Contractor Conundrum

The most terrifying thing possible for a young physician without any considerable post graduate training is to be alone in the middle of Africa with an overweight, hypertensive, diabetic, middle aged male that starts complaining of the tell-tale crushing substernal chest pain. Oh yeah, and without any real cardiac drugs. Spend enough time in one place and the worst case scenario will eventually happen, and it eventually happened to me. 

Generally speaking the workload in Africa is pretty laid back. Most of the people I’m with are fairly healthy, and there are not many of them. So my typical day might revolve around a couple sniffles, maybe a sore knee from working out too hard, generally nothing too exciting. The problem of course is what happens when there is something exciting. Most of the places we go to are pretty remote from any western standard of care. We are not on typical military compounds, so my self and the IDMT are the only medics for a given area.  At this particular site the nearest “large” hospital was about an hour and a half away, and the US embassy advised us to avoid it if possible. Generally speaking the go to clinic is typically our little clinic that we set up in a spare bedroom in the house we live in. If someone needs urgent medical surgical care the plan is typically to call International SOS (ISOS), in which case they will dispatch a jet from either South Africa or London that with any luck will get there in hopefully 12-ish hours. So when I got the call at 9am that a fairly rotund military contractor was in the clinic complaining of crushing substernal chest pain, sweating profusely, and having trouble breathing I knew the cards were stacked fairly against me. Speaking in terms of western pre-hospital care, his door to balloon time was essentially fucked from the get go.

We did what we could with what we had, which wasn’t much. Some aspirin, some sublingual nitro, maybe a little morphine, and that’s all we could really offer. I hooked him up the monitor, and got a quick EKG. Now, I would like to tell you some insightful commentary about all the minuscule concerning things I saw on the EKG, but let’s be honest. I haven’t really looked at many EKGs in the last couple of years, so It was more or less  squiggly line squiggly line, sort of normal, not overt heart attack, maybe something about a left bundle branch block, not really sure, what the hell does it matter anyway #Ihavenomeds.

This gentleman turned out to be quite lucky as we just happened to have a plane taking off and heading to the nearest large military facility in Djibouti within the hour. So I pulled some strings and threw him on the back. I grabbed some trauma gear, a monitor with a defibrillator and jumped on the plane with him for the 4 hour and change flight. I think at this point in my short military career I’ve done about 8 or so CASEVACs, and this was by far the scariest. Despite what I could offer his chest pain never really abated, his blood pressure was something in the absurd territory of 190/115. Again, I really didn’t have any decent BP meds to offer him, but oh did I have everything I needed in case he crashed and needed to be shocked, and intubated, so that’s good, right? Oh, and on the flight over he started mentioning to me that before he deployed he was having similar chest pain. He states that he went to the ER in the states and was supposed to have a full cardiology workup, but decided that he could just do it when he got back.

Anyway, he survived the flight and I handed him off to the ER doc in Djibouti, I left him there for a full workup and got back on the plane to return back to where I came from.  About a day later we got word that the ER “ruled him out” for a heart attack, and wanted to send him back. He was scheduled to go home anyway in about two weeks so he would eventually get his workup was their thought. I flipped out, and so did my medical command in Germany. No way was this guy, who we were convinced was probably a walking time bomb going to come back to a place where if something went wrong he would be in a world of trouble. Eventually we won the argument, and he was on the next plane home back to the states. The story concludes with him getting home, and within 48 hours of being back home having a massive cardiac event requiring emergent open heart surgery, quadruple bypass, and a pacemaker placed. So, I guess life saved, maybe not a figure of speech this time.

I would like to say this was an isolated event, that most of the military contractors that we deploy are held to similar medical standards as our active duty population, but that would be a great and terrible lie. The truth is that I’ve seen these examples of medical powder kegs in remote places where they can’t get the care they need before, and I’ll see it again I’m sure. I’ve seen chain smoking asthmatics in the middle of Africa complaining of worsening wheezing, and even a gentleman with a recent blood clot in his lung on heavy blood thinners in the middle of Afghanistan. How are we allowing these guys to ever be cleared for any kind of deployment to any place in the world that doesn’t have a level 1 trauma center down the street you ask? The Wu-Tang Clan had it all figured out in 1993 when the said “Cash Rules Everything Around Me”. Yup, it’s all about the CREAM.

I did some digging, and what I found out was that most of the contractors that deploy in support of military ops have very very loose standards in their “medical pre-screening”. Essentially what I figured out was that they typically go to a civilian doc to get “cleared” to deploy. But, this civilian doc can’t possibly have any idea where they are going, or what kind of resources exist there. In fact I bet if you polled 10 civilian providers, 8 out of 10 would probably say that something that constitutes as a “military deployment” probably means that it’s in a place that’s fairly built up with large M*A*S*H like medical facilities. Which is hardly ever the case anymore. So that heart condition you have? No worries, the mythical cardiologist downrange can take of you. I asked if there was any guidance these well meaning civilians docs were supposed to follow. I was assured their was, I dug and I dug, and nothing standardized every panned out.  So why not change this, have them see military providers to clear them? Because of how the contracts are likely written. I’m sure it’s more cost effective to send them to a civilian provider than have them actually cleared by the military which would be some bureaucratic insurance, contract, money fiasco no doubt. Not to mention, what would happen if we did impose stricter medical standards? I think the answer is clear. We would catch more people that should never deploy, which is of course bad news if you own a large military contract and now a large percentage of your employees are not fit to deploy. So, although my brief conversations with the leads from some of these contract companies lead me to believe they were on my side, and definitely wanted to do everything they could to protect their guys, I smelled CREAM with subtle notes of bullshit, and I smell it everywhere.