Thursday, February 18, 2016

gratitude (Ana)

There are many details I could share with you from this week: the successful teaching by all on academic day, the highly engaged residents providing complication free patient care in the ORs, the palpable momentum for developing a rotation in San Francisco for our Rwandan resident colleagues, a fun Chinese dinner with people we just met who are also engaging in social service-minded projects in Rwanda, but I feel like painting with broader strokes.  

Since quitting my academic position in April 2015 for a more balanced life in private practice, a lot has changed in me.  I first noticed its effect on this trip while hiking in Volcanoes National Park.  I realized I was completely enjoying the hike, the scenery, and the people around me.  It was somehow different than the many hikes I’d done before.  Not that I didn’t enjoy hiking before, but there was always a subtle sense of haunting obligation.  I had a responsibility to my university employer, a compulsion to expand our Global Health program, and a duty to ensure my US students got the most out of their experience.  

Being in a place far away from home and engaging with a culture unlike your own, creates a fertile place of contemplation of your life and your story.  I feel lucky.  The privilege to be with these amazing Rwandans and to witness their strength after atrocity and their optimism under burden is truly inspiring.  Twenty-two years since the genocide, much of the world still wonders if Rwanda is safe to visit, but over the last 6 years I have been fortunate to bear witness to progress at a speed surely unmatched.  Infrastructure continues to expand, business development and foreign investment is obvious, and stability is sensed in greater quantities with every visit.  Fortunately, this progress includes healthcare improving the quality of people’s lives.  

Being able to collaborate with Rwandan colleagues, feeling their enthusiasm and confidence has taught me much about my life’s work and my time spent on this rotating globe.  In the words of my dear colleague, Paulin, the world is a “big village” and it’s important to consider “what seed you are planting” and its cultivation.  I am still fulfilling commitments to the university, my students, and the global health program, but my drive is not longer clouded by obligation.  It is refined by my passion.  I am convinced I have learned more than I have taught and my heart is filled with gratitude for the privilege. 

We will leave tomorrow and I will look forward to next year until it comes.

XOXO

Ana 

Monday, February 15, 2016

gorillas, almost for free (Ana)

Friday
The morning was spent with senior resident, Francoise, assisting her with preparations for her Monday morning lecture on pulmonary embolus. We departed around noon with Emmy to drive to Ruhengheri to spend the night at the Muhambura hotel.  It is always stunning to drive across this country with its tiered hills covered in lush green agriculture and beautiful people in bright patterned clothing bent over in 90 degree angles tending to their land.  Women carry baskets or sacks of vegetables on their heads.  There are small herds of roaming goats and cows follow by young boys with sticks, the slightly older siblings of other little boys playing with old bicycle wheels by pushing them along with sticks to see how far they can get before the wheels topple over onto their sides.  Markets with brightly colored fruits and vegetables for sale dot the roadside otherwise lined with red mud houses and storefronts painted with bright colors and advertisements. And everywhere there are people walking.  They walk along the side of the road far too close to the moto-taxis and large cargo trucks coughing black smoke into the hazy air.  T-shirt reading is quite entertaining here.  “World’s Greatest Grandpa” and  “McLovin” are two that I have seen on young men that made me chuckle.  Many of the clothes, especially in the rural parts of Rwanda, are second-hand and clearly come from western donations.

For dinner, Lauren and I shared a savory traditional Rwandan “hot pot” or stew made with vegetables and chicken.  We had dinner on the outside dining patio during an early evening downpour. I retired to my room early but stayed up late finishing “When Breath Becomes Air,” a memoir by a Stanford colleague who recently passed away after a diagnosis of lung cancer receive prematurely at age 36.  I would highly recommend it to anyone curious about facing the inevitable end to life.

