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.

Mizungu!

Today is Good Friday, and perhaps more importantly in Rwanda, marks the beginning of a national holiday week memorializing the start of the Genocide.

I passed the day touring Kigali with 3 young Rwandan physicians who are working at the Central University Hospital of Kigali (CHUK) – a Rwandan version of SF General. They were terrific hosts, and picked me up from my residence in a vintage, 1983 Toyota Corolla. The car is in excellent condition with 80k miles on the odometer, and a left-hand drive steering wheel (somewhere in Africa, there must be drivers on the wrong side of the road). The car belongs to Rajabu, a young gynecologist in training.

The tour’s first stop was the Genocide Memorial. We were disappointed to hear from the guard that the memorial had just closed. We weren’t sure if it was an official closing schedule, or that the staff wanted to take an early lunch. Next we visited the pride of Kigali – a shiny, brand new shopping mall, complete with plenty of underground parking, gourmet coffee shop, sunglass hut, and the piece de resistance – a grocery/department store to make Sam Walton proud. Despite the long aisles of fresh food and packaged goods, the store was conspicuously empty – like a ‘Safeway’ when it’s closing time and they’re locking the doors while you hurry to make your final selections. Of the handful of people shopping today, half were Westerners.

I walked away largely unsatisfied, which is the same feeling I get whenever I’m dragged to a sterile, suburban shopping mall. I asked the docs, “Isn’t there an outdoor market somewhere that’s a bit more authentic?” Rajabu turned to his friends, and in French, made some remark that contained the word ‘ordinaire’. “Yes!” I said with a smile, “Let’s go to that place.”

We drove a kilometer through town to an unmarked entrance off the paved road. Rajabu carefully navigated through the throngs of locals on foot, as we traveled the dirt road past storefront shanties jammed together. We parked the car and walked into ground zero. I followed my friends as they descended into one of the shanties. Imagine a massive wardrobe, dimly lit, full of everything you might find in a packrat’s cluttered closet. Add to that an endless maze of tight corridors, more densely packed that a kitchen at a high school keg-party, just before the cops show up.

With all the attention I drew, I might well have been Brad Pitt himself. This is where I first heard the word ‘Mizungu!’ shouted mostly by young children. ‘Mizungu’ in Swahili has several meanings – ‘white person, something remarkable, baffling.’ Laurent told me that it means ‘money.’ I smiled and thought to myself, “Johnny you’re so Mizungu, and you don’t even know it!”

Moving quickly with the children hot on our tails, Paulin smiled pointing at me and exclaimed, “THIS is why you don’t take a Mizungu to the Market Ordinaire!”

Rajabu, Paulin (anesthesiology resident) and Laurent (aspiring emergency medicine physician) know each other from medical school, and all three grew up in Eastern Congo, a mostly rural area known for it’s mineral resources, diamonds in particular. Eastern Congo has an infamous reputation for terrible civil wars, ethnic conflicts, child soldiers, militant clans, internally displaced persons and Rwandan refugees from the genocide. Many of the perpetrators of the Genocide, known as Genocidaires (Interhamwe) now live there, and their presence continues to raise ethnic tensions. My three physician friends moved to Rwanda after graduating medical school in 2002, in search of better employment opportunity, which exists in scant supply in their home towns.

Here are some interesting economics shaping the lives of a young Rwandan physicians. After taxes, they each earn a monthly income of $600 per month (this follows a significant raise from the previous salary of $200 per month). From that, rental housing costs roughly $150-200 per month. The usual living expenses add between $150 to 250 per month depending on whom you have to feed, clothe, house, ect.

Laurent, being a single guy with a small apartment, a girlfriend of 6 months, and no car, can sock away $300 per month in savings on his resident’s salary. Of this, he sends $100 to his parents who still live in eastern Congo, and keeps $200 for himself. Minus miscellaneous annual expenses, Laurent can save $2000 per year.

