One hour too late

June 2, 2006

The author will forever wonder what might have happened had heacted sooner.

I'll never forget the three years that I served as a locum tenens. My stint, which ended in 2004 when I returned to a hospital-based practice in Idaho, took me to four continents and introduced me to sights and cultures I might not otherwise have experienced. But one painful lesson I learned in a remote region of the South Pacific will stay with me forever.

My six months in Nukunonu were nearly at an end. Despite limited resources, I hadn't lost a single patient. After being on call 24/7 for so long, I was relieved to be heading toward Apia, the capital of Samoa, on my way to my next post in New Zealand.

Nukunonu has no airstrip, and travelers to and from the island must rely on a single boat, the MV Tokelau, which runs once every two weeks or so between the three Tokelau Islands and Apia harbor. The rolling, 30-hour ride had left my wife, Dale, and our two daughters seasick and groggy. We were all happy to see the blue-green tropical island rising up on the southern horizon.

Kamilo was ill, suffering from renal colic and was, I believed, in the process of passing a kidney stone. We had been administering normal saline during the trip, with the bag tied to a pipe overhead. When I reached them, though, the bag wasn't dripping. I checked the setup, pulled the venous catheter, bandaged the site, and tossed the bag into a nearby garbage drum. It was the last unit of fluid we had on board with us. The IV line had lasted for over 36 hours and seven liters of infusion.

"How's he feeling?" I asked Nive.

"Much better," she said. "He hasn't vomited since midnight, and he sat up to drink."

"Urine output?"

"Really good. Twice during the night." I counted Kamilo's pulse, pulled the file from the dry corner where I'd tucked it, and updated his chart. Nive looked exhausted.

"We're almost docked," I told her. "Apia got my e-mail; they'll be waiting for us."

Kamilo had been on another island when he fell ill, and had needed to wait for the M.V. Tokelau to finish a run before he could get home to Nukunonu. Once there, he'd continued to vomit and soon was too weak to stand. By the time I saw him, he had started to appear dehydrated, was oliguric, and his UA dipstick was positive for gross blood. I gave him IV fluids and started him on levofloxacin. I had then arranged to have him transported to the hospital in Apia, and asked to have a car at the wharf to take him directly there.

A worsening condition, and a red-eye flight

When we stepped off the boat at Apia, I spotted several familiar faces in the crowd. My parents had flown in from Texas to spend some time with us before we moved on to New Zealand; my father's boots and cowboy hat were unmistakable.

I also recognized Dr. Pehio, the medical director for the Tokelau island group. He was stationed in Samoa, and with his nurse, Fenuafala, handled transfers from our island hospital. I'd e-mailed Dr. Pehio with Kamilo's condition.

A few moments later, Kamilo came down the gangway, haggard but now ambulatory. I felt satisfied-he was much better than he had been, and was moments away from a hospital with lab diagnostics, radiology, consultants, and fully staffed surgical theaters. We kissed Nive and Elizabeta and said good-bye.