You can die!, I can break your teeth!

One of my colleagues advises every patient of this. He has a thick Czech accent so you have to be there.

Dental damage is of course an inherent risk of anaesthesia. I have never broken or chipped teeth but I have at least 10 years to go so I know it is going to happen. I am however becoming aware of how frequently (by which I mean a couple of times a year) it happens because as department head I seem to find out about it. Our hospital has a very active disclosure policy and usually on the discovery of any complications, the patient is inundated by risk management people. The result of this is often that the patient starts to see dollar signs. This usually leads to a claim against the hospital once the patient goes to his dentist. I am beginning to believe that when a dentist hears that teeth were damaged during surgery, they too see dollar signs.

I shouldn't comment on events so recent but the following case is so silly and so outrageous that I just have to post it because in 2-3 years I will have hopefully forgotten about it.

I got an email from our patient concerns office copied to the medical director. The story is:

A patient had surgery at our hospital. Some time postoperatively he had a cardiac arrest. A code was called and someone attempted to intubate. In our hospital, that would usually be an RT. The intubation was difficult, anaesthesia was called and fortunately they weren't tied up with some ortho "emergency" and intubated the patient with some difficulty using a Bougie.

The patient survived and woke up in ICU. Most people would be relieved and thankful but however the patient also woke up with..... a broken tooth. Which they want someone to pay to fix.

As I told patient relations, I couldn't see from the chart they gave me who chipped the tooth, I suspect it was the RT. As I told them our medical protective association fights most dental damage claims no matter how small just on principle but if in fact the RT was the culprit, the hospital might be liable. I also mentioned I thought that any judge would probably award a tiny amount of damages for having one's teeth broken while one's life was being saved. Maybe I underestimate our judiciary.

This reminds me of another case on which the statute of blogging limitations has expired.

A patient presented for some type of day surgery procedure requiring intubation. She had veneers which the anaesthesiologist noted and checked off on the record that she had warned the patient (maybe not in a Czech accent). Surgery was uneventful, the recovery room nurses did not notice any dental damage. Someone between recovery and day ward, her veneer fell off. Worse still, it ended up in her stomach (better than her lung anyway). Naturally her dentist wanted 5 figures to fix it. Not happy with her prospects in the civil law system she went to a higher court.

The Global Troubleshooter.

So it was then that I got a phone call from the medical director asking if I would go on TV and discuss this case. "Are you fzcking crazy?" I was thinking but there was a temporary disconnect between my brain and mouth and anyway I like being on TV. First of course I had to meet with the risk management people to discuss what I should say and what I shouldn't say. I actually took at media relations course once and I learned that it is important to stick to the message. My message was going to be "dental damage is an inherent risk of anaesthesia no matter how competently performed, discuss this with your anaesthesiologist".

For authenticity they wanted to shoot the segment in an operating room, so we chose our block room which has a machine. I put on my greens, my favourite OR cap and got a selection of laryngoscopes, airways and suctions to demonstrate all the ways your teeth could be broken. I thought the interview went well, I stayed on message and I thought I had done an educational service to the community. The risk management lady who sat off camera the whole time agreed.

I never asked when they were airing it and I don't watch the 6:00 news (especially Global) so I only learned about it a couple of days later when people told me they had seen me on TV. (America's Most Wanted? I asked). Fortunately Global archives their broadcasts on their website so I was able to see my performance.

It was not pretty.

They had taken the patient's side. The show started out showing the outside of the hospital from a curious oblique with the voice over, "they broke her teeth during surgery and now they don't want to pay". My interview was heavily edited and I was usually cut off mid sentence so everything was out of context. They at least acknowleged that it wasn't me who broke her teeth.

I should learn but I suspect I would probably make the same mistake again.

Big Pharma

I was having lunch with the local Pfizer rep when he told me an interesting story. His company makes a drug for Alzheimer's. A doctor had contacted him to help with a presentation she was giving. His company had developed an assessment tool for dementia and she wanted him to attend to show the attendees how to use it. The problem was that the talk was sponsored by our University's CME department which has recently taken a hard line on pharmaceutical sponsorship. In fact the doctors attending were actually paying out of their pocket (or their corporation's pocket) to attend.

The rep realized that he might not be welcome and so he phoned the CME department to ask if they minded. As expected he got a sanctimonious lecture on the evils of pharmaceutical sponsorship and was of course told he could not attend. Fine, he said, where should I drop off copies of the assessment tool? Our office is in the << insert corporate robber baron >> building, said the CME person.

So.....

It is okay to sell naming rights to your university buildings to the highest bidder; it is not okay to accept money or any other help from Big Pharma.

I of course sold my soul years ago. In the last millennium I think. I have always given CME talks. I never really cared how much I got paid for them or how much income I was losing by not doing something else. In the 1990s I was evangelical about chronic pain. I can't remember the first Pharma talk I gave or who I gave it for. All I know is that pretty soon I was doing a lot of talks for various companies. And making pretty good money for it.

