Saturday

This morning we were taken to the new health centre where the Rwanda Palliative Care Hospice organisation team had come on their day off to show us their new building.

Peace (nurse) and Emmanuel (Driver) who Victoria had met last time are still there and still funded by an American Charity, they are supported by a team of volunteers, Theodosie (manager), Magnus (Psychologist) and 2 Doctors (Olive and Vincent – Who we met at the training) who take it in turns to be on-call – this week it is Vincent. This makes up the entire palliative care home team for Rwanda!

Our first visit was to a 38 year old man with metastatic osteosarcoma, he has responded well to morphine for his cough, and his phantom limb pain is being helped by amitriptyline. His biggest problem was an aphthous ulcer post chemo and we were able to advise a treatment strategy for this, we also advised on his morphine dosage as it was a little strange. (See pic)

Our second visit was to a 42 year old man with end stage brain tumour, with significant symptoms caused by raised brain pressure, we were able to suggest the use of dexamethasone and demonstrate ease of administration by dissolving it in a small amount of water, as well as adding in paracetamol to his morphine for headache.

We are now back in the hotel and for the first time this week we have treated ourselves to dessert as we felt we had earned it, again no pic, it didn’t last long enough! We are spending the afternoon in the café writing our report before flying home tonight!

Friday 15.5.15 - which Dr Vincent says means you have to have 5 beers!
Our final teaching morning went well with a very lively morphine quiz and only minor injuries  received as a result of our throwing of sweets as prizes! We were sent off with a Rwandan round of applause and progress has been made
Our journey to Kigali was equal to the white knuckle ride on the way out and we stopped to buy bananas but not the live chickens also on offer. Kigali has that capital city feel , hot and chaotic and apparently all the local African leaders are in town to discuss Burundi so we are in high company.
We are off out for a curry with JC and his wife tonight, so just your typical Friday night in Dudley really!
Home visits planned for tomorrow and then off to the airport to come home! Although were not really looking forward to our night flight and 6 hour stopover in Brussels airport!
Will see you all soon
Victoria & Julie x

Thursday

We are past the halfway mark and our new group arrived this morning (eventually). The numbers are slightly down at 24 but we are not complaining as we have changed rooms and its a lot smaller! (read stuffy and hot!)

 The plus side however is that this is a much more engaged group who are eager to learn and not in the least bit feisty, there is also no Mr Grumpy! It has been a long day as they are trying to fit the three day programme into two days as many of the trainers are otherwise engaged on the Saturday - us included as we are on home visits with Dr Vincent.

We did have some thunderstorms and heavy rain today but we managed to dodge these on our way to lunch, we are clearly becoming regulars with everyone knowing our drinks order and the hotel knows our room numbers better than Victoria does!

As we said, todays group is 100 times better and the teaching has gone much more smoothly with less overlap than it did when we did it on Monday, they are very impressed by our conversion chart which Victoria just so happened to have in her bag! We even got a role play in which was interesting especially when he said you will continue living till you die!

Tomorrow we have to pack as after the training we head back to Kigali, and Chez Lando ready for our home visits on Saturday which we are looking forward to. We are both very tired, this training lark is exhausting but we have a free evening so hopefully we can get some R&R.

 

 

 

Wednesday

 

Wednesday

 

A funny old day started with feeling the after effects of last nights beer and kebabs in a  local restaurant with our lovely hosts JC and Dr Egide. we exchanged family photos , discussed everything from football to the situation in Burundi which sadly we have seen the escalation of today with the attempted coup which seems to have affected everybody here.

 

This mornings closing session became very lively with intense discussion around breakthrough and regular dosages stimulated by our quiz! We feel that by the end we have made great progress even with Mr Grumpy! Several stayed around for a post course photo, those who didn't missed out on chocolate so their loss really!

 

The cash situation has been successfully resolved although our dollar exchange took place in an unmarked, unfurnished shack with the money appearing from under the counter!

We used our dollars to see Musanze caves, volcanic dug outs, dark, wet, precarious and leading to a bat colony (Victorias worst nightmare) we were escorted by armed soldiers (to scare off the wild dogs apparently) - if we had known this beforehand we'd have seen the gorillas!

 

As if that wasn't enough we have just had an hour counselling the course organiser on his future career path! Julie has also been asked if she will stay in Rwanda, she told them she is on strict instructions to return to the hospice!

 

Tomorrow we do it all again to a new set of 40 delegates!

 

Victoria & Julie

Tuesday 12^th day 2

 We are now not just the only European women in our hotel but also the only non-uniformed persons as the Peace Academy is in this town and appears to train forces for all neighbouring military and clearly camouflage uniform is compulsory dining room attire!

