Replaces all plastic construction and will have running cold water.
Saturday, April 26, 2008
Food, speciality care, sadness and success
The biggest difference in food here is that we rarely have dessert and only fruit which is very good. Familiar items include regular and small bananas which take two years to grow on trees, mango, limes, and pineapples. They have a small type of passion fruit and wrinkled plum. Breakfast is white bread with peanut butter if lucky, rice, bananas, and occasionally fried eggs. Most of the people I work with drink tea and not coffee, both of which are grown in Rwanda and surrounding countries. We eat lots of starches. Rice is almost always served as are potatoes in multiple forms. I have had a few French fries! Meat is usually beef cooked in a tomato or peanut sauce. Occasionally we have fish from lakes (ocean fish is too expensive) or chicken. Fresh peas are in season and good, though not as sweet as garden types in Minnesota. We’ve eaten carrots, cucumbers, tomatoes, onions and some green somewhat like cooked spinach. I’ve been eating only cooked or pealed vegetables and have had no intestinal infections.
Specialty and technologically advanced medical care in Rwanda is markedly different from the U.S. There are only four pediatricians in the country and they are attempting to form a residency program. Only on urologist and endocrinologist work here. There is one CT scanner in the country of eight million people and no MRI scanners. I estimate the service area of Mercy Hospital in Coon Rapids, MN, which has 300,000 people, has 5-7 CT scanners and 3-4 MRIs. Many patients are treated by their primary doctor or nurse as best possible. Many primary care physicians learn to do procedures such as C -sections and treat complicated conditions. Of course many people do not receive what we would consider reasonable care. Recently a teenager did have a CT scan of the head. A month earlier he had head trauma, loss of consciousness and expressive aphasia (loss of speech with retention of ability to understand). Seizures were also present. His CT was normal so we instructed the family in some speech therapy techniques and referred him to neurology for evaluation and an EEG. The neurologist apparently wants a psychiatric evaluation. I hope to receive some follow up, although it will likely be sketchy and the family will likely not have much to report.
I’ve been impressed by the interest of the medical workers at the refugee camps in learning more about diagnosing and treating their patients. Those who speak or read some English have shown enthusiasm about the books and information I have brought. Teaching sessions are well attended and the questions show an interest in learning. This week the staff and management at one camp decided to start work 30 minutes earlier so that they would have more time for learning. The nurses requested the French version of a World Health Organization (WHO) detailed guideline on evaluation and treatment of ill and malnourished children. I had the English version on my computer (free) and printed a book for them. After several tries I found and printed the French version. I am hopeful that this will help improve patient care. Last weekend a five year old died of malnutrition two days into starting treatment in our hospital.
This week I became aware that we have had several deaths and many patients with difficult and depressing conditions during my six weeks here. I should not over emphathasize these because there have been many more happy and successful outcomes. This week a four year old with fever, dehydration and coma was successfully treated with IV fluids and quinine for cerebral malaria and was sent home after four days of treatment. Several healthy babies were born to happy mothers, several cases of pneumonia recovered and we received and started the clinic’s first patient on antidepressant drugs.
Specialty and technologically advanced medical care in Rwanda is markedly different from the U.S. There are only four pediatricians in the country and they are attempting to form a residency program. Only on urologist and endocrinologist work here. There is one CT scanner in the country of eight million people and no MRI scanners. I estimate the service area of Mercy Hospital in Coon Rapids, MN, which has 300,000 people, has 5-7 CT scanners and 3-4 MRIs. Many patients are treated by their primary doctor or nurse as best possible. Many primary care physicians learn to do procedures such as C -sections and treat complicated conditions. Of course many people do not receive what we would consider reasonable care. Recently a teenager did have a CT scan of the head. A month earlier he had head trauma, loss of consciousness and expressive aphasia (loss of speech with retention of ability to understand). Seizures were also present. His CT was normal so we instructed the family in some speech therapy techniques and referred him to neurology for evaluation and an EEG. The neurologist apparently wants a psychiatric evaluation. I hope to receive some follow up, although it will likely be sketchy and the family will likely not have much to report.
I’ve been impressed by the interest of the medical workers at the refugee camps in learning more about diagnosing and treating their patients. Those who speak or read some English have shown enthusiasm about the books and information I have brought. Teaching sessions are well attended and the questions show an interest in learning. This week the staff and management at one camp decided to start work 30 minutes earlier so that they would have more time for learning. The nurses requested the French version of a World Health Organization (WHO) detailed guideline on evaluation and treatment of ill and malnourished children. I had the English version on my computer (free) and printed a book for them. After several tries I found and printed the French version. I am hopeful that this will help improve patient care. Last weekend a five year old died of malnutrition two days into starting treatment in our hospital.
This week I became aware that we have had several deaths and many patients with difficult and depressing conditions during my six weeks here. I should not over emphathasize these because there have been many more happy and successful outcomes. This week a four year old with fever, dehydration and coma was successfully treated with IV fluids and quinine for cerebral malaria and was sent home after four days of treatment. Several healthy babies were born to happy mothers, several cases of pneumonia recovered and we received and started the clinic’s first patient on antidepressant drugs.
