on the way home

This will not be the final blog entry as I know Ariane has more to add and I would like to include a final reflection. Ariane and I have just reached Brussels and said goodbye. She is on her way to Israel to spend a week with her brothers and I am on the way back to Halifax.

It has been an incredible month and far exceeded my expectations. Perhaps the overwhelming theme is how vivid everything is: intensely awful smells in the OR and PACU; spectacular green terraced hills; beaming children toughing our hands on the way to work; complete chaos and imminent disaster most of the time in the OR; the bliss of a warm shower at the Serena hotel; fruit salads with mangos, passion fruit, papayas, bananas and tree tomatoes; horrific toilets; joyous teaching situations such as with the nurse anesthesia students at KHI or academic day with the residents; immensely frustrating teaching situations with some of the weaker residents in the operating theatre; our huge success at bringing OB together with Anesthesia for M and M rounds; developing a lively morning report, which was a teaching situation for the nurse anesthetists; spending time with Emmy, our amazing guide; warm hugs with our dear friends; in short it has been rich and very vivid.

It has been a complete privilege to share this with Ariane who feels this has been the best experience of her residency. She rose to the occasion again and again and kept her humour and equanimity. She learned how to teach on any subject without any warning or preparation. We shed a few tears and many laughs (rabbit eating fish, for example).

As difficult as this experience can be at times ( and it really does have horrible moments), it was absolutely worthwhile. Our partners in Rwanda are so grateful and we see such huge improvements. I am thankful to everyone who made this possible.

Lots of love to all.

Patty

Pediatrics

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.

Children in Rwanda for whatever reason are impeccably behaved when they come to the operating room. They are brought in alone, lie down on the OR table, and may stay there along for a considerable period of time until someone else comes into the room (note - this is for older children, babies are watched much more carefully). Sharp contrast to pediatric ORs in Canada, which are fairly chaotic: both parents and children may become hysterical, making it very difficult to get anything done. Parents who do not discipline their children (and who want to be their kid's best friend) are seen pleading with the child, arguing, or trying to bribe them. Not so in Rwanda.

Today we did a pyloric stenosis repair on a 2 month old child. In retrospect, it would probably have been easier (and safer) to have done this under local anesthetic. We were working with our weakest resident, and it was a struggle to get him to even draw up the correct drug dosages

for a 4 kg baby, not to mention the clinical skills of getting an IV or intubation. Frustrating. I have to resist the urge to do everything for him: so much easier than teaching someone who quite frankly should be considering a specialty other than Anesthesia.

The intubation was not straight-forward, but we were able to bag the patient back up each time. It has been 8 months since I have last done pediatrics, so I was nervous! But everything went well in the end.

a huge success

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.

The attendance was excellent. It was standing room only with 45 to 50 people present. All the CHK anesthesiologists attended as well as excellent representation from Obs/Gyne, family medicine and nursing. We understand there was some initial reluctance from Obs/Gyne as they thought this might be a finger pointing session. In fact, it went far better than anyone expected.

One of the OB residents presented a short summary of pre-eclampsia then Ariane presented the case (the same one we used on the web conference). She deserves a lot of credit for presenting in a clear and diplomatic way. The discussion was excellent. Although we didn't agree on all points, it was harmonious and everyone acknowledged the need to try to improve the management of pre-eclampsia and other obstetrical emergencies. Many people expressed the wish to continue to have M and M rounds.

In 2009, CHK managed 2,589 deliveries, almost all of which are high risk as low risk deliveries are managed elsewhere. Of these 6% had full eclampsia.

Both Ariane and I feel a huge sense of accomplishment that these rounds happened at all and were so successful.

Shopping for African fabric

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.

The colours are incredible, and of course Rwandan women are tall and willowy, which makes pretty

much anything you put on them look stunning.

Not overly applicable to the rest of us, though: Emmy and I tried on the fabrics... well, I suppose you can judge for yourselves...

