Regardless, I was on the side of a steep hill, beside a mud hut, and beneath the welcome shade of some banana trees. The inviting downhill track had petered out into a warren of narrow ledges between banana plants, sorghum fields, mud huts and startled chickens. I was four hours into a Sunday afternoon ride and it was now time to get back.
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| A short ride from town |
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| A different ride requiring some transport my riding buddy's bike |
It's an analogy of course. That bike ride and the life I lead here. Something thoughtful happens each day it seems. Unheralded, something sad, something maddening, something startling, something ugly, something encouraging, and somethings beautiful unfold before me. I suppose this happens to some degree to everyone everyday everywhere. I find these events are more apparent here though - it is as if I have momentarily set-aside my telescopic lens of habit & home. My view on the landscape is now seen through a wide-angle lens and situations and images careen uncontrollably into my field of view.
I haul my bike past a barefoot young woman. She has a baby on her back, a pile of scavenged firewood on her head and is listening to Rumba music on her mobile phone.
There is a similar girl who tends the cobblestone street near our house. Every day she is on the road. Her job is to use a small length of iron bar to clear the grass from between the cobbles. I recently watched a crappy two-stroke motorbike taxi, spewing exhaust, chug by her. The passenger was carrying a fridge and the motorbike engine strained at the effort. So focused was the girl on the fridge transfer, that she only just managed to leap out of the way of a red Mercedes. The sleek sedan sped away over the clean cobblestones, oblivious to all of us on the roadway.
I'm not lost in the ED, but I sure the hell don't know where I am sometimes.
Coming to understand the cases, the resources, the expectations and the realities has been a challenge.
As the only ED (and fledgling at that) in this low-income country, we are relatively well-supplied. We have nurses, we have workable drugs, we have stretchers, we have housekeeping staff, we have intubation equipment, we have an ED ultrasound machine, we have an ICU (often full), we sometimes have running water, we usually have a CT scanner, we almost always have power, we sometimes have bedsheets, we never have paper-towels, we often have soap, we can't measure electrolytes, our ECG machine is broken, there are no infusion pumps, and we don't have ventilators. There is no social worker, no clinical coordinator, no discharge planner, no hand clinic, no cath-lab, no stroke team, no clinical pharmacist, and no trauma team. There is a limited medical insurance plan, mutuelles de sante, that doesn't cover nearly enough. If you can't pay for the meds, for the imaging, for the treatment, you don't get it. Unless you are dying and get into room 9. Then if you survive your subsequent hospital stay, you stay to pay your bill later. We have a large room at the end of the ED hallway ironically called "Serena Ward." Here patients stay under guard. They are "cured" but have yet to pay their hospital bill. A relative has gone home to the countryside to borrow or raise money by selling some land, or a cow, or perhaps a bicycle. The patients sit and wait amongst a colourful cacophony of packages, belongings, and hangers-on. The view from the window of this room looks over to the fanciest Hotel in Kigali, The Serena. The room's namesake. The Serena Hotel never runs out of paper towels....
It is the inevitable daily case of an avoidable death that pushes me off my map. Today it was a 7 year-old girl who was burned in her bed from a candle alighting her mosquito net. After 4 days in a district hospital, she was transferred to CHUK ED in septic shock. Too late to catch up on fluid and infection, it was a long code before she died. How to push for the provision of basic emergency care upfront, care that would likely have prevented her death, is where I'm less certain of my direction. There is just so much dysfunction on so many levels.
My fellow EM colleague and I have carved out a bit of physical order in the ED chaos by establishing ourselves in room 9 and 8. The resuscitation bay and step-down ward respectively. In these two rooms, we can care for up to 14 patients. It is here where we spend the majority of our clinical time. In this space, we have better control of medications, of equipment, of teachable moments and of care delivery.
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| Room 9 |
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| Room 8 Whiteboard Plans |
Having this space makes me feel less lost.
The first 3 modules of the basic emergency medicine training course are now complete. The lectures, simulation sessions, module exams, bedside teaching and shared patient care have all been very absorbing and positive. When I step back and look in, I see a difference from even 6 weeks ago. It is a small difference, but the care provided in room 9, by both residents and nurses, is obviously more confident and competent.
There is great distance to travel, but the general direction seems clear. It is an exciting journey.
Thanks for reading.
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