Saturday
We woke early for breakfast at Muhambura before heading to Volcanoes national park so that Lauren could trek gorillas and I could hike up a volcano to Crater Lake.  I felt so excited for Lauren. Visiting the gorillas is such a surreal experience.  This was the second time I would hike to Crater Lake, however, this time our group was caught by cold rain and wind at the top and we slid most of the way down.  It was a challenging hike that took about 6 hours with 1411 feet elevation gain in about 2.5 miles.  I was filthy and tired from using every muscle I had to stay upright in the slippery mud, but it was definitely worth it.  I met a couple American ladies, one an emergency medicine physician working in global health, so we talked shop during the hike.  We even saw a gorilla on the way down which is amazing since the cost of my hike was 75$ and the price to trek gorillas is 750$!  Amazingly, two years ago the same thing happened when I hiked this trail.  Lauren had an amazing experience seeing a family of gorillas but had the same cold and muddy trek.  Exhausted, we left for the two-hour drive to Gisenyi and Lake Kivu around 4 pm.  Luckily we stayed at Paradise Malahide (one of my favorite places!) and the showers were hot.  I remembered several of the hotel staff, and they remembered me, at least they said they did.  Exhaustion plus dinner made for an early night and sound sleep.

Sunday
This morning I slept in… meaning I didn’t set an alarm.  I still woke at 6:30 am, which was actually great because it was in time to catch the traditional fisherman returning from their all night excursion.  The traditional fishing boats are beautifully carved wooden boats with huge boons that extend out to the sides. Typically the boats are connected in threes and the men row in aggressive synchrony bringing back their catch of small sardine-like fish, which they dry and sell in town.  Sometimes they sing and chant which adds to the excitement of their hurried rowing.  Sunday mornings are also remarkable for the singing and music that floats across the water from the churches to the hotel.  There are hundreds of types of colorful birds, lizards, and flowers that also define this place as paradise. Breakfast is by the water with strong coffee, an omelet, and crepes filled with honey.

After breakfast, I pack my bag and do some work until Lauren wakes up and has her breakfast.  Emmy arrives and we leave, have a beer at Tam Tam public beach, tour the Congo border, and then make the long trek back to Kigali.  In Kigali we buy chocolate for Valentine’s Day and head straight to the airport to pick up Michelle, who is also joining us from Stanford.  Incredibly capable, motivated and organized, she is the Global Health administrative director and is here to observe and evaluate the Rwanda program assisting with current and future endeavors.  I am incredibly grateful she is here because she is so effective and will be key to expediting the Stanford rotation for Rwandan residents that we want to create.  Back at the apartment in Nyamirambo we settle in for an early night in preparation for Monday’s academic day.

Happy Valentine’s Day!!!



Matt teaching regional anesthesia

Teaching in the sim centre


Friday, February 12, 2016

Baby Cow and Pearl

Tuesday, February 9 2016

Today was my second day at the main teaching hospital in Kigali.  Academic day is on Monday and is filled with lectures, case presentations, and simulation sessions luckily broken up by an hour and a half lunch at the nearby buffet.  This year is really remarkable because rather than giving most of the lectures, our role has transitioned to supervising the senior residents’ teaching. This was the goal of the program when it began in 2006 and it is rewarding to see it come to fruition after years of investment by many volunteers and organizers.  Teaching the teachers and training qualified anesthesiologist are much more sustainable endeavors than flying in to provide “mission”-type services.  I always feel a twinge of guilt for possessing the severe dislike for the expression “mission trip” when applied to my work realizing people’s good intentions.  But, it really is much more than providing temporary services.  It is changing the healthcare system’s human resources to eliminate its dependence on foreign volunteers.  Teaching a man to fish is always better than giving fish or importing fish from remote locations.  Fish go bad easily.

The residents did a great job preparing, but there was plenty of feedback, primarily the gross misuse of PowerPoint and the easy mistake of boring your audience to sleep. I am hoping to pull them far away from reading their text filled slides and push them towards becoming dynamic, engaging, and interactive presenters. It is exciting to help them develop into effective teachers and leaders.

Lauren, the anesthesia resident from Stanford arrived last night after safe and uneventful travels.  It is always fun to share this place with someone new and observe their experience of this amazing place and these amazing people.  A stunning redhead with perfectly ivory skin, Lauren, not surprisingly, gets countless intrigued looks from the people walking on the street.