Genocide Memorial at Nyamata

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.

The Waterfall in Nyungwe National Park

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.

Inside the park, you have the option of staying at a lovely little lodge that is run by ORTPN, the Rwandan national park office. It is very basic, but clean and well-kept, with a lovely garden and some of the best food we've had in Rwanda (not to mention the fastest service). There are several hikes with maintained trails, as well as the option to visit chimpanzee colonies and colobus monkeys.

Similar to the gorillas in Ruhengeri, there are certain groups that are habituated, and can be visited by tourists, and others that are wild, studied by researchers.

Nyungwe is surrounded by tea plantations. They blanket the countryside with a vivid green

colour. Tea is picked by hand, only the top leaves that are the lightest green colour. From over the tea plantations you can see Lake Kivu from here, on the border between Rwanda and the Democratic Republic of Congo. Lake Kivu is huge: total surface area of 2700 square kilometers, and the 15th deepest lake in the world. Tilapia are fished here - a light fish that is the staple of pretty much any restaurant in Rwanda. I've actually never seen another kind of fish served.

We chose to hike to the waterfall, accompanied by Emmy, our tour guide and driver extraordinaire, and Vedaste, our ORTPN guide. They pointed out many species of plants, medicinal trees, as well as the calls of hundreds of species of birds. The hike itself is somewhat challenging: the rocks are slippery as they are perpetually wet, and the descent to the waterfall is steep, but the trail is very well maintained. The waterfall was stunning: LOUD, and powerful. The spray was so strong that it jetted out sideways, was ejected up into the air, and fell again in a sort of vortex. Incredible.

After a lovely day, we were unfortunately greeted by an apartment with no water and no power, again. Particularly frustrating after a muddy hike and a 5 hour drive back. Rwanda is such a dichotomy: stunning natural wonders; an industrious, warm, and friendly populace; and daily aggravations that we take for granted elsewhere.

Everything is a balance, I guess.

Nyungwe Forest

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.

Another day in the OR

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.

We also have daily challenges with the residents. Today's challenge was to get them to pay attention to the monitors, in particular the alarms. Alarms exist for a reason: if they are ringing off, usually in an annoying, high-pitched way so that you pay attention to them, at least have a look as to why. I cannot comprehend how it is possible to ignore a sound that irritating. Plus, it is a clue that you need to respond to what is going on in the case: another important learning point. When the heart rate goes up precipitously, or the saturation goes down, you can hear the change in speed or pitch, and act accordingly. The resident I was working with today did not appear to be responding to anything, at least with any degree of haste (or in a timely manner). I had to point to the monitors to direct their attention to abnormalities. The supply-demand ST depression the patient was developing from an increasingly rapid heart rate was interpreted by the resident as "peaked t-waves". There is work to be done.

Spinal anesthetics appear to be much safer. Both residents and anesthesia technicians are quite proficient at them, patients are extremely stoic and tolerate being awake for even repairs of femur fractures, and they provide consistent and predictable operating conditions. These are not fool-proof, however, as the resident Patty was supervising had a patient with a systolic blood pressure in the 50s, and it was a struggle to get him to correct it immediately with some ephedrine. In a 72 year old, who was actively bleeding.

We keep reminding ourselves that we have seen major improvements since Patty was last here 18 months ago.

Medical Students

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.

Both anesthesia and surgery have difficulty attracting candidates to residency, because the salary is not as good. Many students go into public health or general medicine where they can benefit from the huge amount of international aid funding that goes into HIV/AIDS or malaria. The medical students expressed concern that even in these areas, a lot of the funding goes into epidemiology and "administration", rather than any clinical medicine.

