I'm not leaving.

So, we've attended our last morning report, said our teary goodbyes, had a swim at the Serena Hotel, packed our stuff and drowned one last cockroach. Emmy will be here to pick us up in about half an hour. I've been spending the last few minutes frantically figuring out how to lock myself in the safe from the inside. It is a bit cramped in here, and my internet connection is fading but otherwise I won't complain.

This really has been an amazing month. I've met so many wonderful people and seen such beautiful things. There have been some difficult times as well, but far outnumbered by the good. I was telling Patty that I feel a bit selfish for all that I am taking away (not just the banana beer) but I hope my teaching was effective and the residents seemed truly appreciative.

Except for a few large blowouts, Patty and I got along well and are planning a trip to Namibia. It's not so much that she enjoys my travel companionship rather she is using my special ability to secure emergency exit seats on all our overseas flights (awesome!!)

Thanks for reading and emailing and I'll see you soon. Can someone please shovel my driveway before I get home?

saying goodbye

In a few hours we will get on the plane for a very long journey home. We are both very sad to leave Rwanda and would happily stay for another month.

I began the day with a final run up Nyamirambo hill. There was a slightly overweight woman running on her own and we teamed up for a bit. It is heartwarming to see all the runners and especially women, as we never saw any female runners last March. She told me that she runs every morning as she has back pain and it helps. Maybe she can talk to some of my patients!

Nyamirambo hill starts off as a steady incline before reaching Everest like gradients. At the top, you turn onto a cobblestone road and have a view of Kigali and the surrounding hills. There are many birds, as the cobblestone road goes through a quiet neighbourhood with trees and flowers. It is a brisk descent to the market, which is already a hive of activity at 6:00 AM. There are men with huge bags of coal, made from eucalyptus trees. There are always tons of fresh fruits and vegetables.

We attended morning report, started the OR list, and then made the rounds to say goodbye. It is very sad and quite emotional to receive the gratitude of all the people we have been working with and teaching this month. One nurse asked me if I would be back in two months and looked devastated when I said it would be a year. We had a few teary moments in the garden outside the OR looking at the avocado tree and watching the birds.

Shannon has been a terrific companion and we've had a great month.

Rocketbus to Kigali

We’ve just returned home from a lovely dinner out with the residents and local staff. It was great to get together as a group outside of the academic setting and learn more about everyone. Alfred, the chief resident, gave a lovely speech about the residents’ commitment to hard work and thanked Patty and I for our help over the past month. It was a little sad to say goodbye to the junior residents as they’re heading back to Butare and we won’t see them again before we leave.

Lake Kivu, our weekend destination, was beautiful. Patty calls it the Rwandan Riviera. I saw a real hot spring bubbling from the earth and cooked some potatoes for dinner. Then I poached a salmon. Patty and I got a key piece of beach real estate and watched the sunset over the mountains in the Congo while people swam and fished in the orange glow. I certainly will add this to my list of best ever sunsets. What I won’t add to my “best ever” list was the hotel without mosquito nets. I think I got around 350 bites and spent most of the night defending my eyelids from mosquito mouthparts. Now I’ve quintupled my malarone dose and gone psychotic.

Sunday’s return trip to Kigali was a success. Patty had been fretting about the trip all week in anticipation of the bus ride. We decided to take the public bus home from Gisenyi. We drew up a careful dehydration plan so neither of us would have an accident on the bus (the bus stops for NO reasons on the way home). We showed up extra early to get good seats but Patty ditched me shortly into the trip and I ended up sharing my space with half of Rwanda. I think 5 people sat in 3 seats. I even had a little boy on my lap. I tried to get him to teach me how to count in Kinyarwanda but he was too entranced by the bus TV which blared “BET” dance videos for the next 3 hours. It actually wasn’t that bad and since we drove at Mach 3 we made it back to Kigali in record time. Patty secretly loved the bus.

Gisenyi

Shannon on the beach in front of the Serena Hotel, Lake Kivu.
This photo was taken from near the top of the hill on my bike ride.
This is just outside of Kigali on the road north. In the foreground are banana trees.

