9:15 PM 2/15/2010 Rwanda Tour Report April 2007 University Hospitals: Kigali and Butare To: Drs Angela Enright and Dr.Phil Bridenbaugh From: Dr. John Stanec Date of Arrival April 3rd Date of Departure May 5th 2007 Introduction: It was a tremendously positive experience for me to work with the nurses and physicians at the Central University Hospital in Kigali (CHUK) and briefly, at the National University Hospital in Butare. The residents, nurse anesthetists and nursing students were all very eager to learn topics in anesthesia. During this report, I will first state the requested facts, then provide further details of my teaching experience, and finally, offer my thoughts concerning specific obstacles impeding the training of the anesthesia residents. I will also provide and update on previously addressed concerns. Lectures given: Anesthesia Residents (approx 10 hours total) o Pain Physiology and Treatment o Introduction to Regional Anesthesia o Regional Anesthesia for the Upper Extremity KHI 2nd Year Students (approx 5 hours total) o Pain Physiology and Treatment o Introduction to Regional Anesthesia Morning Report (approx 2 hours total) o Pain Physiology and Treatment – given in short segments over 2 weeks. All lectures were given in PowerPoint and we subsequently downloaded to the Anesthesia Office computer at CHUK. In addition, many of the residents carried memory sticks to which I transferred my PowerPoint lecture files. 9:15 PM 2/15/2010 Items Donated Braun Nerve Stimulators (qty: 2 – Kigali and Butare) Braun Insulated Block needles (qty 50) Fast-Trach LMA (#3,4,5) Peripheral Venous Catheters Pediatric touhy needles Atlas of Regional Anesthesia, David Brown Daily Operating Room interaction: There was one anesthesia resident present daily at CHUK, Paulin. Since I could only coordinate one visit to Butare (more on this later) the bulk of my teaching was focused on this one resident. Two other residents started their formation during my month at CHUK, Chantelle and Antoine. Their first rotation was in the Intensive Care Unit (ICU) under the direction of Bart Troubleyn. I spent one day at the hospital in Butare, where I was able to work with 4 anesthesia residents (Drs. Bonaventure, Teogene , Teogene and ). Another anesthesia resident, Grace, was assigned to King Faisal hospital. All residents, except the two - 4th year residents in Butare, attended my Wednesday afternoon lectures. Issues at CHUK Pre-Op Height and weight are still not recorded on the pre-op assessment. When I inquired about this (repeatedly), the answer varied. One explanation was that a scale was not available to weigh the patients. A simple bathroom scale would suffice. At the very least, pediatric patients should be weighed, and rough estimations of adult patients would suffice. This becomes important in calculating maximum doses for local anesthetics in regional cases. ASA class assignments are beginning to deviate appropriately from the previous method of labeling every patient an ASA I. A chalkboard would still be a very useful item in the morning report room. Operating room starts remain unpredictable. Machines and Monitors The Glostavent machine does work for the OR at CHUK, but I don‟t believe it‟s the best choice. Since waste gases are not scavenged, and the system is „open,‟ the staff is exposed to daily doses of halothane. Most nurses run 4-5 liters per minute of fresh gas flow over the halothane vaporizer, and all of this flows into the immediate vicinity of the anesthetist. I found myself getting headaches after spending several hours in general anesthesia cases. The reservoir bag for adult cases sits in the back of the machine and therefore make visually monitoring respirations difficult. Although most anesthetists did apply a precordial stethoscope. For pediatric patients, they use a Mapleson circuit attached to the outlet side of the Glostavent machine. In theory, this practice is fine, but 9:15 PM 2/15/2010 the anesthetists need to be aware that the Glostavent machine works like a pop-off valve. If the sliding weight is not positioned appropriately to provide a maximum desired inspiratory pressure, the positive pressure generated by squeezing the bag goes backwards into the glostavent bellows. Most anesthetist gave me a puzzled look when I attempted to explain this. Paulin understands the concept. The anesthetic monitors could be adequate for the needs of CHUK. However, since the peripheral devices are not replaced when damaged (i.e. pulse oximeter probes and blood pressure cuffs) the full capability of these monitors is not realized. This was a problem in 2 OR‟s at CHUK, so oxygen saturation monitoring was lacking in half the cases. There were a couple of specific instances in which an adult patient in one room had full monitoring (BP, O2 sats, and EKG) while across the hall, a 2 year old child under GA was monitored only by EKG. Blood pressure measurements are routinely used in adult cases, and during my rotation, I was able to convince most anesthetists to use adult cuffs for monitoring lower extremity blood pressure on pediatric patients. I