heading back to Canada

Each year I come to Rwanda with an ever more ambitious "to do" list and the expectation that "this will never happen". But somehow it miraculously does. I'm heading to the airport in a few hours content with the feeling that we made a powerful contribution to anesthesia practice in Rwanda.

The VAST Course was a huge hit. We've already received requests from within Rwanda, and beyond, to be included in the next course. Stew and Allie have fallen in love with Rwanda and promise to return. Adam, Christian and I are planning the next steps for VAST.

Each year the resident group is a little stronger. New leaders are emerging. The Rwandan Society of Anesthesia is rejuvenating. Such good news.

I am thankful to all the members of the dream team and especially happy that Michelle keeps coming back to Rwanda with hockey bags of materials and boundless good cheer. It is privilege to work with Michelle, Adam, Stew, Allie and all of our Rwanda friends. Thank you to Yvon, Luke and Daniel for joining us early on for a week of adventure before the hard work started. Let us continue.

Lots of love from Rwanda.

Patty

Adam on VAST (worth the wait)

It’s alive…It’s alive!

Victor Frankenstein recounts how he “infused a spark of being into the lifeless thing at his feet”. The idea for the VAST Course sprouted in July 2017 and for months, it existed only on my hard drive. Without the enthusiasm and support of the team around me, there is no doubt that VAST would still be a lifeless entity. With the financial support of CASIEF and Dalhousie University, we were able to commit to piloting the course in Rwanda in January. In late December, the series of subfolders and files materialised into a set of tangible printed materials, resources and VAST paraphernalia. The great unknown was how all of this would transform into a 3-day simulation course.

We were off to an auspicious start. The first thing our eyes were drawn to at the Rwanda Military Hospital (RMH) Simulation Centre was an expansive banner heralding the piloting of the VAST Course. The months of meticulous preparation, testing, refinement and co-ordination were over and it was time to launch the first of three pilot courses. Throughout VAST, we focus a lot of attention on anaesthetists’ non-technical skills. Our team had to draw heavily on these same set of skills to effectively launch this project.

Team working

In the months leading up to the VAST Course, Patty had on several occasions referred to us (Michelle, Christian, Patty and I) as the ‘dream team’. My initial concern was to wonder I if had to settle for the role of the “Hick from French Lick” aka Larry Bird. Come game time, despite having never worked before together in this capacity, we functioned like a well-oiled machine.  The first pilot course was underway and we were running two parallel groups through the various components of the course. Michelle behind the scenes, setting up rooms, Patty and Christian riffing off each other in debriefing sessions and I taking the helm of facilitating and debriefing the other group. It wasn’t long however before the line-up of the dream team was to get some fresh faces.

Stewart was certainly a prized recruit to the team. After a quick ‘pre-season’, namely the VAST Facilitator Course, Stew held a firm place in the starting five. In fact, by pilot week three, he was the front runner for MVP, having to step his responsibilities when other key players were out due to illness and a late season trade to the Butare Black Mambas. Rotating strongly off the bench we also had an injection of talent from our trainee facilitators. With some on-going coaching from the side-lines, these ‘trainee’ members of the team were soon more than pulling their weight, running and debriefing sessions following the VAST playbook. More on the surprise recruit, Laurence, later.

No team can function without an extensive support network. Daily buffets at both RMH and CHUK hospitals kept our energy levels high. The team transport was dutifully and punctually conducted by Alphonse. Christophe at the CASIEF apartment was working overtime ensuring our team uniforms (scrubs) were cleaned and pressed ready for game time each day. In all of this, like in any well-functioning team, there was a real sense of camaraderie and common understanding that developed amongst the team members.

Task management

There is a lot of focus in VAST on managing complex tasks, particularly on how to assess and organise available resources. Day 1 of the first week of the VAST Course is now a bit of a blur. The unknown of the mechanics of the running the course were playing out in front of us. Fortunately, we had the invaluable resource of Michelle to draw on. With Michelle at the helm co-ordinating set up and changeover between scenarios, the rest of us were able to focus on the other tasks of session delivery and mentorship of the trainee facilitators.

Decision making

Many of the decisions regarding course logistics and design had been set in stone months in advance. There was opportunity however for some on the fly experimentation with order of sessions, timings of breaks and finer details of how some sessions were to be conducted. This helped to maximise our short period of time with participants and to promote a favourable learning environment.

