Saturday, January 30, 2010

The cases I did not do

Just in case you are thinking this is all about partying in Rwanda, a bit more about work.
In some ways the cased I declined to do say more about the situation here than the ones I did.

On the first day they wanted me to do a 3 day old 3 kg baby for a bowel resection. I declined, and a local staff anesthesiologist did the case expertly, although there was confusion about the dose of narcotics so the patient got a double dose and had to be ventilated in the neonatal ICU postoperatively.

At CHUK there was a child with some sort of congenital cyanotic heart disease who had an ejection fraction of 20% and ventricular hypertrophy. In the absence of a cardiac echo expert this was all the information we had. He weighed 11 kg and needed a craniotomy for a brain abcess. His O2 sat was 85% on 5 l oxygen. I did not offer to do the case. Later that day I found him being operated on under local, with puss coming out of his brain. A nurse anesthetist was monitoring his saturation, but not his blood pressure or ECG. There was no medical anesthesiologist in sight. He seemed to be doing remarkably well.

The last couple of days inButare I saw some tragic cases. A child of about 7 who had a neglected ulcer on his leg which had become gangrenous, and now required an above-knee amputation. He had malaria, with a spleen below his umbilicus, and looked very pale. After discussion with a local staff anesthesiologist, I decided we should wait for a blood count and possible transfusion before operating. I came back from seeing the next day's patients to find the anesthesia techs intubating the child. Four hours after it was requested, the blood count result had not come back, but the techs did not seem to mind that.

There was a 22 year old guy who had had something fall on him, resulting in a complete fracture dislocation of his neck at C5 with complete quadriplegia. He could shrug his shoulders but not move his arms or legs. The surgeon wanted to fix the bones of his neck, but no-one, no-where can ever make his spinal cord work again.

He came to the operating room in respiratory failure. With only the diaphragm to breathe with he was retaining secretions, and could not cough. He was tachypnoiec, had a fever, and his oxygen saturation on room air was 74%. I explained to the surgeon that it was no problem to give him an anesthetic but that once we had intubated hiom there was no way we would be able to get him off the ventilator. He did not have the strength to breathe on his own now, and would never regain it. At best, he would live on a ventilator, totally dependant on others, until pneumonia, kidney failure or bed sores killed him. After much discussion with the surgeon and the local intensivist I got the case cancelled and he was returned to the floor for palliative care. The surgeon was a Cuban, and I had didfficulty understanding him in either English or French, but he seemed OK with this provided it was explained that the problem was that anesthesia did not have the facilities to look after the case post-operatively.

We then did an 11 kg child with a huge subdural on one side and a brain abcess on the other. I was quite comfortable letting the Rwandan residents do this case, partly beacuse they actually prepared in advance a list of all the drugs and equipment they needed, and partly because the child had virtually no functioning brain left and could not be made much worse!

The other case done in Butare that day was a 2,3 kg, 16 day old, baby for an omphalocoele. This was expertly done by a local staff anesthesiologist. You have to have nerves of steel to do a case like that with the best equipment in the world. To do it with an Oxford Miniature Vapouriser, Halothane, an Ayres T piece and no agent or CO2 monitoring takes real skill and guts.

I had one easy case in Butare this week - an adult woman with an ovarian cyst. This seemed to good to be true, until I saw the anesthesia equipment. They had basically cannibalised two anesthesia machines to make one that worked, provided you knew how to connect them together. The resident had no clue, but fortunately I was able to find a local staff anesthesiologist to show me how to connect things up.

Clubbing on a Friday Night in Kigali

Greg, the R2 from Winnipeg who has been a great support to me on this trip, and an ardent teacher of basic science and basic principles to the residents, has to go back on Tuesday. He has an overnight flight leaving 10 pm Tuesay and he is back on call in Winnipeg Thursday night.
Before he left, he wanted to investigate the night club scene in Kigali, so we set out to do that.

We began at 8 pm with a late dinner at Khazana, the best Indian restaurant in Kigali. Curried chicken and tilapia, kashmir pillau amd peshwari naan ( or was it the other way around?) were delicious, although the bill came to about $48 for the two of us, which seems a lot for Rwanda.

We were told that there was no point turning up at the Cadillac night club before midnight, so we took a cab to the Repulika Lounge. This is a nice restuarant on a balcony, and a lounge with comfy sofas. We relaxed over a gin and tonic and a couple of Mutzigs, entertaining ourselves by watching the prostitutes pick up the single guys drinking at the bar!

