July 21st & 22nd - Rwandan hospitals

I had another couple good days in the ORs this week, and I was able
to do more and take more responsibility during the procedures. It's
nice when you start to get to know to people working in the OR, and
Dr. Alfred, a second year resident in anesthesia, has been very
welcoming and generous with his teaching.

The ORs here are somewhere in between what I've seen at the national
hospital in Muhimbili and the ORs at Ifakara, in terms of equipment
and resources available. There are still things that I see in theatre
that make me cringe, but in general they're doing a pretty good job.
Beyond resource differences, the biggest change for me is in patient
autonomy. The doctoring here is behind the times in allowing the
patient to make their own decisions and is thus very paternalistic:
Doctor knows best. Unfortunately this manifests as a feeling that
doctors don't need to tell patients what the procedure is going to be
or what to expect during and afterwards, or even when they're going to
stick a needle in someone's back. Maybe these are luxuries in our
country? There must be some evidence out there that we achieve better
outcomes if we treat our patients as a member of the health care team
instead of a child who doesn't know any better. The nice thing is that
the training that the anesthesia residents are receiving is starting
to change this attitude.

CASIEF is Canada's Anesthesia society, and they've been sending staff
anesthetists and Canadian residents over to Rwanda to teach for the
past 5 years. During and after the genocide in 2005, only a single
anesthetist remained in Rwanda (I got to work with her for a day:
wonderful woman. The strength she must have is mind boggling). CASIEF
is trying to help by training Rwandan residents to the degree that
they will be able to take on the teaching themselves and become
self-sufficient. I think it is an exemplary program because it follows
the old "Teach a man to fish" adage. When my training is complete,
CASIEF's is the type of program with which I'd like to be involved.

I was lucky enough to see the program in action on Thursday
when Roger, a staff anesthetist from Australia, and Rob, a 4th year
resident at Dalhousie, came down to Butare for two days of teaching. I
had known that Rob was going to be there at the same time and had
briefly met him prior to departing, so it was nice to see a familiar
face half way around the world. They spent the morning in the OR with
the residents doing clinical teaching, the afternoon doing a short
didactic session and then a webcast seminar on pain. I was glad to see
the quality of teaching that CASIEF is putting together and also to
chat about the experience in the hospitals frankly and honestly with
people who share my frame of reference.

Just a couple of short anecdotes: On Wednesday, a little girl of 7
was brought into the OR for a repair of a broken forearm. They sat her
up on the table and starting getting everything ready for the surgery.
However, the anesthetists don't like to put the patient asleep until
they see the surgeon in the room and being the first case of the day,
we were waiting for about 30 minutes that morning (fairly typical wait
time). The little girl was just sitting on the table in the OR,
waiting for her surgery and no one was really talking to her. I pulled
out my pad of paper and a pen and started drawing animals for her. She
came back by drawing a house and a person and then oddly the 5 vowels.
The segue was apparently lost in translation, but we also covered
numbers up to twenty in English, which she was clearly quite proud of.
Dr. Alfred got in on the action and made a latex glove balloon person
to play with. Hopefully it helped take her mind off the scary room and
the throng of doctors with masks on for a few minutes. The nurses were
clearly amused.

On Thursday the surgery was to insert a big metal rod in someone's
fractured femur. The problem was that the rod they had was too long
for the woman's femur, so instead of scratching the surgery, as they
would in Canada no doubt, the large scrub nurse, dressed in sterile
gown and gloves, grabbed a massive pair of bolt cutters and started
going to town on this rod. Then he got out a hammer and started
wailing on the cut end of the rod so that it wasn't as sharp. It was
quite the sight to behold, but far better I think than for the
patient, who was awake with spinal anesthesia but unable to see the
spectacle. I can only imagine what she thought was going on, hearing
the massive crashes of a blacksmith's hammer in the OR.

July 20th - Muraho Rwanda

The trip back to Dar Es Salaam on Saturday was good, but
packed, hot and dusty. We ended up squishing an old man into the two
seats along with Jeff and I, so it was an akwardish ride, because he
didn't even really acknowledge we were there, even when I offered and
he accepted snacks and ice cream I purchased along the way… weird, but
I guess that can be customary here. He redeemed himself by breaking
out a big smile and "Asante" as he was getting off the bus. Ha, I love
old people. Most of the girls on the trip had considerably younger,
but equally as cute charges, as mothers forced to stand in the aisle
hoisted their children onto open laps. I guess this is also customary,
and I had a lot of fun playing games and drawing pictures of African
animals with the little girl sitting on Lauren and Meredith's lap
behind me. The best part though, was when Jeff gave the little girl
one of his ear buds. Jeff only listens to hard metal… like really
really hard death metal. The kid loved it!

