Things that go 'Crackle' in the Night

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The list of things that will have you up at 3 am cleaning your apartment (and by cleaning, I mean down on your knees with a sponge and bucket, cleaning) must be a short one.  To that list, if not already present, I respectfully submit one…

• Unwittingly, and quite-nearly, setting your apartment building on fire.

10 hours prior…

After several weeks of chilly days in my new apartment, I decided it was time to try a little supplemental heat.  My place occupies the first floor and front half of a 100 year-old Victorian 3-plex, owned by a pleasant German couple from the Oakland Hills.  The living room has a medium-sized space heater which stands vertically against the wall about 3 feet high.  It's encased in a metal cabinet the shape of a small bookcase with a grill that faces forward to vent the heated air.  A simple flip of the thermostat on the wall, and the electric ignition kicked in, igniting the gas with that characteristic ‘whump.’  Moments later, a beautiful radiant heat emanated from the metal casing and I cozied onto a nearby couch, grateful for yet another small miracle of modern living. 

Later the same day, now 9pm, I returned home from an evening swim with the local Masters swim team.  Because my apartment doesn’t get any direct sunlight (i.e. no south facing windows), it takes forever for a damp towel to dry, and the firm rectangular corners of the warm heater were just begging for one to be draped over them - which I now did.  As both wet towel and suit gradually warmed, I smiled, envisioning a warm dry towel by morning and a healthy dose of humidified air.  I left the apartment and rode my bicycle 10 blocks to a local bar, the night’s designated spot for swim team’s monthly Thursday social night.  

After returning home around 11 pm, I checked on the towel, now mostly dry and feeling so toasty.  I spent another hour surfing the web before climbing into bed for the night, satisfied that all was in order.

I don’t know why I woke up.  Was it the smell?  The heat? The gentle ‘crackling’ sound?  Or perhaps the flickering light radiating from the living room.  Whatever it was, when I did wake up, it was like being shot from a canon - for all my sensory inputs converged into an epinephrine charged outburst to move - quickly!

From my bed, the living room was a step away (more an alcove than a bedroom), and once there, my mind instantly snapped a memorable photograph of the frightening scene.   From the corner of the room, where the heater sits between two couches, my swim towel and suit were ablaze, with bright yellow flames clawing towards the ceiling.

I grabbed the edge of the towel and pulled the ball of fire to the floor. The burning cotton towel produced the bright yellow flames, while my petroleum-based polyester swimsuit added the heat and acrid smoke, quickly filling the apartment in a hazy glow and triggering the fire alarm which shrieked in protest, alternating between screeching beeps and a commanding woman’s staccato voice, “Fire. Fire. Fire.”

I threw open the front door, scooped the flaming pile into my hands, and backed my way across the room.  The towel and suit broke apart into several pieces as I moved toward the front door, each one now burning like a little campfire on the beautiful oak floor.   The melting polyester burned my hands and dripped like flaming candle wax.  Once outside, I threw the flaming ball off the wooden front porch and onto the concrete walk below.  I made several more round trips between the living room and front porch pulling the remaining fireballs outside, tossing them into a single heap, burning brightly, and safely, on the concrete.    

While taking a moment to gather my senses, a couple from next door hurriedly walked over, the woman already on the phone to 911.  I stood there in my underwear, shaking the hot plastic off my hands and facing them with what must have been a look of crazed disbelief.  The male neighbor looked at me, the burning pile, and the smoke pouring out the front door, and made a reasonable assessment.  “Dude!  Does somebody around here not like you?”

Exasperated, I could barely form a coherent sentence, beyond “It’s ok.  It’s ok.”

The woman talking on the phone nodded with me in confirmation, “Yeah, it looks like the fire is out.” I took a moment to explain to them the situation, and thanked them for coming over.  Realizing how close to disaster I’d come, I felt a compelling urge to give them both a huge hug of neighborly love, but my half naked state stopped me short.

Slowly coming to my senses, I opened the windows, gathered a bucket, some sponges, a scraper, and  went to work cleaning up the mess.  Ever so thankful of the divine.

Snake Alley Criterium 2008

Hey Guys!

