Letters (a year later)

Transcribed verbatim from a handwritten letter. Since it is my own handwriting, I can still read it 35 years later.

Early February, 1988, El Esquirín, Nicaragua

I am in a war zone. This year there is no mistaking that. It is only 11 months since I was here last, just 10-15 miles down the road, but it is another world.

As the congressional vote on Contra aid approaches, the war situation worsens. Each time Congress is approached w/ an aid request, a new Contra offensive is mounted to show legitimacy and effectiveness in order to “justify” additional aid.

Two weeks ago, 2 co-operatives and a state-owned farm were attacked in pre-dawn raids. At one co-op, all of the houses were burned to the ground – houses built with Italian aid. At the other, the main house was destroyed, leaving several families homeless. At the state farm, 4 houses were burned. In these attacks the Contra killed 15 and wounded 58; all civilians. I doubt that you heard this on the 6 o’clock news or read it in the paper. It happened near here.

Security is stepped up everywhere. If I go down to the river to wash clothes, I have to return at 4:30 because of Contra sightings along the river. They took advantage of the government’s unilateral cease-fire to enter the country from Honduras.

Vigilance has been stepped up, with nightly patrols increased. As of today, all farm production has been halted in order to devote full time to defense needs. All brush is being cleared from the area around the houses & tents to improve sight lines. A shelter is being built to protect us in case of a mortar attack. (In the usual pattern, a farming co-op is “softened up” by mortar fire before troops actually move in. “Softening up” means to cause injury, occupying people in caring for the wounded, destroy homes, and strike terror in the hearts of the people. This makes it easier for the Contra to attack without encountering resistance.) Finally, a network of trenches is being dug so people can move around and communicate during an attack.

Parallel to the plans for the co-op are the plans for the brigade. If at all possible, we will be evacuated prior to an attack. Our evacuation plan is being drawn up this week. The Nicaraguans do not want to see U.S. citizens injured in an attack. If danger is near, we will be moved out. On the other hand, unless U.S. strategy has changed, the Contra will not attack while we are here. [Ed. Note: Each of us had a “Go Bag” with us at all times in case of an emergency evacuation.]

Last weekend we went to the town of Matiguás to help with their defense system. We were digging trenches and shelters to protect the town. Groups worked on the edge of town in all directions, in beautiful hills. The combination of the breathtaking scenery & the warm companionship w/ the knowledge that this was not a Sunday picnic but preparation for survival was powerful.

Recent intelligence reports reveal a Contra plan to simultaneously attack 4 towns and cities in this area. Matiguás is one of them, as is Muy Muy. These are the 2 towns nearest to us.

In Matiguás I stayed in a small subdivision on the edge of town. The people of the neighborhood put us up in their homes & fed us. A few of us went to a wedding reception on Saturday and were fed there as well.

The work was a volunteer project of the entire neighborhood. A wide variety of people came out to work on Saturday. At noon Gordy wished out loud for a beer. Instantly, a case of beer appeared, being carried over the hill. Lunch soon followed. Over lunch I talked with a local woman. She, like most of the adults in the community, takes responsibility for vigilance once a week. This means she stays up all night to be on the lookout for a possible attack. This doesn’t mean she gets the next day off from work.

After a few beers and lunch we went back to work.

Sunday mostly kids came out to work – a large contingent of 6-12 year old girls – an army unit also helped out. (The army seems to function a lot like the CCC [ed. note: Civilian Conservation Corps] did during the U.S. depression.)

When it was time for us to leave for a meeting, a neighborhood organizer called for a break & we all gathered on a hilltop for a closing ceremony. We were thanked for our help, support, and solidarity. We had done a lot of digging, much of it through rock.

He also apologized for the primitive living conditions & observed that maybe, being from the United States with all its privileges (and the source of the funds & leadership for the attack we were preparing for), it was a good experience for us to have gone through. I agreed.

We were invited back and asked if, next time, we could bring bats and gloves to help them start a Little League in the barrio. Whaddaya say? Got any baseball equipment I can bring next time?

[Ed note: some time has passed, but the letter isn’t dated here.]

Today has been wild. It has rained most of the last 2 days & everything is a sea of mud. It is too slippery to drive the trucks, so we carried the milling equipment out of the woods. It’s difficult to walk, slipping and sliding, w/ 5 lbs of mud on each boot. O, for my 4-buckle rubber galoshes! After work I wrung out every piece of clothing as I took it off. It has rained part of every day for a week. I haven’t shaved or gotten clean in 3 days. My tent stays dry, thank goddess and North Face.

