Coconut Trees and Sky

It’s been a little over a year since my husband and I suffered a terrible accident in Philippines.  Though I was insignificantly injured, he sustained great injury to his torso area resulting in seven broken ribs.  Over the past year, I’ve had the opportunity to reflect and process many aspects of my (our) life as a result of the accident, which in many ways I no longer see as an accident.  The following is my account (with some input from my husband) of the events surrounding the accident:

THE DRIVE

We were driving from a place called Kuting Reef, a touristy spot approximately two-and-a-half hours from Sogod. I thought we were going to snorkel around the reef, as we had at David’s mother’s house, but it turned out this place was a private resort with overpriced activity packages.   David and I were sitting in the back of his uncle’s multi-cab (a mini truck-like vehicle), which is enclosed in the back; we were each seated across from each other on the built-in seats, holding on to the side handles.  I could feel the breeze of the salty bay tickling my face and the sunrays flirting with my skin. Emerald green lined the road, and I remember feeling heartbroken that Carmen would not be there to share the experience with David and I.  I felt so alive amidst all the beauty around me, and I closed my eyes to invite the smell of all that surrounded me – sweet salt, humid soil, mango slices of sun, roasted fields of rice, green rivers of coconut juice, and the occasional lingering sage-like smell of firewood from someone’s kitchen.

THE ACCIDENT

My smells were interrupted by a violent jolt, which abruptly opened my eyes as my head hammered into the roof. Simultaneously as I felt the car flip, I saw David’s legs and feet in the air, as he grabbed a hold of the handle bar, instinctively trying not to be thrown out of the truck.  I landed inside the bed of the truck on my right shoulder and hip, and lay still between the realm of reality and nightmare.  David told me later that when he first saw my body motionless and limber, he feared the worst, and immediately thought of Carmen.  I heard David’s voice in the distance, and I realized I was lying on a shattered window; I slowly began to prop myself up with my left hand and saw David lying in the same line segment as me, but his body toward the opposite direction.  He wasn’t getting up.  At that point my adrenaline kicked in, and I was kneeling right by his side.  Blood covered his forehead and ran down the sides of his face, nose, and mouth.  He asked me if there was blood coming out of his mouth, I responded no, but I couldn’t really tell.  His eyes were rounded with fear and shock as he felt tremendous compressing pressure on the left lateral side of his torso, and in a gasping voice said, “I can’t breath, I need air!”  I thought his lack of air might be do to the pressure he was feeling.  First I scanned to make sure he did not have any open wounds, and immediately I steadily used my hands to apply pressure and support to the area around his ribs.  In my peripheral sight I saw David’s cousin, Long, who had been sitting in the front passenger seat, and shouted that he please call an ambulance; we were an hour to an hour-and-a-half from the nearest city or hospital.  There was a huge crowd of people surrounding us; unfamiliar faces speaking in a tongue so distant to me as my home.  I then asked Long to take my water bottle and wet a small towel I was carrying in my backpack. I asked his uncle to get a towel so that I could roll it and place it as leverage to relieve the pressure in David’s rib area.  No one moved.  I continued to apply pressure with one of my hands, as I used the other to wipe the blood from his face and ensure that the blood was only coming from the gash on his forehead.  His breathing was labored and the humidity lay as a thick blanket on us.  I reassured him that I was going to make sure he was properly cared for, and as long as I was with him, everything would be okay.

Finally, in the distance I heard a siren.  When the ambulance arrived, a group of men approached David in an attempt to carry him into the ambulance.  I shouted for them to stop, holding on to my husband as securely as I could.  I knew we needed some type of board to stabilize his head and back before getting him into the ambulance.  I realized immediately these were not trained paramedics, and I would have to ensure David made it safely to the nearest hospital.

Someone in the crowd brought a board, and just as I was going to guide the men in positioning the board under David, a doctor and the Mayor of the province showed up, and the doctor guided the men.  There was no oxygen or IV in the ambulance, no straps on the gurney, no attending paramedic to check David’s blood pressure – just me praying that David would live. We rode for what seemed an eternity before we arrived to the hospital in Sogod – this would be the first of three heart wrenching ambulance rides.

