Wrap-up

LIfebox Ceremony

This last week has been a flurry of activity.  Highlights included academic day, Joint journal club between the surgery residents and the anesthesia residents, a visit to Kigali Health Institute to meet the new director of anesthesia services, a trip to Rwanagana to take a look at the conference center as a possible site for the SAFE obstetric anesthesia course in January, a trip to the ministry of health to obtain a letter of support for the safe course, arrival of the Lifeboxes, organizing and hosting a Lifebox donation ceremony, and of course, our daily clinical activities.  I didn’t have much time to blog all of my activities.  It is hard to believe that the month has come to an end and I am headed back to Atlanta to my life at Egleston.  Much has been accomplished this month but most of all I have made new friends and developed new relationships that I look forward to cultivating in the future.  For as many of my tasks and goals I have checked off my list, I have many more added.  Despite the amazing curriculum that has been developed by CASIEF and the hard work by all of the Rwandan anesthesia residents, anesthesiologists, and the CASIEF volunteers, there is still much work to be done.  I keep reminding myself that it is the small steps that make the difference over time. 

If you are interested in following the next two CASIEF volunteers in Rwanda, you can go to their blog at:   UvaRwanda.wordpress.com

Bona showing us how to use the Lifebox

The Final Week

It is hard to believe it is our last week here in Rwanda.  We spent the end of last week in Butare working with the 1^st and 2^nd year anesthesia residents at CHUB.  We had grand aspirations of working with them on how to use a defibrillator.   We were excited as CHUB was reported to have 3 working defibrillators. (CHUK has none) After searching around the ICU, we found a defibrillator that was reported to be functional.  I wasn’t quite familiar with the model (very old) but seemed to have all of the working parts.  I showed the residents how to use it which was rather amusing until I realized they have not really been taught ACLS so they were not as familiar with algorithms to treat the various arrhythmias as I hoped. (Another area to consider adding to the curriculum)  I did show them how to use it.  I don’t think this part made Michael very comfortable as I think he was afraid the unit would short circuit and he wasn’t ready to resuscitate me.  Luckily, the rest of the day was uneventful.

On the way back to Kigali we stopped at the National Museum of Rwanda.  It is a beautifully presented collection of exhibits on Rwandan history and culture surrounded by beautiful gardens.  I would highly recommend a visit for anyone visiting Rwanda.

This past weekend I decided to go with some friends to visit a small eco lodge in Uganda called Bushara Island Camp.  It is only 1 ½ hour drive north from Kigali.  The camp is a small lodge on an island in the middle of lake Bunyonyi.  There is no electricity on this island yet it had amazing food and provided hot showers.  The profits from the campground assist local communities around the lake with activities such as orphan care, income generation, education, agro-forestry.  Despite the rain (that I kept hoping would go away) it was beautiful and very relaxing.  I have never seen (or heard) so many birds in my life.  There are reported to be over 200 species of birds on the island.  (and many more insectsJ) The time away from Kigali was well worth it.

tent (my room) on the island

Today was the start of our last week at CHUK and our last academic day.  I gave a lecture on caudal anesthesia and then we had several case presentations.  One by Sylvestre on the management of a terrible burn patient with an impossible airway and then by Michael who reviewed some important teaching points from the month. The day finished with a test to review the key points from the month.

residents thanking all the people who donated much needed equipment to CHUK

This evening was a real treat for me as we had dinner with Emmy who is a good friend I met in Rwanda 2 years ago who has just returned home to Rwanda after spending the last 9 months in Norway.   He was very happy to be home with his family and friends.  It was great to catch up with him.

my good friend Emmy.  I am glad he is home!

CHUB-take two

Today we were back at CHUB (teaching hospital in Butare) working with the 4 junior residents.  (3 first year residents and one second year resident)  The cases consisted of GYN cases (hysterectomies, mastectomies), a skin graft, varicose vein stripping, fracture repairs, and a re-excision of a hematoma after inguinal hernia repair.  On first glance, it looks like what you might see on the operating room schedule at any OR in the US.  However, when you look at a little closer, you realize there are many differences.

The most striking difference today was in the skin graft procedure.  The patient was a young woman who had been in the hospital since November after suffering a 18% 2^nd and 3^rd degree burn on her left arm and leg.  The wound is pretty well-healed except for a few small areas.  Unfortunately she has a contracture of her left arm and leg . Today’s procedure involved a skin graft to a small area on her left arm and leg.  I expected to see the zimmer skin graft mesher.  What I saw was something quite different.   A simple straight blade was used to harvest the skin.  It looked both primitive and very difficult.   What is a fairly straight forward simple procedure at home ended up being incredibly difficult and tedious.

The residents as well as the anesthesia techs were a complete pleasure to work with. They were eager to learn and well prepared.  Despite my “American” English, we were able to communicate quite effectively.   All of the operating rooms have a “surgical checklist” on the wall.  They haven’t quite adopted its use but they seem to communicating with the surgeons pretty well.  The surgeons were some of the most patient surgeons I have ever met. 

prepared syringes for induction of anesthesia..

