The next day we hit the ground with a bit more pizzazz, and I was able to start only slightly later than our pre-arranged time of 9:00AM. We covered cardiac ultrasound techniques with good success. After our session, several of the radiology residents pulled me aside and asked me to come down to the radiology department in the afternoon.

In the absence of sonographers, radiology residents are the ones that typically perform ultrasounds at Aliabad. So, I joined them in their exam room and they brought in patient after patient referred in from the outpatient clinic for scans. I began to feel a deep empathy for my colleagues that live behind screens, as far too many patients came in with strips of paper saying ‘abdominal scan,’ without any clinical context or further prompting. I need to know what we’re looking for, what organ system, or what symptoms are prompting the scan to begin with. I could see the footprints of lackluster clinical work in several patients, and one in particular stood out.

He was an elderly man, likely in his sixties. As he walked in the door I could see he was walking uncomfortably with a big protrusion in the lower portion of his abdomen. He handed us a slip of paper that read ‘bladder scan for urinary retention.’ I didn’t even need to scan the patient to answer the question, I could see it from the door. Percussion of the mass in his abdomen produced a resonant sound. When asking the patient if they were urinating, he told us that he hadn’t gone reliably in several weeks and was only getting periodic leakage. Additionally, he told us that he has a previous diagnosis of an enlarged prostate and had to have a catheter placed before. This upset me. To nobody’s surprise, he had several litres of fluid in his bladder on our scan. We sent him to the emergency room to get a catheter placed and then have them follow up with his clinic doctor and a urologist.

These are the perennial frustrations of medical care in low resource settings. The patient was seen by a clinician who heard the same story and could see the same obvious things I was seeing from the door. Why they sent the patient to radiology to continue waiting for several days while his renal function continued to be impacted was a waste of time at best and mismanagement at worst. I try not to cast judgment on another doctor’s decision making, but sometimes watching patients suffer makes it difficult. Before I started this journey in humanitarian medicine I expected to be grossly under qualified against the master clinical doctors in systems that depend far less on imaging and lab work. However, I have found that to seldom be the case. The master clinicians are out there somewhere, I’ve met them, but almost never at the bottom of the barrels where I found myself scrounging. This is why I feel strongly that a development of education systems is a place where I can likely have the biggest impact.

Throughout the afternoon I helped out as best as I could, teaching the radiology residents the extent of what I knew with regards to liver, gallbladder, kidney, and bladder scanning. Importantly, I had to remind them often that I was not a trained radiologist and many of their questions were outside the scope of a point of care evaluation. People are always so surprised when they ask me a question and my response is ‘I don’t know.’ These are three words that I think doctors should be far more comfortable uttering, despite our ever-present nature to have all the answers and never go wrong. Once we saw the last of the patients, I packed up and met the others for a trip to a local street market.

My off-time in Afghanistan provided interesting points of reflection throughout my stay. Coming from the West, I didn’t really know what to expect daily life to be like. The food markets teemed with life, as did the carpet vendors, tailors, and jewelers. I went to an antique shop full of timeless relics and got a few take home trinkets. Despite the low GDP and associated trade restrictions, it seemed like life was finding a way. If there was anything I have learned in my travels, it’s that life always finds a way. However, I have to always remember the caveat that I was accompanied by armed guards in the economic capital and largest city in the country.

In the coming days I continued the training and we had a lot of success. The residents and attendings were picking up steam, asking us to scan more patients after the training sessions. On the third day, we scanned a patient on the wards with bloody urine of unknown cause and found her to have an enlarged kidney with some stones, prompting the resident to call the urology team immediately after the scan to get an urgent consult. We found two patients who had new heart failure on scanning, several others with fluid in their abdomen, and another with fluid in her chest who got a drain placed with assistance of the ultrasound. They were picking up the skills and using them to make real decisions for their patients, which is the best advertisement for this technology I could ever provide.

After one of our morning sessions, we went down to the male ICU. Dr. Abdullah had a group of residents on one side when we came in. Walking in, I lingered at the back of Adullah’s group as he taught. After some time, a few of the lady residents pulled me aside and asked me to help them scan one of the patients, so I took the probe and followed them to the patient’s bed closest to the door.

She looked awful. Next to her bed, a ventilator connected to a five foot tall oxygen tank breathed into her. Likewise, on the window sill behind her rested a monitor with several number tracings of different colours. I noticed her eyes were open despite being intubated, which told me she was likely under-sedated. I looked at the infusions hanging next to her and saw normal saline and an antibiotic; not on sedatives at all. She was fully awake with a tube lodged into her windpipe.

