By Alyssa

As one of the most developed hospitals in a small country, we get our share of VIPs, and there is always a tension at to how much time and energy to spend on them versus the rest of the patients. My sense is that this is a challenge in lots of places but especially for mission hospitals in developing countries where the goals of medical excellence, compassionate care for the poor, quality education for trainees, and financial sustainability can sometimes seem impossible to pursue simultaneously. 

Kibuye Hope Hospital's vision is to: 

"Develop a university hospital of excellence where the love of God is manifested to his creatures."

Our mission is:

"To glorify God through quality physical and spiritual care accessible to all and through the training of healthcare professionals and disciples of Jesus Christ."

I'd like to share about a few patients I saw yesterday who aren't particularly prominent by the world's standards but who I hope experienced the love of God at our hospital. I would love for them to walk away from this place after receiving quality healthcare by compassionate healthcare workers with the sense that they are seen and known as Very Important People in the eyes of our Heavenly Father.

1) Mama D (pictured above with one of our nurses, picture taken with permission). This mama is so faithful to care for her little girl through so many heartbreaking challenges over the last few months. She has been in and out of the hospital multiple times and has often stayed for weeks at a time due to complications from probable tetanus. Her mother faithfully keeps every appointment, feeds her and give her meds through an NG tube (and amazingly, the little girl is not losing weight or malnourished), and is attuned to every new symptom that means she needs to bring her back to the hospital. We had the chance to encourage Mama D yesterday that she is doing such a great job in caring for her daughter, and she just beamed. She and her husband display great faith in praying for their daughter and not despairing despite the myriad of challenges their little one faces. 

2) "Isaac" is a 13-year-old boy who came to his follow-up appointment in peds clinic yesterday for cyanotic congenital heart disease. When they checked his oxygen level in triage, they were so concerned that they sent him to the emergency room instead of clinic. But then they came to find me and I explained that his oxygen levels are always that low. Sure enough, Isaac entered my clinic walking and talking normally a few minutes later despite his oxygen saturation of 65%. Isaac is one of the oldest patients I have seen here with cyanotic congenital heart disease (probably Tetralogy of Fallot for the medical folks). He's actually still attending school and can walk short distances around the hill where he lives. It's difficult to decide what medicines to treat him with because the medical literature generally assumes patients with this condition had surgery to repair it as infants. He's currently taking three heart meds and seems to be relatively stable, so we refilled the prescriptions and gave him a follow-up appointment in three months. 

3) "Emmy" is the 7th child in her family and there were complications with her birth. She was resuscitated for a prolonged period of time and that resulted in neurologic complications. Now she is 2-years-old but doesn't walk or talk or even sit up on her own. This is unfortunately a very common story here. Her mom brought her to peds clinic to see if we could help with her development. Emmy smiles and seems aware of her environment but has very little muscle tone. We gave her a referral to a center nearby that provides physical therapy, but there's not a lot else we can do for her. We did explain that she is a beloved child of God, and her mom readily agreed! 

4) Mama A brought her son to the hospital because of a huge tumor in his eye. She heard that there was a center here that could treat this condition, so she traveled from quite far away with her son and his little brother. The boy has now been hospitalized in the malnutrition service for over a month. Unfortunately the cancer (retinoblastoma) was very advanced and already metastatic when they arrived. We have given chemotherapy with the goal of palliative care (to shrink the size of the tumor and decrease his pain), but the boy is still not well enough to eat or drink or talk. He will likely go home tomorrow to continue palliative care. I hope the mother leaves with the sense that she did everything she could for her child and that there is no shame or curse associated with the condition he has. I will miss greeting her and the little brother each day. 

5) "Arthur" is a 4-year-old boy with epilepsy who came to clinic for follow up. Thankfully his seizures are well controlled on treatment. He has only had one seizure in the last year. He has some developmental delay as well, but he is making good progress. His mother is pleased with how he's doing. We refilled the medication and gave him a follow-up appointment for early next year. 

