Somewhere Else

It's Friday after work. End of the work week happy hour. John, my Rwandan co-resident says, "Let's not think about the hospital this weekend," as he savors his bottle of Tusker beer.    

I've had this conversation countless times before. Back in Connecticut, there are times when I have to work hard to mentally separate myself from my patients' stories and situations once I step out of the hospital. But here, that becomes an even tougher challenge. As physicians, we like to be able to tell patients, "We did everything we could." In the US, we are often fortunate enough to have "everything" be everything that medicine and science are capable of. Here though, it's "everything" that happens to be available in the country, or in stock near the hospital, or performed by a specialist who is actually in the country, or whatever the family can afford.

What's it like to know that somewhere else in the world, the 22-year-old girl with kidney failure and heart failure would reliably get her diuretics every day so that she could breathe, and would have a hope of getting dialysis and then a kidney transplant? Somewhere else in the world, the 18-year-old girl with pancytopenia (very low levels of her white blood cells, red blood cells and platelets) would have gotten her platelet transfusion at the right time in order to do a bone marrow biopsy, and perhaps a diagnosis, and perhaps some treatment for the problem, and would not have died of overwhelming sepsis from her hospital acquired infection, at least not last week. Elsewhere, the 21-year-old girl with cough and lymphadenopathy would have gotten her CT scan and lymph node biopsy weeks earlier, and perhaps would not have died so quickly, of unknown causes. And somewhere else, the 37-year-old woman with five children, who just gave birth to her sixth child by c-section three weeks ago, would not be laying on her bed with paralyzed legs because of the tuberculosis that had destroyed her spine during the pregnancy, without a CT scan or neurosurgeon nearby soon enough to try to repair the problem, before it was too late. These are the patients I tried to clear from my mind as I sipped that cold beer. I think John was too.  

Friday was my last day on internal medicine. After five weeks, I'd like to take the last week for some pediatric time. John told me he didn't want me to leave with a bad impression of medicine here. He asked me what I really thought. I told him what I've been writing here these past five weeks. How impressed I've been with the residents and attendings, with the knowledge and teaching, with the technical skills of the residents who are required to work for two years after medical school as general practitioners, doing everything from simple pediatric visits to c-sections and splenectomies, before starting residency. In the US we're all so specialized, even in our residencies, that many of us lack the entire set of practical skills that physicians once possessed. And we rely so much on imaging and laboratory investigations that our physical skills have atrophied. I told him I know how much of it is about the resources, and the system here. He seemed satisfied with that answer. The more you now about what's available elsewhere, but not here, the harder it gets. The more you need to step away, disconnect yourself. In that process, do you grow too immune to the suffering? Sometimes you just have to get away.

I finally made it out of Kigali this weekend. Took a trip with a bunch of the US doctors to Kibuye, and beautiful little town on Lake Kivu, in the western part of the country. Indeed, I can now say that not only Kigali, but Rwanda, is breathtakingly beautiful. Nothing but green, verdant, terraced hills and mountains, as far as the eye can see, between Kigali and Kibuye. Green hills dotted with little huts, and clusters of trees, and patches of farmland. As the road approaches Kibuye, the mountains give way to the volcanic lake nestled between them. Lake Kivu was originally part of the Nile River watershed, but got closed off as a tributary when cooled lava essentially created a dam. The alternative folk story is that Lake Kivu was formed when a farmer's wife, as punishment from God for bad behavior, could not stop urinating, until her urine created Lake Kivu, among the top 20 freshwater lakes in the world for depth and volume of water it contains. The other interesting thing about the lake is the large amount of methane gas trapped beneath, which could, at any point, tomorrow or in 1000 years, cause an explosion and widespread destruction as it is released from beneath the lake. This thought was only at the very back of my mind this weekend, as we relaxed by the water's edge, boated, kayaked, and climbed a hilly island with a huge colony of fruit bats. Despite its beauty, it has remained largely underdeveloped, with a small village feel, and the ability to be out on the water and feel entirely alone and at peace. It's the kind of place that makes you not want to leave at the end of the weekend, makes you wish the hospital would open an annex there. I'd be the first person to volunteer to work there. 

I will have one more week to learn here. One more week of seeing pathologies I would never see at home, either because of geographic considerations or because nothing would ever advance that far at home. I will have one more week of seeing families faced with impossible decisions, or decisions that have already been made for them. Another week of doctors truly doing all that they can, and wishing they could do more. I may be sad, and I can write about it, and reflect, but then I can leave, and go back to a place where it's easier, if only just a bit. 

On dying, on possibilities, and finding the real Rwanda

My cell phone rang yesterday, and the caller ID flashed the name "Menelas," one of the residents I worked with at King Faisal Hospital. "Hello Sarah! How are you? Would you like to come with me to go visit a cancer patient at her home this afternoon?"

Not your typical invitation for a Saturday afternoon, but one that was worth changing my plans to go bowling with some of the American doctors here. I wasn't sure what to expect, who was this patient, what sort of home would she live in? Menelas picked me up a couple of hours later, and we drove to a nearby, upper middle class neighborhood, through the gate of a nice sized home up on a hill, within hearing distance of the big stadium. As we drove in, an older gentleman smiled and waved at us, as he leaned on one crutch and then swung it in the air as part of his wave. This man was actually a well established physician here, and the cancer patient was his wife. Seven years ago she was diagnosed with breast cancer, which was treated and had gone into remission, but had now returned, this time making itself known by her new axillary lymph nodes, and its invasion of her lungs. Although she had spent some time in the hospital, she was now at home, in her own bed, being cared for by her amazingly loving husband and children. Home care is a rarity in Rwanda, and getting home oxygen even harder, and often quite expensive. However, given her husband's position and his profession, there she was, laying comfortably and poised in her very own bed, in a lacy nightgown, with nasal cannula in her nose and oxygen flowing. I almost felt as if I was walking into the bright and cheery room of Forrest Gump's mother, when "she had got the cancer," when Forrest went to visit her at their home in Alabama. In this room, the sheer curtains fluttered over the open window, a gentle breeze filtered in, along with sounds of cheering from the stadium. The oxygen gently bubbled through the water chamber.

