Adventures of a Surgery Resident in Rwanda

SURGERY IN RWANDA

I'm a general surgery resident at the University of Virginia with a passion for global surgery . . . and I'm headed back to Rwanda, so I thought I'd update my blog along the way . . . I'm headed back for a month-long clinical surgery rotation, so I'll share some of my experiences and insights. Check further back in the blog for old posts from my two years doing research in Rwanda on surgical capacity and development, beginning in 2010.

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Heading South . . . Butare

I spent the second week of my rotation at the university teaching hospital in Butare, a small university town in the Southern Province.  You might learn about Butare if you go to see the new documentary “Sweet Dreams” about a Rwandan women’s drumming group who opens the country’s first soft serve ice cream shop.  I haven’t seen the movie yet, but anyone who has ever been to Butare with me knows how much I love this ice cream shop.  If they have refrigerant and electricity, it is fabulous!

 

My week at CHUB was very different than my time in Kigali.  For one, Butare is very quiet—it’s smaller, so it is a smaller community of people as well.  The National University of Rwanda is here, and so there are a lot of students around town.  The surgery department in the hospital is structured a bit differently as well.  They start at 6:30 in the morning with a lecture (I was asked to give one on cardio-respiratory management in the critically ill surgical patient . . . let’s just say that critical care here is very different than at home).  There are a lot of students roaming about, all bright-eyed and eager in their first clinical experience, and I was very impressed by the way the consultants involve the students on rounds and in the OR.  When I was here before, the students never came into the OR, so I was glad to see the active learning.  Now, of course, the CT scanner that had arrived at the hospital sometime in the spring of 2012 when I left and was still in the box when I returned in January is yet to function (but, it is out of the box and assembled), so some things never change . . . The paint (probably lead based, and they were doing an asbestos removal in a building nearby) is chipping off the walls on the wards, which are open with 20+ patients per room.  There are limited nurses, and patients are expected to have an attendant (family member) to do a lot of their care.  The resource limitations are probably a separate (and lengthy) discussion, but I will just say that it is AMAZING the enthusiasm (and frustrations, sometimes) of the new faculty with the HRH program, but a lot of the progress that would be possible is still severely hampered by logistical problems and resources.

 

Anyway, I was graciously hosted by one of the HRH faculty who is staying in Butare.  A bit awkward to call someone up you don’t know and say, “Hey, can I stay with you for a week”, but it worked out well.  Ntakibazo (it means “no worries”, kind of like Hakuna Matata in Swahili).   On Sunday night, he was called into the hospital to help gynecology with a case, so I joined.  It was a very sad case—she was a 20 yo female who underwent a c-section for fetal distress 6 days ago.  She labored at a district hospital 5 minutes away from the referral hospital, but it was still too late, and the baby was born dead.  She developed progressive abdominal pain and distention and was taken back to the OR.  I’ll simplify and just say that her uterus was dead and most of her abdominal wall—she died two days later.  The whole situation is typical of so many patients here—bad problems, delays in care, lack of materials—we just don’t see this volume of bad outcomes in the US.  In Rwanda, patients who present to the emergency room or as complications on the wards with peritonitis present very late—often up to a week or more after some sort of perforation, so it usually looks like a bomb has gone off in their abdomen.  This wasn’t the first case like this I’ve participated in while I’ve been here.  In the US, these patients would be lucky to survive and would be in the ICU.  With limited ICU space (and even more limited medications available and no materials (even improvised) to do an open/damage control abdomen, taking care of these patients is difficult.

 

On a bit of a brighter note, I was pulled in to help with several of the educational activities for the week, including helping with oral examinations for the finishing Doc 1 students.  Let’s just say they definitely struggled, but it is really good to see the department so invested in the education of the most junior students.

