:: Yeesh in Rwanda::

my 3 week trip to Kigali, Rwanda

Rwanda – Ch. 13 — October 4, 2018

Rwanda – Ch. 13

I would like to apologize in advance for this post. I made some new friends who are horrible influences. So this post is coming at you with one eye closed and the other squinting:

Morning report today was interesting as usual. There was a possible leiomyosarcoma who is going to the OR today, and another abdominal hysterectomy for fibroids. There was also a maternal death overnight. A 23 year old patient who had a cesarean section for fetal reasons. She began to get hypotensive and was transferred here for further management. On arrival she coded and never regained consciousness. She had a belly filled with blood on ultrasound done post mortem. I think that is the hardest part about Obstetrics and Gynecology in a setting like this. These deliveries and procedures are performed by these “General Practitioners” who could be physicians who just graduated medical school and entered the work force (no residency training). I cannot think of a logical reason why this patient had to die. It was very upsetting to everyone.

Next I met up with Blaise, the administrative chief of the residency. I came here to formulate a curriculum and have been having the hardest time mostly because the residents are EVERYWHERE and NOWHERE all at the same time. No two days are the same and it’s rare I work with the same person twice even though I’ve stayed in the same wards most of the time I’ve been here.

He’s always running around and said he needed to go to the ER to see a consult but that’s he be back- yeah right. I’ve been chasing him all week. I propose I go with him to see the consult and we walk and talk. He agreed and told me it’s a pregnant patient with TB. Cool. We get there only to find out, it’s a pregnant patient with TBI! Traumatic brain injury. Big difference. It was interesting seeing the emergency ward. It was like a vast wasteland initially with little nooks with tons of beds and patients. Ambulances. Screaming. Ok, we go find our patient. She is intubated and sedated. We get collateral information from the consulting ER physician and do an US. She was supposedly 8 weeks pregnant but was having a miscarriage. Blaise examined her and we did a sono. The uterus looked very thin and like there was no pregnancy. We gave some cytotec and left the ER.

Blaise suggested that we go to breakfast. So we went to the restaurant in the hospital and ironed out what would be a worthwhile rotation for future residents coming from Stony Brook. It was very productive. He has very high expectations. We also talked about research and how that can be carried out during the rotation too. We talked about when the IRB needs to be submitted to their hospital and even talked about resident help on the Rwanda side for American collaborative projects. It was awesome!

Next I went back to the labor ward. The Belgian student Maxim was there. As promised we reviewed Electronic fetal monitoring. We probably spoke for about 2 hours and even found a white board. We reviewed ectopic pregnancies, antenatal testing, abortions, STDs, GTN, and cervical cancer. I looked at my watch and it was already 2 pm. There were 2 active patients so we decided we would eat a quick lunch to get him back for the deliveries. Yeah right. At lunch we met up with some of the other Belgian students as well as Arjun, a 3rd year internal medicine resident from Yale doing a rotation. He’s so awesome! I wish I met him sooner. We joked about home, mutual acquaintances, and pop culture. It was also nice using English slang and getting an appropriate reaction. So after all this chatting as you can imagine we missed both deliveries- SORRY MAXIM!

Afterwards my new friends invited me out this evening to Inema Arts Center. I didn’t have plans but to be in bed by 9:30 and read more of For Whom The Bell Tolls By Ernest Hemingway. I asked Maxim how they were getting there, he proclaimed, ” Were taking motos!” And proceeded to show me a video of about 10 students riding on the back on 10 motos like a motorcycle gang. I’m such a wuss! Whatever. I messaged Alphonse that I would need a ride at 8:30 PM.

I met them there, and was severely underdressed. Here I was thinking we were going to an art gallery- NOPE. This was a full on outdoors night club. OY. I wore a frompy romper and a target sweater. Thankfully, I had my red lipstick in my purse which I threw on really quick so I could look somewhat descent. In any case, apparently this is the place to be on Thursday night in Rwanda. We definitely had the club turnt up, on a Tuesday~. Me and my new friends danced all night to East African, American, Indian, and Carribean music. It was awesome!! I felt like I was in the “Unforgettable.” Music video! The beer was cheap (~2 USD, hence the squinting) and the dancing was amazing!! I was so concerned about my dress code but I frequently found myself fighting the men off me. Rwandan men are VERY forward.

So some new characters in the mix. I already mentioned Arjun, he’s a character in himself. He’s very cultured and knows all about Carribean music and Jamaican culture. He’s Indian and someone I very much enjoy spending time with. He showed me Mars and is a huge astrology fan (although if you ask to many questions he is unable to answer hah). He’s very fluent in Carribean culture and must have a lot of Jamaican friends as he knows all the music and dances.Next is Hazel, she’s Belgian and dating Maxim. I’ve made her an honorary American (fall back trump) . She was very taken aback by the dancing style and asked me if this is how we dance in the US. I explained ” yes, but with much less clothes and a lot more gyrating.” She was intrigued. She quickly became the queen of the dancehall and was the center of the dance floor. That’s why she’s an honorary American. She takes no bullshit from no one! I love it! I try to explain to her she’s an OB/GYN but she’s stuck on this pediatrics thing. Next was Brendan. He’s an American Med student from Dartmouth. He’s been here forever and knows everyone. He’s awesome. My only regret is I haven’t gotten to know these people sooner!! They’ve become so special to me in just a few days. To my Belgian friends- you always have a place to visit if you come to the U.S! And to my new American friends- just name a time and place and we can meet up and continue what we’ve started!