The next morning, all my companions went their separate ways early,
before I needed to be up. I had a relaxed breakfast and chatted with
Anna, the maid/server who was nice enough to teach me a little Swahili
every morning over kahawa, ndizi, mpapai na mayai. It's an odd feeling
going out on my own in Africa… partially because I still can't really
believe that I'm in Africa. The flight was good, but it had an
unexpected (for me) stop in Bujumbura, which is east and south of
Rwanda… I haven't looked it up yet, but I'm guessing in Burundi? There
was a big white UN cargo plane on the ground and a couple choppers.
Neat to see.. I wonder what they were doing there?

The flight into Kigali (the capital city of Rwanda) was great… the
hills of Rwanda are beautiful and the agricultural terracing that
covers many of them makes the approach to the airport almost
breathtaking. Kigali airport is located on top of one of those hills,
to the east of the city centre. I hopped on a bus to take me from the
airport to downtown, much to the mild amusement of everyone around of
course, but the driver and fare collector were very friendly and
helpful.

The city of Kigali is perhaps one of the most beautiful cities I've
been to. Period. Forget fancy architecture or feats of engineering or
thousands of years of history of Europe. What Kigali offers is pure
natural beauty. I hate to keep harping on these hills, but everything
here isn't named "Milles Collines" for nothing… there are a lot of
hills, and they are steep hills, with many houses nestled precariously
on their slopes. The terraced fields are evident even in the city
proper, and the valleys tend to be reserved for rice paddies. The
roads are winding and fun to experience on the bus (in addition to
being surprisingly well maintained!). Not much traffic on a Sunday,
and I got to the bus station without a problem and hopped on the next
mini-bus to Butare, a 2.5 hour drive over and around… you guessed it:
more hills! There was just too much beauty to adequately express in
words what I was seeing. I would have taken pictures, but I'm at a
weird ethical place now, where I'm not sure how I feel about taking
pictures of peoples' lives for tourism's sake, nor flashing my
expensive camera around when many people here will never have the
opportunity to own a digital camera. Sorry. I'll get over myself in a
couple days a take some shots to prove how beautiful it is.

My French has really come in handy here, as many Rwandese do
not speak English, the national language being Kinyarwandan. I'm able
to muddle my way through most conversations with the French I'm
dredging up from my high school years and the people here are
incredibly accommodating with my limited vocabulary and strange
accent. Nonetheless, I've managed to have some great conversations
with students and nurses in the hospital about medicine, cultural
differences, just about anything… except maybe what I'm most
interested in (and perhaps you, reader, are most interested in). I
haven't brought up the genocide with anyone. I don't know that it is
my place as an outsider to bluntly ask. I might take a trip to a
memorial on Friday, in which case I wouldn't have as much of this
worry. The genocide is such a chilling and relatively fresh piece of
this country's history that most of the people walking down the
street, or working behind the hotel desk or coming to the hospital
have experience violence or death from it. How does one even go about
addressing that? The government here seems to have done a fairly good
job, and Rwanda is now one of the calmest countries in Eastern Africa.
I might leave more discussion on the genocide for after my trip to the
memorial.

This is sooo long. The hospital has been great so far. Worked
in ICU on Monday and in the ORs today. The anesthetist staff and
residents here are great and have been very welcoming, if somewhat
amused that I am only staying for one week. Nonetheless, I think it
will be a great learning experience… hopefully both ways. I was able
to offer some suggestions both in the ICU yesterday and in the theatre
today that seemed well received and useful. There are a bunch of new
5th year medical students rotating through anesthesia, and I think
that I have a lot to offer them in terms of clinical anesthesia for
the med student, even with my limited exposure thus far. Unfortunately
none of them have aspirations of anesthesia yet, but maybe I can help
light a spark in them.

Alright, you've been tortured enough, and I'm getting hungry.
I went into town the afternoon to a little bakery, but the samosas and
croissants are wearing off. If you've read this far, congratulations.
If you've checked in just to see what people have commented (you know
who you are), don't worry, that's what I do too.

June 12-16th Last week in Ifakara

Pics are shots from the vehicle on the road to Lupiro, trying to
depict typical rural living in Tanzania.

My last week in Ifakara was a nice continuation of what was a
valuable learning experience in the hospital and a further exposure to
the rich Tanzanian rural culture. Clinically, I spent the week with
surgery, paediatrics and internal medicine: doing rounds with the
interns and physicians and attending clinical meetings in the
mornings. Things really slow down here in the afternoons and most of
our afternoons were free to relax or explore the city and the city's
fine establishments for a cold one after work with the interns. I'll
just relate a few particularly telling anecdotes about my experiences
this week.

