final reflection

I’m back in Halifax and looking at our quiet, snowy garden.   The month in Rwanda has been excellent and each time I go back there has been noticeable improvement.

Still, there are terrible challenges such as broken equipment, lack of drugs, overworked and poorly reimbursed staff, very ill patients, few role models, chaos, and poor team communication.  The Rwandan hospitals are not easy places to work.  The reward for visitors is the enthusiasm to learn and improve by the local staff, residents, technicians and medical students.  Everyone is so grateful for our help and friendship.

Being in Rwanda reminds me of how very fortunate we are.  Each day you see people in Rwanda who are warm and cheerful even when coping with great adversity.  I just hope I can remember this in the months to come.

Special highlights:

·      Sharing laughs, tears, scary cases, serious cycling, great food, and inspiring teaching with Lauren and Terri

·      Bona as a great leader in the OR – often running 6 rooms and putting out fires with great skill.

·      Paulin teaching the residents at academic day – they were so proud to be taught by a graduate from their program

·      Christian telling everyone in the room to be quiet during a chaotic and noisy pediatric induction

·      Academic day – great fun, very interactive, seeing light bulbs go off

·      Bringing low fidelity simulation to Rwanda and finding a potential space for the Rwandan Simulation Centre!

·      Bona introducing the Surgical Safety Checklist at CHUK

·      Great meals at Khana Khazana

·      Mountain biking along Lake Kivu for two days – absolutely gorgeous country and very far from the noise and chaos of Kigali

·      The waterfall hike in Nyungwe…

·      Serena Hotel – swim, whirlpool, shower, sauna, tea, salad Nicoise, coffee ice cream and wifi

·      Smiles, hugs and handshakes with my many, many friends in Rwanda

Who knew you could make neurophysiology fun and interactive???

Great impromptu teaching by Lauren

Bona - a pillar of strength

This is me looking happy and relaxed

Our low-fidelity simulation program

Teaching paediatric intubation (Benjamin and Gaston)

Washed coffee beans in Kinunu.  We stayed overnight at the coffee washing station.

Biker chicks

Coffee washing station.  They lay the beans to dry for two weeks and need to turn them regularly.

Tea plantation near Nyungwe

Rwandan resident group

welcome to Karim

These are two of my new friends – Benjamin and Gaston – first year anesthesia residents.

Terri and Lauren are back in Canada and Karim arrived yesterday.  His flight was messed up by the snow in Europe and his luggage didn't come with him.  Fortunately, it has been found and he's off to the airport to retrieve it.  Karim gets great bonus points for initiative.  He grabbed a cab at the airport and asked for the Merez petrol station in Nyamirambo (the closest thing we have to an address).  He found a guy with a cell phone and called me from there.

We had academic day today and, as always, the residents are very keen to learn.  I spent some time discussing their various research projects.  Each one must complete a project during residency.

I get quite sad when my time in Rwanda starts coming to an end.  It never feels long enough.  It has been a pleasure to teach such a great group of guys.

Moral Corruption

Christian and Claude at Khana Khazana

Gaston with his guitar

Well, it's our last day in Kigali today and it's quite hard to believe that we're leaving since are time here has gone so fast. Our flight has already been delayed so maybe that's a sign that we should be staying longer! Patty is here for one more week without us and is awaiting the arrival of Karim who will replace us (big shoes to fill though!).
This week was filled to the brim with teaching activities, days in the operating room, work on our projects and lots of goodbyes.  We made time for a memorable dinner with Christian and his lovely wife Grace who hosted us for a traditional African meal of maize pate, sombe, fish, chicken and plantains, one of our best meals yet!

Our simulation teaching of Anesthesia Non-Technical Skills

Thursday we did our last paediatric case, a 2 month old with pyloric stenosis.  Everything went really well and you can see the enormous benefit monitors like the Lifebox are making especially with the lack of paediatric sized equipment.  It was also great to see yet again what an influential leader Bona is in the operating room, making these difficult cases run so smoothly.

