Kibagabaga - Monday and Tuesday

My last week in Rwanda. I've got two more hospitals to visit. Kibagabaga Monday morning is a suburb of Kigali and Kibilizi on Wednesday is supposed to by close to Butare.

I'm scheduled to visit Dr. Gatsinda @ 9:00 am until noon Monday. I'm able to leave the house @ 8:30 catch the matata to Kimironko market then a moped sized moto out to Kibagabaga hospital and I'm at the gate right @ 9:00 am. This is a lovely new facility, just a couple of years old. beautifully landscaped with modern style doors, rooms, fixtures and equipment. We head to the "Echography" room and I meet Dr. Benard who is introduced as the gynecologist.

The ultrasound unit is a French Kontron Sigma 330. I'm not surprised to have never heard of it. Of the dozen ultrasound units I've seen in Rwanda I've not seen two by the same manufacturer. This one adds an additional challenge in that all of the buttons, soft keys, user's manual are in French. The nomenclature for the abbreviations is also a bit foreign: Biparietal Diameter which we abbreviate BPD is "BIP" and Head Circumference is "CP" (Circumference Parietal). The unit has Doppler and Color Doppler but only a single curvilinear transducer and no printer. I'm able to show how to use the obstetrical calculations package and to retrieve the report. Up to this point each time they did a measurement they'd write the values on a piece of paper which would later be transferred to the referral slip. An inexpensive thermal printer and they could print the entire obstetrical report including ratios, estimated date of delivery based on averages and each of the measurements with associated plus minus ranges.

We scanned 4 near term obstetrical patients in a row. On all 4, head measurements came out about 4 weeks younger than the rest of the measurements and last menstrual period dates. The calipers are measuring correctly but the associated dates added to the calculations is incorrect which skews the expected date of delivery and estimated fetal weight. One of the Doctors confirms that it's pretty routine that the babies are bigger than expected based on the ultrasound measurements. I've got another appointment to teach the Anesthesiology residents about ultrasound guided vascular access so I can't stay longer but asked to borrow the manual and return tomorrow (Tuesday) with an answer. I'm pretty sure that there are a number of options in the calculations package and if I can find the right sequence of button pushing I should be able to get into the system setup and see which has been chosen and then reset it for a more appropriate one.

Throughout the time I'm here Dr. Benard is in and out but we're joined another Dr. who also attended the Physician's conference and a couple of other doctors who are interested in learning more about their machine. Then Dr. Gatsinda brings in a a couple of Americans. Dr. Hal Goldberg is a Cardiologist here with a team of physicians, ancillary staff and other volunteers who are working with the docs @ Kibagabaga hospital. I get an invitation to supper and ask that Terry can join us as well. They've brought their own ultrasound unit a portable GE unit (although the Kontron unit has a cardiac calculation package there is not a cardiac transducer).

No wild and crazy findings today, but I've got to split @ 12:00 to make my next appointment. In all of the hospitals, the docs I've worked with are on duty and have their normal case load plus the time they are trying to spend with me. Three or four hours is really the max that they can carve out of their packed schedules in one day. Dr. Gatsinda takes me to meet the Medical Director and gets me a ride back to town in the ambulance. I'll try to get a picture of one of the ambulances for my Paramedic friend Randy Pierson.

That night, I find that only the first half of the manual is in French. Sections 5 - 8, which have the calculation tables information, is in English. I'm pretty sure that the tables can be changed and I've got a good idea how, but it'll still take a bit of playing to get the right sequence.

The ambulance drops me @ Kigali Business Center "KBC" where I'm to meet Dr. Terry Loughnan and his Anesthesiology residents for lunch. Afterwards we'll walk to King Faisal hospital where I've made arrangements with Seth to use the ultrasound unit for a couple of hours. Terry has found this "hole in the wall" lunch buffet restaurant. He has repeatedly mentioned the quality of the meal and afterwards I agree that it's a real jewel of a place were a meal and fruit juice is $3.60 U.S.. The place is packed and you can choose to stand and eat or sit at a table with strangers (which actually doesn't seem very strange at all in Rwanda).

When these five residents graduate and join the Rwanda health care system there will be 16 Anesthesiologists in the country. Currently, full anesthesia is only administered @ CHK, King Faisal and the hospital in Butare. Dr. Loughnan has an interest and a lot of experience in ultrasound guided access to jugular line placements as well as upper extremity nerve blocks. Today we're showing the possibilities (not training for competency). This two hours session is very low stress for me and the residents are obviously intelligent and anxious to learn how they might use this tool. As a bonus, I get to see my friends @ King Faisal again.

