I had a patient come into the ER having been run over by a car. The family that brought him stated that he was a known drunk in a neighboring town, and they had found him on the street, run over, and so they brought him in. He looked terrible. He had a broken left lower leg that swung freely like an extra joint. He had a broken femur (upper leg) that did not swing freely but was bent like an extra knee. His forearm was broken and floppy. He had a broken pubic bone and a broken sacrum (basically a fractured pelvis), he had a broken clavicle as well as 8 broken ribs on the left side. Both lungs were collapsed. His urethra was ruptured so that he could not empty his bladder. His right ear was ripped partially off. Surprisingly he was still alive, and actually somewhat awake. We stabilized him, and during the process the older woman who had brought him in stated that they had to be honest and that they had run over him while backing up their car in the dark. The drunks in town will fall asleep in the middle of the road, and they can be hard to see in the pitch dark where there are no street lights. Especially when you are backing up. The next morning the patient was intubated with lots of medicine to maintain his blood pressure, but stable. We cannot treat this type of trauma in our hospital, and this man needed many operations to get better so the decision was made that we needed to transfer him to Cuzco. However, we had a serious concern that he would die, not during the transfer, but soon after the transfer. Patients that are this critical often do not do well in Peruvian hospitals. The patient’s family has to go buy the medicines and all the things that are needed to care for the patient. The hospital will not provide them charitably. About this time the people who brought him in admitted to us that they were actually the patient’s family. We wondered if the older woman was going to eventually come back and tell us that she was his wife. People are so concerned about the costs of medical care, about troubles with the law that they will lie to avoid issues and to avoid paying. It can make caring for patients very difficult. We did manage to transfer this patient. He died in Cuzco the day after our transfer, just as we were concerned might happen. It is a tough spot to be in. We could keep him alive, but we could not make the definitive treatment that would heal him. So we had to transfer, even though we knew that he might die for lack of care at his destination. A tough choice.