All posts by Marcel

Professor at the University of Virginia.

Bees and taxis-moto

by Marcel

Sometimes it’s hard to know where to start… This day was another busy one, with lots of things happening. Paul and I were commenting how it’s hard to believe we’ve only been in Rwanda about 5 days. It seems like weeks…

Okay then: rode to work, packed in the little car that picks up Seth and one of his colleagues in the morning. We got to the hospital around 7:30, but the OR doesn’t usually start until 9, so we had plenty of time to go over a new ICU admission of the past night: a very typical story of an elderly patient, transferred from a district hospital in severe septic shock because of bowel perforation (probably typhoid, but the lab results will not be back for at least a week). He was operated on in the middle of the night. The state of his gut was so bad that they just did a “damage control” procedure, i.e. remove the dead piece but not reconnect anything – he’ll have to go back to the operating room in a few days to finish the procedure, if he lives that long. Now we were battling severe hypotension with fluids and high doses of dopamine. Monitoring was almost impossible since neither the blood pressure cuff nor the pulse oximeter would work on his cold, underperfused extremities. Paul and the resident tried a transthoracic echo to assess his left ventricular filling status, but it was difficult to get good views.

Paul doing TTE on a septic patient.
Paul and his Rwandan counterpart doing TTE on a septic patient

These cases happen a lot and usually have bad outcomes: extremely sick patients, operated on under difficult circumstances, and then in the ICU one is severely limited by the lack of monitoring and therapeutic options (essentially: dopamine and epinephrine). We’ll let you know how this patient winds up doing.

Then to the OR, where there was… nothing going on. There were cases posted, but no patients or surgeons. Someone told us that “the surgeons aren’t here”; someone else said there was a problem with sterile supplies. Either way, there was nothing for us to do (which always stresses me out…) so we made use of the time by walking around the campus and checking out some of the wards.  The last time we got an update from the OR, around 11, nothing had happened there yet.

At 10 we did ICU rounds. I enjoy those greatly, although I’m painfully aware all the time that I haven’t worked in an ICU for a very long time. Still, people constantly want suggestions and help on various issues, so one does the best one can. It’s great to have Paul here who has much more recent ICU experience. Since ICU management is much simpler here than in the US, because of limited options, I hope even my limited knowledge may have some use.

Then, around 12, we took off for Inzozi Nziza, the ice cream place, where we met with Vincent, the beekeeper. The story of how we got involved in beekeeping in Rwanda is long, and I’m not going to repeat it here; there’s a pretty comprehensive entry in our 2012 blog. Suffice it to say that Vincent is beekeeping consultant for the University of Rwanda, and in charge of beekeeping training. He was going to show us some of his recent work.

We found him in Inzozi Nziza, where we were soon joined by Sarah, in whose house we’re staying. We had a coffee while Vincent told us an intense story of how he had treated a woman with a bad breast abscess using his honey, and then we were ready to go. I hadn’t seen a car outside, and when I asked him about it he said: “Oh no, we’re going by taxi-moto“. Now, in a previous entry I wrote that minibuses are responsible for many of the traffic accidents here. But the motorbike taxis may be even worse (this despite the fact that they carry a helmet for the passenger). But there has to be a first time for everything, so soon after we were buzzing our way through Butare traffic.

We then walked through the woods to Vincent’s training apiary, where we looked at his new topbar hives, gave him the donated equipment from Valley Bee Supply, and he gave a highly entertaining and animated explanation of how he had got into beekeeping.

Vincent and one of his topbar hives.
Vincent and one of his topbar hives.
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Sarah and Paul learn about beekeeping.
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Discussing equipment

And then, back on the taxi-moto and off to his house, where we were to have lunch. This ride was slightly scarier than the first, since we left the surfaced roads, bumping along for a while on dirt, and my helmet visor was so scratched and dirty that I could barely see where my chauffeur was going, which was a little disconcerting.

As last year, the visit with Vincent’s family was memorable. He lives in a very small and bare house, but his wife (who speaks only Kinyarwanda) is the kindest person and makes the best lunch on the fire in her small kitchen.

Vincent's wife
Vincent’s wife

We sat and chatted for a long time, as a torrential rain burst loose over the Butare area. We exchanged honeys, and his two children (both dressed their best for the occasion) entertained us with poems and songs (in English, French and Kinyarwanda) they had learned in school.

