snow in Istanbul

Smooth sailing in Halifax in Toronto but there is Istanbul.  Go figure.  The airport is chaotic but we are still hoping to make our evening flight to Kigali.

ready... but not too ready

The first snowstorm of the season came to Halifax yesterday. Winter has definitely arrived.

In two days, I'm heading back to Rwanda with my friend, Michelle. She will follow up with the operating room nurses to find out if they have been able to implement what they learned in the peri-operative nursing course last year. She will also offer her great skills to the simulation program.

It is impossible to feel ready for what is to come. We can prepare a bit but must be guided by our partners. We need to be prepared but flexible. The toolbox is ready but I'm not sure what we will have to pull out.

The scope keeps increasing. In addition to the anesthesia residency program, I want to put effort into a new nurse anesthetist program, the simulation centre, pain management program and a major collaboration for maternal, newborn and child health in Rwanda.

But the true joy is always people. An example is Christophe. He grew up in a small rural community in a remote part of Rwanda. He found his way to Kigali and got a job cleaning the CASIEF apartment where our volunteers stay. He spoke no English or French but that didn't stop him from being incredibly loyal in attending to the needs of our volunteers. He is the quintessential hard worker. One of our volunteers generously provided funding for Christophe to attend evening university classes in information technology. This was enormously difficult at first due to the language issue but, with his dedication, Christophe was able to move his grades up to scale to end up with many As. A few weeks ago he received his bachelor degree. We are so proud of Christophe.

Michelle and I leave on Dec 30 and we arrive in Kigali about one hour into the new year.  Please give us a few days to get the technology working and then we will try to post regularly.  We are taking a few days vacation at the beginning to cycle along the Congo Nile Trail near Lake Kivu.  Michelle's young nephew, Derek, will be joining us.

Best wishes to all of you for happiness and peace in 2016.

With love,
Patty

time

Today was the final day of the Teaching and Learning Course. Again, it is impressive that staff and residents are willing to sit in a hot room on Friday afternoon to discuss feedback and mentorship. Amélie and I realized the feedback scenarios that Ruth and I had designed for Halifax would not fit in Rwanda. Theo created a couple of scenarios that worked beautifully - involving themes of communication with techs, fragmented responsibility for the patient etc. Amélie did a great job role playing as the learner. The group participated in a good discussion of mentorship and they now are planning to build mentors into the residency program.

Then we had the sad task of saying "goodbye" to everyone. This was not fun.  A year seems much too long to be away from them. The goodbyes only reinforced our close friendship and bond.

Needless to say, they all want Amélie to come back.  Amélie and I are working on a "5 year plan" that will ensure she returns...

Time is a mystery.  On one hand, it seem like ages since we arrived in Rwanda, jet lagged and without our bags. On the other hand, time has flown by. There is no complacency here. The overwhelming quality is vivid. Each day was rich with experiences, both disturbing and joyful.  Even a little thing like crossing the road requires great attention and care.  There are few routine anesthetics. The work is tough but rewarding. People here always have time to talk, hug, share a meal.

Amélie and I will head to the airport later tonight to get on a flight at 2:15 AM tomorrow morning.  We fly to Istanbul together and then she will go on to vacation in Morocco and I will return to Halifax. I am so grateful for her wonderful companionship, humour and enthusiasm.

Best wishes to you all,

xo
Patty

Michelle and Patty with new young friends

people

I used to think the work in Rwanda was all about programs but it is becoming more apparent that it is all about people.  It means mentorship to support partners in fulfilling their goals. It means helping them to give skills for success.  It also means trust.  More and more this visit I've been pulling back a little and marvelling at the capability of my colleagues and students. The residents are bright and keen to learn.  The junior staff are blossoming in leadership positions.

Rwanda is not only warm physically.  The people radiate open heartedness.  So many smiles, so many hugs. It begins with the most wonderful expression, "you are welcome".  I feel incredibly lucky to have Rwanda as my second home.

On the bright side, nobody almost died today

Amélie here.