One key decision that was suggested to us early on by Dr Paulin was the inclusion of Laurence, the sim centre co-ordinator from CHUK hospital. Laurence joined Michelle from the beginning of the first week of pilot courses, shadowing her every move and learning from the best. By the start of the second week of courses, Laurence was setting up stations and preparing the rooms for subsequent scenarios. Come week 3, Michelle was back in Canada and Laurence stepped up to the plate to independently run the ‘back of house’. An unexpected highlight was to watch Laurence spring to action on academic following the completion of the VAST Course pilots. Patty had tasked the residents with designing their own simulation scenario and within moments Laurence had the equipment set up in the same systematic manner in which we organise the gear for the VAST Course. This is just one example of what we have now seen as some of the ripple effect of the VAST Course…positive implications that are extend beyond our initial set of objectives.

Situational awareness

Language posed one of the key challenges to conducting these pilot courses. Whilst English is the official language in Rwanda, there is a transition from French and ubiquitous use of Kinyarwanda. Our participant group was also not uniform in their level of English. Being aware of this dilemma was of crucial importance. As much as possible, we encouraged Christian to deliver his sessions in French/Kinyarwanda. For the rest of us, it was important to take the time to meter our pace of speech, allow for translation and explanation amongst the group. It will be important that once the course materials are finalised post pilot, that we make the effort to translate resources and as much as is feasible, deliver of the program in a more ‘comfortable’ language.

It is still a little hard to come to terms with what has been achieved over months leading up to the piloting the VAST Course and subsequent course delivery. Certainly, there have been lots of lessons learned. Components of the course can be tweaked, elements that we should dedicate more attention to and some less effective components that can be pared back. In essence however, we are chalking down the previous few weeks as a great success. There is an encouraging amount of local support and endorsement of the project moving forward from both official channels and from participant feedback. The next exciting steps will involve refinement of the course and conducting formal evaluation of future courses delivered. I wholeheartedly thank everyone that has been involved to date with this project and  I certainly look forward to the future of VAST in Rwanda and beyond.

The Dream Team: Adam, Patty, Christian and Michelle

Starchy buffet lunches (potatoes, fries, rice, beans, chapatis)

Michelle enjoying a moment in the sun

Official photo with visiting dignitaries

Classroom

Simulated trauma patient

Participant reading notes to prepare for role

Simulated scenario

VAST Course booklets

Stew has a baby

emotions

Life in Rwanda is vivid and at times an emotional roller coaster. There is such joy in teaching breakthroughs, friendly greetings and warm welcomes.

There are also moments of feeling frustrated and down. My team abandoned me this weekend to go to Akagera Park (the safari in eastern Rwanda). I had to print the quiz for teaching and finish off some preparation for academic day. I got caught in a downpour and drenched my sandals in mud.

Then I had a really bad night in Nyamirambo...

This is from my SOS email:

At 6:10 AM on Sunday morning the music is still blasting from the bar across the street. Despite ear plugs, a fan turned up high and sleeping pills, I’ve slept poorly and been awake since 4:00 AM. The booming music is relentless and the mattress has a deep valley in the middle. 

The water has been off all night. This is not because of drought - it’s rained every day. It is because the landlord shuts the water off to save the pump. So, I flush the toilet by pouring water from a bucket into the bowl. I wash my face with stagnant water from the bucket. 

We had two power outages yesterday evening. These continue frequently.

I contemplate moving out for the last three nights but I’ve spent thousands of dollars already this month with no income. I guess it’ll just be three more nights of sleeping in the bar.

Okay. It was not a good moment. Dylan and Chil have adopted me and I am spending my last few nights in comfort in Kiyovu.

As we get close to the end of our time in Rwanda, it always strikes me how strange the whole notion of time really is. Each day here is so rich and different that it feels as though we've been in Rwanda for six months. It seems ages ago that we were on Lake Kivu.

As always, I've had a great team.

Allison promises to write a post about Akagera and Adam promises to write a post. Stay tuned.

xo
Patty

Allison's reflections

This week has resulted in a fair amount of reflection. It makes sense to interpret and process situations based on your own cultural values and beliefs – it’s human nature. That being said, viewing a developing country through a North American lens is exhausting. It’s incredibly useful to take a step back.

Someone recently said to me that the people I meet probably think ‘oh, what does she know…she’s just going back to her privileged life in Canada.’ Interestingly, this hasn’t been my experience at all. If anything, I think it illustrates the ‘North American’ lens concept – we tend to think our way is the better (best) way and then project this view on to other situations. The people in Rwanda are happy. They’re happy despite their history, despite their poverty, despite what we perceive as a ‘lack of.’ And it’s key to recognize that.

This inevitably brings up the more versus less debate. Canada is a culture of more; Rwanda is a culture of less. Our children have iPads and video games; these children have sticks and tires. We have excessive amounts of processed and imported food; they have small amounts of locally grown food. We strive for more stuff; they are content with very little. These values are clearly reflected in the dichotomy of our pace of life. We rush from one thing to the next and take great pride in being busy; they savour a more relaxed way of life. The relationship between expectations and happiness is, undoubtedly, a major player here. This has been a wonderful opportunity to reflect on my own expectations and how they impact the way I interpret the events of my life.

