Rwanda Day 10/11: Reflections on Rwanda

January 30/31, 2018

This morning we returned to the Lemigo Hotel for the last day of the trauma course taught by the students we trained last week. It was again inspiring to see these new educators helping to expand SAMU and improve trauma care throughout Rwanda. The goodbyes were difficult knowing I won’t likely come back to Rwanda. My husband, Amir, will hopefully be making the next trip towards the end of April if things go as planned. I’m excited for him to meet these wonderful people and share some of the same moving experiences. Travel is something we love to do together. In this case we are both sharing a travel experience, just 3 months apart.

The end of a trip is always a time for reflection. Interestingly, my goals in keeping this daily travel journal have expanded since I first started. Day 1 I was trying to capture my observations for the benefit of my own memory and perhaps to help educate my daughter. But what I found through the power of social media, was that the audience wanting to learn about Rwanda, SAMU and the efforts by VCU was much larger. As each day drew to a close, and I struggled to do justice to the beauty and energy of Rwanda with my photos and writing, I somehow received more feedback, more questions, more people engaged in learning about this unique place.

In full disclosure, I have chosen to make some edits to my earliest posts. As I learned more about the culture, tradition and pride of Rwandans, I realized that as a guest invited to their country, I wasn’t always respectful of that invitation. I haven’t written anything untrue, just adjusted my perspective and henceforth my words. Trust is a difficult thing for Rwandans (as expected when neighbors turn on neighbors), and I just want to give it due respect.

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One of my major goals both personally and professionally was to understand Rwanda’s EMS system. I’ve written much about the training, equipment and staffing, but only briefly mentioned how their 912 (911) system functions. Mobile phones aren’t widely available in rural areas of Rwanda. The country has designated a team of laypeople as citizen responders throughout these regions. When someone requires 912, they often do not have a phone with which to call. Instead, they physically go to the citizen responder who does have a mobile and that person dials 912. As described in my Day 2 post, the call is answered by one to three individuals (staffing is variable) who have a single mobile phone that rolls to a single backup should the first be busy. Calls are tracked in an Excel spreadsheet where data is manually entered and then the information ultimately filed away by day. Ambulances do not call the hospital directly, rather they call the 912 dispatcher to provide their patient report. This can be problematic for many reasons. The 912 dispatchers vary in their medical training, anywhere from no medical training to Nurse Anesthetist. So, it is possible that a patient report could be called to a dispatcher without medical training, who then has to call the charge nurse at the receiving hospital to relay that information. It’s literally the telephone game.

Additionally, there is no formal process for online medical direction. Since the ambulances don’t speak with the nurses or doctors at the hospital, they can’t easily call and ask them questions or request orders. In speaking with many of the SAMU staff, often individual providers will have relationships with certain doctors and happen to have their mobile number. One nurse anesthetist described a case where a man had suffered a spinal injury during a motor traffic accident (MTA). On physical exam, he had an obvious step-off deformity of his thoracic spine and no movement in his lower extremities. Unclear how to safely immobilize him given the severity of the step-off, she dialed up the Neurosurgeon directly for guidance.

Everyone I spoke to had at least one story where they called a doctor directly to ask a question. But, if you are new or just don’t know the right specialist, you are on your own. Given the severity of injuries and frequency of polytrauma in this system, I feel bad these guys are out there doing it on their own, without the support of online medical direction. It’s a testament to their professionalism and ingenuity that they can do what they do without that support. The good news is that in speaking with the SAMU leadership, dispatching, online medical direction and protocols are a top priority for development. There are plans in place for SAMU to borrow best practices in dispatching from the Richmond Ambulance Authority, and work is underway to modify the ODEMSA protocols to fit the needs and challenges of Rwanda. After all, if you’ve seen one EMS system you’ve seen one EMS system.