Although I could not communicate with her much beyond the usual greetings in Kinyarwanda, we smiled, and we held hands, I listened to her talk with the others, we all prayed together and we wished her well. She wanted us to feel her new lymph nodes, and check her oxygen saturation. After, we sat with her husband on their balcony, sipping beer as the sunset, and spoke of health here and elsewhere. He told us how she had asked him to make sure he told us all about her health issues, to get our opinions. He told us how much it meant to her that we had come to visit.   

I left their home imagining for her, at some point, a comfortable passing, in her own bed, with her family close by and thought how fortunate she is, especially in this country.  I contrasted that with the passing of another of my patients this past week. This type of death, unfortunately, is all too common here. Bed thirty four strikes again. When our heart failure patient died a couple weeks ago, the next occupant was a lovely, refined, beautiful, 47-year-old woman with newly diagnosed HIV and tuberculosis. Even on admission to the hospital, she looked well put together. From the way she carried herself, I could tell she was accomplished and well respected. She carried an intense pride that I have not seen in many patients on the crowded ward. In the end, I think it may have been this pride that contributed to her untimely death. As it turns out, she was a successful government administrator, and she likely knew about her HIV diagnosis for at least twelve years if not longer. However, from whatever combination of denial, embarrassment, shame and pride, she did not seek any treatment until last month, when her CD4 count had already dropped so low that it could no longer defend her body from any infection. In a matter of days, we watched her deteriorate, from just a bit weak, to completely short of breath laying in bed and soaked in sweat, as the PCP pneumonia bloomed in her lungs. The simple oxygen on the ward was not really enough to support her breathing, but there were no available ICU beds at our hospital. So with her family at her side, she worked to breath, more and longer than anyone in a hospital should have to, until we could transfer her to another hospital's ICU, the next day. The IV form of the antibiotic she needed was also not available anywhere in the area, and so we had to make do with the oral formulation. We got word that she died the following evening.  

This past week I was able to attend the 16th annual Rwanda Medical Association conference. It serves both as their annual big administrative and policy meeting, an opportunity to hear talks on a certain theme, and also discuss the continued development of medicine and its specialties in Rwanda. This year they tackled the topic of non-communicable diseases like diabetes, heart disease and cancer.  Although HIV has reversed the life expectancies in many of these countries, the recognition and treatment of chronic diseases as people age is growing. Although I sensed this before, one thing that became so much clearer to me through hearing these talks is the severe shortage of specialists in Rwanda. There are essentially no fellowships here. If you want to be anything like an oncologist, a endocrinologist, a cardiologist, you must go abroad after internal medicine residency. I heard that there are only TWO urologists in the entire country of 11 million people. There are only FOUR dermatologists. At the new cancer hospital in the north of the country, the hospital opened by Partners In Health, although they are making great strides in cancer treatment, they have yet to have an on site pathologist. Every single biopsy taken to make a cancer diagnosis is actually flown back to the USA and read by a pathologist in Boston. Here at the guest house where I have been staying, I met an oncologist who is actually Ugandan, but takes a long bus ride from Kampala to Kigali once a month to care for patients here. The 22-year-old girl in bed 36, who has been in the hospital with a terrible cough for more than three weeks now, is still waiting for the pathology read on her lymph node biopsy. We're hoping to find a lymphoma, because we're pretty sure it's not TB. But for now, all we can do is give her oxygen, and wait.

One thing I took away from the conference was that Rwanda has made great strides in medicine, but there is so much further to go. Everything here, not just in medicine, seems to be marked by 'before 1994" and "after 1994." It's hard to even picture what it was like here before, because there has been so much intense development after. Sometimes I just picture village life everywhere, even here in Kigali, without even a foreshadowing of the tall buildings and wide, busy, paved roads that were to come.  The Rwandan Medical Association was not even in existence before. Now it is a large and strong organization, a way for the small but close knit medical community here to connect, and to plan and to dream about what can be.

This afternoon one of my co-residents here, John, was kind enough to take me on a hike. I wanted to climb Mount Kigali, the biggest mountain in the city, just topping 6000 ft. This is not your typical hike through the forest and up a quiet mountain path. People actually live a fair way up the mountain. And so our hike was an energetic stroll of sorts, up steep dirt paths in front of people's humble cinder block homes, with little children peaking through their curtained front doors, smiling and screaming "mzungu!!!"  Some of the people asked John in Kinyarwanda why he was making me work so hard (dripping with sweat) and climb up there. We smiled and continued upwards. Chickens pecked lazily beside the path, women carried loads on their heads and babies on their backs, and the children ran around barefoot. We reached the highest point just as the day's rainstorm turned from a mist to a torrential downpour. We took shelter in a schoolhouse at the top, along with eight shrieking children who thought it was hilarious to rub their hands on the blackboards and then use the chalk dust to paint their faces. A couple of women also took refuge from the rain, laying down their loads of pots and baskets, until it was dry enough to continue their work. I couldn't help but feel I had finally left Kigali somehow, and entered a village. Finally the Africa that felt more familiar to me, the one I had been shocked not to have really found yet in Kigali. I just didn't know how to find it before. But then from the windows of the schoolhouse, at the top of Mt. Kigali, was a perfect view to downtown, to the tall buildings, to the new luxury hotel under construction and the upper class housing development across the valley. Kigali is really quite small, and even from up in the mountain village, it didn't seem so far away.

One day there will be more medical specialists here. One day all people here will be able to die with dignity at home just like the doctor's wife, or die knowing that they've had access to all the possible medical resources to help prolong their lives. People here say to me, "You must come back in five years! Just imagine what it will be like then." I think I can imagine. I just hope there are still chickens and running children too.   

