To the men, women and children working on ambulances around the world.

CONTENTS

COVER

TITLE PAGE

DEDICATION

INTRODUCTION

OUTBACK AMBO – AUSTRALIA

RUNNING WITH THE LEOPARD – SOUTH AFRICA

SHEIK, RATTLE AND ROLL – ENGLAND

ALL QUIET! NEWS BULLETIN! – THE PHILIPPINES

DR AQUARIUS AND THE GYPSIES – MACEDONIA

ISLAND OF THE MONSTER WAVE – THAILAND

A COUNTRY TO SAVE – PAKISTAN

THE NAKED PARAMEDIC – ICELAND

DEATH IN VENICE – ITALY

A HULA SAVED MY LIFE – HAWAII

THE CROSS OF FIRE – MEXICO

AUTHOR NOTE

GLOSSARY

ACKNOWLEDGEMENTS

ABOUT THE AUTHOR

BY THE SAME AUTHOR

COPYRIGHT

ABOUT THE PUBLISHER

INTRODUCTION

From the day of its invention the ambulance has attracted a magnetic curiosity from humans around the world. This vehicle racing to the scene of accidents and illness demands attention. When you hear one coming, you turn. When you watch it pass you wonder, if only for a moment, where it might be going, who is inside and what horrific mishap the patient has suffered. After fifteen years spent in the back of ambulances I’ve come to realise that medics and paramedics are endlessly fascinating to the public.

But despite our appeal, the truth about us is largely hidden from view. It is hidden because, in the instant we drive past we have carried our secrets away, leaving nothing more than the wail of a siren. We are hidden because the usual depiction of paramedics on film and television is mostly a fantasy. The title of hero is forced upon us, and what is lost is who we really are.

Right now, as you read this, more than a hundred thousand ambulance medics in all manner of unusual and remote locations across the planet are responding to emergencies. They are scrambling under crashed cars, carrying the sick down flights of stairs, scooping up body parts after bombings, comforting the depressed, resuscitating near-dead husbands at the feet of hysterical wives, and stemming the blood-flow of gunshot victims in seedy back alleys. A good number too are just as likely to be raising an eyebrow at some ridiculous, trivial complaint their patient has considered life-threatening. Each of these medics could fill a book just like this one, with adventures many more extreme, dangerous and shocking than those recounted here.

My fascination with the lives of people from countries and cultures other than my own is driven by my ultimate desire to understand humanity. And so I travel at every opportunity to observe how people interact, and learn why they believe what they do, how they live and how they die and how they grieve. From the age of nineteen, during periods of leave each year, I have worked or volunteered with foreign ambulance services. Whether acting as a guest or consultant, I stayed sometimes for a month, other times more than a year. Every day it has been a privilege. There are few professions like that of an ambulance worker – we have a rare licence to enter the homes of complete strangers and bear witness to their most personal moments of crisis.

Globally, the make-up of ambulance crews is varied, though it’s generally agreed there are two models of pre-hospital care delivery – the Anglo-American model based on one or two paramedics per ambulance, or the Franco-German model where the job is performed by doctors and nurses. Over recent years, a number of Anglo-American systems have also introduced paramedic practitioners with skills that, until now, have been the strict domain of emergency physicians. Pre-hospital worker profiles also include drivers and untrained attendants who can still be found responding in basic transport ambulances across many developing countries. Since cases demanding advanced medical intervention represent only a small percentage of emergency calls, it would be a mistake to judge ambulance workers as ‘good’ or ‘bad’ solely on clinical ability. Consequently, I have chosen to explore the world of many ambulance workers, no matter where they are from or what their qualifications. It is true that ambulance medics are united by the unique challenges of their job. They are members of a giant family and they understand one another instantly. While the work may differ in its frequency, level of drama and cultural peculiarities, there is no doubt that medics the world over experience similar thrills and nightmares.

As a paramedic and traveller, I’ve enjoyed the company of my brothers and sisters in many exotic locations. I’ve lived with them, laughed with them and cried with them. And wherever it was I journeyed, my ambulance family not only showed me their way of life, they also unlocked for me the secret doors to their cities and the character of their people, convincing me that paramedics are the best travel guides one can hope to have.

More than a story about the sick and injured, Paramédico is about the places where I have worked and the people I have worked there with. It’s about the men and women who have remained a mystery to the world for long enough.

So, climb aboard, buckle up, and embark with me on these grand adventures by ambulance.

OUTBACK AMBO

Australia

For two weeks I have sat here in this fibro shack along the Newell Highway listening to the ceaseless drone of air-conditioning, waiting for the sick and injured to call me. Coursework for my paramedic degree is done and all my novels are read. Now I wait, occasionally wishing, with guilt, for some drama to occur, some crisis, no matter how small, anything to break the monotony of my posting.

From time to time my mother sends me a letter or her ginger cake wrapped in brown paper. For the second time today, I drive to the post office in my ambulance.

I’m stationed in Peak Hill in central New South Wales, a town some locals might consider their whole world. But to me, a nineteen-year-old city boy with an interest in surfing and clubbing, I am cast away, marooned, washed up in the stinking hot Australian outback.

‘Sorry, champ,’ says the post officer. ‘Nothing today.’

And so I drive my ambulance around the handful of quiet streets where nothing ever changes, where I rarely see a soul. Shutters are down, curtains drawn, doors shut. Where are they all, I wonder, these people who apparently know my every move?

I turn down towards the wheat silo and park, imagining how I would treat someone who had fallen from the top of it. After that I go to meet a flock of sheep with whom I’ve learnt to communicate. Much of it is non-verbal. We just stand there, the flock and I, face to face, staring quietly, contemplating what the other’s life must be like. Now and then we exchange simple sounds by way of call-and-response. Whenever I think I’ve gone mad I remind myself that most people talk freely to their pets without a second thought.

Earlier in the year, the Ambulance Service of New South Wales sent my whole class to remote corners of the state. I understood, of course, that in our vast country with its sparsely populated interior, everyone is equally entitled to pre-hospital care. Only problem is that few applications to the service are received from people living in the bush. Instead, young, degree-qualified city recruits from the eastern seaboard end up in one-horse towns.

As I entered the Club House Hotel in Caswell Street on my first night, twelve faces textured like the Harvey Ranges turned my way, looked me up and down taking in my stovepipe jeans, my combed hair and patterned shirt. As if my appearance was not out of place enough, I foolishly ordered a middy of Victoria Bitter and the room erupted in thigh-slapping laughter. Before I ran out, a walnut of a man nearest to me leant over to offer some local advice.

‘Out here, mate, it’s a schooner of Tooheys New, got it?’

I never went back to the pub, at least not socially. When called there in the ambulance for drunks fallen over, I was always greeted with the same row of men in the same position at the bar, like they had never gone home. It didn’t take me long to realise I’d need to find entertainment elsewhere.

In less than a month Kristy Wright, an actor playing the role of Chloe Richards on the evening soap Home & Away, has become the object of my affection. As the elderly will attest, a routine of the ordinary brings security of sorts, a familiar comfort, and Home & Away is just this for a lonely paramedic with too much time on his hands and not enough human company. Kristy is not particularly glamorous, nor is she Oscar material. Perhaps it’s her likeness to my first proper girlfriend, a ballerina who ran off to Queensland, married someone else, and broke my heart. Whatever the reason, I’m deeply smitten and make sure never to miss an episode.

For a small fee I have taken accommodation in the nurses’ quarters on the grounds of Peak Hill’s tiny brick hospital with its single emergency bed. Adjacent to the hospital lies the ambulance station consisting of a small office, a portable shed with air-conditioning and a garage containing an F100 and a Toyota 4x4 ambulance for difficult terrain. My new home next door is a freestanding weatherboard cottage, a little rundown but quaint nonetheless. Lodging at these nurses’ quarters initially sounded quite appealing to a young, single man, but the place never came with any nurses in it.

At 8 pm I ladle some lentil soup out of a giant pot I prepared earlier in the week, heating it up on the electric stove. After dinner, at 9 pm, I run the bath, making sure my blue fire-resistant jumpsuit is hanging by the door and my boots are standing to attention below, ready for the next job – if I ever live to see it, that is. Two slow weeks and I’m beginning to think they should close the ambulance station down before their assets rust away. The population plummeted a few years ago when Peak Hill’s gold mine hit the water table and ceased operations. Locals left behind would disagree, but maybe ambulance stations ought to come and go with the mines.

When the call finally comes it catches me off guard, just as I knew it would, cleaving me from a deep 4 am sleep.

‘Huh?’ I grunt into the phone. The dispatcher in the Dubbo control room 80 kilometres away sounds just as vague.

‘Okay, what we got here, let me see, ah, semi rollover on the Newell Highway six kilometres south of Peak Hill … well, that’s about all I have, mate … good luck with it.’

I hang up, slide out of bed in my jocks, splash my face at the bathroom sink, head to the door.

Keys, keys, ambulance keys. I teeter on the remains of sleep, trying to think of where I put the keys. When I throw my legs into the jumpsuit I’m relieved to hear them jingling in a pocket. My boots are on and I’m out.

The engine of the Ford springs to life, the V8 gives a mighty roar, a call to action. Adrenalin, like petrol charging through the lines, ignites me for the fight. I flick on the red flashing roof lights, the grill lights on the front, and then, as I skid onto the highway, I let the siren rip through the stillness. There’s not a car in sight, no one at all to warn of my approach, but this run is for the hell of it. I’m doing it because I can, because for two weeks I’ve been bored out of my brain and I’ll be damned if I won’t make the most of a genuine casualty call.

The Ford is a missile; eight cylinders of muscle thundering down the highway. In no time I cover the six kilometres, wishing the crash was further away for a longer drive. Last month it took me sixty minutes on the whistle travelling at speeds of 150 kilometres per hour to reach a child fallen off a horse at a remote property.

Up ahead a pair of stationary headlights in the middle of the road beam at me. They appear, at first, to be sitting higher than normal, but when I get closer I realise the semitrailer to which they belong has flipped upside down. It’s a most peculiar sight.

