Improving Access to and Safety of Anesthetic Care in Rwanda through Education Part 2:

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.