Had a great time today racing road bikes in Burlington, Iowa at the "Snake Alley Criterium." You can check out a good video showing the race course on YouTube. Burlington has magnificent old homes, built on 200 ft hills overlooking the Mississippi River. You can imagine how bustling this town must have been in the early 1900's, when riverboat traffic merged with the Burlington Railroad heading west.

Raced in the Cat 5 (beginner's) class - which you pretty much have to do when you begin cycling races until you've accumulated enough experience to advance Categories.

Tracy and I raced this together, and since we waited to register until race day, they made us start at the very back of the pack. Well, this switchback, cobblestone alley was perfect for our style of riding, which favors hill climbing over drafting and sprinting. I took us one hill to pretty much pass 90% of the field, and by the start of the 3rd lap, I was in the lead with Tracy right on my butt. We swapped leads for the rest of the race (8 laps in all) and in the end, Tracy had a bit more left in the tank when we attacked the final hill. He rolled across the finish line first, and I, second. Standing on the podium was hilarious for this 41 year old!

Minutes after finishing our race, Tracy and I lined up for the Cobblestone Alley Challenge - a straight up hill climb over some pretty rough cobbles. This has typically a Mountain bike only event. We decided to give it a shot on the road bikes! Photos

Later in the day, we cheered on the advanced race Categories, culminating the day with the Pro's race. It's an awesome event! The Snake Alley makes for spectacular viewing because it slows everybody way down, and you can see the pain on everybody's faces as the laps roll by. After just a few hours, you'll be a cycling fan for life! Mark this one down on your calendars and throw it in the Bucket.

Ultrasound in Africa

Two words summarize my review of the SonoSite Ultrasound MicroMaxx on this trip to Rwanda – incredible utility. It’s been used in nearly every way imaginable for patient care during my month. Here’s just a summary of some of the jobs it’s tackled:

• Roughly 30 transthoracic echo-cardiograms performed by a visiting cardiologist from Belgium
• ICU diagnosis of 4 symptomatic pericardial effusions. Real-time visualization of therapeutic drainage procedures.
• 10 pleural effusions and subsequent drainage.
• Obstetric use in both prenatal ultrasound (I carried the unit to Paulin’s house and performed an exam on his wife who is in her 2nd trimester). He was thrilled! Another exam was done to verify a potentially viable pregnancy in a woman with intermittent vaginal bleeding.
• Deep Venous Thrombosis (DVT) diagnosis in a woman of 35 years.
• Educational use for the residents displaying block anatomy during afternoon lectures.
• 10 peripheral nerve block procedures in the OR. One done on a patient with severe dyspnea, in need of a below-elbow amputation for an advanced, hemorrhaging tumor. The case was done with just an infraclavicular nerve block.
• Central line access on a 2 year old with 2nd degree burns over 40% of his body.
• Trauma surveys in the Emergency Department.

My good friend and local ICU doc, Bart Troubleyn has already threatened to steal the machine before my departure (Kim, are you hearing this?). If I don’t make it back alive to the States, follow the ultrasound machine! (see: Watergate Scandal)
Unfortunately for the hospital, the Micro-Maxx machine costs roughly $60k (I know this because my hospital in Walnut Creek just bought one), which is obviously beyond the financial means of a university hospital and trauma center that can’t even afford a CT Scanner (currently, patients in need of a scan, must be transported to a local private hospital who owns the only scanner in the country. There, they must beg staff for a scan on a patient who obviously can’t afford the fee).
The portability of the Micro-Maxx make it the perfect ultrasound machine for a hospital like the Central University Hospital of Kigali (CHUK). This machine looks just like a laptop computer and fits into a nifty backpack which has internal pockets for the transducer heads and power supply. Many hospital based ultrasound machines are roughly the size of washing machine, are incredibly heavy, and rarely leave their home department.
For instance, during the day in the OR, my cell phone would ring and Mark, the cardiologist would politely ask, “John, can I borrow the ultrasound machine?” Of course, I would say, ‘yes.’ He just walked across the path to the surgery department, put the back pack strap over his shoulder and walked back to cardiology. Five minutes later he would be examining the heart of a 35 year old woman complaining of severe dyspnea on exertion. A moment later he had his diagnosis – cardiomyopathy, with an ejection fraction of 15-20%. An hour later, Bart had the machine over in the ICU tapping the lung of patient with a recurrent pulmonary effusion.