Ok guys- goodnight. Last day of work tomorrow 💔

Rwanda – Ch. 12 — October 3, 2018

Rwanda – Ch. 12

Today on the way to morning report, there was a strange crowd of about 30 people standing around the door. Diomede was also there and what stood out was many of these people were white (naturally this is an odd thing to see in Africa). I rushed into the room and mouthed to Diomede “What’s going on?” He shook his head and smiled. Diomede walked into morning report about 30 minutes later. It wasn’t until later that I found out this was a group of belgium students who started today ! They’re rotating on all specialities but we have two! Astrid and Maxim. They’re very cool. They’re 6th year Med students and will be choosing specialties in the upcoming 2 weeks (this is their last year before residency). So now, all 3 of us were in the labor ward with poor Emery to keep us entertained. To keep them busy I showed them around and taught them all the tips and tricks I’ve learned over the last week and a half (I.e bring your own toilet paper because there is none anywhere! Etc), you know, the essentials. I told them of my stalkerish tendencies and how I find the residents once they disappear. I’ve even gotten my hands on the daily resident schedule for the month so I know which resident to look out for each day! Next we went back to the labor ward. There wasn’t anything too crazy going on but there was an IOL for gestational hypertension who was getting ready to deliver, the same IUFD from yesterday who was maxed out on cytotec and needed a Foley balloon, and a IOL for oligihydramnios.

So we stared with the Foley balloon placement which is very different from how I do it at home. They do it with a speculum and everyone gets cleaned with clorohexadine (internally and externally) before anything is done. I always think to myself, but the vagina is so dirty… Whatever it’s Africa, guess it can’t help to be a little extra clean. So I assist Emery in his venture. The Foley gets placed and it’s attached to a Foley bag, filled with normal saline, and placed on gravity- interesting. We usually just tape it to the thigh back home. I like this way better. That way I KNOW it’s on tension instead of crossing my fingers and hoping that the nurse is tugging every few hours.

Next while Emery did paper work- me, Maxim, and Astrid talked about bread and butter obstetrics. We talked cervical exams, methods of induction of labor, and hypertensive disorders in pregnancy. I sent them a practice bulletin on fetal heart rate monitoring which were going to review tomorrow. I told them to take advantage of this, they will never again have a chief resident in their back pocket like they way they do this week. They are great though and they pick up on things very quickly. When we were finishing up, one of the inductions was delivering. So maxim went in to watch, next thing I know I am summoned by Emery to partake. I’m down. The delivery ended up being quite dramatic. The baby was bradycardia so she ended up with an episiotomy. Ehhhhh. I watched Emery do the repair and then went to lunch with Astrid and Maxim. I met the other Belgium students and even met 3 Internal Medicine Residents from Yale! One even went to stony brook for medical school and undergrad! For lunch I ate Safrinas left overs from last night that I couldn’t touch because I was so full. Finding creative things to do with all this food is overwhelming.

When I got back to L&D, Emery seemed like he had a lot on his plate. I asked him if I could help… he responded, “YES! I need you to do a c-section with Eugene!! They’ve started, I have so much to do, can you go?” “Sure.” I really wanted to scrub in on the hyst they were doing next door, but this c-section would have to do. I already delivered in my work clothes, white coat, and sandals (they don’t wear scrubs here for deliveries…and I’ve already gotten yelled at for not wearing my white coat) I drew the line at a c-section though. I ran and changed into scrubs and my danskos. I walk into theatre and Eugene looks at me like Jesus walked in. “I AM HERE TO SCRUB!” I proclaim! Naturally as the Rwandans do, he said, “thank you, thank you.” They’re always so polite. They hit a vessel in the OR and begin profusely apologizing. So we scrubbed and did this repeat cesarean section together while singing Enrique Iglesias’ Hero, and struggling to get the baby out. Again, very dramatic experience. That baby was floating in the North Pole. After some serious fundal pressure (that I liken to body slamming the patient while on my tippy toes because the bed was so high) the baby popped out. We closed and then I dismissed myself for the day as no residents were to be found.

Next I went to the tailor to try on the items she made! Everything was beautiful! Some of the items were too big so she will alter them and meet with me tomorrow!

Rwanda – Ch 11 — October 2, 2018

Rwanda – Ch 11

Today was a good day. Woke up, late as usual. Safrina made some crepes for dessert last night so I took one for breakfast and walked to work. I was only about 7 minutes late but I always feel bad strolling in after they’ve started. So I took a seat in the back and intently listened.

A lot of interesting cases- really too many to even write about so I’ll focus on the few I was involved with. First, there was a 23 year old transfer from an outside hospital for a huge ovarian mass, almost up to her xyphoid process (her chest bone). There was an interesting discussion on whether this was neoplastic or benign but the plan was made for a unilateral salpingoopherectomy today (remove the ovary and tube on that side). I love when there are oncology cases during morning report, so educational!

