Elliott Woodward, MD
Resident in Anesthesia, BWH
PGY 4
Much progress had already been made
in terms of transferring the role of primary educator for the Foundation and
core curriculum from visitors to the local Rwandans by the time I arrived in
Rwanda. So, my role during these
sessions as a visitor assisting CASIEF was to work alongside local anesthesia
attendings to support senior resident led teaching. The educational focus during the month of my
visit was on neurology and perioperative management of patients with
neuropathology and/or those requiring neurosurgery. 
Each week, a senior resident was assigned the
role of teacher. This resident was
provided with a list of the subjects to be covered during their week approximately
one month in advance as well as instructions to provide an interactive lecture
environment for the rest of their group.
From the time the assignment was made until the day that the teaching
was provided, I worked with the resident teacher to help them prepare their
presentation, key readings, and questions related to their topic which were to
be distributed to the rest of the residents a week before the lecture.
On Mondays, I sat in on the lectures, helped
to steer the discussions, provided guidance for the presenters when needed, and
answered any questions that arose that the student teacher was unable to
answer.
Some Rwandan residents excelled in
the role of educator while others required much more support. Regardless, I can honestly say that I learned
as much as I taught in this role over the course of the month. I spent many nights during my time in Rwanda
pouring through “Big Miller”, (a comprehensive anesthesia text authored by
Ronald Miller referred to as Big Miller for a very good reason….)
just to be sure that I could answer any tough questions that might arise. Still I found myself challenged and often in
the role of the student when faced with the day-to-day of Rwandan
practice. For example, while it is relatively
straight forward to teach the effect that various anesthetics have on
intracranial pressure (ICP) and to discuss the approach used in our hospitals
at home when managing patients with with elevated ICP,I found this discussion
much more complex when reflecting on management of the same patients in
Rwanda.
Many of the hospitals in Rwanda either
a) don’t have access to the medications that we would normally use for these
cases or b) don’t have easy access to treat the known side effects (such as
hypotension) related their use. This led
to some interesting discussions delving into the complexities of polypharmacy in
order to balance the desired and undesired effects of the available
medications. I walked away from these
talks with some reading to do after my Rwandan counterparts referenced a number
of papers on the subject that I was not familiar with. I reviewed the literature and later, while
trying to relay what I had learned, I found myself in some of the most
rewarding and perhaps most educational interactions that I had in the whole
month. While these discussions were
meant to relate back to our original topic of neuroanesthesia, I found that the
most valuable teaching points that came out of these were instead related to
the critical appraisal of medical literature.
Though unfortunately there was not enough time formally dedicated to
this topic in the current curriculum, it was something that the residents asked
me to revisit with them multiple times over the month during downtime in the
operating rooms. Ultimately I think that
a number of them left these interactions with a more structured approach to the
assessment of the quality of evidence presented in medical literature and a
better understanding of how to apply it to their setting. This is a skill that I hope will stick with
them as they embark on the rest of their adventure as practitioners and,
hopefully, lifelong learners.
Though our role as “classroom based
educators” was primarily a supportive one as previously described, we were occasionally
asked to give lectures ourselves. While
challenging and a learning process for me in a different way, this ultimately proved
to be equally rewarding. One such
lecture was on the topic of fluid management and was one that I am fairly
certain will result in a very real change in practice by the residents which I
hope will trickle down to the anesthesia techs that work closely with
them. Prior to the lecture, the
residents seemed to be choosing fluids for patients in the operating rooms and
ICUs on a whim. For example, while
working with a resident in the ICU one day, I noticed a patient who was in the
process of recovery from septic shock who had a significant hyperchloremic
nonanion gap metabolic acidosis after resuscitation with multiple liters of
normal saline.
This complication is a
well recognized side effect of resuscitation with large volumes of this fluid,
yet this patient was still receiving it.
When discussing the case with the resident, it became clear that their
choice of fluids (colloid vs crystalloid as well as crystalloid vs crystalloid)
was very practitioner dependent and almost exclusively at random. After an hour-long lecture to the entire
group of residents the following week, they reported a significant improvement
in their understanding of fluid therapy and were able to clearly articulate and
defend their reasoning behind choosing certain fluids when quizzed after the
lecture and when discussing patient care in the operating rooms and ICUs later
during my trip.
Clinical teaching was another
important part of my duties which took up much of my time Tuesday through
Thursday each week. The residency program sent residents to four main teaching
hospitals, three of which are in the capital city of Kigali with the fourth
located in Huye in the South of Rwanda. I
spent my first few weeks of the trip in Kigali and one week primarily teaching
in Huye. While in Kigali, Tuesdays and
Fridays were spent at University Central Hospital of Kigali (CHUK), Wednesdays
at Rwandan Military Hospital (RMH) and Thursdays at King Faisal Hospital (KFH) providing
intraoperative and ICU-based teaching. With
only 11 clinically active anesthesiologists in the entire country, it was the
norm to have entire hospitals including the ICU, labor and delivery, and the
operating rooms with up to six ORs running covered by a single
anesthesiologist.
While cases that were
expected to be particularly challenging were identified ahead of time and
discussed each morning with the anesthesiologist on duty, techs were
responsible for providing the majority of anesthetics and, in the absence of
visitors from CASIEF and HRH, for much of the early hands on intraoperative
resident education. While it is
absolutely essential to again recognize the important role that these techs
play in the Rwandan health system, their ability to problem solve issues that
deviated from the norm was obvious and residents were clearly very happy to
have myself and Dr. Stewart Chritton around to provide teaching and guidance
with respect to the intraoperative and ICU based care of their patients. While I would like to believe that some of
that teaching will benefit future patients by shaping their clinical practice
for the better, I can say with relative certainty that we were able to improve
the care that was provided to some of the patients that were hospitalized during
our time there.
Perhaps the
most obvious example of our influence on clinical care relates to the use of
regional anesthesia. Despite the fact
that many patients that present to the ORs in Rwanda are excellent candidates
for regional anesthesia, either as their primary anesthetic or to help improve
post operative pain control and therefore perioperative outcome, use has
historically been limited due to the fact that none of the current Rwandan
anesthesia attendings are trained in these techniques. A visiting anesthesiologist from Canada
working with HRH who completed a regional anesthesia fellowship set out to
change this during his four months in Rwanda.
He developed a regional anesthesia education curriculum including
didactic lectures and hands-on simulation in the simulation lab. He also worked with the local surgeons and
other visitors to help create an environment that was open and appropriately
supportive of efforts to promote regional anesthesia. His time in Rwanda overlapped with ours and
we found ourselves intimately involved in almost every aspect of his efforts
including supervision of blocks in the OR.
While the blocks that we supervised certainly helped the patients that
they were used on, my hope is that the education that we helped to provide in
and out of the ORs will serve as early steps toward the development of a robust
regional program that will help patients for years to come.
Overall, I
had an absolutely amazing experience in Rwanda.
The people were welcoming, the country was beautiful, and the resilience
of those in the medical field was inspiring. On a personal level, I learned more than I could have hoped about being an
educator during only a very short time.
Most importantly, however, I hope that, small as it may be, Dr. Critton and
I were able to make a lasting contribution to the efforts to improve access to
and the quality of anesthetic care in this amazing country.