What was really interesting was what I found hung on the wall next to the “surgical checklist.”   It was an  “Anesthesia Checklist” designed specifically for CHUB.  The junior residents use it to help remind them what they are expected to do everyday to prepare for the case.  One of the residents commented how much it had helped him to stay organized and how after a few months it had become second nature.    The effectiveness of this checklist was striking as they do not use anything like this at the other teaching hospital, CHUK, and the lack of organization there definitely shows.

Portion of anesthesia checklist

Satisfied Patient in recovery room

The day ended with a journal club with the residents at a nice restaurant in town.  I have now eaten at the same restaurant Ibis 5/6 dinners.  There are not a ton of options in Butare.  I wasn’t really ready to venture back to the Chinese Restaurant as I had learned my lesson from our last visit.  The residents chose an article looking at Tranexamic acid use in trauma.  An interesting discussion ensued and the question arose whether tranexamic acid should be included on the WHO list of essential medications.   As much as I appreciate the drug when I am doing cardiac cases at home, not really sure I consider it an “essential medication.”

It has been a full day.  Hard to believe that tomorrow will be my last day in Butare as we will head back to Kigali mid-day.  Until then…..

still not so good at figuring out the OMV vaporizer

How Lucky We Are...a day in the life at CHUK.

A day in the life of anyone working at CHUK, whether it be doctors, nurses, residents, support staff, is just plain hard.  Everyone tries to do their job to the best of their ability but when you don’t have manpower, mentors, medicines, equipment it seems almost impossible yet everyday the employees of CHUK return to work to take care of their patients to the best of their ability using what resources they have.  It is easy to be critical when a resident does not perform to your expectations; however, you have to constantly remind yourself that they are doing an amazing job considering the environment they are working in.  Just finding a working piece of equipment such as an EKG cable, working pulse oximeter, or blood pressure cable for a neonate can be an arduous task.

In a resource poor country, it is always interesting to see how creative people can be to solve what I would consider a simple problem.  For example, when I am at home and I want to charge my phone, I just plug it into the wall.  In Rwanda, it is not so simple and not everyone has access to a simple plug. Outside of the hospital, there is a person who provides just this service.  You can come and recharge any of your electronics for a fee.  For that matter you can get something copied as well.  It isn’t exactly Kinkos but it works.

charging station by entrance to CHUK

copy station by entrance to CHUK

The ICU at CHUK makes the ICUs at home look like the Ritz Carlton.  There are approximately 8 beds in the ICU and they are all usually filled.  Ventilators are available; however, they beep incessantly and no one really knows how to make them stop.  I tried to reconfigure the alarms to the appropriate settings but unfortunately all of the instructions were in French so I didn’t have a ton of luck.  Many of the patients are trauma victums, but you also get a multitude of other problems.  Some are things you might see in the US such as heart failure but others are unique to this environment such as cerebral malaria or organophosphate poisoning.  The doctors and nurses work tirelessly to care for these patients despite the fact there may not have adequate supplies, no epinephrine in the hospital or even a working defibrillator.  (Interestingly there is a CT scanner in the hospital that seems to work pretty well) It is sometime difficult to comprehend that this is considered a “referral hospital.”  However, the district hospitals are even worse off.  Many of their operating rooms do not even have an anesthesia machine, oxygen or essential medications as defined by the WHO.

a student nurse from Belgium works with a patient

I have asked my anesthesia colleagues to give me a wish list of non-disposable supplies that they desperately need so that I can start to work on obtaining them when I return.  I told them no promises but I would try and help them.  That is the least I can do.

Butare Part Deux

We are now safely in Butare and plan on being here for the next couple of days.  This has been a week of work so far.   (well mostly work).  Monday was another academic day.  I was responsible for a lecture on mitral valve disease, while Faye stuck with the preoperative evaluation of the pediatric patient.  I thought that both of the talks went very well.  I also felt that the residents were engaged and wanted to learn about both of the topics.  How much they actually got from the lectures will be determined next monday when we give them the test for the month.  This will actually be my first time creating a test and I think that it will be pretty fun.  

On monday night, Faye and I had a meeting with the staff anesthesiologists at CHUK along with Pauline, who trained with them, but is currently at King Faisal Hospital.  I thought that the meeting went really well, not only because the Mutzig was flowing, but because of the conversation.  Both Faye and I brought up issues that we had seen with the residents during the month.  There are many issues in the Rwandan medical system and most of them I do not understand.  After the meeting though, I felt that we had both given our perspective on the residency and hopefully this can improve things in the months to come.  Both Faye and I stressed to the staff that they have to hold the residents accountable.  We insisted that they are the bosses and that they should tell the residents what to do.  Trust me, in residency and fellowship, I have definitely been told what to do and I realize that this is how you learn without hurting patients.  

Tuesday was another day in the operating room.  Surprisingly, there have been a good number of kids, which is perfect for Faye and myself.  Other than work, Tuesday was a pretty laid back day.  

