Let's talk medicine.

My experience in the hospital really has been very great so far. As I think I may have mentionned before, what I was hoping to gain from working here more than anything, was how to work with less. And boy am I learning quickly! We are in a teaching hospital here, and we have an xray and an ultrasound machine. That's it for imaging folks! I never realized how GREAT a CT scan was, let alone MRIs! And bloodwork is severly limited as well...sometime we cannot even get a CBC. So it really feels like you're working in the dark sometimes, which can be scary. But the docs do what they can with what they have and what they know, and generally the patients do well, which is comforting, and something to learn from as well.

We see tons of osteomyelitis here. It's incredible. For a long time I couldn't figure out why we were seeing SO much of it. Then it was explained to me that a lot of the kids we were seeing were malnourished, and thus predisposed to infection, which unfortunately seems to seed in their bones. We saw one boy who's hip had been dislocated for weeks, without anyone having noticed (even though he was in the hospital setting!) and the other hip had been completely eaten away by his infection. When this case was presented in the morning it was hardly even discussed. There is nothing we can do for this boy in Rwanda. He is about 12 years old and need to have both hips completely cleaned out, needs systemic antibiotics and needs bilateral hip replacement. That was depressing.

I'll write about one more depressing case then I'll try and come up with a positive one to end the story with, ok??

We had a child come in last week with an acute abdomen. He was about 1.5 years old and was pretty much comatose on arrival. We realized very quickly that he had an ileus (absolutely silent distended abdomen-so scary) and when we were placing lines (in his scalp) he didn't budge (also a very scary sign in a young child). Afterwards we discussed his case and we figured that he was already in heart and lung failure and that his kidneys had shut down. He had had a history of diarrhea for about a week and had been vomiting prior to presentation as well. What happened was that his electrolytes were completely out of whack and his bowel stopped working, which basically poisoned his blood and eventually killed him. When we were doing CPR on this tiny body it just felt wrong. They tried surgery but honestly, I think no matter what we would have done for him, he had presented too late. Like many of our patients, unfortunately.

So happy time! A lot of the kids who come to hospital present us with happy times! They may be around for awhile (with burns or osteomyelitis) but that means we get shrieks and smiles and giggles, especially as the white girl! One child had a seizure and fell into a fire (from what I understood) and though he'll be permanently disfigured, some plastic surgeons worked on him last week and he can now close his eyes again. And though he lost both his hands to amputations, he has prostheses available to him. And he always comes running to place his stumps in my hands and to receive a hug...which is just great! The kids in the hospital do not treat him any differently and we can only hope that these friendships will help him through what will certainly be a challenging life.

I will stop by saying thank you to everyone for their support and positive wishes over these past several months! I got my first choice for residency programs, and will be starting family medicine on July 1rst in the Greater Vancouver program run through UBC. I am so incredibly excited, but am trying not to let that affect my last several days here in Butare. I've got a great weekend planned and can't wait to tell you all about it, next week! Big hugs!!

I am having such a fabulous weekend - which is exactly what I needed considering we are now less than 36 hours away from determining where I shall be training these next couple of years!

I started my adventure Friday when I met a Rwandan friend at the bus station and rode into Kigali. There the German medical student I was traveling with and I each hopped on the back of a motorcycle taxi to make our way to a suburb to meet friends. Reminiscent of my Cambodian days, I had a backpack on, the girls' wheelie suitcase balanced on my lap, and my phone rang (which I of course had to answer!) Still got it!

We met the American that I had met in the airport three weeks ago (the coach for the National Rwandan Cycling Team) at this lovely, expat restaurant. A little bit of culture shock, I have to admit, but the latte I had was just out of this world! Shortly after arriving the German girl got a lift to Ruhengeri with the American's new mechanic, and I got on the back of the American's motorcycle and we rode the 1.5 hours through the rolling mountains to Ruhengeri. It was such an amazing experience - exhilarating and quite the adventure. We got stopped twice by the police...one time to tell us to slow down, but really they just wanted to stop us and find out what two muzungus were doing on a motorcycle in Rwanda! Once in Ruhengeri, I decided to join Jock (the American) on his venture to Gisenyi, where he was meeting with possible donors. We drove to the border with the Democratic Republic of the Congo and stopped in a fancy hotel where we met with the investors. There I met many many Canadian-Rwandans, one of whom lives about a 2 minute walk from my apartment in Toronto! What a small world - and hopefully my schmoozing helped the team out a little :) We drove back to Ruhengeri in the rain - which was really quite beautiful, with lightening in the distance over Goma. And you could see the active volcano as well, glowing red in the mist across the border.

