Capri.

by Kristi

Today.  Today was the day that made it all worth it.  It was our last academic day – the day we spend all hours (minus the 1.5 hr lunch that can not be interrupted) in a warm classroom giving lectures and discussing cases.  This is one of the main functions of the CASIEF volunteers – is to provide the anesthesia curriculum through weekly lectures.

Adolphe, the chief resident, told us that after the academic day, it was tradition to meet at a local restaurant near our apartment for drinks and brochette (basically kabobs) to celebrate the end of the month.  As we were walking home after the academic day, headed towards Capri, Marcel and I both commented on the fact that it was a bit of a challenging day.  We wondered if what we were teaching them was getting through and if they were really getting it.  Their understanding was good, yet their application of what we had been talking about seemed marginal.

Capri restaurant

Adolphe

We arrived at the restaurant, sat down and ordered drinks.  Slowly, most of the residents trickled in to fill spots around the table.  It was a warm evening, just breezy enough that the mosquitoes were not terribly pestilent.  After a first round of drinks, everyone ordered a second round and the menu finally showed up.

Waiting for everyone to arrive

marcel sports gaston's hat

Adolphe said fish brochette was the house specialty and the goat brochette was also great.  Having eaten my fair share of brochette in Rwanda, and feeling quite confident that would be something I would never miss again – I told him I was going to order croque monsieur.  He said, “Kristi, I think you will have fish brochette.”  End of story.  I guess I was eating fish brochette then.   He proceeded to order fish and goat brochette for everyone.  As the evening went on, a few small clues materialized that Marcel and I were the hosts of this little party. There was never any explanation or even asking us if it was ok, we were just told there would be a celebration dinner for everyone.  From there we slowly figured out that we would be the ones ultimately footing the bill.  Once it dawned on us, Marcel and I laughed across the table from each other, realizing that our experiences here are never short of little surprises.   That made the fact that I couldn’t get croque monsieur even funnier – since I was paying for the whole meal, yet couldn’t decide what I would be eating.  Writing this now, it sounds very authoritative and almost hostile.  But it was really very sweet that Adolphe wanted us to have a good experience and have a good old-fashioned Rwandan delicacy.

In all, seven of the 11 residents showed up (one is in Canada whom we never met, and one is taking a leave of absence – so really 7 of 9).  We laughed, told some jokes and ate brochette  – which was actually quite delicious – all in the dark since the power went out just as the food arrived.  When the evening was winding down, Adolphe stood and said he hadn’t prepared a speech for the occasion but wanted to say a few things.

Dinner in the dark

Adolphe giving a speech.

He addressed Marcel (they always call him professor) and told him how grateful he was he had come, how grateful they all were for his teaching – especially his new methodology of using the ASQ’s, and how happy all the residents were to do them.  He talked about how much they had learned and how hard they try. He then turned to me and thanked me for taking the time to come during my final year, he said they thought it was a huge sacrifice for me to come and they appreciated it.  It was all so sweet and tender and really put our whole trip into context.  The whole time we had been wondering whether our teaching has been useful for them, if they appreciate it or if they have been getting anything out of it.  His few simple words made it come full circle and made the whole trip worth it.

Residents and one medical student after dinner

Advertisements

Bees

By Marcel

Today we spent some time examining hives full of pretty active African bees… Not what we had planned for the day – it was to be a get-up-whenever-we feel-like-it morning, relaxed breakfast, quiet ride back to Kigali. But we’ve learned to go with the flow.

I myself have two hives in my backyard (see our bee-blog), and was intrigued when I noted a beehive behind our guesthouse, with a sign explaining how they are trying to move beekeeping out of the Nyungwe national forest. Emmy, of course, knew all about it: they moved the hives to cooperatives, who had various locations around the forest edge. In fact, if we wished, we could stop by one that we would be passing on the way back to Kigali. Then he made some phone calls, to talk to the head of the cooperative. One thing led to another, and so we not only stopped by the cooperative to look at the hives placed there, but then had lunch with Vincent, the main beekeeping instructor of the area, and then he took us to his training site at the university in Butare, and we spent a good amount of time there learning about African beekeeping.