The next patient was a patient with a molar pregnancy at age 55 but it was so fascinating the way she presented. It’s like you were reading a text book. In any case- plan was made for TAH/BS (abdominal hysterectomy and removal of the Fallopian tubes) as she was done with child bearing and the concern for neoplasia.

So Eliziphan (sp?) and Gilbert scrubbed in. They’re both 4th year residents. I asked if I could assist, Gilbert said sure. That essentially meant I was scrub tech (there are none here!!) which was slightly demoralizing since I was the same level of training as them but there was no way I was doing this hysterectomy without an attending. As a general rule of thumb- I don’t do anything here that I wouldn’t do at home. So I assisted and weighed in a lot. “Wait, why are you doing that like that?” “Why did you do it one way and Gilbert do it another way?” There was nothing textbook about this hysterectomy. And it was very difficult so my hats off to them. It was not beautiful by any means but this patient needed this surgery and it was safely performed today and in a timely fashion (also while I swatted flies off the surgical field!). As usual, I was impressed. In the labor ward today was Aimee. The 3rd and final female resident here. There was only 1 patient on the ward and she was an induction for an IUFD (intrauterine fetal demise). So there was a lot of time to chat. “So are you married?” One of the first questions Aimee asked me. “Nope, no ring on this finger!” Aimee is recently married and about the same age as me. I had to thoroughly defend my martial status. She asks a lot of personal questions, but then again, so do I. She is great.

For the first time today I met a resident from a different specialty. Quel suprise! I cannot remember his name and I tried so hard to read his ID badge, but it was dangling off his hip and you can only stare so long below the waist before people start to question your intentions. He was a 4th year anesthesia resident and we chatted for what seems like hours. He is brilliant and always 3 steps ahead. His general medicine knowledge is impressive. First off he was the anesthesiologist on the two cases discussed above and he had many concerns. Thyroid storm, metastasis, the difficulty of the case. I’m telling you- these physicians have PTSD here! Every patients is a time bomb and it’s up to them to beat the explosion. When things go right, they are in disbelief and continue to wait for the tables to turn. In any case, Gilbert and Aimee were dealing with the IUFD so I literally bedside rounded with him. Explained the Gynecological portions and why the surgery was warranted while listening to his concerns and validating his opinions. We decided we would have blood available for both cases and discussed the treatment of thyroid storm since the patient with the molar pregnancy presented with elevated thyroid hormone levels. Afterwards the patient got very agitated and I suggested he check her glucose and it was extremely low. After that, we were tight. After things quieted down we talked about his path to anesthesia and how he is also doing critical care and plans to do a fellowship. We also talked about my home and how “everyone just wants to make money there!” LOL. I find it so interesting other people in the worlds perceptions of Americans. I swear, they think we’re monsters! In any case, it was interesting collaborating with him today and to have 3 chief residents struggle in a difficult hysterectomy.

After work, I went to my favorite hang out spot in town. You may laugh, but it’s the Marriott!! (I’m so American but whatever) It’s conveniently located on the way home from CHUK and I can grab some wine and snacks before heading home. They also have WiFi and TV so I catch up on my CNN. Super clutch. I had the same waitress as usual- Neema. I always tip her well so she follows me to my seat whenever I walk in.

Rwanda- Ch. 10 — October 1, 2018

Rwanda- Ch. 10

I’ve said this several times before, but the people in Rwanda are sooo nice- too nice. I woke up bright and early to Pascal greeting me. He manages the house on the Rwanda side and we have been speaking a lot via WhatsApp. He said last week he would come greet me, didn’t think it’d be at 6:30 AM. FINE. I went and got ready for work, just barely leaving me enough time to walk. Great! This is my last week and I’m running low on RWF, want to save it to buy lunch so minimal moto usage this week! I walk out to the living room now only to see Safrina! I hadn’t seen her all weekend (and subsequently went to sleep hungry at times). I hugged her!! She insisted I sit for breakfast. I tried to explain to her that I had 20 minutes before I needed to be sitting at morning report, but one thing I’ve learned about Safrina- don’t bother arguing, she will win. We compromised and decided I would take my omelette to go. In the meantime, Pascal wanted to chat. He’s a very attractive young gentleman and there’s something about Rwandan men, they’re always in suits!! His teeth are perfectly straight and he has a very nice smile. His English is horrible, ugh just speak French. I say goodbye as he offers me for the 3rd time to take the master bedroom in this 4 bedroom house I live in alone. “No, thank you, I like my room. It’s cozy.” By the time all was said and done, I had 8 minutes till I had to be at work- MOTO! Made it just in time, Tupperware with omelette in hand!

