The Week from Hell WARNING: This May be the Most Depressing Post Ever

     This week has royally kicked my butt. It started off with a bang and just never stopped. It doesn't help matters that I've been extremely exhausted for no particular reason on top of it all. I apologize in advance for this depressing post, but it's therapeutic to share it. I don't blame you if you don't want to read it. I will completely understand. Nurses are usually built with thicker skin than most, but this week has resembled my time spent in Haiti and it just sucks, big time.
     Isaac is my senior (attending) on this week. Just as we were about to start rounds on Monday morning an Internal Medicine resident came into the ICU and asked for some help on an emergency. In the US if someone says there's an emergency, you drop everything and go. Here, there isn't the same sense of urgency. I'm not sure why. It may be that they are so resource poor that they often know there isn't much they can do. I don't know. The nurses, students, and physicians are so smart here. They all have more textbook knowledge than I could ever possibly imagine. But from what I've witnessed thus far, there is a disconnect between that knowledge and action. It's just a completely different culture.
     Anyway, when Isaac asked the resident what the situation was she launched into a very detailed history while we all just stood in the ICU. Finally, mainly because we didn't think from what we were told it was that urgent we all walked down to Internal Medicine together. Julie was hovered near the patient in question. We looked at each other and I knew before I even saw the patient that it was going to be helpless. Sure enough, when I turned and saw the patient she was already agonally breathing and unresponsive with blown pupils. Isaac looked at me and asked my opinion. My opinion was to turn down the oxygen and give a dose of morphine after talking to the family. Isaac was exasperated. He said that he was helpless to do anything in this situation and he was right. We were notified too late. I was baffled because we had 4 open beds in the ICU all weekend. After meeting with the family and explaining that while we understood they wanted to take her home (over 3 hours away) to consult traditional healers, she wouldn't survive the journey. They agreed to let her stay in the hospital and I believe she passed away Monday night or Tuesday morning.
     While in the wards Onyema, a short-term HRH Infectious Disease physician who has been coming here since year one of the program, asked if we could take a look at another patient. By the time we got there this patient was also agonally breathing. Isaac decided we could intubate and transfer this younger patient to the ICU. Her saturation when we checked was about 63% (for non-medical people your oxygen saturation should always be above 95% unless you're a smoker). Then came the task of trying to get oxygen. There was none. The first patient who was going to die had way too much oxygen on because they didn't feel comfortable turning it down or off and here was a young twenty-one year old that we could save and there was no oxygen. It was a disaster. I can't even describe it all. We got her to ICU eventually and two hours later she was dead. I spent all day on the unit with Isaac rounding with him. We work well together and he is always asking my opinion, which sometimes I have to laugh because he's the one who went to medical school, not I. But it is very nice to know how much I am appreciated and respected here by others.

Dr. Isaac teaching nursing students about central line placement.

     Tuesday wasn't too bad. I spent a good deal of time in meetings and working on some research and lectures because I hadn't done anything but clinical work the day before. And we admitted another child from surgery. This child (13 years old) for a reason I don't think anyone really knows was suffering from gangrene in all four of her limbs. You can imagine what the treatment for gangrenous limbs is. After a week, her parents consented to surgery. They amputated all four of her limbs. Both arms above her elbows, one leg below her knee, and one above the knee. There are no prosthetics here. And what's worse, the infection is still around, which essentially means that this girls limbs have all been cut off, there is no way she'll ever get out of bed ever again, and she is still going to eventually die. The good news is that my other patient is a very cute 5 year old boy who is improving from his 18-20% burns from a house fire. I didn't realize I would be learning so much about pediatrics when I came here. A few of us also taught the student nurses CPR in the afternoon, which was great fun.

Nursing students learning proper CPR technique.

They had a lot of fun learning.