Rujabu, the owner of the aforementioned Toyota Corolla, moonlights at a local, private-pay clinic where he can earn $4/hr seeing patients. Today, he’s noticeably better dressed than his compadres - in pinstripe slacks, button-up shirt and shiny shoes. He works shifts at an exclusive private clinic to boost his gynecology salary. Rajabu is able to add an additional $400 to his monthly income, for a net of $1000. I imagine with the additional car expense, larger apartment, and finer luxuries, he likely saves $500 per month. He also provides money to his extended family.

Paulin, a 32 year old man, has bright eyes, a permanent grin and a wonderfully gregarious nature that makes him seem much larger than his short stature. I’m sure most of you are lucky enough to have someone like Paulin in your social circles back home. He’s the one with the right mix of enthusiasm, confidence, self-deprecation, an underdog's hopeful optimism, and a resigning smile. They're the friends we always seem to poke fun at, because we know they'll laugh, too. And somehow in the end, we'll all feel better about ourselves. When I walk with Paulin, he seems to shake hands with half the town.

Paulin is in his second year of anesthesiology training at the Central Kigali University Hospital (CHUK). He and his wife are mid-pregnancy with their first child. Hopefully, Paulin will soak up the bulk of what I have to teach in Rwanda.

Over lunch with Paulin and Laurent, I asked them some pointed questions.

To be continued….

Antwerp and Friends

I’m in Antwerp Belgium for a bit of a layover prior to leaving for Kigali. After traveling for 10 hours, it was terrific to see a friendly face waiting for me at the airport in Brussels. Who else, but an old friend from Missouri – Jeri Weber-Meckel.

Jeri and I grew up just 2 houses away from each other in the burbs of St. Louis and were reacquainted a year ago at our 20th high school reunion – ‘Go, Parkway North!’

I’ve had the pleasure of staying with Jeri and her family in Antwerp, where she lives with her husband, Hannis, and their 2 lovely daughters Hannah (8yr) and Lillie (4yr). The girls already speak English, German and Flemish (Dutch) with equal fluency, and are doing their part to keep Barbie-doll phenomenon alive and well.

Last night we feasted on steamed mussels - a Belgium National Dish, prepared by Jeri, in a soup of olive oil, wine, butter, onions, garlic and herbs. Unbelievable! We drank wine and discussed topics ranging from Global Warming, chronic pain, getting enough attention as children (yes, we did), living abroad, and the prospect teaching medicine in Rwanda.

Today, Jeri, Hannah, Lily and I rode bikes into the center of Antwerp. The network of urban bike lanes and the amount of bicyclists really puts our US cities to shame. We’ve got a long way to go, but I’m seeing progress all the time. In the end, it will be consumer demand that drives the change in urban planning - so get out their on your bikes and start commuting!

I just returned from a Jewish Seder event at the home of friends of Jeri and Hannis. I learned the story of the Passover, and dined on homemade traditional Israeli food. They we very welcoming and made sure to include me in the songs and readings. A crew of kids kept the event lively and forced the conductor to keep the ceremony moving along.

Jeri and Hannis were terrific hosts, and I truly enjoyed hanging out with them. The girls even admitted that it wouldn’t be too much of an imposition if I wanted to visit again. Tomorrow morning, the Weber-Meckel family leaves for France, and I depart for Kigali!

A hearty 'Thanks!'

While it’s fresh in my mind, I have to send a hearty ‘Thanks!’ out to my sponsors of this trip – which will all be discussed specifically in later posts, and include – B.Braun, SonoSite, Civco, the American Society of Anesthesiology, John Muir Medical Center and Sequoia Surgery Center.

A recently added sponsor has been Civco. They produce products for the ultrasound imaging industry and are headquartered in Iowa – which is quite fitting, since it’s merely a few miles from where I’ll be studying chronic pain at the University of Iowa beginning this July.

SonoSite, whom I’ve been working with for several months through their rep extraordinaire, Kim Roberts, very generously loaned me a portable ultrasound machine to take with me to Rwanda. Ultrasound uses sound waves (at frequencies above the human ear’s capacity to hear), which penetrate the skin, bounce off deeper tissues and give a picture of what structures lie beneath. It’s much the same way a navy submarine uses Sonar to map the oceans depths. Most of you who are blessed with children are familiar with ultrasound in the obstetric setting.