Morning report was especially long today. It was 2 hours. It’s a new month so the residents all changed rotations and the patients were new to them. I decided that this week I would focus on obstetrics. So I went to the labor ward afterwards. A resident didn’t show up for about an hour and a half so I read my book, For Whom the Bell Tolls, and offered my assistance to the midwives. They love me, not sure why but it may have to do with the fact that they think my name is Brielle ( my white coat reads Ayisha Brielle Buckley, MD and I think they selectively only see Brielle) , whatever I’m not going to correct them, it is technically my name, just my middle name! BRIELLE! BRIELLE! BRIELLE! Sometimes I forget to respond. In any case there was a woman getting ready to deliver so I stayed close. Next thing I know a resident appears! Emery. He’s a second year. He speaks so fast, I explained to him that if he wishes to speak to me in English, he’s got to enunciate his words!! By the end of the day, I told him to just speak to me in French rather than asking him to repeat every other word. We rounded on all the patients on the ward. Few inductions, 35 weeker with malaria, postpartum IUFD (baby died in utero). Nothing too crazy. We finish and he began piles of paper work. The patient with malaria was getting discharged and all she needed was a BPP to leave so I did it whole Emery caught up on charts. In this time 2 patients delivered- Emery didn’t budge from his seat. I asked him if that’s typical- he said he’s delivered “millions of babies” so he only goes if its complicated. I love delivering. I will always catch my babies no matter how far in my career I get! Apparently here before residency there is a prerequisite of having to work as a general practitioner in these district hospitals where to manage everything (c-sections, vaginal deliveries, men, blah !) , Emery did that for 3 years prior to coming to CHUK to focus on OB/GYN. So he did a fair amount of OB/GYN prior to this. Still weird, I have 2 additional years of residency on him and still love to catch a baby. Next we went for lunch by this point it was 2 pm, we chatted a ton about his family (he is the youngest of 6 and both his parents passed away) and goals for the future. I always find it fascinating, these residents have so much life perspective, they don’t perseverate over the things we do back home. I even gave him some resources I use to study – he has a study schedule and is super motivated to read and learn which I admire.

On my way home for work, I was stopped by a man who spoke English. He told me he was neighbors with me and started naming all the security guards, pascal, and Safrina. I smiled and nodded and shook his hand. I’m freaked out deep down. Next thing I know, he’s inviting himself over next Monday. Sure, sure. Monday is fine.” Only agreeing because I know by Monday I’ll be sitting in my New York apartment. “I love you!!” OK HOMIE, YOU CROSSED THE LINE.” I smile, turn the other way and legit run home- knees to chest. People here are too nice!! I don’t know how to respond, and at times it freaks me out. Guess that’s what happens when you live in NY and get a scowl if you say “good morning” to peppy.

Thank God, Safrina’s still there, jeez. She left almost at 7 pm all the while forcing me to eat all evening. I felt like a child. She said, “your mom will be so upset when you go back skinny! She will blame me!” I told her, “she will thank you if I come back skinny!” She laughed. She thinks I don’t eat, but I do- she just makes so much food it is far too much for an individual person to eat, I share with the security guard as and there is still a ton left over!! I also cannot use the stove which is a huge barrier. Essentially if she doesn’t come that day, I don’t eat .

Im getting a little stir crazy in the evenings. No one around, barely working internet, no TV, and everyone back home who I would talk to is 6 hrs behind. Also- Magnifique is in Senegal for a conference (good for him bad for me). I have brought books with me but I’m getting irritable. Tomorrow I think I will walk to town after work to get a coffee.

Safrina making an omelette in seconds

Rwanda Ch. 9 – Nyamirambo — September 30, 2018

Rwanda Ch. 9 – Nyamirambo

Muraho (Hello) ! I did a lot of exploring today. Long post with lots of pictures. I started off my morning at the Nyamirambo Women’s Center. This is an initiative started 17 years ago by a group of 18 women looking to empower themselves and create a better life for them and their families. The mission is simple- provide education and training to disadvantaged women. YAAAAS. This initially began with the 2 literate women in the group of 18 teaching the others how to read and write to now offering free classes in literacy, English, basic computer skills, handicrafts, and sewing to the women in the community. They also started a library which offers books in Kinyarwanda, English, and French as well as activities which are all free to the children in the community. They provide homework assistance as well. It seems as though there are 2 ways these initiatives are funded, for one, Umutima (which means heart in Kinyarwanda) which is a training and employment for the women – they make housewares and children’s wear at the Centers shop which gets sold and the women pocket some of the money. So the great thing is this both employs these women from the community while also funding the classes and educational resources for the women. Women helping women ❤️. Secondly, this is funded through community based tourism- the walking tour of Kigali was about 15 USD and all proceeds go to the initiatives of the center.

I OBVIOUSLY LOVED EVERYTHING ABOUT THIS! Before the walking tour they taught us some common phrases in Kinyarwanda so we could interact with the people in the community which definitely came in handy. We met friends a long the way who decided to follow us along. A little back history of Nyamirambo- it’s the oldest and biggest township in Kigali.

First we went to the library which is across the street from the women’s center. There are now about 3,000 books which the children can use for free. They meet several times a week for praying, times tables, cartoons, and even homework help. Seems like anywhere between 3-15 children participate daily.

Next we went to a local Hair salon. We learned about local hair styles and even historical ones and their significance. One of the women on the tour even got her hair braided!