THE FIRST STOP

Sogod is a small town located in the Province of Southern Letey, and a hub for many of the surrounding villages. The hospital there is minimally equipped.  We arrived through a side entrance to a small emergency area where David lay for approximately five to ten minutes before a nurse took his blood pressure – it was 90/60.  No doctor was in sight.  I was then handed a referral form which required me to go to another facility a few blocks away to pay so that a technician could come to do a hemoglobin test, which we never got the results for because we transferred to another hospital three hours away in Maasin City.  David waited on the Gurney for almost one hour before the doctor showed up and he got an IV and pain medication.  People came and went, poking their head in the room staring at David as he lay there staring at the ceiling amidst a few flies and the sound of goats grazing outside.  At some point I had to request that one of the nurses tend to the wound on his forehead.  I could feel the heavy muck on my face, arms, and legs of sweat and debris.  My mouth dry with an after taste of vinegar and rusted metal.   I needed a hug; I wanted someone to caress my hair and kiss me gently and tell me they loved me.

The doctor examined David and explained, based on David’s response to the doctor’s probing, that it seemed that he had trauma to his rib area and probably several fractured ribs.  I overheard his family, who had arrived shortly before the doctor, discussing his transfer to a hospital in Tacloban city, but the attending doctor said there would not be a doctor available to receive David, so instead he wrote a referral to Salvacion Hospital in Maasin City.  It took another hour-and-a-half to process the ambulance transfer and wait for the ambulance to arrive. The ambulance, the gasoline for the ambulance, the oxygen tank, and the two nurses traveling with us were all individually coordinated and paid for.  We had to look for nurses that were done with their shift and would agree to accompany us as a private service.   David continued to have extreme compressing pressure and trouble breathing.

The ambulance ride to Maasin City was approximately three hours; ironically we would pass the accident site.  Inside the ambulance lay David with glossy, dazed eyes.  I sat there by his side holding on to the sides of the sheet he was lying on, using it to leverage him during sharp cambers.  His mother sat next to me gazing at the back window and rubbing his legs and feet.  His aunt and two cousins rode in front. The siren drowned my thoughts.  We had to open the windows to break through the somber mugginess that saturated the ambulance, which smelled of stagnant mildew.  I focused on the sensation of the wind’s caressing hands on my skin and imagined my grandmother’s touch.

THE SECOND STOP

When we arrived David was immediately triaged, and Dr. Tromata, the trauma surgeon on duty, ordered x-rays.  The x-ray results were in – David had five rib injuries – four complete broken ribs and one extensively fractured, a collapsed lung, and possibly organ injuries, which at the time the doctor could not assess because the hospital did not have any diagnostic apparatuses such as MRI, Ultrasound, Pet Scan, etc.  The doctor explained that David had sustained extensive trauma to his left lung and surrounding area.  Because of the impact, David had a contusion to his left lung which cause air and blood to accumulate in the chest cavity.  This accumulation of blood and air caused the lower part of the lung to compress toward the heart; this is what was causing so much pressure.  He would need to do an emergency operation to insert a thoracic tube in order to drain the blood and evacuate the air in order to avoid future blood clots and complications such as lung infection and possibly major surgery to clean out his lung area.   The doctor then explained that if David’s blood pressure continued to drop, and given that David had pain in and around his abdomen, this might be a sign of other internal trauma.  With an impact of such magnitude in the left lateral side of the chest, there is potential risk for trauma to organs such as the kidneys, liver, and splint.  And he would need to operate to examine his abdomen and surrounding organs.  Open up his abdomen!  Not in a hospital that wasn’t completely equipped.  But what if he had sustained injuries to other organs and had significant internal bleeding – what then?  I could see fear in David’s eyes, an uneasy expression of regret.  I insisted that we delay on operating his abdomen, and luckily his family also agreed.  The thoracic tube was inserted and substantial blood with the consistency of syrup drained into a glass container that sat next to his hospital bed.  The tube would remain inserted into David’s left thorax for the next six days, until we transferred him to a hospital in Tacloban City, where a new thoracic tube would be inserted once again.

