The paper on the top of the stack directed her to bed 8. There, Rosie was surprised, having identified obstetrics some buildings ago, to find a patient in labor, healthy labor from the look of it. When she investigated further, she was even more surprised at what she found between the patient’s spread knees.
“You’re the mechanic,” she could not quite stop herself from saying.
K grinned. “Also midwife.”
Improbable though this seemed, K the mechanic seemed to have everything under control, but she asked Rosie to stay anyway.
“Early,” K explained. “She schedule C-section in hospital next month but she not make it.”
A scheduled hospital caesarian delivery somewhere this rural and remote struck Rosie as nearly as improbable as an auto mechanic delivering a premature baby. “Why did she have a C-section scheduled?”
“She have scarlet fever when she was child.” K delivered from the patient’s clenched fist a damp, crumpled envelope from which Rosie extracted a letter, faded and ancient and, besides all that, in a script she could not name, never mind decipher. The patient paused between contractions to look very proud.
“She have scarlet fever and then two-week walk to city to see doctor. Probably her family have some little money. Doctor took picture, looked her heart, wrote down some note for if she pregnant. She lucky. But then she labor early.”
Was Rosie here to treat mother or baby? “How early?”
“Maybe thirty-two week.”
Rosie looked around. It wasn’t just that she saw no NICU incubators, no mechanical ventilators, no bili lights. It’s that asking about them seemed absurd. Surely if they had a neonatal cardiopulmonary monitor, they’d also have sheets and actual beds? “And the letter? What does it say?”
K shrugged and made soothing sounds at the patient as the baby crowned. “Cannot read all. And very short. But damage. Lesions. You know?”
Rosie at once did and did not know. She’d never seen heart disease caused by rheumatic fever—they were so careful with strep these days, and it was so easily treated—but patients with the sort of damage it caused were generally advised against pregnancy, the stress of not just labor but the pregnancy itself too great on compromised heart valves. That ship having clearly sailed, the only tack left was to wait and see who needed help afterward: mother with a too-weak heart or baby with too-weak lungs. Rosie stood and held her hand while the patient pushed and cried and waited, panted, pushed, and cried, while K eased out the head, turning gently, then the shoulders, no hesitation, the rest of the baby rushing out wet and slick as an otter, the baby crying, the new mama crying, even Rosie tearing up a little. It had been a long time since she’d been on this end—either end really—of labor and delivery, and she was jet-lagged and overwhelmed. And relieved. The baby was very small, too small, but pink, crying—if not loudly, if not lots, at least a bit. K swaddled him in a scrap of heretofore T-shirt that read EAST LAKE HIGH BEACH WEEK 2009: SURF THIS! and laid him in his mama’s arms, right up against her scarred heart. The patient was euphoric, weepy-grateful. K and Rosie too and the other waiting, watchful patients on their wooden platforms all around them. All was miracle and celebration. Through the haze of this wonder, Rosie gazed over the throngs of people still waiting and decided to leave the coda of this case in the car mechanic’s apparently multitalented hands.
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 ne
ar 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.
* * *
Bed 15’s patient was leaning up against it rather than lying atop. It was a woman with infant twins, one in each arm, and a tree branch stuck inside her vagina, an (obviously) desperate and (so far) failed attempt to terminate a pregnancy. After her, there was a boy younger than Poppy—than Claude—with a snakebite that looked poisonous, had to be poisonous, came from one of eight venomous snakes he’d seen near his home and casually but proudly ticked off on his fingers like he was naming cartoon characters, but then, miraculously, the swelling went down and it wasn’t poisonous. There was a baby with infantile beriberi, which Rosie had only a vague recollection of ever having studied. There was a man who claimed to be fifty but looked eighty with colonic tuberculosis, a diagnosis that seemed jaw-droppingly rare to Rosie and jaw-yawningly common to the nurse helping her translate. A case of Ludwig’s angina had gone so long without the simple antibiotics needed to stop the infection that the patient needed a tracheotomy.
But mostly that first day, as every day before, as every day to come, there was diarrhea, diarrhea and fevers and patients who were dehydrated and emaciated and exhausted. It wasn’t that Rosie didn’t see such symptoms in family practice. It was that here they were worse enough to seem something else altogether, and they were. Here, they were a portrait of what happened when avoidable things occurred instead and then festered, when the treatable went untreated, when the affordable could not be afforded, when the ambiguous got misread, mislabeled, misdiagnosed, misaligned. Here, fever wasn’t caused by that flu that was going around, nor exhaustion by the SATs coming up and college applications coming due and a field hockey coach with unreasonable demands. Here, they were caused by dim, insomniac mosquitos. Here, they were caused by water that was dirty or food that was infested or not having shoes. They were caused by lack of aid or aid diverted or aid misspent or aid ambiguous. Here, they were causing each other. Malnutrition left the body too weak to fight off bacteria. Diarrhea stripped muscle and flesh and reserves. Fever rendered patients unable to eat. So what made any given patient so thin and sick and tired? Who could say?
In the first week, she saw twenty-one different presentations of malaria. She saw what land mines did to tiny hands that picked up something shiny in the grass and what those hands looked like after walking three days through jungle to reach the clinic. She saw more upper-respiratory infections than she had in her entire career thus far. And she saw what she always saw, what she had always seen—what sick children did to their parents, what aged parents did to their kids, how worry and fear and lack of options finished off what mosquitos and land mines and bacteria began. She did not have a facility and a staff she knew like her own kitchen. She did not have an ER with all the comforts of home—CT scanners and MRI machines and a blessed echocardiogram. But she possessed those most important of skills: reflex without panic, action without alarm, cool head and cool hands, mild grace under extreme pressure.
