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Report of the ASA OTP/ CASIEF to Kigali Health Institute and Central Hospitals
in Kigali and Butare
From May 2 to May 31, 2006
Shigemasa Ikeda, M.D.
430 Cheshire Farm Court
St. Louis, MO 63141
Thank you for giving me the opportunity to work as a volunteer in Rwanda. It was a brief
and enjoyable, yet frustrating month.
Operating Room
Kigali:
Dr. Bonaventure Uwineza (Bona) was the only resident in Kigali. I was with him from
the first case in the morning to the end of the day. However, from the third week of the
month, he had to leave OR at noon to attend biostatistics lectures (a requirement during
his training). From the third week to the end of the month, I was with him in the morning
and with nurse anesthetists and/or nurse anesthesia students in the afternoon.
Though he is a 1st year resident, most of time he supervised nurse anesthetists
and/or nurse anesthesia students. I could not judge his clinical skills in the operating
room (OR). But I had ample time to discuss anesthetic management in the OR, and spent
as much time as possible in the anesthesia office. His knowledge and clinical judgments
are acceptable as a 1st year resident, but he still needs to learn some more basics of
anesthesia – knowledge as well as clinical management in the OR. He is eager to learn
and the book “Clinical Anesthesia Procedures of the Massachusetts General Hospital”
and several CD all residents received from Dr. Enright will help him study more.
Clinical anesthesia administered by Kigali Health Institute (KHI) students has
very little to do with classroom teaching. In other words, the classroom lectures do not
replicate or prepare students for the actual practice of anesthesia. Moreover, many
students lack the very basic skill of administering anesthesia – maintaining the airway
during induction and intubation skill, etc. The students need opportunities to acquire
practical skills and knowledge. This could readily be accomplished by teaching them
during the conduct of clinical anesthesia.
Though staff members – two anesthesiologists at Central Hospital in Kigali
(CHUK) and anesthetists from KHI are present to supervise/teach, I saw little instruction
by these supervisors in OR. I am doubtful if students/residents could improve practical
clinical knowledge and skill, unless the instructors spend more time to teach in OR.
Almost all of the students I talked with were interested in discussing clinical management
of the patients. I tried to spend time with them as much as possible, but it was not
necessarily easy to explain how I might manage a similar case differently without directly
criticizing the techniques they were taught by their instructors. I also found that some
students seemed reluctant to apply new techniques/knowledge in the presence of the
anesthesia staff. This needs to be addressed and student learning should make a priority.
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I also believe and hope that the ASA-OTP/CSAIEF volunteers spend more time in OR
than in the classroom.
Butare:
I traveled to Butare twice. I left Kigali early in the morning and spent a night in
Butare. Since I spent only four working days in Butare, the following comments may be
superficial and biased.
I was with Dr. Paulin Ruhato (1st year resident) for all four days. Other resident,
Dr. Theo Twagirumugabe (4th year resident) was supervising nurse anesthesia students in
OR. He joined Paulin and me for discussions in the afternoon. Theo seems to be very
knowledgeable and competent. I hope he joins the department as a staff member after
additional training in France this year. I think he will become a very good teacher.
Not like Bona in Kigali, Paulin did all cases by himself. He seems to be interested
in obstetric anesthesia. He wants to be an obstetric anesthesiologist as his future career.
Whatever subspecialty he chooses, he needs to learn some more basics of anesthesia –
knowledge as well as clinical management in OR.
Classroom teaching
I preferred OR teaching to classroom lectures and spent more time in OR. When I
first met Charles Rangira, Director of Nurse Anesthesia Program at KHI, he asked me to
schedule meetings with his students in the morning, though I preferred afternoon
meetings. I was told no elective cases were scheduled after 2:00 pm at CHUK. But
Charles had already scheduled a series of lectures in the afternoon. He was reluctant to
change the schedule. I did give lectures to nurse students twice in the morning at KHI.
But after I found Bona had to leave OR at noon, I thought I had better stay in CHUK and
spend more time with him, instead of going to KHI to meet with nurse anesthesia
students.
I also gave lectures to a group of medical students twice during their two weeks
anesthesiology rotation. This was requested by Panjat.
Though some discussions with Bona and Paulin were not necessarily relevant to
their current curriculum and practice in Rwanda, they felt these discussions appropriate
and asked me many relevant questions.
Living in the guest house
I did not have any major problems at the guest house, except for occasional power
failure during the first two weeks and lack of hot water in the bathroom. The power
failure was no longer a problem after a generator was installed in the second week.
I was able to use the internet (wireless connection!) from the day I arrived. I
exclusively used the internet for communicating with my family, friends and colleagues. I
also used the internet to download several articles from the medical school library I am
affiliated with. But in the middle of the second week, we lost the connection. I was not
able to use the internet for a week until I called the Rector. Though the internet was reconnected the day after I called the Rector, the speed of the connection was extremely
slow and I had difficulty downloading large files. The technical service I received from
the KHI Computer Service was not necessarily satisfactory.