Somewhat off-topic but of interest (at least to me), is the continuing education (CE) process for medical staff at all levels in Rwanda. Just like the US, Rwanda has category 1 and 2 requirements, with credits granted in 1 hour time blocks. Ahead of our trip, Dr. Sudha spent significant time working with the Ministry of Health to ensure our Trauma Care Course met all continuing education requirements for the nurses, nurse anesthetists and doctors taking our course. After passing the final exam for the course, students received a certificate of completion and an official government stamp in their CE books. The Medical, OB/Neonatal and Pediatrics courses the team will return to teach later this year will also count towards CE for the SAMU staff. Now if only it counted for physician or EMS CE for me.

Lastly, there’s something that’s been haunting me since visiting the Genocide Memorial. I’m the first to admit that unlike my husband who can recite dates and motives for every international conflict since the existence of man, I am not a history buff.  Like most, I knew of various genocides throughout history, but I had never taken the time to truly understand how a nation and its people propel towards that tipping point. In visiting the Genocide Memorial, you see how the two ethnic groups at the time in Rwanda, Hutu and Tutsi, suffered under a systemic campaign to pit one group against another and eradicate the Tutsi. It didn’t happen overnight but rather over years.

Propaganda, which as a child of the 80s growing up during the cold war, I thought of as a Soviet, communist tool, filled the radio airwaves and newspapers across Rwanda. In April of 1994, I was finishing my sophomore year in high school. Privileged to attend one of the best public schools in Virginia, my biggest worries were whether or not Pearl Jam was going to break up, and how to best prep for my PSAT. Across the globe in Kigali, someone was importing thousands of machetes and distributing them to the Hutu, all while the government spread a message of hate and violence.


In one compelling exhibit, the Genocide Memorial features skulls of many of those killed, “hacked by machete” as the plaques read. Nearly all of the skulls have obvious fractures if not complete holes, the consequence of which is obvious, even to the untrained eye. Thousands of Rwandans, including babies and children, died from traumatic brain injury (TBI) during the Genocide. As I rounded this week in the hospital, I couldn’t help but note how TBI (now mostly from MTAs) still plagues this country. I felt like I had PTSD – my mind flashing between the images of the Genocide, heads wrapped in makeshift bandages, and now patients in CHUK, heads wrapped in gauze.

As I expected to be the case, multiple people I met on this trip lost multiple loved ones during the Genocide. I’ve deliberately not told those stories by request for privacy, but please know that they are real. How someone can survive a Genocide, recover from losing nearly every member of their family, and then devote their lives to helping others… it’s overwhelming to think about.

I am leaving Rwanda feeling honored. Honored to teach such resilient and passionate people. Honored for the opportunity to see and learn about genocide at the Kigali Genocide Memorial. Honored to have met the survivors themselves – been entrusted with their stories, and seen first hand how you can rise to inspire others, even after you’ve lost all hope.

If you are ever lucky enough to travel to Rwanda, visit the Kigali Genocide Memorial. Head east to Akagera National Park to enjoy the animals. If you see an ambulance or find yourself in hospital, say “thank you” to the staff.  When you meet a Rwandan, don’t ask if they are Tutsi or Hutu. It’s not that it will offend them, but rather it is a waste of your time. Every answer you get, from the President to the street sweepers, will be “I’m Rwandan.”


Explore more days in Rwanda:

Rwanda Day 1 | Rwanda Day 2 | Rwanda Day 3 | Rwanda Day 4 | Rwanda Day 5 | Rwanda Day 6 | Rwanda Day 7 | Rwanda Day 8 | Rwanda Day 9

Rwanda Day 9: Seeds to Blooms

January 29, 2018

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.

Dr. Noah and the team see patients on Rounds
Coffee and tea at the ready in the SAMU office – a sign of a well-prepared EMS agency

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.

USA far left, Germany back left corner and the rest CHUK ED staff, a diverse crowd discussing Event Medicine this morning.

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.

The very first class of course organizers and instructors


Explore more days in Rwanda:

Rwanda Day 1 | Rwanda Day 2 | Rwanda Day 3 | Rwanda Day 4 | Rwanda Day 5 | Rwanda Day 6 | Rwanda Day 7 | Rwanda Day 8 | Rwanda Day 9 | Rwanda Day 10/11

Rwanda Day 8: Rest and Recovery

January 28, 2018

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.

Kids playing football in a field near Kigali

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.

