No longer a Muzungu

It was a great end to the trip. Emmy, the excellent tour guide, gave me a lift to the airport as dusk settled in. A quick and easy check in, then a walk across the tarmac to the plane, which left on time.

I have been back in Toronto for just over 24 hours. It's good to be home, and I don't even mind the -10C temperature. Its nice to be back on my own computer which runs quickly and has a decent internet connection. Slowly getting over the jet lag and sorting my stuff out.

As a white person in a black country, a "muzungu" you get used to being different, special, and privileged. Things which are expensive luxuries for locals you buy without a second thought. You get driven everywhere and can get your clothes washed and folded for $6. Its sad to lose that status, and just be an ordinary member of the crowd.

It was a fascinating experience. I am already beginning to look at the photos and think "Was I really there?"

I will have to spend a fair while talking to other people and thinking about things before I can work out how worthwhile the medical part of the trip was. Clearly there is much which could be done to improve the safety and efficiency of perioperative care in Rwanda, its just a question of who can do what, and what is really feasible in an African setting. Its easy to get pessimistic: Standard sayings are "You don't change Africa, Africa changes you"; "TIA - This is Africa" - meaning don't expect things to work - and "AWA - Africa wins again" - when the wheels fall off something.

But things can change, and Rwanda is certainly changing fast, albeit with the aid of vast amounts of donor money. The roads are good, there is little crime or corruption, the buses and planes depart on time, the Eco Bank is starting to accept foreign Visa cards, and the anesthesia equipment is improving dramatically in some hospitals. It is slow and frustrating to work within the system, slowly trying to get the local residents to understand what quality anesthesia care is, but perhaps there are no real short-cuts.

Going to see about adding some pictures to the blog now I have a faster connection. Look for them on Flickr at http://www.flickr.com/photos/jpoyston/

Last entry from Rwanda

Three pm today I was swimming in the pool the Milles Collines. All being well, three pm tomorrow I will be home. Jet travel and a seven hour time difference make for jarring changes.



The new resident arrived at 1:26 am this morning, a phillipino-iranian-canadian whose parents met in Japan who was doing a trauma/ICU elective in South Africa when the position in Rwanda became available. He's got the internet at our apartment working, something Greg and I could never do.

Had a last meal in Kigali. Wanted to go to Heaven, but Heaven is closed at lunchtime. Had a good indian and a couple of Mutzigs which seemed like a great idea at the time but now a mid-afternoon hangover is brewing.

Yesterday I finished early as there was only one case. A second case, a strip craniotomy on a 8 kg 15 month old with partly treated pulmonary atresia and a cleft palate was on hold pending the availability of rhesus negative blood. I asked how long this would take and was told its rare in Rwanda and might be two or three days away. Decided not to wait.

Had a leisurely evening mooching around the neighbourhood, getting off the main streets into areas only polupated by locals. Found a couple of car washes, and a place where vehicles are fixed, with mechanics making bits over charcoal braziers. Watched people play games bythe roadside. It was fun and I will miss it.



Its been a heck of a trip. I feel like a twenty-something again, backpacking around the world with medical students and residents. Loved everything except the work. I'd like to come back and do something different, but it would be odd to just be a tourist and not contribute anything. Don't think I'd like to be some functionary of an NGO with a nice suite somewhere taking lunches by the poolside and entertaining visiting dignitaries at Heaven. Maybe in this imperfect world I am doing the best I can, making the most useful contribution possible, and the stress that comes with that just means I am trying to do my job to the best of my abilities. Yeah, I like that idea..

Thanks for following this blog. I may put in a postscript or two later, and I hope to add some more photos once I get home.

John signing off from Rwanda

The Natives are Friendly

Its taken me a while to get used to how nice Rwandans are and how safe it is to walk around here. People sometimes shout "muzunga" (white man) but they are just pointing you out to friends. When people say "How are you?" they are not hussling, they are just being polite. Kids often just want to practice their english (or french) and are happy with a brief conversation even if they have a go at begging for money. Even poor areas (I am in a very local internet cafe a block away from the main street in Nyamirambo) people try to speak english and are doing their best to be helpful.

Went into a local style supermarket at lunchtime. Bought a whole pineapple, four bananas, an apple and a very small tub of margerine for a total of 2000 RwF., about $3:50.
Lunch in the hospital cafeteria is 900 RwF for an all you can eat buffet of rice, potatoes, sauce, veg stew and lumps of stewed meat. It seems extravagant to pay another 400 RwFr for a coke or fanta. On days when that seems too much I get two or three samosas from the stand outside the hospital for about 300 or 400 RwFr.