Terry & I catch a ride to mumunge, swing by a forex, search out a place to by hair clippers and then realize that the restaurant where we're meeting the American team is back in Remera and not in town. Down to the matatas but we're here @ rush time and the scene is close to anarchy. For this trip we can take a Remera bus but are unsure how close to our destination we'll get (as we've never taken that route before) and don't want to get stuck walking a couple of Km. The more sure option is a Kimironko bus but we can't find one. As we ask the drivers and bus porters they keep pointing to the one ahead. Terry later says that the pointing doesn't actually mean the one ahead but rather "not me, , , , but you might try the one ahead, , , , it might be". The taxi to Chez Lando will be expensive from here and we know the matatas and just keep trying. The crowd of individuals who are also looking for a Kimironko bus keeps growing in size and tension.

After 15 minutes, I spy one of the Hiace vans rolling in with a sign that says Kimironko. Hopeful riders grab the open windows as it slowly cruises in. They are running along side to ensure a seat when the slider opens. The driver purposely pulls in so close to a parked bus that it effectively skims off all of the folks hanging onto to the side. I'm able to obtain a spot in the qeue near the back of the bus but it's a pure melee to enter as there is another merging qeue at the front also trying to get into the sliding door. The attendant is trying to block a path so the current riders can get out but that effort fails and 4 people get stranded in the back until the attendant gets the word and redoubles his effort to finally get them out. In the midst of the scrum an old woman says "Pardon" in French as she hits me with her elbow to try and gain advantage. (Terry later tells me I shouldn't feel special as she had already elbowed him as well). Teenage school girls duck their heads and try to go under the outstretched arms and when they get their bodies in the flow are basically swept into the van. The woman in front of me hopes to secure a seat by passing her bag in through the window to hold a seat. When I last saw her, the doors where shut and she was standing outside (Terry thinks the bag was passed back out the window but I didn't see it happen). I'm pretty sure I could have found a spot but there was no way that Terry would have made it so I bailed out of the line (to the delight of the old woman who was able to weedle past the woman in front of me who was smaller). We decide it may be time to grab a taxi.

I snuck this video Sunday. It's not a melee, but captures a bit of the atmosphere of a slow day.

Supper with the folks from Spokane @ Chez Lando. The group is on their first trip and are trying to figure out the system and the opportunities for service. They are a pretty sharp group of people with a Neonatologist, Cardiologist, G.I. Oncological Surgeon, Psychologist, Medical Oncologist and accompanying staff members plus some family. Logistics and some of the prepratorial details have them with some questions and they hope we might be able to share some insights. Gradually more and more of the team arrives but by 9:00 we're both tired and excuse ourselves. They insisted on paying for our meal and we caught a taxi to Kimihurura.

Tuesday morning I say goodbye to Dr. Konn who is flying out this morning. I reviewed the Kontron manual again, send the company an e-mail asking for an electronic version in English and head back to the hospital. In fifteen minutes I've got the unit calculating using Hadlock's tables and I'm on my way back for lectures @ KHI. I run into Benard & Patrick in town and we walked together back to the KIST canteen. Dr. Konn has had ticket problems and was forced to buy a new ticket on the spot for the flight from Kigali to Kenya. She had been issued a paper ticket but only had the boarding pass and they wouldn't let her on without both. After lunch there are issues about time and not having a room available when we were scheduled to begin. Today was originally scheduled as a day off so I could wrap things up but I've added the trip to Kibagabaga and the lecture so the pressure is mounting. If the lecture isn't high enough on the priority list to have a room I decide I must have been mistaken about how much it was desired. It's already past time to start and no room, so I cancelled and went to try and cash the re-imbursement checks (which I've been warned repeatedly must be cashed before leaving the country). It ends up only taking 45 minutes to convince the National Bank Rwanda to cash my two checks.

On to get a few more presents and then back to the house where I'm meeting Said for supper. I chilled out for about 45 minutes playing my autoharp when Patrick & Benard arrive. Soon Said gets here and the group of 5 all decide to eat together @ the Chinese restaurant. We spent quite a bit of time discussing the advantages and disadvantages of marriage. Terry takes the tack that the three of them should wait and not hurry. I take the tack that life is too short not to have a best friend to share it with. The whole thing is a bit mute though, as none of them has anyone they are even dating. (though I've repeatedly pointed out that the cashier girl @ KIST canteen really blossoms every time she sees Patrick)

Things are starting to wind down.