This morning Jane and I returned to Central University Hospital of Kigali (CHUK) for Rounds and then to give lectures on Event Medicine, MCI and START triage. Here in Kigali SAMU is often called upon to staff everything from high profile international business meetings to football matches with 50,000 fans. They are challenged by short notice for the events, which sometimes leaves little time for planning. Fortunately everyone seems to recognize that Rwanda is growing and becoming more high profile, and with that the need for Event Medicine management increasing.
The lectures were well received, probably because we started by passing out Toblerone chocolate bars Dr. Sudha bought in the Amsterdam airport. Free food at a meeting or lecture is universally well received.
After lectures at the hospital, Jane and I rejoined Dr. Sudha and Basil at the SAMU Trauma Course. Last week we taught this course to 25 of SAMU’s brightest providers with high potential to be great educators. Friday, Basil taught them fundamentals of medical education in the adult learner. Today and tomorrow, those 25 are now teaching the same course to 25 more SAMU staff from district hospitals all over Rwanda.
The change can be felt already. Yes, the test scores were significantly improved last week, but more importantly, the SAMU staff have already incorporated their trauma training into their regular practice. While at CHUK this morning, the residents told us that SAMU was no longer performing reductions on extremities with intact pulses. The residents asked for clarification so that everyone would be on the same page. The change in practice was apparent to the hospital staff.
Sitting back and watching these instructors teach was quite inspiring. Just a few days ago, they too were uncertain and had only a fragile confidence. The preparation they invested over the weekend was obvious. Switching between three languages to ensure they are meeting the needs of all students, they delivered the content with enthusiasm and grace.
It’s a good thing these new instructors are strong, because I can barely follow what they are saying in French or Kinyarwanda. Every few sentences I recognize words or phrases like “stay and play” or “scoop and run.” It’s amusing to discover that some of these expressions are universal no matter where you practice EMS.
One thing I’ve been asking myself is “how important is creating a culture of EMS?” What does a star of life patch signify? How do awards and recognition of heroic calls help motivate providers? In a line of duty death, the traditional funeral exercise that follows…
Are these traditions specific to EMS in the US, or are they something universally necessary to growing and sustaining a productive EMS system? Would SAMU of Rwanda benefit from connecting with other International EMS agencies? How can we help SAMU grow without imposing too many of our own values that may not be what’s right for SAMU. It will be interesting to watch the SAMU staff grow and develop over the next few years. I’ve seen them grow so much just this short week.
Sunday is a day of rest in Rwanda, with most people attending church or mosque and many of the businesses closed. I opted for the same. I’ve been going to bed around midnight each night and waking up between 5:00am and 6:00am each day, so sleeping in was a high priority. Last night I finished typing my safari recap and made a point not to set my alarm. I still woke up at 7:30am.
I threw on some clothes and headed to brunch before showering for the day. I couldn’t resist that morning latte much longer. Our table was much smaller this morning as both Basil and Frank attended local church services with their respective denominations. From the window in my room all morning, I’d been hearing an auditory collage of church bells, choir singers and the Islamic call to prayer, all layered atop the typical sounds of the city. In an attempt not to over-plan my day, I had committed to nothing, and now found myself with nothing to do all afternoon besides review my lectures.
Eric, a student in our course, offered to give me a driving tour of the city. The rest of my team explored the city by taxi earlier in the week, but I had opted to take a nap and missed out. This seemed like a good opportunity. Not to mention I still needed to buy a little something to take back to my husband who has been holding down the fort at home with a sick baby.
Eric is the same age as me, 39. He grew up in a village not far from Kigali, the youngest of 10 brothers and sisters. When “1994 happened” (how he refers to the genocide), he was in art school studying drawing. Eric doesn’t say much about 1994. He’ll tell you he prefers to think of Rwanda’s bright future rather than dwell on the past.
What’s fascinating and admirable about Rwanda is its ability to heal. Years later, with prisons overcapacity and no way to sustain them, thousands of prisoners, convicted of both violent and non-violent crimes, were released back into their communities. For some this meant living next to the person who had killed their family member.
Prior to coming here, I read a great book based on the film “As we forgive,” which profiles a few of the family members faced with this uncharted challenge. Yet somehow, Rwanda healed. Eric explained that while things were difficult, the government made positive changes that gave people hope. The people started to be able to envision a new future, which helped them heal from the past.
