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.

Busy, busy, busy!

     Every Monday when I arrive at work, I automatically ask myself why I haven't done more work over the weekend. Then I realize that I'm not required to do work on the weekends and I really ought to stop being such a work-a-holic. So this past weekend I took it easy in hopes of taking better care of my mental health. Vanessa had a surgical department meeting on Friday in Kigali and so Julie and I tagged along. Upon our early arrival to the "big city" Julie and I ran an errand or two before settling into a cushy couch at the Serena Hotel (basically the nicest hotel in Kigali at $400+/night) and did work until Vanessa's meeting was over.
     Kigali is a pretty bustling city. It has a population of 1 million and didn't become the capital of the country until independence in 1962. Initially with independence, Astrida (aka Butare, my town) was the leading contender to be the capital of Rwanda. As I've previously mentioned, Butare was the intellectual capital of the country and as I've learned since then, it was the colonial seat of power prior to independence. Kigali was chosen over Butare to become the new capital due to its more central location. Let me me also explain the naming of towns because I can't remember if I have or not.
     As we all know, there was a war and genocide here in Rwanda just over 20 years ago. The worse part of the genocide occurred in April 1994. Kigali was initially the center of the genocide before it eventually spread to the souther province and Butare. After the 100 day war, as locals will sometimes refer to it, the country went through a type of purging process. Wanting to focus on the future and not the past, just about every city and town in Rwanda was re-named. Butare is the name post-genocide of where I live. Astrida was the pre-genocide name. Kigali stayed the same. I'm not sure why, but so it goes. Many of you reading this I am sure have seen the movie, Hotel Rwanda, which focused on Kigali and the Hotel Des Mille Collines. Speaking of which, Julie and Vanessa decided to stay there for the weekend. Rwanda is known as the Land of a Thousand Hills. Kigali, is certainly one of the most hilly areas. The Hotel Des Mille Collines is situated on top of a hill with a beautiful view of the city.
     Friday afternoon the three of us ran errands got a fabulous lunch and went our separate ways to relax for a bit before gathering for dinner and drinks and dancing. I stayed with Jessie and her roommate Dana, which was quite fun. Jessie and I of course ended up working and brainstorming and obsessively editing these forms we've been collaborating on until 7 pm and then I forced her computer closed and we headed off to meet the Kigali crew for a cocktail at Heaven. Heaven is the Kigali, go to Friday night happy hour bar, which caters to wazungu (white people, muzungu = white person). After a cocktail (or two) we were ready to hit the town. We went dancing. It was so much fun. Francis, is our neurosurgeon here in Kigali. He is originally from Cameroon and is a big, suave man. We walked into the club at Hotel Des Mille Collines and the next thing we knew we were in a private room just off the dance floor and it was a full blown dance party. Who would have guessed that Francis is secretly twinkle toes too. He spun us all around the dance floor as a salsa king and for once in my life, I let a man lead. We danced for hours and had so much fun. It was just fabulous to get dressed up, go out, probably spend a little too much money (though nothing compared to fancy drinks in DC or San Francisco), and have a blast. It was much needed all around for the Butare Girls. We all work way too much, partially because there isn't much else to do in our town, but also because there has been a precedent of previous HRH staff members. We don't mind it, but we need to let our hair down once in a while.

Dance Party

Francis took every lady for a spin

Francis & Becky
(Becky taught my sister in nursing school)

Twinkle Toes & Me

We stayed up WAAAAAAY past our normal bedtime!

     Saturday morning was a little slow for all of us. But I eventually made it back over to the hotel to meet Julie, Vanessa, Jen and Ashley for breakfast. Jen and Ashley are our UT colleagues. Jen has been here since January and is located far South East of Kigali near the Tanzania border at a district hospital and does pediatrics. Ashley, is new like Julie and I and is located at the private hospital, King Faisal in Kigali doing Internal Medicine. Jen is preparing to go home shortly, which is so sad for us! She has been so incredibly helpful before we arrived in helping us pack, giving fabulous advice, and encouragement. I am really going to miss her. But also completely understand that she is ready to get on a plane home.

UT Nursing Faculty
Julie, Jen, Ashley, Me

I had to be taught how to "Hook 'Em" being the
only non-Texas resident in this photo

The rest of Saturday turned into a pool day. I fully intended on working by the pool, but to my great disappointment, there were no outlets. And my ridiculously old computer has a battery life of maybe 1 hour. I had to settle for relaxing, napping, have a nice cool drink, swimming, and playing cards instead. Life is rough sometimes. The weather was absolutely beautiful and the rains didn't roll in until late afternoon. Saturday night I took it easy, but my other 2/3s went out dancing again until almost 3 AM. They successfully napped in the afternoon, which I did not. But it is a little pathetic my lack of motivation when I am the youngest of the group.

