An Accident Abroad: What I learned being a Patient in Rwanda

An Accident Abroad: What I learned being a Patient in Rwanda

By: Megan Wojick

I’m in an emergency room. I’ve been in a room like this one many times before during my clinical rotations. It’s one of my favorite places in the hospital. The excitement. The adrenaline rushing through me while I throw on a gown as a trauma patient is being rolled in. This time is different though because I’m not the medical student. I’m the patient. And I’m not in the U.S. I’m in Rwanda.

It was two days before my flight back to the states. I had just spent 8 weeks living in Rwanda’s capital city, Kigali. I participated in a medical research project with Kigali’s formal emergency medical services, Service d’Aide Medical’s Urgence (SAMU) and spent most of my days at the university teaching hospital, University Central Hospital of Kigali (CHUK). I was soaking in the views of the city while sitting on a ledge with some friends when I went to stand up and my foot slipped. It all happened so quickly but the next thing I knew I was lying on the concrete 10 feet below.

My friends immediately decided they would bring me to the hospital. There was a private hospital across town where many ex-patriots go for care, but I had worked so closely with the doctors in the ED at CHUK that I adamantly wanted to be taken there. On arrival to the CHUK ED, the doctors immediately started performing a trauma protocol quite similar to the traumas we run in the states. Most of my pain was on the left side of my chest and my left hand. I luckily had not hit my head and had no signs of internal bleeding. I received morphine and oxygen before being taken to x-ray, which were initially read as negative. At this point my vitals were stable, so I was placed in the moderate acuity level room for observation until the ED rounds started in the morning.

That night was one of the worst nights of my life due to the excruciating pain in my ribs on my left side. I was in and out of sleep but still have very vivid memories of that room. Patients filled the beds that lined all four walls without any curtains for privacy. I was the only Mzungu in the ED (Swahili for “white person”) and felt like everyone was staring at me, wondering why I was there. English has recently become the national language in Rwanda, but patients generally come from rural areas in the country and mainly speak the native language, Kinyarwandan. There were only a couple of residents working during the night but I didn’t know them and rarely saw them over the course of my stay. I felt very alone, very scared, and I struggled to communicate with anyone.

Finally, morning came and word had gotten around to the SAMU staff. I’ll never forget the feeling of relief I had when I saw a familiar face of one of the SAMU nurses walking up to my bed. Within an hour, I had been moved to a private room in the private sector of the hospital and was awaiting the results of my CT scan. My scan showed multiple fractures in all but two of my ribs on the left side and a small pneumohemothorax (blood and air in the lung sac where there shouldn’t be blood and air).

My attending in the states had reached me by phone, as well as one of the deans of my school and started “pulling strings”, so to speak. The level of care I received from that moment forward was vastly different from my night spent in the ED just because of the connections I had. There are not enough nurses in the hospital, so patient’s must have a caregiver, usually a family member, who attends to their needs including bathing, going to the bathroom, and providing food. My caregivers were two of the nurses that worked with SAMU and one of the ED residents that I became close with prior to the accident. They alternated shifts while also still attending to their everyday jobs. I am overwhelmed by the gratitude I feel for all three of them and the extent to which they all went to care for another human being. They each had only known me for 8 weeks, but they cared for me like family all without me even asking them. I honestly don’t know how I would have mentally survived without them.

The process of getting me home was long and complicated. Luckily, my school had medical evacuation insurance, but this ultimately took 6 days to organize. A doctor and nurse from the states was flown to Rwanda to accompany me on my flight back. While my injuries were not life-threatening, flying with a pneumothorax is generally not advised due to the pressure differentials in an airplane and the risk of collapsing my lung, so I required a chest tube. Usually, a chest tube is placed bedside with a little local anesthetic to numb the skin. If you have ever witnessed one being placed or known someone who has had one, you will know how extraordinarily painful this procedure can be. Since I was an American, my Rwandan attending decided it was best to place my chest tube in the OR while I was under conscious sedation, which I would say rarely, if ever, would happen in the U.S.

