All posts by Paul De Marco

Our final entry

by Paul

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.

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Difficult Airways and the Military

by Paul

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.

by Marcel

(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.)

Waking up in Paradise then back to Kigali

by Paul

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.

Breakfast view
Breakfast view
My bungalow
My bungalow

The beach

The beach
The view from the lounge chair
The view from the lounge chair

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…

Truly the land of 1000 hills
Truly the land of 1000 hills

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.

Some of the oh so happy fans
Some of the oh so happy fans

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.

Gorillas in the Mist

by Paul

Here I am next to a blazing fire in the beautiful open air lodge of the Paradise Hotel here in western Rwanda on the shores of Lake Kivu.  To add to the ambiance a storm has rolled in, so there is the occasional flash of lightning and roll of thunder.  I am enjoying these surprisingly succulent deep fried tiny little fish, some peanuts, and a bottle of Mützig.   In a little while I will dive into some fresh tilapia and we will see what happens with dessert.  All in all a perfect end to an incredible day.

The day started, as many of our days here have, at around 0530.  Time enough to get up, get dressed, get breakfast (coffee, juice, bread with butter and jam, and a plate of fresh fruits), and meet Emmy to head out to the staging area for the gorilla trekking.  We arrived, along with maybe close to a hundred other people.  Then commenced the driver negotiation to get their charges into the best group possible that will best fit their physical capabilities.  I got paired with the Umubano group, the name meaning “Live Together”.  It was formed after the now dominant silverback, Charles, split from another group.  The family is around 15 members strong, including the newest member who is now 5 months old.  Our guide, whose name is Oliver, has been guiding now for 15 years, he was incredibly friendly and equally knowledgeable.  My group consisted of 7 other people also in their late 20s/early 30s.  We were a pretty eclectic group representing 5 or 6 different countries.  After everyone was settled, we all got back into our cars for a 45 minute or so drive to the point where we would begin our hike.  Emmy introduced me to the famous (or infamous) African Wake Up Road (the first level of off road) and then to the African Massage Road (now whether he meant the drive was a massage or that you will need a massage afterwards, I will never know).

African Massage Road
African Massage Road

We finally arrived at our taking off point where we were each given a walking stick (a very nice and very sturdy intricately carved affair).  So, backpacks strapped on tight, boots tied on tight, pants very stylishly tucked into our socks/boots, walking sticks in hand, rain gear at hand, and water in tow we were off.  Hmmmmm… remember me saying something just now about boots tied on tight… well most of mine were.  Some very good advice before going to a new and long trek is not to wear brand new boots that haven’t been broken in.  Some equally good advice that doesn’t usually need to be stressed is not to wear boots that are practically falling apart either.  All of about 5 minutes into the hike and whoops, there goes the rubber sole of my right boot.  Well I thought about it for all of about 5 seconds, I picked up the old sole and kept on moving.  At this point, all we were doing was walking along a path between fields, we weren’t even into the jungle yet.

A little while later, we make it to a stone wall that apparently surrounds most of the Volcanoes National Park.  This serves two purposes, to keep the animals in (the buffalo are notorious for rampaging through the nearby farm lands) and to keep people out.

The Wall
The Wall

After a quick rest and then a scramble over the wall, we are off.  Very quickly it becomes apparent why they suggest tucking your pants into your socks, the mud in places will swallow you whole up to at least your knee (at least that’s as deep as I got at one point).  We are scrambling up and down hillsides and through thick deep jungle.  It was an amazing hike.  But watch out for the stinging nettle, get to close and you are not going to be happy.  We moved steady in and out of deep jungle.  After a while we left the semi-beaten track to head off in a seemingly completely random direction directly through the thick of the forest.  Our guide was literally forging a new trail, because after all we were tracking gorillas and they are not inclined, nor do they need to, stick to well trodden paths.  Trackers had been out in the woods before us early in the day to find the groups and they were in constant communication with our guide to help direct us where to go.  I have no idea how long we trekked, but all of the sudden it was time to stop, put down our bags and walking sticks, and grab our cameras.  We were very close now to the gorillas.

Gorilla Trekking (i.e. blazing a new trail)
Gorilla Trekking (i.e. blazing a new trail)

The first gorilla I saw was a juvenile, a very cute little guy, sitting near a plant, chomping away. Shortly thereafter I saw my first silverback. He is the second in command, under Charles.  We were so close I felt like I could touch him.  Most amazing of all, he simply did not care that we were there.  He would make eye contact from time to time, but mostly stuck to eating.  Nearby there was one of the females, she too was enjoying lunch.  The next gorilla we saw was the man himself, Charles, the senior silverback.  He was massive.  At times they all seemed to make noise very similar to those we might make when we were enjoying a particularly good meal.  Our guide and the trackers would make noises at times in response to the gorilla noises that sounded very similar in nature.

