Modern Day Colonialism

    I feel as though the majority of Africa has a history of colonization, essentially a time where Europe believed they ruled all and knew best. The United States is a result of colonization as most of you reading this are well aware (and of course now believe we know best). 

     Anyway, my point being that while technically colonization has long since ended, I seriously wonder if it truly has. I am by no means exempt from what I'm about to discuss so please don't take this as me pointing fingers at others because I think like every ex-pat, I've made mistakes and some of them I'm not even aware. I often find ex-pats, including myself, discussing work and referencing things such as, "my nurses" and "my staff." Where do I get off talking about my colleagues in this manner? I don't own them and yet the very simple quote, "There's an awful lot to own in Africa," rings true. We, as ex-pats and outsiders, sometimes do speak in ways that imply ownership without even realizing it and one of the hardest things to remember in our roles here is that we are guests, we will eventually leave, and we own absolutely nothing. There has been some disagreement among the USI faculty about the ownership of our materials. Who owns the lectures I've written? Me? My US Institution? The Rwandan Ministery of Health? The University of Rwanda? I have no idea, but chances are, it's not me. I'm low woman on the totem pole. 

     I'm not sure why people adopt this form of ownership in their speech. Do I feel entitled to it? Maybe it's just a way we speak in the US and now applying it to a different context and culture I realize how offensive it is. I have no idea really, but I do actively attempt to be more aware of my pattern of speech than I ever was before. 

     Today is our mid year meeting, which has been modified to be a monitoring and evaluation presentation that has been interesting. The first thing they presented was data from last year about the twinning model of the HRH program. The twinning model is rather unique to this program and has many successes and challenges and even failures just as you see in any program global or domestic. 

     The point of the twinning model is to provide skills transfer to ensure the sustainability of the knowledge we as USI Faculty are sharing. Capacity building is hard. Practices that I think are important are not necessarily the priorities of the Rwandans and if I don't see the point in some of the practices, they certainly don't see the point in almost all of mine. The results of the survey showed varying levels of satisfaction in the program, but the underlying message is that everyone feels as though we need more time with our twins. I was impressed that the USI Faculty and Rwandans both picked this as an issue. It's almost impossible to find 5 hours during my week with my twin because he has so many responsibilities. 

     The other interesting tidbit was that those USI Faculty who have the least international experience (<1 month) have the highest level of job satisfaction. I have my own theories on why this unexpected result is what it is. Maybe because those who have had more overseas experience perhaps are used to calling more of the shots. This program isn't about USI Faculty coming in and fixing everything to how we want it to be; it's about us helping the Rwandan's determine what they want to change and allowing them to take ownership of these changes. I believe I am here in a supporting role. My twin first said way back at the beginning of my time here, "What are your goals?" And my response was, "Nope! What are your goals? Because my goals are to support yours." Maybe newbies to work of this kind are more motivated and optimistic. Or perhaps the majority of experience abroad is in a less hierarchical  program that gives the control to the ex-pat. I'm not sure. But today has been interesting with all sorts of thoughts running through my head. 

Lessons Learned:

1) Words have different meanings and consequences in different cultures/contexts. 

2) I am far from perfect and should strive everyday to be the best version of myself... Always difficult with my Irish-Italian temper (thank you heritage).

Rough Mornings

       There have been a few rough mornings here at CHUB over the last few weeks. About three weeks ago, I walked into work hoping for an easy morning as Amy and I were on our way north to Musanze for our gorilla adventure in the afternoon. I must have jinxed myself because the morning was anything but easy. I had stayed up late (past midnight) finishing a review lecture on mechanical ventilation that the staff had asked me to give them. It wasn't until midnight that I realized the tedious lecture slides I was making, showing them specifically where to find each setting and measurement on all five of our different ventilators couldn't be completed because I didn't have two screen shots I needed. I resolved to get to work early and finish the lecture at 7 before giving it at 8 am.
     I dashed to ICU, snapped the photos I needed and headed back to the office to get to work. Nothing seemed out of place in the few minutes I was on the unit. I was able to complete the lecture and was back on the unit by 8 am. After setting up my trusty projector and computer I thought I'd check on the patient's while the nurses finished their morning tasks. I was immediately drawn to the incubator that was occupying Bed 2.