Patty and I just had the busiest last OR day in Rwanda. We were at King Faisal Hospital, which is by far the most well-equipped in the country. Trouble is, it’s obviously not as well equipped as we are at home but cases got quite complex.

We started off with a simple cysto. No trouble there. The next case was a thoracotomy for repair of a thoracic spine fracture. Lung isolation and arterial line? Sure, you got it. Then Patty helped guide a Rwandan staff in doing facet joint injections for a patient with chronic back pain. No sweat. Or actually, lots of sweat in the heaviest lead gown I’ve ever worn.

It’s all added up to an exhausting day.

Thankfully, we can still enjoy the oasis that is the Serena for another few days.

P.S. I dodged GI illness after the goat brochettes but I’ll be surprised if I leave Rwanda without malaria. The mosquitoes here have the stealth of ninjas.

helping Paulin with facet joint injection

It will be hard to leave Kigali...

African dresses

Today was our last academic day. It should probably have been cancelled because today is a national holiday and it seemed bad form to insist the residents come in for teaching.  This was not our decision.  The morning session went well and was topped off by a fine session of Jeopardy with cash prizes - a huge hit with the residents.  We intended to pop out to the buffet for lunch but there was no buffet, on account of the holiday, and we had to order à la carte.  Huge mistake.  It is a true fact that the food took 2 1/2 hours and even then the chicken brochettes were undercooked. We made the best use of the time by having the residents write the end of unit quiz (one hour), grading it, discussing the quiz and giving feedback for the month.  It has gone much to quickly.

We picked up our tailored dressed today (see photo).

Worms, amoebas and Texans

I’ve just made it back to Kigali after a week with Patty in Butare and a weekend in Nyungwe forest with Emmy.

Butare is a bit of an aggressive city when compared to Kigali but the daily vervet monkey sightings made up for its shortcomings. Working with the residents there was delightful and we made a new American friend, Stephanie, one of the HRH anaesthetists. Patty and I discovered a wonderful trail to hike through the University of Rwanda’s campus arboretum.

Nyungwe was surprisingly… crowded. For a rain forest. I walked the canopy (designed by Canadians!) yesterday with a group of about 50 Rwandans, for whom I seemed to be a complete novelty. I was again the whitest of white girls. My sunblock almost caused a riot. Most people had never seen any.

I hiked a gorgeous trail to a waterfall today with another interesting group. There were people from all over including a fascinating family from Texas. Despite having lived in Africa for over 3 years, the father braved the trail in sandals and had to be counselled not to drink the waterfall water.

Having dodged the amoebas, though, I’ve just had 5 street goat brochettes for dinner. I’ll be ok.  Right?

Amélie

Rwandan hillside

Baboon on the road to Nyungwe

Canopy walk

Mountain monkey in tea plantation

Tea harvest

Amélie on the famous resident rock

Waterfall in Nyungwe Forest

umuganda

Today is umuganda in Rwanda.  This is the community service day that happens on the last Saturday of each month.  Neighbourhood teams gather to clean, repair walls, dig ditches, and other such tasks to enhance their community. This is a required activity; there are roadblocks to prevent all but the most essential car travel. There is no question that umuganda benefits Rwanda.  The country is immaculately clean and constantly improving.

I am having a quiet day at the Serena Hotel catching up on some work and exercising.  It will be good to see Amélie tonight to hear about her visit to Nyungwe Forest.

missing my buddy

Amélie has gone to Nyungwe Forest for the weekend.  Nyungwe Forest is 1,000 sq km of lush rainforest in the southwest part of Rwanda.  I would love to have gone hiking with Amélie but needed to return to Kigali for an anesthesia strategic planning session today and to teach the Simulation module of the Teaching and Learning Course.  Amélie did the canopy walk today – a wonderful walk above the treetops – and will do the waterfall hike tomorrow.  She promised to get a photo on the “resident rock”.  I have a photo of every resident who has accompanied me to Rwanda on this rock (with the exception of Genevieve).

The Simulation module today was well received.  The course participants were divided into two groups and each group had to design, run and debrief a simulated scenario for the other group.  Once again, the quality was excellent. Huge kudos to the group for continuing to show up on Friday afternoons.

