I had to leave the house by 6:45 to get the ticket... I plan to take a matata but after 2 pass without a spot available I grab a moto. It isn't until after I've made my deal about destination
and price that I see this is one is in poor condition. There is no visor on either helmet, and there is a single seat for the driver with a luggage rack and the luggage rack has no padding. But he's a careful driver and we arrive @ Mumunge in one piece without incident. There is a ticket and we'll be departing in about 20 minutes. Here is the bus and the front passenger seat is empty. I take a chance and leave my lab coat on the seat to mark my spot and go to look for food. There is a restaurant @ the Atraco station and I went to see if there was something for breakfast. With the talk about moving I've let my supplies drop @ the house and I'm out of breakfast stuff. They have a large bowl of stew for $6oo FRw. I looks to be boiled potatoes in a tomato based sauce with a few chunks of meat. I'm half way through my bowl when I realize the potatoes are actually bananas. The bowl of food is so hot it takes me about 15 minutes to eat most of it before I decide to go back to the bus. There is one other passenger sitting in the front seat between my coat and the driver's spot. Three minutes and the driver jumps in and we're off , , , just the three of us. We're on our way to Remera station (on the way out of town about 15 minutes distant). Here the rest of the bus fills up in short order and we're on the same road I took twice last week to the other two hospitals in the side of the country. Slowly the bus empties at various stops until by the time the driver drops me @ Kiziguro there are only three other passengers. He points to some distant buildings and says "Hospital"
and price that I see this is one is in poor condition. There is no visor on either helmet, and there is a single seat for the driver with a luggage rack and the luggage rack has no padding. But he's a careful driver and we arrive @ Mumunge in one piece without incident. There is a ticket and we'll be departing in about 20 minutes. Here is the bus and the front passenger seat is empty. I take a chance and leave my lab coat on the seat to mark my spot and go to look for food. There is a restaurant @ the Atraco station and I went to see if there was something for breakfast. With the talk about moving I've let my supplies drop @ the house and I'm out of breakfast stuff. They have a large bowl of stew for $6oo FRw. I looks to be boiled potatoes in a tomato based sauce with a few chunks of meat. I'm half way through my bowl when I realize the potatoes are actually bananas. The bowl of food is so hot it takes me about 15 minutes to eat most of it before I decide to go back to the bus. There is one other passenger sitting in the front seat between my coat and the driver's spot. Three minutes and the driver jumps in and we're off , , , just the three of us. We're on our way to Remera station (on the way out of town about 15 minutes distant). Here the rest of the bus fills up in short order and we're on the same road I took twice last week to the other two hospitals in the side of the country. Slowly the bus empties at various stops until by the time the driver drops me @ Kiziguro there are only three other passengers. He points to some distant buildings and says "Hospital"I start to walk through the village and can hear the children through the open windows of the elementary school doing recitations en masse. Past the large Catholic church and I don't see 
anything resembling a hospital. I ask a pack of teenage boys and they are very amused at the funny sounds that I make. I showed them the card with the information in English and it's equally odd to them and they have no clue where to point me. A quick call to Dr. Kanimba and he's on his way to escort me. Meanwhile the boys find a man who speaks French who is able to point me in the right direction. Dr. Kanimba meets me and we continue on to the hospital. There are 6 doctors assigned to this facility but only two are here now, the rest are @ meetings or have other business. I'm introduced to Dr. Jean Paul and shown the ultrasound unit. In the corner there are the remnants of their old unit which no longer functions. On a cart is a Chinese manufactured portable unit with a single 3.5 MHz curvilinear transducer. I need some time to explore and Dr. Kanimba needs to see patients. The buttons are in the right places and it's not long before I've got it pretty much figured out. I open the box under the unit and find a transvaginal transducer. They must have just forgotten to mention it to me. Dr. Jean Paul comes by with some paper for the printer and a user's manual.