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Vincent’s children. The lady in the back is a random person who had come in to shelter from the rain.

Since the rain didn’t stop, we eventually took a taxi-voiture (a regular taxi) back to our house.

In the evening, though, the rain did stop and we were back on the taxi-moto, since we took Sarah and Seth out to dinner at The Chinese Restaurant to thank them for letting us stay at their house. To paraphrase Churchill: never in the history of my travels have I been received by strangers with so much hospitality, for so long and on such short notice.

Sarah and Paul traveling through Butare on taxi-moto
Sarah and Paul traveling through Butare on taxi-moto
Seth, Sarah and Paul at The Chinese Resturant
Seth, Sarah and Paul at The Chinese Restaurant

Tomorrow we’ll be heading back to Kigali. It wasn’t until late this afternoon that we finally heard how that will be accomplished. Emmy had worked his magic, and had put enough pressure on enough people that the Ministry of Health is sending a car to pick us up (they normally will do this for these visits to Butare, but only if the trip is arranged well in advance). So we can avoid the other option: 3 hours in a packed minibus.



by Marcel

Yesterday afternoon, we found out that – because of sickness and complicated administrative reasons – there are actually no residents in the main hospital in Kigali at this time. This makes it essentially impossible to do any useful teaching in the OR or ICU. Each of the two other hospitals in Kigali has one resident, who is already supervised, and it’s therefore somewhat overkill to go to either of those places. There are, however, several residents at Butare, the other teaching hospital, in the south of the country, and so we decided, on very short notice, to go there for a few days.

The problem was how to get there. Public transportation is possible, but not advised: the minibuses are overloaded, and drive at suicidal speeds. In fact, minibus accidents are one of the most common forms of trauma in Rwanda. We contacted various people, trying to find a ride. At the same time, we worked on a set of neuroanesthesia keywords for the residents. Rwanda is starting to use the US anesthesia keyword system for training – in fact, they are using the lists from Ed Nemergut’s OpenAnesthesia site – but the lists need to be trimmed of anything that’s not applicable.

It wasn’t possible to arrange a driver from the hospital to take us to Butare, but as it happened, Jessie Silver was in Kigali. Jessie is an ICU nurse from UVA, who is doing a year of work in the Butare ICU for the Human Resources for Health program. She was happy to have us drive back with her. So we threw some things in our bag while she made her way to the apartment,  we had a cup of Rwanda coffee, and then we were on the road for a 3-h drive to the south in her small truck: Paul in the passenger seat (since this was his first ride through the Rwanda landscape, he had to have good views) and I sideways on one of the tiny folding backseats. I could have stretched out on the mattress she’d put in the back of the truck (to use it as a camper of sorts) but then I’d have missed the views. And so Jessie drove us through the green and hilly Rwandan landscape, maneuvering between speeding minivans and snail-paced smoke-belching lorries on the way to the DRC.

Cows on the way to Butare
Cows on the way to Butare

What we hadn’t figured out yet was where to stay that evening… (there’s actually something very refreshing about that feeling). But during the drive Jessie contacted a number of HRH people in Butare, and before we arrived, she had found us a place for the night. We ate at the famous Butare Chinese restaurant (named “The Chinese Restaurant”), entertained by the extremely loud sound system from the market across the street, until the power failed and all was suddenly dark and silent. The food was excellent, and it was great catching up with all that Jessie had been doing since the last time we met.

The Chinese Restaurant
The Chinese Restaurant

Then she dropped us off with Sarah and Seth, also on the HRH program. We’ve since both taken hot showers with lot of water pressure, which feels like an amazing treat, even after only three days here. Now the power is back on, we’re sitting in their huge living room, sipping fruit juice, and checking emails, with constant attention from their young dog (when they arrived, they mentioned in passing to the house guard that they’d like to have a dog here during their stay; a few hours later, a puppy in a box was delivered).

Tomorrow we’ll hitch a ride with Seth to the hospital, and see how we can be useful there. And, of course, we’ll have to figure out a way to make it back to Kigali on Friday…


by Marcel

Hello! Just a note to let you know we have arrived safely in Rwanda.