Traditional hives at the beekeepers’ cooperative

It’s an interesting story. The traditional hives are put up high in trees, to attract swarms.

Traditional hive in a tree, waiting for bees…

Once a hive is occupied, it is brought down, using rope and several very determined people (these are African bees, the precursors of the “killer bees” in the southern US). To get the hive down, they smoke the bees, using lighted pieces of dry brush, and occasionally, this results in forest fires. Since there are about 4000 hives around Nyungwe, the amount of forest fires was substantial. In 1997, almost 15% of the whole national park was burned down because of beekeeping! So, they’re moving out the beekeepers: asking them to join cooperatives, providing space to put their hives. The cooperatives provide additional incentives, such as better prices for the honey, opportunities to use the wax to make and sell candles, training, etc. And so far, it seems to work well.

with Vincent in the training beeyard

We had a great time talking with Vincent. Beekeeping might not be of interest to everyone, but it was wonderful to see such a succesful venture that has effectively protected the rain forest, and in the process helps people becoming better at their job! And it’s truly local. The newer model hives being introduced now are constructed by local furniture makers, and women of the groups help by preparing honey for sale (we saw it sold in spirit bottles!) and candle making. The definition of what constitutes a “beekeeper” is very inclusive. Kristi asked Vincent if people who were allergic to bee stings did keep bees. Oh yes, he answered, they can still be beekeepers. They just don’t work with bees! They are involved in equipment maintenance, honey and wax processing, and things like that. It’s a very refreshing approach, and a good lesson to us, who tend to comparmentalize our jobs so much.

So, another good day. After all the bee excitement, Emmy brought us safely back to Kigali, we stopped at La Galette to buy food for the week, and now we’re alternating between power and no-power in good Kigali fashion.

Emmy buys a brochette (goat kebab) at the roadside

On time to bed tonight, for tomorrow is (our last) academic day!

Nyungwe

by Kristi

Marcel and I have been looking forward to Nyungwe Forest long before we even came to Rwanda – and with good reason.  This place is a true tropical rain forest.  It is beautiful and filled with life.

The lodge we are staying in is hostel style, with separate rooms, but everyone shares a bathroom – including the giant moths.  There is a central building where we are served meals along with all the other guests.  There was a group of Dutch cyclists here last night.  Quite bold of them I think to 1) bike Rwanda “Land of 1,00 hills” (and these are not small hills) and 2) do so in the rainy season.  We were quite impressed with them.  But the meals here are probably the best we’ve had so far in Rwanda.  It’s still all very typical Rwandan food – dodo soup, beans, rice, bananas, potatoes, mystery meat – but the difference here is, it’s all flavored so wonderfully.  In fact, lunch today there was a phenomenal curry sauce to spread over all the starches.

This morning, long before the sun even considered showing it’s face, we crawled from under our mosquito nets to meet our guide for the day. All Rwandan national parks are only available to the public via a guide.   Here in Nyungwe, there are kilometers and kilometers of trails – but they can only be accessed via cash in hand and guide in tow.  On the one hand, it makes sense from a conservation standpoint to limit access, especially to places where there are endangered species, and provide a source of income for guides.  But on the other hand – it’s kind of a nuisance.  Every individual trail you want to hike on costs money.  The cheapest trail in the park is for less than 5 km long and $40.  Most of them average around $60.   Then you have to tip the guide at the end as well.   It’s much cheaper for local Rwandans, which I think is good – but they aren’t going to go spend money to walk around the forest when they are surrounded by forest and spend all day outside harvesting beans.  So, it’s an interesting perspective on how to manage their resources.  In this respect, I prefer the American way – pay an entrance fee to the Park – then go where you want.

