journey back

Alex and I made the most of our lay over in Amsterdam.  It was a wonderful ease back to winter.  What a glorious city.

my two homes

I am back in Canada but still not in Halifax.  A large winter storm shut down flights to the Maritimes, so I'm staying with Alex in Toronto.  The city is blanketed with fresh white snow, the cafes and shops of Bloor Street are inviting, and the city of 4 million seems so quiet after Nyamirambo.  

I have known for a long time that I have two homes and will therefore always feel a sense of pull.  I love Canada: the snow, space, clean air, crossing the street safely,  new artistic plastic currency, clean lakes, ocean breezes, our values,  decent kind hearted people, our excellent health care system.  But it is in Rwanda that I truly feel open heart.  It is rare in Rwanda not to find people who greet you with warm smiles and always have time to chat.  "You are welcome" is heard many times.  This means "you are welcome in Rwanda".  There is already a strong pull to the many people in Rwanda who I considered good friends (a number of whom call me Mum) but there is also a wish to be there because everyday the work feels so meaningful.  There is such great potential for impact with all the teaching we've been doing in Rwanda. 

So, much as I love Canada, I consider myself Rwandan as well.  I have two identities and two homes.  As long as I am capable, I want to continue to contribute in whatever way possible to health and well being in Rwanda.  

Here are just a few images of the past five weeks.

One of the many shops we pass on the way to the hospital

Ready for the SAFE Course

Highly enjoyable teaching at the SAFE Course

Megan welcoming participants

Using hands on teaching as much as possible

Michelle bringing joy, and a brand new soccer ball, to a team that had been playing with tied up garbage bags

The "before" picture of the team.  100 kms of up and down on mountain tracks to Kibuye

We cycled through the heart of Rwanda

Beautifully dressed women on their way to church in the backcountry

Okay, I really did ask "how much longer".  Tom, wisely, refused to say.

Dean Patrick, truly one of the greatest leaders I've ever met

Skills teaching and practice at the sim centre

Scenario practice at the sim centre

Peter teaching communication skills

Cricothyroidotomy skills teaching at sim centre

Serena Hotel, our oasis

Joshua and Alex.

There are many ways people can help with our work in Rwanda.  All you need is a bit of passion to make a difference.  We need teachers and supplies for the sim centre.  You can sponsor a child, such as Joshua, at the Gisimba Orphanage for $500 per year.  Visit the beautiful Land of a Thousand Hills, if you are able.  But most of all, remember there are hard working people out there in the world who are able to find genuine happiness in the midst of tough situations.  For having made this discovery, I am truly grateful.

with love,

Patty

sponsoring Karim and Brune

Alex and I are going to sponsor two six year-old children at the Gisimba Orphanage.  The sponsorship will cover their school fees and books each year.  The children are a girl named Brune and a boy named Karim.  They are lovely children who are bright and playful.  Both are HIV orphans.

There is so much more to write about but we are down to the last 24 hours in Rwanda and the pace has not let up.  Alex will post to his blog soon about his safari and successful climb of Mount Kilimanjaro.

Brune

Karim, Alex and Brune

Brune and me

TOT at sim centre

Today was the first day of our training of trainers course at the simulation and skills centre.  Peter, Jon, Michelle, Georges and I have been scrambling to arrange the course in the last few days.  It was a big success.  We had heads of department, senior members and residents from surgery, anesthesia, ENT, OB Gyn, and emergency.  The morning was dedicated to teaching a skill at four different stations – knot tying, intubation, cricothyroidotomy, and suturing.  The afternoon was spent on multidisciplinary team scenarios.  Michelle did a great job as a simulated patient.  There was great enthusiasm about the centre for future teaching of skills and team dynamics.  Tomorrow morning 12 medical students will arrive and the course participants from today will teach the same skills they have just learned to the med students.  Sara, the catering was stellar!

Jon teaching suturing

Peter teaching cricothyroidotomy

Day one of the sim centre

Yesterday we made phenomenal progress on the simulation centre.  This facility is being established so that a wide range of learners in the health profession can have a place to rehearse technical skills, such as suturing, and complex team dynamic, such as managing maternal hemorrhage, without practicing on patients.  There will be capacity to teach nurses how to set up a table of surgical instruments, medical students how to insert IV lines, and residents how to manage a patient after severe trauma. 