     Wednesday was just as busy. I spent almost all day in the office working on research and lectures. Emmanuel worked that day and I could tell something was up; he just wasn't himself. Turns out that his 10 month son was having surgery. He is fine and the surgery was minor and went very well and the baby will go home today. But both of us were just tired and off our game. Not to mention that now my 5 bed unit was filled with four patients. My two children from above and two more surgical patients that were unstable. At the end of the day I decided to walk home just to clear my head and relax, which was very nice. Just before I left Emmanuel and I were chatting and I asked him how much surgery costs here. The wonderful thing about Rwanda is that they have health insurance for all that covers 90% of most care and the patient pays 10%. It's really rather remarkable, although it has its faults. For instance, it does not cover contrast for a CT scan at all. We have found this to be problematic, but overall, it's a decent system for a developing country. Emmanuel started to explain, using his son as an example how much some surgeries cost. I asked after he named a price if that was considered expensive to most here. He said yes. I felt terrible. This man is a father of three and works so incredibly hard on the unit, with the students, with fellow colleagues, and me. He comes in extra on his days off and is never compensated for his extra time. He makes roughly $340 USD/month. I handed him just under $30 in Rwandan francs, which will cover most of the surgical costs and told him he deserved it. He almost started to cry, which of course almost made me cry. I felt good but bad at the same time. I know how much he appreciates it, but it is so easy to give money. I feel as though that is something Americans like to do. Let's just throw money at the problem to solve it. And I'm not saying that's a bad thing, but it doesn't help with systems changes. It's a problem that a nurse might work extremely hard here and not be able to afford a surgery that his son needs at the very hospital at which he works. I have fairly advanced technology here, but run out of Morphine almost daily on my unit because donors like to give physical objects, not medication. It's terrible. I am sitting here in the back office and I can hear Violetta, my 13 year old amputee crying because she is in pain. But we have nothing better than paracetamol (Tylenol) to give her.
     This morning hasn't been much better. I walked in and our two unstable patients were even more so. We hadn't even finished nursing report before one was essentially coding and we had a pulse but could not get a blood pressure on the other. The nurses stopped report and just got to work. It reminded me of home. Eventually there was CPR being done on both patients at the same time. The younger of the two was in a shockable rhythm, but by the time we plugged (yes, plugged) the defibrillator (with paddles not pads) in she was in asystole and there was nothing left to be done. They both died within 20 minutes of each other in the first three hours of work. 50% of the ICUs patients are dead so far today. And rumor has it we have another surgical case that might be unstable coming soon.
     I am now hiding in the back office writing this and listening to Christmas carols. It's a habit I formed in nursing school. My hardest semesters were always my fall semesters and my roommates would often find me listening to carols because in my mind if it was Christmas, that meant that classes were over and I was on vacation. Not to mention that Christmas carols are generally peppy and happy. This Christmas will be my first Christmas ever not at home. I will however be going to Ireland to visit my old patient from my DC days and his wife. I am excited for that. And I'm also excited to get away this weekend to Nyungwe National Park with Vanessa and Julie. It will be a much needed break after this week.
     I don't think I've ever prayed as much as I find myself doing here. I am grateful that Christian, my little burn victim is doing well and I hope that he continues to do so. I think the highlight of my week was the box cake I made for Onyema and Peter's last day here at CHUB. They will be missed. I'd post their goodbye speech, but it's a little too big. Time for more meetings. Sorry this post is so utterly depressing. I just really needed to vent.

Lessons Learned:
1) I am so incredibly lucky.
2) Even more so in the US, sometimes there is just nothing else to be done.
3) Living some place else can really open your eyes and make you realize what is really important in your life.

