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.