Well this blog is ending for me the same way it started…typing it up while enjoying the privilege of sitting in a Star Alliance lounge waiting to board our flight. It’s amazing: the difference in my perspective now versus just three weeks ago. The time has gone incredibly fast and yet so much has happened that I can’t believe it all occurred in only 3 weeks.
Yesterday was a nice completion of the circle, so to speak. We started the day off with a very good discussion surrounding ultimately a very sad M&M case. After which we had the chance to go back to the apartment and pack up. Rwanda proved to us both what the rainy season is really like, yesterday, and how incredibly lucky we have been with the weather during this trip. The sheer amount of water that fell from the sky was impressive and finally justified to me why there are gigantic rain drainage systems all over the country.
We got to see Emmy one last time and as always he had a hand in making sure our exit from the country was as smooth as our entrance. We also got a very nice phone call from Mary and got to thank her again for her wonderful hospitality. Lunch we had at the hospital, one last time, with Rob and Sean. We got the Special (not “Spanish” as we first interpreted it) Omelette, which was eggs, fries (or chips as they like to call them), tomatoes, onions, and something that was either meat or very hearty mushrooms (but I think it was meat). We of course had, what I originally thought was going to be our last Fanta.
Getting back to my completion of the circle comment, the wonderful opportunity I had to come on this trip first truly came to be when I was at my first monthly teleconference with Rwanda, but on the UVA side. I can’t remember now what the topic was, but I remember being there watching one of the residents give a presentation and trying to imagine what it must be like where they were. My only view of Rwanda at that point was part of a room in some random building in a country I had never seen. The end of our day yesterday was a fantastic way to finish our time here. Here I was on the other end of the teleconference, now with a much broader view of where the residents here are, what their situation is like, and even simply where the teleconference room is in relation to everything else (to my surprise it is on the top of a four story teaching institution that handles the lion’s share of medical education for all of Rwanda- I, for whatever reason, assumed it was on the ground floor of likely a relatively small building somewhere near the hospital). It’s funny how your mind builds a framework to surround what you see and it’s quite an experience when that framework is utterly shattered and replaced with the truth.
We had to leave the conference a little early to get back to our apartment, grab our stuff and hit the road. The driver, provided for us by CHUK, picked us up in a minibus, which was great because it was my first experience in one in Rwanda. Luckily for us, it was not packed to the gills like every other minibus in town, there were only four of us in there (including the driver).
We made it safe and sound to the airport and through customs. We then saw what was likely the only restaurant in the airport and decided to pause before going through security (a good thing too, because I’m pretty sure we wouldn’t have been able to get back if we wanted too). Our last meal in Rwanda was a surprisingly good panini with beef and vegetables. Naturally we had to have one more Fanta to go along with our meal before getting on the plane.
Our flight to Brussels was nice and quick, especially given the fact that I slept most of the way. We made a quick stop in Nairobi to drop off some travelers and pick up a few others. Shortly after take off from Nairobi I feel fast asleep. The last thing I remember is them saying something overhead about dinner (chicken and rice and some other option I didn’t quite catch) and thinking to myself, I’m really glad we already ate. I woke up sometime later to find a blanket nicely folded on my lap, I opened it up and quickly fell fast asleep again.
It’s been an amazing trip, one that I will never forget. So much has happened, I am not sure I have processed it all yet. This blog, however, went a long way in helping me do that. I hope you enjoyed this blog as much as I surprisingly enjoyed writing it.
I’ll end with a favorite quote of mine from J.R.R. Tolkien: “He used often to say there was only one Road; that it was like a great river: its springs were at every doorstep, and every path was its tributary. ‘It’s a dangerous business, Frodo, going out of your door,’ he used to say. ‘You step onto the Road, and if you don’t keep your feet, there is no knowing where you might be swept off to.'”
While it may be dangerous, it is also incredibly fun. I hope when we next meet it will be somewhere completely unexpected.
Today was planned to be a quiet day of relaxation prior to our final teaching sessions tomorrow morning and afternoon, and departure tomorrow night. We kind of succeeded. It would all have been well if Paul this morning hadn’t handed me an envelope that he had received yesterday from one of the residents. It contained a check from the University of Rwanda for our expenses traveling to Butare. We realized that we better get it cashed today, or it will never happen. I don’t think my Charlottesville bank will know what to do with a check for 60,000 Rwandan francs drawn on an African bank.
