Legacy and Multiplication: Meeting Dr. Clarisse again after a long time

 (from Eric)

This weekend, I was taking a walk around our housing area with Toby. Standing near where the Harlings live, I saw a Burundian family that I didn't recognize. As I got closer, the dad greeted me in good English with a smile. While wondering who he was, I saw the mom come up behind him, holding an infant in her arms:

"Dr. Eric. It's been a long time. Do you remember me?"

My mind struggled for a moment to put together the different threads when you see a familiar face in an unexpected context. Then the lights came on.

"Dr. Clarisse?"

She smiled.

"Wow. It has been a long time. I thought you were far away."

"Yes, but we are visiting a few months in Burundi, and we wanted to visit Kibuye, because we haven't been here since I was a medical student. It's amazing the work that you have done. It's so transformed. You should be very proud."

"Thank you, Dr. Clarisse. You graduated when? Almost ten years ago?" She nods. "And then you started PAACS surgical training at Galmi Hospital in Niger. You have finished now?" She nods again.

I had heard that Dr. Clarisse had graduated as a general surgeon this past year, and that she and her husband, with a desire to continue to testify to the love of Jesus in a Muslim context, had signed up to be missionaries with SIM and were moving to the north of Togo.

"Dr. Clarisse, I heard that you were moving to Togo now that you are done?"

Her husband nods with a smile. Clarisse says "Yes. You know, for so many in my class, our time at Kibuye with you was so influential in terms of understanding mission, and helping us think differently about medicine."

"Well doctor, I can't tell you how encouraging it is to see you. It encourages us, after so many years, to see how Kibuye has helped people like you to develop a vision of serving the Lord as a doctor."

***

Click here for a great story from Dr. Clarisse via MedSend.

Click here to support Dr. Clarisse and Audace in Togo via SIM-USA.

Dr. Clarisse (center) and classmates at the end of their Kibuye time in 2014

Dr. Clarisse and Audace with their family

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.

Hip hip hooray for medical education

(by Ted John)

A few months ago, I wrote a post on medical education and my experience organizing a 2-week dental course for the medical students, which you can read more about here. It was the first time teaching such a course at our hospital and the first time for me to coordinate/organize a course. Since we don’t have any dentists on site, teaching was done exclusively through audio/video recordings and live video conferencing.

Fast forward a few months, and I have now finished coordinating a new course on orthopedics and trauma. Here’s a table to give you an idea of how they were similar and different, at a glance.

	Dental	Ortho/Trauma
Number of students enrolled	46	52
Duration of course	2 weeks	5 weeks
Number of instructors	3	6
Number of (different) lectures	9	29
% of lectures taught in English (PPT slides in French)	78%	26%
Method of instruction	tele-education	in-person (some distance learning)

Of course, there are a number of other differences. For example, the scope of the ortho/trauma course was broader, but more related to general surgery (at least as it pertains to trauma). Thus, while it would be ideal for orthopedic surgeons to teach the more strictly ortho topics, we did the best with what we had in terms of available expertise. In what other context could you imagine an ortho/trauma course taught by a motley of 4 general surgeons, an ER doctor, and a visiting orthopedic surgeon? 😄

Lecturing in our newly renovated classroom

Another big difference was that not all students were present for the in-person instruction at Kibuye. At any given point in time during the course, there were 8-16 students doing clinical rotations off-site in Bujumbura. As a result, it required more effort and coordination to ensure that these students could have timely access to recorded lectures and corresponding slides. The usual routine was that as soon as an instructor finished giving their lecture, they would send me their recorded audio file, which I would then upload to Dropbox (along with their slides). Then there’s the logistics of administering quizzes and exams in two locations simultaneously, getting scanned copies of the completed off-site quizzes, and grading and reporting all students’ results in a timely manner. Doing this in the US with high-speed internet and ubiquitous Wi-Fi would be challenging in and of itself, so accomplishing this in our context is nothing short of incredible.

