Paramédico

There is a patient with shortness of breath in Shutka, where we spend most of our time each shift. As in the films of Emir Kusturica and their endless parties of drunken gypsies firing pistols into the air, breaking bottles over each other’s heads and tripping over roaming geese, the maalo has an atmosphere of madness even in the absence of wedding receptions. Still, we are rarely called to trauma cases. There is surprisingly little violence in Shutka considering the quantity of the homebrew, rakija, the inhabitants consume. They are not a violent race. Never have the gypsies fought a war or occupied a land.

In contrast to the guarded personalities of many Macedonians, the gypsies are warmer and quicker to smile. Perhaps they feel secure and at peace here. Macedonia may be over-spending public money on bronze lions and flaming crucifixes, but the country has arguably the most compassionate policy towards the Roma anywhere in Europe. By comparison, Italy and France spent much of 2010 gypsy hunting. Although they weren’t shot, as happened under the Nazis in World War II, gypsies were rounded up like cattle and forced back to Romania and Bulgaria. Many were not from these countries in the first place. It’s hard to know what land, if any, a gypsy calls home. Since migrating from India a thousand years ago, they have spread to all corners of the earth and are regularly uprooted and chased away by governments.

Macedonia, however, has allowed gypsies the right to identify as Roma, to live in their own suburb and to have a representative in parliament. With its own mayor, permanent housing and radio stations, it is no wonder Shutka has become host to the largest number of gypsies anywhere.

Not everyone in Shutka is satisfied. Many are disappointed the government is not doing more to help them. Social security is only available to those Roma registered as residents of Macedonia and even then it is a paltry 50 euros a month. With some notable exceptions, including a handful of doctors and lawyers, the Roma are not much interested in education and few end up qualified for decent work. This forces many to rely on the garbage collection, the begging and the thievery for which they are known. Attending a school or a job to become a cog in society holds little appeal. More thrilling are horses and music and fire, all things wild and free, living each day as if it were the last.

Finding an address in Shutka can take a while. Some of the streets are cracked and deeply gouged with potholes and the eccentric little homes rendered in lurid colours have all kinds of madcap decorations hanging on their outside walls, from obscure coats-of-arms to enormous cuckoo clocks. But street numbers on letterboxes are scarce. We stop and ask a group of men sharing a foot-long salami and rakija if they know where our patient lives. After some lengthy argument they point toward the bazaar. Sometimes, even in serious emergencies, we drive around the maalo in dizzy confusion, following several opposing directions. Thankfully, the streets are easy to remember. Without a shred of irony the Roma have given them names like Washington Square Boulevard, John F Kennedy Parade and Disneyland. Shoddily constructed miniature palaces of concrete can be found here. Poorer homes, in many cases, shanty-style shacks are more likely found along Che Guevara Drive, Shakespeare Avenue and Garcia Lorca Lane. At the bottom of the hill there is a quarter of Shutka I have visited that looks no different to a Bombay slum, complete with muddy passages, huts constructed from junk and United Nations water pumps.

Past the smugglers’ bazaar where toothless old men sell lacy bras hanging in rows along rusty fences, where bootleg perfumes and pointless porcelain pigs go for a steal, we pull up at a partially collapsed building and enter a 2-metre-square room, home to a family of seven. Our patient is a forty-year-old woman with six children and a husband in jail. Only a gypsy can peel potatoes while suffering severe respiratory distress, I think to myself. Her mouth is snapping with every breath, as if biting for air.

Everyone seems to have breathing problems in Shutka. It’s either asthma or emphysema or bronchitis or all of these at once. Temperatures in winter can drop to minus 20 degrees. If there is rain the streets of Shutka become rivers of freezing mud and many of the children do not have boots. Chest infections are common. Adults sit all day and night in crowded rooms, chain-smoking the contraband Marlboro their children passively inhale.

Dr Aquarius and Snezhana Spazovska don’t mess about. They promptly administer an injection of Amyphyline and Dexamethasone during which the woman only momentarily ceases her potato peeling. It surprises me that oxygen is rarely given to patients the crew intends on leaving at home, especially those with breathing problems. On this occasion Dr Aquarius is feeling generous and runs the patient on a low rate through nasal prongs for several minutes, though staying on scene too long in the maalo is unwise. News of an ambulance entering the ghetto quickly gets around and it’s only a matter of time – often less than fifteen minutes – before every sick person with the slightest complaint surfaces for treatment. Suddenly the ambulance becomes a mobile clinic and is trapped indefinitely. Many gypsies are not registered citizens and have no entitlement to hospital treatment. For them, the only hope of getting medical help is to bail up ambulances whenever they see them and appeal to the compassion of the doctor on board to get a free consultation.

The sun has dropped below the snow-capped Shari Mountain Range when we pull up at a small house so crooked it could have been built by a child. It is dark as a cave inside and the floor is covered in the shapes of countless bodies wetly snoring under thick floral blankets. A woman who does not bother brushing the hair from her face rolls over and pulls down an edge of her grimy tracksuit pants, exposing a buttock.

