The LMIC Critical Care Patient – A Rwandan Experience

Nana Sefa

PGY 3

Emergency Medicine Critical Care Fellow

The LMIC Critical Care Patient – A Rwandan Experience 

I spent a couple of weeks in the Intensive Care Unit (ICU) of the University Teaching Hospital in Kigali. This was a very informative time during which I encountered a completely different patient population. Two aspects in particular stood out. First, the oldest patient I saw in the unit during the entire two-week period was a 60-year-old female. This patient was actually an outlier when is comes to age. On most days, the 7-bed ICU had patients aged between 18 and 39 years. This is contrary to the ICU population at the BWH MICU, where a 50-year old on most days could be the youngest patient. Additionally, about 50% of patients in the ICU in Kigali were patients with obstetric complications. During my multiple months in the BWH ICUs, I have known of only a handful of obstetric admissions to the ICU.

Without conducting a formal study, I also noticed that the mortality rate of patients was fairly high. The relative young age and the high mortality of patients in this ICU is very concerning. The quality-adjusted-life-years lost would be significant if calculated. It stands to reason that the socioeconomic value of the loss of these patients would be substantial. Additionally, given that these patients are dying during their most productive years, the country is also losing a significant amount of its manpower.  

My observations highlight the need for an investigation that would determine the underlying causes of the admission of a relatively young patient population to the ICU in Kigali, Rwanda and the issues leading to the relatively high mortality rate. Until the causes of these phenomena are elucidated, designing interventions that would meaningfully change these outcomes would be impossible.

My time in Kigali was not only educational on a professional level, but also on a personal level, inspiring me to focus part of my work on shedding more light on the uniqueness of this ICU population and improving mortality and patient outcomes in similar contexts.

Global Health Community Entry in Kigali, Rwanda

Nana Sefa

PGY 3

Emergency Medicine Critical Care Fellow

Global Health Community Entry in Kigali, Rwanda

I arrived in Kigali, Rwanda for a two-week elective rotation in the Intensive Care Units of the University Teaching Hospital (CHUK) and the King Faisal Hospital on October 26, 2018. This was my first visit to Rwanda. One of the objectives of this visit was to establish relationships for future global health collaboratives with staff at this institution and other Rwandan Healthcare facilities.

So how did I ensure a mutually beneficial trip with very limited time and no previous relationships to build on? I started off by meeting everyone I had email exchanges with prior to my visit. These were my initial champions. They helped introduce me to influential clinical staff who run the day-to-day activities in the ICU. Additionally, I tapped into the institutional goodwill and credibility of my mentor and the Brigham and Women’s Hospital. My mentor has been working with the ICU at CHUK for over 5 years and is well liked. This ensured that anyone she introduced me to welcomed me with open arms. Additionally, the Brigham and Women’s Hospital Emergency Medicine faculty were involved at the start of the country’s first emergency medicine residency about 5 years ago. Thus, I was able to tap into some of the goodwill that Brigham has at CHUK.

That said, reliance on the goodwill of people and institutions is helpful only to establishing an initial encounter. I subsequently had to roll up my sleeves and build on these links to establish my own relationships. I started off by asking lots of questions. The clinical practice and protocols used in the institution were relatively different from what I had used, which provided an avenue to learn more about why they did things the way they did. In asking my questions, I had to be tactful so that even for practices that were not evidence based, I did not come off as passing judgement or looking down on the care that was being provided. I also had to understand that some of their practices were influenced by unavailability of resources. This meant that even when I suggested changes, I had to first ensure that the resource I was suggesting was available.

My experience in Kigali also meant interacting with a completely different culture than I had ever been exposed to. But I dove right in. In doing so, I had to acknowledge that there were cultural differences and to let my hosts know that although I was not familiar with their culture, I respected the fact that their culture was important to them. I also had to ask questions specifically about what was culturally appropriate to do or to ask.

Additionally, for each frontline clinical staff I interacted with, I had to find out what was important to them and how I could be of help to them. This inquiry started during the email exchanges before my arrival. For instance, the residents in the ICU were eager to learn and sent me topics they wanted to discuss before my arrival. This provided an initial mutually beneficial relationship that ensured a fruitful interaction even on the first day. What is interesting about asking what was important to an individual is that each person had his or her unique evolving interests that were very different from what the institution or unit head had communicated. For instance, although not mentioned before my arrival, one resident’s main goal during my visit was to learn to do ultrasound-guided subclavian central lines. For this individual, my visit would not have been successful without teaching him this skill. Continually asking what would be important and meaningful to counterparts is thus crucial to a successful global health collaborative.

Although my two-week visit was short by all the means of evaluating a successful global health interaction, I deemed it successful because of the relationships I was able to build. I am sure I will be able to build on these relationships to ensure more productive interactions in the future.