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.

Clubbing on a Friday Night in Kigali

Greg, the R2 from Winnipeg who has been a great support to me on this trip, and an ardent teacher of basic science and basic principles to the residents, has to go back on Tuesday. He has an overnight flight leaving 10 pm Tuesay and he is back on call in Winnipeg Thursday night.
Before he left, he wanted to investigate the night club scene in Kigali, so we set out to do that.

We began at 8 pm with a late dinner at Khazana, the best Indian restaurant in Kigali. Curried chicken and tilapia, kashmir pillau amd peshwari naan ( or was it the other way around?) were delicious, although the bill came to about $48 for the two of us, which seems a lot for Rwanda.

We were told that there was no point turning up at the Cadillac night club before midnight, so we took a cab to the Repulika Lounge. This is a nice restuarant on a balcony, and a lounge with comfy sofas. We relaxed over a gin and tonic and a couple of Mutzigs, entertaining ourselves by watching the prostitutes pick up the single guys drinking at the bar!

We were joined by an English medical student and two Canadians, originally from Toronto, who were resting up in Kigali before cycling to Botswana. On Wednesday they will start a 600 km ride through small villages to some town in Tanzania, where they can catch a boat to take them the length of Lake Tanganyka!

At midnight the five of us piled into a Toyota Corolla taxi and were driven to Cadillac. After a brief discussion we decided the RwF 1,500 ($3) cover charge was OK and went in. It was loud and dark, with lots of UV lights. I went to the bathroom and found I had lost the rest of the group when I got out. As I searched for them I realised I was being followed by a prostitute. I tried to shake her off and managed to find the group. Women in skimpy outfits kept on coming up to our table, putting our arms around us and asking if we wanted to dance. It was difficult to even look around the room at the African couples dancing, as you found yourself making eye contact with the ladies of the night who did not need any more encouragement to come to our table or to dance provocatively.

Even after a couple of beers and a Tequila shot I felt uncomfortable, so I left at 1:30. On the way out a woman asked me where I was going. I said I was going home. She squished her breasts against my chest and from about three inches away, looked into my eyes and asked if she could come with me! I said no, and made a dash for the door. The first taxi in the parking lot wanted RwF 4,000 (about $7) to take me home. That's a fair price, but he could have asked a lot more and I would not have argued. I am a happily married man, get me out of here!

Greg stayed until the small hours of the morning, but had his wallet pick-pocketed, which is sad but perhaps not surprising.

Victory Children's Orphanage

On the way back from Butare we stopped at an orphanage, run by Serena, who we had met in a cafe in Kigali, and her husband Isaac.

http://www.victorychildrenshomes.com and
http://victoryfamilyhomeofchampions.blogspot.com/

It houses 60 orphans in a a couple of dormitories and provides an on-site school for the younger kids. They are trying to be self-sufficient, growing their own vegetables, and keeping cows, goats, chickens and rabbits. They have a generator which they use two hours a day to pump water from the well to holding tanks, The rest of the time they have no electricity. It is set in a few pretty acres just east of the main Kigali-Butare road, a few kilometres from a small village and maybe half an hour south of Kigali.

I admire the couple, who's religious conviction have led them to leave their home and lives in Wyoming to care for some of Rwanda's many orphans. Even with the help of a local manager, they have a lot to learn and adapt to as they work to improve the orphanage and learn to operate a small-holding in Rwanda.

Isaac and Serena gave us a great tour, and invited us into their home for a cold drink, which was very welcome. I had just received some money from the National University of Rwanda to pay for some of my expenses on the trip, which I had not been expecting, so I donated it to the orphanage. The football pitch there is dangerously uneven, and Isaac wants to use the spare soil from the retaining wall project to even the ground, then plant grass seed. It is a small gesture, but maybe with my money they can give the kids a decent, level, even grass soccer pitch!

Wednesday at the Green Corner

It is a tradition that the visiting lecturers take the residents out to dinner after one of the last academic days. I originally thought about Heaven Restaurant but that would be very expensive, so I considered the Karibou which is within walking distance of the hospital. The residents recommended the Green Corner, a local bar in Nyamirambo, which turned out to be a great idea. We piled into a couple of vehicles and were driven up the hill out of town for about 25 minutes. The place looked very basic - concrete floors, brick walls and old plastic outdoor furniture. At 4:30 there was no problem pulling a couple of tables together, and we ordered the first round of drinks.
One resident ordered a coke and tonic - a bottle of each, mixed together. The next ordered a guiness and coke, same deal. The third ordered Tusker, the Kenyan beer which Rwandans always drink two bottles at a time. Greg and I stuck to large Mutzigs.
Once we were all assembled we ordered food. There was no menu. The "chef" came out of the kitchen in a reassuringly clean white apron and there was a brief discussion about what was available. It was decided that three tilapia (a meaty lake fish) and three chickens, all barbecued and served with chips, would serve the ten of us. It took a long time to arrive, so we drank more beer on an empty stomach as the sun slowly set over Kigali. When the food came, iot arrivefd without cutlery. A waiter came with soap, a kettle of warm water and a washing up bowl. We washed our hands and dug in. Lime was squeezed on the fish and we broke it apart and ate it with our bare hands. It was delicious. The chips and chicken were good too. It did not take long to reduce all the dish and chicken to a pile of bones!