anything resembling a hospital. I ask a pack of teenage boys and they are very amused at the funny sounds that I make. I showed them the card with the information in English and it's equally odd to them and they have no clue where to point me. A quick call to Dr. Kanimba and he's on his way to escort me. Meanwhile the boys find a man who speaks French who is able to point me in the right direction. Dr. Kanimba meets me and we continue on to the hospital. There are 6 doctors assigned to this facility but only two are here now, the rest are @ meetings or have other business. I'm introduced to Dr. Jean Paul and shown the ultrasound unit. In the corner there are the remnants of their old unit which no longer functions. On a cart is a Chinese manufactured portable unit with a single 3.5 MHz curvilinear transducer. I need some time to explore and Dr. Kanimba needs to see patients. The buttons are in the right places and it's not long before I've got it pretty much figured out. I open the box under the unit and find a transvaginal transducer. They must have just forgotten to mention it to me. Dr. Jean Paul comes by with some paper for the printer and a user's manual. This is a nice little machine that can store 32 images, has a good obstetrical package. I take a few
images adjusting the printer and change the hospital name in the memory and set the date/time correctly. By the time Dr. Kanimba is free I'm ready to give him the in-service. He is quite surprised to see the T.V. transducer as none of them knew it was here. Dr. Jean Paul says they can find some condoms. He is equally surprised that we've gotten the printer working and that they can produce an obstetrical report using the calculations package. The M-Mode works as well and now they can calculate fetal heart rates as well. Additionally the transducers are both broad bandwidth and have a nice wide range of possible frequencies. He's also quite happy to find they can store and retrieve images. After the in-service we start scanning patients.
images adjusting the printer and change the hospital name in the memory and set the date/time correctly. By the time Dr. Kanimba is free I'm ready to give him the in-service. He is quite surprised to see the T.V. transducer as none of them knew it was here. Dr. Jean Paul says they can find some condoms. He is equally surprised that we've gotten the printer working and that they can produce an obstetrical report using the calculations package. The M-Mode works as well and now they can calculate fetal heart rates as well. Additionally the transducers are both broad bandwidth and have a nice wide range of possible frequencies. He's also quite happy to find they can store and retrieve images. After the in-service we start scanning patients. First, a couple of obstetrical patients. It's the same here as elsewhere, they want to know how to tell the sex of the fetus and then how to do the measurements (one fetus shows us she's a girl and the other obstinate one never did expose it's genitals). A pelvic ultrasound but the bladder is not full and we ask her to start drinking. Then a patient with a large epigastric mass. The mass is plainly visible extending from the umbilicus about halfway to the pubis. Sonographically it's too 
large to measure, fills the pelvis and lower abdomen and is mostly solid with some areas that are quite bright and shadowing and some hypoechoic regions as well. First we check to see if it's attached to a kidney or liver (as expected, it is not), no ascites and I can't define a separate uterus or ovaries. They think it may be a fibroid but I'm leaning more to an ovarian mass. I suggest that this may be a time when the transvaginal transducer might help. If we can see a separate uterus then we can tip the differential diagnosis towards ovarian. They talk to the patient and I showed them how to prepare the transducer. Almost immediately we can see that the uterus is completely separate but dislocated by the mass. There has not been an abdomen radiograph but if they see a tooth in the pelvis that would be consistent with a large dermoid.
large to measure, fills the pelvis and lower abdomen and is mostly solid with some areas that are quite bright and shadowing and some hypoechoic regions as well. First we check to see if it's attached to a kidney or liver (as expected, it is not), no ascites and I can't define a separate uterus or ovaries. They think it may be a fibroid but I'm leaning more to an ovarian mass. I suggest that this may be a time when the transvaginal transducer might help. If we can see a separate uterus then we can tip the differential diagnosis towards ovarian. They talk to the patient and I showed them how to prepare the transducer. Almost immediately we can see that the uterus is completely separate but dislocated by the mass. There has not been an abdomen radiograph but if they see a tooth in the pelvis that would be consistent with a large dermoid. An elderly man with possible chirhosis is next. The liver brightness appears normal when compared to the renal cortex but there is significant ascites (which they've drained twice already) massive splenomegaly and a splenic vein measuring 14mm (even larger portal vein).
