First day nerves!
on Melissa Hipkins (Rwanda), 12/May/2010 05:19, 34 days ago
Well, the day has finally arrived; I am in a cheap hotel in Musanze having done my first day lecturing and taking a practical. It might so nearly not have been.An email sent on Friday night by Anselme, my contact in the college, detailed the coming week's timetable with my notable absence from the schedule. This, after assurances that I would start the first Monday in May caused me much upset. I left messages on his phone but no contact was established and Melissa and I had the feeling that I was due another idle week. So much so that we went out on Saturday morning to buy some paint, brushes and cement (to fill all the nail holes) in the expectation that I would have the time to decorateThe shower room is very dark because there is only a tiny window and the floor is plain smooth cement darkened by time. The space normally occupied by tiles round the shower is cement render painted the deepest of browns and the ceiling is still raw plywood. It's depressingly gloomy and what's more we can't see the mosquitoes that we can hear, so it needs doing on health grounds.We got all the kit from the quincaillerie with the old boy shinning up a ladder that was only supported by a wobbly stack of paint tins. We had little choice of colour, a variety of cream for the gloss round the shower and a variant on ecru for the emulsion. We discovered on arriving home and reviewing our resources that we are short of cloths to clean brushes or to mop up spills. White spirit is unknown here so we have to use kerosene to dissolve the oil paint, it's probably no worse for smell and it seems to do the job. Probably OK for lighting the charcoal still.Our shortage of rags and our fear of getting paint on the few clothes we have meant that Melissa was down to the nether garments while painting. A memory I shall cherish during my lonely nights at Bamboo, my hotel in Musanze.When at last Anselme responded to my messages, he still maintained that the lack of chemicals was at the seat of the delay and nothing more sinister. It took a little while to convince him that I could do practicals without anaesthetising animals. I had already suggested that some cattle feet be sought from the abattoir and the students could cut and suture those. On that basis he climbed down and I started on the third.This radically altered the perspective with relation to the decorating. I would be fully occupied during the week and have no time for DIY except for Saturdays. Melissa reluctantly agreed to don the skimpies and finish the room on Sunday afternoon. We hadn't time to warn Jacky that the paint might be wet, and Melissa would have left before Jacky's arrival. I hope the smell of new paint and the lack of kerosene would make it obvious. She's a clever girl.Most of Sunday was very wet here in Nyanza and in Musanze. Anselme met me off the bus to remind where the hotel is and to show me where the buses to the campus leave. An evening meal was offered by Bamboo but I would have to wait until 8.00 before it was ready. Albeit it was served in my room (there is no dining room) it scarcely qualified for inclusion the next guidebook, being 98% stodge and cold.Breakfast on the other hand was prompt. Over prompt really as I had to turn out of bed to unlock the door, it being before the appointed hour of 6.00. So I had plenty of time to walk the 10 minutes to the bus. I had been told it went at 7.00 but by 7.05 and without seeing the bus or anyone waiting for it I became uneasy. At 7.10, a bus turned up and a crowd of people appeared from the cracks in the wall and we all got on. Anselme admitted after that he got the venues and times mixed up.My first day had been scheduled with lectures and a practical; 4 hours of lectures in the morning and then 3 hour practical for the afternoon. All my presentations are on PowerPoint and it made me sweat a bit when the electricity went off for the last 2 hours. I had a bit of paper on which I had jotted the syllabus and a lot of sticks of chalk to get me through until lunch.Practical for 28 students with 8 ox feet to share between them doesn't sound promising, but after forming them into teams and making them prepare and disinfect as if a real op, together with proper preparation for surgeons and assistants, they began to enjoy themselves making incisions and suturing in turn. The next day I got them to decide the approach to find the artery or vein at the back of the leg and to ligate it in the approved fashion, then suture it all up.The third day we had fun amputating digits pretending that the anaesthetic was already in place. It is a lot more difficult without the foot attached to the cow, so we lashed them all to the table legs and sawed them off with "sciefil" or cutting wire. After the success of reducing these feet to suture ridden stumps, it was now time to bother live animals in the next session.I needed to make some halters, there being none and having noted the usual method of restraint namely a rope tied around the front leg below the knee, or simply a noose around the neck I felt improvement was necessary. What I requested was 12mm diameter rope of polyester, hardwearing and easy to work with. What I got was 6mm rope of polypropylene. But at least I got 30 metres, enough for about 5 halters and a casting rope. Lucy's cable ties formed an integral part of the construction. The students were enormously impressed by the ties and the Gerber multi-tool I used to tighten and cut them with. Thank you Lucy and Nicholas.Putting the halters on cattle not used to such restraint proved a challenge, and after an initial period of them attempting to fall over or jump out of the race, they became more used to the idea. The students spent some time taking temperatures and measuring heart rates, auscultating the lungs and listening to the rumen turn over. Only 5 of the 28 had ever had the chance of doing a rectal examination before this, so with a maximum of 5 different arms per startled cow I tried to reduce their inexperience. With only 4 cows in the race between 28 there seemed to be no satisfactory way for them to do enough, especially as working with a vet during their free time is not common.They are all very keen and crowd round to such an extent it is difficult to supervise what's going on. I count myself lucky that during the scalpel and suturing sessions no-one was cut and no-one was kicked or stepped on during the session with the cows. What's more it was only after a while that I noticed that only about 5 students and myself were wearing rubber boots, albeit none of had steel toe caps. I had wondered why a good proportion did the rectal exams while perched on the rails of the race and not with their feet on the ground. The fact their was 2" of cow crap in the race surely