The International Writers Magazine: Philipines

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From Fighter to Paramedic A Brooklynmonk in Manila EMS School • Antonio Graceffo Having spent most of my life learning to end life, it is a bit of a change learning to save it.   “Bakers cover their mistakes with frosting. Carpenters cover their mistakes with paint. Paramedics cover their mistakes with dirt.”

The course began with a playing of the Philippine national anthem, followed by a prayer. Being in a Catholic, rather than Buddhist country, it was so refreshing not having to take of my shoes. And, unlike Thailand, I was permitted to point my feet at anyone I wanted and even rub their head. It’s good to be among my own people…sort of my own people.
 
Sir Aidan is the owner of our school and the primary instructor. He hates George Bush, which is a good thing. He hates Americans, which I could understand but could also do without. Being Irish, he also hates Britain, which I feel ambivalent about. So, when class gets boring I bring up stories of my family being driven off their land by imperialist British soldiers who burned our thatched hut.
 
“The F…ing British.” Aidan begins. “They are worse than the Americans.” Once I get him on this subject, we are guaranteed at least twenty minutes that we don’t have to take notes. Or, just one note, in case it comes up on the test, I simplified the British/Irish thing for my classmates. It reads “British bad, Irish good.”
 
I enjoy studying with the Irish. They are one of my favorite translucent people. And as organ sales are common in Philippines, being the owner of two healthy kidneys, I try to make friendships with rich alcoholics who may need to buy one. Or is that the liver that alcoholics need? Probably not. Liver and alcohol upsets your stomach. Anyway, I could sell them one of my livers if things got really desperate.
 
You do have two livers don’t you? That would be an example of one of those times when I should have been taking notes instead of winding Aidan up.
 
As for EMS emergency medical services, Aidan is recognized as one of the leaders in the world. I was googling his name the other day and was blown away by how many times he is mentioned in professional journals. He founded the EMS systems in a number of countries, higher the staff, trained them, bought the ambulances. He is really amazing. In terms of his practical knowledge, he was a dive paramedic, and a member of the faculty at the dive academy in the UK. He was a military paramedic, and who knows what else. Maybe he was a rescue swimmer like Kevin Kostner in “The Guardian.” The man knows his stuff.  

Ma’am Joan, is Aidan’s wife. She is a Filipina, and is certified as both an RN and a paramedic. She is our second primary instructor. Aidan and Joan both said that once you learn EMS you don’t want to do normal nursing anymore because ongoing patient care is boring in comparison.   My friend and classmate Ben is RN, but he is becoming an EMT because he didn’t want to wash the patients. “Sometimes you even have to clean up their poop.” He confessed. I could see why four years of really difficult university studies, followed by intimate contact with excrement could be a downer.

Aidan’s take on EMS versus medicine was, “We see the patient from the time of the injury, to the time they get through the emergency room. After that, they become boring. We are lucky to have them at the most interesting time.”
 
It also seems that in EMS when you rescue someone, they thank you, and the family thanks you. But once they are in the hospital as long term patients, they behave like hotel guests and start complaining.  Once again, to have four years of university studies capped off by complaints about dinner…It would feel like being a highly specialized waitress.
 
“I am the only RN who ever came back to my country.” Said Joan.
 
Ben told me that the normal RN salary in Philippines is 5,000 Pesos per month (about $120 USD). In most of the world, with the exception of the USA, paramedics actually earn more than nurses. The reason is that the US set up their paramedic programs in the 1970s. So, they are already established and well-manned. In the rest of the world, 911 type response systems are new, and training programs are either developing or non-existent. In these countries there is no shortage of doctors or nurses, but a fully qualified paramedic is a rarity.
 
Most of the course is taught in English, but the students sometimes ask questions in Filipino. It is OK, I am trying to learn the language. Generally, even the instructors don’t know the Filipino words for the specialized medical vocabulary. This country is so America-centric it is amazing. I think it is one of the few places on Earth where they still like us. When I walk down the street people always shout, “Hey, Joe.” The first time it happened, I looked around for my father, but then I realized it was me. We all look alike.
 