I had a most welcome swim and shower after 4 days in Butare with only a cold drizzle of a shower.  Being clean is such a pleasure! 

Amélie will be back in Kigali tomorrow night.  In the meantime, Emmy is taking good care of her.

Amélie in the Butare OR with upgraded machines

Tidy set up for spinal anesthesia

monkeys hopping all around

Highlights from today:

oodles of monkeys hopping around Butare

clear blue sky

discovery of a great hiking trail on the university grounds - tall trees, wonderful forest smells

teaching Francoise

ice cream at Inzozi Nziza

coffee at Cafe Connection  (best coffee in the world, according to Mat)

What more can I say?  Another great day in paradise.

Monkeys on the building next to our hotel

new paved road to the hospital

garden at Mont Huye Hotel

Butare

We are sorry about the huge snowstorm in Halifax and hope everyone is doing okay.

Amélie and I are in Butare for a few days.  The drive from Kigali to Butare passes through green hills, banana plantations, rice fields, and small farms.  We arrived too late to go to the OR so took the opportunity to visit the beautiful National Museum of Rwanda, which contains a great collection of cultural artifacts and many photographs of life in Rwanda from 80 - 90 years ago.

Yesterday was a very full day with lots of teaching, simulation and planning to improve maternal health in Rwanda.  There is emerging leadership from the junior anesthesiologists and residents. One anesthesiologist commented, "We use to sit in the OR waiting for the Surgeons and OB the bring us the agenda, now we are on the table to draw the agenda: politically, scientifically, academically and skills and knowledge transfer...that what I realised yesterday."  It is incredibly satisfying to see these new leaders. 

We will be in Butare for three days and then Amélie will visit Nyungwe Forest and I will return to Kigali for the Teaching and Learning Course on Friday.

We send warm thoughts to melt that snow.

Amélie at the grounds of the National Museum of Rwanda

Just a quickie…

Just a short post from me tonight. I am toast after doing the weekend challenge workout with Michelle at the Serena on Saturday and the most challenging city walk ever today.  I’m quickly learning not to trust any Rwandan about how difficult or long a hike might be…

I was telling Patty this week that my preconceptions about Rwanda and its health care system as a low resource setting have been quashed.  I’ve come to see that for most, the fact that it is a low resource setting (albeit not the worst I’ve seen) doesn’t define the situation here.  Rather, I see people who want better and who are willing to work for it, in the hospital and all around.  What’s struck me most is the pride and dignity they carry themselves with.  I very much want to hang onto that when I head home.

That might be a bit corny.  Must be time for bed.

Amélie

Meraneza Club (hard core)

Kigali view with banana trees

just two or three mountains

Michelle had some drop-dead gorgeous outfits made for her at the Rw&a clothing store, so Amélie and I were inspired to do the same.  Our outfits will be ready in a week. It was great fun to choose the style and then get measured and fitted out.

Michelle left last night to fly back to Canada.  We already miss her delightful humour and cheer.  Needless to say, of our Rwandan friends made her promise that she would be back.

Bona is one of the Rwandan anesthesiologists and a long time friend.  He invited Amélie and me to come hiking with him this morning with his hiking club. He said, “We will climb two or three mountains. It will be easy”.  I asked if perhaps we could climb just one mountain. Amélie and I were feeling pretty confident after our five-hour hike last weekend, so off we went with Bona and his friends.  Let’s just say it was humbling.  Four hours later Amélie and I practically crawled into our apartment having walked up and down the hills around Kigali at an exceedingly brisk pace.  At times the group broke into a run - up the hills! Despite our exhaustion we saw Kigali in a new way. Once we left the traffic behind, we walked enjoyed the eucalyptus smells, birdcalls and greenery.  But with the burning in our legs, this might just be a one-time event…

Jocelyn, at the Rwanda Clothing Co.

