|Seems fitting that the last case I was involved with during my month in Rwanda was a 9 year old girl with AIDS having cataract surgery (somehow related to the disease or the drugs). Somehow this case represented much of the tragedy and the optimism that I witnessed these last few weeks. I used the opportunity to get the senior resident to try a Trach-light intubation (they still use those wierd metal things to intubate there!). Ironically it was so easy it was hard- that is to say the girl was so emaciated that no matter where the light was it looked like it was in the right place!
I found Rwanda to be a country full of contradictions. On the one hand, this is a place striving to modernize, with a phenomenal amount of development aid assisting it. In the capital city, there are new buildings springing up, advanced communication with wide cellphone and internet coverage, modern hotels and restaurants, and many international companies establishing bases. There are increasing health and safety initiatives that are found mainly in the West, such as smoking restrictions, and seat belt and motorcycle helmet laws. Yet basic drugs, supplies and equipment are scarce, with frequent lack of endotracheal tubes, analgesics and common antibiotics. The operating rooms do not run anywhere near to their potential capacity, there are only a handful of ventilated beds in the ICU’s, and many procedures that we consider routine, such as heart surgery, cancer treatment, and joint replacement, are virtually unavailable. Furhermore, even run-of-the-mill surgery, such as open reduction of hip fractures, routinely takes weeks to months to get to OR, if the patients survive the wait. Advanced medical care is usually reserved for the wealthy, although in theory the Ministry will fund required treatment which is not available in the public hospitals.
Meanwhile, the Anesthesiology training program which we have been contributing to has now graduated four Rwandan specialists, all of whom are now working on staff in the two teaching hospitals in Kigali and Butare. All of these new graduates have received two years of training in Europe and elsewhere in Africa. Five more residents are working their way through the program. Although the intent is that ultimately the entire program will be able to be completed in Rwanda, it is likely, and in my opinion desirable, that at least part of the program will continue to be completed overseas.
My last week in Rwanda was busy: I was asked on Monday by the head of the nurse-anesthesia training program at the Kigali Health Institute to give two lectures to the second year class- on Tuesday and Wednesday! So I hit the Powerpoint and slapped together two talks on preoperative assessment (somehow not part of the curriculum of this three year program!) and preoperative testing. The students were interested and seemed to understand at least most of my French (which seemed to me to get tougher as the weeks went on!), and my understanding of their many questions was sometimes a challenge. My impression was that this diverse group of students was dedicated to the cause, and knew that they would be faced with tremendous responsibilities at the end of their training (ie. being responsible for most of the anesthetic care in the country with limited backup).
Just as I finished these hastily prepared talks on Wednesday, I was told that I was to be the external examiner on the thesis committee of the newest graduate from the Anesthesia residency. Thus I received a copy of the thesis (prepared in excellent French) on Wednesday, to prepare questions for the examination on Thursday. I tried hard to come up with some challenging points regarding the methodology and conclusions of the study, although I had the feeling that the result was a forgone conclusion.
And so ended a month in Rwanda, representing the International Education Foundation of the Canadian Anesthesiologists’ Society, which was at once fun, fascinating, frustrating and, I hope, fruitful. I do think that the program is making a difference; the knowledge, and in most cases, the culture of professionalism, of the residents is improving. The final tally of activities we were involved with is as follows: twenty days in OR (at least part-days…), fourteen resident teaching sessions, participation in three resident-presented sessions, two formal lectures at the Kigali Health Institute, and one session as thesis committee examiner. In addition, I expect that two publications will be generated in conjunction with our Rwandan colleagues, and likely future research collaborations. I felt that our time and expertise were usually made good use of, although improvements can be made in the time efficiency of the volunteers and in communication. I believe we made at least a small difference to the residents’ experience, and our hounding of the residents to accept a greater responsibility for overall perioperative care will likely stay in their minds. The experiences I shared with so many Rwandan people will certainly stay in mine.
I ended my trip to Africa with an awesome two week holiday in Tanzania with my son Simon, who flew to Kilimanjaro airport to join me. I finish this diary with a group of photographs taken during our one week camping safari in the Serengeti, Ngorongoro crater and surroundings, and our week on the coast of Zanzibar. Enjoy.