The trip went quite well. We slept a few hours on the transatlantic portion, arrived in Brussels at about 7 am, and got our boarding passes for the second leg without difficulty. We had enough time to get some Belgian croissants and coffee, and then on to Kigali.

Paul in the Brussels lounge.
Paul in the Brussels Airlines lounge.

The flight to Africa was long – about 8 hours. We again slept some, and enjoyed the views of the Mediterranean and the Sahara. By the time we landed in Kigali,8 pm,  it was completely dark.

Sahara desert
Sahara desert
Sunset behind cloud formations while approaching Kigali.
Sunset behind cloud formations while approaching Kigali.

Immigration and customs went reasonably fast, our bags arrived in good shape (we had been a little worried because of the confusion regarding our booking in Washington), and waiting for us was Emmy Runiga, the driver who usually takes care of the people on the CASIEF program, and who has become a good friend. It was great to see him again, and for Paul, who’d heard a lot about Emmy from various people, to meet him.

Emmy drove us to the CASIEF apartment in the Nyamirambo district of Kigali, and there we were welcomed by Melanie Gipp, a pediatric anesthesia fellow from Stanford, who has been teaching here the past month and will return tomorrow to the US.

Quick cup of tea, and then to bed! We both slept quite well.

Today was used to organize our things, to take a walk to the hospital, and to do some preparation for teaching, which starts tomorrow. We’ll start the neuroanesthesia teaching block; since Melanie is still here, she’ll share her expertise by adding a lecture on pediatric neurosurgical emergencies, and Paul is getting ready to teach venous air embolism management in the simulation center.

The living room in the CASIEF apartment. In addition, there are 3 bedrooms a kitchen.
The living room in the CASIEF apartment. In addition, there are 3 bedrooms and a kitchen.
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The road next to the apartment

As you can tell, we’ve also worked out the internet. We not quite there yet, but we bought internet time for one of the two USB modems until midnight tonight – enough to check and send some email, and update the blog!

The apartment is in good shape, apart from one of the toilets that has a mind of its own on whether to flush or not. But everything is well organized and sparkling clean, thanks to Christophe, a student who manages the place on a day-to-day basis and does the cleaning. He also was present last night to welcome us.

Hopefully by tomorrow we’ll have more permanent internet, so that we can let you know how the first day of teaching went.

Beekeeping equipment?

by Marcel

Beekeeping equipment
Clockwise from left: pollen trap, small entrance feeder, gloves, another feeder system, and an issue of Bee Culture. Beneath it all is a propolis trap.

Yes, indeed! As a sideline to the medical work in Rwanda, we have a connection with a beekeeping group there, and we’re bringing them some equipment samples that they can use to help design and build their own. The equipment was graciously donated by Valley Bee Supply in Fishersville, VA, where I picked it up today after work.

The Valley Bee Supply store (with the donated equipment on the counter).
Shane Clatterbaugh, owner of Valley Bee Supply, with a hive component made by one of his amazing machines.

The story of the Rwanda beekeepers is quite interesting, and I’ll write more about it when we will meet up with them in a few weeks. Suffice it to say that my wife Marijke and I are (very) small-scale beekeepers ourselves (see Marijke’s bee-blog), and that it has been great fun to get involved, in a (very) small way, in helping develop bee culture in Rwanda.

For now, it means I’ll have to cram some more stuff into my bag…

Malaria and other threats

by Marcel

Malaria is not particularly common in Rwanda, especially not in Kigali, where we will be spending most of our time. But it’s still recommended to take prophylaxis, and to prepare all clothing by spraying it with the mosquito repellent permethrin. This I usually do outside, but because of an unseasonable snow storm in Charlottesville, it had to be done in the basement this time.

Permethrin-impregnated clothes drying in the basement
Permethrin-impregnated clothes drying in my basement

We’ll carry a small supply of permethrin with us, mostly used to spray around any holes we may find in the mosquito nets that are everywhere over the beds in the country.

In addition, we’ll be taking  malarone for malaria prophylaxis (one pill per day, starting two days prior to departure, and until we’ve been back for a week at the end of the trip). Apart from some vivid dreaming, I’ve had no side effects from the drug at all on previous trips.