Part of the purpose of our talk on Thursday was to give the medical students an idea of the field of anesthesiology, the scope of practice, the physiology being played out in front of you in the OR, the team environment, hands-on procedural skills, and involvement in resuscitation (codes, traumas, etc). We brought a CPR mannikin from the skills lab, and taught them how to bag-mask ventilate and do chest compressions, which they were all very keen on. I described a bit about how your average day might go in CHUK hospital as an anesthesia resident, and talked them through our case of the 2.7kg, 5 month old baby with achalasia, along with the anesthetic considerations. There were lots of interested questions as we gathered around the mannikin to practice some of the skills.

This was so inspiring for us to have such an enthusiastic crowd, and we hope that this will translate into some stellar candidates for the anesthesia program here.

happiness is...

When the oxygen supply comes on again just as the child's saturation is hitting 78% and he can be bagged up to 98%.

The joy in children's faces as they run with the muzungus.

Listening to music on the drive to Butare – past terraced hills, banana trees in the sun, women with colourful dresses and baskets on their heads, farmhouses, rice fields and children everywhere.

Watching the residents have "eureka" moments.

Swimming and a hot shower at the Serena Hotel.

Teaching super keen students.

Sharing all this with Ariane, Brian and Daniel

live from Rwanda

Today we had a web conference between Halifax and Kigali through Wimba classroom. It was quite exciting to bring together the anesthesia residents in both cities to discuss a very difficult case we had. It was wonderful to hear from Paulin and Bona, who are two Rwandan residents doing a 6 month elective in Halifax. The residents in Kigali hope we can do more web conferences as they would love to share in our educational sessions. It was very successful.

Brian's luggage has finally been found. It has been an enormous headache and multiple phone calls. It seems the luggage was hiding in Burundi.

Our power is out because KHI has not paid the bill, darn. Candlelight, headlamps and mosquito coils.

Tomorrow we are off to Butare again and Ariane and I hope to do the waterfall hike in Nyungwe Forest. Next Monday will be dinner in Heaven (popular Kigali restaurant) with the residents as our time here is winding down.

Teaching

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.

The difficult cases are often booked first, so after this discussion everyone disperses to their various operating rooms. These cases generally go much more smoothly than I expect, because each aspect of the anesthetic is carefully planned, and all members of the team are

on the same page as to what we're doing. Morning report is an important part of our teaching here because it involves both the anesthesia technicians as well as the residents and local staff anesthesiologists. It also keeps us on our toes, because the topic of the day could be anything under the sun, and we not only have to identify the important teaching points, but also come up with a discussion of the anesthetic considerations without any preparation!

One day a week is devoted to an academic day with the residents. Both Patty and I give an lecture on a pre-arranged topic (we are doing endocrine diseases this month), a resident gives a presentation, and we finish with a case discussion. We try to make these as interactive as possible, with lots of questions, and lots of diagrams of various physiological mechanisms.

On Tuesday afternoons we give talks to the anesthetic technician students. This is a 3-year program out of high school that trains technicians to provide anesthesia care for 80-90% of surgeries in Rwanda. There is an extreme shortage of anesthesiologists - only 11 for 9 million people. The training that the technicians receive is largely based on practical skills, with very little discussion of the physiology and pharmacology that guides our practice. They have a few guest lectures per year from the anesthesiologists at CHUK, the main public tertiary care hospital in Rwanda, but the anesthesiologists are so overworked that they rarely have time.

We are doing a 3-session talk to pain management - they anatomy and physiology of pain mechanisms, diagnosis, treatment, etc. We are trying to identify barriers to good

treatment in Rwanda, where they don't even have oral morphine. Cancer patients have no access to chemo or radiotherapy, and are left to die slowly at home with no pain medication beyond ibuprofen and tylenol. The concept of palliative care here needs a great deal of improvement.

We very much enjoy teaching the anesthesia tech students: they are keen, attentive, and ask interested questions. Also, they are very grateful for any extra teaching provided.

But all is not sunshine and roses here in Rwanda. The residents in all specialties, not just anesthesia, have not been paid in 2 months. Something with the government, although I'm not sure what. Most of them have families, with up to 4 children - I'm don't know how they are able to manage.