 

I definitely saw a range of cases and consults throughout the week.  Here are a few that we might not see in the US:

 

  • Hit by a cow 1 week ago with a hip disarticulation
  • 23 yo with a GSW to the forearm (we freak out if there is a GSW that comes to the ED—there’s not so much a sense of urgency here)
  • Huge mass in former burn scar with contracture from 20 years ago (She never had her burn treated, and this is likely squamous cell cancer, but there are no reagents in pathology).
  • 17 yo with abdominal pain and vomiting . . . then begins vomiting worms (I didn’t actually see this patient)
  • Duodenal atresia in a 1.5 kg neonate that was already 2 weeks old (we operated, and fortunately for the baby, it was a malrotation causing the duodenal obstruction and not an atresia—but he had been without any nutrition for 2 weeks.  The anesthesiologist bagged the patient for 2 hours after the case because there are no infant ventilators in Butare)
  • In clinic, we saw many referrals for varicose veins and hemorrhoids.  Seriously.  All of this untreated surgical disease, and people are referred for varicose veins . . . (They were not put on the operating room schedule).
  • While rounding, I noticed that seeing flies on patients is a very common thing . . . it is a bit more challenging in the operating room, but that happens as well.
  • We saw several consults in Internal Medicine for extrapulmonary/abdominal tuberculosis.  Let’s just say, there is a reason this disease was called “consumption”.  Malnutrition is not as big of a problem as it was 10 years ago in Rwanda, but you definitely still see it, particularly in patients with chronic disease.

 

So, my time in Butare was highly educational.  I hitched a ride Thursday night back to Kigali in order to attend the Annual General Meeting of the Rwanda Surgical Society . . . but more of that later.Image

The CHUB cafeteria . . . and laundry area . . .

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Orthopedic teaching in the ER.

 

 

 

 

 

 

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Monkeys at the hospital!!!

My rotation in Rwanda . . . Week 1

Following morning report on Day 2 (perforated appendicitis and a strangulated bowel case), there was an interesting discussion initiated by Dr. Georges, the Academic Head of Department.  He was scolding the interns (senior year students) in their patient presentations for only listing HIV status as Past Medical History.  It’s an interesting point—there has been so much focus on HIV in Africa, and there may be some detriment to the overall health system by focusing so much (they’re called vertical development projects) on only HIV.  Fortunately, the students are learning now.

 

There were 3 cases scheduled for the OR today for our team.  Unfortunately, due to delays, we only completed one case.  Turnover takes quite a while, and the PACU was full, so they could not continue many of the cases.  Our case was a pyloromyotomy in a 2 month old.  Interestingly, babies with suspected hypertrophic pyloric stenosis often spend a week or so on the pediatric ward waiting for an operation.  There are several separate rooms in pediatrics—along with general rooms, the oncology ward, the cardiology ward, the malnutrition ward, the high dependency unit (for patients requiring oxygen), and a pediatric ICU (3 beds).  Babies with pyloric stenosis are placed in the malnutrition ward—which at first, I thought was a bit odd, but they often take quite awhile to reach the referral hospital from the districts, so they are malnourished when they arrive.

 

There also is not always a scrub tech in the case, and the medical student (if they are present) are often asked to handle the instruments.  They have to teach themselves quite a bit.  Our medical student today was not familiar with surgical instruments, so I used a handy iphone app to review some basic instruments with him as we waited.  One of the reasons the last case was canceled (the patient was actually in the OR room and taken out) was because there was a patient on the ward with spontaneous hemoperitoneum (blood in the belly) after starting anticoagulation for a DVT.  There were a couple of things about this case (which ended up not getting an emergent operation but going to the ICU) that I found interesting.  First, once labs returned and showed elevated liver enzymes and creatinine (kidney injury), the team held a multidisciplinary conference in the patient’s room—the primary internal medicine team, the surgery team, the head radiologist, the ICU and anesthesia team to determine a few things: A) Was an operation indicated or safe?  B) Did the patient need to be moved to ICU?  Was there a bed?  If she needed to be intubated, was there a ventilator available?  C) Could we get additional imaging to help in making decisions?  Overall, I think that communication between teams here has quite a bit of room for improvement, but this was an example of really, really good communication.  At the time, there was not an ICU bed, and as the patient had community insurance, she couldn’t be transferred to the other hospitals in Kigali with ventilators.  Fortunately, she was able to be transferred to the CHUK ICU and improved over the next few days.

