Good morning. I am alive.

"Maramutze."

  It means "good morning" in Kinyrwandan.   Before noon, everyone who comes into contact with you - shopping, commuting, working, banking, observing or conversing will say it to you.  Or you to them.  The reply is often "Maramutze nmezi" ("I am well this morning") or if the exchange is more fleeting, or if there is a big load being carried or a hoe to be wielded, the reply is a simple, "yego, yego" ("yes, yes") and attention is quickly turned back to the task at hand.

Regardless, a greeting and a reply are always conducted. It is what is done.

Riding 400km around the northwestern corner of Rwanda along the border of Uganda and DRC for 4 days on small paths with 2 friends, we said and replied to literally thousands of "Maramutzes."    It was a truly memorable trip. Getting lost, getting found, getting hungry, getting fed, getting wet, getting benighted, getting worked, getting humbled and getting found again and again. Each village similar to the last - people farming, herding goats, collecting firewood, tending fields, cooking starch, breaking rocks, hauling loads, carrying water....living and surviving.

It was my final week in Rwanda and my melancholy about departing hung heavy.

It was also when I learnt that "Maramutze" doesn't literally translate to "good morning", but actually means,"I am alive."

I was floored when I found this out.  For the last year, I have said "Maramutze" to friends, co-workers, patients, taxi drivers and shopkeepers on a daily basis.   I am not naive, but I figured that I understood a decent chunk of Rwandan social niceties and realities....but no. I am humbled yet again by just how harsh and fleeting life can be - reflected in the lexicon  - "Hello. I am alive....so by that definition, it is a good morning!"

I write this in Canada.  My time in Rwanda is over.  I miss not saying "Maramutze" anymore.

I have returned to my Canadian ED work and have left the CHUK ED training to others with fresh legs.

I am trying not to be overly frustrated by patients complaining of problems that are not emergencies, or by patients expecting me to fix their painful and chronic condition during their visit, or patients that complain that they have waited over and hour to see a doctor.  These situations are common and expected.  They come with the territory of being an emergency physician  - everyone has a problem that  is "their emergency" and all emergencies are relative.

What has been hard is adjusting to the underlying psychological and social problems that have to be managed in the Canadian ED.  Patients presenting with florid sepsis and major trauma are blissfully rare in the Canadian ED.  When they do present, a well-run and multi-disciplined team provides the best of care.  Care that could barely be imagined most days in Rwanda.  What grinds an emergency department worker down here are the chronic problems of the many patients who are homeless, or live in a lousy one room hotel. Patients who scratch a life out on the streets - often using methamphetamine, crack, heroin, alcohol, or anything for some sort of high - any kind of drug to distract from  the pain and emptiness of their present.   Turning tricks or crime to fuel the escape.  An escape from their present, from their abusive and neglected past, and often to escape from their future. Their lives are truly chaotic.  As emergency care providers, we can treat the overdose, the injury,  or the acute psychosis of a chaotic event, but there is no emergency treatment for the underlying chaotic life.  Here we are largely hopeless.

Over the course of my first night shift back I was sworn at, spat on and punched.

Each by a different patient.

I was trying to put a tracheostomy tube back in place the time I got punched to the ribs. He kept pulling it out in jail.

I was spat on by a 21 year old homeless girl cranked up on meth who briefly thought I was a satanic angel dragging her back to the underworld.
Nope, I am just an emergency  doc trying to treat her rhabdomylysis and sepsis.

I was sworn at 3 times by the same patient on 3 different visits on the same night. He kept coming back (in an ambulance each time) after injecting too much heroin. I kept getting him breathing again with naloxone. He was pissed to be woken up in the ED hallway - again.

Late in the shift, my guard up and my edges frayed, I saw that another (notorious) "frequent-flyer" patient was next to be seen.    This particular patient had slugged multiple nurses in the past and has a vocabulary that would make a sailor blush. She has lived close to the street for most of her 40 years. Toothless and belligerent, her alcohol-fuelled rages are legendary. As are her seizures and stamina to resist most care offered.  I grabbed the chart, wary of what condition I might find her in.  Happily surprised - stunned even -  by her greeting - "hey Doc, I haven't seen you for a awhile."  She was sober and she was a charmer. I had never seen her so.  She has a new boyfriend and had a question about a sore on her lip.  We discussed a diagnosis and a plan, she gave me hug,  and then she left.

Riding home in the rain, I realised that I can no more imagine the difficulty of life on the streets as I can imagine the life of a Rwandan mother having to bury her child from a treatable medical condition.  Both lives are so constrained, so limited, and so hard to escape from.  And so worth the effort of providing care.

"Maramutze" - I am alive.  I am going to teach some of my patients here that phrase.   They too, can say it for real.

Thanks for reading.