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

Fall Funk

     Well it's official. After being out of country for just over 60 days I had my first (and I'm sure not my last) cathartic sob fest. Let me fill you in because yet again time has gotten away from me, though partially this time because I just didn't feel like writing. It's been a dark couple of weeks and I really didn't feel like bumming everyone out again.
     Two weeks ago, I walked into the ICU thinking it was just going to be like any other Monday. Granted, it would be like any other Monday here in Rwanda so never the typical Monday you're thinking of I'm sure. In fact, that particular Monday was Columbus day, so the mere fact that I was at work and some of you weren't makes it special. Anyway, it wasn't long before my tired, groggy, un-caffeinated body that hadn't slept well over the weekend, found out that our newest patient happened to be my Head of Department (medical director)'s mother. When Claude, the Senior taking over that morning found out his eyes became as big as saucers. I had an uneasy feeling.
     Tuesday morning was worse. Théogène was on his flight back from Sweden where he had been for a month working on his PhD. His mother had taken a turn for the worse and it was not looking good. I kept checking to make sure she had a pulse I was so nervous. The unit was hectic and I pushed lecture to the afternoon because otherwise I'd be lecturing to myself about the importance of calculating patient's fluid balance. The next thing I knew a different patient started to code. I don't even remember his patient story. It all happened so fast. The code ran extremely well and I was very proud of the nurses and of the doctors. We have a new General Practitioner for the ICU, Oscar, so he's still getting his feet wet, but he, Claude, and the nurses did a very good job even if in the end they were unsuccessful in reviving the man. I will say that I was able to cross another first off my list though... I thought they only used paddles on defibrillators in old tv shows (think early years of ER) and movies. Nope! They use them here too. I was the one who squirted the gel onto them. I felt as though I was in a time warp.

Claude working hard to save a life.

     Meanwhile, we were all hoping and praying that Théogène's mother would hang in there until Wednesday when he'd be back in Butare. I finally I had to leave the unit to have a bite to eat and when I came back about 25 minutes later I discovered that they had started to code her. Claude and the nurses worked tirelessly and I will admit to doing some CPR as well. But all efforts were to no avail. She died at 2:05 pm Tuesday afternoon after 30 minutes of coding. It was terrible. Théogène's brother works at the hospital as well and the rest of the family was present, but it was just awful that he wasn't there. We all felt terrible, but they had done everything that they could to save her. I went back to the cafeteria and bought everyone in the ICU a Fanta as a little pick me up. It helped a little. I didn't sleep well for the rest of the week. Nor was lecture very successful for the rest of the week. I had 11 of my 15 staff nurses come in the first week and 5 of the 15 the second.
     Friday was the funeral. Not sure if I could really handle the depression I was happy to walk up to the post office in the morning and pick up a care package. The box was almost falling apart, but it arrived, in one piece from good old Monkton, Maryland and my friend Dan and in it was a wonderful surprise... CHEERIOS! I LOVE CHEERIOS. I'm just sad that the milk here isn't fabulous, but I'll eat the entire bag dry. I don't mind. I also received more Berger cookies that at this point my housemates have fallen in love with as well and we enjoyed them very much. This prompted a super excited Facebook post, which resulted in a very funny status from my friend Kara, who is one of the sisters I met two years ago in Croatia. Unfortunately, my enjoyment of my care package was quickly brought to an end as I attended the funeral.

 

