The Last Week

We have come to the end of our 4 weeks in Rwanda. My family arrived to spend this last week in Kigali with me, and of course this has resulted in less time for writing!

It feels far too soon to be finished here. I feel like I finally understand how I can best contribute and what areas need particular attention. I remember this feeling from when I was a resident, changing rotations every 4 weeks. You finally felt like you were getting the hang of things and it was time to move on.

This was a short week, as Easter Monday is an observed holiday in Rwanda. We ran the academic day on Tuesday, complete with the required quiz on the last 4 weeks of curriculum. Following the quiz, we had a spirited debate over the answers to some of the questions. Once again, the resident group inspired me with their enthusiasm for learning and dedication to the “book work”.

Margaret and I spent our last 2 days here in the OR at CHUK with the residents. We both had the opportunity to work with the Chief Resident and this gave us some great time for discussion about his thoughts on the program and the future of the department here at the University of Rwanda.

I finally found my stride in how to teach a different approach to the pediatric patient to senior residents and to review/teach the basic anesthetic considerations of the pediatric patient to Year 1 residents.

It was a successful and rewarding week, but I will miss being here and working with these residents and the local Rwandan anesthesiologists. They have all be so welcoming, even though at times, I know we were an added burden to their day.

I now feel I have a much greater understanding of both the CASIEF program and the partnership between the University of Rwanda and Dalhousie University. Now I must ponder my future involvement – I know I definitely would like to return!

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A Busy Week 2: Butare/Huye

Due to the NOTSS course, the academic day for anesthesia residents was moved from Monday to Tuesday morning. We spent another fantastic morning with the residents teaching each other and engaging in passionate discussions over the best way to do difficult cases. After the half day was finished, Margaret and I were picked up for our drive to Butare.

Butare (now named Huye) is in the Southern province and it takes about 2.5 hours to get there. It was the original intellectual seat of Rwanda – the university was founded there and the other main University Teaching Hospital (CHUB) is located there. While in Butare we stayed with the wonderful family of one of the anesthesiologists (who happened to be in Halifax of all places, so I did not get to meet him).  It was lovely to stay in a home with children and puppies and gardens and a wonderful host. It was a short trip to Butare due to the NOTSS course and the Good Friday holiday. But it was very worthwhile.

We had the opportunity to work the residents currently on rotation in Butare and also to meet Dr. I – the first and one of only 2 pediatric anesthesiologists in Rwanda (a third will be joining the team in the summer).

On our first morning, the resident was doing a pediatric case – a 9 month old for a routine procedure. He had an excellent plan and back up plan. Unfortunately, things did not go as planned and we ended up struggling for over an hour to keep the patient’s oxygen saturation up and stabilize him for the surgery. It was very stressful as I still don’t have a full grasp of the equipment here and I am always wondering in the back of my head if there is something I don’t about this  machine or this place that is causing the problem! We called Dr. I to come and help but he was running a code somewhere else in the hospital! We finally managed to get the patient on the right track. Upon review, we can only assume the patient had a cold that hadn’t declared itself and definitely a component of reactive airway disease. But this was a much more dire situation than I would normally experience at home. Many things may have contributed: perhaps malnutrition played a role, perhaps the pre-op assessment hadn’t elicited important details, and perhaps the anesthetic we chose based on the available resources wasn’t the best choice.

It was yet another sobering experience for me. The patient did well – he tolerated our anesthetic and recovered well, although it was a lengthy recovery. But I am wondering why I have seen and heard of so many adverse events in pediatric patients here. It is true there is a high proportion of pediatric patients, but the anesthesia residents have strong skills and good plans.

Is it possible our most vulnerable patients are more susceptible to the extra challenges that anesthesia in a variable context imposes. And if this is so, how can we improve our care?

A Busy Week 1: NOTSS – VRC

This last week has found Margaret busy with teaching, travel, and even attending a course. Last Monday, the first ever Non-Technical Skills for Surgeons (NOTSS) in a Variable Resource Context (VRC) was conducted here in Kigali.  NOTSS is a well known course on the “softer” but equally important skills for surgeons. It is the surgeon focused version of the Anesthesia Not Technical Skills (ANTS) Course that many of us in my specialty are familiar with.