No one has motioned me to stop. In fact, there is no one about at all, not even Doug the policeman. Further down the road I spy another truck pulled up with its hazard lights on and assume this driver must have called the job in.

The motor of the upturned semi is still idling. It’s an eerie sound in the absence of any other. I decide that, for the purpose of making the scene safe and preventing an explosion, I ought to switch it off.

From what seems to have been the passenger side of the truck a steady stream of blood runs slowly to the shoulder of the road. The entire cabin of the semi is crushed and when I call out ‘Hello there!’ I don’t even get a grunt of acknowledgement.

This is my job, I remind myself. It falls on no one else. It is precisely my duty, without further delay, to climb underneath the overturned truck, attempt to turn off the ignition and ascertain the number and condition of its occupants.

With a small torch in hand, I get down on my chest and crawl into a narrow passage about a foot high with twisted metal and shattered glass all around, my head is turned on the side, oil and bitumen brush my cheek until I reach an opening in front of me. Here I’m able to lift my head up and take a look around. When I do this my heart jumps like a stung animal as I find myself face-to-face with the driver, his head pummelled into a mushy, shapeless mess, his mouth gaping wide and a single avulsed eye glaring at me. For the first time ever I am simply too startled to shriek or utter any sound whatsoever. Confined like this makes a rapid retreat difficult. Instead, I am frozen in horror, just as the driver’s face may have been in the moment before it was destroyed by his dashboard.

After a few seconds, when I regain a little composure, I reach up to the keys dangling in the ignition and turn off the engine. At the same time I see a photo of a woman and child, smiling at the camera, some birthday party. Perhaps it was the last image the man saw before exhaling his final breath.

Almost as slowly as I entered the cabin I extract myself and return to the ambulance, shaking ever so slightly, to give Dubbo control a report from the scene.

It takes Peak Hill’s SES Rescue Squad five hours to remove the driver’s body. Most of this is spent waiting for a crane to arrive from Parkes. I stand in the shadows clutching a white folded body bag, reluctant to join the rescue volunteers, all ex-miners and rough farmhands cursing and spitting and slapping each other on the back.

At the hospital, the nurse on duty has called in Peak Hill’s only doctor, a short Indian fellow, to sign the certificate. When I unzip the body bag and pull it back, all colour drains from the doctor’s face, his eyes roll into his head and he grips the wall to stop himself from passing out.

‘Doc may need to lie down for a while,’ I say to the nurse as she leaps forward to prevent him falling.

By the time I finish at the morgue the sun is high over the Harveys and I reverse the ambulance into the station, putting it to bed for another two weeks.

Most of Peak Hill’s indigenous population lives in what is still known as ‘the mission’, a handful of streets on the south side of town once run by missionaries. In comparison to many Aboriginal missions in the Australian outback, the houses are fairly tidy and the occupants give us little trouble. Except for Eddy and his extended family, that is. When things become too monotonous in Peak Hill one can always rely on Eddy to get pissed, flog his missus or end up unconscious in someone’s front yard. Empty port flagons line the hallway of his house, a house without a door and with every window smashed in. Half the floorboards have been torn up for firewood in the winter.

Jobs often come in spurts and on the day after the semi rollover I scoop Eddy onto the stretcher and cart him to the hospital for his weekly sobering-up. In straightforward cases like this I work alone, making sure to angle the rear-vision mirror onto the patient for visual observation. Occasionally, to be certain the victim doesn’t pass away unnoticed, I attach a cardiac monitor for its regular audible blipping. This way I can keep my eyes on the road ahead.

Longer journeys are a little trickier. For these I must evaluate a patient’s blood pressure every ten minutes or so by pulling over and climbing into the back. It is hardly ideal, but sometimes necessary when I’m unable to find a suitable or sober candidate to drive the ambulance for me. A strategy the service conceived many years ago was to recruit volunteer drivers from the community, people familiar with the names and location of distant cattle stations and remote dirt tracks.

Charlie, a hulk of a man with handlebar moustache and hearty belly laugh is the best on offer. Unfortunately his job as a long-haul coach driver means he’s rarely in town when I need him. Perhaps one day he will join the service full-time.

As for Lionel, Peak Hill’s only other volunteer officer, he is simply too crass to take anywhere at all. Unshaven, slouchy and barely able to complete the shortest string of words without adding expletives, Lionel is my last resort. Nonetheless, his job as the hospital caretaker means he torments me with racist, redneck tales and invitations to bi-monthly Ku Klux Klan gatherings held at secret locations in the Harvey Ranges. His open dislike of ‘boongs’ – a derogatory term for Aboriginal people – is another reason I don’t take him on jobs in the mission. Lionel’s most beloved pastime is ‘road kill popping’, which involves intentionally driving over bloated animals with his Ford Falcon in order to hear them ‘pop’ under the chassis. Worse still, less than a month after my arrival in Peak Hill, he snatched a snow-white cooing dove from the eaves of the ambulance station and ripped its head off, whining about the ‘pests’ inhabiting the hospital rafters. This callous act prompted me to slam the door in his face.

When my family drives up from Sydney to pay me a visit I take them to the Bogan River, just out of town. It’s a sorry little waterway but there are several picnic spots to choose from. In the shade of a snow gum we spread out a tartan blanket. My mum unwraps her tuna sandwiches and pours out the apple juice while my dad reflects on the subjects of solitude, meditation, Jesus in the desert. My sister and brothers are not normally so quiet and I sense everyone feels a bit sorry for me, as if I have some kind of incurable disease, all because I’m stuck here in Peak Hill.

Later that night, as no volunteer drivers are available, my dad offers to join me on a call to the main street. He’s still tying the laces of his Dunlop Volleys in the front seat when I pull up at the address. Above the newsagent, in a room devoid of any furniture, an eighteen-year-old male is hyperventilating and gripping his chest. The teenager is morbidly obese for his age, thanks to antidepressants and a diet of potato chips and energy drinks. What he is still doing in this town, estranged from his parents, roaming about jobless and alone, is beyond me.

‘My heart,’ he moans.

As I take a history and connect the cardiac monitor, I relish this rare moment. Doesn’t every son secretly dream of impressing his father with knowledge and skill? Our patient hardly requires expert emergency attention, but Dad observes my every move and his face is beaming.

Suspecting the patient has once again consumed too many Red Bulls, I offer him a trip to hospital and he nods. If I were him I too would rather spend my evening with the night-nurse than sit here alone. Once loaded up, I throw Dad the ambulance keys and give him a wink.

‘Wanna drive? Someone’s got to keep him company.’

For a second or two Dad stands there looking like a kid on Christmas morning.

No one visits me after that for the rest of my time in Peak Hill, but six months in I’m less concerned about isolation. Routines I’ve constructed help the time pass. I’ve also begun to feel the subtle tension that simmers below the surface of every country town, the whispering voices from unseen faces and the contradiction of personal privacy coupled with the compulsive curiosity to know the business of others. A lady in the grocery store last week was able to recite to me my every movement for three consecutive days: what time I left the station in the ambulance, where I drove to and what I did there. Sheep are dumb animals, she told me. My efforts to communicate with them at Jim Bolan’s property were futile and stupid. I was speechless. Never on any visit to my fleecy friends had I seen another human being. Perhaps the sheep themselves were dobbing me in? Back in Sydney, where people live side by side and on top of one another, a person can saunter about naked in the backyard and no one pays the least bit of notice. Those who imagine they will find some kind of seclusion in a country retreat should think again.

It’s August and my cases last month entailed an old man dead in his outhouse for at least a fortnight, a diabetic hypo to whom I administered Glucagon by subcutaneous injection and a motorcyclist with a broken femur on the road to Tullamore.

After browsing the internal vacancies around the state, I decide to apply for Hamilton in Newcastle. One of the controllers in Dubbo is a keen surfer like me and whenever he calls for a job we joke about starting a Western Division surfing team. I regret telling him about the Newcastle position because he immediately says he will go for it too, his length of service giving him a clear advantage.

As steady as I may be going in Peak Hill, the month ends with an accident that changes everything, an accident forcing me to leave town for my own safety.

At 10 pm on a Friday night I am in bed, lying awake in a silence one never hears in Sydney, imagining the wild time my friends are having there, bar-hopping around Darlinghurst and Surry Hills, seeing bands and DJs, laughing and flirting with girls.

When the phone rings, I jump back into the cold, dark room, sit bolt upright, snatching the receiver.

‘Peak Hill Station.’

‘Yeah mate, let’s see … some kid hit by a semi on the main street, says it’s near the service station. I’ll sort you out some back-up from Dubbo. They’re just finishing a transfer so it might be an hour or so, maybe forty-five – if they fang it. Booked 10.01, on it 10.02. Good luck.’

No matter how many truck drivers Doug the policeman books for speeding through the main street, few semitrailers slow down much. They have a tight schedule and Peak Hill is just another blink-and-you-miss-it town clinging to the highway.

As it turns out, the fourteen-year-old Aboriginal boy lying in the gutter has only been ‘clipped’ by the semitrailer, a hit-and-run, although I suspect the driver wouldn’t have noticed. A crowd from the mission has quickly formed and they urge me to hurry as I retrieve my gear.

‘C’mon brudda, ya gotta help tha poor fella, he ain’t in a good way mister medic.’

Relieved to find the boy conscious, I put him in a neck brace and begin a quick head-to-toe examination to ascertain his injuries. As I’m doing this I feel a hand squeeze my buttocks, more than one hand, in fact, until a good many are occupied with my bum cheeks. I look around but the crowd encircling me is too dense to identify a particular culprit. I wonder where Doug the policeman is, he always seems to arrive well after a drama is over.

The crowd shuffles back half a foot when I ask for some room, but pushes in again when I take a blood pressure reading. A second time I feel the hands, this time squeezing and caressing my buttocks with renewed enthusiasm, one of them even giving me an affectionate little slap. Such a thing is most distracting in emergency situations. Moreover, it’s shameless sexual harassment. I grab my portable radio, calling for urgent police assistance. That should wake Doug up, I think to myself. Again I demand the onlookers move away, but my request is ignored.

‘Listen brudda,’ says an elder among the group. ‘We don’t trust you whitefellas, we gotta watch you, make sure you do us a good job, you know wad I mean?’

