This Is How It Always Is(95)

Then, in a language Rosie had never heard before in her life but understood as if it were her mother tongue, the patient wheezed that she could not breathe. Her inhalations became short then gasping all in a seeming moment. Her face went gray, her eyes then her head rolled back, and it was K who had the presence of mind to grab the baby as he tumbled from her slackened arm.

Rosie listened to her lungs and heard wet, like a conch shell, though in this case she heard not water, not waves, but crackles like a campfire of wet wood: rales. Pulmonary edema. The patient was drowning. Was there a ventilator? She supposed a mask would do for the moment.

“Oxygen,” she said to K.

But K shook her head. “Have mask,” and she looked proud at that but, “and one tank oxygen but empty. Request more three month ago but not arrive yet.”

Rosie took that in. The rest of the patient’s skin was going gray. Sputum, pink with foreboding, frothed at her mouth and nose. Rosie would have to treat the heart and hope that allowed the lungs to do their job as well. She knew but nonetheless asked, hoped, prayed, Hail Mary’d: “Echocardiogram?”

K shook her head again.

“Her chart at least?”

K waved the crumpled letter. Rosie closed her eyes to practice proceeding without senses, without sense. No patient history, no way to ask about her symptoms, no information as to what might once have been tried and worked, tried and failed. No way back to those moments, moments ago, when all was shiny and suffused with joy. No picture of the heart in question, the heart in failure. Were her damaged valves leaking or scarred nearly shut? Was her heart straining with too much blood or too little? Should they speed her heartbeat or slow it down? There were answers to these dichotomies; they were not ambiguous. And with answers, there were clear treatment plans, effective and straightforward. But Rosie had been blindfolded, numbed, handcuffed, and tied to a pipe halfway across the room. Absent an echocardiogram or X-ray vision—and the former seemed as fantastic as the latter in this place—there was nothing she could do.

There was one thing she could do. Even with her hands tied and her fingers numbed and her eyes blinded, she could listen. It was possible, she knew, to hear which valves leaked and which stuck, which ventricles filled and which backed up, where blood flowed and where it flooded. She bent. She listened. The heart sped and sped. Was that making things better or worse? She couldn’t tell. She closed her eyes again. She shut it all out. She broke it all down. She listened for aortic versus pulmonary valve closure; she listened separately. She listened for increased venous return and negative intrathoracic pressure. She listened for the right ventricle to empty and for mid-systolic clicks. She listened to see, to peer with her ears, to force them into servitude as organs of imagination, precognition, and miracle. She tried to hear in the too-fast, too-loud, panicked pulse a story, tale and detail, what it meant and what it foreshadowed, its history and backstory. But she couldn’t make it out. Doctors used to do this, she knew, before echocardiograms and EKGs and chest X-rays. But that was well before her time. She had done it once, maybe, in school, as an exercise. At 130 frantic BPM in the melee of this limping clinic shoved wall to corner to wall with the frantic and the feverish, it was beyond her. She could only guess.

“Esmolol?” she asked K. K shook her head. Rosie wasn’t happy, but she also was not surprised.

“Labetolol?” Esmolol would have been better. It was rapid onset but short duration so they could see. If it helped, great. If it made it worse, that yielded enough useful information to make it worth the risk, and when it wore off five minutes later, they’d know how to proceed. But Labetolol would do. Slowing the heart rate was a good guess, and Labetolol was much more common and inexpensive; she should have known it was the drug they’d have on hand.

But K shook her head at that too.

Rosie felt the adrenaline come on like a reckless but not unwelcome old friend, one you were glad to see but would regret in the morning. She would have to make do with morphine. It would calm the patient at least. It would ease her pain. It would slow her heart and dilate her blood vessels and buy her—buy them all—a deep breath.

But K shook her head at even cheap, easy, ubiquitous morphine. “So sorry,” said K. “We are have not.”

Rosie backed away from the patient, one step, two, and sat heavily into a plastic blue picnic chair. “I’m sorry,” she apologized to the patient, to K, to the large percentage of the world that did not have what the other large percentage of the world took for granted. They had blue-ribbon hospitals a forty-minute flight away in Bangkok. They had blue-ribbon hospitals for elephants. How could this place be so near and so far?

“I also,” said K.

Rosie thought back to the time, three minutes earlier, when she’d have traded a son for an echocardiogram. It wouldn’t have mattered. Knowing what the problem was didn’t help if none of the solutions were available in any case. “What do you do?” she said to K.

“Next case,” K said.

“We just let her die?”

“Not let,” said K. “We watch, help ease, be witness. Next time be better.”

“The next patient?”

K shook her head. “Next life.”

“Can’t we put her in your truck and drive her to a hospital? A real one?”

“Cannot spare,” K said sadly, and whether what could not be spared was the truck, herself, the medicine, or a favor from an underfunded hospital for a patient not likely to make it at this point anyway, Rosie neither knew nor supposed it really mattered. She did the only thing left to do. She went back to the pile of intake forms and picked up the next one.