I have to say however I was never told what to say or to promote any particular product. I had a generic talk I mostly gave where I reviewed all the treatments for chronic pain. I did use slide kits provided by the companies because they often had good pictures that I could use. If I didn't agree with something on the slide, I either modified it or didn't use the slide. I inserted my own slides, I mixed and matched various slide kits. I also searched Google for really funny pictures. I had a good time preparing the talks and a lot of fun presenting them. I had visions of getting on the national speaker tour but I never got beyond the local dinner circuit.

I should mention that I was never told what I should prescribe either. I did a ton of talks for Purdue even though at that time I mostly prescribed methadone because of the tertiary care nature of my practice. Pregabalin as I tell the Pfizer rep is a nice drug but unfortunately it is isn't covered by most drug plans so there is no point prescribing a drug that they can't afford. Besides gabapentin is just as good (I don' tell them that). Likewise CR tramadol which three companies released at the same time in Canada setting off a marketing frenzy to the benefit of the local restaurants. Duloxetine the same. When it gets covered I will prescribe it. Very few of my patients can afford it. This doesn't stop me from giving talks on it. I have read the research I know they are good drugs at least based on what has been published.

At the same time I started to get involved with the national pain society and got to meet many of the heavy hitters in chronic pain management. And with a few exceptions they were all on the Big Pharma lecture circuit for multiple companies.

Along the way I have gotten to go to some interesting venues courtesy of Big Pharma. These include Vienna, Sydney Australia, and Glasgow for IASP meetings; Cancun, Stockholm, Bermuda, New York, Phoenix, San Diego, Memphis and who knows how many trips to Banff, Toronto, Montreal and Vancouver. Some of these trips I even got paid for in addition to the free trip. I like to think I did some networking, most of the "friends" I have in the chronic pain world I met at these meetings. The trip to Stockholm which was sponsored by Pfizer was an excellent scientific meeting and only mentioned pregabalin once.


Gradually over time Big Pharma developed a code of conduct and the rules changed. They started to get accreditation for their talks for example. What accreditation meant was you had to stick to script. If you didn't like a slide, you could delete it but you could not modify it. You could not add your own slides and no funny pictures. I have done a few of these and they are absolutely unrewarding and I get the sense that the audience is as bored as I am. A real paradox. Without University accreditation I don't have to follow the script and can say what I want. With University accreditation I have to stick to the script which more or less makes me a shill for whatever product I am supposed to talk about.

Between the new rules, the economy and mergers of Pharma companies, I am doing less and less of these. I don't really miss it that much although I wouldn't mind the extra money.

Obviously a bleeding heart liberal like me should be no friend of Big Pharma. If fact most of what they do disgusts me. The problem is that without Big Pharma support most CME would either not exist or be horrendously expensive. I recently went to two meetings that had no pharma sponsorship and they both cost over $2000. I realized early on that the small number of chronic pain consultants in our area and I could not treat everybody and that the primary care docs had to be educated on this. The problem was that nobody really wanted to pay for this so when Big Pharma came calling I jumped on the bandwagon. The opportunity to get to talk to the family docs who sent patients to the pain clinic was the impetus, the money and the nice suppers were secondary. I later was the treasurer of our national pain society and I can tell you that without Big Pharma funding, there would be no meetings and probably no society.


Those of us involved in CME do a delicate dance with Big Pharma. We want to teach other docs about chronic pain. They want to sell drugs. We actually prescribe most of those drugs anyway and we actually want family docs to prescribe those drugs when the indications are appropriate. We actually want them to do a whole lot more and those supper meetings actually give us a pulpit from which to preach our gospel. At least that is what I like to think. But of course I have lost most of my soul.

I volunteered in Africa and all I got was this lingering feeling of disillusionment.

It has now been 14 days since I returned from Africa where I spent 4 weeks teaching in Rwanda and 1 week recovering on Safari in Kenya.

Firstly it was probably the greatest holiday of my life, I saw rain forests, savanna, chimps, gorillas, lions, more types of antelopes than I ever thought possible, giraffes, zebras and hippos. I also got to stay in some fantastic hotels (and some not so fantastic). I also lived in Kigali in an apartment, so had a chance to live amongst the Rwandans. We bought food in the local markets, ate in a local restaurant, walked everywhere and drank the local beer in the local bars. On that alone the trip was a success.

Why do I feel so disillusioned and somewhat unworthy?

Some background.

At the end of the genocide, there was only one certified anaesthesiologist left in Rwanda. That doesn't mean that patients having surgery in Rwanda were biting bullets; anaesthesia was presumably performed by nurses, technicians, surgeons and doctors with little or no anaesthetic training. A call for help went out to which Canadian (and some American) anaesthesiologists responded. The problem with training specialist anaesthesiologists in Rwanda and other developing countries is that it was necessary to send them overseas to Belgium or France to get the specialty training. Of course once they got their overseas specialist credentials, very few of them really wanted to come back to a country where they would have to work harder for much less money. It was decided that the country needed to develop a local training program to meet the needs of the country which would produced well trained consultants but consultants whose certification had no value in France, Belgium or other desirable places. To help with this goal, a Canadian anaesthesiologist +/- a resident would go down to Rwanda each month to teach formally and in the operating room. In addition each Rwandan trainee would get 6 months of training in Canada.