Medical students taking one of their weekly quizzes

Here’s a condensed list of the content we covered:

• ATLS/Burns
• Trauma of the spine and chest
• Trauma/fractures of the upper extremities (shoulder, humerus, elbow, forearm/wrist, hand)
• Trauma/fractures of the lower extremities (hips, femur, knee, ankle)
• Musculoskeletal infections and tumors
• Differences in the pediatric population (plus congenital abnormalities)

Skeleton models of bones and joints were available for students throughout the course 

Much of the content goes well beyond the expertise of a typical general surgeon, so we are thankful for a French textbook that we used as the foundation for our instruction. In reading through this book and preparing slides, I’m certain that each instructor learned something in the process, whether deepening their own medical/surgical knowledge or perhaps learning additional French words for specific terms. For instance, I learned that the commonly used English abbreviation ORIF (open reduction, internal fixation) does not translate exactly into French as with other terms and is probably closest to réduction sanglante avec contention interne (which is literally “bloody reduction with internal compression/immobilization”). One can only wonder if this is actually what is colloquially used in France. In this sense, it felt like I was earning continuing medical education (CME) credits.

We’re also thankful for Joel Post, an orthopedic surgeon who visited for 2 weeks during the middle of the course. We intentionally planned the course to correspond with when he was around so that we and the students could benefit from his expertise. With Dr. Post’s fellowship training in orthopedic oncology as well as traumatology, he was the perfect person to give the lectures on osseous tumors and ankle fractures (which I view as generally more complex both in terms of injury patterns and management). As I sat in the back of the room listening to him, with stories of patients from his own current clinical practice, I couldn’t help but think, “Wow, this is so interesting. I wish Joel could teach all the ortho lectures!”

My family with Joel just before his return to the US

Overall, though, I’m quite pleased with how the course turned out, and I think the students learned a lot. As with the dental course, I recognized the top performing students, but this time with little bags of calcium supplements (tums) for fun. I even trialed an electronic post-course survey through google forms to solicit feedback, the template for which others can continue using in future courses going forward. In response to the question of what was the best part of the course, a good number of students said “everything”. Yet, I know there’s room for improvement, and will take to heart the students’ suggestions for the next time this course is taught again in a couple years. For now, I can redirect my attention elsewhere, perhaps in helping with the start of a surgery residency training program in the coming months. Tibia continued...

Group photo with the Kibuye cohort of students at the end of the course

A Tale of Tele-Education: Mouth Matters

(by Ted John)

A big part of our ministry in Burundi is medical education, a topic which has been previously written about and most recently here. A couple years ago, there was a major change in re-structuring the medical school curriculum such that med students would do nearly all of their clinical rotations at our hospital (whereas it was only about a third of their clinical time with us in previous years). Awesome! This continuity and increased face time had many positive implications, including more opportunities for building relationships at a deeper level and for medical education and discipleship. 

Not surprisingly, this transition also came with some added responsibilities, including the organization and teaching of more coursework, much of which was previously taught elsewhere by others. Thus, there has been increased time and effort putting together resources, creating PowerPoint presentations, and organizing courses to fulfill the med school curricular requirements (especially if it’s the first time a course is being taught at Kibuye).

It makes sense that the pediatric course would be taught by pediatricians, and we are thankful that the knowledge and expertise was contained within teammates on site. It’s no small task to organize a 75-hour pediatric course! But what about the courses for which we don’t have the specialties represented here at Kibuye? For example, Cardiology, Psychiatry, ENT, PM&R, Dentistry, Ortho, and the list goes on. Well, nowadays with modern technology, it’s possible to do this creatively in the truest sense of tele-education and distance learning using a combination of audio and/or video recordings and live video conferencing, often in both English and French.

I am certain each course has its own story behind it, but I will share a little about my personal experience of how I (a general surgeon) ended up organizing a 2-week, 15-hour dental course (“cours de stomatologie” in French), implemented and completed in December 2021.

Med student courses are usually taught in the hospital chapel

Back in August 2021, not long after I returned to Kibuye, I remember having a conversation with one of our teammates about how the dental course had been postponed due to the challenge of finding instructors. Then I thought about my dentist friends in the U.S., many of whom I had befriended when I was a med student at the University of Michigan (which also has an excellent dental school!). So, I contacted some of these friends (big thanks to Amy, Dave, and Ben), who all expressed interest in being part of the development of this course.

