Day one: scary bacteria, aggressive drug reps, and crazy gym class instructors

Day one. Infectious diseases consult service, los infectologos, as they say here. Although there are many infections here, there are not as many infectious disease specialists. And while Cali is blessed with many hospitals and medical schools, they don’t have enough specialists to go around. Each one is required to cover multiple hospitals, and they can’t always visit each hospital every day. My hospital, Hospital Universitario del Valle (HUV), was not lucky enough to have an ID attending present on Tuesday, or Wednesday as it turned out. The numerous consults awaiting him- the 19-year-old girl recovering from a severe pneumonia that put her in the ICU for one month, the man with pulmonary fibrosis waiting in the ED transitional unit for days to be admitted, the woman with the psoas abscess causing intermittent bacteremia, all had to keep waiting. In reality, none of them looked that sick to me. I think if things were different, and the outpatient milieu stronger, I think some of them would have already been discharged from the hospital. Unless their primary teams decide to proceed with plans or discharge patients without ID’s advice, the patients will probably keep waiting, until they are seen by all the requested consultants. They might be waiting a while.

Luckily, one of the other ID specialists was seeing patients at a different hospital, and we were able to join him. The backlog from the long weekend meant there were 13 patients to be seen on Tuesday morning, which made for a busy morning. Many of these are the standard problems we would see at home- diabetic foot infections, cellulitis, abscesses, pneumonia, sepsis. Some infections were slightly less common at home, like extra pulmonary TB or HIV with altered mental status.  Of course, there are always the questions of which antibiotics to use for slightly more resistant bacteria, or as sometimes the case here, very resistant bacteria. It is unclear how prescribing practices evolved quite the way they did here, but currently, they use some of the broadest spectrum antibiotics available (like meropenem) as the first line treatment for sicker patients, before cultures become available. They use meropenem the same way we use vanco and zosyn, which are usually quite sufficient. At home, sometimes we have to beg and plead with ID fellows and antibiotic pharmacists to get some of the antibiotics that they use every day here. That process usually annoys me, but I think now I’m more content with it. Yesterday, my very first day, I saw a pseudomonas isolate that was pan-resistant, and I mean resistant to everything. When asked what to treat the patient with, the ID attending chose three antibiotics (two of them quite strong) seemingly at random, hoping that together they would treat what each individual one could not.

Aside from the antibiotic use, much of what I’ve seen at the hospital seems very familiar. Although HUV is considered the public hospital, the not-as-nice hospital, I think it’s probably as nice as the nicest hospital in Rwanda. There are still open wards, but not as crowded, and with more private rooms. There are more nurses, more available medications and diagnostics (CT, MRI), more specialists, more computerized information. There’s even an electronic medical record! As of last week, HUV’s Emergency Department is entirely electronic. Want to check the ED note? Better go over to a computer.  Also very familiar are drug company reps. They are everywhere. They supply the residents with lunch almost every day of the week. After only one afternoon at HUV, I got myself a Lantus pen, an Amaryl notebook, free samples of an oral Factor Xa inhibitor (an anticoagulant) and just missed out on a pack of highlighters. Training a whole generation of doctors who are used to getting their drug information from the drug reps.  Guess the No Free Lunch organization (http://www.nofreelunch.org/index.htm) hasn’t made it down here yet. 

How better to top off my first day than joining the gym across the street? Somewhat reminiscent of my gym in Panama, it has that 1980s feel of muscular men and beautiful women using old weight equipment, looking at old posters on the walls of more muscular and beautiful people. The exercise class, run by one of those muscular men, involved lots of jumping, squatting and tension band pulling, with him yelling at us to keep going. I have to say, it kicked my ass. Today I am very tired. I’m going to call this Insanity, Cali Style. Let’s see what happens in 56 days.