Today is our travel day to Butare.  The first part of the day was spent in the operating room.  There were 4 kids scheduled for surgery today so there was a lot to do in the morning.  Christian and I were involved in a laparotomy pull through for Hirschsprung’s disease.  Christian did a great job of preparing for the case and he had the appropriate plan.  Even more of a help was that ALL of my monitors worked.  Booyah!  The case went well and I think that Christian will make a fine physician once he is done.  

On the way out of the hospital, I was able to stop by Operation Smile, which is also going on in our hospital.  It is a group from South Africa, but they have physicians from all over the world.  They are here for a week and I believe they plan on doing ~150 surgeries.  Operation Smile looks like a great program.  They have two rooms with three operating tables in each room.  For each of the 6 tables, they have an anesthesiologist, surgeon, and scrub nurse.  It is quite impressive and efficient.  I included a picture to show how busy these two rooms are.  After being here for a while and meeting people, I have realized that there are many programs going on in Rwanda, which are trying to help in their own way.  I am very proud to be part of that process and I hope that I have made a difference this month.  

On our way to Butare, we stopped at local pottery place called poterie de gatagara.  It was about 1 km off the highway and well worth the trip.  We were able to see both the production of the pottery and the finished products.  I picked up a couple of gifts for people at home.  The first picture is of a man who grabbed me and wanted to show me how he made the vase that I just bought.  I thought that it was incredibly nice.  The second picture is of the small showroom that they have at this place.  Although they sell some of their work there, the majority of their products go to other stores in Kigali.  It was very cool to see one of the local pottery shops. 

And of course, within ten minutes of being in Butare, I had to go get ice cream at my favorite place in all of Rwanda.  They are just so nice and their ice cream is amazing!

Gorilla trekking!!!!!!

  Today was probably the best day of the trip so far.  Although it didn’t involve any anesthesia, the experience was once in a lifetime and something I will not forget.  The day started off bright and early at 615.  We had to initially drive to the main office.  Chaos is definitely the word to describe the early morning.  There are no set groups, so your driver is supposed to negotiate what group you get.  We really wanted to be with the Susa and Faye using her many contacts was able to get us on the Susa group.  Our guide started off his intro to the gorillas by telling us that we were virtually VIP because so many people wanted to be on this group. 

Just a little history about the Susa group.  They are the largest group of gorillas that the tourist are allowed to see.  Currently, they have 39 members. In a group, there are babies (1-3 yo), adolescents (4-7 yo), childbearing females (8+), and silverback males (12+).  The Susa currently have 3 silverback males.  Of the silverbacks, one is the well defined leader, one is second in charge and being trained to be leader, and the last silverback is sort of left out.  A gorilla group is very hierarchal in that the leader really makes all the decisions for all 39 members.  Its quite impressive.  Also in the group are two sets of twins, one set are adolescents and one set are 10 months olds.  The 10 month old twins are absolutely adorable and playful.  They are pictured above.  Gorillas are actually very peaceful.  They mainly eat trees, routs, and fruits.  They are accustomed to humans and are not threatened at all.  That being said, there are a few rules to follow.

The hike was probably 6-7 miles long in duration and unfortunately only about half a mile of this was on level ground.  The first half of the hike up the mountain was through fields and people’s farms.  This was quite beautiful.  The second half of the hike  up the mountain was through the jungle with brush above my head.  Needless to say by the end of this part, my shins were sore from constantly hitting against the brush.  

At the top of the mountain we reached the gorillas.  We dropped our bags/hiking sticks off and hiked another 200 meters to the gorillas.  This was unbelievably cool.  We were able to see all 3 silverbacks.  The second in charge was the gorilla that I got the most pictures of.  The ones that I will remember the most are the two twin 10 month olds.  

         The attached Youtube video is of the two twins playing on their mother’s back.  I got so many pictures of them with their mom and playing in the tress/on mom.  So stinking cute.  About halfway through our time with them, the leader got up and moved.  I was standing very near the second in charge and then he started to move.  I was caught a little off guard and the guide had to pull me up and out of the way.  The second silverback walked right past me and his family and twins followed.  So many good pictures. We then followed the group through the brush.  Our guide with the machete would either make a path or we would just follow the lead silverback gorilla. 

     The leader's 200 kg body actually created quite a nice path to follow.  One other picture (below) was of two silverbacks sitting next to each other.  The guide said that they were planning where to go next.  You could see the hierarchy.  The leader chooses, the second said something and then they left and the group followed.  There was no path, we were climbing over tall brush.  So much fun.  Babies traveled on their mom’s back.   Amazing experience. 

On the way down, a group of about 10 kids followed us down the mountain.  They were fascinated by the Muzungu, white people.  They wanted to get close, but then they would get scared and fun away.  We got back just as it started to rain.  Booyah.  This was one of those once in a lifetime experiences.  I am truly thankful that I was able to go on this hike and I hope that these pictures show how cool it really was.