our trusty guide

Our guide had told us we needed to be on the road by 5:00 am to improve our chances of catching chimpanzees eating breakfast.  So we woke at 4:30 and were on the road by 5:00 sharp.  Given the early nature of our departure, the kitchen prepared us with a  “to go” breakfast the night before – cheese sandwiches and boiled eggs – that we ate in the car on the drive there.   Now I am a car eater.  During the days when I drove my car on a regular basis, I would say I took a good 40% of my meals behind the wheel.  So I am pretty good at it.  However, Rwandan roads are different and can make eating in the car a real challenge.  In fact, there is categorical hierarchy to the roads here.  There are basically four main roads in the country – all breaking out from Kigali in the four directions.  These roads are paved.  However, there are the German paved roads and there are the Chinese paved roads.  The German built roads generally last and don’t require mandatory spare parts be in your trunk at all times.  This describes the four sprouting roads from Kigali.  Then there is the rest of the country.  You take a step down to the Chinese built roads, which are labeled “wake up roads.”  These roads are of the T2000 quality, and provide enough bumps, obstacles, and potholes to wake you up – and can be either paved, partial paved, dirt, or just rocky.  These probably make up the majority of the rest of the roads throughout the country.  And lastly, we get to the “African massage” roads.  You may recall the pathway I tried to characterize in the blog about gorillas – it wasn’t really a road.  That was an example of an African massage road – getting bounced around in the car enough that by the end you feel all nice and massaged (or in severe need of a massage).  But we managed to get our breakfast down despite the manhandling the road dispensed.   We drove for another 1.5 hrs.  Again, not because the distance was anything daunting – but the “wake up” road required some tactful driving that can be quite time consuming.  We arrived at the trail head and took off into the jungle by 7 am.

We descended very quickly into the thick of the forest.  Our guide, who has had 12 years experience walking the mountains of the park, explained that we needed to move quickly to try and catch the chimps and that we could talk and ask questions on the way back.  But for now – we needed to move.  We hiked for over an hour and were then told to be quiet and move slowly.  We stopped in the middle of the trail and about 20 yards in front of us, was a giant tree dotted with several chimpanzees taking their leaf breakfast.  It was fun to watch them swing limb to limb, communicate through grunts and yells, and gingerly pick apart their meal.  Admittedly, I can’t say that it was quite as thrilling as being less than 5 feet from a 200 kg silverback gorilla – but watching these monkeys play around for awhile was incredibly enjoyable.

Can you see the chimp in the trees?

One thing I will say about having guides though – they also work in close walk-talk (walkie-talkie) range with trackers.  And without them, I’m pretty sure we wouldn’t be able to find and see the chimpanzees – so from that respect they are extremely useful.  In fact, many times, even with guides and trackers, a lot of people are never able to see the chimpanzees.  So we were extremely lucky today.

Marcel in the forest

We then took our time walking slowly back – enjoying the sounds, sights, and smells of a rich, teeming jungle.   Back at our lodge, they built an impressive fire, despite the water soaked wood.  It was nice to have the smoke as natural mosquito repellant rather than lathering ourselves in DEET.  Marcel and I told each other stories of our childhood before enjoying another delicious dinner.   This is our last weekend in Rwanda, time is drawing closer to returning – it hardly seems possible.  I’m not sure I want to go back.

Journal club

By Marcel

Well, a bit of consternation this morning among our residents… As Kristi described so beautifully yesterday, Friday OR was to be light, done by noon, and then all would depart for vigorous exercise in the refreshing open air. So we had planned to do a journal club this morning. But now, on arrival, the residents found out that – contrary to all expectations – the whole cancelled OR schedule of yesterday actually had been moved to today! So there were lots of cases to be done. Some discussion with Theo, the program director followed. He decided that since the journal club had been planned for a while, it should continue. There’s the benefit of having anesthesia technicians: the whole OR can run without residents!

It still took an hour before things got started – the planned conference room had been taken over by someone else, there was running around the various hospital pavilions to find another suitable place. Plenty of time to drink some tea.  But eventually, we found ourselves in an office in the dialysis unit, with a projector. Isaac presented a paper on the use of tranexamic acid in trauma, with some good discussions, and I then gave a talk on how to use the medical literature.

