There is a stretch of interstate highway just to the east of where we live. We can hop on this highway and drive in a straight line, for thirty minutes of more, at speeds of roughly 65, 70 miles per hour (or more, depending on your proclivities), with barely the slightest curve or bend in the road to challenge you. I can cover a span of approximately 30 miles in approximately 30 minutes. This is what we are used to. But our ambulance lumbered out of the beach parking lot and onto the main road, it was a whole different scenario.

In St. John, you don’t ever drive for more than 30 feet without the road bending, significantly. The posted speed limit signs indicate a maximum of 20 miles per hour. This sounds ridiculous to a person from the midwest. I mean, I pull into my driveway at 20 MPH, for God’s sake. 20 mph is maddeningly slow.

Not, however, if you’re driving in St. John. The roads are narrow — incredibly narrow! — and curvy and winding, with switchbacks, steep inclines, sudden valleys, and drop-offs of something just less than 90-degrees. St. John is a volcanic island, with lots of peaks and valleys, and a terrain that is anything but smooth and gentle.

It is a mere 7 miles long, by 3 miles wide, and yet to drive from the point where we stayed – Coral Bay – to the opposite side of the island – the side where most of the shops, restaurants, and the solitary gas station are – would take us roughly 30 minutes, and when you finally got there, you’d be exhausted. This is not like driving in Illinois, where you can actually use your knees to steer your car for a brief stretch. Oh, and, just to keep it interesting (as if the wildlife and the terrain weren’t already enough), it is customary to drive on the left-hand side of the road, which is completely opposite what we are accustomed to at home.

There are other things to contend with, too, like donkeys – yes, donkeys - blocking your way, as they cross from one side of the road to the other to continue their leisurely grazing. But wait! There’s more! There are also wild goats, with all their small brood, and chickens, and deer and even cows, that you will come upon, all of a sudden ~ along the side of the road, or maybe crossing the road. To be sure, driving in St. John is quite an experience.

But when you have an emergency, and all you can really think about is getting from Point A to Point B in as little time as possible, well, 20 MPH?!!! What the hell is that?!!

Actually, we crept along at much less, even, than 20 mph. The ambulance driver was trying not to jostle Carsten around too much, which was, indeed, very kind of him. But when the ambulance driver creeps along at less than 20 mph, and then also stops, on occasion to let a herd of donkeys finish crossing the road, or to s-l-o-w-l-y work his way around a pothole, and your son is lying in the back of said ambulance, in pain, and with his arm broken……Well. You might think of yourself as a sane and rational person….. and, you and the people who know you might think that the description of “calm, cool, and collected” aptly describes you most of the time……. but I can promise you, that no matter how sane and rational and understanding a person you might be, or how, on a good day, you might be the kind of person who could broker peace between nations, but you will start to LOSE YOUR FREAKING MIND over the amount of time it is taking (20 minutes, to be exact, to cover a distance of roughly two, maybe three, miles) to get your child to — no, not a hospital — the health clinic.

Did you know? Because, we didn’t know, that St. John doesn’t even have a hospital! They have a health clinic. A clinic that is staffed by an icy cold receptionist, a handful of nurses, and a physician assistant. That’s right: no doctor.

So after enduring an excruciatingly long ride in the ambulance to what we thought would be our Medical Salvation, it was a little disconcerting to start piecing together all the facts of our situation. What choice did we have, though, but to go with what we’ve got? His arm certainly wasn’t going to fix itself.

***

The first thing that had to be done was to take an x-ray, to find out what kind of fracture we were dealing with. The films came back, and they were not good: both bones in Carsten’s left arm were broken, and not only that, but the bone fragments had been pushed, a good couple of inches, up towards his elbow. His arm was about an inch and a half shorter than it should be, and all signs pointed to this being a surgical case. But guess what? You can’t have surgery in St. John! Because they don’t do surgery there! If you need surgery, you have to drive to Cruz Bay, the only port of entry to the island, catch a 20-minute ferry ride over to St. Thomas, and then catch a taxi to the hospital there.

At that moment, all I could think was, Isn’t one nightmare a day enough? But now, this? Really, I should know better than to ask if things could possibly get any worse, because they always can, can’t they? And the coil of anxiety that had been winding up in me all afternoon, ever since the realization that Carsten’s arm was broken, turned and tightened another notch. How much longer, I wondered, before it snaps?

 ***

After looking at the x-rays and all but concluding that surgery would be necessary, the PA also tells us that our only option for surgery is not a good one. He tries to be largely diplomatic in telling us about the chaos and the lack of care we would receive in St. Thomas, and he strongly recommends that if it is at all possible to avoid St. Thomas, it would be in our best interest. And so the coil ratchets tighter another notch, and now I am in full-blown panic mode, because when one of their own kind is telling you hey, I wouldn’t do that if I were you, about what is looking like your only option, well, what do you do?

He proceeds to tell us that he has done a lot of reductions (the medical term for manipulating the bones back into their correct position). He is also honest and straightforward with us about the fact that sometimes it works, and sometimes, the patient is no better off than before the attempt. There are simply no guarantees. He offers us an attempt at a reduction which, if it is successful, would enable us to avoid having to go to St. Thomas. But the possibility of failure also lingers, which means Carsten would have to endure a whole lot of pain, with the end result being surgery anyway. I wonder, for a moment, if the weight of the actual world could feel heavier?

