#2: "Do Not Harm Enemies Who Surrender: Disarm them and Turn them over to your Superior"
- From the United States Marine Corps Common Skills Handbook, Core Principles of the Law of War
January 2023
I've spent the first year of the war filling out applications to every medical NGO that has operations in Ukraine. At long last, it looks like I'll be accepted for a volunteer deployment to Ukraine as a Paramedic, this spring. I'll spend my last two months in Africa hiking up the hill to the "cell spot", in order to do interviews and process onboarding paperwork for Ukraine.
Our rural West African clinic is busy today. Dozens of men, women, and children wait outside the clinic; this is the only free medical care available within 3 days' walk. They chat, share food, and migrate patiently along with the shifting shade of the mango tree as the day progresses. Each evening at the local teahouse, the village men gather around a shortwave radio to listen to BBC. Major news, and a favorite topic of today's conversations, is the war in Ukraine. The general anticipation that Kiev will fall within a few days has turned out to be wrong. Right now, much of the world is rooting for the underdog in this fight. I'm hungry for more details, but information is limited in our remote village.
Local disease outbreak history here includes Ebola and measles, so we are careful to arrange as much social distancing as possible for our waiting patients. No inside waiting room. In any case, conditions are far more sweltering inside the clinic than outside. Last night a thunderstorm gave us an early taste of the coming monsoon season, and humidity remains high. We have no fans, but we open the windows and doors to maximize airflow.
In the crash room we currently have a pediatric patient whose initial presentation would stir panic in the heart of any seasoned US doctor or paramedic. She is 3 years old, limp, listless, dehydrated, semi-conscious, with a racing pulse and raging fever. She might be a critical case in the US, but for us, she's a run-of-the-mill kid with Falciparum malaria. We see several similar cases each week, once the rains start. We'll trial a dose of oral ACT (Artemisinin-based Combination Therapy- malaria has become resistant to many single-drug therapies, so a combination of drugs is now needed). If she doesn't throw it up, she'll almost certainly be stable and sleeping comfortably within an hour or two. If oral drugs don't work, we'll give her intravenous antimalarials, which pretty reliably yield a similar positive outcome. Without antimalarial drugs, she would be in grave danger. Falciparum is the most serious strain of malaria, and it is the country's leading cause of death. Rapid treatment is key. Our door-to-antimalarials time is less than 10min for most serious cases.
While caring for the girl with malaria, we are serenaded by the continuous crying of a 3-day old girl, brought in for a well-baby checkup by her mother. The heat, high patient load, and cries of the newborn are conspiring to create a fairly trying day. As soon as possible, we frontload the newborn. She is mom's first baby, and the pregnancy and birth were uncomplicated. The baby is a bit feverish to the touch. When we undress her, we discover she has a severe cord infection, and is dehydrated and tachycardic. We evaluate options for transport to higher care. The nearest hospital with a neonatal ICU is a 2-hour bike ride away, down very rough roads. Our motorcycle ambulance has already left town with another serious patient. I send a runner out to search for any bikes in town.
We start an IV. Our care options are limited; we have no oxygen, and the infant is too young for us to safely dose with a starting load of antibiotics. As I watch her, her breathing speeds and slows, and her limbs go blue, then return to pink when I stimulate her. With each episode of slowed breathing, the blue cyanosis spreads further, until it rings her mouth. I pat her feet and bounce her gently, and her breathing and color improve. I look up to see that the village Chief has entered the room. Generally we are respectful with the Chief, but this time I order him loudly: "I need a motorbike to the hospital for this baby immediately".
Ten minutes later a driver, mom (still recovering from birth), and I are stacked three deep on a bike, headed down the steep, slippery hill to town. We jolt over ruts and splash through puddles. I can't imagine how hard this ride must be for mom. She holds the infant and I monitor baby's breathing, vigorously tapping her feet each time the cyanosis creeps back. I'm afraid to try using a bag-valve mask to breathe for her during this bouncy ride. It's easy to over-inflate a newborn's lungs, even under good conditions. My plan is to promote awakeness and breathing through tactile stimulation, and to give her mouth-to-mouth if she goes into complete respiratory failure. That way I can fill my cheeks with air and control the air volume she gets on this bouncing bike.