The Lifebox paediatric pulse oximeter

Friday afternoon Lauren and I went to the genocide memorial at Nyamata. We were hosted by our friend Steven who Patty met four years ago at the same memorial. It will take us a long time before we can fully process what we have seen and heard but we are very grateful to Steven for sharing his experiences with us.
Friday evening we had one last dinner out at Heaven restaurant with Bona and his wonderful wife Adelene as well as fellow surgery residents and even an epidemiologist, it was a dinner of great minds!!! (and great wine!).  We had a memorable taxi ride home with our first female cab driver and it wasn't long before Patty was dancing with the rest of us, we even taught her to "fist pump", she will forever be changed.
This is mine and Lauren's last blog, but not Patty's we'll see how her week goes without us and we're off to battle the snowstorms that are keeping us from our families back home.
Terri

Buhuro, Buhuro

Slow by slow. That was how we made it through this grueling yet incredibly beautiful mountain biking trip along the shores of Lake Kivu.  When we asked Tom how many more hills there were, he said well take 1000 hills, and subtract the number we've done, and that's how many we have left :).  

We started our biking trip at Tom's house (our guide) and met our porter Tuciere. We were thankful that our Tuciere was a former member of the Rwandan national cycling team, carrying extra bags was definitely not a problem for him.  After trying out our bikes and helmets, and of course a group photo, we were off on our 80 km bike ride.  

We saw a side of Rwanda you could never see unless traveling by bike or foot into the rural areas. We saw coffee washing stations and fishing villages and everyone stopped to say good morning (even well into the afternoon) as we went.  There was even a small town where instead of "good morning" all the children yell what's up! at the same time, they have definitely been taught by a muzungu!

We spent the night at Kinunu coffee washing station and were treated to a swim and a great meal.  We were very proud of our long day of cycling yet aware that we had to go all the way back the next day! Although we were slightly stiff in the morning we managed to get back up that first hill and with Patty's new skills in downhill mountain biking we made record time on the way back (well record for us :)). It was an incredible trip and definitely a highlight of our time here.

It was mine and Lauren's last academic day on Monday.  We filled it to the brim with teaching and left just enough time for a quiz that the residents really aced.  It was such a great feeling to know that our teaching had been effective and they had gained a better understanding of some really difficult concepts.  I think we're a really tough act to follow for those coming next month! :)

After a long day we headed to our favorite place, Khana Khazana for one last group dinner.  We were joined by Dr. Jean as well as the staff from King Faisal Hospital, and of course, the residents and staff from CHUK.  We had a great meal and even got serenaded by Eustache and Gaston on the guitar!

Just a few days left here and so much to do! Still working hard on our studies, some difficult cases tomorrow in the OR and trying to squeeze the last minutes out of this month to teach as much as possible. We will certainly need to recharge our batteries when we get back!!

Terri

Nothing beats seeing a grown man try ice cream for the first time!

We had an incredible day teaching in Butare yesterday. We started the morning with the 3 first year residents, going over things like anesthesia considerations and how to make an anesthetic plan. They were extremely enthusiastic and eager to learn, and it was very encouraging to see how quickly they are improving. They are so motivated and thirsty for knowledge – it is a pleasure and an honour to teach them!

In the afternoon, we were delighted to have two of the first years, Benjamin and Gaston, join us at the medical school to teach basic communication skills to a class of second year medical students. Without any preparation at all, the anesthesia residents blew our socks off and much to the delight of the medical students, provided outstanding and comedic presentations on how to communicate effectively with patients. They outlined with maturity that was both humourous yet extremely powerful, how they had dealt with difficult situations in the past and provided advice for the students on how to deal with challenging situations. They are amazing role models and are natural teachers and leaders. We are all so excited about the future of anesthesia in Rwanda with so many incredible residents already in the program, and hopefully the future students who will be inspired by these residents to join us in what we know to be the best medical specialty J

We also had the opportunity to speak with some female medical students (who remain few and far between) and commend them on what they are doing, as well as encourage them to thrive in a world that at them moment seems very male-dominated. They were amazed (and hopefully inspired) to hear that in Canada, there are now more women entering medicine than men.

Thursday night we held journal club for the Butare residents and had an excellent discussion about critical evaluation (I personally never thought I would have an excellent discussion about this, but seeing the looks of understanding on the residents’ faces as we explained different topics to them was really gratifying) over ice cream. One of the residents even tried ice cream for the first time - it was incredible watching his face as he first felt the coolness of the cream which then transformed into an explosion of flavour! Can you imagine going your whole life without ice cream? That's probably why they have such nice teeth here...

