There’s good news and bad news!
on Melissa Hipkins (Rwanda), 19/May/2010 05:17, 34 days ago
To continue the story of the unfortunate ram and the complications of a relatively simple op, it was still alive this morning and looks as though it will pull through if the sutures hold. The class and I had a post mortem, not literally yet, over what went wrong, what succeeded and how we should change the procedure next time. Much precious time was consumed and I outlined how we would do the same op that afternoon but using a different method of preventing contamination of the abdomen.I also had to emphasise the importance of post op care as the poor brute had had to endure a night in the clinic's "in patient facility" without a scrap of food or water for 14 hours and behind locked doors. There seems to be a culture of extreme insecurity with every door locked as soon as the last person leaves and the person with the key disappearing for 2 hours for lunch or a meeting...I thought I might as well try the in house instrument sterilisation service, i.e. the pot over the electric stove as today there was water at the clinic. It took 40 minutes for the water to boil and furthermore the maximum temperature I measured during the hour of boiling was only 89°C-we are at 2200mtrs.I was further disheartened watching this afternoon's patient being carried upside down by the legs across the main road between the campus and the clinic. It then quite rightly refused to move and lay down on its side despite all proddings and cajolings. While on my way to the rescue of this animal I had to dissuade by gesture a 6 year old from belaying it with a stick. I had a depressing feeling that all would not be well and this one would not stand up for long.Modifications had been agreed to the technique and I began the preparation with the ram on the floor while I clipped and injected the local anaesthetic. I did contemplate doing the whole op on the floor but my knees wouldn't have stood it. Once hoisted on the table, now with a blue cotton apron tied on the surface for anti-slip, and the antisepsis completed the operation went almost without a hitch. It was as good as gold, only threatening to go down a few times. I even had the confidence to allow some of the students to suture up. Let's see how it looks tomorrow.I have come home this evening past the local electrical sub station, which is furnished with the only formal street lighting columns in the town. The scene reminded me of conker trees and autumn back home; children gathered in droves around the base of the columns looking upward into the dark at swarms of insects flying around the lights. Their object was to harvest these insects as they dropped from exhaustion or collision. The tension waiting for one to succumb was palpable and intense rivalry between groups was evident. As usual the youngest and smallest were left out and had only yells and howls to contribute, the Kinyarwanda equivalent of "it's my turn" or" it's not fair" I suppose.The attraction is so great that even the next morning on my way to the college, children are picking through the rubbish or turning over stones to find stragglers. I have found these insects in my room at the guest house; we even had a wagtail in the classroom with one in its beak! They are slimmed down versions of locusts and a deep green. I can only suppose they are a great delicacy and only are seen occasionally but I have yet to find an authority to verify this.This observation was made after having had the biggest meal since our stay here in Rwanda. I had to admit defeat. It was a bar/restaurant that I had marked down to visit on evening meal circuit. I had a beer and wanted to look at the menu. In this, as in many of these bars, there was no menu so I had to be guided by the waitress, our conversation in broken accented French. I gathered that rabbit was available to eat at 3000Rfr with chips and salad to bring it to a round 4000Rfr. What I failed to understand until later was this would be enough for 2 people. When she explained I thought "bring it on, it can't be that much". All I can say is they must have Flemish giant in this area. Not only was it a whole barbecued rabbit but included was the liver and the head split in two.After hearing me talking to the waitress in French, the men on the neighbouring table fell into conversation in French about where I came from and what I thought of Rwanda and the climate in Musanze. I was able to offer them the uneaten remains and some chips. Altogether a pleasant evening from nothing really.The first sheep continues to improve and now looks a good deal better than the second sheep who's operation went with hardly a fault. It's very enlightening to follow operations on farm animals. One rarely gets the chance in normal practice; the only time we go back is if there is a problem. We don't even hear until weeks later if it died, usually when the bill is due. I even have the opportunity to check a castration on a calf over a period of days which I've never done.In order to plan my practicals for next week, I have been looking through some of the cows in order to find a lucky individual with a big calf inside so I can