Thursday, April 1, 2010
One of the areas of proficiency that is fairly critical to anesthesia in Rwanda is pediatrics. These cases are considerable, as 44% of the population is under 15 years of age (2005 data). Most cases are of fractures, but some common pediatric diagnoses such as pyloric stenosis exist.
Wednesday, March 31, 2010
Those of you in the medical field will know that M and M rounds (morbidity and mortality) are essential as they provide an opportunity to review unfortunate outcomes; to learn from these and to make improvements in future care. To date there have been no M and M rounds in Rwanda.... until today. We are very proud that this morning we had a combined M and M round with Obstetrics and Gynecology and Anesthesia to review the tragic case we had earlier this month of maternal death from severe pre-eclampsia.
Tuesday, March 30, 2010
One of the most enjoyable parts about walking about in Kigali is seeing the wonderful fabrics that the women wear. Our plan is to take fabric back to Canada to make OR hats, and sell them as a fundraiser for CASIEF, the Canadian Anesthesia Society International Education Foundation, who sponsors the residency program in Rwanda. Also, to have skirts made.
Sunday, March 28, 2010
Note - a word of caution: this may be somewhat graphic for some people.
We met Steven outside the genocide memorial. It is a rather non-descript, one-story brick building surrounded by a high white metal fence that used to be a Catholic church. In 1992, 2 years before the genocide, an Italian nun named Tonia Locatelli sheltered many Tutsis against the sporadic violence that had already begun. 680 tutsis were killed in the village of Nyamata, and the rest were driven from their homes, dying of starvation. Many tutsis had started moving to this area to flee violence in the rest of Rwanda. She brought international attention to the situation: “we must save these people. We must protect them. It is the government itself that is doing this”. She was assassinated outside her house, later that year.
In 1993, tutsis were told that it was safe to return to their homes, which they did. But by 1994, when the persecution began again, they came back to this church which once was safe. For 3 days Hutu forces waited outside. They shot tear gas into openings in the roof, weakening the people inside who were already sick and starving. Then they stormed the church, killing 10 000 people in one day, mostly with machetes and blunt objects. The pews still stand, holding the clothing of the people that died there. Some of their possessions, such as rosaries, and a knife and a machete, remain on the altar.
From there you descend into a white tiled morgue, where you see the coffin of a pregnant woman, who was raped, stabbed in the abdomen, and then through the groin up to her brain with a sharp wooden pole. Skulls and other bones are stacked neatly beside. Identification cards, leftover from the Belgian regime, clearly state ethnicity: tutsi.
In the back yard there are 2 large mass graves. Approximately 40 000 people are buried there, from the church massacre as well as others in the area. You descend down narrow concrete steps into the dark tomb. Another narrow corridor leads between the rows of coffins, barely wide enough for my shoulders to pass. I don’t want to brush against them. I feel like vomiting, like shrinking into myself. There are more stacks of skulls, arm and leg bones, that were recovered from a pit that had been dug to dispose of the bodies. The families took them and cleaned them, according to their tradition, and tried to keep the bones of family members together.
Our guide is Steven. He is from Nyamata. His parents and older brother, as well as numerous extended family members, were killed in the genocide. Patty first met him when he was a guide at the memorial, and they have kept in touch since then. He and his family hid in the sugar can fields for days, starving. You drive past these fields, as well as a river that eventually drains into a major river in Ethiopia, and into the Nile. Militias killed thousands and dumped the bodies in this river, saying that they would return to their homeland (tutsis are decscended from the tall, slim Ethiopian tribes). Steven’s friend Charles is also a guide at the memorial – he was one of 7 people who survived the massacre. He was 8 at the time. Patty remembers him from the last time she visited, in 2008.
I just don’t know what to do with what I have seen, what I have experienced. It is revolting. The skulls have obvious fractures, giant holes that have been bludgeoned. Tears seem so useless. Your whole face crinkles into this mask of pain and disgust and misery. It is a very raw experience, unlike the genocide memorial in Kigali. I’m so glad Daniel did not see this one. He was horrified enough by the Kigali version.
Nyungwe National Park is something of a hidden treasure in Rwanda. It somewhat recently became a national park, the largest protected high-altitude rainforest in East Africa. And rainforest it is: at times I can't tell if it's raining, or if I'm experiencing condensation from the trees, or if we're hiking through a giant cloud.
