(Pictures aren’t working. Will correct in < 24 hours if internet allows…)
January 20, 2022
‘Can you please come over quickly? I just woke up and found Mom on the floor. Try as I might, I can’t get her to wake up!’ My father-in-law is typically cool as a cucumber, what one might expect of a 79-year-old general practitioner from rural Oklahoma, slightest hint of a relaxed drawl thrown in for good measure. But it’s 1:30 in the morning, and any time I can quote Rollin with an exclamation mark, I know it’s serious. Within ten seconds, I’m out the door and calling all my nurses to see who’s awake and can meet me at the guesthouse and get Mom’s IV. First two don’t answer, third says he’s on his way. Call a fourth who also isn’t there.
Dolores and Rollin Bland are Bere Adventist Hospital alumni, serving as missionaries in Chad six years, 2012-2018. Our hospital was finding itself once again in a pinch, and once again, they answered the call. Danae Netteburg, our fabulously attractive and competent OB/gyn (and also my wife, so maybe a hint of bias), had been filling the role of general surgeon alongside Andrew Trecartin since the Blands left in 2018. But it just so happened Danae needed a hysterectomy and, unwilling to allow me to do her spinal and then hold the mirror while she operated on herself, she needed to head to Cleveland Clinic for the minor procedure. (I’ve just been informed a hysterectomy for a 24 cm inferior and posterior fibroid with bilateral ureters running through the fibroid qualifies as a ‘major’ procedure. Who knew?) Rollin stepped up to replace Danae, since January is very busy at our hospital, averaging 40 major cases each week, far too much to reasonably expect Andrew to tackle solo. And of course, our children were thrilled to have their grandmother come dote on them just like old times.
(Nana, Papa and the grandkids a few days earlier.)
Once here, Dolores seemed to never quite be able to kick her sore throat and fatigue that had been nagging at her for a week. We figured it was the omicron variant of COVID. Sure, they were both boosted, but it was appearing as though this may be a variant capable of occasionally evading the vaccine-inspired immune system of some folk. She even had a fever for a few days, and since this is Chad, we started Malarone to treat presumed malaria, just in case. Yesterday, I had told her to stay in bed and see if rest could get her back in front of the eight ball.
Walking into the small and open guesthouse, I find my mother-in-law on the floor beside their bed, snoring. My father-in-law is smacking her on the backside and yelling (he’s a bit deaf, so between that and the excitement of finding his wife unconscious, a little yelling is understandable), ‘Hey! Dolores! Honey! Wake up! You’ve fallen on the floor!’ She’s unresponsive to all of this. The nurse isn’t there, so I call more.
Her Glasgow Coma Scale would be measured at 3, but her pupils are still reactive and symmetric. One nurse shows up, but can’t get an IV. Another nurse is located in the operating room with a cesarean and there’s a laparotomy to follow. Mom picked a busy night to pull this stunt. Finally Sonam and Pawel arrive and we get an IV, start fluids, get her back in bed, and haul over a monitor from the hospital and an IV pole. Her tongue is occluding her airway as she lays on her back, so we turn her head to the side and bring over oral and nasal airways to ease her dyspnea, and an ambubag to assist her when she seems to need a little extra, although the nasal airway and a jaw thrust seem to get her fairly reliably to an oxygen saturation of 96%. Things are moving quickly in parallel as my crack team divides and executes all the orders I’m giving. Second IV, not hypoglycemic, let’s start quinine in D5 for malaria, let’s treat all the infectious causes we can think of, since our diagnostic abilities are so limited. The lab isn’t responding so I go wake them up. Hemoglobin 14, electrolytes hemolyzed. Let’s go with ceftriaxone 4g, dexamethasone too. A foley goes in and 800mL immediately rush out. In a few minutes there are 1200mL in the bag. Pulse is 120, temperature is 103.6 and her skin is quite hot.
Rollin, an extraordinary physician in his own right with a career of experience, defers to me as his wife’s treating physician.
All this happens in less than an hour, in the hospital guesthouse, in the middle of the night. We stop and breathe and reassess.
(At this same moment, Danae is in Cleveland, having had her pre-hysterectomy appointment with a baby, my Aunt Bekki and my dad, oblivious to anything amiss until I’m about to start texting her, “Your mom isn’t doing well,” a message she won’t see for another hour.)
Throughout the rest of the day, mom’s occasionally needing a little help breathing with some ambubag support. We bring over an oxygen concentrator as well. Despite the concentrator, still occasional respiratory support is needed. She’s trying to breath 38 times per minute. We’re assuming a metabolic acidosis and her lungs are working hard to compensate.
Mom also seems to require a little blood pressure pressure support and we set up a dirty drip with imported norepinephrine but without a proper pump to measure what she’s getting. We set it up to run as slowly and as dilute as we can make it.