***

Meanwhile, while all these discussions are going on, a nurse has been trying, unsuccessfully, for quite some time, to get an IV going in Carsten’s arm. The intention was to give him some morphine intravenously, to alleviate the pain. Carsten is freaking out about the needle, to the extent that he almost seems oblivious to the fact that he’s got a much bigger problem going on on the other side of his body, and he is crying and screaming every time she makes an attempt.

She sticks him once.

No luck.

She tightens the tourniquet, and sticks him again.

Still, no luck.

Remember: she has only one arm to work with, and there are only so many times you can stick a person in the same vein.

She repositions her light, she readjusts her tray, and she fiddles about with who knows what for far too long, telling stories that I don’t care to hear. She holds Carsten’s one good arm up in the air, examining its surface, turning it from side to side and tap, tap, tapping on it – like she is checking the ripeness of a melon – to find a vein. It is maddening to watch.

She remarks about how dehydrated he must be after a day at the beach (perhaps true)….and he probably hasn’t been drinking enough (perhaps also true)…and he’s probably swallowed some salt water (no doubt)…..and, and, and —

WHATEVER. She offers up excuse after excuse for why she can’t do what her only job is to do in that moment.

The bottom line is: SHE CAN’T GET THE NEEDLE IN HIS VEIN.

And all I want is for her to JUST OWN IT. OWN IT, and also, ASK FOR HELP.

Because, we are not here to judge her, we are not here to criticize. All we want, for the love of God, is a little bit of pain relief for our son, and in that moment, she is the one thing standing between him and just that.

One hour has elapsed since our arrival at the clinic, and still, no IV, no morphine.

It may be Carsten’s arm that is broken, but WE ARE ALL LOSING OUR FREAKING MINDS RIGHT NOW.

As diplomatically as possible, Noel tries asking her if this is perhaps something the PA might be able to help her with? Her response, in complete and utter seriousness, is that she’s the best there is at the clinic, and the PA wouldn’t be very helpful because he just doesn’t do many IVs, you know. That is the nurses’ job.

Noel and I just stare blankly at her because, really, there are just no words.

The IV, it turns out, never happens; she is unable to get it in. The best they can offer Carsten, at this point, is a shot of morphine, which the same nurse administers into his deltoid – a curious move which inspires the PA, upon walking in and seeing the nurse giving Carsten the shot, to remark, “Oh. Well. I guess you can give it there…” What little shreds of confidence I was holding onto at that point, just blow right out of me, carried out to sea on the island breeze.

***

The issue of whether or not to allow the PA to attempt a reduction on Carsten’s arm was still hanging in the air, and with it, a whole lot of mental hand-wringing. Because this is the thing: we are Consumer Reports kinds of people. Almost to a flaw, whenever we (but especially Noel) need to make a decision about something, we research it: cameras, cars, refrigerators, washing machines, kitchen appliances, books, you name it. We like to consider all the angles, and make what we feel is the best informed decision as possible. (People who know Noel in person are laughing and nodding their heads in complete agreement right about now….)

Had circumstances not been what they were, Noel no doubt would have had a two-column spreadsheet, with the pros and cons for our two choices listed out in excruciating detail. But as it was, time was of the essence, and weighing and analyzing every angle just wasn’t possible. Our decision came down, basically, to this: if we wanted to avoid surgery in St. Thomas, how much faith should we put in this guy — this guy who stood before us in a pair of blue scrubs, with his tanned skin, and his sand-colored hair, pulled back into a small ponytail, whom I could more easily picture on the beach, surfboard in hand, than in the role of doctor –  how much trust do we place in him? Because let’s be honest: a PA does not have the same training, expertise and medical background as an orthopedic surgeon. Though he told us he’d “done a lot of these reductions,” what, in fact, does that mean? That he’s done 25? 85? 500? In that moment, with my kid in the worst pain he’s ever known in his entire life, what I wanted was an expert: I wanted the guy who does 10-kajillion reductions every year; the guy for whom doing a reduction is no more complicated than putting on his socks in the morning. But we don’t always get what we want, and we were beginning to understand that choice, when you live on a tiny island, is an otherworldly luxury.

***

No, what we had to work with that day was the PA, who by all accounts appeared to be  calm, yet authoritative, and he was – or so he seemed – to be completely honest with us about his ability, and about the odds of success with the procedure. Also, he appeared to be breaking ranks a bit, by being forthright with us about the sub-par medical care he thought we would receive if we went to St. Thomas – a move which, I admit, did seem to establish, rightly or wrongly so, a certain modicum of trust between us.

With these few, indiscriminate facts at hand, we had to decide: knowing that sedation was off the table as an option, do we go ahead and let this guy manipulate our kid’s bones, under no pain medication more powerful than a shot of morphine in his arm, and an injection of Lidocaine in the fracture site? I’ve made plenty of ‘gut decisions’ before in my life, but none have felt, perhaps, quite so monumental as this one did.

***

In the end, our decision was to let the PA at least make an attempt at doing the reduction. How we came to the conclusion was based not so much on facts and evidence and the analysis of those very concrete things, but rather, mostly, it was based on what we felt very strongly that we did not want to do, which was to travel to St. Thomas and undergo the surgery. It just seemed like we should do whatever we could to avoid going that route.

And just like that, in a matter of mere minutes, two people who sometimes have trouble deciding what to eat for dinner, had made a decision that they knew was going to cause massive amounts of pain to their child, but with the hope that it would, ultimately, be for the best.

(To be continued in Part III, which, I promise, will be the end of the drama!)

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