Dr Aquarius sighs and nods at nurse Spazovska who flicks open her black briefcase again, cracks a few ampoules, draws them up and stabs them in. The woman pulls the blanket over her head, falls back to sleep and we are out the door.

Two minutes and thirty-five seconds and not a word exchanged between medic and patient.

‘Did you know her?’ I ask, perplexed.

‘Not personally,’ says Dr Aquarius, climbing back into the ambulance.

‘How did you guess what was wrong with her? Or what to give her?’

‘You should understand by now. When they want an injection straight up it’s the same thing every time. Vitamin B1, B6, B12 and C for good measure.’

If they’re agitated, Valium is part of the cocktail too. And gypsies are notoriously prone to agitation. Should the Valium run out, the doctor will resort to aqua injections – plain water or normal saline. Few patients know any better. It is not about the drug anyway but about the spritz. With the exception of heroin addicts I’ve never met a patient enthusiastic about injections. Many Roma, however, can’t get enough. This is because they have what Dr Aquarius calls ‘injection jealousy’. Should a gypsy observe her neighbour receiving two vitamin injections from an ambulance crew, she will later call up and try to outdo her rival by asking for three. Roma are very jealous people. Angry scenes occur if ambulance crews don’t give the maximum number of injections, regardless of whether the patient needs them or not.

‘Once, in Shutka alone, I gave one hundred and thirty injections over a single week,’ boasts Snezhana Spazovska through the slide window.

Seems to me a bad precedent has been set. A community expectation has been established from which these medics find it difficult to escape.

‘Most of the time the Rom are very peaceful,’ says Dr Aquarius. ‘But, well, we give as many injections of Valium or vitamins or aqua as it takes us to get out of there quickly. It is not only Rom. Other Macedonians are like this too. No patient in our country is satisfied without a spritz.’

Injections are a matter of service efficiency rather than pandering. If a crew decides to leave without giving a jab, the patient is likely to wait fifteen minutes or so then call again. Indeed, they will call and call until they get an ambulance crew willing to give them one. Repeat callers are not unique to Macedonia and are a problem anywhere, in any country. Some callers in Australia are known to have our easy-to-remember three-digit emergency number on speed dial. In exasperation, some paramedics manage this problem by transporting the patient to hospital to remove them from their home phones so they won’t call again. Of course, this simply shifts the problem. Treating patients in the field is more desirable, but whether it is ethical to inject a patient for the sake of operational efficiency alone is an interesting question. Maybe a little bending of the rules is justified for the greater good, allowing ambulances to be more readily available for life-threatening cases. I can’t help thinking, however, that if injection-jealous gypsies knew that the party was over, the call volume would drop and the burden would ease naturally.

Girls with gold hoop earrings smile and wave and kick up bright floral dresses as we pass them trailing a mob of grubby children. Their look is a welcome flashback to the gypsy aesthetic of old in a township where most of the women have long ago discovered Adidas and cheap bling.

We pull up outside a peppermint-green house with a waterfall feature built against the front wall. Inside a middle-aged woman lies theatrically collapsed on the hallway carpet, hyperventilating. A dozen family members and relatives shuffle in behind us to have a look.

Dr Aquarius asks the woman a few questions, which she answers with excessive gasping and groaning and rolling about. Spazovska is next to me and whispers, ‘Pain all over.’

Right. Pain all over. As if I couldn’t have picked it, that classic ailment of the chronic neurotic. How it makes us laugh when we hear it! Not in front of the patient – never in front of the patient. Oh, but how we laugh. From what I can tell, Dr Aquarius is examining the patient in the same manner I do in such cases. Slowly she palpates every region of the woman’s body. What about here? And what about here? And here? And every time the woman groans or winces or pulls away, even when Dr Aquarius has reached and squeezed the tip of her pinky finger. What drives an unusually thorough examination like this is a hope that our looks of confusion in response to the patient’s unspecific complaints will be a hint to her and her relatives that we are not convinced and that perhaps, to avoid embarrassment, someone should put an end to the entertainment before we are forced to do so in the back of the ambulance.

‘She requesting something special,’ Spazovska says.

Gypsies love a bit of drama. This I can appreciate – life is great when it’s thrilling. Less forgivable are the patients who have an ambulance called for the sake of attracting attention. Attention-seeking exists in every country and in every cultural group, and is particularly prevalent in very large families. A person feeling left out or snubbed for some reason may decide that by feigning a medical emergency they will get what they crave. The strategy usually works well and they soon find their extended family standing around them saying pointless things like, ‘Oh my God! Oh my God! Oh my God!’ and rushing wet towels from the bathroom. Perfect! So long as their symptoms are as ambiguous as ‘pain all over’ and appear severe enough, the little fakers may even get a ride to hospital. Of course, on arrival they will make a miraculous recovery and discharge themselves before a doctor has even seen them.

Because these are delicate situations I wait out the front of the house. From where I stand I can see a ten-metre cherry tree belonging to a regular emphysema patient. A week ago I was up that tree picking cherries for her as she’d complained about being too old and breathless to climb a ladder. After that day Kass and I ate cherries for breakfast, lunch and dinner.

