Thesis Whirlwind

by Logan

Whew! In some ways it feels like I can finally come up for air. The specialist doctors at Kibuye have just finished a ridiculously busy time, supervising research, editing papers, and judging the thesis defenses for over 40 medical students in about a month’s time. 

Carlan Wendler, Alliance Niyukuri, George Watts, Greg Sund, and Logan Banks chat in between students' theses

Why this sudden sense of urgency?

Burundi recently changed the way that they authorize doctors to practice medicine in Burundi. In the old system, as soon as a medical student defended their thesis (a final research project that is the final step before finishing medical school) they could apply for a license and start practicing as a physician. There was no pressure to finish before a certain deadline, so the work that this thesis project represents could be spread throughout the year. This also means that the work for the specialist doctors that act as “directors” of the students could be spread out as well. If someone was directing 4 or 5 students, they could do perhaps one a month so that the work wouldn’t be overwhelming.  

But a few months ago, the government said they would only authorize these new physicians once per year. This meant that a large group of medical students were suddenly desperate to finish their final research projects before the end of the year. 

What is it like to direct a thesis project?

The student comes to a specialist and asks them if they would be their director. Depending on their workload, availability, and other factors, the doctor agrees. The director helps the student come up with a research idea, review the research process, edit the paper (several times actually — which is more like a book, with an average length of around 60 pages), and help the student get ready to present the research and answer questions about it in an oral “defense.” This represents several weeks to months of work for the student, and several days to weeks of work for the director. 

When the student is ready to defend their thesis, the director recruits two other specialists to sit on the “jury” with them, and after a 15 minute oral presentation by the student, each person has a chance to make comments about the study and to ask questions to the student. 

Jason Fader, Alliance Niyukuri, and Ted John sit on a jury

The whole process from start to finish takes over an hour. Then the grade is given, and the student immediately takes the “Serment de Genève”, the French equivalent to the Hippocratic Oath.  

Just some of the 41 medical students as they take their "Oath" after successfully defending their theses.

This process was then repeated over 40 times between December 6th and January 11th. 

Greg Sund, Rachel McLaughlin, and Logan Banks celebrate with the new doctor Abel Nzoto after he successfully defended his thesis.

As you can imagine, this was an incredibly busy time for all the doctors at Kibuye. There are 10 specialists doctors currently at Kibuye. 41 students x 3 doctors per jury = roughly 123 times that a combination of 3 doctors sat on a jury. Some days there were 5 theses in the same day. That is nearly 8 hours of defenses. Sometimes one doctor would sit on 3 juries in the same day, reading and critiquing research in French for 5 hours. During this month-long period, one doctor actually sat on 26 juries, 9 of which as the director. 

This also meant that all the other doctors at Kibuye (the Burundian generalists and interns in the Stage Professionnel program) all had to pitch in to help the hospital services continue to run smoothly during this time. There were days that I was supposed to be rounding on Pediatrics that I could hardly make it over to the ward. I am so thankful (and I know all of us are) to the other doctors on our services that helped keep things going during this hectic time. Carlan even organized a “Thank You” dessert for our Burundian colleagues.

"Thank you! Thank you! Dear Colleagues!"

We are so thankful for the help from all the doctors at Kibuye. We are so thankful for all of these new doctors that just finished their theses. These 41 new doctors represent so much more than the work that went into the past month. They represent years of hard work -- on their part, and on the part of all the professors that taught them (whether in the classroom or on the wards) how to care for their patients in a compassionate, Christ-like way. 

Forty-one new doctors to help care for patients in Burundi (and beyond). What an answer to prayer!  That makes all this craziness worth it. 

But for the moment at least, I know that we are all ready for a nice long break from any more theses.  

A View from the Construction Sites

Hello! My name is Jessica Lembelembe. My husband, Mathieu (Matt) and I are here in Kibuye for a 6 month season supporting construction at the hospital...and on a few other building sites nearby! We are happy to be here and share a bit about what's going on in our corner of Kibuye.

