A day in the Life of a Visiting doc in Rwanda March 2005

Kibogora Pediatrics, PC

This is a ‘day in the life’ at Kibogora for a visiting American pediatrician.

6:10 AM: Another day in paradise. It is daylight. It is always daylight after 6AM and before 6PM. Kibogora is somewhat south of the equator but the days are almost identical in length. One can and does set one’s clock by the sun.
Step One: is there electricity? Most days there is and that makes life easier.
Step Two: is there water? Better by far to learn that the water is off before you flush the toilet (for what may be the last time is hours.)
Step Three: Unlock kitchen door for Simeone (pronounced Sim-e-OH-nee), our kitchen help. He will work most of the day but leaves in the early afternoon and will lock up, pushing the key under the door.
Step Four: A quick wash up before breakfast is on the table: Rwandan coffee (dark roasted and pungent), toast, local fruit (small bananas, pineapple and papaya) with yogurt and water (I never seem to be able to drink enough).
7:20AM Leave my laundry (to be done in a venerable Maytag complete with electric mangle) for the muganda, the outside worker cum launderer.

Start my commute to the hospital. The front gate of the hospital is within sight from the front of the house but actually getting there requires a walk over the ‘hump,’ up and down a hill that is the spine of the Kibogora peninsula. I lock the front door and keep the key to let myself back in after Simeone leaves. (Africa: the land of keys). As I go I see the small flock of greenbuls, robin-like birds with the attitude of blue jays. They have started their bickering at dawn and will continue except during the hottest time after noon. It is important to watch one’s step as the fallen guava or grenadilla (passion fruit) make the brick walkway hazardous for the unwary. I unbolt the gate as I go through. Our zamu (guards) have been up all night making their rounds among the several houses which make up the compound. The missionaries, their families and single female nurses live in housing within the compound. An attempted armed break-in at Dr. Belindwa’s home 2 weeks ago has people scandalized. His mother used this as an excuse to come from Congo to visit her son…and daughter-in-law of 2 weeks duration. At the hospital gate I will greet the guard with a “Muramutse”, as it is morning.

7:30AM Morning Prayers: At least one song (sung in Kinyarwanda) and a homily by one of the hospital chaplains or a visitor. This may be translated but usually not.
“Morning report” amounts to a reading of the admissions from a log…in French. There is no discussion.

8:00AM Rounds start. We have a full team today: Dr Thompson, a family practice resident from Orlando; Dr Archippes Belindwa, a recent graduate from Congo, a staff nurse, Martin, and myself. I usually start in Maternity, which is where they keep the premature infants, my major interest. I have been following a set of twins born 2 months early and weighing about 3 Ibs a piece. At two weeks old, they are doing well with their tube feedings every 2 hours. Mother is there to provide. There is no storage refrigerator. They are replaced into a wooden incubator powered by 2 lightbulbs (that is to say NOW 2 lightbulbs, as when I arrived there was only one working. Who knows for how long.) Since there has been electricity I believe they have been warm enough but I have yet to be sure that the idea has been accepted that these babies need to be warm EVEN IF the electricity goes out. It seems absurd that I am worried about temperature in the tropics but indeed that lesson is probably the most important one given.

I was asked to keep an eye on an adult patient who I have been feeding through a jejunal tube. He has been so poorly nourished that he does not heal his wounds after surgery. A feeding tube was placed directly into his intestine and I have been tasked with getting him nourished enough to heal some of his massive surgical wounds. We have been going at it a week and are just now getting into target range or 3000 calories a day. He is skin and bones, every rib standing out and looking like a scarecrow. He is complaining that he wants to walk around a little. I write the order.

Finally to Pediatrics, all the way at the bottom of the hill near the garbage fires and the latrine. Children are always give short shrift, even in third world countries. The ward consists of five rooms with about six beds placed down each side. There is a three feet clearance down the middle and 4-6 inches between the beds. This however can represent about 15-18 patients, as sometimes there are two patients (meaning 4 people) per bed. A parent and usually at least one sibling accompany each patient. Fortunately, at Kibogora there are no beds on the floor; unfortunately this is because there is not enough floor. The windows are unscreened but every bed has a mosquito net suspended above it, giving the appearance of a flock of blue hammocks roosting, suspended about 3 feet off the ground when “up” for rounds. Each room exits onto a wide, covered walkway with a view down the hill to the hospital gardens. Patients or their families may pay off some of the fees by working in the garden, which in turn supplies some of the food for the patients.

Rounds are conducted in an Anglo-Franco- kiSwahili-Kinyarwanda pidgin, which is a hoot. It can take a long time to get ideas exchanged. The ‘educated’ language is French and only occasional individuals have even a little schoolbook English. I find that if I am careful to use very precise English medical terms, they are frequently recognizably good French medical terms. When we each slip into slang, the troubles begin. I have learned to read enough medical French to get through a typical admission note, bad writing and all. The frustration levels were lowered once I learned to use the French terms. (Thank you Agatha Christie and Hercule Poirot.)

Most patients have malaria or have had it within the last six months. Quinine is the most common treatment for resistant “P. falciparum” malaria, the bad kind. I haven’t seen any of the good kind (P. ovale, P. malaria, or P. vivax) since arriving however. Most are therefore anemic. We don’t transfuse for any hemoglobin above 7 gm%. We have no blood available about 4 of 7 days on average. Last night a woman died because of its unavailability. Occasionally cerebral malaria is encountered. Very discouraging work, that. A six-year-old with convulsions was brought in. When I saw her 2 days later, the quinine had dropped the fever but she was comatose and rigid. I was more startled when I went to examine her. Every area of her body from head to legs was covered in cuts varying from 3-12 CMS. They are administered by a healer (what in less politically correct times we might have described as a witch doctor). He is obviously quite skilled. None of the cuts goes all the way through the dermis. By now I have seen any number of these wounds and they all seem to heal without infection. Since she has gotten over her malaria she has been unable to walk or talk or follow directions. Over last weekend she started eating, the day after we prayed with the family for her healing.

