End of Tour Report of visit to University Hospitals by onm20503

VIEWS: 5 PAGES: 8

									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.

								
To top