NOTSS (and ANTS) try to tackle the very important concepts of leadership, situational awareness, decision making, communication, and teamwork. In our specialties, the importance of technical ability has always been known, but it is often not what creates error or challenges. It is the other, “softer” and much more difficult to teach and assess skills that get us into trouble and can ultimately compromise patient safety. The NOTSS course addresses these skills and issues in a formalized way.

For the course here in Kigali, a team of Human Resources for Health Care surgeons had worked to develop the course specifically with the variable resource context in mind. In Canada/USA/UK we don’t have to worry (very often) about not having a piece of equipment we need or a medication or even a flow of oxygen! But in Rwanda, these challenges are a part of daily life and make non technical skills arguable more important. For, example, 3 languages are routinely spoken in the OR here: Kinyarwandan, English, and French. You can imagine the communication challenge of knowing who to speak to in what language at any given time!

Last Monday’s inaugural NOTSS – VRC course brought together surgical residents and staff from different disciplines, anesthesiology residents and staff, and operating room nurses. We all took the course together. The highlight of the course, I think, was watching the video vignettes which were filmed here in Rwanda by Rwandan film students and starring local staff and residents. They were highly entertaining and definitely delivered their key messages about non technical skills!

I was honoured to be present for this course and even more honoured when I had the opportunity to facilitate one of the small groups.  I was very proud to see the anesthesia residents (who now feel like “my residents”) participate actively, thoughtfully, and with confidence.

It was an excellent day that I think we all enjoyed. Huge kudos to all the effort made by the great group of people to adapt this course to the VRC and deliver it so successfully.

 

Learning to Teach Hands-Off

During my time in Rwanda, I have been confronted with learning about my style of teaching. In general, it would appear that my style is very hands on. I like to demonstrate, to help, to work together with the plan and the skills.  Full disclosure, I do not consider myself to be a particularly good teacher. I feel I am often impatient, worried about time, and distracted with my out – of – OR commitments to really focus on teaching. It is something I would like to improve about myself.

However, the goal of this trip to Rwanda teaching! What a luxury! I do not have out of OR commitments, I am not directly responsible for an OR list or any other patient care activities. I can devote myself entirely to teaching. It should be easy, right?

It has been very difficult to figure out how to teach without putting my hands on the patient. At home I will discuss a plan with the resident and we will fine tune the plan together and then do the case together. I am able to tweak things quickly as needed or completely alter the plan in an instant if necessary. In Kigali, I am in a supervisory role. The residents and I still discuss the plan. Usually we take the time to discuss the pros and cons of the possible options before deciding on a plan, but then I have to sit back and watch. As well, our plan often has to be altered in light the available resources. Once the case starts, I cannot rescue. I can make suggestions, but the residents and NPAs make the ultimate decisions, and occasionally the Rwandan staff weigh in when necessary. This has been very, very hard.   Continue reading

A Real Day in Kigali…

This morning Margaret and I set off for King Faisal Hospital, another hospital associated with the University of Rwanda Anesthesia Residency Program. We left before 7, with the plan to arrive around 7:15. However…traffic had other plans.

This week, Kigali is hosting 22 heads of state of African nations at the African Union meetings. This has the city in chaos! On Monday, we were offered a drive to the CHUK fro our neighbour only to discover that all the roads leading to CHUK from our apartment were blocked to cars! This was largely because the presidential residence is on our walk to CHUK and the security was tight! After driving around for 30 minutes we got out and walked. It was a lovely walk as…no cars!!! But many police with very large weapons.

Today we set out in a taxi to get to King Faisal, which is located beyond our walking distance, and….all roads leading to King Faisal are closed to cars! Apparently, today’s meetings were located in the convention centre which is close to King Faisal Hospital! Traffic was insane and finally, we asked the taxi to let us out and….we walked. Again, lovely walk..no cars. We arrived after 9am – 2 hours after we left home. Fortunately, the OR case had not started yet as the surgeon was also caught in the traffic jam!