We hoped to get this taken care of at a local bank in Nyamirambo, but no luck: the check was issued by the National Bank of Rwanda, and can only be cashed there. And so our day of rest turned into a long (about an hour) and pretty hot walk all the way to the center of Kigali.
The National Bank is quite imposing, with tight security not dissimilar to an airport. To actually enter the compound you have to push through a rotating door made out of metal bars, which only turns when one of the guards holds a card to a sensor. Inside, though, the building looks more like the lobby of a large hotel than a bank: a huge high hall with seating areas and vines cascading down the walls. We found the right place for check cashing, and after long looks at my passport, and me writing pretty much my whole CV on the back of the check, we received our money.
Getting out also involved going through a revolving door, but this time they had hung the required card on a convenient hook, so that you could let yourself out…
Now flush with money, we decided to go spend it at the Serena hotel, the one true luxury hotel in town, and get a drink there. After the drink, sitting in plush chairs in the air-conditioned Sokoni Café in the hotel, we decided we might as well get lunch as well, and (taking into account Rwandan food prep time) the brief break turned into almost two hours. So we did get our rest after all.
The afternoon has been spent going through the presentation for the case teleconference with UVA tomorrow afternoon and answering emails. In a little while, it’s time to go check out one of Nyamirambo’s little restaurants.
PS 1: Just back from dinner at the Kaskito Pub, a tiny, dark place down the street here that makes the best spiced baked potatoes. Paul had his first chipsi mayai (omelet with fries baked in), an east African favorite.
PS 2: The toilet still flushes! Christophe was right in removing the water tank.
PS 3: Rain pouring down outside, and a lot of power failures…
PS 4: (by Paul) Thanks, from both of us, to all our loyal viewers. At some point we decided that it would be awesome if we managed to get 1000 views before the end of the trip and guess what?!?!? it happened today…thanks to all of you readers out there. What’s more is that you came from 12 different countries!
After our wonderful dinner at the Runnels last night, I was invited to go with Sean to the Military Hospital today to see a few of their difficult airway cases. They have a very accomplished maxillofacial surgeon who works with a lot of patients with very advanced facial and oral tumors. From previous global health work, Sean has some very extensive experience with difficult airways and knows how to deal with cases like this. Therefore he has been working closely with Christian, one of the Rwanda anesthesiologists, in developing a good difficult airway algorithm and approach that will fit the system here well.
So my day started off heading to the hospital, CHUK, to meet up with Sean for 7am morning report. They, as usual, discussed an interesting and difficult case from the night before. Sean then discussed an interesting initiative that they are starting to improve interdisciplinary communication for the general surgery patients. This will in fact be similar to a project that was started with the OB/GYN patients and has seemed to have improved the communication around those patients. It was interesting to watch how he stressed the goals and the objectives and pointed out specific items that were left out in order to try and keep this initiative as focused as possible. It was a good lesson is clear communication and since this project is all about communication it seems prudent to start it off that way.
So after that, we took a drive out to the military hospital. This was particularly enjoyable for me, since we were in Sean’s late 80s Toyota LandCruiser that has a 4 cylinder diesel engine, that generates all of about 85-90 horsepower but has absolute ton of torque (comparatively). It is a thoroughly enjoyable car and would be fun to go romping through a Rwandan game park or mountain trail with. He has had his fair share of issues with it, including the power steering failing recently, which in retrospect he is happy about because the car has just that much more horsepower now.
We made it to the Military Hospital without incident and got ready to start the day. Due to availability of people, we ended up having quite a bit of time to ourselves until everyone was ready to go. This worked out incredibly well for me because we got to discuss difficult airways and how best to approach them depending on the tools you have available. Sean showed me a rather extensive file of cases that he was accumulated over the years of different difficult airways that comprised tons of very advanced pathology that we never see in the US. He also gave me his difficult airway lecture and we even had time to go over some of the tools that he has with him.
