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RUNNING WITH THE LEOPARD

South Africa

Sleep will never visit me, lying on a paramedic’s black leather lounge, imagining the lethal violence steaming across the city. Any moment now the phone will ring. My stomach is taut, turning with readiness, primed for action. Few men and women have slept, truly slept I mean, waiting for emergencies on a Jo’burg Friday night. Even Neil Rucker – The Leopard – is wide awake behind shut eyes.

A paramedic employed by Netcare 911, South Africa’s second biggest ambulance service, The Leopard drives a late-model Audi and is permitted to work from home. The Leopard’s modest red-brick house lies in a suburb close enough to the tough suburbs of Hillbrow and Berea for a quick response but far enough away to avoid bodies on his lawn in the morning.

‘Like to be around my cats,’ he says, pointing to a gallery of framed prints depicting handsome leopards crouching on the veld. Others recline on the boughs of trees yawning at sunset. The Leopard’s colleagues told me earlier in the day Rucker’s nickname was inspired not only by his passion for the big cat, but his own cunning intelligence and skill, in particular his masterful intubation of patients with severe oropharyngeal trauma. He’s got the veteran’s look too – shaved head, a few good scars, eyes narrow and a little icy.

The Leopard lights some lotus incense with his Zippo and puts on a CD of meditation music. Slow synthesizers complement the sound of trickling from a water feature standing among indoor ferns. Despite the atmosphere of an Asian spa I still can’t unwind. When the first call comes in I’m up like a jack-in-the-box.

Before we head off, The Leopard ducks into his bathroom and pulls the door shut. When he comes out he is wired-up, sniffing and rubbing his nose in the way a person would after snorting cocaine. I pretend not to notice. He may be suffering allergies, sinus problems.

‘Here, put this on,’ he says, passing me a bulletproof vest. It sits on my shoulders like a sack of rocks.

‘Wow, it’s heavy …’

‘Ja, it’s inlaid with ceramic. Don’t worry, we won’t be going swimming,’ he says dryly.

The Leopard pops some chewing gum in his mouth, punches the air with his fists and grabs the car keys off the table. Seconds later we are rocketing along roads drenched in the apocalyptic orange light of street lamps, the engine of the Audi revving wildly, my body pushed back in the seat as The Leopard clocks 200 kilometres per hour into town.

Held over a week in a classroom at Witwatersrand – the university attached to Johannesburg General Hospital – the globally recognised Advanced Trauma Life Support (ATLS) course is meant to be intense. Conceived by the American College of Surgeons, in South Africa it is taught by those with perhaps the most experience in trauma anywhere in the world. Even with levels of violence in slow decline since the end of apartheid, Johannesburg makes no attempt to shake off its image as one of the most dangerous cities on earth. In 2008, Time magazine published figures showing an average of fifty-two murders occur in Johannesburg every twenty-four hours. This round-the-clock blunt and penetrating trauma ensures Jo’burg is to medics what Milan is to fashion designers. From Europe, Asia and the Middle East they come – doctors, nurses and paramedics – to learn the craft of saving lives in the ‘golden hour’ after severe physical damage to a human body from external forces.

Endotracheal intubation, decompression of tension pneumothoraces and cricothyroidotomies were all on the menu. I couldn’t get enough of them. Many of the lectures and workshops practised skills beyond my previous level of training, skills I assumed to be out of my scope. Yet here I was, mixing it up with the best trauma surgeons in the world. I may have been transfixed by the experts, their stories and their tricks, yet had I known what the weekend would dish up on the streets of the capital, I would’ve been even more attentive.

After exiting The Leopard’s responder I can barely stand up. My eyes sting from the acrid stench of his smoking brakes.

In the middle of the road, on a hill out of Berea, a man lies on his back gazing up at the starless night. Superstitious Good Samaritans have removed the victim’s dirty takkies, placing the running shoes neatly beside his body, allowing a route of departure for his soul. Spreading from a single point on the man’s parietal skull, a stream of bright red blood shimmers in our headlights, still flowing freely, finding new tributaries in the bitumen, branching out and joining up, coursing to an open drain.

The Leopard lights a cigarette and leans against the car.

I glance at him, then down at the man, then back again. ‘Well?’

‘Well, what?’