Umuganda, healthcare style?

It's disconcertingly quiet for a Saturday morning. On my morning run, and then on my walk up to the Umubano Hotel pastry shop for a special breakfast treat, I passed almost nobody. The occasional moto (a motorcycle taxi) zipping by, a bus here and there, a few pedestrians strolling. It almost feels like the middle of the night. But actually, today is the last Saturday of the month, which means it's umuganda, community service day. This is a mandatory, nationally mandated day of service every month. Everyone who can, from 8 am until 11 am, is required to participate, helping to pave roads, pick up garbage, trim grass and bushes, repair public facilities and such. A pretty amazing concept. Another example of the shared responsibility that is felt here, toward continually making Rwanda a greater place.

I compare this concept of umuganda, with my feelings about this past week of work at the hospital. I'm still absorbing it all. For me, this week has been about figuring out my role, understanding the strengths and weaknesses of the healthcare system here, and majorly resetting my expectations. Many people have told me that the health system and hospitals here are quite good, compared with other places in Africa. I'm having a hard time seeing that, but I have stop comparing it to anything that I'm used to at home. Being the largest referral center in Rwanda does mean anything in the context of western medicine. From my work in Zambia, I had a pretty good understanding of what outpatient medicine is like in developing countries, but it still didn't prepare me for what it would be like on the inpatient side.

I wrote earlier this week about the woman who died because her family had to keep going out to the pharmacy to buy her medications she needed. The same is true of almost everything in the hospital. Each patient has their own bag of supplies they must buy - bandaging supplies, IV lines, IV fluids, gloves. If they run out, well, better hope somebody else on the ward is willing to share. Yesterday a woman started oozing blood out of some sutures she had from her surgery, in a matter of hours soaking completely through the bandages and sheets. We had to walk around the room, asking the other other patients if we could use some of their tape, some of their gauze, to redress her wound. Diagnostic tests must also be prepaid. We may spend hours on morning rounds discussing a patient's presentation, differential diagnosis and workup that must be done. We write "Chest CT scan" in the progress note, and then write an order for it. But that CT chest won't actually get scheduled until the patient's family takes that order, brings it to the cashier to pay, and then brings back the stamped receipt. And if they can't pay, there are social workers to help, with some kind of collective pot, but it's unclear how much and who can get funds from that. And even then, it may not be scheduled for over a week, even for an inpatient. Yesterday we had our medicine attending call his radiology attending buddy, who agreed to reschedule a chest CT for our patient for next Tuesday instead of next Friday, while she has already been in the hospital for over a week, and wants nothing more than to get back to her nine month old child at home.

Physicians, and actually, entire health systems here, hardly have any responsibilities over the weekends. In fact, think of Friday as a half day, even at the hospital, for Friday afternoon is actually a national sport day. Think intramural soccer, doctors versus teachers. When I asked who would be taking care of our ward over this weekend, following up on all these plans we made, the answer was essentially nobody. Just like the night coverage resident, there will be one, perhaps two residents in the hospital to cover all of the wards over the weekend, who have received no formal signout on any of them. But no formal rounding, no new plans, no followup on old plans. They are only there to deal with emergencies with the patients, when the nurses decide to call them. Every order we wrote yesterday had to be clear about its relevance to the entire weekend. IV fluids? Let's hope that even some of our malnourished, hypotensive patients are still on IV fluids when we get back on Monday. I've heard people say patients are lucky to survive through the weekend, and if they can, then they must be doing pretty well. So much for Press Ganey scores.

Never again will I complain at Yale about a particular radiology study that cannot be done over the weekend, that must wait until Monday. At least it can be done on Monday. At least there are still many doctors in the hospital over the weekend, keeping that patient stable, caring for them, until further diagnostics can be done. Never again will I complain about being on call over the weekend, or responding to a code in the middle of the night, because I am doing my part, my duty as a physician, of patient care. So many things that have become so routine in our care of patients at home: our team structure as medical students, residents and attendings, that goes along with our well defined responsibilities and expectations, with accountability, our handoffs to each other of patient information, all of these things do not yet exist here, at least not officially, not entirely, not solidly.  There is no such thing as patient signout. You're done with your work for the day? You disappear. The one night coverage resident is not told a thing about the patients on the wards. If there is a problem, they will try to deal with it. And then won't tell anybody about it in the morning, except in the form of an illegible note in the patient chart. Maybe.

Let me take a step back here. Many of the Rwandan doctors I have met so far, attendings and residents alike, have been excellent. Their knowledge is solid and extensive. Their commitment to teaching is obvious, in the time spent every day teaching students and residents. The attendings demand near perfection in terms of instant ability to regurgitate not only differential diagnoses of symptoms but also medication doses and physiological formulas. Their practical skills are excellent and extensive too, as most medical students are required to work for a couple of years before returning to residency. Many of the residents here have done their share of surgeries, from lymph node biopsies to c-sections, before ever starting their medicine residency. But that's just one part of the equation. The resources, and the overall medical culture are key components too. You can be the most well meaning physician, who may feel it essential to have weekend rounds. But if no other hospital services are available that day, it severely limits how much you can do. 

There's a new initiative here, called HRH, which is trying to slowly address all these issues. Over the course of years, their goal is to twin US doctors, nurses and hospital admin staff with locals in the same role, to slowly improve hospitals and physician training here. After three weeks here, I think this is an amazing and awesome challenge. I think Rwanda is up for it. The pieces are there. But it's gonna be a while.