Now I am not one of those people who did all kinds of overseas volunteer work or electives in third world countries in medical school. While early on in my career I flirted with working overseas, life and children intervened. 5 years ago out of the blue, I got invited to accompany a mission to Ecuador to do total joints and it was like I rediscovered medicine again. I went 4 more times and am going again next January.

Much has been written pro and con about the benefits of international aid and most of what I have read is strongly coloured by the political bias of the writer unfortunately. After one trip to Africa, I don't claim to be an expert on the continent nor do I have any solutions to its problems (stopping selling them weapons would be a good start?). I have always been a believer that it is better to teach a man to fish than to give him a fish and so this Rwandan mission appealed to me for that reason. I had also met with people who had been there and at the last CAS Meeting I attended an exceptionally enthusiastic presentation on the program. I was a little nervous but I thought that I was stepping into a well-oiled machine that was producing results.

Just prior to the meeting I attended the Global Outreach Course which I have previously blogged about. I was really impressed with the mantra of doing the best you can with the resources that you have and looked forward to learning about that.

What I actually found:

Currently there are two larger teaching hospitals in Rwanda, CHUK in Kigali and CHUB in Butare (where the medical school is). Surgery is also done in about 30 district hospitals and in a private hospital in Kigali which I will discuss below. Anaesthesia is for the most part provided by anaesthesia technicians. These are well trained with good airway management skills and are also able to do spinals. For the most part they work unsupervised. There are specialist anaesthesiologists, 2 at CHUK and 4 at CHUB. There is a residency training program with junior residents at CHUB and senior residents at CHUK. The idea is supposed to be that the more difficult cases will be done in part by the physicians while the techs do everything else. This model of technicians supervised by consultants is one that should work well and is roughly similar to the situation with CRNAs in parts of the US. I never actually found out who does the anaesthetics in the district hospitals, I suspect it is mostly techs.

I observed a number of problems almost immediately.

1. Lack of professionalism. The two staff anaesthesiologists at CHUK never attended morning report or arrived late. One of them only showed up in the OR twice during the days I was at CHUK, his side-kick was not much better. The residents were only marginally better, they were almost always late for morning report and for the OR. Some days no physician showed up to the OR at all. This but me in a bad position, my rules of engagement was that I was there to supervise residents and not to give anaesthetics. Frequently on ethical grounds I was forced to give the anaesthetic when the techs found the case difficult (they had fairly good judgement in this respect). This meant I did a number of neonatal cases. (They really are just small adults). More often I just ended up standing around waiting for a resident to show up.

When the residents did show up, they mostly just stood around and watched the techs do the case. Despite 4 weeks of nagging there was never any effect to set up the room, draw up emergency drugs or actually make any plan beyond fentanyl thio sux which seemed to be the only induction sequence the residents knew (with the occasional substitution of ketamine for thio). The technical skills of the senior residents were well below what I would expect from a junior resident in Canada because they never did anything.

This was a problem that seemed limited to CHUK. CHUB in Butare ran much like a teaching hospital in Canada with the 4 staff anaesthesiologist and residents working as a team with the technicians.

2. Equipment. I trained on Boyle machines and I am not overly anal about monitoring (except for SaO2). I wasn't expecting to see the equipment we expect in a Canadian OR. CHUK actually had newer machines and monitors. I suspect they were donated. These were supplemented by Glostavent machines. The problem was of course that most of the monitors didn't have working cables so that often there were 3 different monitors in a room in order to get SaO2, EKG and BP and techs were constantly shuffling monitors and cables between rooms. The machines while new were connected to disposable tubing that was been reused and was heavily patched. Most rooms had nothing resembling an anaesthetic cart, before every case there was a flurry of bringing in equipment and drugs. When I sharply asked a resident why he hadn't got a laryngoscope ready, I was told that there were only 3 working handles in the OR and that a handle would arrive just in time. In obstetrics one suction was shared between the two rooms; a second non-working suction was parked against the wall, nobody had bothered sending it out to be fixed. I never saw an oxygen cylinder on any machine which is a concern because I had been warned that the central oxygen supply had failed in the past.

Now I accept that a developing country like Rwanda may not have the resources that Canada has, however most of the above deficiencies are not that expensive. What was lacking was leadership from the consultant anaesthesiologists who unfortunately rarely showed in the operating room.

3. Dysfunctional OR. It has been my observation that dysfunctional ORs make for bad teaching environments. The OR at CHUK is one of the few ORs in the world that actually needs more rather than less administration.

4. Techs vs. Physicians. As I mentioned the techs for the most part did a very good job. Which made we wonder, what exactly is the plan for anaesthesia in the country. Clearly there is not going to be a physician-only model in the near future or ever which makes me wonder if we really need to be training as many anaesthesiologists as we were training.

5. Training doctors to work overseas. One of the reason that there were only 2 physicians at CHUK was that 3 people were doing subspecialty training overseas. I was told that one of them had no intention of returning and it was doubtful whether the other 2 would. Great I thought. We are giving their training program the Canadian Seal of Approval so that they can get jobs in Belgium.

6. Lack of QI process. Early on we noticed that we were getting a huge number of obstetrical horrendomas. For example I knew of at least 4 Caesarian hysterectomies during the 4 weeks I was there. One of the anaes. was shocked when I told him I had only even done one. We had a number of cases of obstetrical sepsis and/or hemorrhage transferred in. When we raised the issue of why are we not discussing these cases to find out why they are happening and can we prevent future occurrences, this was met with blank stares.

