Sometimes Saving a Life Isn't the Right Choice

After completing my Disaster Medicine Fellowship at Harvard, I returned to Canada to begin a new role as an Ultrasound Fellow and faculty physician at the University of Ottawa. I’d come to see ultrasound as the new stethoscope—portable, affordable, and indispensable in both emergency departments and field settings.

Before starting in Ottawa, I received an invitation from the director of the ultrasound program, who was on sabbatical teaching in Rwanda. He asked if I would join him for a few weeks in Kigali to teach ultrasound to local physicians and residents. It was an ideal fit—global health work, teaching, and hands-on ultrasound. I booked my flight.

It was the fall of 2014, and Ebola was surging across West Africa. Fear gripped the world. An American physician I’d once worked with—my senior resident during medical school in New York—returned from an MSF mission and tested positive. Instead of being celebrated for his courage, he was vilified in the press for “bringing Ebola to America.”

Back home, people were panicking. But in Rwanda, life carried on. The outbreak was thousands of miles away, across multiple borders. And yet, much of the world spoke about Africa as though it were one country instead of an entire continent.

The country was still healing from its traumatic past. In 1994, Rwanda suffered a horrific genocide while the world stood by. In the years since, it has undergone a remarkable transformation, including major efforts to modernize healthcare and train local physicians.

The main teaching hospital in Kigali felt more like a field hospital than a modern emergency department. A collection of low buildings surrounded open courtyards, it had only two working faucets in the ED. Patients supplied their own gloves, and families purchased medications from a central pharmacy. Infection control protocols were rudimentary. Every few days, cleaners flooded the department with bleach and pushed the dirty water from one end of the ED to the other with long-handled squeegees—a crude but necessary reset.

And yet, against one wall stood eight gleaming ultrasound machines—each more advanced than anything I’d used back home. The probes alone were worth hundreds of thousands of dollars. But the machines were largely untouched. Electricity failed almost every day, and few clinicians had been trained to use them.

That’s where we came in. Teach physicians how to integrate ultrasound into their physical assessments.

There was one simple rule: teach, don’t touch. We were there to build local capacity, not manage patients. The Rwandan residents were supervised by experienced American emergency physicians who had embedded in the department for months. Our role was to guide, not intervene.

Simple in theory. Much harder in practice.

My first day, I worked with a sharp second-year resident. She knew the textbook cold and scanned kidneys, hearts, and bladders with confidence. I was impressed.

Then a trauma code came in.

A young man was carried from the back of a pickup truck, barely conscious, with obvious head trauma.

His airway was compromised. One pupil was fixed and dilated. He was posturing. His blood pressure was soaring while his pulse slowed—a pattern every emergency physician recognizes as impending brain herniation.

He needed to be intubated immediately.

But the resident didn’t seem alarmed. She began a careful, methodical trauma assessment from head to toe. Her attending stood nearby, quietly observing. I assumed she was giving the resident room to think before stepping in herself.

I waited.

Then I couldn’t stay quiet.

“He’s not protecting his airway. You need to intubate. Now.”

They acknowledged me.

But nobody moved.

His oxygen saturation dropped into the seventies. The resident continued her examination without changing pace. The nurses log-rolled him to assess his spine.

He began to seize.

I turned to the attending.

“He’s going to die. Why aren’t you intubating him?”

She looked at me calmly.

“I understand this is hard to watch. But this is how our residents learn.”

I stepped back.

Furious. Powerless.

From the doorway, I watched his condition deteriorate. Eventually his heart stopped. And just like that, he was gone.

Later, the attending found me.

“I know that was difficult,” she said gently. “It doesn’t get easier. But there are things about this place you don’t yet understand.”

She was right.

The emergency department had only two reusable endotracheal tubes—and one ventilator. It was already in use. Even if we had intubated him, someone would have needed to manually bag him indefinitely. There was no neurosurgeon. No neuro ICU. No realistic chance of survival.

The attending had known the outcome from the moment he arrived.

She hadn’t failed him.

She had made a triage decision—to preserve desperately scarce resources for patients who still had a chance.

It still felt like a betrayal.

During my time in Kigali, we taught what we could. We trained emergency medicine residents in ultrasound. We helped obstetricians use POCUS for prenatal care. We showed surgeons how to perform ultrasound-guided breast biopsies.

But what stayed with me were the things we couldn’t teach.

We were teaching sophisticated ultrasound techniques in a hospital that struggled to provide reliable running water, dependable electricity, and basic airway equipment.

Technology alone cannot build a healthcare system.

Global health is messy. Teaching is noble. But the line between helping and harming is razor thin.

Sometimes the most humane act is to do nothing at all.