There’s a palpable energy in Rwanda, as if everyone here knows something big is about to happen. The country is achieving unimaginable successes economically, and is on the radar of multiple multinational corporations as a hidden secret gem of opportunity, about to explode with growth. If I am lucky enough to return in a few years, I’d bet I may not recognize the place, but will still recognize its lovely people.
First on the agenda this morning after breakfast was a meeting with staff from the Ministry of Health to discuss the goals and vision for this partnership between VCU, Rwanda and Rotary International.
In April 1994, Rwanda experienced a 100 day genocide that resulted in 800,000-1,000,000 people killed, an estimated 20% of the country’s population. The genocide left the country economically and socially in tatters. It’s a complicated story, but well worth learning about if you are unfamiliar.
Next, we visited the Kigali Genocide Memorial. Our hosts were kind enough to escort us there and even provided us with flowers to place on the mass graves. I’m not even sure how to describe the experience, so I won’t try. But the museum is a sacred place, offering much to learn about humanity’s checkered past, and provides insight into how we can learn from all past genocide and work towards preventing any future conflicts.
Incredibly, Rwanda has not only been able to heal from its history, but is on a track to reach middle-income status by 2020. President Kagame, who came to power after the genocide, established the Vision 2020 development program. He made healthcare one of the top priorities in his plan, the effects of which can be seen throughout the country.
Per Wikipedia, “Rwanda has seen improvement on a number of key health indicators:
Between 2005 and 2013, life expectancy increased from 55.2 to 64.0,
under-5 mortality decreased from 106.4 to 52.0 per 1,000 live births,
incidence of tuberculosis has dropped from 101 to 69 per 100,000 people.”
In our meeting, this focus was echoed. Working with SAMU, we are playing a small part in an overall strategy to improve healthcare by elevating and standardizing medical education, recording and analyzing data to assess patient outcomes and making evidence-based improvements to care. Rwanda is doing incredible things considering its resource limitations and is emerging as a thought-leader in healthcare delivery on the continent of Africa.
“Whoever saves a life, it is considered as if he saved an entire world.”
This was imprinted on glass at the Genocide Memorial. Today’s visit makes our work that much more meaningful. We are a part of the miracle of healing and rebuilding a nation and its people.
Coordinating the safe and timely travel of 2 physicians, 2 paramedics/RNs and 1 Rotarian from 2 different states and 3 different cities is no small undertaking. In addition to personnel, we had the added challenge of getting 300+ pounds worth of medical training equipment including CPR mannequins, needle decompression trainers and oxygen bottles to Rwanda with us. We found out about 4 weeks before we were to fly that these things aren’t readily available for purchase where we are headed.
We are going to Kigali, the capital of Rwanda, to teach. Our mission is to help build and solidify a formal EMS system with top-notch Prehospital trauma care. Ambulances in Kigali are currently operated by SAMU, but the providers are nurses rather than Paramedics or EMTs. That’s because there are no formal EMS certifications or programs there. Our aim is to provide the current workforce with prehospital-specific trauma training to improve provider safety. 50% of all EMS calls in Kigali are for motor vehicle collisions (MVCs). MVC trauma is a major cause of morbidity and mortality across Rwanda.
We carpooled from Richmond to Dulles. Basil, the creator of the Trauma Course content, was kind enough to offer up his Ford Explorer. More challenging than the traffic on I-95 though, were the back seat drivers offering our opinions on the best route. Dr. Sudha, a Trauma Surgeon and myself, an Emergency Physician – we are accustomed to being the pilots.
Fortunately the traffic gods showed us mercy, and we arrived at Dulles slightly ahead of schedule. The next challenge – get the 300+ lbs of luggage and equipment from the Explorer into the international terminal. It didn’t take long for the bellcap to notice me struggling to hoist a gigantic red backpack onto my back while desperately reaching for my rollerbag that was attempting to escape into traffic. He hurried towards us with his cart and began stacking our ridiculous assemblage of oversized bags. I can only imagine what he thought of us – between the bags marked “adult/child/infant” and “torso,” he must have thought we were body smugglers or really bad parents.