Interesting tidbit of information: this paper (the CRASH-2  study), shows a 1.5% reduction in trauma mortality when tranexamic acid was used, and we explained how this translated to a Number Needed to Treat of 67 or so. Each patient received 2 gram of tranexamic acid. Cost per gram in the US is a few hundred dollars, so we calculated out that each live saved would cost at least $50,000 – with the lesson that, maybe, that money could be put to greater use elsewhere. But our Rwandan colleagues countered that tranexamic acid was cheaper in Africa. In fact, they called the pharmacy, who called someone else, and the answer was: tranexamic acid in Rwanda costs $2 per gram! That makes the cost per live saved a little over $100, and tells you (if you didn’t know already) how absolutely random our drug pricing is.

And then it was time to say Butare goodbye. A final icecream at the store, and then Emmy showed up with his “VIP car” to drive us to Nyungwe forest, even further to the south. Along the way we visited the Murambi genocide memorial – a place where around 50,000 people sought refuge in a school building (64 classrooms full of people). There, they were attacked, killed, buried in mass graves which were then bulldozed closed. These have later been opened to provide a more dignified burial, and 1800 of those remains, mummified and turned chalky-white by lime, are on a permanent display in a number of the school rooms. It’s a chilling sight, all those mangled bodies streched out side by side on bare wooden stands, babies, kids adults, some still with a bit of hair or a scrap of clothing clinging to their distorted shapes. It’s very modbid in a way, but also a stark reminder of the horror of the genocide. We won’t easily forget it.

Now, a few hours later, we’re sitting in a small lodge on the edge of the forest. Mist floats through the valleys, constantly changing the landscape. Monkeys jump through the trees. Just beyond the forest edge we can see the light green of the largest tea plantation in Rwanda.

On a more prosaic level, the water heater has only just been turned on, so a shower before dinner is out of the question. This is unfortunate, because it would be nice, after dinner, to go to sleep right away. Tomorrow morning, we’ll have to get up at 4, to go search for chimpanzees in the rain forest…

And yes, I do feel better, thank you!

Cancelled

Today was the ultimate example of the stark contrast between an American OR vs a developing country operating theater.  We are now in Butare (2 hours south of Kigali) where we are spending time teaching the residents at CHUB.  It rained last night, all night long.   The kind of hard rain you worry that surely the roof will start leaking.   All evening the power was flickering on and off – but I was drifting off to sleep and didn’t care what was happening with the power.  I just enjoyed the tap, tap serenade of the rain lulling me into a slumber.  We woke to – yeah, hot showers this time!!  Walking to the hospital, we arrived at a timely 7:45 – even though we knew full well, the OR wouldn’t really get started until at least 9:00.   We met with the residents and Theo (the Ed Nemergut of Rwanda) at the “big board” – i.e. the chalkboard with the cases for the day scribbled in some kind of semi-organized fashion, and discussed who would be doing what cases.

Kristi and Adolphe - two chiefs.

As we split up to get the rooms ready, things seemed to be going slower than usual.  No one was really around.   Both Marcel and I made the comment – “where are the patients?”  We walked to the preoperative area (basically a bench with a curtain) and just saw some people folding scrub hats.  It seemed very strange and almost eerily quiet.

This is pre-op area (actually in Kigali). Patients come in the door and stay behind this bar until they push a stretcher up against the edge and have them hop on.

Then finally around 9:00ish – someone tells us, there is no power and the OR is cancelled today.  Ha!!!  Can you imagine – canceling the OR?  Not delayed or postponed.  Cancelled.    (FYI side note: you may wonder why we didn’t just realize there was no power…..but the OR’s here in Africa all have a ton of windows throughout and are extremely well lit during the day without the use of additional lighting.  So it’s not that unreasonable that we weren’t able to just tell the power was out).

