In my weeks at Karapitya Hospital in Galle, Sri Lanka, what I remember most is my first patient who died. A twenty nine year old with nephrotic syndrome who developed worsening renal failure, metabolic acidosis and died while waiting for dialysis. His death was not unexpected. It is perhaps an odd thing that I keep running the events through my head. After all, I am a physician, I have had patients die before- this is not my first trip to the rodeo. In fact this isn't even the first time I have worked in a developing country. I spent two years as a Peace Corps volunteer in West Africa before medical school. People died in my village every week. People would come to my house and ask for help for their loved ones and while I could pay for the taxi fare to the hospital, I was otherwise useless in the face of their need. I always dreamed of being able to go back after finishing my training and actually be able to do something. To diagnose. To treat. To be of some use. I looked at Karapitya Hospital as a dry run to see what it would be like to work in a developing country. To see if the intervening years of medical school and residency had made a difference.

At first it was startlingly similar to my inpatient rotations at Duke, despite the differences in the physical environment. Morning spent watching medical students frantically running around trying to have all the information on their overnight admissions ready for rounds. Pre-rounding with the registrars and house officers, the equivalent of junior residents and interns respectively, and then rounds with the consultant aka the attending. Rounds were fast, we had to get through anywhere from 30 -70 patients. And work-ups limited. Patients were often discharged in a few days with follow up in the hospital clinics. The goal was to make sure we would have beds available for the next casualty or admitting day. Because even if there were no physical beds, patients would still be admitted to the hospital. I thrust myself into the routine without much difficulty. And most days went by without incident although it was difficult to become accustomed to the omission of tests and studies that I would have ordered if back in North Carolina.

Then one morning I came in to find my patient with nephrotic syndrome on 50% facemask in acute respiratory distress. He had been diagnosed with membranoproliferative glomerulonephritis as a teenager, but had been lost to follow up. He had shown up in the hospital clinic two weeks prior with severe anasarca, shortness of breath and metabolic acidosis. His family had been working on obtaining a kidney transplant for the past several months, but had been unable to find a donor. In Sri Lanka, there are no cadaveric organ transplants. In order to have a transplant there must be a living related donor. He had been dialyzed twice after being admitted due to his metabolic acidosis on the only dialysis machine in the hospital. He again needed dialysis, but the machine was already committed to two other patients. There were no other machines in the southern part of Sri Lanka. There was no where we could send him. We gave him morphine to help with his shortness of breath and continued with rounds. Over the next half an hour we could hear him struggling for air. There are no private rooms. The patients all lay together in an open air ward. There was no escape from the sounds. After rounds were complete, one of the house officers called me over to the bed and we waited while he took his last few agonal breaths. The family stood at the foot of the bed and watched as we checked for a heart beat. The patients in the beds next to him watched as we pronounced his time of death. A registrar turned to me and said, "It costs 2500 rupees ($25) for dialysis. For lack of 2500 rupees he died." There was nothing I could say in response. I had nothing to offer to make up for the lack of a dialysis slot. All my training still could not save this one life.

Throughout my time in Sri Lanka I have been grateful for the camaraderie, patience and expertise of the wonderful and dedicated clinicians with whom I have worked. However, my true debt lies with the patients who graciously allowed me to practice my profession and who smiled even when there was nothing I could offer. As for my twenty nine year old with nephrotic syndrome, I am grateful for the chance to have known him. And for the reminder that my training comes with a responsibility to not only work to make my patients better, but to work to correct the differences that lie between the developing and the developed world. I hope to return to Sri Lanka in the future intent on achieving both goals.

Divya Bappanad is an Internal Medicine Resident at Duke. She worked at Karapitiya Hospital in Sri Lanka during her global health elective.