Hand and Burn Surgery in Kigali, Rwanda- Week 2

Lydia Helliwell, MD
Resident in Plastic & Reconstructive Surgery, BWH

PGY 6

Our first week at the University Teaching Hospital of Kigali (aka CHUK) was a whirlwind of tough surgical cases. We completed 14 cases in just 3 days, covering a wide range of hand surgery problems- congenital, post-burn, tumor and fractures. We were exhausted by the end of the week, but after a couple days off for Easter (Catholicism is the dominant religion in Rwanda), we returned to the OR Monday morning refreshed and ready to tackle several complex burn and reconstructive cases.

The approach to burn care in Rwanda is different from ours in several ways, and likely because of several factors, but notably, where we prioritize early excision and grafting, this is not done here in Rwanda. This delayed approach may be secondary to staff, instruments and OR rooms being needed for more life-threatening issues. Therefore, burn excision and grafting is delayed and results in patients requiring several days to weeks of dressing changes prior to reconstruction, which is not only painful, but also leads to more complex post-burn contractures. Unfortunately, most of our burn patients were children, as they are a population very vulnerable to burn injuries in Rwanda. We also cared for a young woman who had been attacked and burned by acid during an argument. She suffered burns to her face, arms and legs and was developing very severe contractures. All of these patients had been admitted to the burn unit undergoing painful dressing changes until their wounds were ready for grafting.

In addition to the difficult burn cases, we undertook several large soft tissue reconstructions. One was a young woman who had been hit by a car, resulting in a large anterior knee wound with an exposed joint. Another was a young man who had developed necrotizing fasciitis of his anterior abdominal wall, resulting in a large soft tissue defect. A third was a young woman who developed a serious infection of her C-section incision, resulting in another large soft tissue defect. These were all patients who the only plastic surgeon at CHUK had been tasked with taking care of and we worked with him directly to develop and carry out complex reconstructive procedures for these 3 patients, as well as several burn patients.

Over the course of Monday and Tuesday, we performed several split and full thickness skin grafts, a medial gastrocnemius flap for knee coverage, an abdominoplasty for abdominal wound coverage, and even a circumcision to obtain a full-thickness skin graft for a severe hand burn. It was amazing to both help all of these patients, and also pass on some of our knowledge and experience with burn, hand and soft tissue reconstruction to the local surgeons, residents and medical students, so they may continue these difficult reconstructive procedures after we have gone.

We wrapped up our final full day in Kigali with a morning lecture to the medical students and residents on acute burn care. We followed this teaching session with a general plastic surgery clinic. In the course of one morning with Dr. Fausten, CHUK’s one plastic surgeon, we saw the full gamut of plastic surgery, including hand injuries, breast cancer, lower extremity reconstruction and various wounds. Although we will not be around to work on these problems ourselves, it was great to discuss with Dr. Fausten and formulate plans for future surgeries.

Overall my experience in Rwanda was one of the best I have had in residency. I not only gained further experience in hand, burn and plastic surgery, but I gained experience in resident & medical student teaching, as well as exposure to the ups and downs of global health collaborations.  I was greatly impressed with the determination and dedication of the doctors in Rwanda to take care of a very complex patient population with much fewer resources than are available in the United States. I am glad that we were able to directly help the patients we operated on, but I am also hopeful that some of the knowledge and skills we taught will be utilized after we have gone. Finally, it was incredibly eye opening to travel to a country that prior to planning this trip I knew very little about. I am thankful that I was able to learn about the history of Rwanda and its recent genocide from the people that live there. I finished this trip with a much greater understanding of hand surgery, global health and East African politics….which is certainly more than I learn in a typical two weeks back at home!