Finally Doug turns up, huffing and puffing and waving at the crowd to move on. Reluctantly they do, now giving me space to load the patient. Doug offers to drive the ambulance to the hospital and I call off my back-up from Dubbo as the boy seems to have suffered little more than minor abrasions.

Early the next morning I am woken by the sound of a car with holes in the muffler going up and down the dirt road beside the nurses’ quarters. Crouching low, I crawl in my underwear to the kitchen where I’m able to peek out between the lace curtains on the window above the sink. Idling on the grass outside my place is a beaten-up, cream-coloured Datsun packed with Aboriginal girls.

‘Shit,’ I curse to myself. From my position at the window I can make out their conversation as they speculate on my whereabouts.

‘He ain’t come out from that house all morning, I reckon he in there, he in there, I’m telling ya.’

‘Maybe he gone walkabout.’

‘He ain’t gone walkabout! Ambo guys don’t go walkabout, they gotta be ready, you know, READY!’

‘Yeah, and we seen two ambulance in that big shed, means he in there, he in there for sure!’

Not wanting to get caught undressed, I crab-crawl my way back to the bedroom and throw on my uniform, complete with all its formal trimmings. Maybe if I wear the tie and jacket with gold buttons down the front and speak with a firm tone I can scare off my stalkers. By the time I psych myself up to step out and challenge the girls – a butter knife in my pocket for reassurance – the Datsun does a donut, whipping up a cloud of dirt and farts off towards the highway. The girls catcall before the car shudders over the cattle grate at the end of the track and disappears.

I phone Doug and explain the situation.

‘Yeah, I heard,’ he says.

‘Heard what?’

‘The blackfellas are a bit upset with you.’

‘Me? Why? I did fine with that kid last night.’

‘Sure you did but you also got yourself a big problem in the process, mate. Those Koori chicks are trouble and you’re the talk of the mission today. Heard they even got a special name for you, what is it again? Ah, Romeo! That’s it!’

‘Romeo?’

‘Romeo, as in Romeo and Juliet, you know, that movie that’s just come out?’

Baz Luhrmann’s sexy contemporary interpretation of the Shakespearean classic had recently done good business at the Australian box office. Even Aboriginal kids in Peak Hill, miles from any cinema screen, knew about it. Unfortunately I didn’t look anything like Leonardo DiCaprio. How could the girls have come to such a comparison based on the quality of my arse alone?

‘Take it from me mate, whatever you do, don’t be going down the mission on a job, understand? You’ll either be set upon by the women or a jealous bloke will glass your throat.’

He paused for a moment. ‘Actually, you got to get out of here.Those girls won’t let up until they pin you down. Literally.’

‘But Doug, you’re a cop for crying out loud!’

‘Come on. Cops can’t touch no blackfella these days, let alone a female of the species. You know that. Sorry to tell you this, mate, you’re on your own.’

Never have I covered the 20-metre distance between the nurses’ quarters and the ambulance station in less time. Whatever door I pass through, I make certain it’s bolted behind me. Despite Doug the policeman’s fear-mongering, if a call comes in for the mission I have every intention of making an official request for his assistance. This way he cannot, by law, refuse to help me. The idea of driving anywhere near the southern part of town has put me on a knife’s edge. What’s to say a bitter indigenous bloke down there doesn’t ring triple-0, fake some illness and jump up to strangle me with my own stethoscope?

My hopes of being nothing more than a passing interest are dashed the following day with the approach of the Datsun again at 10 am. It circles the ambulance station five or six times, coughing and backfiring. The car eventually skids to a stop and one of the girls gets out and peers through the window to see if I’m inside. Lying motionless behind the lounge, hiding for a good ten minutes, I wonder what my job has become. There is no question in my mind how different a situation like this would be if I were a female paramedic and my stalkers were male.

The Bogan Times comes out on Monday and ‘Peak Hill’s Romeo’ is front-page news: ‘Local Ambo Talk of the Town!’

Management in Dubbo are concerned. My wellbeing is under threat and the service has a responsibility for my safety next time there’s a call to the Peak Hill mission.

Within a week I get surprising news. Out of all the applications for Hamilton Station, mine has been selected and I’m offered the position. With little hesitation I accept. Although I’m told the merit of my application won me the position, I’m unconvinced. My transfer takes effect immediately, which rarely happens. It seems obvious to me that the Newcastle job offer and my report of sexual harassment are no coincidence at all.

On the afternoon I get my transfer letter the Koori girls arrive again for their daily patrol. This time I lounge on the verandah in my underwear and give them a wave. Having eluded them for a fortnight, the girls scream in delight. A moment later the Datsun stalls and skids into a ditch. As the girl driving curses and tries starting it again, her accomplices lean out of the windows, yelling at the top of their voices.

‘Hey, white boy!’

‘Love your arse, white boy!’

‘How about it, white boy!’

None of them actually leaves the car, and I sense for the first time they are too shy to come any closer.

‘Love you, white boy!’

‘Come and see us, white boy!’

Finally the engine splutters back to life. Before they pull onto the track again I make sure to blow them a kiss.

‘Thank you, girls! Thank you!’ I call after them.

The Datsun tumbles down and away in a flurry of hooting horns, wolf-whistles and flailing arms. When the dust settles and the road is quiet again, I’m overcome with shame for my unfounded anxieties. How harmless these girls were in reality, making the most of their life in this drab, nowhere town. A little innocent fun is all they ever wanted. Having finally lured the white boy medic from his house, I know in my heart they won’t be back.

But neither will I.

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.

SHEIK, RATTLE AND ROLL

England

On the rain-drenched morning Henry takes the wheel I am secretly relieved the old man we are carting from one sad nursing home to another is afflicted by a state of dementia so advanced he is seemingly oblivious to our existence and stares silently ahead into a land beyond. Normally I wouldn’t wish the illness on my worst enemy. But as Henry pushes the siren and races down Herne Hill towards Brixton at the speed of a Grand Prix driver on amphetamines, it’s a good thing our patient – someone’s dear grandpa – is numb to it all. The old man bounces around like a leg of ham in a delivery van. In fact, groceries and daily mail probably get better rides than this in London.

Approaching the intersection of Milkwood Road and Half Moon Lane is where we have the fourth near miss of the day. A car appears from nowhere, as Henry puts it afterwards, making it sound like a supernatural phenomenon beyond human comprehension. While hurtling through the red signal without slowing I assume this apparition has approached from the right, but I see nothing at all as I’m riding in the back clutching a crossbar with one hand and the patient’s shoulder with the other. When Henry plants his generous weight on the brakes I’m only half ready for it. Equipment flies into the front cabin, some of it catching me while passing. Airborne oxygen masks and kidney dishes are the least of my concerns. Our old man, drooling and wide-eyed, has long lost the instinct to hold onto the stretcher rails and our extreme deceleration threatens to catapult him through the windscreen. I have little choice but to throw myself on top of the patient, his brittle bones digging into me as I pin him to the mattress with my body. A sound of screeching tyres and angry horns is followed by the choking smoke of burning rubber pumping into the back of the wagon.

‘You all right, geezer?’ Henry asks once he has pulled over past the intersection, his face pale and puffing.

‘Think so,’ I say in a neutral tone, until it occurs to me how pissed-off I really am and I add, ‘Why the urgency anyway, mate? We’re going to a bloody nursing home.’

‘He should ’ave seen me comin’, tha bastard.’

But Henry has only himself to blame and he knows it. Lights and sirens are merely a request for people to give way, not a demand.

Henry’s hands are trembling as he collects the bits and pieces littering the front cabin. Though he seems shaken, I know he will do it again, maybe even today. Like a poker machine that eventually pays out, we’re long overdue for a prang. And if eventually he kills a man, or more than one, I want nothing to do with it.

Got to quit, got to quit, got to quit.

What am I still doing here?

With its prestigious-sounding name no one would suspect a shoddy operation from this private Harley Street ambulance service. Ambulances plush as limousines, I thought. Only these would satisfy the British high society and foreign millionaires who visit the nation’s famous strip of specialist rooms and luxury clinics.

Perhaps the greatest insult one can give a genuine paramedic is to call him or her an ambulance driver, yet this is what I was, my paramedic degree as useful as a sheet of toilet paper. The art of driving grannies to doctors’ appointments had, as I recall, never been covered. Why my skills were unattractive to the London Ambulance Service (LAS) when I applied for recognition of prior learning, I just don’t know. The LAS was naturally my first choice, but the process facing foreign paramedics hoping to get on London’s ambulances is known to be so long and painful that most don’t bother. Ironically, ambulance services in sunnier countries of the world like Australia and New Zealand have made quite a business of poaching British paramedics and have done this so aggressively over the past decade it has created a shortage of paramedics in England, and a minor political storm.

Wasted skills aside, better money can be made working for private patient transport services anyway, even if it represents a significant drop in action. Nor is it wise to remain jobless while waiting for the bureaucratic process of the National Health Service. As Iraqi doctors and Iranian surgeons flipping burgers in London’s takeaway joints can attest, survival rules over pride in this cruellest of cities. Yes, we’d all like to work in our chosen careers, but decent heating and square meals are the only way to get through winter, and Kass, my then girlfriend now wife, needs a new woollen coat. Still, I wish we had chosen Barcelona over London when deciding on a city in which to base ourselves for a few years of European exploration.

It’s colder than deep-sea diving off Alaska. Even with the windows up and my green fleece zipped tight I feel like an ice sculpture. We drop the patient off at his five-star nursing home – quite literally ‘drop’ as Henry claims he ‘wasn’t ready’ with the head end of the stretcher at the moment I called ‘one, two, three’. I’ve come to expect this kind of thing when Henry is way past his fried chicken and chips time. It will be his third lot in a single morning. Another of his shirt buttons is sure to pop before the day’s end.

We park at a Harley Street corner so we can make a rapid response to the next boring transfer. As the rain thunders on the window, I watch Henry munching fried chicken, getting it tangled in his scraggly ginger beard and dropping it down the front of his uniform. In fact, his uniform is already stained from previous fried chickens. With a belly like that there’s only one place falling chicken tends to land.