The next morning I woke up early, hopped on the back of the motorcycle and made my way to Kinigi where I met up with a group to go trekking for gorillas. This is a ridiculously expensive venture, but I've heard the cost is going to double in the next year - so I took the opportunity to get out and see these lovely animals. And I did it by the cheapest means possible, which I am pretty proud of! We hiked for about 1.5-2 hours up the side of a volcano that borders with the DRC and then bushwacked our way down a slope until we were meters away from the animals. At one point, one of the guys was yelling my name, but I wasn't paying attention until I felt something brush against my leg - a gorilla! haha! Our group was the Amohoro (Peace) group and consisted of 16 individuals. Two fluffy little babies, a ton of teenagers and one silverback. We bushwacked with the group for about one hour before we decided to take a different trail back to the vehicles. This required more bushwacking and was like no hiking experience I've ever had! Aside from a whiny mother-daughter duo from Europe/UN, we had a great great time, and watching them literally summersault over one another as they fell down a portion of the hill kind of made up for their poor company!

I was going to hike another volcano today, but everything is so muddy in the rainy season, and the views would have been similar to what I saw yesterday, so I decided to save myself the hefty hiking fees. Instead I'm going to borrow a mountainbike from Jock and a small group of us are going to try and bike a 40 km route to where we should get a lookout over two lakes up closer to the Ugandan border. The weather looks great so hopefully it will hold out!

I've been thoroughly spoiled these last couple of days. I have this gynormous bed, access to a HOT shower and dynamic wonderful people who are doing some pretty great work in this part of the world. Last night we had a big dinner and we had an 18 year old kid from America over who is teaching 5 year old children in the local school (no teaching education, thought he was coming here to assist!) we also had two CEOs for different African NGOs over...as well as Jock, who is running at least two to three NGOs that I am aware of, Suzanne who is building a prayer shelter for a school and has just finished building a library for another school, myself and another medical student and the brand new American mechanic for the National Rwandan Cycling Team.

I could not ask for a better life.

The Weekend (continued from below)

This memorial was created in the location of an old school, where 50,000 people had come for shelter when the killings had begun. The killers came and tried to kill people but the 50,000 were strong enough to keep them at bay. Then the interahamwe came with grenades and machetes and they managed to kill nearly everyone at this site. 48,000 people were buried in mass graves, and 2,000 bodies were placed on display, to remind people that there was a genocide in Rwanda and that it should never be allowed to happen again. What I didn't realize was that the bodies had been preserved - so in each of the 20 rooms we had to walk into, you were greeted with a stench as well as the atrocity of seeing bodies in very unnatural positions. David had visited this site before, and still walked with me from room to room, though we didn't say a word throughout the whole visit. The French, when they eventually came, used this as one of their homebase sites, and had unknowingly built a volleyball court over a mass grave. I have to say that I was a little disappointed that I was the only tourist at this site. If you go to any of the Jewish death camps in Germany or Poland you'll find busloads of tourists paying their respects. But here it was just David and myself, and the survivor who took us on our tour.

After finishing at the site (and leaving a 2000 Rfr donation - food was going to be tight!) David and I slowly walked back to Gikongoro. While walking he talked to me a little about his own experience and together we tried to understand, as a younger generation, how people could hate so strongly as to conduct mass murder. It truly is incomprehensible.

The rest of the day was very pleasant. I couldn't go out dancing with David because I had so little money (and nowhere to stay post-midnight!) but he invited me to his place for dinner (score!) and we spent the evening chatting, comparing cultures and looking at photographs.