Friday, March 26, 2010
We are spending the night at the ORTPN guesthouse in Nyungwe Forest in southwest Rwanda. The guesthouse is very basic but delightful in its simplicity. There are calla lilies just outside our door and gentle forest sounds with a light rain falling. We are with Emmy, our wonderful driver and guide. We seem to be the only western guests but there are a few Rwandan guides here. After dinner we sat around a campfire and Ariane sang then later Emmy sang some songs in Kinyarwanda and drummed the beat on the table. Delightful to be here.
Every day is a new challenge. Some days it involves a new anesthetic machine, or combination of several: one machine to deliver anesthetic agents, with a non-functioning ventilator, a separate ventilator-only (much older), a console with EKG and pulse oximetry, except there is no cable for the pulse ox and that is a separate machine altogether. Many of the drugs we use here are completely foreign to me: many are no longer available in Canada, or haven't been in common usage since the 1980s. The onset of action is often very slow, or takes forever for recovery of anesthesia.
Thursday, March 25, 2010
On Thursday afternoon we gave a talk to the medical students studying at the National University of Rwanda (NUR) in Butare. The system here consists of 6 years of medical school, directly out of high school. The first few years are basic science oriented, followed by clinical years (internship), and 2 years of general medicine (community service) at a district hospital after graduation. Only after these 2 years can they choose to do a speciality.
Wednesday, March 24, 2010
Tuesday, March 23, 2010
Our teaching comes in many forms here in Rwanda. Each day begins with Morning Report from 7-8am. We start with handover of the previous night's cases on call, then review one or two interesting cases that are planned for the operating room that day. For example, today we had a case of a 5 month old infant girl who has pretty much been vomiting since birth. She weighs only 2.5 kg and is severely malnourished. She has been diagnosed with achalasia, a thickening of the muscle around the esophagus, basically squeezing it almost closed. The surgery will be to cut out some of the thickened muscle (myomectomy). Patty and I lead the discussion, and the residents (3 or 4 of them) and the anesthetic techs (maybe 20 of them) suggest various concerns that can be identified about the case, come up with a problem list, then we review the anesthetic considerations of a pertinent part of the case, such as general considerations for pediatric anesthesia. Finally, we come up with a plan.
Sunday, March 21, 2010
Saturday, March 20, 2010
This weekend we travelled to Ruhengeri to visit the world's entire population of mountain gorillas, that straddles the borders of Rwanda, Uganda, and the Democratic Republic of Congo (DRC). It is quite a well-organized system: 5 groups of 8 people apply for permits, which allows them 1 hour of one-on-one time with the gorillas. The permits are very expensive ($500), divided into the gorilla conservation and research, local community projects, and the cost of guides and trackers. Prior to this system, the gorillas were significantly threatened by poachers. Rather than tossing these poachers in jail, the national park has hired them as trackers (after all, who better to understand the mountain areas and gorilla habitat). Each day the trackers identify the location of various gorilla groups, consisting of a silverback (alpha male), several females, juvenile males, and a couple of babies.
Thursday, March 18, 2010
For 2 weeks of our stay, we spend two days per week in Butare, the second largest city in Rwanda. It is the home of NUR, the National University of Rwanda, along with the medical school and CHUB, the local referral hospital. The pace of life in Butare is much more relaxed: not as many crazy cases in the OR, more staff available to the residents for teaching, and no nightclub across the street blaring music at all hours of the morning. It is also cooler in temperature, and much more rainy.
Tuesday, March 16, 2010
Monday, March 15, 2010
Well, they were only 2 days late. After a re-routing through Heathrow, Nairobi, and Burundi, they are now safe and sound in Kigali, sans luggage. The guitar made it (carry-on), so we have already had several impromptu concerts.
Sunday, March 14, 2010
Today we travelled East towards the border with Tanzania to Akagera National Park. The scenery is just stunning: hilly, with terraced agriculture and lots of well-kept little villages. People here are poor, and their houses may be made of mud brick, but they are managing to survive on subsistence agriculture and keep their houses and yards spotless. The roads were not busy, as there are few large towns east of Kigali, and if it wasn't for crazy truck drivers, it would be a fantastic place to cycle. We did see evidence of this in the remains of a horrific traffic accident that looked like it took place the night before. Trucks may not have headlights, or proper brakes; in this case we saw at least one body under a blanket at the side of the road.
Saturday, March 13, 2010
Today we checked out our local market. Stalls crammed high with piles of cabbages, tiny bananas, pineapples, papaya, potatoes, onions, tree tomatoes - you name it. The air is full of dust, voices, and that distinctive smell of rotting fruit peels that characterizes our walk to work. Everyone seems to be in a good mood, chatting and bartering and laughing. We are fairly sure we mzungus are getting ripped off, but at $0.40 per pineapple, it's hard to argue.
