The Insulin Express

by Oren Liebermann

  I was in the worst kind of trouble. I hadn’t yet finished my instrument rating—a certificate that lets me fly in zero visibility—and I was in a plane that wasn’t well equipped for instrument flight. No GPS. No autopilot. And the weather was supposed to be so perfect that I hadn’t brought my instrument charts. Young pilots in this situation survive an average of three minutes, a statistic I decided not to tell Cassie.

  Out of options and in need of immediate help, I hopped on the radio and called Norfolk air traffic control. It took about twenty minutes, but they got me lined up with Norfolk International Airport’s runway and safely on the ground. Cassie and I had no problems polishing off a bottle of wine that night—not a standard bottle, but one of those big Yellow Tail bottles.

  That night (before the wine), I talked to my flight instructor, and we broke down every moment of the flight and every decision I made, both good and bad. One thing he said always stuck with me.

  He explained to me that experienced pilots with thousands of hours can sometimes get in trouble flying into zero visibility if they’re not prepared for it. If they expect good weather and they get it, they’re great. If they expect bad weather and get it, that’s no problem. But if they expect good weather and find themselves flying in bad weather, they sometimes make very serious, very fatal, and very avoidable mistakes.

  “Why? How is that possible?”

  “Because the brain is wired for denial. Your brain wants you to believe that everything is going well. That everything is okay. Even when you face a growing list of things that are going wrong, your brain still wants you to think you’re fine. The brain is wired for denial.”

  My instructor’s final line keeps running through my mind as we make our way to the main road to catch a taxi to the doctor’s office. The brain is wired for denial. Staying alive as a pilot is a matter of understanding and managing risk. Many of the lessons learned in the air can be applied to life. This is one of those lessons.

  We arrive twenty minutes later for my fasting blood sugar test. A quick, cordial “hello” is exchanged, and Dr. Griffiths’s assistant tests my blood sugar.

  5 … 4 … 3 … 2 … 1 … 306.

  My blood sugar is still sky high, and my diagnosis is confirmed. The third check after breakfast—my blood sugar is 319—is a formality to corroborate what we already know. I have type 1 diabetes. My official diagnosis comes on Valentine’s Day. I ask the doctor for a urine test to check for ketones. I tell him I have a fruity taste in the back of my mouth. He conducts the test and, a short time later, says I have no ketones.

  “You are okay to travel home,” Dr. Griffiths reassures me in a way that is not at all reassuring.

  Cassie and I race home. We have a busy afternoon before we catch our flight, and we have to work fast. But I am still feeling awful, and when we cross the gate to our host’s house, I sit down on the stoop and cry.

  “Are you okay?”

  The brain is wired for denial.

  I shake my head no.

  “Do you want to go to the hospital now?”

  The brain is wired for denial.

  We have less than four hours until our flight to Kathmandu, where I know there is a modern hospital with doctors trained in Western schools, yet I feel too weak to last that long.

  At some point, I had become addicted to the idea of my own health. I ignored all the warning signs, using excuses like being in a desert, hiking in the Himalayas, or being in Nepal during the dry season to explain my never-ending thirst and subsequent need to always run to the bathroom.

  The notion of good health was a drug I could not do without, and as my health deteriorated, I kept increasing the dosage. My brain was wired for denial, and I had hardwired it to stay that way. I was unwilling to accept what would’ve been obvious to anyone else and perhaps even to myself if I weren’t facing a constantly changing set of circumstances in an ever-growing list of locations.

  I can do something about it now, or I can tell Cassie I don’t want to go to the hospital, and I will be in Kathmandu at a Western clinic by dinner-time, only a few hours away. It would bring me one huge step closer to home, since it’s much easier to coordinate a flight out of Kathmandu without the added complication of getting on one of the few daily flights from Pokhara to the capital.