Sunday I made my way into Kigali where I secured a gorilla trekking permit for this coming weekend (woot!) Getting this permit was a pain in the ass and is a story in itself. Then I walked to the official Genocide Memorial Museum (to complete the Genocide weekend!) where 250,000 bodies have been buried. This Memorial was very well put together and I was happy to see that there were more tourists visiting it. I spent two hours walking around and reading and found it interesting in that there was very little information surrounding the events that led up to the Genocide, but there was tons of info about when and how the victims were killed. Is this because we just don't have the details? It was pretty striking.

Oh and just to keep the food story going...that morning I had leftover popcorn and water for breakfast. I then ate a chocolate bar that I had bought a week ago for lunch - but it was so disgusting! The chocolate had turned white and powdery, but I needed to eat something! Then, happily, I was able to find some guys on the street who gave me an excellent exchange rate (better than the bank!) and I then headed directly to a restaurant where I got myself the requisite plate of carbs :) The things we take for granted! haha!

Ok. I should probably get back to the research I came here to do. One of the interns has asked me to teach him about abnormal heart sounds and I need to refresh myself so as to avoid confusing them, and myself!

The Weekend

I had a great great weekend, and it all pretty much started on Friday afternoon, when I decided to stick around the hospital in the afternoon, because some of my favourite interns were working, and I can provide them with comic amusement and the occasional tidbit of relevant medical information. Sometime mid-afternoon when it was a bit slow I ended up chatting with a fifth year medical student I hadn't met before. When he asked me what my plans for the night were, well I didn't really have any - so I got invited out to some party he was planning on going to! Random but that's the way things seem to work for me here. Then (very fortunately) I found out from the interns that on the last Saturday of every month ALL businesses in Rwanda close down for the morning. So the banking I had been planning on doing the following morning, I now had 45 min to do. I literally ran out of the hospital to my room and then 'downtown' to get to the bank before it closed. Because I was in such a hurry, I didn't count how many Rwandan francs I had left - which becomes important later in my story.

So I met up with Jeado, this 5th yr med student and we had an awesome cheap dinner of carbs and Fanta. Then we met up with some of his other friends and walked about 35 minutes into a part of the city I had never been to before. There we found the house of these two Danish girls who were hosting the party. It was great! We danced, drank Primus and ate birthday cakes (it was no one's birthday - but who cared!) We decided to bring the party to the dance club around 1 am and it was only then that it dawned on me - there's only one rule at the place I'm living in and it's this: doors close at midnight. And they don't open again until 7 am. Crap! I had completely forgotten. So I ended up having to rent out a room that night in a small local hotel. This is where the money side of things starts to kick in - I had enough to pay for the room but it would leave me with very little to get me through the rest of the weekend!

The next morning, as the city lay silent until noon, I wrote postcards and tallied that I had just about 3000 Rwandan francs for food for the next 48 hours. That is just under 6 US dollars. Not too too bad. In the early afternoon I met up with one of the interns and he and I hopped into a matatu and made our way to Gikongoro, a city about 35 min from Butare. There we decided to hop on the back of two bicycles to make the 2 km trip down to Murambi. What a ride! The scenery was absolutely spectacular and I decided to focus my attention on that, because we were riding fast and I've seen some of the injuries that result from bicycle crashes in this country! When we got off, my friend David even commented on how fast we had been riding! woot!

So I wanted to visit Murambi because it was supposed to have quite a striking Genocide Memorial. David was incredibly kind to have volunteered to come with me, especially once I realized what we had gotten ourselves into. (to be continued...)

A day in the life of...

So the typical day would have me wake up around 0640. I then sort of stumble around getting out of the mosquito net, washed and changed so that I can run across the road in time for "staff" which starts at 0715. Basically these are morning rounds, where the interns (final year med students) who were on call the night before present the interesting/challenging cases from their 24 hour shift. They get *grilled* and I'm happy to just sit back and ask questions ;) These rounds are done in English, which actually slows things down considerably. The old official languages of Rwanda are Kinyarwanda and French but in recent years the government has introduced English as the mandatory language of training so these poor chaps have had to learn a new language in the past 3-4 years.