‘So, you is telling me you once got a hundred quid tip off a Arab?’ he says as he eats, displaying the contents of his mouth.

‘Yeah, Kuwaiti royal family.’

‘Kuwai-i royal family?’ he licks his lips, looks annoyed. ‘I neva got nufink offa tha Kuwai-i royal family. Took one of ’em in too, I did. Had a hip done, he did. But tha Kuwai-i royal family never looked arfta Henry, did vey.’

I sigh and glance at my watch, wondering what the Kuwaiti royal family would have thought about an ambulance stinking of fried chicken, driven by a maniac.

‘Mate, you know we got a Arab later on,’ says Henry, ‘four-firtey in from Heafrow …’

‘An Arab, Henry, it’s an Arab.’

‘Yeah, dats wot I said, a Arab.’

Worst thing about having an ambulance with a broken stereo is that it forces one to listen to a partner chewing fried chicken and using bad English in England.

‘Well,’ I reply, ‘it’s nearly two o’clock, and you know the traffic.’

Henry knows the traffic all right. This is part of the problem. He loves nothing more than to plan his day so that unless we use our lights and sirens we’ll be late to every appointment and pick-up. This is because, quite frankly, he loves to use the lights and sirens. When I first met Henry I spotted him right away as a wannabe paramedic who never made the grade. Being an ambulance driver is a little boy’s fantasy as much as being a train driver or bus driver. In most emergency medical systems, however, ambulance drivers must also use clinical skills normally reserved for doctors. This naturally excludes a good number of candidates, Henry included. Society is full of disappointed men and women who have longed to drive ambulances from the age of five when they spent each day constructing matchbox car crashes and sending matchbox ambulances to the scene. Recruitment departments of public emergency services are perpetually inundated by such applicants and spend half their time palming them off.

The only other qualified paramedic working at the company was fired from the London Ambulance Service for visiting a Kensington barbershop while on duty. When I heard this I told him it sounded like unfair dismissal. Medics are normally permitted to visit coffee houses and corner stores in their catchments so long as they can quickly respond. Why not a barbershop? I mean, how long does it take to throw off an apron, brush down a uniform and go out with half a cut? Not long at all. If anything, the gentleman’s commitment to looking sharp and tidy in the workplace should have been commended. As much as I’d prefer it I’m never assigned to work with him. Our boss wants one qualified medic per wagon. And apart from the two of us, the rest are a bunch of fantasists who recently discovered a community college somewhere outside London conducting a five-day first-aid course they believe allows them to use the title ‘paramedic’. Never mind it took me four years of study to earn the same. While I don’t bother wearing anything at all to identify myself as one, these men could not be more decorated. From emergency service catalogues they have mail-ordered paramedic insignia of every description. Cloth patches, embroidered epaulettes, shiny badges, clip-on pins, reflective vests and so on, all emblazoned with the word ‘paramedic’; one ambulance driver is so covered in pins and badges he looks like a walking Christmas tree.

Then there is the gear. While I have trouble locating my stethoscope most days, these men have got every imaginable utility dangling from their belts. There are Leatherman knives, wallets for gloves and scissors, phone holders, torches of various sizes, rolls of Leucoplast, radio holsters, mini disinfectant dispensers, rubber tourniquets and various other oddly-shaped black pouches containing everything but handcuffs. All these are attached for the prime purpose of looking as much like a paramedic as possible, or at least how they imagine a paramedic must look. This I find most entertaining and wonder how I’ve managed to do the same job for so long with nothing on my belt but a buckle.

While some veteran medics would be irritated by such things, I am way more frustrated by the widespread and reckless use of emergency warning devices.

Prince Abdullah al-Sabah’s private jet is to land at Heathrow in twenty minutes and, as I remember from my last conversation with an al-Sabah, they are not fond of tardiness. The Sabahs are thought to hold the largest number of shares in almost all blue-chip companies in the Western world and to have a combined family wealth of US$200 billion. On first meeting the Kuwaitis, my politeness to a veiled female family member was generously rewarded with a crisp fifty pound note pulled from a wad of cash thick as a brick and dispensed by a keffiyeh-wearing aide. Accepting money from patients beyond the agreed payment for services is considered unethical in the medical profession and strictly forbidden for government ambulance workers and hospital staff. But in London’s private health care, tipping seems somehow acceptable and is not uncommon.

‘White car on the left!’ I warn Henry as he comes dangerously close to clipping a sedan that has failed to pull over far enough.

My head is throbbing with the beat of the siren. The Ford Transit parts traffic out of the city like Moses did the Red Sea. It’s slow going, but we’re getting through faster than anyone else.

What is the public thinking, I wonder, those distressed commuters struggling to edge out of our way, imagining the worst? What if they knew that Henry was using his lights and sirens because he thinks it’s fun, because he intentionally ate his fried chicken slow enough for the traffic to build up? And what if they knew I was letting him do it because I’d hate to be late for the Kuwaiti royal family, because I’m hoping for another tip, more than last time – if I’m lucky.

Back in Sydney severe consequences result from the inappropriate use of lights and sirens. Not that we’d bother, anyway. We’re so busy most of the time it’s a relief when the siren is off, allowing us a little peace and quiet. Warning devices are only a novelty for those who don’t use them much.

‘Ow of tha way! Comin’ fru! Move it! Move it! Move it!’ shouts Henry.

‘They can’t hear you,’ I say, wishing he’d shut up.

‘All right, but vey can see me, can’t vey.’

‘See you what?’

‘See me yellin’. Yellin’ and gesticalatin’!’

I don’t know how many private ambulance services there are in London, but ever since routine patient transport was outsourced, every little boy rejected from the LAS could finally drive an ambulance as fast as they like with ‘blues and twos’ – blue flashing lights and a two-tone siren. It was absurd and out of control. By my second day at this company I’d survived three near-death experiences and one flying patient. But when I raised the matter with the boss – a middle-aged, chain-smoking, sarcastic woman with the face of an East London gangster – she looked me square in the eye and croaked, ‘You know by now what the traffic in London is like, son, don’t you?’

And I replied, ‘Yes, but it’s dangerous going fast without a pressing reason.’

And she said, ‘Harley Street patients are special, you understand. They expect the best. They have never waited for anything in their lives. They don’t expect to lie in ambulances while our drivers inch along in traffic, do they now?’

But a day later she inadvertently revealed her true reason for ignoring the fun crews were having with lights and sirens when Henry called up and told her we were unlikely to complete two jobs in the designated time frame.

‘Well,’ she said via the crackly radio, ‘what have you got those pretty lights on your wagon for, Henry?’

Turnover. It is all about turnover and profit. The faster we do a job, the quicker we’re on to the next. We make deliveries like any courier company, but because we deliver human cargo we can make our deliveries in half the time by halting on-coming traffic and momentarily paralysing city intersections.

Henry brakes heavily. ‘Wanka!’ he shouts.‘Got evry fink on, idiot!’

And with everything on we skid into Heathrow making such a racket that for a second airport security must think some hijacking has taken place without their knowledge.

But no, all this Arab wants is a quality heart bypass.

We meet the patient sunk into a deep leather recliner in the lavish corporate jet building, a man in his sixties wearing a stiff white dishdasha and rockstar sunglasses. He’s very pleased when I greet him with the traditional Assalam Aleikum but looks with a little disgust at Henry who struggles to negotiate a leather ottoman with the stretcher.

‘How was your flight?’ I ask the sheik.

‘Bekhair,’ he says, and his aide appears, a different one from last time, and translates.

‘Fine, he says flight is fine, thank you,’ says the aide.

Henry is by my side now. I can smell him.

‘Good to go ven?’ he asks, looking at the aide expectantly. But no wad of cash appears and we stand in awkward silence, a silence like the one after hotel porters take your bags up and you don’t have any change to tip them with. Why Henry expects the sheik will slip him some cash before he’s been driven anywhere is beyond me.

After half a minute, Henry readies the stretcher and we help the sheik climb on.

It’s a rough ride back to Harley Street. I’ve strapped the sheik down well but notice the skin over his knuckles blanche while gripping the stretcher rails. The sheik says something loudly to his aide, raising his voice over Henry’s siren. I fear that any chance of getting a tip now is out of the question. But I’m wrong. Instead of lodging his complaint about the journey, the sheik’s aide leans over and thrusts a fifty pound note into my palm.

‘No, no, I’m not supposed to take this,’ I protest.

But Henry’s siren is so loud I can’t really hear myself and when I try to hand the money back the sheik’s aide takes it and forcefully stuffs it into my top pocket. There is a certain desperation in the way he has given me the tip that makes me think for a moment I’m being bribed to take the wheel and slow things down. When Henry veers sharply to avoid something and leans on the horn for thirty seconds, cursing grotesquely, I consider it. In Kuwait, my partner would be promptly executed for driving like this with an al-Sabah on board. ‘Allah, Allah, Allah!’ cries the sheik.

Really got to quit, I think. The fifty pounds in my top pocket will hardly tide me over until the next job. But I don’t care.

After dropping off the sheik at a cardiologist, Henry curses the Kuwaiti royal family for not helping us out and how the House of Saud is far more generous.

I shrug, choosing not to mention my tip.

‘Henry,’ I say politely as we reach the Baker Street tube station, ‘you don’t mind dropping me off here, do you?’

‘Right ’ere?’ he asks, raising his eyebrows.

‘Yes please. And do me another favour, will you?’

‘What’s tha’?’

‘Tell the boss I’ve resigned.’

ALL QUIET! NEWS BULLETIN!

The Philippines

Lumbering like the giant propellers of an ocean liner, the fan blades turn too slowly and too high above us to cool the night. But the loose chugging and whooshing is sending me to sleep. Behind a heavy wooden desk illuminated by a strip of neon screwed into one of the peppermint-green walls is the chief of the Philippine General Hospital’s Emergency Medical Service, Manolo Pe-Yan, a plump man, unusually serious for a Filipino. Seriousness, however, does not always translate to professional appearance and Manolo is wearing the same singlet he’s been wearing for a week, stained by a dark bib of sweat, his head tipping forward then up again as he sleeps.

