Rwamagana - Greatest immediate impact thus far

I've been invited to go to Rwamagana hospital today by Dr. Etienne Amendezo (or as the Rwandans write it Dr. AMENDEZO Etienne). Rwamagana is about half way between Kigali and the border of Tanzania. It's supposed to be 45 minutes from Kigali (and it is if you drive directly there without stopping). I get to the matata station in Mumunge before 9 but the Atraco bus company sign that I'd located the day before was not the place to get tickets or catch the bus. By the time I walk to the correct location I've missed the 9 am bus and have to wait for the 9:30. One fortunate side effect is that I'm the first person on the 9:30 bus which means I get that coveted front passenger window seat.

The trip is very pleasant. We made a stop @ the Remera bus station and I see that it has it's own little market of all the things that a traveler might need; Sun glasses (or as my Aussie friend terry says "Sunnies"), tissue paper, small packs of cookies/crackers, gum, 2 piece suits, belts, shoes etc. . . The suits on a rolling rack are the oddest of this eclectic assortment of offerings. Dr. Etienne and I phone each other a couple of times throughout the morning first confirming that I'm coming and the time and later my progress. The hardest part of reporting when I'll arrive is that neither the driver nor the other passengers seem to speak any English so the pantomimed question of "When will we reach Rwamagana??" creates much discussion and comment in KiniRwandan but no answer for me. Along the way I see a trench being dug for what appears to be telephone or power cables. I arrive just about 11:00 am.

The hospital is directly across from the bus station and I walk into the courtyard and await Dr. Amendezo. A tall handsome Dr. Eric comes to greet me. He speaks English very well and is going to join us in learning more about their ultrasound unit. Soon the Director of the hospital comes to say hello as well and then we are joined by Dr. Amendezo and we head towards the Maternite Ward.

The ultrasound unit is a biosound unit that looks as though it might have been an early portable model. I've included a link and if you have any information you can share especially a users manual. There are a couple of stickers indicating that the unit was donated by Pie Medical and I'll e-mail them so they can know that their donation is being used (and to ask for a user's manual). Since there is no manual I ask Dr. Amandezo to give me about 20-30 minutes to explore the buttons and figure out how each of the controls works. Ultrasound units are similar to cars , , , , once you've driven one and learned all of the "car" controls you should be able to drive just about any car. The buttons may look different, may have another name and will likely be in another location but they are all still there. This unit is relatively intuitive for me and I've got most of the major controls figured out by the time the other 4 doctors arrive for the impromptu inservice.

The biggest thing I discover is inside the transducer case that was stored under the machine. I looked inside for a manual or printer cables and found an endovaginal transducer. The physicians were as surprised as I was to find it. Their primary use for the ultrasound unit is obstetrics and gynecology. Having an endovaginal transducer can significantly improve the quality of the sonographic information available to them. The other thing that I discovered is that when calculations are entered appropriately it calculates the standard fetal biometries including heart rate, expected date of delivery and estimated fetal weight based on the averaged biometries. I showed them how to start an exam with "New Patient", how to select an exam type from the presets, once scanning how to change the overall gain, depth, TGC, dynamic range. We spent quite a bit of time reviewing how to enter calculations and make measurements. I wasn't able to quickly figure out how to delete errant measurements, but know there must be a way. I also can't answer if the unit averages all of the measurements for a specific biometry or only the last measurement of that specific biometry. Hopefully someone from PIE will be able to help me.

After the basic inservice they have patients lined up with specific questions that they want answered. First an OB patient and a demonstration on a live patient on how to do the calculations and show a report. They are wistful for a printer that they might be able to easily document the report sheet quickly. I can sense that they want to ask me about the gender and are trying hard to be polite, so I can finish showing them how and where to do each of the measurements. Finally the question comes up and all affirm the desire to see the baby's bottom. Luckily for my demonstration, the gender is quite obvious as we can plainly make out the labia. Next, there are two patients who are questionable for retained products of conception after miscarriage/abortion (one positive, one negative).

Another patient has a pelvic mass found during physical examination. They want me to scan the pelvis and abdomen. Her bladder is not quite full enough for a standard transabdominal and is too full for a routine transvaginal examination. On the preliminary scan I see that her uterus is significantly retroflexed and the tansvaginal should be much more helpful. She attempts to void but is unable even though she has close to 300 cc of urine. I note subjectively a thickened bladder wall. I look around the abdomen before switching tho the T.V. transducer. The right kidney is enlarged with massive calyceal dilatation and a right ureter diameter that measures almost 17mm. I can trace it from the renal pelvis all the way to the uretero-vessicle junction. When I check the left kidney it is not quite as dilated in the renal sinus but the left ureter is basically the same diameter as the right and can be traced by it's large size down to the same basic location of the bladder trigone. Additionally, she has large bilateral pleural effusions, a peri-cardial effusion, splenomegaly and a very large Inferior Vena Cava (which they confirmed as congestive heart failure). This lady is very sick. The T.V. exam showed bladder wall thickening in the are of the trigone and an indiscrete mass in the cervical area. All of this is consistent with her dilated ureters and inability to urinate. They knew she was quite ill and suspected each of the things we found. The sonogram was able to clarify the gravity of her situation. This patient helped to clarify for me the value of a good ultrasound unit with trained individuals operating them.

Finally an HIV patient who has a pelvic mass which they would like to evaluate as possible fibroid. They also want to look through the abdomen for other pathology especially lymph nodes. I've had Dr. Amendezo scan the last couple of patients with help. The other physicians have been paying attention and are able to quickly point out which button to push for measurements and image correction as he scans. I'm very encouraged that the few hours I've spent here today have had the most immediate impact on direct patient care in Rwanda thus far.

Like other busy days, the next thing you know and we've almost missed the lunch hour (it's 1:30). I went with four of the young physicians to the local hotel a few hundred meters down the road. It's a lovely setting and serves a fantastic African lunch buffet. After lunch I sat down at the unit by myself while Dr. Amendezo does an emergency, exploratory surgery for soft tissue neck trauma and possible carotid transecting/bleed. I find how to change the name on the machine to say Rwamagana Hospital, the steps to delete those errant measurements, how to change which transducer that is selected with exam start up and how to adjust the other imaging presets. We scan a couple of volunteers with three of the physicians. They are delighted and I'm relieved when this baby also proudly displays his genitals for the expectant and grateful audience. After surgery, I'm able to show Dr. Amendezo the steps I've discovered. He walks me to the bus stop and we visit while waiting for my 4:30 ride back to Kigali.

The future medical care for Rwanda will center around physicians such as the ones I've interacted with all this week. From my perspective they have a hill to climb to get where they can see they need to be, but I've seen the will, the energy and the commitment to be successful in these men and women. Link to all of my Rwamagana Pictures