By and large what seems to work well for him is a combination of a videolaryngoscope (for visualization of the glottis) and a fiberoptic scope (to be used as an introducer of sorts). This is a great technique, one that I have used with and is championed by our very own Dr. Randy Blank, home at UVA. The 22 y/o male that we were going to take care of today had what turned out to be some sort of fibro-chrondro-calcified tumor that was where his left maxillary bone (check bone) should have been. It was large enough to distort his face pretty significantly and it was pushing up in to his left orbit (eye-socket). Thankfully it was still a fair distance away from his brain and it was not invading or significantly distorting his palate or his pharynx. There was the possibility that we could have secured his airway by simply taking a direct look like we do for any standard case. But given the possibility that the tumor could still have gotten in the way and that we were worried about being able to effectively mask ventilate him, we decided to use the technique that I described above. In addition to that, because of the potential for the difficult mask ventilation, we decided to slowly titrate in some propofol and halothane to get the patient off to sleep but keep him breathing on his own. That way if we were not able to effectively mask the patient, we could have woken him up and found another way to secure his airway. The most important thing about this is that this whole plan was discussed ahead of time, everyone in the room knew the plan before we started, and everyone had tasks to perform – this is all things that Sean has been trying to hammer home over the last several months to improve communication and prevent hesitation and poor outcomes when these situations get hard/scary.
Thankfully, we did not have a lot of trouble getting the patient off to sleep. He was difficult to mask ventilate, which was first attempted by one of the anesthesia technicians. She was fairly petite however and was having trouble making an adequate seal. After a little while, I was given the opportunity to try and with my significantly larger hands I was able to make an adequate seal at which point we paralyzed the patient and then intubated him using the videolaryngoscope /fiberoptic scope technique. It was an interesting case to watch and had lots of good teaching points which led to many good discussions. It took quite a while to complete which meant the palate tumor case that was to follow needed to be rescheduled for another day. Oh well, that would have been very interesting to see as well.
After work, Sean needed to make a pit stop at one of the cellphone places to get his wife’s internet modem reloaded with the monthly internet access plan and he decided to pick one up for himself as well. This led to a very interesting discussion about how travelers or ex-pats often try and find the way to get the fastest internet possible here. There is the misconception at first that it is likely or even possible to get internet access speeds that approach those that we have in the US. It can apparently become an utterly all-consuming mission for a few hapless souls, which almost universally leads to complete disappointment. There are all sorts of rumors about finding exactly the right person to talk to, who knows how to get hold of a device that allows you to connect multiple USB modems together thus quadrupling the speed, etc. Needless to say this does not exist and short of buying/installing a satellite dish (which I don’t even know if it is truly an option), you will not have similar speeds to those that we see at home. However, how much does this really limit you…overall not that much. Streaming video is difficult, netflix or similar services is all but impossible…youtube works sometimes and somewhat slowly, but on a good day is pretty reasonable. The question is, do you really need this? For a short-term trip like the one we are on, absolutely not. But for those people who are here for 6 months or a year, I can see wanting that connection to home for at least some of the time. I am glad for now that my first experience here is short term like this so that I can avoid this issue, because I could totally see falling into this trap and wasting an inordinate amount of time trying to eke out every last MB/s that I could from whatever connection capabilities that I had.
(and me ? I spent most of the day waiting for arrangements to be complete for a meeting with the Human Resources for Health management at the Ministry of Health. Unfortunately, the Honorable Minister of Health had called an urgent meeting for the HRH group, so my planned 9:30 meeting eventually became 4pm. It gave me plenty of time to get some reviews written and deal with other accumulated stuff in my Inbox. But it all worked out in the end. The ministry sent a car and driver to pick me up at the hospital, we had a thorough meeting of the minds with senior HRH management, and afterwards they even dropped me off at the Nyamirambo apartment.)
This morning, after our usual breakfast of Rwandan yogurt with muesli and a cup of coffee to wash down the malarone pill, we took a walk down to the Kigali Health Institute or KHI. To be precise, it used to be called KHI. Under a complete revision of the university structure, however, it’s now the Divisions of Allied Health Sciences, Nursing Sciences and Community Health Development of the College of Medicine and Health Sciences. This is quite a mouthful, so it’s generally now referred to as “former KHI”. It is a large building, full of people and classrooms, where nurses, physical therapists, anesthesia technicians, dental technicians, eye technicians, orthopedic technicians and others are trained. These are in fact the people who keep the health system in Rwanda running: outside Kigali and Butare you find very few doctors (no anesthesiologists at all, for example), and the 40 or so district hospitals function largely because of the people trained at “former KHI”. Their training is limited; the anesthesia technicians, for example, enter a 3-year program right out of high school. They often are not able to buy a textbook and have very limited internet access. Almost all they learn comes from paying good attention during lectures.