Now the obvious question is –“how do we get one of these ultrasound units for CHUK, without forcing Bart to poison my coffee and steal it?”

SonoSite Micromaxx


Pericardial effusion


Yes, I can breathe much easier, now.


Bart (with Minnow), Mark and Apoline

Gorillas!

Hey Everyone! I hope you’re all doing well. It’s been awhile since I’ve posted, and a lot has happened since, which I hope to document later. But for now, let me tell you about today’s outing – which as you may have guessed from the title, involved a visit to the mountain gorillas of ‘The Volcanoes National Park of Rwanda.’

Only 300 mountain gorillas remain in the world, and they live exclusively in the Virunga Mountains, a high altitude, volcanic rain forest covering 420 sq-km. Unfortunately for the gorillas, their home straddles the border between 3 countries - Rwanda, Uganda and the Democratic Republic of Congo (DRC), and is therefore prone to variations in political stability. No one knows how large the population of mountain gorillas may once have been. The first written discovery of the species occurred in 1902, and the first published population survey in 1960, estimated the number to be around 450. Given the limited nature of the mountain gorillas habitat, it is thought that no more than 1000 may have ever existed at any one time.

Today, more than half of the world’s mountain gorillas live in Rwanda’s Volcanoes National Park. In 1978, the first gorilla tourism project was initiated in the park, and despite many problems in the region during the intervening 25+ year (including the murder of Dian Fossey, invading rebel militias, a civil war beginning in 1991 culminating in the genocide of 1994, and various poaching incidents) incredibly, the gorilla population has remained relatively stable.

Revenue from gorilla trekking in Volcanoes Park is a huge chunk of Rwanda’s annual revenue. It’s somewhere between the #2 and #3 largest contributor to the GNP. Over $12,000 per day can be collected in park permit revenue alone.

Gorillas live in distinct communities know as clans. One alpha male dominates a clan of roughly 15-20 individuals and has exclusive mating rites with the 3-4 females under his control. Other males must leave the troop and find a female (usually pulled a neighboring clan) to start a clan of his own. There are many clans living in the Virunga Mountain chain, but only 5 are exposed to regular tourist visits, and have been thoroughly habituated to tolerate human intrusion. Gorillas have a regular daily schedule of activity which includes feeding, lounging, social time, etc. Tourists visits are limited to 1 hour of contact per day.

The park authorities employ professional Rwandese gorilla trackers, who keep track of each group’s daily location. Since gorillas are fairly sedentary, and travel only short distances (less than a Km per day), keeping track of their location is fairly easy. So when you plunk down your $375 at the park office, it’s a guarantee that you will see gorillas. In fact, you’ll be amazed at how close a proximity you’re allowed to get to these guys! The park guides who accompany each small group will tell you that the desired limit from human to gorilla is 7 meters. This is done mostly for safety, avoiding undue stress on the gorillas, and limiting the chance for disease spread from human to gorilla. But I can tell you from first hand experience that you get much closer than that. Most of the today’s viewing was at a distance of 10 feet! Of course the gorillas have their own set of limitations, and curious ones have been known to get very close. But, I’m jumping ahead of the story…

This morning, 4 friends from the local hospital and I climbed into a very well-used 4x4 taxi and set off for the park entrance. Showing up at the park headquarters at 6:30 am is a requirement for all the gorilla tracking customers, and it is during the morning gathering, that the tourist groups are assigned to specific gorilla clans. One has limited input in the park supervisor’s decision to assign tourists groups to gorilla clans, but despite this, I had my hopes set on visiting the ‘Susa’ group, which touts itself as the most remote and arduous trek required to reach the gorillas. Depending on the ‘Susa’ clan’s location, the hike can take as long as 4 hours, up a steep volcano pitch thru dense vegetation. Other gorilla clans live in closer habitats to the parking areas, and are more easily reached along gently sloping terrain. The park info recommends the ‘Susa’ group only for ‘extremely fit’ individuals. Of course, I wanted to take on the challenge.

