Sunday, February 9, 2014

home again

Mat and I are back in Halifax after a very long journey. It was probably 30 hours of travel, or more.

This is what I woke up to.



Canadian winter can be most beautiful - sunshine on bright snow, cold air, blue sky...

I am always struck by contrast when returning from Rwanda.  It is a great privilege to live in two places  and to have Africocanadianization (as Paulin calls it).  It was wonderful to have Mat's companionship and, of course, great to share Rwanda again with Michelle.  The Rwandan people are incredibly warm and appreciative.  We see improvements in medical practice and overall infrastructure each visit.  There are always moments when I ask how much longer I can keep doing this – usually when in the midst of GI illness, after a couple of days of not eating – but I will try.  Rwanda is all about open heart.  I feel very fortunate to be able to live in two very different, but wonderful, worlds.

Stay tuned for next January...

With love,

Patty

Thursday, February 6, 2014

Mat teaches cricothyroidotomy

It's day 2 of the Basic Surgical Skills course and Dave and Brock are seeing a lot of progress with the residents.  This is the first time they've had direct instruction with hands on practice.

Mat taught the cricothryoidotomy session and found the residents were keen learners.

Orientation to the anatomy

Effective, but gross, neck model

Demonstration

Practice

Getting ready for day 2

Dave teaches chest tube insertion

Chest tube practice

Abdominal wall closure (don't pop the balloon inside)


Wednesday, February 5, 2014

more from michelle

Hi gang,
to the Halifax crowd....hang in there with the weekly snow storm!  If it makes you feel better there have been a couple of monsoon rain storms but luckily they only last about 1/2 hr.  And warm rain is better than snow any day.

There is not a lot of time to sit down at the computer and write.
We are busy with the " Basic Surgical Skills" course today and tomorrow.  Day one went very well.  They are a bunch of enthusiastic and engaged first year surgery residents.  Two of our Dalhousie surgeons Dr. Vair and Dr. Amirault flew here just to teach the course.
They are fantastic instructors and bring a wealth of knowledge.
For me it is just like a good day in the Skills Centre except we wash the instruments by hand at the end of the day.

Enjoy the opening of Olympics....I will really miss that and all the great action.  Go Canada Go!
Sounds like it is a good thing that they are starting as some of you are telling me how bad my Canucks are playing.

xo michelle



Michelle, could anyone be more glamorous handling pig bowel?

Course

youth and experience


Our surgical colleagues, Brock and Dave, have joined us this week to help teach the Basic Surgical Skills course for first year surgical residents.  This is a two day course with introduction to surgical essentials.  The residents are able to learn together in a relaxed atmosphere.  Two senior surgical residents are helping teach, thus building sustainability for the course.  

Mat and I have spent some time in the ICU in the last couple of days.  The whole disease profile we see in Rwanda is very different than in Canada.  There are many paediatric, obstetric and trauma cases.  Obstetrical complications, that would be rarely seen in Halifax, are common.  There are many cases of sepsis and also complications from infectious disease.  Generally, the people are fit and strong but one thing goes badly awry. 

I feel pleased with what we've accomplished this month.  I am able to give a little more with each visit as I continue to learn about the local needs.  The understanding that has come from long term relationships is incredibly valuable.

Mat has had more teaching opportunities this month than ever before in residency.  Some teaching, such as our formal presentations, has been well planned but often he is called upon for impromptu teaching.  He definitely understands that it is not simple and even good teaching does not ensure learning.  Nevertheless, we have both had exciting teaching moments.  

It works very well for a bright young resident to teach with a more "mature" staff person.  His knowledge bank is mind-blowing; I bring local knowledge, partnerships, perspective and understanding of the working environment.  We are a good team.  



Basic surgical skills course

Knot tying
Michelle with Christophe, who looks after the apartment

Monday, February 3, 2014

final academic day

We are into our last week in Rwanda and I'm starting to feel sad.  The time has been wonderful but it's gone much too quickly.  There have certainly been moments of frustration and disappointment but they are far outweighed by successes. It was a pleasure to teach the Respiratory block with Christian.  He taught some of the morning sessions and ran a number of simulations.  This afternoon we had the final quiz – it was all short answers and proved to be difficult.  Christian was with me to give individual feedback to each resident.  This was so helpful as he was able to make some points in Kinyarwanda and to share his experiences with the residents on the exam process and importance of studying hard.  In short, the experience with Christian was a great example of the co-teaching we would like to do more of with our Rwandan colleagues.