Saturday, April 19, 2008
Cases of the week and records
This week I gave some more training sessions for the nurses. I was prepared to give more talks but patient care was more urgent and two sessions were canced. Through consultations with nurses about individual patients I am able to do some teaching and they have taught me about malaria and other subjects. There were three cases of probable TB this week. The reason I say probable is due to lack of diagnostic tests and resources. The first was TB of the spine and the other two lymph node involvement. The latter two cases I referred the patient back to the regular clinic physician who was at a conference this week. I want his opinion before starting treatment.
Another 28 year old man came in with knee pain. Seven years ago he had an infection in the knee and now has severe osteoarthritis and walks with crutches. We started the process of referring him to a specialist for knee replacement. This is a long process and he may not qualify or the United Nations Health Care for Refugees may not have funding. Another 62 year old patient was found to have inoperable cervical cancer. She probably will have no treatment. Cervical cancer is the most common cancer to cause death in women in much of Africa.
Today while seeing a child in the hospital with pneumonia his mother told us about fever, headache and backache. She immediately became a patient to be treated without registration or pulling a chart. After her temperature was measured and found to be normal and a brief exam, I ordered a malaria smear and acetaminophen. This order and prescription were written on a blank piece of paper which will be taken to the lab and pharmacy. One of the nurses will follow up on the smear when it is completed later today.
Out patient records either are totally absent or consist of a pocket sized note pad that has brief descriptions of previous visits for that patient and other family members. Lab information from the past may be listed in the pad or on loose pieces of paper. X-rays are rolled and carried by the patients. One from a year ago was totally useless as it was bleached out and covered by smudges.
We have been discussing improving the records system, particularly since in the next year the clinic expects to start treating people with AIDS who are now being referred to a local clinic.
Another 28 year old man came in with knee pain. Seven years ago he had an infection in the knee and now has severe osteoarthritis and walks with crutches. We started the process of referring him to a specialist for knee replacement. This is a long process and he may not qualify or the United Nations Health Care for Refugees may not have funding. Another 62 year old patient was found to have inoperable cervical cancer. She probably will have no treatment. Cervical cancer is the most common cancer to cause death in women in much of Africa.
Today while seeing a child in the hospital with pneumonia his mother told us about fever, headache and backache. She immediately became a patient to be treated without registration or pulling a chart. After her temperature was measured and found to be normal and a brief exam, I ordered a malaria smear and acetaminophen. This order and prescription were written on a blank piece of paper which will be taken to the lab and pharmacy. One of the nurses will follow up on the smear when it is completed later today.
Out patient records either are totally absent or consist of a pocket sized note pad that has brief descriptions of previous visits for that patient and other family members. Lab information from the past may be listed in the pad or on loose pieces of paper. X-rays are rolled and carried by the patients. One from a year ago was totally useless as it was bleached out and covered by smudges.
We have been discussing improving the records system, particularly since in the next year the clinic expects to start treating people with AIDS who are now being referred to a local clinic.
Sunday, April 13, 2008
Health conditions and training
My goal here is primarily to teach skills to the health workers at ARC's camps. The first four weeks have allowed me to see partially how the health care is delivered.
last week I spoke with the managers, physicians and some nurses about where to focus my efforts. Last week I gave three informal training sessions on diagnosis of pneumonia in children and adults without x ray, use of the otoscope and ear pain, and some skin infections. Photos from books and the internet were very helpful. I used some French terms and a translator was present part of the time. The books which were donated by many of you have been enthusiastically received and will stimulate learning and lead to improved care. The physician who just graduated from med school said he couldn't afford books, so used the in the library.
Now that he has a job, he wants to buy some books. I told him I would ask Martha to bring one in July. He was interested in information from the World Health Organization that is free over the internet. We will put some of this information on his flash drive for use on a computer. He has no computer now but can use one occasionally. Where he stays during the week he has no electricity nor light to read.
A newborn died of asphyxiation immediatly at birth last week. He had a heart beat, but toook only one breath. Meconium inhalation is the only reason known. I was in another area during this. We plan to review resuscitation proceedures, obtain better suction equipment and look into oxygen. A three weekold with pneumonia and menningitis survivrd three respiratory arrests and two episodes of bradycardia requiring epinephrine. He heeded 3 hours of hand ventillation Thursday afternoon but was improved the next day. Hopefully he continues to improve.
There have been several refugees who seem depressed. There is some very limited consoling available but no meds, so we have requested some meds. I'm unsure how much effect this will have.
last week I spoke with the managers, physicians and some nurses about where to focus my efforts. Last week I gave three informal training sessions on diagnosis of pneumonia in children and adults without x ray, use of the otoscope and ear pain, and some skin infections. Photos from books and the internet were very helpful. I used some French terms and a translator was present part of the time. The books which were donated by many of you have been enthusiastically received and will stimulate learning and lead to improved care. The physician who just graduated from med school said he couldn't afford books, so used the in the library.
Now that he has a job, he wants to buy some books. I told him I would ask Martha to bring one in July. He was interested in information from the World Health Organization that is free over the internet. We will put some of this information on his flash drive for use on a computer. He has no computer now but can use one occasionally. Where he stays during the week he has no electricity nor light to read.
