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.