There are innumerable dialects and languages spoken throughout the more than seven thousand islands of the Philippines. Tagalog was chosen as the national language simply because it was spoken in Luzon, the big island where Manila is located. Many Filipinos resent being forced to speak Tagalog when they meet their country men from other parts of the country. Since they don’t speak to each other’s dialects, English was seen as a politically neutral lingua franca. So, it is normal for Filipinos to speak English to each other if they have trouble communicating in dialect. It is also normal that university and school courses are taught in English. So, having me in the class only slightly alters the language usage. Still, I am amazed that the Filipinos are so polite that the presence of a single Cano (Americano) causes them all to speak English.
 
While their accent is American, unlike Hong Kong, their pronunciation is at times, a bit…creative. At first I thought I was the only one missing out on one word in seven, then I realized they have trouble understanding each other.
 
Ma’am Joan was saying something about blacking the arteries, we asked her to explain what that meant and she wrote on the board, “Blocking the arteries.”
“OH! BLOCKING the arteries. That makes more sense.”
“Yes, blacking the arteries.” She repeated. “Try to listen more closely next time.”
 
I have no idea what it will be like when I start doing my practice on the streets of manila and people are shouting at me in a language I don’t speak, and then I discover it is English.  

Our first lessons were on human anatomy. Here I had another linguistic adventure in trying to understand Sir Aidan. Apparently, in nearly all biological terminology, the people from those islands, UK and Ireland, put the accent on a different syllable than the Americans. The spelling is the same, but they move the accent in capillary, bronchioles, and many other words. They also refer to the gurney or stretcher as a cot. Which was doubly hard for me because, when I used to have a British girlfriend, she taught me that in UK, a cot was what Americans call a crib. But now, in the ghetto, crib is what Americans used to call an apartment. And in EMS class, a cot has wheels on it and is used for moving injured patients.

Many of our training videos are from those islands where leprechauns run free, and everyone drinks tea instead of coffee, and lives in a castle. Most of the English ones aren’t too bad, but Aidan has a slue of videos from Scotland. Those people should just be fitted with a subtitle generator at birth. I have no idea what they are blabbering on about. Judging by the glazed look on my classmates faces, they don’t understand Scottish any better than I do.
 
This confused me, because in school we were taught that the British invented our language, but none of them seem to speak it. When I protested, Aidan mumbled, “Bloody American.”
 
Converting my mind from Martial arts to paramedic has been difficult. I normally refer to the patient as an opponent. I also learned a lot of new terminology like blood is called hemo, and unlike when I am fighting, the blood, I mean hemo, is supposed to stay on the inside.
 
Through years of martial arts training, I knew some of the anatomy, like carotid artery. This is where I strike with a chop, to knock a man out. This technique is often referred to as a “Jap drop.” Not very PC, I know. Kidneys are something I hit with a knee. Trachea is with the open hand. The armpit contains the axially artery, which is one that has to be done with a knife thrust
 
Aidan told us, “As an EMT you will have life and death in your hands. And what you do will decide if the patient lives or dies.” As a soldier, I was taught almost the same credo, but sort of in reverse. 
 
During this course I am always amazed at what a wide variety of things we learned in high school. We had basic anatomy, biology, chemistry…I didn’t think I had learned anything useful in those classes, but when we see it in EMT class, although I don’t know it cold, I know I have seen it before. What I like abut EMT is learning all of the life saving techniques without having to struggle through biology, chemistry and math which would be impossible for me. That’s why doctors have to be right clever people to get through their years and years of education. I have huge respect for them now.
 
Our goal in EMS is very simple, to keep oxygen going to the brain till the patient gets to hospital. Without oxygen, the brain begins to die in four minutes. Organs take 50 minutes, skin and muscles take five hours.
 
The EMT must assess quickly and decide to “load and go” or “stay and play.” You have to make a lot of decisions, in a short period of time, with the pressure of life or death hanging over you. Being an EMT is not so different from working on Wall Street or even boxing. It appeals to me.
 