Shannon and I traveled with Emmy to the Northern Province again this weekend. Our first stop was at the former home of Rosamond Carr, who was an American woman who moved to Rwanda in the 1950s and ran a pyrethrum (natural insecticide) plantation for many years until she converted the plantation to an orphanage after genocide. I have read her biography "Land of a Thousand Hills" about her many years in Rwanda. She lived to age 96 and when she died she was Rwanda's oldest citizen.

It was wonderful to visit her former home, which is still being run as an orphanage. We had a tour and met some of the young people who live there. There is a magnificent flower garden for the house and flowers are also grown as a source of income for the orphanage. They have a large vegetable garden and goats and cows, so there is plenty of food. Currently about 100 children live there. It is a tranquil place and I can well understand why Madame Carr chose to spend her final 57 years in Rwanda.

We continued on to Gisenyi, which is a small town at the northern part of Lake Kivu. It is right next to the border of the DRC. We visited a hot spring where boiling water pours out of the earth. People use the hot water to cook potatoes and wash clothes. There were a number of bathers when we visited.

Emmy brought the bike I gave him, so my big thrill was cycling about 6 or 7 kms back from the brewery to Gisenyi. There was a pretty good hill to climb, which made for a very fun descent. I could happily have cycled in the area for hours but Emmy had to drive back to Kigali.

Shannon and I stayed overnight in Gisenyi and spent some very pleasant hours sitting on the beach at the Serena Hotel and watching people swimming and the sunset.

We took a bus back to Kigali today. It was jam packed and poor Shannon had five people squished into three seats with her.

Tomorrow is our last academic day and then we will have a lovely dinner at Heaven to say goodbye to the staff and residents.

7 Shots

This has been an interesting week. Monday was another successful “academic day” with the residents performing in their first ever simulation. Later in the day we bribed the residents with candy for correct answers to their homework assignments. This technique worked very well with avid participation but there was quite a lot of leftover candy (even though I handed out many secretly while Patty was on a quick break from the classroom). The leftover candy is now being used for directional purposes. I have been having trouble finding my way around CHUK (despite being here for 3 weeks now) so Patty leaves trails of candy between the OR building, the ICU, and the maternity suite and I’m able to find my way quite quickly now between each venue.

We had our first patient death this week which is obviously very upsetting. It was a case of a 9 day old 2 kg baby with multiple congenital abnormalities for omphalocele repair. This tiny boy was much too fragile to survive despite our efforts. We’ve discussed the case over and over again and certainly we have learned a lot but I think we’ll sting from this experience for a long time.

This evening I tortured all the residents with a journal club. I think it was pretty successful in the end. The guys picked up some snacks and drinks on their way to our apartment and Patty made a delicious salad. We stressed that the most important point of journal club was the food, and then the actual article. It was great to see everyone making such an effort to work through the paper and hopefully they will continue to host journal clubs in the future.

The picture is from our big night out at the Mongolian Grill. Sender and Emmy joined us. I’m glad they came, mostly for the company… but I would have had trouble carrying Patty home on my own.

highs and lows

Shannon and Sender did not have the 7 shots!!

We've had some very sad cases in the past few days but have also had some good moments. Shannon discussed our very sad death of a 9 day old child. We are heartbroken and hope we call all find a way to learn from this tragedy.

On Tuesday we spoke to the nurse anesthesia techs at Kigali Health Institute. It was a good group of about 25 and they kept us late asking questions. Shannon and I keep bring impressed with how keen everyone is to learn. They also knew most of the answers to our questions.

Today we presented the rationale for the surgical safety checklist to a group of 25 or 30 people at King Faisal Hospital. The program was well received and many of the surgeons and anesthetists are keen to implement it. Some staff from CHK also attended with favourable response.

Tonight we had the residents over to the apartment for journal club – Alfred brought drinks and samosas and we had a lively discussion. Shannon and I were impressed with their level of preparation. Shannon's charming picture of me was taken at the Serena Hotel, where we went for dinner last night with Emmy and Sender. We joked about taking home the shot glasses for banana wine shooters for the residents if they did well at journal club.

We are planning a trip to Gisenyi this weekend. It is at the north end of Lake Kivu, which I have yet to see.

