Busy busy day

Today was a long day.

I got to enjoy my first night back at Shyira Chalet last night. The one bad thing about my temporary oustment by the German guys was that I was in a house with a really small coffee press, when I was so used to my large one here at Shyira Chalet. Needless to say, mornings have been difficult without it.

This morning, we started out with morning report. Then we went to the maternity ward and saw our two sets of twins, one set that was born the night before I arrived. By prenatal first trimester ultrasound and by Dubowitz exam, they are 28 weeks old. In the US, they would be in an incubator and would be getting IV fluids and tube feeds, but here, they get tube feeds only. The recommendation in a setting without incubators is to do a kangaroo. The mother straps the naked baby onto her bare chests with a cloth, and they stay like that all the time. With twins, you get the father to do it too, and if he can't, a grandmother or older sibling. Unfortunately, in our case, it's just the mom who's around. The babies just stay bundled up.

Preemie boy, with a broken arm from being rotated from a breech position in the womb.

Richard is a very good teacher. He always asks me to say what I would ask the parent, and then he has me do the exam and watches me while he asks the parents in Kinyarwandan. Afterwards, he's sure to let me know if I've missed anything. He will then ask me my findings, and then he'll ask me about the differential diagnosis. Then, he'll quiz me on each thing in the differential until I run out of things to say. Then he'll be sure to let me know if I have missed something. Sometimes he asks me some questions, but then he won't say if my answer is right or wrong. Those times, I'm suspicious that he doesn't know the answer.

Today, one of the other doctors was around while we were examining this baby with a poor suck. He started to ask Richard what he was doing, and Richard turned to me and said, "tell him how to do an exam." So I did what I knew. Then after all that, we spent this afternoon watching videos on how to do a newborn baby exam. (and my entourage was peaking in through the window at us the whole time)

Also today, we had a woman bring us this boy with mental retardation. Her chief complaint was that the kid had spent the last five years in the first grade, and now the kid is 12 years old. Richard was certain that the boy had Marfan's because of his body shape, but I kept saying "Marfan's doesn't cause mental retardation!" I used to baby-sit for this one super-smart kid who had Marfan's, and I've known several others who weren't there. After a very through physical exam--but none of the developmental testing that they do at the Dennis Developmental Center at Arkansas Children's Hospital--we took a break for lunch and then spent the afternoon looking up Marfan's (MR is not included on Up to Date's criteria), Fragile X, and Klinefelter's because Richard was intent on finding the syndrome. The kid fits nothing we could find. I think I'm going to take pictures back to Arkansas and see if I can find some of the pediatricians to look at them. I just wish I had the developmental stuff to help them diagnose.

We hope that the boy can eventually go to a school for the handicapped in southern Rwanda, where he can learn a trade. Right now, he is being harassed a bit by the kids in school, and he's not going to be able to take care of himself in the future. Shyira isn't the best place for him, unfortunately, but we don't know the criteria for sending him to the handicapped school nor what the cost would be.

He was a really pleasant fellow. I gave him one Cars sticker and then I gave his mother all the rest that there were on the sheet, which was about five stickers. The boy gave me a really big smile every time I saw him around the hospital later.

He really is a cute, sweet kid.

Tonight I also have a Kinyarwandan lesson. I have to say it's a pretty complex language. There are 10 classes of nouns, and depending upon the class, there are certain prefixes that go on every adjective, possessive, and verb. It's ridiculous. One of the other African doctors told me that I would be fluent in this language only after I had lived here and studied it for 5 years. (Caleb and Louise have been here for 7 years and they are not fluent.)

After the lesson, we have dinner with the Kings. Louise's parents are here. They are a surgeon and a gynecologist, and they sometimes help out around here. They come to Rwanda for a few weeks at a time every year.

So until tomorrow! Ni ah'ejo!