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 Café 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

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

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

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 

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

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.

off to Gisenyi

Hello. Perhaps it is a bit odd to be reflecting about winter whilst in 28-degree weather. Nevertheless… My colleagues at home had a SNOWDAY!!! On Wednesday afternoon. Glorious. Perhaps the best thing about winter (one of). Why you ask? Well if I decide to do work it is bonus productivity. This productivity reduces my stress level and my overall wellness increases. If I decide to go out and do activities, they are guilt free because I am living on bonus time. Obviously, this too increases my overall wellness. Basically, snowdays increase wellness.

Now generally, I don’t ‘feel bad’ for the Rwandans. It is my experience that most of them are very happy with their lives. And, in fact, many that have been away from Rwanda want to promptly return.

But they don’t have snowdays… And as we have previously established, snowdays=increased wellness. Perhaps to increase wellness in Rwanda we should consider increasing the number of snowdays… I will get back to you on this.

On another note. It rains here. It come suddenly, fiercely then disappears without  warning. I also learned that not showing up on time (or at all) is completely acceptable if it is raining. And I completely agree. Perhaps we should institute that rule at home. It may increase wellness.  

Am I right? Because if an idea works in one place it always works everywhere…

Shout out to Dr. Sender who is leaving us tomorrow. Not sure what I am going to do without my food safety inspector.

Also, Rwanda I believe has more portable ultrasounds than the HI and VG combined. Think of the potential for bedside ultrasound diagnostics!!!

Later

M

Our lunch table at Serena

Hi Everyone,
We are off to Gisenyi on Lake Kivu this afternoon.  Tomorrow we will meet my friend, Tom, for a boat trip down Lake Kivu. It's hard to believe we've been in Rwanda two weeks.  It has been a rich and wonderful time, with some moments of utter frustration or sadness.  The joy of teaching keen people makes it all worthwhile.

Mat is a stellar resident, even if I don't understand his blog posts.  He has been teaching non stop - simulation, classroom, OR, M and M, journal club... The residents are so glad to have Mat here and they all want more time with him.

I'm not sure how easy it will be to post tomorrow (from a boat on Lake Kivu) but we plan a day of catching up on work and a little exercise on Sunday.

xo
Patty

will we be blown away?

Mat and I had the pleasure of breakfast with Prof. Patrick, Dean of Medicine.  He is always thoughtful and gave us valuable advice on next steps for the anesthesia program.  After that we visited Francoise (second year resident) and Paulin (anesthesiologist).  The four of us had a delicious lunch at a nearby Chinese restaurant when a great storm blew up.  Rain poured down and wild winds rattled the tin roof. I thought we might all blow away.  We escaped back to King Faisal by taxi.

Mat taught Francoise extensively today, including cardiac echo.  She is so keen to learn and it was a pleasure spending the day with her.

It was great to be with Paulin again with this wonderful humour.  He says he needs a loading dose of "Canadianization".  

I'm stressing Mat.  He is teaching nonstop, has to lead journal club tonight, M and M tomorrow and run a simulation for the anesthesia staff and techs on Monday.  I was pushing my "graded assertiveness" a bit too much by telling him he's overdue for a blog post.  He promises to post tomorrow.  

the joy of patients with low BMI

Mat helped supervise anesthesia for a 7 day old baby today and it went well.  There are many pediatric cases, so it's good he is planning a career in peds anesthesia.  I spent much of the morning with Willy working on a pain management program for the hospital and taught him how to do intercostal blocks on a patient post-thoracotomy.  There are no catheters for epidural or paravertebral.  Intercostals are quite easy when the BMI is 20:-)  

a fine job in the OR

One of the junior residents did a fine job today managing a rather complex case in the OR.  This case was certainly one of the most smooth I've seen at CHUK.  It was a great joy to have propofol, working monitors and good vigilance.   We taught the anesthesia tech students in the afternoon.  Mat skillfully guided low-fidelity simulation sessions supplemented by the SimMan software (this allows the students to see and hear all the changes in the vital signs).  He did a stellar job.  When one student took a little too long to intubate, Mat allowed the oxygen saturation to fall.  

Smooth sailing with working monitors

Well functioning OR

Scavenging:-)))

Propofol, yeah

New machines

Mat with tech students

Active learning in the sim centre

cats and dogs

When it rains in Rwanda it is as if a ginormous bucket of water is being emptied.  Everything is instantly flooded and young men with rubber boots brush the water off balconies with brooms.  But it is a losing battle when the skies open.  We were having lunch at Camillia's with Francoise and Egide, discussing their elective in Halifax next year when the rains began.  Emmy, our knight in shining armour, came to the rescue and took us back to the sim centre for the afternoon session.  By the way, I am loving the second year residents.  What bright sparks.

Mat's gorilla experience

Oh hello again. You didn’t think I would be back did you? You may be surprised or even shocked…How about some GORILLA photos to calm your nerves! Quick rush to the bottom for photos and a movie! Then come back straight away.

Friday was quite a day! We made a trip up to Ruhengeri. 2 hour dive, beautiful country blah blah.  Arrived at our hotel. Emmy of course saved us about 10000 Rwandan Franc’s. Not quite sure what he said to the hotel manager, but I am pretty sure he is Rwanda’s version of the Godfather.

Anyway, we had a simple dinner of shallow vs deep (still debating the difference) fried tilapia and fries. A meal, from which, it is impossible to get a GI illness. Right? Wrong. Our general surgeon colleague may have the most sensitive GI tract on the planet. Which is odd right? He gets GI illnesses q 3 days for no apparent reason with the same food as everyone else. I think the best part is that this time he took immodium and antibiotics! Now, not everyone on this blog may know this but (get it), you are not supposed to take immodium with infectious diarrhea. The idea is you prevent the bacteria from being forcefully expelled and thereby worsening the internal damage. I am sure our colleague knows this.  It is my belief that he feels that simple expulsion from the colon is insufficient punishment. He seeks the death penalty. This immodium is used to keep the bacteria inside and Cipro/Flagyl is to extract his revenge.

Enough about that.

The hike to see the Susa Gorillas was the most pleasant experience of my life. A leisurely stroll up nice gentle inclines. I still cannot explain when the 24 year old marathoners had to leave halfway through. Our guide felt it was because they were American and therefore made of weaker stuff. As a mostly Canadian I mostly agree. My German friends in their 50’s wearing designer jeans also had no problems.  The Gorillas were amazing. Ask me about it later I am not going to go on about it here. I will say that, although I am going to have to re-finance my surfboard, I am really happy I was able to see the Gorillas. Time magazine put out a list of 10 places/things you should see in the next 20 years (because they likely wont be there after that) and Gorillas in Rwanda is one of them. So go see the Gorillas! Support the economy and conservation! Volcanoes park was the first national park in Africa.

Silverback

Mama gorilla

Juvenile male

In thin air...

 

gorillas and golden monkeys

Mat had a very intense day hiking to the Susa group of gorillas yesterday.  He'll write more about that adventure later.  Sender and I saw the golden monkeys, also a wonderful experience.  There are over 200 monkeys in the group.  We saw them leaping from branch to branch, grooming each other and males fighting over (highly abundant) bamboo.

Here are a few photos but stay tuned for Mat...

TGIF, Mat enjoyes a well earned beer

Golden monkeys

Very personal grooming

Farms at the base of Volcanos National Park