Day to Day Life

     I just got home from Kinyarwanda class with Julie and Vanessa not long ago. Dianne has arranged for Fidele, a 4th year medical student (medical school is 6 years here) to teach for roughly an hour twice a week. I was dreading going to class just because I was a little tired after work, but it ended up being great fun.
     For starters, Dianne is an amazing baker. She had 4 different types of cookies and I was all too happy to try them all. Julie is a fabulous teacher of science/nursing/medicine... but language skills don't come naturally to her. While we've been teasing her for the past month, class is an absolute hoot listening her. We all laughed at each other, but did fairly well. Vanessa's background in Swahili (thanks to her Tanzanian family) gives her a massive advantage. The other participants included Veronica, the pediatric/PICU nurse educator, Stacy and Jeff (and their little tot Sam)-- who are the newest members of the Butare clan having just arrived last week from San Francisco. Jeff is an Internal Medicine physician (and Blue Devil) who has done lots of work in Africa and Stacy is enjoying being a stay-at-home mom with Sam who is 5 months old. Finally of course we have Dianne and DeVon, whom I think I've mentioned previously, but they are both retired from Salt Lake City and DeVon is an Infectious Disease Specialist.
     The biggest surprise learned from class tonight is that everyone says "Rwanda" incorrectly. In Kinyarwanda the 'rw' gives this g-qu sound (it's rather difficult to even explain phonetically this language) resulting in the real pronunciation sounding more so like "Ju-quandra." Mind blown. Fidele is very patient and very kind and is even teaching us cultural aspects that will help us in our transition here. Will report back on my successes and failures as class continues.
     Life here is very simple. I usually wake up just before sunrise at 5:45 am. I should actually re-phrase this. I get out of bed at about 5:45 am. I am actually woken up by roosters at 4:30 am. Oddly enough, my parent's rooster at home starts to crow at 4:30 am too. It must be a universal truth that all roosters decide 4:30 is the perfect time to wake up. I did wonder this morning if the roosters happened to become dinner because I did not hear them at all this morning. We usually head for work just before 7 am (I have to have at least one cup of tea before leaving) and arrive ten minutes later. It is always fun driving to work for a couple reasons... the main street of Butare is nuts. No one uses the sidewalk so there are pedestrians and school children everywhere. The pedestrians are sharing one lane of the road with the bicyclists who have massive sacks of fruits, veggies, and goods to sell at the market strapped down tight. Then you have a lane for cars, motos weaving in and out, and oncoming traffic that in attempting to avoid pedestrians, ends up in your lane headed straight for you. Thank goodness I don't drive. I honestly don't know how Vanessa stays so calm, but you get pretty use to it. I am amazed there aren't more accidents though. The other fun we have in the morning is attempting to guess which route we should take to get to the hospital. They are paving all of downtown and so every day a new section is blocked to thru traffic and of course it changes from morning to evening, day to day. Keeps us on our toes if the caffeine hasn't kicked in yet for sure.
     Once at work my days vary. Sometimes I'm in meetings all day long of various topics, either with Rwandan staff or USI faculty, sometimes I'm in the office working on research and planning, other times I'm on the unit observing and listening to rounds. Today several of us taught the nursing students for two hours basic concepts. I'm still trying to figure out my groove. It's been a little difficult because Emmanuel was on nightshift all last week, but I'm hoping that he and I will get some serious planning done this week. I am enjoying it despite rough and tough situations daily.
     I've included some photos below of a few things, nothing too exciting, but I know that people like the photos. Be grateful as it just took over 30 minutes to upload these... slow internet this evening for no apparent reason. Oh Africa!

Lessons Learned:
1) Kinyarwanda is the hardest language I will ever attempt to learn
2) I should have packed my high school French textbooks.