Inside the terminal, he unloaded our bags. I reached for some cash, knowing I was one of the few of us with smaller bills. In our pre-trip prep, Sudha advised us ahead of time to get $100 bills from the bank. In Rwanda, the larger the bill, the higher the exchange rate. I handed him the money and was met with a confused look. “Not enough, I said?” feeling confused and bordering on embarrassed. He mumbled something unintelligible but his face told me it wasn’t good. Frank, the Rotarian accompanying us on the trip, quickly slipped him more cash, which seemed to placate him as he then scurried away.
I have Dr. Sudha to thank for the opportunity to be on this trip. She’s a fellowship trained Trauma Surgeon with a focus on International Medicine. She and I have worked together for over three years in the Emergency Department at VCU taking care of trauma patients who suffer accidents and injuries throughout Central Virginia. She first travelled to Rwanda 7 years ago during her fellowship and has since made over 20 separate trips. (I get the sense she just stopped counting at some point). In October 2017, she was awarded 3 grants totaling over $700,000, one of which was from Rotary International; hence Frank’s presence with us on the trip. If you know her, you understand why she was trusted with so much money. She’s just impressive.
The 5th person travelling with us is Jane. A nurse and a volunteer paramedic in Deltaville, VA, Jane worked at VCU for years in multiple capacities. Over time, she’s carved out a niche in International EMS, so she was an obvious choice for the team.
At the KLM* counter, we were met with friendliness and curiosity regarding our absurd quantity of baggage. We opted to check the medical equipment and carry-on our personal belongings. We didn’t want to take a gamble on the reliability of baggage transfer from Amsterdam to Kigali and end up with endotracheal tubes but no underwear.
I’ve decided for the privacy of those with me on the trip that I won’t include them from here on out. After all, this is just my perspective, and I don’t want to give the false appearance that I speak for anyone else. I will say I’m with a unique group of people and look forward to getting to know these like-minded folks. At dinner Dr. Sudha asked if we’d rather spend our 2 days off on a safari or at museums. The reflexive and immediate consensus was “SAFARI!” I knew then this was going to be a great trip.
*Bonus points for the free drinks on KLM.
Jan 21, 2018
“Day 2” is a bit of a misnomer. Technically it’s the 21st, but only because we just jumped ahead 6 hours by time zone. That didn’t stop KLM from feeding us breakfast just 1.5 hours after we’d eaten a full dinner.
We landed in Amsterdam without a hiccup. The last time I was in this airport was December of 2002. I’d just spent 5 months living in Spain, taking advanced conversational Spanish classes. What I didn’t realize then was just what a turn my life would take. I’d gone to Spain for a reset. I’d hit some professional hiccups in my last job and went to Spain, I thought, to do the study abroad I never had the chance to do while at UVA. Yes, I became fluent in Spanish, but I also found myself and my way forward.
What’s amazing about your twenties is the same thing that makes that time very lonely. You’ve left the nest, launched into a wide-open world full of opportunity, choices and possibilities. But you’ve left your nuclear family. And unlike decades prior, your independence isn’t quickly followed by love, marriage and establishment of your own nuclear family. There’s a gap now, a road with thousands of potential turns, each of which could lead to an entirely different life. Endless opportunity can be paralyzing. After standing at that airport, I came home, applied for and landed a job, which resulted in a successful career in Internet Marketing. I also joined my local rescue squad.
The view from the window on this leg of our journey, Amsterdam to Kigali, can be summed up in one word: tan. I finally gave in to my body’s repeated requests and took a 2 hour nap. Since waking up, I’ve seen nothing but desert. I did have a view of a beautiful part of Africa on the plane itself. Wearing a handmade, yellow and green gown with her hair secured tightly in a bright yellow wrap, everyone’s eyes focused on this woman when she appeared at the boarding gate. I looked down at my hold-over maternity pants and Merrill shoes and suddenly felt boorish and underdressed.
We arrived on time into Kigali. I had hoped for daylight as we landed so I could take an aerial survey of the city, but this close to the equator, night overcomes day very quickly, with sunsets happen in about 10 minutes from daylight to darkness.
We’re staying at the Gloria Hotel , which is just the right combination of nice but not stuffy. My only regret again is that it’s dark, and I can’t fully appreciate everything the area has to offer. I’m settling into my room as we have a long day tomorrow spending time in the Emergency Department, on the SAMU ambulance, and hopefully paying our respects at the Genocide Museum