Rwanda Report, February 18, 2008
All elective surgery cancelled today at the “tertiary care” university hospital in the capital city of Kigali. The reason would be unusual for us, not that rare here: only a few endotracheal tubes left in the whole hospital, which must be reserved for emergencies. This is a recurring pattern with equipment, supplies and drugs, and a source of endless frustration for the established anesthesiologists here and in Butare. By day’s end a supply was located, and tomorrow they will resume the lists of six month old fractures and other way-too-advanced surgical conditions.
Aside from the work frustration, the month in Rwanda has been wonderful. I have planned more or less all of the available time outside work with excursions around the country. This weekend headed north to the foothills of the Vurunga volcano range, which divides Rwanda from both Uganda and the Congo. The biggest attraction there, aside from the scenery, is the presence of 7 different families of mountain gorillas, spread around the hills. Every day, permits are issued for up to eight visitors to track each of the seven families. At $500 for each visitor to spend one precious hour with a gorilla family, this brings in up to $28,000 per day of badly needed funds, used for gorilla conservation projects as well as re-investment in the local communities. Aside from those involved in tourism, the local people are mostly poor farmers, living in extremely primitive conditions. However, tourist dollars have improved the health and education of these communities considerably, although the standard of living is still extremely basic.
The gorillas were fantastic; our group of eight visitors spent an hour among a small family of adult, baby and juvenile gorillas, who are quite habituated to human visitors peering at them and snapping photos and video (see some pics posted on this site). There is a lot of interaction between the spectators and gorillas, and the “official” distance of 7 meters we are instructed to maintain is rarely kept, as the gorillas often assert their sovereignty by brushing past their human visitors. Occasionally the silverback male will charge, usually at one of the guides (who subtly and very unofficially provoke them, undoubtedly for entertainment value). One of the trackers was suddenly flattened in our group in this way; unfortunately my video camera was pointed the other way. Each group of up to eight visitors is accompanied by two soldiers armed with semi-automatic weapons. This is ostensibly to protect visitors from roaming buffalo or elephants (almost never seen). Poaching is still a problem in the area, and the vast park is patrolled by armed rangers at all times.
The following day we trekked through thick bamboo jungle for an hour to find a group of around 80 Golden Monkeys playing all around us in the trees. This was quite entertaining, and although there is not the same degree of interaction as with the gorillas, there were dozens of monkeys swinging and scampering quite closely all around. Made for great photography and video. Although there were only two of us in this trek, we were still accompanied by the requisite guide, two armed soldiers, and eventually the three trackers who locate the group of monkeys each morning.
Back to reality, our time in the OR’s at the two hospitals in Kigali and one in Butare have been interesting, challenging, frustrating, and of course fun. We continue to be involved in cases that are far more complicated than many we see at home, including unusual medical conditions and advanced airway obstructions. The personnel do manage well, despite the limitations in equipment. Thoracotomies, craniotomies are just done, all without art lines or capnography. In neither of the two university hospitals in the two cities have we been able to obtain electrolytes on any patients, due to equipment problems. On our two day trip to Butare, the main university town two hours south of Kigali, I delivered the surplus Spacelabs monitor kindly donated by the biomed people in Kingston (that I have been carrying half way around the world). This was much appreciated, as the monitors and machines in Butare are quite old and in varied states of repair. Its first use was during a laparotomy for a huge abdominal tumour in an 11 year old boy who weighed only 20 kg (and that was BEFORE the tumour was removed). Our anesthetic “machine” consisted of parts of four different pieces of equipment all connected together: the flow meter and Halothane vaporizer from one, connected to the CO2 absorber and circuit on another, connected to the ventilator on a third, with a suction machine from the fourth. The case was a bit of a roller coaster, but we got through it with a stable patient. Unfortunately he had other tumours in his abdomen, and there is a complete lack of chemotherapy or radiotherapy services in Rwanda at the moment. Pathologic reports are slow and unreliable as well, and so the only certainty for this poor child is the hopelessness of this whole exercise.
At the end of the case I wandered to the next OR, where the anesthetist happened to be in the midst of struggling with a difficult intubation. I offered some assistance, and found that I was completely unable to visualize this patient’s airway. He had an advanced tumour at the base of his tongue obstructing the blade of the laryngoscope, which was bleeding profusely at this point from the manipulation. Fortunately (or maybe not…) he was ventilatable by mask, and I assisted him until he started breathing and I let him wake up. The Cuban ENT surgeon at this point figured the tumour was inoperable anyway, and again, since no chemo or radiotherapy is available, he will be discharged without treatment, without tracheostomy, home to progress to what will undoubtedly be a very uncomfortable death.
On the other side, the teaching program has been going well, with the residents by and large keen and interested in what we have to offer. Our third year resident today even asked us to join him in a preoperative consultation on an emergency pediatric case, so that he could present his list of “considerations” to us and aid in preoperative preparation. This is a big advance, and shows that the tireless work (and badgering) of the volunteers each month has been having a positive impact on the attitudes and problem-solving skills of the residents. We continue with OR teaching, Core Program presentations, and other impromptu sessions, which are all well appreciated. The residents are finally also getting used to my sometimes tangential and (rarely!) off colour comments, which Kara likes to point out are gradually getting less lost in the translation.
Meanwhile, life in Kigali has been quite pleasant. After a very rainy week, the past few days have been very nice. I’ve finally gotten my bearings in this very hilly city. I have located the only excellent coffee house in town (complete with wireless internet and too many foreigners), and frequent it too often. The house in Kigali is getting a bit crowded. There are the two Canucks, an American woman, an American couple teaching here, a Nigerian man (and his occasional “friends” that come by), another Nigerian who has now brought his whole family to join him, and a new fellow from Burundi. That makes 11 in all, sharing a kitchen two bathrooms, and the common room. Well, it works, for the time. The water is very occasionally hot for a shower, and the electricity only went out once last week (for non-payment of the electric bill by the hospital). Along with the fortress-like gates, the mosquito nets, and the tremours of the occasional earthquake aftershocks, the experience can sometimes be quite surreal….
One more note of interest: George Bush is paying his first visit to Kigali tomorrow. We will be working at the private hospital all day (the only one any non-Rwandan would attend for care), and hoping that George Dubyuh will not be needing our services….. Uncommonly, they seem to like him here.
More to come,