When I teach self-defense, I always tell people not to fight especially if the assailant has a knife. Self-defense is like baseball, the goal is to run home. If you reach your destination alive, you are a winner. In EMS, the goal is to help the patient reach the hospital alive. In most cases, you don’t stay and fight, you run away and save a life. 
 
Aidan and Joan are very religious, and they have a nice philosophy which they live by. “People arrive on the scene and see problems. We see solutions.” That was Aidan’s EMS motto, but his next statement was like a lifestyle mantra. “The only true problem is death, because once it happens it can’t be solved. Everything else has a solution.”
 
He asked my class, “Have any of you had a problem in your life? Yes, but you solved it didn’t you? So, you didn’t really have a problem. You had a solution. And you know how I know? Because you aren’t dead yet.”
 
We learned about the circulatory system. An adult heart pumps 5 Lt of blood per minute. An adult body contains 5 – 6 Lt of blood. That will cause some dry cleaning issues. I remember my Uncle Sonny telling me he preferred a .22 to a .45, “That way your suits will always stay nice and fresh, after a job.” He never went to school, but he had a certain homespun wisdom that you could live by.
 
The rule book said, Safety first: Size up the scene. Make sure it is safe for you and your patient. Don’t go from being a paramedic to being a patient.
 
Relating this to going back to Burma as a combat medic, however, you are in the same danger zone as your patients. And you can be injured, but have to focus and work. I had that experience when we had an accident on the Burma border. I was knocked unconscious, but still had to crawl around and render aid. A friend working for a security contractor said that they hire both SWAT and ex-military to work as security contractors. He said that they were both good, but the problem with the SWAT guys was that when they were rushing into a building to get a sniper out, they assume that their back is safe. The danger is only coming form inside the house. But, in real combat the whole area is hot. There is potential danger on all sides. It is the same for combat paramedic. You are almost never safe. In fact, since you are traveling with the troops, then it stands to reason, if they are injured, you are in an unsafe place, but you still have to go about your work.
 
My family and friends keep sending me emails that say things like, “We are so glad you are out of Burma and safe in Manila.”
 
I like the people here, so I don’t want to insult anyone, but Manila is a lot more dangerous than Burma. Violent crime is rampant, and people get shot here all the time. And, unlike the States, you can’t trust the police or emergency services to come help you. We are the best EMS in the Philippines, but we didn’t graduate yet. According to Aidan, in Manila, of 280 EMS calls per hour, less than 20 get answered.
 
One of the UK training videos we watched was of a paramedic on a motorcycle. The idea is motorcycles can arrive at the scene faster and start rendering aid while waiting for the ambulance to come and evacuate the patient.
“Any comments?” Aidan asked, when the video had finished.
“Cool uniform.” I said.
“We all wear that flash-green jacket and helmet in the UK.”
“No, I meant the leather pants. Do we all get to wear leather pants?”
“No, EMTs don’t generally wear leather pants.”
“Well, is there some other career I can pursue where I do where leather pants? I don’t want to throw away six months of hard work and study only to continue wearing cloth.”
 
The only career I could think of where I could wear leather pants was go-go boy, but I had already done that one. My go-go license had lapsed, and there were no course openings in Manila.
 
Aidan told us that in the UK all people are assigned a primary care physician from birth. “For the rest of our lives, if we have a medical problem, we get free medical care. If you are injured and need to get to your physiotherapy appointments, the ambulance will transport you for free. That is what a government can do if it sets its priorities on the people.”
 
Yes, maybe in a perfect world. But, if governments squander their tax budgets on medical care how will they fund the military?
 
Saving lives is a calling. Aidan served in the military, but in UK an army medic is a noncombatant. In the US military he is a soldier first. He is armed and must engage the enemy if called upon to do so. The same is true in the war in Burma where no one can afford to specialize. I want to learn paramedic skills to help save lives, but I favor a military solution in Burma. I believe there are times that violence is justified or even called for.
 
Aidan, on the other hand, finds killing appalling. For this reason he is better at his job as a paramedic. “Only God can take life.” He said.
 
I wondered if he would hate me for my willingness to pick up a gun. It made me a bit sad and introspective. With the exception of psychopaths like Hitler and the Junta who run Burma, no one wants to be the bad-guy. It pained me that someone might point at me and say that I am the villain.
 