did not see a gas analyzer being used at CHUK. Meds Sedation was primarily achieved with diazepam (when available). Shorter acting agents are not currently available. Given the sporadic nature of post-operative pain control, perhaps utilizing a long-acting sedative is not such a problem, although I‟m sure it contributes to delayed awakening at the end of cases. Analgesics – primarily fentanyl and morphine. I discussed these 2 agents with the residents and anesthetists at length. My suggestion had been to use fentanyl for inductions and morphine during, and at the end, of cases and for post-operative pain control. The problem with this technique is that the 2 drugs are often not available on the same day. Ketamine – this medication always seems to be available for use. I encouraged low-dose ketamine (0.2 – 0.3 mg/kg) for analgesia during procedures such as nerve blocks and due to it‟s convenience and availability. The anesthetists seem very comfortable with the use of ketamine. I would continue to encourage its use. Local Anesthetics – I brought approximately 15 x 50 mL vials of 0.5% bupivicaine for use during nerve blocks. I know that this is not a sustainable solution, but I felt that success in nerve blocks needed to be assured if the residents and nurses were going to „buy‟ into regional anesthesia. This seemed to be successful during my visit. Spinals continued to be done with the locally obtained 0.5% preservative-free bupivicaine in single-dose glass vials. There have been reports regarding onset time of this medication. I have not had a specific problem. Airway The nurse anesthetists seemed to be quite keen on the use of LMA‟s for general anesthesia. Caution here is advised, as I don‟t feel they yet have a firm grasp on evaluating the quality of placement and or how to evaluate airway obstruction (e.g. epiglottis obstruction, inadequately seated LMA). There is a tendency to place an LMA at induction, and then fail to consider anesthetic depth prior to incision. There were 9:15 PM 2/15/2010 several instances when patients weren‟t deep enough at incision and subsequently developed stridor with the LMA. Furthermore, anesthetists seem quick to diagnose any airway obstruction as „bronchospasm.‟ This often seems to occur at emergence, when the application of CPAP and good airway support would be adequate to assist patients through Stage II. This seems to be especially prevalent with pediatric cases. Given the likelihood that anesthetics will continue to be performed without pulse oximetry, I would lean towards reserving LMA‟s for adult patients only. Endotracheal tubes are not re-used at CHUK. Consequently, it is another inventory that must be monitored and re-stocked. Unfortunately, during my time at the hospital, the ET tube supply „ran out‟ and I was told would require several weeks to months to be replenished. The OR schedule was immediately reduced to emergency cases, or those cases that could be done under regional anesthesia only. I believe that this situation involved a certain degree of posturing by the anesthesia department (i.e. they want their needs to be take seriously by the hospital administration, and are not willing to tolerate repeated cases of supplies not being re-ordered in a timely manner). This is something that the anesthesia department must work out with the administration. I did not choose to insert myself in the middle of this controversy. It the hospital wants to take itself seriously as university institution, it should have more pride than to allow something as simple as re-stocking inventory to bring the OR schedule it to a halt. I‟m sure this won‟t be the last of these problems. I did not notice any syringes being shared between patients. Vials of fentanyl and morphine seemed to be used for one specific patient only. Post-Operative Patients continue to be extubated in the OR – which I feel is appropriate given lack of monitoring in the PACU. There does seem to be a long time for emergence from GA‟s. I didn‟t notice any patients having received more than 4 mg of diazepam, so congratulations to Dr. Finucane. The relatively slow turnover time did not seem to upset anyone, although it definitely slows down the day. I didn‟t spend much time in the PACU, and therefore don‟t have much to add to the previous reports. Safety Issues I agree that CHUK is not up to western standards in terms of safety. Needles continue to be used for venting the plastic IV bottles, despite having vented IV tubing. Sharps seem to be properly disposed of in plastic gallon jugs on the floor. Hypothermia continues to be a problem in the OR, as there is no means to measure temperature intra-op. This makes pediatric anesthesia very risky. There was one specific instance in which a 1 year old child was receiving an operation for ileostomy reversal. When I became involved in the case, it was late, when the patients had falling oxygen saturations. Dr. Ibrahim and I attempted to resuscitate the child with ACLS maneuvers, but we were unsuccessful. From my best guess, the child developed myocardial depression and possibly an arrhythmia