It’s 1 am on a Saturday morning. Two white uniform shirts are hanging on the posts of a single steel bed beside me. Snoring soundly upon it, curled up together despite the heat, is a crew of emergency medical technicians (EMTs) seemingly content with the status quo – a parked ambulance and no calls on a night when all manner of accidents and murders are occurring in the action-packed metropolis. A stone’s throw from where these medics are sleeping there is a constant stream of jeepneys, taxis and tricycles screeching to a halt outside the hospital emergency department. Onto the doorstep their contents are dumped: an assortment of stabbed and mauled victims; unconscious men with occluded airways, bodies made limp by the fractures of long falls and pedestrians with broken necks. Last week I worked a few shifts in the emergency department and dragged these people in, seeing how nasty and critical injuries and medical cases become without pre-hospital care. And while I did this, across an island of lawn and flowerbeds, under a low tin awning, two beautiful late-model Chevrolet ambulances stood washed and polished – and silent.

‘Okay, tayo marinig ng ibang song!’ Another Filipino hit is announced on a little transistor radio. It’s all we listen to. A World War II ceiling fan and cheesy music, neither of which is ever switched off – the ceiling fan for obvious reasons and the radio because, in its truest definition relating to ambulance work, we are listening out for jobs. There is still no central emergency number in The Philippines, no control room or ambulance dispatch. So we wait, as we do most days and nights, monitoring the half-hour news bulletins on ordinary FM radio and the occasional updates between Pinoy rock classics by Sugar Hiccup and Tropical Depression. Occasionally, maybe once a week, a member of the public will arrive breathless at the ambulance station, pointing in the general direction of some traffic collision nearby. But mostly we wait for a radio announcement – sometimes for weeks on end – about a pile-up on one of the many highways and skyways crossing Manila. Last month, both ambulance crews took it upon themselves to respond to a train derailment after hearing a report on the radio, but have since done little else.

The air is thick with humidity and the smell of green mangoes. I look around the room and see I’m the last one awake. Having no comprehension of Tagalog, the 1 am news means nothing to me. Half of Manila may have gone up in flames and I wouldn’t know. Nor would my colleagues stir from their slumber. There is nothing to do but stretch out on a bench near the door and submit to the urge to close my eyes.

In heat like this my dreams are always bizarre. The emperor of a mighty country, suddenly inspired into a random act of generosity, orders all hungry tramps in the land to be issued a jar of his finest caviar. But one of the tramps is unhappy and says, ‘Just give me a damn sandwich!’ The tramp says this about the same time I wake up and turn over. While I drift off to sleep again I comprehend the dream may well have been about our two ambulances donated by the United States government. They came with the latest, high-tech equipment, with pulse oximetry, twelve-lead ECG machines and pneumatic ventilators. Like caviar to a tramp are these ambulances to The Philippines’ largest public hospital. Only yesterday we took a patient in from another facility hooked up to our automatic ventilator and found there were no ventilators in the intensive care unit of the hospital. How odd it was to see our state-of-the-art device replaced by a simple bag-valve-mask – a bag manually squeezed every four seconds or so by the patient’s beloved without interruption, sometimes for months. No wonder the bag-valve-mask is known here as as a ‘relative ventilator’. And because the chain of health care is only as strong as its weakest link, there was considerable discussion among the EMTs about why they bothered connecting the ventilator in the first place. More interesting to me was to volunteer in a country where ambulances are better equipped than the hospitals they deliver to. It’s May 1998 and I’m only here for six weeks – half my time ambulance-riding, half island-hopping – far too short a period to help create awareness of a paramedical service among twenty million people in the most densely populated city in the world.

Manolo nudges me with a Philippine breakfast plate of champorado – a combination of sticky chocolate rice served with salty fish, a fish which I detest and usually discreetly dispose of so as not to offend my hosts.

‘We have very important meeting in the evening, Joe,’ grunts Manolo, using the rather annoying nickname I share with every other Western male who bears the slightest resemblance to an American GI. Manolo’s face doesn’t give anything away, even when I know he’s being funny. I’m certain it’s his own type of humour, that he’s one of those straight-faced funny men.

I raise my eyebrows and take the bowl.

‘Chinese Fire Brigade again?’ I ask.

‘You’ll see, Joe,’ he answers.

The two EMTs, Juan and Fermin, are awake. Fermin is brushing his teeth in a sink by the door while Juan runs a comb through his hair over and over again, staring ahead with a drowsy gaze. Neither of them bothers getting into their uniform shirts. They only do this if a job comes in or while escorting me across town to the headquarters of the Chinese Fire Brigade where I lecture in first aid. Three nights ago they also turned out nicely for a dinner with the fire chief whose selection of deep-fried insects and marinated grubs revolved on the centre of the table like a carousel of horrors. With this grisly platter still in mind, I hope this evening’s meeting will be nowhere near Chinatown.

Manolo snaps at Fermin to turn off the tap.

‘All quiet! News bulletin!’ he barks.

Roadworks have begun on a new flyover and taxes will go up for a year to pay for it. Joseph Estrada, one of the country’s most popular film stars, is running for the next election and looks likely to win it. The temperature is 36 degrees Celsius with 98 per cent humidity. Heavy showers are predicted for later in the afternoon. And Silvana cookies – according to a radio promotion – now come in the flavours of coconut and purple yam. That’s all. No bus accidents, ongoing hostage situations, no gangland massacres or people threatening to jump off buildings.

With nothing better to do we mop the ambulance for the tenth time in a week. Considerably more mopping goes on here than any treatment of patients. Mopping detergent with detergent, as Juan always says. Oxygen we check too, and not because it is used for patients short of breath, but for the chance that a slow leak may have dropped the levels. This is the life of a public ambulance service medic in Manila – mopping, cleaning, sleeping …

And waiting for news bulletins.

Our meeting after work, as it turns out, is merely a visit by the rest of the station staff, three of them in all, who, out of pure sympathy for the boredom suffered by their colleagues on shift, have come to bring us a hot dinner. Sunny – a young EMT behind The Philippines Emergency Medical Technician’s Association (PEMTA), which presently boasts a total of seven members – lugs in a small television set and box of cables. He connects them up and tests a microphone with a crackly ‘one, two, two!’ Moments later we are sitting round drinking San Miguel beer, singing karaoke.

‘You have choice,’ says Sunny when it is my turn with the microphone. “New York, New York” or “Barbie World”.

Great! Cringing, I tell Sunny these are not the most interesting songs but see few alternatives in the open catalogue. Reluctantly, I ask him to start the Sinatra.

To my great relief, after just one ‘New York’ into the song, Manolo interrupts.

‘All quiet!’ he yells. ‘News bulletin!’

DR AQUARIUS AND THE GYPSIES

Macedonia

Saints are always good for a holiday. A couple of weeks ago it was Saint George and, now, in the middle of a Balkan summer, it’s Saint Nicholas who really ought to be celebrated at Christmas. But who cares if they want to honour him twice? It’s an excuse for a party and the fact that I’m working all weekend is no obstacle. Not in Macedonia, not among the doctors and nurses and drivers of Skopje 194.

Along the potholed road into the city, looking out from the peeled tinting of the side window, I catch glimpses of grubby youths half-heartedly kicking footballs in overgrown parks under the bleak housing blocks where they live. None of them waves at the ambulance as kids always do back home, hoping for a blast from our siren. On benches, watching them play, stumpy old men sit with motionless wives, saying nothing. At a corner where we pause for a red light a little boy sells eggs from a tray. A gypsy girl does a half-hearted tap dance in front of cars and someone throws her a coin. Homeless dogs scratch themselves in the heat. At a nearby kiosk with torn beach umbrellas outside, a row of bicycles lean against a sun-cracked wall. Behind that, the spire of a mosque rises between apartment blocks where laundry flaps from narrow windows. Here the best suburbs can look like decrepit public housing estates. Like my parents’ photographs from their European travels in the 1970s, everything seems faded and bathed in a vinegary orange light, as if one is moving through an era long passed.

Skopje is littered with the evidence of better times. This city was a base for Alexander the Great, the birthplace of Mother Teresa, the place made beautiful in the Byzantine era and under the Ottomans. It was still beautiful on the day before the earthquake of 1963 when 90 per cent of the city was flattened. Rebuilt by Yugoslavs with a concrete obsession, Skopje became something else and then, when communist rule ended between 1990 and 1992 (and Yugoslavia broke up with Macedonia claiming independence in 1991), the money for public works dried up. Once grand fountains ceased their squirting but still remain as concrete eyesores in every empty plaza. City gardens are knee-high in grass and weeds, pavements are fractured or caved in completely and a whimsical Socialist-era fun park on the edge of town has not changed in forty years. As for the Macedonian dress sense, everyone appears to be clothed in drab and mismatched garments they have quite conceivably selected from suburban charity shops while blindfolded.

Three months earlier in Sydney, my paramedic partner and I were called to a woman originally from Macedonia now living in a small flat crammed with imposing floral lounges, a woman who felt the need to phone our emergency ambulance for what she described as a ‘burning tongue’. There is, of course, no documented protocol for such a complaint, but as far as we could gather her tongue was not alight, nor did it look particularly red or swollen or suffering the effects of hot curry or chilli pepper or any other such thing. What we did observe about her, however, was a level of nervous tension that commonly precedes inexplicable symptoms like this and is more often related to mental rather than physical origins.

As a lover of Balkan music I knew a little about the Roma gypsies residing in Eastern Europe, many in the small country of Macedonia, a country of just two million people, landlocked by Greece, Bulgaria, Serbia and Albania. What I didn’t know was that Macedonia is also host to the largest community of gypsies in the world, most of them living in a ghetto – or maalo – known as Shutka.

After the burning tongue I got to thinking about where on earth it might be appropriate to call ambulances for such a complaint. And although people call for some pretty interesting things just about everywhere, my mind persistently returned to Macedonia. Eager to explore not only the blood-and-guts of my industry but the varying cultural peculiarities that affect it, I booked a ticket.

