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CASIEF/ASA-OTP in Rwanda May 2008
Shigemasa Ikeda, M.D.
St. Louis, Missouri
I wish to thank the CASIEF/ASA-OTP, and Drs. Angela Enright and Philips
Bridenbaugh for providing me the second opportunity to work with anesthesiologists and
anesthesia technicians in Rwanda. It was again an inspiring experience that I am grateful
to have had.
Teaching
In May, 2008 there were five residents: two at CHUK (Bona, 3rd year and Rose,
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2 year); one at King Faisal Hospital (KFH) (Paulin, 3rd year); one at CHUB (Antoine,
2nd year); and one at CHUK- ICU (Theonest).
Teaching sessions:
Teaching sessions at CHUK were scheduled at1400 on Mondays and Wednesdays,
though lectures by a cardiologist prior to my arrival had been scheduled on the first two
Mondays of the month. I conducted six teaching sessions overall at CHUK, four sessions
used for my assigned topics on “Cardiovascular physiology and pharmacology” and two
sessions for residents’ presentations (see below). I also conducted two sessions at CHUB.
During and after presentations residents asked questions not only to me, but amongst
themselves in what was a lively and participatory environment. This was entirely
different from the teaching sessions I experienced in 2006, when there was only one
resident at CHUK and CHUB. Of note, two staff anesthesiologists attended one of the
sessions at CHUK and participated in the discussion as well.
At the first session at CHUK, I asked residents to present a case report or a topic
they chose during the last week of May. The topics they presented were: Is bleeding time
required as a routine preoperative test?; aspiration pneumonia; anesthesia for liver
diseases; physiology of periopeative hypothermia; and cardiac arrest during spinal
anesthesia. With the exception of one resident, everyone requested references for his
(her) presentation. I chose several articles published in peer reviewed journals. All
residents used PowerPoint and were impressive in their presentations. Several past
visiting faculties had mentioned that residents should read more. I think the PowerPoint
presentations seemed to encourage residents to read articles/textbooks in order to cite and
incorporate them into their slides. A few residents expressed that they hoped this form of
presentation would become a regular part of their curriculum. Despite difficulties in
obtaining a room at CHUK, Bona was always able to find a place for us to meet. The
only caveat was that we were rarely able to start class on time.
A persistent concern for me regarding residents’ education was whether they were
receiving adequate teaching help in the absence of visiting faculty. For example, I spent
only four days at CHUB. What training and support were residents receiving the other
20+ days of the month? One staff anesthesiologist at CHUB expressed a willingness to
become a part of the educational program, yet did not think he could effectively step in
without his own training and guidance from visiting faculty. His preference would be to
choose one or two topics he was already familiar with, and then present his chosen topics
to the residents in the presence of visiting faculty. This would allow him to receive
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feedback on how to improve on his presentation, depth of content and ability to engage
residents.
I talked with Dr. Terry Loughnan, the visiting faculty in June, and gave him the
staff anesthesiologist’s name and e-mail. Dr.Loughnan sent him an e-mail message and
gave him two topics to prepare and present on. My hope is that this is the beginning of
the local staff member’s participation in the educational program.
KHI students:
Charles Rangira, Head of the Anesthesia Program, asked me to teach his 3rd year
students for two hours every Wednesday morning. He suggested that I present on
cardiovascular physiology/pharmacology to his students. However, based on my prior
experience with the students, I anticipated that they would be more eager to focus on
clinically related topics. In the end, I presented on five such topics: 1) preoperative
evaluation – using the CHUK and KFH’s preoperative assessment forms; 2) aspiration
pneumonia; 3) hypothermia; 4) preoxygenation; and 5) how a vaporizer works, especially
in a high altitude.
Paulin, an anesthesia residents assisted me during class which was a great help.
To encourage asking questions and joining the discussions, he asked students to speak
French. He then summarized students’ questions and discussions for me. During the
“vaporizer” session, I learned that several students had very limited knowledge in physics
and chemistry. In the future, I suggest teaching students “anesthesia related physics and
chemistry” during the first year of education at KH1.
At the end of our last session, several students requested a copy of my PowerPoint
presentations. Instead of giving a copy of the five presentations to each student, I copied
my presentations to a CD and gave it to Charles. I do not know how many students went
to Charles’ office to copy some of my presentations. Even this week - four weeks after
returning home, students continue to send me e-mails asking for additional references I
mentioned during these presentations.
Clinical anesthesia
CHUK:
Since the new ORs were under construction, only 5 ORs in three different
buildings were used in May; two ORs at the OB-Gyn Clinic, one at the ENT Clinic and
two at the Ophthalmology Clinic. I found the general protocols for case selection and
assignment confusing. Residents were allowed to choose their own cases daily which
often resulted in two residents opting for the same case in addition for one or two
anesthesia technicians to spend the day in the same room. Additionally, the senior
resident acted as supervisors when a staff member was not available- this was not an
exception but nearly routine.
