Sunday, July 5, 2015

Anesthesiology Lessons for Rwandan Residents: Troubleshooting Intraoperative Hypoxemia from the Lounge of a Luxury Hotel

How does a country with 13 anesthesiologist provide anesthesia care for a population of 12 million? In Rwanda, since 1997, anesthesia technicians have provided anesthesia in the operating theater after undergoing a 3-year training program, which they could enter from high school. Prior to the initiation of the first anesthesia residency class in Rwanda in 2006, the country had only 3 physician anesthesiologists who were trained in France and Belgium. The lack of any educational infrastructure prior to independence from Belgium in 1962, and the long-standing ethnic conflicts between the Tutsi’s and Hutu’s have hampered the development of medical care and education system. However, though in its ninth year of operation, the anesthesia residency program currently has only 9 out of its 24 positions filled. In sharp contrast to the rising popularity of anesthesiology as a career choice in the U.S. and Canada, few medical graduates in Rwanda choose anesthesiology due to a combination of high-stress, disproportionate patient morbidity and mortality, low salary and long hours, and excessive clinical and administrative burden.
With this dire shortage of physician anesthesiologists, the clinical role that these residents are expected to fill is utterly different from the role that I, as an anesthesiology resident in the U.S., am trained to fill. Rather than directly providing the anesthesia care, the Rwandan anesthesiologists will be mostly acting as consultants to the anesthesia techs. Currently, the techs could discuss complicated cases with the anesthesiologist on call, and can phone them when problems arise. Consequently, the residents infrequently take responsibility for a case from beginning to end. As well, with the responsibility to take overnight ICU calls, the residents are in the operating theater only about 2-3 days a week. This severely limits their intraoperative training and exposure to the infrequent but high acuity events that require rapid troubleshooting, diagnosis, and decision-making.
A key aspect to highlight is that with the shortage of physician anesthesiologists, in the absence of foreign anesthesiologists, the anesthesia residents would be learning anesthesia mainly from books and the anesthesia techs. This is an educational gap that the U.S. physicians working in Rwanda through the Human Resources of Health (HRH) collaborative have filled. The anesthesia techs perform a very admirable job of placing thousands of patients under general anesthesia and bringing them safely through surgery, especially for patients with advanced stages of disease and uncontrolled comorbidities that anesthesiologists in the developed world are mostly shielded from. However, without having been through college or medical school, they lack the fundamental understanding of physiology and disease processes that would alert physicians to perform more thoughtful preoperative investigation and optimization, and to manage the intraoperative and postoperative course. This became evident when I went with a U.S. attending anesthesiologist and the local resident he is paired with to the wards to evaluate patients with inexplicably high blood pressures, possible untreated heart failure, or pulmonary problems. Although the anesthesia techs had already performed a preoperatively evaluation of each patient the evening before, we felt strongly that further optimization and discussion with the primary team was necessary and postponed the cases. Thus, a critical aspect of the U.S. physicians’ interactions with the anesthesia residents is encouraging them to apply their medical education and years of practice as a general practitioner to think and act as a physician.
Under these circumstances, simulation is a critical component to the residents’ didactics to create opportunities for making managing complicated or emergency scenarios. However, the simulation center was recently shut down due to lack of funding for a managerial administrator. Also, as commonly happens to expensive equipment sent to developing countries lacking the technical support for maintenance, the SimMan requires repair and can function now only as a low-fidelity mannequin. Thus, instead of designing a classical intraoperative scenario, I designed cases where the residents were called on the phone to help an anesthesia tech manage an intraoperative event. Considering the role of anesthesiologists as consultants, not using the SimMan actually better approximates their future responsibility.
Another unanticipated challenge of simulating the case was relocating our class at a moment’s notice to the lounge of a hotel. We learned just when class was about to begin that no room was available at the college due to exams. This experience in teaching anesthesia in a low-resource country has challenged me to identify educational and knowledge gaps through careful observation, to tailor lessons to local practices, and to be flexible in adjusting to surprise circumstances. Thankfully, the two first-year residents I worked with were very obliging, and engaged fully in the scenario. Meanwhile, we were able to enjoy the perks of having class at a 5-star hotel – high-speed wifi, plush couches, and fine Rwandan coffee.