Good morning. I am alive.

"Maramutze."

  It means "good morning" in Kinyrwandan.   Before noon, everyone who comes into contact with you - shopping, commuting, working, banking, observing or conversing will say it to you.  Or you to them.  The reply is often "Maramutze nmezi" ("I am well this morning") or if the exchange is more fleeting, or if there is a big load being carried or a hoe to be wielded, the reply is a simple, "yego, yego" ("yes, yes") and attention is quickly turned back to the task at hand.

Regardless, a greeting and a reply are always conducted. It is what is done.

Riding 400km around the northwestern corner of Rwanda along the border of Uganda and DRC for 4 days on small paths with 2 friends, we said and replied to literally thousands of "Maramutzes."    It was a truly memorable trip. Getting lost, getting found, getting hungry, getting fed, getting wet, getting benighted, getting worked, getting humbled and getting found again and again. Each village similar to the last - people farming, herding goats, collecting firewood, tending fields, cooking starch, breaking rocks, hauling loads, carrying water....living and surviving.

It was my final week in Rwanda and my melancholy about departing hung heavy.

It was also when I learnt that "Maramutze" doesn't literally translate to "good morning", but actually means,"I am alive."

I was floored when I found this out.  For the last year, I have said "Maramutze" to friends, co-workers, patients, taxi drivers and shopkeepers on a daily basis.   I am not naive, but I figured that I understood a decent chunk of Rwandan social niceties and realities....but no. I am humbled yet again by just how harsh and fleeting life can be - reflected in the lexicon  - "Hello. I am alive....so by that definition, it is a good morning!"

I write this in Canada.  My time in Rwanda is over.  I miss not saying "Maramutze" anymore.

I have returned to my Canadian ED work and have left the CHUK ED training to others with fresh legs.

I am trying not to be overly frustrated by patients complaining of problems that are not emergencies, or by patients expecting me to fix their painful and chronic condition during their visit, or patients that complain that they have waited over and hour to see a doctor.  These situations are common and expected.  They come with the territory of being an emergency physician  - everyone has a problem that  is "their emergency" and all emergencies are relative.

What has been hard is adjusting to the underlying psychological and social problems that have to be managed in the Canadian ED.  Patients presenting with florid sepsis and major trauma are blissfully rare in the Canadian ED.  When they do present, a well-run and multi-disciplined team provides the best of care.  Care that could barely be imagined most days in Rwanda.  What grinds an emergency department worker down here are the chronic problems of the many patients who are homeless, or live in a lousy one room hotel. Patients who scratch a life out on the streets - often using methamphetamine, crack, heroin, alcohol, or anything for some sort of high - any kind of drug to distract from  the pain and emptiness of their present.   Turning tricks or crime to fuel the escape.  An escape from their present, from their abusive and neglected past, and often to escape from their future. Their lives are truly chaotic.  As emergency care providers, we can treat the overdose, the injury,  or the acute psychosis of a chaotic event, but there is no emergency treatment for the underlying chaotic life.  Here we are largely hopeless.

Over the course of my first night shift back I was sworn at, spat on and punched.

Each by a different patient.

I was trying to put a tracheostomy tube back in place the time I got punched to the ribs. He kept pulling it out in jail.

I was spat on by a 21 year old homeless girl cranked up on meth who briefly thought I was a satanic angel dragging her back to the underworld.
Nope, I am just an emergency  doc trying to treat her rhabdomylysis and sepsis.

I was sworn at 3 times by the same patient on 3 different visits on the same night. He kept coming back (in an ambulance each time) after injecting too much heroin. I kept getting him breathing again with naloxone. He was pissed to be woken up in the ED hallway - again.