I was asked to make a report at the end of my mission. I waited for over week because I thought I might be more positive however I mostly sent in a report outlining what I have discussed above. Quite quickly the two people in charge of the program emailed me back, to explain that they too had encountered the same problems, that they had raised them with local people and had gotten nowhere. It was suggested that we needed to just keep on plugging.

The question is then, aside from a nice partially subsidized, otherwise tax deductible African vacation, what the hell are we doing taking 4 weeks away from our practices and our family. And of course the answer is: a nice partially subsidized, otherwise tax deductible African vacation which nobody wants to jeopardize. That and of course the warm fuzzy feeling of having volunteered in a developing country.

By the end of the month, I was basically showing up for morning report, going to the OR to see if there was a resident who actually wanted to taught and then bugging out to the comfort of the pool at the Serena Hotel where for $200 you can buy a month's membership. It was only after I left that I had the revelation that probably every doctor before me had done just that, gone to the pool, gone sightseeing or golfed (one of the doctors from Canada raved about the Kigali golf course to me).

As we left the country to fly to Kenya, I had never felt so worthless in my life. I felt that I had accomplished nothing in the 4 weeks; that this must have been due to some character flaw as so many doctors have apparently found the mission professionally rewarding. Then of course the above revelation occurred and I felt a little better.

But I probably will return. Africa has this kind of hold on you.

The Curse of the Digital Camera

I was in Africa (Rwanda and Kenya) for 5 weeks which was a great experience and we really got to do a lot of sightseeing. I know that people are soon going to ask me to see all the photos I took. Therein lies the rub.

We took hundreds of digital photos in Africa with two cameras. Obviously I really don't want to subject anybody to such a slide show although lots of people have no qualms about doing this. At the same time it is hard to decide except for the obvious out of focus shots which ones to discard. And of course with a digital camera it is really easy to just keep shooting. And of course no photo no matter how good really replaces the experience of being there. At the same time if you delete the photo you feel like you have deleted part of your experience.

When I started out taking pictures of course, we used film which was a lot more expensive, plus it came in rolls of maximum 36 exposure. You would come back from holiday, take your rolls of filmm to the drug store and a week or so later you would get your pictures, some of which were good some weren't. If you threw away or lost a print, you had the negatives.

Sometimes I think we take pictures as a substitute for the experience and as a consequence lose some of the experience.

A few years ago I visited Ularu (Ayers Rock) and its sidekick rock, Katajuta. We were taken to Katajuta to watch the sunset one night. It was a really magical experience, we were out in the desert, there were no clouds and as the sun set further and further the rock appeared with each passing moment to be a different shade of red. This we dutifly photographed. When I looked at the photos on my computer a few weeks later, I had about 20 photos of Katajuta all the same identical shade of red. And I haven't had the heart to delete any of them.

Likewise on this trip we spent about 20 minutes less than 5 metres from a pride of lions with 5 cubs. Being that close to a group of animals that could kill you in under a minute and watching them go about their business, playing, sleeping and nursing is one of the enduring images I have of Africa. And of course we have about 30 photos of the that special time.

But I know that on Tuesday people will be expecting to see my pictures, so enough blogging and more editing.

A visit to the cousins (Summer re-run)

Last Wednesday afternoon we left Kigali to go to Butare to teach the junior residents there. Kigali seemed hot, dusty, crowded and noisy and we were happy to get out the city for a while. Our driver Jean arrived promptly at 1400 and we piled into the car, Brady, Mary and I along with Brady's Dad Mike who had “dropped” in the night before. We left Kigali to the west travelling along a valley and sound ascended into the hills surrounding Kigali. When they call Rwanda the county of a thousand hills, they are perhaps understating things. There seem to be a lot more than one thousand. We went literally over hill and dale. The hills were terraced with crops, the valley bottoms heavily cultivated. Every 15 minutes or so we went through a small town, not even slowing down much. Everywhere along the road, we saw people walking, women carrying loads on their head and school children returning home in their uniforms. The vistas as we drove along the sides of the hills were incredible. We tried some drive by photos and we couldn't stop for a photo op. After 2 hours we entered Butare and checked into the Hotel Credo.

After freshening up, we decided to go out to what was described as the best restaurant in Butare by our guidebook. Guidebook....FAIL. I will probably post on this separately.

We were sleep deprived from the heat in Kigali and our noisy neighbours and in the cool quiet of Butare we slept like logs. Until.....at 0500 the sound of what was for 0500 beautiful singing. It turns out there is a Mosque about 500 metres away complete with loudspeakers to call the faithful to prayer. In case the faithful missed it, it was repeated at 0515. We got up, ate breakfast on the terrace; a bean soup which was quite good, a plate of fruit and toast plus coffee. Just after 0745 Dr. Theo arrived to pick and Brady and me to go to the hospital.

