They heard it before they saw it, their first impression of the clinic, as they biked in the next morning just after sunrise, no overnight cool for the dawn to burn away, the air sodden already. There was the sound of metal on metal, a whine like a train whistle, woesome thunks, and shouts Rosie could not identify as Thai or Burmese but knew for sure were curse words. She guessed someone yelling at cats in battle or maybe heat, though they’d seen only dogs and dogs and more dogs so far, and never in her life had she heard a dog make a sound like that, a high-pitched keening, more screech than scream. Some kind of insect maybe? It would have to be bigger than she was willing to think about so early in the morning. A monkey? An army of frogs? Animal attack? And indeed, when she and Claude arrived at the mouth of the chewed-up dirt drive leading into the clinic, they found soot-caked, mud-stained feet and scratched-up shins kicking desperately at the end of a body otherwise entirely consumed by a voracious, growling maw.
When it revealed itself, the battle proved age-old but not animal: motion versus stasis, senescence versus youthful tenacity, the maw in question neither beast nor human but mineral: an ancient, heretofore pickup truck. It had a mechanic swearing under its open hood and two small children giggling in its cab, one on the floor using two hands to depress and release (usually all at once) the clutch, one shifting and turning the key (with more tenacity than would have been ideal) as directed.
“Truck” was a generous term. It was more rust than engine, more dirt than vehicle, and not the kind of dirt you could just wash off with a good scrub either because Rosie had a feeling this dirt was load bearing. The body had once been green and probably lovely. It was one of those pickups from the 1950s with the bubbled hoods and rounded wheel wells that someone at home would have dressed up with whitewall tires, a chrome grill, a thousand hours with a Q-tip and a cloth diaper, and then paraded for the Fourth of July. This one didn’t look like that. Apparently, it didn’t run like that either.
The filthy truck spit out a filthier mechanic. “You new doctor?”
“I am. Rosie Walsh. This is my dau … um, son,” she stammered. “Claude.” She glanced at him to see if she could apologize with her eyes, but he was staring at the ground and wouldn’t meet them.
“You drive?”
“No, we biked.” She turned back to the mechanic, distracted. “The guesthouse where we’re staying lent us bicycles.”
“Sorry, my English.” The mechanic tried again. “You can drive? Manual shift car?”
“Oh. Yes!” Rosie’s own English comprehension was apparently jet-lagged.
The mechanic shooed the two children out of the cab, performed final ministrations under the hood, and gave Rosie the international sign for “Pray to your gods and hit it again.” The motor turned over like a well-trained seal. There was much rejoicing. Rosie’s first procedure at the clinic was a success. The patient—improbably, it seemed to her—lived.
The mechanic was slick with grease from the elbows down, but fortunately, greetings in Thailand involved not shaking hands but pressing your own together in front of your chest and bowing toward one another. “Very glad to meet you. I am K. Do not ask what K stand for. It stand for so much. We happy you here. I show you around. First, meet Sorry Ralph.”
“The truck is named Ralph?”
“Sorry Ralph,” K corrected.
“Why?”
“He very sorry.”
“I can see that.”
“Sorry Ralph is ambulance. Also fetch medicine and supply if there is medicine and supply. Also hearse. Usually sorry though so hope you do not need.”
Rosie nodded. She was surprised to see that the mechanic was both female and the apparent welcoming committee. K turned and headed off at what appeared to be a saunter, but Rosie and Claude found themselves practically running to keep up. At each turn, their entourage grew, everyone eager to welcome them with pressed hands and a bow and to trot alongside, everyone happy to let the mechanic lead. Claude was whisked away, and Rosie reached for him as if the wreckage they clung to had suddenly split in stormy seas, but he was already too far off, waves of people between them. Rosie felt at once swept along and struggling to keep up. A chorus of voices in a variety of languages informed her what was where and offered helpful hints that were probably important. A shoe tree of fingers pointed in all directions at once.
There was a building that was clearly obstetrics. At least you could tell obstetrics by looking. There was a workshop from which disembodied limbs hung—legs and feet mostly in various states of doneness, some still being assembled, a band saw, a drill press. There were patients sitting in chairs or wheelchairs whose legs ended before their pants did, so she could see where they belonged too. There was an open-air portico—really just a swept dirt floor under a roof of flattened cardboard boxes tied to the underside of a tarp—littered with plastic lawn chairs, sleeping bags, and blankets in piles where whole families seemed contentedly camped out. Whether they were awaiting treatment or news about someone else receiving treatment or something else altogether, Rosie could see only that they were not bleeding or moaning in pain or about to give birth. There were half-formed, halfhearted lines everywhere. There was an eye chart taped to a cement wall at the end of a rock-strewn dirt path. There were stray dogs wandering lazily in and out of all the buildings, including the one labeled Surgical Department, a building with holes for doors and windows but with no doors or windows filling them. There was a large patch of dirt with lounge-style lawn chairs and then the regular sitting-up kind behind them, and though patients were reclining, openmouthed, on the former, and though there was a medic, lab-coated and rubber-gloved, on the latter, Rosie could not quite believe this was a dentist’s office, but she was wrong.
The buildings were cinder block with barred windows or patched plaster with grated cutouts like lace. Corrugated metal roofs covered in debris gapped several inches over the tops of the walls. Curling linoleum floors, their patterns worn nearly away, spilled onto dirt or cement spaces out front. Empty, open drains lined all the walkways, auguring a rainy season that must turn all the dirt floors to sopping, sticky, insect-harboring mud. All of it un-air-conditioned, unsterile, unsealed, and undifferentiable. But the entrances, the doorways, the open spaces where doorways should have been, were all heaped with flip-flops and plastic clogs and sandals, a broom made of straw always propped nearby, and so, though the walls and ceilings were grimy with decades of dirt, the floors were miraculously, significantly, clean.
Her seeming entourage led Rosie to the largest building and ushered her in. It was unlike anything she’d seen before in her life—it was beyond imagining—but she recognized it immediately as home. The rush of the few doctors and nurses at hand, the focus of the medic doing eye-of-the-storm triage amid the rest of the room’s hurricane, the tang of blood and panic, the antiseptic smell augmenting rather than assuaging all the other ones, equivocal spills best avoided, patients unable to ask, afraid to know: an emergency room.
There were no gurneys, no beds, no curtains, no monitors, no machines. Patients lay on plain wooden platforms covered in scraps of sheets or old, felt-lined tablecloths falling into tatters. Patients lay spooning other patients in a tangle of IVs. They shivered against the walls, trailing blood or vomit or bandages into the corners. They sat on the floor between the wooden platform beds so the staff darted around them like swallows. It was impossible to tell who was waiting for treatment and who was waiting for a loved one, whose mangled and missing limbs were emergent and whose had been that way for decades, whose drawn and pallid faces, damp brows, hollow, shining eyes bespoke fever and whose fear and whose had merely frozen that way after too many years in that sorry state. There was a small folding snack table just inside the door with a foot-tall stack of papers weighted down by a rock: single-sheet intake forms.
It was not yet seven a.m.
Having deposited her where she was clearly meant to be, Rosie’s entourage faded away, back to whatever posts they had temporarily abandoned in order to welcome her. Who had taken Claude, and where? There was no one even to ask.
“Ready?” A teenager at the folding table nodded encouragingly toward the pile.
Rosie wasn’t sure what she’d been expecting. A jungle orientation of some sort? An HR tutorial on tax and benefit forms? A lecture from Legal on sexual harassment? Somehow, she’d expected calm assurances regarding her child and what he would do while she worked. Somehow, she’d imagined something between truck repair and meeting patients. But there was nothing.
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 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.
* * *
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.