Late in the shift, my guard up and my edges frayed, I saw that another (notorious) "frequent-flyer" patient was next to be seen.    This particular patient had slugged multiple nurses in the past and has a vocabulary that would make a sailor blush. She has lived close to the street for most of her 40 years. Toothless and belligerent, her alcohol-fuelled rages are legendary. As are her seizures and stamina to resist most care offered.  I grabbed the chart, wary of what condition I might find her in.  Happily surprised - stunned even -  by her greeting - "hey Doc, I haven't seen you for a awhile."  She was sober and she was a charmer. I had never seen her so.  She has a new boyfriend and had a question about a sore on her lip.  We discussed a diagnosis and a plan, she gave me hug,  and then she left.

Riding home in the rain, I realised that I can no more imagine the difficulty of life on the streets as I can imagine the life of a Rwandan mother having to bury her child from a treatable medical condition.  Both lives are so constrained, so limited, and so hard to escape from.  And so worth the effort of providing care.

"Maramutze" - I am alive.  I am going to teach some of my patients here that phrase.   They too, can say it for real.

Thanks for reading.

Short Rains and Looming Departure

Plough & fuel in hand

Well, the riding paths are tacky and the dust has settled from the air.  The short rains have come. The concrete-hard brown earth is greening.  Fields are being ploughed for the  third planting of the year.  The farmers have had a few weeks "off" at the end of the dry season - where nothing grows- time spent buying cows, adding walls, rooms and repairs to the mud home, and brewing some banana beer. 

On some Saturdays this month, we have ridden into villages hungry and been unable to find anything other than banana beer for sale. It's recipients sitting back against a wall, sipping the brew from 2L fuel jugs, quite drunk by 9 in the morning.   We have been thankful that hardware shops stock a few biscuits...

Brick works

The Rwandan farmer - approximately 85% of the population- almost always has work to do.  For the next few weeks, it is hand tools moving tons of earth before planting. The brick makers are also back in business with the rains. Moulding mud into bricks, building a house-sized stack about some eucalyptus charcoal, then baking the structure for several days from the inside out.

Some boyz and a flower

The tracks are smother and faster - which is good as the riding has increased. A circular five day 400 km off road tour of Rwanda is looming. Light packs, a stack of francs, a toothbrush and 2 similar-minded friends. Ride all day, find some beans and brochette to eat, a beer, sleep in a village, and repeat. 

Fortified town of Carcassonne

I miss the girls.  We parted in France after a Paris stint and a 10-day VW camper van tour. Visiting old haunts and good friends from the Carcassonne triathlon days. The Girls are re-entering "Canada Life" and I'm orienting three new HRH EM staff to the challenge and the burgeoning reality that is EM training in Rwanda.




It is a bit of an unsettling time to arrive. There are skirmishes along the Rwandan and DRC border, and Ebola fear grips the country. ....everyone is a bit twitchy.

 For Ebola, the government is orderly and organised tho- there are airport checks and quarantine stations. We have started to screen all ED patients and visitors, but in reality, people and patients pass thru the ED as river water thru a wicker basket. Malaria, TB, and typhoid are all common presentations and can look very similar to Ebola. It is hard not to let one's guard down.




 The trauma also continues to pile in. 31 people died this weekend in "road traffic accidents". Another 5 died when a soldier opened fire in a bar over a dispute involving a girl. 2 more children died when the grenade they found exploded while they were playing catch with it.  It is also the time of year when everyone has to pay for their yearly medical insurance - Mutuelle de Sante. Many haven't been able to put aside the money.  As a result, elective out-patient medical visits are down.  Late-presentation of serious medical illness' to the ED are up.  

The strain on ED resources and care-delivery from the combination of trauma, Ebola fears and exacerbation of non-communicable disease, is impressive. Unfortunately, the ED response to caring for these cases is less so...I can't help but see the ED through the eyes of the new expat staff I am orienting who are fresh from their resource-rich(er) practices.  No matter how experienced they are with resource-limited health care delivery (and they all are), the first few days and weeks of immersion are intimidating and frustrating at best and shocking and cruel at the worst.