At 0830 I'm allowed to leave and I run to the hospital restaurant (I believe the name is: Yuppie is Yummy) where I grab a meal of bread and tea. The tea here is flavoured with copious amounts of sugar and powdered milk. The first sip is always a pleasant jolt.

Then I usually find an intern who can tell me what is going on. I either join them in "duties" which is basically a kind of emergency room or I do the "consultations", which can often be quite good. What I've gathered more than anything so far, is the doctors' abilities to diagnose by clinical suspicion. They have an xray here. And an ultrasound. No CT scan - if they want this, the patient must be sent to Kigali - 2.5 hours away. And I don't think there's a MRI in the country, though I'm not sure. So when the head injuries come in you have to do everything you can to get the information from history, physical and xray. It can be quite impressive. There is one intern that I work very well with and we will work up patients together. Last week we diagnosed a patient with Brown-Sequard Syndrome as well as an Anterior Cord Syndrome! The patient had been in a car accident 4 days previous.

I generally finish work sometime around 1600 and then make my way to "downtown" Butare - basically the main road, about a 15 min walk from the hospital. Here I can find supermarkets, restaurants, banks and internet cafes. And the entire population of Butare! I have been told that with the surrounding areas, the population is about 500,000. I'm not convinced, but it's certainly larger than the 75,000 I initially read about! I usually hang around downtown either with another medical student or on my own, writing in my journal, reading my book about the genocide or starting today, my new project: learning Kinyarwanda. I learned a new word this morning: mwaramutse, and boy did it make a huge difference! It means good morning...but everyone reacted so positively that I feel just a bit more effort will make a things that much easier for me...and if I could bargain in Kinyarwanda...the world would be my oyster! Though I did just buy 5 passion fruit and 12 bananas for about 50 cents...

Other than working, last weekend I made it up to Nyungwe Forest, which is only about 100 km from here but that meant about a 2-4 hour bus ride, depending on your vehicle. Plus the roads get bad about halfway through the park. We did a trek on the Saturday that brought us through amazing primary forest, complete with all the sounds of a rainforest. And at the end of the path, an enormous 40 m waterfall! And on our way back, we happened upon a group of baboons! The next day we hitched into the park to a path that would bring us to a troup of colobus monkeys. We then stood there for at least an hour just watching. There were at least 200 of them, and probably more. I wondered if they could fall from a tree and then watched as a mother with her baby misjudged a jump! I think she was ok but she probably fell 20 m at least!

Everyone here is incredibly nice. I feel like I have a massive group of brothers at the hospital now, watching out for me. One of them even made me call when we had arrived to the forest and when we had arrived back in Butare! Speaking French makes a huge difference as well, and I can often speak with the people on the street, which is great. So yah, I think that is pretty much it for me at the moment. One funny image: a patient came in with a hydrocele, and the doctor wanted to show the med students how you could differentiate between a hydrocele and a scrotal hernia by shining a light into the scrotum. Unfortunately none of us had a flashlight with us...so he pulled out his mobile, turned on the torch on the mobile, and held it against this kid's scrotum! Resourceful!!

Wow - it's been awhile since I've posted something on this site. But my friend Jenn was asking whether I would be updating people, and after spending the last 20 minutes trying to remember passwords and such, it would seem that yes, I will be able to update those who wish to check in!

I'm in London right now, working on three nights of poor sleep, about to embark on one last overnighter flight...to Nairobi. Got to go into the city for a couple of hours and see all the necessary sites and visited with two British friends I met last summer diving in Egypt. So far, so good, as far as trips go.

Will update this as regularly as possible - maybe with photos as well. Two more flights...just two more flights...

Well, I have been back in Canada for nearly a month now...wait, it's been exactly a month. Don't really know if I'll be checking back to this site very often, but I thought I'd put up a note for anyone still checking back. You'll notice that in some places I refer to a child or patient but there is no accompanying picture. It would seem that U of T has specific guidelines, regardless of whether the patient has agreed or not, and so I've had to go through what I've posted and delete any pictures where you could see the patients face.

Still dreaming of Cambodia :)