Into second week in Rwanda and it’s been a fascinating and eventful trip so far. I wanted to provide you with a taste of the experiences encounted during the first part of the visit here. The elements conspired against, with the huge snowstorm in southern Ontario on the day of departure, which threatened to cancel our flight. However, made it to Toronto airport, and to our surprise took off before midnight for Amsterdam. Spent the afternoon there, then a second all-nighter to Nairobi and finally a short flight to Kigali, 36 hours of travel in all. The second brush with the elements occurred shortly after arrival in the house shared with a number of other foreigners, which is provided by the hospital. While resting up after the flight, there was a sudden feeling of the house shaking, which I initially thought was due to the brisk wind. Later that day I heard about the large earthquake in the south-west of the country which killed many and injured hundreds, the aftershocks of which have been felt widely. This was also to provide us with some interesting orthopedic and neurosurgical cases in the next few days.
Kigali is a clean sprawling city of 800,000 or so, very hilly like the rest of the country, which is why Rwanda is called the Land of a Thousand Hills (seems more like 10,000 or so). The main hospital, CHUK (Centre Hospitalier Universitaire de Kigali) is (in part) a fairly primitive complex of small buildings spread over a large area about 15 minutes from the house. We are provided with a driver every morning at 6:45 to take us to work. My mandate is that of visiting faculty to provide teaching to the residents in the fledgling anesthesiology training program. One volunteer from Canada (via the CAS) or the States (via the ASA) comes monthly. Kara’s mandate is that of a "senior resident", teacher and role model for the residents, who benefit a lot from her patient teaching. Up until the past couple of months, there were really only three practicing anesthesiologists in Rwanda, a country of 9,000,000 people! Recently, two graduates who went on to spend time in France and Belgium have returned on staff, and a third is starting on staff as he completes his thesis. By far most of the service in the country is provided by nurse anesthetists (really technicians), who operate mainly by recipe, and who seem generally over their heads in much of what they are expected to do. In fact, one of the busiest places is a separate maternity hospital in Kigali which does most of the O.B. in town, including 10-15 c-sections in a typical day. It is staffed entirely by anesthesia nurses, with no staff or residents to help. They do only spinals for c-sections, with occasional emergency GA’s under ketamine without intubation. The maternal mortality is extremely high by most standards.
Kara and I spend the days in ORs with the 6 residents who are in the program at one of three hospitals. There is CHUK, the large public hospital, as well as a better equipped private hospital built by the Saudis, and then the university hospital in Butare, two hours south of Kigali. The cases are by and large interesting, with lots of stuff we don’t see at home. Overall, the cases are way more complicated due to the advanced state of disease at the time of presentation (huge goiters, facial and laryngeal tumours etc). Most orthopedics involves fractures which occurred weeks to months before. Our “within 24 hour” ORIF of hip fractures is a pipe dream; they are generally done weeks or months later if they survive, and involve re-breaking of the now poorly healed fractures, lots of blood loss and prolonged surgery. I guess considering there are at the moment only
Getting cases done is generally a frustrating experience due to the poor state of equipment, supplies, drugs etc. Despite what must be a severe backlog of cases, things seem to move at a snail’s pace most of the time. The ORs always start late after the 8 am schedule, the residents rarely have any idea about the patients’ history and have rarely developed a plan of action before starting. This will likely be our main project during this month: I have established a routine of starting the day by the cornering the residents for a discussion of anesthetic considerations and their plan for the first cases of the day. What we take for granted is somewhat of a novelty around here. Previous volunteers have tried, but if nothing else, I will consider the month a success if we can get across the concept of preop “considerations”.
Similar to the lack of preop evaluation, the concept of preparing the OR is a bit lost. No one seems to realize the importance of checking the machine, or making sure equipment and drugs are at hand. Most of the patients seem to get atropine and diazepam, but finding the ephedrine in an emergency often requires a 10 minute hunt. Ketamine/sux is the typical induction sequence, with thiopental often used as well. At the main hospital there is no midaz, only pancuronium for relaxation (no twitch monitors anywhere in the city), no propofol, no nitrous, and only halothane for maintenance. Spinals are used frequently, epidurals almost never, other blocks are used more and more. Analgesia often depends on what happens to be available in a given day, usually fentanyl is unavailable except in special circumstances, but morphine has been there. Recovery is a huge weak link, there are no PAR nurses, just the anesthesia techs who hang out with the patients for a little while, then the patients are left alone. Only in special cases are the patients monitored there, and there may only be one or two sources of oxygen. The ICUs have just a few ventilators. After the earthquake the ICU at the private hospital was full of head injury patients. Another patient with multiple fractures and presumed ARDS due to fat embolism had to manage on oxygen by mask with an O2 sat of 79%, as all the ventilators were occupied.
