A previously healthy 29 year old female arrived in the ED via motor taxi, accompanied by her family, early in the afternoon on a day I was working in the outpatient clinic. I stopped by the ED on my way home, and saw that Turno doctor had her hands full with the patient, so I stopped to help. The patient was hypoxic (74%), tachypneic (58 breaths per minute), and somewhat hypotensive (90/50). She complained of chest pain and shortness of breath for 3 days, and also thought she may have had a fever although she was afebrile on arrival to the ED. Her EKG showed sinus tachycardia, but was otherwise normal (we were only able to obtain limb leads). She appeared chronically ill. We were unable to get labs because of the time of day, and the patient was too unstable to transport for a chest x-ray. Pulmonary embolism was a major concern even though she had no risk factors, thus we gave Heparin for anticoagulation and started to arrange transfer to Guatemala City for diagnostic testing and treatment. After two hours of preparing for transport, collecting supplies (as there are none on the ambulance), and deciding which family member was going to accompany the patient, we were finally ready to go. Just prior to departure, the lab was able to run a rapid HIV test, which came back positive. This added more to the list of possible diagnoses. By this time the patient was on 10L O2 and a Dopamine drip. We added on several antibiotics for possible infection, and started the journey.
The ambulance is a van without the back seats. There is a bench next to the stretcher for family and medical staff. Our crew consisted of the driver, his co-worker, a nurse from the hospital, and me. The patient's husband accompanied us in the back of the ambulance. The terrain in this area of Guatemala is incredibly rugged, and the roads suffer much damage during every rainy season, thus the ride was anything but smooth. During the first 30 minutes of the 3 hour trip, the batteries to the portable pulse oximeter died. I was able to replace these with batteries from my flashlight. A few minutes later, the patient's oxygen saturation dropped from 80% to 60%, signaling that the first oxygen tank of three partially full tanks was empty. The driver pulled over, the other bombero jumped out and changed the tank, the patient recovered, and we got back on the road. We realized that we should have been able to go about twice as long on that tank of O2, meaning we had a leak or a problem with the regulator. If the next two tanks had the same problem, we were not going to have enough O2 to make it to the city. During the next few minutes, the infusion pump stopped working due to dead batteries meaning I had to push medications through a needle into the established IV. After another hour, the second oxygen tank ran out, leaving only 1000L of O2 in left on the ambulance enough for about 30min and we still had more than an hour to go to the hospital in Guatemala City. We had to find a closer hospital that would either care for the patient overnight or give us an oxygen tank so we could make it to the city. The bomberos took us to a nearby hospital, we wheeled the patient inside, and explained our situation. They were happy to give us the oxygen tank; their beds appeared full and their staff already too busy for a very sick patient. The last hour went as smoothly as could be expected under the circumstances. We arrived at the hospital in Guatemala City, took the patient inside, and told the doctors there what we knew. The bed we took the patient to was in the middle of a room full of ill appearing patients. There were no monitors, no private rooms, and very little space to move around. They started her on oxygen and got to work with labs and medications. The nurse and I walked out of the hospital, relieved that our patient had survived the trip.
I don't know what the diagnosis of the patient was or if she survived. At home, this patient would have undergone imaging of her chest, lab testing, been transferred to an ICU, and would have received the appropriate care for the diagnosis found on labs and imaging within hours of arrival in the ED. In Guatemala, she received 3 hours of supportive care in the back of an ambulance, nearly died twice when we ran out of O2, and hopefully was able to receive a diagnosis and care at a hospital hours from her family and home. The nurses and local physicians back in Santiago Atitlan were doubtful that the patient would receive much, if any, treatment given her HIV diagnosis.