CHUB was a refreshing change from CHUK. We changed in Dr. Theo's office before going to the OR where we were met by Isaac and Adolphe two of the junior residents who greeted us dressed in clean white OR scrubs. We had a great day working with them, they were enthusiastic, asked a lot of questions and were open to suggestions. After our list finished I had the usual Rwandan buffet lunch with Adolphe before heading home. We all dined that night at the Hotel Ibis along with it seemed just about every other ex-patriot in Butare. I ate the special grilled rabbit. It really does taste like chicken.

After another sound sleep until 0500, we had breakfast and Brady and I walked to the hospital. Friday is a short day in Butare with only emergencies scheduled. Dr. Theo met us and asked us whether we wanted to attend their Friday morning case presentations or do the three emergencies. We decided on the case presentations. We all sat around in the store room. Dr. Theo quietly asked that we start the meeting with a prayer and everyone (except Brady and I) joined in, in a beautiful hymn followed by a short prayer. We certainly don't start our meetings in Canada that way although sometimes we could use a little prayer.

Butare lies in the southern part of the country as does the Nyumgwe National Forest, one of the must sees in Rwanda. Unfortunately tourism is not that well developed in Rwanda. We got very little information from the tourist office in Kigali and our Bradt travel guide wasn't that much help either. We had originally thought of just staying in Butare and commuting to the park on Saturday and Sunday until we learned the park is actually 3 hours from Butare. They looked so close on the map. We therefore booked rooms at the Gisakura guest house. We still figured that we could get there on the bus which Bradt said was possible. At the last minute we decided to ask our driver Jean how much he would charge to drive us there Friday and pick us up on Sunday and he quoted a very reasonable rate.

Therefore at 1300 on Friday we set out west from Butare. We first when up a broad valley which was heavily cultivated with some fish farms as well. We soon however got into hilly country. The hills were terraced with farming often up to the top of the hill. Some of the hills stuck out like sugar loafs circled with terracing. Again we passed people on the road and small towns. As we got farther west we started to see tea planted on the slopes. After an hour or so we reached Nyungwe National Park. The road very quickly got very rough even by Edmonton standards. Our driver tried as best he could to steer around the larger tank traps often going onto what shoulder there was or into the other lane. We were surrounded by hills covered by jungle with deep valleys off the side of the road. We could see the dense canopy. At one point we saw our first group of monkeys at the side of road, necessitating a photo stop.

Unfortunately at that time our driver noticed he was leaking brake fluid from his rear brakes. We check the fluid levels and he seemed to have sufficient fluids plus hey the front brakes work and we were out in the middle of nowhere so we pushed on.

After some time we passed the Gisakura Tea Plantation which is on the western side of the park and which was close to where we were supposed to stay. We saw no sign for our guest house and we figured that our driver knew where he was going so we pushed on for another 30 minutes. At that point our driver stopped to phone someone and it was at that point we realized he didn't know where he was going either. We consulted the guidebook, turned around and headed back. At every village our driver stopped to ask directions. As a man I could feel his pain. Eventually we arrived at the Gisakura Guest House.

Some travel guides have not been kind to the Gisakura Guest House and I was expecting some spartan and not particularly clean accommodation. I was surprised. The guest house is a series of brick buildings, surrounded by nicely manicured grounds with the jungle just past the fence. The staff welcomed as and showed us our rooms which were clean and comfortable. You do of course have to share a bathroom. We had an excellent buffet dinner with the small number of guests later that night.

National Parks in Rwanda are different from National Parks in Canada. Firstly as we found out, you really need a driver to get around. Uwinka were many of the good trails are is 20 km from where the hotels are. To see the chimps is a 30+ minute drive. Fortunately we ran into our driver Jean who had decided not to drive back and were able to negotiate his services for Saturday and Sunday.

We all decided we would like to see the chimps. This involved phoning a ranger to book the trip and it was already 1800 and the rangers had gone home from the Gisakura Ranger Station. Fortunately a guard was still there who knew the phone number and we called a ranger. We then had to each come with $90 US, give it to Jean who took it to the ranger who would sleep overnight at the Gisakura Ranger station. Oh by the way, we are leaving at 0430.

We went right to bed after dinner. Our alarm was set for 0400 but we woke around 0345 and got into the clothes we had put out the night before. The guesthouse had given us the key to kitchen and had put out small bananas, bread and most importantly coffee for us to eat. 0430 came and we met Ranger Robert in the pitch black night. We piled into the car and headed west down the bumpy road. In time we turned onto a dirt road that was strangely smoother than the “paved” road. In the headlights we frequently came across people out walking in the predawn. We passed small villages as we went up and up the winding road. The sun began to come up. We passed a large group of people out running in the dawn. Finally our truck pulled over. We got out. Another ranger and 4 trackers were awaiting us. They all wore green uniforms with their pants tucked into their gumboots. Below us we could hear the “cousins” whooping it up.

Ranger Robert handed us each a walking stick. We figured this was a nice touch for the tourist. We headed down a steep trail cut into the side of the hill. There was a wooden handrail which probably wouldn't have taken my weight. “The vegetation will stop me, “ I thought but I wasn't really confident. We walked mostly downhill with the occasion uphill. Periodically Ranger Robert would talk on the radio to the trackers. Eventually we stopped. The cousins were not coming to us, we were going to have to go to them. We backtracked and suddenly left the trail onto a narrower “trail”. Vegetation was dense and I had to crawl under obstacles. The camera I had at the ready for my chimp shot went into the backpack as did my hat. We were perched on the edge of a steep hill. The soil was very loamy and it was hard to get a foot hold. It was that when I realized what the walking sticks were for. After about 20 minutes of hard slogging we stopped. “Chimps” somebody whispered. High above over 20 metres in a tree we saw an adult male perched on a branch in a perfect pose. Too bad the camera was in my backpack. We saw a total of 5 chimps including 2 babies up in that tree. Around us we could hear the whoops of the tribe who we had disturbed.