First a little more about us: Matt is an architect with Engineering Ministries International (EMI). Because we are based in East Africa, he had the chance to visit Kibuye on several short term project trips, when a team of engineers and architects have come to develop and flesh out the hospital masterplan. Since we met in 2016, Matt's been telling me about the project, and when we got married last year, he promised to bring me along to see this special community. We were happy when the position for a temporary construction manager in Kibuye opened up at a time when we were also available for a new assignment. So here we are!

Taking a tour through the blog archives, I found several posts that tell the story of how the hospital has expanded and already fulfilled parts of the 20 year growth plan. One of the earliest steps in the process was the development of a physical masterplan with the help of a team from EMI in 2013 (see post here). If you look at the Vision tab on the blog you'll see the picture below, showing how the hospital looked when the Serge team first arrived. It had about 100 beds and many medical students - but not many doctors.

Fast forward to 2019, and this is the view we saw when we arrived:

All of those new blue and red roofs represent growth in this community. And recently, the team celebrated the fact that there are now over 20 Burundian doctors serving alongside international doctors. God has been moving in this place!

From our vantage point, getting to dive into this movement of God midstream, it is so encouraging to look back and to look ahead with hope. Often, the daily work of building up institutions, and hospital wards, is slow and tedious. Transformation is hard to put your finger on. So we hope that this little tour of construction sites around Kibuye gives you a taste of the new life that is unfolding here.

Looking back, I found a post about the impact that new ORs have made on the hospital - allowing the staff to multiply the number of surgeries offered each month. Medical staff and patients are also benefitting from the new surgery patient ward (photo below), which Matt helped design on a previous project trip to Kibuye. Seeing it completed now is gratifying for the whole Kibuye team, and the EMI team, too!

Just next to the surgery patient ward is the future paediatric ward - which will soon be the biggest structure on campus.

The roof trusses are already installed, and soon, there will be more blue roofing sheets covering this three story building. We hope it will be open to serve kids by June next year. This will add 130 more beds to the hospital's capacity, bumping the total to 359! Why do we need so many beds? At the height of malaria season this year, there were 130 kids admitted to receive treatment by Alyssa and her team, but many were sharing beds with other patients, because the current ward is too small.

The muddy site above might not look like much now, but in a matter of months, it will be home to more doctors and their families who come to live and work in Kibuye. Part of the long term vision for the hospital, of course, is to ensure that Burundian medical staff, including specialists, are equipped to lead here. See the digital render of the future 8-unit residential building below.

Another fun ongoing project is the construction of a basketball court (below) in the nearby town of Bukirasazi. Clearly, Kibuye hospital provides essential services that are appreciated by families in the region, but recreation space for youth is also important to the community. So the Kibuye team is sponsoring this project to build stronger ties with our neighbors.

It's not only physical transformation of this village that encourages us. We can see God moving in the lives of the construction crew, too. Meet Quinzaine (red hat next to Matt below), the foreman of all the construction workers. He has served here faithfully for years, and is an expert brick layer. He is also a respected leader, and he coordinated the crew under him to contribute part of their salaries to purchase a drum set for our local church worship team. He traveled to Bujumbura himself to pick it up, and the gift was received by the congregation with much jubilation when it was unveiled for the first time on a Sunday morning.

I am encouraged to see such clear evidence of God's creativity and generosity in the crew of masons, welders and plumbers who work long hours to build this place, brick by brick. Their ownership of the hospital and the church assures me that the good work going on today will continue for generations to come.

Matt and I taking in the view of Kibuye from above.

Paternalism

by Rachel

“We want autonomy for ourselves and safety for those we love.”  —Atul Gawande

 I’ve had a lot of bad outcomes lately.  I guess things tend to run in spurts…bad things come in threes, or multiple patients come in with the same diagnosis after months of not seeing that diagnosis at all.  Lately, I’ve been thinking about multiparity, or really, grand-multiparity.  For the non medical folks, “parity” refers to the number of times a woman has given birth.  When that number reaches 5, she falls into the category of “grand.”  When I was doing my training in residency, it often seemed that the first pregnancy was “the worst."  Meaning, if you were going to get a complication, it would more often happen with the first one.  Walking in to Labor and Delivery and seeing a whole unit full of “nullips” (first time delivery) meant a long day and/or night of unknowns while we watched and managed and hoped that a C-section wouldn’t be necessary.  A unit full of women who were on their second or third deliveries was much more upbeat, fast paced, certain.  Of course, it wasn’t very common to have a unit full of women on their 5th, 6th, or 7th deliveries.

