The faded curtains hanging between patient beds in the sweltering non-AC open air ward, patients spilling out onto the hallway floors, electricity going out in the midst of procedures, labs returning in the mornings with sometimes unreliable numbers, one dialysis machine and one cardiologist for the whole southern region of the country...

In the first week - actually, make that in the first hour - of being on the Karapitiya Hospital general medicine wards, I knew we were going to have a very different environment to practice inpatient medicine in than on the eighth floor of Duke Hospital. With so many stark contrasts between the two hospitals, which became readily apparent on a daily basis, what struck me most about my whole experience in Galle, Sri Lanka, though, was what we and the Sri Lankan residents ultimately had in common. We struggled with ICU beds all being taken and having to manage patients with pressors on the floor, with miscommunications between the interns and surgical consult residents, with attendings demanding workups for esoteric diseases, with nurses who had missed a set of vitals, with junior residents unwilling to discharge patients days after their acute problem had been managed. We shared a social life of talking about our patients, medicine, and the hospital, wishing for more hours in the day to spend with our families and friends. Of course, the resource limitations we faced on the wards were a continual reminder of how much more challenging it was to work at Karapitiya. We saw patients die because there weren't enough ventilators to get them through a COPD flare, from toxic ingestions because the supply of antidote was out.

Then one day, Thursday April 16, I came face-to-face with a much deeper difference between our experience and that of the Sri Lankan residents. We were having tea with a few other senior residents at the Canteen after rounds, when the 2004 tsunami came up in conversation. Two of the residents had been the interns on call December 26, 2004, and they began to tell the vivid story of bodies after bodies being brought to the hospital. They only had four ventilators at the time, and even though they knew there was no way to stabilize the hundreds of remaining patients with respiratory distress from aspiration, they desperately did chest compressions on men and women and bag-masked children for hours, finally realizing the futility. And then they were left with a 600-bed, 3-story morgue, with cadavers extending way beyond the hospital grounds. In the days that followed, they talked about not only the physical death that pervaded the town, but the hopelessness and resignation that was overwhelming. When international aid agencies came to provide medical help, they said there was such an influx of acetaminophen that in the following weeks, there most frequent admission was for acetaminophen overdose.

Even now in 2009, the number of admissions I saw at Karapitiya for attempted suicide in three months was more than I'd seen my entire three years at Duke. The background of the civil war between the government and Liberation Tigers of Tamil Eelam (LTTE), we discovered, was also part of this, as so many young men had died in battle, and mothers and wives were left to pick up the pieces. One of the Sri Lankan men working at the guesthouse we lived at told us about his brother dying in the war, and even the mention of the city Jaffna often stirred a distracted blank stare.

These stories gave me an appreciation for the unique context Karapitiya Hospital operates in and a great respect for the residents who work there. I developed both personal and professional ties that I hope will bring me back to the country in the future.

Neela Goswami is currently an Infectious Disease Fellow at Duke. She completed a 3 month global health rotation at Karapitiya Hospital in Galle, Sri Lanka, from February-May, 2009.