Various B&W patterns can be found on buildings, sidewalks and artwork across Kigali

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.


Explore more days in Rwanda:

Rwanda Day 1 | Rwanda Day 2 | Rwanda Day 3 | Rwanda Day 4 | Rwanda Day 5 | Rwanda Day 6 | Rwanda Day 7 | Rwanda Day 8 | Rwanda Day 9 | Rwanda Day 10/11

Rwanda Day 6: More Motortaxi Morbidity

January 26, 2018

This morning Jane and I returned to Central University Hospital of Kigali (CHUK) to attend Rounds once again. Like Monday, we began in the RED Resuscitation room to see the most critical patients who arrived overnight.

In Bed 1 lay a man who initially went to a district hospital and had been transferred to CHUK just a few hours earlier. Previously healthy, about 3 weeks ago he began having fevers and then his whole body started to swell, which was followed shortly by trouble breathing. As soon as he arrived, the Emergency Medicine Resident performed a lung and heart ultrasound, and discovered fluid on both his lungs as well as a weak heart that didn’t squeeze as a heart of a man in his mid 30s should. I looked at the ventilator, and his oxygen reached only 85% at best. He’s likely suffering from a myocarditis. At home, this man would most likely be on ECMO, an advanced heart-lung bypass machine. Of course that’s not an option here, as ECMO isn’t even accessible in many places in the United States. His chances are slim if his oxygen levels do not improve.

Also in the RED room, we find a 10-week-old baby boy who suffered a severe TBI after a motorbike accident. Is it the same one my student was describing yesterday in class? The age is right, but this baby isn’t paralyzed. There must be two. Two 10-week-old babies with devastating neurological injuries after motorbike crashes. I can’t even imagine myself on one of these motorbikes nevertheless my infant daughter. I looked at the CT scan of the head and cringed – the skull was in 4 separate pieces, and somehow this baby was still alive.

The team rounding on YELLOW room patients

Over in the YELLOW room, I discovered the same man I met Monday, with the fractured femur, but with no money to pay for the operation to fix it. His doctors have been struggling all week to find him help, as they don’t want to send him home with a fracture that, without repair, will likely affect his ability to walk. I inquired about the cost of the surgery, remembering the suggestion of Dr. Noah that we all chip in to help him. Dr. Joe, today’s EM Attending, explained that bills for services are usually rolled up into a single line item, making understanding and predicting the cost of specific medications or procedures extremely difficult. Sounds just like the US. “If I had to guess, around $100,000 USD,” he says. There goes the dream of us funding his operation.

Triage is calm this morning

We shuffle as a group to the next bed, when overhead we hear, “CODE BLUE, Room 9 – CODE Blue Room 9.” We walk with purpose back towards the resuscitation room to discover a man with metastatic liver cancer who is unconscious and not breathing. The residents jump into action, bagging the man while they prepare for intubation and the potential for CPR. The man’s family is close by, and the Senior Resident takes a moment to discuss with them goals of care, as CPR and ventilator support will likely not help this man with terminal cancer. He uses words and phrases provided by Dr. Noah in his End of Life lecture from Monday. The man stabilizes with the respiratory support provided by the Resident, and we return to rounds, goals of care still unknown.

Families wait to pay their hospital bills.  Discharges don’t happen until all debts are settled.

After Rounds, Jane and I walked back to our hotel, stopping to photograph some sights and for “African Tea” at the Camellia Tea House . It’s a mix of ginger tea and warm milk, sipped slowly and served with a butter cookie. Yum.

Jane has been on the hunt for some traditional Rwandan music to take back with her. We can’t seem to find CDs anywhere. I’m unsure if that’s because like back home, CDs are a dying format, or if we just haven’t stumbled upon the correct store.

A woman walks with a sack of something on her head

After shopping, we settled in for some lunch at our hotel. The food is good, but its appeal is more so the tropical balcony overlooking a busy intersection that lends itself to some excellent people watching. I’m cringing less each time as the motorbikes fly by, except when I see a baby on a mother’s back or a small child sandwiched between two adults on the same bike. There’s a stoplight at the intersection, but today it’s not in use. The convergence of cars, buses, motorbikes, pedestrians, cripples and cyclists is frenetic. I’m amazed there are no collisions. Back home in Richmond, our house too sits on the corner of an intersection, which despite much less traffic, has logged many more accidents and countless near misses.