“Dad, have you and mom ever had DNR/DNI conversations?’
‘No,’ is a slightly sheepish reply from a primary care physician in his late 70’s who should know better.
‘If it comes down to it, do you want me to intubate Mom?’
‘Yes.’
We have a ventilator, but we’ve never used it. We get it ready, just in case. We feel prepared for respiratory and cardiac failure, as ready as we can be, and we have the guesthouse now thoroughly set up as our best ICU. A white blood cell count comes back at 11.2, with an absolute neutrophil count of 1120.
I step back and run a differential through my head. I have a 78-year-old woman with chronic lymphocytic leukemia found unconscious with prodromal illness of sore throat and fatigue. I know I gave four grams of ceftriaxone an hour ago, but let’s do a lumbar puncture.
I aspirate several cc’s of very cloudy, yellow-tinged fluid.
Now I have a 78yoF with CLL in rural and resource-deprived Chad, a 12-hour car trip from the capital, which really doesn’t have improved medical services beyond what I can offer, requiring occasional respiratory and blood pressure support… with bacterial meningitis. She will die.
But we will do our best. We add Zosyn and vancomycin from America to our ceftriaxone. The lab says the cerebrospinal fluid has more white cells than they can count, and the glucose in the CSF is practically nonexistent. This reaffirms bacterial meningitis to us. We continually run through differentials, but we keep coming back to the same.
The sun has yet to rise on this chaotic morning when I text my friend, Gary Roberts, mission pilot extraordinaire. ‘Gary.’ ‘Help.’ Gary starts contacting everybody he can think of regarding a medical evacuation for Mom. Gary himself is in America on working vacation and finds a friend’s plane in Belize, a pressurized turboprop. He’s quite sure he can milk the plane to Brazil and across the Atlantic and to Chad, eventually, but it will be an eight-country voyage to get her back to the States.
Throughout the day, Dad and I contact their four children in America, including Danae, who is scheduled for hysterectomy in five days and immediately says she is cancelling her surgery to return to Chad, a decision we talk her out of, since we have ascertained Dolores’ medical issue is neither obstetric nor gynecologic. We talk repeatedly at length about the options of medical evacuation, but return each time to the final conclusion Mom would not survive transport in this state. And based on our working diagnosis, which we feel fairly confident in, she’s getting the same treatment here she would receive in America. Gary stands by.
As evening comes, Mom stirs. Her eyes open. She moans. We pinch her and she raises a raise toward the pain. It might not be much, but it’s a drastic improvement from where we were. We will take it. I’m now running on one hour of sleep over the last 42 and my father-in-law can’t have slept much more. He drifts off while sitting on the couch, stubbornly refusing the second bed in the guesthouse and also refusing my comfortable mattress at home. I have a wonderful Polish nurse in the house whom I trust, so I sneak off to bed, leaving Mom behind for a few hours, terribly sick, but stably so, and in good hands.
January 21
My alarm was set for the right time, but the wrong day. I sleep five hours instead of one. My kids are amazing and we talk about how Nana is likely to die, in a guesthouse, in Chad, about 100 yards away, would they like to go and see her? They aren’t sure, but they decide to go.
My father-in-law is thoroughly beating himself up for his selfishness, his desire to come to Chad and do surgery, instead of taking the safe option and staying in America. If he hadn’t come to Chad, Dolores wouldn’t be sick. He gets up off the couch and goes to Mom’s bed and resumes his mantra for the day, ‘Wake up, Honey! It’s time to wake up! Hey, what are you doing! Wake up!’
Our care intensifies, but Mom doesn’t improve over the course of the day.
Mom still has intermittent fevers. We decide to start ampicillin for Listeria, even acyclovir in case we’re wrong and her meningitis is viral. Her nasogastric tube accepts the crushed acyclovir pills. Andrew even finds some meropenem. We add that too. We discuss starting fluconazole and metronidazole or tuberculosis medications for the really exotic infections, but we decide that’s overkill. As if ceftriaxone, meropenem, ampicillin, zosyn, acyclovir and quinine isn’t already overkill.
Andrew takes over as her ICU doc and does all the ICU things. We rig up the head of her bed to 30 degrees. We find some lovenox sitting around. We start practicing oral hygiene and properly measuring ins and outs. We lose IVs and get new ones in her feet, the last place we can find, and only with the assistance of ultrasound. We reposition frequently. We bathe her. Andrew’s wife, Megan, one of our family practitioners, starts NG tube feeds of fruits, veggies, peanut butter, tahini, and anything else she thinks might help. A missionary physical therapist from Dominican Republic massages Dolores. Nurses from Cameroon and America help give reprieve to the Polish nurse. Our fellow missionary and local pastor come to offer prayer and spiritual support. We ask for an anointing and are humbled as the olive oil touches Dolores’ forehead. Meanwhile Sarah and Staci, our two other American family practitioners, are holding down obstetrics and medicine and pediatrics and all the other goings-on at the hospital. An American midwife is helping care for my children during the day and the Polish nurse’s wife is keeping the kids at her place at night.