I have learned a lot about pediatrics in my time here, but still not enough to feel extremely confident. However, it didn't take me a minute to figure out the child was in distress. I asked the staff who was taking care of the baby. They hadn't decided yet. Glancing at the flowsheet there were no vitals beyond a heart rate that was way to fast and a temperature written down. The baby had pulled it's oxygen mask off and there was no saturation being picked up. His feet were cold. Again, I asked the staff who was the nurse assigned to the patient. After what seemed like hours of debate, which in reality was only a few seconds, one of the newest ICU nurses said he would take care of him. When he came over to the incubator I asked him, "Why am I concerned about this baby?" Fortunately, the nurse had been a good student and was able to rattle off some textbook answers about airway, breathing, and circulation that were pretty close to being accurate. I asked him to find our pediatric blood pressure cuff while I adjusted the oxygen mask and tried to get a saturation reading. No blood pressure cuff to be found. I finally called one of my pediatric colleagues and got a quick response of, "Can I call you back we're in morning report." The newest member of our team didn't know that if I'm calling you during morning report, it's not to chit chat. I explained that I really needed a BP cuff for a neonate and that I was extremely worried about the child. She promised that she would get back to me. I then texted my ICU Senior on that day, which was Claude. He came immediately to the bedside. The IV wasn't working so we started by trying to get a new one. With Claude handling the situation, I dashed off to pediatrics to get the precious BP cuff.
     Use to dealing with adults and in an ICU, I like my numbers. In fact, I learned very quickly in Haiti that I'm too reliant on them when I looked above the cot and discovered there was no monitor there. Natural reaction to an ICU nurse to look for more numbers and data to give us more information. I was told by my colleagues that in a neonate the blood pressure was really the last thing I needed to be monitoring and to simply trend my other vital signs. I was pretty exasperated at this point. "I have a heart rate that is way too high, no saturation, the child is blue, and it's temp is almost 39." It was all I could do to keep the panic out of my voice. I didn't have much to trend, but what I did have I knew was bad. Thankfully, Veronica sensed my panic and came back to the ICU with me. She immediately was concerned too. I was glad I wasn't over exaggerating the situation.
     The nurses had been unable to gain new IV access in my absence but they had finally checked a blood sugar and discovered it was dangerously low. At this point I wanted to throttle the night shift. They have heard me say a million times over, "You cannot document what you did not do" and "It is important to document all that you can to paint a clear picture of the patient" at least a thousand times. And overall they have improved dramatically in their documentation skills, but on this particular night with this particular patient... I was so upset that all my time and energy appeared to have been wasted.
     Was this an overreaction I was having in my head? Probably. But at the end of the day, the baby died. He was five days old. And I know that he died because of poor care. A resident from the pediatric team or surgical team should have checked on him overnight. The ICU resident should have checked on him overnight. And the nurses should have known better. It is so difficult to be understanding here at times. Did I throttle a nurse? No. But I was so extremely upset at the situation. All it would have taken was for a nurse to notice the coloring was off, which would have been reflected in the poor or lack of a saturation reading. I don't know what happened, but it was too late by the time action occurred. I know we can't save them all and there are a lot of hopeless cases here. But this was one that should have survived and he didn't.

     Then last week I received a phone call from Jeff, HRH Internal Medicine Physician, asking who was on for ICU because he was concerned about a patient. In the U.S. easily 75% of the patients in the Internal Medicine ward would be in an ICU. So if you think I have it rough, you should take my situations and multiply them by 20, and that's what Julie is working with. So needless to say, if one of the IM doctors is calling, they're really concerned about a patient. I gave him the information for his resident to contact the ICU General Practitioner but offered to come down to take a look and perhaps speed the process up. The patient in question didn't look that bad and I was happy because sometimes the ICU refuses patients because there simply isn't anything else to be done. But this woman looked as though she would pull through if we got her to ICU. 

