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.