Our guesthouse/ICU continues to amaze me as I look around at the debrillator, the intubation setup, the suction machine and everything else. We continue to wrestle hourly with the decision to evacuate or not. My friend would probably spend $50,000 in expenses to get Mom back to America. The evacuation companies are all $250,000. And at this point, it seems as though we are evacuating to get her home to die. She’s receiving in rural Chad the same treatment she would have in America anyway. We keep all options on the table and people around the world remain on standby, ready to swoop in and help whenever we pull the trigger. The mission plane is prepared to fly from the capital to Bere and back again at a moment’s notice to save us the 12-hour road trip on horrific roads. However, the real challenge remains, Rollin and I don’t believe she would survive the trip. She is simply too frail. Intermittent respiratory and pressure support would be treacherous en route. The odds of a positive neurologic outcome are approaching zero, and we know it, but we leave it unspoken, as we think silently of whether we bury Mom in Chad or repatriate the body when the time comes. There is still no evidence she can hear us or process anything we say.
January 22
I’ve slept about seven hours in four days, as I was up most of the night even before Mom fell ill. I doubt my father-in-law has slept much more. In his younger days, he wouldn’t have even noticed. He was that old-school rural general practitioner they wrote stories about. Six years as his boss in Chad, I learned to appreciate his workaholic tendencies. A couple decades ago, it looked a bit different. Wake up and be at the hospital at 5am to round in several different hospitals, run his typical outpatient clinic, be interrupted for an appendectomy and a cesarean delivery during the morning, tend to his scheduled hip arthroplasty in the afternoon, go open the free clinic he started in the evening, accepting non-currency payments on occasion, then get home in the dark and hay the 180 acres to feed his sixty head of cattle before going to bed at midnight and doing it all over again the next day.
Those docs were just built differently.
Now I look at the man. He’s looking older than I’ve seen him before. He’s tired. He doesn’t want to be. He doesn’t want to miss a minute with his wife. Because it feels any day could be the last. I mention to him that one of my myriad phone calls and emails overnight yielded a potential private jet in Las Vegas a donor may allow us to use for free, or cost, to get Mom to Loma Linda. He’s encouraged. He and Mom had been using the second bed as a shelf to keep the suitcases and clothes and sundries on. I take it on myself to clear off the bed. Dad has only slept sitting upright on the couch for three days. I make him lie down on the bed, finally horizontal, but he only accepts when I tell him his only other option is I force him to go to my house and sleep on my own mattress. It can’t be but thirty seconds and he’s fast asleep.
My team of nurses are tending furiously to an unchanging patient. I decide to go home and clean and do chores that have been neglected for a while now. I find the private jet in Vegas is off the table, wait, no, the same guy has a second jet, wait, no, that jet is also unavailable. There’s a Canadian evacuation jet delivering a patient to France, already in our hemisphere. It’s run by a friend of a friend, and they will get Mom from N’Djamena, the capital of Chad, to Fayetteville, Arkansas, where Dolores’ daughter is a boss in their emergency department, for $120,000. I pull the trigger. Gary has pulled every string he has, which is a lot of strings around the globe, and this is our best option.
Overnight, Mom didn't required any help breathing besides oral or nasal airways and oxygen, and was weaned off norepinephrine. This may be her best chance to survive the trip.
Her GCS still waxes and wanes, never less than six and never more than eleven, for a couple days now.
I begin to work with the family in America to ensure we are all on the same page. The jet has room for one passenger. I assume it will be Dad. Danae’s family now decides I should be the person on the flight, being an emergency physician and theoretically being a hair more objective than Mom’s husband. I refuse to elbow Dad off the plane, but he wakes up and agrees with the family. Dad was always the guy I asked for medical advice, so I’m a bit intimidated, but I accept.
I talk to the kids and explain I’ll be gone for a week. They are incredible troupers.
We plan to fly to the capital tomorrow at 10am, get to Fayetteville at 4pm, same day, four stops later. Adventist Health International decides to front $120,000 so evacuation isn’t held up. Normally all our volunteers come through AHI and have evacuation insurance. Somehow, being our family and being past missionaries here, we never thought to run Mom and Dad through AHI this time.
January 23
Evacuation day. Mom gave us a spontaneous smile this morning. Nobody has any real answer as to what she was actually smiling at, but everybody has their own ideas. For days, a steady stream of well-wishers has come through Mom’s room to sing to her and pray with her and coo to her. But she never follows commands. She never makes any intelligible sound. GCS has still never topped 11.