‘He’s breathing.’

‘So? It’s agonal. You wanna tube him? Here,’ says The Leopard, casually opening the boot of the responder, retrieving his kit, passing it to me with his cigarette between his teeth, standing back again, entirely disinterested. Now that’s burnout, I think to myself. Typical burnout. Speeding to the scene, then doing nothing.

‘You won’t do it?’ I ask.

‘He’s chickenfeed, mate, all yours. Remember, don’t pivot on the teeth. If there’s blood in the airway, if you can’t see the cords, forget about it. We’re not going to stuff-up our suction this early in the shift.’

The vocal cords are Roman columns in the guy’s throat and I sink the tube easier than expected. Once connected to a bag, I breathe him up. The Leopard steps on his cigarette. He slinks over swinging his stethoscope casually, pops it in his ears and listens over each side of the chest and once over the stomach. Without saying a word he nods his approval. From the leather pouch at his waist he whips out a pen torch, flicks it over the wounded man’s eyes. The pupils are fixed on a middle distance, dilated to the edges, black as crude oil.

The Leopard chuckles.

‘Fok my, do all you people come here for learning miracles? Makes me lag, eh.’

He points to my knees either side of the patient’s head.

‘By the way, you’re kneeling in the brains.’

Early that morning I’d done a shift at Baragwaneth Hospital on the edge of Johannesburg’s sprawling Soweto townships. With three thousand beds it is one of the largest hospitals in the world and treats more than two thousand patients a day. Half of these are thought to be HIV positive. A constant stream of ambulances unloaded their sorry cargo onto rickety steel beds lined up side by side until, by mid-afternoon, there was barely room for any more. Teamed up with Simon, an Australian doctor with whom I’d participated in the ATLS, we cannulated, medicated and sutured non-stop.

While joining a doctor’s round in one of the wards, a boy of about sixteen was lying on a bed and as we passed by, he grabbed my wrist, pulling me close. His eyes pleaded as tears welled up and spilled onto his cheeks.

‘Please, friend, take it out, please take it out.’

On his right chest I could see a small bulge, the shape of a bullet sitting just beneath the epidermis. Exit wounds are not always a given, I’d learnt.

‘What’s your name?’

‘Treasure.’

‘What happened to you?’

‘Some men tried robbing me in Mofolo, I told them I had nothing to give but they klapped me hard and after I ran they shot.’

‘Bastards. Did it enter your back?’

‘Ja, bullet hit my spine, they told me it is shattered, they told me I am never walking again. When I fell down on the street I knew that. What will happen to me now? Last year my parents died in a minibus crash. There is no one to care for me.’

Already the doctors were three patients ahead – a ward round at Bara doesn’t wait. Treasure squeezed my arm tighter, sensing my urge to move on.

‘Please, brother, don’t go, please, take it out.’

‘Mate, I’m sorry for what happened to you, I really am. But the bullet is not interfering with any body function now, the damage is done. Maybe it will push out on its own one day.’

When I heard myself saying this to him – lying there unable to get up and walk to the open window, no father at the foot of his bed, no mother who named him her treasure holding his hand, no friends to help him pass the hours, the time he would forever spend turning over the memory of that one moment – I was filled with pity.

‘Just want this evil thing out,’ he said.

‘One minute,’ I told him. ‘I’ll bring a surgical kit.’

As I incised over the bullet, removing it with tweezers and dropping it into a steel kidney dish with a clink, I could feel Treasure’s muscles relaxing under the drape. A deep sigh passed his lips and his face smoothed out with relief.

‘God bless you, God bless you, God bless you,’ he whispered with his eyes closed, as if I had just exorcised an evil spirit. ‘God bless you forever.’

Among the pumps of a service station The Leopard unzips his bumbag. After looking around to make sure we are alone, he pulls out a 9mm semi-automatic handgun and slides out the magazine to show me its full load of rounds.

‘Got another one strapped to my ankle,’ he says.

With a sporadically effective police force, it is not unusual for paramedics to find themselves caught up in gunfights. Triage, the concept of sorting patients in multi-victim situations starting with the most critical, is superseded here by sheer self-preservation. If a member of one gang requests a paramedic to treat their own before those of an opposing group, it’s usually at gunpoint. The Leopard takes no chances.