In the mean time though, what is my role? If I try to be the type a, controlling, a little OCD, organized resident that I'm used to being, I'm just going to burn myself out. A weeks worth of checklists did me no good, because trying to review those checklists with the team after rounds, or really, really being sure that those things have actually gotten done, just doesn't happen very well. Not all the time. Orders get forgotten or lost. Or they remain as an unpaid sheet of paper by the patient's bed. How about solidifying team structure. You! Lowest medical student on the team, this is your role! This is what I expect of you! But if they decide to leave after rounds without helping implement the day's plans, what can I do? I can't change a whole culture in the few weeks I'm here. So that leaves teaching. In some in-between land between being a resident, and being an attending, that leaves me, teaching what tidbits I can, imparting what sense of patient duty and team structure and note writing I can. And definitely learning a whole bunch about diseases I don't see often or ever at home.

Hopefully, I can return to Rwanda in ten years, and see the fruits of all these efforts. That sense of duty about umuganda, extending truly and deeply into the healthcare culture as well. As one of my attendings says now to the Rwandan residents, when talking about our young patients on the ward, "these patients are the future of Rwanda, take care of them." Hopefully this will become a system in which we truly can. 

Bed Thirty Four

Two quick weeks have passed, and my time at the private hospital is through. Yesterday I began working at the big university teaching hospital. The similarities and the differences between them are numerous. The private hospital follows a more western model, attempting at more private rooms, more nursing, and more services for the patients like serving food, having more medications on hand. The teaching hospital is more what you may picture for a developing country, with large open wards full of beds, filled with as many family members as patients, doing more nursing than the nurses. Both these hospitals have many attendings dedicated to teaching, and both are filled with medical students and residents eager to learn, but who are somewhat limited by their resources - by lab services, radiology services, specialists. Perhaps the private hospital is almost more dangerous in a way, because it looks so western, and your expectations are such, but the care is still somewhat what you would expect in a resource poor country. But I think a death at the government hospital is seen as that much more normal, expected, and unnoticed.

Today I learned that at this government hospital, patients' families need to go to the pharmacy and pay for almost EVERY SINGLE medication they are prescribed while inpatients (not including the Emergency Room), except for medications for TB and HIV. You're admitted to the hospital and have high blood pressure? Here's your atenolol prescription, go get it. You need antibiotics for pneumonia? You can go pick that up for yourself, and the nurse will be kind enough to attach it to your IV. Oh, you're having an asthma attack? Better get your spouse/sibling/child to go run fast and get some albuterol and a mask for the nebulizing machine, we don't stock those on the ward. Today I watched a woman die over a period of about five hours due to some combination of severe heart failure and asthma. Yes, she was ninety years old. Yes, she had heart failure, and her overall prognosis was poor, and she likely would have died in the relatively near future. But yesterday, on morning rounds, she looked fairly well and we were planning to discharge her home today. Overnight, she deteriorated, and this morning our team arrived to find her floridly fluid overloading, wheezing, and gasping for air. In the time it took for her family to obtain all of the medications she needed to get her through the morning, as well as a functioning nebulizer mask to ease her breathing, it was too late. We actually wrote a prescription for her son to go get dopamine, a medication normally given as an infusion in the ICU, a last ditch effort to keep her heart pumping and improve her blood pressure, just before she took her last breaths. He was not even at her bedside when she did.

She passed away on bed 34, the third bed along the wall from the right, below a high window, next to a large aluminum storage cabinet on her left, and about 3 feet away from the young girl with the kidney failure and hypertension on the right. It all happened very quickly after that. The nurse brought in some extra IV poles, to hang some sheets on and create a small curtain and block the bed's view from the others in her area of the ward. A couple of other workers came in, removed her IVs and her foley, cleaned her and dressed her and covered her up.

By the time we returned from lunch, there was a new patient laying in bed 34, a 46 year old woman with newly diagnosed HIV and tuberculosis, and likely Kaposi's Sarcoma too. This woman has probably had HIV since the early to mid 1990s. She lost her husband in 1995 not to HIV, which she suspected that he had based on his symptoms at the time, but to the war. But she never checked her own status until now, until she was so sick and weak that she had no alternative.

So tonight, I think about her, and bed 34's previous occupant, and hope for the best.

Moving forward

Living on the equator is a study both in colorful variety and also unrelenting sameness. More tropical climates seem to nurture a kaleidoscope of patterns: the flora and fauna, the varied fabrics of women's head wraps and baby slings, the spicy music and spicy food to go with it. But being closer to the sun also means that it rises and sets at just about the same time every day, all year long. No depressing dark mornings, but no late, light evenings to savor. The coming and going of the rains mark the passing of seasons more so than the color of the sky at 6 pm. Weekends also do not seem to differ very much than weekdays for many. The sun is up, it's time to get up, there's work to do! Kigali is growing fast, we're moving forward in the world, and we need to make that happen, even on a Sunday!

Thus, despite a relatively late night at the Great Rwandan Beer Fest, with more than my share of Mutzig, Primus and Turbo King, I awoke this morning bright and early, to a strong sun and the rhythmic banging of the tools being used to construct the new houses across the street. Further sleep was impossible, so I decided to do something, that would not be enjoyable per se, but that I wanted to be sure to do before leaving Rwanda. I paid a visit to the Kigali Genocide Memorial Centre.

Kigali is built over several hills and valleys, and the memorial is built on a hill at the northwestern corner of the city, across a small valley from the downtown area. As I stood on the peaceful terraced hillside, among the mass grave site of over 250,000 people, surrounded by rose gardens and fountains, I reflected on the modern city across the valley. There are several tall buildings, that could almost be considered sky scrapers by African standards. There are fancy cafes and expensive grocery stores. There I stood among the remains of the people who would never get to be a part of that growth, and yet were perhaps, somehow, the catalyst for that growth even being possible.

Inside the museum, there is a hall of pictures. Photos hanging on little clips off of strings of wire. The kind you could buy at Bed, Bath and Beyond. These are not photos behind glass cases. These are strings of photos that families have clipped up of their lost loved ones. I could imagine them looking through their old photo albums, choosing which ones to put in that place. These are not old, black and white photos of people who look like they lived impossibly long ago, like you may see at a Holocaust museum. These are modern, color photos, of people with early 1990s hair and clothes, clothes I remembered wearing.  Snapshots from Uncle Fabrice's birthday party or Christine's christening or just because. These people were here not that long ago, walking up these hills, headed to their jobs downtown, perhaps even shopping at some of the stores I have passed by.  Now they lay here, on this beautiful hillside, as each same day passes under the unpatterned sun, as a reminder of what has been but also of the only way forward.

