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If you have ever wondered about the standard of medical care in Syria, this blog entry should satisfy your curiosity. My journal is unfortunately MIA, so it's from memory. I've left out most of the gory bits but it's still a bit graphic. Names of people and some place-names are left deliberately ambiguous or abbreviated.

March 1, 2010

Jebl (Mount) Qessayun contains the sprawl of Damascus to the north of the city – an urban dam. On one of its summits sits the presidential palace, surrounded by orchard-perfect lines of cedar trees and a heavily guarded ring road. On the greater summit, a few hundred feet east, sprout an imposing array of military apparatuses and antennae. Cutting through the side of this central expanse of the mountain is another road, which is publically accessible, and leads to a number of cafes, restaurants and what would be make-out spots were the mountain in America. These are generally populated by families and groups of shabab smoking hookah and drinking tea.

The view from Qessayun is superb at night: spilling out south, white lights punctuated by green minarets, from the grandeur of the National Museum and Four Seasons all the way south to the Jeramana and Yarmouk camps. Removed from the honking and pollution, even the traffic seems orderly from this road.

Walking through the Old City with my friend P., we ran into my Syrian friends N. and H. We sat together at a cafe for a few minutes, and N. suggested that we drive up Qessayun to enjoy the view. P. protested, but I convinced her to come along anyway. N. was enjoying the fast drive in his new sedan: light traffic near midnight, windows down, Alice in Chains on the stereo, the counterpoint to the stuffy, choked service schleps that you put up with all day to get anywhere for the cost of a piece of bread.

N. cruised up the middle road on Qessayun, with the Doors' Riders on the Storm playing loud. Didn't feel like Syria. He sped into the opposite lane to pass a slow driver, and the wheel under P.'s passenger seat struck a deep pothole. We careened side-long across the road in slow motion, and t-boned the cement divide on the side of the road. The cars' airbags exploded out and it smelled like burning paper.

I walked with P. to the edge of the mountain to assess the situation. P. and N. weren't hurt, but everyone was shaken. My left side hurt a bit, but I couldn't figure out from what. A bunch of cars stopped off to help, and N. insisted that we accept a ride home from a couple of guys since he could get in trouble with the authorities for having foreigners in his car. They asked sympathetically after our health and bought us candy bars and coffee. We exchanged numbers. P. and I stumbled back into my apartment in Jeramana, careful not to arouse the suspicions of my religiously conservative landlord who forbade girls from coming over after hours.

(On signing the lease, the real estate agent warned me that I would lose the apartment if the landlord found out I was running a karakhaneh, or brothel, in it. By brothel, he explained that he meant an apartment in which an unrelated girl might spend more time than it would take to drink a cup of tea. The landlord reiterated this caution, but since she lived right across the hall and had a video camera installed on her intercom, it was pretty obvious that she knew I wasn't in compliance. Still, we kept up the pretence of 'sneaking in' to save the landlord face, and she didn't complain to save me embarrassment. It was a workable compromise.)

I woke up the next morning thinking I'd slept the wrong way on a cinderblock. My left love handle was red and three times its usual size. No other symptoms, so I decided to wait and see. We called N. (my friend who was driving and got us into the accident) repeatedly, and he finally picked up the phone around ten in the morning. He told us that he'd waited by his car until 6 am, not willing to leave it but unable to drive it home. Some guys in a Suzuki flatbed sidled up to his car and offered to help. They robbed him of his wallet and some car tools and might have punched him in the face.

Days passed, and my injury went from red to bruised blue to black and purple. It grew from the size of a fist to that of a footprint, and then to that of a Shaquille O'Neal footprint. It felt like a water balloon about to burst. Every so often, I'd reach down to grab a book from the floor, and it felt like I'd torn some fleshy membrane on my side, provoking my surprised and extremely loud exclamatory. My friend Robb once commented that coming over to my apartment was exciting because you never knew when I was going to scream.

After a couple weeks, P. convinced me to see a friend of a friend, who was a doctor. He was leaving for America shortly, and was very thorough in his questions and examination, eventually concluding that the wound wasn't serious and that the bruising would subside in a few weeks. So I let it go for another week and a half.

Just about everyone urged me to seek medical attention: even the Marines from the embassy laughed that they'd be on their way to Germany with a booboo like that.

March 20, 2010 (approx.)

Finally I'd had enough, and got myself to the F. Hospital in Damascus for a diagnosis. The admitting nurse wouldn't tell me where to go, so I tried my luck at another wing of the hospital. There, I happened to run into an older surgeon, Dr. S. He introduced himself as the head of a department at _______ University. He offered a quick assessment, which I took him up on. The waiting room was full of fidgety older men and sad older women. The receptionist answered the phone curtly and watched soaps on her desk TV.

According to the certificates on the wall, Dr. S. had trained at some well-known hospitals in the US and in the Middle East as well. His English was good, which was a miracle since my medical Arabic and French are (or were, at least) basically nonexistent.