Now while we were supposed to stay 7 meters away from the gorillas, they knew absolutely nothing about this rule and at times would walk right through our group.  One time, one of the juveniles even brushed up against my leg.  As the gorillas moved to find better food, we simply followed (as best we could – they moved through this area much better than we did). What was great, was that this was a relatively open area (compared to others), which gave us great views of the family and made it relatively easy to walk around.  I use the term walk around loosely because we were machete-ing our way through thick green growth and spent most of the time “walking” on the plants and not actually on solid ground.

About half way through our time with the gorillas we finally found the female who had recently given birth.  And with her of course was the absolutely adorable little 5 month old.  He like any 5 month old was bright eyed and curious, and seemed to delight in trying to climb all over his mother and copy her actions, including trying to eat some of the greenery.

Best of all, at the end of our hour with the gorillas they were done eating and it was time for an afternoon nap.  We followed the group to a spot that Charles had picked out to simply sprawl out.  One by one, the various family members started to settle down around him. The baby, quite a first decided now was a good time to use mom as a jungle gym.  Two of the juveniles decided that rough housing was the appropriate thing to do, and one of the juveniles, who clearly felt slightly left out, climbed over top many of his siblings and literally fell over into a pile with the rest of the family.

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This was an awe-inspiring experience and I truly feel incredibly lucky to have taken part in it.  The gorillas are amazing creatures, so different and yet so like us.

After we were done, we started our trek back to the cars.  We ducked, weaved, bodily pushed, and even crawled our way through the dense jungle until we found the final paths back over the wall and through the fields.  My boots made it almost all the way.  The leather on the bottom of my right boot held out remarkably well, though by the time I was back at the car with Emmy, I was no longer looking at leather but looking at the underside of the insole of the boot.  I was covered in mud almost up to my knees, I was exhausted, and I was extremely happy.

What's left of my right boot
What’s left of my right boot

This will be an experience that I never forget.

Cross-country… well sort of

by Paul

So we began the day down in Butare, which is in the south region of Rwanda.  We were up on the early side so that we could attend morning report in the OR.  Like last time, there were some very good discussions surrounding the various cases that had been done overnight over the past several nights.  There was enough to talk about that morning report lasted for over an hour and a half.  Marcel and I had to duck out a little early so that we could meet the driver who was taking us back to Kigali.  It was thankfully a quick and uneventful drive, which got us back around 1130, giving me about an hour and a half to get unpacked and repacked to meet with Emmy who was going to take me next to the northern region of Rwanda.  This would get me within 20 minutes of the initial staging area for the gorilla trekking to make tomorrow morning as easy as possible.

It was about a 3 hour drive with a couple of stops along the way to get to Ruhengeri, where I am staying at Hotel Muhabura (which, interestingly enough, is the hotel that Dian Fossey often stayed at when she wasn’t with her gorillas, but a little more on that later).

First, the drive.  It was highly entertaining.  Emmy is a great driver and guide, he is very talkative and highly entertaining.  Shortly after getting out of Kigali we turned northeast and the landscape started dramatically changing.  Emmy likes to point out that despite being a relatively small country the four regions of the country are visibly different.  The northwestern portion is truly where Rwanda gets its slogan “land of a 1000 hills”.  They apparently use the term hill very loosely, because some of these hills rise to almost 2000 meters of elevation.  Even more astounding is how many of the hills are heavily terraced and used for agriculture.  When driving at the base of some of them and looking up, it’s absolutely astounding to see people working the hill side.  During our first step climb up the first mountain we got stuck behind this large truck hauling empty beer bottles back to the factory.  Shockingly there were two bicycle riders holding onto the back of the truck for a ride up the hill.  Another bike rider saw this and decided to join them.  He managed to catch up to the truck and held on briefly, but he must have let go of the handlebars completely for a split second and in that time he fell over and off the bike, right in front of us.  Thankfully, Emmy was driving very slowly at this point (about 10 km/hr) and had quick enough reflexes to easily get around the fallen biker.  Thankfully everyone was okay (and the truck driver probably never even knew anything happened).  Kids DON’T try this at home.