Somehow, almost impossibly, the Rwandan people have managed to live among each other again, move forward and do amazingly well. Perhaps it's due to the success of their development and progress as a country, and because the alternative, reopening those wounds, would lead to more of the unthinkable.

My being here, in this place, with this history, is a part of the push for progress.  I am only here for six weeks, but some of my medical colleagues are here for a year or more. There is so much further to go in improving the medical system here, but there is so much more here than there once was.

Some thoughts on technology, egos and knowledge

Another week come and almost gone, and while I feel I have had made some strides, I can't help but leave the hospital each day feeling frustrated and somewhat powerless to help. A large range of issues: operational, organizational, knowledge, skill, ego and political, all seem to combine in quietly smoldering ways. And you better believe that if patients here had any power to advocate, speak up or question, that these issues would be explosive, leading to patient relations calls and lawsuits, in addition to the deaths they can already be associated with.

A broken machine in the lab, leading to a delay in blood test results, then delays the order for subsequent imaging, which is delayed by the fact that the actual order for that imaging is on paper and it perhaps makes it (or doesn't make it) down to radiology, and when this test actually gets done, it may not be read until the next day, or even later, whenever the radiologist feels like filing the report. Apparently, I've also learned, if I am viewing the CT images on a computer on the ward, the radiologist is not able to also look through those images AND file the report at the same time. The skill of the radiologist in interpreting this wide range of images (MRI, CT, ultrasound, xray) is also unreliable. There is no radiology residency in Rwanda, they must all go abroad and come back, and there is certainly no further fellowships or specializing, they are expected to read all types of imaging. Is having the only MRI scanner in the country really that good, if the reads on those results cannot always be trusted? All of these delays lead to periods of diagnostic uncertainty, which are longer than you'd really want them to be. These are periods of time, sometimes weeks, where a patient may just sit around and wait for us to figure it out, without any further interventions. In that period of time, they may remain stable, or they may crump.

Do we owe it to our current patient, who was admitted on September 14th, with a still as of yet undetermined malignancy, to stop chasing the diagnosis (is it lung cancer or liver cancer or a germ cell tumor or a GI cancer), to stop accusing other consultants of not having done a good job ("Well, maybe they didn't really do the bronchoscopy well, maybe we should do it again"), to stop questioning the MRI scan read, now that he's so sick and we're not going to give him chemotherapy anyway, to stop letting him lay there in bed encephalopathic and altered, and just give him some freakin' morphine and let him be comfort care?! We certainly do! But this morning the attending insisted we had to wait to talk about him at case conference tomorrow, before we completely stop looking. This was despite the fact that I told the attending about the end of life discussion I already had with the family the previous evening, which seemed very reasonable to me and the other residents, to which the family were completely understanding of and wanted to proceed with. This evening, although the patient's kidneys are shutting down, my co-resident did not feel comfortable calling the attending to change the plan, because he worried the attending would be upset that we won't get to talk about him tomorrow, and won't ever reach a diagnosis. There is no room for this kind of egos in medicine. I almost feel as if having some of these diagnostic tools available to us here, has the power to make things worse, when managed poorly or unreliably.

At least our Congolese lady with the massive ascites, still as of yet of unknown origin (don't even get me started), who has been in the hospital for two weeks, is otherwise stable and quite happy, waddling with her huge stomach and she walks down the hall to the bathroom each day. And we've had fun with paracenteses with her too. Every morning we greet each other with the tiny bit of Swahili I still remember. Habari! Nzuri!

I've made some strides though. I've finally pulled the interns and residents out of their shells. They actually speak up and talk when I ask them a question, and ask me questions and ask for guidance. I've gotten the interns to take on more responsibility. They are now writing full progress notes, as opposed to the residents scrawling down some quick plan for the day, as dictated by the attending at the bedside during rounds. I've gotten the interns to take initiative and be the first person to present each patient case, as opposed to them turning to their resident to do it. I've practiced presentation skills with the interns, helping them to synthesize the patient's story, and the data. It was beautiful, this morning, the intern who never used to speak, stood up at the head of the bed, took out his notebook with all the notes written down as I had suggested, opened up his mouth to begin his presentation and.....SHOT DOWN!!! The attending cut him off and said, "So what's the diagnosis?!!" This was before he picked up his ringing cellphone mid-intern's answer to the question, so that he could then say he was heading off to his clinic, and we could finish rounds with a different attending, whose decisions he later disagrees with and tells us not to proceed with. 

Come onnnnn, really?!!!!!! How can I instill good habits for future learning and floor team functioning, if the attendings undermine it? How can you attend on the wards and then leave mid rounds, and then have such a big ego as to undermine the clinical decisions of another attending you asked to help you out?

I don't mean to make all the attendings sound bad. Some of them are really fabulous teachers, and some of them would have gladly and carefully listened to the intern's presentation. Some of the attendings have pushed me to the far boundaries of my retained knowledge. What I once knew cold before my anatomy exam during my first year of medical school (seven years ago), is no longer in my daily, working knowledge bank. Yesterday, we spent 1.5 hours discussing the neurological exam at the bedside, and only got through about 1/3 of it. It was as much a basic anatomy review as it was a practical review of physical exam skills. It's humbling, as medicine often is. Old school teaching like that doesn't happen as often at home anymore. 