It is also fun that the Rwandese (yep, not “Rwandans”) have such amazing memories. I am always surprised by how many people remember me from my previous visits.  From the doorman at the Serena hotel, to the young guys working in the gym, to the hospital staff and nurses, everyone is so welcoming to a familiar face.  Some of them even greet me by name.  

After work we, of course, return to our oasis at the Serena hotel utilizing the Wi-Fi connection to work on teaching materials and catch up on emails before grabbing a workout and dinner.  There is always the buzz of hotel guests wandering around the hotel or congregating in little groups in the lounge areas.  I imagine they are all business people investing in developing opportunities in Rwanda.  Lauren and I fall silent and into our work at our table by the window in the upstairs lounge area overlooking the pool and waterfall.  

Another beautiful thing about Rwanda is the afternoon storms.  The pale grey sky grows black and threatening, lightening begins to flash, the air turns thick and cool, and the inevitable downpour begins.  Being from the south, thunderstorms are something I definitely miss in Northern California.  After the gym I order my usual nicoise salad washed down with a glass of sauvignon blanc and a bottle of water before we grab a taxi back to Nyamirambo.  I turn on the fan on my room, one to cool the room down, but also to drown out the noise from the bars outside.  I take down the mosquito net and crawl into bed, my eyelids heavy with jet lag, excitement, and wine.


 Wednesday and Thursday, February 10th and 11th, 2016

Wednesday we had a driver pick us up at the apartment and spent the day at the military hospital.  We taught “modes of mechanical ventilation” and “pulmonary embolus” to one of the first year residents, Brigette.  She is in her first year of training and is doing well and catching on quickly.  She was formally a pediatrician and switched to anesthesia when she realized that anesthesiologists are the ones everyone else calls for help when patients are very sick.

I was also able to see and catch up with Dr. Jeanne who is someone I admire greatly. The first female anesthesiologist in the country and one of only five anesthesiologists in country before 1994, she was the only one left after the genocide.  She has years of experience, an unyieldingly positive attitude, is incredibly skilled, and I learn from her every time I am around her.  She also has the most contagious laugh and smile that you can’t help but love.  I guess it doesn’t hurt that she envelops me in a giant bear-hug every time I see her.

We skipped our workout at Serena and opted for Khana Kazana, an amazing Indian restaurant in a fancy neighborhood near the presidential palace.  Sleep came easily but unfortunately was abruptly over at 12:38am.  I think my California clock came back to haunt me.

Thursday

We got to commute in a rideshare bus this morning provided by the hospital with several others making their way into work.  It was fun and almost gave a feeling of what it would be like to live and work here.  Today was spent in King Faisal hospital, which is the major private hospital in Kigali.  Private means well resourced and well funded. We attended grand rounds in the ICU before heading to the ORs to work with another first year resident, Eugene.   

Eugene was phenomenal.  Not only does he possess an amazing fund of knowledge, but he is also research oriented, empathetic, and loyal to serve the people of his country.  This last point has turned out to be a huge issue as we watch several of the residents we’ve trained to become faculty leave the country for greener pastures.  It is called “brain-drain,” and I am hoping that by developing people like Eugene, it will decrease as the situation in Rwanda continues to improve.

It amazes me how the personality of a surgeon transcends cultures and ethnicities.  The surgeons in Rwanda are just as cheeky and overconfident as in the United States.  Today Lauren and I received Kinyarwandan nicknames assigned to us by a surgeon.  Lauren’s name is interpreted as “little gem” or “pearl” and mine means “baby cow.”  Apparently both are complimentary.   According to some, baby cows are known for being very cute and another person even says it is a sexy nickname.  I’m not sure I’m going to understand this anytime soon…baby cow?....sexy?..., so I just said “thank you.”

So, Baby Cow and Pearl had a nice workout at Serena before we went to a restaurant called Heaven to meet up with Gaston, a previous student who is now faculty, and a guy named Ryan who Lauren knows through Stanford.  It was a fun dinner with lots of great conversation and laughter.