Candles were lit and vinegar was spilled on the table to keep bugs away, not that I noticed any. Greg decided he should eat the hot pepper and follow this with a drinking challenge. He, representing Canada won against a resident origianlly from Congo, and I representing the UK lost to Rwanda. Slowly people drifted away home. By 10:30 I had had my fill, and one of the residents came home with me on a minibus to make sure I got back safely.
It is a while since I've spent six and a half hours drinking. I woke up at 3 am, drank a couple of glasses of water, took a tylenol #3 just in case then slept until 5:45, waking up feeling OK.
The car arrived at 6:30 am to take us to Butare for a couple of days.

Monday, Working at CHUK

Actually enjoyed working in Rwanda today, I think for the first time.
I am getting used to the pace, and beginning to accept that sh*t happens.
Our driver was ten minutes late, so we came into the middle of the morning case presentations. When the presenter speaks loud enough I can follow his French. I think I made a few useful points (in English, I'm afraid). Had a decent discussion with one of the senior residents about a couple of cases. Got to the OR and there was no-one there. Looked over one of the old anesthesia machines and tried to figure how it worked. Went to the tea room and did some reading.
Eventually the first case arrived, but there was no endotracheal tube of the correct size. I made a big fuss about this. This is the University Hospital of the capital city, where they do a lot of paediatric cases. There is no reason why they should not be able to keep a supply of paediatric sized tubes in stock. After much prolonged discussion I cancelled the case. I talked tot he only staff anesthesiologist around, whio was in the ICU, and he eventaully found the rightr size tube in ICU and the case was un-cancelled and done in a different room by a nurse anesthetist, who decided not to use the tube I had found but the smaller one I had said was too small. Odd.

I was getting very frustrated working with one of the weaker residents, who seems not to remember anything I tell him, so I decide to go for an early lunch. As I headed out I saw a trail of fresh blood leading into one of the other ORs. This is never a good sign,,,,,

I wnt in to find one of the final year residents dealing with a patient who had a massive burn . A gas explosion had burnt his face, chest, both arms and upper thighs, about 30% of his body in all. He also had a depressed skull fracture and was bleeding from a skull laceration. At this time he was talking but not co-operative with examination. Two IVs had been started and the resident was working on a third. I put on the monitors and oxygen. No BP was obtainable. He has a slight tachycardia and a saturation of 90%.

Clearly he needed intubation, And clearly it would be a challenge.....
In the end I was able to topicalise the airway, and with a little sedation and two people holding him down we decided we could see enough to intubate. So we did a modified rapid sequence induction with a small dose of propofol, checking we could ventilate with cricoid pressure in place, then sux and a 7 tube with stylet. That all went well.

The surgeon did a debridement and we gave fluids according to the Parkland formula. Originally the BP was around 90 but then it shoyt up to 220/110 for no good reason, In the end I moved the cuff to the other leg and the BP returned to normal.

Had as sensible discussion about a variety of issues:
Should we trach him now? I thought doing a tracheostomy through the burn was a bad idea, especially as hopefully in a week or so the swelling would go down.
What do we do about his head injury? The surgeon could palpate a depressed fracture. Obviously he should have a CT scan, but this would require a transfer to King Faisal Hospital, about 30 mins away. In the end we decided to monitor him clinically and hyperventilate him, and cross our fingers we are not missing a surgically correctable problem.

At the end of the day I called Joseph, who is in charge of the drivers, and asked for a lift back to the apartment. He decided to drive me himself, in Landrover Ambulance. When we got to the roadworks, they let down the barrier for us. When we got to the actual working area, we just drove up onto the pile of dirt and drove straight over it. Very cool.

Stopped at the gas station across the road for yoghurt and juice, then went home. The houseboy (yes, that's what people call him) knocked onthe door with my washing, all neatly dried and folded. I paid him 3000 RwF, less than $6. Sweet deal!