Morning run

Ariane has written about our visit to the Kigali Genocide Memorial so I will not add anything.

We have been doing some runs in our neighbourhood. If you go out to Nyamirambo Road there is a huge hill and half way up the hill becomes very steep. The descent is though a quieter neighbourhood with views of Kigali and the surrounding mountains. We usually do one loop but today did two. Sunday morning at 7:00 AM is a very popular time for running and we passing many groups of runners who were singing, chanting and offering lots of calls of "courage" or "esprit". I've never seen so many runners outside of a race. Rwandan people have a very healthy lifestyle.

Next week's challenge will be three loops....

Genocide Memorial

This afternoon we visited the Genocide Memorial in Kigali. There are several genocide memorial sites in Rwanda: Nyamata is the location of a church where 5000 people were slaughtered, and Gikongoro, where over 1800 bodies from the 27 000 that were exhumed from the mass graves have been placed on display in the old technical school. The memorial in Kigali was set up in 2001, mostly as a site of burial for some 250 000 bodies that had been recovered from the 1994 genocide. One of the mass graves is pictured on the left. As perpetrators come forward and identify locations of those they have killed, and as remains continue to be discovered, these are added to the mass graves, and their identities recorded on the Wall of Names (below).

The Kigali Memorial is a much more sterilized experience than the Nyamata and Gikorongo sites mentioned above, which have been preserved in the state they were left following the massacres. Some have blood still on the walls, clothes of the victims, or parts of bodies preserved in lime. I haven't seen either of these. Apparently it is a grim and shocking experience.

The memorial did an excellent job, however, of exhibiting the pre-existing remnants of colonialism and racial tension that set the stage for the genocide, as well as involvement of UN, Belgian, and French troops. Lt Romeo Dallaire knew that the Hutu majority wer

e stockpiling weapons, but the UN security council refused to take action. Belgian UNAMIR (United Nations Assistance Mission for Rwanda) withdrew from the Gikorongo technical school where they had been providing protection for thousands of Tutsis - they were all subsequently massacred. All in all, approximately 1 million people were killed, about 1/9 of the population, with many more victims of war rape, injuries, and amputations. Almost everyone in this country has known or is related to either a perpetrator or victim of genocide. One of our residents is the sole survivor from his entire family.

In many towns and villages you see painted on signs or on houses a reference to the genocide (the rest is in Kinyarwanda), with the English words: Never Again.

Mountain Gorillas

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.

The hike to see the gorillas was 2 hours of trekking through thick jungle, cutting our path with a machete. There are no roads, and the existing paths are narrow pathways of sinking mud. But it was all worth it to spend time with these gorilla families. Gorillas are hilarious. The young males lie around lazily, scratching themselves, until they decide to thump the next guy on the chest, and wrestle rather violently for a few minutes. Then they return to lolling around on their backs.

At one point, a gorilla reached out and grabbed Patty's blue windbreaker that she

had tied around her waist. (We think it might have been going after her wallet). You're not supposed to react or behave aggressively towards them, so fortunately the guide pulled her away immediately. Still a scary moment!

As usual, we soaked up the beautiful Rwandan countryside along the way. Children in the Ruhengeri area are a bit more used to mzungus (tourists), and are a bit more aggressive about asking for money (or pens, or water bottles), which Patty felt was worse than when she visited 18 months ago. However, there were also lots of friendly local people going about their business, carrying impossibly heavy loads on their heads (50kg sack of potatoes, giant yellow jerry-can full of water).

An exhausting and wonderful day.

off to the gorillas

We are leaving later this afternoon for Ruhengeri to see the gorillas tomorrow. Stay tuned for a blog update on Sunday..

Butare

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.

