It's Friday after work. End of the work week happy hour. John, my Rwandan co-resident says, "Let's not think about the hospital this weekend," as he savors his bottle of Tusker beer.
I've had this conversation countless times before. Back in Connecticut, there are times when I have to work hard to mentally separate myself from my patients' stories and situations once I step out of the hospital. But here, that becomes an even tougher challenge. As physicians, we like to be able to tell patients, "We did everything we could." In the US, we are often fortunate enough to have "everything" be everything that medicine and science are capable of. Here though, it's "everything" that happens to be available in the country, or in stock near the hospital, or performed by a specialist who is actually in the country, or whatever the family can afford.
What's it like to know that somewhere else in the world, the 22-year-old girl with kidney failure and heart failure would reliably get her diuretics every day so that she could breathe, and would have a hope of getting dialysis and then a kidney transplant? Somewhere else in the world, the 18-year-old girl with pancytopenia (very low levels of her white blood cells, red blood cells and platelets) would have gotten her platelet transfusion at the right time in order to do a bone marrow biopsy, and perhaps a diagnosis, and perhaps some treatment for the problem, and would not have died of overwhelming sepsis from her hospital acquired infection, at least not last week. Elsewhere, the 21-year-old girl with cough and lymphadenopathy would have gotten her CT scan and lymph node biopsy weeks earlier, and perhaps would not have died so quickly, of unknown causes. And somewhere else, the 37-year-old woman with five children, who just gave birth to her sixth child by c-section three weeks ago, would not be laying on her bed with paralyzed legs because of the tuberculosis that had destroyed her spine during the pregnancy, without a CT scan or neurosurgeon nearby soon enough to try to repair the problem, before it was too late. These are the patients I tried to clear from my mind as I sipped that cold beer. I think John was too.
Friday was my last day on internal medicine. After five weeks, I'd like to take the last week for some pediatric time. John told me he didn't want me to leave with a bad impression of medicine here. He asked me what I really thought. I told him what I've been writing here these past five weeks. How impressed I've been with the residents and attendings, with the knowledge and teaching, with the technical skills of the residents who are required to work for two years after medical school as general practitioners, doing everything from simple pediatric visits to c-sections and splenectomies, before starting residency. In the US we're all so specialized, even in our residencies, that many of us lack the entire set of practical skills that physicians once possessed. And we rely so much on imaging and laboratory investigations that our physical skills have atrophied. I told him I know how much of it is about the resources, and the system here. He seemed satisfied with that answer. The more you now about what's available elsewhere, but not here, the harder it gets. The more you need to step away, disconnect yourself. In that process, do you grow too immune to the suffering? Sometimes you just have to get away.
I finally made it out of Kigali this weekend. Took a trip with a bunch of the US doctors to Kibuye, and beautiful little town on Lake Kivu, in the western part of the country. Indeed, I can now say that not only Kigali, but Rwanda, is breathtakingly beautiful. Nothing but green, verdant, terraced hills and mountains, as far as the eye can see, between Kigali and Kibuye. Green hills dotted with little huts, and clusters of trees, and patches of farmland. As the road approaches Kibuye, the mountains give way to the volcanic lake nestled between them. Lake Kivu was originally part of the Nile River watershed, but got closed off as a tributary when cooled lava essentially created a dam. The alternative folk story is that Lake Kivu was formed when a farmer's wife, as punishment from God for bad behavior, could not stop urinating, until her urine created Lake Kivu, among the top 20 freshwater lakes in the world for depth and volume of water it contains. The other interesting thing about the lake is the large amount of methane gas trapped beneath, which could, at any point, tomorrow or in 1000 years, cause an explosion and widespread destruction as it is released from beneath the lake. This thought was only at the very back of my mind this weekend, as we relaxed by the water's edge, boated, kayaked, and climbed a hilly island with a huge colony of fruit bats. Despite its beauty, it has remained largely underdeveloped, with a small village feel, and the ability to be out on the water and feel entirely alone and at peace. It's the kind of place that makes you not want to leave at the end of the weekend, makes you wish the hospital would open an annex there. I'd be the first person to volunteer to work there.
I will have one more week to learn here. One more week of seeing pathologies I would never see at home, either because of geographic considerations or because nothing would ever advance that far at home. I will have one more week of seeing families faced with impossible decisions, or decisions that have already been made for them. Another week of doctors truly doing all that they can, and wishing they could do more. I may be sad, and I can write about it, and reflect, but then I can leave, and go back to a place where it's easier, if only just a bit.
