Worsening signs.

The cabin of the Learjet is dark, the heart monitor a metronome over the drone of the engines and pulse of the mechanical ventilator. I’ve been watching my patient’s cardiac rhythm, with ominous hackles rising on the back of my neck while my partner naps. Over the course of the journey the man’s inherent tachycardia has slowly shifted into a sinus rhythm that might seem like normalization on a paper medical report, but feels wrong. After all, this patient is dying. He is returning to Egypt to die amongst family after last-ditch cancer treatments in America have failed.

“Not on this flight,” I think to myself. “Not until Cairo.”

The plane banks as it descends into the Newfoundland night. The cabin vibrates with turbulence; St. John’s may be the most easterly North American fuel stop, but its position on the Atlantic all but guarantees unpredictable weather. The lights of the town sparkle below as my partner rouses, pops his ears, and stretches.

“Look at his heart rate,” I say, quietly. “Pressure’s okay, though.”

“Yeah,” he says. There’s an unspoken accordance between us. We’ve flown together enough—been trapped in small planes for countless hours, evaluating and collaborating—that we easily discern each other’s thoughts and can speak volumes in a few words, or a glance.

The language of love.

Twelve hours and another crew of pilots later, we finally cruise over the Mediterranean Sea. Little of consequence has happened. The patient’s heart rate has continued to slow but his blood pressure has held steady. He no longer breathes over the rate set on the ventilator. His numbers seem stable, yet he is not. He seems less of a sentient being than a bundle of technology, all electrical impulses and muscle contractions on an assisted autopilot.

In the hours we’ve had of light, I’ve been acutely aware of the man’s wife. She sits at the foot of the stretcher, holding his feet and palpating his pedal pulses, comforting herself by touching the proof of life she can feel while she quietly prays. I can only wonder at this love. It is unbeknownst to me, as my own marriage, though long, was devoid of this depth for so many years and possessed a language barrier greater than any ordinary one I’ve ever known. This deeply felt chasm, as I witness such grief in the face of great love, strikes me mute. What is there to say, after all? There is nothing to say.

Dismissed.

We land in Cairo after flying over the three Great Pyramids. Pointedly, no one remarked on them. After the cool and muted light of the Learjet, the sun is harsh and blinding. The landscape surrounding the airport is flat. Everything in sight is the golden hue of brushed brass and shimmers in the heat. The patient is essentially unchanged. His chest rises in time with the ventilator, his heart beats on, but he doesn’t open his eyes or move.

The local ambulance waits at the end of the runway. It slowly pulls up to the plane. My partner and I begin delicately orchestrating the removal of the man from the aircraft. We position the ventilator and oxygen tank over his torso, arrange the foley catheter bag and IV pumps, securing everything with seat belts and hemostats. We gingerly extract the stretcher, maneuver it carefully through the jet door, and lower it to the tarmac.

I am approached by a stocky man in white scrubs and a diminutive woman in a loose-fitting dress and hijab, and I begin giving them report.

“We can talk more on the way to the hospital,” I say, after relaying a quick summary of the man’s condition and care.

The woman looks taken aback.

“You are coming to the hospital?” she asks, in perfect, but heavily accented English. “You can. No one ever has, though, and it is a very long way. I am the doctor and he is my patient. I am with a paramedic. Your presence is not necessary.” Sharp black eyes and the firm line of her mouth belie her otherwise soft appearance.

It is now my turn to be taken aback. Rarely have I been summarily dismissed in this way. But I acquiesce, ducking out of the heat and into the back of the ambulance with my partner, where we begin the slow, careful process of transferring the man from our transport equipment to the ambulance’s gear—changing the electrodes, reloading IV pumps, swapping the blood pressure cuff.

Change of plans.

The exchange of mechanical ventilators is the final step. The doctor configures the ambulance’s vent and then handily attaches the vent circuit to the man’s tracheostomy. All are silent as we pause for a moment, watching the monitors and the man. And then the man’s heart rate begins to drop.

“It is fine,” the Egyptian doctor says briskly. “You may go.”