 

The following day was Academic Day.  Following morning staff meeting, we had morbidity and mortality conference.  We also found out that there were no reagents available to do full blood counts (CBC) or HIV tests.  As far as lab tests are concerned, patients have to be able to pay for the lab tests (which they often can’t), and tests like electrolytes usually take about 3 days to return.  That means that decisions are based very much so on history, physical exam and available resources.  Both M&M cases were patients that were mismanaged at district hospitals and presented as delays and/or complications.  A few days after this, a patient presented from a district hospital with a burst abdomen and anastamotic leak.  The presenting resident said when they operated on the patient that whoever did the original operation had macerated the fascia, and it was very clear that they did not know what they were doing.  One of the staff members asked (facetiously) “Did they use a machete?”  Resources are very limited, even at the teaching hospital.  One morning, there were still 6 patients with open orthopedic fractures who had been waiting for 1-4 days for an operative debridement.

Murakaza Neza! Back in Rwanda . . .

So, I am back in Rwanda once more.  Who would have thought when I first came to Rwanda four years ago that I would begin to think of it as my second home?  It’s been absolutely amazing, and I am very happy and lucky to be the first resident from my program to come as part of an official clinical rotation.  I have to start this blog thanking my program director, coordinator, faculty and co-residents for being so supportive of the program—in terms of time, money, and call responsibilities.  It’s certainly a tribute to the whole program that we’ve been welcomed by the staff and residents at the National University of Rwanda.  Oh, and my family for putting up with me—I know it can be a challenge.  I hope to collect observations and clinical experiences throughout the month to share with everyone back home.  I’m continuing this blog on the blog I previously kept during my two years as a research fellow in Rwanda, so please explore the archives :)

 

My adventure started early, of course, for I am doomed to excitement when I travel.  In all honesty, though, considering the distance and number of connections, it was a relatively smooth 25-hour turned 32-hour journey.  I made it. My luggage made it.  I don’t think I have a DVT.  My 4 hour layover in Addis Ababa was unexpectedly extended to 11 hours.  Despite their poor communication about the delay, Ethiopian Airlines did take an eclectic group of travelers, pile us into a mini-bus, and take us to a hotel for three hours (It took some time to arrange). Interestingly, the last time I was in Ethiopia, I needed a visa to leave the airport, but somehow “No problem” seemed to work.  Hmm . . . I was actually a bit excited by the large banner on the hotel façade regarding a leprosy convention.  I must have been too jet-lagged to find the leprosy convention . . . or maybe they just didn’t want me to join in.

 

I landed in Rwanda in the evening on Sunday and was met by one of the UVA HRH surgical faculty, Rashna, who had checked email throughout the day as I stood next to the first class lounge in the Addis airport mooching internet and knew about my long delay.  (Travel pointer: Stand outside the first class lounge for internet.  Try to look nonchalant.)  I’m staying in the house I lived in when I lived here, so it really was like coming home.

 

On Monday, I went to CHUK for morning conference.  CHUK stands for the Centre Hospitalier Universitaire de Kigali . . . Or, you can call it UTH-K, the University Teaching Hospital of Kigali.  While we are naming things, the Kinyarwandan name for hospital is ibitaro and the word for doctor is muganga.  CHUK is one of two government referral and teaching hospitals in the country and has a little over 500 beds (530 beds when I did my research).  Like our safety net hospitals in the US, it is full to capacity (more about this later).  Unlike many hospitals throughout Africa, patients do not share beds and are not placed on the floor, except during mass casualty incidents. 

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Every morning, the residents and students (3 levels of students, with the senior students functioning as interns) meet with the surgical faculty for morning report. Some attendings take call, but for the most part, the resident who is on call operates independently and reports both for signout and critique in the morning.  There certainly is more discussion and oversight than the first time I arrived in Rwanda, and more structure overall.  If the Human Resources for Health program for surgery accomplishes nothing else, they can claim success in organizing the residents into teams (called firms), creating an operative log of all cases performed, and in creating patient lists for each firm.  The pre-list and post-list experience is revolutionary.  I know this sounds like an exaggeration, but it’s true.  One of the attendings on the service I am on for the week was a junior resident when I first started coming to Rwanda (um, actually, both of the attendings on my service were) and always seemed to be resistant to change.  Well, I was rounding with him and the team on Monday, and he kept harping on the residents and students to update the list, and if a patient was not on the list . . . Anyway, when I first started coming to Rwanda, there were so few faculty members that there was little structure, and now, there are teams that round every day and patients in the hospital have an assigned team and doctor.