I gave the ultrasound to the three lady residents, flagged one of the residents taking care of her, and asked him to walk me through the case. We stood at the foot of the bed and he began explaining a clinical course involving respiratory failure, shock, and renal failure when the lady doctors called my name.

‘Doctor,’ they said. ‘This is barely moving. Sinus bradycardia, no?’

I saw them holding up the tablet with a long axis view of the heart and they were right, the walls were squeezing with very long intervals in between, probably something around 30 beats per minute.

‘Can we check blood pressure?’ I said. Then I turned back to the resident. ‘You told me she’s in shock?’

‘Yes doctor, she is on norepinephrine now. Her last blood pressure was in the 80s over 40s,’ he answered.

‘How much norepi is she on?’ I asked.

‘Uhh…’ he hesitated. ‘Since we don’t have medicine pumps it’s hard to know exactly. It’s running at a fixed rate.’

‘Sorry, say that again?’ I said

‘Without the pump it’s not exact, but probably somewhere around 20.’

‘20 micrograms per minute? Okay then. What’s the blood pressure now?’ I asked calling out to the lady residents near the head of the bed.

I watched them mess around some more with the monitor resting on the window-sill behind the bed. One of them looked up at me.

‘We’re not getting one,’ she said.

Right, of course not.

‘Can you check her pulse?’ I said, turning my head across the unit. ‘Abdullah! Could use your help.’

His tall frame came closer as I moved towards the patient and ushered the residents the other way.

‘Sorry, I know you rounded on this patient earlier,’ I said. ‘We’re not getting a pressure on her and she’s bradycardic.’

His expression turned serious and he started calling out instructions to the nurses. ‘Atropine, let’s get some atropine!’

With him now moving to the patient I continued to ask for details from the resident. I turned around for a moment as he showed me some results in her chart to try and piece together what might be going on. When I next looked up, I saw Abdullah doing chest compressions.

This was now a cardiac arrest.

I slid back to the foot of the bed and turned to my right towards the ladies. ‘Can you put gloves on? We’re going to need you on the chest.’

Still with eyes open, our patient’s body shook with every compression.

‘Can I get one of you to keep time?’ I said again to the residents next to me. ‘And let’s get some epinephrine ready please.’

Just then, Abdullah paused compressions for a moment and someone felt the patient’s groin.

‘She has a pulse,’ they said.

‘Great. Strong?’ I asked.

‘Strong.’

We did a standard post-cardiac arrest assessment with a blood pressure now in the 180s/90s. Success. Another patient brought back from the dead. For now anyways.

Going over her case with the resident, we picked apart some more details. She was admitted initially for gallbladder sepsis that spiraled into a hospital acquired pneumonia on maximum ventilator settings complicated by worsening shock and kidney failure. She was going to certainly need complete kidney replacement with a dialysis machine, which is essentially impossible to do in a patient in shock as it drops the blood pressure further. The resident would have to discuss that with a kidney specialist, of which they did have one somewhere in the building. The honest truth was that she was dying of multi-organ failure and was not long for the world, so I encouraged the resident to have an open discussion with the family as her biggest priority.

Shortly afterwards, in one of the other wards, another one of the residents pulled me aside. He was young, probably around my age, and had been one of the more keen ultrasound users in our short time together.

‘Teacher,’ he said. ‘Can I ask you a question about do not resuscitate?’

‘Of course,’ I said.

‘Is it our place to withdraw care when still there is a possibility, no matter how small that the patient may improve? We can never truly know what is going to happen,’ he said.

Uh oh, I thought to myself. Tread lightly here Lopez. Pausing, I thought carefully before answering.

‘You raise a valid point. There is no right answer here,’ I said. ‘I can tell you what my practice is in the US. I think it’s very important for us to be direct about how sick patients are and give their families the right to make decisions. If I see a patient getting sicker, and I expect them not to do well, I think it is part of my duty to inform the family. They may opt to pursue an aggressive management plan, even if that might prolong suffering in a patient that is unlikely to improve. They may also decide to pursue comfort and minimize suffering even if that means the patient will die. These are not my decisions to make, but I do think we have to play a role in informing that decision for the family.’

‘This is not right,’ he answered. ‘We are not to decide to remove a patient from a ventilator if they have some chance of survival. Even if impossibly small. We cannot say what will happen.’