What went into putting this course together? In a nutshell, these were the major steps that occurred during the subsequent 3 months (in mostly chronological order):

•         Determine educational content based on provided learning objectives and context
•         Organize the material into 1-hour lecture blocks
•         Divide work amongst presenters
•         Create PowerPoint presentations
•         Translate English slides into French, if applicable
•         Pre-record each presentation as a video, in French if possible
•         Write quiz/test questions for each lecture (and translate into French)
•         Coordinate selected lectures over live video conferencing (Zoom) over different time zones
•         Proctor, grade, and submit results of quizzes and final exam

Dr. Ben Kang giving a lecture on inflammatory diseases of dentistry over live video conferencing (Zoom)

Things didn’t always go according to plan due to unforeseen circumstances, and an element of flexibility was required. For example, on the first day of the course, we had planned for a live Zoom lecture, but earlier that same day, lightning struck the hospital and damaged the Wi-Fi equipment. As a result, I had to re-arrange the schedule and show a pre-recorded lecture instead. It also happened that there was a concurrent anesthesia course, so the schedule had to be adjusted a couple times such that there was no overlap.

Dr. Dave Chiu giving a lecture on the temporo-mandibular joint

In the end, the content was delivered, even if not in the originally planned order, and all the students passed the course successfully (which I’ll take as a surrogate measure that some learning has taken place!). I even recognized the top performing students with a new toothbrush each.

I also gained some cultural insights about teeth and dental care in Burundi. For example, have you ever thought about what people in other countries and cultures do with their baby teeth? Most Burundians apparently throw it under their legs (described to me in the manner of hiking a football) and say the phrase, “nyamanza tora iryinyo ryawe unsubize ryanje ryiza,” which rougly translates as “a small bird will take your tooth and give you another (permanent tooth) that’s better.”

While I was glad when the course was over, it was definitely meaningful and worthwhile to be able to be part of teaching and equipping these future medical doctors with basic dentistry knowledge. Since it was the first time teaching this course, there was more upfront time and energy invested in content creation. But in future years, we should be able to use the same didactic content, and focus our attention instead on how to make the course better.

Group photo with all 46 students at the end of the course

What’s next? Well, there's actually a 45-hour "synthesis" course already underway, which is being coordinated by Eric and taught by many of our teammates. After that, I'll be coordinating a new 45-hour trauma / orthopedic course, currently being prepared for a tentative start date in mid-February. It’ll be a bigger undertaking than the dental course, but thankfully we have a French textbook as a reference and 5 surgeons involved (one of whom is an orthopedic surgeon who will be visiting Burundi at that time).

Looking back at my own med school days, I can say that I took the courses and the quality of education for granted. Funny how God is using my role as an educator now to give me a new perspective and deeper appreciation for anyone and everyone involved in medical education.

COTW: Tuberculeus Adenitis, PEPFAR and Education

 (from Eric)

Over the weekend, some of us were talking about the recent lack of medical blogs.  This is largely driven by the fact that, when you've done something daily for several years, you start to think "what is there to talk about?  It's just everyday normal stuff."  Not only is our daily work not-normal for the majority of this blog readership, but we in the daily grind need fresh ways to "see" what is around us, particularly when it proclaims goodness and hope, though the white noise of the everyday threatens to drown it out.

So, in that spirit, our first Case of the Week (COTW) in the last 11 months.  =)

My first morning back on Internal Medicine last week, my students guided me to the bedside of a new patient.  A young man in his early thirties, he had swelling on both sides of his neck that was quite painful, in addition to multiple weeks of fever and poor appetite.  Just before coming to the hospital, he had gone to a local nurse-run health center, which had tested him for HIV, which was positive.

The students wanted to know if I knew what was causing this neck swelling.  Yes.  Yes, I do.

Note the swelling on the side of the neck and the skin breakdown where it had been oozing.

Painful swelling of the lymph nodes on either side of the neck muscles in an untreated HIV+ patient with a couple weeks of fever and poor appetite in Burundi is about 99% certain to be Tuberculosis.  In fact, he even had the classic matted appearance and evidence of past oozing fistulizations which are typical of TB. We put him on TB medications (which are free) and contacted our HIV nurses to come and get him into the system to start ARVs in the next couple weeks (which will be free).  He slowly started to feel stronger and we let him go home yesterday, but he'll return in a week to start HIV medications.

***

For me, this guy is about as simple as my cases get, but I peel back the veneer of a To-Do list checkbox and find a number of things to celebrate:

1. THE PATIENT: This young man is probably going to do great.  Yet without a proper diagnosis and the medications for his problems,  he would likely die, from his TB alone, even more so from HIV.  His TB is curable.  With proper treatment, he can live a long and healthy life with his HIV.  It is a changed life, and I got to be a part of it.