The adult daughter of the drama queen comes out and forces a cigarette between my lips. Her smile reveals a big gold tooth flashing in the sun. She wears yellow lycra leggings and a decorative red belt with a playboy bunny buckle. After she lights my cigarette she puts her hand on my shoulder and comes very near.

‘You are married?’ she asks directly.

I nod.

‘Not matter for me,’ she purrs, exhaling smoke in my face.

With a daughter like this it’s no wonder the patient has pain all over, I think. What kind of woman tries seducing the medic while her mother is near death?

From inside the house comes the sound of yelling. Something crashes and breaks. This is followed by a short scream after which Dr Aquarius saunters out, peels off her gloves and gives a wink.

‘She not wishes to come with us,’ says the doctor.

Sometimes it seems the crew is more effective when their international guest is not in the room.

Intense verbal exchanges are the norm in Macedonia. What sounds like an argument may be just as likely the whispering of lovers elsewhere. Macedonians, like Italians, Greeks and Arabs, for that matter, can have a simple interaction about the weather while sounding like they’re about to strangle each other.

An exchange like this occurred during one of my many meetings with ambulance service director Maja Poposka. The afternoon started badly when she showed me a video clip of a major incident exercise on a highway near the Serbian border. The footage had been set to a heart-wrenching song, Game Without Limits by Tose Proeski, a young Macedonian singer recently killed in a car accident. His death had been traumatic for the entire country.

‘I chose this song because I like it very much,’ Poposka tells me, looking off into the middle distance, just holding back her tears. ‘Sometimes in our profession we also push the limits.’

There is so much she could have meant by this, but I sensed she was referring to the risks, both physical and mental, that ambulance workers subject themselves to. Surrounded by craziness, by things going wrong, by lives twisted up, we risk losing perspective on our own reality. If this happens, anything is possible in terms of our personal behaviour. If we lose our grasp on rational thought our work may indeed become a game without limits.

We talked then at length about adrenalin and its toll on us over time, finding common ground in our mutual experience of adrenalin withdrawal. My wife Kass has often wondered how it’s possible for me to be so upbeat at work, even at the end of a rough day, yet arrive home grumpy. When adrenalin wears off some of us simply ‘crash’. Adrenalin is, after all, a type of high. It creates euphoria and for this reason people engage in all manner of dangerous activities to pursue it. But like every other high, it is only high because it is preceded and followed by a low and ambulance workers are by no means immune. Indeed, some even orchestrate drama in their private lives to maintain their adrenalin levels artificially.

It was about this time in the meeting that Boban Vivovski, the humpty-dumpty fleet manager, entered the room and said something to Poposka that didn’t please her at all. A shouting match ensued. She slammed down her diary with an almighty slap, pushed her swivel chair out and chased Vivovski into the corridor. The door slammed shut behind her. Outside the room the argument continued, punctuated every now and then by a loud thud, as if one or both of them were whacking the wall or throwing the other against it. All I could do was remain in the shade of her indoor tree, quietly embarrassed, listening to them blowing up outside. For the CEO and her fleet manager to behave this naturally in front of me was surely an honour, though I would have been less concerned were it not the day after a Macedonian doctor at one of Skopje’s main hospitals stabbed her fellow doctor seventeen times in a fit of rage. On the television they said she had a ‘brain snap’. As the scene of this stabbing played out in my mind while listening to the yelling in the corridor, I swallowed hard.

When Dr Poposka came back into the room, unscathed, she sat down and let out a sigh, giving me a measured smile.

‘It’s not only the gypsies who are passionate peoples. Anyway, I would rather yell at my fleet manager than at my road staff. You will never hear me yell at ambulance teams. They work hard and don’t deserve it. They are my friends and I always take a cigarette with them. Without their respect I can achieve nothing.’

One day, when Dr Poposka is tired of her position, she would consider working the road again and wants to be sure her legacy as director will not make her unwelcome there. As for the conflict among her management team, she insists it is ‘a type of love’. In my opinion she is suffering from plain and simple adrenalin withdrawal. For a former ambulance doctor there is a clear excitement deficit that comes with a management position and the office environment. Yelling matches and fist-fights are, one could say, the methadone of adrenalin withdrawal.

Evidence of the Roma’s Indian origins can be seen on walls we pass in the ambulance, white painted designs identical to those I have come across in small desert villages of Rajasthan and Gujarat.

We follow two boys running towards the Shutka bazaar clutching trumpets. Their eyes in our headlights are wide with excitement. The smell of barbecuing lamb wafts through the open windows of our ambulance and in the distance we can hear the sound of a brass band playing. When we reach the intersection of the bazaar a large crowd of gypsies surrounds a group of men on horns and drums. Slowly we edge the ambulance through a throng of scruffy kids with bleached spiky hair and gold chains dancing wildly. Their look is hip-hop but their moves are pure fireside Bollywood.

‘This will be us at 3 am,’ laughs Dr Aquarius. Snezhana Spazovska giggles and Sammy yelps the siren and waves at the mob. Some of the kids whistle in return and drum their hands on the ambulance as we go by.

‘We are now going to village in the hills,’ says Dr Aquarius. ‘The sun is down. You know what it means when sun is down on festival of Saint Nicholas?’