We were joined by an English medical student and two Canadians, originally from Toronto, who were resting up in Kigali before cycling to Botswana. On Wednesday they will start a 600 km ride through small villages to some town in Tanzania, where they can catch a boat to take them the length of Lake Tanganyka!

At midnight the five of us piled into a Toyota Corolla taxi and were driven to Cadillac. After a brief discussion we decided the RwF 1,500 ($3) cover charge was OK and went in. It was loud and dark, with lots of UV lights. I went to the bathroom and found I had lost the rest of the group when I got out. As I searched for them I realised I was being followed by a prostitute. I tried to shake her off and managed to find the group. Women in skimpy outfits kept on coming up to our table, putting our arms around us and asking if we wanted to dance. It was difficult to even look around the room at the African couples dancing, as you found yourself making eye contact with the ladies of the night who did not need any more encouragement to come to our table or to dance provocatively.

Even after a couple of beers and a Tequila shot I felt uncomfortable, so I left at 1:30. On the way out a woman asked me where I was going. I said I was going home. She squished her breasts against my chest and from about three inches away, looked into my eyes and asked if she could come with me! I said no, and made a dash for the door. The first taxi in the parking lot wanted RwF 4,000 (about $7) to take me home. That's a fair price, but he could have asked a lot more and I would not have argued. I am a happily married man, get me out of here!

Greg stayed until the small hours of the morning, but had his wallet pick-pocketed, which is sad but perhaps not surprising.

Victory Children's Orphanage

On the way back from Butare we stopped at an orphanage, run by Serena, who we had met in a cafe in Kigali, and her husband Isaac. and

It houses 60 orphans in a a couple of dormitories and provides an on-site school for the younger kids. They are trying to be self-sufficient, growing their own vegetables, and keeping cows, goats, chickens and rabbits. They have a generator which they use two hours a day to pump water from the well to holding tanks, The rest of the time they have no electricity. It is set in a few pretty acres just east of the main Kigali-Butare road, a few kilometres from a small village and maybe half an hour south of Kigali.

I admire the couple, who's religious conviction have led them to leave their home and lives in Wyoming to care for some of Rwanda's many orphans. Even with the help of a local manager, they have a lot to learn and adapt to as they work to improve the orphanage and learn to operate a small-holding in Rwanda.

Isaac and Serena gave us a great tour, and invited us into their home for a cold drink, which was very welcome. I had just received some money from the National University of Rwanda to pay for some of my expenses on the trip, which I had not been expecting, so I donated it to the orphanage. The football pitch there is dangerously uneven, and Isaac wants to use the spare soil from the retaining wall project to even the ground, then plant grass seed. It is a small gesture, but maybe with my money they can give the kids a decent, level, even grass soccer pitch!

Wednesday at the Green Corner

It is a tradition that the visiting lecturers take the residents out to dinner after one of the last academic days. I originally thought about Heaven Restaurant but that would be very expensive, so I considered the Karibou which is within walking distance of the hospital. The residents recommended the Green Corner, a local bar in Nyamirambo, which turned out to be a great idea. We piled into a couple of vehicles and were driven up the hill out of town for about 25 minutes. The place looked very basic - concrete floors, brick walls and old plastic outdoor furniture. At 4:30 there was no problem pulling a couple of tables together, and we ordered the first round of drinks.
One resident ordered a coke and tonic - a bottle of each, mixed together. The next ordered a guiness and coke, same deal. The third ordered Tusker, the Kenyan beer which Rwandans always drink two bottles at a time. Greg and I stuck to large Mutzigs.
Once we were all assembled we ordered food. There was no menu. The "chef" came out of the kitchen in a reassuringly clean white apron and there was a brief discussion about what was available. It was decided that three tilapia (a meaty lake fish) and three chickens, all barbecued and served with chips, would serve the ten of us. It took a long time to arrive, so we drank more beer on an empty stomach as the sun slowly set over Kigali. When the food came, iot arrivefd without cutlery. A waiter came with soap, a kettle of warm water and a washing up bowl. We washed our hands and dug in. Lime was squeezed on the fish and we broke it apart and ate it with our bare hands. It was delicious. The chips and chicken were good too. It did not take long to reduce all the dish and chicken to a pile of bones!