The pack moved north and we decided to follow them. This involved about an hour of bushwhacking thru the underbrush, clambering up impossibly steep slopes and descending treacherous downhills. We gave up eventually but has some more bushwhacking to go to get back to the trail after which we could walk back to our truck where Jean was waiting for us.

Then came the decision of how much to tip. We huddled briefly and decided that 10,000 Rwf between the four of us would be appropriate and gave this to Ranger Robert. He looked a little displeased so we came up with another 10,000. I remember how one of his men had possibly saved my life when I started to fall backwards and came up with another 5000.

It was now 1000. We had been up for 6 hours already. We backtracked along the dirt road passing villages and tea plantations until we got to the main “road”. We passed multiple villages. Finally we stopped in a small village. Jean pointed to the gas gauge. Almost empty. We had agreed to pay for gas. There is of course no Esso station. Ranger Robert yelled out the window and in time someone appeared with a large Jerry can of diesel. There was a negotiation, and the proprietor inserted a hose into the Jerry can with one end inserted into the gas tank. He then blew over the opening of the Jerry can to force gas into the hose which was then syphoned into the gas tank. He had to repeat this several times. Meanwhile the whole village gathered around to watch. Later after Mary asked about corn, we stopped in another small village, Ranger Robert yelled out something and four cobs of roasted corn appeared which somebody paid for. They were delicious.

It was just after 1130 when we arrived back at the Gisakura guesthouse. After a hot shower(!) and a delicious lunch, it was time for a nap. Later Mary and I sat in the gazebo in the midst of a major thunderstorm and reflected on our day and what we were to do the next day.

Pictures to follow once I get a decently fast internet connection.

The Nyamirambo Road (Summer Re-run)

When I found out the neighbourhood our apartment was in, I got out my guidebook to try and figure out where it was and more importantly where it was relative to the hospital. We are in a neighbourhood called Nyamirambo. Try pronouncing that a few times quickly. On the map there was a long road which leads to the hospital and to central Kigali. The distance looked about 5 km.

Here is what Bradt's guidebook on Rwanda says about our neighbourhood.

"...lively busy district of small streets and colourful little local shops. The atmosphere has a touch of London's Soho about it."

The centrepiece of this road is the Nyamirambo Road. We have now walked this road back and forth between the hospital several times including twice on one day. A map of course cannot convey what a road actually looks like.

The Nyaraminbo Road is a two lane road which carries all the traffic between our neighbourhood and central Kigali. It is hopping with cars, minibus “taxis”, trucks and the ubiquitous motorcycle taxis. On each side of the road are small shops. About every 10 feet there is either a hair “saloon” or a small bar. The are also multiple cell phone shops, tiny grocery stores, clothing stores and who knows what else. There are narrow sidewalks on most but not all of the road. You have to be careful because there is a 1 metre wide ditch alongside some of the sidewalks. There are also 30 cm deep trenches on the western side of the street to allow rain to drain downhill in the rainy season and if you aren't careful you can step into one of those as I have twice already.

The roads going off to the side are dirt roads which we have not explored much but those that we have walked on have their own small shops and bars. These dirt roads are irregular and rutted from the recent rainy season.

Kigali seems to wake up at 0530 and we usually leave to walk to the hospital at 0630. The street is bustling even more at the time with people walking to work and kids walking to school wearing their school uniforms. Quite often to pass people or to yield to people coming in the opposite direction, we have to step off the sidewalk onto the street which means taking your life into your hands as motorcycles, minibuses and cars are whizzing by, often as close to the curb as they can.

For the last two days we have walked home around 1700 which seems to be when school gets out which means that the kids have a very long day. Today I got "swarmed" by a group of school children who all wanted to hold my hand and failing that my arm. In other countries I would start wondering about my wallet. Many of the young children like to high five us or will ask us "how are you doing" in English.

There is a market nearby called (of course) the Nyamirambo Market. While certainly not the Otovalo market, it has a wide selection of local fruits and vegetables and is overall quite clean. You can get clothing made for you there although Mary and my first try didn't work out that well.

Buying beer in a grocery store is a major endeavour. A 750 ml bottle of beer goes for about 600 Rwandan francs ($1). If however you wish to take it out of the store you have to pay a 500 Rwf deposit. That makes 1100 Rwf for your beer. Still less than $2. The first time we did this however the lady sternly warned us over and over about this and only reluctantly let us buy the beer. Now .... the next time your want a beer, you bring the empty back to the store and you can buy another one for 600 Rwf. And so on and so on. The problem is, that the beer you bring back has to be the same as the beer you want to buy so if you buy something you don't like, you are forever doomed to drink the same beer over and over. Plus if you did like we did and let the people who cleaned our house take the empties, you are back where you started. This sounds a little impractical, however there is absolutely no broken glass on the street, and people don't drink in the streets. Plus there is are at least two bars every 50 metres and it costs the same to drink a beer in a bar as it does to buy it in a store (without the deposit).

