In my 18 years of urology I have seen, heard, smelt, felt, and dealt with quite a smorgasbord of humanity emanating from people’s bodies. Here in Rwanda is more of the same. However, here it is more raw, more real, more exposed. Many of the patients are from rural areas (over 80% of the population) with no running water (not sure about the numbers). Bathing often requires a trip to the river and the smells can be strong. At home, when a smell gets real intense, I just apply special smelling salts kept in the OR under my nose and the smell goes away. In the States we mask all of our unpleasantness, from anti-depressants, anti-deodorants to Facebook. Here, just breathe it all in and act like nothing happened. When in the operating room, you are already hot, sweaty, thirsty, and it already smells a bit, and then a raw smell hits you, it is more intense, like a shock to the system, and you just have to take a deep breathe, and face it head on and then move on, keep working. This is Rwanda and I have a job to do, I tell myself, life could be a lot worse, I have it pretty easy and have all my life.
In the USA, we call it the operating room. Throughout Africa, it is the Theater, a microcosm of a country that is a culture shock to the uninitiated, very satisfying and maddening all at the same time. Kind of like having a baby. A book could be written about this place.
Like Rwanda, the Theater is a work in progress that started in the late 90’s. The hospital I work at is CHUK (Centre Hospitalier Universitaire De Kigali), founded in 1924 and has served the country since as a major public hospital and referral center. Again, I return to the genocide, Year Zero. As I stated in a different post, the genocide of April-July 1994 destroyed the country and left it with nothing. There is a memorial on the hospital campus with a large list of victims who worked at the hospital including many doctors and nurses. The hospital functioned during the genocide and people were murdered here just as they were throughout the country.
The buildings are old and the theaters’s skeleton has not changed in generation now, there are Rwandan surgeons in all the major fields working in this referral center with 6 Theaters running at full capacity 5 days a week with emergencies and add ons during the weekend, just like at my home institution.
Like Rwanda as a whole, the Theatre has the basic equipment they need to do the job and like Rwanda as a whole, Everything is reused. Everything always seems like the opposite of the USA when I make a comparison. We dispose everything in the USA whether it is in the OR or in our lives. If we don’t like something, chuck it, get a newer one. Gotta have latest phone in the USA! Our companies make the battery die at home so you have to get a new one. A lot of the “disposable” items in the operating room in the USA could be reused saving a lot of $$, but our society is wrapped up so tight in its own ass that the idea of reusing some items is blasphemy. Here in Rwanda, even if an item is marked as single use only, it is reused. In the theater here, in urology, they have 3 or 4 wires, which are used in endoscopic procedures. Cost 129 dollars back home, single use then it is tossed. Here, that same wire sees is reused hundreds of times. It may look a little warped, but it still works if you know how to manipulate it a bit. Other disposable, single use items that are used again and again in urology are endoscopic blades, bovies, and electric loops. Items in the theatre are reused and seem to die, but then miraculously, a way is found to keep them going for a time, sometimes using tape even to hold it together. Imagine getting an operation with Rwandan duct tape holding your surgeon’s elik evacuator together! But it works just fine. It’s like a Hollywood movie where someone gets shot 10 times and dies, but manages to get back up.
What’s it really like? It’s hot, stuffy, not climate controlled. The lighting is not the best but adequate. In fact, Africa as a whole has a lot less lighting than we are used to and my eyes have adjusted, so I don’t need as much light as I did before. It’s not as sterilized here as back home. That being said, I was in some OR’s in NYC in the 1990’s which themselves were quite old and not the cleanest. The gowns here are not waterproof so you have put on an extra apron to protect your body but your arms are still vulnerable. I learned not to rest my forearms on the patient because it would get wet with blood easily. Sometimes the running water runs out so you have bend down to scrub your hands before surgery using a large water cooler that drains into a big bucket. It seemed like infection rates would run rampant because they are breaking half the rules we have in the States, but the reality is that their infection rates and no worse than ours. We probably have too many rules. I have been here a few months and none of our patients that we operated on have had a post op infection and a study was done here at CHUK hospital that proves that as well.
