Wednesday, September 25, 2019

Heart Failure and Cardiac Ultrasound Training in Rural Rwanda


Sheila Klassen, MD
Cardiovascular Disease and Global Health Equity Fellow at Harvard Medical School
(Formerly PGY8 Advanced Echocardiography Fellow at the Massachusetts General Hospital at the time of COE travel grant application)



Teaching basic echocardiography in rural Rwanda
Non-communicable diseases (NCDs) account for 44% of all deaths in Rwanda according to the WHO country profile fact sheet from 2018. Within that, cardiovascular disease and cardiovascular risk factors make up a large proportion of NCD mortality but there are only 6 cardiologists in the country, based in the capital city of Kigali. Within this context, I’ve spent the last 2 weeks teaching nurses, general practitioners, and internists from the rural district hospitals and smaller cities in the outer provinces of Rwanda about heart failure and demonstrating basic echocardiography skills which they can employ within their own settings. Their commitment to learning was palpable! Without having visited their home hospitals, I could tell from their level of interest and their questions that heart failure and cardiac disease was commonplace and that they struggled to know what to do with suspected cases of heart failure.

My students become teachers for each other!
My first week was comprised of a formal training session organized by the Ministry of Health in a central location in Rwinkwavu, located in the Eastern province of Rwanda. I taught on basic principles of ultrasound, basic echocardiographic views, normal cardiac anatomy and the most common cardiac pathologies affecting low resource settings such as Rwanda. After 3 days of training, it was amazing to see the transition from student to teacher – they were already starting to share cases and answer each others’ questions about echo findings and medication titration, particularly about strategies particular to the setting such as how to navigate stock at the local pharmacies for the heart failure drugs I was teaching about. I spent the second week in the NCD clinics of 2 district hospitals in the Northern province with nurses and local physicians. My role was to supervise, coach, and help them consolidate the knowledge they’ve gained and it was encouraging to see how capable they had become in a very short time. The next 2 weeks will be spent visiting the other 4 district hospital sites and doing the same.

The limitations at the district hospitals are difficult. There are many patients who don’t have access to life-saving diagnostics and treatments we take for granted. In the span of several days, I saw a 9-year-old with severe congenital mitral and tricuspid regurgitation in heart failure, a 16-year-old with dense hemiplegia from a stroke due to large left atrial thrombi from severe mitral stenosis, a 36-year-old with severe malnutrition and cor pulmonale. Even ECG machines are not readily available, nevermind cardiac cath and chest CT. But it was encouraging to see hypertensive heart disease now being adequately treated, severe cardiomyopathy on therapy, and my trainees counseling on low sodium diet. More to come in the next 2 weeks!

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