 

Anyway, back to Monday morning.  The first order of business was morning report.  Since it was Monday, all of the cases operated on over the weekend were written on the whiteboard (also new).  Just to give an idea of the range of cases seen by the on call team, here’s the breakdown of diagnoses and operations:

 

  • right upper extremity crush injury – debridement
  • chronic subdural hematoma – burr hole(3 patients over the weekend, chronic because they presented late after injuries)
  • open fracture – debridement
  • strangulated inguinal hernia – repair and bowel resection
  • burst abdomen/anastamotic leak (from district hospital operation—I think it was a bowel obstruction after c-section) – laparotomy
  • wet gangrene – amputation
  • TB pleural effusion – chest tube
  • 2 cases of imperforate anus (4-day old premie and 5-day old term) – colostomy
  • 2 year old with an inguinal hernia – open repair
  • 2 year old with a liver abscess (unknown pyogenic, amoebic, tuberculous) – open drainage and drain placement

 

Quite a range of cases!  Yet, there were many more that were still waiting on an operation.  It seems like every morning, there are 2-4 cases presented that received an operation overnight and an additional 2-4 cases added to the pending list.  As such, there is a huge backlog of cases, with elective cases often getting cancelled.  Many of the patients pending an operation can wait days before they get to the OR. On Monday, the pending list included 5 open fractures, many closed fractures (reductions with fluoro take place in the OR), and a 14d 1.5 kg baby with jejunal atresia.  To give an example, one of the open fractures was a patient who sustained an injury, was sent to a district hospital, where the wound was sutured and sent on to CHUK two days after the injury.  She had an open distal tib-fib fracture.  Because the OR was so full, the residents on call tried to transfer the patient to another hospital in Kigali that takes orthopedic referrals but the patient was sent back because she couldn’t pay separately.  She did not go to the OR for a debridement for two more days.

 

After morning report and staff announcements, I rounded with my team—the Yellow Firm.  I have two attendings that completed the residency at NUR within the past couple of years and have not had any additional fellowship training.  One of them, my good friend Edmond, is an aspiring pediatric surgeon and has essentially set up the service over the past year.  We have one PGY3 resident, 2 PGY1 residents, a DocIV (senior medical student, functions as an intern), and 5 Doc III and IIs (junior medical students).  We cover all pediatric surgery and inpatient general surgery referrals from Internal Medicine and OB/Gyn.  There is another Trauma/ACS team that covers ER consults.  My first few days repeated a theme of there being no beds.  Elective cases are admitted the night before, and this week, some of them had to be sent home because there was no bed.  In a population that mostly live on a few dollars a day, that is certainly an unnecessary expense!  I suppose if things were delayed in order to make progress on the incredible backlog of emergency cases, it might be okay, but even these cannot be done because there are no PACU or inpatient beds for post-op.

 

That evening, I ventured into town (mumugi) to run a few errands.  Unfortunately, I got thoroughly drenched in a rainy season downpour and had to make a change to my walk home since the route home is now blocked by two hefty military men with AK-47s (I took the long route).  And the adventures continue . . . I went home to prepare for the 3 cases I was going to scrub the next day.

Reflections and Impressions

Well, I have been downright awful about maintaining this blog over the past many months, but I promise to redeem myself in my last month in Rwanda . . . that’s right, I only have one more month living in Rwanda, but I know for certain I will be back.  I think I’ve made tremendous inroads in the research that will keep me VERY busy over the next several years, I’ve developed professional relationships and learned ever so much from my colleagues, and I’ve made some incredible friends . . . Over the next month, I’ll update some of my research and reflections on global surgery . . .

In the meantime, I want to draw attention to some of the blogs from colleagues that have visited Rwanda.  I’m always fascinated by the impression Kigali, Rwanda, and Africa in general can make on visitors–having lived and worked here for almost two years, I sometimes forget some of these first impressions . . .

