Friday, January 22, 2010

Butare and email

I am working with a slow internet connection in Nyamirambo. The keyboard is Belgian, so the first line is azerty and to get the at sign I need to use ALT 64 so excuse odd spellings.

My john7 emqil qddress is not working so please copy all emails since Wed to oyston at please. May not be able to reply.

Been to Butare qnd back. Very pretty journey through hills and farmland. Bananas and avocados growing everywhere, also rice.

Credo Hotel was OK and there was a pool. Butare is small for the third city of Rwanda. The hospital grounds are nice but the hospital itself is quite poor.

Only did two cases. The first day was a depressed skull frqcture in an adult. The second day we did q Hart,anns and revision colostomy in an 11 kg 15 month old. Finished by & so did nqtional museum then stopped at local market on way back for ingredients for a very fresh omlettte.

Tomorrow to Gisenyi then lodge near Volcqno National Park to go Gorilla Trekking Sun morning.

Wednesday, January 20, 2010

More pictures - Nyamirambo

A street scene in Nyamirambo, where I am staying, taken from the balcony of the cinema. Note the big mosque, which is a landmark. Their 5:30 call to prayers sometimes wakes me up.

The mosque. When I took the picture a group of young teenagers behind me said "You are taking picture of our mosque". I thought I was in trouble. They said "Take more pictures it is beautiful. This is an independant country"!

Greg outside our apartment. This is where we wait for the drivers who often show up late!

A nice fountain and park in the middle of a downtown roundabout, with hills in the distance. The public spaces and parks are very well kept up.
A patient in the operating room. Note the new anesthesia machine, and the fact that the patient is totally alone in the room with no monitors in place.

Video Blogging from Rwanda??

This is an intersting experiment in technology. My iPod has quite a good digital camera built in, so I have been taking a few very short videos (the iPod is nearly full and I am having difficulty deleting files from it).
This is the view from our second floor apartment inNyamirambo.
Let me know if it works!

Third Case in Kigali

(This is for anesthesiologists only)

On Monday 18th we did our first day of work at CHUK (pronounced See-atch-ka), the Kigali University Hospital.

After the briefing it was decided that we should do a case of a facial tumour with one of the residents. It sounded like a good case - a patient with a golf-ball size tumour inside the cheek. Did I mention that it was a child, about a year old, weighing 10 kg? No- I don't think I heard that until later, either.

They have brand new anesthesia machines in CHUK which would not be out of place in a Canadian hospital, but for this small a child the plan was to intubate and then use an Ayre's T Piece and manually ventilate on halothane and oxygen. I thought a 4.0 oral Rae tube would be handy, so everyone searched. We found a 3.5 and a 4.5 but no 4.0. So we looked for a 4.0 normal tube, but we could not find one. We found a paediatric laryngoscope blade - not one of my favourite designs, but a fairly standard one.

The kid was healthy, and from the lower lip down the airway looked normal, but the tumour looked like it might make bag and mask ventilation difficult. We decided on a gas induction, start an IV, give atropine, then intubate. We had a small LMA available for back-up. The induction went smoothly but the kid had no veins. Took about 15 mins to find one. The senior Rwandan resident let the junior resident try to intubate but he could not, so the senior took over. He inserted the 3.5 tube, but the bend was almost a full centimeter out of the mouth. However, the kid was easy to ventilate and there was minimal leak, so the tube was secured, end tidal CO2 monitoring instituted, 10 mcg of fentanyl were given, the surgeon inserted a throat pack and surgery began. The surgeon kept moving the head and his assistant kept telling me not to worry about the tube. I discussed with the residents how we would know if the tube was displaced and what we would do.

After an hour the end-tidal CO2 dropped to zero. I bagged the patient and there was no air entry. Told the surgeon to stop, he removed the throat pack, and I looked in. I could see the larynx did not have a tube in it any more! Tried to reintubate with a clean normal 3.5 tube but was not able to. Got the patient deeper and had the senior resident re-intubate, which went OK. The rest of the case went smoothly until….

After the surgery was over we waited till the kid was wide awake before extubation. Took the tube out and the kid was thrashing around in pain. Clearly the fentanyl given 90 minutes ago had worn off, so we gave another 10 mcg. The kid stopped breathing. No big deal, just some narcotic-induced respiratory depression, nothing that a little bag and mask ventilation or a small dose of naloxone would not fix. WRONG. The kid was impossible to ventilate, there was a laryngospasm I could not break. The pulse oximeter had fallen off but the kid was clearly blue and the heart rate had fallen into the 60s. Fortunately I had insisted on their being a spare dose of sux available (I brought my own supply from Canada!) and the Canadian resident gave a dose, the spasm broke immediately, and all was well.

Quiz Night In Kigali

Monday after work I met up with Andrea, who runs Carleton University's Rwanda Initiative. It’s a program designed to teach journalism students in Rwanda, allowing for exchanges and visiting lecturers. I was interested partly because it is very similar to CASIEF. One could argue that a free and effective press and safe surgery are both fundamentals of a civilized society. Also my son is a journalism student at Carleton.

We met in the Serena Hotel, which has about the nicest lobby of any hotel I've seen, complete with a baby grand piano. We went out onto the mezzanine above the pool and had drinks overlooking a fantastic pool with multiple water features.

After I had pumped her for career advice for my son, compared notes on our experiences dealing with Rwandans, and made tentative plans for the next crop of exchange students to write up the CASIEF project, Greg arrived. He'd been doing research for his presentation at an internet café.