     I wasn't sure if it was appropriate for me to go initially, but everyone said that I should so I went. Out came my black dress (though I spiced it up with my red heels, color does not matter here for funerals) and I walked up to one of the churches in my neighborhood for the service with Melody. There we met Jessie and Beth (an ICU physician from Kigali) who had driven down in the morning for the service. It almost started on time and was a very nice service. The music was very beautiful. One of the things I've always appreciated about the Catholic mass is your ability to follow it no matter what language it is said in. Well... Kinyarwanda might be that exception. It was very difficult to follow, but I think I said the proper English responses where appropriate. Actually probably not. I probably said the old English responses that are reflexive and not right anymore. There were about five words of Latin that I understood for the 2.5 hour mass. When Théogène's aunt stood up to speak I got this feeling, a feeling I understood all too well. Ever since my brother died when I was 13 I get these feelings. It's of shear terror and panic revolving around death, which is an odd thing for an ICU nurse to experience I suppose. I hadn't had that feeling for a very very long time and when it hit me, I felt as though there was nothing I could do to stop it. Here I was sitting in a church and I was about to have a full blown panic attack. Fortunately, it was afternoon at this point in Rwanda so I quickly pulled out my phone and text Meredith and one of my best friends who has always known about this visceral gut aching, take your breath away feeling Luke. Dith responded as she fell asleep. Luke was able to distract me enough that I didn't end up completely freaking out. Disaster averted. But I hate that feeling.
     After the service we went to the burial. That was a very new and interesting experience. First off, the grave yard was on a beautiful hillside that overlooked rice paddies and appropriately in my opinion, the hospital is across the little valley on the opposite hillside. It was quite picturesque. However, the experience was very different than the US. First, there were prayers and singing and then they lowered the casket into the ground. That's not typically done in the US, but it didn't stop there. While we were praying and singing they started to build the gravesite. There was no dirt thrown on top of the casket, just Holy Water, but they then took boards and covered the site. Then laid down paper, and then a grid, and then concrete, and then made a headstone from brick, and then placed a cross with her name and dates on it. They entombed her. I'd never seen that done and it took me by surprise. But it certainly solidifies that she is gone. It was beautiful that her family was there until it was all said and done, but it was also immensely depressing.

Beth overlooking the valley

ICU nurses laying flowers at the gravesite

    Afterwards I went home extremely exhausted about six hours of funeral. I was home alone and just wanted to curl up and watch a movie. But of course, there was work to be done. Emmanuel and I needed to finish our goals for the year. So he came over and he wrote his goals out with my help and I cooked dinner. I made him stir fry. He'd never had it before and he claims he liked it. I hope so. It was a good bonding evening for us, even if I gave him too much wine to drink. I finally crawled in bed, couldn't sleep of course, and got a couple of hours of sleep before I was up and ready for a better day because I was off to Nyungwe Forest again!
     One of our pediatricians, Emily had a birthday and we decided to go hiking and then to the Forest Lodge for an evening of relaxation and fun. The hike was amazing! We climbed the highest peak in Nyungwe where at the top you can see Burundi to the south and Lake Kivu and the Congo to the west. Pretty amazing views... Ours looked more like this...

View from the top.

Yep... it was a little cloudy and mysterious so it didn't result in the best views. It did result in the spotting of some monkeys and interesting birds and some white wine with our picnic lunch and a lot of laughs as we played a game called Contact, which became infinitely more fun and difficult as we consumed wine. On the way down it started to rain. And then POUR for about 2 hours. By the time we got back to the car we were soaked, freezing, and the wine buzz had worn off.

Jared carried the white wine to the top

Mountain monkeys just hanging out

Hiking through the jungle/rainforest

By the time we got to the Lodge I also felt as though I was going to vomit. The last 30 minutes winding through the forest is gorgeous. It's also the worse part if you tend to get car sick, which I do. It was bad. I was so excited to get to my lovely room and take a very long hot bath and/or shower. You can imagine how I felt when I discovered that I had somewhat lukewarm water and that almost all of my clothes for the weekend were not only wet, but stained from my no longer waterproof day pack. So to recap, I'm soaked to the bone, freezing, feel like I might vomit, exhausted from lack of sleep for about 10 days at this point, have almost no dry clothes, and basically no hot water...

     Yep, you guessed it, cue the completely ridiculous breakdown. I could not stop crying for about an hour and a half. I FaceTimed my mom and when she asked me what had happened I even admitted that nothing had happened. I'd just had a fabulous day with my friends. And yet there was I bawling my eyes out and saying I wasn't going to go to dinner. I was being completely ridiculous. Julie and Vanessa finally were able to coax me out of my room and put me in a hot bath in Julie's room and scrounged up some dry jeans and a shirt. Fortunately, the dress I had packed for dinner was remarkably dry and unstained and I put it on and rallied for drinks and dinner and we all ended up having a really great time celebrating Emily's birthday.

The Butare Gang (L to R): Jared, Tiffany, Veronica, Emily, Julie, Jim, Vanessa, Steph

The birthday girl and her homemade cake with sparkler!

