Apparently Christmas Time is Here

     Having never spent Christmas anywhere that didn't have four distinct seasons and actually got cold, it's incredibly difficult for me to recognize that Christmas is less than a week away at this point. The short rainy season has moved on and we no longer have cooling rain every afternoon. Instead it has been getting hotter here averaging 80-85 degrees by midday. There are no carols on the radio, no decorations... I have to keep reminding myself that it's really December.
     Tomorrow night my roommates and I are hosting a holiday party before most people split for winter break. I almost feel as though I'm back in school with the conversation of winter break. But anyway, Joe brought back all sorts of goodies from the states on his Thanksgiving trip and I think everyone is looking forward to enjoying a nice night together relaxing. It's been pretty stressful this month getting ready for COHSASA's visit. They have been spotted stalking around the grounds this week, but they come to ICU today. It should be interesting to say the least. By no means do I think the hospital will gain full accreditation, but I think they are certainly on the right track to gain partial accreditation. And furthermore I can't help but laugh a little. I have never seen the hospital so clean, the beds made with fresh white linens, and everyone in perfect uniform. It is just like back at home. One of my managers at GW wanted to get rid of the tables we (nurses) used to sit and chart (back in the day of paper charting). Because they weren't Joint Commission regulated because then our hallways weren't wide enough. She  mentioned it several times and then noticed when the Joint Commission and/or the Health Department showed up, the tables... just miraculously disappeared. They were gone for the entire time the outsiders were around. And as soon as they were gone... the tables were right back in their normal positions like always. It is the same here. Though I'm hoping this time, things won't revert and we will keep moving forward.
     As for my Christmas, I will be spending it in Ireland with dear friends, the O'Hara's. Mr. O'Hara was a former patient of mine in GW in April 2011. I was his nurse for 8 hours, but because I mentioned my mother and I wanted to visit Ireland when I finished grad school, we formed a bond. This man was so funny that when I checked up on him when he was out on the floor the nurses were considering calling a psychiatric consult on him because he kept joking about the CIA. They didn't understand that he's Irish... and a whole lot of blarney comes out of their mouths. One year later, my mom and I did go to Ireland and the O'Hara's came to our hotel with a dozen roses for me and a box of chocolates for my mother and whisked us away for a nice country drive, lunch, and Guinness of course. They are lovely people and Mr. O'Hara (Himself as he often signed his postcards) and I have been writing postcards and notes to each other ever since. They are always highly amusing with him telling me about his failed attempts to become adopted by other couples they met while cruising.
     Having asked me many times when I was coming to visit again, I invited myself to Christmas, which of course was well received and I was really looking forward to it. However, Himself was misbehaving as usual and did not tell me how he was really feeling. On Monday I got two postcards that had taken awhile to arrive, which of course had me laughing and excited. He informed me that the Irish guards and a red carpet would be ready for my arrival, he just needed to put the final touches together. But, there won't be anymore postcards.
     Wednesday night Jean (Mrs. O'Hara) called me and told me that Himself had died and they had buried him. She wasn't sure how to tell me or if she should wait until I arrived on Christmas Eve, but I'm glad she told me now. I am upset. Originally I was hoping to visit in October and then I got this job and I pushed it back. I am absolutely heartbroken that I wasn't there and that I missed him. Jean has told me to put myself into work mode (i.e.- stop bawling my eyes out... which didn't really work that first night, but I tried) and to go get a hug from my roommates and she would see me Christmas Eve morning. I know she has much to tell me and I know that we will have many good laughs reminiscing and toasting to the lovable Sean O'Hara. Oh how I will miss him.

Quite possibly my favorite patient of all time

Me and the O'Hara's in Dublin April 2012

Hanging in the gardens of St. Patrick's

Showing off his dance moves for the ladies

Guinness stop

Last night in Ireland.
Himself & Mom

How could this guy not make you laugh?