The medical evacuation physician is a bit nervous about her condition, despite her now being over 24 hours without respiratory or blood pressure support. He wants to take her to a neighboring country for CT scans, cultures, all manner of other items we don’t think will change the plan. We say this is a deal-breaker, we’d rather stay in Chad. Finally, the evacuation to Europe is decided to be middle ground, and then onward to America. But the debate has now pushed everything back another day.
But that smile this morning makes us wonder if we can’t get Mom tuned up and fly her commercially in a few weeks.
January 24
Today is Danae’s birthday. Tomorrow is Danae’s hysterectomy. As a hopeless romantic, my birthday present to my wife will be her mother on a plane to France.
We needed an accepting hospital in Europe for Dolores to make her stop and get worked up before being medically cleared to travel across the ocean to America. Overnight, I finally found a solution in the form of an old friend in southern France. An oncological surgeon, Marc also happens to be chief of staff at his hospital. We will land in N’Djamena at 3:18pm, spend an hour getting Mom into the jet, then take off at 4:18pm and fly into Avignon, arriving 9:34pm. Marc will have an ambulance ready to transfer us to his hospital in Carpentras, where we will get all the things done to satisfy the evac doc, then fly to Shannon, St Johns, St Louis, and finally Fayetteville private runway the next morning. The ambulance will take Dolores to the emergency department where her daughter is in administration. At that point, I will Uber to Tulsa and pick up Dad’s car and get swabbed for a COVID test to prepare for my imminent return to Chad. I’ll then pick up Dad and drive him to the hospital, then Uber to the airport for my own 6am commercial flight to Cleveland. By then, Danae will be two days after her hysterectomy and I will drive her back to Fayetteville to be with her mom. I should get back just in time to catch a flight to Chad, arriving 11:55pm the next night in N’Djamena. I will get a few hours sleep and then grab the 5am bus to Kelo, then two hours on a motorcycle taxi to Bere, arriving about 4pm, just in time for my son’s birthday the following day. He turns thirteen and becomes my first teenager. Danae will return to Chad whenever her own surgery recover, as well as her mother’s recovery, allows.
It’s a beautiful plan. Tight, but beautiful.
But things go sideways and I will not be delivering my expected birthday present to my wife.
We land in N’Djamena on time. The jet pulls up beside our mission plane. They swab Mom. She’s positive for COVID. They can’t take a COVID-positive patient in their jet without being intubated. They can’t have her exhaling her virus in a tight space. They want to call an ambulance to take her across town for intubation in the government hospital. I refuse. I am vastly more qualified to intubate my mother-in-law than anybody at the government hospital. They told me years ago nobody even intubates there, although I’m sure that’s changed by now. Regardless, the last thing we need at this moment is Mom being whisked away by Chadian COVID protocols when she has bacterial meningitis. I am setting up to intubate her in the back of the mission plane. This isn’t ideal, but then the evac jet will receive her intubated and have no reason to cross the capital in a Land Cruiser-cum-ambulance.
Suddenly I realize how little I wish to intubate my COVID-positive 78-year-old mother-in-law. Intubated elderly with COVID have proven themselves impossible to extubate. No. This isn’t right. So I make a stink.
The evac company decides they can take her unintubated only if she is zipped into an isolation pod. Perfect, I think. Let’s do that. The company is flying a jet from Canada to a different African country several borders west of here. They will bring us a pod.
Next, they swab me. I apparently, too have COVID. Dad next, who thankfully is negative.
The sun has now set, and it is getting dark and cold outside this hangar in a quiet corner of Chad’s only international airport. The evac crew walks away from the jet and heads to the most expensive hotel in the country. We, however, have nowhere to go. We need to hunker down somewhere in the capital for the next 48 hours. We have no place to stay and no way to get there. This is a rollercoaster and I want it to stop. I want out. My stress level is through the roof. I want to throw up my hands and walk away. But I can’t. What will happen if I do. Something needs to be done and I need to do it. It’s Danae’s birthday, after all.
We call a mission guesthouse in the capital and tell them we have somebody with an infectious disease who’s awaiting medical evacuation in 48 hours. We need a place where we can all isolate and take care of her. He asks no questions and says he has a place. The mission pilot takes a motorcycle taxi home across the capital and gives us his pickup keys. We sit mostly-comatose Mom up in the back seat and lean her against the door, trusting the locking mechanism to not open. We drive across town, stopping at police checkpoints. ‘She’s fine, just a little sleepy. It’s late.’ Once at the guesthouse, we bring out a kitchen chair, strap Mom into it, and carry her in to a bed. Out in the garden, we find some mud bricks and prop the head of the bed up. We collect all the pillows and stuff under her. We set up her monitor and IV fluids and turn the kitchen table into our pharmacy and ICU. We need an NGT back in to resume her feeds. And then we sleep in shifts.