     Jeff finished talking the Théogène who in turn agreed to accept the patient. Then of course, it was discovered that there was no portable oxygen. This isn't the first time (or the last) that this has happened. Jeff and I both made the call that we could rush her up to the ICU and she would be fine. She had been sitting in IM without her oxygen on for the 15-20 minutes I had been there anyway. Jeff went with the patient and grab the box of belongings and waited for the family so that they would know where we were going. By the time I got to the ICU, a full minute after Jeff and the patient, they were coding her. Jeff said that she just out of no where gasped about 100 yards from IM and stopped breathing. At the end of the code about 45 minutes later, after time of death had been declared, I told Jeff, "I was not anticipating that." He'd had it worse, apparently she was the eighth patient of his to die in two weeks. Neither one of us saw that happening. Her mother was so upset that she ran away from the staff because she didn't want to hear the bad news. I ended up slamming my office door I was so angry at the situation.

     On Friday of last week I walked into the ICU and the staff told me they had coded our male patient at 5 AM. I took one look at him and knew he was going to die that day. Patients will do something that medical professionals call "guppie breathing." I have never had a patient guppie breathe that was still alive my next shift. What was worse is that we could not for the life of us get this man's oxygenation saturation above 85%. I texted Théogène... "I'm sure at this point he already has anoxic brain injury. How do you do this every day year on end?"

     I knew what I was getting into when I came here. Théogène even warned me multiple times upon my arrival how depressing it can be. And I shrugged it off. I'm use to death in my job. It is my job. Sometimes the only thing keeping someone from completely dying are chest compressions being performed by me (because in reality, if I'm doing chest compressions, the patient is already dead). I've been at this for years... and yet it finally got to me. Sometimes these situations are just so beyond frustrating that I can't even describe them. I didn't wait around last Friday to watch him die, but rather went home and ended up spending the entire weekend in bed or on the couch sick.

     I give the Rwandans so much credit. What they experience here is more than I ever have to experience back home. Most of the time it seems their efforts are fruitless so why even bother?

Lessons Learned:

1) Eventually, anger you didn't even realize was there will come creeping out. It may result in slamming of fists into doors, making loud noises with books or doors, and/or having extremely ill thoughts towards others.

2) What matters most though is how you handle this anger... All the above are not going to help the situation. Sometimes it's best to just pause, take a deep breath, repeat yourself a million and a half times more, and encourage the culture change as best as possible.

Gorillas in the Mist

     I haven't been in the mood to write recently despite having so much to tell. Not sure why, perhaps it's because I spend at least 80 hours a week doing work on my computer for my job, or maybe I've just felt like being lazy. The last few weeks have been busy and I have been all over the place and while life is an adventure, sometimes, I just wish I could sleep in past 7 am. Anyway, we last left off with Amy, Julie, and I heading back from Akagera to Butare...
     I really needed to get some work done and unfortunately, it turned out to be a super busy week that Amy visited. So she busied herself with exploring Butare (I will admit not a whole lot) and watching town go by while I worked. She was able to come to the hospital and I was able to give her a grand tour and introduce her to Dr. Thoégène and some of the staff nurses and USI Faculty. She spent much of her time Thursday with our housekeeper Vanessa and Stacey and Sam while I was occupied with assisting in BLS class and I think she really enjoyed herself just soaking up Rwanda.
     Friday of the week she was visiting arrived and I was hoping for an easy morning before enjoying "sports Friday" and heading home at lunch so that she and I could hit the road north. It was anything but, however, that's another story for another time. I got home and Amy was packed and we loaded yet another thankfully borrowed car from friends and off we went. We drove an hour towards Kigali to Muhanga before turning left onto the new road and heading north. I had never driven this road before and it was absolutely stunning. It was by far the most beautiful twisty curvy drive I've done here in Rwanda. Amy and I stopped several times and got out just to look and snap some photos.

     Four hours later we reached the northern town of Musanze and settled into our hotel for the evening. Dinner wasn't anything super spectacular but it got the job done. I had trouble sleeping but was raring to go the next morning. I was really excited to see the mountain gorillas! Along the way to the meeting point we stopped and picked up two of the park rangers who ensured that we would get a good group. We discussed the gorilla "attack" that had occurred a few weeks earlier and they assured us that it was the photographers fault for not listening to the trackers and guides, but no, they wouldn't put us in that group.
     We hung out at the meeting spot enjoying the crisp morning and volcanoes and mist and then I noticed and Orioles baseball cap in the crowd. Sure enough, there was an entire contingent of people from Hopkins doing a 1 week surgical mission at King Faisal. I had to giggle a little. Faisal just has so much more resources than CHUB. I'm sure they came and thought, "how do they do everything they do here with so little?!?" Now imagine having 1/4th of the material and that's my hospital. We get it done with nothing... I like to brag. Regardless, it was super nice to talk to people from home and wish them luck in their week stay here.

