Kibogora Week Three

6 April 2012

--see also http://teamrwanda2012.blogspot.com

On Saturday most of the group walked to Kumbya Retreat, a beautiful, quiet spot on Lake Kivu owned by the Free Methodist Church since 1944.  While most went in the morning, Micki and I decided to go after lunch. By that time a large thunderstorm had covered the area, rattling windows with powerful explosions of thunder that followed closely on the heals of brilliant flashes of lightening over the lake.  Storms here come up quickly in this rainy season, often with an accompanying light and sound show, but most last only a short time and roll quickly on over the next mountain.  Those who did go to Kumbya either walked back early and were soaked or sought shelter on the porch of the house there and waited it out. All seemed to have been glad they went.

Sunday was not a day of rest. Just as we were preparing to leave for church, my local cell rang with a call for help--a small preterm infant with respiratory distress had been found in its incubator  with cyanosis and a dangerously low heart rate. There are no heart monitors, so infants often are in extremis by the time anyone realizes there is a problem. Dr. Ngoy (our Congolese friend) had bagged the baby back to viability by the time we arrived, but the infant could not  be sustained without intubation and ongoing positive pressure ventilation.  I intubated him to give all of us time to consider our options--continue bagging for days with only a glimmer of hope of success or stop right then and accept the limitations of life where we were (this infant has a 98-99% survival in our NICU's in the States). The group of students (really doctors for all intents and purposes except for a piece of paper) quickly committed to setting up a schedule to bag the infant during the evening and night, with the nurses to carry on during the day.  The latter part of our plan proved to be the undoing of the baby's chances, as just as the first folks from our team arrived the baby was discovered to be without pulse, a nurse sitting beside the baby, her hand not on the Ambu bag--she was unaware of what had just happened. William Perez gives a moving account of that afternoon in the group blog, teamrwanda2012.blogspot.com.

Unfortunately, the death of that infant was not an exceptional event. Infants with respiratory distress are placed on a nasal oxygen cannula with no means of assessing oxygen levels in the delivered gas or in the babies blood.  Without heart rate monitors and with inadequately functioning saturation monitors, no ventilators and inadequate numbers of staff to watch the babies, unattended deaths are not uncommon. There have been at least four since our arrival.

 On Monday afternoon we attended a stat c/section for a mother with a bleeding placenta previa (a dangerously low lying placenta) at 29-30 weeks gestation. We intubated the infant in the delivery room and then extubated the infant and placed her on a cannula with oxygen in the "nicu".   She weighed 1300 grams (about 2 pounds 14 ounces).  She did reasonably well until Tuesday night when a power outage stopped her oxygen concentrator from working--we went down to find her blue but breathing, with a saturation below 50 (acceptable is greater than 88 in a baby her age). Her father was at bedside and used his cell phone light to help us assess her.  After 10-15 minutes the auxiliary generator came on and she recovered her color.  We said goodbye to her dad and left, praying that the power, which goes out almost daily here, would be sustained until her oxygen needs were gone.  Early the next morning she was found without pulse or any sign of life.  Another infant with a 95+% chance of survival in our country had succumbed to the lack of support here. Lack of artificial surfactant, no mechanical ventilato, no monitors, and an unpredictable power supply were obstacles she and this delivery system could not overcome.

Early in the week, Carl Albertson, the orthopedic surgeon and our group leader after Duane's departure, was asked to see a one year old whose hand had been severely cut by a machete wielded by an slightly older sibling. The injury will require several hours of restorative surgery by Carl and his team, and months of recovery and rehabilitation will follow.  The injury was preventable merely by keeping dangerous tools out of the hands of children.  As I write this, Carl and his team are laboring to return that boy's hand to usefulness-- a critical determinor of his eventual ability to earn a living in this agrarian culture.