Surgeries were still cancelled due to a complete lack of
anesthetic drugs. Even emergency C-sections were only receiving
minimal anesthetics, so it was a slow week in surgery and a sad week
to be doing rounds and surgical clinics, having to tell people to
maybe come back in a week or two for a better chance to be treated.
Even sadder when those surgeries that had to be done immediately were
done without anesthetic. I didn't see this personally, but a boy with
40% burns to his body had to undergo surgical debridement (removal of
dead tissue) without even a pain killer. It's hard to believe what can
and will be done when you don't have any other options. However,
perhaps the hardest moral issue I've been faced with has been related
to the cost of medicine here. Everything in the hospital costs money
and must be paid for before receipt of service. This even applies to
the burn patient in ICU mentioned above, who was not receiving any
antibiotics despite septic wounds simply because he could not afford
it. Even a child with a sever complication of diabetes (ketoacidosis)
could not be monitored closely with electrolyte levels because each
electrolyte cost 5$, a price too high for her family. This just
screams "wrong" at me on so many levels that I had a hard time not
pulling out my wallet and paying for the meds or tests myself.

Despite not participating in the theatres for the week, I did
enjoy doing rounds for multiple days and starting to know the patients
and the cases. I felt like I was legitimately able to contribute to
the care of the patients, and felt like my opinions were valued and
respected. As an example, it didn't seem as if many people in the
hospital felt comfortable reading EKGs, so I was able to spend a few
minutes going over the basics with some of the interns in peds. It
felt nice to help out, even in a minor way.

I guess to summarize my experience at St. Francis: I saw that a
resource starved hospital is doing all that it can for its patients,
sometimes against odds that are stacked heavily against them. The
level of care and the nature of the patient-doctor relationship are
markedly different between our country and theirs. I hope that in the
coming years these physicians will not only continue to make
technological advances, but also advances in how patients are treated
once they walk through the doors.

On Wednesday afternoon we managed to take a field trip to Lupiro
Health clinic, and smaller clinic with 20 inpatient beds and 3 staff
physicians. Susan had been there 4 years ago with her group and said
that it was worthwhile seeing a smaller facility. (I actually tracked
down her name in the guestbook they had there! It was a great feeling
to recognize her handwriting and have a little piece of my wife
sitting there in that book, half way around the world.) Lupiro didn't
have many patients when we arrived, but we could see that it has been
well-used for many years. The buildings are all pretty dilapidated and
certainly not a place that would promote healing. There are water
stains in the ceilings and large portions that are just missing
roofing altogether. The beds look uncomfortable, but not necessarily
cramped. There are even dividers between many of the beds, a step up
from muhimbili or St. Francis! The physician in charge graciously
showed us around and explained some of the difficulties he faced. He
also showed us the medication store room, which unfortunately was a
bit of a stretch for all the empty shelves that were inside. We
decided to donate some money and some of our clinical things to Lupiro
once we finished our clinical experience in the hopes that even little
bits would help.

On Friday we went to see the hippos on the river, but alas, the river
was too swollen and the hippos were nowhere to be seen, favouring
smaller rivers where vegetation is presumably easier to get at. We
wanted to go along for the ride anyway, and it turned out to be a
great trip in an old school, 40 year old dug out canoe. We spent an
hour and a half on the river and saw many species of river bird,
including stork, herron, pelican, skimmers, bee-eaters, eagles etc… it
was a nice and relaxing end to the week. Unfortunately I didn't get
any pictures for fear of losing my camera in the green and greasy
Kilombero river.

Kinda sad to say goodbye to Ifakara… It was just starting to feel
like we were settling in nicely. However, we're all excited to be done
the program proper and moving onto to our own separate adventures. I'm
off to Rwanda!! 5 others are going to be climbing Mt. Kilimanjero and
one will be heading to Zanibar.

June 10th and 11th - Internal Conflict

Pic 1 - The game of Bao. This was a dirt version... some boards are
carved ornately into wood.
Pic 2 - The Weaver's shop, with Joyce, our guide.
Pic 3 - An Old man that we met at the Leprosarium. He and his 6
friends were working together to make a little bit of money by selling
small reed brooms. We bought a few from them and threw in a little
extra money.