The use of ultrasound in the field of regional anesthesia (including nerve blocks) is currently witnessing an explosion of interest and research. Ultrasound imaging enables the clinician to accurately locate nerves. Once located, these nerves can be targets for specific therapies, including the blockade of pain transmission with local anesthetics.

Although ultrasound technology is currently quite expensive and perhaps beyond the financial reach of Rwandan hospitals and physicians, my hopes are to use the educational power of real-time imaging to illustrate the anatomy of nerve location. Once the anesthesiologists have a feel and confidence for locating nerves, they can work without the ultrasound machine, using cheaper, existing technologies.

SonoSite expressed shipped the ultrasound system to my door a week before departure – perfect! Sherry Guthrie, a fantastic ultrasound technician who works for SonoSite to educate medical professionals, visited with me at the Sequoia Surgery Center early in the week. In the same way the character ‘Q’ educated James Bond with each new gadget, Sherry showed me the important functions of the SonoSite MicoMaxx system. Unlike James Bond, I didn't get a Aston-Martin coupe and there was no ‘red’ button to operate an emergency ejection seat.

After getting to know the system at work on real patients, I soon realized that I didn’t have any of the necessary sterile packs and ultrasound transmission goop (gel) to accompany the system in Rwanda. Enter Civco…

On Wednesday, just 3 days before my departure, I sent a brief ‘Help Me!’ plea to the company’s central email contact address. Within 12 hours, I had a phone call from Amy King at Civco, asking me what I needed. By Friday afternoon, a massive package from Civco arrived on my doorstep in Berkeley. Inside, I found a care package that would have made any mother proud – bottles of ultrasound goop, sterile barriers, a huge bag of Civco promotional writing pens (which the Rwandan staff will love), and some company literature illustrating their products - all for absolutely no charge! Go Civco!

PS.

How could I possibly forget Lisa Craig from B-Braun! Lisa has been a tremendous supporter of medical outreach trips, supplying the ever-important nerve-blocking needles and electrical stimulators. She first assisted me when I visited Ghana back in 2003. I guess when one make everything so easy, like Lisa always seems to do, you run the risk of slipping past recognition!

Rwanda Coming Soon....

Hey Everyone,

this Saturday (March 31) I leave for Rwanda! I'm going to be teaching anesthesia techniques to local residents and nurses for the month of April. This is part of a joint program with the American and Canadian Societies of Anesthesiology. I became involved in this program at the suggestion of a former professor at Stanford, Alice Edler.

For several years, Alice has been taking Stanford anesthesia residents to countries such as Tanzania and Ghana to help in teaching local physicians under sponsorship of the American Society of Anesthesiology's (ASA) Overseas Teaching Program (OTP).

I'll be teaching various techniques in pain management - both acute and chronic. Acute pain is a phenomena all of us have experienced in our lives, and typically follows tissue injury - which includes post-surgical, trauma or an acute disease process. Typical medications for the mitigation of acute pain runs the gamut from drugs as simple as ibuprofen and tylenol to more potent opioids such as morphine and demerol. In addition, local anesthetics such as lidocaine, and it's longer-lasting cousin, bupivicaine, can be quite handy when used to block pain transmission signals along nerves. Nerves can be "blocked" with local anesthetic meds at any point from their origination in the spinal cord all the way to the distal extremities.

The application of local anesthetics typically involves the use of needles to deliver the drug to its site of action. Nerves lie beneath the skin (both shallow and deep) and therefore are hidden from view. Finding them requires a knowledge of human anatomy and specialized instruments. Stay tuned, cause we'll be discussing these instruments later.

Pain becomes chronic when it lasts 3 months of longer, and may or may not involve ongoing tissue damage. Chronic pain is typically much harder to effectively treat than acute pain, and unfortunately, in large section of patients, may never be cured completely. Sometimes the best we, as physicians, can hope to do, is reduce someone's pain enough to restore some degree of function. Improving function can mean being able to take a walk with a spouse, hold a child in your arms, return to work or simply being able to sit in a chair. It is the field of chronic pain the I'll be studying during a fellowship year beginning July '07, at the University of Iowa.

