ABCs intact. Airway. Breathing. Circulation.  Blood pressure adequate to supply critical organs. Oxygen saturation—wait, that’s lower than it should be. Patient’s awake, ok. Crepitus around both side of his chest---a palpable crunch over the ribs. Respiratory rate picks up, breathing becomes more shallow. Patient is now requiring a little more encouragement to respond.

All my training would agree that the next step in the care of this trauma patient—a victim of a road traffic accident with severe pulmonary contusions secondary to multiple rib fractures—would be to secure his airway, place a breathing tube to help the man failing before my eyes. This was also something I had the training to accomplish. I knew what equipment I would need and the steps of protecting this man’s ability to breathe. But wait, there was something crucial that I knew we did not have. There are no more ventilators available in the hospital. This hospital in Kenya had five adult ventilators—more than most of the surrounding hospitals—but not enough to care for this victim of trauma. Our option was to stabilize him as much as possible then try to locate another accepting facility that could give him the breathing support that he needed. Ambulances are also not easy to come by, and transport would have to be arranged which would require payment before he could be moved.

Limited resources lead to difficult decisions that providers are forced to make.  Knowing where to invest system effort and energy and where to draw the line is a constant challenge. What kind of therapy do you offer the confused, debilitated, tired gentleman with advanced metastatic cancer while his family of limited means stands around you? His kidneys have only recently stopped functioning after he travelled all the way to Nairobi for two weeks of chemotherapy.  Do you aggressively correct his blood pressure and electrolytes when that could result in catastrophic hospital bills for the family? What is reasonable for you to offer? The doctor-patient relationship, especially in Africa where power and race differentials are often more skewed, makes patients particularly eager to do what the doctor asks, especially in times of illness when they are anxious and afraid. What is your response when they ask you “What would you do doctor?” And what if this takes away an opportunity to help another patient?

These decisions are difficult. These conversations are uncomfortable. I have found myself frustrated and restless--even wanting to go back to my surgical practice where the resources are endless and cost is not a reality I wrestle with every minute. But here is where the need is greatest. These are the places where hard decisions need to be made for a greater good. Here we must fight to preserve dignity even in despair and hope even in the midst of heartache. Physicians in these settings must make impossible decisions to accomplish the greatest amount of good for the most people, families and communities. We are forced to wrestle with what is reasonable and this is not taught in any textbook.