The drive to Butare takes around 2.5 hours, and is stunning. Terraced fields of pineapple, corn, sugar cane, rice paddies, avocado - you name it. The people are also less used to having mzungus around. Children with broken arms coming for orthopedic surgery are either

hysterically frightened, or the opposite reaction, one saying "I know I will be okay because a mzungu is here". For better or for worse, we are quite the spectacle, 4 mzungus all in one place.

In Butare, we stay at the Credo Hotel: still no functioning toilets, but it had a pool (yay!). We had a chance to meet with Dr Theo (the anesthesia program director) and Dr Patrick (acting dean of medicine) to discuss future directions for the program. They are doing an amazing job with few resources and the existence and quality of the residency training program is a credit to their hard work.

Off to Butare

Brian and Daniel are getting settled in but still without luggage. Daniel is finding it hard to have people staring at him, laughing, running and calling "muzungu". Still, he loves seeing the smiling faces of the children.

We had another tough day in the OR yesterday. The Datex monitor showed the room temperature hit 30.9 and there is no ventilation. However – very exciting – they now have scavenging hoses connected to all the anesthesia machines with tubing going out the windows. This way we are not also breathing anesthesia gases all day. We still find that with the heat, smell, poor ventilation and general chaos, our days are quite exhausing.

Ariane had another very challenging case yesterday of a patient with HIV/AIDS with a massive airway tumor (probably Kaposi's sarcoma) and severe respiratory distress, who needed a Cesarian section for her fifth baby. This woman will not likely live more than a week. They did the surgery successfully with spinal anesthesia.

Last night, my friend, Steven, came over. He young man who is a genocide survivor. I met him last November at one of the genocide memorials. At that time he was sweeping the streets of Kigali for work but was hoping to write a book based on the experiences of himself and others in 1994. Genevieve and I told him that since he spoke such good English, he should do private English tutoring. We gave him some encouragement and I have stayed in touch with him by e-mail. This time I brought him many materials such as English grammar books, books on writing, dictionary and a netbook so he can write.

Steven has accomplished so much in a year. He has many private English clients, has a regular teaching job in the morning with school children and has applied for a government loan to go to university. He has been working on his book with a pen and paper so was very happy to get the netbook last night.

He told us more about how he actually survived during the genocide, when he was eight, and on his own. He is a strong person to have made it though.

We are not sleeping well for all kinds of reasons but managing to keep ourselves quite well. We are cooking healthy meals every night and exercising regularly. The warm hearts of the people keep us going.

Brian and Daniel have arrived

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.

Kenyan Airlines has promised to deliver the luggage when it arrives. Trouble is, we don't have an address (no one really has addresses in Rwanda). We have instructed them to send it to:

Mzungus (white people), near Merez petrol station, Nyamirambo. The Merez petrol station part is kind of redundant, but good security as pretty much everyone knows where it is.

The city that never sleeps...

Some of you may have thought that New York is the city that never sleeps. Actually, it's Nyamirambo. We live in a lively neighbourhood with people laughing and running around at all hours. Because of roadwork, there is a detour by our house, so trucks honk and spew dust in the air. There is a "bar" down the street, which is a lively spot till 5 AM. Then there's a short pause until the man with the megaphone comes at 6 AM on Saturday morning for public service announcements in Kinyarwanda. You might think I'm kidding.... if only. For me, being in Africa is all about letting go.

We've taken to using the "motos" when we come home at dusk. These are the all pervasive motor cycle taxis. A couple of biker muzungus we are.

Brian and Daniel are due in at midnight tonight after having missed a plane connection with a long detour through London and Nairobi. Good thing there's a cold Mutzig in the fridge.

Akagera

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.

The park was not busy either: we saw only one other vehicle the whole time. This is probably because you have to bring your own 4x4 - the dirt roads in the park provide ample experience of the "African massage". Our first encounter was a large buffalo that was standing in the middle of the dirt track, looking very unimpressed by us. He was covered in caked dirt, with several birds perched on his back. Eventually he allowed us to pass. Further down the road was a watering hole with a family of lazy hippopotomi. They didn't even acknowledge our presence beyond some snuffling of water through their nostrils.