There are two reasons why Macedonian ambulances are always snug in the front seat. Firstly, both doctor and nurse sit beside the driver. That’s three in a row. Secondly, most medics at Skopje 194 have a considerable girth, for which the Macedonian diet is clearly to blame. Here, a meal without yellow cheese is considered inedible, even fresh salad is topped with it. Nevertheless, winters in Skopje can be nasty and the cuddly warmth of a colleague is always welcome.

While all the drivers are male, most of the doctors and nurses are not. Unlike many ambulance services that struggle to attract female recruits, in Macedonia ladies run the entire show. Dr Maja Poposka, the surprisingly young and attractive director of the service is fond of black power suits and high heels, and is a stark contrast to the legion of women she commands who mostly have the attitude and build of lady prison guards. Even in their white scrubs, wooden clogs and dainty black doctor bags, these women could suffocate the toughest male paramedic in their fathomless bosoms. They bark at their patients in voices deepened by Marlboro Reds and give every physical indication that they mean business.

For the weekend of the 2010 Saint Nicholas holiday I have submitted to being the plaything of a lively lady doctor with a black beehive and cherry-red lipstick. She is known simply as Dr Aquarius and she calls me Benja. Dr Aquarius is assisted by a nurse named Snezhana Spazovska who has several sparkling diamantes set in her front teeth and painted fingernails so long she needs five precious minutes to get them into latex gloves. Sammy Rudovski is our driver, has been around a decade or two, and knows the drill. Generally he keeps quiet. Like all the ambulance drivers he is permitted to wear casual clothes, and on this festival night is decked out in a three-piece denim suit. None of them is happy about being on shift while the rest of the country is celebrating.

Like the sound of witches round a cauldron, regular cackles of laughter emanate from the front cabin. The witch analogy is not about evil spells, but rather the wicked sense of humour they share with ambulance workers worldwide.

Just over the river, in the shade of the ancient Kale Fort, we pull up and Dr Aquarius slides back the perspex peep window.

‘Benja, we have a heart problems!’ she shouts.

I appreciate her informing me, as the usual indication I get that we have been given a job is when the ambulance suddenly careens into oncoming traffic with the cry of a siren, throwing me off my seat. Riding in the back like a pet dog is not my idea of a good time. There are few windows and it’s hot, stuffy and claustrophobic.

After a few minutes we move back and forth between apartment buildings; down the driveway of one, reversing up again, going around in circles. Most blocks are identical to one another and confusion is common. When we finally find the address Sammy has picked it by little more than a tiny number scrawled on a wall in white chalk.

Dr Aquarius leads the ascent up a graffiti-sprayed stairwell to the eighth floor carrying her little black doctor’s bag containing a blood pressure cuff, stethoscope, her leopard-skin purse and cigarettes. When I see her do this I lament the many backbreaking years I have lugged every box and piece of equipment to top floor apartments without cause.

By the time we reach the fifth level with three to go, nurse Spazovska is gasping loudly behind me. Like a commando in the jungle, Dr Aquarius motions with her hand for us to stop. We pause a little for Spazovska to catch her breath, and she’s no picture of health. Her heart and lungs are shot by years of relentless fagging, her arteries clogged with Macedonian cheese. Needless to say, performing this job on a regular basis in a city of apartment blocks without elevators ought to keep her in better shape.

By the time we reach the patient’s door, Snezhana Spazovska seems close to respiratory arrest. Our patient, on the other hand, is calmly sipping a cup of tea. There must have been a mix-up, he says. He made it very clear to the call-taker that what he had done was slam his finger in a door. There’s no question that slamming a finger in a door is painful, but calling an emergency doctor and nurse to apply an ice pack hardly seems reasonable.

It surprises me this one has slipped past the control room at Budapest Hospital. When I sat with them a week ago I’d become convinced that only the meanest nurses were assigned to work there. Every second emergency call received would have them abusing the caller for not being sick or injured enough to warrant an ambulance. Phones were continuously slammed down in the ears of helpless victims as services were refused outright.

Nurse Spazovska is pale and sweaty and can barely speak. She leans over the patient’s glass coffee table while Dr Aquarius – who no doubt has seen this all before – rubs her back. Just for a moment I wonder whether I’m witnessing some drama created to give the man with his bruised finger a demonstration of what a real sick person looks like.

‘I … my … is … tachycardia,’ Spazovska splutters.

It’s bad news when someone with shortness of breath speaks like this, catching air between each word.

Her heart is doing double-time when I take her pulse, convincing me she’s genuine enough. Meanwhile the guy with the finger looks on with confusion. Despite our offers, Spazovska refuses medication and we patiently wait ten minutes for her to regain her composure. A recovery of sorts is made but it’s no way to be starting a night shift.

Macedonia is a guarded nation with a great suspicion of outsiders and not many places have had me feeling more like a foreign agent than Skopje. No one gives much away here. Few people are open or candid. Faces are stony, scrutinising you with narrowed eyes. This is understandable considering the country’s communist history, not to mention that ‘a writer is something of a spy’ as Graham Greene once wrote in Stamboul Train. Thanks to a shared block of Schogetten Stracciatella chocolate, the ambulance team now considers me a true colleague and that respect is unreserved.

Zoran Kostovski, the Australian Honorary Consul in Skopje, is a man with incredible personal energy and vibrant enthusiasm. He is also connected at every level of government thanks to the success of his private company, Motiva, which he started after reading Body Language by Australian author Allan Pease. The objective of Motiva is to provide its clients with training in superior communication techniques – particularly of the non-verbal variety – and it is through his delivery of these workshops to politicians that Zoran has not only befriended Nikola Gruevski, Macedonia’s current prime minister but, to my great fortune, the current health minister, Dr Bujar Osmani.

When I first shared a bottle of Macedonian wine with Zoran he revealed there were only ever ten or fifteen Australians with no family connection to Macedonia visiting the country at any one time and that despite this minuscule number, they managed to keep him busy round the clock. This may have sounded like a complaint had Zoran not reassured me that he thoroughly enjoyed the entertainment his position afforded him. There was a poet who fell off his chair and fractured his hip. ‘Dangerous work, poetry,’ he said. Not long after, he was called to the police station for a female with schizophrenia found wandering the streets of Skopje in a state of undress. She had run out of medication while on holiday. Then there was the man who got so depressed after arriving in the drab city he promptly threw himself out of the second-storey window of his hotel. As anyone in ambulance work knows, the second storey is a half-arsed attempt at suicide. Once, I tell Zoran, I went to a man threatening to jump off the first level of a high-rise parking station. Ridiculous. Most interesting of all, says Zoran, was the man from Melbourne who arrived in Skopje at the time of the Victorian bushfires wearing little more than shorts and a T-shirt, carrying a handful of possessions in a small plastic bag. Apparently he wanted to get as far away from the fire as he could.

My request to meet the health minister, in order to acquire permission to join ambulance crews in Skopje, was a comparatively easy one, Zoran assures me. ‘And he’s an outstanding guy, in the toughest job, trying to do his best to bring reform.’

Indeed, on the day I’m meant to meet Dr Osmani, the front page of every newspaper shows hospital doctors walking off the job in protest at their low wages. In Macedonia, public hospital doctors earn little more than 400 euros a month, while nurses get 350 euros. Because the average rent is around 150 euros and electricity in the winter another 100 euros on top of that, most in the medical profession cannot even afford to visit a restaurant or have a drink in a bar. The wages are so low that over time it has become common practice to ask patients for money. Jumping the queue for surgery is achieved with cash alone and those without it may wait for a decade. The poor have enough trouble getting a prescription.

There is probably never a good time for an Australian paramedic to take tea with the health minister of a country burdened by such challenges. Nevertheless, I was invited to do so by Zoran and we sat in the very pleasant company of a softly spoken Osmani as he elaborated on his work.

Most significantly, his effort to stop kickbacks in the form of over-supplied medical materials to hospitals has put many of his public hospital doctors offside. At a Holiday Inn conference in 2008, Zoran introduced Dr Osmani to a patient classification software developed by Australia that keeps track of hospital resources and is known as the Australian Refined Diagnosis Related Groups (AR-DRG) system. Many countries suffering the effects of health service corruption have installed this program with enormous success, including Saudi Arabia, Greece and Romania. On behalf of the prime minister, Zoran negotiated the purchase of the AR-DRG software by Macedonia for a very modest price. Two years later it is ‘still in the process’ of being installed. Across Macedonia, hospital heads have made every effort to block its introduction, revealing just how many people are dependent on medical supplies kickbacks to supplement their incomes. As effective as the AR-DRG system may be, it does not address this root cause of corruption.

As for my placement on ambulances of Skopje, Dr Osmani has no objection and simply warns me not to injure myself. He is unconcerned I might pen something critical about the Macedonian health system. ‘It wouldn’t be news,’ he says. ‘Everyone knows the country is poor. Why should we pretend it to be otherwise?’

At a roadside kiosk Dr Aquarius buys us bottles of Pimp Juice, a local soft drink we sip through straws on the way to the next job. Earlier in the week I saw a billboard for the beverage depicting a smiling gangster with gold teeth. This is what many of the young men look like in Shutka, the capital of gypsies, and I wonder if it’s bottled there.

For my benefit Sammy takes the ambulance past the house of Esma Redzepova, known globally as the Gypsy Queen, a singer whose remarkable voice carries the collective emotions of the Roma, and whose music I have followed for some time. In opposition to those who react angrily to being labelled a gypsy, Redzepova encourages the Roma to be proud of the term and has always used the earnings from her record sales to distribute free medicine to the poor.

A little further on, near Topaana, one of the earliest gypsy maalos, stands the ominous new American embassy. Rumour has it this is not just any embassy. The complex is so vast one would need an hour to walk around it. Much to the dismay of Topaana gypsies it has also taken up every inch of what was once the beloved city park they used for weddings and picnics, forcing them onto a small, cramped traffic island in the embassy’s shadow.

Just off the Krimska Road, a family of rotund Macedonians has had a fierce argument during which the father has shattered a framed photograph of his wife and stormed from the house leaving her and his three adult children in a state of hysteria. The two daughters, both in their mid-thirties, are howling uncontrollably on the lounge while a younger man, probably in his late twenties, kneels at his mother’s feet sobbing. One would think the woman’s husband had passed away, but he has only gone to the pub. Were it not for the fact we attend jobs like this every day in Skopje I would not be so cynical. Nor would I be wondering why so many simple disagreements in this country result in group hyperventilation or all-out brawls.