Waiting repair

Rm 9 window view

CHUK evening

Say "ambulance" 5 times fast in kinyrwandan

I'm on the way out...but I'm still so very much here now.   And I will be till the plane leaves. Then I am not here and the life and the work and the people that are in these spheres are suddenly out of my immediate life.  My role here will be over and gone - my desk, my view, my friends, my home, my practice - poof!  Like that....I return to another fabulous life. Sort of crazy really.  I can't get my head around it...yet.




 I've stretched myself and my family- I think mostly for the better. I am motivated to capture the time and wrap it up neatly, pin it on a board and frame it for future viewing.  But it can't be hung like that!  Vain attempts have repeatedly failed.  The experience doesn't fit in a bottle and it can't be dried and stored. I move on then....thankful that pieces of the smell, the colour, the edge and the light of the life here will always stay somewhere with me.  

Thanks again for reading.

Getting burned. Moving forward. Finding a name.

The babe didn't have a name yet. His face, most of his torso, and his entire left 

arm and hand were badly burned though. He was 18 days old when the mosquito net 

around his parents bed caught fire. At 21 days old, he developed a secondary infection. By day 23, he had been transferred to us at CHUK ED in septic shock. We put IV lines in his burnt neck and gave him fluid and antibiotics, a nasogastric tube for expressed breast milk, an anesthetic dose of ketamine, debrided the dead tissue, dressed the newly exposed pink skin with honey, wrapped him in clean sheets, tucked him in a rusty stretcher with his 

mother, and hoped for the best....but we all expected the worse.  

Why wouldn’t we? More kids die than survive in our ED setting who present with complications from burns. I used to remember all of the cases of childhood deaths, but now their faces blur in my mind like fragments of half-remembered dreams.

The care-delivery matrix is grossly under-developed and under-funded in this busy public hospital. It is not even just the hospital- it is the entire health system. It has improved so much over the last 5 years, but there are still so so many challenges to overcome and systems to bolster. Some days, it feels unattainable. 

But it can't be, or else we are all wasting our time. I have to remember that Rwanda is a G167 country, not a G7 one like where I am from. One has to be patient, one has to know when to push, when to pull, and when to stand still.  One has to accept that despite best efforts and intentions, time is needed for these big system improvements to filter through the bedrock of positive developmental change. 

This is a candid assessment, but it is also a brutal truth for those who have to deliver, or don't have the means to deliver, emergency medical care in Rwanda. 

All to often, patients die unnecessarily. As emergency care providers in this  resource-limited place, we sit at an uncomfortable interface. We see and understand where and how the national system needs to develop, but we also see and feel the patients dying literally in our hands for want of that positive change. 

This juxtaposition rattles me. 

The families look on hopelessly, I subconsciously withdraw my emotional patient investment. I detach. I callous. I inadequately process the daily death around me. I catch myself doing it. I then try to reconnect.  To stretch back out to the human connection of the patient-doctor relationship. I speak to the families who lose their children or spouses. I sit patiently and try and answer their questions. I speak frankly about grave prognoses, I try to empathise and comfort. 
I am a teacher here, I try to mentor appropriate behaviours. I engage the patient, I discuss death and dying. I try to be honest, respectful and caring….but some days I can't. 

Some days, I just try and wall myself off. Some days, caring seems hopeless. Caring can’t seem to improve the system.  It is maddening. Instead, I  want to curse and shout my frustrations. I want to throw broken resuscitation equipment across the room.  I want to blame someone for the system failure.  But I don’t. I can’t. In this immediate context, such a rampage will only make the system more dysfunctional. I simply try to resign myself to the approaching poor patient outcome.

So it was this day with this young babe. Burned, volume-depleted, hypoglycemic, and now in septic shock , he was going to die. I was resigned to this fact.  I went through the motions of care and went home for the night. 

The next morning he was still alive. Same too the following day. He remained nameless, but he began to breast feed. We called him Buddy. Bernard, the EM resident of room 8, became invested in Buddy. I saw it happen. He fed Buddy's mother chapatis he would buy on the way into the hospital. He scrounged bandages and honey to offset her medical costs, he lent her his phone to call back to Buddy's father still in the village. In the true spirit of the word, he cared for them. 