The most recent blog is an active blog right now by two UVA anesthesiologists–it’s really exciting to have more people from UVA involved . . . http://UvaRwanda.wordpress.com/

Marcel and Kristi’s blog builds on two other anesthesiologist’s blog: Faye and Michael. http://marchrwanda.blogspot.com/

Not to be outdone, here are a couple blogs from surgery residents that have come to Rwanda over the past year: James from Colorado visited last March: http://blog.travelpod.com/travel-blog/jcromie/1/tpod.html.  My good friend Amber came to visit and participate in research in May, and I find her reflections particularly insightful: http://amberrwanda2011.blogspot.com/

Enjoy these reflections as I gather my own . . .

Murakoze cyane!

Make Surgery Sweet . . . Advocacy for Change

One of the things I had not planned on doing as much as I have is political advocacy and something I’ve termed “communication facilitation”–getting stakeholders to talk to each other. I certainly respect the importance of health advocacy, and I am thrilled that surgery in Rwanda is getting to that stage.  You can’t really improve surgical capacity, can you, without advocating for surgery to have a priority spot in healthcare planning?

One of the phrases that has stuck with me from our March Strengthening Rwanda Surgery meeting came from one of the Rwandan surgery residents.  “You have to make surgery sweet,”  he said.  So true.  I wanted to make t-shirts.  That phrase sums up a lot of the issues surrounding surgical capacity.  Around the world, there is a severe dearth of surgical services to the poorest of the poor (more than 2 billion people without access to emergency and essential surgery!).  A large part of may be due to lack of proper surgical materials, but much of the burden is due to a scarcity of surgical providers.  You can buy materials and build facilities . . . and once surgery enters more properly into the global schema of healthcare and more funding is allotted to surgical development, this can be addressed.  Training a surgeon, though, takes a team.  Right now, there’s not much draw to become a surgeon in many places where surgeons are scarce (could be extrapolated to rural America, couldn’t it?).  So, what’s the incentive?  To improve surgical capacity, there have to be more trained surgical providers.  So, how do you make surgery sweet?

The March meeting was phenomenal in that it brought together a group of international stakeholders and Rwandan surgeons and health officials to discuss just that.  The hope was that it would get everyone on the same agenda–Rwanda’s.  It certainly was a good start, I think.  It really helped to form and strengthen relationships, which is key in moving forward for any real, sustainable change to happen.  Since then, a core group of international stakeholders and Rwandan surgeons have continued the conversation and planning via Skype teleconference.  When a large educational / human resources for health scale-up meeting was held in Kigali in May with 16 US universities, surgery was ahead of the game . . . this gave us another opportunity to brainstorm and plan together.  It also gave me a chance to meet President Kagame and mention the word “surgery” at least 3 times in his presence.

I don’t know if what I personally do will make a change but maybe by facilitating communication and helping the Rwandan surgeons and trainees to find their voice, there will be a way to make surgery sweet in Rwanda.

Until next time . . . the pictures below are from the March meeting and then the May meeting.

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Busy, busy bustle . . .

I’ve been driving in Rwanda for nearly three months now, and although I discovered that my fuel gauge is not 100% functional and that more than 3 people in the car leads to nasty grinding sounds, there are still a few things which continue to baffle me:

1. There is some sort of unspoken language for drivers, complete with complicated hand signals and varying degrees of honking . . . I still cannot discern the utility of flashing your brights at me, apart from blinding me.  I’m not very good at deciphering the other signals either.  I mean, when does a right turn signal NOT mean a right turn?  Sometimes the left turn signal means a right turn?

2. Is there a utility to repaving the same road every two weeks?  Really?  And it’s not just one road either!  Any road that gets repaved is bound to be torn up again in 2 weeks . . . and 2 weeks after that . . . and 2 weeks after that.  They are quite smooth and lovely to drive on the first time . . .