Burundi is very fertile country, in more ways than one!  The average woman will have 6 babies in her lifetime.  My clinic is flooded with women who can’t conceive, so it stands to reason that for every one of those women, there’s another on her 10th pregnancy.  And, soberingly, a woman stands around a 1:30 chance of dying due to a pregnancy complication during her lifetime (UNICEF statistics from 2010).  It also stands to reason that the MORE pregnancies you have, the more risk you expose yourself to.  I had an attending who liked to say that getting pregnant was the most dangerous thing a woman could do with her life.  OK, I think that’s a bit extreme.  But oftentimes, especially in the US with a well developed medical system, we forget about the potential risks of pregnancy and childbirth, especially because the risks seem so minimum in comparison to what you get out of the deal.  Even with all my training and knowledge of the complications of pregnancy, Eric and I decided to go through the process three times! (And let me tell you, I do NOT take the fact that we had three uncomplicated deliveries and three healthy kids for granted).

So, back to my bad outcomes.  I had two maternal deaths in March with almost identical stories, women who should have had a straightforward delivery.  Two previously healthy women, both on their 7th pregnancies, both with 6 living children, who presented to another hospital after prolonged labor.  Both had a ruptured uterus (where the uterus basically tears open because it’s been working so hard to get the baby out) and a dead baby.  Both received surgery to attempt repair, which failed, and were transferred to me for “better management”.  Both arrived in shock.  Both received hysterectomies to try and stop the bleeding.  Both died within 12 hours of arrival due to coagulopathy.  

I felt very powerless in the process.  I felt like my best efforts were not good enough.  And I felt regret for a system that tries but isn’t good enough to save these women and ensure their children grow up with a mother.  And finally…I felt myself wishing these ladies had just stopped having babies.  If only they had decided 5, or even 6, was the perfect number of children.  If only.

These are not the first two women who have died after similar circumstances.  In fact, after doing some research I found that it’s shockingly common in the developing world to develop a ruptured uterus because of long labors or limited access to care.  And experiences like this color my opinions and decision making.  If it can happen to those two women, why not others?  

So I keep advocating for better care, and better birth control.  I perform a C-section for a woman…it’s actually her 5th, and she has two living children.  The surgery is a mess and takes forever, due to layers upon layers of scar tissue.  At the end I tell her that we should tie her tubes because this is getting too dangerous for her.  She refuses.  Multiple times.  I take one tube, and then the other, in my gloved fingers and think about how easy it would be to tie her tubes right now, even without her knowing.  Even without her consent.  Surely, she doesn’t have enough knowledge or experience to know how dangerous another pregnancy could be for her.  I could probably be saving her life if I tied those tubes.  Or at least, saving her from terrible complications in the hands of the next, possibly unexperienced doctor who tries to perform another C-section on her in the future.  I am the one who spent years and sweat and tears and money to receive my medical training, to be able to advise and treat…my knowledge base is far superior to her own.  

And then I think about why I am here in Burundi.  About how much I care for these women, all of whom have suffered so much at the hands of family, husbands, an incompetent medical system, life.  About how they are all fighters, and how I want what’s best for them, to empower them.  And I realize that taking away one of the only choices she has, to make a decision for her, is exactly what I’m fighting against.  And I slip the uterus back into her pelvis and close up the layers, and hope that she never gets pregnant again….but if she does, I hope, I hope, I hope that she lives through it.

I don’t know.  I doubt myself.  But I know that change does not come by taking away autonomy.  I want these women to be safe, yes.  But there are other ways to bring safety.  If only…

Medical evacuation, part 2

By Alyssa 

In the last few years of team life, we have experienced several "all hands on deck" crises - such as the flash flood at the waterfall in 2016 and the failed coup d'état in 2015. These events definitely bring us together as a team in ways beyond what we experience through day-to-day life and work together. We regularly reference those intense bonding times and they go down in team history to be retold again and again. Well, we recently added another crisis to the team lore with our second medical evacuation (for the first one, read here.)