Dr. Sudha arranged a lovely dinner at a restaurant with live music and traditional Rwandan dance to celebrate the conclusion of the courses for the week.  Representatives from the Ministry of Health and Rotary joined us, as well as a few SAMU staff.  Jane and I both wore African print dresses, because “When in Rome…,” right?

Tomorrow morning we are taking a safari tour to the Akagera National Park, just to the East, near the border with Tanzania.  There’s potential to see leopards, lions, hippos, giraffes, zebras and more.  We’re leaving at 6:00am to get there early before all the animals hide for the day.


Explore more days in Rwanda:

Rwanda Day 1 | Rwanda Day 2 | Rwanda Day 3 | Rwanda Day 4 | Rwanda Day 5 | Rwanda Day 7 | Rwanda Day 8 | Rwanda Day 9 | Rwanda Day 10/11

Rwanda Day 5: #WomeninEMS

January 25, 2018

Today was Day 2 of the Trauma Care Course.  Things continued just as well as yesterday, so I don’t have too much to share.  I gave two lectures, Musculoskeletal Trauma and Special Populations (Peds, OB, etc), then ran the students through the MCI/disaster table-top trainer.  The students took their final exam, and based on the tests I graded vs the pretest, the improvements were remarkable.  I can’t wait to see the statistical analysis of the score changes.

Memorable for me today was when one of my students asked me a “what would you have done?” question regarding a pediatric patient he had evaluated months ago.  Motorbikes are common here as they are across Africa, and while there are helmet laws, there are still frequent, serious crashes.  He responded to such a 912 call where 3 adults and a 10 week old baby were riding on a bike which crashed.  Everyone but the baby had a helmet to protect the head.  When he assessed the baby, he found it would not move its legs and indeed had a spinal cord injury causing paraplegia.  He wanted to know how he could have stabilized the baby’s spine given that a cervical collar would not fit.  I’m not sure I ever adequately answered his question because I couldn’t escape feeling a desperate hunger for a public health education program that might prevent such a crash entirely.

My favorite moment of the day was taking a photo with all of the inspiring women of SAMU.  See, what’s interesting about Rwanda SAMU, is how many women they have on staff.  I’m not sure if its because the staff all come from either nurse or nurse anesthetist background (both majority female) or something else, but a large portion are female.  In the States, on average EMS is still male dominated since so many EMS systems are fire-based, and fire is disproportionately male.  SAMU is third service (EMS separate from fire).  I think these two things contribute to the number of amazing, unique women in the service.

I mentioned on Day 1 how captivated I was by the woman on the plane in the beautiful yellow dress.  The clothing here is striking.  Handmade dresses, blouses, wraps and jewelry in bright colors and patterns – Kigali rivals Europe in terms of fashion.  I know I may be an independent feminist, but I also happen to believe fashion and feminism can coexist quite marvelously.  Hence why I was desperate to take this picture with the inspiring, intelligent, gorgeous women of SAMU.

The women of Rwanda SAMU   #WomeninEMS

Tomorrow the students begin a new educators’ course taught by Basil and Dr. Sudha to learn theories and best practices in adult education and EMS instruction.  Monday and Tuesday next week they will then instruct the course they just completed today and propagate that knowledge to even more SAMU providers.  I’m excited to hear how tomorrow’s course goes.

Jane and I will likely be at the hospital again for Rounds like Day 2.  I say likely, because what I’ve quickly learned in Kigali, like many low and middle income countries, is that timelines and plans are fluid, and when things change (which they often do), you have to just go with the flow.  So with that, I’ve set my alarm and will see where tomorrow takes me.


Explore other days in Rwanda:

Rwanda Day 1 | Rwanda Day 2 | Rwanda Day 3 | Rwanda Day 4 | Rwanda Day 6 | Rwanda Day 7 | Rwanda Day 8 | Rwanda Day 9 | Rwanda Day 10/11