We went to “former KHI” to meet with Etienne Nsereko, who is the head of the anesthesia training program. In one of the conference rooms in the library (with windows wide open – the warm weather here is so nice!) we discussed for over an hour the technician training program and how we can possibly assist with it. We were happy to hear that he is planning to only take nurses (with 3 years of training) into the anesthesia training program. That will undoubtedly raise the quality significantly. And then we spent a lot of time fleshing out how various groups teaching here can help him. Like so often, there are multiple groups working here, in a somewhat uncoordinated fashion: the CASIEF/ASA program that Paul and I are on, the Human Resources for Health program, a nurse anesthetist from the US who has been working on refresher courses for the technicians, Health Volunteers Overseas… Getting all those people to talk with each other and coordinate their activities is not easy. What Etienne wants most is some help for the people out in the district hospitals, who rarely get a chance to refresh or upgrade their knowledge. So we’ll try to move to a system where visiting anesthesia people can help with refresher courses, similar to what Christina Hayhurst and I did last year in Malawi.
After this discussion, we wandered downtown to Camellia, a nice little restaurant where we had a croque monsieur for lunch, and then made our way back to the apartment. We took a few little detours along the way. First to the Camp Kigali site where, at the very beginning of the genocide, 10 Belgian soldiers were murdered. I had not been there before. There’s reconstruction going on in the area, and we had to climb through some work areas to get there, but it was worth it. It’s a simple and stark memorial to 10 young men who had no idea what they were getting into when they got that job assignment. Most of them were married; about half had children, and one had his first child due the same month he was killed.
Then to the Nyamirambo market, where Paul hadn’t been yet. It’s only a few blocks from the apartment, but a completely different world: dark, cramped, packed full of rickety stands with women selling their (really good) fruits, lots of second-hand clothing, and some stalls on the periphery (the somewhat nicer ones) selling western goods like phone chargers and school backpacks. As a sign of how different Nyamirambo is from the rest of Kigali: people in the market tend to greet you in Swahili instead of Kinyarwanda! This is because it’s the Muslim area, and so culturally more connected with the African east coast. We negotiated a good price for a fresh pineapple, which Paul subsequently expertly carved. Delicious.
We had a few hours in the apartment to get some work done. When we are at home, we are about every half hour interrupted by very soft knocking on the door: that is Christophe, who is paid by CASIEF to take care of the house, and wants to show us that he is doing his job. He’s the nicest person, and keeps the apartment spotlessly clean, but there always seems to be something for him to do when we’re home. He needs to check the garbage, he needs to replace a towel, he has found one of our shirts that – carelessly – we had left on our bed, and which he has therefore taken and washed, and which now needs to be ironed… Today he appeared with someone who came to repair our toilet. One of the two toilets totally has a mind of its own when it comes to responding to the flush lever. Sometimes it works, sometimes it works a few times in a row, and then it will fail for a long time. We have therefore, for the past month, been provided with an enormous water container to do the flushing manually.
But today Christophe introduced a person as “the technician”, and together they spent about half an hour in the bathroom, left for a while, came back, and eventually announced that it was fixed. In a sign of remarkable optimism, Christophe immediately emptied the big water container and put it away. So far the toilet has flushed twice in a row – maybe his optimism is warranted.
Talking about the apartment, it was fun to see the hotplate that Kristi and I contributed two years ago still there, albeit dusty and little used.
And, funny enough, it looks as if we’d started a trend:
The evening had a nice treat: Sean and his wife Diane invited us over to dinner at their enormous house on the other side of town. Hamburgers on the grill – we were sooo ready for that!
The connection to WordPress is a-g-o-n-i-z-i-n-g-l-y slow tonight, so this will be a brief post.
Hard to believe, but it’s our last week in Rwanda already! Five more days and we’ll be back in Charlottesville…
We did the last of our academic days today. Morning report with the technicians and medical students was good, as always. Around 8 it started raining hard, with the result that at 9 only two residents had appeared: most don’t have cars, and were apparently waiting out the rain. So I didn’t start my lecture on head injury until 10.