Sun breaking through the mist in the hills around Kigali

Members of Bona's hiking club up ahead

Kigali

Teaching and Learning Course week 2

We held the second session of the Teaching and Learning Course that Ruth and I developed today in the simulation centre.  Today was about effective large group presentations and teaching technical skills. Friday afternoon from 1 - 4 PM is a difficult time slot but everyone kept engaged.  Amélie did a fine job with large group presentations.  Two real medical students were kind enough to come as learners for the technical skills session.  It's been a busy week so we are excited about the upcoming weekend.  Michelle and Amélie are off getting tailor made dresses.  The time is going much too quickly. We love being in Rwanda.

Amélie teaching large group presentation

student learning IV insertion

student learning intubation

Michelle's wrap up

Hi everyone,
 
After planning for  year with Jocelyne for the nurses training in Rwanda I can't believe the journey is over.
Yesterday  was the final assessment of the nurses skills and then "graduation"...and what a celebration it was!
Very bittersweet as we congratulated them...we are so proud of each of them but very sad to say goodbye.   
At one point they broke out into Rwandan song and dance, this white person looked like Elaine from Seinfeld trying to bust a move with them.
 
From everyone's point of view the program was a  great success.  The difficulty going forward is the nursing shortage here.  But the OR nurses are now empowered with knowledge and so excited to put their new skills to work.
 
I could not have asked for a  better colleague to do this mission with...Jocelyne was amazing.  Her wonderful husband Brian was a huge support for both of us.
I have vowed not to come back to Rwanda unless my husband is with me....I really need to share these experiences with him.
 
I am poolside at the Serena Hotel enjoying my day off and once again reflecting on how lucky I am to have this time in Rwanda and to have all of you in my life.
 
xo michelle

periop nurses

Michelle and Jocelyn's perioperative nursing course finished today.  It might seem impossible but surgery is frequently done here without a scrub nurse.  Now there are fifteen OR nurses who have been trained how to gown, glove, set up a sterile table and pass instruments.  All this learning happened in the simulation centre.  Each nurse had to pass a written and practical test at the end.  They were all successful! The graduation ceremony was very moving.  The nurses were so happy and grateful for all they had learned.

Amelie and I have spent the last few days teaching and solving Rwanda's problems one by one.  I had a full day meeting with Paulin yesterday, as he is the new program director.  I could not be more proud of all he is doing to make the residency program excellent.  There is no question that leadership skills are increasing among the recent graduates.

Michelle and Jocelyn congratulating the periop nurses

Emmy and his lovely partner, Mary

Mama Michelle

blogging with halothane MAC 0.4

Amélie and I have spent the day in the OR and as there is no functioning scavenging we are slightly anesthetized from breathing anesthetic gases.  I have, once again, put in a plug for connecting the scavenging system.  Today should have been straightforward, as the patients were healthy adults for minor surgery, but somehow everything becomes more complicated when there are strained resources.  We did our best to teach around the issues that arose.

There are moments of delight and moments of frustration.  We met a bright young medical student who was spot on in answering the questions we asked about anesthesia assessment.  She was completely organized and systematic.  It is a pleasure to see a new generation of engaged learners.  Other moments are so sad, as the fragility of life is apparent.  The experience in Rwanda is often one of great contrast - amazing natural beauty and gracious people contrasted with the harsh reality of disease and death.

Michelle is doing a phenomenal job teaching sterile technique and scrubbing to a group of 15 nurses. She and her colleague, Jocelyn, are offering a two week course in the simulation centre.  All the nurses have the opportunity to immediately apply what they are learning by gowning, gloving and setting up surgical trays with good sterile technique.  Infection is a big problem; we hope this course will be part of the solution.

Amélie and I are finding regular exercise at the Serena Hotel vital to keeping us calm and sane. Some days we sneak in a before work workout and after work swim. When we are not in the OR or exercising we spend a lot of time on preparing our teaching material for upcoming sessions. Our time here is going much too fast.