I arrived in the states after a 13-hour flight; trust me when I say you will never want to fly with a chest tube in. I was directly admitted into our private hospital suite at VCU for another couple of days of observation and to obtain a battery of tests. I had access to a nurse with the press of a button, an attached en-suite for my dad to stay in, and a special dining menu to choose from. Aside from the fancy amenities, my care at VCU was not much different from the care I received in Rwanda. If anything, I felt more compassion from every single member of my Rwandan healthcare team and caregivers. What they lacked in resources, they made up for in truly hands-on patient care.

During my hospital stay in Rwanda, I had a lot of time for reflection. My experience was in stark contrast to two patient cases I had previously witnessed while shadowing in the ED a few weeks prior to my accident. One patient was a 13-year-old boy who had a sinusitis that progressed into an orbital cellulitis and then into a brain abscess. His family lived in the southern province about 70 km from Kigali. They had waited so long to seek treatment because taking him to the doctor meant losing income for the family. Now he was on a ventilator and in need of brain surgery.

Meanwhile, I was in the ED within minutes of falling. The second patient was a boy in his mid-20s. He had battled an infection that left him in acute kidney failure, and he needed dialysis but didn’t have insurance. During rounds, the residents and attendings discussed the plan for him. His CT scan showed acute versus chronic kidney disease, and the national insurance wouldn’t cover dialysis for a chronic condition. The patient was on oxygen, but he was sitting up in bed and talking. He was not much younger than me, yet his chances of survival past 6 weeks were very slim. I remember speaking with one of the residents about my frustrations because in the U.S. this patient would’ve received dialysis without a second thought. Dialysis is very expensive and limited in availability in Kigali. Giving a single patient dialysis three times a week for 6 weeks, which is what this patient needed, would drain the entire health care budget for the rest of the year.

So, it came down to saving one patient versus saving 100 other patients. This case made me realize the challenges and limitations in the provision of care in Rwanda. The difference in patient care between the US and Rwanda is not from lack of knowledge or training by the physicians. In fact, CHUK’s ED residents are taught by physicians from all over the US and are held to the same standards. The difference comes from the dilemma of using limited resources for one patient as opposed to another. Yet with all this being true for Rwandans, I received special treatment my entire hospital stay all because of the color of my skin.

Witnessing those two cases, I felt I had experienced care delivery in different ways and truly had a better insight into how patients often feel in the hospital. But then the accident happened and I experienced an entirely new perspective. I truly felt how scary and isolating being a patient can feel, especially if you don’t understand the common language. I felt the frustrations of not knowing what’s going to happen to me nor how serious my injuries were. I understand what it feels like to go to sleep in an OR and wake up confused and disoriented. I understand what it means to literally place your life in the hands of your doctor, even for a minor procedure. However, I still cannot fully understand what it felt like to be the boy in the ED who needed dialysis but would never get it. How would his life have been different if he had been given the level of care that I had received? What made me so special? How many other people will face these medical challenges in low- and middle-income countries? How do I “fix” this?

Two years have passed since my accident. It was the most traumatic experience of my life, but the personal growth both emotionally and professionally that I underwent during it shaped me into who I am today, and the doctor that I will become. Those eight weeks in Rwanda made me a doctor who can empathize with her patients in a very unique way and understand the emotional impact that a trauma can have on a patient. I will take away the knowledge that sometimes less is more and compassionate patient care may be better than any medicine that I can prescribe.

Dr. Lisa Adams stated it best in her TEDx Talk on Global Health Partnerships. “We need to drop the single-story assumption that everything we do in a high-income setting is better or preferred. In fact, we may be less innovative and more wasteful because we can be.” Having become a patient in a low/middle-income country and experiencing their system firsthand, I have become cognizant of the patient experience and ethics of having access to different treatments based on affordability, availability, and even patient nationality. I was given everything from a private room in the Rwandan hospital to a medical evacuation with a first-class plane ticket. We are lucky to live in a country with unlimited resources and access to surgery, and we should use our privileges to fight for accessible and equal healthcare for all. I believe that we have as much to learn from our Rwandan colleagues as they have to learn from us.

I am so thankful for my experience in Rwanda. I fell in love with the country in 8 short weeks, and I confirmed my desire to continue working in global health/surgery as I advance in my medical career. I look forward to the day that I can return to the “land of a thousand hills”.

Megan is a 4th-year medical student applying to general surgery. You can follow her on Twitter via @mtwojick.

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