I've had this conversation countless times before. Back in Connecticut, there are times when I have to work hard to mentally separate myself from my patients' stories and situations once I step out of the hospital. But here, that becomes an even tougher challenge. As physicians, we like to be able to tell patients, "We did everything we could." In the US, we are often fortunate enough to have "everything" be everything that medicine and science are capable of. Here though, it's "everything" that happens to be available in the country, or in stock near the hospital, or performed by a specialist who is actually in the country, or whatever the family can afford.
What's it like to know that somewhere else in the world, the 22-year-old girl with kidney failure and heart failure would reliably get her diuretics every day so that she could breathe, and would have a hope of getting dialysis and then a kidney transplant? Somewhere else in the world, the 18-year-old girl with pancytopenia (very low levels of her white blood cells, red blood cells and platelets) would have gotten her platelet transfusion at the right time in order to do a bone marrow biopsy, and perhaps a diagnosis, and perhaps some treatment for the problem, and would not have died of overwhelming sepsis from her hospital acquired infection, at least not last week. Elsewhere, the 21-year-old girl with cough and lymphadenopathy would have gotten her CT scan and lymph node biopsy weeks earlier, and perhaps would not have died so quickly, of unknown causes. And somewhere else, the 37-year-old woman with five children, who just gave birth to her sixth child by c-section three weeks ago, would not be laying on her bed with paralyzed legs because of the tuberculosis that had destroyed her spine during the pregnancy, without a CT scan or neurosurgeon nearby soon enough to try to repair the problem, before it was too late. These are the patients I tried to clear from my mind as I sipped that cold beer. I think John was too.
Friday was my last day on internal medicine. After five weeks, I'd like to take the last week for some pediatric time. John told me he didn't want me to leave with a bad impression of medicine here. He asked me what I really thought. I told him what I've been writing here these past five weeks. How impressed I've been with the residents and attendings, with the knowledge and teaching, with the technical skills of the residents who are required to work for two years after medical school as general practitioners, doing everything from simple pediatric visits to c-sections and splenectomies, before starting residency. In the US we're all so specialized, even in our residencies, that many of us lack the entire set of practical skills that physicians once possessed. And we rely so much on imaging and laboratory investigations that our physical skills have atrophied. I told him I know how much of it is about the resources, and the system here. He seemed satisfied with that answer. The more you now about what's available elsewhere, but not here, the harder it gets. The more you need to step away, disconnect yourself. In that process, do you grow too immune to the suffering? Sometimes you just have to get away.
I finally made it out of Kigali this weekend. Took a trip with a bunch of the US doctors to Kibuye, and beautiful little town on Lake Kivu, in the western part of the country. Indeed, I can now say that not only Kigali, but Rwanda, is breathtakingly beautiful. Nothing but green, verdant, terraced hills and mountains, as far as the eye can see, between Kigali and Kibuye. Green hills dotted with little huts, and clusters of trees, and patches of farmland. As the road approaches Kibuye, the mountains give way to the volcanic lake nestled between them. Lake Kivu was originally part of the Nile River watershed, but got closed off as a tributary when cooled lava essentially created a dam. The alternative folk story is that Lake Kivu was formed when a farmer's wife, as punishment from God for bad behavior, could not stop urinating, until her urine created Lake Kivu, among the top 20 freshwater lakes in the world for depth and volume of water it contains. The other interesting thing about the lake is the large amount of methane gas trapped beneath, which could, at any point, tomorrow or in 1000 years, cause an explosion and widespread destruction as it is released from beneath the lake. This thought was only at the very back of my mind this weekend, as we relaxed by the water's edge, boated, kayaked, and climbed a hilly island with a huge colony of fruit bats. Despite its beauty, it has remained largely underdeveloped, with a small village feel, and the ability to be out on the water and feel entirely alone and at peace. It's the kind of place that makes you not want to leave at the end of the weekend, makes you wish the hospital would open an annex there. I'd be the first person to volunteer to work there.
I will have one more week to learn here. One more week of seeing pathologies I would never see at home, either because of geographic considerations or because nothing would ever advance that far at home. I will have one more week of seeing families faced with impossible decisions, or decisions that have already been made for them. Another week of doctors truly doing all that they can, and wishing they could do more. I may be sad, and I can write about it, and reflect, but then I can leave, and go back to a place where it's easier, if only just a bit.
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