A few monkeys swung nimbly through the trees in the distance. Not so for the baboons: every time they bounced down to another branch the tree swayed dangerously in a loud flurry of rustling leaves and crackling twigs. They are not particularly subtle.

(I wish I could post the animal pictures: I took them with Scott's big digital SLR camera, but didn't bring the USB cable. I will try to amend this post in a few weeks when I get home).

By now we had driven out to a large plain, very lush. I think it used to be a lake, years ago. Herds of zebras, impala, topi (a kind of antelope) and another large group of buffalo seemed to coexist in relative harmony. I am baffled by the zebras. They have such impressive stripes, but it's really not very good camouflage. You'd think they would have chosen shades of brown for their hide. Some guy in their R&D department is about to get fired.

The giraffes were possibly my favourite. In one thicket we came upon a family: father, mother and two young, likely twins. We got out of the car and tip-toed towards them for a better look. They didn't seem too concerned about this, although they eventually meandered on their way.

I have no idea of the name of the bird in the photo above. It was wandering around where we were having lunch.

Contest: name the above bird. Creative suggestions encouraged.

our local market

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.

We have very much enjoyed cooking in our little kitchen here. There are so many fresh vegetables, as well as beans and rice, that we often make a curry or stir-fry for dinner. So far we have avoided eating much in the way of meat. The chicken tends to be tough

and stringy, and every time we walk past a butcher shop a battalion of flies are attached to the beef. But the fresh fruit is the highlight of every meal.

a tough day

Yesterday we had a tragic case with an extremely ill pre-eclamptic woman with a dead fetus. The extent of her pathology was far beyond anything we have seen in Canada. Unfortunately, despite the efforts of two staff anesthesiologists, two senior residents and an nurse anesthetist, she died on the operating table. Ariane and I were very upset by this but wrote a detailed account of the case with some recommendations as to how we can improve care in the future. We will be arranging a combined rounds with anesthesia and obstetrics to discuss this case.

Sometimes you can't save everyone.

OXYGEN!!!

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.

This is sub-optimal.

We went for a tour of the technical services for the hospital in the hopes of addressing this problem. Halfway across the hospital compound, there are banks of cylinders ready to be filled (once the part arrives to fix the oxygen concentrator), which explains the delay in changing these tanks. Perhaps I will construct a small cart that I will pull behind myself, loaded with an oxygen tank, so at least my patient will get tidal volumes and maybe an anesthetic, partway through their neurosurgery.

food for thought...

Friday afternoons in Rwanda are designated "Sports Day", and each citizen is expected to do some form of exercise during that time. I can't help but think that if Canada picked this up, perhaps we could afford our health care system...

first academic day

Today was our first day of didactic teaching and it went well. The residents have improved so much in knowledge, organization and ability to speak English. We kept the sessions very interactive with many questions and case discussions.

I will answer some of Richard's questions here. We are in a different apartment than last year, when we lived in a guest house with many other roommates. It was not a very good situation as there were dirty dishes in the sink and TV or radio going at all hours. The one part of the old guest house I miss is the large balcony with a breathtaking view of the hills of Kigali.

The new situation is an apartment just for CASIEF volunteers. It is very comfortable and seems to be free of rats (unlike the last place). We have three bedrooms, two bathrooms, kitchen and living/dining room. The apartment is in a working class neighbourhood. The streets are all dirt with lots of potholes and can be very dusty at times. The main street is full of shops with fruits, colourful fabrics and cell phone cards. We really enjoy walking to work and seeing all the children with their school uniforms – complete with sweaters! The walk to work is 25 minutes going down then up a hill. There is definitely no sidewalk so you walk along a dirt embankment or try to dodge the cars and motos. Nearby is a large covered market with great heaps of fruit and vegetables. We walk a lot because downtown is a further 20 minute walk from the hospital.