Children here are often left unattended at very small ages, something we noted while walking through local villages.  While driving here from Kigali it was common to see three and four year old children walking right beside the road unattended by an adult as buses and cars drove by at 50 mph. Life's value here, to many, is discounted.  The costs of risks are often not clearly counted except in the retrospective agony of injury or death. This rather pervasive attitude appears to be part and parcel of the apathetic and fatalistic view of life that an animistic culture produces.

On Wednesday Micki and I, with an afternoon free of medical activities, decided to walk to Kumbya Retreat with the hope of some quiet rest by the lake. The road to Kumbya is a dirt and rock road (mud and rock with heavy rain) that descends steeply from Kibogora, winding through the countryside, an occasional village, across one field of coffee beans, and down to an inlet to Lake Kivu, where Kumbya sits on a small peninsula.  The walk is about 3 miles, or in Rwandan distance, one to two hours, depending on how fast one walks and how many pictures of the beautiful countryside you choose to take.  No walking trek in Rwanda is taken alone, for children follow everywhere, often shouting "mazuka" and asking for money.   Somber adults speak if spoken to, and smile if they see you smile, some saying "good morning", no matter the time of day.  Children here are now learning English as the new official language so they tend to know more English than the rural adults, but everyone seems to know some form of greeting in English and/ or French.

At the retreat we watched the local boats going to and fro across the lake. They are dugouts, hollowed tree trunks that natives use for travel and fishing. Some came within a few yards of our waterside perch, their occupants waving and speaking if we acknowledged their presence, and laughing if we took their picture.  We did not swim, though the water is quite inviting-- the thought of contracting schistosomiasis, a common pathogen in lake soil and water with serious consequences for the liver, dampened any enthusiasm we had.

After a peaceful hour at Kumbya it was 4 o'clock and we headed back in order to return before dark; traveling at night on foot on the rural roads is not recommended for expatriates-- for all manner of reasons.  We decided to take the local's short cut across a field to shorten the more laborious trip back up to Kibogora.  We did not know that path involved walking across a rapidly flowing, muddy stream on two flattened logs with nothing to hold onto. Micki hesitated a moment and calmly walked across. I didn't.  I stood paralyzed, knowing a muddy dunking would make travel back very uncomfortable and would almost certainly kill Carl's cellphone, which he had loaned us for the walk  (we had excellent cell coverage the whole time).  A Rwandan woman, quietly amused at my indecision, walked over, took my hand, and without a word led me across.  When I thanked her she smiled shyly and walked on, her good deed done and my ego only slightly dinged.  What she did for me--taking my hand and showing me the way with quiet confidence and humility--is a template for all believers.

Someone offered us a hand in our walk of faith, perhaps knowing we were having a difficult time taking that first critical step.  Our vertical relationship with our heavenly Father  and our human relationships both involve a hand reaching out in humility and a hand grasped in gratitude. St. Paul said that the greatest attribute in life is love (1st Corinthians 13). No other accomplishment can take the place of love; all of our best put efforts added together are a "clanging (worthless) cymbal" if we lack love.  Agape' love, unselfish, other-motivated, selfless love begins with the hand of Jesus reaching to us, and continues as we reach out and share Him and His love with others.

Everyone on this trip has been frustrated by inadequacies--sometimes by the facility, sometimes by the attitudes, sometimes by our own shortcomings, sometimes by the obstacles put before us here.  But, as Oswald Chambers said so eloquently in My Utmost for His Highest, God does not give us overcoming life, he gives us life as we overcome--the struggle is part of the process of maturation and without it we would not grow closer to Him or to each other.  Gratitude, Obedience, Dependence is the acronym of a whole and holy life--taking His hand, offering our hands to others, and letting Him be responsible for the results.  Kibogora--the hard working Rwandan and Congolese physicians, the staff who labor under unfavorable work circumstances, the patients who wait in stoic patience for their care, the limitations of the hospital's infrastructure, the very remoteness of its location--is a lesson in offering what is possible and letting God be in charge of the outcome.