2. PEPFAR: I don't think that most Americans are aware that the US has spearheaded the largest global health effort against a single disease (until Covid) via PEPFAR, which is the US President's Emergency Plan for AIDS Relief.  It was started in 2003 by George W. Bush, and has continued since then.  This fund has provided care in over 50 countries and is estimated to have saved over 20 million lives, largely in Sub-Saharan Africa.  The US is not extraordinary in regards to foreign aid compared to other rich countries, but PEPFAR is a great example of something America has done that has truly changed millions of lives.  

15 years ago, medicines for HIV would likely have been unavailable for this young man.  Around 10 years ago, it was found that, if someone is well treated with ARVs for their HIV, their ability to spread it to someone else drops dramatically, which has caused policy makers to try to get everyone with HIV on treatment, since it was prevention as well as treatment.  Now, though considerable challenges exist in implementation, the difference feels palpable to me.  Yes, this guy came in with previously undiagnosed HIV, but these cases feel increasingly uncommon.  This is a very good thing.

3. EDUCATION: I don't know the mental image of the above story that automatically comes to you.  But if it didn't include the white coats of at least 15 trainees or various stripes (medical, nursing, allied health), then it wasn't accurate.  All of this was an opportunity for these growing professionals to see a problem that they should be able to correctly diagnose and manage the next time.  HAU currently has hundreds and hundreds of graduates that trained at Kibuye that are now working all over the country and the region, and this was another small moment to help them to do that future work better.

The Hardest Thing

 by Jess Cropsey

Our life in Kibuye is pretty comfortable. We have a nice house with appliances, indoor plumbing, and tile floors, all luxuries that most Burundians don’t have. We (now) have relatively reliable power, water, and internet. So when people ask me, “What’s the hardest thing about living in Burundi?”, my answer has always been pretty immediate — being away from family. Yes, for sure there are a host of other challenges including cultural and language barriers, limited resources, and conflict. But the hardest for me has always been missing out on time with family and sharing special events like birthdays, holidays, and family vacation. We’ve had nieces and nephews that we never got to hold as babies. While I appreciate how travel and communication are much easier than they once were, that separation has always felt like the biggest sacrifice, only now the scope has widened.

Last weekend, 3 Kibuye families dropped off their kids at Rift Valley Academy (RVA) in Kenya, a boarding school for missionary kids. The Watts were the first brave souls from our team to embark on this venture. Faders and Sunds sent their oldest girls there last year. This year, it was our turn too. For 4 years, I have watched these parents grieve sending their kids away and navigate parenting from afar. I’ve listened to their pain and watched them weep. I don’t know why it surprised me how incredibly hard it was to leave our daughter Elise (8th grade) last Friday. 

Of course it didn’t help that we faltered on our final decision multiple times in the days leading up to travel due to a rapidly changing situation with new information from the school about online options, rising covid numbers in Burundi & Kenya, land borders closing in Burundi, changing test requirements for travel, and increased mandated quarantine times, all of which made us second guess this decision.

And yet as our family considered the situation, we remained convinced this was the right choice for Elise. In her 7 academic years in Burundi, she’s had an age mate twice for less than a total of 1-½ years and both were boys. Over the last few years, one after the other of the older kids she was grouped with have gone away to RVA. She’s longing for friendship with others her age in her heart language and we can’t provide that for her here in Kibuye. She needs discipleship, social interaction, extra-curricular opportunities, and a larger community.

Elise with new classmates

RVA is an amazing place with staff who are dedicated to loving and serving students and their families in a wholistic way. Yet as a parent, it feels like such a big loss to send her out of the nest 5 years earlier than most people have to. The cost feels immense and I’m so jealous that other people are going to be the ones to hug her when she’s sad, to make her birthday cake, to help her with a problem, to answer her questions about homework, to make special memories with her, etc. 

Elise's dorm parents who, I hear from many people, are amazing!

Elise's dorm, complete with a really nice yard and beautiful view of the valley

Getting settled in her new room

I know the time always comes when parents relinquish those roles, but it just feels too soon right now. And while I know in my head that RVA is a good place for her, my heart is broken and so very sad. I now really understand the feelings that my teammates have shared over the years.

Getting some final snuggles in during orientation

Lord willing, tomorrow I’ll be getting my 4th covid test in 12 days (technically 5 since one guy decided to give me both throat & nose tests in the same sitting) and after a negative result the following day, will be released from a 7-day quarantine at a hotel in the capital city. I’m looking forward to seeing John and the boys again but I know that grief will linger as I walk by Elise’s empty (and now always clean!) bedroom, set 4 plates on the table for meals instead of 5, or realize that I don’t need to order as much produce each week or do as much laundry. 

