byerswithoutborders

My time in NYC is proving to be a lonely, challenging experience. Jen has encouraged me to journal about it. “Brain dumping” she calls it. I secretly think she means “onboarding your therapist”.

I didn’t expect the physical challenge to be so great. Twelve hours sweating in a bunny suit. It is a chore to take them on and off, and each time you risk another exposure event. So I try to hydrate before my shift. Not too much mind you, I don’t plan on peeing for the next six hours. My goal is to make it to one a.m. The halfway mark. After that first six hours, I justify the hassle and risk of doffing all my gear and finding one of the respite rooms. Occasionally there are donated trays of pasta, pizzas, Cliff bars. There are always cases of water in the 7th floor room. I usually head there, to chug water, and sit down for the first time that shift. Halfway and I’m already wondering if my back and legs can withstand another six hours.

Everyone has their own PPE system. With so much donated gear, there is no standardization. You find what works for you, what you can rationalize as safe. Some providers are more lax with their gear than others. Some only don an N95 and a paper-thin yellow gown. Maybe it’s overconfidence, maybe it’s fatigue. Others wear full suits, rubber gumboots, and full face respirators. The wide variations give it all a sense of personal ritual. Like war paint, totemic charms, and found bits of armor. More a band of viking raiders, than a professional standing army.

And I’ve developed my own ritual. A system of layering I hope will protect me for this month.

It starts with the bunny suit. I try and always hunt down the style with a hood attached. Beyond the head covering, the material of this style is less permeable. It reminds me of Tyvek house wrap, and breaths about as well. In the beginning, I had to hunt three floors and as many nursing offices for one of these. As such, I’ll try and reuse it for 4 shifts. Once on the unit, I’ll wrap my ankles in tape so I’m not tripping on the footy bits all night.

On my hands, I’ll put on sterile surgical gloves as a base layer. These are less permeable than the exam gloves that are all over the unit, and they come up my forearm past my wrists (my wrists were exposed quite a bit my first shift before I found a stash of these gloves). I’ll wear this base layer glove continuously, sweating, and turning my hands pruney throughout the night. One modification will be ripping off the index finger on my right hand. I’ll need that fingerprint a hundred times to access the locked medication cabinet. Throughout the night, I’ll purell and wash my hands in these gloves as if they’re my own skin. Ontop these gloves I’ll wear a pair of exam gloves that will be changed between patients to prevent cross-contamination.

Next, a lunch lady bouffant hat before I don my N95. The duck-bill version is the most available here. I know I have a good fit because my nose immediately feels pushed down onto my lip. Next comes a regular surgical mask on top of the N95. That’s the throw away mask. The N95 being too precious. It’s key to find a tying surgical mask and not one that loops over the ears. Two hours in with the loops and it feels like your ears are being sliced off your head with dental floss. Goggles before the hood of the bunny suit go up. Cap the whole thing off with a face shield and I’m already feeling the urge to itch my nose.

By the end of the shift, my hands will be prunes, and the urge to rub my face and nose will be unbearable. I’ll have a headache from the strap on the face shield. Taking the gear off comes with its own ritual. I rub myself down with bleach wipes then try and reverse the donning procedure. If it were normal times, all would come off inside out and go straight to the trash. But these aren’t normal times, I carefully extricate myself from the suit trying not to touch the “outside” of it. It joins others of its kind on IV poles near the front of the unit. Coat check for a bunch of infectious Olaf costumes.

The scrubs I wear to and from work, are different from those I wear on the COVID unit. Even so, back at the hotel, I strip down to my underwear in the hallway before entering my room. No one bats an eye. The only guests here are emergency medical workers. Immediately inside my room is my “dirty station”. Here I wipe down my phone, my badge, put my scrubs into a bag and go straight to the shower.

Finally being able to rub my nose and face is bliss.

That’s when I’ll try and rub out all the mask lines on my face, and cry out all my tears, before I FaceTime Jen and the kids.