Friday started off with morning report in Butare, which was opened by a song and a prayer shared by the group – it was quite a lovely experience to take part in, and we think it really helps to build the sense of teamwork that we see in Butare. We then discussed some of the cases they had seen over the past few days, including some incredibly challenging cases in the ICU – things that would make us quiver in our boots if we were faced with them on a Royal College exam!

After morning report, we got a ride to Gisenyi, where we will overnight before starting on our strenuous bike ride tomorrow (I say strenuous because I know what kind of rides Patty has convinced me to do in the past!). The drive was gorgeous – fortunately the road is quite new so there wasn’t a lot of traffic on it (although that didn’t stop me from having the occasional arrhythmia as my life flashed in front of my eyes). Along the way, we passed the Rwandan cycling team (which Patty saw when she was in Gisenyi last weekend). They were biking – or should I say barreling - up the longest hill I have ever seen in my life. I think it would take me at least 3 days to walk up the hill and they were already near the top at 10:30 in the morning, still riding their hearts out! They will wear the yellow jersey proudly at the next Tour de France I’m sure!

Now we’re lounging lakeside at the Paradis Malahide in Gisenyi, listening to the incredible sounds of life. We just saw dozens of fishing boats heading out for a catch, and heard the fishermen chanting in unison as they rowed their way out into the middle of the lake. Just as they passed, a chorus of singers began their rehearsal just a few hundred metres away. It truly is magical here!

Lauren

P.S. Terri and I tried the banana wine that we bought last weekend – unless you like to lick ashtrays, I would recommend staying away from it!

Guinness and Coca

Last night we had journal club with the Kigali residents at Le Capri, a restaurant down the street from our apartment.  It was a relaxed evening over fish brochettes and the Rwandan Guinness and Coke combination. Terri lead a stimulating discussion of relative risk, absolute risk, and confidence interval.  We talked with the residents about leadership and being the change you want to see.  We again discussed the frustration of working with broken and inadequate equipment.  The residents are a great group of guys who are super keen to learn.

We are back in Butare and heading over to the hospital to do some small group teaching with the junior residents.

This weekend we will be out of communication as we are cycling along the shores of Lake Kivu on the Congo Nile Trail.  Yeah!

xxoo Patty

There are no stairs in Kibungo!

We had yet another successful day of teaching at academic day. This was our most ambitious day yet and included sessions on neurophysiology, a resident case presentation, Anesthesia Non-technical Skills, an airway workshop, and a session on hypertensive emergencies. Dr. Paulin joined us for the afternoon teaching and did an incredible job teaching the residents about hypertensive emergencies. He also reviewed how to take a history on functional status with the residents and reminded them how to tailor their questions, such as not asking if a patient can climb stairs without getting chest pain if they're from a place with no stairs! The residents continue to be so keen and enthusiastic at academic day and we're encouraged by how much reading and preparation they're doing.

Patty's accommodation at the Paradis Malahide!

Lauren and I are still recovering from our 9 hour gorilla trek, 9 hours!!! We did end up seeing the Susa group and had such an incredible experience spending time with over 15 gorillas! One even took a liking to me and was posing for the camera. This week we head back to Butare again for more resident teaching and we're also holding journal club this week as well as M and M rounds, busy busy busy!!!

More news to come in the near future!

Terri

Intore Dancers welcoming us to our gorilla trek

My "special" gorilla friend!

Getting a good bite to eat

Relaxing after a big meal, he looks like he's watching TV!

not the muzungu cycle tour

Lauren and Terri managed to see the Susa group of gorillas, which is the largest gorilla family.  They are still working their way down the mountain, as the Susa group is very high up at the moment and the hike up to see them was six hours!

After four trips to Rwanda, I can definitely say that today was my greatest immersion in African culture.   I had a 28 km cycle tour around Gisenyi with a guide.  We began on paved roads along the shore of Lake Kivu but were soon cycling potholed dirt roads on the far side of Gisenyi.  The streets are lined with simple dirt houses and there are people everywhere.  Children call “muzungu, muzungu, how are you?” while running after the bikes. Women carry everything imaginable on their heads.  There are fields of vegetables or flowers here and there.  Small shops carry vegetables and the ever-present cell phone cards.