Julie's newly planted seeds protected by banana leaves

Our massive amounts of lettuce in the garden

The Catholic Cathedral in Butare

Rwanda countryside

Patient Mortality in the ICU is 65%

     This was my first full-time week in the ICU. Some days were better than others, but the overall mortality was 40% in the unit. I've been told that the annual mortality rate in the ICU is about 65%. They are so resource poor that often times there is nothing to be done with our patients. Thursday was by far the hardest day. My ICU senior (attending) was called into an emergency. Out of no where two of the five patient's blood pressures started to drop. One was suppose to be taken to the OR but had gotten bumped for a different emergency. She was desaturating and even on 100% FiO2 we could barely get her sat above 88-90%. I was very proud of the nurse, Céline. She was attempting to troubleshoot and was suctioning, checking for a cuff leak, everything that I would hope would be done. I was very proud. However, post-surgery when I went to check on her I took a few minutes to look at her vital signs and heart rhythm and knew that she was going to be dead within two hours. I walked out and went to the office to do work. An hour and a half later Vanessa, my general surgeon roommate, who had operated on the patient told me she had died. The other unstable patient died on night shift. There was nothing to do be done. Both of them were maternal cases. One had given birth I believe less than 10 days before.
     The nice thing about this week is that Vanessa has been in the OR (or theater as they call it) and therefore we share a number of the patient's. It's nice to be able to discuss the surgical patient's with her because I always understand the patient story. It's been hard to follow nurse report at times because it's in a combination of Kinyarwandan, French, and English. Not to mention that report is extremely different here. One of the goals that my Head of Department (Medical Director) has given me is discussing accountability with the nursing staff and helping take ownership and responsibility for what they do. Not the easiest task in the world, but fingers crossed. It still amazes me how different nursing is around the world.
     The other good thing about this week is that I now have a multitude of projects to get started on it. Other than that, not much has happened this week. We are finally feeling settled in our house, which is beautiful and made so much better by the hiring of a housekeeper. Our house keeper is also Vanessa. What are the odds. She was trained by the nuns in culinary and is very hard working. She is a fabulous cook and everyday I come home to find my bedspread fluffed and arranged as if I were in a hotel. It's marvelous. I am going to be so incredibly spoiled this year. She cleans, cooks, does laundry, and is my new favorite person. Our guards are also adorable and will do just about anything we ask (or don't ask... they clean our borrowed car every morning at 6:30 am so it's ready to go by 7 am). This morning Julie planted some seeds she brought with her in a section of our garden that they had tilled for her. They are so great and make us feel very secure, even in our very safe little town.
     Julie and I are going to go for a little hike through the local arboretum this afternoon as Vanessa is on her way back to Kigali for a surgeon's meeting tonight. We need to burn some calories since I fixed Nutella and bacon stuffed french toast with fried sweet bananas and fresh passion fruit juice for breakfast this morning. It was lovely. We ate it out on our veranda. While chowing down, we noticed a rather large flock of birds circling and wondered what they were after. It was then that Vanessa pointed out that they were bats. Sure enough she was right. I've never seen bats in broad daylight before. And they eventually roosted in a tree across the street. Not sure why they were out but man do they make quite the noise! Screeching to beat the band! Now we know that it isn't birds making that sound though. We just assumed it was, now we know better.
     Off to enjoy this beautiful day! Photos posted to Facebook and my iCloud Stream for those that have iPhones. More to come! Lots of love.

Lessons Learned:
1) There are going to be a lot of days where there won't be anything anyone can do for the patients.
2) I'm going to learn a lot about OB and Pediatrics this year... my unit is the only one with functional oxygen, therefore we get all ICU patients. (Any stateside help would be nice)

Emmanuel

Emmanuel assessing the patient

     Yesterday was my second full day on the unit. Thank goodness Emmanuel was there. Wednesday was my first "full-time" day at the hospital and I went into panic mode a little. I was suppose to meet with Nasson, my director of nursing, but then he got pulled into an all day meeting. The next thing I knew I was left alone in the ICU, with staff who had never met me, some who don't speak English, and I floundered quite a bit. For the first few weeks we are suppose to observe in order to really understand why things are they way they are and to get to know the staff and for them to know me. The last thing in the world I want to do is come waltzing in and step on toes. But, yesterday was rough.

     Alarms constantly going off, the central monitor was not on, no running water in the building, unstable vital signs, and nurses and students sitting during all of this. It is very different and very disturbing coming from the US. I was rescued by Steph, the neonatal/pediatric nurse from Maryland who gave me a complete tour of the hospital and also gave me the ins and outs of everything. She is so fantastic. I am sad that she is going home for a month! I'll be very happy for her safe return here to Butare with goodies from home though (hopefully Berger cookies are included in this)!