  But as much as I want to get home quickly—more than anything else in the world, I want to be with my parents in New Jersey—I feel too weak to last even a few more hours. The twenty-five-minute flight to Kathmandu feels like an eternity away, and if something goes wrong in the air, it’s not like Nepal is littered with major airports we could divert to, let alone high-quality hospitals near those airports where I can find decent treatment.

  It is time to play it safe, to break myself of the addiction to the fantasy of my own good health. I am in bad shape—very bad shape as I would learn—and I am getting worse. After misdiagnosing my symptoms, I come to believe the doctor in Pokhara misdiagnosed the severity of my condition.

  So when Cassie asks, “Do you want to go to the hospital?” the answer is …

  “Yes.”

  A moment later, we tell the cab driver to bring us to Dhital Educational Hospital. The first stage of my journey home had been so close. A few hours away, it was an imminent reality. Now, it is once again a distant dream. There may be some sort of light at the end of a proverbial tunnel, but the tunnel keeps getting longer and the light in the distance is fading.

  We walk straight into the emergency room of what looks like a large, modern medical center. Inside the emergency room, blood stains the floor, along with other bodily fluids that I’d rather not attempt to identify. There is no heater here, so even though the daytime temperature is quite warm, it’s freezing inside the hospital. In the bed next to me is a young girl who keeps vomiting on herself, her bed, and the floor. The least repugnant and most pleasant object in the room to stare at is the ceiling, so I keep my concentration focused straight up as I wait for medical attention.

  The doctors run every conceivable test on me over the next two hours. Blood tests, urine tests, ultrasounds, x-rays, even an HIV test. I find out I have a six-millimeter kidney stone, which the technician describes as “small, do not worry,” but to me sounds absolutely enormous. At every test, I am pushed to the front of the line. This is racism in reverse. As all the Nepalis wait their turn, I am tested immediately because the hospital knows I have money. The battery of tests costs a total of four thousand Nepali rupees—forty dollars.

  I am brought to the room in the special ward of the hospital that will be my world until I am discharged. As we come to learn, “special” means “foreigner.” The Nepalis stay in the general ward, which is a fancy term for what is actually the lobby. They simply lie down on a mat around the nurses’ desk and sleep on the floor every night until they are discharged. The setup resembles camping far more than it does emergency medical care. About twenty or thirty Nepalis are in the general ward when I walk through. I can’t imagine what this ward must look like when the hospital is busy.

  My room is the last room at the end of the hall on the left. When I arrive, I am the only person in the special ward. This room is far too expensive for your average Nepali—it costs ten dollars a night—so the hospital reserves this ward for Westerners who suffer altitude sickness on a trek or catch a stomach bug in town. I wonder if I’m the first Westerner to be admitted with newly diagnosed diabetes.

  We have two beds. I take the one by the window; Cassie takes the bed by the door. The hospital has no Wi-Fi, so Cassie has to run out to email my parents that I’m in the hospital. And since our room is freezing cold, she goes to pick up our sleeping bags. They got us through a Himalayas trek; they’ll get us through a few nights in a hospital.

  A nurse immediately sticks an IV on the back of my right hand, between my middle and ring fingers, and starts pumping fluids into me. In my first forty-eight hours in the hospital, I gain about fifteen pounds. That’s how dehydrated I was. My body was missing two gall
ons of water, which explains why I was constantly thirsty and why my skin looked like it was hanging off my face and arms those last few days.

  We see the first doctor fairly quickly. He is middle-aged, maybe in his early forties, dressed fairly casually, as if my admittance to the hospital disrupted his other plans for the day. He doesn’t smile or betray any emotion but speaks to me very matter-of-factly in a monotone he must’ve learned in one of his med school electives. This doctor isn’t Nepali; he’s Indian, and so are all of the other doctors here. He is accompanied by a team of med students, all wearing lab coats, and they are using me as a lesson. For my entire stay in the hospital, every time I see a doctor, med students follow him—here the doctor is always a him—plucking up kernels of advice that fall from the mother hen.

  He explains my situation and treatment to me, including how soon I’ll be given my first shot of insulin, but there is only one question that interests me.