     Things have gotten a little better. The initial excitement of moving here has officially worn off though so last week was still a little rough with a lot of "I wish I'd never come here" and "Why did I leave San Francisco?" going on in my head. I was still having trouble sleeping despite Benadryl and Dramamine supplements so I worked from home on Tuesday because I just couldn't for the life of me wake up and I ended up sleeping in until 10 am. It was much needed. The end of last week I went to Kigali with Emmanuel and Cécile the In Charge of the unit and visited the three hospitals there and the ICUs to get some ideas on what we can do to improve with accreditation. I think it was very successful.

     Friday night Vanessa and Julie decided that I still needed some cheering and so I hadn't been home for five minutes before a tasty adult beverage was in my hand. We went to Chinese dinner with a group and Emmanuel joined us, which was very nice. I like treating him to dinner and such when I can. And oddly enough, Chinese has become quite the comfort food. Who would have thought. Especially since I haven't regularly ordered Chinese since I was 20. Of course it started to torrentially downpour during dinner and geniuses that we are decided to walk home... we were slightly damp by the time we reached the main drag and hopped a taxi so that we wouldn't have to slosh through the mud.

Emmanuel and I at Chinese dinner.

Vanessa, Me & Catherine in the pouring rain post dinner.

     The weekend was quiet as Julie has officially gotten me addicted to Downton Abbey and I couldn't resist watching several episodes... ok, I will admit that I managed to get through both Season 2 and 3, but it was a quiet rejuvenating weekend that I needed. We did purchase some awesome whicker furniture for our back veranda that we are all really enjoying, particularly in the morning. It's in the perfect spot to enjoy the sunrise.

The newest addition to the household

It's good to be back at work and busy. The busier I am the easier it is to keep my mind off things. Today is my 70th day in country according to the IRS. Which really means I only have 56 days to go until my Christmas vacation in Ireland with my former patient and his family. Sorry that this post is so long, but I wanted to catch everyone up. Thank you to my good friends Em & Emily who have respectively sent me a funny postcard and care package. I really appreciate how much support I am getting from back home. Keep the emails, notes, packages, texts, Facetime, and any other form of communication you can think of coming. It really really helps. Love to all!

Lessons Learned:

1) Everyone needs a cathartic breakdown session every now and then.

2) I must be one of the most truly blessed people on this planet.

Class is in Session!

     Well, last week I started lectures in the ICU for the course I'm teaching (that I'm making up as I go along) aptly named the ICU Accreditation Course. So far so good! 11 of my 15 nurses currently working (I have one out on maternity leave and another in school) came to class last week. They are very interested in learning. Sometimes it is a bit of a negotiation to get them to come to lecture, but once they're there, they are very engaged.
     Last week I taught two lectures. One on accreditation and the other clinical audit results for August and September that I had done. If I haven't mentioned it, CHUB (we do not say chub instead we pronounce each letter in French, so it sounds like Say-Ach-OO-Bay) is working towards accreditation by the South African group called COHSASA (Council for Health Service Accreditation of Southern Africa). It is quite the process, for instance, just a few weeks ago the first hospital wide policies were rolled out... there isn't a single policy written for ICU care... yet. Next week I am going to start working with my In-Charge (manager) for ICU on writing simple policies. We'll see how that goes! The clinical audit that I did was compliance of charting. Jessie (predecessor) worked hours upon hours on end last year in developing an ICU flowsheet for the nurses to chart. They rolled it out in July and I wanted to see how well the nurses were doing with the new material. Turns out, they aren't doing so bad! They document everything about 50% of the time, which I realize isn't perfect or anywhere near perfect, but considering that prior to this flow sheet they didn't chart an assessment ever... I think we're doing pretty well. Lots of "areas of improvement/opportunities" as I keep positively referring to them, but that's ok. Baby steps it is.

Make-shift classroom in the corner of ICU.