Similar to family life, each of us has team "roles" in addition to our hospital, school, and community work - tasks such as facilitating the weekly market order or the vehicle upkeep. One of my roles is to be team doctor. Usually that means handing out Zofran for stomach bugs, answering questions about malaria prophylaxis, or maybe putting steri-strips on a wound.

Cleaning and steri-stripping a minor wound for Abi

But last month our team dealt with an unexpected medical crisis for a visiting American boy that went way beyond minor! Cole was visiting with his family so his father, a surgeon, could help cover the surgery service for Jason. One day after running Cole complained of leg pain. As he was a healthy, active 12 year old, we didn't worry too much about it, but the visiting orthopedic doctor did check him out during lunch. The next day his leg was still hurting and he had developed a low grade fever, so we brought him up to the hospital for x-rays and lab tests. The x-rays were normal but the labs showed signs of infection and inflammation, so we started antibiotics. The leg still looked normal with no visible wound, swelling, or redness. The following day, however, he developed swelling in the leg and an ultrasound revealed a deep fluid collection near the bone. He definitely needed to have it drained in the operating room. We looked into sending him to Kenya for the operation, but it would be at least 24 hours before there was an available flight, and almost all the orthopedic surgeons we knew in Kenya were at a medical conference in Greece. We had a visiting American orthopedic surgeon at Kibuye, and he and Cole's father, also a surgeon, decided it was better to operate right away. Thankfully the surgery went well and the surgeons found and drained the infection near Cole's fibula. We now had a diagnosis: acute osteomyelitis (infection of the bone.) We hoped Cole would begin to recover with continued IV antibiotics.

Pre-op on left, post-op on right

The next morning, Cole was sitting on the couch reading a book when I came to check on him and give him his antibiotics. I listened to his lungs and noticed crackles in the left base that weren't there before. Then we checked his oxygen level and discovered it was lower than it should have been. And then he had another fever and significant tachycardia (fast heart rate), too. These were all concerning symptoms and meant without a doubt that we needed to get Cole to a hospital with an available intensive care unit ASAP! We were concerned the leg infection was now in his bloodstream and he could develop septic shock as a result.

This is the moment when the team mobilized into high gear like a well oiled machine. We were few in number as most of the doctors were at the medical conference in Greece, but everyone remaining dropped everything and came running to do the work of many more people. These are the folks you want by your side in a crisis! As Cole's dad spent hours on the phone with the med-evac company, the Serge Kibuye team packed up all the suitcases for the family of 7, looked at flights and arranged guesthouses for the mom and other four children in Kenya, drove cars (including a makeshift ambulance for Cole, his dad, and me) to Bujumbura, made lunch and fed all the kids, facilitated quick goodbyes, texted our Kenya connections to receive the family in Nairobi, connected with Kenyan doctors/hospitals, and of course monitored and cared for Cole. He got worse with a medication reaction just before we got into the vehicles to head for Bujumbura but thankfully responded to a breathing treatment.

Susan driving our "ambulance." A definite answer to prayer is that Cole actually started feeling better, and his oxygen levels increased as we drove down the hill towards the airport. The lower altitude and the vancomycin helped, but mostly people were praying around the world! Thank you! 

We waited for the airplane with our Serge teammate and peds ER doc Randy Bond, and thankfully Cole remained stable in the interim. Again Serge teammates served the family by caring for Cole's siblings and mother until their flight the next morning.

Cole and his father flying to Nairobi

Driving right onto the runway in our "ambulance" with our special patient 

As we drove back to Kibuye the next day and recovered from the chaos of the previous few days, Cole and his family's journey continued in Nairobi. He went back to the operating room multiple times and was finally stable enough to fly back to America where he was immediately hospitalized in Michigan for a few more days. And two and a half weeks after the ordeal began, he finally went home (though he will continue treatment for several more weeks from home.)

Cole thanking the Kibuye kids for their Get Well cards. Even the kids prayed for Cole and cared for him!