So, I will apologize for my blogging absence and hope that you enjoyed the guest blog from Rebecca.  It was quite a delight to have her here.  For me, the past several months have been very busy.  I spent the holidays in the US (between Kentucky, Virginia and Alabama) and returned to Rwanda mid-January.  Since then, I have been busy with finalizing the report on the surgical capacity survey for the Ministry of Health, showing visitors around (a radiology resident, my surgery program director, and more . . .), and planning an international surgery meeting.

So, Albert and I finished the survey of surgical capacity–having visited every government-supported hospital in Rwanda.  I presented the results at the first Strengthening Rwanda Surgery meeting held a few weeks ago here in Kigali.  I won’t go into too much detail on the results here (the suspense is killing you, right?) because I would much rather report on the changes and impact of the information . . . time will tell.

One of the things I will comment on is that with all of the visitors to Rwanda and the push to increase surgical capacity, it is very clear that human resources are the biggest need.  Not only are there not enough educators, but there aren’t enough students going into surgery.  What’s the enticement?  How do recruit students to pursue a career in surgery?

One of the ways is by providing mentorship and stability in the education process.  There are a lot of pushes to do this with academic partnerships, which I commend.  I also can’t speak highly enough of my Rwandan mentors–their job isn’t easy!  One of the very positive things the past several months was participating in an Essential Surgical Skills training session in January for the new interns (senior medical students) . . . There are a few pictures of that and other adventures below.

More adventures to come . . .

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Rebecca’s Radiology Visit

I’VE BEEN QUITE REMISS IN MAINTAINING MY BLOG, BUT I PROMISE MORE IS TO COME.  AS I PREPARE MY THOUGHTS, HERE’S A GUEST BLOG ENTRY FROM REBECCA, A VISITING UVA RADIOLOGY RESIDENT:

Rebecca teaches radiology to a group of junior medical students at CHUK

Now that three weeks have gone by in Rwanda, I cannot believe that I am headed back to the States. It seems that I did so much in that time, it warrants some recap.

I boldly proposed to travel to Rwanda for my dedicated research month during my residency program. I am delighted, as compared to prior classes, that my month was allocated in my 2nd year and not my 4th. Last June, I met with a mentor of mine Dr. Rheuban who mentioned that there was a team of surgeons doing work in Rwanda. From that, I contacted my colleague, and now friend, Robin Petroze to learn about what her plans were. Fast forward, many discussions and emails with her, paperwork to get permission, ACR travel grant, contact with RAD-AID, and Rwandan Hospital Ethics committee approval, I came to Rwanda to carry out my ambitious research project.

I say ambitious because, as I learned quickly, time in Africa is different than time in the States. I planned to go to 8 hospitals in less than 15 work days, not knowing anyone except for Robin initially and a few important email contacts of Rwandese physicians and medical professionals, not having a car and reliant upon drivers, and not speaking the prior formal language (French) or local language (Kinyarwandan). However, it all came together, and in fact I had completed my radiology needs assessment with not just 8 sites, but 9!

My goal was to complete said needs assessment of select hospitals prior to helping initiate a collaborative between CHUK (the main teaching hospital in Kigali) and UVA Hospital. Once done, I expected to and do have better idea of what resources are available and can cater our support appropriately, specifically with respect to the adjunct of radiology education during surgical teleconferences. Little did I know that my questionnaire may be very straight forward if I spoke to the right person, but often this person was gone, or did not speak English. Often I felt like it was a struggle to get every response. I completed as much of it as possible, with a focus on less financial-based questions and more radiology-oriented questions.

Oh but wait – let me explain how I chose my hospitals. I selected the main teaching/referral hospital in Kigali, the main teaching/referral hospital in Butare (where the medical school is), King Faisal Hospital (private hospital), and 6 district hospitals (referrals from health centers) – 2 in the greater Kigali area, and 4 in each geographic quadrant of the country. Themes that emerged included some of the following:

-         Radiologists: There are 8 radiologists for the country of 10 million. All of which are working in Kigali, none of which are in smaller cities/towns. Training was from nearby African countries as currently there is no radiology residency program and no mention, at this time, of creating one as needs are more on a non-specialist, primary care level.  The private hospital has 4 radiologists, district hospitals have none – reliant on radiographers and general practioners to make their own “impression”.  They, collectively and individually, could not have been more welcoming with respect to their reception of me. I felt like one of the group right away, enjoying reading by the light box/work station side-by-side, with diagnoses not commonly seen in the States: sequelae of chronic developmental hip dysplasia, seizures secondary to Neurocystercosis, advanced (gross morphology included) hydrocephalus as sequelae of meningitis, and innumerous fractures due to “road traffic accidents”. Trauma/emergency radiology is certainly not lacking.