Bed 26 on day one slept a family of seven, the youngest of whom had run through the ashes of the apparently but not actually dead fire that burned every night in front of her home. The ashes looked like the snow she’d seen in a picture book that had come as part of a first-aid and family-support package. The child had second- and third-degree burns and an infection, a lot of pain, a long recovery ahead, but it wasn’t her Rosie was worried about.
The father spoke a surprising amount of English, the most of any patient she saw all day. Rosie explained carefully how to keep the burns clean, apply the salves, change the bandages. She asked if he had any questions. “Yes,” he said. “Where I make mistake?”
“What do you mean?”
“If I do not light fire every night, mosquitos come, bring malaria. If I do not go to fields every morning, first light, I cannot feed family. If I bring daughter to fields with me, she do not learn, run, play. If I do not let her have book, she never get better life. But book make her see ashes is snow. Fire to keep away mosquito and disease no matter if she burn. I make mistake. Where?”
Rosie went back over his story, but she couldn’t see it either. “No mistake,” she told him, which in fact was more horrifying than what had happened to his daughter as a result.
“Must,” he said.
At the end of this first day, Rosie was spinning herself, trying to reckon, to accept what this father had to balance and account for. “Parenthood is like that.” She tried to be doctorly. “The harder the choice, the less likely any of the options are good ones.”
“Here, so many bad thing. You can protect from some but never all.”
“Here and everywhere.” This was true. But here it was truer. “And always. You’ve done well by your family. Her burns will heal, and someday she will see real snow. You’ve saved that for her. And you’ve saved her for that. You’ve done very well.”
When she emerged at the end of that first shift to find the morning gone and the afternoon gone and the night come on, she also found the crowds of people—the waiting-patiently patients, the waiting-patiently families, the people waiting patiently for nothing in particular—gone. Admitted by other doctors? Absorbed into other departments? Healed and sent home? Just sent home? She did not know. It was hard to imagine where they’d all gone. It was even harder to imagine they’d all be taken care of. But Rosie was too tired to puzzle it out. She needed to find Claude and know all about his first day. Had it been as foreign and familiar as hers? As known and unknown and whirling? Was he okay?
But as she took her first steps toward the tree where she’d left her bicycle, what she found she lacked more than the machines and a lab and a pharmacy and sterile bedding was Penn. There was no waiting room as such, but had there been, he would not have been in it, waiting to tell her stories and listen to hers, waiting to take her home at the end of a long day of patients and prose so they could talk together and be together and make love and family together. Instead, there was a wall of humidity and an infinity of screaming insects and a daughter—son—nowhere in evidence. And this was a poor trade indeed.
Novice
Claude’s first day at the clinic began with breakfast, which was actually, literally called “joke” and probably was one since it looked like watered-down kindergarten paste sprinkled with grass clippings and had a raw egg cracked right into the middle of it. The sight of it made Claude woozy. Or maybe it was the smell of it. Or maybe it was just the fact of it. He had not been hungry since what had happened, happened. He thought it was possible he might never be hungry again. But he managed to eat at least a little bit of it. He didn’t want to hurt anyone’s feelings. And now that he knew they ate still-jumping shrimp in Thailand, he thought it prudent to force eggs when they were on offer, even raw and in jest.
There were infinity people who wanted to meet and thank and say nice things to and about his mother and then take her away. “Do not worry,” a woman with white smears painted on her cheeks and nose called after his mother. “We take good care your child,” but his mother evidently was already no
t worried because she didn’t even turn around. “So”—the woman squinted at Claude from under a ratty straw hat—“what we do with you all day?”
Claude couldn’t even guess.
“Your mama is big helping us. Maybe you big help us too.”
It took Claude a little while to understand that the building he’d been brought to was a school. Schools had classrooms, desks, whiteboards, computers, art projects, homework trays, and playground equipment. This place had a dirt yard out front with a bunch of old tires sinking into dust and one big, open room with a falling-apart bookcase piled with papers spilling out of folders and small heaps of ancient-looking books and a stack of dog-eared, water-stained flash cards in English. The students were mostly younger than he was, and there were a lot of them, spread over the thin, tatty linoleum, its bluebells and buttercups faded to rumor, chatting in small groups or napping curled up against the wall or just sitting and staring into nothing. If Claude sat on the floor at school staring into nothing, he’d get in trouble for being off task, but he could see that there were not many more productive alternatives available here.
“You teach?” the painted woman asked.
What did this mean? She could not possibly think he was a teacher. Even people who imagined this worn, wounded room a school would not imagine a ten-year-old a teacher. Would they? “No?” Claude guessed. “I don’t teach?”
But apparently that was the wrong answer because the woman grinned and shook her head. “You sit here. I bring student over. You teach English.” She left and came back moments later with three smiling pigtailed girls and a stack of picture books. She said something to the girls about Claude in some language that didn’t sound like Thai but was just as incomprehensible, and the girls looked at him and giggled. Even in Thailand, everyone laughed at him. He understood why they did though because he knew he looked completely absurd. His lumpy head was ugly. His lumpy clothes were even uglier. And every time he walked or sat down or crossed his legs or stood back up, he had to think about how to do it because whatever natural movements he used to just have seemed to have gotten lost in transit. He would laugh at him too. At least they had that in common.
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