All posts by Marcel

Professor at the University of Virginia.

Returning to Rwanda

by Marcel

Hello all!

I will be returning to Africa in two weeks for another teaching trip. With Kamilla Esfahani, one of our residents, I will be teaching in the CASIEF/ASAGHO program in Rwanda for a month.

We’ll be blogging the trip here, and we look forward to your comments!

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A day of rest – sort of…

by Marcel

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.

The newspaper we perused in the Serena actually had an article about Nyamirambo. Probably to small to read, but the subtitle says it all.
The newspaper we perused in the Serena actually had an article about Nyamirambo. Probably too small to read, but the subtitle says it all.

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!

1000 Views!!!
1000 Views!!!
12 countries!!!
12 countries!!!

“Former KHI”

by Marcel

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.

A picture of Nyamirambo market taken on our trip in 2012. Not much has changed.
A picture of Nyamirambo market taken on our trip in 2012. Not much has changed.

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.

The toilet and the manual flush system
The toilet and the manual flush system

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.

The Marcel & Kristi Memorial Hot Plate
The Marcel & Kristi Memorial Hot Plate

And, funny enough, it looks as if we’d started a trend:

We've started a trend
We’ve 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 last week…

by Marcel

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.

David
David
Emmy, Mary and David
Emmy, Mary and 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.

 

Butare, again

by Marcel

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.

Paul on the terrace of Hotel Credo in Butare
Paul on the terrace of Hotel Credo in Butare

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.

Needle thoracostomy
Needle thoracostomy

(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.

Chest tube placement
Chest tube placement

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.

Teaching in Kigali

by Marcel

After a busy but fun weekend, we did our second “academic day” today: each Monday, all the residents come from various locations for a whole day of lectures and case discussions.

We started with morning report, where instructive cases that happened during the night are reviewed. The case discussed today was of a small child with a hand burned so badly that it needed to be amputated. Just terrible.

I followed with the second lecture in the neuroanesthesia block, with a great amount off discussion, which was wonderful! Then one of the residents did a case presentation – a case with a bad outcome, which again stimulated lots of discussion.

We then headed over to the hospital cafeteria to eat some lunch while we discussed the session we were going to run that afternoon in the simulation center with Damascene, one of the junior attendings.

In the cafeteria preparing the sim session
In the cafeteria preparing the sim session

The simulation session was fairly chaotic, but overall went well. Sean Runnels played the patient, and we have a neat software system running from a laptop that can create a patient monitor on a second screen with values we can change on the fly. One thing the residents are being taught is use of the Stanford crisis checklists for intraoperative emergencies – a system we just introduced at UVa a month or so ago.

Sean Runnels in trouble
Sean Runnels in trouble
Venous air embolism
Venous air embolism
Using the Stanford crisis checklist to direct the treatment
Using the Stanford crisis checklist to direct the treatment

After Sean had survived his venous air embolism and the group had been debriefed, Paul and I took a walk downtown, where we visited our friends Aparna and Gina at Rickshaw Travels to pick up Paul’s gorilla trekking permit.  The young couple that runs the Rickshaw travel agency has been immensely helpful to us and others over the years; they are strongly recommended in case anyone needs a travel agent in Rwanda!

After picking up the ticket, we met with Sean Runnels to discuss some Human Resources for Health issues over a Fanta, and then were picked up by Jessie Silver, the ICU nurse working in Butare. She was in Kigali because she  is leaving tonight for two weeks vacation back home in Charlottesville, and we wanted to get together before she took off. So we had a nice dinner at Heaven, one of the “white bubble” restaurants here (meaning that it is frequented by expats rather than by locals).

Dinner with Jessie at Heaven
Dinner with Jessie at Heaven

Then a walk back through nightly Nyamirambo – an indescribable experience: people everywhere milling about, ranging from hiphoppers to Muslims in long dresses, talk and laughter everywhere, music booming from all directions, shoes for sale on the sidewalk, taxis-moto, popcorn stands, minibus horns… Wonderful!