At 6:30, the park headquarters was Mizungu-city, with about 30 westerners, each having paid $375 cash, eagerly awaiting the gorilla tracking experience. Fortunately for my Rwandan friends, the park gives a huge discount to residents, and they only had to pay the equivalent of $20 each.

From my best guess, each morning when the tourist groups arrive at the headquarters, the park supervisor sizes up the visitors, decides who’s cut out for the more difficult treks, and makes his assignment for each group to one of the 5 clans. It’s a bit like being picked for kickball back in grade school – it’s a bit if a pride swallow if you get drafted in the late rounds.

I started sizing up the Anglos asking myself what chances our team would have in getting a ‘Susa’ assignment. The Euro/North American contingent looked very well prepared in their Gore-Tex jackets, camelback packs, hiking boots, hats, rain pants and shiny new 4X4 vehicles, complete with driver. In comparison, my group of Rwandan friends looked like a Jamaican Bobsled Team who lost their corporate sponsor. Only 2 of the 4 brought rain jackets, Chantelle showed up wearing flats on her feet, but with perfectly applied makeup and a very cute umbrella, and Laurent wore jeans with a cotton short-sleeved shirt. The current conditions – about 50°F, and raining. The situation looked hopeless. We were surely going to be assigned to the gorilla clan set aside for obese westerners on the verge of congestive heart failure.

My prediction proved true. One by one the other tourist groups got their assignment, and I was beginning to think we may have been overlooked us entirely. Finally, the park supervisor directed us to the little stand-up sign marking our gorilla clan. The name on the sign was in Kinyarwandan, so I couldn’t understand the meaning of the name. My guess was ‘Senior Citizen’. My taxi driver, knowing my desires to take on the ‘Susa’ challenge, arranged it with the supervisor that I could separate from my Rwandan friends and join the ‘Susu’ team as a free agent. I thought about it for moment, took a look at Chantelle’s spotless outfit and perfectly coiffed hair and Laurent already trying to shake off the morning cold, and made my decision. “No thanks,” I said. “I’ll stay with my friends.”

I tried to conceal my disappointment as I trudged past the ‘Susa’ tourists, looking like they were ready for the cover shot on next month’s ‘Outside’. The consolation to the morning was that Laurent was able to purchase a tracking permit at the Rwandese resident price (which he had been unable to do back in Kigali, due to his Congolese citizenship), and by no means could afford the non-resident fee. We thought he would be turned away at park headquarters and would have to wait for us to return, but decided to try just in case. Fortunately, our taxi driver know all the park rangers by name, took an interest in our underdog status, and chatted up the man issuing the precious permits. He agreed to let Laurent purchase the discounted ticket.

As we gathered with the guides to hear a pre-trip briefing, our group was joined by Hideaki, the lone Japanese tourist who arrived in at park headquarters in a suped-up Mitsubishi sports car. Turns out, he’s in Rwanda for the upcoming ‘road rally’ (pronounced ‘load lally’ by the Rwandese) and is in the hunt for the ‘Africa Cup Road Rally Championship’. My team climbed back into our rusting taxi, and the 2 guides hopped a ride in Hideaki’s sports car. We drove about 30 minutes until the road became impassible, and then we started walking.

I reluctantly accepted the fact that there would be no ‘Susa’ group for me this year. But I reminded myself of the bright side - Laurent would be able to attend, and that I would get to see local Rwandese experiencing for the first time, what is undoubtedly the biggest attraction their country has to offer in tourism. This would be good enough I told myself.

At the trailhead, the guides gathered our rag-tag band for one last briefing before entering the park. Then he told us something that changed my entire tune. One of the females in the gorilla clan we were approached, had only 3 days ago, given birth! The reminded us that the mother is very protective of newborns, and will not release her continuous hold on her baby for several weeks. We may not be lucky enough to see the new baby. But this hope brightened my thoughts tremendously. Ain’t no baby in the Susa group!