DRC/Rwanda/Uganda border on the mountain behind me.

In the mist.

     We were placed in the Titus group with 8 total hikers. I was hoping for more details on the formation of the family, but in my excitement, I actually forgot to ask. But as some of you may know, Titus was the Gorilla King made famous by Dian Fossey and we got to see some of his direct descendants! Titus sadly passed away in 2009 at the age of 35. More surprising, his replacement into the Titus Family was Rano, who died young at the age of 21 last summer. Which meant that our silverback was very young at only 18 years old. Titus Group is a small family with only 7 members. The silverback, 3 females, 1 male juvenile, 1 female youngster (2-3 years old), and 1 baby (3 months). To put it in perspective, some of the families have over 40 members and there are 480 mountain gorillas on the Rwandan side of the Virunga Mountains (Volcanoes National Park) with another 400 in the DRC and Uganda. One of the volcanoes is actually the border where all three countries meet, so not only did Amy get to wave to Tanzania while we were in Akagera, but now she was able to wave to both the DRC and Uganda too.

Man picking flowers on our hike up.
Not sure for what they're used.

All of our trackers

Our Ranger/Guide

     Our hike was moderate, a little steep in places, and mud up to our ankles but it was only about an hour and a half long. We crossed back into the park (we drove about 30 minutes from the meeting point to the hike start) and within ten minutes we were told to leave everything but our cameras in a spot because we were going to get our hour with the gorillas. And man was it quite the experience. The family was spread out over a small, incredibly densely forested area. So dense that all of our trackers had machetes to get through the brush. The first gorilla we saw was the silverback. He was hanging out eating some plants, roughly 200 kilos, and he hit me.

Yep. You heard me. I got whacked by a 200 kilo silverback gorilla in Rwanda. According to our guide it was a playful movement, but it sure as hell felt like a ton of bricks went into my thigh. Everything was fine initially. The website and the guides all say that you are to stay 7 meters away from the gorillas. But we were much closer than that and the guide and trackers seemed ok about itt. I was about 6 feet away from this guy (as was the rest of the group). He was fascinating to watch and roughly 10 minutes into observing him I crouched down to get a photo of him at eye level. As I was looking at the camera I realized this silverback was staring right at me. The guides told us it was ok to look them in the eye so I wasn't worried. Then he batted the plant stalk directly in front of him to get a better look at me. I slowly stood back up and glanced towards the guide and Amy about five feet to my left.

Last zoomed photo before he whacked me... the brach to the
left is the one he batted down before approaching me.

     My attention was immediately drawn back to the silverback as he stood up and came to all fours. Now when gorillas stand up they naturally come forward onto their extremely long arms, thus closing the distance between him and me by 2 feet. Then he started to walk towards me. He made no noises, he wasn't running, it was as if he was just done with the spotlight. He was within a foot of me when he veered slightly to my left to pass and then it happened. WHACK! His left arm went out intentionally and he walloped me in the thigh. It almost knocked me over. Then he decided to climb the tree behind me and continue with his day. Since he didn't charge me or make any noises the guides said it was friendly play behaviors that he exhibited. I wasn't so sure, but I figure if he wanted to, the gorilla could have done some serious damage. And after all of that... I didn't even get a bruise. I have no idea how because I bump my legs into things and bruise easily and yet, nothing. It was sore for several days, but nothing to prove it. It was incredibly disappointing, I'm not going to lie.

Then he decided to climb a tree

And eat some more

     We next found one of the mothers with her 2 year old again, just hanging out and eating. Beyond them in the trees were two more, mother and child. And finally, the mother with her 3 month baby. It was utterly fascinating. Gorilla's DNA is 97% similar to our own.

Much closer than 7 meters

Sure they look different and their arms are long and they don't speak our language... but wow. They are freakishly similar to us. It was one of the most thrilling hours of my life to just observe them.