Next is a an adult woman who has never menstruated. On pelvic exam the physician feels a possible imperforate hymen. Based on the apparent age of the patient, an imperforate hymen and never a menstrual cycle she should have a huge fluid collection in the distal vagina. She has 
developed breasts and has some pubic hair. But the patient's bladder is empty and we're hesitant to go directly to T.V. exam. By now it's close to 2:00 and the doctors want to take some lunch. I'll wait until the patient has filled her bladder and rescan after eating. The day is quite pleasant and the local restaurant serves goat brochettes with banana. Back to the hospital and the patient is moving quickly (as full bladder are apt to do) but there is a similar amount of bladder filling. But I don't see any masses or for that matter a uterus. We decide to do a T.V. exam and even though we look in every corner of the pelvis there is no apparent uterus. All we see beyond the vagina is peristalsing bowel in every direction. No ovaries either. I don't understand the discussion between the doctor and patient but the patient seems not happy about the results.
developed breasts and has some pubic hair. But the patient's bladder is empty and we're hesitant to go directly to T.V. exam. By now it's close to 2:00 and the doctors want to take some lunch. I'll wait until the patient has filled her bladder and rescan after eating. The day is quite pleasant and the local restaurant serves goat brochettes with banana. Back to the hospital and the patient is moving quickly (as full bladder are apt to do) but there is a similar amount of bladder filling. But I don't see any masses or for that matter a uterus. We decide to do a T.V. exam and even though we look in every corner of the pelvis there is no apparent uterus. All we see beyond the vagina is peristalsing bowel in every direction. No ovaries either. I don't understand the discussion between the doctor and patient but the patient seems not happy about the results. Another physician arrives who had attended the seminar. He has a patient who has had an abortion but they are concerned about retained products. The uterus is large and we can plainly see there is quite a bit of retained products and they plan a curettage procedure. There are no more patients and it's about time to go to the bus station. I've got an appointment to meet Terry @ the Serena hotel for supper this evening @ 7:00 pm. All three doctors walk me to the station and after purchasing my ticket, wait with me for the Hiace van (bus). Again, I'm impressed that these dedicated young physicians are a real sign of a bright future for Rwandan medicine.
The bus and driver are the same ones that dropped me off 7 hours earlier but this time the bus is max full. They've over-sold by one and a young man has to get off to make room for a woman who had an earlier reservation. When we get to the next village, someone who was in the front seat disembarks and I'm back in that front passenger seat by the window. It's dark by the time we reach Kigali. A quick moto to the Serena through the gate and I'm back in America. This hotel could be any 5 star facility in the U.S. Terry has found a group of Australians congregate here each Wednesday evening and I've been
invited to tag along tonight. The food is outstanding with a buffet including the first drink, a selection of appetizer soups (I had leek) a wonderful salad bar that has the first cheese I've put in my mouth in 7 weeks, a Mongolian grill (Rwandan style but still tasty), an additional hot bar with a great selection of Indian cuisine (It was all fantastic) and a desert bar that was just decadent. Plus there was frequent resupplying of fresh warm breads/rolls. I had decided I would stay away from this place as I wanted to experience Rwanda and not a substituted American experience but it was definitely a very nice supper. Although the price was a bit high I've been to other places in Kigali where I've spent $8,000 FRw and not been treated nearly as well or to as high a quality food.
invited to tag along tonight. The food is outstanding with a buffet including the first drink, a selection of appetizer soups (I had leek) a wonderful salad bar that has the first cheese I've put in my mouth in 7 weeks, a Mongolian grill (Rwandan style but still tasty), an additional hot bar with a great selection of Indian cuisine (It was all fantastic) and a desert bar that was just decadent. Plus there was frequent resupplying of fresh warm breads/rolls. I had decided I would stay away from this place as I wanted to experience Rwanda and not a substituted American experience but it was definitely a very nice supper. Although the price was a bit high I've been to other places in Kigali where I've spent $8,000 FRw and not been treated nearly as well or to as high a quality food. Home by shared Taxi and I'm back where I started by 9:00 pm. The generator is running as the power has been shut off. Philbert has been busy with other things and the bill didn't get paid. I'm tired and go to bed not thinking about what the power situation will be later. When I wake up to Blog Thursday morning, the house is dark and quite. In the morning we find that they also ran out of diesel for the generator. Luckily, there is still water in the hot water heater and there is water pressure so the shower is pleasant if brief. We managed to get 3 people showered with the warm water. Around 7:45 am a call to Abdullah reveals that if I wait I'll be made late so it's off by moto.
1 comment:
Leif, this is so eye-opening every time I read your blog about your trips to other towns and hospitals. They have the tools, nice machines, and supplies that been been donated, but nobody to teach them about how it all works and what they can do with the donated items. What an awesome experience it is to have you on the ground, teaching them how to use the donations to help their own people.
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