  “Our goal is to get home as quickly as possible. How long will I be in the hospital?”

  “We need to flush the ketones and maybe twenty-four hours after that. So maybe two days.”

  For the first time in a long time, I feel optimistic. This stretch of feeling weak and awful has an end in sight, and I will be on my way home soon.

  “What do I eat?”

  “Oh, do not worry. We have a diabetic menu we will bring you.”

  “Thank you, Doctor. Thank you very much.”

  Then a nurse arrives and hands Cassie a list of supplies to buy, and we realize we are very, very far from Western medical care. We assumed this hospital would work like any hospital in the States. We get treated, they give us a bill, we go home. If we stay long enough, they give us the right food. It’s a simple arrangement that I didn’t think needed improvement.

  In Nepal, it’s almost the exact opposite. You pay for everything up front, including supplies, medicines, and tests. Then you bring it to the nurse, and the nurse administers the medicines. Cassie is sent on a scavenger hunt throughout the hospital complex to find the medical supplies store, the pharmacy, and the payment window, none of which are located near each other. Then, after she finishes those errands, she has to go to the cafeteria to buy me food, since it’s not served to patients here. The food consists of the same vegetable curry and rice that we’ve eaten since arriving in Nepal, only now it’s served in little plastic bags instead of on plates. They’re reluctant to give Cassie a tray with my food since they fear she may not return it after I finish eating.

  I never quite figured out how I would’ve gotten all the supplies and my meals without Cassie. Did they really expect me to walk around the entire hospital to get everything I need? Forget the fact that I’m incredibly weak for a second. I’m hooked up to an IV, and they don’t have the IV stands on wheels like they do in the States. My IV hangs from an immovable pole attached to my bed. For me to walk around, I need to unhook my IV bag, hold it high in my left hand, and keep my right hand down so the fluid keeps going. Is that what would’ve happened? God, I hope not, but that’s exactly what I have to do every time I go to the bathroom, holding my IV bag above my head in my left hand and my penis in my right hand. If I were to try it the other way round, blood would flow out of my hand into the IV bag.

  The doctor returns to my hospital room after a few hours. “I would like you to move to the intensive care unit. We can monitor you better there.” The doctor gives us his pitch as to why I should switch from my luxurious corner office to the ICU. “You can take a look at the intensive care unit. It is across from the nurses’ station.”

  Cassie and I walk down together. We are shocked by what we see. Or rather, who we see. A dozen beds are lined up against the walls, spaced five or six feet apart. I think each bed is occupied, but I don’t stick around long enough to double-check. That’s because everyone in the ICU looks like they’re about to die. Each patient is hooked up to an aging array of medical devices, yet the beeps and bings of the medical machinery don’t seem to be helping. Every patient looks like they are moments away from passing on. If I wait long enough, they may be able to relabel this room “The Morgue.” I have no doubt that I would receive better care here (and they have heat in this room!), but I refuse to let the hospital treat me like my life is in imminent danger of ending. As politely as we can, we tell the doctor there is no fucking way I’m switching to the intensive care unit. Thankfully, he doesn’t argue. He just asks me to sign a waiver releasing the hospital from any liability.

  The first night in the hospital is the only night that qualifies as not bad. We have a room with a TV, so we watch whatever Olympic sport is coming in on the sports channels. I catch up on curling, downhill skiing, and a random assortment of other winter events. The nurses wake me up every two hours to take my vitals, which means I barely sleep, but I don’t mind too much. I am on the mend, and that means more to me than a few hours of rest. I sleep with most of my body enclosed in the warmth of my mummy bag; only my right arm is outside so I don’t risk unhooking my IV.

  I wish I could say the emotional breakdowns stop, but they don’t. Everything that’s happened is still nearly impossible for me to comprehend. Just a few months ago, I was perfectly healthy, wandering around Europe without a care in the world. Now I’m in a hospital in Pokhara, Nepal, trying to figure out how close I came to killing myself with undiagnosed type 1 diabetes on a trek through the Himalayas.