My knowledge has also been pushed to grow by the demand for my teaching. These students and residents are so eager to drink it all up. You have a lecture about diabetes?!! We want to hear it. You can tell us about liver failure?! Bring it on. You have an EKG lecture? We'll sit here for a third lecture. Who cares about lunch, we want to learn. I guarantee you, if you put a bunch of Yale residents in a room with an attending who is lecturing, extending into lunchtime without a chance to actually go and get lunch, you'll have lots of impatient glances at watches. I packed the room while talking about EKGs today. And I think because of that, I actually know them better than I did before.

Tomorrow is my last day at this hospital, and next week I'm moving onto the next one, where I will be for four weeks. There was more than one complaint from the residents today about why I can't stay an extra week at this one. That too was humbling. I think they like having me around.

Kigali Weekend

I think all the weeks of traveling and exploring new places is finally catching up to me. As I sit here on my balcony, overlooking the lush hills across the way and the golf course in the valley below, listening to birds chirping as they flutter around the trees in my yard, an occasional motobike taxi scooting along the dirt road, and the distant clapping and singing of a church service, as I watch the clouds clear from the delightfully heavy noontime downpour that sprayed me with a fine mist on my covered balcony, I can't imagine moving from this chair anytime soon. Partly because of utter exhaustion, and partly because if I try to step out of the house and through my front gate, I know my guard will quiz me on the Kinyarwanda words she has been teaching me ("Amakuru? Nimeza!")

This weekend has certainly been full of exploring. Both yesterday and today, I started off the day with a run through various nearby neighborhoods, on paved and unpaved roads, down hills and UP hills, big hills (this is the land of a thousand hills after all), past gated mansions and modest concrete homes, I began to get oriented to this city. Amazingly, there are no slums here like there are in Lusaka, or in so many other African cities, which makes it safer and nicer to run and explore, without ending up in a place where you wouldn't want to be. To put you at ease, I could run from my house to the American Embassy in about 12 minutes.
This morning was the inaugural run of the new Kacyiru (pronounced ka-CHEE-roo, the name of my neighborhood) Running Club, with a grand total of two runners, including myself.

Yesterday also included much walking.  An hour+ long walk in a failed attempt to find the art collective where the pottery class was. Kigali has the interesting quirk that NOBODY used addresses. You couldn't even if you wanted to because there are none. The few streets downtown that actually have names, nobody uses. The streets out in this part of town all have number but nobody really uses those either. When I get directions, it involves landmarks ranging from roundabouts to banks to "that store selling all the plants outside." You can imagine this poses a challenge too, when trying to describe to a taxi driver where you would like to go, if you yourself have never been there, and he has not heard of the specific mzungu hangout which you seek. Too bad the African Bagel Company (http://tentmakersofrwanda.com/present_ministries/african_bagel_company) is such a well kept mzungu secret, because that taxi adventure finding it also became a very long walk. But in the end, I was rewarded with a toasted cinnamon raisin bagel with cream cheese. Maybe not a New York bagel, but pretty darn good.

It was there I finally managed to meet some other doctors and nurses who are here for a new initiative, Human Resources for Health (HRH). They are providing American doctors, nurses and hospital administration staff to come here for long term commitments, and be twinned with Rwandan counterparts, in an attempt to improve the quality of medical training and care here. After a week spent mostly on my own, or with Rwandan residents and students, it was nice to find an expat group to relax with. Yesterday evening I was invited to join their potluck dinner, which was reminiscent of the many dinners and gatherings we had back in Lusaka, which seems so long ago now. It was also interesting to hear their impressions and frustrations, as they have begun their new and very challenging jobs here. I also got the lowdown on where to find the larger grocery stores.

Which is how I found myself this morning at the MTN center, an actual indoor shopping mall, complete with supermarket and coffee shop, Bourbon Coffee (http://bourboncoffee.biz/), a sleek and sophisticated looking coffee shop that could be at home anywhere in the US, and uses all Rwandan Coffee. In fact, there is one in Porter Square in Cambridge. Bostonians, go check it out! Sitting on their balcony sipping my cappuccino, enjoying my excellent view of the city (every place here has a good view because there are so many hills), I couldn't help but feel so fortunate to be here, in this lovely city, coming to learn about Rwanda, its history and culture, its people, and given the challenging task of helping to make the medical system even a tiny bit better.

To add to my experience, I have been reading a book called A Thousand Hills: Rwanda's Rebirth and the Man Who Dreamed it (http://www.amazon.com/Thousand-Hills-Rwandas-Rebirth-Dreamed/dp/0470120150) which I feel has added tremendously to my understanding of what is going on here. I won't say too much about it here, as I would go on and on and bore you, but just to say that what Kagame has done for this country is amazingly complex, with both positive and negative aspects, and makes Rwanda absolutely unique among all African nations.  There is something very special happening here, and hopefully, it can continue.

I will leave you with that thought, as I should go brush up on my physical exam skills, as teaching them makes me realize what I know, and what I don't know as well as I could.

First week's impressions

Well, it's been a long week, mostly occupied by rounding on the medical wards. In observing and understanding how the medical education system here works, I've been trying to figure out my role here, and how I can best contribute. To be fair, I've only been at one hospital so far (a private hospital) and have yet to go to the University Hospital, where things may be very different. But these have been my impressions so far.

If I thought rounds at home took too long sometimes, I won't think that anymore. It's not uncommon for our rounds to last hours. Hours upon hours of standing (or inconspicuously leaning against the wall for added back support) while I listen to the medical students and residents present patients and while the attending teaches. This may sound very much like home, and it is, except for a few quirks:

-Students here tend to speak very slowly and quietly, and also seem very timid about speaking up, or even answering questions they know the answer to. This results in a gaggle of people standing around a patient's bed, while they all strain to hear what the presenter is saying, and then stand there expressionless and quiet when the attending asks a question. In that sense, it's a good thing that patients here don't feel more empowered to participate in medical discussions like they do at home, or they would probably be very openly frustrated with us. Disorganized presentations turn into prolonged teaching sessions at the bedside, which then often result in no clear plan for the day (or no change from the previous day) and then the whole group walks away. I get the feeling the patient has no idea what just happened, what will be happening that day, or how much longer they will be staying. I should mention that lab results and radiology results are so slow here, it's not uncommon for a patient to be waiting for three days for a result, with nothing happening to them in the interim. So if there is no plan for the day, it may truly be because nothing has changed from the previous day. We have patients who have been in the hospital for three weeks or more.