The infant's head almost gave the impression of a full head of human hair, particularly with his little ears sticking out. The gorillas reproduce very similar to humans, however we were told that up to 60% of the babies die due to hypothermia. I was not expecting that when residing 200 miles from the equator. But our guide indicated that during rainy season it can get quite cold in the mountains, which I certainly believe. I sometimes think I didn't pack enough warm clothes for Rwanda, but I never translated my feelings of cold to what it might do to the animals. Eight hundred, eighty gorillas might sound like a lot, but when they are only located in this region... that's all the mountain gorillas in the world. The guides told use they were due for another census of the gorillas soon, the 880 number is from 2012, so hopefully, the numbers will be higher.

Hiking down

     All in all it was a fabulous trip that Amy had and I'm glad I got to experience both Akagera and Volcanos Parks with her. It was very good to have a piece of home with me despite it being such a short time.

Lessons Learned:

1) Gorillas aren't very warm and fuzzy no matter what your roommates say (Me: So I just got whacked by a 200 kilo silverback. Vanessa: Awww he was just hitting on you!)

2) Near or far your friends will always be your friends, but having them closer is always better.

Amy & Akagera

     Amy is a good friend from my days in Washington, D.C. While older, we both started our nursing careers at the same time at George Washington University Hospital, Amy in the Emergency Department and me in the ICU. The friendships I formed at GW have lead me on trips to the Grand Canyon and Hawaii, but this time, someone was coming to me! I was excited and happy for a distraction from loosing Steph.
     Amy ended up landing 24 hours after she was originally suppose to, but that was ok, it all worked out. She had wanted to see Istanbul and with her flight delayed she ended up getting to spend 24 hours there. I picked her up at 2 am (there are several weird flight times in and out of Rwanda) and was so excited to see her come around the corner and walk down the hallway to me. I was so excited she thought I was drunk. But she has no idea how awesome it was to see someone from home in Rwanda.
     By the time we got back to the hotel it was almost 3 am and we were both pretty tired. We crashed and slept in Sunday morning. The hotel included breakfast so we ate breakfast in the little garden where Steph was able to join us. We ran a few errands, met Julie & Vanessa and moved stuff from one car to another. Before I knew it we had dropped Steph back at the hotel gave her big hugs goodbye and Julie, Amy and I were headed into the unknown territory of Eastern Rwanda... our final destination... Akagera National Park.
     The Eastern Province of Rwanda is very different from the Southern (where I live). Julie and I kept repeating this so much that Amy must have thought we were crazy. The hills look different, the soil isn't as deep a red, the grasses are taller, the trees are different, just everything is different. But not in a bad way, it's still absolutely breathtaking. Amy probably wasn't enjoy the views on our 3 hour drive east quite as much as Julie and I were as she was a little nervous about our driving. As Julie likes to say, "Driving here is like a competitive sport." She's right. It's pretty crazy. And every time I went to pass a slow moving truck you would hear little gasps from her. She got much better as her week long visit progressed.
     We finally reached the edge of the park after some bumpy dirt roads it wasn't much further of a drive to the tented lodge where we were staying. As we pulled to the entrance we stopped to allow the gate man not open the gate, but rather remove the electric wire that ran across the driveway. This was to keep the elephants out of the lodge grounds. We picked to stay at the nicer tented lodge mainly because it was my choice and I wanted to see water. There are 9 lakes within the borders of Akagera and each and everyone of them was beautiful to see. We quickly settled into our tents, Amy declared it was cold as the sun started to set (it was probably 65 degrees) and we made ourselves comfortable on the deck as we enjoyed a zesty adult beverage before dinner.

 

As we were waiting (for what turned out to be a very fabulous meal) a hippo was spotted swimming nearby. As we enjoyed our meal around a nice big campfire with the rest of the guests the hippo came out of the water and started to eat the grass.

Campfire for dinner

I should probably mention here that the deck and walkways from tent to tent (as well as the tents) were all raised so to allow some wild animals onto the property. It was very cool to see the hippo and the men working at the lodge grabbed a spotlight so that we could see not only the hippo but also some crocodiles that were floating about. It was very cool. After a glass of wine and one awesome meal, we all tucked into our tents.

Hello tent!

Amy was ready to crash almost as soon as we arrived.