      Emmanuel, switched his schedule so that he could be here with me. He is absolutely amazing. He wants to improve not just his nursing skills, but the unit, and really the healthcare system here in Rwanda. The first thing after nursing report is to give bed baths... not assess your patients, but to clean them. Similar to Haiti, nurses are not taught to critically think here and that is largely what we are trying to change. Culturally, stethoscopes are for doctors only. My predecessor, Jessie, worked very hard to change this and even gifted the unit six stethoscopes, one for each ICU bed for the nurses to use. However, it's still challenging to change the unit culture. Emmanuel gave probably the most thorough bed bath and oral care that I have ever witnessed and then informed me it was time to assess. It was almost 10 am at this point. I can imagine my good friend Karen (and fellow MPH/ICU nurse) having a slight heart attack reading this... if her patients weren't done being assessed by 8:15 am something was wrong. But this is Africa and things move slower here and are completely different. So Emmanuel told me that he wanted to make sure the student nurses could do a proper head to toe assessment. We had about six or seven nursing students who are part of te E-learning system. Essentially, these are US equivalent diploma or associate degree nurses who are "upgrading" to a bachelors degree. Emmanuel rounded up four or five of them and started to teach away. He asked for my input on occasion and all of a sudden I found myself demonstrating the differences between decerebrate and decorticate posturing and the students were peppering me with questions. What English they didn't understand Emmanuel was able to explain in Kinyarwanda. We make a good team. It was slow going, but went well and I'm excited to see how the students do next week.

     Thank God for Emmanuel. I am so lucky to be paired with him.

Emmanuel helping the students.



Lesson Learned: It's ok to have a bad day

Orientation Week in Kigali

     I realize that it's been over a week since my last post but it has been a crazy week of travel, socializing, and activities. Last weekend was slow and calm, nothing to exciting. We explored the town of Butare and walked through the neighborhood where we will live to get our bearings. When I say "we" I mean my two roommates, Julie and Vanessa, and I. 

     Julie is originally from Missouri, but has spent about ten years living in Texas and is my University of Texas colleague. She is older, a complete night owl, has a terribly hilarious singing voice, and is game for just about anything. She has also coined our two favorite roommate sayings already... We all "enjoy zesty adult beverages" often and find ourselves saying the very southern "bless her heart, poor dumb thing" when teasing each other. Julie has done a little bit of everything in nursing though her love is oncology.
     Vanessa is actually Canadian (I'm still trying to figure this out as her mother is Tanzanian and her father is British). She grew up close to Vancouver and just finished her trauma surgery fellowship at Harborview Hospital in Seattle. She has already adopted the role of housemother, which Julie and I were happy to allow. She has spearheaded the house search and is truly a lovely person. Plus, she speaks some Swahili, which is a little bit useful here. Essentially, she keeps Julie and I in line and can drive a manual, which will come in handy.

Julie, Vanessa & I at the start of orientation

     Tuesday we all piled into a car and made the drive back to Kigali for orientation. Julie and I were able to attend a nursing meeting Tuesday afternoon, which was lovely. We met many of the USI faculty that are all nurses and were able to share thoughts and a little bit about ourselves. Turns out I am the only Maryland alumna, but that the majority of the nursing faculty is employed by Maryland. Which means that not all but some are also from my home state! Steph is a neonatal/pediatric clinical mentor who grew up in Bel Air and attended Fallston High School. She will also be in Butare and is a second year faculty. I really like her. Several other nurses lived in Laurel and one even worked at Washington. Hospital Center for a few years during my tenure at George Washington Hospital. Another faculty member, Becky White was a professor at Montana State. I must ask my oldest sister if she had Becky for psych class back in the day. 
Candid of the Butare Girls

     Orientation was busy busy. The first day actually provided a lot of information about Rwanda and their history. They are an incredible nation and have come so far in just 20 years, but still have a long way to go. Their goal by 2020 is to be a middle income country. There are about 12 million Rwandans living in one of the smallest African nations, making it the most densely populated country in Africa. Over 50% of the population lives below the world poverty line of $1.50/day. GDP per capita is approximately $1,500. To put in perspective, when I was in Haiti that the majority lived on less than $4/day and they are the poorest nation in the Western Hemisphere.

     The median age is 18 years and only 2.5% of the population is over the age of 65. To put this in perspective, my twin, Emmanuel is 34 years old. He has most likely already lived half his life. The genocide has skewed the population age, although children were far from safe during that time, but more on that later. The WHO recommends that there are 2.3 healthcare workers for every 1,000 people. Currently, Rwanda is at 0.8/1,000 with 6 physicians for every 100,000 and a total of 9,937 nurses/midwives/mental health workers for the entire country. Twenty years ago, there was no academic staff and no one could even tell you how many healthcare workers were left in the country, in fact they basically tell you everyone was killed during the genocide. It's slow progress, but it's progress.