Suicidal Bike Riders
Suicidal Bike Riders

The rest of the drive was thankfully much less eventful.  We made several stops to take some pictures and often would find some children nearby who Emmy would give some clothes to before we left.  Emmy always has some clothes or toys or other small items in his car to give to children that he finds during his travels.  We stopped at a rest area of sorts that Emmy refers to as the “Obligatory Stop”.  Here I was able to try my first goat brochette and fire roasted potato, which were delicious.  I also got my first taste of banana beer, which actually was pretty good.  It basically tasted like ripe bananas with a kick, but watch out because it is 14% alcohol and according to Emmy can really sneak up on you.

Enjoying goat brochette and roasted potato
Enjoying goat brochette and roasted potato
Banana Beer
Banana Beer
Land of 1000 hills
Land of 1000 hills

So we finally made it to Hotel Muhabura and wow what a setting.  Three dormant volcanoes in the background, a truly awesome site.  Mom and Dad, don’t worry, this won’t be the Ecuador trip all over again.  (A volcano erupted close to where I was during a trip to Ecuador and knocked out the power for three days so I couldn’t get any messages out…oh and I had been climbing a different dormant volcano shortly before all of this).

Three volcanoes - the summit of the tallest is over 4000 km above sea level
Three volcanoes – the summit of the tallest is over 4000 km above sea level

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Dian Fossey's old room
Dian Fossey’s old room

There is a nice tribute to Dian Fossey next to the entrance to the room.  Apparently it has been kept exactly the same since she last stayed here.

I had a good dinner and it is now time to get ready to get to bed early because I will be up early in order to make it to the staging area a little before 0700hrs where I will find out what group I am paired with and which family of gorillas I will be hiking to see.  I can’t wait, I am really excited and hope I am able to get to sleep soon.

Lost in Translation

by Paul

So I am actually going to start today’s blog with a little story from last night (Wednesday night). It’s about our dinner. We decided for both the ease of it as well as the fact that neither of us had ever had a meal at the hotel we are staying at in Butare, we would “stay in” for dinner. They offered us both an a la carte menu and a set dinner menu which consisted of a three course meal – appetizer, main dish, and dessert (two choices in each group). We both opted for the set meal. For the appetizer, the choice was easy, soup vs salad. We both went with the soup and it was really very good. It had just enough salt in it to balance out the very malty beer I was having. As a side note, the beer was called Virunga Mist (Virunga being part of the volcano chain here in Rwanda), so you could call it Volcanic Mist, both of which are fantastic names for a beer. This is the fourth of the native Rwandan beers I have tried and was overall pretty good. Maybe some other time I will go into a little more about the beers here. For the main course, Marcel had beef stroganoff and I had rabbit. Both were good, and both neither of us immediately recognized as what we ordered. One of the funniest parts was that listed as part of the main meal was “tropical vegetables”. Those tropical vegetables turned out to be peas and carrots. That in turn left dessert. A choice of vanilla ice cream and biscuits or coffee/tea. Marcel and I were both feeling adventurous and were very excited about the prospect of some ice cream (especially since the local ice cream shop that I’ve heard so much about was still without their machine), that we both went for the vanilla ice cream and biscuits. What came out was two biscuits on a plate with some green pepper slices as decoration. We kindly asked our waitress about the ice cream and she said she would look into it. Well about 20 minutes later the explanation we got was that there are two kinds of ice cream, the one made with cream and the one that’s in powdered form. Apparently this biscuit included the ice cream in powdered form that was baked in. This may be true, there was a sweetness to the biscuit that Marcel and I both noticed and could not immediately place, or this may simply have been a case were something was lost in the translation. In the end, it was a decent meal, just a little different than we expected.

"Vanilla Ice cream" and biscuits
“Vanilla Ice cream” and biscuits

On to Thursday. It started out with a very good, but at first glance very strange breakfast. This consisted of coffee, fresh fruit, rolls, and mushroom soup. The mushroom soup was surprisingly very good and all of the tropical fruits were extremely good, including the passion fruit, which I had apparently never had before. It’s a very delicious yet extremely odd looking fruit. If you have never had it or seen it, google it. I am very glad my father had fully indoctrinated me into eating all sorts of various forms of sushi because this reminded me very much of cracking open some random sea dwelling creature and digging in.

After breakfast we headed into the hospital to go to ICU rounds. Unfortunately when we got there they were working on very unstable postpartum hemorrhage patient that had come in from one of the outlying hospitals. Ultimately there was very little that could be done. It was an incredibly sad and yet incredibly realistic look at what we can do with what we have and what we can’t. Thankfully, from there on in the day was much smoother. One of the more recent advancements in technology here is the introduction of ultrasound. As we mentioned yesterday we used it to look at/diagnose a pneumothorax and today we used it to perform an ultrasound guided supraclavicular block. They have been performing a fair amount of nerve stimulator blocks, but these procedures are limited by the amount of nerve stimulator catheters that they have. Ultrasound guided blocks are a nice technique to add to their repertoire because they can be done with more standard needles (which are consequently more readily available), especially in the patient population here which tends to be much skinnier. The residents were very excited about the block and it seems to have worked well. There is one of the attendings here who is doing a lot of training in peripheral nerves blocks and who hopefully in time will be proficient enough to do more teaching of these techniques with the residents.

