Introduction
Dr. Gisele Juru Bunogerane is a general surgeon in Kigali, Rwanda and COSECSA Fellowship trainee in Paediatric Surgery. She completed her undergraduate and postgraduate surgical education completely in Rwanda. As part of an ongoing educational collaborative with the University of Florida, she was invited for a one-month observership to the University of Florida. The goals of this exchange are cultural exchange, exposure to complex critical care, and in-depth teaching and instruction. The experience is tailored to the needs of the trainee in terms of exposure after discussion with their local program director. Travel and local accommodations are provided. The global surgical literature is rife with reflections on the benefits of international exchange for North American students, but the opportunities for partners on the other end of the world are often few and far between. Although many visiting trainees to the United States are unable to scrub due to malpractice and licensing requirements for a short term exchange, reciprocity is key to partnership. I delighted in reading Dr. Juru’s reflections and following up with her as the months passed following her experience. It teaches us something about ourselves to see our practice reflected, and highlights the importance of diverse educational opportunities for trainees in all environments.
Robin T Petroze, MD, MPH, FACS, FAAP
Associate Professor
Pediatric Surgery
University of Florida
Reflections
It was with an immense pleasure that I finally responded to my invitation from the Division of Pediatric Surgery and the University of Florida Global Surgery and Health Equity Program in Gainesville, FL for a four-week period in the spring of 2022.
It was in the frame of a developing educational and research collaboration between our institutions that focuses on educational development.
Actually, I am a general surgeon… and the first trainee of the pediatric surgery program in Rwanda. I needed additional clinical exposure to advance pediatric surgery and specifically wanted to focus on minimally invasive surgery, neonatal clinical care …This invitation could not have been better timed.
I did not have clinical responsibilities or patient-care privileges, and I participated in an observership including clinical shadowing and educational exchange focusing on advanced pediatric and neonatal surgical, trauma, and critical care.
What I narrate here is part of what I observed during this time.
Let’s start with the beginning…
That said, it was not easy since I had to wait a long time before obtaining my visa for the United States, because of COVID-19. My departure date had to be changed several times, and I had to make multiple arrangements at my home program just to make it work. The visa process makes definitive planning a challenge!
In short, everything was finally in order and I took my flight to Florida. I landed in the city of Jacksonville, where I spent the night at the hotel before taking the road the next day to Gainesville where the University of Florida is located and renowned for its truly advanced health services. It was an interesting trip with a medical student (who had previously been in Rwanda) who took care to show me everything I needed to see on the way to Gainesville.
I was warmly welcomed by my mentor, a really fantastic pediatric surgeon whom I know well from her many annual visits to my hospital. We are always so happy to work with her. She did me the honor of welcoming me into her home where I had a truly memorable stay.
The next day, I was excited to go to the hospital and see with my own eyes what a children’s hospital looks like. As I expected, the building was huge. I was fascinated by the many colors that embellished one of its facades. I then went to the department of pediatric surgery, where I was warmly welcomed by everyone–the surgeons, the nurses, the administrative assistants. I didn’t really expect that…I rather thought that no one in the USA would be interested in a fellow from Africa, from Rwanda…but no, everyone was interested and curious to know everything about my country and about my training there.
I was then given my badge and the adventure could begin.
The first thing I visited was the operating room. It was cluttered with a lot of brand new equipment. Honestly, I had never seen a room equipped with a lot of devices and equipment–so many screens …It was beautiful…It was also the moment of my first selfie…
I was always curious to know what a NICU looks like. I still can’t believe what I saw…I counted at least 20 ventilators… and I stopped because I couldn’t finish it. It was like counting the stars at night. Compared to my hospital which only has one ventilator machine for newborn babies, you understand how I felt at that moment!
I then went to hospitalization. Each patient has his own room… and well equipped…
To be brief, I suddenly understood that nothing is going to be comparable to what I had already seen and that maybe adapting will not be as easy as I thought.
To my surprise, I received help to adapt–Everyone from this wonderful team helped me to familiarize myself with the places and the sudden change in my work environment. As I was only hoping for my mentor’s help, I was really pleasantly surprised.
Unfortunately, one day I wanted to fly without wings, and I went down from the sixth floor where the offices were to the 2nd floor where the operating room was. Until then everything was fine. The problem came when I wanted to go to the NICU, which was on the third floor. I got lost, and the worst thing is that I couldn’t find my way back to the office where I had left my phone… I could not call anyone. It’s hard to understand how I got lost…but I swear there were so many hallways…so many elevators that I found myself going around in circles for more than two hours…I was so ashamed that I almost didn’t tell anyone that day!
Time comes for serious things…
With daily teaching rounds with the Division of Pediatric Surgery, I had a unique opportunity to observe team dynamics and teaching daily. I have been invited to participate in multidisciplinary trauma quality improvement, trauma simulations, ECMO rounds, oncology team meetings. A good example for development of multidisciplinary rounds in Rwanda.
I had also the opportunity to participate in mock oral examinations with the many faculty members of the Division of Pediatric Surgery. It has been of great importance in helping my own development as I am preparing my exit pediatric surgery exam with the College of Surgeons of East, Central, and Southern Africa (COSECSA) this year…but also it has helped me to develop as a teacher and trainer as I always engage in training of medical students and residents in my home country.
I really enjoyed rounds in NICU and PICU. I learned a lot with the consultants and fellows … I had exposure to complex neonatal management, nutrition, and critical care in general. This was particularly very interesting as we are looking forward to develop pediatric and neonatal services in Rwanda …THIS PART WAS REALLY HELPFUL.
ECMO rounds were interesting and impressive to finally see something I had exposure to in textbooks… but I think I haven’t had enough of them at all…next time maybe…
The first operation I observed was a laparoscopic cholecystectomy. I remember it well because I had the impression that I had gone to the wrong room and was in the adult room. The child was almost my weight, and believe me, I have pounds! It was cool to see how everything was organized. When the surgeon came in, all the instruments were well prepared. The operation lasted 45 minutes if I remember correctly.
And then there were laparoscopic appendectomies, more cholelithiasis, pilonidal cysts, and more and more again.
Then came the long-awaited moment of seeing my first thoracoscopy. It was for esophageal atresia. I was really moved to see how they managed to ligate the fistula and make an anastomosis in this tiny thorax using three small holes and instruments.
My second moment of happiness was during a splenectomy. It was spectacular to see how this huge spleen could be shredded piece by piece and removed from the abdomen without leaving a single small part.
However, as time passed, I got tired of just observing. I missed that unique feeling the surgeon has of being able to touch the scalpel—it was my last week…and also I was missing my two wonderful children…I was missing my whole family…I was missing Kigali.
But there was still a big event to come that I was looking forward to—the annual pediatric surgery research symposium, with a visiting prominent guest speaker. During that, I took the occasion to present our 10 years’ experience in managing gastroschisis at my hospital. People were really impressed with our improving outcomes despite very limited resources … but still, there is a long way to go…
In summary, this was really a great one month experience! If I had to do it again, I would do it without hesitation. I hope this collaboration will continue to allow other fellows to live this great experience.
And of course, we will be truly happy to welcome surgeons, nurses, students, residents and fellows from our partner institution who would like to visit our country of a thousand hills and at the same time visit the department of pediatric surgery…I’m sure you’ll like it.
Dr. Gisele Juru Bunogerane
Pediatric Surgery Fellow
Kigali, Rwanda
Robin T. Petroze, MD, MPH, FACS, FAAP
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