     Friday was an incredible day. It started with a surprise guest at orientation (for those of you who follow me on Facebook it won't be a surprise). We were all not looking forward to yet another lecture (I mean our tea and coffee break was suppose to occur) when they announced that Paul Farmer was there. I felt like a groupie. I was in complete awe. He was at the University Hospital in Haiti one day I was working but I never saw him. He spoke for about 30 minutes and answered questions for another 40 or so. It was so fantastic. I was able to voice memo all but the first two minutes of the talk. I really enjoyed it. And after the fact I went right up to him, was first in line to talk to him, shook his hand, introduced myself, and told him how fabulous the Partners in Health (PIH) physicians were in Haiti and I thanked him for a comment or two that really struck me. If I can figure out how to post a voice recording to this blog I will. Or if I can't and you would really like to hear it, let me know and I can email it to you.
Paul Farmer
     Friday afternoon we were given the opportunity to go to the Kigali Genocide Memorial. It was incredibly moving. The Rwandans will tell you, "We want you to know our history. It is ours and we own it." It has actually surprised me at how frequently the Genocide comes up in everyday conversation. We were told before our departure that it is not discussed. However, the Rwandans will discuss it minimally. I have not been told anyone's personal experience, but they use the Genocide as a historical marker and often speak of before and after. They will explain why some of their family still live in Uganda, all related to the Genocide. I guess it's pretty impossible to escape the horror of that time. One person did tell me that he didn't feel as though there had been any improvement in the first 5 years after the genocide, that the streets of Kigali were littered with bodies and that it took a very long time to exhume the mass graves and give everyone proper burials.

The entrance of the memorial museum. No photos inside.

According to the museum, they don't believe that they ever found all of the graves. At the end of the museum they did discuss the trials of those involved and it dawned on me that the prisoners I see on the sides of the road working very well may be serving sentences from the Genocide. Here in Rwanda if you are guilty until proven innocent. Those who have been accused wear bright orange scrubs and those convicted wear pink. This is why I left my prized pink Shock Trauma scrubs at home.

Off the beaten path

     Saturday was Umuganda. Umuganda occurs on the last Saturday of every month. It is a nationwide community service day. Everything shuts down for the morning; we even got stopped by the police on the way to the community health center where we essentially were a human plough and cleared two small fields. It was fun to drive off the beaten path and wave to the children alongside the dirt road. They were funny and so excited to shout some English words and smile and wave. Finally, when we got back to the hotel/conference center we were greeted with hamburgers and chips (fries) and a lovely traditional dance performance. I will try and post some video of it later if I can. My roommate Julie needs to send it to me!

Universal colonial game

All the locals who came to Umuganda

     Because an unexpected nursing meeting came up, we all stayed in Kigali through yesterday. It gave us more time to socialize with the staff and most importantly, do some shopping. We discovered a German Butchery and we stocked up on some good meats to bring back with us to Butare. The variety of food and supplies you can get in Kigali is pretty astounding when compared to other parts of the country. There is very little that you can't get. Apparently General Mills does not import to Rwanda... so I can't get my Cheerios, but Kellogs does so we actually picked up some Rice Krispies today. Have not tried them, but will report if they taste the same.
     We are officially moved into our new home as of last night, which means I finally have an address (see below). But there is still a lot of organization to be done. I will post photos once it doesn't look as though a tornado went through it. It felt so good to shower with my own shampoo and conditioner last night. The hot water heater isn't working on my side of the house, so I can't use my shower, but hopefully that will get fixed quickly. Anyhooooo I am blogged out. I will try to be better about blogging more frequently to keep the entries shorter!

Lessons Learned:
     1) I really need to learn how to drive a manual transmission.
     2) No matter how small, progress is progress.
     3) Dream big. You'll never know what you might accomplish in the process.

Address:
Name
Southern Province
Huye District
P.O. Box 137 Huye
Butare, Rwanda
Tel: 0781521965 (if telephone number is placed on letter some place they will call me if it gets lost)

Umuganda Before

Umuganda After