Paul demonstrating supraclavicular block imaging on Marcel
Paul demonstrating supraclavicular block imaging on Marcel
Issac, a senior resident, trying his hand at the imaging
Isaac, a senior resident, trying his hand at the imaging

The two HRH physicians, Sean Runnels and Rob Jarrett, from Kigali came down to Butare for the first time yesterday, which was great because we got to show them around the hospital here and then we took them to Inzozi Nziza for lunch.  After lunch we got to meet with Dr. Théogène Twagirumugabe, who at this point is both the program director and department chair (can you imagine? he is incredibly busy).  It was a very interesting meeting talking about the residents, how the training was going, what’s working, what’s not, and how best to utilize the resources we have.  Following that meeting, we all sat around Dr. Runnels’ phone for a conference call with several HRH personnel from both the US and Rwanda.  It was a very interesting meeting and showed me a lot about what works and doesn’t work in large scale/long term international work.

We took a quick tour through the National museum.  I particularly enjoyed the exhibit about the various medical devices that used to be used and the process they use for making Banana Beer (which I may try at some point, maybe).  After that, we headed over to a restaurant that is run by a local convent for journal club.  What’s really interesting about this restaurant is that they encourage you to order your food ahead of time (even a day before), that way they can serve you more quickly than usual.  We had a good discussion, Josue did a great job presenting the article, and it generated a pretty good discussion overall.  We had a very good dinner consisting of fish brochette and “local” chicken.

To end the night we were hoping to have some ice cream and coffee, but alas, while the machine was back from Kigali it was not quite set up yet.  They say it might be up and running by morning…we will keep our fingers crossed.  Ice cream and coffee would make a great breakfast.

(Friday morning update): No ice cream 😦 Now they say it should be ready this afternoon/evening, unfortunately it will be too late for us, but maybe when I make it back here someday I will get to try it.

Now we are back on the road and I am getting geared up for an almost cross country journey which will culminate in a hike up to see the famous mountain gorillas on Saturday.

Kigali with Emmy and the Genocide Museum

by Paul

Today had a nice lazy start, I got to sleep in until around 0700. I had the chance to then catch up on a few emails and enjoy my morning coffee. Emmy was coming to pick up Marcel and me at 0900 to tour Kigali and hit up a few of the highlights. Marcel and I were running low on our Rwandan francs so we decided to walk to one of the local ATMs (which are often hit or miss if they are working, but we were feeling lucky). Unfortunately about 45 very sweaty minutes later we had tried three different ATMs and no luck. It was almost time to meet with Emmy so we had to head back to our apartment.

Emmy, as usual, arrived promptly at 0900 on the dot. He gave us a very entertaining overview of Kigali over the next several hours. Much like any major city, Kigali is full of different neighborhoods, all with very unique personalities. I learned today that where we are staying, Nyamirambo, is the oldest neighborhood in Kigali, and that is part of why it has so much character. Kigali was named Kigali because of how large it appeared (and is). Kigali means just that, Big. Many of the neighborhoods have very practical names like that, often in reference to either what is or was prevalent there. Again, like most big cities I have visited, there are poor sections and very affluent sections. Kigali is also organized, at times, around large traffic circles. One of the most beautiful and elaborate ones that I saw was for the various ministry buildings (ministry of defense, ministry of tourism, ministry of taxes – which is apparently separate from the ministry of finance, etc).