For an American muzungu like me, it’s a microcosm of the country. In the States, it’s all handed to me. amazon.com, drive everywhere, air-conditioning in the car, great lighting inside, customer service, whatever I want, it’s there. We live like kings! If I am not happy, then I can complain. Here it’s not quite like that. Complaining gets you nowhere. In the OR back home, it’s all handed to me. Literally, In the States, we have a scrub tech who puts your gown and gloves on you, counts and organizes the instruments, makes sure you have all what you need, and hands the instruments to you during surgery. They will replace bad instruments with good ones, give you what you need and help you out. It’s standard operating procedure It’s uncomfortable at first. Here, there is no scrub tech. You are your own scrub tech and have to do all that stuff yourself. Then when the case is done. you have to organize the instruments, get rid of the needles and count the lap pads to make sure you didn’t leave any in yourself. In the States we (the scrub tech that is) count everything at the beginning and end. Not here, just don’t be a complete dumbass and leave a clamp in the belly. you also have to clean up the patient and get rid of all the sheets that cover the patient. Last week, we had a 25 cm renal mass and we had a medical student scrub in and I had to explain to him how prepare the ties and sutures in case of sudden bleeding. He never did that before, but he did really well in the heat of the moment. Don’t worry about time though. You have plenty of time because turnover is very slow. This is the maddening part. There is no sense of urgency and case turnover is painfully slow, unless of course the big man is operating. If the boss is operating, the turnover is quick, like lightning.
I generally only operate when I am teaching and during most endoscopic cases. I teach the 4th year urology resident as well as the newly minted home grown urologist who will be a leader in urology in East Africa one day. I am sure of it. The cases I teach are oncology and endoscopic cases, like radical prostatectomy and laparoscopic nephrectomy. It’s extremely satisfying to teach and and operate. It can also be frustrating and nerve racking at the same time. The instruments are dull and the clamps come apart easily, so you have to go slowly or clamp will come apart and the bleeding starts. They always have the suture you want but not the needle size and curve. Sometimes you ask for a large suture and it is labeled as such, but when you look at it, it is thinner and weaker. So much for Indian sutures. They label them thick and make them thinner because it saves them money. I want to look like a pro every time, but life is not like that. You have to just work with it, Therefore, I have to go slowly, otherwise I could stick yourself. Just like driving in Rwanda itself, it is safer to not rush. Rushing leads to accidents and could even lead to death. It can be frustrating, but just don’t show it, as anger is not an acceptable behavior in society here. If you start yelling, I am told, that all you will get back are blank stares.
All the sutures and catheters here are made in India, and the quality is variable. The first time I put in a catheter I couldn’t get the balloon to work and I had 5 people watching me in the ER. It was quite a spectacle.
The surgeons here are excellent surgeons doing the best they can with the resources available. I am impressed with their knowledge, patience, and true empathy for their patients. They sacrifice their time to really help these patients and go the extra mile for these patients who are all so vulnerable and have nothing. We American doctors could learn from them. I know I have.
In the States, scissors are routinely sharpened and clamps that don’t clamp are replaced. If a clamp doesn’t work, the surgeon often goes ape-shit and the scrub tech makes sure never to hand the surgeon that bad instrument again. Here, there is no one to complain to and nothing is replaced and the scissors don’t cut, and the clamps work but are loose and come apart easily so you have to close them slowly to make sure they don’t come apart (then bleeding happens). That means you have to operate slowly. Cut with the scissors slowly. The sutures are sometimes dull, but if you rush and push it too hard, you can stick yourself. Take your time. Suture slowly. Surgeries take longer just like everything else in this country. Don’t drive too fast or you will get into an accident in less than a minute. It’s ok. nobody is in a rush. Being late is ok. Being really late is ok too. Being on time means you will probably have to wait.