Standing at the Threshold of Heaven

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Status: Finished  |  Genre: Non-Fiction  |  House: Booksie Classic
The conclusion of a Pennsylvania medic's journey through the ruins of northern Japan following the March 2011 earthquake and tsunami

Submitted: January 12, 2013

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Submitted: January 12, 2013



I was last in Tokyo's Narita Airport six months ago. If someone had come up to me then and told me what the next half year would be for me and the world, I would have laughed. Now, at the end of it, I must laugh anyway. It is either that or cry.

For one thing, I certainly did not think I would have experience in treating radiation sickness and burns because of a nuclear generating station that is leaking poison into the ocean and the air. Many of the Shirakawa evacuees began showing (or revealing that they had been experiencing) symptoms after they were brought to Sendai through more than ten times an acceptable dose of radiation. The potassium iodide medication had done its job well; in fact, we were treating more patients for side effects of the medication than radiation sickness. But there were several people with skin reactions and vomiting after they stopped taking it. The Pennsylvanians kept looking at each other as they treated patients, saying "Alara" under their breath. It had meant "as low as reasonably achievable." We now used it to mean "at least airborne radiation alights." Unfortunately, radiation was the least of our problems.

Ryan, the critical care fellow who I met at MediShare in Haiti, reminded me of many things I have come to expect in good pediatricians. As I remember from my time at Children's Hospital of Pittsburgh, the specialty requires patience and fortitude bordering on the infinite, as well as accepting that your best and worst days will be due to work. In short, you need to stare Death in the face and honk his nose.

Hiroko is the pediatrician serving our camp. Her practice was destroyed by the earthquake; she barely escaped the tsunami with her life. She lost many patients and has many more staying with us. Most of them are very well attended to; the children are given first priority by everyone here. Hiroko gets the right of way even when walking to the water tank. She bows and smiles, even to her young charges, and creates explosions of laughter and joy by puffing up her cheeks or grinning intently. She almost never speaks but translates the demands of children into the demands of Japan better than I could ever think to. During a quiet moment, I taught her how to make an origami frog to entertain the children. In return, she showed me a new intubation technique.

I was called to a room in the school for a body removal. When I arrived, Hiroko was standing just inside, speaking softly to a woman brimming over with tears. The woman held a bundle that had been her child a few moments earlier. Hiroko began to cry as well; I assumed she was enacting sumimasen, the art of expressing apology (Miruyama-san had demonstrated it to me once in an exaggerated display when he acted like a minor infraction of his duties as host had brought great dishonor on his family). I waited in the door, hands clasped and head bowed, until Hiroko gestured for me to come in and take the body. I handled it as gently as if it was still alive. I remembered this child. He had been declining in health despite the formula we made out of powdered biscuits and milk. I didn't know why he died.

When I returned to Hiroko, she was still crying. I had no idea what to do. The idea of her actually crying had never crossed my mind. Then I thought of her last three weeks. Her home and practice had fallen into ruins. She nearly died. The children she loved and protected were dead and dying. She was standing between them and Death, and Death won again. It was too much to contemplate. With nothing to offer in comfort, I began crying with her.

One more child died later that morning and six were critically ill with a respiratory ailment that presented as a cold and then grew quickly worse. I was selfishly worried for a time that it was the same thing Masumi and I had been working through. It turned out to be catastrophically simple: pneumonia. It shouldn't have surprised us, with the weather and air the way it is. As soon as Hiroko said it, my heart sank. I wanted to hit myself for taking azithromycin that could have medicated two infants. But it was too late. I used the remainder of my pack to medicate the most critical child and got on the comm system to find more.

An hour later, an infant stopped breathing after he had spent more than an hour wheezing around a lower airway obstruction. I got to show Hiroko a frontier intubation (I did one in Haiti three weeks ago), using a cable inside a nasogastric tube to get past the obstruction. She looked disgusted at the process, but it succeeded in opening the airway and returning some color to the poor boy's face. He still had some fight in him.

The medical kit I had carried in Haiti was with me and it held enough azithromycin powder for oral solution and erythromycin tablets to mount a decent one-day attack on the illness, which had then forced ten people into our makeshift ICU (formerly our office; we moved to a tent outside the school). Masumi and I went farther into Sendai to pick through the remains of a pharmacy that had collapsed and been pushed inland two streets from where it had previously stood. A detachment of Hiroshi's troops came along and began blasting through the wreckage in search of what had been the dispensary. Masumi and I stopped dead as the men shifted a large piece of concrete. A woman lay crushed under it. The troops froze until the master sergeant ordered two men to remove the body and continue on. We never found any usable drugs.