‘Last year two of my colleagues were held up. Actually, it was an ambulance-jacking, they were left stranded in a bad place.’

As he drives me through Hillbrow, Johannesburg’s most densely populated urban slum of decrepit high-rise buildings, I see a neighbourhood I wouldn’t want to be stranded in either. Shopkeepers sit nervously behind thick iron bars and the blinking neon of pool halls and strip joints flickers on the figures of haggling prostitutes outside, their bodies shimmering with sweat.

‘Some of us call it Hellbrow. New Year’s Eve is the worst. People take pot shots with their guns from balconies, they let off fireworks horizontally, they throw furniture and other projectiles from windows, trying to hit people below. Few years back a fridge landed on a Metro ambulance. You never know what will come at you.’

Even ordinary party nights can be lethal in Jo’burg. Saturday evenings are difficult in most Western cities but here it’s a war-zone. Streets are jammed with people overflowing into the path of our car and the expectation of impending violence is palpable all around us. The Leopard locks the doors of the responder, says we’ll avoid the worst parts of the suburb, places even he won’t go unless accompanied by a police flying squad. He ignores red lights too, without being on a call. ‘You’ve got to keep moving. Robots will kill you in Johannesburg,’ he says, referring to the traffic signals. Rarely do I entertain irrational fears, but all heads seem turned on us tonight, eyes following the Audi as we pass, shady characters ready to pounce. In reality they could be just as well hoping we’ll stop and join them for a drink, take a break, have a laugh. But as we draw level with the next pub where words stencilled by the door read ‘No Guns Permitted’, I’m not so sure.

‘Zero Zero Three, come in.’

‘Three, go ahead.’

‘Man off a bridge, Yeoville.’

‘Rrrroger.’

Tossing individuals off bridges and towering apartment buildings is a preferred method of murder for some gangs in Jo’burg. Without witnesses and no weapon or identifying wounds, these deaths can be easily mistaken for suicide.

As The Leopard does a U-turn he points to the tallest building in Hillbrow, the notorious Ponte City Apartment block. This cylindrical skyscraper with a hollow core was built in 1975 as a luxury condo fifty-four storeys high. After the end of apartheid many gangs moved in and the penthouse suite on the top floor became the headquarters of a powerful Nigerian drug lord.

‘Once, we got half-a-dozen bodies in a week at the foot of that one,’ he says, flicking on the siren. But this was 2003 and things were changing. Using the South African Army as back-up, developers were evicting undesirables. Whether Ponte City’s former glory can be restored remains to be seen. Selling luxury apartments in the heart of a suburb where visiting the corner store for a carton of milk can get you killed will be tricky.

Half a minute down the road in Yeoville the traffic is backed up and we use the breakdown lane, our red and blue lights bouncing off the vehicles we pass. Under a freeway overpass we pull up behind a police van and see the officer in lane two standing over a young man lying face down, illuminated by the headlights of a late model Mercedes.

‘Lucky he missed the poor lady’s car, nice Merc that one,’ jokes the policeman. A woman in the front seat dabs her cheeks with a tissue.

I look up. The overpass is a good 20 or 25 metres high. No wonder the patient is groaning in agony. I’m surprised he’s even conscious.

Behind me The Leopard approaches with our gear. Seems the case has inspired him to show me what he’s made of. Or maybe the siren of our back-up ambulance wailing towards us has compelled him to act.

The policeman helps by manually stabilising the patient’s head. Calmly the Leopard scissors off the man’s shorts and T-shirt to expose him for a better examination. He slips a wide-bore IV into the cubital fossa without blinking and throws me a bag of Hartmann’s solution.

‘Five minutes on scene or we get docked,’ scoffs The Leopard. ‘Patient’s got an open-book pelvis with jelly legs, but it’s all about those five bloody minutes.’ He shakes his head and I know what he means. Time to hospital is the essence in trauma, but proper immobilisation, effective analgesia, cautious extrication and transport strategies will all, in the long run, reduce morbidity. Only by working the road can one truly appreciate ‘time’ as but one factor among many upon which an ambulance service should be judged.