Poolside at "Hotel Rwanda"

     Sunday was errands and driving back home and nothing very exciting. It was just so very good to get away from work. Monday per usual was crazy busy. I feel as though I am juggling about 17 projects right now and have nothing accomplished. Plus, now I feel as though there is a major time crunch. Steph is leaving us at the end of January as I mentioned before, so now we are trying to finish two pediatric projects I've been working on with her in the next 2-3 weeks. The first is a pediatric reference manual. My nurses take care of ICU pediatric patients all the time, but have never had formal education in pediatrics, so Steph and Veronica are going to give 2 weeks of lectures before winter holiday and we are going to (hopefully) have the manual done by then. What started as a little project has turned into a 30+ page (in English, still need to translate it into French), 2 MB project. We are excited to finish it and get the book bound.

Working with the A0 students
Julie playing patient

     In addition to the pediatric projects we have nursing students of two different levels so we are doing two different classes/activities with them during the week, I am still lecturing my staff, redesigning the emergency trolleys for the entire hospital, helping my twin and in-charge write their report on last months visits to the other ICUs, all HRH nurses need to teach 120 staff members CPR and certify them prior to our external survey next month... the list goes on and on. The other day I worked for 15 hours until my daily internet allowance was all used up! Last night however I decided to chill and watch a movie. Life is busy, which is good. I like being busy. I work better under pressure and it keeps my mind off of other things that may not be going the way I had hoped.
     Finally, as we approach Thanksgiving back home in the States, I really encourage you to support a project that some German medical students started in August when they were working here. They are feeding patient's because as we all know, good nutrition leads to better healing. It is a great project, sustainable and the matron of surgical nursing is trying to expand the project hospital wide. Please look at their website and consider a donation. A donation of $10 will feed 7 patients a substantial meal. One meal = ~$1.45. If you have questions or want more information please contact Oswald Benimana, Matron of Surgery Department/CHUB at:

benoswaldino05@yahoo.fr
https://www.betterplace.org/en/projects/21664-eat-to-survive-your-disease

Thanks so much in considering supporting this project!
     My next post will maybe be from Italy! I am really looking forward to seeing old friends. Julie has forbidden me to take my computer with me tonight when I leave, which will be much appreciated. I feel a little guilty ditching my nursing colleagues to teach Monday, but I need the break.

Lessons Learned:
1) Multitasking is a well learned skill
2) A night or weekend off never hurt anybody
3) Wazungu make a very good, 7200 miles away from home support system. I am so thankful for all my colleagues here.

Delicious Kigali Food!

Life is Good

     So I realize that the majority of my posts are full of sad, depressing, and frustrating stories. So this one isn't going to be about any of that, because to be honest, the last five days have been fantastic!

     Steph and I came to work Wednesday and discovered that our Rwandan colleagues had finished all 105 students the day before as we suffered from slight GI distress. It was nice to arrive at work and realize that we could go back to the million things we had planned for our respective units. One of these is a joint effort in educating my nurses more about pediatrics. We currently do not have a pediatric ICU here in Butare so my unit gets all the little patients. At one point, I had no adult patients and all pediatric patients. Definitely not my area of expertise. Fortunately, it is Steph's.

     Together we are developing a pediatric reference manual for my staff. We are also hoping that Steph and our other pediatric nurse, Veronica, will be able to give some lectures. Our final project is developing a Broselow tape for the ICU. I had never heard of a Broselow tape until this week. Essentially it's a massive measuring tape that can only be used on pediatric patients. You measure the length of the patient and this tape, gives you a weight for the patient and then dosing for emergency medications. All pediatric medications are weight based versus in adults where only some are. Seeing how we don't readily have scales here, the physicians are often guesstimating weights. From what I've seen, my ICU doctors are pretty good at this, but the tape is easy to use and may prove to be an interesting study. Steph wants to compare what the doctors guesstimate, what the tape says the patients weight is, and what the patient's actual weight is.

   

Arts and crafts time with Steph!

It's been a lot of fun collaborating with Steph. Sometimes here we all get so involved in our work and our units that you don't realize how alone you are. Having projects together is just so nice and refreshing. 

     Also this past week, my twin, Emmanuel presented his first PowerPoint presentation to the staff. He presented the clinical audit data from the month of October. It went really well! The staff was very engaged and asking lots of questions. Partially because they were upset they didn't meet all the goals we had set, but also because they could just ask Emmanuel very easily in Kinyarwanda and I was there to clarify if need be. 

Emmanuel and staff

The staff met one of our three goals for October, but ironically, they met the goal that I thought was going to be the hardest. We will continue to work at the goals we didn't meet and see how we do. I think Emmanuel and I were able to explain and clarify questions the staff had, so fingers crossed, we will see more improvement this month. 