The troops left but Masumi and I continued to the airport. I kept hearing the poetic way that Joel had set the conditions for the evacuation of Shirakawa: "kore ijo kono chi de shinde iru" - "no more dead on this ground." I spoke to a lieutenant in the U.S. Marine 3rd Logistics Group at the small tent base in the airport parking lot. I may suggested that I would be interested in joining the Naval Reserve Healthcare Program if the Marines had the drugs we needed. He looked at me as if Captain Bligh had just landed, haggard and scrawny, at his dock. Then he spoke to a quartermaster and sent me back to the school, saying he would do his best.

Then the waiting began. Any soldier can tell you the wait before a battle is worse than the battle itself. All of your skills are for naught, and you end up playing out in your head all the ways you can fail. Hiroko, Masumi, Gary, Kathy and I all sat in and around the ICU. Occasionally, one of our twenty patients' vital signs would plummet and a couple of us rushed in to stabilize them. The rest of us just sat stunned, waiting to see if it would work. We never felt relieved, but we never felt devastated either.

Hiroshi came in at one point and said he was getting medication sent in from his base on Hokkaido. It was a day away. It would never arrive in time. Joel kept coming by to ask if I had gotten any word, always looking like it was his fault that we hadn't been more prepared. I'm lucky I'm not the leader; anyone would have done the same thing, but he's the one who would have kicked himself for it.

With less than eight hours until we were slated to leave, the U.S. Marines came through, delivering a case of erythromycin and replenishing our stocks of azithromycin, ciprofloxacin and all the other vital antibiotics to fight the major medical ailments our patients were facing. In sixteen hours, we only lost one patient: an 86-year-old asthmatic. All the children were alive, even if three were still critical. Patience had beaten Death.

The Marines also donated three pallets of MREs (Meals Ready to Eat - emergency rations, also known in grunt lingo as "Meals Refused by Ethiopians"). Anything was an improvement after three days on World Health Organization high-energy biscuits. I had almost traded my helmet for a Canadian MRE (salmon!), which would have been quite the sacrifice as the helmet saved my head some trouble during the excavation of the pharmacy. It wasn't ridiculous to wear it after all.

At five in the morning, an Indian emergency response team on an extended mandate from the Japanese Government arrived at the school and reported to Joel. As he explained our situation to their commander and introduced him to Hiroshi and Masumi (our "military liaison" and "local logistics chief"), I helped the rest of the Pennsylvanians pack and clean up. The floor of the ICU had been littered with broken ampules and spent tubing; Hiroko and two volunteers had swept it all up in a minute, as they still had nothing to do but wait.

I paid my respects to one of the best pediatricians I have ever met with a paper frog folded out of our mission plan, as well as a drawn diagram of how to make it. Hiroko bowed to me and held my hand for a moment, saying "watashi tachi wa tengoku no irikuchi ni tatte" - "we stand at the threshold of heaven." It is a reference to an ancient legend about the guards of heaven, who decide whether or not a soul gets in. It is not judgment of quality but judgment of time. One is refused entry if it is not one's time to die. In that dark classroom, we were the guards, and our verdicts were accepted.

Gary and Kathy had the same look that I saw on the faces of departing crews at MediShare in Haiti. They were smiling and laughing with wide eyes and lingering expressions of extremity, barely containing their shock at what they had seen and done. I sat with them for a few moments as the Indians and the Japanese rushed around with new supplies and equipment under the direction of Hiroshi, who had already said his solemn farewell. I traded insignia with the master sergeant; he wore my paramedic patch and I wore his regimental shield. He saw me, pointed to his shoulder and gave me a smile and a thumbs-up. Hiroshi was not pleased but said nothing about it. Oh, well, captain. War is hell.

Masumi was already busy shifting supplies to a central depot, something we never had the time or organization to create. I waved to him and he stopped his truck, got out, came up to me and did the South Philly handshake I taught him. Then, unexpectedly, he gave me a hug. "Uchi," he said - it is the word for insiders. I could not imagine a higher compliment.

We got a flight to Ibaraki Airport and took a bus to Narita Airport, both outside Tokyo. It was the only time any of the Pennsylvanians got to act like tourists. We stopped for photos of the scenery, bought a few souvenirs for people back home and then rushed to the terminal. I left another page of our mission plan, rendered useless in its third day by changes of venue and unending confusion, in the shape of a swan at the small Origami Museum in the terminal. The keystone, a symbol of Pennsylvania, is showing on one of the wings. Let that be our remaining legacy.

I am now sitting at the departure gate, eating sushi from the airport restaurant and wearing fatigues given to me by the Japanese to replace my ruined clothing. I can feel sleep crawling up my body and preparing to take me. In less than a day, I will be home. I hope that, on the way, I dream of things getting better quickly here as this battered country gets the help it needs. I hope that, when I wake up, it is true.

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