Academic Elective in Global Anesthesia: Post-Elective Reflection January 2017 By Kitt Turney Since returning from Rwanda several weeks ago, I find myself using the same phrases to try to convey the experience. I know what I sound like. I sound like any other resident who has returned from this extraordinary place. It was incredible. Clinically, you wouldn t believe some of the stuff we saw. Teaching, and preparing for teaching, was exhausting and exhilarating, but most importantly, extremely rewarding. The residency program has come a long way, and the residents are so keen! The Rwandan people are amazing. So friendly and welcoming. The gorillas. Wow. I sound like a broken record, as I tell multiple different people every day about the elective. The funny thing is, I can remember talking to other residents who had done the elective and had said the very same things. But nothing truly sinks in until you have had the experience yourself.
The elective is a unique opportunity within the Department of Anesthesia at Dalhousie. According to the official description of the elective on the department s website, residents travel to Rwanda for one month to experience the practice and challenges of anesthesia in low-resource settings as well as to become involved in a longstanding, sustainable educational partnership. Although this is correct, it is so much more than this. Rwanda is 23 years out of one of the worst genocides in recorded history. I had read about that terrible event before travelling to Rwanda. I had also read about the country s fascinating rebirth. Legatum Institute, a UK-based think tank, listed Rwanda as the most improved country in their 2016 Africa Prosperity report. This report not only takes into account economic aspects, but also indicators such as healthcare, education, and governance, among others. It seemed incredible to me that a people, and a country, could do such an about-face. It didn t take long for me to realize that Rwanda was a country going places. It started as soon as we took to the streets out of the airport. I don t believe I have ever seen such clean streets, and I am including Canada in that estimation. Yes, there are many street cleaners; however, something else extraordinary is at play here, and it is an example of what makes Rwanda special. On the last Saturday of every month, almost every able-bodied person in Rwanda gathers to participate in Umuganda, which can be roughly translated from the Kinyarwandan as coming together in common purpose to achieve an outcome. Communities come together to do a variety of public works tasks like infrastructure development and environmental improvement, which includes street cleaning. What a wonderful community-building idea. The Canadian Anesthesiologists Society International Education Foundation (CASIEF) makes this elective possible. Donations from interested members pay for the flights and accommodation, and staff go as volunteers. I had the pleasure of going with Dr. Patty Livingston, our supervising staff and medical director of Global Anesthesia at Dalhousie, and Kyle Jewer, a fellow 4 th year resident in the anesthesia program. CASIEF volunteers stay in a nice apartment in the oldest and most lively neighborhood in Kigali. It is a 30 minute walk along bustling streets to the hospital, where one must narrowly avoid women carrying babies on their backs and 100 pounds of goods on their heads, as well as the roadside rain gutters, or ditches of death, as Patty calls them. I ll never forget the first time we met the Rwandan residents at morning report. We heard about a tragic case of uterine rupture and maternal death, among several other cases of very sick patients overnight. Here we were, 4 th year residents who had never seen or heard of uterine rupture in our time in Halifax, listening to a 1 st year describe his night as if it were any other night on call. I looked over at Kyle and Patty, wide-eyed, both excited and terrified to be starting a month of obstetric anesthesia teaching. Who would be teaching whom? The Simulation Centre, built with Patty s vision and her Grand Challenges Grant, is a fabulous venue for teaching, right on the hospital grounds. The space is ideal for the program s expanding numbers. The anesthesia residency program currently has ten 1 st and ten 2 nd year residents, and one 3 rd year resident. On Monday mornings, the 2 nd and 3 rd year residents meet
in the Sim centre after morning report, and have a core teaching session lead by the CASIEF volunteers. All the residents then gather for a case presentation by one of their colleagues. After lunch, all residents take part in several simulations, developed and run by the CASIEF volunteers. My favourite aspect of academic teaching days was the preparedness and keen attitude of the residents. Every academic day they came armed with answers to our pre-reading questions, and were fully immersed in lively discussions. They thrived in an interactive learning environment. It became immediately clear to me that we were dealing with an intelligent and motivated crowd. During the other days of the week, we spent our days observing the residents in the operating rooms, mostly at CHUK, but also for a few days at Rwanda Military Hospital and King Faisal Hospital. The residents impressed us with their preparedness for cases, and having good overall anesthetic plans. It was striking to see the types of cases even the 1st year residents were handling on their own. It was not atypical for residents and anesthesia technicians to be running cases without staff supervision. For instance, a shortage resulted in one staff on call for an entire week for the OR, ICU and maternity. One day during that week, there were 4 emergency ORs running with 3 junior residents and several anesthesia technicians, and no staff in the building. This is obviously not an ideal learning environment.
