Tuesday 20th September

Sunday morning was spent at the genocide memorial museum and each visit there provokes a new thought, the story of a young man who had only fellow students to invite to his wedding as he was the sole survivor  from parents , siblings, aunts , uncles ,cousins neighbours and childhood friends, was chilling.

Sunday pm Emmanuelle drove us 2.5 hrs to Sorwathe (society of Rwandese and the commercialisation of tea) tea plantation guest house. A tea processing factory set up by an American for the local tea growers to process their leaves near to their fields. A fair trade co-operative. The last 18km of our journey took an hour along unmade roads through a sea of tea plantations; it is a spectacular and peaceful place on earth but very bumpy to get too.

The plantation manager drove us the 5 km to the hospital on Monday, it is a 4 year old state of the art hospital with few patients and even fewer staff. Rwanda is short of doctors, Gilbert the 27 year old medical director told us there were no doctors left after the 1994 genocide and the country now has 80 doctors graduate per year , they hope one day the hospital will be fully staffed and utilised. The old joke about doctors and policeman looking younger is a reality here and mentorship for the medical teams here is vital, one cannot book learn experience.

We undertook a very productive ward round with the new consultant (old at 29 - See pictures below) and he was very receptive to ideas of palliative care needs, not ordering  investigations that will not affect management, looking at patients holistically and keeping an open mind , he confessed to finding it very difficult to tell people there is nothing more he can do – he is right. He does not have the advantage of team support as we do at MSH.

Today we have a full day teaching the home based care workers who are coming to the end of their 4 month theoretical training, which is followed by 2 months of practical work, so in true style last evening was spent busily preparing slides whilst swatting mosquitos!! The first half of the day has gone well though and we have found some wifi access which is pretty limited here so who knows when the next instalment will come!

quick update as unsure of future wi fi availablity

A quick post as we have been unable to establish if there is wi fi in Kinhira and have yet to purchase a dongle. we will travel there this afternoon , we think about 2 hours away by car. this morning we are going to visit the genocide memorial as Jane has not been there before. Yesterday Jean Claude and our hotel porter spontaneously told us of their personal harrowing experiences of the 1994 genocide but I think not for this blog

we had a typical African lunch with Jean Claude , our first experience of peanut soup , more of a source to accompany our 'irish potato' but very tasty

The extremely positive news was that NSAIDs ( ibuprofen , diclofenac etc) have now been trialled by doctors here for more than the previous limited 5 days allowed and this has all gone well and is being rolled out.  Some may recall reading in the original blog that it was conversations with Christian at Chapel St dining room table that alerted us to the restricted use of ibuprofen , which then  led to the meeting of Christian and Julie to discuss the safety evidence for NSAIDs and now patients in Rwanda have use of another effective analgesia / anti inflammatory on the same availability basis as in the UK!! Also having had heated debates with both Christian and Jean Claude regarding the restriction of the contraceptive pill to 1 months supply, he said with a smile yesterday , I suppose you want to know what has happened about contraception ?? the answer was that they heavily promote injections or implants as long acting agents but if ladies still prefer tablets they receive ........3 months , excellent  news ( especially if it requires a long walk each month to the health centre to collect).

we were so excited to hear all this progress from a very proud Jean Claude and we obliged by taking the beers in 2s as he says a beer order is always for 2 not 1 bottle !!

A hot afternoon spent at a local colourful market see the pics.

September 16th 2016 (A little Late)

 

Our last day in Bjumba was spent debriefing the team, key points discussed included

1) Lack of time dedicated to palliative care due to all of the teams other duties.

2) Other clinical teams being unaware of palliative care input

3) Lack of recording current activity and ensuring that the MDT discusses current patients

4) Further Training needs and ongoing support

We were able to make a list of suggestions to take to the medical director (le Dieu) and agreement was made over the following

1) Being excused from the 7am daily whole staff meeting once or twice a week to hold their own palliative care meeting.

2) Use of a palliative care team stamp to highlight PC involvement.

3) Acknowledgment by Le Dieu that the time needed to do an appropriate PC consultation was much longer than a standard consultation.

More contentious issues included

1) Ongoing CPD and further training as he believes this is a central issue to sort which is a shame as the team is so keen to develop the practical implementation of their skills further. Le Dieu is on board and uses the successful HIV management programme as a template for how Palliative care will develop over time. Perhaps we are slightly more impatient for this to happen.

Other successes of the week include:

1) Grace has made it home and the four other patients we were particularly involved with have a plan of action and are now much more comfortable.

2) The palliative care team very quickly noticed and then followed our holistic style of palliative care management including compassion, gentleness, affection, touch etc.

IN other news, conversation at last nights suppers was difficult due to exhaustion and a monsoon like downpour - very noisey (we have video footage), it is dry this morning but there is more rain forecast. We are awaiting the arrival of Jean Claude who is taking us out for a typical African lunch - whatever this may be!

VIctoria and Jane managed a swim in the rather cloudy outdoor pool, hope they don't live to regret it (unusually they kept their mouths closed!).

September 15th 2016

       

Another productive day in Bjumba reviewing old patients and meeting new ones – The first lady who we mentioned on Tuesday was sitting up and smiling when we arrived, she is doing really well on morphine and wants to go home to be with her family, we are hoping this can be arranged for today to allow her some quality time with her loved ones. We couldn’t say goodbye without a group photo though.

We then went and saw a lady with a colostomy and awful wounds, we tried to advise as best we could, thankfully this lady had a small supply of colostomy bags (you can see Victoria washing one out in the picture) as they are not stocked at the hospital so when they are used up and cannot be washed anymore the nurses will have to fashion one out of either medical gloves or a plastic bag and tape – interestingly medical gloves are also used as conveens here! Another interesting blue peter creation was the fashioning of an incontinence pad out of gauze, cotton wool and cotton wool!