     This weeks lecture is on our October Focus Points, specifically Intake and Outputs/Calculating a patient's Fluid Balance. Each month, based on the audit results I am picking goal(s) to strive for and essentially bribing my nurses with a surprise if the goals are met. I am then doing follow up lectures to clarify and educate on weaker areas that we are focusing on. Already I've witnessed improvement, but I've also witnessed some set backs that I didn't see coming. The ethic of teamwork here is incredible and it puts US nursing to shame. Never does someone complain when another asks for help, nor do they ever complain about listen for all the patients for each others 2 hour lunch breaks (the majority of my nurses go home, eat, and return and they live a distance). However, I've discovered that while fabulous, it hinders a few aspects of nursing. Mainly, they don't like to see each other fail so they cover for each other. The idea of individual accountability is non-existent. So when I mentioned that one area of improvement for the future would be to update our nursing assessments on night shift (or indicate clearly that nothing has changed overnight) I never expected to catch a dayshift nurse putting lines through the night shift assessment, thus indicating that there had been no changes overnight. I have no idea how I'm going to approach this topic. May need to consult some higher ups in the hospital organization to figure it all out and to have a better understanding of the practice. Always hiccups when you're teaching. I never expected this one and it will be hard to develop a solution without damaging the fledgling relationships I am building here.
     Anyway, last week was successful and the weekend fun. Our newest roommate Joe who is living in the guest house had a grill made and we had a little BBQ Sunday evening. It was very nice to have other faculty over to hang out for beers and brats!

Facetimed my dad to check in while mom was away.

Sunset from our yard.

Moonlit clouds

A fly really liked my Coke one day at lunch.

Sunrise from my bedroom window.

Afternoon rain at the hospital.

This is short rainy season (hospital)

Storm clouds clearing as I head home from work.

Joe BBQing

I'll write another post about this week later today if I can. Love to all at home!

Lessons Learned:
1) It's best to give the same lecture multiple times... you learn quickly what needs to be edited as I was informed that my phrasing of "print and sign names" is incorrect. To print is to print something from a computer :)

2) Again, hiccups will occur that you never expected. It's good to always look for solutions!

It is Every Girls Dream to have a Waterfall in Their House

     Friday night Julie and I were hanging in our living room enjoying each others company as Vanessa had callously ditched us for Kigali for the night (ok not really, she had a meeting and did some shopping for us). We had both just commented on how hard it was raining, that we were impressed we still had electricity, and how slow the evening was dragging. We had already watched the second episode of The Good Wife (I've discovered I can use the hospital Wifi to download from iTunes) and were reading our latest novels.
     I was about to say just how loud the rain was pouring off the roof when it dawned on both of us that that wasn't what we were hearing... earlier in the week as invalid Julie was home we had some crazy rain and a leak appeared in our guest room, which happens to be on my side of the house. Julie had told us that it was pretty crazy and we sent an email to the Colonel letting him know. By the time Julie and I got to the guest room it was way too late. Water was POURING in from two corners of the room and from all the walls. The water had spread across the room, down the hallway, and half way into my bedroom. Thankfully, my shag carpet proves to be very good at soaking up dirty roof water. We grabbed our laundry tubs and started to squeegee the water into my bathroom which has a drain in the middle of the floor. Good design. At one point the water was coming in so quickly I couldn't dump the tubs fast enough into my shower. Our guard Charles didn't know what to do. Then the light fell and water started to come from the fixture. We turned off the electric to that room. Then the waterfall came. A legit waterfall from a new place all down onto the bed.
     Thankfully, the rain finally stopped. We shut all the electric off to be safe and opened a bottle of wine. It was quite the experience. I slept in Vanessa's bed just to be safe that night too. Hopefully the Colonel's maintenance man, Robert will be able to get here today and see what he can do. I think this was to make up for missing out on the waterfall hike last weekend. Every girls dream is to have a waterfall in their house.

Waterfall entry point

The aftermath of night one

That is indeed a water spout coming into the room.

A second (or third or fourth at this point) water spout.

     Well, I didn't get around to posting this before the weekend was over due to African internet, however we had a second waterfall in the guest room yesterday. Seriously, who knew I'd be living the life of someone rich enough to have an established waterfall to decorate their house? Thankfully, Robert was present during the second waterfall and agreed that we were not making it up or exaggerating in the least when we stated we had a waterfall in our house. He climbed up onto the roof in the middle of the torrential downpour/thunderstorm and discovered that indeed we had a plastic container blocking the drainage pipe of that section of roof. So far, we have had no more leaking or waterfalls, but I'm keeping my yoga mat at the base of my door just in case.

Lessons Learned:

1) Every bathroom should have a drain in the floor... it was a godsend this weekend.

2) Always be prepared... you never know when you're going to need an extra laundry tub to catch a waterfall.