Sorry for the lack of posts in the past few days: evenings
have been busy with either world cup finals or meet and greet with
other students at the TTCIH. I'll catch you up on the weekend.
This past weekend was a great couple of days for a number of reasons.
The first of which was our visit to the Leprosarium, a complex of
buildings that is only a few minutes' walk from here. We went with
Joyce, who we've got to know really well over all the breakfasts and
dinners we've eaten at her house. She took us to a weaver's shop on
the way there, where the owner took some time to show us how they used
the old fashioned looms to make all sort of fabric for bedding,
curtains, kitchen etc. It was neat to get that feel of local products
being made by hand in the old-fashioned manner. We all bought a few
things to support her business.
The Leprosarium both wrenched and lifted my heart when I saw the
institution. The staff weren't really around, but we were greeted by
an old man with a big toothless smile, two milky white sightless eyes
and a complete lack of fingers or toes. It was a shocking first
exposure to leprosy, but the warmth of his smile was humbling and
great to see. He was happy to chat with us for a couple minutes and
welcome us to the place he now calls his home. We later watched a
group of men afflicted with leprosy play a game of Bao, which is a
confusing array of nuts piled in small cups in a board. We have no
idea how it's played or how you win, but the old men seemed to really
enjoy it. Again, the contrast of emotions was evident, as the old men
had no fingers with which to grip the nuts and had to rely on younger
men to make all their moves for them.
The toughest part of the visit came when we went to see the old
women's dormitory. 7 women, most of whom were blind, were sitting on
the concrete in a small shaded courtyard. None of them had full use of
their hands or feet and most had to crawl on their knees, callused
thickly from too many years on concrete. They have the help of a
nurse, but life must by unimaginably hard for them: I could see it in
the wrinkles and creases of their weathered faces. Perhaps on par with
the cases of polio we've seen here, advanced leprosy seems like a
monstrous disease, slowly and unforgivingly stealing what function
these people have left. Thankfully this center seems to take good care
of these patients and provides them with some dignity in the remaining
months or years of their lives. I'm glad I was able to witness this
center and some of the people it is trying to help.
On the way back to the TTCIH, we passed through a community where 30
children were sitting around watching some girls play basketball,
although the net was only a small reed bent into a circle and tied
onto the top of a wooden pole. We stopped and a few of us even played
around for a few minutes. I totally dominated those kids… they had no
chance. I made them all cry and then brought out the smack talk. Ha.
Nah, it was great, and afterwards Jeff brought out a couple balloons
he had and they went nuts playing with it, then they went nuts when I
brought out a couple Canadiana bouncy balls I had brought for just
such an occasion. Kids are awesome.
Sunday was spent relaxing, doing my jail-house workout with water jugs
(watch out P90 X), swimming in the pool and playing Frisbee. We caught
the final of the World Cup in the bar on the compound with a few other
students. Great weekend.
Pic

June 8th and 9th - more adventures in the hospital

Pic: Guess which one I am.

On Thursday and Friday I was hanging out with the surgeons
again and saw some more surgeries, both minor and major. Of note,
there was a circumcision of a boy who we put under with ketamine.
Circumcisions are still a regular occurrence here, even while in
Canada, they are entirely elective and you have to pay for the
procedure out of pocket. I think it is a matter of hygiene here more
than anything else. In any case, it was a quick procedure, but it is
disconcerting to hear the child cry out in pain, even though they are
probably hallucinating and would never remember the experience. It's
been a rather common experience actually: unless there is a reason to
use a gas anesthetic, quick procedures only receive ketamine, and many
of the patients visibly grimace or try to move their limbs while
under. I guess that with the limitations on drugs, they don't have
much choice, but its hard to see.

More drug woes here today: All the anesthetic drugs are
depleted and elective surgeries have been cancelled. It's only the
C-sections that seem to be going, unless the procedure can be done
with local anesthetic. Maybe by Monday, they say. We'll see.

On Friday I attended the surgical department's meeting and
rounds, which was really interesting for me, because I hadn't seen the
wards in a Tanzanian hospital first hand. We visited many of the
surgical patients in the hospital, including those who were in the ICU
and paediatrics. It was a good exposure, not only to the typical
surgical case here (ortho!) but also to the dynamics of the hospital
(nurses play a different role here and the hierarchy is obvious). It
was also interesting to see the level of the residents here, compared
to Canada. It seems as if they are on par with Muhimbili, so perhaps
not as far along their training as I think we would be in Canada. It
also exposed me to a few cases that we'd never see in Canada: a hippo
bite (broke the skin and fractured the bones of his foot) and Maasai
spear wound (in the back, causing some neurological deficits).