First set of pictures...

https://plus.google.com/photos/106419429553511755451/albums/5934767487323835441

La vida en Cali, y Cartagena también

October 9th - October 14th

This trip is going to be different. Far away, but really not that far at all.  Flying a couple thousand miles south of New Haven hasn’t changed much in the way that I and many of my neighbors will be living our lives the next two months. Except it’s all in Spanish, and maybe it won’t be quite as cold.

Cali. Nestled into a valley between two mountain ranges. Watched over by a smaller version of the same Cristo Rey statue that watches over Rio de Janeiro. A snapshot of the morning commute would look a lot like it does at home. Commuters wait on the bus platform, waiting for the “Mio,” the local transportation system, to glide down its dedicated traffic lane, pick them up and carry them downtown. To skyscrapers, to their investment banking jobs, or maybe to a hospital. As they wait on the platform, bored, or multitasking, they scan their smartphones for new information, refreshing every few seconds. Rows and rows of compact yellow taxis whiz by. They pass by bakeries, and cafes, and little bodegas selling fruit and newspapers. Many have Halloween decorations up in the windows. There’s even a street of Christmas stores already open, glowing Christmas trees and waving Santas in the windows. I am told it’s cheaper to buy it all now than in December.  Give me a holler if you’d like some cheap Christmas goods. Cali’s main boulevards are not exactly pretty, but they’ve got everything you could need and the people are by far, the friendliest and most helpful I have ever met. Feel free to ask anybody walking on the street for directions, and they won’t just point, they might even show you themselves. 

Yesterday I experienced the artsy side of Cali. The national library was holding a Fernando Botero exhibit. Amazing how one person could produce so many paintings on the same topic (Jesus and the crucifixion) in such a short period of time (2010-2011). He did jazz up some of the pictures with modern clothing, self-cameos, and references to Central Park and the Statue of Liberty. We also visited the Museo de Arte Moderno La Tertulia and although small, contained some very cool pieces, all by Colombian artists. This was rounded out by enjoying lunch at an excellent hand-made pasta restaurant with heavenly pesto sauce, situated on a quiet little square near the museum. As we reveled in the culinary delights, a passing thunderstorm beat down upon our covered patio, sending the little park’s painters for cover. There was also a stroll along a riverside promenade, with an exhibit of pained cat sculptures reminiscent of the painted cow statues in New York City many years ago.  Finally, we saw Cali’s equivalent of the Big Dig, with some High Line mixed in. A lovely pedestrian walkway over a busy tunnel, with stylish wooden benches and tasteful landscaping. 

Today Nora and I, along with three of our housemates, a Peruvian surgery resident, a microbiologist, and a student, took a hike up the Cerro de las Tres Cruces. A mountain top to the west of Cali with three large crosses, looking down over the city. Locals tend to do this hike on Easter, but there were plenty of people hiking up today too, from four year old girls carrying ½ liter water bottles to muscular men running up shirtless. There’s even an outdoor gym area at the top, complete with dumbells made of concrete blocks and parallel bars. Our hard word was rewarded with fresh orange/carrot juice at the top. Cali is beautiful from above. 

Outside of Cali, the roads can get a bit rougher, so I am told. Due to the difficult and time consuming cross-country road travel, domestic air travel is a staple of efficient transportation here. Domestic flights leave full and often from all of the country’s major cities – Cali, Medellin, Bogota, Cartagena. Well-dressed businessmen check their watches, children play video games, women stroll gracefully in their high heeled wedge sandals up the aisles.  I know all of this because, even though I just got here on Wednesday, I took another flight on Thursday to the city of Cartagena. 