We settle into the long, familiar ride. The roads are very bad. Riding like this is probably the most dangerous thing we do here, so it's nice to focus on something else. I figure I'll fare better in a crash if my body is relaxed, not tensed. I alternate between watching the infant's breathing, tap-tapping her feet, and looking at the greenery passing by. I wonder what is happening in Ukraine right now. My favorite song, "Whistled By", is playing on repeat in my head. I imagine the patient is a trauma patient, the rig a beat-up, ad-hoc ambulance, and the roads the morass of the 'Rasputitsya' mud season.
The news has been featuring stories of kidnapped Ukrainian children being spirited off to Russia. I find these stories particularly ironic, given that there was no shortage of unwanted street children in Russia during my exchange program time there. Shouldn't Russia see to them, before stealing extra children from Ukraine? I recall living in Vladivostok, and helping serve daily soup and bread to street kids after my Russian classes were over. I worked with several dedicated, kind-hearted Russian volunteers. I got to know a couple dozen of the kids pretty well. Some of the teenagers were my peers. They had their own peculiar street ergot, so I didn't always understand all of the stories they told me about their lives. But I understood enough to know that these kids didn't have the luxury of justice, or of choosing right over wrong. For them, the strong devoured the weak, and that was it.
A few denizens of Vladivostok must have seen me often enough with the street kids to think I was one of them. One day, enroute to class, and being a day-dreaming teenager, I stopped to admire a sailboat at anchor in Golden Horn Bay. I stepped a short distance off the sidewalk to do it, into a used car yard, and for a better view I used a toe placed in the chain link fence to boost myself up a couple feet. As I gazed at the bay, I imagined exploring the world on that boat.
I heard a little click. I looked to my left. I took in many things quickly. A hundred meters away was a trailer. On its porch stood a large man in soiled work clothing. His shoulder held open a storm door, and he was rising up, having apparently just clipped something to a bolted chain on the deck.
What he clipped was a lead, attached to an enormous black rottweiler mix.
The dog was silently, teeth bared, making for me, at top speed. His sprint was low, fast, filled with rage and deadly intent, and a chain bounced along the ground behind him. He had already covered half the distance to me. I had a split-second debate: try to climb the fence and hop over, or try to retreat beyond the reach of the dog's chain, before he reached me?
Seeing as time was not on my side, I went for the option that involved the aid of gravity. I pushed hard off the fence, leapt back and sideways several steps, and then the dog was closing on me. His teeth flashed towards my leg, and I kicked out and rolled backwards over my right shoulder. Arms over my face I rolled several more times, backwards and away from him along the line of his chain. I rose and ran backwards several more steps, but as I looked at him, I saw he had reached the end of his chain. He jerked at it, snarling, spittle flying. As I rolled, he had seized my left pant leg and torn the lower half clean off. Miraculously, the skin of my calf had suffered nothing more than an abrasion.
I looked up at the man. He stood, arms crossed, watching. The dog was very large and I was fairly certain it would have torn my throat out if able. I was also fairly certain the man had seen me, quietly opened the door, and let his dog loose on me. I was worried about the dog's lunging pulling out the bolt that restrained him, but I was far more worried about the man's intentions. He was large, and very possibly armed. I strutted away nonchalantly, showing no fear. But as soon as I was out of view, I ran as fast as I could for friends and safety. 'Well', I reflected, 'there's an accidental taste of life as a Russian street kid for me.'
Over my years of travel, I have developed a habit of rating a culture by how it treats its street kids and stray animals. I've been to places where the stray cats come up and bump your legs, and roll over to show their bellies for caresses. But not in Russia- it has some of the wariest street kids and strays I've encountered anywhere. I've never been to a place with so many mutilated animals wandering the streets- tail-less cats, nose-less dogs. What will this country do to an enemy in a war? The Katyn massacre, mistreatment of civilians and POWs... that behavior from our ally all got white-washed during WWII. Now we have cellphone cameras, satellite imagery, and social media. What will we see from this post-tech-revolution European war?
I relax on the back of the motorbike, comfortably filled with deep thoughts that don't involve the possibility of crashing. The baby girl keeps breathing, and we transfer care to the Neonatal ICU in town. After two weeks of hospitalization for sepsis and acute liver failure, she is discharged with an excellent long-term prognosis. It's been a good day.
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