two things i know to be true

— graciously contributed by Anjoli Anand, M.D., a practicing Emergency Medicine physician and writer in Brooklyn, New York

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Make me a radical.

Make me a revolutionary.

Make me stand for what I know,

And fear not the critic.

There are two things I know to be true.

First, I am an activist.

If I feel a way about something, then you’re going to hear about it. And it feels good to take to the streets and loudly protest inequality with your community surrounding you.

It makes you feel like you’re doing something.

You’re being productive.

And if we’re being honest with ourselves, so much of emergency medicine is framed in that way. We’re the ones who fly in with our capes, diagnosing that STEMI, or that stroke.

Treating that sepsis.

And it feels good. Productive.

And then, I went to Uganda, in the middle of my PGY3 year, where I spent a month in the largest government hospital in the country, staffing the infectious disease ward.

I knew nothing going in, and it turns out that in Uganda, attendings only come round twice a week. So those other days, you’re it.

Well, I had an intern who had been on the job for 4 months, so you know, totally helpful. And of the countless patients I could describe, I want to focus on three.

The first happened to come to us on a day an attending was actually present. We had finished rounding on our usual patients when the attending mentioned that there was a new intake in the TB ward. This was, of course, a formality, since the entire hospital was, in effect, a TB ward, and anyway she was here because of tetanus.

I don’t know how many people here have actually seen a person die of tetanus, given how often we vaccinate against it, but she was everything they describe in a textbook. All full body spasms, with stridorous moans and groans. It turns out that she had a mental illness and had accidentally run out into the street a few days prior, had some orthopedic injuries that were operated on, and then developed signs of tetanus a few days later. The orthopedic team managed her with Flagyl, which is actually in the WHO protocol, but after no improvement, they sent her to us on day 3 or 4 of illness.

She had no IV.

There was no monitor.

At this point, she was so clamped down and spastic, there was no chance of IV access, and even if we had been able to place a line, to what end? Intubation and paralysis, hoping to ride it out? Our hospital had two ventilators, and both were in use. She died an hour after we left her bedside.

The second patient I want to mention was actually on my last day in the ward. There was no attending on staff that day. With only a few more patients left to see, we heard a commotion outside in the entrance to our ward. A new intake had been brought up from A&E. We went over to see what the case was. I could make out a woman on the stretcher, eyes closed. She wasn’t doing much. I picked up her intake file, and the only bit of it I remember seeing was this phrase, “GCS 4, consider intubation.” No monitor, no supplemental oxygen.

We looked at the patient, then at each other, and without a word, turned our backs and returned to our rounds, leaving the head nurse to sort it out.

Make me stand for what I know and fear not the critic.

Which brings me to my second truth, and the third patient.

She was a young women who was displaying symptoms of meningismus. Fever, profound neck stiffness, confusion. Again, no monitor, rarely had vital signs, no isolation. We drew labs, and she had had an LP, but anyway it was Christmas that week and the lab was closed, so we just assumed it was probably some kind of bacterial meningitis and prescribed her ceftriaxone and fluids. For about a week and a half, we continued on this path, wondering why she wasn’t improving.

In Uganda, as in most Low Income Countries, patients depend on family or friends to care for them in the hospital. It’s the responsibility of the caregiver to buy the medicines we prescribe, to bring food, to insist that nurses actually hang IV meds.

She had no caregivers.

Finally, after about a week and half of the status quo, we happened to look down at her stretcher. Lying there were several, unopened bottles of ceftriaxone. She had never received the medications. We had assumed that our orders were being carried because her file had little check marks next to the medication each day, but she didn’t even have an IV anymore. So, I placed an IV, and brought the head nurse over. She took charge of the patient and within 2 days, the girl was up and out of bed.

To borrow from Samuel Beckett, “Ever Tried. Ever Failed. No Matter. Try Again. Fail Again. Fail Better.”

My second truth is that my cape is frayed and full of holes from being caught, from all of the times I could only stand by in silence

There’s a lot of ego and bravado to being an emergency medicine doctor. We think in minutes to hours. We are constantly on the move, all action and reaction. We exalt in our spectacular saves, and we’re crushed by the ones we couldn’t.

But in Uganda, I learned to accept that I wasn’t the protagonist of this story. That sometimes, bearing witness is all you can do, as you learn to fail better next time.

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