We paid another visit to the pharmacy today and we found a register of sorts, which allowed us to map the amount of morphine used over the last year – its not much but it’s a start and actually what is positive here is that it doesn’t appear that the team are fearful of using morphine, more that they lack the experience of when they should use it – hopefully we have helped with this during the week, we have already doubled their use since we’ve been here.

This afternoon we have reviewed 7 randomly selected palliative care notes, which was really interesting if not a little confusing at times – especially when they switch from English to French! – but again the outcomes from this will be positive and will hopefully aid the team in the future.

Finally, Victoria took one for the team and volunteered to go on a home visit with Anastasie, the social worker who has diligently looked after us whilst we’ve been here – I am therefore typing this in her absence – (she already told me she will edit later) – have to say though we're all feeling a bit guilty especially as after such a lovely warm day it is now the weather has changed and its looking decidedly stormy!

Tomorrow is our last day in Bjumba,  it has been an eye opener and an experience, it really does make you realise just how lucky we are to have the resources available to us that we do, and not to have to think that a patient may not survive just because they can’t afford the treatment they need.

I am back from visit and no need to edit !! washing out colostomy bag exhausted all my bon homie and ways of saying , 'its fine its no different from a babys nappy' (I lied of course) but the nurses here are not very hands on so one likes to be encouraging ! got caught in rain on walk back from visit but we about to order  for our meal which may arrive in under 2 hours but unlikely so all good !!

An early start today for the team meeting (handover) which begins at 7am - we then met with the medical director (his middle name is le dieu and he likes to be treated like God), progress was made and we then began our work for the day.

Our first patient, was a young paraplegic man with a pressure sore who had been an inpatient here for the last 6 months as a result. We were able to advise on holistic palliative care needs from postural hypotension to wound care (although not easy when all that is available is gauze and saline!) Victoria made use of her acting skills (fainting, dizziness etc) - although she promises not to give up the day job!

We then saw a patient with  an inexplicable external bowel protrusion who was clearly very poorly. We were able to make her more comfortable and formulate a rational end of life plan - it was very sad to witness although the hands free tap was an experience! (foot pedal operated)

Our pharmacy visit was also an eye opener, patients looking through the bars in the picture above are collecting medication not prison visiting (although we have are many inpatient prisoners handcuffed to beds here). Lots of information was collected to enable us to create a flow chart of the morphine trail - something we were asked to do pre visit by the Rwandan Biomedical Centre. Julie was a little concerned by the lack of record keeping although she thinks the nurses at the hospice would love it!! (not a chance it happening though!!!!)

We then went on a general medical ward round highlighting that  pain is not the only  palliative care need. The Dr in charge of the department has only been qualified 5 years so there was much knowledge and practical advice offered.

We,re back at the hotel now and its raining, and a little cool not that we,re jealous of the sun back home - we also are enduring another power cut! We,re hoping dinner comes more quickly than the 2.5hrs it took last night although with said power cut one has no idea.

Thought we best post a pic of our wonderful translator Daniel posing with the nearest we will get to wild animals this visit.

september 13th

We have been joined by the wonderful Daniel a Manchester uni final year med student who is doing medicine with French and an invaluable translator although we are pitching in !
A very long day with definite successes. This morning we were introduced to a lady not opening her eyes and distressed with pain, after discussions with her team, we made a plan to address the pain, we followed the patient journey throughout the day advising on the prescribing, dispensing and practical administration (crushing tablets) of morphine together with frequent review. The outcome was the photo that you see above plus drs witnessing affectionate care and nurses learning new techniques.
Following on from this we have also developed a 5 point plan of action for the next three days (a bit ambitious?).

On a lighter note before leaving Kigali yesterday we met with Jean Claude (pharmacist overseeing morphine production for Rwanda) as there had been some issues with the last batch of liquid morphine due to the preservative used. However we were told we couldn't call it a preservative in Rwanda as this actually means condoms! We were told we should use the term conservative - jean claude  said Rwanda is having problems with the conservatives and we joked so is the UK!! (Ha Ha).

7am start again tomorrow for a hospital meeting - such fun!

September 12th 2016

Hello from Rwanda, Victoria, Julie and our new friend Jane who is a nurse educator from Oxford with lots of African palliative care experience. You can see our smiley but tired faces after a 2 hour self "guided" walking tour around Kigali (with no map)!

We had an interesting lunch with Dr Christian, we met Liam who is now walking and talking - he is adorable as you can see in the picture. A particular useful take home message for us was putting practice into context, e.g. it may be difficult for a health care worker here to empathise with a patient who has cancer if they themselves have lost their entire family in the genocide whether they be victims or perpetrators. equally a patients pain or symptoms can often be worse during the anniversary period of the genocide (April to June) and should be considered in the holistic approach. And whilst in the UK we do not  have this context every patient will have their own contextual situation.

As the Vicar of Dibley had several Christmas meals we then went on to have dinner with Diane (Palliative Care Co-ordinator for Rwanda) where a fascinating evening of discussion took place. There were many take home points but the one we found most significant was that an organisations sustainability is improved if the infrastructure of workforce, finance and planning is embedded within it rather than reliant upon one individual or dominant personalities.

An unusual aspect to our evening was a city wide power cut, but this did not stop the evenings fun allowing us to play Jenga in the dark with Diane's lovely children (Again see pictures).

we finally arrived back at the hotel at Midnight (Cinderella style) with brain overload - it has been a really useful day though with lots to think about.

Today we are hoping to meet with our friends from the training last year - JC And Dr Vincent to carry on our discussions before we are "Driven" to Bjumba to start the mentoring aspect of our journey.