Letter from the field: A Kigali Rotation Reflection

Over the past four weeks I have had the incredible opportunity to rotate at the Rwanda Military Hospital (RMH) in Kigali under the supervision of Dr. Ainhoa Costas-Chivarri. I went into the rotation to observe and learn—I knew that in the grand scheme of things I had little to offer, and that I was being given an opportunity, a privilege of learning about the Rwandan medical system.

My day consists of waking up and enjoying breakfast on the outside patio of my B&B. The walk to the hospital is only about 15 minutes up a dirt road accompanied by school children running after me and crying out “Muzungu!” I attend the morning staff meeting of all the surgical specialties, where we review the overnight updates. Afterward, we round with the attending on call. I then join one of the general surgeons for outpatient clinic, called “OPD” for out-patient department, or for operations, both elective and emergencies. I take call with the residents, and we see a variety of traumas including gunshot wounds, falls, and blunt trauma, as well as other general surgery emergencies.

It has been fascinating to see surgery performed in a completely different setting. First is OR availability – for this 400-bed hospital there are two ORs shared across general surgery, orthopedic surgery, plastic surgery, and neurosurgery; for comparison, Stanford has a bed capacity of about 610 beds and more than 50 ORs. Many nights we have a limited tray of instruments to perform major exploratory laparotomy cases. There is a constant push to maximize resources, from extending the use of vicryl sutures by performing innumerable instrument ties to tracking the number of referrals for core needle biopsies we make per week so as to not overload the system. At night, and even during the day, there is only one intern and one general surgery resident covering the entire hospital.

There are also more subtle differences. There is a high reliance on the physical exam for diagnosis, and a lower threshold for exploratory laparotomy without a definitive diagnosis given radiologic and diagnostic limitations. I was used to having an abundance of diagnostics at my disposal, but in Rwanda I must really trust my physical exam to guide my decision-making. In addition, there is a greater degree of family involvement in patient care, with family members providing valuable information on patient’s clinical status and participating in basic nursing tasks like dressing changes. Finally, trainees operated under a different level of accountability, and responsibilities can change depending on the time of day and attending availability.

But at the heart of it all, the passions of the surgeons are the same—to serve those who are hurting and assist those in need. I spoke about this extensively with Dr. John Paul Shumbusho, one of the general surgeons at RMH and a mentor throughout my rotation. He reflected that the reason he continues to work so hard is that he cannot sleep at night knowing that so many of his fellow Rwandans are suffering from problems that he could fix with a surgery lasting just a few hours. I spoke with Dr. Costas-Chivarri, who has spent the previous decade plus serving the people of Kigali. She stated that the reason that she remains in the country is due to the visible impact she is making through the development of one of the few breast cancer clinics and training programs in the country.

I deeply value this opportunity to leave my Stanford home and experience surgery in a completely new environment. While I found many differences between Stanford and RMH, I am more astonished by how much there is in common across the surgical discipline. Despite the language barrier, my surgical training held true, I can still accurately diagnose patients and determine the most appropriate management. In the operating room, my surgical techniques are refined and have to accommodate equipment limitations, but the surgical principles etched into me transcend economic and cultural boundaries. I have met wonderful people and mentors: in the words of Dr. Shumbusho, we are all part of a tightly knit surgical family, and we should do what we can to support each other, not knowing when our paths will cross next. To take a moment in residency to experience a different country, with its culture, history, languages, peoples, political systems, foods, entertainment, and medical system was a unique opportunity.

I am grateful to Dr. Weiser and the Global Engagement program, as well as my mentors Drs. Yihan Lin and Ainhoa Costas-Chivarri, for giving me this opportunity. I will take what I have learned into my upcoming professional development years, where I hope to work with training programs in Rwanda to develop innovative methods of developing surgical skills. Each step will contribute to developing my career in global surgery, to serve those with the least access to safe surgical care, and to ease the suffering of those we possess the means of helping.