Not only do the residents become very familiar with difficult cases with minimal supervision, they also have to contend with critical drug shortages. For our entire visit and the 3 months leading up to our arrival, CHUK had no supply of succinylcholine. Dealing with this requires creativity and adaptation. Kyle and I did our best to debrief the various cases we observed, in real time and at the end of each day with each of the residents. Not surprisingly, in their fairly independent learning environment, there were still many aspects of each day that needed improvement. At the conclusion of one of our academic days, we were visited by the Honourable Minister of State in Charge of Public Health and Primary Healthcare, Dr. Patrick Ndimubanzi. The residents were given the opportunity to bring up some of the issues that they face on a daily basis, and advocate for change on their own behalf. The residents had great suggestions as to how the interdisciplinary delivery of health care could be improved, including better drug tracking, joint Surgery and Anesthesia M and M rounds, and more incentives to promote retention of locally trained anesthesia staff. Kyle and I had a chance to advocate for the residents to be granted more preceptor mentorship. At the end of the day, no matter how well they manage given the limited resources, the residents need more teaching and mentorship. The minister let us all know that our collective messages were heard.
Two other notable teaching experiences during this elective were the delivery of the Essential Pain Management course in Butare, as well as the Teaching and Learning Course in Kigali. The former was a two-day course in basic pain management techniques, developed by Drs. Wayne Morriss and Roger Goucke, which focuses on a simple method to RAT: recognize, assess and treat different types of pain. We delivered the main course curriculum one day, and then ran an Instructor course the next. At the conclusion of the course, it was obvious that the participants were keen to disseminate their new knowledge, and hopefully shed light on the problem of inadequate pain management in their work environments. The Teaching and Learning Course was taught by its creators (Dalhousie s own Dr. Ruth Covert and Dr. Patty Livingston) on the first day, and then taught to another group by Kyle, myself and two of the staff participants from the first day. I felt I had the chance to further develop and refine my teaching style within the structure of this fabulous interactive learning course. Along with the busy academic schedule, we filled up our weekends with leisure activities. There are so many things to do in Rwanda. We explored Kigali and the genocide museum. We went mountain biking in Ruhengeri. We travelled to the Congo border and stayed in the beautiful town of Gisenyi. We hiked in the canopy of Nyungwe rainforest. We had memorable visits with friends who came to Halifax on elective as residents and are now staff in Rwanda. We hiked into the Virunga Mountains to see the gorillas. I can t even begin to explain the feeling of standing beside a 400 pound silverback in the wild. In short, we were not wanting for adventure. Before going to Rwanda, I had set out some objectives for myself. Not only did I hope to help enrich the teaching in their residency program, but I also hoped to further develop my skills as a teacher in both didactic and simulation-based environments. I probably had more teaching experience in one month than in the all the other years of my residency combined. I also wanted to learn about another culture, and adapt to the challenges of teaching in a clinical setting that was so different from my own. By far and away, though, it was the sustainability of the whole initiative that was the most important aspect of my elective. Having done some more informal global health work in the past, I have struggled with programs that do not focus on empowering local programs. I feel confident that we helped contribute to a sustainable model of teaching that will provide long-term solutions to the problems of anesthesia training in Rwanda. I am inspired by the leadership of generous donors, of staff who volunteer their time to partake in global health initiatives, and by the amazing people I met in Rwanda. I hope to continue the advocacy of programs like the one at Dalhousie. This elective has definitely solidified my desire to incorporate Global Health into my future practice, wherever that may be.