Our first big stop was at the old President’s house which has now been turned into a national museum. This is the President whose plane was shot down the evening of April 7th, 1994, on approach to Kigali airport, which in turn started the genocide. The house was fascinating to behold. It was looted during the genocide, but some of the original furniture and other items remain. It is an incredibly large house with something like 25 rooms. Furthermore, it demonstrated the level of paranoia this dictator had. There were secret passages and escape routes. The main stairway in the house has sensors in the steps that the president would arm at night when all of this children were asleep in bed. The sensors when tripped would ring an alarm in the president’s bedroom alerting him to someone coming up the stairs. The tone of the alarm would even change depending on how high the intruder got, thus telling the president how far away or near they were. The grounds are beautiful, with many gardens, and are now rented on the weekends for elaborate weddings. There was a pool in the back for the family and guests to use. There is even a separate pool in the back for the president’s python! The python disappeared after the president’s death and no one knows what happened to it. This was no small pool for the python either, it was easily the size of a large above-ground pool. The last and most dramatic stop on the tour of the President’s House was a walled off area just outside (but still attached to) the compound. In this area was what remains of the wreckage of the president’s plane that was shot down. There is very little remaining, partially due to the severity of the crash and partially due to looters stealing some of the pieces. No pieces are left in the gardens of the estate, but at the time of the crash pieces of wreckage and many many bodies were strewn all over the property. While I was walking through the gardens on the guided tour a plane flew overhead on approach Kigali airport, exactly the approach the president’s plane was on when shot down 20 years ago. What is particularly interesting about this is that when the President lived in this house, no planes were allowed to take that approach vector into the airport, except for his own private plane. It is for this reason that when the plane was shot down and crashed, it crash-landed in his own backyard. To give a very disturbing twist to this story, the President’s body was ejected from the plane (with many others) and landed near his swimming pool where his kids where playing. This is a story so unbelievable, that not even Hollywood would dare come up with it.

After a little more driving through various parts of Kigali, including one nick-named “Hollywood” because of its very elaborate and affluent houses, we stopped at a shopping center to try and get some money from an ATM and have lunch. Three ATMs later, I finally was able to successfully withdraw some Rwanda francs, but unfortunately Marcel was not so lucky. Thankfully he had come prepared for this eventuality and he had some US Dollars on him that he was able to exchange. This is actually partially a benefit because you end up getting a better exchange rate, but in general it is really not worth the hassle (except when the ATMs are more of a hassle, which today they were). Our lunch was at this very nice hybrid of a high end coffee shop and sandwich shop. It was on the top floor of this shopping center and had a great views of Kigali. We had a very pleasant lunch and were all quite full and post-prandial by the time we were done. But that drowsiness did not last long because our next stop was the genocide museum.

The Genocide Museum is extremely well done. It is also currently partially under construction as they are preparing for this April 7th/Memorial Week which will be the 20th anniversary of this tragedy. Emmy, a survivor, understandably did not want to go through the museum again, so he elected to stay outside while Marcel and I went through. After completing the tour, I have, in at least some small way, an appreciation for why Emmy elected not to go through again. The first part of the museum tells at least part of the story of what led up to the genocide. There are a lot of good books out there which give other points of view of both the history of Rwanda and what led up to the genocide, which are good to read to try and get a more complete view. I was able to stay somewhat emotionally detached during the first part of our tour, including the parts that were fairly graphic videos/photos/depictions of the atrocities. The middle section got harder, this is where they have pictures of a small portion of the victims, which families have donated to the museum, and they even have some of the bones of victims on display. The part where I completely lost it (which is very similar to the place where I lost it and it hit closest to home when I visited Auschwitz) was a children’s section. Here they had photos of individual children with their names, what they were like, their favorite toys/food, their dreams, the last thing they said before they were killed, and how they died. There are no words that can adequately describe this. I almost had to leave, right then and there after seeing the first two children. I really didn’t think I was going to be able to make it through. But after several minutes, I managed to pull myself together and was able to read about each and every one of them. I felt I owed it to their memory and to their families who helped construct this section of the museum.

The final part of the museum paid tribute to other genocides that have occurred in our world’s more recent history. The overall point of this section (and part of the reason why I forced myself to make it through the children’s section) is that we need to first learn about these atrocities, with the goal being once we have learned about the genocides that have occurred, we will be better armed to prevent future ones. It is astoundingly scary, the similarities between this occurrence and past ones.

The day ended on thankfully a much happier note. I met with probably the most promising of the current anesthesia residents here in Rwanda to discuss cardiopulmonary bypass and more specifically pediatric congenital heart surgery. She has the opportunity next week to be involved with a group that is coming to perform this surgery. She has never seen adult heart surgery, let alone pediatric heart surgery. So to try and help out a little, we spent about 2 hours going over the principles of bypass surgery and did a very very quick overview of some of the congenital heart defects and their repairs. I was thankfully able to get a hold of both our pediatric cardiac “cheat sheets” and Dr. de Souza’s “Introduction to Congenital Heart Disease”, to give her some material to read in preparation and use as a reference during her experience. It was a great experience for me and I hope helpful for her. It definitely gives me a better appreciation for what our attendings go through in trying to teach us and prepare us for our various rotations.

Now it is time to again get packed up and ready to leave bright and early to head back to Butare. Only time will tell what happens next.