Monday, December 23, 2013

Anesthesia in Kigali, Rwanda - What is the BIG Difference?

At CHUK, I had the opportunity to work with HRH faculty that have been in the country for a period of time. In speaking to them, their thoughts are that the current medical system doesn’t lack professionals with medical knowledge but the issue is that the system itself and the cultural background that it runs on is ineffective. There is no effective OR scheduling systems. Elective cases bump emergency cases. There’s no system in place to book emergent cases. Anesthetized patients are often left alone during the procedures. Most of the cases are performed by anesthesia technicians who are trained at a local technical college without any education by a physicians. The local attendings are not often involved in the OR cases despite being the ones responsible and definitely never do their own cases. The residents similarly are extra staff. They are extra hands that are not essential to the running of the OR. Their rooms are completely set up by the technicians who have sole control over the anesthesia supplies. The ICU consists of 5 beds who are constantly full. “ICU boarders” in the PACU are essentially homeless patient with no primary team and no one following them in the PACU and often end up in what is called a “slow code.” It’s a system of survival of the fittest. I had asked if this was a product of a lack of man power and resources or a systems issues and his answer was that it was that it was the system.

The PACU and pre-op area was one of the first areas where my first thought was “this was  medicine a third world setting.” Basic principles of anesthesia in CHUK(Central Hospital University in Kigali) I’m told are to make sure that I have any equipment I need available. Many of the things are not in the room so definitely do a pre-op check and do not rely on anyone else. Second, do not trust anyone else’s’ preop. Patients are often seen the night before by a technician but their exams are not often reliable. Patients are not often pre-oped until they are in the OR, lying on the OR table. Communication is big issue in all aspects of care: hand offs, discussion with surgeons, PACU signouts, designation of roles and etc.

A summary of what I know so far:

Operating Rooms at CHUK:

Main OR: 6 ORs

OB: 2 ORs

About 6 surgeries are performed each day in OB. This is the only place where I've seen daily exploratory laparotomies for peritonitis from botched C-sections from the districts. I didn't even realize that could happen from C/S. A total of around 70 operations performed each week in all the operating rooms.

There is not an effective scheduling system for the rooms. Elective cases bump urgent and emergent cases frequently. There is a hand written schedule on a white board but cases often get moved around. Patients do not have identifying wrist bands or other identifiers and therefore confirmation of the right patient and right surgery is completely dependent on the nurse.

-          There is no morphine. Pain control consists of fentanyl, IV tramadol and IV Tylenol. I thought this was crazy but apparently patients don’t complain of pain much postop. Rwanda is a palliative care nightmare. There is no palliation even if you want it.

-          Patients have to pay for their surgery and buy the drugs they need for their surgeries and take it with them on the day of surgery in order for the procedure to occur.

-          Limiting factors for the OR

o   Supplies for the OR

o   Electricity

o   Water – although with water outages, the surgeons just have buckets of waters that they use to scrub

o   Staffing

o   Anesthesia machine – all of them are broken to some extent. There are only limited numbers of ventilators so if one is used by a patient in the PACU then one OR can’t run.

o   Patients who require ventilators postop who are spontaneous breathing are attached via a endotracheal tube elbow that is then connected to a wall O2 source when a ventilator not available. There is also a shortage of monitors so generally you keep your fingers crossed and hope that the patients continue to spontaneously breathe and assume that their vitals are normal…until you get called for a code.

o   Only 2 main OR anesthesia machines have capnography

o   There is now a code cart in one of the rooms after the recent failed accreditation visit. But there are not any defibrillators around.

-          Surgical safety checklist is being implemented by the HRH staff

-          ICU only has 5 bed and is constantly full. Patients cannot be discharged from the hospital until they pay their bills. For the patients that cannot afford to pay for their bill, they stay in the hospital in definitely. As a consequence, patients from the OR who needs an ICU bed are brought out to the PACU where they are monitored and suffer what is called a “slow code” until they pass away.

-          PACU, where over 10-15 patients are consistently and is managed by 2 nurses. Only some patients have constant vital sign monitoring. Ventilated patients who requires the ICU are not consistently managed and there is no physician who takes responsibility for these patients and many of them end up dying.

-          Patient are usually pre-oped the night before by anesthesia techs who do not relay the information to the day team. Patients are usually first seen by the anesthesia team when they are rolled into the OR and have been moved to the OR table. This is where the short preop assessment is made and the IV is started.

-          Anesthesia residents and anesthesia techs routinely leave the room leaving the anesthetized patient completely unattended.

-          Each OR is manned by either 2 anesthesia techs or 1 tech with a resident.

-          The tech is responsible for setting up the room, getting the airway equipment, drawing the drugs. The airway equipment is often not in the room during induction and are stored in a locked locker that only the techs have access to.

-          The techs are usually not supervised by anyone as the consultants who are supposed to be responsible are generally not around. The techs are the ones that usually train the residents initially and therefore they usually pick up their bad habits.

o   Machines often are not checked

o   Not all monitors may be on before induction

o   Suction is not on(only long soft tipped catheters are used)

o   Airway equipment often not checked, laryngoscopes not checked and not in the room, oral airway not available

o   No working ambu-bag

o   Not all drugs available

o   No real personalized anesthesia plan is developed for each patient, airway exam, preop assessments often are not performed

-          “infected” patients are operated on as the last case in the room in order to prevent contamination of subsequent patients no matter how urgent/emergent the case is – the HRH people are trying to stop this practice. For example, I have seen many instances where an elective C/S or D+C is performed before a peritonitis ex. lap. There is definitely a difference in the sense of urgency.

Overall I think the most important thing that I have experienced is that the physicians and residents often do have medical knowledge and have access to book and information. What needs improvement is systems based problems such as overall organizational skills, thinking over anesthetic plans, the implications of anesthetics and its actions on patients and etc.

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