Given the rainy conditions, the walk turned out being perfect. And it was just long enough with sufficient bush-whacking through the forest to give you the impression of remoteness. When we first came upon the gorilla clan, I could just make out one climbing in the tree overhead. Then, I turned the corner to see the big chief himself, mister silverback sitting in a patch of grass lounging away. He size was very impressive – must have been around 300 pounds. Gorillas are strictly vegetarians, and the guides told us that they can consume as much as 60 kg a day of raw food. Gorillas don’t drink water, for they get an ample supply from the plants they consume.

Of course, the highlight of the experience, to be sure, was seeing the mother gorilla caring for her 3 day old infant. I’m not going to say much more here, because I’ll let the pictures do the talking. Suffice to say, we had a terrific time and all went home thoroughly satisfied. Life’s little lessons never cease. Cheers, all!

PS. Check out the short gorilla movie!

Team Rwanda gathering at Park Headquarters


Pre-Trip Briefing

Hiking In


Laurent in borrowed jacket


Silverback Alpha Male


Mom and newborn


Maternal instincts?


Chantelle

The Bad News Bears

Oxygen, anyone?

Patient monitor minus oxmetry and blood pressure.

Had a great few days at the Central Hospital of Kigali (CHK) this week working with the residents and nurses in anesthesia department. Obviously the OR runs a bit differently here in Rwanda than at John Muir Medical center back in Walnut Creek. And the practice of anesthesia is no exception.

Oximetry is an extremely useful and relatively inexpensive monitoring device to give a real-time measurement of a patient’s oxygen saturation. Most of you walk around with oxygen saturations of near 100%. Climbers on Mount Everest would be at 80% or less without supplemental oxygen. Most people will go unconscious and their skin turn a shade of blue below 75%. And irreversible brain damage will occur if oxygen saturation levels fall to critical levels (say, less than 40%) for greater than 10-15 minutes. The near 100-fold increase in the safety of general anesthesia over the past 40 years is in no small part due to the invention and widespread distribution of oximetry monitors. No anesthesiologist in the US or Europe would anesthetize a patient without one. I’m doing it here, in Rwanda.

Most of the monitors in the operating room here are equipped with oximeters. The reason they are not being used is because they are missing the readily available, plug-in cord to attach the monitor to the patient. Apparently the original cord broke, and they are waiting for it’s replacement to arrive. When a cord breaks at John Muir Medical Center, someone merely walks to the stock-room and grabs another from the inventory. For whatever reason, be it financial, lack of assigned responsibilities, or failure to realize the importance of backing up critical equipment, rarely does something get done here until there’s a problem. And until enough people scream about it, the problem remains. C’est la vie en Kigali.

Lecture with the anesthesia residents

Gave a lecture to the anesthesia residents yesterday afternoon at CHK. I had about 10 people in attendance for a talk on the management of acute pain. My voice was cracking due to a recent case of laryngitis, so I could hardly speak English, let alone French. At first everyone was very quiet, and it what looking like I was going to spend the whole 2 hours listening to myself talk while everyone else dozed. Fortunately, bribing them with Civco ink pens got the questions going, and pretty soon, I was having to moderate some heated discussions. It was a smashing success! And since this is same the group I’ll be lecturing every week for the next 4, things should go well.

They are very bright and asked some tough questions (I’m supposed to know the difference between an ‘enkephalin’ and a ‘dynorphin!?’). Every resident, including some on their very first week of anesthesia, seemed very engaged in the topic and excited about their training. I just hope the funding keeps coming.

Watched a 2 month old baby’s heart squeeze it’s final beats in the OR today. The poor kid was already pretty ill with an intestinal disorder that would have made long-term survival very difficult. And he had already survived 2 abdominal surgeries. There are no incubators in the entire hospital, save the one in the Intensive Care Unit (ICU). This kid would have been an obvious ICU case in any hospital I know. He arrived from the general pediatric ward, no more than 3kg in weight, and already hypothermic.

I have no way to know what his core body temp was upon arrival, because I wasn’t involved until later. Since the scheduled surgery was not an emergency, the proper thing to do would have been to cancel the case, and send the kid back to the ward until his temperature was normal and his circulatory status assured. I don’t know why they forged ahead. Perhaps because it may have been the only day this week when the pediatric surgeon was available.