For many of us, the name "Rwanda" conjures images from the Genocide brought to our attention recently in the film "Hotel Rwanda". In the spring of 1994, during a period of only 100 days, nearly a million people (roughly 1 in 10 citizens) were slaughtered along mostly ethnic divisions. The genocide came to an end when the rebel movement, composed of mostly ethnic Tutsi and led by current Rwandan president, Paul Kagame, seized control of the capital city of Kigali.

When telling friends and family of my plans to teach there, several have asked, "is it safe there?" From what I've read, and messages from other docs in the field, the answer is a unanimous, "yes!" It seems as if the people of Rwanda are struggling to simultaneously remember the past, yet move forward as a unified country.

Coffee has once again become an important export crop for the country's growing economy. The tourism industry, know for it's national parks and endangered mountain gorillas, is also on the rise.

A recent surprise discovery to me, is that Rwanda apparently has quite a bicycling community. In fact, local bike component manufacturer, Ritchie has adopted Rwanda for a very enthusiastic outreach program with the appropriate title, "Project Rwanda." The picture here was borrowed from the Ritchie website, showing a young Rwandan lad on his wooden bicycle. Check out more of these great pics here.

This recent news has prompted me to bring along my Surly/Xtracycle made famous right here in the "Chronicles of Mania" report on the Costa Rican Bike Adventure. I think the bike will be a perfect means to transport myself around town and mix it up with the local peeps.

Bike tour in Costa Rica

From the comfort of my home in Berkeley, bike touring in Costa Rica seemed like a great idea. Pack up a bicycle, bring a few a clothes, some sunscreen and a rolling adventure awaits. As usual, the adventure doesn't follow the script, and you sort it out when it's all done. Here we go....


Prologue

I had 2 weeks in a row of scheduled vacation time at the beginning of March, and had already made plans to meet some buddies in Sun Valley for week of back-country skiing. This left the second week open, which I had tenatively planned to spend working on my attic rennovation. When my pal JJ (aka Julian, Jerome, Jay) Grove called to tell me that he had the very same week available, and that he was in dire need of a good vacation from his busy Pain Managmenet practice in Baton Rouge, Louisiana. I couldn't resist the temptation to travel.


He suggested a trip thru the adventure travel company, BackRoads, which specializes in active travel for folks with more cash than time. I'd never taken a trip with BackRoads, but I resisted the idea of having someone else in charge of my own adventure. Having another person plan the whole outing down to the last details, just seemed a bit too scripted for my tastes.

"How about us doing our OWN BackRoads trip?" I suggested. "We bring our own bikes, carry our stuff in panniers, and cruise a route of our own choosing."

JJ was all over it, despite the fact that he later admitted to not knowing what a 'pannier' was. "Just follow my directions," I promised, "and it will be all good."




Day 1-2:

Arrived in Liberia, Costa Rica to meet JJ . After crashing at a local hotel, we awoke to a sunny day and started assembling our bikes. JJ, who openly admitted to not knowing the first thing about putting a bike together, was an enthusiastic assistant. Together, we pieced together my Surly/Xtracycle and JJ's new Gary Fisher mountain bike. JJ decided to give a go at clipless pedals. Those of you who have mastered the use of clipless pedals know where this is going. After a quick breakfast, we loaded up the rigs and headed into the heat of a midday Guanacaste sun.



Afer a few easy miles on good roads followed by a satisfying lunch at a roadside bar, we took a turn south down a gravel road known by the name of "The Monkey Trail." This road could be described by several choice adjectives which include 'rolling, gravely, washboardy, dusty, hot, undulating, and sucker summit.'

Despite of the adverse road conditions, and JJ's occasioanal tumbles into the gravel when he forgot to unclip from his pedals, we remained in good spirits and gradually pressed onward. We finally rolled into the little seaside pueblo of Potrero, covered in a thick layer of Costa Rican dust just in time to catch the sunset over the bay.