Candles were lit and vinegar was spilled on the table to keep bugs away, not that I noticed any. Greg decided he should eat the hot pepper and follow this with a drinking challenge. He, representing Canada won against a resident origianlly from Congo, and I representing the UK lost to Rwanda. Slowly people drifted away home. By 10:30 I had had my fill, and one of the residents came home with me on a minibus to make sure I got back safely.
It is a while since I've spent six and a half hours drinking. I woke up at 3 am, drank a couple of glasses of water, took a tylenol #3 just in case then slept until 5:45, waking up feeling OK.
The car arrived at 6:30 am to take us to Butare for a couple of days.

Monday, January 25, 2010

Monday, Working at CHUK

Actually enjoyed working in Rwanda today, I think for the first time.
I am getting used to the pace, and beginning to accept that sh*t happens.
Our driver was ten minutes late, so we came into the middle of the morning case presentations. When the presenter speaks loud enough I can follow his French. I think I made a few useful points (in English, I'm afraid). Had a decent discussion with one of the senior residents about a couple of cases. Got to the OR and there was no-one there. Looked over one of the old anesthesia machines and tried to figure how it worked. Went to the tea room and did some reading.
Eventually the first case arrived, but there was no endotracheal tube of the correct size. I made a big fuss about this. This is the University Hospital of the capital city, where they do a lot of paediatric cases. There is no reason why they should not be able to keep a supply of paediatric sized tubes in stock. After much prolonged discussion I cancelled the case. I talked tot he only staff anesthesiologist around, whio was in the ICU, and he eventaully found the rightr size tube in ICU and the case was un-cancelled and done in a different room by a nurse anesthetist, who decided not to use the tube I had found but the smaller one I had said was too small. Odd.

I was getting very frustrated working with one of the weaker residents, who seems not to remember anything I tell him, so I decide to go for an early lunch. As I headed out I saw a trail of fresh blood leading into one of the other ORs. This is never a good sign,,,,,

I wnt in to find one of the final year residents dealing with a patient who had a massive burn . A gas explosion had burnt his face, chest, both arms and upper thighs, about 30% of his body in all. He also had a depressed skull fracture and was bleeding from a skull laceration. At this time he was talking but not co-operative with examination. Two IVs had been started and the resident was working on a third. I put on the monitors and oxygen. No BP was obtainable. He has a slight tachycardia and a saturation of 90%.

Clearly he needed intubation, And clearly it would be a challenge.....
In the end I was able to topicalise the airway, and with a little sedation and two people holding him down we decided we could see enough to intubate. So we did a modified rapid sequence induction with a small dose of propofol, checking we could ventilate with cricoid pressure in place, then sux and a 7 tube with stylet. That all went well.

The surgeon did a debridement and we gave fluids according to the Parkland formula. Originally the BP was around 90 but then it shoyt up to 220/110 for no good reason, In the end I moved the cuff to the other leg and the BP returned to normal.

Had as sensible discussion about a variety of issues:
Should we trach him now? I thought doing a tracheostomy through the burn was a bad idea, especially as hopefully in a week or so the swelling would go down.
What do we do about his head injury? The surgeon could palpate a depressed fracture. Obviously he should have a CT scan, but this would require a transfer to King Faisal Hospital, about 30 mins away. In the end we decided to monitor him clinically and hyperventilate him, and cross our fingers we are not missing a surgically correctable problem.

At the end of the day I called Joseph, who is in charge of the drivers, and asked for a lift back to the apartment. He decided to drive me himself, in Landrover Ambulance. When we got to the roadworks, they let down the barrier for us. When we got to the actual working area, we just drove up onto the pile of dirt and drove straight over it. Very cool.

Stopped at the gas station across the road for yoghurt and juice, then went home. The houseboy (yes, that's what people call him) knocked onthe door with my washing, all neatly dried and folded. I paid him 3000 RwF, less than $6. Sweet deal!

Did some work preparing for the academic day on Wednesday - anticholinergics, anticholinesterases, patient positioning, and anesthesia for ENT surgery - then took the bus into town (20 cents). Doing this blog then out for the expatriate Pizza and Quiz night. Not a bad day....