January 25
The med evac doc is now telling me Mom won’t do well supine in the isolation pod. She will be claustrophobic. Well, seeing as how she has extremely little understanding of what’s going on around her, claustrophobia is low on my list of worries. He believes it’s 50/50 she will require intubation en route to France, and has no chance going across the Atlantic. Fine, whatever. The med evac doc is an emergency physician and I’m quite certain he’s more than capable of intubating her in the back of an airplane, although he seems less certain. Plus, maybe his time spent flying with her and her time stable in France will convince him she’s fine. Comatose, but extremely stable. Whatever, let’s just get her on the plane.
The doc’s report back to base in Canada gives Dolores a GCS of 8 (1/2/5), which is the threshold for requiring intubation. I’m livid. He clearly fixed the game. Her eyes were spontaneously open, so she should have been a GCS 11, which is not routinely intubated. I feel he lied. My nurses also were with him while he examined Dolores and agree her eyes were spontaneously open. He also reports back to base a differential diagnosis including acute coronary syndrome, pulmonary embolism and loads of other ridiculous notions in a comatose woman with CSF WBC ‘too numerous to quantify,’ CSF glucose off the scale low, fever, nuchal rigidity, etc. He continued to voice his opinion she should be hospitalized in Chad, without any knowledge of the medical capabilities of Chad. I offered to pick him up and give him a tour of Chadian hospitals, but he declined. We can’t do the troponin he wants for her presumed ACS, never mind the fact there are no lytics in the country. He feels I am unethical keeping her in a private guesthouse.
He also reports to his base he will not transport the patient unless we agree to making her DNR/DNI. This is not something my father-in-law desires. We have a long and tearful conference call with his children in America, including Danae, who is currently in the pre-operation bay at Cleveland Clinic, literally minutes from her scheduled hysterectomy. This isn’t ideal. But 100% of the family agrees to make her DNR/DNI for transport, and reinstate her as full code when she lands in America and leaves the care of the transport team. His daughter in Fayetteville assures us the emergency department physicians there will have no qualms with this plan.
I relay our acquiescence to the evac doc, who then informs me I am furthering my unethical activities by making her DNR under stressful circumstances, and he will not accept our DNR order. I’m so confused! He insisted he wouldn’t take her unless she’s DNR… so we agree… and now he refuses!!!??? How are we supposed to make that decision without a stressful situation!??? My mind is blown and I feel we are back to square one. What on earth can we do to convince this doc to take her?
We go back and forth with our friend flying his private plane over. It would have been faster to do that already! Or maybe in a couple weeks staying in the capital, we can fly her back commercially. Sometimes you can purchase two rows of seats and fly a patient. We also look into buying a suction machine and an oxygen concentrator here in the capital. Mom is stable, but how much longer will we need to bunker up here?
Med evac calls back and says he’s 90% certain she will occlude her airway and die if she’s DNR. So he will take her full code. I think his home base has put some pressure on him.
Danae is anesthetized and losing several kilograms of uterus at the moment, but the rest of the family pow-wows once again. The plan has altered and she will fly to France tomorrow, full code, where our friend Marc will arrange everything. We feel confident she will handle that flight well and be flown to America without large delays.
Dad gets on his evening flight to America. Mom should be through France and to the States right after Dad lands. Things are looking up.
January 26
Things are not looking up.
Marc says his hospital in France has no COVID ICU beds. Since med evac is insisting she may require intubation mid-flight, he insists on having a COVID ICU bed reserved before takeoff. They should be leaving with Mom in an iso pod in 15 hours. I’m on the clock. Marc tells me there are no COVID ICU beds in all of France. The pandemic is in high gear. Landstuhl, the American military base in Germany, has beds, but can’t reserve squat for non-military. They wouldn’t turn Mom away if she rolled up to their doors as an American citizen with a life, limb or eyesight-threatening illness, but it would be shady to arrive without AFRICOM approval first. I talk to state department and senators and representatives and the doc working in the Landstuhl emergency department. Everybody wants her there, but nobody can give approval.
Finally, we get an ICU bed at Waldfriede Hospital in Berlin, and Adventist institution. They don’t really have a bed, but they know the dynamics and they are having people shifting around every few hours. They know a bed will open one way or another between now and Mom’s arrival, and they will tell the other hospitals in Germany they are full and save that bed for Mom. We are so incredibly grateful. Med evac buys the story and we are good to go.
Suddenly beds spring open everywhere. There’s one in Caen, northern France, another now in Belgium. We will stick with Berlin. Mom has been completely off pressors and oxygen for several days now. We even strap her to a chair and take her into the shower to clean her up.
Back into the pickup to head across town once again in the dark. We pull up to the hangar and I walk back. The evac team isn’t there. I shuffle and pace, leaving my nurses in the pickup with Mom.
