Returning to Rwanda

I left for Rwanda again in January and have settled back doing what I feel called to do at this stage of my life, trying to make system changes and adding my tiny drop of water in the very big ocean of need. My return was quite humbling, embraced with wide open arms in the hospital: midwives, doctors, residents and even cleaners and gate keepers were seemingly excited. My landlord insisted he would reserve my old apartment with four bedrooms all ensuite, for me, equipped with a cleaner and gatekeeper. My Chinese neighbors, who never talk to anyone are also still there (smile).

It was hitting the ground running as a year is so short and now as I write, I realize I have done a third of my initial proposed stay. Time is truly flying. So what have I been up to these four months? A lot!

January

I had to get a car and obviously no self-respecting Dukee will get anything other than DUKE BLUE BABY…..eat your heart out, UNC fans! The rivalry continues even far away in Rwanda. Nuff said.

Duke Blue Baby!

Of course, the African queen accompanied me back to Rwanda and is being treated according to custom: being spoilt drinking African tea!

Needless to say, my obstetric colleagues were delighted to see me back as they knew things will be shaken up.

A few days later, we drove up the country side to attend an important event: the opening of a new University with all the bells and whistles of American infrastructure and design and what a stunning beautiful place it is. The website is https://ughe.org

The Rwanda president and many of the ministers came in. And of course, Paul Farmer and Ophelia Dahl and many others were all there. The president had flown overnight from Davos just to get here on time. He told us the story of how the university was placed here, high up on a strategic hill. Paul Farmer had toured the area and as he is known to do, finds the most remote area to place an institution because of his philosophy of reaching the people. He finds this hill that belongs to the military and thought the vantage point was so breathtaking and simply asks for it. Lo and behold, the military gives the land to him. You can see the video the construction and how inspiring it is. https://ughe.org/butaro-academic-campus-construction-timelapse/

But that is not all. So I decided to play a trick on Paul Farmer. I walk up to him with a picture of both of us and simply ask where it was taken, feeling quite smug. Beaten at my own game. Not only did he know which country (Ghana) and which airport (Kotoka) but he also knew which gate we took the picture (gate 4). Here are the series of picture that captured the moment of me being schooled by my friend. Picture two is me being smug and cocky and picture three is Paul saying “Booyaah, gotcha!” Hope we get to do some life changing project together in Haiti…

First clinical day, a patient came in short of breath and they had a preliminary diagnosis of a pulmonary embolism and were awaiting an expensive delayed investigative test. Well, I had taught them how to diagnosis DVT so I marched the residents to the bedside and frankly, it was a beautiful demonstration of femoral vein DVT. I informed them not to bother with the expensive CT angio, start the anticoagulants and this single moment endeared me to the team. The patient went home treated.

You can see the artery patent and the vein engorged with a clot and with no blood flow and not compressible. Ultrasound is revolutionizing low resource countries in terms of diagnosing critically ill patients. More on that later. The queen celebrated her birthday with the dean of the school of medicine, Stephen Rulisa and his very lovely wife, Alice. I did receive some sad news back at Duke about Dan, a wonderful CRNA I worked with for a few years. Salt of the earth kind of person….RIP, Dan.

Dan

February

Sometime early February, I received some visitors. It was my first ever epidural for a labor patient from my last years’ visit, coming to say thank you, bringing the little laddie and also bringing another pregnant friend who wanted to meet me and got me to promise to help her also. If one does not feel appreciated, please come to Africa. You will be loved here.

Don Moen, a gospel singer came to town and we decide to attend the concert with a resident from Wisconsin who wanted to stay with Lola and I. I am telling you. Other residents are taking advantage. Where are my duke residents??

Even Dave, an Australian anesthesia resident came and stayed with me.

Page, Lola and I at a Don Moen Concert

Dave

Now for serious clinical work, I have to introduce you to Esther. First, I have permission to share her story. Esther is simply the sweetest patient I have had. She has HOCM, in Africa, almost a death sentence. She has had it for 10 years and unfortunately became pregnant and we have nursed her now for over 2 months. Our first CSE procedure and first arterial line placement in maternity and following success cesarean section, she then went on to develop a subarachnoid hemorrhage!! Come on, Big Man upstairs, give her a break!! She recovered but It has been the most difficult course and care we have done. She has spent over two months with us and everyone in maternity unit know Esther. Our current dilemma is how to help long term. We have no answers. We need help.

March

In March, I visited a young lady in the countryside. Let me give you a small recount. Last year, this young lady and her sister were both pregnant. They both delivered lovely babies but her sister died following delivery. I had interviewed her about her sisters passing as part of my research. I decided to visit her as she was now responsible looking after her sisters’ baby. Here is the baby whose name is Yves. The young lady holding Yves is the older sister of the baby. It was her mother who passed away. Due to her mother dying, she was compelled to help her aunt raise her own brother. Her education was suspended. The tragedy of maternal mortality extends far beyond simply a young woman dying. Its impact reverberates through the whole family and community. I have not been able to abandon some of the people I interviewed. Just cannot.

We did have our own tragedy in maternity. One of our midwives, Edith, also passed away following childbirth. We all attended her funeral. A very sad experience. A few of the midwives hitched a ride with me. I wanted to show you the Rwanda attire for events.

While there they showed me another graveyard. A family of six involved in an accident, husband and four kids killed and wife survives. If stories like this does not move you to appreciate your own family and put aside those tiny irrelevant things that divide us, not sure what will. Please appreciate your family.

Since I am so far, I have had to skype the kids. Here is the lovely Rach and I skyping. Rach is Tobi, my son’s girlfriend and just an angel. And just in case Gracie is reading this, so is Gracie, Tomiwa’s girlfriend!! Even though she is a die-hard UNC girl…..