-I have also found the attendings to be even more hierarchical than they can be at home. They have no problems openly insulting and chastising the residents and students for things they do not know the answer to. I'm not used to this, and I think it's counterproductive to a positive learning environment. The attending I've been working with this week, while a very good teacher with a huge knowledge base, can be pompous and insulting at times, in a totally irrelevant way. I don't want to hear your personal views on a patient's religious beliefs, or your frustration that a patient's skin biopsy was actually sent to Germany for analysis ("A colonial hangover!").

-Finally, I've found that overall, the knowledge of the more senior residents I've met so far seems behind that of the same level resident at home, although it's hugely variable. And they don't seem to be leading or teaching the interns/medical students. This in turn makes the interns lazy, and they do not seem to be doing the jobs that are expected of them, leaving the residents to do all of the work (write all the notes, ensure orders are in and consults called).  I've actually watched the interns start presenting a patient, and then not know anything that happened to them in the past 24 hours, have no vitals signs or lab results written down, and to not have done a physical exam that day.

I think this last piece is something I can help with. Not only teaching some clinical knowledge, but helping them to be better teachers and leaders of their interns, and in turn, teaching the interns to be better organized and more responsible. All of that said, in the small teaching sessions I have done so far, they know their book knowledge very well, and they seem very eager to learn. And trying to teach them things I have been doing so routinely for so long, has made me realize what I don't know as well as I thought I did.

Lots of reading coming for me this weekend. In addition to going to a pottery class, an ultimate frisbee game, and a run with the running club.

Welcome to Kigali

At midnight, I couldn't enjoy the view I normally love when landing at African airports, but as soon as I exited the plane, that smell was in the air, that bite, that subtle combination of sweet yet stinging burning garbage, vastly open spaces, and in this case, a thick and heavy fog shrouding Kigali's lovely hills.  And I'm back.

Except that Kigali is unlike the other African places I've been.  Even on the drive from the airport to my guesthouse in the dark, I could see it plainly. I could see, there were lights! I could see the hills, and the valleys, and the roads that connect them. There were wide, nicely paved roads, connecting to other nicely paved roads. Fairly tall and modern buildings. Plants and trees everywhere. A beautiful, clean, spacious, airy guesthouse, overlooking a golf course. In the daylight, it's even greener and more beautiful.

As I walked around King Faisal Hospital's neighborhood today, and then downtown this evening with one of the interns showing me around, there was this sense of, calm. Despite the hustle and bustle of the downtown commerce, the evening's last shopping, the commuters heading home, everything just moved along calmly. People greeted each other often on the streets. Cars moved carefully. People walked with purpose yet politely. Nobody approached me, or called out to me. Even the minibus driver wasn't hawking anybody, and made sure I got out at the correct stop.

My first day at King Faisal Hospital included joining in on morning rounds (lasting till 2 pm!) with no less than 4 residents and 6 interns, a cardiology lecture, a range of patients including 25 year old with recurrent chronic headaches, two strokes, a 60 year old with massive ascites vs. massive ovarian cyst (her weight was so big she almost broke the CT scanner table and the study was incomplete), lung cancer, metastatic breast cancer, a few patients with underlying HIV newly diagnosed, and a spinal tap performed by me within a few hours of entering the building, to rule out cryptococcal meningitis on woman who seized during our lecture.

The residents are lovely and welcoming. The attendings teach with that old fashioned flair. They expect you to know EVERYTHING. Do you remember the formula for oncotic pressure? You don't?! Better go look that up, medical school wasn't THAT long ago. 

It's going to be an interesting six weeks.
 

Telavi

Has been a very relaxing two days in Kakheti, wine country. Yesterday spent most of the day lounging at Chateau Mere, a vineyard, winery and hotel. Today we hired a driver to drive us around the area. Saw some churches and monasteries, ranging from old to very very old. One cathedral, the second tallest in Georgia, was built in the 11th century, with the original wall paintings still visible, although sadly faded. There aren't a lot of funds for church restoration or preservation here. Another monastery we visited dates back to the 4th century! That one was built up on the side of a mountain, with breathtaking views of the countryside below. And just behind us, further up the mountain, and over, is Russia, specifically Dagastan. Invaders used to come over these mountains, and this church would be the first watchtower, the first to send out the smoke signal to others further south and west, about the coming attack.

Finally, can't visit wine country without some wine tasting. Although our wine tasting was more like being invited in by the owners to sit down at their table and drink and eat with them, including two large jugs of wine that kept somehow refilling our glasses.

As if we haven't seen enough churches on this trip, our excursion on Monday involved driving two hours outside of Tbilisi to the remote cave monastery of David Gareja, overlooking the border with Azerbaijan. This part of the country is a desert, a vast wasteland, in contrast to the lush wine country to the north. Our guide explained that centuries ago when the Persians invaded (more than once) they would purposely come through from this area, and destroyed the trees and landscape, so as to make it inhospitable for Georgians to live there.

We also stopped by a convent where the original woman who brought Christianity to Georgia is buried. There is a spring there with holy water. Our guide insisted that we take some. So now, I've got a whole Vitamin water bottle full of holy water. Let me know if you want some.


More pictures up:
https://picasaweb.google.com/106419429553511755451

First set of pictures up...
https://picasaweb.google.com/106419429553511755451/Tbilisi?authkey=Gv1sRgCJyhnr6rj9WzVg

Reflections on Georgian Elections

Telavi

Georgian wine country.  Mountainous, green. After a windy mountain ride, up to almost 2000 meters and down again from Tbilisi, we find ourselves at Chateau Mere, an old castle looking building, functioning vineyard, winery and hotel. The swimming pool, flanked by stone walls with wide open windows, made to look like roman ruins, looks down on the countryside below. I sip my deep red wine, from some of the oldest grape vintages in the world, nibble on my khachapuri, and ruminate about the past several days.