Children are the future everywhere. Children are certainly the hope of this small and crowed country.  Almost half the population of Rwanda, over 5 million people, are less than 18 years of age. They are the ones who will move this country beyond it's genocidal past.




Though already 20 years old, the genocide is still so young.

http://www.rwandanstories.org/origins/real_differences.html

  There are laws defining what and how to speak of the genocide and reconciliation and reunification rhetoric pervades the social fabric.

“All Rwandans are Rwandan” is the official doctrine. 

The country develops rapidly and strides steadily forward towards remarkable improvements in health, education, industry and infrastructure.      

But how can there not be some tension? Some distrust?  How do neighbours who killed each other with machetes re-become 

being neighbours? Being villagers? Working at the market, in the fields, and attending church together? Beneath the controlled surface of social interaction, there is a tension. 

The process of healing for one individual, one family, one village, and one country is far beyond my comprehension.  Amazingly, some have claimed recovery -  http://www.kwibuka.rw/  - but most will need a generational buffer. A generational gap between being hunted, being a killer and being killed. 

The Rwandan children now and the Rwandan children to come are key to Rwanda’s peaceful and prosperous future. 

Other room 8 patients came and went. Some died, others went to the ward and a few 

returned to their district hospitals. Buddy remained- day 7, day 11, day 15 - he required less and less bandaging. IV lines were removed, antibiotics stopped. Then one day, he was no longer Buddy.  He was no longer nameless. His Mom stood happily during rounds and announced his name - “Graceadieu Dieudonne Fabrice”.  Bernard already knew.  We on the emergency staff always feel hope during such times as these. I think it is a large part of what drives us. It has to. 

The next day they left the hospital. Back to their village, their community and their future.  

Thanks for reading.

Today

Today:

There was a gecko skin shed into my briefcase.
There was a round worm curled in my shoe.
There was a small cockroach rampant in my hospital footlocker.

There was the return to Kigali after a fabulous 2 weeks away on spring break vacation.

There was the return to work, the return to school, the return to the home we have made here.  There has been a return to the mental state that we are far away, that we are challenged, that we are privileged, that we are so fortunate.

There was the realization that my time here is now half over.  I've hit the arc and am now running down the back half.  So much to do. Exciting, intimidating and a little relentless at times...

There has been the acceptance of blog radio-silence.  There is no way to catch up on what has been felt and thought and completed. There never is. Just have to re-start. Just have to keep going - take it in and appreciate the process, the path and the light.  So goes the work and the writing!


There was the team of gum-booted hospital cleaners in the ED on arrival. Splashing water on the floor, mopping and squeegeeing. Puddles of bandages, blood and syringes.  Floating caps, wraps, and tubes. There was the trail of my dirty footprints across the ED floor towards room 9.

There was a ride earlier. There is still a single-speed in play. The rear derailleur remains wrecked. Twisted beyond resuscitation by an errant branch almost a month ago.  There are no XT derailleurs to buy in East Africa, let alone Rwanda.


There was a man selling high-heeled shoes though.

He was walking the road carrying several pairs in his hands.  Red ones with a cork heel - Just in case there was someone else walking and needing such an accessory this morning.  There was another man carrying blazers for sale - One in brown suede and another with purple velour. They didn't look my size.  Such walking selling wouldn't be done if it didn't work. If the sellers couldn't sell, they wouldn't walk. I marvel at the ability to buy and sell party shoes and formal clothes while walking through the muddy paths of the rural outskirts of Kigali.  Testament to a hopeful nation on the move. On the up. It hopes.

For a new derailleur, I  am hopeful. There is a riding friend with access to a diplomatic pouch. He believes that a derailleur can come from the UK in the pouch. It has been done before.

There were kids racing to school on the ride. They smiled and waved and yelled greetings and questions at me. Incessantly. They chased after me and called me muzungo. They ask for money, but I think really they are only asking to be noticed, to be greeted, and to share in a slice of the wider world that is riding by.  More than any of their family before them, they will do.


