Simulation labs have become quite sexy in medical education over the last decade; every medical school has one or wants one. They are usually the equivalent of a trauma bay in a teaching space, with medical carts, gear, and a patient bed used to simulate real cases. This enables trainees to mimic real medical situations and work on their teamwork and communication for rapid patient response; often they comes with synthetic patient-robots that open their eyes and make weird noises. I remember at the College of Surgeons in Ireland they loved to boast about all the money they spent on the multi-thousand dollar mannequins that can produce murmurs on exam and say ouch when you poke them with a needle.

I think the mannequins are overrated.

What isn’t overrated though, is the use of simulation-based training to harden medical students and prepare them for the realities of acutely sick patients. I formed a team for the Irish national tournament in medical school and the training it provided has been one of the most important facets of my skill set to this day.

Part of the UGHE curriculum included a simlab with the life-like mannequin pictured above. I was lucky enough to be invited to help lead the training session for our cohort of senior clerkship students. The students were split into two groups, and they would run two simulations each. Myself and Olana took one of the cases, a patient with acute respiratory distress from extra fluid volume in the lungs and an arrhythmia, while Adeline and Sol took the other, a patient with elevated potassium causing dangerous changes to their heart function.

Sitting behind a two way mirror, I watched the students enter the patient encounter and organize themselves the best they could. They squirmed as anticipated. After a time, they settled and did most of the right things. In reality this case was set with a very specific trap, and it was designed to teach a very important lesson.

A lesson that would have prevented a death in Butaro just the week prior.

That was the case of a 24 year old woman who came to the emergency department with signs of excess fluid volume and heart failure. She had a history of rheumatic heart disease, a condition (eradicated in most of the developed world) that comes as a result of untreated strep throat in childhood which then triggers an immune response that causes inflammation of the heart tissue, primarily at the heart valves. The valves can then undergo a physiologic change that stiffens them, causing lifelong heart problems. In severe cases, the valves can be so diseased that it causes complete remodeling of the heart, leading to heart failure like in this patient presenting with severe respiratory distress in Butaro. None of the medical attendings were there at the time, and the patient was managed by one of the interns in the emergency department. She was noted to be in heart rhythm called atrial fibrillation, which commonly happens when you have a remodeled heart. The doctor in question became fixated on this heart rhythm and gave medicines to decrease the heart rate. However, in acute heart failure, the heart rate is high because the heart is fighting as hard as it can to push fluid forward. This means that when the doctor ordered nifedipine and atenolol, both medicines that decrease the contraction strength of the heart, our patient went into full-out shock. By the time any senior doctor was made aware, Sol had come running to the department to find her already entering cardiac arrest. She died.

In more cynical terms, we killed her.

This was at a rural hospital, yes, but a district one with many highly trained staff in the building. Sol and Adeline used the case as a teaching point for the students, and when they told me about it the next week, their words were thick with sorrow. It was a stark reminder of how far we have to go. I think about how commonly these events happen in small rural communities all over the developing world, understaffed with underpaid and underqualified staff doing their best. This is the world for many people still.

So, we set the trap and watched the students react. They were now close to ten minutes into the sim and uncovering more diagnostic information, establishing the patient was in clinical heart failure and looking at the heart rhythm. I heard them discuss from the other side of the screen.

‘The patient is in rapid atrial fibrillation,’ one of them said.

‘We can give… Uhh…We can give…’ the other said.

They were all thinking it.

‘We cannot give beta blockers,’ the first one said.

Yes! I thought to myself.

‘We can give diuresis and watch for urine output because of the acute heart failure,’ they concluded.

A few more minutes passed as they did more things, and then we went into a separate room and debriefed on the case. Job well done.

Then they moved on to the other station and the other group came to our side. One of them looked like he had just been dumped by the love of his life.

‘Feeling alright, Patrique? I said.

‘No sir,’ he said, bringing his hands to his face. ‘Our patient died!’

I couldn’t help but laugh. Poor Patrique.

‘Well let’s hope this one goes better,’ I said.

It did. They saw the trap and skirted right past it. Well done UGHE curriculum.

Debriefing, Olana and I milked the scenario for every last drop of teachable pearls. Both cohorts were engaged and showed immense growth as the day and weeks progressed. I loved every minute of it.

God I love my job so much it’s fucked up.

The incredible luck I have been granted doesn’t go unappreciated. I get to do what I want, when I want, see the world, and maybe help some people in the process. There is a good chance I am the luckiest person that has ever lived, and I will never take that for granted.

