There’s something important in life about doing something that was never on your radar, or, better yet -–frankly-– scares the shit out of you.
For many rural Rwandan patients–- I think it scares the shit out of them to journey to a district hospital. The hospital is where people go to die. What could be scarier than visiting a place with such a high mortality rate? What could be more logical than avoiding presentation at said place for as long as possible?
Things that Western parents would rush their children to the hospital for are observed with a sense of patience and courage that I can only admire, but not emulate.
I’m no longer surprised when comatose children are brought in days after initial head injury. When 3rd degree burns from a week ago do not present until the point of limb compromise. When hemorrhagic shock ensues from a small head laceration in an infant. Exsanguination from advanced cavitary TB. Pre-eclamptic to the point of expiration on arrival…
I hate so much that it’s possible to summarize what represents an entire individuals’ suffering in the span of incomplete sentences. But there are so many cases to bear witness to, and I’m not sure what’s the best way to go about it.
Despite the mortality, the hospital is amongst the best I’ve worked at: resources optimized on all fronts, the clinicians excellent in empiric management. It is brave to choose permanent practice in a place where, as a specialist, you cannot get any of the tests that you were trained to rely on: no electrolytes, no microbiology, no ultrasound, no ECG, no CT scanner, xrays only come PA despite the daily quest for an adjunct lateral.
Instead of CT heads, we dispense prophylactic Mannitol for RTA head injury like candy … I wonder if the effect is only similar to candy…
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In the ex-pat community, one speaks of “third culture kids” as those who don’t feel exactly at home anywhere, having adopted a meshwork of different cultural reference points as they grew up in multiple countries.
I wonder if someone has already coined the term “third culture physician.” Not comfortable in your home practice – the ease of access to tests and disproportionate amount of resources dispensed on a daily basis, unsettling.
More comfortable in the resource-poor setting, but still unsettled because you keep the knowledge to yourself that so many of these deaths are preventable. Not wanting to add further psychological distress to hard-working Rwandan clinicians in a health-care system that is visibly improving. Not wanting to deter patients that are becoming increasingly brave and presenting earlier and earlier, exercising a newfound faith in modern science.
Everyday, it pains me to not speak enough Kinyarwanda to provide that extra bit of reassurance that I’m convinced could make the difference between life and death in many cases. I know that it costs 10,000 kinyarwanda for a CT scan in Kigali, but: was the 9 months of pregnancy, and 5 years spend raising your child not already a huge investment? I am ashamed to admit I spent the same amount on a swimming pool here. But the more you practice where patients can’t afford needed tests & treatment, the more you know it is unethical to sponsor some patients but not others -– unequitably equitable.
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I am going to run the Kigali marathon tomorrow, and I’m not entirely sure why the goal has become so important for me.
I am, truthfully, afraid. Afraid of feeling like death hitting “the wall” in tropical heat. Afraid of the consequences of my recent gastrointestinal illness. Afraid that my time will be permanently posted, and… well, given the altitude, mammoth hills of Kigali… it will be less than impressive, not even Oprah-level-qualifying…
Part of the “why” is some kind of sick desire to participate in the suffering that intrudes on the majority of those that inhabit the world. My life as a western women so ‘cushy’; long-distance running a socially acceptable way to induce discomfort.
Running a marathon is usually an achievement we boast about in Western culture. Ironically, I would be somewhat embarrassed were it known to local colleagues and my patients that instead of working the weekend, I am escaping to Kigali to willingly induce 42K of pain. And I’m paying to do it…(?)
Regardless of contradictory cultural goals, I’m strangely looking forward to it. Importantly, the many hours of hitting the pavement has also given me inordinate amounts of time to reflect on the many people in my life who have inspired me towards this goal. And, for that, I will lace-up my runners tomorrow with enthusiasm:
Much love and… please send your fast-leg, tropical-heat-loving, hill-happy vibes to Kigali tomorrow.
xo
Your marathon-hopeful Annie Aspler
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