Our time in Rwanda is going quickly. I've found this trip to be easier than the others as I have a good idea of what to expect and am now with friends. I meet more of the staff and develop a clearer understanding of what is needed with each trip. It has been good to see incremental improvements – particularly the level of ability in the residents. Shannon has been an excellent traveling companion (even if she makes jokes about my drinking). It has been fun having Sender in the apartment. He will make a huge contribution to surgical training. We've made great use of our Serena pool pass!! However, it is disturbing to see the increase in traffic. The air quality in Kigali is worse than a couple of years ago.

Monday will be our last academic day and that evening we will all go to Heaven (a restaurant in the centre with beautiful views - al fresco dinning- and great food). It is the goodbye dinner with all the residents and staff, as some residents have to travel back to Butare.

Simulation

We did it! We ran a low fidelity simulation in the OR today with the residents. This is the first time the residents have been part of a simulation and they did a great job.

We took over an empty OR and assigned the residents roles. They were told to set up for an elective vag hyst under spinal. After they had set up, we sent in another resident to play the obs/gyne surgeon who announced there was an emergency GA Cesarian for severe fetal distress. I played the distraught patient and the anesthesia resident had to shift gears quickly.

It went well and the residents found the experience a great learning opportunity. They would like to have a chance to practice more simulations.

Tomorrow we will be going over to KHI to teach the nurse anesthesia students for the first time this trip. On Thursday we will have the group over for journal club at our apartment.

Shannon and I have really appreciated the variety of teaching experiences we've had.

Nyungwe Forest

First of all, for the record, I did not drink the Primus!

Nyungwe Forest, in southwest Rwanda, has over 1,000 square kilometres of virgin forest. Getting there is not fun – too many hours over bumpy roads getting the African massage. However, the forest is worth it. The forest is home to a huge variety trees, ferns, mosses, vines and flowers. There is silence (so rare and welcome here) except for the bird calls.

The highlight for me was the canopy walk, which goes above the treetops – 60 metres at the highest point. It was the most marvellous feeling to be suspended in air in the forest.

The lower photo is a fish farm on the way to Butare. Ariane will remember it well.

Nature's Toilet Paper

We are now back in Kigali after an excellent adventure to Butare and Nyungwe. I enjoyed our 3 days teaching in Butare. The junior residents were so keen and the pace was much less chaotic that CHUK. The anesthesia machines were pretty sketchy though. The first day in the OR we had a total ventilator failure that resulted in having to bring 2 more anesthesia machines into the room; one for its functioning ventilator, and one for its vaporizer. It was pretty crowded!

Something worth describing is the “cafeteria” at the hospital in Butare. They used to have a little place called “Yuppy is Yummy” but that is gone. It has been replaced by a building with 5 pots sitting next to a stack of plates and forks. I just peeked quickly into the pots and that was frightening enough. Patty and I decided just to grab a couple bottles of water and eat our usual crackers and peanut butter (which we carry everywhere, just like our passports). Unfortunately, beverages at the hospital cafeteria were limited to Coke and 1L bottles of Primus, the local beer. Patty got 2L of Primus and I settled on a Coke (which actually turned out to be some homemade concoction that tasted like salty rust disguised in a coke bottle).

Nyungwe was beautiful! It was just like a tv rainforest with vines and mist. Emmy convinced a guide to take us on the canopy trail even though it was closed for the day. It was around 4pm and the sun was shining. The walk was amazing. It involves a short hike down to a suspended trail over the treetops. I’ll admit that it was a bit scary with the bridge swaying as we walked, but the view was well worth it.

Yesterday we hiked to see a waterfall. Emmy joined us and we had a blast. Again we lucked into sunshine. Our guide pointed out many different trees with leaves used for traditional medicines. Nyungwe forest has 3 types of “toilet paper”: urticarial TP, procoagulant TP, and soft TP. It is important to learn the difference.

Butare teaching and further animal adventures

Shannon and I have spent the last three days working in Butare, a much smaller city than Kigali and home of the National University of Rwanda. It is cooler here and I find I am wearing a sweater much of the day (yes, I know there won't be much sympathy from Canada).