Sorry I haven't been posting many pictures. Our internet connection is quite slow and I have not figured out yet how to shrink the pictures down to a more uploadable size.

Visiting the in-laws (summer rerun)

I did some interesting blogging on my travel blog that I would like to share with my other audience.

gorillas

From gorillas

Any visit to Rwanda of course requires a visit to see the Mountain Gorillas. This requires the purchase of a permit at $500 per permit non-refundable. And no they don't take Visa or any other credit card for that matter. The only payment is by bank draft and hope they don't lose it. Buying one once you arrive in Rwanda is risky as a permit may not be available. Therefore to simplify matters we got a local tour company to buy one for us. I did this back in January and had of course completely forgotten what I had booked and really only had a voucher and the local phone number and email for the tour company.

There are at least two ways to travel in developing countries. One method is to use your travel guide, read everything you can about the area, chose a hotel, hope the travel guide writer actually visited this hotel, book the hotel and use local public transport to get to where you are going. Then there is the way we went.

Our day started out in Butare where we were teaching. Butare is two hours away from Kigali where our pick up was and we were supposed to teach all morning. We were finished around 1130 and our favourite (actually our only) driver Jean was ready to leave around 1200. Jean has an interesting approach to driving. Any vehicle in front of him must be passed, no matter how much traffic, how narrow the road or how steep the hill. Also his SUV is right hand drive which meant I was sitting on the left side. After about the 20th time pulling out into traffic, I figured out that some special force must be protecting Jean and stopped worrying.

We arrived in Kigali around 1400 and repacked for our Gorilla trip. Our driver was supposed to come at 1600 but we were ready early and he was able to come early so around 1530 he pulled up in front of our apartment in a huge Toyota Land Cruiser FWD. Surely a little overkill, I thought, for such a well travelled tourist route? We piled in and our driver Shema, explained that the trip was going to take 3 hours. We also learned that he was our personal driver for the weekend. We had had visions of being crammed into a bus with a bunch of other tourists so were very happy.

We left Kigali and headed west and then northwest, climbing a huge winding hill out of Kigali. We were going thru a forest of Eucalyptus and other trees. Soon we reached the top and were driving along a ridge with spectacular vistas on either side of us. We descended another winding hill into a broad valley which we followed for a while before ascending yet another long and winding hill. After about 2 hours we drove through Musanze which is the gateway town to Gorilla trekking. We were heading towards Virunga Lodge. “Do you know anything about the hotel?” Mary asked. “Not the slightest” I replied. We continued onwards and after about 2.5 hours we turned off the main road. Shema pointed towards lights that he but not I could see and said that is your hotel. The road meanwhile got rougher and steeper. It was getting darker but we could see lakes on either side at least 1000 feet down a steep hill. Finally we pulled up to the Lodge.

Staff came out to welcome us and we were directed to two couches to be oriented to the lodge. Virunga Lodge is an Eco-lodge which is entirely off grid and solar powered. After further instructions two staff headed quickly up a moderately steep hill to our cottage carrying our bags. We opened the door to discover what is probably the nicest hotel room we have ever stayed in. There was a huge bed, hardwood floors in the bedroom and a stone floored bathroom that was about the same size as the bedroom. The staff explained that the shower was solar powered as well. It was now about 1840 and we grabbed a quick solar powered shower which was hot enough that we had to add cold water.

From gorillas

No bed bugs here!

Then it was up the hill to the main lodge for dinner at 1900. Dinner it was explained was served family style to allow guests to share their trekking experiences. It was cocktail hour when we arrived and a waiter quickly approached us and took our drink order. There were about 10 other guests seemed to know each other although one or two came over and introduced themselves to us. We were then summoned to the common table in another room. Our co-guests were a collection of fairly wealthy Americans and one Swedish banker. We had ordered our entrees on checking in and they were delicious accompanied by an excellent red wine with which our servers kept our glasses full. After dessert we were asked what time we wanted our wake up call, whether we preferred tea or coffee to be brought to our rooms and what would we like for breakfast.

After a sound sleep we arose at 0500 and sure enough someone was outside our door with a pot of coffee which we drank quickly which getting dressed and packing. At 0530 we were in the dining room where our breakfast arrived quickly accompanied by more coffee. A large packed lunch also appeared still warm.

At 0600 we were down at reception where Shema was waiting. We headed down the hill, in the morning light we could now see the incredible vistas on either side of us. All along the road, people were walking starting their day. Today was the “Naming of the Baby Gorillas” ceremony to be attended by the President as we drove towards the staging area, the road was lined with people. I felt regal as we drove by.

The staging area was a mass of activity. A group of about 10 dancers were dancing traditional dances lead by a small Kwa man. There was also a traditional medicine man and a lady grinding sorghum. All the gorilla trekkers were milling around. We had aspirations of the Susa group, the largest but also most inaccessible group but our driver had judged me as not Susa worthy and we were assigned to a group with an older couple, 3 teenagers and a New Zealander.