Lauren and Emmy


Ana - Rwanda: Take 6 (Feb 7)

It was raining when we landed and the air was hot and humid disguising the usual waft of smoke that greets you when you step off the plane.  The airport looks nice.  I’m not exactly sure what has changed, but it definitely looks more modern than last year and a shuttle bus is waiting to take us from the tarmac to the arrivals corridor sparing us the hustle through the light rain.  I line up in the visa payment line not remembering how much it costs or whether I was supposed to fill out some paperwork to apply.  I am only slightly concerned when I notice others shuffling through papers and readying their passports.  This is in stark contrast to the first year I came to Rwanda with a folder of neatly organized papers documenting every thing from my connection with the university, to my yellow fever vaccination, to my birth certificate.  Now I know I can get into the country with a valid passport, a smile, and an “amakuru!?”

My dear reliable friend Emmy jumps out of the crowd of people outside the arrivals exit to greet me.  Dapper and smiling as usual, he immediately begins to gush his usual compliments and inquiries into my well-being.  He accuses me of bringing the rain but says it’s lucky.  He would make an effective politician but excels in his role as tourism guide and logistical host for our program in Rwanda.  He is wearing the Hugo Boss watch I bought him a few years back and still bragging how he wears it to special occasions and gets compliments on it often.  His son is now 2 and a half and his daughter is 6 months and both he says are tall for their age, a trait they undoubtedly inherited from Emmy.

There are bright stadium lights up on a hill.  The Democratic Republic of Congo and Mali are playing in the Africa cup.  It sounds fun and a small part of me wants to go check it out but I am more tired than I remember being in the past after this 24+ hours journey.  I also know I better be tired because it will be hard to sleep over all the partying in Nyamirambo, our program apartment’s neighborhood.  Emmy jokingly calls it “Nyamirambo Vegas.” 

Christophe meets us at the apartment building gate to greet me and help me with my suitcase up to the third floor.  We moved from Charles’ apartment on the second floor because he never would get around to fixing the broken things, the water never worked, and he was blatantly unconcerned about the happiness of his tenants.  Our new apartment is owned by his younger brother Antoine and is much nicer anyway.  Christophe just graduated from college for some trade I unfortunately don’t remember. Distribution management? Something business related.  His graduation is a huge accomplishment since he started out as the building's “house boy” usually barefoot and from an incredibly poor village family with seven siblings.  Someone in our program motivated and financed him through the process and I am sure all of us have given him additional encouragement along the way.  I bought him a graduation card and have a crisp bill to place inside it but it is buried somewhere in my suitcase, so I tell him I have a graduation gift to give him tomorrow.

Emmy and Christophe say goodnight and leave and I unpack my suitcase.  I am so grateful that Patty left milk, eggs, and coffee because I am way too tired to run out tonight for tomorrow morning’s breakfast.  I can hear the constant hum of music and voices outside the apartment. There is a roach in the bathroom sink. There is a gecko in the kitchen.  It is good to be back in Rwanda.

Saturday, February 6, 2016

back to winter

The last few days in Rwanda were a whirlwind. During academic day on Tuesday we had the usual morning teaching and in the afternoon all the residents had a simulated scenario, a written quiz and an oral exam. Then there were parting words: thanks and a heartfelt wish by our Rwandan colleagues for Tristan to return.

Wednesday we attended morning report then spent some time in the OR with the residents. That afternoon Tristan surpassed all previous swimming records by swimming 80 lengths of the pool without stopping.  I did the same distance but with some pauses.

The journey home was long but there were no blizzards and all the luggage arrived. We even got moved up to an earlier flight in Toronto! Nevertheless, I am finding the travel ordeal more difficult physically (little sleep, not enough water and some last minute GI illness).

However, it is becoming emotionally easier to toggle between these two worlds. Rwanda – with its warmth, open hearted people, slower pace, crowds, crazy city traffic, peaceful green countryside, a thousand hills, and superb teaching opportunities – and Halifax – so quiet, orderly, icy cold, bright, safe water from the tap, and no cockroaches in the bathroom! It is an incredible privilege to be at home in these two wonderful but very different places.