We made a number of short stops including a huge market full of fruits, vegetables and used clothing.  People were laughing their heads off at us with our bikes and me wearing a Project Rwanda cycle jersey and bike shorts!  It helps to not worry about one’s image…

We got lots of thumbs up and cheers of enthusiasm from the Rwanda cycle team when they cycled past on their road bikes and spandex gear. 

We also stopped at a community centre that serves people with disabilities.  They teach disabled adults various crafts (sewing, knitting machine, woodwork, basket crafts) and have a program for deaf children and mentally challenged children.  The centre is sponsored by the zoo in Columbus, Ohio.  Don’t ask me the connection! 

My guide introduced me to a friend of his.  This person has had both hands amputated midway down the forearm – clearly an act of war.  It is incredibly sad and I can’t imagine how he is able to live with this horrendous disability.

This is a country of such contrasts.  Almost without exception, the Rwanda people I’ve met radiate kindness.  The land is spectacularly beautiful.  I am looking out over Lake Kivu where people chant and sing while race large wooden canoes.  

Lake Kivu

This morning I met with a group of six nurses from several wards at CHUK to hear their challenges in caring for their patients with pain.  It certainly is tough.   We explored the obstacles and some potential solutions.  I am always inspired to see such committed staff despite the enormous difficulties they face.

We packed our bags and left Kigali in the early afternoon.  Our driver dropped me off in Gisenyi, on Lake Kivu, before taking Lauren and Terri to Kinigi.  They will be trekking to see the gorillas tomorrow.  I’ve been able to see the gorillas before and preferred to have a quieter weekend in Gisenyi. Tomorrow, I will join a small group to do a cycle tour of Gisenyi!  Lauren and Terri will meet me tomorrow evening after the gorilla trek.

The Paradis Malahide is a slightly funky hotel on the shores of Lake Kivu.  The gardens are lush with greenery and mango, banana, avocado, and orange trees.  This evening I watched a race of traditional boats on Lake Kivu.  

When monkeys attack...

 On very short notice Bona managed to gather together a group of about 50 surgeons, anesthetists, nurses, and technicians to discuss the implementation of the WHO Surgical Safety Checklist.  Bona spoke passionately about dreams and dedication being a powerful combination.  It is very inspiring to see him manifesting such leadership.
There was also a meeting of the Rwandan Pain Society today.  Paulin founded this organization about one year ago and they have accomplished so much.  We spoke about the need to begin educational programs this year.  Perpetua, the wonderful Director of Nursing, has arranged for me to meet with a small group of nurses from a variety of services on Friday to explore how they are implementing pain management strategies on their wards.

Mountain Monkey :)

Deep in the Nyungwe Forest

The Resident Rock

Gilbert and his ladies

Lauren and Terri have been doing some great teaching with the residents.  We have been working hard to promote non-technical skills like communication, planning and anticipation.  There is still a challenge transferring theory to good clinical practice.
Outside of work, we've been swimming at the Serena Hotel and relaxing by the pool.  I probably shouldn't tell you but Kigali has a near perfect climate! Lauren and Terri are knocking back some very large beers as I write.
We had a most wonderful day last Saturday.  We hiked to the waterfall near Gisakura Guest House.  After being told we were very unlikely to see any monkeys, about 5 minutes into the hike, we came across a large group with four different species of monkey.  They were leaping through the trees around us and one even threw a small branch at us.  After the hike we headed to the Nyungwe Forest Lodge for lunch in an most idyllic setting overlooking the tea plantations.

Tea plantations surrounding the Nyungwe Forest Lodge

The Kamiranzovo Waterfall

Coming up this weekend is a trip to Gisenyi and gorilla trekking for Lauren and Terri.  They have promised to post some photos tonight.
We have some very challenging peds cases tomorrow...
Love to you all.
Patty

More monkeys!!!

Relaxing poolside at the Serena

A quiet day in Kigali

Terri and I began the day with a run up the Nyamirambo hill.  On the way back, we stopped in the local market just as it was opening up and stocked up on fruit and vegetables.  We spent the rest of the day working on our teaching program and enjoying the pool at the Serena Hotel.  Sender (McGill surgeon) and Heather (McGill surgery resident) arrived tonight and joined us for dinner along with Paulin and Matthew (our physiology expert). 
Patty

From Butare to the Nyungwe Forest...