We took off again in our Landcruiser and turned off onto a dirt road which rapidly deteriorated into what was more of a creek bed with 20 cm round volcanic stones. The truck ahead of us spun its tires and lurched around and I wondered whether we would have to get out and walk. We soon came the parking area however. We elected to hire porters to carry our packs and with the group set off through potato fields heading gently up the hill. We had to cross a medium size creek and the guides and porters arranged stepping stones for us. After about 15 minutes we crossed a crude stone wall that was the boundary of the park.

One of the trackers carried an submachine gun which our guide explained was to scare off buffaloes and elephants that we might meet and we saw fecal evidence of both. As the brush got denser and the trail narrower I felt like I was in Apocalypse Now what with the machine gunner walking point in front of us. After an hour or so our guide stopped us. We were according to him now 100 metres from the gorilla troop. We had to leave our packs, walking sticks and proceeded on with only cameras. Soon we could see in the distance a gorilla in a tree. I tried to point this out to Mary in front of me but she had already come almost face to face with an almost fully grown gorilla at the side of the trail. As he got up and ambled towards us, our guide shooed him off with a low pitched growl. He passed us and lay on his back shovelling food into his mouth.

From gorillas

We moved on single file and soon we were in the middle of the troop. As our guide had explained to us, we are supposed to stay 7 metres away but gorillas do not know what 7 metres is. The next hour was incredible as we saw all the gorillas in the troop. There was a mother with a small baby who we watched for a long time, two young gorillas fought each other, one scratched his manly bits, the Silverback alpha male casually ambled through the group, and a gorilla high in a tree let out a stream of urine which just missed us. Everywhere you looked there was a gorilla!!! They are such docile, fun loving creatures who happen to be built like “brick shit houses”...After shooting terabytes of pictures it was time to leave.

From gorillas

We left two of the trackers, submachine guns at ready to guard the group. The walk back was anti-climatic and we soon arrived at the parking lot. After paying our porters and tipping our guide we headed off down the bumpy road.

The Bruins

I have been a Bruins fan since the 1967-68 season. I was rewarded early on with two Stanley Cups in 1970 and 1972. While the Bruins remained a dominant team for the rest of the 1970 and 1980 into the early 1990s (establishing a consecutive playoff appearance record that will never be broken); they became a less dominant team in the 1990s, started missing the playoffs, and finished last overall one season. I moved to Edmonton, started cheering for the Oilers even when they played Boston. I began to accept that I would never see the Bruins win the Stanley Cup in my lifetime. In some ways I was right; I was in Africa during the final series. So it was that the morning after Game 7 against Vancouver I took my computer upstairs in the Credo Hotel in Butare where they have wireless internet and learned that the Bruins had beaten Vancouver in convincing fashion and had won the Stanley Cup. I had to take it all in before going down to wake up my wife (a Habs fan) with a bad rendition of "We Are The Champions"; something I couldn't finish because I started crying, which I knew I would do if the Bruins ever won the Stanley Cup again.

In a sense along with winning the Stanley Cup, this playoff was an exorcism of the Bruins' playoff failures.

The Bruins can't beat Montreal...they did albeit winning Game 7 in overtime.
The Bruins have never won a series after trailing 2-0....they did it twice.
The Bruins' record in Game 7s is abysmal...they won all three Game 7s
The Bruins' record in overtime is abysmal...they won their first 4 OT games and only lost one to Vancouver
The Bruins record in Game 7 OTs is abysmal...they beat Montreal in OT.
Other teams always had the hot goalie...the Bruins had Tim Thomas this year.

And this of course exorcises all the playoff failures; the losses to Montreal in the 1970s and 80s. Getting out-thugged by Philadelphia. Losing twice to Edmonton in the final. Having to trade Ray Bourque to allow him to win the Stanley Cup with another team. Ulf Samuelson sticking his leg out and essentially ending Cam Neely's career. The disappointment of the Joe Thornton era teams. This current version of the team losing Game 7 in OT against Carolina; and blowing a 3-0 series lead against Philie.

More impressive is that the Bruins top offensive player Marc Savard missed the entire playoffs, Milan Lucic only scored three goals, Nathan Horton missed most of the last 5 games of the final, they couldn't buy a goal on the power play and they still won.

People often ask why I cheer for an American team.

When I started following hockey there were only 6 teams, two in Canada. Growing up on the west coast, I had no natural affinity for either Toronto or Montreal. I did however grow up in a Habs household. My older brother however told me I couldn't cheer for Montreal. (I am not sure whether to be grateful or not). Cheering for the Leafs in a Habs household was out the question. Therefore I first hoped for Chicago who had (and still have) the coolest crest and then after I played my only year of minor hockey on "The Bruins" I switched to Boston. You must rememember that in the 1960s either player in the NHL was Canadian. The two dominant stars of the 1960s Gordie Howe and Bobbie Hull played for American teams. Even today with all the Europeans, and Americans in the NHL, the Bruins carried 14 Canadian players, more than Montreal or Vancouver who they faced in the playoffs.

I am writing this after having returned from Africa yesterday, sitting in my Cam Neely replica jersey and I hope I never lose this feeling. Sorry to gloat but I have waited 39 years for this.