Dr. Livingston returns to Rwanda (4th edition)

First time at CHUK and the Sim Center – Friday, January 18, 2019 (from Mary)

Rwanda has taken possession of me. Until last Saturday night I had never set foot on African soil. I knew in my heart that I would come here one day, this was made a certainty when, several years ago, Gaston, with his guileless look, said “Mary, when are you coming to Rwanda?” My response, at the time was “When you and Patty can use me best, I will come”.

As it turns out the first International Rwandan Pain Conference was the occasion chosen. I will tell you about that wildly successful event in the next “from Mary” blog. First I want to share some stories from CHUK and the Sim Centre. I was delighted to join the team (on this occasion Patty, Jon, Stephen and Chris) for Monday teaching at the Sim Center. It was a privilege to meet the residents and to discuss difficult cases under the avocado tree outside of the Sim center. The cases were complex but the tools are here to manage them. There are not as many drug options in Rwanda but there is a basic pharmaceutical suite (acetaminophen, morphine, tramadol, amitriptyline, gabapentin, ketamine and lidocaine) which used creatively can assist with most problems. It was interesting to me to learn that serious burn injuries in babies and cesarian section pain are big issues here. It was especially fun to co-lead with Patty, an opportunity we do not get when in Canada.

I was very impressed when Magnus, the psychologist, arrived under the avocado tree. Here I have to digress for a minute to tell you that in the morning I was very fortunate to meet Dr. Lisine Tuyisenge, consultant pediatrician and Director of all Medical services at CHUK (pronounced “say-ash-u-ka”) (University Teaching Hospital Kigali). On this particular day Dr. Lisine was also serving in an acting capacity for her boss so there were people bringing in important looking documents for her review and sign as we met. Lisine is the local lead for the Microresearch project that our very own Dr.Noni MacDonald and collaborators are facilitating in Eastern Africa. Lisine connected me with Magnus as he is on the pain committee at CHUK and we are aiming to get pain teams involved with the micro research initiative (www.microresearch.ca) which is all about helping develop research projects to find sustainable solutions for local health care problems. Lisine sent Magnus over to the Sim Center and as he strode up the hill to join us under the avocado tree all the residents reached out to shake his hand and greet him warmly and he greeted them all by name in return. After Magnus left I asked the residents how they all knew Magnus so well. I was curious because, in Canada, the Anesthesia residents do not necessarily know the psychologists. They said that Magnus did a lot of work with them in the ICU. I thought Psychologists in the ICU! … how wonderful, I said Canada has a lot to learn from Rwanda! Spoiler alert: this is not the only thing we can learn from Rwanda.

Meanwhile, inside the Sim centre it was fun to see Jon lying on the stretcher with one of the trainees using the ultrasound (there were 4 working ultrasound machines!) to identify what I assume were vascular and neural structures in Jon’s axilla. Jon with head turned toward the monitor was instructing and acting as patient all at the same time, well done Jon! Stephen did a great job summing things up for the group and commending them for their hard work. Chris, who is also here for the first time, from Toronto, was an integral member of the team and it all came together as if this crew had worked together a hundred times. The residents were engaged, enthusiastic and the place was full of positive energy. I was impressed to see this Sim Center that I had heard so much about and so proud of Patty and the team. We also had the chance to meet Claudine one of the residents who will be coming to Halifax soon.

If I could share with you… – Friday, January 18, 2019 (from Patty)

We can send words and photos but I would also send you:

• the smell of fertile earth mixed with aromas of eucalyptus trees
• gentle breezes through leafy Kigali
• the taste of a perfectly ripe avocado, mango, pineapple, banana, passion fruit
• strong African gingery tea when one’s caffeine levels have reached rock bottom
• Africancanadianization, that wonderful phrase developed by Paulin that speaks to the magic that happens when the best of our Rwandan and Canadian cultures merge
• the lightbulb moments when learners understand
• the smiles, always the smiles
• friendship, is it ever this good?
• cinnamon ice cream at Inzozi Nziza
• green terraced hills with misty mountains beyond

I send you this and more.

Zero Pain and ice cream – Friday, January 18, 2019 (from Mary)

We had a beautiful 3 hour drive across Southwest Rwanda to Butare where the conference took place. We were pleasantly surprised that our accommodation at the Maison Sifa was situated on a hillside with an incredible view and was within a 10-minute walk to the conference venue. The word “walk” does not do the experience justice. It was a walk through gardens and sunflower fields with European style stone walls covered with flowers and cobblestone streets with birds singing all around and yes this was in the middle of deepest Africa, not that far from the origin of the Nile which Chris, Stephen and Jon may find this coming weekend.