All that said, there are elements of this life that make me realize that it can’t last forever, and for that matter I don’t want it to: Living out of a backpack has its Spartan allure, but I am not sure I will find it as enthralling at age 40. You also don’t belly laugh as often when all of the people in your circle have only been in your life for 12 days at a time, and I do miss having a community. On the more personal side, at my core I am a romantic, continuing to search the world for that person who makes me want to give myself away entirely and start a family; I don’t know how conducive my current lifestyle is to that. Also, the elephant in the room, it turns out salary-paying gigs in the humanitarian space are hard to find—I am doing all of this for free.

At some point I will need to make money to eat.

So, despite my vagabond soul feeling right at home eating cheap street-food and doing laundry in the bathroom sink, I have to face the reality of modern living. I have been able to sustain this rodeo thus far with savings from residency and the unfathomable privilege I had to finish medical school debt free (gracias mama y papa), but now the accounts are running dry and my blood pressure spikes when I pay for flights to satisfy my endless commitments. A tragedy, I know.

My mind calls back to that formative conversation I had with Tayseer, my humanitarian mentor in chief, at a plastic table sipping beers in the guesthouse at Kyangwali Refugee Camp in Uganda.

‘Jwan,’ he said, taking a drag from his cigarette. ‘If you want to be a real humanitarian, you will wind up sad, broke, and alone. If you ask me? Do the Alex thing. Have your stable job, have your house with a beautiful wife and family, and then take whatever time you want to work in the field. One month, four months, six months, that’s plenty. But all the people I know that do field work for a living have no money; they still pay rent, and when you are 45 with kids your priorities will change and you won’t be able to come back into your clinical practice in Europe or the US. I don’t want this for you.’

So, where is this all going? It lands me on a conference call, headphones on, in the back of a Chinese restaurant one Thursday evening in Kigali. On the screen in front of me was the head of medicine at Beth Israel Hospital in Boston.

‘You have an impressive CV, Juan,’ he told me. ‘We’d certainly be interested in having someone who has practiced medicine on four different continents. Why don’t you tell us what you’re looking for and we can talk about what we could do to bring you on board.’

‘Well,’ I started. ‘Let me start by telling you my story and where I find myself in my life right now, because I think that will help you understand my position and answer your question.’

So I did.

‘That’s helpful,’ he said.

Now came the time to make my demands clear

‘I would need to be H1B visa support given the above’ I said. ‘Ideally, I would be looking to work 4 months a year, preferably in the summertime, as many hours as possible, on a teaching service so I can train residents and get in with leadership to build some global health projects with the aims of eventually transitioning to a faculty type role.’

His face showed the expression I was anticipating. I could tell he was thinking how to eloquently phrase that I was out of my mind. This was a negotiation process, so I had to start with my utopian scenario, right? If I could read minds I would have heard his inner voice.

‘This guy is out to lunch.’

Instead of saying that though, he spoke more professionally.

‘Okay,’ he said. ‘Let me explain to you how our hospitals are staffed and all the possibilities for someone in your position.’

So he did.

The details don’t matter, but the takeaways were the same I got everywhere else. Nobody wants to sponsor a visa for someone working less than full-time. Even then, full-time positions with the biggest need were jobs working nights, where you hammer-admit patients and put out fires over clinical teaching. In a system like Beth Israel, they had several different hospitals and harness the nocturnists to cover multiple hospitals in different parts of the Boston area. For me, this would mean moving to a very expensive city, working only at night in several hospitals, with debatable ability to get my foot in the door to build a real humanitarian medicine program with my ties abroad. If I wanted to work in the US, that was the setup; they use the visa candidates to fill gigs that others don’t typically want. Beggars can’t be choosers. 

So the search continues. As I write this, I am plotting, and paperwork is being drafted. You’ll hear more in due time.

Now back to the good stuff.

In a blink, the month in Rwanda flew by, and now I was packing my bags in Kigali before heading off to Singapore to meet with a trio of former flatmates from my days drinking too many pints in Dublin.

Rwanda proved to be an aspirational project. The way the country has re-written its story after one of the most brutal atrocities of modern history and welcomed the world to participate in its remodeling is a case study in good governance. UGHE is embedded in the system wielding all the muscle of Occidental philanthropy to create the next generation of healthcare leaders, manifesting in its surge into the top five universities in Sub-Saharan Africa (Sub-Saharan Africa University Rankings 2024 | Times Higher Education (THE). I look forward to the chance to come back, and hope to emulate their work someday.

Next time I’ll even wear a button up shirt to the gala.

While the job hunt percolates in the background, I find myself looking at another 100 day stretch on the road after the holidays. This one promises some different colours: despite my best efforts to avoid the cold, somehow I find myself wearing a down jacket sitting next to a space heater not far from the Himalayas.

To be continued.

Best,

Pez