chaos and order

Given my OCD nature, I often struggle to cope with the chaos of the operating rooms here. It is a strong testament to the skill of the PGY1 resident, that I was able to remain calm during our list. The quality of residents is getting better and better.

The usual problems exist: lack of team coordination and communication, few supervisors, broken or poorly functioning equipment and no scavenging of anesthesia gases – meaning the whole operating room team is partially anesthetized. Shortly after the resident and I discussed how spontaneous breathing is an advantage to LMA (especially in this context with no neuromuscular monitors, older drugs like vecuronium, and erratic supply of reversal) the tech gave vecuronium without discussion with the team. This is just an example of how it can be hard to reinforce good practice when there are too many anesthesia providers without clear leadership.  

Despite this, Butare is an oasis of order in comparison with the other place we usually work.

At Gaston's home

From Patty:

Gaston is our dear friend who is an anesthesiologist in Butare. He has recently bought a home for his family.  We are thrilled to be his guests.  The home is in a quiet neighbourhood - such joy after the noise of Nyamirambo.

The house is stunningly beautiful. There is a large garden with mango and avocado trees.  Gaston has planted a garden, so there are lots of fresh vegetables.  He recently installed solar panels, so there is solar power.  We are so happy to be guests of Gaston and Florida.

Gate to the house

Gaston in the vegetable garden

Kitt looking at the mangos

Gaston is growing passion fruit

Gorgeous livingroom

Kitt and Gaston 

Monkeys down the street from his house

rich days of learning

From Kitt:
Hi all! I hope this finds you well.

Where did we leave off? So much seems to happen on a daily basis here, it can be easy to miss things. 

After our beautiful walk through the hills of Kigali yesterday morning, Kyle, Amélie and I went to the Genocide Memorial in town.  A total of approximately 800,000 - 1,000,000 people died in 100 days in 1994. Over 250,000 people are buried on the museum site. The grounds are a place of remembrance for many visitors who lost loved ones.  

The museum displays the history of not only the Rwandan, but also multiple other genocides of modern recorded times. The resounding feeling after visiting is an understanding and acceptance of the past so as to not repeat mistakes in the future. 

It was a powerful place to visit.

Our somewhat comtemplative mood was soon cut short, replaced by the fear of death by head on collision in a taxt. After a few wrong turns, we ended up at Francoise's house, where we ate a fantastic meal with 8 different dishes and fruit salad for dessert. Francoise even taught me how to tie her adorable baby on my back using a blanket. It was so kind of her to prepare such a feast for us that I thought it impolite to run away with her youngest child, so I reluctantly left him behind.

Today, we had another full academic day, with a focus on post partum hemorrhage (PPH), which is the leading cause of maternal death in Sub Saharan Africa. The residents are extraordinarily prepared for teaching sessions, and discussions are lively. Not as lively as Jeopardy, though, where not even my shrieking whistle was able to reign in the competitiveness. The resident case report today was presented by Brigitte, one of the second year residents.  We were pleased to see that she incorporated many techniques she learned from the Teaching and Learning Course, including not relying on a Powerpoint presentation!

Amélie joined us in the afternoon to run an oral exam station. Patty ran a simulation where she played an obese patient with placenta previa. (She didn't eat dessert at dinner tonight).  Kyle and I ran a full OR scenario simulation for PPH The residents had to both manage severe hemorrhage after cesarean section under spinal anesthetic, and then convert to general anesthetic after the patient lost consciousness. Simulation can be stressful and overwhelming, but the residents are quick learners. 

At the end of the afteroon session, we were visited by the same Minister with whom Patty and Angela met last Monday. The residents, Paulin, the Dean of Medicine, and the Minister had a great discussion about some of the issues facing the residency program, including, but not limited to, lack of resources and retention of clinical teaching staff. The minister seemed very receptive to their suggestions. Overall, it was a very productive day.

Patty and I are looking forward to going to Butare tomorrow, while Kyle will spend another day here with Amélie before leaving for Butare on Wednesday. Next stop, Essential Pain Management Course! 

Kitt

Feast at Francoise's home

Amélie with Francoise's adorable baby boy

Francoise's daughter all ready for school the next day (so happy!)

Kitt learning how to be an African mother

Kitt didn't want to take him off

happy family

PPH simulation

Patty as obese pregnant patient 

Alcade at the head

Amélie teaching on the grounds of the sim centre

Welcoming the Minister

Paulin invites the residents to share concerns with the Minister and Dean of Medicine

goodbye Ruth, hello Amélie

The final night before Ruth departed to return to Halifax, we had a wonderful evening at Khana Khazana, the Indian restaurant.  We needed to lift our spirits after the inauguration.  We ate delicious food, enjoyed each other's company and talked about whether humans are inherently good or not.