When I talked with Francois Safari, the chief anesthesia technician, who assigns a
technician (sometimes two technicians) to a case, he told me that whenever a resident
wishes to start and finish a case, he will ask anesthesia technicians to step back, unless
the resident asks for help. I do not think there is a declared minimum required number of
cases during their four years’ training. This is probably a needed mandate in order for
residents to acquire satisfactory clinical experience.
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Preoperative evaluation by an anesthesia technician was often incomplete. I heard
several reasons as to why residents were unable to see patients the day before surgery. I
do not think all residents attend the morning meeting every day from 7:00 till it concludes,
and the first case in the morning rarely started on time. Residents should have time to
review the chart and interview their own patients preoperatively. Even if residents do not
have time in the early morning, they should be able to review the technician’s
preoperative evaluation immediately before induction of anesthesia or during the turnover
time, and interview the patient. At that time the resident should add any missing
information to the preoperative evaluation form. I often witnessed that preoperative setup
was incomplete and observed anesthesia providers going out the room to get drugs and
equipment, leaving the patient alone in the room.
Residents are interested in learning continuous epidural anesthesia. One Friday
when a resident was “in-house call” on that day, a continuous epidural anesthesia was
administered as a main anesthetic and the catheter was left for postoperative pain
management. The resident gave additional local anesthetic whenever needed
postoperatively. Both the patient and the resident were satisfied with management until
the catheter was removed before the resident went home in the afternoon on the first
postoperative day. I agreed with Panjanto that residents should learn continuous epidural
anesthesia during the training, but that without 24/7 coverage by an anesthesiologist, the
catheter should be removed before residents leave until anesthesia technicians on call get
adequate training for postoperative pain management.
Monitoring in OR:
Almost everyone complained about the lack of monitors, equipment and drugs,
etc. However, even when the monitors were available, they were underutilized. Many
times, I found anesthesia providers were not watching the monitors and/or did not react to
abnormal values. In several instances, I did not see any blood pressure changes during
induction and intubation. When I looked into possible reasons for this, I discovered that
the blood pressure monitor was set at every 15 minutes!
One reason the anesthetists did not respond to abnormal values, such as the end-tidal
pCO2 of high 50s mmHg, is that they simply were not aware of the clinical implications.
Their education is critical.
CHUB:
Though there were similar problems to what I observed at CHUK. Supervision
seemed tighter and various cases – both adult and pediatric – have been performed.
Overall, it appeared that first year residents received better training. Also, a resident
generally started and finished any case he was assigned without anesthesia technicians.
KFH:
Among the three teaching hospitals, this was the best – distinguished by better
equipped, nuanced cases and the chief of anesthesiology’s willingness to teach residents.
This is the only hospital where thoracic surgery has been performed. One-lung anesthesia,
continuous thoracic epidural anesthesia, and direct arterial monitoring have been
routinely performed. A fiberoptic bronchoscope donated by an April 2008 visiting faculty
was being used. However, only the size 39 Carlen’s tube was available. Four end-tidal
monitors were available but rarely used. There must have been some misconception even
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among staff anesthesiologists – end tidal monitoring is indicated only during laparoscopic
surgery when CO2 insufflation is used. A difficult airway cart was available in OR, and a
CPR cart was available on all patient floors. Finally, continuous epidural service for
delivery on the obstetric floor and acute pain management services were pending.
Though I rarely saw a staff anesthesiologist in OR, I feel that KFH is a good training
hospital for 2nd or 3rd year resident if/when a competent anesthesiologist is immediately
available.
A Meeting with residents
After one Wednesday afternoon meeting, I sat down with all five resident in a
nearby restaurant and listened to their comments about their training.
A summary of their comments:
1. CHUB is the best place to start the training. Training at King Faisal should be reserved
for 3rd year residents.
2. Every local staff anesthesiologist should play an active role in education programs.
3. They want to see visiting faculty spend more time at ICU.
4. Lack of visible leadership at CHUK
5. They like to see visiting faculty’s list of topics presented to them prior to his (her)
arrival.
6. A resident, who spent her first year at KFH where the Glostavet is not used, had to use
the machine without any orientation from Day 1 at CHUK. She thinks resident should
undergo a thorough orientation at the beginning of the rotation.
At the meeting I made several suggestions; 1) the importance of reviewing the
previous anesthesia records, though residents told me it was almost impossible to retrieve
old records. 2) each resident records every case during training, and the case log book
should be periodically reviewed by local and/or visiting faculty; 3) starting a type of “Intraining examination” – either multiple choice questions or a few essay type questions every six and twelve months to evaluate each resident’s progress. I did not get any
affirmative response to any of my suggestions from them.
