A new trip, a new blog…

by Marcel

Hello, all of you faithful followers of the Rwanda blog!

I want to let you know that a new trip is coming up, and a new blog will be started to chronicle it. You may be interested in following along with our adventures again.

I will be accompanying Christina Hayhurst, one of our senior residents in anesthesiology, to Blantyre, Malawi. She received a grant to go teach there for a month. We’ll be departing 2 weeks from now.

The new blog is here. If you want to follow it, please register on the new site.

Thanks for your interest, and we look forward to your comments!

Postscript: Human Resources for Health

by Marcel

I really feel that Kristi’s last, beautiful post should have been the final one of the blog. It summarizes it very well, and I have  little to add to it, apart from letting you know that we had a smooth and uneventful trip home. Ethiopian Airlines really has joined Star Alliance at just the right moment, giving us better seats on the planes and access to their lounges. The Cloud 9 lounge in Addis Ababa is something ro remember!

But I do have a promise to fullfill: in the “Background” post, a month ago, I wrote that I would give some information on a more structural solution for Rwanda’s shortage of anesthesiologists and other health providers. So this is a little postscript to describe that program. It’s called Human Resources for Health (HRH) and it’s a very large-scale project that will be getting underway this summer.

Basically, Rwanda is in a bind: there are not enough staff physicians to train many residents, and since there are not many residents trained, there is no increase in the number of staff physicians. And this holds not only for physicians, but similarly for nurses, dentists and other health care providers. HRH will address this problem by sending US health care workers (organized through 9 US universities) to Rwanda as teachers, for periods of time from several months to a year. This will allow a great expansion of the training programs, and that, after a number of years, will allow hiring of the graduates as new faculty. The US presence can then gradually be scaled down, until the HRH program stops, 7 years from now. It is a large-scale and well-funded project: the plan is to have more than 100 people on the ground before the end of this year, and the participants will be paid and have additional support for travel and housing expenses.

The CASIEF/ASAGHO program that Kristi and I were on will continue, and in fact will be immensely helpful for the anesthesiology branch of HRH, as it has already created a detailed curriculum, and many of the issues associated with bringing in foreign teachers have already been resolved. But instead of one FTE, there will now be six! Five additional HRH anesthesiology teachers  will be organized through Harvard, Dartmouth and the University of Virginia.

HRH is an ambitious and exciting program, and I really look forward to its implementation. If anyone has an interest in participating in the program or just learning more about, the HRH website was recently opened and can be found here. Or email me directly.

And with that, we’ll close the blog. It has been a great trip, and if our Rwanda colleagues got even half as much out of it as we did, it has been very successful! I want to thank the Canadian Anesthesiologists’ Society and the American Society of Anesthesiologists for their support. I particularly want to thank Kristi for being an unbelievably wonderful travel partner through all the high and low points of the trip. And I want to thank all our blog followers. It was very good to know that, every day, about 100 people from all around the world were reading our adventures.

As they say in Rwanda: “Thank you for appreciating”!

 

Blood Can Be Very Bad

Well, we are leaving this afternoon – headed into a near 24 hr journey back to Virginia and I have to say, I am quite sad to be leaving.  I’m not really ready to go back.  Many of the times at the end of a vacation I am quite eager to get back to my routine, the comforts of my surroundings, and quite frankly my incredibly wonderful bed.  But we have developed our own little routine here, found some comforts – and the bed is not that bad.

We spent our last evening going to dinner with our driver Emmy at one of our favorite restaurants, “One Stop Café.”  I was soooo looking forward to their amazing cabbage, but apparently so was the rest of Nyamirambo because they were out for the evening.  We settled for chipsi-mayai (omelet special in Rwanda – basically omelet with tomatoes, onions, and potatoes), which was quite delicious.  Each of us opting for our favorite Rwandan beverage: Marcel – orange fanta; Emmy – African tea (spiced tea with milk); Kristi – ginger tea.  It was a warm, pleasant evening.  We sat outside watching the energy and pulse of a Friday night in Nyamirambo – lots of people just out on the street laughing, talking, and music from various places joining the conversations.