-         Radiographers: There are about 100 radiographers now that have been trained in a 3 year program at the Kigali Health Institute. After graduation, technologists are placed in a district hospital without additional support. By this I mean, little if at all technical support, no quality assurance program, and variable degrees of radiation protection. There is a push for radiographers to have the opportunity to learn more about sonography, at the current time done by either radiologists, general practitioners, or OB/GYNs. I cannot begin to express my degree of respect and admiration for the lone radiographer, working often entirely by themselves, hand developing their own films, and relying on old equipment full of “personality”.

-         Equipment: A spectrum of functionality, not entirely to my surprise. As one Hospital Administrator said, “the only difference between us and a health center is technology [radiology]”. Most all equipment is donated. Unless there is a warranty associated with the equipment (such as at King Faisal Hospital), broken equipment may go months without being repaired, if at all. A few district hospitals had a machine I had never heard of: Shiumadzu, manufactured in the 1950s, now many of which broken as there are no longer spare parts made and no one knowledgeable about how to fix them. Conversely, CHUK had 10 impressively working ultrasound machines scattered around the hospital campus. Regarding cross-sectional imaging, for example at King Faisal, the MR machine has its own warranty/technicians that would help with repair (from Kenya). With projected/planned acquisition of more cross-sectional imaging equipment, I wonder just how feasible it will be to maintain these machines. I mean, it is challenging enough at home! For a juxtaposition, see my pictures!

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-         Insurance: What’s American’s excuse? All Rwandese, to include anyone who wants to buy in (foreigners alike that is), can get basic medical insurance for the equivalent of 2 dollars. Immunizations, basic medications, basic health care, radiology examinations… are provided for. Also to include preventative/screening care, if that is a priority of the individual patient. With the current system in place, there are three tiers of medical insurance, the cheapest of which was already mentioned and patient’s payment of 10% of the total cost, government’s payment of 90%. Comparison from the district hospital level, even the tertiary referral centers where some district hospitals were superior in terms of donated/new medical equipment, to the private King Faisal Hospital was profound. Taking into account the gross national income of just a few hundred dollars a year, difficulties with clean water, the vast majority who use walking as their primary transport outside of the capital city, and reliance on agriculture for all life activities, the basic services provided are undeniably a step in the right direction.

-         Education: Beyond training, nothing formal (as we think of CME). Radiologists complete 6 years of medical school (to include 1 year internship), 2 years practicing in hospitals, and then a 2 year radiology residency (in a non-Rwandan country; most commonly Tanzania, South Africa, and Kenya). Radiographers have three years training as mentioned before. General practitioners have no required, formal training in ultrasound. Which lends itself to many practical questions: How does one maintain skills? How does one learn how to use imaging modalities? How does one refine their knowledge base through feedback? Even without the medicolegal environmental mess that is the USA, how can one make the right diagnosis? There are many missionary, ex-pat groups doing work, some individuals and some teams – specifically, Israeli OB/GYN teaching radiographers by laptop to the very comprehensive Emergency Sonography manuscript and associated trainings at Parters-in-Health affiliated hospitals. To my great surprise, there were no overt radiologists/radiology groups teaching about imaging. Rather, it was the ED and OB/GYN physicians teaching relevant, basic ultrasound. Ultrasound – ostensibly the hardest imaging modality (as there is a great art in creating images in addition to interpreting the images), only second to Nuclear Medicine. In my opinion, I saw this as a missed opportunity for the global radiology community and promised myself to raise awareness of it upon my return. Especially given…

-         …Future endeavors: Impeding projects/developments include the formalization of the Rwandan Radiology Association, 64-slice CT for CHUK (currently 1/9 radiologists is in India completing a specific CT training), digitization of CHUK radiology department, activating the already laid down governmental cable to permit about 30 hospitals in Rwanda to be linked for teleconferencing purposes.

