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.

Asking for Direction

I couldn't decide which way to go. Up or down?  I wasn't lost, but I wasn't sure which way to go either.

Regardless, I was on the side of a steep hill, beside a mud hut, and beneath the welcome shade of some banana trees.  The inviting downhill track had petered out into a warren of narrow ledges between banana plants,  sorghum fields, mud huts and startled chickens.  I was four hours into a Sunday afternoon ride and it was now time to get back.

A short ride from town

Not only was I hungry, but I also wanted to avoid the looming thunderstorm and curtain of equatorial night that was soon to fall at 6pm.

A different ride requiring some transport
my riding buddy's bike

 Resigned to the fact that now was not a good time to get lost,  I shouldered my bike and retreated back up the steep track.  I chose the path I knew rather than push a route I wasn't sure would work, but if it did, would have made for a cool outing.

It's an analogy of course.  That bike ride and the life I lead here.  Something thoughtful happens each day it seems.  Unheralded, something sad, something maddening, something startling, something ugly, something encouraging, and somethings beautiful unfold before me.  I suppose this happens to some degree to everyone everyday everywhere. I find these events are more apparent here though - it is as if I have momentarily set-aside my telescopic lens of habit & home.  My view on the landscape is now seen through a wide-angle lens and situations and images careen uncontrollably into my field of view.

I haul my bike past a barefoot young woman. She has a baby on her back, a pile of scavenged firewood on her head and is listening to Rumba music on her mobile phone.

There is a similar girl who tends the cobblestone street near our house. Every day she is on the road.  Her job is to use a small length of iron bar to clear the grass from between the cobbles. I recently watched a crappy two-stroke motorbike taxi, spewing exhaust, chug by her. The passenger was carrying a fridge and the motorbike engine strained at the effort. So focused was the girl on the fridge transfer, that she only just managed to leap out of the way of a red Mercedes.  The sleek sedan sped away over the clean cobblestones, oblivious to all of us on the roadway.

I'm not lost in the ED, but I sure the hell don't know where I am sometimes.

Coming to understand the cases, the resources, the expectations and the realities has been a challenge.

As the only ED (and fledgling at that) in this low-income country, we are relatively well-supplied. We have nurses, we have workable drugs, we have stretchers, we have housekeeping staff, we have intubation equipment, we have an ED ultrasound machine, we have an ICU (often full), we sometimes have running water, we usually have a CT scanner, we almost always have power, we sometimes have bedsheets, we never have paper-towels, we often have soap, we can't measure electrolytes,  our ECG machine is broken, there are no infusion pumps, and we don't have ventilators.  There is no social worker, no clinical coordinator, no discharge planner, no hand clinic, no cath-lab, no stroke team, no clinical pharmacist, and no trauma team.  There is a limited medical insurance plan, mutuelles de sante, that doesn't cover nearly enough. If you can't pay for the meds, for the imaging, for the treatment, you don't get it. Unless you are dying and get into room 9.  Then if you survive your subsequent hospital stay, you stay to pay your bill later. We have a large room at the end of the ED hallway ironically called "Serena Ward." Here patients stay under guard. They are "cured" but have yet to pay their hospital bill. A relative has gone home to the countryside to borrow or raise money by selling some land, or a cow, or perhaps a bicycle.  The patients sit and wait amongst a colourful cacophony of packages, belongings, and hangers-on.  The view from the window of this room looks over to the fanciest Hotel in Kigali, The Serena. The room's namesake.  The Serena Hotel never runs out of paper towels....

It is the inevitable daily case of an avoidable death that pushes me off my map.  Today it was a 7 year-old girl who was burned in her bed from a candle alighting her mosquito net.  After 4 days in a district hospital, she was transferred to CHUK ED in septic shock.  Too late to catch up on fluid and infection, it was a long code before she died.  How to push for the provision of basic emergency care upfront, care that would likely have prevented her death, is where I'm less certain of my direction.  There is just so much dysfunction on so many levels.

My fellow EM colleague and I  have carved out a bit of physical order in the ED chaos by establishing ourselves in room 9 and 8. The resuscitation bay and step-down ward respectively.  In these two rooms, we can care for up to 14 patients. It is here where we spend the majority of our clinical time. In this space, we have better control of medications, of equipment, of teachable moments and of care delivery.

Room 9 

Room 8 Whiteboard Plans

Having this space makes me feel less lost.





The first 3 modules of the basic emergency medicine training course are now complete. The lectures, simulation sessions, module exams, bedside teaching and shared patient care have all been very absorbing and positive.  When I step back and look in, I see a difference from even 6 weeks ago. It is a small difference, but the care provided in room 9, by both residents and nurses, is obviously more confident and competent.

There is great distance to travel, but the general direction seems clear.  It is an exciting journey.

Thanks for reading.

Prisoners Wear Pink

At least the prisoners on the hospital ward do.

I learnt this on my first morning at Centre Hospitalier Universitaire de Kigali (CHUK). More specifically, I learned that the pink is for those convicted and the orange suits are for those that are accused.  The pink was beautiful in the early morning sunlight.  The irony is obvious.

This first full week in Kigali has been full of learning actually!

I'm learning that looking for a home to rent allows one to see many Mobutesque mansions,  cookie-cutter housing estates, and homes of faded elegance that are slowly succumbing to the inevitable creep of the untended jungle vine.  I also know that the Realtors seem to have prior knowledge of my housing allowance and enjoy pushing that envelope!  The search continues for the ideal family home....