I have been trying to think about what it is about this place that has got a hold on me.  There a few things:  The people here are so very kind and gentle – appropriately suspicious, but then quick to come around to open and inviting.  Everyone we have met has been so enjoyable, easy to talk with, and very genuine in their “pleased to meet you.”  The people are not just good to us, but also to each other.  Marcel has remarked how in our month here, we have only seen one incidence of violence come to the hospital.  Now, I’m sure it happens and this place isn’t perfect – but in Charlottesville, there is always someone showing up who was beat up or stabbed.  And there doesn’t seem to be a lot of violence and hatred here.  In the villages, they all help each other out with their homes, their gardening, etc.  In fact, this morning – all shops are closed and no one is working in commercial businesses because it is “community work day.”  Everyone is supposed to go to their villages and help work on any community projects that might be needed to get done.  Kigali is shut down right now.

I will miss some things about the food, I have fallen in love with their tea, chipati, sambusas (samosas), and “very goods” – which are essentially an egg roll with spicy cabbage and peas.   The food is also very simple – which I like a lot.  It would be easy to be vegetarian here, which is also nice.

I like the idea of being in a place that is just coming to, it’s like watching a kid grow up.   There is a reason this is referred to as a developing country.  And there is such a dichotomy between the city and the villages.  In the city, they are trying to mount a modern feel – everyone uses cell phones, there are wi-fi cafes, clothing shops with western fashions, cars and moto-taxis buzzing around all day and all night, running water and non-dirt floors, push to use credit cards, and you can even buy your home elecricity on your cell phone now.  Contrasted with the majority of Rwandans who live in the villages and don’t even have power, they travel several kilometers daily with large jugs to get clean water at a well, dirt floors in mud plastered homes, daily life focused on acquiring sustenance – not wealth.  So here is a country with such divergent worlds, and even the city life still struggling to be modern – and it’s so different then what I am accustomed to, and I really enjoy being a part of it.  Not that it doesn’t come without its struggles and frustrations, the medical system has huge needs and gaping holes (and don’t even get me started on the internet!!).  But part of the excitement is, seeing or even being part of the needed changes, can make a remarkable difference and have huge impacts.

And finally, I have really enjoyed the purpose for which we came – teaching the residents.  I really enjoyed the interaction with the residents and seeing them learn from what we have taught.  Like I have said many times before, they are extremely bright.  They have incredible book knowledge – they clearly read all the time, but the practical application is where they need help.  And so talking to them and going through cases has been so great to see how they “get it.”  Our last day with them, Friday, Marcel gave an amazing impromptu lecture on reading CT’s with the mnemonic Blood Can Be Very Bad – and the residents did a fantastic job.  I like teaching and want to get better at it.  Being with Marcel and seeing him in action has been very good for me – because he is an excellent teacher and an example to aspire to.

For me, this experience has been incredible.  I have absolutely loved learning about the culture, seeing the way other people live and interact, trying new foods, smelling new smells (although there are lots of terrible smells here that I will be extremely glad to leave behind), meeting wonderful people, learning anesthesia, observing another medical system, interacting with the kids (black babies are way cuter than white ones), enjoying all the new plants and trees, sharing it with Marcel (who has been an amazing travel partner and friend) and just getting outside myself.  I think being here for a month is a good amount of time – any shorter and you aren’t able to get a good feel for how things run.  I think even more time would be better – but alas, I am still a resident and have some obligations to fulfill.  So for now, I will head home – back to the grind – with my memories and pictures in tow, and immensely grateful for my time and experiences here.

One more day at King Faisal

By Marcel

Our days in Rwanda are quickly drawing to a close, and we’re kind of trying not to think of the inevitable, because it will be sad to leave.

Today was spent at King Faisal hospital – one more day in the ICU with Christian, the senior resident. There are several medical students here, from Belgium and Denmark, who have an interest in anesthesiology, and who have become an integral part of the our teaching program. So today two of them came with us to King Faisal.

The morning was relatively light – several of the patients in the 6-bed ICU are actually ready to go, but are waiting for beds in the stepdown unit to be freed up after the departure of a cardiac surgery team that is currently visiting King Faisal. So there really were only one or two critically ill patients. In the afternoon, though, the speed picked up. Just when I had logged on to a teleconference with the US, there were sudden calls for help: one of the cardiac surgery patients in the stepdown unit had suffered a cardiac arrest. Kristi and the students went over to help the team, but despite a long resuscitation, the patient died. It was the only death in an otherwise very succesful cardiac surgery trip.