Pediatric wing at CHUB

To not be a complete waste of our time driving to CHUB, we decided to take the morning and do some lectures with the residents.  We found an empty room in the very fancy pediatric wing of the hospital and Marcel gave an excellent talk on “the poor man’s epidural – lidocaine”.  As always, he did an excellent job and I think the resident’s really appreciated the information.  Then around 11:00 – we noted that the power finally came back on.  I said, “oh great!  We can go back to the OR!”  They just laughed, oh no – OR is cancelled today.   The surgeons all went home back to bed.  Unbelievable.  I was shocked.  I asked if tomorrow will be a pretty full day to make up the cases that should have been done today.  Again they laughed, a laugh that said, “oh so naïve Rose…”  Apparently, the minister of health has commanded that Friday afternoons be reserved for “sport”.  So the OR’s only run until noon, so people can get out in the fresh air and get some exercise.  A nice ideal thought – but seriously cuts down on hospital productivity.  Also, the residents said, most people just go drink on Friday afternoon anyway.  So much for mandated health.

Hospital cafeteria after learning the OR was cancelled.

Lunch from the cafeteria - luckily they cook over charcoal ovens so no power means still delicious lunch.

Finishing early today did give us the opportunity to walk several kilometers down the road to the National Museum where we learned about Rwandan history and culture.  It was a nice walk with no rain, and we were happy to get in some of that minister of health stipulated exercise.

We returned home for a cup of tea – which interestingly we have noted – if one gets tea in the morning, it is brought in a tea pot; if one gets tea in the afternoon, it is brought in a thermos.  It’s quiet quaint and predictable.   We will see tomorrow what happens at the hospital.  One thing is for sure – there is never a dull moment and you just have to roll with whatever floats your way.   I really wish we could put up some more pics on the.  I realize that makes it more interesting….but both Marcel and I have had trouble getting many to load.   But he was able to post some Akagera pics on his Picassa website if you want to check those out.

Sick…

By Marcel

I kind of had to laugh at myself, for the situation was surreal. Here I was, sitting on the cold tiles of a bathroom floor somewhere in the heart of Africa. It was 3 AM. Distorted rock music poured in through the tiny bathroom window, coming from the radio that plays 24/24 at full volume somewhere behind our house. And it was the third time I was sitting there that night, slowly recovering after throwing up in the toilet…

Yes, I got sick. Kristi and I had already congratulated ourselves on making it through two whole weeks without any stomach upset or other health problems. We were too optimistic. I developed a cold, a little fever, and last night my GI system gave in. Cipro time! Now, almost a day later, I’m feeling a little better again. But it has kept me out of the OR for a day and a half.

Yet, these days have seen some positive changes as well. Probably at the top of the list is the brand new “Marcel & Kristi Memorial Hot Plate”! We’ve not done much cooking here, but if we do (or even making coffee in the nice little italian device) we have done it on the gas stove.  Gas comes from a big bottle, is expensive, and is a hassle, as someone needs to be sent in a taxi to exchange the bottle. Therefore, when it ran out, we decided to donate an electric hot plate to the apartment. It comes from the infamous “T2000” store (pronounced “T-deux-milles”), where cheap chinese wares are sold at reasonable prices. Quality is suspect; we’ve been told that anything bought at T2000 is “single-use”! But so far, the hot plate has been an excellent addition to our living environment. The inaugural meal was a expert creation by chef de cuisine Kristi: hot cheese croissants (Rwanda gouda, 3000 Rwf per kilo) with avocado and fresh pineapple. One of the very best meals we’ve had here.

We also have finally caught up with Robin Petroze, the surgery resident from the University of Virginia who is finishing up two years of research in Rwanda (and who has maintained an excellent blog about her experiences). We had dinner together last night at a great little restaurant (although – I got sick after that meal…) and had a lot of things to talk about. It is great to be able to bounce some of the many questions we have off someone who comes from our own background and has spent so much time in this country.

And now we’re back in Butare for two days of teaching. I’m writing this on the hotel terrace – but I’m not sure if I will be able to post the entry today, as the internet speed is appalling. It also explained why there is no photo of the new hot plate…

I’ll go to bed early, and hopefully, there won’t be a need this night for sitting on bathroom floors.

i am grateful

by Kristi

There is always a story.  Marcel very astutely asked the other day, “how long will it take before the experiences of this new place will become routine and no longer impressive or surprising?”  Even when that happens, there will still be a story.  Today my story starts first with gratitude for what I have, and what I know.  I am grateful for the conveniences and life I have in America (especially reliable internet!!!).  I am grateful that I have a skill and knowledge that is contributory and instrumental in caring for human life.