Friday, March 12, 2010
Where do I begin... let's just say that oxygen is essential to life both in and outside of the OR. In almost every case of any duration thus far, we have had oxygen pipeline failures. The oxygen concentrator for the hospital has been "fried", so they are forced to buy oxygen in large cylinders. These inevitably run out, as medical air is not available and all patients are ventilated on 100% O2. Instead of having someone replace the cylinder when empty, they wait until the supply fails, someone gets called, and up to 30 minutes later the flow is restored. There are no backup cylinders on the anesthetic machine, either. Most of the time, we have to bring in an old-school ventilator from the 1950s with its own oxygen concentrator (and no end-tidal CO2), hook it up to the circuit (under the drapes, during a craniotomy) until oxygen returns to the original system.
Wednesday, March 10, 2010
Tuesday, March 9, 2010
We had a stimulating case discussion with the anesthesia residents and about 20 nurse anesthetists this morning. The previous arrangement was to very briefly mention something about each patient for the day. We have a new format of picking one interesting case and discussing it in depth. This was well received and we had a lively discussion this morning. Following this we headed to the OR and gave the anesthetic to the patient – a very sick 85 year old woman with a hemoglobin of 5.8 and gastric cancer. These were her initial vitals on the right. She had profound ST depression (better than you see here) at rest, room air sats of 92%, and weighed probably 35 kg. (Also note the room temperature, on the bottom left: 25.4 degrees in the OR, and it got hotter and more humid as the case went on).
Monday, March 8, 2010
Today is Jour de la femme, a national holiday in Rwanda to celebrate women. What a great idea! There was no elective surgery today so we took the opportunity to tour the operating rooms with Franco, the head of CASIEF. It is incredible how much things have improved in one year. The operating rooms are spacious and have new anesthesia machines and monitors. There are still some older Glostavents, which Franco is demonstrating for Ariane. The OR's are hot, humid and smell musty but we are hoping this will improve when the windows get bug nets and we can have some ventilation. There is no scavenging so people are breathing halothane all day and getting sleepy.
Sunday, March 7, 2010
Franco picked up some macadamia nuts at a plantation run by a friend (of a friend) of his. He has around 150 trees, and each produced 15-20 kg of nuts per year. The downside is that they are VERY difficult to crack. Most plantations use a special machine. Here is Casa Nyamirambo, we use the time-honoured method of BBQ fork and two rocks.
This is where we will begin work tomorrow. It is the main public tertiary care hospital for Rwanda. There is another hospital in Kigali called King Faisal, which is private and has access to much greater resources. The kind of pathology seen in CHUK includes disease entities that are rarely seen in Canada (probably never in Halifax).
Patty and I got up early and started the day with a treat we’d been planning on for more than 36 hours: a run. The temperature was perfect: low 20s and cloudy. We had expected to take a little ribbing from the local population. The last time Patty was here, the accommodation was in a rather posh embassy neighbourhood. She and Genevieve were the only ones ever running, which looked like a crazy waste of energy to the local population. Here in Nyamirambo, a much more populist, mixed neighbourhood (not really that mixed, we are the only white people), we found a bunch of people out running! Tons, in fact. We ran up the unforgiving hill (Rwanda is the land of a thousand hills, after all), and realized that many of the runners, dressed in all sorts of clothing and all condition of footwear, were congregating at the local soccer stadium. They shouted “bravo” or “courage” as we persisted up the hill, red-faced and puffing (Patty much less so than me, obviously). Wonderful! Obviously there is still going to be a contingent of those who shout out Mizungu! (white person or foreigner) or make this hissing sound they do when they’re hitting on you. Still others were dressed to the nines on their way to church, singing. Overall a great way to get to know our neighbourhood.
Saturday, March 6, 2010
Friday, March 5, 2010
After an INCREDIBLE week at the olympics in Vancouver with the family, I had a short week for last-minute Rwanda preparations. 8 months of no vacation, then this turnaround! (Although I'm not in any way deluded into thinking that Rwanda will be a vacation... most people have found that they work more, and need a vacation to recover from it).
This will be a long journey into Kigali - around 28 hours if everything goes according to plan. I'm already regretting not having brought a pillow, but looking at the size of our luggage there would never have been room for it. I generally try to pack light, but 4 weeks on the other side of the world with medical equipment, work clothes, hiking gear, etc. adds up in a hurry.
One thing at a time: next stop will be Auntie Annie's pretzels in Newark airport.