Friday, January 8, 2010

Delayed already!

Decided to check the airport web site before I finished my packing. The flight to Brussels is delayed 1 hr 50 mins. As there was only three hours to catch the connecting flight to Kigali this does not look good. Called the airlines who passed me from Canada to New York back to Canada and eventually told me to call my travel agent. Yes, I booked the old-fashioned way, although I'd already done my research and knew exactly which flights I wanted.
Trek Escapes already knew about the problem and had started researching solutions. I was very impressed. If I miss the flight there is another one the next day, but it does not go directly to Kigali, I would have to change planes somewhere. No-one has any clue if tomorrow's Brussels-Kigali flight will be on time anyway. I may be spending way too much time at a snowed in Brussels airport with thousands of other disgruntled passengers.
The original plan seemed not too bad, as I would have a full day to recover from the trip before starting work. Now it looks like I will really need the time to recover but won't have it!

Jet Lag/Culture Shock

Despite all the hassles of present day airport security, it still seems to me almost miraculous that this Friday afternoon I am in Toronto and on Sunday morning I will be waking up in Kigali.

Today, I am in an affluent Toronto neighbourhood, a thirty minutes walk from downtown (not that anyone would actually walk that far!). Here people who mow their own lawns are in the minority, the preferred mode of transportation is the airport limo, and anyone who sends their children to the public (i.e. state-run, taxpayer funded) high schools is considered to have left-wing tendencies.

On Sunday I will be a thirty minute walk from downtown Kigali, in what is considered to be a lower middle class neighbourhood, whatever that may mean….

My priorities will be:
Get the safe working. This is important as there has been a break-in at the apartment in the past. I have five different sets of instructions as to how to work the safe, which is temperamental. It prefers Rwandan batteries to Canadian ones, and has been damaged by the previous break in. Every volunteer sets the password to a new number, and I don’t know for sure which of the five I have is the latest. Assuming any of them are!

Get my communications set up. Bell will charge me a fortune to use my Blackberry, but I may text with it for a while until I get everything else set up. There is a computer with a USB wireless stick which should get me internet access. Topping up the device sounds complicated. It involves buying time, removing a SIM card, putting it in a phone, dialling a number and entering a code. I think its one of those things which sounds more complicated on paper than it is in real life. There should be a Rwandan phone (programmed with all my local contact numbers) in the safe, once I can open it!

Find out how to get into and out of town by myself. One thing that makes it clear that Rwanda is different from Canada is that the apartment does not seem to have an address. You go along a main road to a specific gas station, turn onto an un-named dirt road, and it’s a block away. Usually I keep the address of my hotel on a slip of paper in my wallet. If all else fails, I can hail a taxi, show the address and for a few dollars I can get whisked back home. That won’t work in Rwanda.
There is some sort of regular minibus type service along the main road into town, so I need to figure out how to use that and how to identify the right place to get on and off at each end. I don’t want to be wandering around after dark trying to find the apartment.

Wednesday, January 6, 2010


How do I anticipate things turning out?

The Trip
It is about eight hours overnight from Toronto to Brussels on Jet, a three hour lay-over, then another eight hours directly to Kigali on Brussels Airline. Should be met at the airport and driven to an apartment.
If that all works out, things runs reasonably on time, and my luggage arrives, it will be a good start.

The Accommodation
There is an apartment for CASIEF volunteers in a suburb of Kigali about 30 mins walk from the city centre and the hospitals. At first I was not pleased to find I would be so far away from downtown. However, they will provide a car and driver to pick me up and drop me off, which is an unaccustomed luxury. Also the neighbourhood has a character of its own, with shops, cafes, a mosque and night-life. It’s written up in some guides as a suitable place for backpackers to stay.

The Country
It seems to be pretty. I’ve seen pictures of hillsides terraced to allow for farming which look a bit like the foothills of the Himalayas in Nepal. The roads were built by the Chinese and are good. The country is small enough that most things are within a 2 – 3 hour drive from Kigali. The climate sounds pleasant, and it never gets too hot, which suits me. Gorillas, an African lake which is safe to swim in, and a game park all sound enticing.

Money is a significant concern for me. Most places do not take credit cards. If they do, Mastercard is preferred, while I carry Visa and American Express. Sorry, but if you want to attract tourists, you just have to take the major credit cards. Better still, you need bank machines where I can put in my Canadian debit card and get local currency out. It can be done in almost every small town in Europe; it should be available in the two main cities of Rwanda.
Travellers cheques are rarely accepted, so visitors have to bring their money in as cash, preferably in $100 US bills printed after 2006.

I will be at two hospitals in Kigali and one in Butare. I have talked to an anesthesiologist who has been there and it sounds rather worrying. They do quite big cases, often on children. Many of the patients are sick. Postoperative care is not up to international standards, so patients really have to leave the operating room in good condition. There is a hodge-podge of equipment, not all of which works.
The overall attitude is very relaxed. Apparently I will have to get used to finding that equipment has not been maintained, and that basic preparations have not been done in a timely fashion. As I am used to working quickly in a fast-paced operating room, this will be a major challenge for me.


I have a niece who measures time by the number of “sleeps”. For example, she will say it is three more sleeps before Christmas.

