Expectations and Anesthesia in Rwanda

Daniel Gessner

Resident in Anesthesiology at Brigham and Women’s Hospital

PGY 4

Expectations and Anesthesia in Rwanda 

My trip to Kigali, Rwanda in February 2018 was my first real experience with clinical care and clinical teaching outside of the United States. I spent each day paired with other anesthesiology residents at work in the operating rooms at their main teaching hospital, the University Teaching Hospital of Kigali (CHUK). As I got oriented to the new working environment, and got to know the other residents, I found that beyond the obvious differences in resources and equipment, there were remarkable differences in what is expected from the residents in Rwanda. And I discovered that it is very difficult to compare practice patterns or outcomes in anesthesia specifically, let alone the entire Rwandan healthcare system, when the differences between their hospitals and my own home hospital are so notable.

Brigham has about 40 operating rooms, divided into specialized “pods” that fairly strictly house only one surgical specialty, allowing for some standardization. CHUK has only 6 operating rooms, which cover nearly all the surgical specialties. Three are designated for orthopedics, though are often the location for non-orthopedic pediatric surgery and neurosurgery. The other three are designated “general”, and house a mix of general and trauma surgery, urology, burn, and ENT, plus the occasional neurosurgery and pediatric patient.

During a typical day at Brigham, a given operating room is assigned to just one or two surgeons, who will do a series of typically similar cases, with typically similar anesthetics. A normal day in a given OR at CHUK can include newborns with meningomyelocele, young adults with femur fractures from mototaxi accidents, middle aged patients with inguinal hernias, and elderly patient with subdural hematomas or acute abdomens. Each case can bring a new challenge and requires different preparation.

Power outages are a rare event at Brigham, and have also become a rare event at CHUK, but other utilities are not as reliable. The wall oxygen supply often fails, several times a week, only briefly but long enough to set off many alarms and interrupt the ventilators. And at Brigham we have occasional shortages of medications, but at CHUK pharmaceutical availability changes on a daily basis, and classes of drugs that we consider “standard” or “must have” are sometimes simply not available.

These remarkable differences mean that academic anesthesiology attendings and residents in Rwanda must be absolute generalists, able to provide anesthesiology for all sorts of surgeries in all sorts of patients. They are required to take care of a much wider variety of patients than we take care of, and must do so without the reliable foundations of infrastructure and supply chains that we take for granted. I was impressed by the Rwandan residents’ ability to adapt to changing situations and their efforts to provide excellent patient care despite the wide variability in the environment around them.

Critical Care and Anesthesia Simulation in Rwanda

Daniel Gessner

Resident in Anesthesiology at Brigham and Women’s Hospital

PGY 4

Critical Care and Anesthesia Simulation in Rwanda 

During February and March of 2018 I spent a month helping to teach anesthesia and critical care in Rwanda. I travelled there under a program that is a collaboration between the University of Rwanda, the American Society of Anesthesiologists, and the Canadian Anesthesiologists’ Society International Education Foundation.  The program places North American anesthesiology residents and attendings in Kigali, Rwanda monthly to help collaborate with local leaders in developing the local anesthesiology resident program.

One of the biggest takeaways, for me, was the seemingly universal value and applicability of simulation in the teaching of anesthesia and critical care. This was my first exposure to clinical teaching in a lower resource setting. When I imagine a simulation session back at home, I think of a fancy dedicated facility with full time staff, expensive robotic mannequins and simulators, realistic monitors, and microphones and cameras throughout. But during my time in Rwanda, we made extensive use of simulation for both anesthesia and critical care teaching, without many of the resources we typically require.

The Rwandan residency program has a weekly academic day every Monday that often incorporates simulation, and their main teaching hospital has a basic but excellent simulation center, with a dedicated freestanding building and a specialist employee to help organize and coordinate simulations. The center has a full complement of mannequins and simulators, including intubation and airway models, IV insertion and ultrasound phantoms, and an anesthesia machine and monitor. It also has advanced airway supplies and equipment including fiberoptic bronchoscopes, double lumen tubes, bronchial blockers, and video laryngoscopes. We taught several well-received simulation session on regional anesthesia including upper and lower extremity blocks, and on thoracic anesthesia including lung isolation and bronchoscopy.

At the program’s sister hospital in Butare, we also used simulation to teach critical care to a

multidisciplinary group of learners in the intensive care unit, as part of a training course on a new ventilator. This group had minimal experience with simulation, and there was no formal simulation center at the hospital. We assembled equipment for scenarios from extra supplies around the unit, and set up a simulated intensive care bay including an iPad connected to a small speaker serving as a monitor. We used the setup for two days, running through multiple situations including hypoxia and emergent intubation. Instead of recording the simulations for later playback, we simply split into two groups and had one half observe as the other half did a simulation, and then swapped for a slightly varied scenario.

My experiences in Rwanda showed me that it is possible to create exciting and instructive simulation scenarios that use minimal resources but are still engaging and high fidelity.