     But despite not meeting all the goals, I am rewarding the staff with treats this week. Today I made 7 loaves of banana bread. We saved one for us, but the idea is to bring a loaf for each shift this week, which means I have four more to make. 

     I love to cook and over the past few years since I finished grad school I've really been able to take the time to cook. Julie and Vanessa informed me that they are sorely disappointed that I haven't cooked some good brunch recently... Particularly the bacon and Nutella stuffed French toast. But last night I made tomato soup from scratch, which I had never done. 

     Now anyone who knows me, knows that I am quite the sucker for tomato soup. It's absolutely one of my favorites. I ate dinner at Stacey & Jeff's earlier in the week and absolutely loved the soup Stacey had made so she sent me the recipe. I experimented a little with it because it's hard to find good cream here, so I made it with fermented milk. And it worked! It turned out to be this creamy tomato soup that was absolutely delicious. 

And of course, I made grilled cheese to go with it. 

     I've learned to stop doing so much work on the weekends and to actually enjoy myself. Prior to cooking I spent some time in the garden with our guard, Vénuste picking a ton of green beans that he planted. I washed them off and made nice little packet of beans and avocados from the garden for both Vénuste and Charles (our other guard) to take home. I had music blaring, laundry going, the kitchen was a mess and I cooked up a storm. It was such a good day yesterday. Today too! I worked out, baked, and read some of my latest novel. 

     I got a mini lecture from Becky, a mental health nurse (who ironically taught my sister, Nora at Montana State) the other week about taking better care of myself. So I've also decided to take a weekend away from Rwanda and Africa for that matter and go to Italy for 72 hours. I'm going in two weeks time to visit my friend Tim who is stationed there with the US Navy. Tim and I met two years ago on a ferry from Croatia to Italy and he will be stationed back in Newport come the new year. I was talking with him and he mentioned how it sounded as though I'd been having a rough month. I certainly had been. So he invited me to visit and so I'm going to! I'm already dreaming of pizza in Naples. Can't wait. Since Naples isn't my favorite place in Italy we might drive down the Amalfi Coast, but in all honesty, I don't care. I just need to recharge my batteries!

     But overall, things are going well here. I'm enjoying it as frustrating as it can be at times and am really glad I've had this opportunity. I am one of the luckiest women in the world with the support I am continually getting from my friends and family and my crew here. Thank you. 

Lesson Learned: Working all the time because there isn't much else to do in town isn't always the best idea. Mental health care is uber important. 

