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When ER came to Hlabisa

The relative solitude of the resuscitation bay is abruptly invaded as the doors from the waiting area slam open. A trolley bursts in, surrounded by people dressed in the white and red garb of the Emergency Medical Rescue Service, KwaZulu-Natals ambulance organization. They look a little bewildered. One of them is squeezing a breathing bag attached to the tube that issues from the mouth of the body that lies on the trolley. The door opens again and a big man in an orange jump suit strides in. His label identifies him as a member of AMS, the Air Mercy Service – the charity that runs the air ambulance and other high tech services.

He catches my eye. “Hi doctor. So this lady came to clinic with 3 weeks of breathlessness and I happened to be visiting the clinic when the ambulance came for her. I thought she looked bad so I followed them.” He grins. “Just as well because she stopped breathing half way through the game park. I tubed her and gave her adrenaline.” He looks around. “Where are your ventilators?”

I mutter something incoherent. I don’t like to admit that we only have one and I checked it the other week and a piece is missing. It probably hasn’t been used since it was purchased. He then rattles off a string of information in ER-speak. It feels like a little piece of Johannesburg or Chicago has dropped into Hlabisa. And Hlabisa does not really know what to do. He turns to the nurse.

“I think you need to set up an adrenaline infusion.” The nurse looks at him blankly and then to me, her eyes pleading for help. No one has ever asked her to do this before.

“There will be some adrenaline in the resus trolley,” I say helpfully. The AMS tech rattles off doses. I move over to the patient and quickly assess her. She has clearly been unwell for sometime and is almost certainly infected with HIV. She has probably developed PCP, a specific form of severe pneumonia not uncommon in those with advanced HIV. She is making no respiratory effort at all – all the breathing is being done by the now rather bored looking nurse who is squeezing the bag.

The jump suit dressed man tells me he is nipping out to do the paperwork. He leaves. Everyone looks at each other. We have no ventilator. We have no ITU. The nearest unit is 2 hours away and they will not take people with advanced HIV and hopeless pneumonias. A nurse could squeeze the bag for a few days I suppose. It will be difficult to find volunteers. This poor lady is going to die. I find myself strangely embarrassed that following all the efforts of the paramedic there is absolutely nothing we can do.

I examine her again. Nothing has changed. Her pupils are fixed. If I stop squeezing the bag she makes no effort to breathe. I write up the notes and my examination findings. I look up. The AMS tech has left on another job. The nurse and I look at each other and in unspoken agreement (confirmed immediately after in word and writing) we disconnect the tube.

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