Andrea suggested we adjourn to an Italian restaurant in Remera (which turns out to be miles away) for Pizza and Quiz night with some Canadian Ex-pats. The restaurant, O Sole Luna, was beautiful, with views of the lights of Kigali. The evening was cool and mild. The pizza menu was extensive. I had the Kibuye with Tilapia, Onions and Tomatoes, which was a bit overly adventurous. Fish pizzas are rare for a reason! The gang was very pleasant and cosmopolitan. One came from LA, and another was from Delhi on a contract to teach English. Some ran businesses, others worked for NGOs. The 25 quiz questions covered everything from Rwandan development to Ms Piggy's cleavage to fashions in shoes to the weight of body organs. We got a respectable 9 out of 25 which put us in the top half, and we would have done better if someone had not persuaded me that Kigali was at a higher altitude that La Pas!

At the end of the evening Andrea used her Kinyarwanda skills to negotiate a good rate in a taxi for us. The group was very impressed that we are living in Nyamirambo. Apparently it’s a trendy real neighbourhood, a sort of "Queen Street West" of Kigali.

End of First Week

Just finished my second wednesday all-day teaching session.
The driver came 90 minutes early, so I sent him away and he came back later and gave us a massive detour around the road works, a guided tour of Kigali
The academic day went fairly well. I began by commenting on my first week, saying that things had much improved since a year or so ago. The residents are doing their reading and asking good questions. They are getting new equipment - CHUK got new PACU monitors installed yesterday. But they need to makae more effort to anticipate problems and be ready for them.
Greg led a discussion on muscle relaxants in french, which I could follow, but when I had something to say I spoke English. A Rwandan resident talked about innervaton of the airway, then we had lunch. I could not persuade them to take less than 1 hr 45 mins for lunch, so Greg and I had a large buffet. In the afternoon I did a 75 minute talk on anesthesia for eye surgery.
Tomorrow we hope that a driver will pick us up at 06:30 am to take us to Butare to teach. We are staying at the Hotel Credo which is supposed to have a pool. We get back on Friday evening and on Saturday we are being picked up at 9 am (god willing) to go to Gisenyi for the day, then to see the gorillas on Sunday morning. Might not have time to write much and technical problems with internet access are getting tedious.

Sunday, January 17, 2010


Various pictures of the first few days

By pool at Hotel de Milles Collines
View of Kigali from King Faisal Hospital balcony

Reading menu at Heaven Restaurant

Greg in Apartment kitchen

Our second patient, in OR at King Faisal Hospital

Life in Kigali

We are getting used to things here. Its not much different from many Caribbean islands I have paid to go on vacation to. The accomodation is perhaps at the low end of the range of holiday cottages you might rent in Europe. There are a few kids hassling for money, a lot of people trying to sell newspapers, but nothing too bad.
The climate is quite pleasant. Today is a bit hot, but if you keep to the shaded side of the street its OK. Most days are bright and partly sunny, with rain one night. So far, few mosquitoes, even at dusk. We have mosquito coils in the apartment but have never used them. I put up the mosquito net over my bed every night but don't think I really need it.
We met a couple of women who run an orphanage just outside Kigali in the Bourbon Cafe today. Its the Kigali version of Starbucks, with wireless internet for those who are eating, burgers and a usual western bar menu. I had a vegetable panini and a cafe au lait for $8 US. They gave us useful tips, like how to text message the local cinema to find out what is playing. Some things work well, others seem complicated. Saturday night we heard a British soccer match commentary coming from a local sports bar, so we watched an Everton v Man United match projected on white wall, maybe 12 feet across. Greg went to the bar to order two beers. This took 15 minutes to figure out, in a place which was basically a sports bar. How hard can it be to figure out that when two guys enter a bar they probably want a cold beer? The staff were actually very friendly and seemed to be trying to be helpful but something seemed to confuse them. One problem is you never know what language people are trying to speak. The waitress came to me and said "Verre?". Only after she left did I realise that she was asking me in french if I wanted a glass for my beer.

We think its a big deal coming here for four weeks. We met three women who were here with VSO living in a village for a year with no running water or electricity. One of the two women rom the orphanage has signed on for two years, with her husband and three year old.

I have lots of great photos already, so as this is the best Internet connection I have found so far I will try to post some.

Friday Night in Kigali

Its now Sunday and I am in a new Internet Cafe with the highest speed connection I have found so far, using my own laptop plugged into their network.
This is a post about Friday night which I wrote yesterday but could not put on the net until now:

Even after only a three day work week in Kigali, Greg (the R2 anesthesia resident from Winnipeg who joined me for this trip) and I felt the need for a good break.

Friday after work we went to a café and checked our emails, then wandered to the Hotel de Milles Collines. This is the famous "Hotel Rwanda" where many Rwandans hid during the genocide, although the movie version was set in South Africa and used a different hotel. (The Rwandans were not happy about this, saying that Rwanda is much prettier than South Africa.)

For 500 Rwandan Francs (about $8) they will let you use their pool. They provide a beach towel and a change room. The pool is surrounded by tropical vegetation, with a view across the valley to the suburbs of Kigali. The water seemed cool at first but is very refreshing and you get used to the temperature. This pool was the water source for many Rwandans during the genocide, and it saved many lives!

Refreshed, we walked three blocks downhill to the Heaven Restaurant, a highly-touted place ("The best food in Africa" according to one contributor to Trip Advisor). As we walked across the parking lot, the security guard said "Welcome to Heaven". We were blown away by the place: a large open area, with nicely set tables, spot lighting, a large veranda and views as the sun set over the city.

We ate excellent barbecued chicken and tilapia (fish) tacos, downed with Mutzig beer, followed by a brownie and cinnamon ice cream. Spent most of the evening there, watching the fuss as the American Ambassador to Rwanda arrived with his family for dinner. Amazingly, there were no mosquitoes, and as it got dark it was pleasantly cool. The bill came to about $30 each. We took a cab home and were pleasantly surprised to find someone had set up our TV to get cable so we watched a soccer match.