The pediatric wards have a huge variety of diseases once one gets beyond the malaria, intestinal parasites (of several persuasions) and occasion miocrofilariasis. Some of the severity of illness harkens back to my internship. A 12-year old has a cough, weight loss and night sweats and the consumptive demeanor to make a Mimi jealous. On exam she has all the auscultory signs of cavitary tuberculosis including egophony. Three days on quadruple therapy and her fever is gone, she is gaining weight and a smile has returned. She has 5 more weeks of isolation before she can go home. Another 11 year-old comes in with a mother who tells in voluminous detail how her cough keeps her up at night. She is blue, dyspneic and her hands are cold. She has a thready pulse and ascites, which throws her off balance as she walks. She has pneumonia of course but also rheumatic heart valve disease (PS, PI, MS). After 3 days of digoxin and amoxicillin she has lost about 9lbs (15% of her entire weight), reduced ascites, has opened up her right middle lobe and sleeps through the night.

Other diseases are familiar from my previous assignments to mission hospitals. Kwashiorkor, severe malnutrition causing red hair swelling, fluid retention, apathy and susceptibility to infection is sort of an old friend. I lost about 3 children a week to it when I was in Zambia in 2001. So far I haven’t lost any of my kwashiorkor patients. It is indeed nice to work in an affluent country. We haven’t run out of milk powder since I’ve been here.

Today however, was a red-letter day. I sent home “Mother Teresa.” She is a twelve year old girl who weighs about 15kg (33lbs). She was already in hospital since before I arrived. I would find her all over the hospital (climbing up and down the equivalent of 3-4 flights) dressed in the same dress with a shawl over her head. She kept losing weight. It developed into a bit of a cat and mouse game between us. I would forbid, coax, cajole, make funny faces, and pretend to cry when I directed her to squeeze my hands. She would reply that I was a grown man and she didn’t believe I should cry. I bribed her with toy balloons, bread from one of the waduka (shops), and when all else failed threatened her with a “sonde,” a naso-gastric tube. It took one experience and she knew she could not count on the crazy umuzungu to act civilized…so she started to eat. She has gained a kilo and a half since the showdown and smiles at me, walks with me and gives me hugs when I am near her rather diminutive height. I learned that her mother had abandoned her in hospital at the beginning of her stay. Mother showed up today. Teresa is to return in two weeks. I presented her with a throwaway camera to bring back with her. I have arranged with one of the national doctors to forward the film on to me.

AIDS is alive and well in Rwanda. The prevalence is about 30% and of my patients, about 10% are affected at any one time. Many are merely dwindling down and admitted for malnutrition. One little 6 month old has what I think to be a fungal infection. He was deteriorating daily before we took the potentially dangerous step of using Amphotericin even without a culture (not available here). He has been afebrile for the first time in a week and has started eating again.

We see each patient, discharge the willing and listen to the new admissions and to their mothers; the air is hot and moist, the children are all dressed for Michigan in February. After the two acute wards we do the gastroenteritis wards and finally Isolation. We averaged 65 patients/ day last week. This week the load is less and about half the time I can finish by noon. Some of the time rounds are interrupted by the huge rainstorms that sweep up from Burundi. It is impossible to hear enough to continue until the storm passes. At noon the resident and I are expected to have lunch at one of the houses. This is the major meal of the day and usually well worth the 7-8 flights of stairs to get to it. Today talapia, potatoes, carrots and green beans, carrot cake and tea. (“Go to Africa, Treat Malnutrition, Get Fat!”).

We will not restart rounds “until 14;” 2pm. I return to the house and try to be cool. The house is about 85F and the humidity is 60-70% until a storm comes by to cool things off briefly. I spend my time usually reading Manson’s Tropical Medicine or learning a little Kinyarwanda. Frank Ogden usually takes a siesta. Very civilized. By “14” the air is no cooler but lunch is well digested and we start again. We are almost always finished by 5PM in time for a short breather, shower and time to appreciate the sunset before dinner at 6:15PM.

Tonight I am to have supper at the Sudell’s, a family that has come for a year from Lancashire, UK. From thence they have brought a love of football (soccer) and table tennis as well as a profound distrust of things Scottish (at least on David’s part this having much to do with a disputed football match some years ago). It was he and his youngest, Emily (Ems) who picked me up in Kigali and got me here. The Sudell’s are tall and unrelentingly blond: John 16, Phillip 14, Ems (10) and Mary, the mother of them all. David has been involved with setting the “station to rights” and a building project among the Ba-Twa, the pygmy-oid indigenous people of the area.

Supper is light: soup & salad. After dinner we gamble…for who does the dishes. My losing streak is finally broken and David is elected. He has the good grace to grumble about it, which grumbling makes us all feel well out of it. Sunday and Thursday night we have a Bible study. Once or twice a week we will see (again) one of the recorded movies available. Tonight however, I must go back to the house.

The paths among the houses are quite dark and one of these announces “N’amakuru.” I call back to the zamu, “N’ mesa.” (“What’s the news?”… “It is good.”) There are a few fireflies in the grass and rather more toads of impressive dimensions trying to have them down for “light” dinner. I hear out over the lake the fishermen “singing to the fish” as the three-hulled fishing boats slowly seine Lake Kivu. There are drums on Ijwa tonight. The clouds over Congo are lit every few seconds with lightning but no thunder. Overhead the sky is clear. Jupiter is climbing, Orion is falling and the Southern Cross wheels about the Milky Way. I come in and sit down to write: “This is a ‘day in the life’ at Kibogora…”