Finally, the evac team shows up. They want to set up for Mom before I bring her over and officially put her in their care… and put them on the hook. They are ready and I see the isolation pod. Please, we can get a few pillows under her back and still keep the plastic off her face. She will be completely fine. GCS still 11. Protecting her airway great for days, no interventions required beyond IV fluids, NGT feeds, turning her and cleaning her and giving her antibiotics. Piece of cake.
Then I see them preparing for intubation. ‘Ok, bring her over.’ Wait wait wait wait wait. You don’t need to intubate the 78-year-old with COVID! We brought the iso pod so she would’t need this! That was a 48-hour delay for nothing?! If you’re intubating her anyway, pack away the isolation pod, there’s no need. At least look at her first!
It’s no use. My nurses and I stand helplessly to the side as we watch him clumsily intubate my mother-in-law. ‘Twenty-six at the teeth,’ he says to his respiratory therapist, indicating the depth of measurement of the endotracheal tube in centimeters. I gape and stare wide-eyed at my anesthesia nurse from Poland and my ICU-experienced American nurse. ‘Twenty-six at the teeth,’ echoes the respiratory therapist calmly, as if that was normal.
‘Pawel, have you EVER seen a tube at 26 that wasn’t in the right mainstem?’ I ask.
‘Never.’
‘Maybe their measurements are different in Canada. Walk over and peek at the tube.’
Pawel dutifully and confidently walks over, looks at the tube, and returns to me slack-jawed.
‘Twenty-six.’
I feel like a complete failure. I’ve failed Mom. I’ve failed Dad. I’ve failed my wife. Was I really helpless? Could I have been more aggressive in refusing intubation? Could I have intubated her myself and avoided her right mainstem? I know I won’t forgive myself until she’s extubated.
Whatever. I need to block that out and allow my pragmatic side to win out. She can travel at altitude on one lung. Her respiratory status has been perfectly stable for days now. Worst case scenario is she has atelectasis in seven hours when she gets to Berlin. They can fix that there.
At 11pm, my nurses and I are standing alone on a dark, international runway on the edge of the Sahel desert, watching a small private jet barrel along, lift off, retract gear, and slowly disappear blinking green and red into the distant north sky. Surreal.
There’s nothing we can do now. We huddle and pray. We drive across town. We collapse into bed and sleep without stirring for five straight hours. Exactly one week ago now, Dad found Mom comatose on the floor.
January 27
She was supposed to have arrived in Berlin at 6am. I’ve heard nothing. We woke and walked the half mile to the bus stop a bit before 5am, hauling all our heavy medical gear with us. It seemed a lot smaller and lighter on the plane flying up. I ride melancholy, agitated that I allowed my mother-in-law to be intubated after a 48-hour delay specifically to avoid intubation, but knowing there’s nothing I can do about it now, except to preemptively beat myself up if she is never extubated. So I let it go. We arrive in Kelo and hop on motorcycle taxis, arriving home a couple hours later.
It’s 3pm and I can’t wait any longer. The med evac doc has been radio silent since he took Mom and closed the jet door. I call the ICU at Waldfriede.
‘I don’t know why she’s intubated,’ is the first thing the ICU attending says to me. ‘She has minimal oxygen and pressure support. I can’t decrease either without extubating her. She’s already fully weaned.’ I explain to him what’s going on. ‘These guys always do this,’ he commiserates with me. ‘And they gave us nothing to work with. So we scanned everything. Her endotracheal tube was in her right mainstem, so we pulled it back to 21cm. There’s no evidence of COVID and our testing shows she isn’t infectious. We are not isolating her. She doesn’t need a tube to prevent infecting anybody. We don’t know the diagnosis, but she’s imminently stable to fly.’
I tell the ICU attending about the cloudy CSF with WBC off the chart high and glucose off the chart low.
‘Oh, then clearly this is bacterial meningitis. That explains it all. If you say she’s been on ceftriaxone for over a week now, sounds great. We will continue that. But if they aren’t going to fly her out, we have no choice but to extubate her here and transfer her to neuro rehab. But why shouldn’t she be home in America for that? They can come and pick her up any time. We aren’t doing anything with her.’
I’m frustrated because I wrote a beautiful report outlining everything, a report which never made it to the physician assuming care of my mother-in-law a continent away. I feel brushed off by the physician responsible for getting my mother-in-law to America. That report, or his own report, if it had reflected reality, would have saved the ICU team precious time, which isn’t in surplus in the ICU during a global pandemic.
I notify the evac doc of my conversation and give him the ICU physician 24-hour number, as well as his personal cell. I also inform his bosses in Canada of the ICU’s opinion.
The evac doc writes back to say his pilots require rest until 9pm. Apparently they require 15 hours off, which I find disconcerting for the world of medical emergency evacuations, but I suppose everybody has their protocols to observe.
I’m going to go hug my kids now. And collapse.