Michelle is on fire.  She is now shifting her attention from the simulation centre (already thriving) to the operating room nurses.  She met a very committed OR nurse today (Australian) who plans to spend a few years in Rwanda helping to build the program for OR nurse.  I think Michelle just found the right partner.

Academic day

Mat getting ready to be the simulated patient

Christine writes the exam

Christian debriefing simulation

Sunday, February 2, 2014

Mat's thoughts on Butare


Butare is a gem.  Great teaching, great hospital, great staff great residents, great Fanta, great samosas. What else do you want? How about coffee? Well guess what? They have that too! Possibly the best cappuccino in the world. Yep, the world. In Rwanda. Amazing. They need to have a "to go" system. Because the guy that works at cafĂ© connexion is certifiable (like the coffee).  Also, he described his business model to me. It reminded me of my lemonade stand (sell refreshing lemonade for less than cost and then have dad bail me out).

Anyway, split my time between the residents in Butare. Great trauma cases deftly handled. And one of the residents did their first ultrasound guided popliteal block! It was like he had been doing it for 20 years. NBD.

What a time we had in the jungle!  The only bad part is karma has final caught up with me. I believe the GI gods (AKA Zeus god of thunder) punished me for my earlier comments about Dr. S.  Yeesh. Nothing a stat infusion of Serena won’t fix!

With any luck you will only have to read about 2 more of these from me.

Bam.

M

from Michelle


Hello from warm Kigali....only 28C!
Sorry to rub that in.

One of the joys of being here is lack of internet access.  When you really think about it it is a healthy break.

My journey to get here was seamless (got out of Canada between snow storms).
I was so warmly welcomed by my friends Emmy, Mary, baby David and Christophe...felt like coming to my second home.

My first day visiting the Skills Centre warmed my heart.  It is so busy and being used by many different groups of healthcare professionals.   Angelique is amazing and doing great work.  She is glowing with her first pregnancy...I was happy to unload half of my suitcase filled with baby clothes for them.

I traveled to the university city of Butare on Friday to meet Patty and Mat who have been teaching anesthesia for 3 weeks already.  They were ready for a hike in the incredible Nyungwe National Forest. 
It was a rainforest, lush and tropical.  We did 2 hikes, day one the Canopy Walk, suspension bridges over the tops of the trees and day two a 4 hour hike to a waterfall.  We were extremely lucky on that day to see a family of Mountain Monkeys swinging from tree to tree.  Rwanda is filled with beauty, not just the typical savannah grass lands you picture when you think of Africa.

The drive to and from Nynungwe from Kigili is 4 1/2 hrs  but fascinating....passing through hills planted with crops of bananas, sweet potatoes, coffee, eucalyptus, and sunflowers.  Fields are full of rice and tea.  But truly the part I enjoy most is watching people.  Walking everywhere, packing the most unbelievable things on their heads, kids playing soccer in every corner and people working hard.  And very sobering was passing the Kigeme Refugee Camp (the last photo) for Congolese refugees.
We are incredibly lucky to be Canadian!

So it is time to prepare for a week of work....I am excited to help run the Basic Surgical Skills Course this week with Dr. Vair and Dr. Amirault as well as the Rwandan doctors.

big hugs to everyone and GO SEAHAWKS GO!!!

xo michelle

Christophe with his Canadian Olympic t-shirt

Sim centre

Kigeme Refuge Camp

Patty and Mat before the Canopy walk

Igishigishigi tree ferns

Nyungwe Forest and waterfall

Saturday, February 1, 2014

resident rock

Tea plantation around Nyungwe Forest Lodge

The waterfall hike is a four-hour hike in Nyungwe Forest.  It begins in a tea plantation but the path goes through the lush rainforest, along a couple of rivers and finally ends at a gushing waterfall.  It is an enjoyable hike that I’ve done many times.  There is a rock near the waterfall where I’ve photographed all the residents I’ve travelled with, except Genevieve (we did a different hike). 


It has been wonderful to share my time in Rwanda with an excellent group of residents, some of whom are now staff anesthesiologists.  


Genevieve - 2008
Ariane - 2010
Shannon - 2011




Terri and Lauren - 2012


Michelle - today
Mat - today





Friday, January 31, 2014

trees and greenery


Today might have been our best day this visit.  We began with a teaching session with three residents in the morning.  They are hungry to learn.  Mat covered sepsis and modes of ventilation.  They were still asking questions even after the session was done.  Mat was very touched when the residents asked him to please come back to Rwanda to continue to teach them.