‘I hear you,’ I responded. ‘I can only tell you my practice, which is based on the culture where I come from. If families want that, I have no place to stand in their way, even if I may disagree. Likewise I have worked in other places where the culture swings the other way; when I was in Ireland, the critical care specialists would decline to offer some interventions like intubation or CPR if they felt it was futile. I am not one to decide these things, but I have to honour what families and patients want for themselves. Take in Covid for example. How many patients did I perform CPR on when I knew breaking all of their ribs to bring them back would not fix the underlying problem of their lungs inability to provide oxygen to their tissues?’

‘Yes, my father died of Covid as well,’ he said. ‘I was the one to decide to continue all care for him.’

‘This was your decision to make,’ I said.

I write about this because it has come up several times in my work abroad, and I find cultural differences in our approach to end of life very intriguing. When I was in the ICU in Botswana, I remember calling a family once when their patriarch, admitted for post-surgical sepsis who had worsening shock and kidney failure, began to circle the drain.

‘Hello,’ I said. ‘I am sorry to call you like this but I wanted to offer an update on your father. I am afraid that I don’t have good news. Since we last spoke his condition has continued to worsen. I am afraid that with his worsening blood pressure despite all of our medicines, the infection is spreading and he is becoming unstable. We are entering territory where I think there is a real possibility he may die, and it may happen quickly, unexpectedly, and soon. If anyone in the family wanted to see him, I think time is short, and the only time I can guarantee they can see him again is now. I wanted to give you the chance to come see him now if you felt inclined.’

His daughter on the phone seemed flustered—how could she not be. Despite this, she thanked me and I heard discussions in the background.

‘We are several hours away, but we will come now,’ she said.

‘One of my colleagues will be here,’ I answered.

Shortly after getting off the phone, one of the ICU nurses approached me.

‘Doctor, you cannot tell patients their family member is going to die. We do not do this here,’ she said.

I turned white and didn’t know how to respond.

‘I understand, thank you for telling me. Also by the way, the family is coming soon.’

The patient died overnight two hours after the family came to say their goodbyes.

Similarly, I once cared for a lady from sub-saharan Africa at Penn. In fairly typical fashion, she had nearly 20 family members come in together when I called them to tell a similar story and offered the chance for them to see their loved one more time. I remember telling my intern there was a good chance they wouldn’t even hear the idea of DNR. I was right.

‘Despite our best efforts, it’s highly possible she will pass soon,’ I said. ‘If someone wants to keep her company overnight so she is not alone, we can arrange for that. If we decided we wanted to prioritize comfort in the process, we can also arrange for that to spare her suffering.’

‘Doctor,’ her son said to me, not angry, but emotional. ‘We are African, we do not do this. We will not be staying. Thank you for everything and please continue to do your best for her.’

All twenty shook my hand and filed out. She died alone in her room several hours later.

When I was in Jordan, one of the critical care attendings laughed at me when I asked a question about goals of care.

‘In Jordan, DNR does not exist. The patient may be 99% dead, with their body in one bed and their head in another, and we never withdraw care. This is not our culture. We do not do this.’

Culture is the lifeblood of human existence, and I am not one to be critical of such things. Interestingly, I think we are taught to believe that Western medicine has gone off the deep end with extending suffering and excess care in patients that shouldn’t be getting it. In reality, in my clinical practice, I think we offer patients far more autonomy to choose comfort than many other places. Ireland probably swung the other way, with consultants regularly taking a slightly more paternalistic approach, which I think is also fair. After all, patients and their families haven’t seen the things we have seen, they haven’t felt broken ribs beneath them, coding a 92 year old with dementia whose soul left for better places long before they wound up in the hospital. As physicians we are so quick to recommend plans ‘you should start this med,’ ‘we need to do this to control your diabetes,’ why do we get shy recommending plans that we believe to be in the best interest of our patients when it comes to end of life? Food for thought, there is no right answer here. The point is that it’s not my place to impose my culture when I am abroad, I can only tell people how I do things.

Still though, it would be foolish not to point out that one of the reasons I’m invited abroad is because I have something to share in terms of how things could be done better. This comes up all the time in my humanitarian work. If I came here just to practice as a local doctor would, then my presence here has no point. It’s a fine line to walk sometimes, especially when I am working clinically.

My conversation with the Afghan resident continued with some more back and forth, drawing a small crowd. I was respectful of his position, while reaffirming my own. Whether or not he took anything from it was out of my control. At the very least, he got to hear a different perspective.

Sometimes that is the best we can aim for.