REPORT OF VOLUNTARY WORK IN RWANDA
January 7 – February 7, 2008
Dr. Julie Williams
I would like to thank the organizers of the Rwandan program for the opportunity to be part of the project. It was a challenging, but rewarding experience.
CHUK, KIGALI
CHUK is a busy referral center presently staffed by 4 anesthesiologists, Drs. Panjato,
Willi, Nepo and Bosco. Dr. Panjato is the chief of the department. Dr. Panjato is also in charge of resident education at CHUK. Dr. Willy was in the ICU mostly, Dr Nepo in maternity, and Dr Bosco in the main OR suite. Dr Panjato worked occasionally in all these areas, but had very heavy administrative demands to do with annual reporting and reconstruction in the main OR block at this time.
There were 2 anesthesia residents at CHUK, Dr. Bona and Dr.
Antoine. Dr. Bona was just starting at CHUK, after a stint at CHUB. Dr. Antoine started at CHUK in April 2007 and is completing one year there. Drs. Rose and Paulin were assigned to King Faisal
Hospital. They also joined the Wednesday lectures every week. Dr.’s Paulin and
Theoneste missed the first week, because of vacation. Dr. Theoneste came from Butare for two Wednesday sessions, and I gave one lecture to him in Butare.
The majority of my time was spent at CHUK. The day begins at 0700 hours with the morning meeting with the anesthesia technicians, residents and staff. The patients of the previous night are described, as well as the patients slated for surgery that day. All preops are done by the anesthesia techs. Interesting cases occasionally stimulate discussion. The residents would benefit greatly from participation in the preops and presenting cases. At
Butare, I was told the resident routinely sees several preops each week. This should be put in place and maintained at CHUK (apparently it has been done before at the urging of other volunteers, but slides away when the volunteers go). The preops done by the techs are often lacking in sufficient depth. Hopefully, having the residents do some would gradually improve the level of all assessments.
After the meeting, I would either follow Dr Bosco on his rounds through the Recovery
Room and ICU or get ready for the OR. There are 2 ORs in the new maternity wing, which is now fully open and running. The day I spent there with Drs. Antoine and Nepo, they alternated between the two ORs to improve changeover times. There is only one laryngoscope shared between the 2 ORs. There is no wall or cylinder oxygen in either
OR, but there is one backup cylinder with regulator in the recovery area. (By the end of my month, there was a backup cylinder for the OR as well.) All the sterilization for the hospital is now done in a new central sterilization area in the maternity wing. Materials are then distributed throughout the hospital. There are two large labour suites with bays for between 4 and 8 patients each. I have only ever seen one patient in either. Apparently most deliveries are still done at the Muhima Maternity Hospital, but they transfer the high risk cases to CHUK. This results in an average of one to three caesarean sections every

night. There is a small neonatal unit. They have no ventilators, but have 5 incubators. The day I walked through, 4 incubators contained sets of premature twins and one held a term infant with esophageal atresia awaiting transfer to Uganda for surgery (although I think I saw that baby at King Faisal Hospital a week or so later).
Within the OR the chief tech assigns the techs to a room. Residents were not being assigned to a room, until the last week of my stay. At the moment the chief tech also does the resident assignments, but the resident may request a certain room or case. The resident tends to choose the room that interests him, as well as the room that has assigned technicians with whom the resident can work. The resident and techs work very independently. Drs. Panjato or Bosco are available for consultation and hands on assistance if needed. I generally would pick one resident to work with each day and alternate between Bona and Antoine, depending on who was present or post-call. Dr.
Bona is starting his third year of the program and is quite knowledgeable, but still needs to improve prioritization and judgement. Dr. Antoine is in his eighth month of the program and is a very weak resident. He lags behind his year mates Rose and Theoneste, particularly in application of knowledge and clinical skills. He needs continuous, daily encouragement to read the charts and confirm the patient history before proceeding with the anesthetic plan. He is quick to answer his cell phone and slow to recognize a deteriorating situation. He relies on the techs to have everything ready and does not check anything himself unless specifically asked. Organization of anesthesia in the OR and the concept of having everything ready and organized in the OR before starting a case varies according to who is giving the anesthetic. Some of the techs are quite organized. Others will go for one thing at a time and set up takes forever. They are somewhat hampered by having to share laryngoscopes and other equipment between rooms.
The anesthesia technicians are a talented group. Several new graduates have just been recruited and started work in late December or early January. They now number 28. They are rarely supervised. In the morning meeting, the presenting technician proposes the types of anesthetic to be given for the upcoming patients. Bosco or Bona may offer insight or opinion, but generally things will proceed as read. Dr Bosco has an interest in regional anesthesia and will be sure to be available for any case demanding a regional procedure other than a spinal. During a procedure, should a problem arise, one of the techs will find a staff to provide help. Many cases are done with spinal anesthetics.
There are two techs assigned to each OR, usually one for the Recovery area, one for stock, one for the emergency department and one (occasionally 2) for the preop visits.
Now that the ORs have been reduced from 4 to 2 in the main block, there may be three techs per room and usually two on preops. The degree of patient monitoring is uneven.
Cases are done without an EKG and sometimes, especially in pediatric cases, no BP monitoring. This may be due to a lack of size-appropriate equipment. There are a few reusable EKG electrodes, but not enough for each room. The techs do use saline soaked cotton or gel and tape the electrodes to the skin. This gives a reasonable trace. Part of the reason for not using the EKG may be the techs are unable to interpret it. Another practice
I have occasionally observed with the techs is that a syringe of drug (especially morphine or fentanyl, which are often in short supply) is prepared at the start of the day and used for multiple patients. This appears to be a persistent problem.