influenced their decision. Some of the girls were in kitten heels or sling backs. The cost of a pair of boots is 5000Rfr, about£6.00, and lack of money is the main reason why there are so few but I wonder how many ruined shoes are equal to the cost of boots.Racing on a bit, I have now completed my first week and on the whole I have begun to enjoy it. However, considering the lectures I have completed and the time left I have to fill makes me happy that I have more practicals than lectures left-my presentations are rapidly diminishing. The biggest problem with the practicals is still the shortage of materials and medicines.It was very nice to get back to Nyanza and Melissa and some home cooking even though it's only for 36 hours. The visit was made more pleasant by the luxury of a wine box bought by Melissa with some expenses paid to her by VSO. We treated ourselves to a tumbler or two while toiling over the weekly stew. The beans are getting a bit tired now and the numbers of beetles seen is on the increase. We might give them a bit of a miss until this season's beans are ready. There is a lot of activity drying and shelling beans but the bulk are still in the fields. While home I inspected the patch of ground Aphrodise has let me have. It's doing well, far better than the patch round our house but the soil looks superior next door. Courgettes and melons are best, and even the artichokes have germinated and look good. The weeds of course are about a foot high but nothing very pernicious evident. If anything they help shelter the soil from the fierce heat of noon and conserve some moisture, but I'm afraid the gardener in me won't tolerate weeds; they have to come out.I needed to leave Nyanza by 10.30 Sunday to get to Musanze before dark and devote quite a bit of time to my homework. On the previous Friday, I gave my first lecture on X-rays and medical imaging. Talk about blank stares. I sensed early on there was a lack of rapport with the subject and I have the feeling the basics are not in place. I pleaded for questions and stipulated they needed to be written down and anonymous so there would be no stigma. The questions flooded in and I was able to rank them by relevance and popularity. I needed to get information myself to answer their queries fully and accurately; I knew I must come up with the goods and not belittle the daft questions to get them to repeat the exercise. Time will prove whether I have enlightened or further confused.Bureaucracy and lack of communication rule as any other academic institute. This class that I had inflicted X-rays and medical imaging told me that they did not think they had to do this course, and Anselme Shyaka agreed; it was the fifth year and not the fourth year that needed instruction. I duly apologised to the class, agreed that their turn was next year and not this, and suggested they negotiate the cost to them of photocopying notes they no longer needed with the fifth year.This morning Anselme tells me without embarrassment that it's not the 5thyear but the 4thyear that have to be taught the dreaded physics and I have to apologise all over again.I am struggling to fill the practical sessions; they all have to be planned and executed by me. We still have not had the medical equipment and supplies promised so on Monday, lacking any real kit, I thought we would prepare a sheep for Rumenotomy but not actually do it. I was curious how a sheep might react when placed standing on a table for an hour or so. I needed it in a prominent position so the students could see well and I did not do my back in crouching on the ground with a sheep of only about 12kg. I need not have worried; it behaved almost perfectly, tolerating being clipped with a brand new and very expensive set of Hauptner sheep clippers. It was so good I decided to see what happens with a small dose of Xylazine sedative. I calculated the dose of 0.1ml in the muscle that being the smallest dose a 5ml syringe will go to. It all went as predicted, it's great when that happens and everyone was impressed.Pride cometh.. today I operated for real on a bigger sheep. I don't like the Rumenotomy operation, it's messy and I'm not convinced half the indications warrant such intervention. Particularly on a sheep, no farmer I know would pay good money on an operation on a sick sheep therefore it's not something I have ever done. But what the hell, the students need to see an operation or two and it won't use much of the scarce materials. It was not a good start when it rained for the entire morning rendering the flock of available sheep soaking wet. Trying to keep clean when handling wet sheep is impossible, but none of the students looked willing to pick it up and put it on the table. I needed to do it really in order to get an idea of it's weight for the pre-op injections(a big one at 25-30kg). It clipped up a treat; the Hauptners are worth the money, only I managed to cut it with the clippers.I lost sight of the area I had injected with local, I only shaved it after I had injected it and that not very well. That may account for some of the struggling. It behaved well while making the laparotomy and tolerated me suturing the rumen to the skin to seal off the abdomen. Second mistake; not making the rumen-skin sutures distinct from the sutures I would be using for the actual rumen wound.Entry into the rumen went well and I made sure it was to small to insert my arm, no flash stuff I thought. Scooped out enough rumen contents to be impressive and thought it was time to suture up and finish. It was at this stage the sheep decided it had had enough and began to lie down. In an effort to control it better, it's feet were held by the students which it violently resented causing it to kick and struggle. All the while the rumen wound is still open and gobs of content keep emerging like a green volcano masking the field and contaminating me. By degrees I slowly managed to complete the closure of the wound, but then I was unable to clearly distinguish the rumen closure sutures from those I had to remove to detach the rumen from the skin. I was in fear of re-opening the rumen and battling to close it again. I then put second layer in as the book said (never demonstrate a technique you have not done before that you got off the internet!) Even if the book had not said to do another layer I don't trust plain catgut in these circumstances. By now the rumen itself was coming out and my brave but trepidatious student assistant had the job of holding it in while I completed the skin sutures.Once off the table with sutures complete it looked fine. We will have to follow it up over the next few days; I hope it looks as well tomorrow.I will try to do another tomorrow, but using a different technique (from the same book!) There's nothing like keeping going while you're ahead.