Ma’am Joan taught our next block of instruction. She talks a lot about the rights of patients. The Philippines is a very stratified society, where half of the haves don’t have very much, the other half have everything. The have-nots comprise nearly 80% of the population, and they have absolutely nothing.
 
“In the Philippines no one is to blame if they are poor. Being poor is not your fault.” She paused to let that sink in. Then she added, “But being rich is. If someone in the Philippines is rich, we have to ask where the money came from.”
 
Corruption is rampant in the country and is often identified as the single most crippling force holding back the economic development of the people.
 
Joan gave a lengthy lecture on discrimination against poor patients in the hospital. Sometimes these people were abused verbally and even physically. She said things like “Don’t try this with white people. They will stand up for their rights. But we Pinoys let people push us around.”
 
Organ sales are common, and apparently, some medical staff accept a commission for brokering the sales when a patient dies. “This is unethical.” Joan told us, as if maybe we didn’t already know. “Let the families make their own arrangements to sell the organs. It is illegal and awful, but poverty makes people desperate.”
 
This phrase, “poverty makes people desperate,” is a recurring theme in the Philippines. There are a lot of cases in the news of people jumping off of bridges or committing violent robberies that are so public and stupid, they seem more like cries for help. Money is really tight for me during school, and I live in very basic, jail-cell-like conditions, but I still can’t imagine the grind of real poverty. To know that you can’t provide for your family and that there is no hope that tomorrow will be any better must be absolutely incapacitating.
 
Doing my anatomy homework, it occurred to me that this stuff is freaking hard. There is a reason that doctors study for ten years.  In Manila, however, anatomy study is slightly easier, because I can just drop by the market and pick up a human kidney and practice in my room.   
 
For all of their education and training, the Filipino’s approach to diet and exercise is dated. In fact, everyone smokes. They are all fat, and no one exercises at all. The course had a unit which said EMTs should be fit, exercise regularly, and eat right. Joan repeated what was written on the overhead, basically, “You should exercise every day, eat a healthy diet, and keep fit.” But that was the end of it. We went on to the next slide. No exercise program was laid out, nothing was planned. It occurred to me, how many times in my life have I sat in an orientation at a school or a company where they said, “You should do fifteen minutes of aerobic exercise per day, keep fit sleep and eat right, next slide.”
 
In America, kids are required to attend gym classes but they don’t work out or do any serious exercise. The kids who are fat or have no fitness or muscle tone in September are fat and have no fitness or muscle tone in May. I think the kids should be given a fitness test at the beginning and end of the year. If they fail, the gym teacher should be fired. Seriously, if we are going to eat up an hour of class time per day, why don’t we demand fitness?
 
According to a July report, the National Center for Health Statistics indicate 15 percent of children ages 6 to 18 were overweight in 2000, up from 6 percent in 1980. Fifteen percent of youngsters ages 6 to 19 and 10 percent of children 2 through 5 were considered seriously overweight. Sources: AHA.
 
According to the Weight Control Information Network, which may or may not be a reliable source, today, more than 65 percent of adults in the United States are overweight or obese. Obesity puts people at increased risk for chronic diseases such as heart disease, type 2 diabetes, high blood pressure, stroke, and some forms of cancer.

In our EMT course we learned that heart disease is the number one cause of death in the world. WHAT are we waiting for? Get off the freaking coach already. And as for the kids, kids shouldn’t be fat. And parents shouldn’t make the kids fat. If kids get fat later, at least they had a choice. But as children they rely on their parents to take care of them. Once again, parents of overweight children should be fined. I spend less than 45 minutes in the gym per day and I am probably fitter than 90% of people. Why can’t we do this for our kids?
 
The next slide was a dietary advisement right out of the 1950s when bacon was thought to be good for you. It had a picture of the food group pyramid and it said that 60% of our diet should be composed of carbohydrates. Joan stressed to us, “If you want to lose weight please don’t cut carbs. Your brain can only function on glucose.”
 
