Report, voluntary work in Rwanda (Oct. 3rd-26th)
I am very grateful to have been given the opportunity to take part in this project of
teaching anesthesia in Rwanda. This was a unique experience in term of learning to work
optimally with limited resources, identifying group/individual weaknesses and build
knowledge to improve these and it was also a great social experience with local people.
Here is my humble opinion about different aspects of this experience so the teaching to
the nurses and residents could be optimized.
As decided prior to our arrival, we provided teaching mainly in the operating
room, except for the loco-regional anesthesia module which was given as 3 sessions
outside the OR. We discussed every day with the resident or the nurses topics related to
the cases being performed (although the emphasis was put on teaching Bonaventure). We
also did am daily sessions for the whole team from 7h00 to 7h30 or 7h45. A topic was
shortly presented by us or Bonaventure (he was asked to do 2 short presentations during
our stay) or a pertinent case was discussed. The list of the majority of these topics is
joined as an attachment to this document.
The residents
In CHK, Bonaventure was the only resident working in the OR. We saw on
arrival that he was not assigned daily to patients, was not evaluating the patients himself
and relied on the nurses to prepare the equipment and drugs necessary for the anesthesia.
We then assigned him every day, with Dr Punjat, to 2-3 cases he had to start and finish.
We also forced him to prepare his equipment and drugs, which he was doing more
efficiently when we left, but is not yet routine for him. We reinforced the need to practice
his clinical skills and not to rely exclusively on the nurses (ex.: for iv insertion). He still
needs to practice those skills daily, he is weaker considering he’s finishing his first year
of residency. He has great teaching skills and uses them daily with the students which is
good. We also emphasized physical examination of his patient while providing anesthesia
and recognition of possible life-threatening conditions (ex.: respiratory distress, shock)
which he did not always evaluated correctly. He still has to be supervised closely since he
doesn’t know yet some basic knowledge. Although he is very motivated, he should read
more about the cases he’s performing. Jules, a senior resident, was working in the
emergency department during that month, so we had limited interaction with him.
Since we were in total only 3 days in Butare, we got limited time to teach and
work with Paulin and Theogene. Paulin is much more independent in performing the
anesthesias and prepares the equipment himself. His skills appeared very good in general.
His basic and clinical knowledge are ok, but he also should read more routinely. I think if
mandatory readings (in their MGH handbook) were added in the curriculum for each 3months period for example, they would both get a better idea of what to read (ex.: airway
management, difficult airway, spinals, pediatric anesthesia, etc.). They are often
performing acts without knowing exactly why they have to proceed a certain way.
Reading about their cases also has to be reiterated. Theo seems to perform well and has a
good judgment. He has good knowledge and seems to read in recent anesthesia journals
too.
Strengths and weaknesses in the CHK anesthesia department
I have identified many strengths during my stay in the hospital, but also many
situations requiring improvement. The strengths of this team are their dynamism and their
motivation. Most of the nurse-anesthetists are open-minded and interested in improving a
technique or learning something different when adequate supervision is available. For
example, we supervised them to use a bougie in case they need it and teached to ask the
surgeon to infiltrate the skin with local anesthetic for any abdominal incision. They are
also thinking about evaluating post-operative pain and improving its management. With
the help from future volunteers, and hopefully a future voluntary pain nurse, I have no
doubt they will succeed in improving patient comfort.
The major weaknesses at this time are the lack of organization/leadership in the
OR and the lack of supervision by the anesthesia team in situ. The rooms are starting late
every day even though everybody arrives around 7h00 am. The main reason is the nonoptimal efficacy in preparing the rooms in the am and between the cases. This has an
important impact considering there are always patients waiting for weeks or months to
have a fracture repaired! Someone could be in charge to make sure things are being done
efficiently. There are 2 anesthesiologists working at CHK at the present time: Dr Punjat
and Dr Ibrahim. They are both very nice, but are not working consistently in the OR and
rarely provided teaching during our stay. I strongly believe the volunteers bring
something important to the group in general, but the knowledge or techniques taught have
to be reinforced by the persons working already in the department in order to improve the
retention ratio. I think these 2 staffs should be more involved on a day to day basis. This
would also improve the supervision of the nurses or residents since over this month, me
and Dr Carli were often supervising the nurses in an emergency case when they felt
slightly uncomfortable.
I also think in order to provide good teaching in Butare facilities need to be
provided to the volunteers, otherwise they may decide not to go. We didn’t mind not to
have a hotel there and decided to leave early in the morning. However, it was difficult to
be there before 9h00 am, so the first cases were already started when we arrived. In
addition, we went there mainly to teach the loco-regional anesthesia module, so the time
available to teach in the OR was restricted. I would tend to think, that if feasible, the
residents in Butare should come in Kigali for 3 afternoons to get the module teaching. I
believe this would help them to understand/remember better the subject since each
resident will ask different questions than the others and this would create more
interactions. They would also then benefit of more clinical teaching when we go in
Butare.
As a remark, the residents told us many times that they can read some English,
although slowly but don’t understand as well when a teacher speaks English. I would
suggest in order they benefit maximally from every volunteer coming that these
physicians should be fluent in French. I don’t think this will be an issue anymore in 5-6
years maybe, since the medical students now are bilingual.
We also appreciated the great work of Esperance during our stay, she helped us a
lot at many occasions. Having a driver to go to CHK or Butare was also very helpful. Our
driver changed after 2 weeks (Hassan then Canisius), but they were both very
sympathetic and helpful.
Facilities
The house provided by KHI is big and pretty, I really liked the little “gazebo”
outside which is a quiet place to read. Philbert is a nice and helpful guy. The computer
and Internet service were great and the cell phone very useful. There were frequent lack
of power around 18h30 or 19h30 which rarely disturbed me. The generator worked once
but is very noisy. We had to give some money to Philbert to buy electricity sometimes,
but I was told this is supposed to be provided by KHI. The only comments would be
about the sub-optimal cleaning of the kitchen every day, the unreliability of the fridge
(our food wasn’t always remaining fresh long enough), the lack of water in the shower on
the left side of the house and the toilet which broke in the last week and was not repaired
yet at our departure. I think these can all be improved easily for future volunteers.
Otherwise the bed, bed net and table for working are good.
Needs
It would be very helpful to have a printer and photocopy machine for the
volunteers, since we liked to give summaries of some of the topics discussed to the nurses
and residents. It is not that easy at this moment to copy at CHK.
I thank you again for this great opportunity you gave me to come in Rwanda. I
sincerely think this was a unique human and work experience I will remember for life. I
strongly believe other senior residents should benefit from the opportunity to come in
Rwanda for a month. I was confronted to different values, pathologies, operative
techniques. I got a lot personally from this experience, learned to supervise colleagues
and improved my teaching skills.
Sincerely,
Catherine Paquet
R5 anesthesia resident, McGill University