It is fascinating that in the name of security, the traffic police will close off roads and routes completely – leaving no apparent alternate routes!

After work, we went to pay for our gorilla trekking permits (which took 2 long hours as the government website was taking its time). Then our guide, Emmy, tried to drive us home. It should have been about a 15 minute drive and again…over 1 hour in the hustle and bustle of motor vehicle traffic and foot traffic…I tried to take in the sites and sounds of Kigali…but I will admit I was tired. It was a long day of driving, walking, bargaining with taxis, waiting, and that doesn’t even include the work day.

Finally, we were home. We heard a beeping and realized we were out of electricity. As we left to go pay for more, the young man who is the property care taker started running after us and yelling. He is a very nice young man, who only speaks Kinyarwandan. After trying to make him understand we knew we needed more electricity (the reason he was running after us) we set off to the supermarket to buy some more and perhaps some Kenyan whiskey as well.

We finished the evening with a supper of chips and guacamole (amazing avocados here) and perhaps some adult beverages. All is well.

Anesthesia Residency in Rwanda

Margaret and I have now been here for a week – a whole week! I can already tell that this time is going to pass by too quickly. We have spent 5 days in the operating room with the residents and one day helping to run the academic day.

I am learning SO much, everyday.  I can only hope that the residents are learning something from me as well. The residents here are simply amazing. Due to the extreme shortage of doctors, in particular specialist doctors, in Rwanda the residents have a huge responsibility almost from day one of their training.

From what I understand, medical school last 6 years after which time each new doctor must practice as a generalist physician for at least one year. Usually their posts are out in the “district” – small hospitals all over the country. Many choose to do this for much longer or for their whole careers. Others choose to return for specialist training.

At CHUK, there are 6 operating rooms in the Main OR, plus 3 in the maternity area, and the ICU (Anesthesiologists run the ICU as well). In addition to anesthesia staff and residents, there are Non-physician anesthetists (NPAs). We have spent most of our time in the Main ORs as I am focusing on teaching paediatric anesthesia and that is where the kids are!

For the entire 6 ORs, there will be at most 2 staff anesthesiologists supervising ALL the rooms, and usually there is only one staff available. There are 2 rooms that are for residents only (not for NPAs). These rooms have the cases that require “more active participation” as one resident told me. The NPAs manage the rest. The senior residents (Year 3 or 4) will often have a Year 1 resident with them to teach. But often, due to staffing, the Year 1 residents will have to do a case or a list independently.

The cases range from anything from a 10 day old baby for a laparotomy to a 76-year-old patient for gastric tumor resection. And the lists are always changing depending on which patients are ready, emergencies, and other various issues. The residents largely practice independently out of necessity, but the staff is always around and available to help or answer questions, they just aren’t able to be in the room all the time.

Last week I was with a year 2 resident as he managed 2 very young babies for neurosurgery with great skill. Today, I helped a Year 1 resident with a plan for a bronchoscopy for foreign body removal. The 3 year old patient was very sick and took a long time to recover after his very long bronchoscopy. The resident had not done an airway case until today, and it was quite a learning opportunity!

The residents have a huge responsibility for teaching  junior residents and NPAs, managing cases, and knowing when to ask for help well in advance (as the staff cannot be in all of the rooms at once). And they do this with ever changing resources available to them. One day they will have the appropriate endotracheal tube available to them, another day they won’t. One day a drug is available, the next day the supply is gone. They have to be creative with their plans as well as safe.

These residents are extremely dedicated to their work. They start at 7am, they finish whenever the list is finished (often after 7pm) and then they read and prepare for their academic time. And of course they have lots of night and weekend call because there are so few of them. I have yet to hear any of them complain about their schedule…perhaps they just dont’ know me well enough yet 🙂

I feel so privileged to work with these residents. The are proving that there is a bright future for safe surgery in Rwanda.

Addendum to original post: I realized that I had not put in any context about how anesthesia residents works in Canada when I wrote this. In Canada, we have a consultant anesthesiologist (staff) for every operating room running. The residents do not run rooms without direct and individual supervision until they are very senior. And even the seniors are similarly supervised for any complex case, young child, or medical fragile patient. They are rarely, if ever, left to run a case completely by themselves. This is a stark contrast to what happens here in Rwanda.