When I arrived to the OR room after being alerted of trouble, the baby was already on death’s door. Her extremities were white and cold from extremely poor circulation due to a failing heart and profound hypothermia. When I couldn’t palpate a pulse, I grabbed the ultrasound unit and did a quick scan of the heart. It was only beating 40 times per minute, and poorly at best. I knew the child wouldn’t survive, but we went through the requisite resuscitation with CPR and potent drugs anyway. On the ultrasound screen, I watched the weakened heart make one final, gasping attempt to squeeze, and then silence.

Checking out the anatomy courtesy of the trusty laptop.

This is where the needle goes...

Powerful moments

This is the week to commemorate the Genocide of 1994, and every evening, each community church holds a mass for worship. I attended a service Monday evening in a small village on the outskirts of Kigali.

I recently met some film student from Berlin who have been working in Kigali for the past few months producing a documentary of post-Genocide Rwanda. They have focused on young Rwandan’s, age 25-35 years, who would have been children during the April of 1994, the time of the Genocide. One of their subjects is a 22 year old woman named, Angela.

Angela was 7 years old when the Genocide started. Her family was slaughtered before her eyes when their home was sacked by Hutus. She survived the attack by escaping and running to the home of her grandparents. When she arrived there, she found everyone who lived in that house had already been killed. For the next 7 days, she hid in her Grandparent’ house among the slain bodies of her extended family. She was joined by another young girl who miraculously survived a similar attack.

Unfortunately, patrolling Hutus heard some noise coming a the house that had already been marked as ‘dead’. When they entered the home, they found Angela and the other girl hiding. The attacked Angela, hacking off her left arm above the elbow, slashed her in the head and legs, and left her for dead.

Again, she survived.

The capital city of Kigali was soon overthrown by the Tutsi run revolutionary army, which had invaded from Uganda to the north. Angela took refuge in the home of her uncle.

In country like Rwanda, communities are composed of extended family units. Angela’s family was from the village of Kabuye.

After the church service, I joined the Berlin students, who were filming their segment of nearly three months work. Together with Angela and the church pastor, we sat in greeting room behind the church, and visited awhile. The pastor handed me a stack of loose papers, some typed, some written by hand. There were about 40 pages in all, each representing a family unit.

On each piece of paper, a simple column of names, either typed or neatly written ran down the left side of an otherwise blank page. Each page listed at least 10 names, many over 20. These were the names of the people who were killed from each family unit. The page representing Angela’s family listed 23 names. Every single person in her family is listed on that piece of paper, save one.

Meeting Angela, I never would have guessed that such atrocities could have happened to this beautiful young woman. She smiled shyly every time our eyes met across the room. I sat down with her at the dining room table of her uncle’s home (his family was largely untouched by the genocidaires, and Angela lives in his family’s home). Speaking very good English, Angela asked me questions for the rest of the family to hear. I think they were proud of her mastery of English, since most of them only speak Kinyarwandan and French. She wanted to know things like, how old I was (yes, I told the truth!), , what kind of doctor I was, did I have a girlfriend back in the US, why not? ect… The family really seem to enjoy the conversation and we all had some good laughs.

Angela want to return to studying at the local university. She has mentioned that she would like to be a film producer/director. The family doesn’t have enough money to pay for her schooling, so the film students from Berlin are working to direct any proceed from their documentary to Angela’s University fund. I sincerely hope that life brings good fortune to Angela and her new family.

Tonight I watched a film on the Genocide at the Intercontinental Hotel. I watched the most intense film I think I’ve ever seen. If you liked ‘Hotel Rwanda,’ you owe it to yourself to see ‘Un Dimanche a Kigali.’ It’s a love story between a Canadian journalist and a local Tutsi woman during the time of the Genocide. If you really want a feel for what it must have been like in Rwanda during the Spring of 1994, see this film, you will not be disappointed.

Film Festival commemorating the Genocide. I'll have to catch some of these.
Walking through Kigali.
Paulin and I waiting out an afternoon rain.
Rajabu's moonlighting gig at the private hospital. Consultation with a physician cost $10.
Laurent and Mizungu at the Market Ordinaire.