Next we went to “the tap.” It’s a government provided water dispensary for the community. People were becoming very sick with water borne illnesses so the government provided this area where you can get clean water for 10 RWF. That is something like pennies in USD. These are all over the country. Next door to the tap was the charcoal center. Here community members can buy enough charcoal to cook for their families for a month. Costing about 9,000 RWF. (~ 10 USD).

Next we walked passed a Mosque and learned that this area is predominantly Muslim. We also learned that during the genocide while pastors and priests were betraying their congregations and leading the militia to the Tutsi members causing their deaths, this mosque acted as a safe haven and Refugee for many of the Tutsi.

We walked through the markets interacted with the people in the town and learned how to pound cassava leaves! The tour concluded with a delicious lunch prepared by one of the women in the center in her home right in Nyamirambo. It was interesting to meet all the other people on the tour- some people from Germany focused on tech start up in Rwanda, an optometrist from the UK helping screen children in the community, and even a group of Americans here just to see the endangered gorillas. In any case, our participation supported their initiative. I even bought the cutest baby dress for Maisie made by one of these strong women with love. 💕

After the tour and lunch I contacted my taxi driver to take me to another stop. The Kigali Genocide Memorial. Nyamirambo means “the place where dead bodies are found” in Kinyarwanda. It was named this because after the genocide bodies were literally piled in the city. I wanted to learn more. Several of the people on the walking tour had the same idea. I went on the free walking tour of the memorial and it was touching, saddening, and heavy all at once. It took me a long time to even bring myself to write this blog post because my heart was so heavy. This memorial is where 250,000 victims were buried of the approximately 1,000,000 murdered during this killing spree. Hearing these stories of survivors watching every one of their family members killed during the genocide or seeing the faces of the thousands of children who were not immune to this fate was very impactful. The propaganda, the warning signs that were ignored, and the international community turning a blind eye were all so troubling. How many times has this happened in history, why don’t we ever learn? I’m glad I was able to see it. It makes me appreciate this amazing country that much more. In spite of all they went through those 100 days in 1994, they are unified and resilient!

Murabeho! (Goodbye!)

Rwanda Ch 8 — September 29, 2018

Rwanda Ch 8

WEEKEND!!! No work 😊. I’m not gonna lie, I originally had 0 plans today, so I woke up late. No safrina = no breakfast. I washed my hair and took a long shower. Then I FaceTimed friends from home and decided to email a friend I met last weekend here in Rwanda, Francoise. I liken her to a promoter back home. She’s someone who knows everything and everyone. I very much wanted to get some African dresses for friends and family at home. So she met up with me and we went to the market to choose some material and then to the tailor to choose some styles of dresses and clothing. I got 5 items made for 70 bucks! Totally worth it, can’t wait to see how they come out! After we were getting ready to leave the market, I got reprimanded by her for wearing shorts. Apparently I was not conservative enough- OOPS. I wore a sweater for goodness sakes, it’s like 85 degrees out! Whatever.

Her driver, Alphonse, is so much better than Aimable. For one, his English is impeccable. Secondly, and most importantly, he doesn’t over charge me!! Aimable is like paying for an uber in a 3rd world country. Alphonse is like paying for a taxi in a 3rd world country – dirt cheap. On the way home- I was famished. I hadn’t eaten all day so I asked him to drop me off at the best restaurant in Kagali. He took me to Repub Lounge. It was this roof top bar over looking all of Rwanda. I invited Magnifique who came later but while waiting I made 2 American friends. Jakob and Ethan, while simultaneously drinking way too much Rwandan wine- called urawagwa- my waitress told me it would be too strong for me but she must not know how often I go to happy hour. Rwandan wine has nothing on me!!! In any case- Jakob recently graduated high school and is joining the navy (congrats!) Ethan- proud dad- gifted his son a voyage around the world. This was the first leg of their trip and they just landed in Rwanda on the way to Kenya and Uganda. They stopped here for dinner after landing and we had a great conversation and great laughs. It was nice seeing other Americans. To mindlessly joke about politics or laugh about nothing at all. I wish them the best on their journey and hope they have the trip of a lifetime!! Also- please check out peep, their traveling companion who has a Instagram page (which I already forgot the name) documenting all his travels!

Anyway, more exploring tomorrow!