Dr Aquarius tries to calm the lady, gives it about a minute or so, looks at her watch, then twitches an over-plucked eyebrow at nurse Spazovska and rolls up the sleeves of her lab coat. Spazovska knows the drill and opens a black briefcase she has taken into the house. In it are rows of glittering glass ampoules tinkling like little wind chimes whenever she handles them. It’s pretty much all the nurses ever carry, the drugs – the first line of emergency care in Macedonia. The only other items apart from medications are cotton balls for swabbing, needles and saline, and a bunch of thin candles to light for the dead. With nimble fingers Spazovska removes an ampoule of Valium 10 milligrams, snaps its neck, draws it up and hands it to Dr Aquarius.

Seconds after stabbing it in, without further ado, we are out the door.

Valium, valium, valium. Half the briefcase is full of the stuff. At a guess there’d be at least twenty ampoules in there and even that is not enough some nights. Morphine supplies may be out of stock, while some doctors buy aspirin for heart patients with their own money. But the Valium never dries up. This surprises me as the drug is dispensed like candy. So popular is Valium in this city that it is common for ambulance crews to administer ‘one for the patient and one for the relative’. Balkan funerals are the worst. At these there can be fifty, even a hundred, distressed mourners demanding a shot.

Our next job – or ‘invitation’ as the medics endearingly call them – is to a woman with high blood pressure and a headache. Again, along with a prescription for Monopril and a beta-blocker comes intramuscular Valium.

‘We take the Pimp Juice, they take the Valium,’ laughs Dr Aquarius afterwards. ‘That is how the world goes round!’

An hour later everyone is thrilled to have discovered an apartment block with an elevator, none happier than our smoking asthmatic nurse. On the top floor a man has been vomiting for a week. Exciting stuff, I think to myself.

The apartment is painted a deep red and decorated with kitsch throne-like furniture more suited to a medieval castle than a tiny bachelor pad. Gold candelabras rest on a narrow black table in the centre of the room along with a giant porcelain tiger and a vase of plastic irises. Macedonians have less money now than they did in the communist era yet give the impression they are enjoying the spoils of capitalism. All over former Yugoslavia one can find this same quasi-bourgeois aesthetic. If you want to know how a two-dollar shop can make you look rich, just ask a Macedonian.

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 used there since its donation to the country a year earlier.

Chaiar Station is little more than a few cold rooms in the wing of a small clinic, lit by a tiny television with bad reception that everyone put in for. Few want to miss the Macedonian version of Wheel of Fortune known here as Wheel of Happiness. For those who know that money does not guarantee happiness, the game show is followed by an addictive Turkish soap opera. As we settle in to watch the next episode of Yabanci Damat, Drenousha helps us get into the spirit of things by serving Turkish coffee.

Ambulance stations of Macedonia become drop-in medical centres after hours and on the weekends. So an additional doctor is always on duty at night and has a separate consultation room. For the festival night of Saint Nicholas, Dr Save Bobonovski is on shift, his first name ensuring great popularity among his patients. At one time he also worked on the ambulances, but that was ten years ago and he quit after attending a nasty accident at Alexander the Great Airport. On 5 March 1993, eighty-three people died when flight crew forgot to de-ice a Macedonian Airlines Fokker prior to departure and it crashed seconds after take-off. Save was first on the scene. As he tells it, bodies and body parts were scattered as far as the eye could see. He decided soon after he was more suited to working indoors.

A second crew comes by on their way to a chest pain and picks up an ECG machine. At present there are not enough to go round and Chaiar ambulances have to share a single ancient Hellige box with its little rubber suckers and wide leather straps that bind to wrists and ankles and around the chest. It must hark from the 1960s or thereabouts and looks more KGB than ECG. We’ve used it plenty of times, and vintage though the Hellige may be, it is still a functional 12-lead cardiograph.

Dr Aquarius scoffs. ‘Our government doesn’t have money for new ECG machines, but they sure have it for bronze lions in public squares. Have you ever seen a bronze lion save a life?’

To boost morale, reinvigorate patriotism and attract tourists, the government of Macedonia has created a controversial building project known as Skopje 2014. By crossing the old stone bridge over the Vardar River in the direction of the central mosque, one can see where work on the multimillion denar project has begun. A highly fanciful preview of what the completed dream may look like is also available on YouTube as a musical montage. Ridiculous oversized monuments are superimposed on city intersections, including a sky-scraping Alexander atop his rearing horse in the main square. Imitation baroque buildings line the banks of the Vardar where a troupe of dancing fountains shoot from the murky rapids.

Continued Greek denial of Macedonian identity is certainly part of what has prompted Skopje 2014. But for unemployed and hungry Macedonians it is all too much.

‘Remember how Ceausescu died in Romania?’ says Dr Aquarius. ‘He built an Arc de Triomphe replica in Bucharest while his people were starving and was executed by firing squad.’

There is a patient with shortness of breath in Shutka, where we spend most of our time each shift. As in the films of Emir Kusturica and their endless parties of drunken gypsies firing pistols into the air, breaking bottles over each other’s heads and tripping over roaming geese, the maalo has an atmosphere of madness even in the absence of wedding receptions. Still, we are rarely called to trauma cases. There is surprisingly little violence in Shutka considering the quantity of the homebrew, rakija, the inhabitants consume. They are not a violent race. Never have the gypsies fought a war or occupied a land.

In contrast to the guarded personalities of many Macedonians, the gypsies are warmer and quicker to smile. Perhaps they feel secure and at peace here. Macedonia may be over-spending public money on bronze lions and flaming crucifixes, but the country has arguably the most compassionate policy towards the Roma anywhere in Europe. By comparison, Italy and France spent much of 2010 gypsy hunting. Although they weren’t shot, as happened under the Nazis in World War II, gypsies were rounded up like cattle and forced back to Romania and Bulgaria. Many were not from these countries in the first place. It’s hard to know what land, if any, a gypsy calls home. Since migrating from India a thousand years ago, they have spread to all corners of the earth and are regularly uprooted and chased away by governments.

Macedonia, however, has allowed gypsies the right to identify as Roma, to live in their own suburb and to have a representative in parliament. With its own mayor, permanent housing and radio stations, it is no wonder Shutka has become host to the largest number of gypsies anywhere.

Not everyone in Shutka is satisfied. Many are disappointed the government is not doing more to help them. Social security is only available to those Roma registered as residents of Macedonia and even then it is a paltry 50 euros a month. With some notable exceptions, including a handful of doctors and lawyers, the Roma are not much interested in education and few end up qualified for decent work. This forces many to rely on the garbage collection, the begging and the thievery for which they are known. Attending a school or a job to become a cog in society holds little appeal. More thrilling are horses and music and fire, all things wild and free, living each day as if it were the last.

Finding an address in Shutka can take a while. Some of the streets are cracked and deeply gouged with potholes and the eccentric little homes rendered in lurid colours have all kinds of madcap decorations hanging on their outside walls, from obscure coats-of-arms to enormous cuckoo clocks. But street numbers on letterboxes are scarce. We stop and ask a group of men sharing a foot-long salami and rakija if they know where our patient lives. After some lengthy argument they point toward the bazaar. Sometimes, even in serious emergencies, we drive around the maalo in dizzy confusion, following several opposing directions. Thankfully, the streets are easy to remember. Without a shred of irony the Roma have given them names like Washington Square Boulevard, John F Kennedy Parade and Disneyland. Shoddily constructed miniature palaces of concrete can be found here. Poorer homes, in many cases, shanty-style shacks are more likely found along Che Guevara Drive, Shakespeare Avenue and Garcia Lorca Lane. At the bottom of the hill there is a quarter of Shutka I have visited that looks no different to a Bombay slum, complete with muddy passages, huts constructed from junk and United Nations water pumps.

Past the smugglers’ bazaar where toothless old men sell lacy bras hanging in rows along rusty fences, where bootleg perfumes and pointless porcelain pigs go for a steal, we pull up at a partially collapsed building and enter a 2-metre-square room, home to a family of seven. Our patient is a forty-year-old woman with six children and a husband in jail. Only a gypsy can peel potatoes while suffering severe respiratory distress, I think to myself. Her mouth is snapping with every breath, as if biting for air.

Everyone seems to have breathing problems in Shutka. It’s either asthma or emphysema or bronchitis or all of these at once. Temperatures in winter can drop to minus 20 degrees. If there is rain the streets of Shutka become rivers of freezing mud and many of the children do not have boots. Chest infections are common. Adults sit all day and night in crowded rooms, chain-smoking the contraband Marlboro their children passively inhale.

Dr Aquarius and Snezhana Spazovska don’t mess about. They promptly administer an injection of Amyphyline and Dexamethasone during which the woman only momentarily ceases her potato peeling. It surprises me that oxygen is rarely given to patients the crew intends on leaving at home, especially those with breathing problems. On this occasion Dr Aquarius is feeling generous and runs the patient on a low rate through nasal prongs for several minutes, though staying on scene too long in the maalo is unwise. News of an ambulance entering the ghetto quickly gets around and it’s only a matter of time – often less than fifteen minutes – before every sick person with the slightest complaint surfaces for treatment. Suddenly the ambulance becomes a mobile clinic and is trapped indefinitely. Many gypsies are not registered citizens and have no entitlement to hospital treatment. For them, the only hope of getting medical help is to bail up ambulances whenever they see them and appeal to the compassion of the doctor on board to get a free consultation.

The sun has dropped below the snow-capped Shari Mountain Range when we pull up at a small house so crooked it could have been built by a child. It is dark as a cave inside and the floor is covered in the shapes of countless bodies wetly snoring under thick floral blankets. A woman who does not bother brushing the hair from her face rolls over and pulls down an edge of her grimy tracksuit pants, exposing a buttock.