Jaime, our amazing host, a gastroenterologist, the attending who is in charge of us on this rotation, has already been treating my co-resident Nora to his family’s incredible hospitality and weekend adventures. It just so happened that my first weekend was the one they had chosen to take us to Cartagena, to stay in the luxury apartment that belongs to the hospital’s physicians’ association. If you want to play golf in Cartagena, this is the only apartment complex to do it. Picture three, six-story sleek white buildings, each with a picturesque and asymmetrical beautifully tiled swimming pool, beside a rolling hill golf course with lakes, beside the Caribbean Sea. Our art deco, wall to ceiling windows apartment, had ocean views and to the busy skyline of Cartagena beyond, similar to Miami and Panama City. The old city of Cartagena itself is a walled city, established in the 1500s, and has been growing ever since then. To me, it was reminiscent of Panama City’s Casco Viejo, with a smattering of Sevilla, Spain, Campo de Fiore, Rome and Essouira, Morocco. Narrow, cobblestone streets are lined with two story buildings, many with colonial style second floor balconies, dripping with greenery and flowers. Storefronts range from simple tiendas selling basic food items to trendy clothing boutiques, salons and gourmet gelato. Hidden plazas house fountains, churches and fancy restaurants with outdoor seating. Friday was also quite a day to be there, as Colombia defeated Chile in the World Cup qualifier. The streets were full of yellow shirted, horn blowing fans celebrating all night long.

Cartagena viejo is meant for strolling. Along the centuries old, fortress-like walls protecting the city from the ocean and foreign invasion, along the narrow streets, through the quiet plazas. I did not visit the new Cartagena, but very much like Panama City and South Beach in Miami, the ocean boulevards are lined with luxury apartment buildings and hotels, a home, or maybe just a weekend retreat, for wealthy Colombians. 

Back at our apartment, sitting in the pool, staring at the ocean, I reflected on the craziness of the past month, the many new opportunities that have just come into my life, and how fortunate I feel to be here. I could not have asked for a more relaxing and restorative weekend.

This was not quite the beginning to this medical rotation I had envisioned. The actual medicine has yet to begin. One brief breakfast orientation for the visiting students and residents, and meeting a smattering of South American residents is all I’ve gotten so far.  But tomorrow, I finally get to see another side of this city, and of life here. The surgery resident shared some stories of the severe trauma patients coming into the Emergency Room, losing massive amounts of blood from knife and gunshot wounds. He mentioned the shortage of central line kits for patients who needed pressors, and how they used neonatal nasogastric tubes to deliver the same thing. Nora shared with me the excessive use of inappropriate antibiotics here, everyone seems to get imipenems and linezolid the way we use ceftriaxone.

There’s going to be a lot to learn this month. Here we go.

Somewhere Else

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. 

On dying, on possibilities, and finding the real Rwanda

My cell phone rang yesterday, and the caller ID flashed the name "Menelas," one of the residents I worked with at King Faisal Hospital. "Hello Sarah! How are you? Would you like to come with me to go visit a cancer patient at her home this afternoon?"

Not your typical invitation for a Saturday afternoon, but one that was worth changing my plans to go bowling with some of the American doctors here. I wasn't sure what to expect, who was this patient, what sort of home would she live in? Menelas picked me up a couple of hours later, and we drove to a nearby, upper middle class neighborhood, through the gate of a nice sized home up on a hill, within hearing distance of the big stadium. As we drove in, an older gentleman smiled and waved at us, as he leaned on one crutch and then swung it in the air as part of his wave. This man was actually a well established physician here, and the cancer patient was his wife. Seven years ago she was diagnosed with breast cancer, which was treated and had gone into remission, but had now returned, this time making itself known by her new axillary lymph nodes, and its invasion of her lungs. Although she had spent some time in the hospital, she was now at home, in her own bed, being cared for by her amazingly loving husband and children. Home care is a rarity in Rwanda, and getting home oxygen even harder, and often quite expensive. However, given her husband's position and his profession, there she was, laying comfortably and poised in her very own bed, in a lacy nightgown, with nasal cannula in her nose and oxygen flowing. I almost felt as if I was walking into the bright and cheery room of Forrest Gump's mother, when "she had got the cancer," when Forrest went to visit her at their home in Alabama. In this room, the sheer curtains fluttered over the open window, a gentle breeze filtered in, along with sounds of cheering from the stadium. The oxygen gently bubbled through the water chamber.