At the time of writing, many challenging changes are occurring at CHUK. The main OR block is closed to undergo significant expansion and rehabilitation. This is a necessary step, but has been launched into very abruptly. All surgery is to be carried out either in the maternity wing or in the two small ophthalmology ORs in the Opthalmology Clinic area. The ENT clinic OR is also being quickly rehabilitated to serve as a Minor
Procedures Room. Moving all the stock out of the Main OR Block and finding new places to store everything has been a difficult process. Computer and library access are even more difficult now than before. Currently, there is no anesthesia office and in fact there is absolutely no place to sit down in the Opthalmology ORs other than the stools in the theatres themselves. Doing any sort of work (ie preparation for lectures) at CHUK is extremely difficult in this set up.
Another major concern at CHUK has been the Recovery Room. Its size, equipment and staffing have been a chronic problem. There is a habit in the hospital of patients lingering in recovery, particularly after they come through Emergency for urgent surgery. There is no bed for them in the hospital and they cannot return to the emergency room. They may stay in Recovery for a week or more. This contributes to making that area extremely unsafe. The chronic patients often used both of the 2 oxygen sources in the old recovery room, meaning immediate post-anesthetic recoveries were almost exclusively done without access to oxygen. The new Opthalmology recovery has only one H cylinder of oxygen with flowmeter, no wall O2. There is no suction in that room. An electric suction could be brought from the OR, as long as it is not needed by a surgeon. There are two working portable OR monitors set up there. The small hand-held oximeter left by a previous volunteer is currently out of order, but may just need recharging. The issues of
EKG leads and appropriately sized BP cuffs are also concerns here. Thus these modalities are rarely used. The anesthesia techs do their utmost to do every single case under regional anesthesia, usually spinal, to avoid needing oxygen. There is only one backup oxygen tank in the ORs and one in recovery. They have moved 2 glostavents with oxygen concentrators up there from the main OR, but if the power goes off, the concentrators will not work.
I gave 1 main seminar per week on Wednesday afternoons. The anesthesia tech students at KHI were still on vacation, so I did not give any lectures there. Monday afternoons were “Scientific Program” at CHUK. January 7, Dr. Bosco presented “Prevention of
Post-Dural Puncture Headache” and January 28, Dr. Paulin presented “Chronic Pain”.
The topics I covered included:
Jan 9-Neonatal/Pediatric Anatomy and Physiology- Antoine, Bona, Rose, Bosco
Jan 16-Neonatal Anesthesia and Pyloric Stenosis
-Approach to Intravenous Access in Children -Antoine, Bona, Paulin, Rose,
Theoneste, Bosco
Jan 23 (and Jan 24 at Butare for Theoneste and Dr. Jeanne)-Pediatric Anesthesia
-Considerations for Reactive Airways Disease
-Considerations for Tonsillectomy and the Bleeding Tonsil-Antoine, Paulin, Rose
Feb 6 – Patient Positioning
- Review of Airway Grading Systems – Antoine, Rose, Theoneste, Paulin, Joel,
Kara
Given at King Faisal:

Jan 29-Patient Positioning-Rose, Paulin
Jan 31 -Modes of Ventilation, Acute Lung Injury and ARDS-Paulin, Rose, Patrick and
Elia (medical officers at King Faisal ICU)
-Pediatric Basic Life Support-Paulin, Rose
Feb 5 – Recovery Room Standards and Care – Anesthesia Techs and OR Nurses, Joel
Parlow, Kara Gibson, Rose
BUTARE
I spent one day in Butare, January 24th. The main purpose of my visit was to meet with
Dr. Jeanne and acquaint her with the challenges at CHUK, as well as my concerns about
Dr. Antoine’s progress.
I arrived about 1000hrs, met with Dr. Jeanne for about 45 minutes, then finished the morning in the OR with Dr.Theoneste. I found the organization of the residents and OR here superior to CHUK. Theoneste reported that he is expected to see some of the preops each day. He is generally assigned to a room by the senior tech. The overall setup of the
ORs and Recovery Room is better than CHUK. There is the possibility of using isoflurane here. The Recovery Room is more than large enough for ten bays. There are outlets for wall oxygen, air and suction in each bay. There is a shortage of oxygen regulators, with only 2 in evidence during my visit. There are no monitors in recovery except one pulse oximeter and any monitor that the anesthetist brings from the OR. The
ORs have wall oxygen, air suction and nitrous oxide, although I have not heard of anyone using nitrous oxide.
I spent the afternoon with Dr. Jeanne and Dr Theoneste reviewing the lecture from the week.
KING FAISAL HOSPITAL, KIGALI
At the request of Rose and Paulin, I visited King Faisal Hospital to work with them. The staff anesthetist there is Dr. Betty. I attended King Faisal on 3 occasions, Jan 29,31 and
Feb 5. I would attend teaching rounds in the ICU with the residents and medical officers and then proceed to the OR to work with Dr Paulin or Dr Rose. Dr. Betty is eager for
King Faisal to become part of the volunteer teaching program as well. To facilitate this, I met with Dr. Joseph, the head of post-graduate training in Kigali and a pediatric cardiologist at KFH and Dr. Kayibanda, the president of the Rwanda Medical Council and a general surgeon at KFH. I handed in the paperwork for the Rwandan Medical
Council, when I met Dr. Kayibanda. He stressed the importance of everyone being registered and that he was emphasizing this to Dr. Jeanne and Dr. Panjato. King Faisal
Hospital offers neuro and thoracic surgery. Their busiest OR days are Tuesdays and
Thursdays. For this reason I have proposed that the volunteer work at King Faisal every
Tuesday and every second Thursday. This, along with the bimonthly visits to Butare, will give the volunteers the opportunity to work clinically with every resident and to see how

the different hospitals operate. They are all quite different, with different strengths and weaknesses.
SUMMARY
The Anesthesia Residency Training program in Rwanda has a superb champion in Dr.
Jeanne. She was very open to my concerns about the program at CHUK and looked hard for ways to help. The bi-monthly visits to CHUB will be reinstated and a weekly visit to
King Faisal Hospital has been introduced.
Any opportunity to have a resident accompany the staff volunteer shouldn’t be missed.
Many staff and residents commented on how much they enjoy this.
It certainly helps to speak French, although all doctors and technicians were happy to practice their English. French is definitely the preferred language of communication, except at King Faisal, where the working language is English.
I would like to see the residents more involved in the morning report. They should be presenting the cases done while they are on call and seeing preops and presenting them.
They would acquire presentation skills necessary for a consultant and serve as role models for the technicians.
Resources remain scarce. It would be helpful for each resident to have a basic anesthesia text. Currently access to the resources at CHUK is extremely difficult. They need to be able to read at home.
A hand-held capnography unit that could move from room to room would be a great help at CHUK. It would permit intermittent CO2 measurement and permit some teaching around respiratory physiology under anesthesia.
Esperanse in Public Relations at CHUK was a great help in arranging transport. A CHUK vehicle picked me up every morning to take me to the hospital. If I requested, one would also be found to take me home, although this often involved a long wait for an available car. There were some issues with the accommodation in Kigali. There is internet connection, however the wireless router is broken, so the one line is shared by all occupants, up to 8 at a time. This resulted in competition for internet time. The router was replaced on Feb 5 and hopefully will continue to work well. I purchased a safe for the house. It is in the storage room. There are two sets of keys for it. It is large enough to hold the laptop, a camera and certainly passports and plane tickets etc. Water was occasionally absent. Hot water to wash with was often absent. Water pressure was virtually always absent. Petty thievery of communal utensils from the kitchen was common. Can openers and Tupperware were particularly likely to disappear. Anything personal that you wish to keep safe should be locked in your room or the safe at all times.
The house boys do the dishes, clean the floors and launder the bed sheets. You must supply them with soap to clean the sheets. Towels or personal laundry costs extra.

A copy of the third edition of the Bradt Guide to Rwanda has been added to the store. I have written some useful numbers for drivers and also names of public bus lines to use for transportation around the country.
All in all, I found Rwanda to be a very friendly and safe country. I really enjoyed the opportunity to get to know the land and its people. Thank you to Dr. Angela Enright for supporting me throughout my time here.
Julie Williams, MD, FRCPC
Assistant Professor, Dalhousie University
Halifax, Canada