I love the concept of ‘maximizers versus satisficers.’ Briefly, maximizers must always make the 
absolute best decision and often worry if there’s another, better option available; whereas satisficers
 are content with the first option that meets their criteria. Generally speaking, I think Canadian culture
 is about maximizing and Rwandan culture is about satisficing. Perhaps we each need to adopt a little
more of one another’s approach in our daily lives!

The exposure I’ve had to the people and culture in Rwanda through home visits has been life-changing. This week, I felt quite emotionally overwhelmed. I’ve seen poverty like never before, and living conditions that are such a complete departure from anything we could imagine in Canada. I’ve seen patients who are sick in ways that we never encounter at home, and who lack access to the basic standards of treatment. I’ve felt frustrated at my inability to effectively communicate with and understand the patients as a result of the language barrier. I’ve felt inadequate in my ability to help. I’ve felt perplexed, and sad, and discouraged.

That being said, I’ve also met many incredible, resilient, beautiful people. I’ve been welcomed into homes with a single chair that they enthusiastically offer to me. I’ve witnessed unimaginable stoicism in the face of inadequate pain control.  I’ve seen families rallying together to provide care like nothing I’ve ever experienced at home. I’ve gotten hugs and handshakes and many warm wishes. I’ve felt inspired, and grateful, and forever changed for the better.

This rollercoaster is a gift. I feel forever tied to the people of Rwanda; they’ve touched a part of my heart I didn’t realize was there.

The nurse, Peace, translated, and we spent most of the visit laughing. This patient said,

 “(in Rwanda) we are sick, we are poor, but we are fine.”

There was torrential rain last night so this morning the air was clear and fresh as we arrived on the tidy grounds of the Butare Hospital campus.

Allie and I made pain management ward rounds again with another team member, Emmanuel. It is heartwarming to see the skill and care with which the pain team operates. They are knowledgeable and compassionate. We rounded today on the obstetrical ward. There were 6 postpartum women in one room with their neonates but the atmosphere was calm and serene. One woman had twins!

One of the twins

We were reminded once again of how risky pregnancy and delivery is in this setting. One lady had an eclamptic seizure a few days ago and was just recovering. Another middle aged woman had had multiple C-sections. Despite the challenges, it was obvious that patient care is improving.

Allie had to borrow Gaston's spare lab coat for rounds, so we had to Dr. Gastons.

Following ward rounds, we had a highly productive meeting with the hospital leaders. They are committed to palliative care, a chronic pain outpatient service, and delivery of the VAST Course in Butare. We left the meeting feeling quite elated. As we were leaving, Gaston introduced us to a 92 year old ENT surgeon who continued to practice well into his late 80s. He was actually the very first student at the University of Rwanda (student number 001). There is an inspiring piece about his work ethic:

http://allafrica.com/stories/201603010145.html

Prof Venant Ntabomvura, a Rwandan leggend

Allie and I celebrated a great morning with lunch at Inzozi Nziza. She got coffee ice cream with cookies and sprinkles topping.

the trans-Africa cyclist in sandals

Okay, true confessions. Allie and I had stopped for a second ice cream within three hours at Inzozi Nziza when a large group of muzungus (white people) arrived. The most eccentric was a man cycling from one end of Africa to the other with footwear of sandals held together by elastic bands. He has been at it since late August. We fear he has not done laundry or changed clothes in this period. In any case, he was quite chipper and none the worse for sleeping out under the stars and riding 60-100 km per day on his mountain bike.

Restored by the coffee ice cream, we headed for a walk amidst the beautiful tall trees on the grounds of the University of Rwanda campus. It was lovely to be in fresh air and quiet. As predicted a few monkeys were hopping about.

After arriving back at Gaston and Florida's lovely home we checked out the garden. Limes, oranges, mango, papaya, avocado, tree tomato, carrots, corn and passion fruit. What a great climate!

Allie checking out the corn

Gaston and Florida's papaya tree

Allie in the garden

where is the ice machine?

Butare is a refreshing change from Kigali. Everything moves just a little more slowly, the air is cleaner and the hospital feels wonderfully calm and organized. Yesterday Terri finished off some interviews and this morning Allison arrived to look at palliative care and pain management services.

Gaston has done a fabulous job of implementing an acute pain service in Butare. He has a set of pre-printed orders for routine and PRN post-operative pain medications. They are regularly using preemptive analgesics (pain medication before surgery). The anesthesia team are conscientious about preventing pain. The pain management orders need to be completed before the recovery room nurses hand over to the ward nurses. There is also a team of non-physician anesthetists (NPAs) who make daily pain management rounds on the wards. Over 300 hospital staff have received training in pain assessment and treatment.

