When Snezhana Spazovska removes a hideous oil painting of a teary-eyed clown from above the lounge where our patient is lying I am momentarily relieved. Unfortunately she has not taken it down to improve the appearance of the man’s apartment but to hang an IV drip on the hook in its place.
The moment she has done this, we leave.
Not one of the three jobs we have knocked over before sundown has had us on scene for more than five minutes and not one patient has been transported to hospital. Only yesterday, a Skopje steelworks employee with a bleeding nose, a case I would normally spend ten minutes or so treating with manual pressure alone, was handled completely differently. Pharmacology was the mainstay and the patient was fixed in half the time. There were jabs of Valium and Frusemide and a cotton ball soaked in adrenalin shoved up the nostril. Again less than five minutes on scene and no transport. Although it could be argued that a certain thoroughness and continuum of care may be lacking here, the Franco-German model of pre-hospital intervention is so far proving highly efficient. In most other countries where I’ve worked, all these patients would by now be clogging up emergency departments. As for the man with vomiting and dehydration lying there on his over-ornate lounge with a drip in his arm, what happens when the solution has run through?
‘We give instruction on how to remove it,’ says Spazovska, ‘How to stop his vein from bleeding. We explain him procedure, don’t worry.’
To a paramedic from a system without physicians such a practice seems daring. Not every patient is bright enough or possessed of the nerves to remove their own cannula and stem a bleed. But these, it seems, are considered worthwhile risks to save a tenuous hospital system from being overburdened.
Our assigned station for the night lies in the somewhat forlorn suburb of Chaiar, not far from Shutka. After a couple of home visits in the Albanian quarter issuing Tramadol to cancer patients, our driver, Sammy, passes the house of Johann the Killer, the commander of a police unit responsible for war crimes against an Albanian village and currently awaiting trial in The Hague. It’s a purple and mauve monstrosity hung with wagon wheels and cowboy paraphernalia, complete with a ten-foot medieval gate. Sammy is also Albanian and finds it incredible the house remains untouched. As we head to Chaiar he tells me how last month a patient refused to get into an ambulance driven by an Albanian and subsequently threatened the crew with a steak knife.
Ethnic tensions run deep in Macedonia. My friends here, even the young and university educated, frequently shock me with their overt racism towards Albanian Muslims. No one even bothers beginning with the customary ‘I’m not racist, but …’ preface as racists in Australia often do. Perhaps this tension is understandable when the last skirmish of gunfire exchanged between Macedonian forces and Albanian insurgents occurred as recently as 2001. And it is only since 2007 that Macedonians dare to walk through the Old City dominated by mosques and ancient bath-houses separated by the worn cobble streets winding to a Turkish bazaar.
Then there is the issue of Vodno, the steep mountain high above Skopje where Macedonians have installed the Millennium Cross, the largest crucifix in the world, sixty-six metres tall. Without a hint of shame my friends admit the cross was placed as a mark of territory rather than a symbol of Christ’s grace and tolerance; ethnic Albanians should be constantly reminded who the rightful owners of the city are. Even by night, from the window of the ambulance when everything is black, the cross on Vodno hovers, brightly lit and imposing against the night sky. It may be a thing of beauty but for me it’s a beauty tainted by the country’s godless divisiveness.
At Chaiar Station, a sweet Albanian nurse with near-perfect English is manning the radio and scissoring small squares of gauze from a giant sheet for sterilisation. Her name is Drenusha Arneri and in our earlier conversations she admitted it took her a year to feel accepted by her colleagues. Now, despite being a Muslim, she celebrates Easter with them, helps colour eggs at the ambulance station and even brings along a plate of homemade baklava. Under Dr Maja Poposka the service has come a long way in creating a positive environment. Whenever she can spare one, Poposka even sends an ambulance to Mecca with a team of Albanian medics onboard to help out.
For Dr Maja Poposka nature helps her deal with stress and that is why in the middle of her office at Bucharest Hospital she keeps a giant indoor tree growing in a pot with branches reaching out around the room and leaning like a friend across her desk. By all appearances this chain-smoking doctor is more Russian supermodel than ambulance service director. Before taking up her position two years ago she had already worked fifteen years on ambulances in Skopje, roughly the same time I have worked on them in Australia.
‘Everything I have seen,’ she says matter-of-factly.
We begin a discussion on the improvements made to Macedonia’s ambulances since she became director. New ambulances donated from around Europe, white uniforms for the medical staff, better training and equipment. It is hard to believe, but up until 2006 none of Skopje’s ambulances had defibrillators on board. Response times were notoriously dismal and the ambulance doctors had a countrywide reputation for being mean and rude.
To some extent, from my random canvassing of locals I have met here, public perception of Skopje 194 is still rather poor. At a taxi stand in town not a single driver could recite the emergency number and an informal survey I conducted at a Bob Marley tribute party in a city park revealed the widespread opinion that ambulances still take forever to arrive and are staffed by ‘bitches’ anyway. Neither of these perceptions is at all fair, as I’ve discovered first hand, and I ask Dr Poposka why the service has not done a better job of public relations since she took office.
‘Problem is we cannot advertise our improvements,’ she replies. ‘It is better for us to go about our work quietly and rely on word of mouth. You see, we are still under-resourced and only just manage to meet the eight minutes response time standard for 90 per cent of top priority cases. What will happen if we tell the world how good we are now, how quick and polite and professional we have become?’
It’s true that public ambulance services do not generally benefit from advertising. The better a service looks the more people will call, leading to a higher demand that will negatively impact on response times. The only publicity campaigns an ambulance service should probably entertain are those that concern prevention and discourage calling for inappropriate reasons. This is a vastly more difficult campaign for a service with general practitioners on every ambulance and a public that knows it.
Maja Poposka’s frustrations working on the road prompted her to apply for the top job when the former boss retired. Four old Russian-built Lada station wagons are still parked in the basement of the ambulance headquarters, cobwebbed and rusty. Only a few years ago they were all the city had.
‘You can imagine our reputation, driving around Skopje in these things,’ said Dr Poposka when she took me to see them. ‘We were always late and even then we couldn’t do much for the really sick ones. See, look how low the roof is. None of us ever did CPR in these cars, impossible.’
‘So what did you do in cardiac arrests?’
‘Drive fast.’
Hearing this I understand completely her reasons for leading the service. Watching people die from a lack of space would be maddening for any ambulance worker, let alone a medical doctor.
Behind her office lies a larger ambulance graveyard containing numerous donated vehicles from around Europe, all hand-me-downs still bearing the logos of their former masters. Here I saw a Johanniter Mercedes from the Germans, a 118 van from Rome and a French Renault from the SAMU. Up until recently Skopje 194 used these vehicles as they were. On any one day it was common to see ambulances from various European nations all screaming through Skopje at the same time. This reminded me of a friend who had visited Fiji and happened upon the same ambulance he had driven around Sydney for years being