While it is true that your brain only functions on glucose, carbs are the first place you should cut when dieting. Otherwise, what are you going to cut? Fish, meat, vegetables, fruit….
 
Time sense is an issue here. You wait for everything. I waited in line for an ATM for twenty minutes the other day. You are always waiting, things take longer and everyone is late. But no one seems to mind. To travel five kilometers could take one and a half hours, but no one ever walks. I walk to the mall and my classmate got lost on the public transport. It’s only like 600 metres, Why not walk?
 
My classmates and I got drunk after class and gave each other tattoos with IV needles. We were working together on an assignment. Aidan had asked us to design an ambulance, inside and out. Ours had Playstation, CD, DVD, and a Borat headbobber. For an engine, I chose a straight twelve Hemy. I am not exactly sure what that is, but I suspected it was wicked fast.
 
When we presented our design, Aidan said, “That all draws current and runs down your battery.” A serious concern in the ambulance is running out of electrical power before getting back to the hospital. Incubators, for example, draw a lot of current. If you get stranded, you increase the chances of your patient dying.
 
Filipinos talk about America constantly. America is the standard by which everything else is measured and still the number one country they want to go to. But according to the Bureau of Labor Statistics, in USA paramedics only earn about $2,500 per month. In the Middle East they can earn $2,500 tax free, and get free accommodations and food. If you did the Middle East deal you could easily save $2,000 per month. In US, after paying taxes and apartment there would be nothing left. In many, many instances my classmates mention that one or the other country in Europe has a better procedure or equipment than the Americans. But America remains the standard. I tried to convince Ben he would be better off as an EMT in Qatar or as an RN in America, but going to America to be a paramedic was not a good idea. They don’t understand that $2,500 is nothing in USA and $2,500 in the Middle East is a better deal.  
 
Sir Aidan always gets talking and forgets about our breaktimes and lunches. I wrote the word coffee in huge capital letters on the back of my textbook, so when it is time for a break I can hold it up. Ma’am Joan always says “just one more minute and I will let you go,” but it’s generally another thirty five minutes. I had to fake a seizure to get us released for lunch. Monday I have to produce a note from my doctor confirming that I have a medical condition called hypo-cafination and need coffee every two hours or I will descend into a state of hypo-cafiosis. That will cost a pretty penny.
After school, before Ben went home, he took his ATM cards out of his wallet. “This is Manila we always have to prepare in case we get robbed.'
 
EMTs here have not cross trained most police and therefore don’t have advanced first aid and EMTs don’t learn rescue. Sir Erik told us “You are EMTs. That means no Spiderman. No rescue, no rappelling, no defusing bombs, and no terrorist threat elimination, you only think about the medical.”
 
Too boring. I want to change courses.
 
Sir Erik told us how to do triage in Manila. “If you have one patient suffering from a gunshot wound and one with a sprained wrist, who do you take to the hospital first?”
Answer, the rich one.
 
We are only supposed to have one patient in the ambulance, but it doesn’t always work out that way. Sir Eric told us that once in the Middle East he had a whole family and a goat, which is strange because in the Philippines, you don’t usually use an ambulance to transport a goat. A pig maybe, a few chickens, but never a goat.
 
 Sir Eric lectured us about the golden hour. Basically the brain starts to die after 4 minutes, but if it is still getting oxygen. It takes ten minutes of no oxygen for the brain to completely die.  Then the next deadline is the internal organs, which start to die after 50 minutes. So, we call it the golden hour, the narrow window of time we have to respond and take the patient to the hospital. Of course the hour starts when the patient gets hurt, not when we arrive. We are told that our goal is to spend only ten minutes on site.
 
In USA someone sees an injured person, they call 911. The dispatcher uses GPS to locate them, gets some pertinent information, and sends out an ambulance. 'But in Manila,' laughs Erik, 'things don’t work the way they do in USA. If they see an accident they call an emergency number. The dispatcher asks, what kind of emergency do you want: police, ambulance, or fire. You tell her which one you need. Then she asks, where are you? It’s not always easy in Philippines to know where someone is, so a long discussion follows. Then the dispatcher looks up your location and gives you a landline phone number for the closest command station. You call them and they refer you to the specific station. You call them and, assuming they answer the phone, they come. A lot of time is lost in traffic in Manila, where it could take over an hour to travel 5 KM. Also a lot of time will be lost looking for the place. When the ambulance arrives, the police are not trained and don't necessarily take control of the situation. Often the crowd is a huge impediment to the rescue workers.
 