Although I could not communicate with her much beyond the usual greetings in Kinyarwanda, we smiled, and we held hands, I listened to her talk with the others, we all prayed together and we wished her well. She wanted us to feel her new lymph nodes, and check her oxygen saturation. After, we sat with her husband on their balcony, sipping beer as the sunset, and spoke of health here and elsewhere. He told us how she had asked him to make sure he told us all about her health issues, to get our opinions. He told us how much it meant to her that we had come to visit.   

I left their home imagining for her, at some point, a comfortable passing, in her own bed, with her family close by and thought how fortunate she is, especially in this country.  I contrasted that with the passing of another of my patients this past week. This type of death, unfortunately, is all too common here. Bed thirty four strikes again. When our heart failure patient died a couple weeks ago, the next occupant was a lovely, refined, beautiful, 47-year-old woman with newly diagnosed HIV and tuberculosis. Even on admission to the hospital, she looked well put together. From the way she carried herself, I could tell she was accomplished and well respected. She carried an intense pride that I have not seen in many patients on the crowded ward. In the end, I think it may have been this pride that contributed to her untimely death. As it turns out, she was a successful government administrator, and she likely knew about her HIV diagnosis for at least twelve years if not longer. However, from whatever combination of denial, embarrassment, shame and pride, she did not seek any treatment until last month, when her CD4 count had already dropped so low that it could no longer defend her body from any infection. In a matter of days, we watched her deteriorate, from just a bit weak, to completely short of breath laying in bed and soaked in sweat, as the PCP pneumonia bloomed in her lungs. The simple oxygen on the ward was not really enough to support her breathing, but there were no available ICU beds at our hospital. So with her family at her side, she worked to breath, more and longer than anyone in a hospital should have to, until we could transfer her to another hospital's ICU, the next day. The IV form of the antibiotic she needed was also not available anywhere in the area, and so we had to make do with the oral formulation. We got word that she died the following evening.  

This past week I was able to attend the 16th annual Rwanda Medical Association conference. It serves both as their annual big administrative and policy meeting, an opportunity to hear talks on a certain theme, and also discuss the continued development of medicine and its specialties in Rwanda. This year they tackled the topic of non-communicable diseases like diabetes, heart disease and cancer.  Although HIV has reversed the life expectancies in many of these countries, the recognition and treatment of chronic diseases as people age is growing. Although I sensed this before, one thing that became so much clearer to me through hearing these talks is the severe shortage of specialists in Rwanda. There are essentially no fellowships here. If you want to be anything like an oncologist, a endocrinologist, a cardiologist, you must go abroad after internal medicine residency. I heard that there are only TWO urologists in the entire country of 11 million people. There are only FOUR dermatologists. At the new cancer hospital in the north of the country, the hospital opened by Partners In Health, although they are making great strides in cancer treatment, they have yet to have an on site pathologist. Every single biopsy taken to make a cancer diagnosis is actually flown back to the USA and read by a pathologist in Boston. Here at the guest house where I have been staying, I met an oncologist who is actually Ugandan, but takes a long bus ride from Kampala to Kigali once a month to care for patients here. The 22-year-old girl in bed 36, who has been in the hospital with a terrible cough for more than three weeks now, is still waiting for the pathology read on her lymph node biopsy. We're hoping to find a lymphoma, because we're pretty sure it's not TB. But for now, all we can do is give her oxygen, and wait.

One thing I took away from the conference was that Rwanda has made great strides in medicine, but there is so much further to go. Everything here, not just in medicine, seems to be marked by 'before 1994" and "after 1994." It's hard to even picture what it was like here before, because there has been so much intense development after. Sometimes I just picture village life everywhere, even here in Kigali, without even a foreshadowing of the tall buildings and wide, busy, paved roads that were to come.  The Rwandan Medical Association was not even in existence before. Now it is a large and strong organization, a way for the small but close knit medical community here to connect, and to plan and to dream about what can be.