Strolling through Dublin

The O'Hara's and Mom

      At the same time, yesterday was the anniversary of my brother, Kerry's death. Many of you reading this back home knew him, or spent the entire day with me when I found out, or I was at your house when it actually happened. It was sixteen years ago and not a day goes by that I don't think about him. I thought that this year maybe I would understand my brother a little more... he died when he was 29 and I was 13. Being the same age is odd and being older than he ever was will be stranger I think. This year hasn't changed much in my understanding of life and death and my brother, but it has been quite the unexpected year.

Kerry and Nora at his high school graduation from Calvert Hall

A rare photo of just the five of us together

     Merry Christmas everyone. Wish I could be home with my precious 10-12 foot tree with the lights glowing, but I think despite the unfortunate events, it will be really good to be away from Rwanda and in Ireland. Fingers crossed the ICU does well this afternoon.

Lessons Learned:
1) Never become complacent, life is bound to throw you a curveball
2) People come and people go in life, but those who are truly special will always be in your heart.

Kerry James Kling
March 3, 1969 - December 18, 1998

Accreditation: The Same Worldwide

     I have mentioned in the past that my hospital, University Teaching Hospital of Butare (CHUB) is going through the accreditation process. I love it (in direct contrast with how I felt about it stateside). Basically, accreditation has allowed me to make changes, while removing the blame and fault from myself. It's fantastic, plus it has really forced the hospital staff to take responsibility for the changes. I help, but I by no means lecture them every day on each and every little tiny thing. They have to make and enforce the changes themselves because I won't be here forever.
    Many of the hospitals here in Rwanda are making this leap with The Council for Health Service Accreditation of Southern Africa, also known as, COHSASA. In the United States hospitals are accredited through the Joint Commission (JC). Now as my healthcare friends know, there are many, many, MANY rules and regulations that the JC have, that during the normal year may or may not be strictly followed. Rules such as no material can be X inches from the ceiling, the width of your hallway has to be such and such, all sorts of documentation requirements, and so on. I had the great pleasure of being interrogated by a JC surveyor one year I was employed at GW. Of course it happened to be during the phasing out of physicians writing notes in the charts, but not all of course. It was lots of fun finding all the documentation (and reading out loud some very illegible handwriting) requested.
     Anyhoo... starting Monday COHSASA will be conducting a survey of CHUB. Let me tell you a secret: accreditation is the same worldwide. There is a vibe of absolute hysteria and panic racing through the hospital. I ALMOST feel at home. But the changes that have happened the past two weeks have been really inspirational. All of a sudden last week squirt bottles of alcohol for hand hygiene appeared at every ICU bedside.

  

Then the emergency trolley (aka code cart) checklist was actually being used and a hand washing station appeared outside of the ICU for visitors (we still have no running water).

  Yesterday I walked into this:

Cécile and the "mess"

Which looks pretty disastrous, but the end result was this:

 August 2014                          December 2014

I didn't say anything about the reorganization nor about checking every medication and material for an expiration date, which is what my In-Charge Cécile took upon herself to do yesterday. She has really stepped up and I am so immensely proud of her developing leadership skills. Meanwhile, I hung the newly revised assessment guides that Jessie and I had worked on together. It's amazing how excited I get over color printing and lamination. Maybe I missed my calling as a teacher.

      Meanwhile, we (the nurse educators) have been working with the Rwandan staff to certify 120 staff members in BLS. First, the other educators (I was still in Italy) put 12 staff members through an instructor training course. Then we essentially let them loose. It is amazing what they have done. While the powerpoint slides were provided by us, they have done all of the lectures, skills practice sessions, and only used us for the exam portion of the day and basically just for the sake of time. While we failed miserably at 120 people, we did certify 51 people in the last few weeks prior to the survey.

Newly appointed BLS instructor Emmanuel teaching

     Next week should be interesting. In 2012 when CHUB started the accreditation process the hospital scored a 40%. ICU scored 43%. Both of these scores are considered (marginally) partially compliant. I am so interested to see how they have hopefully improved over the last two years. Wish us luck!

Lessons Learned:
1) Sometimes people will surprise you with their courage and leadership.
2) Sometimes you will be surprised at how similar things are in completely different cultural settings.

The Truth About Machetes

     I have discovered that if I mention the word “machete” to people back home, they tend to freak out a little. I forgot that when I first moved here seeing them everywhere freaked me out, but I adjusted and I barely notice when someone is wielding an excessively long knife (typically 13-18 inches long) around.