We want to keep growing and improving in the level of care we can provide for all the patients at Kibuye Hope Hospital. And yet as some of these stories show, we can't always provide physical healing for them given the resources available in our setting. But no matter what medicines or treatments are available, we desire that the love of God be manifested to all the patients along with their family members. Our specific pediatric vision includes the phrase "welcoming children, families, staff, and students as Jesus welcomes us." Please pray that this vision will be realized more and more in this beautiful corner of the world.  


Making Virtual a Reality

While a good understanding of anatomy is important for the practice of medicine, it's foundational for the practice of surgery.  Knowing the relationships between structures can be the difference between curing the patient and causing irreparable harm.  Because of its foundational nature, in the U.S. anatomy and physiology is one of the courses taught early in medical school.  Around 90% of U.S. medical schools include cadaver dissection as a part of their curriculum.[1] Even as the pedagogy for medical education is transitioning to a flipped classroom model, the importance of in person time studying cadaveric anatomy is not lost on educators.  In fact, according to anatomy course directors, one of the most common weaknesses in anatomy curriculum was insufficient dissection time, a problem which was only exacerbated by COVID. [1] 

There are many factors that prevent us from maintaining and using an anatomy lab as a part of our medical curriculum here in Burundi.  Both the formaldehyde and refrigeration options for preserving cadavers are very expensive.  Then comes the practicalities of maintaining constant electrical supply or the safe handling and disposing of large quantities of hazardous chemicals.  All this says nothing of the cultural and ethical implications of obtaining cadavers on a regular basis...

So, what are we to do?  

Well, 11% of U.S. medical schools also utilize virtual software to enhance, and in some cases replace, the cadaver dissection portion of their anatomy courses.  In the post COVID era, a full 23% more plan to incorporate Virtual Reality in their anatomy curricula.  [1] While the data is a little old at this point, a 2015 meta-analysis of the educational effectiveness of 3D visualization technologies in teaching anatomy showed that it 1) improved factual knowledge, 2) improved spatial knowledge acquisition, and 3) improved user (aka student) satisfaction as compared to all teaching methods. [2]

Visiting resident Yves Yankunze having some one-on-one teaching time.  We had recently discussed hiatal hernias, so I was pointing out the relationship between the esophagus, vagus nerve, diaphragmatic hiatus and aorta/aortic hiatus.

Since I had the headset and anatomic models ready to go in our (mostly) unused OR 1, I was able to have an impromptu teaching session for the nurse anesthetist students rotating at our hospital.  It was a chance to show them the relationship between the upper airway, the trachea and the esophagus.  A critical understanding for successful and safe intubation of patients. 

When set up in the classroom, other residents are able to follow along with the teaching as I guide the student wearing the headset toward the relevant and important anatomy.

After a few back-and-forth emails, the medical director for The Standford Virtual Heart program graciously provided me with a copy of the software.  So after we finished our chapter on congenital heart defects, our residents had a chance to explore the defects and their associated flow patterns and murmurs in virtual reality.

For now, I'm focusing this virtual experience on our current batch of surgical residents.  Their need for recalling and understanding anatomy is the most pressing.  But the trial run has been well received and quite helpful.  I'm excited about the possibility of significantly expanding our use of VR into the anatomy course taught at Hope Africa University.  

Afterall, it's hard to build a solid house without a solid foundation...

[1] Shin M, Prasad A, Sabo G, Macnow ASR, Sheth NP, Cross MB, Premkumar A. Anatomy education in US Medical Schools: before, during, and beyond COVID-19. BMC Med Educ. 2022 Feb 16;22(1):103. doi: 10.1186/s12909-022-03177-1. PMID: 35172819; PMCID: PMC8851737.

[2] Yammine K, Violato C. A meta-analysis of the educational effectiveness of three-dimensional visualization technologies in teaching anatomy. Anat Sci Educ. 2015 Nov-Dec;8(6):525-38. doi: 10.1002/ase.1510. Epub 2014 Dec 31. PMID: 25557582.