Friday afternoon I spent with an Austrian doctor who is
volunteering his services here for 6 months. We reduced some fractures
and did some casting with plaster of paris. People have to pay for
their casts here… probably about 15$ CDN, a fair amount for many.
X-rays cost 10$, which is often equally prohibitive. They also carry
their own xrays around with them to the hospital and bring them home
with them, as they do with the official drug records and sometimes
even their charts. I find this somewhat bizarre, and I wonder how many
records get misplaced or forgotten about.

July 7th – Monkey falls

We'd heard about an interesting hike from Dr. Pemba in a national
park that is 2 hours back along the road to Dar Es Salaam. Being a national
holiday (they call it saba saba (lit. 7th/7th), we took the
opportunity to visit the Udzungwa Mountains national park for a day hike. Dr.
Pemba was amazing about arranging the experience and even provided the
transport to and from the park (the roomy land rover was much nicer
than the cramped bus on those bumpy roads!). We were planning on a 5
hour hike up the Udzungwa mountains, so we left the center just after
7:00 and were on the trail at 9:30.
We had a great guide with us, David, who's been hiking these trails
for many years and was very knowledgeable about the flora and fauna in
the park. Udzungwa is one of the top 40 biodiversity hotspots in the
world apparently, and includes 2 species of primate that are found
nowhere else on earth. In addition, the trail we were going to hike
would lead us up 600m to a set of three waterfalls, the tallest of which
cascades down a full 170m. We were excited for a great day of hiking.
Right away the guide starting pointing out interesting insects,
spiders and plants: stuff that one would never see in our climate. The
whole time walking up I just wanted to take more and more pictures of
everything I looked at. Well, not the whole way, seeing as it was a
decent ascent at a quick pace… I was breathing pretty hard a lot of
the way! I've include just a sampling of the photos that I took on the
hike, but the trees alone would fill a photo album. The canopy towered
majestically above us, supported by massive trunks and buttresses
below. Large tarzan-type vines hung from branches 100 feet in the air.
The sounds of birds and insects were subdued, but ever-present.
Within 10 minutes of hiking we heard and then saw our first monkeys.
Blue monkeys; not to be confused with the previously mentioned
blue-ball monkeys. There was a family about 50 feet away in a tree,
peering intently at us for a few seconds before going about their
business. Just as we turned to leave, one of the monkeys launched
himself 20 feet down onto an adjacent tree, the whole branch bending
under his weight. It was great. Not 5 mintues later we caught a
glimpse of some black and white colobus monkeys, but they were high up
and not easily viewed.
The rest of the 2 hour hike up to the waterfalls was fantastic, with
many great look-out points, both of the river valley and the
waterfalls. Once we got to the top, at the base of the third and
highest waterfall, the guide told us that we should have a swim. It
was "cold for me, but only cool for Canadians", and after the hike up,
we couldn't say no, despite feeling like we were rolling the dice with
freshwater parasites… I can say that it was legitimately cold, but you'll have to stay tuned for the
parasitic infection. After the swim we had lunch on the rock plateau
that sits just above the 170m waterfall. It was a gorgeous view of the
plains and agricultural fields that surround the area.
The hike down was when we saw most of the action with the primates.
The sun had come out more fully and I think they became more active,
because we saw a small group of Mangabay monkeys on the ground
(endemic to the area) and then as we came to the base of the large
waterfall, we saw a group of 7 red-headed Colobus (unique to this
park) and 5 or 6 black and white Colobus monkeys. These were the
famous monkeys we'd been looking for, and they obliged us by posing
for a few seconds for pictures before scampering off into the canopy.
It was a fantastic sight and one that I won't soon forget: just as I
won't soon forget the whole day. The best Saba Saba holiday I'll ever
experience I think.
The pictures that I've posted are only a sampling of what I wanted to.
I might make an online album later on.

June 7th - Pictures of Udzungwe

Pic 1 - The intrepid group of hikers at base camp.
Pic 2 - Blue Monkey. Female. She has a baby with her, but I didn't get
a good pic
Pic 3 - Some of the buttressed trees, 15 feet around. Hunters used to
hide in these butresses if they got caught out in the jungle at night.
Pic 4 - All of us at the second set of falls. I was obviously feeling
pretty good about myself.
Pic 5 - Self portrait on top of the 170m waterfall, with the
agricultural lands in the background
Pic 6 - Playing around with perspective. Heh
Pic 7 - This is a buffalo spider.. the horns are impressive and
apparently for defense from birds. The unsuspecting group of hikers is
waiting below.
Pic 8 - Red topped Colobus in the tree accross the valley. Amazing
Pic 9 - Me at the base of the big falls. It was awesome
Pic 10 - playing with the super macro on my camera with this
millipede, who was interested in my lens apparently.