Rwanda Ch. 7 — September 28, 2018

Rwanda Ch. 7

Today I went to morning report as usual. Overnight they had a transfer for a uterine rupture. It was a patient with 2 prior pregnancies (vaginal deliveries) who developed severe abdominal pain at about 7 cm dilation. The baby ended up dying and when brought to the OR at this district hospital she was noted to have a posterior uterine rupture. Very strange since she’s had no history of uterine manipulation or surgeries of any sort (that can weaken the uterine muscle and make it easier to tear during labor). The district hospital called CHUK to transfer the patient as the rupture extended into the broad ligament and they couldn’t get control of the bleeding. So they recommended tying a tourniquet around the uterus and transfer her immediately. That is something I’ve never heard of. A tourniquet around the uterus- the chief took pictures, thank goodness because I couldn’t wrap my head around a giant orange tourniquet around the uterus. I’d imagine this is what they must do in the army for acute control of bleeding. Well it worked and probably saved her life. The chief resident overnight did a hysterectomy when she arrived. Apparently the ureter was injured at some point during this whole ordeal so urology was called in to repair and place stents. IMPRESSED. The patient was extubated awake and talking by the time we rolled in for morning report. Also- in other news, the critical patient from yesterday is still alive! Still on pressors and unable to maintain oxygen saturation on a ventilator but alive nonetheless. She probably had a massive CVA. Not sure what her quality of like will be if she survives. Next was a transfer for GTN. Another GTN. JEEZ! This patient is 25 with no children and a huge cancerous uterus now invading her bladder and rectum. She is also thrombocytopenic and severely anemic due to melena (bloody bowel movements) and hematuria (blood in urine). So because of her instability she cannot get chemo which could possibly shrink the tumor down to make her a better surgical candidate and obviously no one wants to operate with the tumors invading into everything. THE CONUNDRUM! We had a heated debate and kind of left things up in the air. No plan as of yet but I feel like you have to mull this over just a bit. She will possibly die if they operate now and chemo may not be a feasible option at this time.

Next, I sat in on their resident meeting. It was 4 hours!!!!!!!! I won’t go into specifics but their concerns are very different from ours back home. They just want a vaginal probe, better ways to evaluate competencies, and to only rotate at hospitals which provide some sort of education. Sounds simple enough. They are also very vocal. It felt as though every single resident spoke. I think back to our resident meetings where you can hear crickets and lasts < 1 hr unless there is some bombshell news to discuss.

The meeting ended at noon. I was literally dying from heat with my white coat on and all 45 residents piled on eachother in this tiny room with no air conditioning. I ran out when it was over to get some fresh air. Magnifique found me in my secret snack spot over looking the rest of the departments and asked me what I was doing for the day…”eh nothing planned I guess.” I told him. So he invited me to the hotel Serena across the street for a conference. The Rwandan Medical Association. They were having a conference on medical emergencies in the context of Rwanda. So all these Rwandan physicians were in this conference hall collaborating and learning. It was great! Of course Magnifique was on some committee for this organization and coordinated the event. He’s such a busy body. He stretches himself way too thin and does everything super fast including speak! It all comes from a good place but it still makes me laugh. In any case it was a great experience and I’m glad I was invited to participate.

Rwanda Ch. 6 — September 27, 2018

Rwanda Ch. 6

I have become quite the native. I walk to and from town/work, am well versed with riding a moto, and finally have Rwandan franc ($$$)! Today started like usual, snoozing alarm 3 times, subsequently running late to morning report. MOTO! Bosco (security guard) looked in shock as I hopped on the back of the moto with a black dress on and placed a helmet over my freshly coiffed hair. WHATEVER. Au revoir sucker! Jean, the weekend security guard wasn’t this judgmental and encouraged me to ride the moto to work!

In any case, made it to work with 3 minutes to spare. It’s a 30 minute walk and I frequently don’t have 30 minute commute time budgeted into my morning routine. I always walk home though (mostly because I cannot explain in Kiryarwanda where the house is). I took my helmet off and didn’t have enough small bills to pay him, he took what I had so as to not over charge me. Merci! I quickly walked towards the entrance of the maternity ward. All I kept hearing are “pssssssts” behind me. I turn around with a dirty look on my face only to find some stranger holding out my earring! THAT HAPPENS EVERY TIME I TAKE THAT DANG HELMET OFF! “Merci bien!” This is how the people in Rwanda are for the most part, kind and always willing to lend a hand. I’ve had people walk me to an establishment because I’m so lost!

Just on time for morning report which is my favorite part of the day. It’s a nice way for me to hear about all the patients, see how they manage things, and even ask some questions (usually quietly to the resident sitting next to me of course). There were 3 interesting cases today.

First, was a septic abortion at 13 weeks. Aimable explained to me later that this is very common here, stating that many times when these patients go to the OR, twigs and wood are removed from the uterine cavity!! Termination of pregnancy is only allowed for life threatening maternal status or lethal anomalies. So frequently these are performed illegally. The residents overnight presented the case and the plan for antibiotics and exploratory laparotomy (atypical for this diagnosis). The plan was essentially to open her abdomen, because they were concerned there may have been a perforation and abscess in the abdomen after this sub par procedure. Diomede (head of the department) disagreed, I echoed his sentiments. She needed a vaginal procedure to evacuate the uterus, not an abdominal procedure. Plan was made to re-evaluate today. Diomede was annoyed that no consultant was involved in the decision making – but I must say in the few days I’ve been here other than Dr. Liza I’ve seen very little consultant involvement with decision making. In any case, Bridget and I did a manual vacuum aspiration to evacuate the uterine contents later in the day. (A bedside aspiration of the uterine contents to get all the infected tissue out).