     The beds were so comfortable and Amy was so jet lagged that she was out in about 3 seconds. I fell asleep in about ten. But after almost two hours there was a noise outside of our tent. My eyes snapped open as I awoke with a start. "Amy!" "Hmm?" "Amy!" "Yeah?" "Amy, there's a hippo outside our tent!" I grabbed my phone and flipped on the flashlight as I crawled out of the tent flap. Sure enough there, about 10 meters from our platform was none other than a hippo basically mowing the grass in front of our tent. It was amazing and the first time I'd seen a hippo in the wild. After about fifteen minutes or so we climbed back in bed incredibly excited for our planned game drive in the morning.

Hippo right off our platform night #1!

     President's Day Monday morning came with a beautiful sunrise over the lake, a lovely cup of tea, and more excitement.

The park driver and our local guide were to pick us up at 7:30 to start our all day drive. When the car pulled up to the lodge it was awesome. It was a huge old Land Cruiser with the top open. It was a true safari vehicle with a packed lunch and binoculars ready for us. Off we went with our driver Emmanuel and our guide Venuste. Venuste was incredibly knowledgable and I swear if you ever need to learn how to drive, Emmanuel is your man.

Enjoying the safari vehicle

They took us everywhere in the entire park. It wasn't long before we saw lots of elephant dung and we were on the hunt for the elephants! Sadly, we only saw baboons. Which were quite cool, but not the same as elephants. We took the mountain road up the ridge where we saw many impalas, oribi, warthogs, zebras, waterbucks, and even giraffes. We paused at the top of the mountain where Venuste told us they suspect that the lions that Rwanda is purchasing from Kenya will  enjoy the views. From the top you could see for miles. We saw half of the lakes we had already driven by and the beautiful different greens of grass and trees. It was absolutely breathtaking. I felt as though I was standing in a scene of Out of Africa.

Pano of the plains

As we continued our drive we happened across a herd of zebras that we enjoyed watching for a little bit before continuing down the ridge and into the valley. Half of the time you could find me standing and hanging on with my head popped up above the roof enjoying everything. I wish I could have bottled the smell in the air and brought it home. It was so enticing that I can't even describe it.

Herd of zebras contemplating crossing the road

     We came to the big plain where we found many water buffalo and others drinking. I was fascinated by the warthogs. They are so ugly and yet so cute at the same time. They stick their tails straight up in the air and trot right along. They are amazingly fast too. I hadn't realized. We moved on to the smaller plain and river where we had lunch. The smaller plain had a bunch of giraffes, which were really amazing to see. And in the river right in front of us where we ate lunch had more hippos. It was a long drive back to the lodge and for sitting around the majority of the day, I was pretty exhausted. Venuste was just asking us how we enjoyed the day as we drove by a ton of baboons and monkeys playing in the road and the trees alongside of it. We had just finished saying that we were disappointed in not seeing an elephant when it happened. There, right where the boats put in for a lake ride was an elephant. It was five o'clock and it was amazing. He was a fairly large male just scuffing his feet along the ground with an egret hanging out. It was so amazing.

Me, Amy, and Julie so excited to see the elephant!

     The elephants in Rwanda are actually known for being aggressive. We are told that this is because when Akagera first came to be there was no way to transport adult elephants across the country. Therefore, roughly 300 adult elephants were slaughtered and the babies were transported by truck and helicopter to the newly established park. Venuste attributed their aggressiveness to not having parents to show them the ways. It was a sad and sweet story. Anyway, it was awesome to see--even if just one--elephant in the wild. We got back to the tented lodge and ate yet another fabulous meal. I stayed up a little longer enjoying a glass of wine under the stars before heading to bed.
     We slept in Tuesday and enjoyed some tea before making the long all the way back to Butare. It was a great drive... despite getting pulled over 4 times (no I was not speeding and no I did not get a ticket, but did have to prove there was a fire extinguisher in the car). But Amy wasn't on the brink of a heart attack for the most part, which was good. The drive really showed her the differences that Julie and I had been going on and on about too. It was a fabulous first weekend of her visit.

Lessons Learned:
1) It's easy to forget that while you may have adjusted to some "crazier" aspects of your current life, others might be taken by surprise.
2) It's always good to have a bit of home visit.
3) Zoos might be easier, but it's nothing compared to seeing animals in the wild.

Hippos

Pregnant giraffe

Topi

Our Elephant

I spent a good portion of the day standing

Julie enjoying the view

Zebras

Amy getting close ups of the many giraffes on the smaller plain

Water buffalo and warthogs