Damascene, the driver was very helpful, especially when I went to Butare. But he
was not available for 6 days, including the day I left Kigali for home. I had to call a taxi
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or ask another guest at the house to take me to the CHUK. I only wished we had a backup
driver and/or car.
Lectures and discussions
May 1:
Holiday
May 2:
Advantages of low flow anesthesia
May 3
Closed circuit vs. semi closed system
Head trauma, control of ICP
May 4
O2 consumption, mixed venous oxygen saturation
How to calculate dopamine infusion rate
May 5
Capnography
Effects on CO 2 and anesthetic agents on cerebral blood flow
May 8
Preoperative evaluation (Resident and Medical students)
May 9
Preoxygenation
May 10
Preoperative evaluation (3rd year nurse anesthesia students at KHI)
Anesthesia machine (1)
May 11
Preoxygenation (Nurse anesthesia students at KHI)
Anesthesia machine (2)
May 12
Transfusion criteria
Non-rebreathing circuit
May 15
(Butare)
Preoperative and preprocedure medications; stop or continue?
Smoking and anesthesia
May 16
(Butare)
Hyperbaric and isobaric spinal bupivacaine
Axillary block using a nerve stimulator
Preoxygenation
How does a vaporizer work?
Factors influencing MAC
May 17
Vaporizer
MAC
May 18
Oxygen therapy (Medical students)
Epinephrine infiltration and halothane anesthesia
May 19
LMA and propofol induction
Preop evaluation of patients with chest pain
Anesthesia circuit and dead space
May 22
Causes of tachycardia during general anesthesia
Shunt and dead space
Dead space and ventilation
May 23 (Butare)
Causes of prolonged emergence from general anesthesia
Non-rebreathing vs. semi-closed circuit
Effect of halothane on intracranial pressure and cerebral blood flow
May 24 (Butare)
Fluid management
Temperature monitor
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May 25
lime
May 26
May 29
May 30
May 31
Positioning
Importance of temperature monintor
Carbon dioxide absorber-chemical reactions and when to change soda
Interscalene block and local anesthetic toxicity
Anesthetic management of maxillofacial surgery
Alveolar –arterial pCO2 differene
Alveolar gas equation
Low flow anesthesia (2)
Acidosis; metabolic vs. respiratory
Massive transfusion and calcium administration
Suggestions:
1. ASA OTP/CASIEF volunteers should spend more time in OR.
Unless we spend more time to teach in OR, residents/students will not learn
clinical managements in OR. Even though the students may not abandon the
CHUK’s cook book practices/techniques overnight they are taught by their
instructors, I think we should continue to teach the up-to-date anesthesiology
practice in OR and hopefully, students will use the techniques/ideas we teach
them after graduating from the program.
2. Everyone complains of the lack of equipment and supplies. I fully understand
they need basic equipment/supplies.* (see “wish list” below) But it seems to me
that they do not necessarily utilize the existing monitors and equipment
effectively. One example is capnography. Capnography is available in one of the
OR in both Kigali and Butare. I found many times the monitor was turned on even
after induction of anesthesia. In other words, the monitor was not used during
critical moment, such during induction and intubation. Even the monitor was
turned on, no one seemed to pay attention to the end-tidal CO2. Even the end-tidal
CO2 shows low 20s (mmHg), no one changes the pre-set tidal volume and/or
respiratory rate. They should be educated to fully utilize the existing equipment.
3. Since there is only one Rwandan anesthesiologist, the volunteer should teach
mainly the residents, who hopefully stay at the department and become instructors
at the department after finishing their training. We could also teach a few selected
nurse anesthetists at the department to be clinical instructors. I met one very
competent anesthetist who is also very good at teaching other anesthetists and
students.
4. A printer in the guest house.
I wanted to give handouts to residents and students (medical and nurse
anesthesia). But no printer was available in OR and anesthesia office.
5. A locker with a key in the staff or anesthesia office.
I did not have any safe place to leave my computer, PDA and several personal
belongings in OR. When I requested a locker to Panjat and an OR supervisor, I
was told there was no extra locker available. I think they do not want to spend
their fund to provide anything to the volunteers.
6. If ASA-OPT/CSAIEF provides a copy (or an edited version) of this report from
the previous volunteers to future volunteers, I am sure the volunteers could utilize
his/her time and effort more effectively.
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For several weeks before I left for Rwanda, Dr. Arthur Ackerman, the volunteer
in April, sent me several e-mail messages to me. Information I got from him
helped me prepare my trip to Rwanda. E mails I received from Drs. Angela
Enright, Philip Bridenbaugh and Ackerman while I was in Kigali made my life in
Rwanda comfortable and enjoyable, and hopefully productive. I only wished I had
some information before I left for Rwanda.
Thank you again for the opportunity to work in Rwanda. I would consider it a privilege to
coming back to the CHUK program if another opportunity were presented.
* Wish list in OR;
1. Monitors: EKG, heart rate, blood pressure (non-invasive and invasive),
capnography and temperature
2. Pulse oximeter and its replacement sensors
3. CVP (and PA?) catheter
4. Blood gas machine in ICU
Residents would like to have a desktop computer in their anesthesia office.