National Nursing Examinations

     I started writing this five days ago, but figured maybe I should finish it now that the week is over. I walked into a surprise last Monday morning... apparently, I had been selected to be an examiner for the national nursing examinations!!! I had no idea what this entailed, I think my directions had gotten lost in my Junk Mail so I was completely unprepared. I quickly figured out though that I would have to put all my work in the ICU on hold for two weeks.
     Here in Rwanda the nursing candidates have both a written exam they must take and a practical skills exam. I have been grading the candidates for the past week on their practical skills. It's been quite the eye opening experience. For starters, I had some serious doubts about my ability to grade candidates  when I don't understand Kinyarwanda and their French is not what I'm use to. But I quickly got use to it. There were four Rwandans and me and another HRH nurse, Steph. Steph works in pediatrics and ironically is my Baltimore pal. She grew up in Fallston and worked at University of Maryland Medical System. She's been a life saver here and I really hope that she extends her contract. She was a mid year hire for year 2 so as of right now she is headed back stateside in February. She is the youngest of us all but so full of wisdom it astounds me at times.
     Anyway... she and I were the lucky chosen ones. The first day we were able to shadow a pair of Rwandans so that we understood the process and what was expected of us. Here is how the nurses practical goes... they are given a patient and are expected to interact with the staff to find the patient's file (chart). After a review of the file they are to suppose to assess the patient and come up with the priority of care and procedure they are to perform. The procedures ranged from medication administration, changing urinary catheters, wound dressing changes, blood draws, placing IVs, and blood administration. After they performed their procedure we were able to ask questions and have them verbally give us a nursing care plan, complete with nursing diagnoses, which they really love here.
     The first few days were tiring, but went well. I was paired with a Rwandan, Martine who works at King Faisal hospital, the only accredited hospital in the country. It's also private. Anyway, Martine was hardcore. She threatened to finish a student's examination because he started to talk back and argue with her over technique. She and I were on the same page in almost every aspect and after three days of testing I had failed 60% of the students I'd seen. It was rough. The most difficult for me was the fact that the vast majority of the student's could not speak or read English. You might be saying, "But Alex/Lexie/Toast (whatever it is you call me) you're in their country, they shouldn't be expected to speak your language!" And I agree with you, although my Kinyarwandan is not really improving despite my attempts at learning. However, the issue is that the Rwandan government has made English the official language of the education system. But from what I've been told, the students are still able to take their licensing exam in French. Not that big of a deal, but the physicians and medical students almost exclusively write orders in English. It just blows my mind that the nurses aren't taught enough English to read the files. In fact, in one of my last cases because the student couldn't read, and didn't ask for adequate translation she wanted to give a medication that wasn't even ordered by the team and she didn't understand why she couldn't just do that.
     I quickly learned that the way that some procedures are just so different than how we do things in the US. For example, my medical friends would be shocked that the students are taught to use saline when preparing to insert a foley catheter (in ICU and pediatrics they use iodine so we don't know why it's different in the wards) and clean from mid thigh, up towards the female patient's va-jay-jay and then down. So different. And I already knew this, but day, after day, watching the same thing over and over again was very draining. I was getting to work at 6:15ish with Vanessa so that I could do two hours of work before starting the examinations about 8:30 am or so. By 1:30 we would just be finishing the third student if we were lucky. Steph and I were at work until at least 7 pm, if not later every night last week (I satyed until 9:15 pm doing work in the ICU one night). It was just exhausting. The language and procedural steps were just the tip of the iceberg too. Questioning their knowledge base at times was painful.
"What classification of medication is amoxicillin?" "A steroid."
"Why are you giving this patient dexamethasone?" "For pain relief."
"What is this patient's medical diagnosis?" "Je ne sais pas."
"If this patient has a sick liver, why are you giving the patient vitamin K?" "I don't know." "Ok, tell me some functions of the liver." "It secretes insulin."
     When a candidate was able to connect the dots I was thrilled and incredibly proud of them. The odd thing is that despite the horrendously wrong answers, some of these students still passed. It was so frustrating to me. The current weight system for grading the students is such that theory and knowledge were less than 20% of their grade combined. 18% of their grade was their behavior, 18% performing their procedure, 6% physical assessment and so on. I'm fairly certain of the 25-30 students I graded over the 7 days, only 2-3 of them used their stethoscopes to listen to the patient's lungs. I was lucky if the candidates did anything more than vital signs. I hope that the National Nursing Council starts to revise the grading system based on the new curriculum that is now being taught in the universities.
     Then there were the staff nurses who just wanted to help the students. I'm pretty sure that I've mentioned that the idea of team nursing is very very strong here, to the point that making nursing assignments is a very novel idea. Some of the staff nurses told the students what procedure they were suppose to be doing. I sent a very frustrated SMS to Steph as it crept on to 6 pm one day:

Me: Sigh. The nurse just handed the student the blood and tubing to be transfused before the student even looked at the chart.
Steph: Oh man. I'm sorry. They know better.
(pause for ten minutes)
Me: It's all good. The student tried to give the blood to the wrong patient anyway.
Steph: At least it was O negative.
Me: Valid point.
(pause for another five minutes)
Steph: I just realized that I've totally forgotten alcohol swabs exist.
Me: Yep. When you watch nursing students wipe tops of vials with sterile gauze for four straight days you tend to forget these things.

We had seven days of the frustration building. But now that it's over, I'm glad I got to do it. It actually has helped me communicate with my staff better in an odd way. Just spending all that time with Rwandan colleagues and the nursing candidates taught me concepts that are important to them and where they come from. It's so drastically different than my nursing education that it's important to have reminders of the differences in my search for common ground.
     Halloween was last weekend and it also happened to be Steph's 26th birthday. I'm impressed she and I were able to have so much fun last Friday night we were so exhausted from the exams. My roommates and I hosted the party and it was great fun. There were snacks, cake, music, costumes, and of course alcohol. We had a good time just hanging out at the house and then someone brought up dancing... so most of us went out at 11 pm to go dancing. And boy did we dance. The Rwandan university students loved us. I made the mistake of asking one of them how old he was... 18. I almost died. But it was such a great time and it was much needed. I didn't get in bed until just after 3 am (and the club we were at has DJs until 6 am mind you) and really slept in last Saturday. Below are some photos. More later!

Lesson Learned:
1) The system here isn't going to live up to my expectations or wants, but there is the hope that things will slowly improve over time.

Julie snapped a photo of me on Internal Medicine doing
examinations with one of the Rwandans.

Stacey & my little buddy Sam

Steph turns 26!

A moto driver (Steph) and her passenger (Tiffany)

Costumes!
Moto Driver, Genie, Fork in the Road, Space Cadet, Fisher Lady
(not pictured Vanessa's kimono)

Steph & I excited that the week was over