I’m not even going to try to match Paul’s beautiful post from yesterday… Today was an interesting day (they all are, it seems to us), but nothing that can rival the experience of the Kigali Memorial.
It was Back to Butare day! Our driver (provided by the Ministry of Health, quite a luxury!) was to pick us up at 6:30, so once again we had to get up early. Yet, just as I sleepily was cooking some Moki coffee on our stove at 6, my phone rang: the driver was already waiting for us downstairs. So breakfast (yogurt and coffee) was a bit hurried, we threw our final things in our bags, managed to lock the apartment safe (the lock has been a little temperamental lately), and we were off.
The ride to Butare went fast and smooth, and we were delivered at our hotel (kindly paid for by the Faculty of Medicine) with plenty of time to have a coffee (for me) and African tea (ginger tea with lots of milk and sugar, for Paul) on the hotel terrace before heading to the hospital.
It brought back good memories of the hours that Kristi Rose and I spent on that terrace in 2012, talking, writing and drinking Rwandan tea!
A little before 10 we wandered over to the hospital for ICU rounds, and to see how the patients have fared that we left behind last week. Two have died, one improved enough to go to the floor, and two are largely unchanged. One of these two, a child with anoxic brain injury, was to receive a tracheostomy today, and was just about to be rolled to the OR when we arrived. However, on switching over from the ventilator to bag ventilation the oxygen saturation dropped to very low numbers. Endotracheal tube position was checked, and the tube was repositioned a bit because breath sounds seemed a bit louder on the right. Tube suctioning helped a little, but only transiently. Saturation remained in the 60-70% range. We were kind of scratching our heads while we took turns ventilating the child. Then, on palpation, we noted crepitations and subcutaneous air: the child likely had developed a pneumothorax, maybe because of overinflation after switching to bag ventilation.
Paul got to show off his ultrasound skills once again, by localizing the pneumothorax to the left (the Rwandan residents were rather confused with terms such as “comet tails” and “waves on the beach” – but we’ll squeeze in a session on lung ultrasound somewhere tomorrow), and a needle thoracostomy resolved all the symptoms.
(Completely unrelated, but talking about symptoms: when giving report of a case, people here are always very careful to note when the symptoms began. It is quite amusing to hear them report on a patient with a leg fracture: “Symptoms started after the patient was hit by a minibus.”)
Isaac, the senior anesthesia resident, then inserted a chest tube, and the patient subsequently did go to the OR for the planned tracheostomy. Altogether a case with lots of teaching moments.
It is interesting to note how the ICUs here are completely closed and completely run by anesthesiologists. Even management of postoperative surgical patients is taken over 100% by the ICU team. In essence, other specialists only seem to appear in the ICU when consulted on by the anesthesia ICU team – quite different from what we are used to.
After all this we had a late and solid Rwandan lunch at the hospital cafeteria with Egide, one of the chief residents, and around 3:30 made our way back to the Credo hotel, where we are now enjoying our afternoon tea, while it has just started to rain from an ominously black sky.