Once the line is clear of air I connect and open it for a bolus. The Leopard double-checks the blood pressure, palpating seventy systolic. Falls from great heights often cause serious pelvic fractures like this, lacerating vessels internally and resulting in massive blood loss filling body cavities. This, in turn, can lead to absolute hypovolaemia – a condition of low blood volume – that could prove fatal.

‘Keep the fluids going wide open, we’ll shut it off at ninety systolic. Don’t go over ninety, got it?’

I nod.

Three paramedics from a Basic Life Support (BLS) ambulance arrive. They too comment on how lucky it is the Mercedes escaped damage. Two of them help with patient care, while the third, a stern-looking African man with spectacles on the end of his nose and epaulettes studded with shiny stars, stands to one side and starts a stopwatch hanging round his neck.

The Leopard looks over at me and rolls his eyes. ‘What did I tell you? Five minutes, let’s go!’ Maybe The Leopard is burnt out but tonight he’s playing the game. We’re being timed like athletes, timed by a stoney-faced supervisor with a digital stopwatch. Crazy.

Medics from the ambulance drag over a flat spine-board onto which we lay some pelvic sheeting. Once the patient is rolled over, we use this to stabilise him from the waist down, wrapped and clamped. Any unnecessary movement in pelvic fractures, even multiple examinations springing the iliac crests, increases internal bleeding and risk of death.

‘One, two, three, lift!’ The stretcher legs lock down and the trolley is wheeled to the ambulance. As the supervisor gets in the front seat he glances over at us and laughs.

‘Hey Rucker, four minutes, thirty-three. Close shave!’

The Leopard grunts and lights a cigarette.

From Netcare’s depot at Milpark we watch a retrieval helicopter descend onto a landing pad at the doorstep of the company’s very own fully equipped trauma hospital.

‘Heard it on the radio,’ The Leopard tells me. ‘Some lion safari gone wrong, a 4x4 rollover.’

Running parallel to public medical services, Netcare has fifty-three private hospitals like this throughout South Africa and Swaziland. Milpark alone employs some of the country’s brightest doctors, offering every imaginable specialty and a staggering ninety intensive care beds. For those who can afford private health cover the company has become South Africa’s provider of choice. But as an act of goodwill to the poorer people of South Africa, Netcare offers its ambulance services free to those who earn below a certain income threshold. Nowadays, the vast majority of emergency calls are made by non-subscribers. These patients are, however, always conveyed to public hospitals. Although it is currently common practice in South Africa to dial 911 – Netcare’s clever exploitation of the widely known US emergency number – bystanders will also ring the government’s metro ambulance service at the same time. In a crisis people will take whatever ambulance comes first.

As a consequence, driving to emergencies has become a frantic race between the public and private services. This ‘healthy competition’ has only improved response times in Johannesburg, according to Netcare medics. Relationships between crews from both systems generally remain harmonious despite this challenge. Stress comes instead from pressure placed on them by management to reach the scene first in order to uphold the service’s image as the quickest.

While good for the public, it’s a dangerous game for medics. In 2002, nineteen ambulances were written-off in the city of Johannesburg, mostly by Metro Ambulance Service drivers. Netcare are not so worried. Official figures show their average response times are five minutes faster than the government service.

‘Sometimes on the way to hospital with the patient we pass the Metro ambulance still heading to the scene,’ chuckles The Leopard. ‘We always give a little wave, of course.’

As we prowl for work in those raw, bloodstained streets of central Johannesburg, I have become The Leopard’s cub, learning to hunt with the master.

‘Are you ever afraid?’ I ask him. Stories of gun battles with drug gangs, resuscitations at knifepoint and snipers taking shots at reflective vests have kept me on the edge of my seat all night.

‘Ja, sure I get afraid.’

‘Of what?’

‘HIV.’

It isn’t what I expected him to say.

‘Average sixty people are shot every day here, ten thousand people die on the roads each year, 90 per cent of our calls are trauma, but HIV is the leading cause of death. At least 20 per cent of sub-Saharan Africa is HIV positive. Just do the math. If you consider 90 per cent of our work is trauma with active bleeding and 20 per cent of these patients are HIV positive, you will understand what we’re really afraid of. Get blood on you in Australia, England, America and you don’t sweat much. Get blood on you here and you don’t sleep till the results come back.’