Thank you to everyone who followed the blog and offered support. Thank you, Dylan, for sharing a wonderful week with us in Rwanda (and giving us a huge laugh when you fell in the pool). Thank you Matt and family for being brave enough to commit to three months of teaching in Rwanda.

I would like to give special thanks to Tristan for being a brilliant teacher, fabulous companion and Rock of Gibraltar. He is thoughtful at all times and has a most delightful sense of humour. And so freaking SMART! It was a huge sacrifice for him to be away from his lovely wife and daughter for a whole month but I only hope he enjoyed being in Rwanda as much as the Rwandans enjoyed hosting him.  May he return.

And then there's Michelle, my dear friend and companion.  She is as glued to Rwanda as I am.  Please keep coming back.  You are so loved by so many.

Big hug and signing off till next year,

xxoo
Patty



Point Pleasant Park, a favourite place to walk

Monday, February 1, 2016

Tristan's long swim

Tristan's swimming ability has improved leaps and bounds.  He had the longest swim of this life today.  Very impressive.


Tristan after his swim
A well earned fruit plate

Invited to Paulin's house for lunch with the Ho family

Tristan v.3 - Hero's Day Holiday

I had mixed reviews on my Feifel Goes West joke on the last blog post (mainly from uncultured heathens... who doesn't know Feifel Goes West?!?!), so I'll be more circumspect today.

Nice to have an extra day to extend what has been a beautiful weekend in Kigali. In addition to soaking up some nice sun and warm weather, it is almost a blessing to have the extra time to prepare for the final academic teaching day on Tuesday. We have a full day lined up, complete with new sim scenarios, as well as written and oral exams to give the residents some practice thinking through anesthetic cases.

I have the feeling that they'll do pretty well actually, considering the complexity of the cases that are the norm here. (eg. for the OB anesthetists reading this: we helped with a G4P3 IUFD at 38wks, prior C/S, pre-eclamptic, morbidly obese, poor mouth opening, malaria, plts 23, BP 210/110 on my first day in the ORs). Their knowledge base seems quite good. Where we come in is helping to provide a framework on which to hang that knowledge in an organized and consistent manner. We've  seen great strides to that end, and the seniors seem quite able to deftly discuss anesthetic considerations and plans. I think we're doing important work here, and making some good progress. We just need more of our graduates to stick around to build the capacity...

Last week was spent in Butare, a smaller town, but large enough to have a teaching hospital (the national university of Rwanda is also there). Only 4 ORs, not all of which are running continuously, so the pace is a little more reasonable and the flow of patients seems quite good. We had a few great days of OR teaching, followed by ice cream rounds, where we taught all sorts of topics in a  relaxed atmosphere with delicious coffee ice cream. I think the 10 new residents have re-vitalized the department here and everyone seems engaged and hungry to learn. The challenge now is that there are so many learners that its hard to get enough time with each of them!

On a less academic note, I'll maybe briefly mention my trip to the Genocide Memorial yesterday, although it is impossible to do it justice... Suffice it to say that the experience is powerful, and the memorial is professional, respectful and honest. It seems to be free of political influence, but I am cognizant that history is often written by the side left standing, when all the dust settles. Regardless, the mass graves, interring  an unthinkable 250 000 Rwandans, are an important reminder that humans can do unconscionable things for ludicrous reasons. I fear for the people of Burundi, who may be facing a similar ethnic struggle, with recent worry of new mass graves by satellite imaging and apparently little heed of the tragic lessons of its neighbor, Rwanda.

Okay. Slightly more positive now, stay with me: Today I swam longer than I have ever swam before... we calculated it out to be 1.25km or thereabouts... 60 lengths of a 22.5m pool. non-stop. I'm not sure I can explain how... the most I'd done previously was 20 lengths, with lots of breaks, but I figured out the breathing and it just felt good to keep going. I never swim. It's just not something I've done, but the pool is inviting, I'm up for learning new things, and Patty has been coaching my technique to help with endurance. I think I might have to take it up at home...

Okay, this has been another marathon blog post... still not my longest. I clearly need to keep working on my endurance...