I don’t want them to see that part, I don’t want them to worry more than they do.

After the shower, I put on my Hanuman t-shirt.

The monkey god feels appropriate here. Devotee of Rama, avatar of Shiva. Hanuman is the killer of pride and the lord of celibacy. Celebrated for his faithfulness, he once mistook the sun for fruit and bit into it, forever altering his face and that of all simians. After a month in an N95, I will not be surprised to have an altered face as well.

Having a mascot for celibacy is just a comical bonus here.

In Hinduism Hanuman is the ultimate servant, a god that wipes out ego and pride.

Some of the CRNAs here balk at taking ICU patients, at performing nursing tasks that are beneath our advanced level of training. But that is where the needs are. Regularly ICU nurses only are assigned one to two patients. Saturday morning I gave a report to a nurse assigned 6. That same nurse had 9 patients the week before (all on ventilators and receiving blood pressure support with multiple IV medicines that need constant titration and attention).

I am proud of the CRNAs who are pitching in at the bedside, I would give them all my t-shirt. They’ve put their ego aside, and are serving where dire need and their unique skill set intersect.

And the need is indeed dire. This chaos is not something I ever imagined seeing in a hospital here in the industrial west.

There is a scene in Apocalypse Now where Martin Sheen is crawling through a foxhole trying to find the commanding officer of an army unit about to be overrun by Viet Cong. In the scene, he asks a soldier where their commanding officer is, and the soldier responds “Man, I thought you were the C.O.”

That’s the feeling here. The units are staffed with people from all over. No one has had an orientation. Many lack computer access, medication access, or even scrub access. Often you’re working at the bedside within four hours of arriving at the hospital.

Physically, the hospital looks like a war zone. Ad hoc ductwork hangs from the ceilings, tied up by bedsheets and pillowcases. An attempt by medical engineering to make entire units negative pressure. In normal times may be a single room in the ER or ICU that might be negative pressure for the occasional TB patient, now we’re trying to make entire wings such.

Ad hoc engineering for ad hoc ICUs. Pre-op, PACU, Cath Lab. All are ICUs now. None were ever designed for such a role, and none can achieve that role 100%. Something is always missing, not connected, not plumbed,

Every unit is full of ventilator-dependent patients. Twenty or so per unit, sedated, and on hemodynamic support. The peak pressure it takes to drive breaths into them is easily twice that of normal surgical patient. We place them face down on the beds, “proning” them for 16 hours straight in an effort to use the larger surface area of the posterior lung to oxygenate them. Scant coffee colored urine in the collection bags is a late sign that their kidneys are shutting down. Any dependent body part swells as fluid leaches into their tissues. Because of the proning, their eyes look like a prizefighter.

If they start to die, we flip them on their backs and start the standard code algorithm minus chest compressions and bagging. That could aerosolize the virus and create a greater risk for us all. We call this style a slow code or a chemical code. No one expects it to work. We tell ourselves it’s good practice for the residents.

We try and facetime the family. Sometimes it works. I can’t imagine how heartbreaking that is. Strangers in space suits showing you a shaking video of your wife’s last moments.

There are five refrigerated semi-trailers outside the E.R. Four are already full of the deceased.

In Luang Prabang, as in the tropics all over, the line between being inside and outside is very thin. The hallways of the hospital are just covered walks connecting different wards. The reception area is a large open-sided pavilion, with the occasional bamboo screen to roll down for shade protection. The cooking areas are open air kitchens with cement troughs for washing, and charcoal braziers for stoves. Mealtime takes place on verandas. Here outside and inside dissolve into one another, rather than abruptly transitioning at a threshold. They embrace and spill into one another, and make the concept of public vs private more fluid than what puritanical westerners are often accustomed to. I’ve always loved this about South Asia, gated communities, garage doors, privacy fences, the things we use to separate us in the west have little traction here. In Laos, and throughout this part of the world, life is lived openly, out in your street. This open-sided architecture forces you to be part of the community. Forces you to know your neighbors and care. 