The three residents working here all joined the program in August, so they are new to me. It has been great getting to know them and we have both been impressed by their organizational skills and work ethic. It seems the bar has been raised and we are starting from a better place. Shannon and I have had a chance to sit down with two of the residents each day for a couple of hours of teaching. I can't tell you how keen they are to learn. We have to cut the sessions off after a few hours when our brains turn to mush but I'm sure they would happily keep on going.

The anesthesia machines here are much older than in Kigali. The top photo is one of the ventilators we've been using.

We are back at the Credo Hotel, well known to other volunteers. Shannon has a great knack for discovering critters of all sorts. Her "roommate" (the amphibian) hasn't been seen for 24 hours but we have discovered a rat infestation down by the pool. We watched them running in and out of the drain pipes while we dined by the pool. Let's just say it put both of us into a state of high anxiety, especially Shannon, who has a huge hole under her shower. I'll let her tell you how she blocked it off. We were very thankful for Sender and his supply of zopiclone!

We have more teaching this morning then we will meet Emmy for lunch and head off to Nyungwe forest. I hope the only animals we find are some birds and maybe a few monkeys.

Animal Highlights (and Lowlights)

Everyone told me before my trip that seeing the mountain gorillas would be a highlight. I was having my doubts while scrambling up the side of a volcano, slipping in dark mud, and plucking nettles from my knees but the experience was more than worth it. I even enjoyed the difficult trek because the view was amazing.

At first the gorillas were mostly up in the trees but they came down as our group approached. We got to spend an hour watching them play and eat. Of course, the babies were the best part. They were extra cute and totally uncoordinated. “Charles”, the silverback and alpha male of the family was huge and lazy. It seems as though he is getting a head start for next Movember after being totally humiliated by Hinkewich in 2010.

Today Patty and I made the journey to Butare. The scenery was so beautiful and we even saw a rainbow in one of the valleys. I was pretty excited about Butare until about 7 minutes ago. Patty and I checked into the Credo Hotel and my room has a double bed, a real toilet that flushes, and a demonic amphibian. At first I thought the newt was just another Malarone hallucination. I was hoping it was really just a lizard so that it would have scales and not wet skin in case I stepped on it in the dark. Patty’s suggestion was to open my patio door (to let more of them in?). Do you see how its eyes glow? Pure evil. Good thing Sender doled out some Zopiclone before we left.

off to Butare

The anesthesia residents at academic day. They are great guys!

Shannon and I continue to enjoy academic day on Monday. The residents are keen to learn and very involved. We keep our sessions highly interactive and try to connect as often as possible to cases. There is always one presentation each week by one of the local residents. The quality continues to improve and they are also much more comfortable with English.

Our morning report is also going well. We are making that very interactive, as well, and use this as an opportunity to teach the nurse anesthetists (techs).

We are encouraging the residents to communicate with the team and to develop leadership skills. There is definite progress but still much more to be done.

We will leave for Butare in a few minutes and will be there until Friday. We are planning to spend Friday night in Nyungwe forest and hike on Saturday. Butare will be good as we will have a chance to work with the three new residents.

Virunga

Shannon and Emmy - road to Northern ProvinceMy African dress

After work on Friday, we drove with our friend and guide, Emmy, up to the Northern Province. I'm sure Shannon will write about her impressions of the countryside. We stayed at a funky little place in Kinigi. It was so cold Shannon had to wear fivelayers to bed (I forgot to tell her to bring thermal underwear to Rwanda).

The next morning, I rode Emmy's bike to the Headquarters where people are assigned to the gorilla groups they will visit. It was my first time on a bike in Rwanda and such a great pleasure. Having seen the gorillas on the past two visits, I decided to hike to Dian Fossey's tomb and the site of the Karisoke Camp. Shannon did the gorilla hike (again, I'm sure she will write about that).

I was the only visitor hiking to Karisoke, so headed out with a guide, a porter, and three armed soldiers. The hike was straight up hill and it was very muddy. It was significant physical exertion! We got to the site after 2 1/2 hours. There is almost nothing left, since after Dian Fossey was killed, people took anything and everything. However, the location of the buildings has been marked and there is Dian's tomb, which is right next to her gorilla friend, Digit, in the gorilla graveyard.