Thinking of Cole on Good Friday brought new meaning to Isaiah 53:4 where we learn that Jesus carried our pain and suffering. And that hope encourages me as I think of the pain and suffering my Burundian patients face as well. We all wait for the day when all things will be made new and there will be no more sickness or suffering or pain. In the meantime, I'm thankful to be waiting with my amazing friends and teammates! 

COTW: The Continuing Story of the Kibuye Triplets and the New Peds Building

(By Alyssa)

I’d like to introduce you to one family who will benefit from the new peds building (click link to see a 3 minute video). Some of the long time blog readers might remember the story of the triplets who Eric wrote about 2 years ago.

Well, the two remaining triplets are now 2 1/2 years old and they’ve been hospitalized three times on the malnutrition service - spending months of their lives at our hospital. 

October 2015 (10 months old)

Their mama understands what nutrition they need and does her best to care for them at home, but repeatedly she watches them become thinner and sicker, and finally she decides to take the arduous four hour walk to our hospital carrying both kids. I recently read a study highlighting the high (20%) mortality rate of twins in sub-Saharan Africa - three times that of non-twins - and that includes countries with much better infrastructure than Burundi. So it’s easy to imagine that the mortality rate of twins or triplets in Burundi is much higher. We always have several sets of twins in the hospital - usually premies in the NICU and kids on the malnutrition service. It’s so hard for mothers who are also malnourished to have enough milk for two babies at once. 

One of the twins with Anna in April 2016 (16 months old)

Eliana (left) and Rita (right) are both 2 1/2 years old!

So for Emery and Rita it’s two steps forward and one step back - especially this month. They were doing great and ready to go home (though still only weighing 10lbs and 13lbs) but I wanted them to stay in the hospital a little longer so they could learn to walk with Judith and Anna through some intensive physical therapy. 

May 2017 (2 1/2 years old)

Learning to stand

Emery learning to walk with Judith

I regret that decision now as they both caught serious infections in the hospital partly as a result of our overcrowding and they almost died. Praise the Lord who healed them one more time! They’re thankfully heading home once again now, and the mother will continue the physical therapy at home. But I look forward to the day when we will have a new pediatric ward with enough beds for each patient and a dedicated play room to help with the development and sensory stimulation for these kids. And I hope that when patients are no longer sharing beds, that the risk of them also sharing infections will decrease dramatically. Please pray with me for Emery and Rita and the many other patients we take care of with severe malnutrition and pray for God to provide the funds for a new well-lit, clean space in which to care for them. 

Going home in June 2017, pictured with Anna and Abi Fader

New Peds Building

(By Alyssa)

Burundi doesn’t have seasons like those familiar to folks who live farther from the equator, but it does have rainy and dry seasons. In the US and Europe, winter is the busy time in pediatrics as everyone is inside sharing all their cold and flu germs. But we also have dramatic seasonal variation in pediatrics in Burundi with rainy season being both respiratory infection season (like winter in the US) and malaria season. And every year I’ve been here, our patient numbers have increased. We had approximately 40 patients on the peds service each day during rainy season in 2014, 60 patients in 2015, and then last year we broke the hospital record with 89 patients (for 30 beds). That’s when our engineers Tony and Caleb came to the rescue and constructed a temporary ward in just 3 weeks adding 20 beds. But this year we smashed the record again with 117 patients (now in 53 beds)! Once again, thankfully, the engineers are saving the day as they have designed a fabulous new 80 bed pediatric ward to serve our precious patients for many years to come. Watch the below video to learn more about this exciting project - and feel free to share it with your friends!


Kibuye Pediatrics from Seth Chase on Vimeo.

First floor

Second floor

Site of the new peds building

Current overcrowding

Patients and mothers sharing beds

If you would like to participate with us in caring for these sweet children in Burundi, click here to donate through the Kibuye Hope Hospital fund (type "pediatrics" in the memo line). All donations are tax-deductible. Thank you!

Saving Kids from Eye Cancer

(by Darrell)

Retinoblastoma is the most common intraocular tumor in children and represents 11% of all cancers in the pediatric population.¹  Thanks in large part to early presentation and advances in treatment in the United States, less than 3% of all patients with this cancer die, whereas in Africa, the mortality rate is 70%.²  

However, in Burundi in particular, it is worse: since John started the eye clinic in early 2014, he has seen between one to three children per month with this aggressive eye cancer.  He has yet to see one child survive.