And now we’re back at the apartment, cup of tea, preparing stuff for journal club later in the week, and waiting for a skype call from home!

Akagera

by Marcel

After a busy first week the weekend is here! I’m very happy how the first week worked out, particularly about the snap decision to travel to Butare, where we got a lot of good teaching done.

We started this relaxing weekend by… getting up at 4:30 to travel to Akagera National Park, the Rwanda game reserve in the north-east of the country. Emmy was to be our driver, but last night he called: his stepmother had suddenly become quite ill and had to go to the hospital, and he had to accompany her. He managed to arrange another driver to take his place, Selim, who, though no Emmy, did a good job. (Update: Emmy’s stepmother is doing well, and back home.)

Up at 4:30, as said, and by 5 we were on the road. We saw it get light in an amazingly short time – about 20 min. A little after 7 we were at the Akagera entrance, where we then spent close to an hour getting our admission tickets, as there were about 10 tourists and only one lady who hand-wrote all the receipts. Sarah and Seth were there as well – they had decided both to come and take a look at the park.

One side note of interest was that the park was having trouble with an aggressive elephant.

Elephant trouble
Elephant trouble

Eventually, though, we were on the road into the park. But after about 45 minutes, and a  good number of zebras, warthogs, and baboons, Selim suddenly announced in his very soft and heavily accented voice: “I have a plan”. I was intrigued, and asked what he was planning. “No”, he said even less audibly, “I have a plan”, pointing to the right front part of the car. Slowly it dawned on me that he was saying “I have a flat”, and indeed, the right front tire was completely empty. Did he have a spare? “Yes, I have” – but he stayed in his seat. When asked why he didn’t go change the tire, he explained that this was the area where the dangerous elephant roamed (we had seen from numerous torn-down branches and trees, even across the road, that this was elephant territory), and he didn’t really want to leave the car. We understood his concern, but by not fixing the tire we were not going to get away from the elephant either. So, gingerly, he stepped outside, and we followed him, all of us looking around carefully for any animal that might be in “musth”.

Now, I must add that I have had extensive prior training in how to deal with angry elephants while on foot (see “Marcel, are you being eaten by a hippo“), but the situation was still a bit scary. The narrow road was lined on both sides by high brush, impossible to look far into, so the beast could easily be upon you in a moment.

Paul and Selim remove the tire
Paul and Selim remove the tire

Paul’s car expertise came in handy, and the offending wheel was soon removed. During this time, however, a car approached from the other side. They couldn’t pass us, and therefore had to wait. It was an Akagera guide with a couple of visitors from Belarus, very jovial, chain-smoking, and speaking virtually no English. They used the time to eat a snack, and were very enamored of a joke they made up: that the sausages were made from an elephant killed by the guard – they kept repeating this endlessly.

Meanwhile Paul and Selim tried to put the spare on. However, it turned out that due to subtle differences between the two wheels, the wrench used to take off the flat tire could not be used to attach the spare. In other words, we had a spare, but couldn’t put it on the car… Now, if the elephant would show itself, we could not even drive away on a flat tire…

But, luckily and amazingly, the Belarusians had a wrench that DID fit, and so we were immensely happy that these people had shown up at the right moment.

Spare tire being placed while a belarussian watches
Spare tire being placed while a Belarusian watches patiently (“Guide shoot elephant, now sausage! Haha!”)

OK, one lug nut somehow didn’t work, and the tire was pretty soft, but we could escape from the elephant (which actually never showed itself). Selim dropped us at the hotel, where we ate lunch and took a nap, while he took the car to the ranger station where they repaired the tire.

In the afternoon we took another long game drive, and apart from getting lost at the end, all went well. We saw quite a lot of animals: below a few samples.

warthog Zebra giraffe

Early to bed again tonight, for tomorrow we have to be up at 5 to continue this quiet, relaxing weekend…