But the man’s heart rate drops further, dipping into the 50’s, and then the 40’s. I grab the ambulance’s ventilator circuit off of the man’s trach and reattach our aircraft vent. Slowly, the man’s heart rate rises back into the 70’s.

The doctor is visibly flustered. She gives rapid commands in Arabic to her paramedic, who frowns and begins tinkering with the oxygen connectors in the ambulance. After a series of tests and ventilator checks, he gives her a quick nod.

“Ok,” she says. “Now we are fine.” She reattaches her own ventilator circuit.

But the man’s heart rate begins to drop again.

“We are fine,” the doctor says. “We will give him medicine and go to the hospital. You may leave.”

The man’s heart rate drops into the 30’s, and a bluish hue creeps over his countenance.

“No . . . he is not dying . . . not here at the Cairo airport,” I think to myself. I want to cry out, but bite my tongue in deference to the Egyptian team. I know that he will be dead so soon, perhaps in a day. But not this day—at least not now. I am determined that his heart will not stop in our care. We have not come this far with this man to witness his death on a tarmac.

I reattach the man to the aircraft’s transport ventilator.

“We are coming with you,” I say, firmly.

A hard ride.

The doctor sighs, but assents, and signals the ambulance driver to depart. We speed off towards downtown Cairo, lights flashing and sirens wailing, while the patient’s wife sits in the front, sequestered from the chaos in the back. The driver dodges traffic, swerving and braking in rapid succession—nothing is visible from the back of the ambulance, allowing no one to anticipate the erratic movement, and now the patient’s heart rate is vacillating and his blood pressure dropping. All semblance of the man’s stability has been erased by the hypoxia of the ventilator trials. The paramedic fumbles for atropine and epinephrine, but the doctor, instead of assisting him, begins to gag. Unable to tolerate the continuous jerks and turns, she curls into a ball at the head of the stretcher and begins steadily retching into a yellow emesis bag.

“Atropine!” shouts the paramedic. It’s the only English word he has uttered thus far.

I kneel to search through a red tackle box full of glass ampules that rattles at my feet. Just as I find one clearly labeled as atropine and stand to hand it to the paramedic, the ambulance’s horn blares and we screech to a halt. I feel myself begin to fly through the air. Instinctively, I reach out and grab at the closest secure thing, a suction canister mounted to the wall, and break it off cleanly with a loud pop. In the drawn-out second of weightlessness as I cantilever through the ambulance, I realize with horror that I am going to land directly on the doctor. And I do. My fall is broken as my full weight crashes down on the doctor.

“Oh, my God,” I think. “I’ve killed her.”

But the doctor squirms beneath me.

“I’m so sorry,” I gasp. “Are you okay?”

The doctor swivels her head and fixes me with a steely glare.

“Don’t get up again,” she hisses, then turns and vomits again into her bag.

And so I remain, hunched near the floor of the ambulance, watching the paramedic administer the atropine through the IV. My presence, now more than ever, is understood to be a hindrance to him and the care he is giving; they only need our ventilator, after all. Amazingly, the impending cardiac arrest is diverted, for the man continues to live.

Arrival.

We arrive at the Cairo hospital, a modern block building with armed sentries at every entrance. The doctor quickly recovers and composes herself and we remove the stretcher from the ambulance and speed through the hospital hallways. Inside the hospital, there is no sense that we are in Cairo. It is a hospital like any other, aside from the dress of those within it. Yet at each doorway, security guards allow the stretcher to pass with the Egyptian team and swing their arms down to halt my partner and me. Each time, the doctor murmurs an Arabic phrase and we are allowed to pass.

When we arrive at the intensive care unit we are not acknowledged. As flies on the wall, we are pressed to the periphery. We stand back and watch the nurses, doctors, and respiratory therapists cluster around the man, assessing him, setting him up on the hospital’s equipment, and settling him into the ICU.

The doctor takes the aircraft ventilator, hands it to me, and says, “Thank you,” with a nod and a glance. And thus we are finally dismissed, left to navigate the maze of hospital corridors alone and find a taxi to the hotel.

Marcy Phipps is the chief flight nurse at Global Jetcare.



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