January 28
I assume Mom left at 9pm last night, when the pilots mandatory rest period was up. I text the med evac doc for an update. No response. I assume this to be a good sign and he has no way of communicating from the aircraft. So I call the ICU to reassure myself Mom was stable when she left last night.
Mom is still there. In Berlin. Sitting on a ventilator that’s doing nothing for her but exposing her to the risks of prolonged intubated ICU stays. I’m livid. The evac doc never called the ICU. I’m even angrier.
The ICU doc assures me Mom is still quite fit to travel. My Facebook emergency physician acquaintances in Fayetteville assure me they are quite prepared and enthusiastic to care for Mom as a VIP as soon as she hits terra firma in Arkansas. They don’t care if they have ICU beds or not, they will gladly babysit her in the ED as long as is necessary. It occurs to me Mom is accumulating unnecessary ICU bills in Berlin, and neither medical insurance policy my in-laws hold covers international hospital stays. Things I learn after the fact, like the credit card they bought their plane tickets with also didn’t cover medical evacuation. (As it would turn out, the hospital in Berlin ate the cost and forgave all medical bills, eager to show appreciation to a former missionary.)
The evac doc finally calls me. He’s refusing transport. He can’t explain why. The ICU attending in Berlin is quadruple boarded in emergency medicine, cardiology, interventional cardiology, and critical care. He says he’s fit to fly. But this evac doc feels he knows better. A third ICU attending joins the fray to insist Mom is safe to transport. They will extubate. She’s off pressors, her EKG is normal, her cardiac ultrasound shows a perfect heart, valves and all. There is no more workup possible. Extubate and send to neuro rehab. They even sent her blood across town to Charité, Berlin’s preeminent leader in tropical medicine, who cleared Mom of any parasitic infection.
Finally the ICU docs convince the evac doc. Begrudgingly, the evac doc has a private conversation with me, saying how sick Mom is. I tell him, fine, I will fly to Berlin and fly her home commercially once she graduates from rehab. The evac doc switches course and wants me to know Dolores has a 15% chance of dying en route and a 33% chance of never leaving the ICU. Really? Because they’re ready to extubate and send her out of the ICU alive TODAY in Berlin! I shut my mouth and accept these risks on behalf of her family. I hang up and inform the family, all now waiting in America.
It’s been nine days. Blood pressure and respiratory support the first several days. Guesthouse in Bere. Guesthouse in the capital. Now another 19 hours to wait before they will leave Berlin. A 54-hour stop in Berlin. I should have just taken my buddy up on his sketchy turboprop across the pond. Forty hours seemed like such a long flight back then.
January 29
For the first time, things go without a hitch. Nothing major, anyway.
Mom gets a surprise trip to Iceland, then Newfoundland, then Ontario.
January 30
After a stop in Missouri, Mom is wheeled into Washington Regional’s emergency department in Fayetteville, Arkansas.
January 31
It’s Lyol’s birthday. We celebrate by heading out to the river for a swim and see some hippopotami sharing the water with us.
Mom gets a COVID ICU bed. The homeopathic dose of sedation she received on the flight is now off. She hasn’t had real doses of sedation ever. Her ventilator setting are still nothing more than symbolic. She continues to fully breathe on her own, essentially, but the tube is still in. Finally somebody repeats her lumbar puncture and tests positive for pneumococcal antigen. Her MRI shows layering of pus in her ventricles, a finding I’ve never seen on imaging before. It also reveals a frontal ethmoidal mucopyocele of 3.7cm. That same night, ENT takes Mom to the operating room and drains it, saying mayonnaise came out. I’m assuming this must have seeded her meningitis and I’m optimistic draining this will turn the tide. I also rationalize she would have required intubation for this no matter what and can now wash my hands of her intubation. It feels like cheating, but I allow myself to relax a little.
Mom still shows no signs of awakening, so the discussion begins to turn toward a PEG tube for feeding and a tracheostomy for longterm airway protection. She may go to neuro rehab, but the prognosis remains awfully grim for a woman who has been comatose now for 12 days, starting out as a 78-year-old woman with bacterial meningitis in rural Chad, Africa. Unfortunately, she’s remarkably healthy for her age, except for carrying a diagnosis of CLL. With antibiotics, pepcid and lovenox, all she needs is feeding, cleaning and wound prevention and she can live as a vegetable quite a long time yet.
February 1
There is no change.
I take advantage of the break to figure out finances.
The flight up to the capital cost $1,284.33. The medical evacuation bill is $120,000. I assume the company lost money on this, seeing as how two jets were involved and several turns of pilots and ancillary medical staff and delays and detours and… it just wasn’t seamless. Regardless, the total expense is $121,284.33. That’s a heavy lift for folks on missionary salary.
Adventist Health International fronted the money. The General Conference of Seventh-day Adventists very generously repaid $75,000 of that debt. So $46,284.33 remains.