It is three more sleeps before I arrive in Rwanda. In fact, for each of the next four nights I will be sleeping in a different bed. Tonight I am sleeping in the hospital anesthesiology on-call room (ugh), tomorrow I sleep at home, the next day I will trying to sleep on the plane (ugh), and the night after that I will be sleeping in Rwanda!

Tuesday, January 5, 2010


For readers of this who are not anesthesiologists, succinylcholine (Sux to its many friends) is a very basic standard anesthesia drug, especially useful in emergency situations when you need 100% muscle relaxation very quickly.

The problem is that Rwanda has apparently run out of it! I've had several emails about this over the last few weeks, begging me to bring some with me. There may still be a few ampoules left in the country, but people are guarding their secret stashes of any remaining succinylcholine.

How bad is it to do anesthesia without Sux? Well, one time I went to do private work in a Toronto cosmetic clinic and they told me they had none. I was about to explain that I would not work without it being available should I need it in an emergency. I was quite prepared to cancel the whole list, give up a day's pay and go home if they could not find the drug. Turns out it was all a misunderstanding, and the drug was safely tucked away in a refrigerator!

In Rwanda, they have been working without it for at least five weeks to my knowledge, with no end in sight.

Even in Canada, its not unknown for anesthetic drugs to be unavailable. All pharmaceutical companies care about is making money. Anesthesia drugs are made in small volumes and are not very expensive, so they do not contribute much to the bottom line. It is no big deal for a company to give up making a drug, either permanently or while they fix up a problem on the production line. But it can be a huge problem for anesthesiologists, who want to use the drugs they are most familiar with and have found the most useful. In this situation pharmacy works overtime to find another supplier, and usually a reserve supply can be found. Sometimes we have to do extra paperwork to justify the use of scarce drugs on particular patients. Eventually the situation is resolved and life goes back to normal. So its disturbing to find that an essential drug has been missing for so long. I don't know yet if its a sign that safe anesthesia is not a priority for the country, if the relevant officials are asleep at their desks, or wether there are genuine reasons for the problem to continue so long.

Sux is not the easiest thing to transport halfway around the world. It is a liquid in glass ampoules. It is also deadly poisonous: five mls would kill you in five minutes if there was not an anesthesiologist standing by to assist you to breathe after the drug had paralysed you.

I heard about a powdered form of the drug, but it turns out that this is only available by ordering from suppliers in China over the internet. I was not prepared to take personal responsibilty for importing Chinese pharmaceuticals into Africa. In the end I found a small supply of regular liquid Sux which I will pack in a freezer bag and take to Rwanda with me. It is, at least, more than I will need for the next four weeks. With luck it will last until propoer supplies are re-established.

Sunday, January 3, 2010

Why I will be in Rwanda

After the genocide, the whole country of Rwanda had just one fully qualified medical specialist in anesthesiology. The Canadian Anesthesiologists' Society International Education Foundation (CASIEF) had experience in setting up an anesthesiology program in Nepal, which was very successful and became self-sustaining. In April 2004 the National University of Rwanda (NUR) asked CASIEF to support an anesthesia training program in Rwanda. In January 2006 the program officially started with volunteers from Canada and USA (as part of The American Society of Anesthesiologists Overseas Teaching Program, ASAOTP), ensuring continuity of teaching to both residents and nurses in the program of anesthesia. The goal of the program is to teach Rwandan physicians to become specialists in anesthesiology using visiting volunteers to teach them in their own country, rather than by sending them overseas for training.

I am fortunate enough to make a fairly good living as an anesthesiologist in Canada. I have always been interested in travel and in teaching. I was interested in anesthesia in developing countries while a resident in anesthesiology in the UK, but no opportunities worked out at that time. So when I happened to be sitting next to Dr Carli at an anesthesia dinner and he talked about CASIEF's work in Rwanda I was interested.

Things checked out: Rwanda is now a stable country, getting a lot of foreign aid, and working hard to recover from the genocide. It is pretty, with rolling hills and some large lakes. Although it is just south of the equator, it is at about 1,500m elevation so the average temperature is about 23 degrees centigrade.

Helping teach local physicians made more sense to me than just going and providing anesthesia services. It turned out that they needed someone for January 2010, and that I could get away from work that month. It is not a coincidence that I am leaving Toronto in the middle of winter to be in Rwanda for the short dry season!

I will be there for four weeks starting on Sat 9th January 2010. I will be staying in an apartment in Kigali, and teaching at two hospitals in Kigali. During the first and third week I will be traveling to Butare to teach in the university hospital on Thursdays and Fridays. Wednesday is an academic day, where I will be giving a lecture, leading an residents' seminar, and listening to presentations by local faculty. The rest of the week I will be in the operating rooms doing bedside teaching.



I am a Canadian Anesthesiologist. Today is Monday January 3rd. In Toronto it is -10 degrees centigrade with a windchill making it feel like -22. There are snow flurries in a 50 km/hr wind and an inch or two of snow is lying on the ground.

On Friday night I will be flying to Rwanda where the temperature is now 28 C, going down to a low of 17 tonight, with scattered clouds.

More later....