Rwanda Report, Part III, see accompanying photos
My last Sunday in Rwanda and only one more week of work to go. The first and only "down day" of the month, during which I had otherwise packed pretty well every non-working moment with various adventures and sightseeing activities. Using the day to catch up on some emails and presentations that I have to give this week, and at the Whistler meeting (talk about contrasts!!) after I return home. Today I took Zahara, the stir-crazy four year old Nigerian boy who has been living with his family in a room in our house in Kigali, downtown for a walkabout, shopping for packing materials, and an ice cream. He's an adorable little guy, but doesn't speak a word of English, French, Ikinyarwanda, Swahili, or anything except his particular Nigerian dialect. Sounds a bit like Pebbles Flintstone when he gets chattering. We've kind of bonded these last few weeks, in a non-verbal way that "boys" can do. Anyway, we stayed together in the crowded streets, as I thought it would be impolite to his parents to lose him. I did put my cell phone number in his pocket in case we got separated. It was interesting to observe people on the street watching the "muzungu" (meaning white guy- that's me, sort of) walking along holding hands with the little African kid, obviously debating amongst themselves what our connection was. We had ice cream at the fancy mall downtown, and hung out at the one great coffee shop where most of the foreigners go. Here the other wazungu were debating the same issue, but from the other perspective. We sipped drinks, listening to radio replays of Brian Adams, Avril Lavigne, Celine Dion... I've heard more Canadian artists blaring in the restaurants and on the buses in Rwanda than I do in an average week at home!
Saturday did a 10 km trek through dense rainforest in Nyungwe Forest National Park, a lush hilly region in the south, bordering with Burundi. The edge of the park is about 25 km from the epicenter of the big earthquake that hit on February 3. A bit of a slog, descending, then ascending about 3,500 feet to over 8,000 ft altitude. The trail was in good shape though, as there hasn't been much rain over the past week. I can imagine that in rainy season it would be a slippery mud bath, similar to the trails in the north that lead to the mountain gorillas. You need to be prepared for all weather conditions, and all the guides wear the same boots to repel mud that urologists and orthopedic surgeons wear in the OR to repel pee and blood respectively. Altogether a long day with a 2 hour drive from Butare, a five hour hike, a two hour drive back, then a 2.5 hour bus ride back to Kigali. And only 5 bucks left in my pocket.
Last week was again eventful in the OR and ICU, with cases that we never see at home, done with not even the bare standards of monitoring and equipment. Seems unnecessary to function this way, since we are working in big city teaching hospitals, not back woods villages. However you do what you can, and generally you can manage well without the luxuries we take for granted at home. I figure in my teaching role, it's not my place to try to change the system, just to educate the residents and nurses as to what the system SHOULD be like, in the hope that they can gradually shape the future.
It seems almost every case is an "oral exam" type situation in its own right. A sample day last week at the King Faisal hospital in Kigali: First up, an emergency C-section at 36 weeks gestation in a woman who collapsed and had seizures while at work. Postop CT scan (the only one in the country, and mostly for those few who can pay) showed a large intracerebral hemorrhage, from which she won't recover. Apparently there have been quite a few similar cases; we are doing a review of them, and will hopefully write up a case series to publish. Case 2: a pneumonectomy for large lung abscess and bronchopleural fistula. Took five hours, and of course no arterial line, no capnograph, no monitoring of halothane concentration. Had to rely on the O2 sat trace to tell us when the mediastinum was being retracted too aggressively. Up to now, they wouldn't even have used lung isolation, but for this case we did use one of the Univent tubes I brought along and blocked the right lung to avoid contamination of the left. The week before we arrived, they did a similar case in an AIDS patient, using a single lumen tube. During manipulation there was a huge spillage of infected junk from the operated lung to the down lung, and the patient died on the OR table! The docs were shaken up about this, but still seem to consider it to have been inevitable. Case 3: a four year old with multiple skull fractures, victim of the earthquake two weeks earlier. Now has a presumed brain abscess, but is also febrile with malaria, so the diagnosis is difficult. Did a craniotomy, elevation of depressed skull fractures, again ECG, O2 sat and NIBP were the only monitors. Did well though, and if the malaria doesn't get him, he should recover from his head injuries. Anyway, after days like this I would think Kara would have no excuse for not acing her Royal College oral questions, none of which would be as convoluted as some of the cases we've dealt with here.
