Letters from the Edge of Emergency Medicine.

Letters from the Edge of Emergency Medicine.
Review by Herman Silochan

A philosophical treatise, a family story about a grandfather with virtues and values, our human globe that connects through pain, hope and loss, medicine is part economics, part politics, fashionable healing fads, pharmaceuticals call the shots, but in the end, a simple aspirin- a hundred year old medication - still goes a long way in a very, very complex world of futuristic monitoring bedside machines.
In the emergency room, you do not vacillate, putting off decisions, you decide now, it creates a work flow among subordinates; to delay is to create chaos, you cannot have chaos in triage at admittance, there are a hundred sufferers waiting in line, no, they are depending on you, they have surrendered their lives for this diagnostic moment, they have transferred trust. In pain there is equality, the mighty and the lowly are in this together.
Doctors and nurses know this; that is why they appear dispassionate as you tug their white gowns with personal questions that go beyond the immediate need for quick assessment.
This is as true as the daily flow of incoming at multiethnic St. Mikes here in Toronto, [possibly the best ER in the world] or in makeshift emergencies in Addis Ababa in faraway Ethiopia, the cradle of human kind, where coffee was discovered by a lowly goatherd a millennia ago, and given to the world.
A funny story here in Addis: Mussolini wanted to create a new Roman Empire, so in the 1930s, he targeted Libya and a free land called by Europeans, Abyssinia. The Ethiopians pushed back, kicking out the Italians, but kept something worthwhile- the espresso machine!
Walk along Queen Street here in Toronto, to be enticed shop after eatery shop with all sorts of coffee brew, to be mentally besieged with java exotica.
The same in fashionable Addis Ababa with a caring culture that never went away in spite of terrible internecine tribal ideological warfare that also engulfed, enslaved, all of northeastern Africa. The coffee brew here is out of this world, accompanied by the musical Amharic language, older than English, French, Spanish and Italian. The nerve of Europeans to assume superiority. And yet the poverty is there, access to basic medicine is a waiting game of lines of desperate, paper wielding sick hopefuls outside the half open gates of their version of ER, real emergency wards.
A broken collarbone in an inaccessible tropical village invites rapid deterioration, death waits by the door even as the family supplicates to the god of Moses, Jesus Christ, the Holy Prophet, twirling amulets amid tears and hope. The trip to the ER in many African towns is a journey of a lifetime.
There is a logic in placing the Emergency Room of hospitals on the ground floor, thus the title of the book. There is the immediate access, from the streets, the all-important triage which determines the rapidity of doctors’ availability, trained nurses, many quite specialized over time, the necessity of security.
After all, if you add to the mix of incoming, people in all sorts of mental states, some suicidal, some maniacal, weeping concerned families, the addicted which generally overwhelms the receiving stations and the returning hypochondriacs. Triage directs to the best availability, to minimise waiting time, at least here in Canada.
This is the story of James Maskalyk, Dr. Maskalyk, who divides his time between Toronto’s St. Michael Hospital and Addis Ababa with MSF, Médicins Sans Frontieres, or, Doctors Without Borders.
You decide if he is a driven adrenalin rushed man or a modern day humble crusader, a gifted writer with a laptop. The sparse language of his chapters keeps the reader moving, to see what is next. I climb on his adrenalin flow.
Maskalyk works in the narrative of his Ukrainian forebears in the Alberta wilderness, his resilient grandfather with his treasured trap lines, where skinning a muskrat is an art as well as a joy. But all the same, rural humanity, life’s meaning, works its way into the measurement of all things, gives sustenance to the philosophy of healing, that there is urgency in dealing with near death.
You shoot a moose, you must skin it immediately, extract the edible parts, you cannot wait for the sorrow of the dying animal to work its way into the meat. It toughens it. That urgency, the removal of sorrow is applied to the incoming at ER.                                    
We chat in the lobby at TVO’s offices at Yonge and Eglinton. Very quiet here. Maskalyk had just come out of the Agenda Room where veteran interviewer Steve Paikin had met all the finalists in the RBC Taylor Prize for the best Canadian literary work of nonfiction for 2017. Sorry, he did not win, but still on par with the others.
 A family story for openers.   I have a cousin, a veteran journalist who has reported for the CBC, ABC, CBS and now a special correspondent for Public Broadcasting. This cousin was present in Ethiopia to witness the massive famine of 1983-85 where he saw in a valley an estimated 100,000 people who were about to die. The dreaded Haile Mengistu Mariam was sorting out his country into friends and foes. It was another 20th century holocaust. My cousin, as the family tells it, has been permanently affected by that haunting panoramic scene of death that was still alive. Another version of the heart of darkness.
How has Dr. Maskalyk been affected, 35 years after that episode, by the 21st century daily incoming of the sick and abused into mainly makeshift ER wards, in modern Ethiopia and the Sudan?” A reference to his other acclaimed book –Six Months in Sudan: A young Doctor in a War-torn Village, published in 2009.
“In East Africa, this is the default world, it looks normal. You become a different person. I will have to reconcile that discrepancy. This is the challenge of our time, people are still dying of war, it is a shame for us.”We talk of Toronto, its ongoing challenge to assist those in need. We talk of Seaton House, about to close, maybe to new and better digs.“Seaton and other places like it houses the socially vulnerable,” Maskalyk says, “we dare not mitigate the consequences, we always need places for healing. If Torontonians can live in multimillion dollar homes, we can afford more Seatons.”
We touch on current medical topics, those which have direct bearings on all Emergency Rooms in this city, and throughout the country. Opioids and the legalization of marijuana.
On opioids, “we are mitigating the consequences of addiction, in order to show that lives do matter, they are not a betrayal of help, and we deal with this every day in ER. But we must bear in mind that in Canada, there is a lack of social bond, opioid is something covering over a wound. This moment is also too painful.”
On Marijuana and its coming legislation, “I don’t want a stoned population, not used to cover up pain, a relief, users shouldn’t be criminals, it’s not necessary, what we want is an intelligent conversation, to enjoy its benefits.”
We close. “I want honesty in medication, of what is valuable in the act of giving, in pharmaceuticals, its only designated purpose is of helping people.
“Yes, I am overdue to visit my grandfather in Alberta.”
February 2018.

Life on the Ground FloorLetters from the Edge of Emergency Medicine
James Maskalyk, M.D. Doubleday Canada 2017


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