Oh so a medical placement is not the same as a vacation?!

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Not having any expectations for this trip was probably a good thing! My Rwandan life so far has been full of surprises and challenges and it's only been a week.

On Monday, June 5th, myself and another med student from NOSM named Julie left from Toronto to head over to Rwanda to complete a 4 week medical placement with the International Federation of Medical Students. I was to be placed in surgery, while Julie was going to be spending her time in internal medicine.

On our way to Rwanda, we had a 14 hour stop over in Amsterdam which was incredible. Unfortunately, neither of us had been attentive enough to really look over our travel itinerary... so with the time difference, we lost all of Friday night, arriving in Amsterdam in their morning, but our middle of the night. Needless to say we were pretty tired but we ended up having a wonderful day regardless.

Randomly, on the train from the airport to the city centre, we ran into another med student in his third year from U of T. Thankfully, he was part Dutch and knew the city pretty well. Since we didn't have any plans and our map was purely Dutch, we were happy to spend the day with him. Amsterdam is beautiful! It was a gorgeous morning. We were in no hurry and just meandered around the red light district (which was quiet except for the occasional drunk party-goer from the night before - it was about 7:30 am). We stumbled upon a small outdoor market and sat on a bench in the sun while we chatted and ate fresh bread with delicious gouda cheese with fruit and coffee. Yum!

Julie & I carried on to the Anne Frank house which I was very excited to have the opportunity to visit. I had gone through an 'Anne Frank' phase when I was about 12 and read Anne's diary and other books about the Holocaust and of her life. Being in the Annex of their hiding place was a surreal experience. Parts of the diary came back to me as I saw the attic where Anne & Peter first kissed and the markings on the wall showing Anne and her sister, Margot's growth during their time in hiding. It was a sobering visit - it's so hard to imagine what it must've been like for their family and other families in hiding.

I was feeling the lack of sleep after our visit and we were definitely hitting a wall of exhaustion, so we walked along the canals and the narrow, slanted, eclectic array of houses toward the Van Gogh museum where we had a picnic on the lawn and eventually fell asleep in the sun for 2 hours! Jeremy, the med student found us there and dragged us off into the museum. Skeptical at first, the visit to the museum was definitely worth the 15 Euros it cost me to get in! The art in the permanent collection was so interesting and I learnt more about his life and his variable artistic style. Jeremy and I also (like the geeky med students we are) also tried to diagnose the pathologies we saw in Van Gogh's subjects!

After spending the rest of the afternoon chilling out in a cafe, we said goodbye to Jeremy and headed back to the airport for our last two flights to Rwanda. Fortunately, everything went smoothly and we arrived WITH OUR BAGS (YAY!) in Kigali, Rwanada's capital on Sunday morning. I felt, and probably looked, like death and was desperate for a shower and a toothbrush. At the airport to meet us, was Anan, a 3rd year Rwandan medical student. He was amazing - we would've been lost without him. He managed to get us a good exchange rate at a very sketchy forex bureau and got us on a bus to Butare. I slept the whole way to Butare - actually, the bus driver had to pull over about 30 min into the trip because I kept falling asleep on his shoulder! hahah he made me switch seats with another woman so I could lean against the window instead!

Finally, we arrived in Butare and Anan showed us to our accommodations which happened to be in a monastery! haha Despite the intense quiet, I was grateful to find running water and electricity - things I definitely wasn't expecting. We fell asleep immediately in our tiny room - our beds are so close that we can hold hands when we lie in them - Julie & I will know each other well before we leave!

So our placement began the next morning at 7am sharp. What an overwhelming day that Monday was! First of all, the hospital is a teaching hospital and like in Canada, there are med students, interns, residents and attendings. The teaching aspect is extremely intense. Students dress in dress clothes and ties and are grilled incessantly by the attendings. Eeep! Further, the surgical department (as well as most of the other departments) are all men - so of course I stand out hugely as a white female. Unfortunately, this also makes me a target for questions regarding surgical cases and also makes me the elephant in the room when anyone mentions ANYTHING sexual which I think is quite funny.

The hospital is huge - I still don't know my way around it. Unlike in Canada, it sprawls out into a plethora of buildings housing various wards - pediatrics, internal medicine, gynecology, etc. which are connected by paths outside. The wards are similar to the hospital I worked in in Ghana - cramped and dirty. It's a sad place. On my first morning, I was taken with the other med students on ward rounds where we stopped at every bed in the surgical wards. The pathologies and conditions that I saw in the first couple of hours of being in the hospital were completely overwhelming. Many of the diseases are incredibly advanced - conditions that would've been treated much earlier in Canada. Of the many cases I saw that day, a few stand out in mind - an elderly man with stage IV squamous cell carcinoma of the penis that had metastasized to the inguinal lymph nodes, a middle aged man with a melanoma the size of a baseball, another young woman with a massive tumor (osteosarcoma) on her shoulder... all of these patients were being treated palliatively. There is no cancer treatment at all in all of Rwanda. Another young boy had broken his femur (open fracture) a few months ago when he was hit by a car. Since then, he had developed an infection of the bone (chronic osteomyelitis) which had caused complete necrosis of his entire leg and gluts. The femur was exposed through the dead tissue and I was shocked that he hadn't already died due to sepsis. It was heartbreaking to help the debridement of all of the dead tissue - although he was 10 years old, his face looked like he was only about 6...