Please pray for Matea (11th), Anna (10th), Micah (9th), and Elise (8th) as they transition to a new year at RVA (and the Sund kids too). While Micah & Elise are the new ones this year, even returning students have adjustments to make as school is so different with masks and social distancing. Pray that they would grow academically, socially, spiritually, and emotionally. And don’t forget to pray for their parents too.

(left to right) Anna, Matea, Piper, Elise, Ella, & Micah, 

all current or former Kibuye Kids now attending RVA

Year 8 Is Going to be Great!

by Jess Cropsey

It's that time of year when we all start to see back to school posts on social media, although this year will certainly be unique as school will look different for most teachers, parents, and students. In two weeks, we'll begin our 8th year of school at Kibuye Hope Academy, the small school we have for our team's kids. Ironically, it's going to look a lot more like the first year than ever before with me and Heather as the main teachers and only six students....but hopefully not for long! 

In recent weeks, we've said goodbye to the three teachers that have faithfully served our team families for the last 2+ years. Kayla finished her 2+ year term with us in May and will be starting a new job at a school in Michigan in just a few days. As the main classroom teacher for our 11-year-olds for the last two years, she invested deeply in meeting the needs of this diverse group of learners. She excelled in asking good questions, sharing her love of writing, tracking student progress, and a host of other skills. We already miss her presence on our team and at the school.

Scott & Lindsay Nimmon have been with us for the last 4 years. Scott -- history buff, king of the cheesy dad joke, lover of all things Star Wars & Marvel, and teller of fantastic tales -- took on the formidable job of classroom teacher for the middle schoolers. His infectious smile and humor were able to cheer even the most moody among them, and the kids adored him. Lindsay has served as our principal, bringing our school to a new level in organization and rigor. Learning experience days, artist & musician study, and clubs were also her brain children and have brought richness and depth to our learning community. Their family is now settled at Rosslyn Academy in Nairobi where they will continue to minister to third culture kids. 

All three of these wonderful people have been such a blessing to our community as they spent many hours night and day thinking about how to help our team's kids grow academically, emotionally, physically, and spiritually. They truly were the backbone to our team, providing stability and support to our team families. 

And I would be remiss not to mention our amazing intern Alexis, who helped in so many ways this last year -- teaching Bible, PE, art, and clubs as well as homework help, reading, and math sessions for individual students. She was a wonderful gift that God dropped in our laps at the last minute, and she has an amazing story to tell about how God confirmed her calling here. She is now in Canada pursuing a career change from education to medicine.

Above: Alexis (center) with Maggie (left) and Sam (right)

Below: Alexis (center) observing in the eye OR with John & Nurse Rubin

Just about a year ago, we knew they would all be leaving and had no prospects on the horizon for their replacement, but of course, in God's kindness, He moved the hearts of several new people to join us and we are really hoping to welcome them here soon!

Erica Ause, from Knox Church in Ann Arbor, will be joining us for 2 years as soon as the Burundian airport opens up! She will be teaching Bible, language arts, reading, and writing to our group of 1st-4th graders. She visited in February for a short trip and also spent several months last fall in Honduras. 

Jenny Sorondo, from Florida, will also be joining us for 2 years. She has over 10 years of teaching experience as well as a variety of cross-cultural experiences. We are looking forward to welcoming her here in 2021. 

In addition to these two fantastic, gifted ladies, we're also thrilled to have Steve and Mary Wiland come for the school year. Steve will continue his counseling practice remotely part-time while also helping out at the school with Bible and PE. We're very fortunate to have Mary bring her decades of teaching experience to help us with science, math, and art. 

Steve (teaching juggling) & Mary's first visit to Burundi in April 2019 with the Heart & Soul team

We want to send a big THANKS to all of you who shared and/or prayed about our need for teachers! Rejoice with us in seeing God's answer to our prayers. If you'd like to give a financial gift to help the new folks on their way here, click on the links above. Feel free to keep sharing and praying too. Teachers are an ongoing need for us in Kibuye and other Serge Africa teams too. 

And please pray that Burundi's embassy in the US will begin to issue visas and that the airport would open soon so that our teachers and returning teammates will be able to travel. Finally, please pray for our small crew here as we do our best to teach the kids until reinforcements arrive. We'll all be stretched in new ways, but Year 8 at KHA is going to be great!