Also today, a woman on the co-op was thrown from & dragged by a mule. 3 brigadistas & the truck took her to the hospital in Matagalpa after administering first aid. She has apparent head & hip injuries. If we were not here, would she have lived? I don’t know. There are no vehicles in this community of 150 people.

With no truck, our work will change tomorrow. No lumber, no water (for construction), no sand & gravel. We’ll carry drinking water by hand ¼ mile.

Then there are the fleas. They’re everywhere but seldom seen. Tonight, in the one room w/ electricity (for 2 ½ hours each evening) I’ve seen & killed 3. They seem to be worse in this room than anywhere else. Oops, we just ran out of gas for the generator. Now I’m writing by kerosene lamp. The rain has stopped and the crickets are singing.

4 Feb

Word came today that the House defeated the Contra aid bill. The news was greeted by a round of cheers which quickly subsided as we realized that it may mean little. When the Boland Amendment forbade aid to the Contra, the Executive Branch went to great lengths to break the law, then cover its track. When that failed they pretended, successfully, that the law didn’t apply to them. Since the Administration & the secret government were so successful at funding & directing the Contra when it was forbidden, why should we hope that mere non-approval of an aid bill should stop them?

Then we remembered the Tonkin Gulf Resolution, when the Exec Branch lied outright, fabricating an international incident to “justify” a major invasion of Viet Nam. With only a year to go in the Reagan presidency, what are the chances of a phony incident, like Tonkin Gulf, like the Nov ’84 “MiG shipment” to Nicaragua, “requiring” a direct U.S. intervention here?

Sat 6 Feb

The storm has lifted. My spirits too. The mountains, heavy with mist, have looked like a Chinese brush painting when they were visible this week. Now the sun shines and they glow a brilliant green. The mud has dried up & it is warm & breezy. Today we worked only ½ day, and it is tranquil. A flock of parrots flew by earlier, and I feel like I’m in a tropical paradise. Sunsets have been beautiful almost every night. The moon is just past full. Such are the contrasts in this life.

Don’t get me wrong. While the war has come closer & life has gotten harder, it is still a joy to be here. Work is progressing well, I’m healthy and dry (except my feet), the people I work with are great, & I understand Nicaraguan campesino Spanish much better than last year.

Thank you for working to defeat Contra aid. Its passage would have greatly damaged morale here. Keep up the work on the home front & I’ll keep it up here. I hope to be back in the U.S. refreshed, renewed, and ready to work this summer. See you then.

This became our unofficial theme song. “The sound of gunfire off in the distance/I’m getting used to it now.” We awoke at 4:30 AM to the sound of mortar fire off in the distance in the days leading up to the Contra aid vote. Like the gallows humor at the hospital many years later, it lightened things up a bit.

Tales from the front

I learned a lot from a two week tour of duty in the COVID-19 unit. First is the unpredictability of this disease.

Details will be obscured so that no patients can be identified. Pronouns will be “they”, “them”, or “the patient”. I am not a doctor, but I play one on TV. A few numbers will make things make more sense. “Oxygen saturation” or “SpO2” is the amount of oxygen in the blood expressed as a percentage, with 100% being the ideal state in healthy lungs. Over 90% is generally not a problem. “FiO2” is the percentage of oxygen in the air being supplied to a patient. Air is about 21% oxygen. 100% FiO2 means pure oxygen. The flow rate of oxygen is measure in liters per minute. Home oxygen concentrators can supply about 5 liters per minute (some up to 10). Normal resting heart rate is around 75. Normal respiratory rate is about 12-20 breaths per minute. There will be a quiz later.

In my world, I am asked to make a discharge recommendation the first time I see someone. (Can they go home? Do they need to go to rehab? Do they need extra help?) If I think they can go home I am to “clear” them for discharge home when I think they are safe to go home.

One patient looked great when the Physical Therapist saw them. She told me she had cleared them to go home and I didn’t need to see them. She thought they might leave that day. The next day the nurse called to say they looked worse, and could we see them? On day 3, they could sit up at the edge of the bed (with two of us helping) long enough to eat a snack. Two days later they were dead.

Another patient was up independently in their room; able to wash, dress, go to the bathroom independently . Two days later, they were on 50 liters per minute of supplemental oxygen (at 50% FiO2), with a respiratory rate of 35, heart rate of 115, and oxygen saturation of 82% – at rest. What happens next, I don’t know. I have a prediction. I will not speak it here.

