Friday, January 18, 2019

Familiar and foreign

From Jon:

The moment I step off the plane the warmth and humidity settle on my skin as I smell the slightly smoky air of a major city which is at the same time fresh - infused with eucalyptus.  The tactile and olfactory essence of this place immediately takes me back to the last time I was here. Even though I anxiously wait for my bags to appear on the carousel, the knowledge that there is a friend waiting for me outside settles my nerves.  The drive from the airport is relaxed. Christophe and I catch up on the last few years as I gaze out the window at the galaxy of lights running through the valley and up the hills.


View near new apartment

Although the apartment is new (and beautiful), I quickly reorient to the city and landmarks.  The remainder of the weekend – aside from sleeping – is sent visiting favorite restaurants, coffee shops, and bars.  The downtown core feels comfortable, my pace slows to match the locals and the heat – except for when I cross the street, timing my stride to the meet the gaps between motos and cars.  Our good friend Emmy comes to pick me up for a chat over a Mutzig at the famed Guma Guma bar in Nyamirambo just under the old apartment.

Old Guma Guma bar

Returning to Rwanda gets easier every time.  It’s a unique experience for me to visit another country where we know so many friends.  The Dal Health Office and Anesthesia and CASIEF have created an amazing interconnected group of people.  There is a completely different feeling when you’ve known local staff for years, met their families, hosted them in your home, and been hosted by them in their home.  All plans and discussions start with the background of mutual respect and a shared history. This obviously changes how priorities are set and plans are executed.

Mary, Rediet, Patty, Eugene, Alain, Christian, Stephen, Chris, Dave, and Gaston

Gaston, Dave, Patty, Christian, Alain, Stephen
Jon, Chris, Eugene
Even in minor ways these relationships make things easier.  If I’m lost, I’m a whatsapp message away from someone to pick me up.  If I need a favour, someone is there and happy to help. We are supplied with advice about transport, restaurants, tourism, and avoiding problems in general.  In short, the experience of Rwanda is increasingly comfortable. Yet, it remains an enigma.

Culture underlies everything we do.  Despite our experience and interpretation by our friends, we have misunderstandings and missteps.  Even Patty on her 14th trip to Rwanda emphasizes that she’ll likely never fully understand the intricacies of the culture here.   We try our best, but we will never replace the knowledge of our Rwandan colleagues.

Road near new apartment

Thursday, January 17, 2019

Rwandan Pain Conference: From need to opportunity

From Stephen:

This week finds our team in the beautiful Butare (Huye). Long the academic hub of the country, the city’s highland setting provides for cooler breezes and more temperate weather than frenetic Kigali. The contemplative weather plays welcome host to this week’s latest adventure: the first ever international pain conference held in Rwanda.

Another achievement in the long collaboration between CASIEF and the Rwandan anaesthesia residency programme, the ZeroPain conference has been organized in its entirety through local expertise. Pain experts among our team, Drs. Mary, Patty, and Jon, stand as equals amongst other local and international invitees to deliver locally tailored content and solicit ideas on future research needs. ZeroPain is truly a coming of age for the Butare Pain Team and their ability to chart their own course as they set out to conquer unrecognized and untreated pain in Rwanda.

With topics from safety in regional anaesthesia, to empowering nurse led recognition of pain, locally informed pain pharmacology, to the vast potential of micro-research, the conference has had broad appeal. Equally broad has been its reach! In polling the audience, we discovered that the conference is playing host to nurses, physiotherapists, social workers, non-physician anaesthetists, residents and staff anaesthetists, and researchers!

In reflecting on the accomplishment this conference represents, I feel something needs be said about the dedication of the attendees themselves. Despite a very busy conference schedule (grueling might actually be more apt), the attendees were unflagging in their attention. While my concentration drifted, the attendees were busy scribbling notes; there was hardly a distracted cell phone scrawl to be seen. The need for a paradigm shift towards the recognition and treatment of pain in stoic Rwanda is desperate; if the indefatigable attention of the conference attendees is any indication, the appetite for change is clearly equal to the task.