A newborn died of asphyxiation immediatly at birth last week. He had a heart beat, but toook only one breath. Meconium inhalation is the only reason known. I was in another area during this. We plan to review resuscitation proceedures, obtain better suction equipment and look into oxygen. A three weekold with pneumonia and menningitis survivrd three respiratory arrests and two episodes of bradycardia requiring epinephrine. He heeded 3 hours of hand ventillation Thursday afternoon but was improved the next day. Hopefully he continues to improve.
There have been several refugees who seem depressed. There is some very limited consoling available but no meds, so we have requested some meds. I'm unsure how much effect this will have.
Saturday, April 12, 2008
Clinic and hone
Waiting at the pharmacy
washing hands at only warwe source in clinic area.
resting at home
Sunday, April 6, 2008
Anniversary of the Genocide
April 6, 1994 was the first day of 80 days of killing of 800,00 to 1 million people in Rwanda by the majority Hutu aginst the mimority Tutsi. The differences in the groups are very minor according to what I have read. They have the same language and religion and live in the same areas. Some say they came into Rwanda from different regions one to two thousand years ago. The Europeans encouraged differientating the groups for their own goals of controlling the people. The Belgians started use of identity cards listing Hutu and Tutsi. One criteria used was if a family had more than 10 cows they were labeled Tutsi.
The first major attack on the Tutsi was 1959 and there have been several others leading up to 1994. By 1994 there were approximatly 1 million Tutsis living outside Rwanda in surrounding sountries.
None of the people whom I have met have told me with which group ther identify. Some of my non-Rwandan friends say it is inappropriate to talk about in public, but that in private the subject does surface as reasons that someone felt mal treated.
A 34 year old woman told me she was caring for children of professors in April, 1944 when the genocidaires took the parents away to be killed and the next day returned for the children. She hid in a bathroom and escaped. She didn't say how she avoided capture but lived to testify at a World Court hearing in Belgium. Her account was described in one of the books I read about the subject. Now she consels refugees.
The Genocide Memorial is a cemetary and a museum in Kigali. The Museum tells the story of the two groupa and Rwandan political history for the last 100 years. There are news stories, including reports about the UN and foreign governments. The Rwandan government and malitias prepared lists of people and gathered weapons includingmachetes ahead of time. Tthe museum shows some graphic photos, cases of bones, family photos of some of those killed and clothes. The last rooms show large photos of children and I thought this must represent hope for the future, however as I read the captions which gave their names, favorite foods and methods used to kill them, I realized that hope for the future still lay ahead somewhere else.
Outside the building are flower gardens and mass graves holding 250,000 bodies.
The museum also describes six other genocides that have happened in the last 100 years. See http://www.museum.gov.rw/ for more details.
Two weeks ago, while making rounds at he Gihembe camp, two little children were playing in the ward where their mothers were being treated. This ward is new, made of brick and has a steel roof and cement floor. The children were interested the door which had a latch that snaped when closed. Each time they heard the snap they would dance and giggle and run to their moms. This was a new experiense because they have a plastic flap or at best a plastic sheet on a wood frame for a door at home. It was good to see the children so happy.
I will add photos whan possible.
The first major attack on the Tutsi was 1959 and there have been several others leading up to 1994. By 1994 there were approximatly 1 million Tutsis living outside Rwanda in surrounding sountries.
None of the people whom I have met have told me with which group ther identify. Some of my non-Rwandan friends say it is inappropriate to talk about in public, but that in private the subject does surface as reasons that someone felt mal treated.
A 34 year old woman told me she was caring for children of professors in April, 1944 when the genocidaires took the parents away to be killed and the next day returned for the children. She hid in a bathroom and escaped. She didn't say how she avoided capture but lived to testify at a World Court hearing in Belgium. Her account was described in one of the books I read about the subject. Now she consels refugees.
The Genocide Memorial is a cemetary and a museum in Kigali. The Museum tells the story of the two groupa and Rwandan political history for the last 100 years. There are news stories, including reports about the UN and foreign governments. The Rwandan government and malitias prepared lists of people and gathered weapons includingmachetes ahead of time. Tthe museum shows some graphic photos, cases of bones, family photos of some of those killed and clothes. The last rooms show large photos of children and I thought this must represent hope for the future, however as I read the captions which gave their names, favorite foods and methods used to kill them, I realized that hope for the future still lay ahead somewhere else.
Outside the building are flower gardens and mass graves holding 250,000 bodies.
The museum also describes six other genocides that have happened in the last 100 years. See http://www.museum.gov.rw/ for more details.
Two weeks ago, while making rounds at he Gihembe camp, two little children were playing in the ward where their mothers were being treated. This ward is new, made of brick and has a steel roof and cement floor. The children were interested the door which had a latch that snaped when closed. Each time they heard the snap they would dance and giggle and run to their moms. This was a new experiense because they have a plastic flap or at best a plastic sheet on a wood frame for a door at home. It was good to see the children so happy.
I will add photos whan possible.
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