Michelle at Lake Kivu

One of the cheerful waiters at Paradis Malahide

beach at Paradis Malahide

Medical student learning in the OR

Blame it on the ma-a-a-a-a-a—larone

Our first work week finished with a fantastic first session of Patty’s Teaching and Learning Course expertly delivered by herself and Dr Théo. Again, the session was very well received and all participants were enthusiastic. It was, however, time to get out of the operating room as I was three for three in terms of days when it was necessary to manage emergencies. It was also time to get out of Kigali, with its frantic pace of life. I haven’t been able to get a good night’s sleep since being here, which I attribute to the malarone, a malaria prophylaxis medication. I also suspect it’s making Patty a bit manic.

A snapshot of the weekend:

BBQ potatoes with “akabanga” hot sauce are the best food ever.

Staff at Paradis Malahide are unforgettable and most energetic (they literally run to get your order).

If a Rwandan tour guide who doesn’t speak English tells you the rest of the hike will be short, don’t be fooled but do it anyway; it’ll be unforgettable.

I fell in love with the town of Gisenyi, on the shore of lake Kivu, and I have a new BFF, Dosine.

I got my first marriage proposal followed shortly by the second one, although the thought of moving to Goma, in the Democratic Republic of Congo, isn’t all that enthralling.

I almost busted white girl dance moves at a great beachside bar, Tam Tam.

Gorilla farts are enough to discourage even the most fervent animal lover.

“This road has always been one way, but maybe for today, they changed it.” – Kigali taxi driver

Hiking near Gisenyi

Dosine is in the middle

Bonding the gorillas

Intore dancers

There were traditional Intore dancers at Paradis Malahide on Friday night.  This is an energetic dance where the men thrust spears and jump to singing and a drum.  After the dancing, the audience was invited up.

Amelie and I attempt Intore dancing

At the hot springs with local children

Michelle's thoughts

(Thursday)

Wow time is flying! 

Day 4 of the OR nurses course done. They are so eager to learn‎, receptive and every day Jocelyne and I admire them more and more.

Their operating rooms had no guaze sponges or water today and they were still doing surgery. We cannot comprehend this.

I truly love their personalities‎....every time I come here I feel like I am blessed with new friends.

We have many,many laughs together as we teach.

Road trip tomorrow after work to Lake Kivu, one of my favorite places in Rwanda. I will be looking for my soccer kids with new balls and shirts from Mark.

Patty is still working as hard as ever solving Rwanda's problems one by one.

Everyone have a great weekend!

XO michelle

(Saturday)

If I was to live in Rwanda this would be the place...Gisenyi.

Situated on Lake Kivu it is the 5th largest town in Rwanda. The fishing boats that are rowed out at sunset and back in at sunrise are one of my favorite sites here.

It doesn't have the craziness of Kigali and has so much more to offer with fresh air and spectacular scenery.

We have had a spectacular day. Amelie and I‎ went for a short run ( I thought Clayton Park was hilly!) first thing in the morning. 

Then all 5 of us went on a hike in the area for the morning....that is where we had the most heartfelt, happy morning with children from the village.

They run up‎, grab your white hands and walk with you.

Many speak some English and it is pure joy to be with them.

Now it is 7pm and we are are sitting by candlelight by the lake waiting for our fish brochettes for dinner...24 C and crickets chirping.

I am a very lucky person.

XO michelle

Fishing boats on Lake Kivu

Michelle knocking back a Mutzig

A marriage proposal and offer to move to Congo (immediately!)

hiking the hills near Lake Kivu

Amélie and I just had a fabulous 5-hour hike through the hills above Paradis Malahide in Gisenyi.  We went with Twiziere, a former member of the Rwandan cycling team with whom I have had previous cycle adventures.  This time we were on foot.  It was a pleasure to be immersed in the lush greenery without having to dodge potholes.  After the pollution of Kigali, the fresh eucalyptus scented air was most welcome.  There were many birdcalls and, of course, numerous children calling “muzungu”. Twiziere speaks very little English.  Amélie and I practiced our limited Kinyarwanda.  This was a wonderful reset after a very busy week.  We are smiling ear to ear. 

Potatoes, goat brochettes and banana beer on the road to Gisenyi

garden at Paradis Malahide

near Gisenyi

lush hills, tea plantation on left

terraced valley in the hills near Lake Kivu

a heavy load for a young lady

old fashioned sewing machine