The centre is a free standing building with two bright, well-ventilated rooms.  We had an important meeting yesterday with the Dean of the Faculty of Medicine, the new Medical Director of the simulation centre, the Head of Anesthesia, and a staff anesthesiologist.  Peter, Jon, Michelle and I wanted the place to look at good as possible before the meeting.  We got up early and scurried around the centre unpacking the many bags of donated supplies Jon and Michelle had brought from Halifax and all the equipment from the SAFE Course.  Then we ran to Nakumatt (the local Superstore plus) where Michelle bought a refrigerator with money donated by her soccer team for the sim centre.  This will be essential for storing animal parts used in teaching skills.  After a quick coffee at Bourbon Café we returned for the 10 AM meeting to a centre that looked remarkably transformed already.

We have been waiting a long time for the official appointment of Dr. Georges as the Medical Director of the Centre.  This has delayed spending the money I received from the simulation grant.  Therefore the space has not been painted and the cabinets have not been built.  During our meeting the Dean got on his cell phone and in fifteen minutes we had a couple of workers taking measurements for all the renovations. 

After a fabulously successful first day on the simulation program, Peter and I headed off to the market to load up on mangos, papayas, pineapples, passion fruits and cheese (all the essentials for life).  There was a lively cooking session with four of us packing into our tiny kitchen.  My good friend, Steven, joined us for dinner and shared many of his insights on justice and reconciliation.  He will be taking many of our team to visit the church in Nyamata on Sunday.

Peter writing a welcome poster in Kinyarwanda

Set up for skills and sim

Michelle adjusting a mannequin

Drs. Georges and Patrick after a very successful meeting

Check out this time lapse of sim centre set up:

http://www.youtube.com/watch?v=-wjYjYo79Mk&feature=youtu.be

in the back of beyond

We've just returned from what is possibly the hardest thing I've ever done physically.  We cycled from Gisenyi to Kibuye over two days.  This was 100 km total but most of it was up and down steep rocky trails.  The second day was nearly 10 hours of cycling.  We saw remote parts of Rwanda with friendly people and spectacular landscape.  These photos cannot possibly do it justice.  We are ever so grateful for Tom at Rwanda Cycle Adventures and his two porters Mansuet and Twisiere.  Tom has been working extensively with the local people along the trail to help with their ability to receive cycle tourists and also to have meal and accommodation options.  Our first night was at the Kinunu coffee washing station.  It is a little bit of paradise with mangos, papaya, pineapples, oranges, and lots of fabulous coffee! Both days we had dramatic thunder and lightening - fortunately the first day it was in the evening when we were cozy but on day two our last ride was in the rain with sunscreen washing into our eyes and one more rocky hill...

We could barely move when we arrived in Kibuye last night but fortunately we were staying at a very comfortable hotel with lovely hot showers.  

Shores of Lake Kivu

Banana plants and Lake Kivu

Fishing boats

We are back in Kigali, safe and sound, and ready to get down to work on the sim centre.  Jon and Peter have joined our group. More to come.

With our fabulous porter

Just outside Gisenyi

Fishing boats

Children enjoying the beach where we stopped for lunch on day one

Beautiful Lake Kivu

Are we there yet?  How many more hills???

I should have used more sunscreen

Our first day was hilly

The second day was more hilly, and much farther!!

Michelle enjoying Rwanda

Michelle is smiling all the time and very happy to be in Rwanda

it's a wrap, now to the hills

The second SAFE Course has finished.  The second week ran more smoothly than the first after a few alterations based on the experience of week one.  Most session were run in outdoor gazebos.  This proved to be an excellent setting with lively bird sounds throughout the day, a light breeze, and bright daylight.   Fortunately, there was no rain until the last day when, just before the post-course skills test, it came down in bucket loads.  After waiting out the rain, we were able to complete the final test before the participants regrouped to write “commitment to change” forms to identify clinical practice changes they hope to make based on new learning from the SAFE course.

Most of the course comprised a variety of small group stations where the participants are engaged in discussion, skills teaching, and simulated scenarios using mannequins or a participant role-playing as patient.  There was enough equipment to provide authenticity to the scenarios.  Participants worked as teams to manage situations such as emergency general cesarean section, ruptured uterus, or post-partum sepsis from retained products of conception.  They employed anesthesia knowledge and skills as well as non-technical skills such as systematic preparation, communication and team working.  The course participants had to role-play as anesthesia provider, assistant, or surgeon.  A faculty member, who was assisted by one or two trainers, conducted each session; trainers are anesthesia residents and senior technicians, who had been identified by the local staff as having leadership capability.  We ran a training of trainers course the first day and then mentored the trainers during the small group sessions so they were able to run the final session independently.

