I know what the right answer would be back in the States, at the tertiary care center where I did my training: ultrasound, external fetal monitoring, and then induction or c-section. But I don't know what the right answer is here, where the midwife is managing the pregnancy and I am managing the pneumonia, where I don't have a doppler and no one has an ultrasound. I can't even get an x-ray, because it is not a Tuesday or a Friday.
I kill time, taking her blood pressure really slowly so I have more time to think. On paper she seems ok, but she looks so tired. I purse my lips.
"Go," I tell her, "go to the hospital." I don't mean the six bed hospital in town, I mean the "big" hospital, forty-five minutes away. "Just to be safe, you should go."
In late-stage emphysema, you often see what is called "an increased A-P diameter," meaning a barrel-chest. All the elasticity that holds the lungs together has basically given up, allowing the ribs to spread wide. My patient looks like an actual barrel with squat little legs and balled fists swinging at his sides. His lungs sound like nothing, as in I literally cannot hear breath sounds. I trust he is living because he has not stopped talking since I called his name in the waiting room and led him down the dim hallway to the exam table. Did I mention the power is out? The power is out.
"The pain was so bad I thought about calling an ambulance," he says, "but what would they even do for me? I don't want to just take pain medication." He grimaces as if pain medication were some known snake oil peddled by ambulance personnel. These Kiwis are tough.
I use my flashlight ("torch") to inspect the itchy rash on my patient's arms, on her son's abdomen, on her mother's thigh. I explain to three generations that you cannot use antifungals to treat scabies. But that was the thing that worked last time. Ok, you can use antifungals to treat scabies as long as you also use permethrin. Deal. I rummage in the surgery's cupboard for both - the pharmacy is closed.
I'm reading Thomas The Tank Engine and the Whatever Whatever when the beeper goes off. I have been living in fear of this sound all weekend. I call dispatch and read the address to Benjamin, who is ready on google maps. It's literally around the corner. I slip on my shoes and run to the car. I pull open the door and realize I'm on the wrong side of the car. Damn this driving on the left.
The ambulance is already there. Our patient is conscious, which is better than what I was expecting. His family is big, there are people everywhere. Even with all their help it still takes what feels like a year to get him into the ambulance at the end of the muddy driveway.
I can't find anything; trauma shears, IV supplies, blood pressure cuff. It's like a mixture of Grey's Anatomy and one of those dreams where you are trying to run but can't move your legs.
I put a hard plastic block in his mouth to stabilize the airway - it comes right back out. I stick electrodes on his chest for an ECG and they won't adhere to his sweaty skin. I place an IV and it blows, the bruise blooming under his skin before my eyes. The more I try to help, the more seconds tick by that he is not on his way to a hospital, someplace with a CT scanner and a surgeon and someone who can place a god damn IV.
"Get out of here," I tell the EMTs - two women with practical hair cuts and green ambulance uniforms. They nod rapidly in agreement. I trip on my way out of the ambulance.
In the morning I hear that he died.
I think of his muddy driveway and the way my needle went straight through the vein and out the other side.