Kyle and Patty

Kitt and Ruth

Rwanda has been nearly completely dry for a month...until last night when a storm hit Kigali. There was lightening, wind and an intense downpour.  We watched the people across the street sweeping water out of the bar with a broom. It was a losing battle.  The power failed, so we lit candles and switched on our headlights.  Rain came through our roof covering almost all the rooms in our apartment with water.  We scurried around gathering our electronics, threw towels on the puddles and resigned ourselves to sleeping in wet beds! Poor Amélie arrived in the middle of the pandemonium.  Somehow, I managed to give Kitt and Kyle a beginning lesson of bridge during the chaos.  They are quick learners!  We need to press on with this pursuit while we have Amélie here as a fourth. Kitt made a 700 rubber right off the bat. Natural talent or two exceptional hands.

We got up bright and early for a 12 km walk around the hills of Kigali. Kyle's gizmo said we did 400m of elevation. This is a good cure for jet lag. It doesn't take much to leave the noise and pollution of Nyamirambo (our home) to be in countryside that looks like rural Rwanda, complete with goats, the odd cow and children screaming "muzungu".

Amélie, looking fresh after a long flight

Christophe, Kitt, Amélie and Kyle

goats

cow and the green hills of Kigali

Damage from the rain, even some cobblestone streets were messed up

Kitt, Kyle and Amélie are going to the genocide memorial this afternoon and then we have been invited to the home of Francoise for dinner.  As usual, we are preparing for a busy teaching day tomorrow. 

xo

Patty

Ending on a better note

From Kitt:
Patty, Ruth, Kyle and I had wonderful Indian food at Khana Khazana again, to shake off the gloom we felt after watching the inauguration. What a somber feeling listening to that speech. I don't look forward to the next 4 years of divisiveness in that country, and possibly much of the world. 

As Patty mentioned, this was such a contrast to Obama in 2008. I happened to be in Ghana at that time, where it was impossible to avoid being caught up in the overwhelming feelings of hope and happiness.
I think I speak for many people, and definitely our little group here, that we will continue to strive for a globally-oriented future. 

Kyle and Kitt in the OR

From Kyle:

It's hard to believe we are already through another week!

After spending most of the week teaching, Kitt and I returned to the CHUK operating rooms today to work with the residents. Three PGY-1s were on the list today, but it appeared that there would not be much going on as CHUK has been in slow down while many staff physicians are away participating in training programs. Only one room was scheduled to run, an elective ENT list with a visiting surgeon; we wondered if there would be much for the residents to do. Of course, several emergencies presented requiring immediate surgery, and by mid-morning one room quickly became four.

Fortunately, there were enough personnel available to accommodate this including nursing staff and surgeons, both Rwandan and visiting. It is impressive to see the composure of the anesthesia residents in these situations. We did not see a staff anesthesiologist all morning. The residents and anesthesia technicians did everything. A clear degree of confidence and strength in the basics of management has developed from this, as the PGY-1s here are more comfortable in these emergent situations than I remember being at that point in my training. 

This independence has its shortcomings, though. Positioning for intubation, proper pre-oxygenation, laryngoscopy technique, ensuring gastric drainage in obstructed patients... there were a few 'near-miss' events this morning. While the close eye of a staff anesthesiologist can often feel overwhelming, frustrating, stifling- it forces you to refine your skills . As the program is training future consultant physicians, we have been impressing the importance of minimizing patient harm during surgery. While we may get away with imperfect technique or incomplete knowledge 90, 95, even 99% of the time, the role of a specialist is to prevent every possible complication. 

We are looking forward to a day free of travel or work tomorrow: maybe a chance to relax and explore our busy neighbourhood and finish up preparation for Kitt's academic presentations on Monday. We are especially excited for the arrival of our friend Amelie!

Window on the OR

a strange symmetry

Here in Rwanda the mood is gloomy as Donald Trump takes office. What a contrast to 8 years ago when Barack Obama was elected.  I also was in Rwanda that day and here is my post from 5 Nov 2008 titled "Joy in Africa":

Genevieve (standing) was the first resident to travel with me to Rwanda in 2008

Everyone here is thrilled about Barack Obama's victory!!! There is joy in Africa. Our house gathered together for a celebratory dinner. The two gentlemen on the left are Kenyan nurses and delighted with the news. Marete, on the left, told us the felt this was a profound change for the world like the fall of the Berlin wall. He believes this is sign that racism is on the way out and there is the dawning of a new era where we work together. Let's hope so.