The next interesting case was a 27 weeker with either superimposed pre-eclampsia or worsening chronic hypertension (essentially her blood pressures were high and it was unclear why, but it may warrant delivery if it can’t be controlled). She also had absent end diastolic flow on Doppler’s (abnormal perfusion of the baby). Otherwise her BPP was 8/8 and her NST reactive (all other markers for assessing the baby were normal). Plan was made to deliver today as she completed her steroids (to help the babies lungs develop in the case of a premature delivery). I was climbing in my chair! Dr. Blaise (4th year resident beginning his shift) was the first to challenge this plan (he believed that since her BPs were normal and all other baby testing normal she did not warrant immediate delivery. I agreed). Aimable (4th year resident overnight) stated she needed to be delivered. The attending agreed. I HAD TO SAY SOMETHING. I raised my hand and suggested that we continue expectant management until we have a more compelling reason to deliver. A 27 weeker in a 3rd world country is no joke!! I recommended bi-weekly BPPs and Doppler’s with labs and delivery for worsening maternal/fetal status. That didn’t fly. “What is she seizes? Or develops pulmonary edema?” “Then we deliver her.” I said. I knew she wasn’t making it to term but I thought we could at least buy her a few weeks. It makes a huge difference with neonatal outcomes. No one was on board with this plan- I think they see too much here. Every patient is a ticking time bomb to these guys. Ok, new suggestion, “why don’t we repeat the BPP and Doppler’s and reassess this morning?” There we go , everyone could wrap their head around this short term plan. Absent end diastolic flow can be transient and in a baby with all other normal testing, I just felt optimistic. Moms blood pressures were normal and I wanted her to get more time. The consultant asked Bridget (2nd year resident) her thoughts, she said ” I would deliver her. We have to consider Mom over the baby. She may decompensate if we don’t deliver her.” Ugh Bridget, I thought we were friends. In the end, the consultant agreed with repeating ultrasound today. I went with Bridget to do the Doppler’s. 1) I’m so impressed she can do them 2) I most definitely cannot (I’m spoiled by official ultrasounds and reads by our MFMs). Thankfully I can do an estimated fetal weight ! SHOOT, Still absent end diastolic flow. At this point Blaise and I throw in the towel and admit defeat. Bridget called the consultant to update and agree to plan for delivery.

The last case that was interesting was a 21 year old who delivered the day prior to presenting who was transferred from a district hospital after having convulsions with elevated BPs. She was bag mask ventilated and brought to CHUK. Overnight she deteriorated and became hypotensive and tachycardic. Now on pressors. She has dilated pupils and the picture Aimable painted was of a very critical patient. There are no beds in the ICU so she is on a ventilator in the recovery area of L&D. There is some concern that this may be a stroke. There was a thought overnight to get a CT scan but since she’s on the vent, she can’t be moved to radiology. One of the consultants chimed in to say, “what’s the point in wasting the family’s money on that, she is going to die.” OUCH. Aimable responded that they have insurance and everything is 100% covered. Sigh, I’ll be surprised is she is still alive tomorrow.

After the heated morning report, one of the other female residents came to me to commend me on my plan in there. I was surprised. We chatted a little about how we would manage this patient and then parted ways. I spent a lot of time with Bridget today on L&D. We talked about her child, and why the field is so male dominated. It seems like it’s lifestyle related according to her. I explained to her the make up of my program and she was very surprised. We ate lunch in the restaurant (she had to explain every food to me though 😬) and Aimable was there too! He worked overnight but was still lurking around the hospital all morning and afternoon looking for the CT angio read for the patient yesterday who was scheduled for surgery for GTN but may have had a PE. I offered again to go to radiology to get the read so he could sleep, but instead we went together. Yep, she has a PE. Surgery delayed for at least a few months. If I am to say anything about this experience thus far, it is that the residents are world class here and the patients are really lucky to have such a hard working and dedicated group of physicians caring for them.

I think that’s enough for today.