We stopped in Ruhengeri at the Muhabura Hotel for some lunch and had a rainy drive back to Kigali.

Sender arrived last night. He is a surgeon who is heading up a teaching program for the surgical residents, much like what we are doing for anesthesia. Ariane and I know him from March. He will be staying in our apartment for a while until the surgical apartment is ready. He's great fun and it's good to see him again.

I've spent most of today working on a talk to present at the Safer Surgery Conference. I did have my early morning two loops of Nyamirambo hill and we just got back from our swim.

On to week two....

Grounds of CHK

Here are some images of the hospital grounds at CHK, the main hospital in Kigali. The patients' families wash their laundry. It was a sunny day and I found a few minutes to wander around (don't tell). There is an avocado tree just outside the OR.

Ariane, the same beggar is still under the fruit bat trees and I saw the albino beggar in the Nyamirambo market.

Christian and Theoneste are coming soon for dinner and we will talk about their trip to Halifax. Tomorrow we head for the Virunga Hills!

Lunch at Karibu

Looks good doesn’t it? I was entirely impressed with the selection and the price…. Until the next day. In fact, Patty and I paid dearly for this choice. Things are better now.

A very interesting day at work today. I got to take part in the case of a 21 year old woman with severe mitral stenosis, aortic and tricuspid regurgitation, and active asthma for c-section. We discussed the case thoroughly at “morning report” and had a solid plan, sans invasive monitors (so, more like a semi-solid plan). Unfortunately our carefully titrated epidural failed so the patient had a c-section with a partial block and halothane by mask. The vitals were stable throughout and mom and baby did very well. The baby was named Kevin (or the Kinyrwandan version) which means “the one who will watch over me”.

This evening Patty and I are having two of the residents over for dinner. These residents are leaving for Halifax in two weeks and we will try to answer their questions. Patty is in the kitchen cooking up a storm while I learned how to parboil and peel tomatoes. Has anyone ever done this? It seemed like an awfully great effort just to avoid a little GI issue. But, then I remembered lunch at the Karibu.

Dawn in Kigali

Now that the sidewalks are paved and there are streetlights, it is possible to run up Nyamirambo hill before daybreak. I headed out at 5:30 and there were many other runners. It's amazing how many people are up and about at that hour. By the time I got to the top of the hill, dawn had come and there was a beautiful view of Kigali. The best part was the chorus of bird calls.

The days at CHK are not easy. I feel for everyone having to work in such a tough environment when so often the equipment doesn't work. I am doing my best to encourage a systematic and orderly approach. There has been clear progress but still much more to do. We are working to prepare a conference to introduce the WHO surgical checklist to Rwanda. I hope this will strengthen the notion of team work, which is so essential to patient safety.

We finished our day early and have been swimming every day after work.

I know we haven't put up any pictures but we promise to fix this soon. We are heading up to Ruhengeri this weekend so Shannon can see the gorillas and next week we are off to Butare.

The House Hippo

First off, the rooster is dead to me. It started randomly crowing at 4:20 am today.

Today was my first day in the OR. I was nervous and had no idea what to expect. I honestly can't say that I was pleasantly surprised but that is why we are here. First case of the day was a small boy having his humerus repaired; straightforward. Second case was an unfortunate woman who had polytrauma after being attacked by a hippopotamus (in her own home, no less)! At first I thought I wasn't hearing the mechanism of injury clearly, but it was repeated and explained and that was the actual situation. It is apparently not uncommon.

It was a long and challenging day for both Patty and me so we were really looking forward to that swim after work. I had a fabulous walk home from the hospital (about 30 minutes, unless you are Anita). I stopped in all the shops along the way in search of crackers. Patty and I go through a good amount of crackers because neither of us care for bread and our work lunches can neither be refrigerated or heated. Cheese and crackers is the perfect option. Anyway, I met lots of people and some spoke English. Finally I found a store that had crackers and Rwanda's only can of Coke Zero (which I obviously bought) and NUTELLA!! I honest to God didn't buy the nutella.

So, overall I'm having a great time but am now beginning to see some of the challenges ahead.

Thanks again for following

We've come a long way...