Our first teaching day in Butare started off with delivering two new Lifeboxes, donated by Jennifer Szerb (a staff anesthesiologist in Halifax who has made multiple trips to Rwanda) and her mother. It's great to know that these are the first few of many that are on their way to Rwanda through CASIEF and are desperately needed for safe anesthesia in Rwanda.

Delivering the Lifeboxes

 We hit the ground running and began our first cases in the operating room in Butare. Residents and technicians presented the cases and together we discussed the pros and cons of different induction techniques and resolved very challenging dilemmas as a team regarding difficult intubations with minimal resources. We also introduced the option of sedation and pre-medication before moving patients with fractures to better positions for spinal anesthesia. This worked really well and both cases progressed easily without any concerns.

I also had the privilege of spending time with one of the anesthesia technicians. I asked him why he went into anesthesia as it's an unusual career to be a technician. He told me he was an OR nurse in the district hospital and there was no technician. He was often asked by the surgeon to give ketamine to patients for anesthesia and they received nothing else. He said he wanted to learn more about anesthesia and do things better so he went back to school for three years to become a technician and now works in Butare. Throughout the day I watched him work and was touched by how much care he provided for the patient, taping the eyes delicately protecting the arms and tucking them in and teaching the residents. His story really inspired me.
Overall a wonderful visit to Butare and I can't wait to return in two weeks.
Terri

The Butare team at morning report

In the evening after our day of teaching, we went for a nice run through the National University of Rwanda campus, which is a beautiful spot saturated in the aroma of eucalpytus trees. As we ran, people would call out "Esprit!" to us, the Rwandan way of encouraging fitness and well-being. We then enjoyed our dinner of croque-monsieur (grilled cheese) and sliced avocado, which somehow took over an hour to prepare.
Friday morning, we again returned to the Butare teaching hospital where we attended morning report and heard about some of the very challenging cases that they manage here. We then did some teaching with some of the residents and technicians on airway assessment and the difficult airway algorithm, which was well received and I think they learned a lot - it will be interesting to see how it is applied in the clinical setting! Patty and I did another interview for our study which was fantastic - it's really interesting to get the Rwandan perspective on things after interviewing so many North American volunteers who have given us their opinion - many ideas are congruent, but we're really starting to understand the intricacies of how things work here.

Amazing views on the drive to Nyungwe Forest

After lunch, our driver Isaac picked us up to take us to the Nyungwe Forest. The drive was absolutely gorgeous (although a bit scary at times - we passed a lot of petroleum trucks on narrow, bumpy roads with sheer drop offs on each side - good thing Isaac is an extremely cautious driver!) - the forest is extremely lush and the landscape is made up of rolling hills dotted with small farm houses... it is very idyllic!
We are spending the night at the Gisakura Guest Lodge which is in a perfectly peaceful spot with brilliantly coloured sun birds flitting about among the flowers. It will be the perfect spot for a restful sleep in anticipation of our waterfall hike tomorrow morning :)
Lauren

A beautiful sun bird

Thank God that guy broke the toilet!

We began our day in the OR/ICU, continuing to be impressed with the enthusiasm, commitment, and motivation of the medical students and other health care practitioners here. Bona, a new anesthesia staff person who joined us in Halifax for 6 months a couple of years ago, thoroughly impressed Patty and I with his excellent management of a difficult neonatal case, in which he was a fantastic role model for the anesthesia technicians and residents in displaying his leadership and communication skills under pressure - we were very excited to see him being so effective in action!
The afternoon was spent in true Rwandan style, waiting over 2 hours for our driver to take us to Butare. I guess there was some mix up in organizing a driver, and of course remedying the problem here is not so simple as picking up a phone and calling the driver... first, one must go to the Ministry of Health to speak with someone, and that person will then go about making the arrangements. Then someone else needed to accompany the driver to our pick up location, we dropped that person back off at the hospital, and then finally, we were on the rode to Butare.
The drive was incredible - amazing green rolling hills, children skipping home from school dressed in cute little uniforms with bright smiles, and tons of new construction everywhere. Our driver was friendly and very safe and we arrived in record time.
Our hotel was a place Patty had stayed many times before and the people were very friendly. Unfortunately we were given rooms in the basement and they reminded us of rooms in a Norman Bates movie. Then as if someone was watching over us the porter was trying to help us with the toilet and he broke it! The next thing we knew we were up on the first floor in lovely rooms and had a great (and much needed!) night's sleep.
Today we're off to Butare to continue our enthusiastic teaching with some of the very keen new first year residents.
Terri