Rwanda Ch.5 — September 26, 2018

Rwanda Ch.5

I legit fell asleep last night with this in hand ready to write. So tired. Jet lag is real. In any case my first few days at CHUK have been very interesting. The residents are very busy. They are essentially the sole providers for the patients which is very unlike the US where we always have to discuss with an attending (at least in the north east), unless it’s oncology in which case Dr. Liza is involved. Yesterday I scrubbed on the most beautiful radical hysterectomy. I told her after that if I had worked with her when I was a junior resident, I might have considered GYN ONC. Operating with her is fabulous. The OR is about 85 degrees but there is music and it is %100 educational. There was no intimidation or yelling, it was the friendliest ONC OR I have ever scrubbing into. I told her I will be in theatre whenever she is. It was phenomenal. These first few days I have been so lost. Every afternoon after theatre the residents disappear…not to be seen or heard from. I found myself wandering aimlessly until finally just dismissing myself. Today I got creative and borderline stalkerish. I followed Charles (one of the chief residents) to his clinic. I also vowed to be helpful and to not be a hinderance. We finished at 3 pm and he said that was the fastest clinic session he had ever had, stating he usually leaves at 7 pm (plus I come with snacks!!) I essentially scribed for him and acted like his subconscious. He types painfully slow so while he spoke to the patient, I would type the note. If there was an admission, I helped him with the paper work. If he was doing a BPP on a 40 weeker and it was abnormal, I’d say, “but Charles, she’s 40 weeks, let’s just deliver her.” As he was counseling the patient to go eat and come back for a repeat scan. “She’s term Charles, let’s place a Foley and give cytotec.” Next thing I know, we’re submitting paper work for admission. WOO! Sometimes you just need someone to bounce ideas off of. Next, were several patients who came just to see Dr. Liza. One with advanced cervical cancer that poor Charles had to counsel on palliative in 5 minutes in Kinyarwanda because he was the only native in the room. Next a GTN, next, likely leiomyosarcoma- schedule for TAH/BSO for diagnosis. Charles did a good job. No attending in sight managing very complicated patients with a nuisance resident at the same level of training asking questions. At the end of the rapid fire clinic session he thanked me, I told him I’d see him tomorrow! Next more wandering- I ran into Aimable. The GYN chief. He was scrubbed on the rad hyst yesterday. He is working tonight but that doesn’t matter here- you still work during the day pre- call. He was tidying things up for a hyst scheduled for tomorrow for GTN. The patient needed a CT scan pre-op and he had been back and forth to radiology looking for the read. He was supposed to go back at 2 pm and this was the only thing standing between him and getting some sleep before his shift. I offered to go for him however as in a residents nature- trust no one. He went back on his own to get the read. She had a possible PE. Shoot. Surgery definitely delayed to work up/ treat this PE. We had a long talk about what it’s like being a chief in the US vs. here. The scheduled benign cases are done by a resident independently. TVH? A chief and a junior perform. I had to ask, “how did you get comfortable doing this by yourself?” He responded honestly, ” I am not.” Jeez. I explained our process of essentially working closely with an attending for everything. He envied me- so strange, he said he wished there was more guidance during this training, saying basically he could be doing it incorrectly and would never know. Interesting. I continue to be impressed by the residents, the make up of which is very different from the US. There are still significant gender roles here. With 14 residents a year (over 4 years – so whatever 14 x4 is) the overwhelming majority are men. The attendings (called consultants here) all men except Dr. Liza and she’s American ! At home, who runs the world? GIRLS! All the residents are women and I can count on 1 hand how many men faculty members there are. Very different. The 2 girl residents here I see, I’m all like YAAAAS QUEENS.

In other fellowship news- rank lists due today!! I knew I’d be in Africa so I certified and submitted before I left ! Will find out results Oct. 10th stay tunedddddddddddd!!

Rwanda- Ch. 4 – CHUK — September 24, 2018

Rwanda- Ch. 4 – CHUK

Alright, so today was my first day on the wards at CHUK (Teaching hospital of Kigali). I came in and went to morning report where the residents present each admission from the weekend and management plans are discussed. The faculty are present and challenge the residents to defend their actions from the weekend. It kind of reminds me of “chairman’s rounds” at my hospital. The residents are the bomb. Can’t stress that enough. They are clinically very good and surgically very strong. They do c-hysts by themselves (a very difficult hysterectomy after a cesarean section for various indications). Attendings aren’t even present. CRAY. They also are forced to manage very complicated medical problems from TB, to DVTs, and a lot of HIV anti-retro viral therapy. Also, everyone has GTN. I was very impressed. It’s not your bread and butter gynecology. It’s the crazy stuff you see maybe once in your career back home or that a consultant manages that they see and deal with regularly. So after they presented the admissions over the weekend and plans were ironed out, they presented the ICU patients, and discussed the 3 deaths over the weekend.

I then started the morning with a tour by Liza. She’s the GYN ONC attending I mentioned earlier. She is still on faculty at Yale but has a contract through the HRH to come to this teaching hospital and do just that- teach. She is 100% here for the residents. She doesn’t have a clinic- her patients are resident patients. She does about 1 radical hysterectomy a week. THAT IS A LOT. There is a huge incidence of cervical cancer here. Naturally I have latched on to her and this is becoming a GYN ONC rotation. She’s exceptional. She essentially dropped her practice in the states to move to Rwanda and train the residents. Selfless much?

In any case after my grand tour of all the wards I waited to round with the GYN team. The wards are pretty standard with a few variations: wards 1-3 are Obstetrics – L&D, antepartum, postpartum. Of course there is a triage. Wards 4-6 are GYN. There’s also a special ward for “dirty wounds” so all the patients with wound complications and infections go there. There are 3 ORs. 1 for OB, another for GYN, and another for infected patients for wash outs etc.

I rounded with the residents and Liza on the GYN patients which was essentially an oncology service. Then the residents dispersed. I learned quite a bit about the healthcare system here- there is healthcare system that costs somewhere around US 35 dollars for a 4 person family and patients pay a 10% copay if they need a service. They can pay a little extra if they want to see a faculty attending. There were no cases so I read up on some of the patients and then went home to run some errands. One thing I love about Rwanda is that it is so incredibly safe. People say that all the time, but really- it is. I walked 30 mins to and from town to exchange money to pay back my beer tab and it was totally fine. Phone in hand walking down the street and not a single person bothered me. I exchanged some US dollars for Rwandan francs and bought some trinkets in the gift shop. Then I made the trek back home in the dark which went smoothly. I went back and paid my beer balance off with the lady next door, I tried to give her a little extra for her kindness but she insisted I give her only what is owed.

Well, catch ya later~

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