BETWEEN LIFE AND DEATH

That night David lay restless, experiencing 101 fever and continuous pressure in his chest.  His blood pressure had stabilized a little, but I wondered if David would live to see the next day.  I sat next to him all night, surrendering to what was out of my control, and giving him all the love that was in me.  I focused on the way his hand felt inside mine, on the softness of his skin, sometimes brutally interrupted by the sharp ridges of his wounds.  If these were the last moments with him, I didn’t want my focus to be my anxiety and my fear, I wanted to focus on feeling him with every breath that I took.

The next day he was very weak, but some pressure had been relieved from his chest.  Now we would have to wait and hope that the air and blood would diminish so that his lung could begin to expand and the risk for infection would decrease.  The hospital lacked so many resources, and my fear was that David’s condition would deteriorate.  When David was brought to the room after his operation, there were no pillows and we had to insist to get a sheet for the extra bed.  The air conditioning output was labored, and pieces of Styrofoam lined the gap between the AC unit and the wall.  The toilet did not flush, so we had to fill a bucket of water with a spigot located to the right of the toilet, and pour water into the toilet after each use.  The railing under the bed was caked with a thick layer of dust, and the small night stands were sticky with grime.  The walls were stained the color of bile and smelled of sickness.  David’s mother made a four-hour trek back to her home to get pillows and clean sheets, along with clothes and toiletries since it was too far to come back-and-forth.

Every time David needed medication, IV fluid, or a syringe, we were handed the prescription, which most of the time we could not fill at the hospital pharmacy because they were usually out of stock.  We would have to walk to the surrounding pharmacies, and then we would bring the medication to the nurses so they could administer it.  The medications were requested on an as-needed basis, so we found ourselves having to fill prescriptions at the pharmacy three sometimes four times a day.

The next day Dr. Tromata ordered another set of x-rays.  David could not sit up and his breathing was still very labored.  A group of men came into the room with a gurney, which they positioned at the end of David’s bed; they wanted to pick David up from his shoulders and legs and carry him to the gurney.  They perceived me with little regard as I tried to explain to them that they needed to put the gurney parallel to his bed and use the sheet under him to slide him over with the least disruption to his torso.  These men were not trained to transport patients, and in fact had no prior knowledge of David’s condition.  After 45 minutes of debate amongst the men and unsuccessful attempts, with my forceful guidance, they were able to transfer him to the gurney, only to learn that the elevator was broken and we would have to transport him down a steep zigzag ramp.  The ramp was very narrow, so it was very difficult for the men holding the gurney, the person holding the IV, and the person holding the drainage container to all pass through; it was especially important to be careful with the drainage container as any misstep could cause a dislodge of the thoracic tube.  Each time David was transported, which would be every single day, I had to endure the anxiety-filled process of making sure he was not carelessly injured.

In Philippines, I learned, there is a much more lenient system of universal precautions and infection control.  David’s family and I had to be extra vigilant about the nurses wearing gloves when cleaning his wounds, handling the syringes with his medication, and reinserting his IV.  Several times we observed the nurses attempting to clean David’s wounds with their bare hands after having touched the knob on the door, and there was no way of knowing if they had washed their hands.   The environment lacked the cleanliness and sterility that a patient in David’s critical condition needed in order to recuperate without complications.  Whether the nurses in the Philippines were trained to insert IV and handle wounds appropriately without gloves was not of interest to me.  I knew how critical David was and I wanted to take every necessary precaution, so I decided to purchase an ample supply of gloves for every nurse that came in the room.  They especially came in handy when they attempted to reinsert David’s IV without gloves.