from profound hypothermia. When I arrived, 9:15 PM 2/15/2010 there was nothing reliable on the monitor as the pulse oximeter had ceased functioning and the EKG showed only artifact. No pulse was palpable, the child felt very cold, and a transthoracic echo should profound bradycardia with a rate of less than 20 and an ejection fraction of 15 percent. I have no idea how long the bradycardia had been present prior to being alerted to the emergency. When I queried the Belgian medical student involved in the case from the beginning, she had said that the child seemed to be hypothermic upon arrival to the OR, and that cold (room-temperature) irrigation had been used during the procedure. Regional Anesthesia This is where most of my educational efforts were focused during my month in Kigali. The physicians (surgeons included), anesthesia residents and nurse anesthetists seemed very enthusiastic about regional techniques. Under my supervision, Paulin, Dr. Ibrahim, and Esperance (anesthetist) performed approximately a dozen nerve blocks. Many of these surgical (upper extremity) cases were done under regional alone. I taught interscalene, infraclavicular, femoral and sciatic nerve blocks. With continued practice, I believe that all upper extremity surgeries can be completed with regional blocks and mild sedation. The majority of lower extremity surgeries (mostly proximal femur fractures) are best performed with spinal anesthesia. Surgeries below the knee could be performed with nerve blocks alone, but the use of thigh tourniquets would likely require spinal anesthesia. I spent considerable effort emphasizing the dangers of regional techniques, especially given the large doses of local anesthetics required for successful nerve blocks. The entire first lecture was devoted to avoiding complications. I think the message was received. The anesthesia offices at CHUK and Butare now have functioning nerve stimulators. Insulated block needles are in 2 cardboard boxes at the CHUK office. I would suggest that the next visiting anesthesiologist bring along a supply of the 10cm (4”) needles. Ultimately, the anesthesia departments at the two hospitals will have to explore the necessary channels to obtain these block needles, but while the departments are still in the honeymoon phase with nerve blocks, I would support them with supplies. I believe that nerve blocks have tremendous utility for surgeries in Rwanda. The avoidance of general anesthesia (when possible) along with great post-operative pain control make this technique particularly advantageous. Efficiency This continues to be a problem area, and I suspect that we won‟t see a change here for some time. Improved efficiency will likely be surgeon driven, and until they become more motivated to increase their surgical productivity, I don‟t see this happening. Lectures See list of lectures above. I attended all morning rounds with the anesthesia staff and gave about 8 I attended morning rounds most mornings and gave brief presentations about 4 times at these rounds. Language differences were a bit of a problem, but I think that I made the best of it. One way I found around this problem was to go over the lecture slides with 9:15 PM 2/15/2010 Paulin on Tuesdays. By Wednesday‟s lecture, Paulin had already seen the PowerPoint slides and could translate into French for the other attendees. Not only did this help improve my French, but I think it helped solidify the knowledge in Paulin. Without question, the residents and nurses are more comfortable in French than English. This could change over the next 5 years as English becomes increasingly more common and expected. Butare The traveling arrangement to Butare is a problem. From my first days in Kigali, I worked with Esperance to coordinate my visits to Butare. I initially planned on visiting Butare twice during my stay. But as each week approached, a new notification from Butare would inform me that regrettably, they would not be able to host me, and that the following week would be better. I never received the messages directly (they were communicated to me from either Esperance or Bart Troubleyn. I was told that the reason for the repeated cancellations was due to an inability to secure hotel accommodations. After the 2 consecutive cancellations, they then requested that I visit Butare during the one week that I had made weekend plans to visit the gorillas. I informed them (thru Bart) that I would be willing to make the trip to Butare on Thursday morning, but that I would have return the same evening in order to make the bus trip to Ruengheri on Friday afternoon. When I arrived at Butare Thursday morning, I finally met Jeane. After greeting me, she immediately asked, “How long will you stay in Butare?” I gave her this puzzled look because I couldn‟t understand how she didn‟t already know the answer. This all left me wondering, „who‟s really in charge down in here?