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.

Summer Air

As I travel this path of practicing mindfulness, I am often struck by how naturally being mindful comes to children. Of course, it comes more easily to some children then others.

About a month ago, I took my older 2 children to see a movie. Being the multitasking, ever-efficient person I am, this treat was paired with a trip to Costco (because the movie theatre and Costco are next to each other). The kids were very patient during our shopping trip on this hot day. As we were leaving, Aurora was riding in the cart and after I loaded the groceries into our car, I went to lift her out. I realized she had been very quiet for a quite some time (very unusual for my chatty girl). So I asked her if she was ok. Her reply:

“I’m fine Mummy. I am just feeling the summer air on my skin”.

There you have it. On a hot summer day, in a shopping cart, my daughter was feeling the summer air. So I stopped to feel it too. It was wonderful.

A Child’s View of Tragedy

Grampie died peacefully earlier this week. Tim was at his side as the life left him.

In medicine, we often speak of good deaths and bad deaths. This is usually referring not only to the nature of the cause of death (for example, traumatic accident vs. old-age) but also to how well prepared the family was for the passing.

My Nanny, my mother’s mother, used to say “There are worse things than dying”.
My Granny, my father’s father, after the passing of her husband of 60 years, “It is very, very sad, but it is not tragic”.

Grampie’s death was a good death. And his extremely poor quality of life at the end, meant that there was some blessing in his passing. But it was still a tragedy. He was only 65. He had been ill and debilitated for the entire lives of his grandchildren. And it feels like he, and we, were a bit robbed. But Grampie himself, used to say long ago: “If I died tomorrow, it would OK. I have had a great life. I have seen my sons grow and be successful”. And so, Tim felt very sad, much sadder than he expected, but he was at peace with the loss of his father. It was time, he felt.

However, as much as we adults can know about bad/good deaths, sadness vs tragedy, to children it is completely different. Our 2 younger children have taken this in stride. I am not sure they even quite realize what has happened. But Micah, Micah is sad. This is a tragedy in his young life. We learned, that to him, his relationship to Grampie was the same as with his other grandparents. Even though Grampie was never able to really play with him, read to him, chat with him, Grampie was able to LOVE him and that was all that mattered. Micah cried and laid his head on Grampie’s chest when we took him to say goodbye. Even though it made him so sad, he wanted to return several times. When I was talking with him afterwards, he told me that was so sad that the only grandparent that lived where we lived, was gone.

This was such a lesson about love for me. Children really do love purely and unconditionally. It doesn’t really matter what you do with them, as long as you show up and are present in their lives. For Micah, Grampie was present. He came to celebrations, he shared his favourite Aero bars with Micah, he love listening to Micah play the violin. Grampie was his Grampie.

Tim and I struggled a lot with how much to include the children in what was happening. Our own personal experiences with death came at a much later age. But Grampie was dying on a weekend, we were all focused on being there for him and for Tim. Relatives were coming and going and children are very astute observers. We decided that we should tell them the truth. And we didn’t want them to be afraid of death. And so we took everyone over to see Grampie, to cuddle him, and to say good-bye. They all did this. They all climbed into bed with him and spent time with him. They weren’t afraid, amazingly.

I think Grampie had a “good” death, if you can understand what I mean. And I think the children had a peaceful, non-threatening experience with it, I hope they did. If there was anything positive to come out of the loss of a grandparent at such a young age, perhaps it is this: Micah is sad, but not scared. And he has another memory of his Grampie and I have learned another lesson about love.

Through the doors…

In the OR suite where I work, there are 2 big sets of double doors that patients must pass through to get to the corridor where the operating rooms are. They say good-bye to their parents just outside the first set. Both sets of doors are automatic doors, so there is a brief interlude where both sets of doors are open and families can watch their children walk away from them toward the operating rooms.

Recently, I have started noticing these moments. They are beautiful, sweet, sad moments all rolled into a few seconds of actual time. Luckily, most children coming for surgery are well, they only need a minor operation and will be on their way to happy, healthy times. Of course, some are not well, and may never be healthy again. But for families that moment of saying goodbye and watching their child walk away is so very, very hard.

As a mother, my heart hurts for them as I think about what that would be like: sending your child into the unknown with a stranger…it would just feel wrong. But so many families do this time and again and they do with strength and grace.

As a doctor, I am struck by the sweetness of the moment. I watch as a nurse walks slowly through the doors holding a small hand, chatting with their patient and pointing out all of the interesting thing that are painted on our walls. This is a beautiful image. A child trusting this nurse enough to walk with them and chat and hold their hands on the way to their operation.

Of course, not all children come so peacefully, some are crying, some are fighting, some are just yelling angry words. But all the nurses are calm, and tender, and doing everything they can to sooth and reassure the patients. Surprisingly, most of these tumultuous children calm down as soon as the second set of doors close and they can no longer see their families. It is as if they realize that this is a new world, with different people in whom to put their trust.

Oh, one more reason I love my job: watching people go through the double doors. And better yet, being the person who gets to hold that small hand or carry the small baby through those doors. Lucky, I am very very lucky to work in this environment.