Sunday, January 31, 2016

Sunday morning

What could be a better start to Sunday morning in Rwanda than a two hour walk with Bona followed by a massive breakfast at the Serena Hotel? The hotel even paid for our breakfast this morning as a reward for being such good customers.

Tristan has gone to visit the Kigali Genocide Memorial.  I am preparing a quiz and simulated scenario for our next teaching day (Tuesday).  Monday is a holiday for Heroes' Day.

More on Heroes' Day:
National Heroes' Day commemorates events that occurred after April 6, 1994, when Rwandan President Juvenal Habyarimana and the president of Burundi were killed when their airplane was shot down. After that, the Rwandan military began to systematically kill all Tutsis and moderate Hutus. Local officials and government-sponsored radio stations called on ordinary citizens to kill their Tutsi neighbors. Hundreds of thousands of Tutsi and moderate Hutus were killed. This is now known as the Rwandan genocide. Victims of this genocide are remembered on Heroes' Day.

During the Rwandan genocide, rebels surrounded the Nyange Secondary School and asked the students to identify the Tutsi students. When a group of students refused to do this, the rebels killed them. This heroic act is also remembered on National Heroes' Day. Wreaths are laid at Nyange in memory of students who stood against the rebel forces. The national Heroes' Day celebration at Nyange features songs, dances, and poems praising the virtues and good example of the national heroes.The people are reminded of the great value in service to the country that the national heroes have shown those who are still alive.



Just downhill from our apartment 

Jean Marie, Bona, Tristan and Patty, happy walkers

It could be rural Rwanda

Cassava plant

Graveyard in the hills

Goats wander untethered

Carrying vegetables on the head

Local shop and moto




Saturday, January 30, 2016

CHAN quarterfinal

Today is the CHAN quarterfinal with Rwanda vs Congo. Busloads of Congolese fans have arrived. The Congo president has promised each player a Toyota Land Cruiser if the team wins this game. People were released from umuganda (community service morning) early to get to the stadium. This is a huge deal. Imagine Canada vs USA gold medal Olympic hockey game times ten. 

Score now 1-1.

Christophe ready to go to Amahoro stadium
Later: Congo scored in extra time, so it is all over for Rwanda.

We are happy to welcome Matt, Charissa, Lucas and Gracie to Kigali.

The Ho family, happy to be in Rwanda

Wednesday, January 27, 2016

teaching, ice cream and monkeys

The sky is overcast, promising more rain.  Dramatic lightening, thunder and intermittent heavy rain in the past few days. Ravens are scratching frantically on the roof.  The air is rich with the earthy smells of last night’s rain.  A cleaner is mopping up while listening to tunes on the radio.  Large thermoses of coffee and hot milk are coming. Morning in Butare.

Butare offers fabulous teaching opportunities, orderly operating rooms and relative calm.  This helps compensate for the limited food options, cold showers and don’t get me started on the Credo Hotel rats. Hence, we stay at Mont Huye.

Jeanne, Theo and now Gaston, have provided steady leadership so the operating rooms have a sense of being under control. Delightful.  Yesterday, Tristan helped his colleagues anesthetize a 5 day-old baby for two-hour surgery – smooth anesthesia and a good outcome.

In the afternoons, we gather a small group of residents for discussions on anesthesia topics. They love it.  They are coming in post call, as they are so eager to receive teaching. We’ve relocated the venue to Inzozi Nyziza (the ice cream shop) so the discussions are augmented by ice cream, coffee and the ever-present Fanta citrone.

Gaston has stepped into the role of staff anesthesiologist beautifully.  He has an onerous call load, as he and Theo are the only two anesthesiologists in Butare. This means they are each on call half the time. Unfortunately, Gaston’s wife and children live one hour east of Kigali.  This means Gaston can only be with them every other weekend. Clearly, this is far from ideal. Tristan and I had dinner last night with Gaston and discussed potential solutions. His family needs to be with him.

We are heading back to Kigali tomorrow afternoon.  Matt is arriving late tonight. It will be great to catch up with him and his family.


Beautifully manicured grounds of CHUB

Ice cream and teaching 

Tons of monkeys on the land behind the university

Our dear friend Gaston at the hotel where he is living