  When we wake up, Cassie and I work out a simple system to make sure I’m okay while keeping my family informed. She will sleep in Lakeside and spend the whole day with me in the hospital. That way, she can send emails and check in with my family at night and in the morning since the hospital has no way of accessing the Internet. Apparently, the term World Wide Web does not apply to the entire world, but it has an alliterative feel that, I must admit, is far more appealing than Partial Wide Web.

  On our first full day in the hospital, I tell Cassie it’s okay to post my diagnosis on Facebook. Only one or two of my friends know I have diabetes, and that seems the most efficient way to let everyone know.

  I am not ready for what comes next. Cassie walks in each morning with a new stack of messages from friends and strangers, each and every one offering their love and support. People I haven’t spoken with in years send short notes that become so powerful for me. Even something as simple as “Thinking of you, Oren! Feel better soon,” or “I just learned of what is going on. I love you and know you will end up adjusting to all of this,” makes each minute in the hospital just a little bit easier. I find it difficult to read more than a few messages at a time without crying. I’ve never experienced such an outpouring of unfiltered emotional support, and there is no way to hold back my own emotions as I go through the messages.

  After Josh had his stroke, I saw him cry as he read the messages of support he received. It didn’t quite make sense to me then. I thought they would make him smile. At the time, I told him to man up. Grow some balls. Quit your bitching. This is good advice, and I’m sticking with it. But I get it now. I understand why these messages can be so emotional. More important, I understand how critical they are in the healing process. While the body recovers, so, too, must the soul. And just as Jen was so important to Josh when he was in the hospital, Cassie is that important to me, if not more so.

  We settle into our own little routine for a couple of days. Neither of us is particularly worried about my health at this point. I have diabetes, and I am in a hospital. Certainly I’m no expert, but I’m pretty sure no one has died of newly diagnosed diabetes while still at the hospital. Yet on the other side of the Atlantic, mass hysteria has sprouted roots in the Liebermann household.

  My parents want by-the-minute updates that are simply impossible to give. The hospital barely gives me any information about my own health, and without Wi-Fi or a calling card, I have no way of imparting this knowledge with anything resembling alacrity to my parents halfway around the world. We quickly realize that the only thing that happens quickly here is
us realizing that nothing happens quickly here. They draw blood each morning to test my blood sugar, but I don’t learn the results until late in the afternoon, which is like a nurse taking your temperature at breakfast but not finding out what the thermometer said until dinner. Same thing for a ketone test. They ask for a urine sample the second they walk in every morning, but I don’t find out anything about my ketone levels for another eight hours.

  The difference in time zones works against us. My parents want a constant stream of information. They want to know what’s going on right before they go to bed, and they want an email waiting in their inbox right when they wake up. But since we’re eleven hours and forty-five minutes ahead of Eastern Standard Time—a difference they fail to take into account—their eight hours of sleep is right in the middle of our day when there are absolutely no worthwhile updates. And our eight hours of sleep are in the middle of their day, when they fanatically check their inboxes for our messages. At first, their emails come every few hours. “How are you feeling? What is your latest blood sugar? What are the doctors telling you?” Soon, they start coming every few minutes, to the point where we wake up in the morning with a chronological firing squad of frantic messages, each a little more panicked than the last.

  It is the worry and concern of loving parents manifested in the growing fear of distant ignorance. They are afraid because they don’t know enough not to be afraid, and they can’t do anything about it because they’re halfway around the world. I become convinced that my mom thinks I have late-stage bubonic plague, not type 1 diabetes. I tell them not to buy flight tickets to Nepal, since I plan on being out of the hospital by the time they would arrive.

  In the isolation of a disconnected hospital, I am insulated from their never-ending stream of emails and messages. Instead, Cassie bears the full force of the digital onslaught. She has a raw deal: she has to take care of me in the hospital and my parents at home. For the only time all week, the tears come from her eyes and not mine.