A third was cleared by another therapist and I was asked to monitor them (look at the medical record each day, see if there were any significant changes that might require our intervention). I decided to go see the patient when I read that they might go home soon. SpO2 was 90+% on 6 liters of O2. Getting up from a chair and standing for 1 minute caused the patient to feel the need to sit down. Half a minute after sitting, SpO2 dipped to 75%. Flow rate had to be increased from 6 to 15 liters/minute and it took 15 minutes of rest to recover and get back to over 90%. I rescinded the “cleared for discharge home” designation. They went home the next day.

Another patient looked great the first day. I cleared them for discharge home. The next day they were placed on a mechanical ventilator – a machine to breathe for them. After extubation (removal of the breathing tube down their throat, removal of the ventilator), the nurse and I helped them to a chair. They were on 6 liters per minute of O2 via nasal cannula. Up in the chair we added 15 liters more via a non-rebreather (a mask with bag attached that looks sorta like what you see on an airplane) in order to keep their saturation level acceptable. Two more days and they are making a great recovery on 3 liters/minute while up in a chair.

This virus also messes with your blood clotting system. A person came in with COVID-19 and a blood clot (thrombus) in the leg. Part of it broke off and settled in the lungs (an embolus), where it became immediately life-threatening. The treatment for this is a heparin drip (a steady release of an anti-clotting agent into the bloodstream). This resulted in bleeding into the muscles of the butt/torso (a hematoma). Now we had a dilemma – stop the heparin to stop the bleeding so they don’t bleed to death, or continue the heparin to break up the clot in the lungs so they don’t suffocate? That’s why doctors make the big bucks, not me. While this person was afraid to get out of bed, then afraid to walk to the bathroom, ultimately they recovered and went home.

That’s only five people – half a day’s work -but you get the idea. So what did I learn? I can’t make a reliable prediction from seeing someone once. I’ve come to write “To be determined” for my discharge recommendation on the first day, and revise it daily. While it is important to be up and moving if possible to help recruit healthy lung tissue, we need to monitor vital signs closely and adjust our expectations minute by minute. One patient talked with their child and the child said they were taking it, not “one day at a time” like AA, but “one hour at a time.”

Usually I scribble quick notes to myself as I go, then transcribe that into the electronic medical record (EMR) when I leave the room. Since every patient on this unit is in isolation, I can’t bring a pen and paper in the room and take it back out, so I memorize all of these numbers and try to write them as soon as I leave the room. After seeing 8 or more patients, I shower, change clothes, and write all of the notes into the EMR at once.

Each patient is isolated from each other patient and the entire unit is isolated from the rest of the hospital (meaning doors are closed unless someone is passing through them – all automatic door openers are disabled – and the unit is negatively pressurized so air does not escape). We wear hospital-issued scrubs (usually reserved for operating room personnel). For each patient we don fresh gowns and gloves that we remove before we leave the room. We disinfect our face shield and hands before we enter a room and when we leave it. We disinfect our hands and the keyboard before and after touching computers. If in doubt, we disinfect our hands before and after touching anything. As such, everything takes longer than usual. The nurses use a PAPR (Powered Air Purifying Respirator – sort of above-water SCUBA). They remove and disinfect it after every patient. Our N95 mask (formerly used once, with one patient, and discarded) is to be used for 7 days. (Image from workersafety.3M.com)

The caseload is going up. The hospital is full. A month ago it was full of non-COVID patients. Now the COVID units are filling up. A newly-remodeled unit will open soon. I suspect it will be diverted from its planned use to being a COVID-19 unit. Elective surgeries are being postponed again (as they were last spring). A 500 bed field hospital has been opened on the State Fairgrounds. A lawsuit has just resulted in an injunction against the Governor’s order limiting crowd sizes. At least the mask order was upheld (different suit, different county). So you can go into a crowded bar and take off your mask to drink, but you need to keep it on to shop for groceries. And of course, everyone in bars stays 6 feet apart, no one talks loudly, and everyone controls all bodily secretions (“say it, don’t spray it”).

I know our president still thinks it is no big deal. Among the things I wish for him, is that he could follow me for a day – change in and out of isolation gear 8-10 times, run from room to room, and then remember what you did 8-10 different times to write it all down later. Mostly I want him to see the people who aren’t him, who didn’t recover and get back to work in a few days; watch them struggle to breathe, to get out of bed, to do the things we take for granted every day. I want him to see that not everyone has a personal team of doctors and nurses who have only a single patient to care for. I want death to not be an abstraction.