I have learned that having people on the ground who have been doing this job for a year are a fabulous resource.  Joe, who is the emergency physician that I am replacing, hails from New York and has been here for one year with his wife, Julia.  She is also with the HRH program in critical care and anesthesia http://hrhconsortium.moh.gov.rw/.  They have become good friends whom have helped me navigate, literally and figuratively, through the Kigali streets, CHUK politics, Rwandan mannerism and finding the best place for Thai food Kigali.  I will miss them when they leave this week.

They have also sold me their  well-loved vehicle - a 2002 Toyota Forerunner Surf edition with a Turbo diesel engine and a chassis that will get us to some amazing places in Rwanda over the coming months.

I'm loving driving it and know that the girls will dig it too.

 Joe & Julia's tutelage has spread to even showing me some local single track - well, the "singletrack" are actually the paths where villagers conduct their lives of subsistence-agriculture.

 Despite people herding cows and goats, carrying firewood, harvesting bananas, pushing cans of cooking oil, peddling fruit and vegetables, caring for their younger siblings, and hoeing, planting and clearing their land, everyone had a happy greeting of "maramutse," or "good morning," for us as we rode by on our fancy velos with unimaginable recreation time!

Gracious, accepting, resigned and resilient are these folk.

I've learned that I'm not yet ready to describe the CHUK ED.

  At least in so far as the caseload, the M&M and the stark realities of what can and can't be done for the many young patients who present  with serious, and largely preventable, trauma or infectious disease.  More to come on that in a future post(s)...

The residents of the inaugural CHUK Emergency Medicine Residency Training Program are engaged to learn and they are what this HRH effort is all about.  It is exciting to be here now, with the development of EM in Rwanda in it's mere infancy.  The frustrations, challenges, and opportunities loom large. Their solutions and systems will hopefully be learned in the times ahead....

Forward with enthusiasm, tempered-optimism and well-placed determination!

A few other things I have (re)learned this week are that Ryszard Kapuscinski is a fantastic writer (http://en.wikipedia.org/wiki/The_Shadow_of_the_Sun),
that you can't always trust what you read (even if it tastes good)

On every table at the CHUK Cafeteria

and that having a sense of humour and humility is essential.

Life is rich.

I hope that all goes well with you all.

Thanks for reading.

That's what the signs say, "watch out for pythons and puff-adders while hiking on Table Mountain."

Watch out I did!  I would rather deal with the potential bear than get envenomated by a puff adder.  Such thoughts of fangs and paralysis were invading my head as I stuck my hands onto warm rocks on the short blocky sections of the India Variant ascent (link). Serpentine fears continued while walking by the geraniums and the uniquly indiginous protea plants

high above the southern Atlantic ocean on a splendid Cape Town Saturday morning.  Every rustle of the wind and lizard had me hyper-alert.

Somewhere on the ascent, I began to think that the python hiking fear would be a decent entry into the blogging world. I have been meaning to start a blog for a while, but I have always stalled at the last minute, losing the story into "why would I write about what I am doing" sands of time...

I almost started this "moving to Kigali" blog a few weeks ago when the concept that I WAS MOVING MY FAMILY TO KIGALI finally hit me hard in the face - an abstract plan had changed to cement-heavy reality.  All this happened while I was quietly drooling saliva down my chin and wincing with bilateral arm pain riding home from the RCMP.  Why was this?!

I dislike going to the dentist. So much so that I refused to schedule the recommended three visits for overdue dental work and insisted that the dentist anaesthetize every nerve in my face and do all of the work on a single visit. She complied and I rolled out of the office with a non-functioning tongue,  a completely numb face and a continuous stream of saliva down my chin.  Next stop was vaccinations. Getting shots in the arms is the next thing I dislike after dental work. Getting shots at a for-profit Travel Clinic where they not only charge you too much money, but also instil fear about bugs, worms, fleas, sun, sand, water, food, jet-lag, blood-clots, yeast infections, bare feet, and counterfeit medications into even the seasoned traveller, is particularly annoying.   Alas, trying to get the doctor to understand my schistosomiasis questions with a non-functional tongue and a copious stream of drool was for naught.  Regardless, some vaccinations save lives and I couldn't get out of there without at least 4 of them.... The North Van RCMP for a criminal record check, required by the Rwandan medical board, was next. At least better than going to the dentist or getting shots - so I thought... The clerk couldn't understand what I was asking and what I was saying  - To be fair, try saying "I'm moving to Kigali and need a criminal record check for the Rwandan Medical Board" while drooling with a hot potato in your mouth, and you will get the idea what I sounded like.  Just when she was about to have me escorted over to the next door LGH emergency department for assessment, she understood and gave me the paperwork.

Anyways, that was another story... Today's story is one of a fantastic outing on Table Mountain, with no puff adder sightings, and a great end to week in Cape Town for the exciting and inspirational EMSSA and AFEM Consensus Conference www.afem.info.  It is also a story of embracing fears - dental work, vaccinations,  and even pythons, all just need to be faced with "grace in your heart and flowers (metaphysical ones) in your hair."  Thank you Mumford https://itunes.apple.com/ca/album/after-the-storm/id354072886?i=354073280

Back to Kigali tomorrow to settle in and get to work. The girls are still in NV until Christmas. I miss them.  I guess it is time to face not so much fears, but to deal with some healthy intrepidation about the exciting work ahead. That too will be another story!
Thanks for reading.