Michelle arrived in Butare and we joined her at CafĂ© Connection for some extra delicious coffee.   She and I didn’t stop talking with each other during the 2½ hour ride to Nyungwe Forest.  We are very happy to be together again.

Nyungwe is over 1,000 km sq of stunning rainforest.  The forest is a feast for the senses: stunning views, earthy smells, and piercing birdcalls.  We hiked to the canopy – a suspended walkway over the treetops.  It is a most wonderful feeling to hang in space surrounded by the verdant forest.

We arrived at the Top View Hotel before dark.  This lovely hotel is perched on top of a very high hill with views of Lake Kivu on one side, Nyungwe Forest on the other and tea plantations surrounding.  We just had a great meal and some belly laughs (Michelle has a wonderful sense of humour).


Nyungwe Forest

Canopy walk

Around Top View Hotel

View from Top View with Lake Kivu in the distance

Happy Michelle


Thursday, January 30, 2014

lots of teaching

It was delightful to sleep at the Mont Huye Hotel last night compared to the Kigali apartment with the saggy mattresses and noisy all night bar across the street.  The hotel is in a quiet garden with lots of birds.  

Teaching in Butare is usually most enjoyable and today was true to form.  Mat and I were in adjacent rooms with two keen residents.  The ORs run well, although there are still problems with equipment and drugs.  Our laryngoscope was truly on it's last legs. I think the resident intubated with ambient light.  Mat taught one of the residents how to do an ultrasound guided popliteal block and also did cardiac echo on another patient.  Mat is extremely fond of ultrasound. 

After a good day of teaching in the OR we headed off to a cafe for oral exam practice with the residents.  This evening we had journal club with ample fish and goat brochettes, fries and large beers (for the guys).  A surgery resident, who is on his ICU rotation, joined us for journal club.

The power has just gone out and a noisy generator is running, so tonight might not be quite as quiet as last.  We will teach again tomorrow morning then join with Emmy and Michelle around noon to head to Nyungwe Forest.   


gardens at Mont Huye
Mat discussing a topic with Egide

Butare journal club

Wednesday, January 29, 2014

Butare

We had a pleasant drive from Kigali to Butare this morning enjoying our conversation with Emmy.  After fortifying ourselves at Cafe Connection with some truly delicious coffee, we joined Egide in the OR.  As always, the ORs in Butare are refreshingly orderly compared to the experience in Kigali.  Drs Jeanne and Theo have done a great job. The anesthesia machines in Butare have been significantly upgraded.  It used to be that two or three were attached together to get one functioning machine.
 Later in the afternoon Mat did some teaching with Egide and Josue while I worked with Theo on the anesthesia department strategic plan.

We are staying at the Hotel Mont Huye.  Great find, Sara.  It is quiet and simple and incredibly cheap.  Dinner (with a large Mutzig for Mat) was about the price of a couple of teas at the Serena. We preordered dinner for journal club tomorrow using our very poor French.

Michelle has arrived in Kigali and will be joining us in Butare on Friday for our Nyungwe Forest weekend adventure.

Jeanne, Mat and Egide


Tuesday, January 28, 2014

unstoppable

My illness in the past few days and sagging energy has caused me to think (yet again) of a succession plan.  Which of you out there will take over for me?  I can hang in a few more years but I'm getting tired.  These thoughts come forward when I've had a few days of no appetite and very little eating.  However, I just jumped in the pool and managed a very decent swim, so feel refreshed.

Mat and I are off to Butare tomorrow.  I'm already prompted him that the food options are extremely limited, other than delicious ice cream at Inzozi Niziza.  We plan to stock up on nuts, crackers and peanut butter at Nakumatt tomorrow to sustain life for the next few days.

Michelle is on her way to the airport.  It will be wonderful to have her bright, perky energy with us in Rwanda.  We miss Sender and his great sense of humour.

Michelle will join Mat and me on Friday for a couple days in Nyungwe Forest.  I've been there each visit to Rwanda and love the peace of the rainforest.

xo
Patty

And now from Mat....