This afternoon one of my co-residents here, John, was kind enough to take me on a hike. I wanted to climb Mount Kigali, the biggest mountain in the city, just topping 6000 ft. This is not your typical hike through the forest and up a quiet mountain path. People actually live a fair way up the mountain. And so our hike was an energetic stroll of sorts, up steep dirt paths in front of people's humble cinder block homes, with little children peaking through their curtained front doors, smiling and screaming "mzungu!!!"  Some of the people asked John in Kinyarwanda why he was making me work so hard (dripping with sweat) and climb up there. We smiled and continued upwards. Chickens pecked lazily beside the path, women carried loads on their heads and babies on their backs, and the children ran around barefoot. We reached the highest point just as the day's rainstorm turned from a mist to a torrential downpour. We took shelter in a schoolhouse at the top, along with eight shrieking children who thought it was hilarious to rub their hands on the blackboards and then use the chalk dust to paint their faces. A couple of women also took refuge from the rain, laying down their loads of pots and baskets, until it was dry enough to continue their work. I couldn't help but feel I had finally left Kigali somehow, and entered a village. Finally the Africa that felt more familiar to me, the one I had been shocked not to have really found yet in Kigali. I just didn't know how to find it before. But then from the windows of the schoolhouse, at the top of Mt. Kigali, was a perfect view to downtown, to the tall buildings, to the new luxury hotel under construction and the upper class housing development across the valley. Kigali is really quite small, and even from up in the mountain village, it didn't seem so far away.

One day there will be more medical specialists here. One day all people here will be able to die with dignity at home just like the doctor's wife, or die knowing that they've had access to all the possible medical resources to help prolong their lives. People here say to me, "You must come back in five years! Just imagine what it will be like then." I think I can imagine. I just hope there are still chickens and running children too.   

Umuganda, healthcare style?

It's disconcertingly quiet for a Saturday morning. On my morning run, and then on my walk up to the Umubano Hotel pastry shop for a special breakfast treat, I passed almost nobody. The occasional moto (a motorcycle taxi) zipping by, a bus here and there, a few pedestrians strolling. It almost feels like the middle of the night. But actually, today is the last Saturday of the month, which means it's umuganda, community service day. This is a mandatory, nationally mandated day of service every month. Everyone who can, from 8 am until 11 am, is required to participate, helping to pave roads, pick up garbage, trim grass and bushes, repair public facilities and such. A pretty amazing concept. Another example of the shared responsibility that is felt here, toward continually making Rwanda a greater place.

I compare this concept of umuganda, with my feelings about this past week of work at the hospital. I'm still absorbing it all. For me, this week has been about figuring out my role, understanding the strengths and weaknesses of the healthcare system here, and majorly resetting my expectations. Many people have told me that the health system and hospitals here are quite good, compared with other places in Africa. I'm having a hard time seeing that, but I have stop comparing it to anything that I'm used to at home. Being the largest referral center in Rwanda does mean anything in the context of western medicine. From my work in Zambia, I had a pretty good understanding of what outpatient medicine is like in developing countries, but it still didn't prepare me for what it would be like on the inpatient side.