There was a comatose child in room 9 today. He had fallen from a tree picking mangos. His family did not have insurance. On my shift, his brain herniated through his right ear. A horrible sight and an inevitable declaration of his clinical outcome.  There was his mother. Stoic and reserved. There was a conversation about futility of intervention and the merits of comfort care. There was her look of understanding, her look of acceptance about her child's imminent death that made it obvious that she has been in this situation before.  This will not be the first of her children she has buried.
There was an attempt to teach the resident and the nurse in room 9 that these conversations about death in the ED are also what we need to do as emergency care providers.  The concept of providing acute ED comfort care is slowly gaining traction.  Thankfully so, for there is much of it.

Returning towards home, there was a discussion with my regular taxi driver about the woes of Manchester United, the increasing cost of school fees for his child and how he collected drinking water from embassy swimming pools while surviving the genocide.

Once home for the evening, there were some happy games of tag and some living room skateboarding action. Then a little homework before the power went off.

After that it started raining.  Then the stars came out.

There is another day tomorrow.

Thanks for reading.

Rules of the Road

When the light is red, it usually means stop. Most of the time. Sometimes it means go. Green almost always means go, except when red means go on the perpendicular road.  White lines in the middle mean several things - You can go on either side,  or straddle the line until someone flashes their lights many times behind you. Lines do not mean anything when turning. Turn as a bunch. If there is room in the stopped traffic in front of you, budge further forward. It is no problem to turn left or right from three lanes over on the opposite side.

If there is a grassy median in the road, you cannot walk on the grass. You also cannot walk barefoot anywhere outside. That is illegal. You cannot walk and eat at the same time. That is thought to be rude. It is noteworthy that picking one's nose during a public conversation is not considered rude or awkward.

If there are trees on the road median, you can't hit a tree with your car. If you do, the fine is one million francs.  That is about 2.5 times the average annual wage.  I believe that the average annual wage is biased.  There are more than a few Rwandans driving fancy vehicles in Kigali that have enough money to hit many trees.  The vast multitude of other Rwandans earn much less than the officially-advertised income of 569USD/yearly.

Here they break rocks for 10 hrs a day for 1000francs. This is less than 2USD/day.

Local coltan mine

If you hit a chicken, you must pay the owner for the chicken. A chicken costs about 4 days of breaking rocks. It is best not to hit anything.

In town, there are many motorcycles. Many, many motorcycles. They are mostly taxis.  Mototaxis are the least expensive and the fastest way to travel in this sprawling and  hilly city.  Everyone has to wear a helmet on a mototaxi. Other than the helmet rule,  there are precious few other rules on a mototaxi. Mototaxis can turn and stop and go anywhere at anytime.  As a mototaxi passenger, you can carry anything you like. Wood, briefcase, a goat, weekly groceries, a fridge, or even a baby.  There are no baby helmets.

"Might is right" on the roads they say. Buses and trucks go where they want, cars move out of their way. Motorcycles - 60-120cc powered "Motos" - must stay out of the way of buses, trucks and cars. If you are on a bicycle or on foot, you must stay out of everyone's way. If you hit a person, and they are still alive, you must take them to hospital, but only after the police have come.  There is no fine. That is what vehicle insurance covers.  It is mostly children that get hit. Mainly by motos. The truck serves into the middle of the road and the car has to move over. Motos often drive on the inside,  just beside the car. When the car moves over, the moto does too. The only place the moto can go is to the side of the road. This is where everyone walks.  Because of this problem, more and more roads in town have sidewalks.

Bikes are a very common form of transport - even on the "ferry"

Throughout this small country however, most roads do still not have sidewalks.

Everynight, all year long, it gets dark quickly at 6:20pm. Streetlights are rare.  You do not put your vehicle lights on until it is truly dark. Dusk and dawn is a dangerous time to walk on the roads. Unfortunately it is also the time when the roads are the most crowded. Everyone uses the roads for transport to home, to work, to school, to the fields, to everywhere.