David still had significant blood and air surrounding his lung, and the left lung was significantly smaller than the right lung.  His blood pressure was normal now, but David had not yet been assessed for any other trauma or internal bleeding, so Dr. Tromata scheduled David for an ultrasound located in a facility a few block away from the hospital.   When we got to the outpatient facility, David was wheeled in and left in the waiting room, amidst all the other patients.  Everyone looked curiously at the glass container approximately 2/3 full of blood.  The Ultrasound showed signs of fluid in the abdomen area, but no presence of blood, and the doctor stated that there was most likely no serious trauma to his abdomen and organs given that those areas were no longer sensitive to the touch, but he was still under intense observation.  In the meantime I had started to investigate options for transporting David to a better-equipped hospital.  His condition was still very critical, and he could take a quick turn for the worse at any time.  That night David had fever again.

On his third day in the hospital, he experienced an episode of severe, uncontrollable chills.  We called the nurses, whom immediately contacted the doctor.  What the nurses missed to observe was his IV drip – had they paid close attention they would have seen that the IV had been dislodged for quite some time, causing severe swelling of his right hand and arm.  It had been a few hours since any pain relief or antibiotics had entered his system.  The IV was reinserted in his left hand, but was dislodged the very next day when we tried to get him to sit up so that he could do breathing exercises so that his lung could begin to expand and also to aid the process of expelling the blood and air that was still accumulated in his chest.  At that point the IV was taken out, and he was put on oral medication in an attempt to let his arms rest.  I was hesitant about getting him off the IV, but his arms were so swollen and wounded from the accident, I was afraid he would develop another complication, so I agreed to let his arms rest.  Needless to say I had to go fill the prescriptions first.  On this particular occasion none of the surrounding pharmacies carried the oral antibiotic the doctor had ordered – the antibiotic was very expensive and the only one that replicated what David was receiving via IV.  Most of the people in the hospital we were in were very poor, so there was no reason for the pharmacies to stock an antibiotic that was that expensive.   I ended up going to seven pharmacies around town before I was able to locate the antibiotic.  That night David had a fever again.  By Friday my heart was feeling unsettled and I was quickly loosing trust in any progress David had made, which at this point was very little.  Dr. Tromata came to do his daily round, and explained to us that the x-ray showed that the blood was clearing, but his lung had still not significantly expanded.  Then he told us he would be leaving out-of-town until Monday, and he would leave another surgeon in charge of David’s case – this of course made me very uncomfortable.

LISTENING TO MY INNER VOICE

That night David’s temperature soared and by the next morning the surgeon in charge told us David’s thoracic tube was clogged.  How long it had been clogged for, who knows.  I had been feeling uneasy about the hospital.  A voice inside of me was telling me I needed to get him out of there.  That morning, David’s second cousin came to visit him.  When she saw his perilous condition, she immediately asked me, “Why do you have him in this hospital?  There are better hospitals in Tacloban.”  That was my inner voice manifested externally.  At that point, I knew I had to get him out of there, and it was a fight for time.  We needed to close all accounts payable, and the administrative offices were opened until noon that day – it was already 10:30 in the morning.  David would have had to spend the weekend there. When I went to the billing office, I realized that the services would all be paid and processed separately: the hospital room, the doctor, the anesthesiologist, the surgery, etc.  They only accepted cash, so I had to run to the ATM and withdraw as much money as I could – a lot of the cash we had at hand had been consumed by the medication costs.  A few of David’s cousins whom had arrived to visit him that day played an enormous role in helping us close out all pending accounts and payments, both because I could not speak the language and  I didn’t have enough cash.  Simultaneously we also needed to coordinate an ambulance, deposit money for an oxygen tank, find a nurse that would travel with us, and the most critical, insert IV into David for the four-hour trek we were about to embark on.  The problem, David’s arms were still swollen, and finding a vein would prove to be the greatest challenge that day.  The surgeon attempted to insert an IV in the lateral side of the wrist and after a couple of minutes of probing into his skin, conceded to the vein’s rejection.  He then attempted to insert another IV into the interior vein of his forearm, and again after a few minutes of painful probing decided to call the anesthesiologist, who luckily had just arrived.  It would be impossible to transport David without IV medication.  This was the last chance for him to get out of that God-forsaken place.  I could see concern in the face of the anesthesiologist whose eyes at one point met with mine as she searched intently for a vein, a window of opportunity.  She was able to insert the IV in the bend of the elbow with a splint on his elbow to keep it from dislodging.  Meanwhile I didn’t have enough cash to pay the gasoline for the ambulance and I still had to pay the anesthesiologist, thankfully David’s second cousin generously offered to help – this trip had been the first time she had met David and I.  She was also the one who recommended the hospital that we would ultimately transfer David to.