Gaston, conference Chair

Rediet, Mary and Patty

Servent (senior anesthesia resident) with two medical students

Wednesday, January 16, 2019

Suffering through pain in Rwanda

From Chris

The first day of the inaugural Rwandan “Zero Pain Conference” kicked off this morning in the beautiful town of Butare, nearly 3 hours drive from Kigali. The two day conference brings together MDs, non-physician anesthetists, physiotherapists, psychologists, researchers and many others interested in pain management. Delegates will have the opportunity to hear from experts in the field of pain medicine, and learn about novel ways to tackle pain both in and out of hospital, with the goal of reaching a “Zero Pain” Rwandan state - a lofty goal, but one that may benefit thousands while striving to reach it. 

Since arriving here last week I’ve heard many times that Rwandans are expected to suffer through pain - whether that be labour and child birth, post-surgical, traumatic, or chronic type pain. The relationship to pain here is unlike any that I have experienced elsewhere. Many feel that pain is something that is meant to be endured, and that in time this may actually lead oneself to become stronger spiritually, physically and psychologically. Many Rwandans are deeply religious and feel that suffering through pain may allow them to become closer to faith. As such, most patients in hospital here do not complain of pain, and would not think to speak with their healthcare team if they felt that the pain regime prescribed to them was inadequate. Chronic pain, in particular, is not a well-known nor discussed topic, and there are currently only fledging programs hoping to change this. 

Access to medications to treat pain are limited by stock-outs, and outpatients who must purchase their only prescriptions often lack the funds to do so. Fentanyl, morphine and ketamine are *usually* available, but these medications are not frequently prescribed on patient discharge, leaving post-surgical patients with limited options to manage their pain upon returning home. It is clear that stigma still exists around the use of these medications for pain management, and given the lack of multimodel analgesia options available, patients are not just accepting of suffering, but are in fact forced to suffer. 

The concept of opioid addiction is complex, and sometimes poorly understood by patients and even their healthcare providers around the world, and that is no different here in Rwanda. Throughout this mornings discussions, the myths around opioid dependence, tolerance and addiction have begun to be broken down. Moving forward, patients and their doctors need to understand that one not need suffer in agony from acute pain purely to avoid the small possibility of dependence or tolerance. Opioids should not be feared, particularly if other options continue to be so limited. Frequent assessment and iterative treatment of pain is essential to ensure that patients do not suffer needlessly, and to prevent the development of chronic post-surgical and post-traumatic pain. 

With the growing community of pain practitioners here in Rwanda, this country is set up to drastically alter the Rwanda experience (and indeed expectation) of pain and suffering. In discussions with the conference delegates today, it’s clear that a wave of change is upon the country - more and more healthcare workers are interested in learning about the pathophysiology, pharmacologic, and importantly non-pharmacologic ways to treat pain. We must continue to support these efforts moving forward, and while we may never see a Rwanda with zero pain, we can certainly strive for amelioration of the suffering that is so pervasive today. 


The best part of global health work is bringing likeminded people together. Then the magic happens. Rediet, an Ethiopian anesthesiologist, has come to learn about how Gaston set up the effective pain management program in Butare. She is hoping to implement a similar program in Addis Abba. Mary, pain specialist from Halifax, has been supporting Gaston for years and now she has bonded with Rediet. It is so rewarding to be part of this exciting network.

Gaston and the Butare team have done a marvellous job of organizing the first pain conference in Rwanda. There are 230 people attending - a mixed group of health professionals from around Rwanda (plus some visiting Canadians and Rediet from Ethiopia).

Banner for the First International Conference on Pain Management in LIC

We were warmly welcomed by medical students in traditional Rwandan dress. Gaston had prepared beautiful conference packages for the attendees.

Registration desk

We heard a range of perspectives today with a good discussion about barriers to pain management in this context. One I hadn't anticipated was a religious view that suffering pain is God's will. I gave two short presentations with the key messages being that pain is complex, touches many aspects of a person's being and treatments must be comprehensive. I encouraged everyone to remember non-pharmacologic options (working with patient expectations, listening, distraction for kids, physical modalities etc.).

Jon co-taught a regional anesthesia workshop with Alain, a Rwandan resident and expert in regional anesthesia. It was a pleasure to see how Alain has matured into the role of confident and skillful teacher.