The case presentation by the resident that followed was, I thought, really good. Nothing went wrong in the case, but it exemplified an issue that we also deal with on a regular basis: taking slow steps that individually don’t look bad, until you suddenly realize you’ve put yourself in a dangerous situation. This case was an abscess drainage on the ankle, done with regional nerve blockade in the prone position. The block didn’t work very well, the resident added some sedation, then some ketamine, then some opiate, and then some halothane, and then realized he was actually giving a general anesthetic in a patient with an unprotected airway in the prone position…
During lunch in the cafeteria, Damascene, the faculty member we are working with for the simulation sessions, was called urgently to go see a patient in the obstetric recovery room. We followed and found a patient who indeed had very low oxygen saturations. The obstetrician felt she needed intubation. Damascene, by suctioning her and making her cough some, managed to bring the oxygen saturation back to normal levels, and saved the patient an ICU admission.
Damascene and Paul’s simulation session today was about a meningioma resection, and I got to play the patient this time!
In the evening, Emmy picked us up for dinner at his house with Mary, his girlfriend. We also finally got to meet their little son, David.
Mary had cooked an excellent and very African meal: ugali (cassava porridge), tilapia in sauce, and mixed vegetables. It was also a good introduction for Paul to eating in Africa: from Mary coming around with a pitcher with hot water to clean our hands before the meal, to eating with our fingers.
All together it was a wonderful evening. We’re very happy to have friends like these in this country.
So I spent the night last night (and thus awoke) in the Paradise Malahide Hotel located near downtown Gisenyi on the shores of Lake Kivu. I was in this great little bungalow where I fell asleep listening to the “waves” crash on the beach and woke up to the sounds of birds. I had an excellent breakfast on their back patio (a patio not of cement but of volcanic rock) overlooking Lake Kivu. I walked around a bit taking more pictures and then settled down onto one of their beach lounge chairs to read and just enjoy the scenery.
After a very relaxing morning, Emmy picked me up and we started our way back to Kigali. But first we drove through the brewery that is in Gisenyi (where Primus, Mutzig, a few import beers, coke, and fanta are made/bottled) and over to a hot spring that is nearby. We also drove up to La Serena Lake Kivu, which is the sister hotel to La Serena in Kigali (the nicest hotel in the country, as far as I know). They let us inside to take a walk around and take a few pictures. While we were there a huge storm rolled through, which caught us outside for just a second, but then we were able to watch it peacefully under protection. Just before it let up, we headed out again and by the DRC/Rwanda border, which to my surprise was very open and not heavily militarized. Apparently, here near Goma, there is fairly open and often travel back and forth between the two countries (but go about 300 km into the DRC and it is a very different story).
After those quick detours we worked our way back towards Kigali. We made a few stops along the way to take pictures and once to pick up some supplies. We, of course, stopped at the “obligatory stop” to get some goat brochette and fire roasted potatoes again. 🙂
This country is very beautiful, even in the rain…
On the drive back, Emmy remembered that there was a huge football (soccer) game tonight between the number 1 and number 2 teams in the country. Not 5 minutes after turning the game on via the radio, the number 2 team (the peoples team – the number 1 team is from Rwanda’s army) scored a goal and pulled ahead 2 to 1. To which Emmy exclaimed “Oh no, Nyamirambo is going to exploded…I don’t think you are going to get much sleep tonight”. Sure enough, when we got back to the apartment there were people lining the streets outside any establishment that had a TV (and thus had the game on). Not long after I was settled in, we started hearing yelling and cheering, clearly indicating that the people’s team had won. We walked out to the main street to see crowds of people running down the street wearing blue and white, waving flags of blue and white, and some making an incredible racket with these blue plastic horns. Mototaxis, buses, and cars were streaming by, honking their horns and carrying ecstatic fans. Every once in a while you would see and fan sporting the colors of the former number one team, black and white. Impressively while they were clearly sad, they were not mean spirited about it and no one (absolutely no one) was giving them a hard time. It was a very exuberant, but impressively peaceful celebration. Even still, I wouldn’t want to be working in the hospital tonight.
Here’s hoping Emmy’s prediction is wrong and I am able to get at least some sleep tonight…I may have to breakdown and use those earplugs Marcel gave me at the beginning of the trip.
Volunteers for April 2014 with the CASIEF/ASAGHO anesthesia teaching program in Rwanda