Malarone is a mixture of two drugs (atovaquone and proguanil). It used to be very expensive (several dollars per pill), but in some strange quirk reflective of our pharmaceutical system, it has now suddenly become unbelievably cheap – in fact, it’s less expensive to get the brand name Malarone than to the two generic drugs it contains… Go figure.

Other medications we’ll carry are ciprofloxacin, wonder drug for traveler’s diarrhea, and a one-week supply of HIV treatment drugs, in case we suffer a needle stick injury or other blood exposure. HIV is common in Rwanda, with about 3% of the population infected. The main hospitals have HIV treatment readily available, but other locations may not, and it’s always better to carry our own supply, just in case. A one-week supply is enough to get you back to the US for definitive workup and treatment. Luckily, we’ve never needed it yet.

Setting the stage

by Marcel

To give a little background on why the Canadian and US Anesthesiology societies are involved in teaching in Africa, here are some excerpts from an article I recently wrote for Anesthesiology, our professional journal (the whole article is available here).

The United States has approximately 25 physicians per 10,000 population. More than 30 countries make do with less than 1/10 of this number; the vast majority of these are in Africa (see map below). The resulting problems with healthcare access are easily understood, but such a dearth of doctors also makes it essentially impossible to increase the number of physicians. Those in clinical practice are overworked, and the few that might be involved in teaching have to devote most of their time to administration. These countries are in a bind: there are insufficient staff physicians to educate many residents, and because not many residents are trained, there is no increase in the number of staff physicians. A critical mass of teachers is required before this problem can be solved, and therefore this vicious circle can be broken only with substantial outside teaching support.

Physicians working around the world. The relative size of each territory on the map corresponds to the proportion of all physicians in the world who work there. In 2004 there were 7.7 million physicians working around the world. If physicians were distributed according to population, there would be 12.4 physicians to every 10,000 people. The most concentrated 50% of physicians live in territories with less than a fifth of the world population. The worst off fifth are served by only 2% of the world’s physicians. Note the disproportionately low number of physicians in Africa (red). © Copyright Sasi Group (University of Sheffield, Sheffield, United Kingdom) and Mark Newman (University of Michigan, Ann Arbor, Michigan). Reproduced under Creative Commons license.
Physicians working around the world. The relative size of each territory on the map corresponds to the proportion of all physicians in the world who work there. In 2004 there were 7.7 million physicians working around the world. If physicians were distributed according to population, there would be 12.4 physicians to every 10,000 people. The most concentrated 50% of physicians live in territories with less than a fifth of the world population. The worst off fifth are served by only 2% of the world’s physicians. Note the disproportionately low number of physicians in Africa (red). © Copyright Sasi Group (University of Sheffield, Sheffield, United Kingdom) and Mark Newman (University of Michigan, Ann Arbor, Michigan). Reproduced under Creative Commons license.
Rwanda has about a dozen anesthesiologists, all employed at the two university hospitals, a military hospital, and one private clinic; work in approximately 40 other hospitals is done by clinical officers (midlevel providers with about 4 years of formal training). The Canadian Anesthesiologists’ Society and the American Society of Anesthesiologists have provided teaching and logistical support to a Rwandan residency program started in 2006. This program has graduated several specialists, who have then spent additional training time in Canada. Currently, a large-scale interdisciplinary program, Human Resources for Health, is expanding residency education in many specialties by an influx of foreign teaching faculty (more than 100 FTE, of which 5 anesthesiologists).

These are complex situations, but they have simple and direct implications for patient care. Although clinical officers often have a wealth of clinical experience and are technically skilled, their limited training in physiology, pharmacology, and the principles behind anesthesia practice is a severe constraint and contributes to the high perioperative mortality in these countries (5–10%, with mortality related to general anesthesia as high as 1 in 150). That clinical officers themselves are in short supply and overworked only compounds the problem.

 We should support well-designed overseas teaching efforts. Because without our help, it will remain impossible for the few, overworked anesthesiologists in Africa and elsewhere to create the critical mass, to train enough residents, and to break the vicious cycle of insufficient personnel that prevents each patient from having access to an anesthesiologist when needed.

(modified from Durieux ME: But what if there are no teachers…? Anesthesiology 2014; 120: 15-17)