Dr Aquarius sighs and nods at nurse Spazovska who flicks open her black briefcase again, cracks a few ampoules, draws them up and stabs them in. The woman pulls the blanket over her head, falls back to sleep and we are out the door.

Two minutes and thirty-five seconds and not a word exchanged between medic and patient.

‘Did you know her?’ I ask, perplexed.

‘Not personally,’ says Dr Aquarius, climbing back into the ambulance.

‘How did you guess what was wrong with her? Or what to give her?’

‘You should understand by now. When they want an injection straight up it’s the same thing every time. Vitamin B1, B6, B12 and C for good measure.’

If they’re agitated, Valium is part of the cocktail too. And gypsies are notoriously prone to agitation. Should the Valium run out, the doctor will resort to aqua injections – plain water or normal saline. Few patients know any better. It is not about the drug anyway but about the spritz. With the exception of heroin addicts I’ve never met a patient enthusiastic about injections. Many Roma, however, can’t get enough. This is because they have what Dr Aquarius calls ‘injection jealousy’. Should a gypsy observe her neighbour receiving two vitamin injections from an ambulance crew, she will later call up and try to outdo her rival by asking for three. Roma are very jealous people. Angry scenes occur if ambulance crews don’t give the maximum number of injections, regardless of whether the patient needs them or not.

‘Once, in Shutka alone, I gave one hundred and thirty injections over a single week,’ boasts Snezhana Spazovska through the slide window.

Seems to me a bad precedent has been set. A community expectation has been established from which these medics find it difficult to escape.

‘Most of the time the Rom are very peaceful,’ says Dr Aquarius. ‘But, well, we give as many injections of Valium or vitamins or aqua as it takes us to get out of there quickly. It is not only Rom. Other Macedonians are like this too. No patient in our country is satisfied without a spritz.’

Injections are a matter of service efficiency rather than pandering. If a crew decides to leave without giving a jab, the patient is likely to wait fifteen minutes or so then call again. Indeed, they will call and call until they get an ambulance crew willing to give them one. Repeat callers are not unique to Macedonia and are a problem anywhere, in any country. Some callers in Australia are known to have our easy-to-remember three-digit emergency number on speed dial. In exasperation, some paramedics manage this problem by transporting the patient to hospital to remove them from their home phones so they won’t call again. Of course, this simply shifts the problem. Treating patients in the field is more desirable, but whether it is ethical to inject a patient for the sake of operational efficiency alone is an interesting question. Maybe a little bending of the rules is justified for the greater good, allowing ambulances to be more readily available for life-threatening cases. I can’t help thinking, however, that if injection-jealous gypsies knew that the party was over, the call volume would drop and the burden would ease naturally.

Girls with gold hoop earrings smile and wave and kick up bright floral dresses as we pass them trailing a mob of grubby children. Their look is a welcome flashback to the gypsy aesthetic of old in a township where most of the women have long ago discovered Adidas and cheap bling.

We pull up outside a peppermint-green house with a waterfall feature built against the front wall. Inside a middle-aged woman lies theatrically collapsed on the hallway carpet, hyperventilating. A dozen family members and relatives shuffle in behind us to have a look.

Dr Aquarius asks the woman a few questions, which she answers with excessive gasping and groaning and rolling about. Spazovska is next to me and whispers, ‘Pain all over.’

Right. Pain all over. As if I couldn’t have picked it, that classic ailment of the chronic neurotic. How it makes us laugh when we hear it! Not in front of the patient – never in front of the patient. Oh, but how we laugh. From what I can tell, Dr Aquarius is examining the patient in the same manner I do in such cases. Slowly she palpates every region of the woman’s body. What about here? And what about here? And here? And every time the woman groans or winces or pulls away, even when Dr Aquarius has reached and squeezed the tip of her pinky finger. What drives an unusually thorough examination like this is a hope that our looks of confusion in response to the patient’s unspecific complaints will be a hint to her and her relatives that we are not convinced and that perhaps, to avoid embarrassment, someone should put an end to the entertainment before we are forced to do so in the back of the ambulance.

‘She requesting something special,’ Spazovska says.

Gypsies love a bit of drama. This I can appreciate – life is great when it’s thrilling. Less forgivable are the patients who have an ambulance called for the sake of attracting attention. Attention-seeking exists in every country and in every cultural group, and is particularly prevalent in very large families. A person feeling left out or snubbed for some reason may decide that by feigning a medical emergency they will get what they crave. The strategy usually works well and they soon find their extended family standing around them saying pointless things like, ‘Oh my God! Oh my God! Oh my God!’ and rushing wet towels from the bathroom. Perfect! So long as their symptoms are as ambiguous as ‘pain all over’ and appear severe enough, the little fakers may even get a ride to hospital. Of course, on arrival they will make a miraculous recovery and discharge themselves before a doctor has even seen them.

Because these are delicate situations I wait out the front of the house. From where I stand I can see a ten-metre cherry tree belonging to a regular emphysema patient. A week ago I was up that tree picking cherries for her as she’d complained about being too old and breathless to climb a ladder. After that day Kass and I ate cherries for breakfast, lunch and dinner.

The adult daughter of the drama queen comes out and forces a cigarette between my lips. Her smile reveals a big gold tooth flashing in the sun. She wears yellow lycra leggings and a decorative red belt with a playboy bunny buckle. After she lights my cigarette she puts her hand on my shoulder and comes very near.

‘You are married?’ she asks directly.

I nod.

‘Not matter for me,’ she purrs, exhaling smoke in my face.

With a daughter like this it’s no wonder the patient has pain all over, I think. What kind of woman tries seducing the medic while her mother is near death?

From inside the house comes the sound of yelling. Something crashes and breaks. This is followed by a short scream after which Dr Aquarius saunters out, peels off her gloves and gives a wink.

‘She not wishes to come with us,’ says the doctor.

Sometimes it seems the crew is more effective when their international guest is not in the room.

Intense verbal exchanges are the norm in Macedonia. What sounds like an argument may be just as likely the whispering of lovers elsewhere. Macedonians, like Italians, Greeks and Arabs, for that matter, can have a simple interaction about the weather while sounding like they’re about to strangle each other.

An exchange like this occurred during one of my many meetings with ambulance service director Maja Poposka. The afternoon started badly when she showed me a video clip of a major incident exercise on a highway near the Serbian border. The footage had been set to a heart-wrenching song, Game Without Limits by Tose Proeski, a young Macedonian singer recently killed in a car accident. His death had been traumatic for the entire country.

‘I chose this song because I like it very much,’ Poposka tells me, looking off into the middle distance, just holding back her tears. ‘Sometimes in our profession we also push the limits.’

There is so much she could have meant by this, but I sensed she was referring to the risks, both physical and mental, that ambulance workers subject themselves to. Surrounded by craziness, by things going wrong, by lives twisted up, we risk losing perspective on our own reality. If this happens, anything is possible in terms of our personal behaviour. If we lose our grasp on rational thought our work may indeed become a game without limits.

We talked then at length about adrenalin and its toll on us over time, finding common ground in our mutual experience of adrenalin withdrawal. My wife Kass has often wondered how it’s possible for me to be so upbeat at work, even at the end of a rough day, yet arrive home grumpy. When adrenalin wears off some of us simply ‘crash’. Adrenalin is, after all, a type of high. It creates euphoria and for this reason people engage in all manner of dangerous activities to pursue it. But like every other high, it is only high because it is preceded and followed by a low and ambulance workers are by no means immune. Indeed, some even orchestrate drama in their private lives to maintain their adrenalin levels artificially.

It was about this time in the meeting that Boban Vivovski, the humpty-dumpty fleet manager, entered the room and said something to Poposka that didn’t please her at all. A shouting match ensued. She slammed down her diary with an almighty slap, pushed her swivel chair out and chased Vivovski into the corridor. The door slammed shut behind her. Outside the room the argument continued, punctuated every now and then by a loud thud, as if one or both of them were whacking the wall or throwing the other against it. All I could do was remain in the shade of her indoor tree, quietly embarrassed, listening to them blowing up outside. For the CEO and her fleet manager to behave this naturally in front of me was surely an honour, though I would have been less concerned were it not the day after a Macedonian doctor at one of Skopje’s main hospitals stabbed her fellow doctor seventeen times in a fit of rage. On the television they said she had a ‘brain snap’. As the scene of this stabbing played out in my mind while listening to the yelling in the corridor, I swallowed hard.

When Dr Poposka came back into the room, unscathed, she sat down and let out a sigh, giving me a measured smile.

‘It’s not only the gypsies who are passionate peoples. Anyway, I would rather yell at my fleet manager than at my road staff. You will never hear me yell at ambulance teams. They work hard and don’t deserve it. They are my friends and I always take a cigarette with them. Without their respect I can achieve nothing.’

One day, when Dr Poposka is tired of her position, she would consider working the road again and wants to be sure her legacy as director will not make her unwelcome there. As for the conflict among her management team, she insists it is ‘a type of love’. In my opinion she is suffering from plain and simple adrenalin withdrawal. For a former ambulance doctor there is a clear excitement deficit that comes with a management position and the office environment. Yelling matches and fist-fights are, one could say, the methadone of adrenalin withdrawal.

Evidence of the Roma’s Indian origins can be seen on walls we pass in the ambulance, white painted designs identical to those I have come across in small desert villages of Rajasthan and Gujarat.

We follow two boys running towards the Shutka bazaar clutching trumpets. Their eyes in our headlights are wide with excitement. The smell of barbecuing lamb wafts through the open windows of our ambulance and in the distance we can hear the sound of a brass band playing. When we reach the intersection of the bazaar a large crowd of gypsies surrounds a group of men on horns and drums. Slowly we edge the ambulance through a throng of scruffy kids with bleached spiky hair and gold chains dancing wildly. Their look is hip-hop but their moves are pure fireside Bollywood.

‘This will be us at 3 am,’ laughs Dr Aquarius. Snezhana Spazovska giggles and Sammy yelps the siren and waves at the mob. Some of the kids whistle in return and drum their hands on the ambulance as we go by.

‘We are now going to village in the hills,’ says Dr Aquarius. ‘The sun is down. You know what it means when sun is down on festival of Saint Nicholas?’

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