Did some work preparing for the academic day on Wednesday - anticholinergics, anticholinesterases, patient positioning, and anesthesia for ENT surgery - then took the bus into town (20 cents). Doing this blog then out for the expatriate Pizza and Quiz night. Not a bad day....

Come to Rwanda, Swim in an African Lake, See Gorillas

It is time for you to stop reading this blog and book a flight to Rwanda!
The more time I spend here, the better I like the country.
On Saturday we wer picked up by a car and driver (A Toyota Land Cruiser in fact) at 9am.
We drove through stunning countryside - a mix of the look of Nepal, the Amalfi Coast of Italy and the Coastal Highway between SF and LA. Huge hills divided up into fields of banana, corn, surghum, coffee and 'Irish" potatoes (not sweet potatoes). We stopped at a brewery for samosas (delicious) and banana beer (revolting, but 14% alcohol and cheap. Some people like it but I could not take more than a few sips). We stopped at a waterfall and I climbed down, accompanied by some local kids. They watch you and talk a little in English or French. They sometimes ask for money but our driver kept on asking them 'What for? You cannot just ask for money, You have to have something to sell, or provide a service'. They were satisfied to find out things like our names and ages and how many children we had.



We stopped for sugar cane bythe roadside. Greg got into peeling the cane with a machete, then dividing it into four lengthwise and chewing. It' s amazingly sweet, like pure sugar.
We drove through Ruhengeri, getting views of the volcanoes, past some dire looking refugee camps, and down to Gisenyi. We stopped for a late lunch at the beautiful Serena Hotel. It was a bit over-priced - $9 for a grilled vegetable baguette with fries and salsad, $2 for a Fanta - but once you had eaten you could use their change facilities and swim on the beach. The weather was grey with bits of rain, but the water was warm, the beach sandy, and the water dead calm.



Greg negotiated with the operators of a 15 ft power boat to take us across the bay to the Congo border for about $8 fopr a 20 min ride. The city over the border, Goma, seemned very prosperous from what we could see from the lake.
Our driver piucked us back up for a spectacular drive around the bay past the brewery to the hot springs where locals wer bathing and cooking corn in the bubbling water which felt to be about 70 degrees centigrade.


We drove back to the Kirigi lodge north of Ruhengeri as the night fell. We had a room booked, then had an excellent steak for lunch. Huddled round a wood fire in the lounge (it was cold and pouring with rain!) drinking tea and talking to other travellers, a mix of tourists and other people doing varous volunteer work in Africa.



In the morning we were up at 6 for breakfast (cold omlette with decent tea, bananas and toast). We admired the views of the volcanoes as we waited for a ride to the park headquarters. By seven we were at there, and joined a group of 6 people who were assigned a specific family of gorillas. Our family was 16 animals, including two mature male silverbacks and several babies. We then drove over the most horrible dirt track you could imagine -so bad that on the way back I insisted on getting out and walking - to a smalll parking area. We wer loaned walking sticks and set off across a potato field to the forest. The views of the volcanoes were spectacular, It was a dry bright cool sunny day. After a few minutes we were in the forest, climbing over fallen branches and vines, pushing our way between dense vegatation only partly cleared by our guides with machetes. Eventaully the guides got in radio contact with the trackers. When we were close we had to abandon everything except our cameras. Ten minutes later we saw the first gorilla, lying in the sun, doing nothing, which was a it of an anti-climax. Then we heard rustling in the bamboo as other gorillas appeared. We saw a couple more up in trees. A baby started to walk towards us, followed by its mother. The guides were freaking out, as we are suppossed to stay 7 meters from the gorillas so we do not give them any diseases. But there was no-where to get away from them, so they walked past us, brushing against Greg's jeans, and wandered off. We saw a little baby try to climb on a dead branch which broke and it fell a couple of feet into dense vegetation. Then it tried to climb a tree and fell off again. Later we saw a baby play-fighting with a larger juvenile. They both stood up and bashed each other with their paws, or rolled over on top of each other.



Just as the guide said our hour was up we came across one of the silverbacks. It was sitting on a branch facing us, looking just like a man in a gorilla suit! It chewed bamboo nonchalently as we watched. We got back just as it began to rain very heavily. We felt sorry for a couple who had insisted on doing the long walk to see the Sousa group. They must have got soaked!

We drove into Ruhengeri and went to the Murahbo Hotel for Goat Brochettes for lunch, then headed back to Kigali, again stopping for photos, climbing up to see some coffee trees, and buying Greg some more sugar cane.

Its a very privileged existence, being driven in a Toyota Landcruiser with Congolese easy-listening CDs on the stereo past people living in houses not much better than mud huts.

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 sympatico.ca 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.

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.

Pictures

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.