Come to Rwanda, Swim in an African Lake, See Gorillas

It is time for you to stop reading this blog and book a flight to Rwanda!
The more time I spend here, the better I like the country.
On Saturday we wer picked up by a car and driver (A Toyota Land Cruiser in fact) at 9am.
We drove through stunning countryside - a mix of the look of Nepal, the Amalfi Coast of Italy and the Coastal Highway between SF and LA. Huge hills divided up into fields of banana, corn, surghum, coffee and 'Irish" potatoes (not sweet potatoes). We stopped at a brewery for samosas (delicious) and banana beer (revolting, but 14% alcohol and cheap. Some people like it but I could not take more than a few sips). We stopped at a waterfall and I climbed down, accompanied by some local kids. They watch you and talk a little in English or French. They sometimes ask for money but our driver kept on asking them 'What for? You cannot just ask for money, You have to have something to sell, or provide a service'. They were satisfied to find out things like our names and ages and how many children we had.

We stopped for sugar cane bythe roadside. Greg got into peeling the cane with a machete, then dividing it into four lengthwise and chewing. It' s amazingly sweet, like pure sugar.
We drove through Ruhengeri, getting views of the volcanoes, past some dire looking refugee camps, and down to Gisenyi. We stopped for a late lunch at the beautiful Serena Hotel. It was a bit over-priced - $9 for a grilled vegetable baguette with fries and salsad, $2 for a Fanta - but once you had eaten you could use their change facilities and swim on the beach. The weather was grey with bits of rain, but the water was warm, the beach sandy, and the water dead calm.

Greg negotiated with the operators of a 15 ft power boat to take us across the bay to the Congo border for about $8 fopr a 20 min ride. The city over the border, Goma, seemned very prosperous from what we could see from the lake.
Our driver piucked us back up for a spectacular drive around the bay past the brewery to the hot springs where locals wer bathing and cooking corn in the bubbling water which felt to be about 70 degrees centigrade.

We drove back to the Kirigi lodge north of Ruhengeri as the night fell. We had a room booked, then had an excellent steak for lunch. Huddled round a wood fire in the lounge (it was cold and pouring with rain!) drinking tea and talking to other travellers, a mix of tourists and other people doing varous volunteer work in Africa.

In the morning we were up at 6 for breakfast (cold omlette with decent tea, bananas and toast). We admired the views of the volcanoes as we waited for a ride to the park headquarters. By seven we were at there, and joined a group of 6 people who were assigned a specific family of gorillas. Our family was 16 animals, including two mature male silverbacks and several babies. We then drove over the most horrible dirt track you could imagine -so bad that on the way back I insisted on getting out and walking - to a smalll parking area. We wer loaned walking sticks and set off across a potato field to the forest. The views of the volcanoes were spectacular, It was a dry bright cool sunny day. After a few minutes we were in the forest, climbing over fallen branches and vines, pushing our way between dense vegatation only partly cleared by our guides with machetes. Eventaully the guides got in radio contact with the trackers. When we were close we had to abandon everything except our cameras. Ten minutes later we saw the first gorilla, lying in the sun, doing nothing, which was a it of an anti-climax. Then we heard rustling in the bamboo as other gorillas appeared. We saw a couple more up in trees. A baby started to walk towards us, followed by its mother. The guides were freaking out, as we are suppossed to stay 7 meters from the gorillas so we do not give them any diseases. But there was no-where to get away from them, so they walked past us, brushing against Greg's jeans, and wandered off. We saw a little baby try to climb on a dead branch which broke and it fell a couple of feet into dense vegetation. Then it tried to climb a tree and fell off again. Later we saw a baby play-fighting with a larger juvenile. They both stood up and bashed each other with their paws, or rolled over on top of each other.

Just as the guide said our hour was up we came across one of the silverbacks. It was sitting on a branch facing us, looking just like a man in a gorilla suit! It chewed bamboo nonchalently as we watched. We got back just as it began to rain very heavily. We felt sorry for a couple who had insisted on doing the long walk to see the Sousa group. They must have got soaked!

We drove into Ruhengeri and went to the Murahbo Hotel for Goat Brochettes for lunch, then headed back to Kigali, again stopping for photos, climbing up to see some coffee trees, and buying Greg some more sugar cane.

Its a very privileged existence, being driven in a Toyota Landcruiser with Congolese easy-listening CDs on the stereo past people living in houses not much better than mud huts.