      I couldn’t tell you where the machete originated. They seem to be all over history with machete-like tools dating back to the Bronze Age. But the machete is commonly used as an agriculture tool. Its long, strong blade makes it useful to cut through thick jungle and rain forest and to harvest certain crops (i.e.- sugar cane, coconuts, bamboo) and for other tasks such as yard work. Since moving here I have witnessed the machete being used by butchers in the market and around the hospital grounds to cut grass. Rarely does a day go by that I don’t see a machete in use in this very agricultural based society (or someone walking around with an AK-47 I might add… though I have not seen those in use). The most common type of machete here in East Africa is known as the panga or tapanga (Swahili). The blade widens on the backside more than those in West Africa and Central America and is generally longer at 16-18 inches.

       Because the machete is so common, it was the primary weapon used by the Interahamwe militias during the Genocide. I recall how much it unnerved me when I first moved here to see them everywhere. I associated machetes only with violence and I couldn’t imagine how the Rwandans felt to see them everyday of their lives after the atrocities many of them witnessed, had done to them, or even performed during the Genocide. As it turns out, the Rwandans kept the machetes around on purpose. Not only are they extremely important in this agricultural society, but also by using them everyday for non-violence, the population has been desensitized to them, very much like me. I don’t bat an eye when I see one… that was until early Wednesday morning when having just been awoken in the middle of the night by shouts I saw our night guard Charles run by with machete in hand.

     I returned from my relaxing weekend in Italy early Tuesday morning. I got to my friend Jessie's house at 2 am where I promptly napped until 5 am. Jessie and I then loaded up and started the drive to Butare where we gave our ICU nurses a retention exam on the ICU Specialization Course that Jessie taught them in the spring. She dropped me back at home just after 2 pm since I was looking very much like a zombie at that point. I showered, put my pjs on and worked on my computer. I skipped a group dinner and was in bed by 9 pm, lights out by 9:15 pm and I'm sure zonked by 9:30 pm. As I fell asleep I heard Julie and Vanessa come in from dinner, chatting and moving about the kitchen.

     The next thing I knew I heard a loud person and at first I thought I was still in Kigali (Jessie's neighborhood noisier compared to Butare) then realized that I was in my own bed and wondered why was a drunk disturbing my much needed sleep. It was just after 2 am. Then I realized that it was one word, incredibly loud, incredibly close, over and over again. I texted Julie and Vanessa, searched for my glasses, heard them in the living room and joined them.

     That's when I realized that we had been burglarized. The television, surround sound speakers, dvd player, stereo system, and some other small items were gone. Glancing out the open window with a broken handle I saw part of our veranda fencing (for lack of a better word) was broken and then I saw Charles run by, machete in hand. There was a lot of confusion, a lot of calling anyone and everyone we knew who could speak Kinyarwanda and translate for us. We finally got the complete story at about 4:30 in the morning, which was that 3 men had come into the house after breaking the handle off the window and went immediately for the electronics. Charles was able to chase them off and apparently even cut one of them with the machete as he was climbing over the wall. Charles was able to recover almost everything, but the tv is gone and I later discovered my battery power pack that Dan sent me a month ago was also gone. I had left it sitting on the coffee table when I climbed in bed. 

     There was no sleeping for the rest of the night and we were all a little nervous. For a second at the beginning of the confusion we thought they had been in my bedroom and taken my backpack, but then realized as Charles hauled it into the light, that it wasn't my backpack. I almost vomited though when I thought they had been in my room and I hadn't woken up. The scariest what-if though is that Vanessa heard them in the living room. She assumed it was jet lagged me wandering around and almost came out to the living room. She fortunately decided to just go to the bathroom and pop back in bed. But what if she had gone out there. It creeps me out but we are all fine, just a bit unnerved.

     Fortunately, the colonel has been pretty responsive. He sent Robert, our trusty handy man from Kigali on Wednesday to repair the window, he allowed a second guard to stay at night, and we now have shiny new razor wire on top of our wall. He has also said we could get a dog if we wanted... I am certainly going to look into this option. I didn't sleep well until last night, but I think that was primarily from over eating at our ex-pat Thanksgiving dinner. 