Allison and I joined the acute pain rounds this morning. We only had time to visit one of the post-surgical wards. The NPA (Aline) leading the rounds was highly attentive and thoughtful. Unfortunately, despite the huge effort by Gaston and team there are many gaps. We found that pain was not being assessed by the ward staff and medications given were not documented properly. Some post-surgical patients were being sent home with a tiny supply of medications (enough for one day) and no clear instructions. In discussions with Aline, we identified some simple things to be done for patients (e.g.raising injured limbs). We kept wishing for ice to give people to reduce swelling and pain but there are no ice machines and refrigerators are non-existant in most people's homes. Such a simple thing but too hard to find.

While we are encouraged by the huge progress Gaston and his team have made, there is still much more work to be done.

Allison and I met Charles, the lead for palliative care. We had an excellent discussion about options and Allison is keen to return to help the team. We have also been working on a proposal for chronic pain services in Butare. Such great potential.

Our lunch reward included the mandatory ice cream stop at Inzozi Nziza.

Gaston showing pain protocols in recovery room

Beautifully manicured gardens in the pediatric ward.

At last, a blog post from Stew!

Days since arriving in Rwanda: 17

VAST courses completed: 2

Near-death experiences with motos: 22

Kilometers travelled by bicycle: 40

Number of times Patty has asked me to write a blog post: 1,438… 1,439 (just got another email) ;)

Rwanda has been dubbed ‘the land of a thousand hills’. It’s a lie. It’s the land of a million hills. The tall-tale about having to walk uphill both ways to school probably originated here, and is likely rooted in some element of truth. My wife, Allison, crashed her bike going downhill during our 40km tour of the northern part of Rwanda. 10 minutes later, she got a flat tire on the same hill!

Ambulatory struggles aside, Rwanda is absolutely breathtaking. Villages snake up the hillsides, ribbons of road follow the natural topography of the land, and everywhere you look you are surrounded by some of the lushest and greenest flora that you’ll ever see. The capital city of Kigali is also uniquely beautiful in its own right. While urban planning and a sensible layout of roadways is essentially non-existent, Kigali is exceptionally clean and hosts a variety of unique and charming neighbourhoods – each with its own characteristic vibe. It’s a wonderful city to explore on foot and there are countless sights to see and things to do.

The people of Rwanda are also wonderful, but there’s one big hurdle you have to get over once you first arrive here. Have you ever had a dream where everyone is staring at you? You know the type of dream I’m talking about… It’s the one where you have a long string of toilet paper stuck to your shoe and, as you walk through the halls of your high school, literally every person you walk past stops and stares. Well, that’s exactly what happens in Rwanda. I’m not talking about quick glances. I’m talking about full on, 180 degree head turns whilst scanning you up and down. I haven’t gotten used to it yet, and I don’t think I ever will. What I have come to realize, however, is that these stares are largely based in an immense amount of curiosity. A quick smile or a friendly “hello” is enough to break the analytical stares and engage the warm and friendly personalities underneath. Not once have I waved, smiled, or said “hello” to a single person here and not had a reciprocal reaction 10x more enthusiastic than my initial delivery.

I have been exceptionally fortunate to have been able to help facilitate the VAST (Vital Anesthesia Simulation Training) pilot course and participate in weekly resident teaching sessions. I’ve also gotten multiple opportunities to participate in teaching in the ORs at CHUK. What an experience that has been. Resourcefulness and ingenuity are absolutely essential in order to be a functional anesthesiologist in this setting, and the Rwandan residents are experts in both of these regards. I liken my experience in the operating rooms to experiences I’ve had in multiple restaurants around Kigali…

(One example of an actual event)

Me: *looking at a menu containing 14 different types of omelettes* “I’ll have the Spanish omelette please”

Waitress: “No, we don’t have that one”

Me: “Ok, no problem. I’ll have the ham and cheese omelette instead”

Waitress: “No. We have cheese omelette, or plain omelette. You can have plain omelette”

Me: “Sooooo do I actually get a choice? Actually, I’ll just get scrambled eggs”

The moral of the story: In the OR - just like in the restaurants - you can ask for it, but it doesn’t mean you’re going to get it; you’d best be prepared to compromise and make the most out of alternative options available to you.

            To date, my time in Rwanda has been everything I’ve hoped it would be. My interest in global health – which, prior to this elective, was primarily idealistic - has been reinforced with real world experience, excitement, and intrigue. Participating in global health initiatives is no longer just a pipe-dream, but something I have experience in and plan on fully incorporating into my future practice.  

Our lively Jeopardy game at academic day

Resident initiative, getting ready for VAST week 3