‟ I found the whole experience rather frustrating. If they (Butare) truly value our expertise and willingness to travel 4 hours on the road to lecture the residents, then how could they let something as simple as arranging a hotel derail the whole operation? I feel, that until Butare sorts out their problems, we should insist on having the residents come to Kigali (as this is where most of the Butare residents spend their weekends anyhow). List of equipment required at CHUK (adapted from Dr. Finucane’s Report) 1. Saturation probes for existing monitors (Planet 50) in OR 2. Saturation monitors for PARR 3. Four ET CO2 monitors for the OR and PARR 4. Pediatric BP cuffs for OR monitors (Planet 50) 5. Temperature monitoring and a method of actively warming patients. Humidification of gases may be the most cost effective way of doing this. A Bair Hugger could be used and blankets could be used multiple times. I realize that this is against the manufacturers instruction, but patients shouldn‟t die from hypothermia. 6. Light source for existing bronchoscope in anesthesia office. 7. Trach Light for difficult airways. 8. Scavenging equipment 9. Upgraded version of the Glostavent machine 10. Reliable vaporizers with temperature compensating devices. 9:15 PM 2/15/2010 Domestic matters: The internet at the KHI Guest House has been unreliable, despite several visits from the technician. I wonder if this has anything to do with a bill from the internet provider not being paid. Transportation issues The driver was fairly reliable for morning pick-up at the KHI Guest House. I wasn‟t able to coordinate with him in the afternoons, and didn‟t want to wait around the hospital once my day was finished. I therefore chose to use the very inexpensive and efficient motorcycle taxis. I know that this will not be for everyone, but from my perspective, you just can‟t beat „em. They get you around the city of Kigali faster than anything else while enjoying a full, 360 degree view. Language issues; Language issues may be a problem and knowledge of French would definitely be a plus. I would also recommend the French lessons at KHI on Mondays, Thursdays and Fridays for two hours beginning at 5:00 pm. The instructor‟s name is Didas. I was able to arrange private lessons with Didas for roughly $10 per hour. We held them at the Hotel Serena (Intercontinental). This was terrific! He is a secondary school French teacher, and excellent instructor, and is quite eager to earn extra money teaching private lessons. I would agree upon a price before starting the lessons just to have that agreed upon before getting too far along. You don‟t have to pay for the lessons at KHI. For French beginners, I would highly recommend Michel Thomas „French for Beginners‟ audio program. I purchased this thru Amazon and listened to the lessons on the long plane flights to Kigali. The lessons were very helpful in developing a foundation for French. Summary: Despite a myriad of problems that exist in the University Anesthesia program in Rwanda, it was an wonderful experience! There is both a tremendous amount of work to be done, and incredible potential to impact positive change. I agree with Dr. Finucane (and Dr. Troubleyn) that there is a disconnect between the affiliated university hospitals - CHUK and Butare. CHUK is where most of the pathology exists (and most of the surgical cases), yet the bulk of the anesthesia residents is in Butare. I‟m not privy to the politics behind the relationship between the two hospital departments. It seems to me that CHUK could support the training of 2 residents simultaneously, but they would have to compete with the large number of nurse anesthetist students from KHI. Since there are 4 OR‟s at CHUK, it might be reasonable to have 2 reserved for anesthesiology residents and the other 2 for nurse anesthetists. Lack of adequate case volume could be the largest impediment to the training of future anesthesiologists. This could be improved by increasing the number of cases scheduled for each OR day. Walking through the wards, there certainly doesn‟t seem to by any shortage of orthopedic patients waiting for surgery. The question is - how to get the most efficiency from the OR, and perhaps more importantly, how to get the surgeons to 9:15 PM 2/15/2010 increase their caseload? I suspect that unless there is an incentive-based compensation package for the surgeons, we won‟t be seeing a caseload increase anytime soon. The residents are terrific! Drs Bonaventure and Paulin seem to have the best command of knowledge and stand out from their classmates (Chantelle, Antoine, Grace, and Teogene). There is another physician named, Laurent, who apparently had been accepted to the anesthesia program, but at this point, no money exists to fund his training. A big obstacle to his funding is that he is Congolese, attended medical school in Burundi, and works in Rwanda. As yet, none of the 3 governments has been willing to fund his training. He currently works as a general practitioner in the Emergency Department at CHUK, and would be a tremendous asset to the residency program. Bart Troubleyn is well aware of the situation, and any ideas we may have in arranging financial support should be directed his way.
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