We begin in the OR

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).

On the right of this photo is Dr.Sender Lieberman, a colorectal surgeon from McGill who is looking at setting

up a similar teaching program for the Rwandan surgery residents. Also note the Anesthesia Team: me (Ariane), 2 Rwandan residents (a junior and a senior), as well as 2 anesthetic

techs assigned to the case. The ORs are quite new (built last year), and while they don't have a ventilation system, the anesthesia machines are basic and function: I feel like if I had to take them apart and put them back

together again, I could! The oxygen supply to the OR tends to run out partway through each case (and no backup cylinders), but just as you're bringing another anesthesia machine with an oxygen concentrator (and delivering almost no oxygen to the patient), it miraculously comes back on again. You learn to be flexible in this country.

Patty: Franco, the Dean of Medicine, Chief of Anesthesia and Anesthesia Program Director then had a meeting with the Minister of Health for Rwanda to inform him of the status of the anesthesia residency training program, discuss a few problems and ask about greater access to opioid analgesics in Rwanda. The meeting went extremely well and we were all happy with the thoughtfulness and support of the minister.

Finally, we discovered the local market – a paradise of passion fruit, papaya, avocados, mangos, and fresh shelled peas.

It is sunny one moment, raining the next or even both together.

Jour de la femme.

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.

We had a very long and productive meeting with anesthesia faculty from the three teaching hospitals. The residency program has made huge progress but there are still many challenges. We talked about the need to set clear objectives and give regular evaluation and feedback.

There is a surgeon from Mcgill who is visiting Rwanda to research setting up a similar program to CASIEF to assist in training surgical residents. He has been warmly received and it looks like this program will be starting in early 2011. The surgical residents admire the anesthesia program and are very excited they will also receive the attention of volunteer faculty.

Macadamia Nuts!

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.

CHUK Hospital

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).

View from the apartment

Sunday in Kigali

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.

In Rwanda

Hi Everyone,

We've arrived safely and all is well. We're tired and jet lagged so will write more once we are refreshed.

xxoo Patty

p.s. in the photo is Esperance, a dear friend who picked us up from the airport. All of our luggage made it in one piece!!

On our way...

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.

We're off

Ariane and I are in the Halifax airport waiting to fly to Newark, then to Brussels then on to Kigali. We should be in Kigali by 7:30 PM local time Saturday evening.

Return to Rwanda

On March 5, I will leave for Rwanda with Ariane, a fourth year anesthesia resident. We will be volunteering for a month teaching anesthesia to seven residents in Rwanda as part of a program with the Canadian Anesthesiologists' Society International Education Foundation (CASIEF).

This will be the first time in Rwanda for Ariane, but it's a return for me as I spent November 2008 doing the same program. I feel much more relaxed this time as I will be returning to friends and a familiar situation but there is still anxiety about difficult clinical situations that may arise and being ill prepared to handle them.

Ariane and I have been working for many months preparing our teaching program. I have been also working on a masters of education and have learned about effective curriculum and teaching methods so this will be a chance to apply some of the new skills. We have done our best to make our teaching program interactive, something I realized was essential during the last visit.

Going to Rwanda means leaving behind comforts, quiet space, privacy, good plumbing and an orderly environment. I am looking forward to a slower pace of life, the warmth of the people, my friends in Rwanda and the absolutely beautiful country. Oh, yes, and the weather.

In addition to my friends in anesthesia, I am looking forward to seeing Steven a young man who lost all his family except his younger sister and grandmother in the genocide. He is a delightful person – bright and thoughtful – who is working on a novel about the genocide. We have been corresponding regularly.

This trip will also be different because my husband, Brian, and son, Daniel, will join us for two weeks and they will be working on a film about the CASIEF program in Rwanda. It will be wonderful to experience Rwanda through their eyes.