I recently did visit the USA and visited my daughters. What a treasure they all are.

Some of my treasured daughters: Gracie, Rach and Tosin

The midwives work so hard so on womens day, March 8th, I surprised the department with some really nice cakes. My stock went through the roof!! It was a hit. “I kept hearing “Noone has ever done this for us on women’s day”…….as Gene Kelly said…I am singing in the rain….

But it is also a subtle strategy. Now we can propose changes in the maternity unit and all will listen. If cake can help improve things, I will buy lots of it. We had our second anesthesia research day conference and I spoke on system changes using quality improvement methodology. Max is an icu / Ro1 Grant recipient standing next to me and whom I hope we can continue our friendship for many years henceforth. Really cool guy based out of Columbia.

One of the most wonderful accomplishment was the return of Edouard to Rwanda having completed his WFSA sponsored obstetric anesthesia fellowship in Nigeria. He and I are like a Bull in a China shop as we continue to see how we can make lasting changes in the maternity suite. Our Obstetric colleagues are embracing this new concept, novel in Rwanda: Having obstetric anesthesiologists in the department. Picture of Eduoard and his family when Lola and I visited in Gitwe, Rwanda. This is going to change for Obstetric care in Rwanda.

April

April is an awesome month. Two Special events took place in early April. Look who came to town to visit me? My own brother!! Aaron Sandler and Alison. What a refreshing visit and what a gift of a visit. Alison is just special. With her in town, I immediately demoted Aaron to Brother in law! Alison is now sister. The experience of shared experience in Africa sure lights a love fire in any relationship. Look at those two!

Of course, he brought gifts for my department. Of course, it was such a memorable visit. Any other Duke anesthesia faculty wanting to visit with their families????

And then April 5th came around and I got a surprised birthday celebration from the midwives. Very touching. With cake and flowers too

The department needed someone to help make changes and boy have we been busy. In many low resource countries, you will see that the majority of mortality occurs in the recovery room for obvious reasons. Surgery is over and the staff there are poorly trained and the concept of close monitoring is ill conceived. So I decided to invest a significant amount of time there. I recovered data going back 2 years of deaths in the recovery and it was simply abysmal. Not acceptable. We have been putting structural, organizational, process and training changes and we have started to bear good fruit. Let me share with pictures what we are doing. Who said that small drops in oceans cant change things, eh????

Every time we needed anything on a patient, we had to run to get it in pharmacy. I understood that was created to ensure accountability but it was too slow for patients decompensating in recovery. Recovery is where we admitted critically ill patients such as hemorrhaging patients, hypoxic from PE patients, Convulsing for several days from eclampsia patients, severely hypotensive patients from sepsis type patients. We needed stuff and more promptly. Now we have two stocks and the midwives and residents are over the moon.

Handover was abysmal, if not nonexistent. We printed the content of handover and pasted it on the wall and now insist that surgery and anesthesia team must present to the recovery staff all patients. Now, we have proper handovers where anesthesia and surgery handover by the bedside, improving communication.

Communication Board by Yemi

Improved Board by Zuzu

No one knew who was to be called should a problem exist. There were too many delays. We created a communication board which is updated every morning. Every teusday and Thursday, we dedicated to teaching an obstetric principle and this is a hit among the anesthesia officers and residents. I was in my elements

We have also started a daily 9am rounding on the critically ill patients in recovery and Ken one of the affable consultants and residents were watching me do a subcotal 4 chamber using my new butterfly portable ultrasound and iphone.

Furthermore, I initiated the 10:30 coffee break and even others are joining us. For tea and biscuits. Its nice to see a multidisciplinary team around the coffee pot

Midwives were taking up more responsibilities including caring for patients on ventilators. They needed training. I initiated a workshop and this was quite successful, looking at simple things they could do to make a difference. I took them to ICU where they witnessed firsthand some of the principles they needed to learn.

We had communication issues with referring hospitals and had started a whatsapp platform. What was really good was actually starting one for emergency cases within the hospital so that all of us were on notice. This has been a great success. I reviewed a summary and was excited to report that for a 30-day period we had 18 hemorrhage cases and 3 cardiac cases with no mortality. A feat in our environment.

April is always the commemoration of the tragedy of the Rwanda genocide. This was the 25 year anniversary. I attended the hospital event. Apparently, many staff and patients were killed here. Especially in maternity where many pregnant women had unspeakable things done to them. Following the laying of wreaths, we had to walk to different areas of the hospital where men with signposts lifted up the names of staff and patients who died. The maternity sign was a poignant one. The lady and gentleman in the picture is the CEO of the hospital and the Health Minister who attended the event. I add a small video clip of the event, the candle lighting.

Amy is an obstetric anesthesiologists from wake forest and has just received her Fulbright to work in the same hospital with me. How awesome is that. She breezed in with her family to check out the schools as they will be here for a year. What an asset she will be.

BisolaOnajin-Obembe, previous Nigeria society of anaesthetists president and a friend, visited Rwanda and I hung out with them.

In May, I am expecting Duke labor nurses visiting and Duke crnas led by Adam. I did briefly visit Duke to fulfil some obligation. I don’t have a picture but that of our faculty sometime back when we were taking a division picture. Thought I would share it. And as usual, someone who will remain nameless would not put a tie on and we had to literally twist arm to get something decent going!Thank you Lily

It’s going to be such changes that will lead to improvement. I am very excited. We will also be starting our epidural analgesia training. Lots of changes coming. The chess set is also awaiting my visitors.

Lola and I spent Easter Sunday together and we treasure every blessings

I will end this with a heartfelt glimmer of hope. Umumuntu is a Rwanda word for humanity. It encaptures all that is positive and can build. Can inspire. Can elevate…..Umubuntu.