It is an architectural style that makes sense given the climate. You can see it echoed across the world. Visitors to Hawaii, Indonesia, or St. Thomas encounter similar motifs, almost always with the caress of an ocean breeze.

Luang Prabang is landlocked. No salt scented breezes here. No daiquiri bars.

It does sit on a bend of the lazy brown Mekong, and somehow uses this fact to marshal a laid back vibe. It is surrounded by impractically steep sided mountains. Their near vertical slopes cloaked in a heavy matt of biomass so green as to be almost black. These karst formations are more like Seuss drawings dollapped onto a page by a cartoonist than real geology. And the misty mornings common here cut them off at their base and leaving them floating in the hazy early morning sun. 

Luang Prabang was an outpost of French Indochina, and French Colonial architecture is dotted about. Black mold running down decaying stucco walls, verandas, galleries, colonnade. It’s decadent the way a good period piece is. Made more so by the numerous French expats making a home here, sipping espresso and chain smoking under lazy paddle fans. 

This neuvo colonial tableau is shot through with lines of orange robed monks, gilded temples, and wet markets selling buckets of writhing eels. It is likely this is the exotic Asia that most tourists are hoping to find as they settle into their trans-continental flights. 

For us Luang Prabang is all of those things but more. It is a community of grass-roots activists, entrepreneurs with an eye toward sustainability, outreach programs and green initiatives. Jen and the kids were able to plug into this scene by volunteering at projects like Big Brother Mouse (an English language tutoring center) and its primary school Sister Mouse. They visited the only buffalo dairy farm in the whole country, where a couple is teaching villagers how to make mozzarella. Jen gave yoga classes and talked about women’s health to weavers at a handicrafts project. There were projects as large as the Elephant Conservation Center and ones as small as discouraging single use plastic straws in favor of bamboo straws.

The atmosphere and setting in Luang Prabang drew us in, but it is the community that we fell in love with. The community of hopeful individuals making an effort to create a better place to live.

The kids were looking forward to their first long haul train journey. Visions of the Hogwarts Express playing in their imaginations. Jen and I were just hoping that the overnight sleeper from Hanoi to Da Nang wouldn’t be as bad as the third class sleepers we have experienced across India. No matter what we were expecting, we knew that 20 hours on a train was going to be trying. Having booked five bunks in a cabin for six, at least we would outnumber whatever fate threw at us in terms of cabin mates.

Thao Thanh turned out to be a woman in her fifties who spoke zero English. This did not deter her from immediately commandeering my phone and making us FaceBook friends. Her stop was around midnight, about 6 hours after the AC stopped working.

The man in the cabin next to ours chain smoked like an AA meeting, and the toilet resembled a Porta Potty on the last day of Burning Man. The Hogwarts Express it was not, but neither was it the rattling sardine can that crosses Bihar to Calcutta. Thankfully the coffee from the trolly was boiling hot and delicious. Coffee culture in Vietnam has deep roots. 

Not surprisingly, the driver we had arranged for pick up at the station did not materialize. Bleary from the journey, we were forced to arrange transport ourselves in the scrum of taxi drivers buzzing about the exit hall of the station. We had tried hard to avoid this because it exposes you to another possible episode of overcharging and transportation scams. In some countries drivers will stop midway to your destination demanding more money for “tolls”, “fuel costs”, or outright extortion.

Luckily this did not happen, even though our “taxi driver” who met us on the steps of the arrival area, ultimately led us to a private vehicle in the carpark. Of course he had no clue where our destination was, despite telling us he knew the place before we departed. A common ruse to get the tourist into your car.

The usual strategy is to drive around until you stumble across your destination or until you give up and get a room at one of the guesthouses you keep passing. This time we were lucky enough to be in the small beachside village of An Bang, and spied a sign for our guest house in short order. Within an hour we were in bathing suits and beers, putting the nights journey behind us.