All Moved in to the New Apartment

For the past 8 years, CASIEF has maintained an apartment here in Kigali. This has certainly made it much easier for the flow of visitors to get settled quickly. Unfortunately, over the last few years, the apartment has become increasingly uncomfortable. The water was more often turned off than on, the building is in a fun but very loud neighbourhood – with music pumping regularly until 4 in the morning, and most recently  there has been a cockroach invasion.

Finally the decision was made to find a new apartment. This was challenging because CASIEF is run entirely on donations and it is important to use that money wisely and conservatively.  Apartments in Kigali (with Western style amenities) are very expensive. Luckily, an apartment was found! Margaret and I were able to move in on Wednesday and today we were able to complete the move.

The new apartment is in a beautiful, quiet neighbourhood, Kiyovu, about a 40 minute walk to CHUK. The work TO work is uphill but coming home is down hill – major plus!

Today, the contents of the old apartment were moved into the new apartment.  I spent the morning with Christophe, the lovely Rwandan man who CASIEF employs to oversee the apartment, clean, and generally make sure the volunteers are sorted. We sorted everything and put everything away. Some of the items were humorous to me – 4 coffee percolators; a giant bin of medical supplies including IV solution and many medications; and a million shoe cover for the OR – Only anesthesiologists.

I would say that we are now officially all moved in and CASIEF has made a very good choice in this apartment. It is very comfortable and well located and I think Margaret and I, and future CASIEF volunteers will be very happy here.

Our First Taste of CHUK

Monday evening, Margaret and I landed in Kigali to being our month long adventure as volunteers with the Canadian Anesthesiologists’ Society International Education Fund (CASIEF) in Kigali, Rwanda. The program is an educational program, focusing on helping the residents become teachers and future leaders and educators.

The Centre Hospitalier  Universitaire de Kigali (CHUK) is a sprawling complex with many different buildings – pediatrics, OB/GYN, emergency, the Operating theatre, clinics, and ICU. Interestingly, ENT had its own building and there were so many people waiting outside – I wonder if there is a high incidence of ENT problems here! Since we were too late to join in the Operating Theatres today, we had the luxury of spending time having a tour and a bit of an orientation. We met up with Dr. E, who very kindly gave us a tour.

We started with the SIM centre, which was a joint project between Rwanda University and Dalhousie University – I have attached a photo of the sign on the sim centre. I will admit, I felt a bit proud to see Dalhousie written there. Dr. Patty, the volunteer coordinator of CASIEF, and a friend of mine, worked tirelessly in the development of this centre. It has many pieces of equipment now, lots of mannequins, an old anesthesia machine and 2 lovely people who are trained to help you plan your simulations for teaching.

Then we toured the rest of the complex. In the ICU, Dr. E asked the anesthesia resident to present some cases to us. I found this awkward, as I wasn’t sure if I was supposed to offer some thoughts….in any case, I thanked the team for their time and we moved on.  Whenever I have started work at a new place, I always feel more comfortable standing back and trying to learn about how things are done before offering any thoughts, opinions, or suggestions. This seems even more important here, where their resources are so poor relative to Canada, that the treatment and anesthetic plans are necessarily very different from what I know! And yet, we are here for such a short time, there seems to be an expectation and possibly need for us to jump in right away.

We also toured the clinic areas and the Ob/Gyn area. In the maternity ward, we ran into Dr. M, an Ob/Gyn from the US who is staying in the apartment with us (or rather we are staying with her). She has been here for 3 weeks and leaves on Friday. She took us on a tour of the labour ward and proudly showed how they have remote fetal heart rate monitoring at the nurses’ station.

During this tour, I was struck not by how much was different but by how much was the same. The conversations about resources and how best to help patients, the paperwork, the rounds presentation, the constant conflict of not having enough ICU beds – all the same. Some things in healthcare remain universal.

Tomorrow, our first day in the OR.

 

Why do you want to go to Rwanda?