Dr. S. said that there was some formation in my left flank, which he'd need an ultrasound image of to diagnose accurately. A few hours later, a perfumed and heavily mustached ultrasound tech covered my side in ultrasound goo, took the requisite images, and left me in the room. It only occurred to me about half an hour later that I wasn't supposed to stick around. I found some paper towels on a counter, cleaned up the gel, and marched out to see Dr. S. He said that what I had was a small hematoma, from which he could aspirate the blood and fluid in a few days. Upon returning, he did precisely that, and withdrew a courageous amount of fluid. It was better for a day, then promptly refilled.

He cut a small hole in my side, through which he threaded a catheter which led to a plastic accordion called a hemovac. I lived with this grotesque accordion hanging off my side for the better part of a week, as an outpatient. I figured out a way of keeping the thing in a messenger bag so it wasn't so obvious that I was carting around a bag of blood attached to my love handle all the time.

This too failed. I sought a follow-up with Dr. S. He said that a minor surgery was the only course of action, since the aspiration had failed. I paid the doctor 4000 lira (about $80) directly and in cash for his consultation and the small procedures.

Surgery wasn't high on my list of things to do in Syria, but I also didn't want to leave the country since my visa and immigration status were questionable at best. (The visa had expired, and the official who had formerly and graciously bestowed me with his immigration stamp of approval had hardened to my plight.) I scheduled the surgery.

I arrived at the hospital ten minutes early to find that there were no nurses or doctors available who could tell me where to go. Bad sign.

Finally, I found Dr. S. They put me under. Five hours later, I awoke. The hematoma was a bit bigger than anticipated. By a factor of four. And the surgery lasted for four hours, not half an hour. A factor of eight.

Dr. S. handed me a see-through plastic jar filled with black liquid and white flesh. It looked like a jar of pickled eggs, but with a shaved rodent inside. Turned out that it was just a sample of the hematoma, and not even of a majority of it. The surgeon asked if I had a friend who could take the sample to a lab. I laughed and asked him if he was serious. He was. P. bravely took the jar (wrapped in another bag) to the lab across town. Tests came back: not malignant.

A Few Days Later

Private room in the hospital. P. had brought fresh flowers and there was a window facing outside. Some of the nurses introduced themselves and injected me with who knows what. I learned the words for injection (prun: eebrey) and painkiller (pron: musakkin). Dr. S. dropped by later that day. He said the incision was pretty big. And it is. I had some trouble getting in and out of bed but didn't feel so bad. A bunch of friends visited me, and P. was always around and didn't act grossed out even though I was leaking fluids all over the place and must have looked pretty nasty. They released me after just shy of a week in the hospital. I went home to recuperate, with instructions to return to the hospital for a follow up a few days later.

Back at the hospital, I lay on the table in Dr. S.'s office clutching my side. It was pretty distended, despite the drainage tubes. Dr. S. cordially removed these tubes and the bandages, and I hopped off the table to consult with him at his desk. It took me a second to realize that the warmness on my leg and foot was blood, gushing from the site of the wound.

"Doctor?"

"Yes?"
"Is this normal?"

He looks at the puddling blood, and exclaims, "Well isn't that nice!"

A few more days in the hospital, then home to my apartment in Jeramana.

Five Days Later

Three in the morning and I couldn't sleep. My side was killing me and I was sweating torrentially. My head was pounding and I hadn't eaten in three days. I couldn't hold down water. Dr. S. had assured me just two days ago that this was probably not an infection, but in any case he told me that I should pick up some antibiotics from the pharmacy. I'd mustered up the strength to get there but it was closed and I couldn't make it a mile to the next closest one. Finally I drifted off to sleep, only to wake up an hour later with my bed covered in pink slime. Called the surgeon, who told me I'd have to take a taxi to the hospital. No ambulances to be had.

Syrian Hospital Part II

I split the task of getting to the hospital from my apartment into minute steps. For every ten minutes of getting up and doing stuff, I'd lie in bed for 15 minutes. First I gathered the absolute most important items: passport, underwear, wallet. Then shut off the circuit breakers. I didn't plan on taking my computer, even though in my state I wasn't sure that I'd ever see the apartment again (it turns out that I didn't). On my way out to a taxi, I passed by the real estate agent. He invited me to a game of cards that night, and I told him that I probably wouldn't be able to make it. Smoke argileh? He asked. I think he saw the fluid dripping from my side as I turned away, because he choked a little on his tea.

This time they put me up in a double room at the hospital, which I did not have to share except for one three-hour period my last day in Syria, when a local tough who'd gotten into a fistfight got a doctor to look at his bruises; he told him that he'd been in a car accident. Some of the nurses recognized me and welcomed me back. One of them pantomimed at me because she thought I didn't speak Arabic.