If you run home from the hospital after a shift, you take side streets and back alleys. You also cut across cornfields and navigate the warren of paths through the ramshackle housing areas. You then run on the cobblestone sidewalks of the leafy embassy streets. It is a great form of transit. Except at high noon during the dry season...and especially at high noon of the dry season after a busy shift where there has been no food or water for 6 hours.  During these times when you feel faint on the road, people will give you warm Fanta to drink and fried balls of flour. They will laugh with you when you try to call home for a pick up and your phone doesn't work. The battery is dead again. The battery has been slowly dying because the charging situations here are harsh. Electricity pounds thru the system at 180-280V. Or it doesn't come at all, or a little bit dimly. The computer shocks you sometimes and other times the ice cubes melt in the freezer. This makes the evening G&T taste less good than usual. Everything works out tho.    Someone lends you a phone. Or finds you a drink. Or fixes almost anything that is broken. There is someone somewhere in this city that will repair your sink, iphone, blender, camera, bookshelf or car door. If you forget your pump on a bike ride and get a flat tire far away from home and far from a paved road, a moto will take you to a the closest bike shop. The most common tool in a bikeshop is a hammer. My carbonfibre Scott mountain bike from Team Rwanda does not need a hammer.

Note the powertool(s) mid-left

It needs a presta tube. There are no presta tubes in this country. "All finished."  To no avail, I have been to many shops and alleys and stalls in town. Rwanda is the second most expensive country in the world (after Antarctica)to ship things to. I will now find someone in a small cubby beneath a  stairwell somewhere downtown to drill the valve hole of my fancy rim wide enough to accommodate the bulky valves of Rwanda.

Before riding, running or working, it is best  to have an omelet at Blues cafe.

This local cafe has great coffee and better food than in The Matrix - it is all the body needs really; local veggies, ham, eggs and french fries all cooked together with a mango on the side. Awesome.

Outside of town, bicycles are the most common form of transport. There are still buses and trucks, and some motos, but most transport is by igare, or bicycle. There are wooden bikes, icugutu, that are made by youngsters with machetes and scrap wood.

They can transport large loads of yams to market. Push up one of the many hills slowly, ride down wildly on the other side!

There are also many Chinese-made bicycles here too. They are locally re-enforced with re-bar segments and fitted with colourful accouterments of blessing and functional transport. Messages about God, football and life are painted on fenders and frames. Ornamental mirrors, plush person-carrying cushions, large vats for milk, baskets for coffee and sturdy racks for 50kg sacs of flour complete the single-speed machine.

Push it up the hill, rip it down the other side. Everyone stays out of their way!






When a bike like this with a 40 kg load of cabbages passes you, stay to the side - dodging rolling cabbages from a burst cabbage-bike sack on a bumpy downhill requires decent bike handling!

A great read on Rwanda's fascinating bike history and Olympic cycling aspirations here can be found in Tim Lewis' book, "Land of Second Chances".

http://www.theguardian.com/books/2013/aug/11/second-chances-rwanda-cycling-lewis-review

The girls on some local singletrack

On of the many onlookers

The girls are enjoying the riding too. It is hot and  crowded, and the goats and superheros  have to be kept in check, but it is fun and each outing is a true adventure. Every corner and each hill and dale holds a new surprise, sight, smell or situation.

All three girls have impressed with their resilience, their adaptability, and their attitude. School is on and the kids have taken it in. Swimming, math fractions, Tae Kwon Do, pottery, science experiments and playdates are already happening. Football season has started and tennis awaits.  KT has started clinical work at an orphanage http://www.rwandanorphansproject.org/ as well as co-teaching a community medicine course at the medical school.

They are fantastic companions.

 As a family, we are all learning various rules and realities of living in Rwanda.

 It is not always easy, and some days involve more "learning" than others, but the family adventure is truly on.

Thanks for reading.