For most of the ambulance ride, David continued to have fever.  I tried not to think about the possibility of major surgery, but the thought seeped into my mind like a persistent leak.  I tried to keep him as comfortable as possible, putting a wet compress on his forehead; luckily this ambulance had AC.  The nurses were also putting cold compresses on his swollen arms, which were hotter than the rest of his body.  His blood pressure was 150/100.  No siren to drown my thoughts this time.

The arteries that connect the villages to the small towns and cities are two-way roads lined with villages and the natural landscape.  As is to expect from a country whose infrastructure is inadequate to say the least, prolonged segments of the road are wall-papered with potholes and chunks of asphalt that have forfeited to the monsoons.  There are vehicles of varying speeds and sizes:  coach buses traveling long distances of ten hours or more; private cars like SUVs, small vans, and multi-cabs; Gipnies and city buses created without windows; motorcycles sometimes ridden with helmets and many times overloaded with three people and children, none with protective gear; pety-cabs – motorcycles with carriages that normally fit five people but often transport ten; and pety-cycles – bicycles with carriages that also overload passengers because they are the cheapest form of transportation other than walking.  Everyone competing for the same space.  There are no sidewalks or crossways to ensure pedestrian safety.  The cities I visited do have walkways but no stop lights or stop signs. The faster vehicles hunk to ensure that the pedestrians and slower moving vehicles move out of the way as they are weaving their way to the front. Even dogs are keen to the sounds of the vehicles.

Along the route to Tacloban City, an infinite parade of coconut trees escorted us to our next destination.  The coconut trees and sky were David’s only connection to the outside world.

THE THIRD STOP

When we arrived to Divine Word Hospital in Tacloban City, we were immediately processed into the emergency room, and trained personnel transferred David from the gurney to a hospital bed; this time I could just hold my husband’s hand without having to instruct anyone on how to care for him.  That night David and I could breather easier.  The next day, Sunday, six days after the accident, Dr. Carpio scheduled David for surgery to remove the thoracic tube that was currently inserted in his chest cavity, and place a new one.  There was still blood and air accumulated around the lower left lung, and he was afraid that because six days had already passed, David’s blood might have coagulated, in which case a major operation would have been unavoidable.  I knew at that point, he would not have survived at the previous hospital.  The procedure was done under local anesthesia, and though David felt no pain, he could feel the warmth of the exploding blood and the pressure from the evacuating air, both during the removal and insertion of the thoracic tube.   At the time of the procedure, David had a heavy feeling of death. He didn’t know that the massive amount of blood that was gushing from his chest was blood that was at risk of coagulating. When David was brought back to his room, he was under great stress and was in significant shock.  He held my hand firmly, and we validated each other in silence.

The new drainage container had significantly less blood, with fluid the color of grapefruit; a drastic difference from the blackened red hue of the previous drainage containers.  Much of the blood that had accumulated between the chest wall lining and the lining of the lungs had evacuated during the second thoracic tube procedure.  With the progression of each day, the fluid transformed into a light yellow hue, and all that secreted from the space between the linings was the normal fluid that acts as a natural lubricant for the lungs to expand and contract.  We could now say with certainty that David would not need to have open chest surgery, and had finally crossed the threshold between life and death.

The thoracic tube was removed a week after, and the sutures removed a couple of weeks after that.  He developed a slight coughing due to the lesions he obtained in his lung.  A slight infection had started to develop, and his coughing was a result of his lungs expelling small secretions from in and around the lesions.  It took approximately two months for his ribs to begin to fuse, and six months for complete recovery.   In the weeks and months that followed he had to work arduously at gaining his physical stamina and psychological strength.