The evening got much better because we had a delightful dinner with Dr. Jeanne the Head of Anesthesia. She has a wonderful way of laughing off all the many challenges they face.

off to Butare

We are heading to Butare today for two days and then will go to Nyungwe Forest for the weekend. Butare is a smaller city in south west Rwanda and home of the National University of Rwanda and the medical school. I believe there will be five residents there now.

Nyunwe Forest is 1,000 square kilometers and the continental divide runs though there separating the waters flowing to the Congo and Nile Rivers. There is a rich variety of plant and bird species.

40/40

Today was our first hands-on day at CHUK. Patty and Lauren were off bright and early for a day in the operating room and I was charged with rounding in the ICU.
Damascene, a fourth year anesthesia resident was in charge of ICU rounds with input from the staff Dr. Bosco. I was surprised and impressed to see 5-6 medical students doing their ICU rotation (something we only do as an elective). They were each in charge of a patient and were required to see them ahead of time and then present them during rounds. I was beyond impressed at their presentation skills and their systems based approach to their patients. They were also inquisitive and asked really thoughtful questions about transfusion guidelines, pharmacology and antibiotics. I can certainly say that when I was a senior medical student my competence in managing ICU patients was not as proficient as that of these students.
Later on in the day I relieved one of the anesthesia technicians so he could participate in Patty and Lauren's study on non-technical skills in anesthesia . There I saw my first Lifebox (saturation probe and heart rate monitor designed for developing countries to provide a low-cost tool for monitoring oxygenation) in action. Although we had a good quality Datex machine and monitor, the cables for the ecg and saturation probe were not available and so it was an essential component to ensure a safe anesthetic.
Terri

Hi Everyone,
I've been ever so glad that Lauren and Terri have been keeping up the blog. Today was an excellent first day in the operating room at CHUK. There were some very scary moments with the first case (a young baby) but fortunately it turned out well. One of the most inspiring parts of the day was the interview Lauren, Christian and I did with one of the anesthesia technicians for our study. It is great to see how much dedication and commitment some people have to seeing anesthesia care improve in Rwanda. It feels like it's blossoming.

We went to spin class tonight at the Serena Hotel and are now sitting by the pool having just had coffee ice cream. This place is great!
Patty

It's interesting how you can be half way across the world, and yet things can be much the same... today, I had my first Rwandan OR experience, and unfortunately, it involved a lot of waiting around, in part for surgeons to make up their minds about their cases (our 2 cases ended up being cancelled because the surgeons changed their minds about the need for surgery - with one patient, this happened after the patient had already been lying on the OR bed for about an hour), and also because of the normal delays that we see so often in the OR - waiting for patients to arrive from the ward, organizing supplies, etc. I also had a good discussion with some of the anesthesia providers about the untrustworthy-ness of surgeons (we were only partly kidding!)... like I said, things are strangely the same everywhere in the world! I was also exposed to some of the challenges that the physicians and technicians face here when a spinal was done but took so long to work that the patient ended up getting a general anesthetic in order to start the surgery, likely because of bad or inadequate drugs. Overall, it was quite the introduction to the local OR culture!
Lauren

"People don't have allergies in Rwanda"

It seems like the days just keep getting better and better.... We started off with our first day of teaching at CHUK, the main teaching hospital in Kigali, with academic day. The day started off with morning report, where all of the cases from the night before are discussed – most of them were pretty tame compared to what I’ve heard from past volunteers, although a couple of cases brought to our attention the severity of disease that is seen in Rwanda and the often limited resources that are available to the health care professionals who care for the patients here. Despite this however, it is clear that everyone is doing the best that they can under the circumstances, and it seems like things are slowly improving in the face of tremendous challenges.