Jon teaching ultrasound guided regional anesthesia

Alain teaching ultrasound on a medical student volunteer

At one time, anesthesia was the least desirable specialty. Alain was recently on the selection committee for new anesthesia residents. The tides have turned and now they pick the best. Indeed, they were not able to offer places to many of the applicants. This is truly a success story.

We have been busy working but found time yesterday to visit one of my favourite sandwich shops, Inzozi Nziza, run by a women's drumming cooperative. Superb cinnamon ice cream with cookie crumbles was a hit with our team.

The pain conference continues tomorrow and then we have a VAST Butare refresher course. I hope we can squeeze in one more visit to Inzozi Nziza.

Cinnamon ice cream with cookie crumbles

Monday, January 14, 2019


Stephen and Chris have written beautiful blog posts about the weekend adventures. I enjoyed it thoroughly and am so happy they had an optimal experience. I have only to add that no trip to that area would be complete without a stay at Paradis Malahide (my happy place). We enjoyed listening to the fishermen singing as they headed out for the evening, dinner by the fire, traditional dancers and catching up with my friend Emmanuel (a longtime waiter at Paradis). Emmanuel arranged a boat trip for us the next morning after a leisurely breakfast by the lake. We returned to Kigali in time for a solid working afternoon of teaching prep.

Lake Kivu from Paradis Malahide
Stephen took the lead for teaching this week. The topic was pre-eclampsia/eclampsia As with last week, we used active learning techniques. The residents did a fine job of submitting answers to the preparation questions in advance. Stephen use a matching card technique for some knowledge-based answers to the topic. The small groups performed admirably. We ran a simulation scenario on pre-eclampsia from the VAST Course (for Adam, 2.2) . This not only helps the residents demonstrate performance but builds familiarity with VAST scenarios and debriefing. Of course, we had to finish our morning session with Jeopardy and prizes. My goodness, it was competitive!

A resident did a fine case presentation that included group work on a patient with mitral stenosis for C-section. I was tickled when she finished by asking the group for take home messages.

Matching cards for drug doses, indications etc for pre-eclampsia
After lunch, we again ran three stations but this time with new arrivals: Mary (pain physician) and Jon (anesthesiologist and regional anesthesia fellow).

Stephen and Chris ran and debriefed the sim scenario (Adam 2.4)

Mary discussing challenging pain cases with the residents under the avocado tree on the grounds of the sim centre

Jon taught ultrasound guided regional anesthesia with a gel model. One of the residents is practicing here.

I enjoyed the day thoroughly. How lovely to been with such fine colleagues and super keen residents!

Sunday, January 13, 2019

Gorillas in the Mist

By Chris

Growing up, “Gorillas in the Mist” played in our household on a near bi-weekly basis. I know the plot (and most of the dialogue!) by heart, and my first inkling that I might one day spend my life travelling from country to country, continent to continent came from imagining myself in Dian’s shoes, immersing myself in a new land and culture while in pursuit of a greater cause. Mountain Gorillas have always had such a incredible appeal - so like us: intelligent, playful, family-oriented. When I first committed to spending a month volunteering with CASEIF, I knew that I just simply had to make time (and money!) to make the dream come true. 

And so this past weekend I was giddy with excitement when I, along with Dave and Stephen, hopped in a car and began the trek to Mgahinga National Park in Uganda to sit in silence with a family of 9 gorillas for a single hour. We chose to visit the gorillas in Uganda, rather than our adopted home for the month, primarily because of the (significantly) reduced cost and the increased availability of permits - Uganda being only a burgeoning spot to visit these majestic apes. Mgahinga, at just 13 square kilometres is the smallest national park in Uganda, and one of two parks in the country where the Mountain Gorilla can be viewed. 

After a relatively painless border crossing near Kisoro, Uganda, we spent a sleepless night in an expectantly dingy border town hotel before embarking on our journey. Early the next morning, we drove up a steep, winding and badly pot-holed road to the park entrance, where we would begin the 2.5 hour trek up the mountain. Or journey through vines, thickets, and patches of sting nettles was worth the sweat and sore muscles. 