Many of the cases we’ve been involved with have been good ones: craniotomies, large obstructive laryngeal tumours (yesterday’s emergency case in an older stridorous HIV patient), and today a large bloody thoracotomy. Monitoring is basic, there are ECGs, NIBP and sat’s in most rooms (only slightly less reliable than our new GE monitors!). There are no capnographs, which does lead to some uncomfortable times. Forget invasive monitoring, thoracotomies and cranies take place with NIBP like everything else. They don’t use double lumen tubes as there is no FOB available. However I brought a pile of Univent tubes to Rwanda, and they found a bronchoscope used by the respirologist at the private hospital we worked at today, so we did the thoracotomy with lung isolation, a rarity for them to see.
HIV, and all the associated problems, is of course a big problem here, and Kara and I have no problem letting the residents here do their own IV’s and intubations. Despite the risks, we often see the nurses putting in IV’s and managing airways without gloves, recapping needles, and never wearing goggles. I have taken lots of photos of cool cases, and also of bloody needles lying around everywhere. One sad result is that the Head of anesthesia at the university hospital, a really nice guy from Madagascar, has been off work since our arrival, due to side effects of a course of anti-retrovirals following a face splash with the blood of an HIV patient. Doing the math, that’s one of the six anesthesiologists in the whole country off indefinitely, so the Canadians are very welcome.
Aside from the OR teaching, we provide Core Program teaching every Wednesday afternoon to the residents, and have other seminars and resident presentations that we attend. Kara has been very involved in these sessions and inspires the residents to want to achieve Western standards of knowledge.
The working language is French, though some of our co-workers stumble along in some English. It has been difficult for a number of the previous visiting staff from the States and western Canada, but it works well for us, and Kara is getting more and more comfortable in communication. My daughter also provided me with a brief collection of Kinyarwanda phrases before I left, so I can even make the odd friend among those that don’t speak English or French as we move around. Rwanda itself is becoming more and more Anglicized as it increases its international exposure. Many of the Rwandans who repatriated after the war(s) in the 1990’s lived as refugees in Uganda, Tanzania and elsewhere, with English as their second language.
Communication here is easy. Everyone who’s anyone has a cellphone, and uses it non-stop, in the OR as well as everywhere else. Cellphones are cheap and have absolutely revolutionized communication in the developing world. In addition, internet is available widely (very slow “high-speed”), and I can text, Skype, email to the point that you hardly feel like you’re on the other side of the world. Kara and I both have cellphones on us 24/7, and can be reached easily locally or from abroad (Kim has our numbers).
One of the most prevalent themes in Rwanda is the memory of the 1994 genocide, which I have come to learn a lot about. As most of us have learned from books and movies and Romeo Dallaire fame, around a million people were massacred in a three month period in a well planned attempted genocide of the entire Tutsi race. This took place all over the country, in the most gruesome ways possible. In addition to the usual tools of war, the most common instruments were killing and maiming with machetes and clubs, as well as mass rape by known HIV positive soldiers to infect as many women as possible. There are genocide memorials all over the country; many are schools and churches which had provided shelter to hundreds of Tutsis, only to be used as contained areas of mass murder. Many of these are left intact with the blood and skeletal remains strewn all over. The number of orphans resulting from the massacre is huge; visited an orphanage in the hills close to the Congo border on the weekend which was run by an elderly American woman until her recent death. They have provided shelter and schooling for hundreds of orphans who would otherwise have ended up with the many destitute living on the street.
This weekend will head to the hills of the border area with the Congo and Uganda to join a trek to find the mountain gorillas of Diane Fossey fame. I have wanted to do this for many years and it is destined to be a trip to remember. More to follow….