A patient coded during rounds. The residents were spectacular: calm, organized, working easily in unison.
I should not have been surprised that a coding patient in a Rwandan emergency department was a quiet event: Rwandans tend to speak quietly - I often had to lean in close just to hear them. But this went beyond their soft-spoken ways. The lack of technology also contributed to the silence: no machines beeped; no one ran around yelling out stat blood test results. It was just a small group of doctors using all the resources they had to save a life.
We were at the University Teaching Hospital of Kigali/CHUK -- I was visiting as part of my Stanford fellowship in pediatric emergency medicine. During my three-week stay, I taught a course in advanced pediatric life support and helped supervised the residents and nurses in the emergency department.
I travelled to Rwanda with a colleague -- Kajal Khanna, MD, JD -- as part of her early research for a new initiative she is developing at Stanford Health Care. The Global Pediatric Emergency Equity Lab aims to use health and law solutions to bring emergency care to children globally, with the ultimate goal of ensuring more children have access to essential, high-quality health care.
Although I'm not part of the GPEEL initiative, I share Kajal's strong conviction that we have a responsibility to reduce health disparities -- both within the United States and between developed and developing countries. Stanford Medicine's continuing relationship with CHUK meant I'd be able to teach while I was there; and teaching and distributing knowledge feels like the most powerful tool I have to help.
I found, however, that I learned from the Rwandan health care workers as much -- if not more -- than I taught.
As a Western doctor who has become increasingly reliant on buzzers and stat data to save a life, I was impressed by how the ED residents cared for patients without the help of reliable technology.
For the patient who coded, the bedside monitor worked only intermittently; To check for a heart rhythm, the residents had to apply the defibrillator monitors temporarily to the patient's chest. In fact, due to failing machines, we only noticed he wasn't breathing when we saw the blueness of his toes. Luckily, after only one round of epinephrine, he had a sustainable rhythm. And we, the mass of doctors, moved onto the next patient in the row.
We took care of two more patients who, like the coding patient, had suffered critical brain injuries in a motorcycle accident.
There also was a robust discussion about whether to start insulin for another patient. She was diabetic, and we wouldn't know her potassium level for hours -- not until lab results were hand-delivered in a paper report.
We had a very real and pressing concern that failing to lower her glucose level would cause lasting damage to her organs - including her brain. However, if her potassium was poorly-controlled, giving her insulin could cause consequences as serious as death: In addition to helping shift glucose into the cell, insulin also causes critical shifts to potassium. Potassium levels that are too high can cause life-threatening arrythmias.
In this case, the patient was growing increasingly confused -- a sign that her electroyle levels were critically askew -- so we decided to start the insulin and watch our patient carefully. It was all we could do.
I left the hospital exhausted and missing my machines -- my endless, noisy, beeping machines, with their up-to-the minute lab reports. Yet I had thought more deeply and relied more on instinct than I have in a long time.
For me, it was invigorating. For the ED residents at CHUK, it was a day like any other. And one they will repeat again and again.
Melissa Hersh, MD, is a pediatric emergency medicine fellow at Stanford Medicine. She spent three weeks in Rwanda last summer teaching and helping to supervise the residents and nurses in the emergency department at the University Teaching Hospital of Kigali/CHUK.
The conclusion of this series is available here.
Photo of members of the third-year emergency department residency class at the University Teaching Hospital of Kigali/CHUK by Melissa Hersh