Next, Adolphe, the chief resident, presented a case that he had been involved in which was fraught with anesthesia conflicts and would be too complicated to even show up on the final exam to certify as an anesthesiologist in Canada... (sorry for those non-medical people – this may not make a lot of sense). He described a woman in her 40s who had initially presented with a bleeding duodenal ulcer. After several days in the hospital, she went on to develop respiratory distress and was felt to have pneumonia. This progressed to chest and leg pain, as well as cyanosis in the lower leg (and possibly hypotension). An EKG demonstrated ischemia, and a subsequent echo should a massive thrombus in the apex of the left ventricle, which presumably was throwing clots, leading to her leg ischemia. At which point the cardiologist put her on a gamut of anticoagulants, including bid lovenox, Plavix, and ASA. Of course then she developed gangrene and required an amputation. So here we have a woman with a recent GI bleed, who has just had a massive MI with a huge clot in her ventricle, on multiple anticoagulants, requiring an amputation. The case generated some extremely interesting discussion and had many great teaching points (including the suggestion to review the ASRA guidelines on spinal anesthesia in the setting of bid lovenox + Plavix + ASA)!




After a quick lunch in the garden at Karibu Restaurant, as well as a much needed coffee fix for Terri, we headed back to the hospital to talk about anesthesia as a specialty and finish off the afternoon with an excellent lecture on cardiac physiology and anatomy by Terri. Since having done many interviews with previous volunteers in Rwanda as part of my research project, I had somewhat of a preconceived notion of the level of knowledge the residents would have (i.e. fairly basic). All of us were pleasantly surprised (especially Patty) to see how far the residents have come – they were engaged, asked extremely intelligent and thoughtful questions, and overall had a great knowledge base on which to build. We deemed our first teaching day a huge success and are excited for how the rest of the month will shape up.

To end off the fantastic day, we celebrated Patty’s birthday with a scrumptious meal at the Khana Khazana Indian Restaurant. We were joined by several of the Rwandan staff anesthesiologists, as well as Matt, and Kelly McQueen, an American anesthesiologist who is here for several weeks, and Patty’s “adoptive son” Steven, a Rwandan she met on her first trip here who calls her “Aunty Patty.” At dinner, we learned that “Rwandans don’t get allergies” – they are a Muzungu affliction.
It was a wonderful way to end off the day, and was made even more fantastic when all of a sudden all of the lights in the restaurant went black, a cheesy instrumental version of “Happy Birthday” came over the loudspeakers, and a procession of waiters came out with balloons and bells and birthday cake for Patty. The best was that “Happy Birthday” became a medley of celebration songs, including one which wished Patty a happy happy 21st birthday! It was hugely embarrassing for Patty which made it even better for us! A+++!!!

Lauren

An A++ Day

Today was our first day in Kigali and our goal was to get ourselves "operational" as Patty puts it. We started with our first Sunday breakfast together and then Lauren and Patty ventured off to the market and returned with a rainbow coloured medley of bean and fruit and veggies for dinner.
Then it was off to get some "cash power" which we found just down the street from us and within minutes we were plugged in again. Not that we really needed it for the day because the apartment has such a nice light during the day and as we later found out we even get treated to a sunset view from the balcony.
Then it was off to get our memberships at the Serena Hotel, we discovered a spinning class which will get our cycling legs warmed up for our cycling trip the third weekend we're here. We walked everywhere today and it was incredibly easy given all the newly build sidewalks and infrastructure. We all agreed that the streets are cleaner than they are back home and the landscaping is truly something to photograph, our favorite was these very bring orange flowers that looked like groups of pipe cleaners.
It was then off to the MTN store (that we've coined the "Mountain Store") for internet access and new SIM cards, hence the first blog post because we are now connected!! We took a detour to the Bourbon Cafe for a bite and some tea and I discovered some yummy and very strong coffee that cured any lingering jet lag.
The second plus in the A++ comes from our shopping trip to Nakumatt for more essentials. We won a gift card for a return trip! We didn't exactly understand why we were so lucky but it definitely added to our successful day.
The last item on our list was a "working dinner" with Matt McNevin, a brilliant future medical student from Canada here on a CIDA scholarship teaching physiology at the Kigali Health Institute. He will be helping us with our cardiac physiology lectures for the resident academic day. We had a great evening and in exchange for dinner Matt gave us some much needed physiology tutoring.
Looking forward to our first day of work tomorrow!!
Terri