Hello friends,

Today was the first time in my life I have independently attempted to give an oral exam to a resident. It was strange. I am giving oral exams to a resident that out ranks me in years of service… but anyhow.
The case was a fairly simple peds case with no major complications. The resident went on and on and on about all the things they wanted to know and all the investigations that may be required.  For the most part everything he was saying was correct, but a lot of it was unnecessary details.  In the end the resident did not finish the question in the allotted time, but still got the major points of the question.
It turns out this resident was the opposite of me during my first oral exam attempt.
Dr. Bird told me after my first oral : “ Mat, I think you have a great approach to the oral exam style and when you actually know something about anesthesia you will be great at this!!” (That was a complaburn).
It seems my Rwandan colleague has the opposite problem.
Together we will be unstoppable!


Otherwise my major lesson of the day: Motos are dangerous. I almost reconsidered my motorcycle ownership.  But then I thought I might be overreacting. And of course I am... Motos  are perfectly safe…

Later 




Monday, January 27, 2014

respect

I've been thinking a lot about what makes teaching work in the Rwandan context.  It's easy to come and think you are a big expert and you should just tell people what to do.  That fails miserably.  In fact, most people don't really like being told what to do.  Most people don't like you droning on with blah, blah, blah.

So what works? First of all, respectful relationships that are developed over time.  This is my seventh time to Rwanda but I still feel my understanding of the local culture is very limited.  It makes a big difference to know my Rwandan colleagues are comfortable speaking honestly to me about what might work or what might not work.  I trust them for guidance.

Active learning.  The interactive case discussions in the morning and simulation sessions in the afternoon have worked splendidly.  We go back and forth between theory and practice.  The residents have a chance to perform well or make mistakes in a safe learning environment.

Empowerment and validation.  When our colleagues are given the chance to teach, they rise to the occasion.  Each time I visit, I'm trying to pull back a little more so that the locals fill in.  Willy did a fantastic session for the techs, residents and staff this morning on role definition.  He's an awesome speaker who engages the whole room.  This is so much better than me standing up and saying the same thing.

Mat nearly had a heart attack when I showed him four ultrasound machines that have mysteriously arrived in the sim centre.  In no time flat, he was having the residents echo his heart.


Francoise performing capably in sim

Christian giving the morning lecture

Mat can't believe the ultrasound machines

Mat's heart

Saturday, January 25, 2014

boat trip on Lake Kivu

Mat and I stayed Friday night at La Bella.  Paradis Malahide, near Gisenyi, was full but that might have been a result of misinformation by a disgruntled former employee.  We had some delicious grilled tilapia from Lake Kivu.


Morning in La Bella

Mat, Tom and Patty on the boat

My good friend Tom, who runs Rwandan Cycle Adventures, arranged a boat trip skirting the shores of Lake Kivu to visit some land he has recently bought.  Over time, Tom plans to build a house and maybe accommodation for guests.  He's does a great job working with the locals to build truly sustainable tourism that is routed in the local culture.  Tom starts his employees out with a low base salary that quickly increases for hard work.  He pays health insurance for all employees and their families.  Tom has been in Africa since the 1990s and speaks Kinyarwanda.  His business is mostly about cycling but he is branching out to create package adventures that include cycling, gorilla trips, cultural visits and so on.  Emmy and Tom are partners for a big 2 week cycle tour with 10 clients coming up in February.
Traditional fishing boats, Lake Kivu


The fishermen head out at night in their wooden boats to fish.  They sing on the way out and when coming back in the next morning.  It is beautiful to hear their song carrying over the water.

We stopped at a local thermal pool being enjoyed by semi-naked children, a man washing his motor cycle and a 94 year old man sweeping up fallen twigs.  Old but incredibly strong!
Emmy makes friends with children everywhere

Enjoying the warm water


Tom told us that the natural thermal pools will soon be taken over by a five star hotel with a luxury spa.  It seems so sad for the local people who have enjoyed that quiet spot for years...

Tom is very keen on birds and had is birding guide and binoculars for the boat trip.  He kept excitedly pointing out birds.  "That's a red breasted golden spectacled worm eater, known in Kinyarwanda as [insert something semi-unpronounceable here].  We did see some very beautiful and colourful birds.
Tom, the proud owner, shows his new land

View from Tom's land

Unripe passion fruit.  Tom also has mangos, papaya, coffee, tomatoes, avocados...

Traditional fishing boats as seen from Tom's land

our friend Emmy

Most of the way back from Tom's land it was pouring rain, so we got pretty wet.
View of Lake Kivu from Tom's current house
We  travelled back to Kigali with  Emmy.  Sadly my stomach took a turn for the worse and I have  some GI troubles.  Today is a day of R and R at the Serena and preparing for our busy week.