Don’t get me wrong, all the travel for my site visits was more than worth it, with the only real challenge being whether or not the car I relied on would 1. Be delivered and 2. Be functional enough if there was a mechanical problem. The rides through the countryside were breathtakingly pretty. Rwanda, known as the “Land of 1,000 Hills”, was more like the “Land of 1,000,000 mountains”. I thought this was stiff competition as compared to Charlottesville. Particularly gorgeous was the north, Ruhengheri hospital, as we approached Volcano National Park (where the mountain gorillas are) and the west, Kibuye hospital, adjacent to Lake Kivu (competition for any of the nicest resorts in the world). I actively/?obsessively took short videoclips to help convey my experiences better once home. Children running up, furiously waving with huge grins asking for pens and water bottles, passing genocide memorial after genocide memorial, and observing what the life of most Rwandese is like – peasants, working their own land with very crude/non-machinery tools, with no dearth of opportunity to socialize and participate in the overt commotion of very busy village life.

When not obtaining my data, other non-medical highlights included many work meetings with other ex-pats at various restaurants around the city, all cuisine available except surprisingly for Mexican food, with “claim” of chapatti as African (not Indian?!); exploring the city market which undeniably outdid the organic produce of Whole Foods! (if you wanted ANY kind of ingredient, you could get it, at your own barter); visiting the mountain gorillas thankfully (and safely) within a few feet so we could really see their expressions, identified not by finger print, but by nose print and the associated arduous journey through potato farm land, bamboo forest, and stinging nettle brush ending with a heavy rain (with delivery of twin gorillas for the 5th time ever in history within a week of my being there);

The artists at Ivuka (www.ivukaarts.com) teach kids at a local orphanage how to paint and help them sell their paintings too.

Ivuka Arts gallery, a co-op of Rwandese self-taught artists whose delightful work is only compounded by their art outreach programs at local orphanages; salsa dancing with our friend Jimi, as some call the “Congolese Patrick Swayze”; going to the National Genocide Museum, to include walls of photos of child victims and mass graves, as well as to Ntarama memorial church with the chilling evidence of victim’s bones organized by type, neatly displayed clothing and items, and even blood-stained walls of children victims; meeting Rwandese friends and bumping into ex-pats in such a way that it seemed everyone was related to one another, no matter how remote the environment; new experiences to include going to the American Embassy for social hour, eating beef brochette, traffic jams with road signs/signals as a mere suggestion at best; and so on… More than anything, I was profoundly moved by how warmly I was received by all the people I met, in general, soft-spoken, with kind smiles and engaging eyes, committed to helping me navigate this new world that is Rwanda.

I should not delay writing any further the extent of my gratitude to Robin. Not only was she my hostess and colleague, but she became a dear friend, quickly assuming the status of “sounding board” for everything that happened and that I was thinking during this experience. She conducted herself with grace, as she organized meetings with groups of, at times, seemingly competing/competitive agendas, demonstrated unyielding dedication to conscientiously corresponding in all forms no matter what time of day/night, and modeling the patience that is absolutely required for an American to be operating in at times, a Kafka-esque African environment. I am also thankful for my mentors, who know who they are, UVA, and RAD-AID’s assistance for their respective contributions to this successful experience.

As I stare out the window at the Atlantic Ocean near Reykavik, regretfully headed home after a full-bodied, exceeded expectations experience, I promise myself a few things to make sure my trip was not in vain. First and foremost, I plan to, as best I can, convey the current state and need of the Rwandan imaging world, through my reports, photos, videos, and impending teleconferencing involvements. Second, I vow to make myself available for continued correspondence with the various health professionals and new friends I have met while there. And thirdly, I want to go back, further along in my training, to work in some capacity as a diagnostic radiologist and educator. For now, I end on the note: Rwanda was just the “dawa” (medicine) the doctor ordered, to fuel my continued dedication to international radiology through investigation of the progress and promise of the Rwandese medical frontier.

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