Travel days are not ideal for homeschooling. The kids are excited and distracted, the WiFi is typically spotty, and their teacher’s preflight Bloody Mary can easily lead to a second round (if inflight cocktails are complementary, the kids might even get a snow-day). But we often spend multiple days getting to our destination, so en route schooling is necessary. We must adapt during these times.

Typical homeschooling days Jen takes the kids to a public library. But yesterday began a three day journey to Hanoi.  So after a short flight from Charlotte, the kids settled into their classroom, JFK’s terminal 5. With good solid WiFi, we were able to log them into their normal online curriculum, Time4Learning. This is the second curriculum we’ve used, and it allows us to schedule their modules to fit our travel calendar. On a travel day with good internet, math and language arts are the focus. As we get farther off the grid, analog backups in the form of Brain Quest workbooks make sure when the wifi quits school work doesn’t. And of course everything their social studies modules get a big supplement in learning about the local countries/cultures we are visiting. In fact this year Jen assigned each kid a country from our current trip to research. Heads up friends and family, expect some PowerPoint presentations this holiday season.

The 12 hour flight to Qatar was a school free zone. A free-for-all of movies and sleep, while our favorite carrier (Qatar Airways) transported us to our favorite airport, Hamad International in Doha. Just 5 years old, spacious, clean, modern, and with big brass sculpture/playgrounds throughout, I do not know an airport in North America that rivals Doha. The concourse is reminiscent of Gattaca, sleek minimalism and high wooden ceilings cut through with thin rectangular sky lights. A ten hour layover might sound horrible, but at HIA it is a respite. It gives us a chance to stretch out, run around a bit and get a little more schooling in before our final push to Hanoi. 

Our little Stella can get motion sick just by watching Deadliest Catch. She’s thrown up on every flight we’ve ever taken to Bhutan, twice on Jen. She’s puked in vans from Big Bend to Lombok. Her record for one car trip is four times (Rwanda). Once when riding in my lap, she threw up on me, which I promptly repaid by throwing up on her (Bhutan). We’ve tried every conceivable treatment; pharmaceutical (benadryl, dramamine, scopolamine, zofran), eastern (activating an acupressure point with Sea-Bands), behavioralism (stare at the horizon), I’ve even stuffed a tissue into only one ear (a trick I first saw on a chicken bus in Guatemala). Our latest stratagem, anti-motion sickness glasses. They’re the orthopedic shoes of eyewear, but hopefully by giving her an artificial horizon in her periphery, they’ll be the breakthrough. And they arrived just in time, on the day we left Santa Fe.

Getting these glasses was just one of a long list of tasks and chores that precedes our big trips. Warn the credit cards of our travel, place a hold on the cell phones, organize homeschool supplies (digital with analog back ups), vaccinations and teeth cleanings, haircuts and state department registration, buy the tiny toothpastes and shampoos, and check the passports.

This last one was especially stressful. Jen’s passport renewal had not been processed as of a week before our launch from New Mexico. So add to our list of tasks, a 10 hour drive to the consulate in Dallas for a 15 minute meeting. Ten hours back to Santa Fe, and then continue with the lists.

For three weeks we’ve been wading through leaf-piles of post it notes and lists, reminders to get visa pictures, renew work contracts and mail service subscriptions, buy an extra umbrella (rain jackets are too sweaty in the tropics), and pack the Elf On A Shelf. We’ve packed and unpacked the bags at least three times. It feels like death by 1000 cuts. But with each little chore completed we move forward, build a little momentum, and get closer to our departure. 

And that momentum has been building since leaving Santa Fe. Amarillo, Dallas, Jackson, Atlanta. Over a week of driving, and yet we still haven’t left. But our route has allowed us to see friends and family along the way, gaining energy and polishing off those last to-do’s. Today we are in Charlotte, tomorrow we finally board our flights east. It finally feels like we’ve accomplished enough to break free of the gravity of our “normal life”. That we have collected enough impetus and thrust to reach escape velocity.