Meanwhile, one of the patients in the ICU deteriorated, and came very close to being reintubated. We had good discussions with Christian about how to determine the time to intervene, and how to intervene if needed. We finally decided to try CPAP, which apeared to be a good choice.

And meanwhile we still managed to squeeze in a few lectures. I gave Christian the same talk I’d given the residents at Butare: how to use the medical literature. And we also had talks about two topics close to my heart: intravenous lidocaine and the use of respiratory variation in the arterial waveform.

At the end of the day, we said goodbye to Christian, and to King Faisal hospital. We walked over to Shokola Lite, a small, excellent (and expensive…) restaurant near the hospital. Robin Petroze would pick us up there, to go to dinner with Sara Rasmussen, one of the pediatric surgeons from Virginia who arrived today in Rwanda for a one-week visit.  Shokola, as might be expected, serves excellent chocolat chaud:

Chocolat chaud at Shokola Lite

Then we had dinner at an Lalibela, a local ethiopian restaurant. Robin’s time is also almost up – she’ll be departing shortly after we do. We chatted about experiences over some excellent Ethiopian food.

With Robin and Sara at Lalibela

Tomorrow will be out last teaching day. Since the Indian team is still at CHUK, we plan the same program as yesterday: case discussions with the residents in the morning, and then teaching rounds in the ICU.

And then it will be time to say CHUK goodbye. It will be a sad moment.

 

A smattering of observations

by Kristi

I have always enjoyed walking.  It started back as a kid when I would ask my dad for a ride to school and he would say to me, “have Tom (pointing to my right leg) and Jerry (pointing to my left leg) take you.”  He very rarely gave me a ride but instead instilled in me a solid dependence on my intrinsic mode of transport.  That said, it stands to reason that I thoroughly enjoy our brisk 25 minute to walk to the hospital every morning.  Yet, it’s not just the blood pumping frontal lobe to feet that I enjoy – but this week school is back in session.  The morning street crowd has ballooned to include young kids in uniforms sporting backpacks and scrambling off to learn Rwandan geography.  The greatest part is their eager excitement at being able to practice English with the mazungu’s.

 

Kid in uniform, “Good morning.”

Kristi, “Good morning, how are you?”

Kid in uniform, “Very fine, thank you.”

Kristi and kid in uniform – giggle, giggle, giggle.

That simple little interaction makes me so happy – and a great way to start our days.  But then again, I’m easily amused.  In fact, let me just share with you a few observations we have made in this country that amuse me.  When we were driving to Butare last week we were pulled over by a police officer.  Not followed in car with lights and sirens – but instead a guy standing in the middle of the road wearing a bright yellow vest so people could see him and not roll over him.  He waved for us to pull over to the side.  He just walked in front of the car, no words exchanged, and started making hand gestures that our driver Joseph new exactly the interpretation.  The result was he checked our head lights, turn signal lights, hazard lights, windshield wipers, windshield cleaning fluid, and horn.  After all those apparently met the officer’s satisfactory criteria – he motioned us to continue on.  Apparently random stops happen all the time and if your car is not in adequate working condition, you can get pretty hefty fines, upwards of $200.

And speaking of the law – there is a law here that everyone has to wear shoes.  When you think about it – it’s actually an extremely smart public health initiative since infection is a huge problem contributing to significant morbidity and mortality – but at face value – a law that everyone has to wear shoes at all times seems kind of comical.    Most of the shoes and clothing everyone wears here is second hand.  There is shop after shop on the street of “couture” but primarily all used stuff.  It’s not uncommon to see someone sporting a sweatshirt that says, “Stanford basketball champions 2004”….or whatever.  But probably the best used t-shirt we saw was a young boy wearing a black shirt with the easily recognized pink breast cancer awareness ribbon that said, “Save the ta-tas”.  I couldn’t stop laughing – that poor boy has absolutely no idea what he is advertising.