“When you have an accident in the Philippines the first people to respond are the onlookers.” In a country where many people don’t have a lot of disposable income and aren’t bogged down by a job which eats up their time, EMS emergencies can be seen as a cheap source of entertainment. “The second group to arrive is the media. Then the politicians.” Ostensibly this ancient system of ward bosses still exists where they would show up and shake babies and kiss hands. “Next comes EMS. Once we are sure the situation is safe the police arrive.”
 
EMS does their work and transports the patient to the hospital. At present there are only three trauma centers in Manila. It could take ages to reach one of these trauma centers only to find out that the hospital is full and you are being turned away.

The golden hour could easily turn into the golden three hours, especially if your patient is poor. For rich people, once again nearly everything is possible with private ambulances and private admission to the best hospitals.
 
In primary assessment training, we ask patient “What is the quality of the pain?”
Quality? It sucks. It’s pain, so, I would say the quality is quite shitty.
 
The book suggests giving the patient a scale so they can measure their pain. The example given in the book uses a scale of 1 to 10, ten being the highest. The book stresses that this is just a suggestion, and we can do it however we wish. Given that creative freedom, I prefer a scale of 3.9 to 11.7 with 11.7 being the lowest.
 
We studied ten ways to tell if your patient is unresponsive. Aidan pointed out it is pretty easy to determine. “Just say hello to him, and see if he answers. Ask him some questions and see if he gibbers nonsense.”
 
All the guys in my class knew that Master Frank is the one who took me to the school. They all love the UFC and knew that referee Big John McCarthy is a paramedic. They love martial arts and found my videos on line. Now, they all want to learn Kuntaw. It was one more sad example of a piece of local culture that is dying. I have studied the ancient Filipino martial art of Kuntaw, but they hadn’t.
 
This course is excellent. I am getting to find out interesting stuff like, what the hell is a spleen? I mean you’ve heard of the spleen, but what is it?
 
I am always amazed at the English spoken here. They do prefer to speak Tagalog to each other but when they have to talk to me in English they are all near native speakers. They watch all of our movies and eat at Taco Bell. So, the cultural differences are not so huge, except for the time issue.
 
I wrote in my notebook, “Cytoplasm is made up of protoplasm and occupies the space between the plasma membrane and the nucleus.” How many times have I written that exact sentence in my life? Probably at least five times between fourth grade and freshman year of college? Why? And why did it always seem new to me each time? Even now it has very little meaning for me. I barely understand what it means and how it reflects to what I need to do to save a life.
 
I daydream a lot in class and start laying out screen plays for movies that should never be made. During anatomy lecture I came up with this one, “Thoracic Park, a trip back to a time when the internal organs ruled the earth.”
 
Sir Eric was excited to tell the guys in our class, “Being a paramedic is one of the only times you get to cut a girl's clothes off.” Of course he meant without buying her dinner first or getting hit with pepper spray. A training video from USA showed us how to cut the clothes off of the victim. Teacher Eric laughed, “They do it wrong in USA. They cut straight up the front. Here in the Philippines you need to cut along the seam, so that the people can have the clothes repaired if they want to reuse them.”

© Antonio Graceffo May 2008
antonio_graceffo@hotmail.com

 Currently, Antonio is in Manila attending paramedic training. When his course finishes he will return to the conflict in Burma as a medical volunteer. He is self-funded and seeking sponsors. If you wish to contribute to his paramedic training or his “In Shanland” film project, you can donate through paypal, through the Burma page of my website.
http://speakingadventure.com/burma.htm
 
 Checkout Antonio’s website http://speakingadventure.com/
Get Antonio’s books at amazon.com
The Monk from Brooklyn
Bikes, Boats, and Boxing Gloves
The Desert of Death on Three Wheels
Adventures in Formosa

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