Ruhengeri - June 4

Today was a day of contrasts. We started the morning at Ruhengeri hospital, where most locals who have little money come for their health care, and ended the evening at a fancy dinner at the Virunga Lodge, a $500 per person, per night eco-lodge built on top of a 2100+ meter hill, with dramatic panoramic views of the surrounding valleys, volcanoes and lakes.

The morning in the hospital began at ”7am sharp” (but not really), when the intern presented the patients he had admitted overnight. There are three interns here, and during the course of the week, they take turns staying overnight for admissions. They provide most of the care to the patients, with attending rounds in the morning being the only time they receive supervision (there is no residency as of yet in Rwanda, so once interns graduate they have, at least officially, completed their training).

Though the hospital has a capacity of 56 beds (which are often all full), the acuity of illness is much lower than what we see in hospitalized patients in the US. In order to be seen in the hospital, the patients must be referred from their local clinics. Often, a patient, who may have walked 10 miles to get the hospital to address his cough and fever, will be offered admission for several days of antibiotics. If he did not bring a family member to take care of him and his nursing, he is expected to do this himself, and he will have to walk to town to purchase food for meals. Therefore, the beds are often filled with patients who look well enough to be home, but given their poverty and the distances they must travel for care, will do better to begin their treatment in the hospital.

At the same time, like anywhere in the world, there are plenty of sick patients in this hospital. However, due to financial and resource constraints, their medical care is nearly identical to that of their much healthier patients. People that we would consider critically ill lay in cots next to those with mild aliments and rarely get extra attention. They too must rely on family members for their nursing care. (Imagine what that means to a family with young children living day to day on their agricultural subsistence when one of the parents gets sick.)

The hospital stay itself, is also much less intensive, as are the diagnostic resources available. Labs are checked once at the time of admission and the results take a day or two to come back. Vital signs, if necessary, are monitored once or twice daily. There is an x-ray machine on site, but it has not worked for several weeks, so patients who need an x-ray must pay for transportation to go to a different town to have it taken and then come back for treatment. There is also a CT scan on site, which does work, but patients often cannot afford the test. The ECG machine broke several months ago, so the interns asked us to do some ECG teaching with them because they have had almost no exposure to these tests.

This morning, there had been three new patients admitted overnight: a man with hypertensive urgency, a man with a one week-long spasm of his entire left upper extremity (his hand was in contracture, his biceps and triceps painfully flexed), and a woman with suspected appendicitis. The intern presented these cases in a small room, surrounded by the doctors and nurses who staff the hospital wards. As is done in medical education around the world, there was some gentle pimping by the attending staff, and then we set out on rounds to see all 30-40 patients on the wards.

Though the patients and nurses speak only Kinyrwandan and (possibly) some French, and though the interns themselves probably began to learn English about the same time they started medical school, rounds are conducted in English. Here in Ruhengeri, there are also several Cuban physicians who see patients and supervise rounds, so Spanish has been added to the general language fray. (Cuba has a strong presence in international medicine around the world, and 2 year medical missions abroad are required for many of their new graduates). Though the medical presentations begin in slow and careful English, it is not uncommon that the medical debate that follows quickly picks up in a fast, colorful mixture of Kinyarwandan, French, English and even Spanish.

As I saw in India – and as is likely common in all places around the world with a large educational/cultural/financial gap between the rich and the poor, doctor and patient – paternalistic medicine is the standard here. While on rounds, the doctors speak gruffly to their patients, yank them out of bed, expose their naked bodies or various deformities for everyone else in the ward to see, and do not explain diagnoses or treatments. The patients stare blankly ahead, make no eye contact, and are absolutely gracious about the care they receive. Procedures like lumbar punctures and thoracentesis are done at bedside, quickly and without explanation or anesthetic, and no patient complains or protests.

Despite the many differences between our medical system and the care we see here, the overall culture and practice of medicine is surprisingly universal. Interns struggle through rounds and whisper answers to each other, attendings capitalize on teaching moments, and the patients often serve as a mere background for medical education. As soon as rounds end, however, they become the focus again, and one can see the concern in their doctors’ faces, as they discuss sadly a case of a dying patient or make frustrated references to the financial constraints that prevent them from providing their patients with the tests or medications they need.

Over the next few weeks, we will hopefully be doing more direct patient care in the hospital. If this trip works out, we may be able to set up a yearly rotation, where residents from our program can come to Ruhengeri and work in the hospital for a month at a time, seeing patients and participating in teaching rounds. The exposure to tropical medicine is in itself worth the trip, as is the opportunity to learn to practice medicine with such diagnostic constraints. More importantly, just as with the visiting Cuban doctors who have answered a critical need here, there may actually be a niche for us to fill. Exactly what that niche will be is something we are lucky enough to have the next few weeks to find out.