I wrote earlier this week about the woman who died because her family had to keep going out to the pharmacy to buy her medications she needed. The same is true of almost everything in the hospital. Each patient has their own bag of supplies they must buy - bandaging supplies, IV lines, IV fluids, gloves. If they run out, well, better hope somebody else on the ward is willing to share. Yesterday a woman started oozing blood out of some sutures she had from her surgery, in a matter of hours soaking completely through the bandages and sheets. We had to walk around the room, asking the other other patients if we could use some of their tape, some of their gauze, to redress her wound. Diagnostic tests must also be prepaid. We may spend hours on morning rounds discussing a patient's presentation, differential diagnosis and workup that must be done. We write "Chest CT scan" in the progress note, and then write an order for it. But that CT chest won't actually get scheduled until the patient's family takes that order, brings it to the cashier to pay, and then brings back the stamped receipt. And if they can't pay, there are social workers to help, with some kind of collective pot, but it's unclear how much and who can get funds from that. And even then, it may not be scheduled for over a week, even for an inpatient. Yesterday we had our medicine attending call his radiology attending buddy, who agreed to reschedule a chest CT for our patient for next Tuesday instead of next Friday, while she has already been in the hospital for over a week, and wants nothing more than to get back to her nine month old child at home.

Physicians, and actually, entire health systems here, hardly have any responsibilities over the weekends. In fact, think of Friday as a half day, even at the hospital, for Friday afternoon is actually a national sport day. Think intramural soccer, doctors versus teachers. When I asked who would be taking care of our ward over this weekend, following up on all these plans we made, the answer was essentially nobody. Just like the night coverage resident, there will be one, perhaps two residents in the hospital to cover all of the wards over the weekend, who have received no formal signout on any of them. But no formal rounding, no new plans, no followup on old plans. They are only there to deal with emergencies with the patients, when the nurses decide to call them. Every order we wrote yesterday had to be clear about its relevance to the entire weekend. IV fluids? Let's hope that even some of our malnourished, hypotensive patients are still on IV fluids when we get back on Monday. I've heard people say patients are lucky to survive through the weekend, and if they can, then they must be doing pretty well. So much for Press Ganey scores.

Never again will I complain at Yale about a particular radiology study that cannot be done over the weekend, that must wait until Monday. At least it can be done on Monday. At least there are still many doctors in the hospital over the weekend, keeping that patient stable, caring for them, until further diagnostics can be done. Never again will I complain about being on call over the weekend, or responding to a code in the middle of the night, because I am doing my part, my duty as a physician, of patient care. So many things that have become so routine in our care of patients at home: our team structure as medical students, residents and attendings, that goes along with our well defined responsibilities and expectations, with accountability, our handoffs to each other of patient information, all of these things do not yet exist here, at least not officially, not entirely, not solidly.  There is no such thing as patient signout. You're done with your work for the day? You disappear. The one night coverage resident is not told a thing about the patients on the wards. If there is a problem, they will try to deal with it. And then won't tell anybody about it in the morning, except in the form of an illegible note in the patient chart. Maybe.

Let me take a step back here. Many of the Rwandan doctors I have met so far, attendings and residents alike, have been excellent. Their knowledge is solid and extensive. Their commitment to teaching is obvious, in the time spent every day teaching students and residents. The attendings demand near perfection in terms of instant ability to regurgitate not only differential diagnoses of symptoms but also medication doses and physiological formulas. Their practical skills are excellent and extensive too, as most medical students are required to work for a couple of years before returning to residency. Many of the residents here have done their share of surgeries, from lymph node biopsies to c-sections, before ever starting their medicine residency. But that's just one part of the equation. The resources, and the overall medical culture are key components too. You can be the most well meaning physician, who may feel it essential to have weekend rounds. But if no other hospital services are available that day, it severely limits how much you can do. 

There's a new initiative here, called HRH, which is trying to slowly address all these issues. Over the course of years, their goal is to twin US doctors, nurses and hospital admin staff with locals in the same role, to slowly improve hospitals and physician training here. After three weeks here, I think this is an amazing and awesome challenge. I think Rwanda is up for it. The pieces are there. But it's gonna be a while.