We had a great teaching day today – we went through some cases and then held rounds in the ICU with all the residents instead of trying to crowd in to the OR with our Indian colleagues.  The residents are responsive to our teaching – but are quite serious about anything we tell them.  A perfect example is Marcel asked a multiple-choice question with one of the answers being, “poisonous hematomatoes”…which of course is absolutely nothing and just a joke.  But the residents raised their hands and said, “we don’t understand answer D, what is a poisonous hematomato?”  And even after explaining to them it was a joke – they just shake their heads and can’t figure out why we would be joking about things that could potentially end up on an exam.

Having some time this afternoon, we decided to take a tour of other parts of the hospital since we have primarily just been in the OR and ICU.  We made a walk through the wards.  There are 5-6 beds in an area, with a shelf in each area where family members can store the dishes and bags they use to bring the patient’s food in.  But, if you have money you can opt to pay for a “private” room – which has only two beds.  The cost difference is about 1,000 RWF ($1.50)/day in the general wards vs 8,000 RWF ($12)/day.  But when you are in the private rooms, everything is more expensive.  When they check your blood pressure, it costs more than when they check your blood pressure in the regular wards.  Ahh, the luxury of being a VIP.

People wait outside the ward building to get to see their loved on

Indian invasion

By Marcel

Never a dull moment… After our succesful final academic day yesterday, and the wonderful dinner with the residents last night, we were anticipating spending the last few days here quietly teaching in the OR. But no. We found out that a large Indian mission team has arrived, and has essentially taken over the OR capabilities of CHUK. They left one OR for emergency cases but use all the others, including the 2 ORs in the obstetric building, which are now being used to do pediatric urology cases. We asked, but the people here truly don’t know what will happen in case there is an emergent C-section to be done.

The Indian team (sponsored by Rotary International) is huge. They have surgeons of various specialties, anesthesiologists, support staff – 30 people or so in all. They have taken over one large room near the OR for storing all their supplies, and another to set up their own break room. They are very energetic and like to do things by themselves, so that the local surgeons and anesthesiologists have basically been reduced to assisting. After watching all this for a while, it was pretty clear to Kristi and me that we were not going to be doing much OR teaching today. Or, for that matter, the remainder of our stay, for the Indians are here through next week.

So here is a completely different approach to humanitarian outreach. These people (undoubtedly of good will) come with a very substantial budget, and in contrast to our shoe-string baby-steps in advancing the training program, where progress is always two steps forward, one step back, they will go back home after a few weeks having helped a large number of patients. What is not so clear is whether they have helped the system here. Interestingly, the cases that they do are by and large those that could easily be done by the Rwandans: orthopedics, some straightforward plastic surgery, and such. In the cases which can not easily be done by Rwandans, there is no teaching, and so after the Indians leave, the Rwandans will still not be able to do them.

Most remarkable, the Indians scheduled several children for cleft lip repairs – while we in the US sent teams to India to repair cleft lips! I can’t think of a better example of the ludicrous situations that can arise in the complex, uncoordinated world of humanitarian outreach. To make it even worse, there are Rwandan surgeons who can do cleft lip repairs. But, we were told, they don’t really like to do these cases, so they just let the patients wait until the next mission team comes along…

Patient with cleft lip, to be operated by the Indian team

My frustration will probably be pretty notable, but I can’t help it. I’m not the only one who’s frustrated. The Rwandan staff and residents were clearly upset, as were the OR nurses and others. The style of communication does not help, as the team (in our eyes) seems condescending and even rude to the local providers – people we have come to know and like over the past month. Rwandan culture emphasizes respect and mutual understanding, and it clearly makes people unhappy to be treated without those essentials.

Indian anesthesiologist intubating, while Alfred, the Rwandan resident, watches

But one has to be practical. Since there will be no OR teaching for the rest of the week, and since the residents are clearly supernumerary in the OR, we have decided to make rounds in the ICU (“No Indians in the ICU”, as Damascene said) with all available residents in the morning, and we’ll do case discussions with them in the afternoon.

Now we’re back home, and have just finished a great meal of soup, baguette and cheese. The preparation was slightly interrupted by a temporary but complete absence of water pressure, but after running downstairs, finding someone who called someone who came to fix it, our cooking could proceed. The soup tasted wonderful. How could it be otherwise, as it was prepared on the “Marcel & Kristi Memorial Hot Plate”!

The MKMHP, as it is affectionately called