There is nowhere in Burundi for these children to receive treatment (for the affluent, there are options just across the border in Rwanda), and after watching so many die despite taking heroic surgical measures, John decided in January to initiate Burundi’s first chemotherapy program for retinoblastoma.

John recruited a group of us, including Alyssa, Logan, Dr Parfait and myself, to travel to Kabgayi Hospital in Rwanda to meet and learn about the treatment of retinoblastoma from a British ophthalmologist named Dr. Keith Waddell.  When I first shook hands with Dr Keith, I had the distinct impression that I was meeting the most important person I had never before heard of.  He immediately memorized our names (and checked them twice) and then ushered us into a sitting room where he began to unfold the story of the years-long attritional war he had been waging with retinoblastoma in Uganda.  His keen eyes, unflagging energy, and ability to remain undeterred in his telling of this history despite my numerous questions were impressive, but all of that quickly paled in comparison with what we encountered afterward in the eye unit.  As we walked into the ward, many of his patients greeted him in possibly the warmest manner that I have ever witnessed—handshakes (of course), then hugs, and later even sitting in his lap and playing with him.  His patients (I actually started to type “children” there) loved him, and  one of the parents even referred to their child as “his” daughter.  There we witnessed true love between doctor and patient. 

All of these patients (with perhaps one or two exceptions), had had one eye removed by him, and sometimes he’s had to remove both eyes.  Many of them have had more than 6 cycles of chemotherapy that have, on each occasion, put them at a high risk for infection and death.  But every four weeks, they continue to come back.

Dr Keith has treated close to 500 patients with retinoblastoma, and he has documented all of their clinical courses in meticulous, working-late-into-the-night detail.  He has published some of his data^3,4, but as he puts it, he needs to find some additional time to finish it before he dies, which could happen at any time.  He is 80 years old after all.

John and I both hope to be old men like him one day (many here at Kibuye maintain that I already achieved old man status last October when I hit 40); regardless, Dr Keith is truly a remarkable person who has fully embraced his calling from God to serve the least of these.  I don’t think we could have assembled and inspired our retinoblastoma team without seeing Dr Keith and his team in action.  In fact, we now have five patients scheduled, nutritional status permitting, to begin chemotherapy on May 2^nd.

Ever since I had the privilege of spending many of my Mondays during fellowship on the Ocular Oncology service at Wills, I have wanted to be like Jerry and Carol Shields who direct it and care for retinoblastoma patients.  If I hadn’t been called to Africa, I would have wanted to pursue a career in their field.  Little did John Cropsey know that ordering chemo drugs one night back in January was going to lead to just the confirmation that I needed from God to stay the course here in Burundi.  Maybe even as long as good old Dr Keith has.

Figure 1. Some of the cancer patients of Dr. Keith

Figure 2. Dr. Keith teaching and caring for patients

Figure 3. Dr Keith in center along with his assistants plus our team.

Bibliography

1.     Wong JR, Tucker MA, Kleinerman RA, Devesa SS. Retinoblastoma incidence patterns in the US Surveillance, Epidemiology, and End Results program. JAMA Ophthalmol. 2014;132(4):478-483. doi:10.1001/jamaophthalmol.2013.8001.

2.     Kivelä T. The epidemiological challenge of the most frequent eye cancer: retinoblastoma, an issue of birth and death. Br J Ophthalmol. 2009;93(9):1129-1131. doi:10.1136/bjo.2008.150292.

3.     Waddell KM, Kagame K, Ndamira A, et al. Clinical features and survival among children with retinoblastoma in Uganda. Br J Ophthalmol. 2015;99(3):387-390. doi:10.1136/bjophthalmol-2014-305564.

4.     Waddell KM, Kagame K, Ndamira A, et al. Improving survival of retinoblastoma in Uganda. Br J Ophthalmol. 2015;99(7):937-942. doi:10.1136/bjophthalmol-2014-306206.