The first thing you notice when visiting gorillas is the sound - grunting, chewing, vines and leaves falling as the gorillas grab hold of their favourite plants. The next thing you notice, the smell: musty, dank, earthy, mixed with a sweaty pungency and a hint of excrement. Never mind all of the that, my first site of a wild, adolescent male silverback was one that I will never forget. Laying in a pile of crushed leaves, almost gingerly lifting his head to observe his observers, before flopping backwards to get comfy again. Of course, the photos do no justice. 

Over the next hour my fellow trekkers and I had the sublime experience of watching this small family, 9 of the mere 900 or so Mountain Gorillas left on this planet. I watched as the babies of the group (two 2-year olds) play, eat and cling to their mothers as they roamed the forest in search of food and entertainment. More than once I scurried back as one of the four silverbacks pushed their way past us, gently but intimidatingly so. And perhaps most emotionally, I watched the 8-year-old female who was suffering from a hand injury after recently being caught in a poacher’s trap - it’s unclear at this time if the damage will be temporary or not, only time will tell. 

In the early 1980’s the population of Mountain Gorillas was nearly extinct - found in just three countries that have had more than a fair share of political and civil turmoil, it’s amazing that a population of just 254 (in 1981) has now exceeded 900. It has been no easy task, and the work of countless conservationists, including the venerable Dr. Fossey, are to be thanked. While it is not an easy nor particularly affordable activity, the money that is raised continues to ensure the protection of these beautiful creatures, and for me that makes it worth it. 

The work that CASIEF does here in Rwanda, while incredibly valuable, places volunteers in challenging situations with long hours, but the opportunity to take a few moments to fulfil a childhood dream adds so much to the overall experience. The Mountain Gorillas are so much a part of the country’s national identity, and I’m so thankful to have had the opportunity to experience them firsthand - and you should too!

Stephen, Dave, guide and Chris

cycling in the hills of Rwanda

From Stephen:

We are now one week into our visit to Rwanda and as I consider possible topics for my first reflection, I am stunned at the volume of experiences I have enjoyed in even this short time. Saturday morning, I awoke to find myself in the Africa Rising Cycling Club. We had ahead of us a 44km cycling trip that Patty promised us wouldn’t be too arduous. Knowing the cycling accomplishments of Patty and the CASIEF volunteers before me, I was nonetheless nervous. In my fretting, I was amazed to discover the many ways this trip itself represents the progression of a cycle.

For myself, this Rwandan visit represents the expression of what drew me to medicine in the first place. In my first week of medical school, with Patty as my case tutor, I recall her prodding us to consider what we could contribute to the global work of medicine. I now find myself in Kigali taking my first, imperfect attempts at teaching fellow residents. I have so much farther to go in my own learning, but I couldn’t escape the feeling that the arc of my own cycle is turning.

Setting out from Africa Rising, likewise palpable was the sense that this place represented the changing of a season for Rwanda too. I wouldn’t claim to understand the nuance of history, but the optimism of this cycle centre was inspiring. As we prepared for our own modest cycling trip, the Rwandan national cycling team played host to the Nigerian national team and trained with a goal no less ambitious than winning the Africa Cup. Having previously captured bronze and silver, their sights were set squarely on the gold for 2019. The momentum of the Rwandan cycling team truly captured something of the spirit of Rwanda itself. Indeed, the Rwandan team finished their +200km race from Ruhengeri to Kigali and back before we finished our own modest trip.

In its own way, CASIEF’s sustained partnership in Rwanda is witnessing the completion of its cycle. The accomplishments and talent on display every day in our interactions with the Rwandan residents speaks to their dedication as well as the coordinated work of many, many CASIEF volunteers before me. From the Simulation Centre, to curriculum renewal, and to the many relationships I myself have built with visiting Rwandan residents in Halifax, the work of this programme runs deep. As CASIEF ponders its next steps in Rwanda, the sentiment that CASIEF’s own cycle is turning is unmistakable.

Like my visit to Rwanda itself, our own cycling trip exceeded all expectations. Flanked by small crowds of curious children, we cycled the beautiful volcanic terrain to a waiting lunch on Ruhondo Island. The pictures below fail to do the vistas justice. As we finally settle back into our apartment in Kigali, I’m excited to consider what our next week has in store.

Rwandan cycling team prepares for a training ride 

Dave at the base of the volcanos

View from our lunch venue