Monday, December 23, 2013

Anesthesia Teaching in Kigali - Life as a local medical student on rotation

I walked into an operating room two hours after inducing the patient with a resident. The patient was covered from head to toe in a green sheet and no one was in the room. My first thought was, “oh no, what happened, how did this patient die?” This was not an unreasonable question given the number of codes that occur in the ORs. But then I heard the steady chirping of the pulse ox and realized that my patient was still alive and seems to doing well under the sheets despite being alone and unmonitored in the room. I went to find the surgery resident to see what the situation was. His response was “we were hungry and it was lunch time so we covered him up and went for food.” This patient was having a craniotomy for a meningioma removal so his brain was exposed where the skull defect was. I don’t remember what my response was because of being so shell shocked. It turned out, after prying information out of the resident, that one of their surgical instruments were not sterilized yet despite the request being made a few days ago so they decided to break scrub until the equipment could be used 2 hours later. A typical example of the going-ons at CHUK operating rooms.

The past two days have been much more satisfying. I gave the medical students a lecture in anaphylaxis yesterday and have really taken on the role of being the medical student instructor in the OR. Having never had the opportunity to teach in the past, I have found it to be a very satisfying and rewarding job. These students are extremely easy to teach. They seem so starved for information and were so enthusiastic about any information that is taught to them. There is currently no real medical student curriculum and no one to teach them or guide them. I remember how terrible it was when I was a medical student feeling neglected during my rotations. It felt like no one really care about what you were doing. This is 500x worst. The reality here is that no one does care about them. They make their own schedules, they show up to the OR and to the ICU when they feel like it and leave when they feel like it. There is no accountability. At first I was shocked by their seemingly lack of motivation but then seeing what their rotation is like, I wouldn’t waste my time at the hospital either if I wasn’t learning anything standing around.

It wasn’t until now that I realized why there was such an emphasis on the painful 10 page H+P and presentations in med school. It pounded in the organizational skills that we needed to have in order to systematically think about problems, formulate plans and perform tasks. We had a set curriculum during our non-clinical years that provided us with our basic science framework and all the rotations that we had had a set curriculum that allowed to learn about the basics of each specialty. It seems though that no one has really provided them with a strong foundation in which to build their medical knowledge on. Things like intracranial pressure is not understood by the students, the idea of ventilation vs. oxygenation is foreign to them. It was with this in mind that along with my attendings, I decided to write a medical student curriculum. The challenging part was to decide how to do this in a way that would be sustainable. We decided to write four modules on topics that I felt like are the most vital for each medical student to know: airway management, fluid and blood management, pain management, basic life support and communication. Each module consisted of a transcript with a PowerPoint, simulator sessions, and discussion points that precisely provided all the information that is needed. The hope is that any anesthesiologist can pick up this transcript and be able to run this module without any difficulty. By providing this framework, we hope that it will create an easy transition to the local physicians who plan continue to this curriculum when both I and my attending are gone.

 Me with our residents and med students after our OB postpartum hemorrhage simulator case. The patient survived.

 My med students. Celebrating after surviving one of our anesthesia modules!

 This was a part of our airway management module with an airway simulator session at the sim center at the hospital.


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.

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!

Thursday, December 12, 2013


Hello again from Western Kenya. As I conclude my trip, I wanted to update everyone on the status of the project. It's been a wild 6 weeks, full of travel. We were able to visit 27 facilities in total - learning a great deal from all of the wonderful medical providers who gave their time to help in this project.

Not surprisingly, we've discovered there is definite room for improvement for emergency care in Western Kenya. Finding out how we can focus our efforts best will be the greatest challenge. We have found that even basic supplies like X-ray and ECG machines are lacking, the providers (especially specialists) are frequently overworked and spread-thin, referring patient's to a higher level of care poses many challenges and can be dangerous, and many providers are requesting more trainings to be able to take care of their patients better.

I was able to pass the torch to another fellow resident who will continue collecting data. When complete, we will analyze our data and work with local medical officials to raise the standards of emergency care in the region. Fortunately, we've already started a pilot training program to train some providers on emergency anesthesia.

Dave Young, MD

Sunday, December 8, 2013

Zuni IHS Community Experiences

Despite the small size of the population and the Zuni Health Center, I believe they are doing very progressive work through community outreach, population health and the group practice of medicine.  I have shared just short tidbits of some of the amazing opportunities I had the privilege of being part of during my short time in Zuni.

Zuni, New Mexico – A Special Place

I had heard a lot of good things, but really didn’t know what to expect upon arriving to work at the Zuni Comprehensive Community Health Center  – a 2 ½ hour drive from Albuquerque on the Zuni Indian Reservation in Western New Mexico, near the Arizona border.  I was welcomed with open arms to a beautiful community that is visually stunning, culturally unique and home to proud and amazing people.  The health center and its healthcare professionals were inspirational practitioners of healing.  They had found their calling working in Zuni and it came through in their approach to medicine and living life.  I could not have been made to feel more welcome to be part of a community and a practice of medicine.

Zuni Comprehensive Community Health Center serves approximately 10,000 Zunis and 4,000 Navajo who live on surrounding Navajo Nation reservations lands. The majority of Zunis are bilingual, with Zuni being their first language. Many Navajo over 45 years may not speak English. There are Zuni and Navajo employees who can assist with translation.  Silver-smithing is the main source of cash income and Zunis are renowned for their intricate jewelry work and fetish carving. Employment for others is through government or tribal organizations, the school system or our facility. The median Zuni family income (1999 data) is  approximately $21,000/year and approximately 50% of the population falls below the poverty level. Traditional ceremonies are the center of nearly all social activities and Zunis follow a calendar of night dances and rain dances which take place in the plaza at the center of the old village. Zuni society is divided into six fraternal kiva religious organizations, 10 medicine societies, and 12 matrilineal clans. Traditional medicine is also an important part of Zuni culture and many Zunis incorporate visits to medicine men, bone pressors, or traditional midwives along with seeking care at our facility.  

Dowa Yalanne (DY) A Sacred Mesa, a shelter to the Zuni People during their resistance to the Spanish (my wife and son)