AHI promised to not ask us to personally repay this. But Danae and I feel quite deeply that it is our responsibility. AHI lets us know $11,000 was donated to AHI specifically for ‘medical evacuation’ in the past couple days. Folks know about the situation and are eager to help.
So now we are down to $35,284.33. Perhaps this is the sign Danae and I should get jobs in the states and make a donation to AHI to offset this unneeded expense for an NGO we love.
Over the course of the last few days, an online group of 26,000 American emergency physicians were aware of Dolores’ plight, and offered diagnostic and treatment assistance and opinions, assistance finding evacuation companies, assistance finding places for Mom to land in Europe and America, and in general an online shoulder to cry on. In the meanwhile, one of those physicians found Danae’s Venmo handle and posted it. I found out and went to check out Danae’s Venmo balance.
Throughout all of this, I was unaware of the what the final bill would be. I was unaware of what the GC would pay. I was unaware of what had been donated to AHI. And I was unaware of what people had sent to Danae. I never asked anybody for money. I never told anybody any specific amount, because I genuinely didn’t know.
Danae’s Venmo balance was $35,273.50.
Our share of the bill turned out to be $10.83. Otherwise known as a dinner date to Taco Bell.
Let that settle in. A bill of $121,284.33. Left with $10.83 to pay. That’s less than 0.01%.
Danae and I praise God for his goodness in this matter. But the matter of Dolores’ health remains. The physicians are pushing for PEG, trach and palliative care.
February 2
Mom grimaces to pain.
February 3
Mom spontaneously moves her hand and leg and opens her eyes. She is still not following commands. She still cannot be extubated. That cursed tube I never wanted in the first place and worked so hard to avoid.
February 4
I attend a Zoom meeting with the hospital chaplain. The chaplain turns the iPad so I can see my mother-in-law’s face.
Mom is extubated.
She opens her eyes.
She looks at the screen and sees my face.
She turns to the chaplain.
‘That’s my son-in-law.’
It’s 10:30pm. The kids are asleep. I’m alone. I switch off the microphone. I stare at the screen. I weep.
Mom spent 16 days in a coma, several of those days on blood pressure support and respiratory support in my care. She was intubated, with COVID, for ten days. From a 78-year-old CLL patient with bacterial meningitis at the end of the earth, comatose in a guesthouse in my hospital, to jetting around the world to different hospitals, transferring in and out of a tiny plane in an isolation pod… to ‘That’s my son-in-law.’
March 6
I’m at my sister-in-law’s house in Oklahoma City. After Dolores was extubated and moved out of COVID precautions and the ICU, Danae flew out to be with her parents. Dolores made her way to rehab. Yesterday I arrived here about 5am, after driving from Virginia nearly 24 hours with the four kids in the car. The kids are such phenomenal travelers. Not many kids aged 6, 8, 10 and 13 can handle that kind of a drive straight.
It’s a joyous reunion after being apart for almost two months. I missed my wife and our eight-month-old, who seems to have changed so much. Danae is still slightly limited as to what she should take on, still less than six weeks after hysterectomy.
I’ve had the luxury of sleeping in this morning, and I make my way downstairs for a late breakfast. There at the counter, chopping vegetables, is Mom. Without saying anything, I come up and hug her. The last time I saw her, she was intubated and being loaded awkwardly, bubble and all, into a tiny jet, unsure if I would see her again. Dad is in the kitchen, and this stoic man begins to choke up.
Mom turns to me. ‘I guess I heard you saved my life. Thank you.’
She’s a simple woman and it’s a simple declaration. But it’s so much.
‘There were a lot of people, Mom.’
Today
Dolores enjoys walking out to her garden and digging in the dirt. She still drives around and runs their small church’s food bank. She recognizes everybody. She doesn’t remember the few days leading up to her coma, but she wanted to make sure her fleece came back to America and the Grape Nuts they brought to Chad didn’t go to waste. The woman is sharp.
These days, what still dominates most of her weekly schedule, just as it did before, are her church activities and the Bible studies she and Rollin give to so many individuals, online or in-person.
As it turns out, God wasn’t quite done with her yet.
It’s impossible to recap all that went on behind the scenes. There were so many people working on this, generously offering time, money, supplies, expertise. And there were so so so so so so many phone calls, emails, texts, WhatsApp, smoke signals and every other communication flying around. It’s a a whirlwind, a rollercoaster, and immensely stressful on our family of seven, split between continents. Revisiting this story will likely always be an emotional experience for me. Painful at times, which is maybe why it took me over a year to write it. But in the end, May God be glorified in its retelling. And pretty much, this is just an opportunity for me to post embarrassing pictures of my mother-in-law which I would normally otherwise be murdered for 🤷♂️ Love you, Dolores 😘😘