do an elective caesarean in the next week or two. However, when it came to examining them for pregnancy, the suggested dates are way out and none of the ones I saw are anyway near big enough. In any case we still have not enough material to do cow ops.The route between Musanze and Kigali reminds me one some of the poorer maintained farm drives I have had the misfortune to drive along. In fact it's worse; the longest farm drive I know is about a kilometre, the distance of this road is 85km. The time it takes depends on the driver's knowledge of pot-holes and the bus's springs. The recognised technique is to slalom from one side of the road to the other in order to follow the smoothest path. The fun begins when another bus or truck is seen in the distance using the same ploy. A trial of nerves determines who stays on the smoothest piece of road and who has to crawl through the broken tarmac. Bicycles and pedestrians are the lowest in the pecking order; they have to hug the kerb or go onto the verge in order to continue unharmed. A severe hooting is their reward if they take up any more room than the driver thinks they are entitled to.There is an effort to renew the surface starting at the Musanze end which is probably the worst section. Another lane is in the process of being consolidated but to get the whole carriageway replaced is going to take years. It should be a showpiece road, being the principal route for tourists on their way to see the gorillas, but their impressions will not be influenced in favour of the Rwandan infrastructure for some seasons to come.Friday was not a good day for me; I had my wallet stolen on the way back to Nyanza. I should have realised something was up when some one gripped my elbow while I was crossing a busy Kigali road. I took little notice at the time thinking it was to restrain me from going under a bus, but after 5 paces I checked my pocket and the wallet had gone. The elbow trick had successfully distracted me from its removal from my pocket.This left me with no money and without the bus ticket I had just bought. I rang Melissa and told her the good news and supposed she would have to come and pick me up. Then we thought perhaps someone in Kigali could lend me some money for a ticket. All the while, the time of my bus's departure was imminent. Melissa suggested I go back to the ticket office and tell them what had happened and see if they would do be a duplicate. I was sceptical but it was worth a try. There are times when it's worth being white and standing out. Indeed they did remember and conceded I could make the journey in the circumstances. It was only when I told Melissa I was on the bus that it hit me what had been lost. About 7500Rfr and 2 phone cards worth 5000Rfr were small potatoes, my VSO i.d. card might be more serious and with a jolt I remembered a cheque for my expenses for 2 weeks was in the wallet. It was worth a considerable sum and I could ill afford to lose it. The cheque had to be stopped.I had a bad feeling that someone could use my i.d. and the cheque to cash it straight away, if so it would be too late to do much. It takes at least 3 working days to clear a cheque into an account so I hoped the usual Rwandan bureaucracy would work on my side. I had no contacts in the college's finance department and neither Anselme nor the dean had their phones on. Eventually I managed to make contact by text and by the time Saturday came, I had a reassuring text from the dean that on Monday after some formalities I should have a new cheque issued.Monday has come and gone and the issue of the cheque still goes on. Because I have no bank account in Rwanda, Melissa has had to open one to deal with her expenses with VSO, the cheque had been issued to be cleared through her account. So the cheque was not crossed. I thought all cheques were automatically crossed but no so here. I may have to wait for up to 2 months for a replacement to be issued, if no-one has been allowed to cash it in the interval.The sheep continue to surprise me with their resilience. All sheep are doing well and we have succeeded in doing all the ops with the sheep standing on a table for up to 90 minutes without them trying to jump off or lie down. I have also tried to show that you usually don't need sedatives; all these have had no sedation at all, just local, antibiotics, and phenylbutazone. This is an attempt to simulate conditions the students will see with cattle. I have never tried to operate on standing sheep before, not trusting them to pay ball, but it's a cheap way for the college to allow experience for students. After the first two that I did alone, I decided that providing they did not open the rumen they could do the laparotomies themselves. They have sutured the rumen to the skin and "closed" the rumen without opening it, too high risk to allow. Thus far all 6 patients are doing remarkably well considering the numbers of hands that have been involved in suturing and even feeling a pregnant ewe's uterus. It's gratifying to think that this should boost their confidence when it comes to doing a laparotomy for real. The difference between 38 years of experience and none seems quite small really.