Planning and preparation for the SAFE Course has taken up much of the past year.  It is easy to ask if all this hard work is worthwhile.  The last day of the course, I had an experience that confirmed the need for this program.  One participant had struggled with managing a scenario that required resuscitation of a sick patient.  She had been unable to intubate and did not recognize that the intubation was esophageal.  When this session was over I stepped away for a bit but when I returned I found our trainer was working with that participant to teach her intubation.  It turns out the participant was trained on the job (no formal anesthesia teaching) and had never been taught how to intubate.  She practices anesthesia in a district hospital.  The trainer recognized the problem and taught the participant how to intubate on the mannequin.  The learner had a huge sense of accomplishment when she performed the skill correctly. 

This situation is an example of both the need for anesthesia skills and the value in training trainers as local champions for promoting safe anesthesia practice.  It also illustrates the value of active, hands on learning.  If we had conducted these sessions as lectures, how would we have found out and corrected deficiencies?

We cannot hope to have solved anesthesia problems in Rwanda with one course but we have begun a journey that involves working together for a common goal.  Anesthesia providers have met colleagues from around the country.  They had a chance to discuss common challenges they face – lack of equipment, relations with surgeons, and isolation were frequently mentioned.  The next step is to implement the anesthesia practice network, which is a system of mentorship to continue to support the anesthesia providers who work in district hospitals.

Megan and I had to leave the course yesterday afternoon in order to transport all the equipment to the simulation centre and for Megan to catch the evening flight back to Halifax.  It was too bad to miss the final banquet for the course.

The past few weeks have been entirely dedicated to the SAFE Course but now it is time to shift gears and work with colleagues in Rwanda to establish a simulation centre for teaching clinical skills and team training.

Michelle, who runs the skills teaching centre in Halifax, arrived safely last night.  She will be sharing her vast experience with our local partners to help create the sim centre.  Before we get to work on Wednesday, Michelle, Faye and I are going to treat ourselves to a three-day cycle expedition from Gisenyi to Kibuye.  “Treat” may be the wrong term as this is route entirely consists of hills… 

Michelle, still gorgeous after 30 hours of travel

The simulation centre - lots of work to do!

Entrance to simulation centre on the grounds of CHUK

smooth sailing for day one

The second SAFE Obstetric Anesthesia Course started yesterday.  The first day ran much more smoothly than last week.  We know what is needed and are ready.  The participants have been incredible: 100% of people who were supposed to come last week arrived, fully participated in the course, and completed course evaluations. Again, 100% scheduled for the second week have arrived. 

The participants and faculty have been very happy with the program.  Initially people are shy but soon jump into role-playing and skills demonstrations in scenarios. 

The faculty and participants have greatly enjoyed meeting colleagues from around Rwanda.  These personal connections are so valuable and will form the basis of the Anesthesia Practice Network.

Preparing materials for SAFE Course round 2

Gaston practicing "giving an interactive presentation" in the Training of Trainers Course

Angela demonstrates the Universal Anesthesia Machine

Adolphe and Alex practice difficult intubation facilitated by bougie

The Calm before the Storm--TAKE TWO

I had a nice relaxing weekend in Kigali in order to prepare myself for Round 2 of the SAFE Course.  I decided not to go to Gisenyi with Patty and Megan as I wanted some time to regroup and relax before gearing up for this week.

Teaching the WHO Surgical Safety Checklist at Kibagabaga

This morning I accompanied Angela Enright and Sarah Kessler (from Lifebox) to Kibagabaga to help with some Surgical Safety Checklist Training. For those of you who are not aware, Kibagabaga is a district hospital in Kigali and has been selected as a the site to pilot the surgical safety checklist in Rwanda.  Sophie Reshamwalla (from Lifebox) and Beth Riviello have spent endless hours at this hospital teaching the staff about the importance of the checklist and working on local implementation. The process has not been easy but I am confident they will be successful.

Angela Enright with the Rwandan Anesthesia Residents on academic day

After leaving Kibagabaga, we stopped by CHUK so that Angela could visit. She had not been back to CHUK in several years and was eager to see all of the changes.  She was quite impressed with the new operating rooms and all that had been accomplished over the past 5 years. I had the privilege of introducing her to the anesthesia residents at academic day.  Without her initiative and efforts, anesthesia in Rwanda would not be where it is today.   She is actually one of the founders of the Rwandan Anesthesia Residency program.

There is no problem that a nice cup of tea will not solve.

Simulation using  the Universal Anesthesia Machine (UAM)

This afternoon, we arrived back in Rwamagana at our home away from home "The Dereva Hotel" to start our preparations for this week's SAFE Course.   Now that we had one course under our belt, we know what we need to do to get organized.  Despite a new crew of local faculty and participants, we are confident that this course will be even more successful than last week's.

Stay tuned.....