     I am glad that Charles is armed with a machete and that Vénuste keeps his police battalion on him and that the entire neighborhood is aware. Not only the neighborhood, but also the army is aware, the police, our HRH staff, University of Texas, the US Embassy, the neighborhood watch, and I don't even know who else. But I think it's safe to say that our house is being well covered and that no one would be stupid enough to come back. But I'm not going to lie... I might invest in a machete myself.

Italian Weekend Getaway

     This last weekend I went to Italy. It was amazing. Really amazing to simply be away from Africa in general. I live in an absolutely beautiful country, but I was in need of a serious break with no computer and the ability to look at water... a lot of water. So for 72 hours I enjoyed southern Italy. It immediately surprised me that I noticed how low in the sky the sun was upon my arrival and I was shocked that the sun set so early. I was sure that adjusting to summer weather and "early sunsets" (6 pm) in Rwanda would be tough. But in Italy I just couldn't believe how short the days were! I've completely missed fall and what has been normal my entire life was now so strange to me.
     Anyway, two years ago on an overnight ferry ride from Croatia, I happened upon two US Navy men on their way back to Naples. As it so happened, that was my first stop in my two week jaunt through the Italian countryside. Sean & Tim were going to offer me a ride, but there was no room in their car. Why was there no space in Sean's minivan? Because a Bosnian nun had rear-ended Tim a week or two previous while on his motorcycle and the two friends were fetching the broken machinery back to Italy to be repaired. So they left me, on the dock, waving goodbye, in Bari, Italy. You can imagine what Sean's wife thought about this. Within moments of having checked into my hotel eight hours later, I had emails from both of them, informing me that I was being picked up and taken out to dinner. Becci's first words to me when she met me were, "Can I hug you?!" She was appalled that they had left me. I meanwhile was perfectly content with taking the train/bus.
     I was thrilled after a relaxing Friday afternoon of cleaning the airplane off me, looking at beautiful water, and catching up with Tim that we were able to meet Becci & Sean for dinner. The four children stayed home with their ritual Friday night pizza, which was a shame, but gave us all a good time to catch up. It was nice to converse with people who aren't a part of my life in Rwanda. I love my colleagues and roommates to death, but inevitably we end up talking about work and while Becci and Sean asked questions about work, it was just so different and I can't even really explain why. But anyway, much like two years ago, the four of us forgot to take a picture, however here is a stolen photo of Becci and Sean so that you can put names to faces.

Becci & Sean

It was really good to see them and I know that I always have a home in Italy so long as they are stationed there. After ordering and eating way too much food I called it a night and fell asleep on the drive back to Tim's place in about 5 minutes. I was slightly lacking in sleep from the previous night's flight.

Napoli sunset...

...from one of Tim's balconies

     Saturday morning I was treated to a delicious breakfast by Chef Tim that was full of eggs, good cheese, bacon, and I can't even remember what else. All I remember is that it was so good and the milk in my tea was out of this world. It's the odd little things you miss when living some place else. For me, I'd die for some 1% milk to go with my Cheerios. But I'll survive.

Chef Tim

As I eased into the day the first stop was a haircut. It had been 13 months since I cut my hair so I was long overdue. Becci had given me some advice as to where to go and she was spot on. My stylist was great and actually cut my hair in a way I've never done before since I wanted to keep it long. It's easier to deal with it long in Africa. The shorter it is, the more out of control my curls can be. Anyway, I think it turned out pretty well!

Outside the New Castle with the New Do

And it was nice being pampered. I was complimented multiple times on my natural hair color (I suppose my shade of blonde is rarely seen in southern Italy) and told that my hair is too dry in the very next sentence. Afterwards we wandered through the sleepy city and decided to check out the "New Castle," which is a nice little museum full of art, but not too overwhelming when you're not in a serious museum mood. Afterwards we grabbed a snack and coffee (shocking I know... I actually ordered coffee, and then proceeded to add an ungodly amount of sugar to it) and then headed back to the apartment to pack for an overnight trip to the Amalfi Coast.

