospital he had what would later be deemed to be sudden cardiac arrest.

From room one we could hear the heart monitor flat lined and the attempts to get the heart restarted. The whole hospital is an open air space, no wall goes all the way to the ceiling except for the children’s ward. So the whole hospital was silent as all listened to the unfolding tragedy.

The doctor’s wife arrived and burst into tears when she learned her loving husband was gone. We cried with her, for her.

The nurses then carried on tending to their patients right through to the end of their shift. There is no crisis counseling here, no time off to process handling the death of a life time friend and colleague. The professionalism of the nursing staff that night and into the morning was beyond impressive. The nurses definitely had the right stuff, the above and beyond the call of duty right stuff.

By the next day my patient was deemed dischargeable and my role as a topang would come to a sudden end. The now deceased doctor had ruled out an appendicitis and adhesions. His final diagnosis, made not more than twelve hours before he passed away, was that the pain was due to a UTI. A later follow-up check would effectively confirm this diagnosis. He had given me back my patient, my wife. Tragically, his family lost him.

Patient and topang

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