Educational material
The HINARI (p.8 of the Information for volunteers in Rwanda) – online, full text
journals- available through a WHO sponsored program is valuable for residents to
prepare presentations and build up their own references. However, I found it no longer
(or temporarily?) available in Rwanda. I asked Dr. Stefan Van Bastelaare, Medical
Director Belgium Tech Corp to call me whenever HINARI became accessible to us.I did
not hear from him before I left.
Library books
Many books are available at the department. However, books are kept in the
office and difficult to access, particularly, when we needed them early in the morning or
between cases. I hope the books will be moved to a room in the new OR to enable great
access.
Rwanda license
When I brought all my documents to Dr. Kayibanda’s office at KFH to apply for a
Rwanda license, I was told I should have sent the documents weeks, even months before
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I had left home. I was also told that I should have brought the original
licenses/certificates, though all documents I brought were notarized as mentioned in the
“Information for Volunteers in Rwanda”. I never heard from his office whether the
application was approved or not. In the Information it clearly stated that “You must
obtain a license to practice in Rwanda,” and I was uncomfortable whenever residents
asked me for help in OR. I repeatedly asked myself if I was practicing medicine or not.
In a clinical setting, the space between teaching and clinical practice is a grey one.
Housing
Conditions at the guest house were no better or worse than two years ago. I was
apparently the last visiting faculty to stay in the guest house in Kimihurura. The Rector at
KHI showed me the new guest house, which was located within walking distance from
CHUK/KHI. The rooms designated to the program at the house have a private bath room
and a large storage room. There is even a swimming pool in the back yard.
In preparation for the move to the new guest house, Dr. Enright asked me for an
inventory of items the program bought or previous visiting faculty had donated to the
program. I was not able to locate a number of previously identified items. Also, several
small appliances the program had bought were no longer working, and most of these had
been replaced by KHI. I would recommend assessing security and the handling of
equipment at the new house.
A KHI volunteer from New Jersey smoked in the guest house and I subsequently
requested that she smoke outside. I asked the rector if the new house could be smoke free
and hope that we do not need to impose a “No Smoking” sign in the residence which Dr.
Enright suggested me to purchase when I discussed the matter with her.
Transportation
This was a consistent challenge and more difficult to negotiate than my
experience two years ago. I was late for a few meetings as a result. After I complained to
Esperance at the Public Relations Office, one Wednesday morning, a driver showed up at
6:45 for an 8:00 teaching session at KHI.
During the first week in May, Esperance told me that it was KFH’s responsibility
to provide transportation to and from KFH on Tuesdays and Thursdays. But from the
second week on, CHUK provided me a ride to KFH in the morning. Esperance told me
KFH was going to provide a ride in the evening, yet in the end, KFH provided me a ride
just twice in a month. I was told either a car or a driver was not available. I was left with
little choice but to walk home or search for a taxi after dark.
In 2006, one dedicated driver picked me up every morning, and dropped me off at the
guest house in the afternoon every day. He also drove to Butare. It was a tremendous
benefit and assurance sorely missed.
Since the new guest house is within walking distance to the hospital,
transportation from the guest house to CHUK/KHI is no longer a major problem.
However, since the new guest house is no longer within walking distance from KFH, we
definitely need dependable transportation. I mentioned this to Esperance before I left.
I went to Butare twice (the first and the fourth Thursdays) without any difficulty.
The driver who took me to Butare on the fourth Thursday was punctual and a safe driver.
He is neither a CHUK nor KHI employee, and works independently. I can highly
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recommend him if a future visiting faculty needs a good driver for his (her) weekend trips.
I cannot recall his name, but his phone number is 08755181.
A suggestion:
All visiting faculty sent their report to the CASIEF/ASAOTP, which are available
on the CASIEF website. Reading the previous reports helped me when I started preparing
my trip to Rwanda. I personally like to see reports from Rwandan residents/staff
anesthesiologists. I can use the evaluation from them to improve my presentations,
though I do not currently plan to go back to Rwanda. I wonder if Drs. Enright and
Bridenbaugh received any feedback from residents and/or staff anesthesiologists in
Rwanda. If the edited version of their reports were available, I think future faculty could
benefit from access to them.
It was extremely difficult for me to be an effective teacher at an institution with a
different organizational and fiscal system. I often questioned myself what was my role as
a short-term visitor. I certainly saw some progress in the past two years, even though the
progress is slow and trivia. I strongly believe in continuing our mission to improve
education in anesthesiology in Rwanda. Thank you again for allowing me another
opportunity to be a part of the CAIEF/ASAOTP.