We returned to work floating on a high from our weekend experience.  Walking into the hospital, we ran into one of the attendings, Bona.  A casual attempt at small talk, I greeted him with, “how was your weekend?”  Not really expecting much more than – “not bad”, we instead received, “ohhhhh, it was terrible.  I had five cardiac arrests.”  Blunt.  We walked toward the room where we have morning report to discuss the overnight cases and any potential difficult cases for that day.   All down the hallway, Bona was saying, “oh yes, not a good weekend.”  I felt a twinge of guilt, or at least, a feeling that I certainly did not want to tell him how my weekend went.  It didn’t seem fair – we had spent our weekend cavorting with primates, while he was at the hospital bouncing room to room doing chest compressions.  Of course, I realize that’s totally unreasonable to think that way.  In this job, you can’t always be on duty.  You need to take time to relax and everyone gets their time taking call.

Bona is a wonderful teacher, very animated, and quite passionate about his job and what he does.  He tells his stories with a lot of power – including hand gestures, impressive voice intonations, and at one point both Marcel and I thought he was going to cry.  His explanations seem theatrical, almost rehearsed – but it’s all because he excels at his job and cares a great deal for it.  That is all clearly evident in the way he relays his experiences.  I wish I had a recording of him relaying his night events. The essential theme to his report was how upset and terrible it was that in having to perform five cardiac arrests (four of whom died) no one knew what to do.  He was essentially IT, trying to direct people to help him, and coaching other staff around him.  The most disheartening is that the majority of people around that weren’t doing any thing – and certainly didn’t know at all what to do, were doctors.  That is unacceptable.

I learned more about the Rwandan health care today.  All the patients get free care.  Kind of.  They have a national insurance, but that only pays about 85-90%, the rest is up to the patient.  For elective surgery, the patients come in the day before to see the surgeon and anesthesiologist.  After the pre-op assessment, they get a prescription detailing the drugs and supplies they will need for the operation.  The patient then goes to a pharmacy to buy the needed supplies.  Then they show up the next day with their box of supplies that are used to do the surgery and anesthesia.  From an anesthesia perspective, example of things they would obtain include: endotrachial tubes, saline, IV’s, syringes, and any drugs (atropine, epinephrine, muscle relaxants, antibiotics, etc).   If patients don’t have the money to buy supplies or pay the additional 10-15% not covered by the national insurance – they don’t get surgery.  It’s that simple.  No money, no surgery.  Just like buying a pair of pants.  Now if you come in emergently because you crashed your motor taxi into a bus, you get care for up to 48 hours, then after that if you can’t pay – you’re out of luck.  No bones, no service.  Also, family members are responsible for supplying food to feed their loved one’s while in the hospital.  And speaking of visitors, they can only come in after six pm.   They start lining up at the hospital gates, which are guarded by armed watchmen, two to three hours before six o’clock so they will be able to get in and see their family members.  Apparently only so many visitors are allowed.

I spent most of the day in the ICU.  I seem to be drawn to that place.  There is a lot of badness there though.  Badness?  Maybe the better word is sadness.  Mortality rate is high, if that gives you a clue.  There is a 20 something old male with tetanus who is heavily sedated but still having contractures and will likely not survive.  There is a patient with presumed meningitis but eyes are fixed and dilated (an extremely bad sign).  There was a one year old who had a 10 cm cyst taken from her neck and post-operatively developed respiratory distress and had to be reintubated with much difficulty.  There is a four month pregnant woman with severe hyponatremia – and I taught the medical students about hyponatremia management and sodium replacement.  We were asked to put in a central line in a patient in the emergency room for septic shock.  The attending let me put the line in.  Of course, no ultrasound (thank you DLB for always insisting I use the landmark technique).   It went well.  The 20 year old girl did not even flinch or make a sound when I sutured the line in place without any local.   I was grateful today, being in the ICU, that I have the knowledge and skills to make a contribution to human life.

Each of those cases is a story.  There is always a story.