Anesthesia Teaching in Kigali, Rwanda

This is my first trip to Africa. Rwanda has only been this textbook entry that I read about in class during to the horrible genocide 20 years ago. It’s hard to believe that I am actually here. I have been waiting and planning for the trip for the past year and yet I felt completely emotionally unprepared now that I am actually here. It’s finally starting to feel real now that I am actually here. First impressions as the plane was making its descent was “where are all the lights.” I was craning my neck with my face plastered against the plane window, searching for evidence of the city where I was going to spend the next month of my life but yet could only make out occasional flickers of light in the distance. I double checked the monitors and saw that we had 11 miles to go, 10, 8… Where were the lights? Slowly more lights appeared on the horizon, reinforcing the fact that I was likely approaching the right place.

My first day of work  at Central University Hospital of Kigali(CHUK) started on Monday, also known as their nonclinical academic day. I got eased into the schedule but sitting through a morning of lectures much like what we do at BWH. The hospital actually reminds me quite like the Hawaii hospitals. Low one story structures that almost look like small bunkers that are surrounded by greenways separating each unit. The operating rooms were surprisingly much bigger, more spacious and nicely warm instead of the frigid conditions that most of our operating rooms operate under. Being from Asia, it was easy for me to ignore the mold on the walls. The Glostavent is an amazing ventilator that I encountered for the first time. It operates in conditions where both electricity and/or oxygen supply is inconsistent. The most glaring difference in the ORs is the lack of a scavenging systems on the ventilators. For the non-anesthesiologists, this is the system that takes the wasted/exhaled gases from the patient and removes it to a scavenging waste system. Without it, the halothane that the patient was exhaling was being dumped into the OR and then being breathed in by us. I had no idea why I felt so exhausted every night after work until I found out that I was essentially being anesthetized on a daily basis.

 

 I saw this on the bulletin board in the OR.

 Our OR schedule, but don't worry, no one really follows the daily room schedule.

 The Pre-op holding area. This is not a place where you want to be when you are sick. There is generally staff taking care of patients here and patients are not often seen by any medical staff until they are lying on the OR bed.

 Our operating room.

 The Amazing Glostavent.

 Our sterile facemasks being hung outside to dry.

 

The saying “change has to come from within” definitely applies here and to the motto of the Human Resources for Health(HRH) physicians and to the foreign staff working here. Their goals are not to join the workforce but to provide guidance to the physicians already there. If they ever establish themselves as working staff, the thought is that the local staff would disappear and simply let them do all the work. One of the mistakes that was repeatedly emphasized to me is the enthusiasm of foreign staff to change the way things are done or practiced. This can happen with tremendous effort on the part of the initiator however things quickly fall apartment once the foreign presence leaves. Change can only be sustainable if a local staff takes responsibility for the project and carries it forward in the system and their peers. However not many local physicians seem to have the motivation to do this. This was not something that I had really considered before when I developed my interest in global health but makes so much sense now that I got to see it in person.

During my first week, it was easy to get lost and often found myself wondering how I could really contribute to training the students and residents here. It wasn’t until a few days into my time at CHUK that I started noticing how neglected the medical students were on their rotation that I decided to make them my students for the month. Rwanda is desperate for anesthesiologists. The country has about 12 MD anesthesiologists while most of the anesthetics are provided by anesthesia techs. The one of the goals of the anesthesia team for Human Resources for Health is to recruit residents. There is no current first year residents. I believe that recruitment should start with medical students. Also after graduation, medical students are required to have an intern year and then practice independently for 2 years as a general practitioner before being eligible to apply for residents. I had a month to prepare these medical students with all the basic knowledge of airway assessment, fluid and blood management and pain management that they needed to take care of patients in the district hospitals when they are the sole practitioner 2 years from now. It was a daunting task!