Tough day

Thursday was a tough day. I was working with a resident in the Maternity operating room. We had finished two cases but an urgent C section arose in a woman with preeclampsia (toxemia.) Her blood pressure was very high and the equipment to do the medically preferable anesthetic was not available. I spent some time reviewing why the anesthetic we were going to do was not the best choice, then we went ahead and did it anyway.
After that we had a case of hysterectomy for cervical cancer. Things were going routinely when I heard the staff surgeon ask for suction. He asked three times urgently, and I looked over the drape to see the surgical field filling with blood. The surgeons couldn't find the bleeding tissues because the suction was not available, one of the lights was not functioning, and as they struggled, the patient lost a lot of blood. I called for help and two fine anesthetic technicians, the resident and I spent the next 90 minutes bringing this patient back from hemorrhagic shock. After things were better, the surgeon looked at me and said "We are struggling here, we have no light. I am sorry. Thank you for your efforts."
Next we were called to help start an IV in a young man who has sickle cell anemia. The resident and I together spent almost two hours trying every vein imaginable, including his scalp veins, but without success. This man had had multiple IVs and all his veins were clotted, inflamed or already used. In the U.S. we would have placed a special IV into a large central vein. But in Kigali they don't have the sort of catheters used for such IVs.
We were discouraged and about to sit for "lunch" at 3:00 pm when a nurse came running down the corridor asking for help in the Maternity ward. A patient 25 weeks pregnant was agitated and gasping for breath, in pulmonary edema. We placed a breathing tube, began treatment, and called to transfer her to Intensive Care. We were told there was no bed and no ventilator available. I ventilated her by hand with a ventilating bag for two hours, and finally we could move her to ICU. When we arrived, the ventilator was attached and nothing happened--it didn't work. I ventilated her again by hand for another hour as a different patient was removed from his ventilator to give to the new patient.
This is the everyday experience of doctors in Rwanda. Having second or third choice options for treatment, struggling with nonfunctioning equipment, lacking the one small medical item that would make a hard case simple, and having to choose between patients for a scarce ventilator or even deciding not to put an ETT tube in a patient who needs one because there is no ventilator available.
How can I even begin to understand these dilemmas? I think of myself as a "patient advocate" but I have never had to endanger one patient in order to treat another. How can I judge outcomes of care in Africa? I have always had the drugs and supplies at hand to give the best possible treatment. How can I teach the anesthesia residents to weigh their choices of anesthetic when they have no options? How can we review cases with poor outcomes when we don't have the vital signs or lab data to explain the downward spiral?
The residents are realistic about such experiences; they persevere in spite of difficulty and continue to care for the patients in adverse circumstances. I try to speculate with them: "What would be the possible causes of cardiac arrest in a patient with a head injury?" "How could we provide anesthesia for this very sick patient if we had any choice of drugs and equipment?"
Today I had lunch with Adolphe, a first year anesthesia resident. I asked him why he chose to study anesthesia. He told me that during three years after medical school he worked in a district hospital and saw "many deaths due to anesthesia." He wants to concentrate on anesthesia so patients can have a better chance of surviving their operations. I have a growing admiration for these doctors--I am amazed at their endurance, their buoyancy, their continued drive for improvement. I hope I can add something of value in my time here. The least I can do is to stand with them as we work and encourage their development. And, walk a mile in their shoes, even on the tough days.