Wednesday was a bit of a wash, as our driver, who had been picking us up later and later each day, decided not to show up at all. By the time we waited around, then made our way to the hospital, the OR's were under way. Kara taught in the OR suite, I went to Maternity. As no residents or staff were there, my only contribution was to answer the question by the anesthesia techs as to whether it was OK to give the Penicillin allergic patient Ampicillin instead (I said no). The only alternative was chloramphenicol. Due to the lack of teaching, I organized a car to go to the villages of Ntarama and Nyamata, sites of two of the most horrific massacres of the genocide of 1994. These sites are kept intact as memorials, to document the immensity of the events that took place. The church and school in these towns were places of refuge for around 5,000 and up to 10,000 people respectively, until a well organized group of thugs closed in and did their "duty". The ceiling riddled with bullet holes, the grenade damage, piles of blood stained clothing, and hundreds of skulls and sets of bones are left on display for all to see (photos in the last posting). The country in its present state is determined to relive the genocide on a daily basis, to make sure such an atrocity never happens again.
The last two days of the week were spent in Butare, the university town to the south. Picked up at the house in Kigali by a very pleasant driver, but who was the slowest, pokiest driver we've seen in this country of reckless Formula 1 wannabes. Also quite possibly the oldest citizen in Rwanda (where the average life expectancy is now 49, having risen from 39 only 5 years ago- I am assuming because of the now free dispensing of antiretroviral drugs to all known HIV carriers). The usual 2 ¼ hour drive took well over 3 painful hours; I was sure this guy would die of old age before we arrived at our destination! The two university hospitals in Kigali and Butare are far less well equipped than King Faisal. A typical anesthetic in Butare employs bits from several machines all daisy-chained together: the flowmeter from one, connected to the vapourizer from the next and the ventilator from a third. Often there's a mid-case change of equipment due to leaks in the system, vapourizer failure, or whatever. I have resolved never to bitch about our new state-of-the-art, pain-in-the-ass GE machines again! However the anesthesia techs and the anesthesiology residents/staff do well with what they have. The bigger problem comes later; there is no real recovery room protocol, in fact no dedicated recovery nurses either. Most patients have no monitoring postop, and it is usually a family member that sits next to the patient, giving them sips or whatever. A UK general surgeon who is on a 2 year contract in Butare tells me he has had a number of cases that go reasonably well, only to die postoperatively, often due to staff shortage and neglect.
As common as malaria and HIV are here, we have also seen quite a few cases of tetanus in the ICU's at the three hospitals. Although vaccination is now available and free, it is obviously not yet universal. Nor is footwear, which explains the high incidence of this condition. We are also collecting up some case histories to write up and publish a case series and review of tetanus with one of the residents here. One of the patients whose case we are writing up died over the weekend of pneumonia and respiratory failure. He did not respond to Ceftriaxone and the family could not afford any further antibiotics, so he was left on his own. After watching them do a tracheostomy on another tetanus patient in Butare, I went for a walk through the local market. The public markets are the most efficient place to take interesting photos, and inevitably attract hoards of curious children. The kids are great about posing for photos, and giggle and laugh when you show them the playback. That might be enough to avoid the demands for payment, though "donnez-moi l'argent" is probably the most common expression I have heard in the past month. I made five fairly grimy and shoeless little friends who became instant film stars, and with tetanus still on my mind, took them to the shoe stall in the market and negotiated for five pairs of sandals. Of course word got around quickly and it looked as though I'd soon be on the hook to outfit every kid in town. I stuck to my five friends, although two of the little kids had their sandals snatched by bigger kids. The tears flowed and of course I had to buy a few more pairs. Not exactly the Gates or Clinton foundation, but I convinced myself that, just maybe, another case of tetanus might be avoided this week...
Back in Kigali, we continue with the resident teaching. Proper preoperative assessment is still lacking among some, despite our nagging and the efforts of numerous volunteers before us. The residents have become quite relaxed with us, and used to my teaching style, and inevitable side commentary. The combination of French presenting with English Powerpoint slides seems to be working out well. This week we decided to spoil them a bit (as the Queen's staff ALWAYS does with our residents at home), and took them from the dingy hospital room to the nice coffee shop downtown to do Core Program. Although they are paid as residents, it's quite meager (about $650 per month), and the Grande Café Mochas were a rare treat. We occupied a corner table in the restaurant with six of us crowded around the laptop, and covered two otherwise boring topics: Kara did electrolyte abnormalities and I did local anesthetic pharmacology; with the caffeine flowing all stayed awake for the afternoon.
Tomorrow starts the final week here in Rwanda, we have several more teaching sessions to do, and I have now been roped into giving two lectures at the Kigali Health Institute, where the nurse anesthesia students are trained. Four more days in the OR, can't wait to see what rolls in next...