 

“Why do you want to go to Rwanda? What made you want to go there?” My mother asked me this question 2 weeks ago – 2 weeks before I was set to travel here. The answer that came immediately to mind was “what do you mean? Doesn’t everyone want to go?”. She laughed and pointed out that no, not everyone wants to go and she challenged me to really answer the question.

I don’t really have a good answer. I have always wanted to go to this part of Africa. In 2001, I had the opportunity to travel to Tanzania for 2 months and work with a private physician and also a team of nurses who were doing outreach work related to the education about and prevention of HIV/AIDS. I learned more about myself and the work than in my prior 26 years. And I LOVED being in Tanzania. I loved the smell, I loved the lush green colours, I loved the little monkeys that were as common in the town I was living as squirrels are to us in Canada. And I really really loved seeing how things were done in another country so different from my own. I didn’t love the time I spent waiting…time had a different meaning to what I was used to. And it took me a long time to settle in to being (albeit very temporarily) a glaringly obvious visible minority. But again, I learned so much from this experience.

I have always wanted to go back but residency, marriage, babies, fellowship, etc. got in the way. And also, I have always been a bit skeptical of “global health medical missions”. I have wondered if they really help and I have heard so many tales of well-intentioned north American medical groups swooping in for a week, using up local resources, and then moving on. Admittedly, I have never been on such a mission and I am sure that many do very important and beneficial work…but there it is – my skepticism.

The opportunity to travel to Rwanda as a CASIEF volunteer has been around since  2006 – the year I finished residency. The program always interested me as it has an education mandate to support the training of residents both to be clinicians but also to be teachers for the next generation. Eventually, the program would be self sustaining – there will be enough attending anesthesiologists to run the academic program! For all of these reasons, I have always been interested but the timing has never been right.

About 18 months ago, a friend posted about being a CASiEF volunteer in Rwanda and I was SO JEALOUS. I had a moment of realization that if the program ended and I had not participated I would really regret it. After a chat with J, I met with Patty (the CASIEF volunteer coordinator, who also happens to be a friend) and began planning.

I guess the answer to my mom’s question is that I wanted to come to Rwanda because I have always been interested in this part of the world, I am excited to finally participate in a global health initiative, and I really believe in the idea of helping create a sustainable educational program.

I am so excited to be going to Rwanda!

***Note: this is blog site I used to keep, and I previously blogged with pseudonyms. If you read old posts, you may be confused by this! Rather than start new, I just decided to continue here.

 

Seasonal Thoughts – Belated

‘Tis the Season – Well, it WAS the season! I wrote this right before Christmas, but never posted it. I thought I would post it today anyway – over a month after the holidays….because, well, why not?

The Most Wonderful Time of the Year.

I do love the holiday season, I really do. There is a long history of the women in my family loving Christmas. My Nanny, my mother’s mother, LOVED the holidays. And she did a miraculous job of providing a lovely holiday every year for her 5 children with challenges of little money and a difficult marital situation. My own mother continued this love of the holidays. We grew up with a beautifully decorated house, magical presents, wonderful food, and many, many loud and happy family gatherings.

Now that I am the one making all the preparations, I have become so grateful for what my mother did each and every holiday. The decorating, the present buying, the preserving of the Santa magic, and on and on. It all seemed so effortless. It seemed like it all just came together. But I know differently now. Like all the work of the motherhood, holiday preparation is largely thankless. And often the mother prepares for everyone else and little is prepared for her. For the most part, I think we mothers feel so happy watching our family revel in the holiday magic that we have created, that we are not thinking about ourselves. I know for me, I used to love and look forward to receiving presents, but now I hardly think about that. I think much more about what I am giving and how excited the receiver will be. I guess that is a part of growing up. This is a good change. I have gratitude for this change.

But everyone once in a while, I think about how wonderful Christmas was for me as a child, and wish I could have that feeling again. I can’t. And that is OK. The new feelings are just as wonderful, although different. But still…

And I think about how Christmas is the perfect opportunity for all of us grown up daughters to say a special thank you to our mothers for all the magic of Christmases past.

And so I will: Thank you Mom. I hope you have (had) a wonderful holiday.