Friday, June 26, 2015

Teaching Anesthesiology to Rwandan Medical Students: Focus on ABC’s and Oxygen

Standing in front of the 10 medical students starting their 5-week anesthesia rotation, I realized that there is one primary objective I need to achieve: teaching resuscitation skills. This is their last clinical rotation; in 5 weeks, they will be disbursed as general practitioners to the district medical centers where they may be the one doctor available to both hold the scalpel and provide the anesthesia care for a C-section. “ABC’s and vitals” is the mantra I keep repeating to them. Ensure that the trauma patient who just comes into the emergency room has a patent Airway, is Breathing, and has Circulation, then check their vital signs to gage whether their heart or lungs may imminently collapse before tending to the specific injuries. These are the skills in recognizing respiratory or hemodynamic instability and the expertise in resuscitation that we cultivate in anesthesiology and are transferable to keeping a patient alive in any setting, not just the operating theater. Teaching medical students in Rwanda, I realize that these are the most important lessons to get across, not the more self-serving desire to show them “how cool anesthesiology is” and to entice them to follow my career choice.
The reality is, likely none of these students will choose anesthesiology as a specialty, at least not as their first, second, or even third choice. The popularity of anesthesiology as a career choice in Rwanda is similar to how it was like in the U.S. twenty years ago. High patient mortality leading to high stress, low pay, over-burdensome clinical duties due to lack of personnel, and limited respect are some of the top deterrents medical students listed on a survey I helped conduct this month on choice of specialty.

This perspective forms part of the context for designing lessons and case scenarios. The other key component is tailoring to their knowledge base. Speaking with anesthesiologists from the U.S. who have been teaching the medical students for almost a year, I learned that the medical students have received only very rudimentary lessons about the complex physiology of the respiratory system. Thus, we started our first lesson by explaining the fundamentals of why oxygen is crucial for survival and how oxygen enters the body. When a patient cannot take in sufficient oxygen (either due to anesthesia or medical condition), anesthesiologists step in as the “Oxygen-Providing Service.” This paring down to the core of what anesthesiologists provide removes the distractions arising from the technical aspects of anesthesiology, and focuses their attention on assessing a patient’s clinical status and intervening expeditiously.

Thus, the case scenario that I designed is set in the emergency room rather than the operating theater. It emphasizes vigilance, reassessment of a patient’s condition, stabilization of a patient’s cardiopulmonary status, refinement of their differential diagnoses, and anticipating next steps –skills that are important in any clinical setting. Faced with the challenge of managing an unstable patient, the students were very engaged, volunteered answers, and asked questions. In an education system where students were expected to simply absorb information and not encouraged to speak in class, this active involvement from the students was very encouraging.

The final class took place in the SimLab, where the students were able to put the theory and skills into practice by working as a team to resuscitate and ventilate the mannequins. Though most if not all of them will not become anesthesiologists, as practitioners in a country where there is 0.6 physician for every 10,000 people, they will likely encounter situations when they would be called upon to oxygenate and stabilize a patient. I hope they will remember the ABC’s from the Oxygen-Providing Service.

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