The New Castle

The New Castle

     We had a choice... drive the old school Jeep Wrangler OR take one of Tim's motorcycles... it was 70 degrees...

...we picked the motorcycle and boy was it fun. I have always enjoyed riding on motorcycles. My father has had one my entire life and up until this year, he's the only one I ever rode with. I don't think my brother Kerry ever took us out, at least not that I can recall. But earlier this year in San Francisco, my Italian roommate, Luca took me for a spin across the Golden Gate Bridge and into the Marin Hills. It was very special to me and by far one of (if not my favorite) San Francisco memories. But now I can say I've ridden a motorcycle with an Italian in the US and an American in Italy. And both were pretty fabulous.

My Italian in America... missing the mustache

My American in Italy

      We left mid-afternoon and hopped on the autostrada and streaked past Vesuvius before taking a small exit that started to wind itself up into the mountains. We snaked back and forth getting higher and higher and giving me a complete view of Naples and Pompeii below and Vesuvius rising in the background. Once over the mountain we started our slow descent down, passing villages, and multiple times avoiding hitting sheep who were grazing on the sides of the roads. I was relieved when we finally broke out of the shadow of the mountain and could glimpse the sea in front of us. Looking at the sea blend into the horizon makes you feel as though it goes on forever. We stayed in a little town called Ravello, which is high on the mountain and provides splendid views of the coast at every angle. I was happy just to sit in the hotel room and relax for the view alone...

Balcony view sunset

Balcony view sunrise

     But we did get dressed up and wandered through the quiet off season town and into a local place for a bite to eat. It was delicious and the owner and cook was your classic Italian mother relaying such things to us as, "You are in no rush, I bring you another glass of wine" (after we'd already had a bottle) and "Have some chocolates" and "Do you like mandarins? I bring you mandarins from my garden" and "Here is also a pear from my garden." She was wonderful and so sweet. We were glad we picked that place seeing how in the off season, there aren't many tourists and we were one of three tables for a total of six people in the restaurant.

The proprietor and I

The next morning I woke up in time for the sunrise, which was so beautiful over the water. I went a little snap happy with the camera so you will have to look at at least some of the photos and be jealous.

After showers and Tim successfully finding his morning coffee, we were served breakfast on our balcony and then went for a stroll through the town of Ravello, which was very cute and lovely and the weather was a little crisp. I really enjoyed the cool morning. It gets cool in Butare, however it's Africa... it's always humid. And I really enjoyed seeing some of the leaves changing color. I've missed fall back home.

 After our walk it was time to put our leather jackets back on and check out of the hotel and head back to Naples. This time though we drove along the coastal road. I managed to keep my camera out and got some good shots of the coast. It was absolutely breathtaking every where I looked. I am so glad we took the motorcycle. It is an experience that I will never ever forget. Sadly, the road had some construction so we couldn't go along the coast the entire way, but as we S-turned up the mountain I felt as though we were on top of the world. You could see for miles and miles. Everyone should ride a motorcycle down the Amalfi coast once in their lifetime.

      We took it easy Sunday afternoon (in tune with the entire trip) and wandered down to the waterfront so I could continue my water fix and of course get pizza. I wasn't leaving Naples without pizza in my tummy. And per usual, it was delicious. After our late lunch and wanderings we headed back to the apartment and I curled up with my book while Tim napped. Eventually, we opened some Prosecco and enjoyed some movies. All in all it was a super relaxing weekend. I was treated to another home cooked breakfast Monday morning and some American goodies were picked up on base for me to bring back for Thanksgiving before I headed to the airport. It was short but sweet.

Naples Waterfront with Vesuvius in the background

Boat yard

Tim & I along the Napoli waterfront 

Lessons Learned:

1) Everyone should be a passenger on a motorcycle down the Amalfi Coast at least once in their lifetime

2) No matter where you go in life, you will be surprised at how quickly you adapt to change and develop a "new normal."

3) Having established a "new normal" you will be surprised at how you ever lived otherwise.

4) Life doesn't stop for you no matter where in the world you are.