Fear not though, 47 participants reappeared for day 2, even Mr Grumpy! We excelled ourselves today with our props and acting skills. Sponges soaking up the water of pain ( bucket borrowed from inside of hotel bathroom bin ) , Julie’s coffee game had everyone up on their feet and as Victoria ran from the room to the loo to suggest diarrhoea side effect of opioid withdrawal there were concerned faces all round !

There have already been flashes of success, question from the floor ‘ I have a patient with melanoma I would like to prescribe morphine , what about the cost? ‘;  A good discussion around the use of ibuprofen for chronic and not just acute pain as current government policy is 5 day maximum prescribing and very good answers to the case discussion group work. They presented figures of current morphine prescribing and it is almost entirely restricted to 3 places one being the military hospital , there is much still to do.

This is a truly beautiful area as we nestle under the volcanoes . We have lunched at the hotel where Diane Fosse would stay when she came down from the gorilla camp , as you see a stone gorilla is the nearest we will get to one !!

We have had another intense long day and had  hoped for a quiet evening but Jean Claude and Dr E are returning to our hotel to take us out for African beers ?? (beer?) hence us blogging now we may be in no state later!

Julie & VIctoria

Monday,

It has been an interesting day; we were warned at the start that due to changes in the financial reimbursement of delegates there might be some annoyance shall we say and there certainly was!

 It wasn’t helped as the circumcision conference had indeed displaced us to the conference room at the seventh day Adventist church headquarters and there were no coffee or lunch facilities on site !!

The Rwandan pharmacists are a feisty bunch we can tell you (not like your friendly Julie Pharmacy)! but  by the start of the presentations everyone had just about adjusted  so we were performing to a packed crowd of 50 (a sell-out you might say)!!

Unfortunately it is clear the Rwandan pharmacists have succumbed to many of the myths regarding opioids. We have had it all today, addiction, diversion, killing people, at one point we were asked why we are promoting morphine but we have held our own we think even if many nearly fell off their seats when we talked about the patient we had on 1800mg BD. (I think they thought we had got our numbers confused due to the language so we had to write it down on the flip chart), there is one guy though who is not for turning , and argued with Julie about receptors  (he lost) and we will try our powers of persuasion with him again tomorrow.

Our concerns about the language barrier have not been as bad as we expected, there have been a few issues, thankfully we have had others with us to translate!  Football clearly is a universal language as our red card system, when addressing myths was understood immediately , and very well received,there are the usual large number of Man U fans !

We have still not resolved the money crisis and this evening we were locked in a bank cupboard  while two bank staff dismantled the ATM, we were so tired we saw the funny side and were liberated in time for our wild evening of 2 fanta lemonades, they always ask us if we want them cold , why  would we want them warm ????

8 am start again tomorrow which means we will be there for 745 and they may get started for 9!!

Sunday

Posted a day late as in spite of the wi fi password being “best hotel” (no exotic or marigold) the wi fi connections do not live up to the password!!

Today we had an escorted visit with Jean Claude (MPPD Chief Pharmacist) to the genocide memorial, words cannot convey the sentiment of this place, and we were left felling that it was a totally manufactured ethnic conflict bought about by the studies of European anthropologists, JC was very keen to point out that it wasn’t a surprise event but had been pre-planned with the help of the media and government propaganda whipping up hatred within different groups for many months before (thank goodness last week we didn’t give Farage a mandate to continue blaming immigrants for all UK ills). We also felt ashamed by the lack of help from the outside world; apparently as few as 5000 troops would have stopped it!

We then had a hair-raising journey through stunning countryside as we distracted our very excited driver (JC) with talk of Morphine, NSAIDs, Contraception and Vasectomies. (note pic 3) where we are nervously clinging on to each other !) We had some great discussions that would have been best undertaken with our eyes closed as they seem undecided on which side of the road to drive!   The scenary was spectacular however and we would  have missed seeing  the cyclist being chauffeured up the hill on the back of a lorry - see pic.  As darkness set in armed  police appeared on the roadsides and army vehicles patrol for fear of rebels returning across the borders who played significant parts in the genocide.

On arriving at the hotel the reception area was full of Rwandan Drs here for a conference on circumcisions which apparently trumps palliative care for the conference room! (pretty sure this is being sponsored!) They joked with us , “ ah morphine – our pharmacists never let us have it “ confirmation this course we are participating in is needed!! Hoping delegates and room appear tomorrow as the  coach our organisers had laid on for participants was apparently less than full, JC still seems optimistic.  We have , however  already shared many ideas with JC re clinical pharmacy and palliative care.

A thought for the day re pensions, life expectancy here risen to 62 years  retirement age 65!

Julie and Victoria