Sometimes I get carried away with being cheap. Last night the motorbike taxi wanted 1000 to take me home from downtown, about twice the usual rate because it was raining. So I walked home, which took about 35 minutes, in the rain. When it was just a cool drizzle, it made a nice change from the 32 degree heat of recent days (going down to 26 at night). But from time to time it came down heavily, so it was not the best move.

Wednesday was my last day teaching at CHUK so I decided to treat myself and go to the Serena Hotel for lunch. Its a beautiful building, with a bistro type restaurant by the side of a fancy swimming pool. The service was impeccable, but the steak sandwich was small and the fries were the worst I have had in Rwanda. They seemed to be frozen. With a coke, it came to RwFr 9,400, maybe $18.

Today I saw four people on a motorbike taxi - the driver, a woman and two kids about 6 and 8. I also saw a man carrying a 4 x 4 ft sheet of glass on the back of a bike. Its an intersting place!

The road crew are finally getting round to putting the road back, just as I am leaving.

Routine

Nothing much new to report, one week is getting to seem pretty much like another.
Greg flew home to Winnipeg on Tuesday evening after we had our last Mutzig beer together, then I went out to the Quiz Night where the questions were hard and we did not do so well.
Teaching out of the OR all day yesterday, did exactly one case today, had lunch, and the resident had given our second case away so I am in town souvenir shopping.
If you are expecting a souvenir, do not get excited, there are slim pickings to be had in Rwanda.
The Rwandans are complaining that its trop chaud - too hot!
There seem to be more mosquitoes than there were so I have gone back to using my mosquito net.
There was a power failure last night. I am still trying to figure out if its just my appartment (which means I have to get someone to pay the electricity bill) or the whole building.
I had to arrange to meet someone today and it took so much effort - about four phone calls and three text messages - just to arrange a time and place to meet. Simple questions like "Where are you now?" seemed to be confusing, when asked in French or English.
I think I am getting tired and am ready to come home. The heat, the red dust from roadworks all around my neighbourhood, and the language problems are beginning to get to me.

Akagera

Had a long day on Sunday, doing a day trip to Akagera Game Park
There were four of us, myself, Louise from Montreal, who works for USAID strengthening Rwanda's Media, Nicola and Muriel, a surgeon and nurse team from Switzerland, plus Emmy, our driver and guide.



We left promptly at 5 and watched the sun rise as we drove east to the park, arriving at the hilltop registration centre a bit after 7, while it was still cool and the animals would be out. A local tracker jumped inthe Toyota Landcruiser and we headed off, driving over some very minor paths through 3 - 5 foot tall grass, searching for giraffe. Instead, we found a herd of cape buffalo. Moving on, we found some impala, and watched them bounding through the grass. We saw a few of the park's 255 bird species, a whole lot of zebra, some warthogs, baboons, monkeys, hippos, and the eyes of a baby crocodile.





We saw some fantastic camp sites, some huge lakes, Tanzania in the distance, papyrus and acacia trees. If there was nothing dangerous about we walked and so we got within about 20 feet of a family of zebras. As the day got hotter the wildlife retreated so we went to the beautiful Akagera Game Lodge for a drink and to admire the view and the pool, then headed to Jambo Bay Beech on Lake Muhazi. This is a popular lakeside bar that serves barbecued food and cold beer to the beat of congolese music. Had a leisurely meal and headed back to the city.
It was not a real big game experience like the Serengeti, but it was a great day out and the price was right. It came to less than $100 for each of us, including food and drink.


Weaver birds nesting by Lake Muhaze

Discussing Safer Surgery by Moonlight

The World Health Organization has a campaign called "Safer Surgery Saves Lives". The concept is that surgery is now more common around the world than childbirth, with 234 million operations taking place every year. If these are done safely and appropriately, this could be a huge benefit. If not, it represents a huge public health risk. A big study published in the New England Journal of Medicine showed that implementing a perioperative check list, similar to a pilot's pre-flight checklist, could have the risk of death and serious complications of surgery in both developed and developing countries.