Our first stop after we checked in to our Mansion (whoops did I say Mansion, I meant to say Maison) was to have lunch at one of Patty’s favorite spots the Inzozi Nziza, a cooperative run by women. Here we met up with Dave who had been on site for a week helping to get things organized. “Lunch” does not capture the experience. We ordered Tacos with avocados (some with egg). What we received were full plate sized scrumptious, thick, slightly crusty crepes with super tasty avocado filling spilling out onto the plate, just straight up slightly salted avocado mashup. Rwandan avocados are the best!

After lunch we headed to CHUB (“Say-ash-u-bay”) the University teaching hospital of Butare. Here we met Wilson who took us to the pediatrics and general surgery wards and showed us the measures of pain posters on the walls of these units. They included the faces of pain scales along with further detail in a very user-friendly format. Most importantly these posters were prominently displayed and are guiding practice.

Dave then led us to the potential site of a future Sim Center to be located at CHUB. En route we were entertained by a very playful group of monkeys. Of course us Mzungus all stopped to take photos. The possible site for the Sim Center has definite potential. After our tour we all agreed an ice cream stop back at Inzozi Nziza was needed. After some coffee ice cream with cookies crumbled on top (for photo of this delicious treat see Patty’s earlier blog entry) several of us went to the museum to learn about the history of Rwandan culture, farming and beekeeping, housing and traditions. I was amazed to see how the bee hives actually look like long skinny baskets, hung in a sideways fashion. Rwandan honey is excellent, it is slightly darker and thicker and more flavorful than Canadian honey. I have been testing a lot of it.

The First International Rwandan Pain Conference 2019 – Saturday, January 19, 2019 (from Mary)

Gaston and the conference organizing committee had done such a great job of getting the word out that 250 people registered and the conference had to be moved to a larger venue. Health care professionals from across the nation were present and it was an interprofessional mix. There was a participant from Uganda and our very own Dr. Rediet was there from Ethiopia. Rediet joined our group in Kigali and we have adopted her. Rediet is an amazing young anesthesiologist who works at the main teaching hospital in Addis Ababa and Patty and some of the team will be joining Rediet in Addis to teach the VAST course after this conference. Rediet has boundless energy, a full time anesthesia practice, 3 children and a wonderful vision for improving the management of pain in Ethiopia. Patty and I are already scheming ways to get Rediet to Halifax for a preceptorship. The Anesthesia Department Head at CHUB, Dr. Theogene was one of the speakers and stayed throughout the conference. The Director General of CHUB and a representative from the Ministry of Health were there as well. In other words this conference had the support of decision makers at all levels. The representative from the Ministry stayed for the entire conference!

The participants were very engaged. I was especially impressed when the groups at my workshop on Pain Research 101 came up with 25 excellent research questions within 30 minutes. Our 4 group facilitators Eugene, Joseph, Stephen and Chris, all recruited with little or no notice, did an excellent job. When a sudden downpour made it almost impossible to hear each other the groups just moved in closer, almost touching heads like a rugby scrum. Our goal was to interest participants in sending a pain research team to the next micro-research workshop and there were at least 20 who indicated they would be interested!

Gaston, who had sprained his ankle just this week went from crutches when he met us at Inzozi Nziza on Tuesday afternoon to beautiful Italian shoes with no crutches on Thursday morning and barely a limp. Gaston was the consummate host. It was a delight for me to see the transformation from trainee to inspiring leader, articulate and elegant. I have to say that I had a similar feeling watching Jon who did excellent presentations on chronic post-surgical pain and regional analgesia! Somehow from his small carry-on luggage emerged a perfectly pressed suit and 2 different business shirts. Rwandan men dress for the occasion in beautiful suits, shirts and ties and Jon did us proud. I had the chance to meet many of the participants and in every case they were optimistic and enthusiastic for change and inspired to bring what they had learned back to their own communities.

But I can’t forget the medical students. The medical students were with us for the entire 2 days of the conference. They took who took care of the registration desk and anything else needed. They were so great. The women even wore some traditional dress and all together they were quite sensational (photo below).

The second International Rwandan Pain conference is already being planned and I have no doubt that momentum will continue to build. Congratulations on a wildly successful event to Gaston and all involved !!

Visit Dr. Livingston’s blog at < https://simcentreopening.blogspot.com/ > to see the original posts, including photos.