I remember academic day when I was in Rwanda with Genevieve in November 2008. At that time it was very difficult to get the sessions started as there was no designated room for teaching and the residents were not very punctual. We'd just get started, after everyone finally arrived, and then would be displaced by another group who had claims to the room. Our sessions were definitely a mix of French and English and often it felt that a lot was lost in the translation.

What a difference now! Morning report with the techs is in English and everyone comes prepared. The list of cases from last night alone could easily be someone's fellowship exam questions. The residents showed up on time to all the sessions today, their English is much improved, the participation and discussion was excellent, and we have a comfortable room just for anesthesia teaching. It is incredibly rewarding to see the progress that has been made in a couple of years.

Shannon was happily woken by the rooster at just the right time this morning. Nyamirambo is as lively as ever. They sure know how to enjoy life!

Passion Fruit Heaven

I've decided I have a few things to say as well. This is my first experience with blogging but I'll try to keep you up to date with my impressions.

I have included a picture of our table and market fare. I'm attempting to exist entirely on passion fruit for the next 4 weeks. Actually I'm not, but it isn't a bad idea.

I wake up giggling in the morning. This is because the neighbours' rooster crows at exactly 6:30. It continues to crow off and on throughout the day which also makes me giggle and I'm not sure why. Unfortunately the rooster alarm isn't set early enough for the work week, so I'm going to have a chat with him later about crowing a little earlier Mon-Fri.

In case any of you were wondering, I did not join Patty on her early-morning-hour-long-up hill twice run. I lounged in bed reading (and laughing at the rooster).

I'm excited for what today will bring. We will be celebrating Patty's birthday with an afternoon at the Serena Hotel followed by dinner out with Paulin!

My favourite experience so far has been meeting Patty's Rwandan friends. These are amazing people with touching stories. Steven joined us for dinner last night and I could have listened to him forever. We actually had dinner by "headlamp" light which added some mystique to the conversations.

My least favourite experience has been the cockroaches. I know they are harmless but they just look so gross. My stomping reflex is steadily improving. I was also put off by the roach who decided to shed his carapace next to the dining room table.

Thanks for listening. I'll try to keep you updated and should have much more interesting things to say once we start work tomorrow.

Birthday Morning

I said I wouldn't keep a blog but I can't help it. Now that I am back in Rwanda again, I want to share these vivid experiences. I may not write as much but let's hope Shannon will jump in.

Today is my birthday and I got up early for the Sunday morning run in Nyamirambo. You might think that hardly anyone would be out at 6:30 in the morning, but the main street is full of runners. Ariane will be super happy to hear that I saw at least 12 women running this time. Of course, there are lots of high fives, "esprit", "courage" and smiles. I am happy to say that I did two loops of the Nyamirambo hill without stopping, before breakfast!

Our journey to Rwanda was as easy as any 26 hour trip can be. We arrived 25 minutes early! Even more amazing, all our luggage arrived, including a bicycle I brought as a gift for my friend, Emmy. He picked us up at the airport and we both agreed it seemed only a short time since he had dropped Ariane and I off. He was thrilled with the bike.

The apartment is in good condition – someone, maybe Chris, had sorted all the books. Shannon and I discovered we are both neat freaks (yeah!) so we cleaned out the apartment yesterday.

The Nyamirambo market is full of pots and pans, old clothing, colourful fabrics, heaping piles of fruit and vegetables, beans, and rice. The great joy is all the people, who are not shy. I've learned a few words of Kinyarwanda (maybe only 5 words) but this makes everyone smile and laugh all the more.

After the market, Shannon and I walked to the city centre to change money, shop, and have a stop at the Bourbon Cafe for lunch. Next stop –no surprise – was the Serena Hotel to sign up for a month membership at the pool.

Last night my friend, Steven, came for dinner and he was very happy with all the books I brought him. He will be starting education college next week. He has been doing some English tutoring, translating and working on his book.

Kigali looks great. Many streets that were dirt before are now paved and they've added street lights and sidewalks. In fact there are sidewalks almost all the way along the Nyamirambo road. We used to have to climb over mounds of mud and avoid falling into pits.

It is truly a pleasure to be back and I am looking forward to the month of teaching.