The first couple of days back in the hospital weren't great. I was leaking fluids and even getting up to get to the bathroom took a herculean effort and involved some stifled screaming. Through my third IV, which they kept in for more than a week, the nurses pumped me full of a large amount of very green, and very cold, antibiotic.

P. came by at least once a day, and stayed for hours. It was painful for her, but she put a good face on it and kept me fed and entertained. A handful of other friends dropped by and chatted and ate with me. It would have been a seriously miserable experience without having had friends there, but with them, it was actually tolerable and sometimes enjoyable. Peter leant me a tall stack of books, which I ran through quickly. His girlfriend Samia brought homemade food, for which I never felt that I could thank her sufficiently. At one point I was left with nothing but a history of the English monarchy, which I ended up reading twice. (Unfortunately, the painkillers they were administering appear to have had an amnesiac effect on my reading memory.)

Meanwhile, I continuously asked Dr. S. if I had an infection, and if so, what kind. He equivocated and would not confirm anything. By my third or fourth day back in the hospital, it occurred to me that I was running a serious risk of death. I'd been talking to my parents about the situation only since being readmitted, and agreed with my dad that I had to leave Syria and get medical attention fast. They arranged an evacuation with my travel insurance company, who sent for an emergency doc to fly in from New Delhi and escort me to California. It took five days to arrange the visa and transportation. Four days before the evac, Dr. S. came to my bedside to examine the wound. He removed the bandages, and told me that I might feel a slight pinch.

Without further ado, he pulled a scalpel from the nurse's cart, and 'opened the roof' over four inches of the wound, which was 9 inches in length horizontally along my left love handle. 'Opening the roof' meant cutting through an inch of flesh along four inches of the wound to reveal the infected abscess underneath – something more than a slight pinch. When I asked him why he didn't consult with me before slicing me open without anesthesia, he replied, "I'm very glad I did that."

The room was large and drafty, and faced out onto a hallway in the oncology ward. Families were always walking by and looking in. Nurses didn't close the door very often, and for whatever reason, they often conducted their personal phone calls on the red line next to my bed. Twice a day, male nurses changed the bandages and debrided the wound, which entailed scraping the inside with gauze and irrigating it with fluid. The janitorial staff would sometimes watch this process, as I lay more or less naked on my side, trying not to make eye contact with whatever random stranger happened to be in the room at the time. Twice the nurses watched cartoons on the overhead TV while they attempted to clean the wound.

Dr. B., the emergency doc, landed the night before we were set to fly back to the States. He came in with his full kit, asked a slew of diagnostic questions, checked out the wound and explained what was going to happen. My wound must have looked pretty superficial compared to his other cases: he's the kind of doctor you call when you sustain a complex fracture while hiking in Kashmir, or when you get more than one limb blown off in Afghanistan or Iraq. In other words, he's exactly the kind of guy you want to hang out with on a twenty-five hour trip.

Lots of tearful goodbyes. I thought I would be returning to Syria in less than a month at the time, since I appeared to be getting better.

Dr. B. instructed me to gather some spare bandages from the hospital. I pleaded with the nursing staff, and Dr. S. promised to put together a kit. Nothing the next morning. Finally it occurred to me that since I'd already paid the bill, there was no reason for them to provide the materials. I slipped them 5000 lira (about $100) for an armful of bandages, then ate a breakfast of tea and an egg and set off.

Dr. B. had to change my bandage in airplane lavatory. We received a few amused looks from the passengers in the row next to the bathroom, but nothing worse than I would have given them, had the situation been reversed.

Security gave Dr. B. a hard time at Istanbul and Munich, probably because of all the needles he was carrying around in metal suitcases.

We landed in San Francisco. The customs guys interrogated my lightly for about an hour. They were amused at my situation and I actually enjoyed the conversation, even though I was holding up my end from the comfort of a wheelchair. My parents met us outside customs and put on a brave face.

Home

The doctors at Stanford Hospital were surprised that I was still smiling with a white cell count four times normal. Lab tests confirmed a methicillin-resistant staph (mrsa) infection, which the Syrian hospital was not treating me for, and probably did not know about despite my frequent requests for further lab tests there. After four days at Stanford, my white count was low enough to return home. They sent me packing with a 'wound-vac' (a vacuum machine attached to a catheter attached to a sponge in the wound site), which pulled the wound together in about three weeks, and a laundry list of medications. Our family doctor took charge of my case and has been absolutely thorough and competent.

Conclusions

My parents handled the situation heroically: they helped negotiate the emergency evacuation with the insurance company, kept me positive on the phone, and were by my side all the time back in California. They also never guilt tripped me about traveling to Syria in the first place or getting myself into a car accident.

Neda and M. called to check in all the time. P. and Peter negotiated my abandoned apartment in Damascus graciously and without complaining. I wish that I'd had the chance to thank them in person. I hope that I'd be such a good friend.