In the mean time though, what is my role? If I try to be the type a, controlling, a little OCD, organized resident that I'm used to being, I'm just going to burn myself out. A weeks worth of checklists did me no good, because trying to review those checklists with the team after rounds, or really, really being sure that those things have actually gotten done, just doesn't happen very well. Not all the time. Orders get forgotten or lost. Or they remain as an unpaid sheet of paper by the patient's bed. How about solidifying team structure. You! Lowest medical student on the team, this is your role! This is what I expect of you! But if they decide to leave after rounds without helping implement the day's plans, what can I do? I can't change a whole culture in the few weeks I'm here. So that leaves teaching. In some in-between land between being a resident, and being an attending, that leaves me, teaching what tidbits I can, imparting what sense of patient duty and team structure and note writing I can. And definitely learning a whole bunch about diseases I don't see often or ever at home.

Hopefully, I can return to Rwanda in ten years, and see the fruits of all these efforts. That sense of duty about umuganda, extending truly and deeply into the healthcare culture as well. As one of my attendings says now to the Rwandan residents, when talking about our young patients on the ward, "these patients are the future of Rwanda, take care of them." Hopefully this will become a system in which we truly can. 

Bed Thirty Four

Two quick weeks have passed, and my time at the private hospital is through. Yesterday I began working at the big university teaching hospital. The similarities and the differences between them are numerous. The private hospital follows a more western model, attempting at more private rooms, more nursing, and more services for the patients like serving food, having more medications on hand. The teaching hospital is more what you may picture for a developing country, with large open wards full of beds, filled with as many family members as patients, doing more nursing than the nurses. Both these hospitals have many attendings dedicated to teaching, and both are filled with medical students and residents eager to learn, but who are somewhat limited by their resources - by lab services, radiology services, specialists. Perhaps the private hospital is almost more dangerous in a way, because it looks so western, and your expectations are such, but the care is still somewhat what you would expect in a resource poor country. But I think a death at the government hospital is seen as that much more normal, expected, and unnoticed.

Today I learned that at this government hospital, patients' families need to go to the pharmacy and pay for almost EVERY SINGLE medication they are prescribed while inpatients (not including the Emergency Room), except for medications for TB and HIV. You're admitted to the hospital and have high blood pressure? Here's your atenolol prescription, go get it. You need antibiotics for pneumonia? You can go pick that up for yourself, and the nurse will be kind enough to attach it to your IV. Oh, you're having an asthma attack? Better get your spouse/sibling/child to go run fast and get some albuterol and a mask for the nebulizing machine, we don't stock those on the ward. Today I watched a woman die over a period of about five hours due to some combination of severe heart failure and asthma. Yes, she was ninety years old. Yes, she had heart failure, and her overall prognosis was poor, and she likely would have died in the relatively near future. But yesterday, on morning rounds, she looked fairly well and we were planning to discharge her home today. Overnight, she deteriorated, and this morning our team arrived to find her floridly fluid overloading, wheezing, and gasping for air. In the time it took for her family to obtain all of the medications she needed to get her through the morning, as well as a functioning nebulizer mask to ease her breathing, it was too late. We actually wrote a prescription for her son to go get dopamine, a medication normally given as an infusion in the ICU, a last ditch effort to keep her heart pumping and improve her blood pressure, just before she took her last breaths. He was not even at her bedside when she did.

She passed away on bed 34, the third bed along the wall from the right, below a high window, next to a large aluminum storage cabinet on her left, and about 3 feet away from the young girl with the kidney failure and hypertension on the right. It all happened very quickly after that. The nurse brought in some extra IV poles, to hang some sheets on and create a small curtain and block the bed's view from the others in her area of the ward. A couple of other workers came in, removed her IVs and her foley, cleaned her and dressed her and covered her up.

By the time we returned from lunch, there was a new patient laying in bed 34, a 46 year old woman with newly diagnosed HIV and tuberculosis, and likely Kaposi's Sarcoma too. This woman has probably had HIV since the early to mid 1990s. She lost her husband in 1995 not to HIV, which she suspected that he had based on his symptoms at the time, but to the war. But she never checked her own status until now, until she was so sick and weak that she had no alternative.

So tonight, I think about her, and bed 34's previous occupant, and hope for the best.