Day 3: Potrero to Tamarindo
God bless tail winds.


Day 4: Chilling in Tamarindo
I'm sure at one time Tamarindo was a beautiful, sleepy beach town full of Costa Ricans and the rare Gringo surfer. Today, however, it has become a veritable boom town with all the undesireable effects that happen when Floridians and Southern Californians discover cheap, beachside real estate in a country in which the almighty US dollar goes a long way towards retirement bliss. Most of the local Costa Ricans (ie. Ticos) have since moved inland in search of cheaper housing and make the daily commute to jobs either serving Gringos or building new condos. The animosity is quite palpable.

While JJ kicked it poolside, soaking up the intense tropical sun (coco butter qualifies as sunscreen, doesn't it?), I made a early morning run to the surf with 3 blokes from a local surf shop. The waves were quite good Playa Negra, if only chest high, and we had relatively uncrowded conditions for at least an hour.

Day 5: Tamarindo to Nosara (The Good, the Bad and the Ugly)

The Good: This was my first experience of true bike touring - and by 'true' I mean a completely self-supported ride in which you carry everything you need on the bike. Any additional necessities, such as meals and sleeping accomodations, you just pick up along the way. I discovered that this is a fabulous way to explore a new land! The combination of the pace, the quiet, and the meditative repetition of the turning cranks makes for a very soulful experience. When locals catch you riding by their homes or places of work, they just can't keep themselves from smiling and waving hello.

The Bad:
Costa Rican roads leave much to be desired. All but a few are paved, and despite their small size and rough conditions, many of the secondary roads see significant traffic - including commercial trucking. The hot, dry, dusty roads, combined with a strong cross wind and hurtling trucks creates a terrible dust bowl. The preferred riding technique - one hand on the handlebars, the other holding a hand towel over the nose and mouth. I was wishing I had the foresight to pick up some industrial strength particle masks prior to leaving Berkeley.

The Ugly: There's nothing worse for a healthy sunburn than a fresh case of road rash. After 4+ hours of riding on gravel roads, we had just about reached the ocean for the first time since our 6am departure from Tamarindo. I had just finished descending a long stretch of road and could hear the surf breaking and feel the cool ocean breeze near the town of Logarto. JJ, just a few minutes back, had just begun his descent, when the back end of his top-heavy bike got into some loose gravel and he went down in a cloud of dust. When JJ wheeled up and casually mentioned the fall, my eyes quickly spotted the blood soaking through his surface layer of sweat-caked dirt. We borrowed a local's garden hose and went to work cleaning the dirt from his wounds. JJ spewed a few choice words while I worked the water, and the locals smiled through sympathetic winces.

An hour later, short on water, and feeling the need to get some food, pronto, we hitched a ride in the back of a truck which delivered us just a few miles from the town of Ostional. On the verge of a serious bonk, we plunged into the first open cafe, and JJ promptly ordered 4 fried eggs and 2 orders of toast (wasn't this a scene from The Blues Brothers?). An hour later, rehydrated and fed, we rode the final 10 miles into the town of Nosara, and our final destination. The biking portion of our trip was over!

We spent the next 2 days in Nosara relaxing. Through Steve Ternlund, a friend and colleague in the Bay Area, JJ and I came to meet Heidi and Rick from Nosara Travel. Their shop was our first stop in town, and they immediately diagnosed our exhaustion. Like a loving mother, Heidi took care of us on the spot by booking a hotel for the two nights, arranging dinner plans and directing us to some cool activities (eg. zip lines over the rain forest). We really enjoyed meeting these 2 expats, and hope that our paths will cross soon. Thanks for the morning surf outing, Rick. And for Heidi - Long live the public library!

Check out our short movie!

Lessons Learned:
1. Bike touring kicks ass (and it surely kicked ours). I will definitely plan more trips like this one. But perhaps I'll check the road conditions first.
2. Whatever anyone tells you, do not choose a bike tour as your first outing with clipless pedals.
3. Coco butter has no sunblocking properties.
4. Easier (ie. BackRoads) ain't necessarily better.