The Leopard plans to enrol in a paramedic research degree, a doctorate perhaps. ‘I need to get off the road. I have children now, they live with my wife but I want to see more of them. You know, I have a responsibility to them, a responsibility to stay alive.’

The streets of Johannesburg seem eons away from the immense beauty of South Africa’s wilderness. The contrast is extreme. But then, some of the most stunning places in the world have a dark underbelly, a place shared by the poor, the sad, the criminal, the beggar, the victim and the paramedic.

‘Zero zero three?’

Reluctantly The Leopard picks up the handset and replies. Our lights and siren ignite the dark road ahead.

‘It’s not a bad neighbourhood, this,’ says The Leopard. ‘We’re less than a kilometre from Hillbrow, I have a drink here sometimes, you know, during the daytime.’

But descending a steep hill we are first on the scene of a chaos like none I’ve encountered.

From what I can make out, a fully laden semitrailer lost control, veered to the opposite side of the road, crushed five cars and continued on to plough through a restaurant packed with diners, finally coming to rest deep within the building.

The carnage is widespread and horrific.

Bodies lie everywhere. Cries and screams and groans puncture the air. Hands pull us this way and that. I’m dizzy and cannot focus on any one patient, there are so many, perhaps twenty, perhaps more. Where do we start? Triage, triage. My French comes back to me. We need to sort them, make sense of it, get perspective.

The Leopard is so cool it shames me. He strides through the devastation like a war-hardened general, calmly slipping his hands into latex gloves. He takes no gear, no oxygen kit, no medicine, no bandages. Just the man and his portable radio. One at a time he stoops down to check the breathing and circulation of those lying motionless. Effortlessly he elicits responses from those who are conscious and checks the smashed vehicles and the truck for occupants. As I follow behind him, I finally hear him speak into his handset, his voice steady and commanding, his report plain and precise.

‘MVA, truck versus restaurant, no persons trapped, four dead, sixteen patients on the ground, unknown number of walking wounded, need fire brigade and as many ambulances you’ve got handy.’

The Leopard grabs my shoulder and points to a man lying near a car that looks like it’s been through a wrecking yard. ‘Start with that guy, he’s not well. I’m going to delegate the back-up as it comes.’

From the responder I get our gear and race back, stepping over the bodies of those beyond help.

‘He can’t feel his legs,’ cries the man’s wife, crouching beside him. ‘He can’t feel them!’

I ask her name. It’s Melanie. She tells me the patient is Martin. Today is their wedding anniversary and he took her for dinner, alfresco, with candles.

‘Listen,’ I grab her attention. ‘Melanie, you’ve got to help me now. Here, take Martin’s head and don’t let it move. Keep talking to him. Stay calm because you need to keep him calm. We’ve got a job to do and we’ll do the job together.’

After fitting the oxygen mask, I mould a hard collar round Martin’s neck and begin a head-to-toe examination. His breathing is rapid and shallow. I place my stethoscope in his armpits and listen. Limited air entry on the right, I’m certain of it. There is movement and crepitus, a popping sound and grating of crushed ribs when I palpate the chest wall. I suspect a collapsed lung. It may be tensioning, in which case an immediate procedure to release the pressure with a needle is required. As I break out in a sweat at the prospect of doing this, a Netcare ambulance team with a senior paramedic join me and begin cannulating and getting ready to board the patient. They will decompress the man’s chest once loaded up, the medic tells me. They work at lightning speed and I wonder if another supervisor is standing somewhere in the shadows holding a stopwatch.

Medics are swarming all over the site now. Metro EMS, Netcare 911, even ER24, a company I’ve not yet come across. Suddenly The Leopard is behind me, leaning in.

‘Boet,’ he says in Afrikaans, meaning ‘brother’. ‘We got to go, we got a gunshot to the head just round the corner, they got no one for it.’

I’m stunned. Broken glass crunches and mixes with blood underfoot as I carry the responder kit back to the car. It’s an awkward response in tragic times, but as I get into the front seat I begin to laugh. I laugh at the sheer absurdity of leaving the biggest accident of my career to attend a shooting. I laugh because it has taken me less than twenty-four hours to reach this point, this point where a paramedic’s work in Johannesburg is encapsulated entirely by a single, staggering moment of madness.

And the night is but young.