Tuesday, November 19, 2019

Clinical Rotation in an Emergency Department in Kigali

Lara Vogel

Resident, Harvard Affiliated Emergency Medicine Residency MGH/BWH, PGY4

In my work prior to medicine, I lived and worked in East Africa for multiple years, focusing primarily on education and the ways the HIV/AIDS epidemic impacted children in Kenya. Working on public health projects in rural Kenya through my twenties pushed me toward medicine, so now that residency was nearly finished for me, it was time for me to go back to the place where my interest in medicine started. Or at least get closer. Through attending’s in the BWH ER Trish Henwood, Alice Bukhman and Regan Marsh, I was able to connect with the new Rwandan attending’s running one of the first EM residencies in Sub-Saharan Africa. The Centre Hospitalier Universitaire de Kigali (CHUK) is about to graduate its second class of residents, and the ER is currently run entirely by its prior graduates. There are three of them. They work a lot.
I technically know that EM is a relatively new specialty in the US but seeing a new specialty establish itself is a fascinating process. This process at CHUK is relatively far along and I had the smallest glimpse, but watching these residents navigate their own hospital system, the ambulances, the insurance system
Nyungwe Forest National Park
(they often have to wait for proof of payment before they can treat), and the consultants’ understanding of patient care was an education in itself. Unsurprisingly, the medicine was the same between the two countries and the residents were exceptionally well trained—their comfort with trauma far exceeded my own, and their ability to make do with much less support from consultants, supplies, and patient’s understanding of disease was incredible—but ultimately, they had many more fights everyday to define the boundaries of their ER to themselves, to their patients and certainly to the hospital system. Their actions were always defined by the best interests of the patient, but when ICU patients spent weeks boarding in the ER, when the orthopedists could not operate or admit and yet would not stop accepting transfers, and when social services did not exist to support patients unable to care for themselves, the question of what was best for the patient became extremely complex and well beyond the scope of what I expect from an ER physician. Needless to say, they all managed it with grace and I was the one left confused.

Friday, November 8, 2019

Heart Failure and Cardiac Ultrasound Training in Rural Rwanda

Sheila Klassen
Cardiovascular Disease and Global Health Equity Fellow at Harvard Medical School

As my month in rural Rwanda draws to a close, I’ve had some opportunity to reflect on the successes and the challenges of healthcare provision in this country. I was able to spend 4 weeks doing simplified heart failure and echocardiography training across 7 hospitals in the country. It meant a lot of time traveling and many hours on the road, but it also gave me an appreciation of health care delivery in Rwanda.

There is a large emphasis on community in Rwanda which is encouraged by the government. There is a community event called Umuganda every last Saturday of the month where citizens are required to meet with their local communities and either perform manual labour tasks to better their communities such as filling in potholes or helping an older neighbor patch their leaking roof. Other Umuganda activities include having community meetings on security or other local issues.
Giving out completion certificates
after heart failure and echo training course
Years ago, the government distributed approximately 3 million cows to rural the rural population as a way of both decreasing malnutrition and creating industry. This has resulted in lower priced milk for Rwandans and in addition has created a sustainable export to neighboring countries. Community members who own cows that eventually calve are required to give away these calves to those do not own cows at no cost. Communities often gather at church on weekends, and the local water pumps are always overrun with children who meet daily to fill their jugs (running water in homes is not yet available). This community engagement could be a strength in health care delivery as community members look after each other. There is potential for shared medical appointments where members of the same community who have similar medical problems (diabetes, high blood pressure) have medical appointments with healthcare providers together so that they can both support each other and alleviate the burden on the few healthcare providers that are in country.

Spending time in rural hospitals, it was gratifying to see my trainees very capably performing cardiac ultrasound and managing heart failure patients appropriately. They still required support and voiced a need for ongoing mentorship but this was a big leap from where they started, which was next-to-no skill in managing heart failure and cardiac disease.

One of my trainees performing an echocardiogram
in a rural Rwandan hospital

Challenges are still many. Limited resources, limited training opportunities, limited expertise, and lack of infrastructure due to lack of resources still pose barriers to adequate health provision in the country. Providers are accustomed to providing care without resources which can make them complacent. There is a very high volume of patients because of the level of poverty of the population and high frequency of the socioeconomic determinants of poor health. At the same time, there is provider scarcity. Procurement of supplies, transportation of medical equipment, and biomedical support is all limited. Despite these challenges, Rwanda has pulled itself from its status as a broken state and poorest country in the world after the 1994 genocide to a growing health system with stable infrastructure. There is a way forward. Capacity building and training as well as continued resource support, possibly involving public private partnerships can continue to benefit the country and improve the health of its population. I’m glad I was able to use this travel grant to both share my cardiac knowledge with Rwandan healthcare providers and be part of Rwanda’s rebuilding as a country.