Care of patients is limited to what the family (if there are any) can give. Family members do all of the non-medical care - feeding, helping patients to the bathroom, cleaning, etc. Unfortunately, not everyone has family members and so the majority of surgical patients have bed sores - ulcers so advanced that sometimes I can't believe what I'm seeing. It's terrible - in Canada, nurses rotate immobilized patients every couple of hours. Here there is just no one to do that and the patients suffer because of it.

The doctor-patient relationship is much different as well. Like in Ghana, the doctors are much more dismissive and 'business-like' in their dealings with patients. There isn't much comforting done and coming from a medical program which forcibly reminds us EVERY day to ask patients about how they are feeling and how their medical problems are affecting their lives, etc. it is something that I can't get used to. The other students must think I'm nuts when I hold someone's had while their fracture is reduced but maybe, if anything, that is something that I might be able to leave with the other students...?

Anyway - so my days have started to become routine. I am at the hospital at 7:15am sharp for a staff meeting where all of the members of the surgical department are present. The interns present cases to the attendings, and they grill the students about their treatment plans, the pathophysiology of the patients conditions, etc. Then after about an hour and a half of that, I stay with the med students for an informal lecture with one of the head surgeons who I love. He is one of the only elderly doctors - most of the doctors are incredibly young, maybe in their late 20s or early 30s and I am wondering if this has anything to do with the genocide and the need to train all new professionals from the very beginning. So far, I've been learning lots from these teachings and am realizing how little I have kept in my memory from this year! I wish I had brought a couple of textbooks!

After the lecture, since I don't have anyone really to report to, I sort of float around. Usually, I go to the OR where I have been observing a number of surgeries. Some of the more interesting ones - a brain tumor the size of an apple, a 12 day old premie with a neural tube defect, a cholecysectomy (removal of the gallbladder) done non-laproscopically... Unfortunately, I don't think I will be able to scrub in on any surgeries since there is a long line of interns and med students who are depending on getting into surgeries for their training. I don't feel comfortable barging my way in and taking away from their education. I am learning much anyway by observing, doing out-patient consultations and by listening to case presentations on ward rounds.

So, since we are at the hospital from 7am until 4pm, we haven't done much exploring of Butare - the city we live in. Also, since it gets pitch black out by 6:30pm, we are pretty limited in where we can go. There aren't any street lights and you literally can see NOTHING after the sun goes down. Slightly dangerous. Unfortunately, it means that our evenings are pretty quiet and we go to bed usually about 9pm! We are starting to make a lot of friends though and I am hoping that people will eventually be willing to take us around at night. We've been invited to a party tonight so hopefully that will be fun!

What we have seen of the city, though, is stunning. Rwanda, as I'm sure most people know, is comprised of a series of rolling mountains. Everywhere you look, you see lush mountains and valleys. It's really beautiful - and cool! After Ghana, I expected to be sweating 24/7, but I am actually wishing that I had brought more warmer clothes! I sleep in my down sleeping bag at night... weird! There are also trees and flowers everywhere which helps to keep the temperatures down after mid-day. I am hoping that this weekend will give us a chance to explore the market and meet some new friends. Apparently, the interns all hang out at the pool at one of the hotels and have been bugging us to go!

Generally, people have been very friendly. I love the way people greet each other as they pass by on the street. Its like a long-lost reunion every time! It's not uncommon to see men strolling along holding hands. In the past couple of days, I've held hands with so many guys that I don't know at all! Everyone is very touchy and affectionate. Communication, though, is much harder than I expected. Although people speak French, it is not anything that I can understand even after years and years of taking french lessons. They also mix their french up with the local language, Kinyrawanda. I'm learning a few words each day and so far, have the basics down pat. It's funny though because people also speak English as well as Swahili, so I NEVER know in what language to greet someone. Most of the time, I try a combination and wait to see where it gets me! I'm getting used to it, but it does make things challenging in the hospital, especially when the attendings are spouting off a million questions. I can barely understand what they're asking let alone hope that I might have an answer for the question! hahah

Anyway - I realize this is getting extremely long, so I'll stop here for now. I miss home but am definitely feeling fortunate to be here. I know I am going to learn lots despite the times where I feel frustrated, tired, lost, etc. I hope that everyone is enjoying beautiful June weather - I really miss the long evenings!

Please email me if you can - I have internet access everyday through the medical faculty at the university so send me news!

Miss everyone lots & send my love.
(pics to follow soon!)

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