Tuesday, November 19, 2019

Clinical Rotation in an Emergency Department in Kigali

Lara Vogel, M.D. 
Resident, Harvard Affiliated Emergency Medicine Residency MGH/BWH, 

In my work prior to medicine, I lived and worked in East Africa for multiple years, focusing primarily on education and the ways the HIV/AIDS epidemic impacted children in Kenya. Working on public health projects in rural Kenya through my twenties pushed me toward medicine, so now that residency was nearly finished for me, it was time for me to go back to the place where my interest in medicine started. Or at least get closer. Through attendings in the BWH ER Trish Henwood, Alice Bukhman and Regan Marsh, I was able to connect with the new Rwandan attendings running one of the first EM residencies in Sub-Saharan Africa. The Centre Hospitalier Universitaire de Kigali (CHUK) is about to graduate its second class of residents, and the ER is currently run entirely by its prior graduates. There are three of them. They work a lot.

Nyungwe Forest National Park
I technically know that EM is a relatively new specialty in the US but seeing a new specialty establish itself is a fascinating process. This process at CHUK is relatively far along and I had the smallest glimpse, but watching these residents navigate their own hospital system, the ambulances, the insurance system (they often have to wait for proof of payment before they can treat), and the consultants’ understanding of patient care was an education in itself. Unsurprisingly, the medicine was the same between the two countries and the residents were exceptionally well trained—their comfort with trauma far exceeded my own, and their ability to make do with much less support from consultants, supplies, and patient’s understanding of disease was incredible—but ultimately, they had many more fights everyday to define the boundaries of their ER to themselves, to their patients and certainly to the hospital system. Their actions were always defined by the best interests of the patient, but when ICU patients spent weeks boarding in the ER, when the orthopedists could not operate or admit and yet would not stop accepting transfers, and when social services did not exist to support patients unable to care for themselves, the question of what was best for the patient became extremely complex and well beyond the scope of what I expect from an ER physician. Needless to say, they all managed it with grace and I was the one left confused.