A couple of days ago one of the senior residents asked me to come to his place to discuss implementing the program in Rwanda, so on Saturday he picked me up and lead me to his place. It sits high on the hills above Nyamirambo with great views. There are concrete walls all around, and a large gate which was opened by a house boy, a small older car in the driveway. He has a wife and two cute small kids. The house was airy and spacious, but very sparse by western standards.

We sat under his fronch porch at a pine table, drinking Fanta, going over a presentation I had made three weeks earlier, using his laptop, the power cord trailing through an open window. It seemed so worthwhile, so pleasant, so professional. We talked about what would work in Rwanda and what would not, what could be done soon and what would take time. With most of the pressing issues resolved for the present, we walked to his local pub. I am getting used to the concept. Bare concrete floors, a lot of the area open to the sky. This place also had a great view as an orange full moon rose over Kigali. I had a breer and we shared gioat liver brochettes and fries.

No doubt there will be lots of twists and turns along the way, but it is nice to think that this evening might result in implementing a program which could halve the perioperative death and complication rate in Rwanda.

The cases I did not do

Just in case you are thinking this is all about partying in Rwanda, a bit more about work.
In some ways the cased I declined to do say more about the situation here than the ones I did.

On the first day they wanted me to do a 3 day old 3 kg baby for a bowel resection. I declined, and a local staff anesthesiologist did the case expertly, although there was confusion about the dose of narcotics so the patient got a double dose and had to be ventilated in the neonatal ICU postoperatively.

At CHUK there was a child with some sort of congenital cyanotic heart disease who had an ejection fraction of 20% and ventricular hypertrophy. In the absence of a cardiac echo expert this was all the information we had. He weighed 11 kg and needed a craniotomy for a brain abcess. His O2 sat was 85% on 5 l oxygen. I did not offer to do the case. Later that day I found him being operated on under local, with puss coming out of his brain. A nurse anesthetist was monitoring his saturation, but not his blood pressure or ECG. There was no medical anesthesiologist in sight. He seemed to be doing remarkably well.

The last couple of days inButare I saw some tragic cases. A child of about 7 who had a neglected ulcer on his leg which had become gangrenous, and now required an above-knee amputation. He had malaria, with a spleen below his umbilicus, and looked very pale. After discussion with a local staff anesthesiologist, I decided we should wait for a blood count and possible transfusion before operating. I came back from seeing the next day's patients to find the anesthesia techs intubating the child. Four hours after it was requested, the blood count result had not come back, but the techs did not seem to mind that.

There was a 22 year old guy who had had something fall on him, resulting in a complete fracture dislocation of his neck at C5 with complete quadriplegia. He could shrug his shoulders but not move his arms or legs. The surgeon wanted to fix the bones of his neck, but no-one, no-where can ever make his spinal cord work again.

He came to the operating room in respiratory failure. With only the diaphragm to breathe with he was retaining secretions, and could not cough. He was tachypnoiec, had a fever, and his oxygen saturation on room air was 74%. I explained to the surgeon that it was no problem to give him an anesthetic but that once we had intubated hiom there was no way we would be able to get him off the ventilator. He did not have the strength to breathe on his own now, and would never regain it. At best, he would live on a ventilator, totally dependant on others, until pneumonia, kidney failure or bed sores killed him. After much discussion with the surgeon and the local intensivist I got the case cancelled and he was returned to the floor for palliative care. The surgeon was a Cuban, and I had didfficulty understanding him in either English or French, but he seemed OK with this provided it was explained that the problem was that anesthesia did not have the facilities to look after the case post-operatively.

We then did an 11 kg child with a huge subdural on one side and a brain abcess on the other. I was quite comfortable letting the Rwandan residents do this case, partly beacuse they actually prepared in advance a list of all the drugs and equipment they needed, and partly because the child had virtually no functioning brain left and could not be made much worse!

The other case done in Butare that day was a 2,3 kg, 16 day old, baby for an omphalocoele. This was expertly done by a local staff anesthesiologist. You have to have nerves of steel to do a case like that with the best equipment in the world. To do it with an Oxford Miniature Vapouriser, Halothane, an Ayres T piece and no agent or CO2 monitoring takes real skill and guts.

I had one easy case in Butare this week - an adult woman with an ovarian cyst. This seemed to good to be true, until I saw the anesthesia equipment. They had basically cannibalised two anesthesia machines to make one that worked, provided you knew how to connect them together. The resident had no clue, but fortunately I was able to find a local staff anesthesiologist to show me how to connect things up.