Georgian elections. I don’t even know where to begin, but I feel lucky and honored to have been on the ground for this historical time for Georgia, and to have had the privilege to speak to so many locals, from so many different classes and viewpoints. Most of the reports you will read in the US papers will not be as informed as they could be, as we have been, from taking the time to ask people here what they think. Here is my understanding of the situation.

Sakashvili, the current president. Western educated, has created a political identity and life for the Georgian people distinct from Russia. Has kept his distance from associating with Russia, is not open to economic exchange (oil pipelines going through Georgia to Russia currently closed off), even started the war with Russia in 2008. In many ways, life is better for people here now than it was in the 1990s. This is now a modern country. Reliable electricity, good roads, clean streets, reliable police. Very safe, in that the level of corruption has been moved up to higher reaches of government.  No longer must you bribe the local police officer.  Locals and tourists alike feel safe walking the streets late at night, even leaving their doors unlocked.  In some ways though, he has hurt the economy with his refusal to associate more closely with Russia, who potentially would be a great market for Georgian exports. People here are feeling the bite of the world recession, of fewer jobs. Older people who used to rely on their pensions during the Soviet era no longer have that safety net. Sakashvili has proposed implementing income taxes, a new idea to many, that they do not welcome.  And lastly, there is the prison scandal. Sakashivili came down very hard on crime, and even petty theft landed people in jail. Seems that most people in the country know somebody who has been in jail. And when a few months before the election, videos emerged of extreme maltreatment of Georgian prisoners (think Abu Graib), there was mass public outcry, especially among the youth. Some people claim these videos were fabricated by the opposition to make Sakashvili look bad.  We probably will never know.

Ivanashvili. Emerged from post-Soviet era as one of the top billionaires in the world.  Was previously very reclusive, although funded many initiatives in this country.  Also, interestingly, was  a big supporter of actors and the arts, after there was no longer a USSR to support them anymore. Would like to turn around the economy and continue to push Georgia forward, which mostly means closer economic ties with Russia.  He has created the “Georgian Dream Coalition” essentially a coalition of several parliamentary parties, to come together to overpower the current party in power. Has also gotten several of the actors he was supporting to become the next round of politicians to run for office.  Wants to improve the economy, further eliminate corruption at the upper levels of government. However, many fear his closer ties with Russia will mean he will be under Putin’s control, even if not overtly.  Our hostess this morning at our Tbilisi guesthouse, a middle class female, who has been successful and hardworking in business with her husband, said she is afraid that all the youth supporting Ivanashvili do not remember how hard Georgians fought to get away from the control and influence of Russia, and how life overall is better now than it was before.

Each side we have spoken with has been fair, well thought out, and wanting the best. There are no good answers here.

While overall the elections seem to have been free and fair at the polls, there seem to have been unfair techniques used beforehand, like state television stations unwilling to broadcast views and material of opposition parties, especially affecting access to information for those in the countryside. Our taxi driver even told us yesterday that the buses were running less frequently yesterday, to make it harder for people to make it to the polls.

Yesterday evening, whether based on exit polls or just the feeling of an overall free and fair election, Georgian Dream supporters were dancing and celebrating in the streets. Honking horns, people cheering, music, rallies. Think post-Super Bowl or World Series victories, nothing scary or threatening. The police watched calmly. I have never seen Americans so excited about or involved with politics.

Enough election results came in today to show a solid victory for the Georgian Dream Coalition, or solid enough for Sakashvili to actually concede. I breathe a sigh of relief. Good for him, to let Georgia actually continue to grow as a true democracy. Whether the outcome of the peoples’ choice will truly benefit them is yet to be seen. 

Tbilisi

Tbilisi

Fabulous conglomeration of very old, sort of old, soviet old, new, and uber new, all in some combination that I've never experienced before. Open excavations of ancient streets below modern streets, next to 19th century two story buildings with Middle Eastern style grates, next to Soviet Block apartment buildings, next to wide tree lined majestic European boulevards, next to glass and steel modern architecture. Churches galore both old and new, a mosque, a synagogue. Influences of Mongols, Turks, Arabs, Persians, Russians, and something unique altogether. Georgia has their own alphabet, unlike any other I've seen.

The people are absolutely lovely. Friendly, talkative, wanting to get to know us in a positive, unpushy, not trying to sell you something kind of way. Every taxi driver has a tourist tip, and a political opinion. The women are beautiful and fashionable, well dressed enough to fit in with any of the great fashion cities of Europe. The men are good looking, although seem to enjoy their overly tight clothing.

Parliamentary elections are tomorrow. The two choices seem to be the lesser of two evils, and even that is giving them credit. The opposition party rally yesterday was the most peaceful gathering I have ever seen, a family day gathering, with people of all ages, classes, manner of dress, gathering with balloons, flags, music. Not a policeman to be seen. Hopefully it will stay that way after the elections as well.

As I stroll my way through town, up and down mountains, through plazas and narrow streets, over bridges and to rooftops, I sample tastes of Georgian cuisine - Khachapuri (cheesy bread), eggplant and walnut puree, cold spinach fritters, smoked cheeses, all garnished with pomegranate seeds, fresh juice galore, and lots of Turkish coffee.

A very cool city through and through.

Well, it's been three years since my last post, on a weekend trip to Zimbabwe, and three years since I left Zambia. Now it's time to return to the great continent, this time to Rwanda. I figured I would start up the blog again too, since many of you had asked for updates.

First I'm headed for a little jaunt in Georgia, then Istanbul, and finally on to Kigali on October 8th.

Check back for more travel details and pictures as I can post them.