Teaching Anesthesia in Rwanda: Dr. Peter Slinger.

he following piece was written by Dr. Peter Slinger in November 2009. 

Rwanda is a small densely populated country in Central Africa, infamous for the genocide of 1994. Following the civil war, which ended the genocide, there remained only one Anesthesiologist in the country, which has a population of 8 million. For comparison, Ontario, which has a similar population, has approximately 1000 Anesthesiologists and GP Anesthetists.

The Rwandan government began a two tier approach to the lack of anesthesia personnel. One tier was to begin training nurse-anesthetists. This has been a reasonably successful program. Most anesthetics in Rwanda are now given by nurse-anesthetists in either one of 40 district hospitals (without Anesthesiologist supervision) or in one of the three teaching hospitals (with supervision). The other tier was to send their medical school graduates who were interested in Anesthesia to France for residency (the official language of Rwanda is French). This program was largely a failure, very few trainees ever returned from Europe after finishing their residency.

In 2002, the Rwandan Ministry of Health approached the World Federation of Societies of Anesthesia (WFSA) and asked for assistance in setting up a post-graduate anesthesia training program in Rwanda. The Canadian Anesthesiologists’ Society International Education Fund (CAS-IEF) agreed to take on this project in 2004. The program is now beginning its fourth year with a total of 9 Rwandan anesthesia residents in the 4 years of the program. The first two residents, now starting their PGY4 year, are due to graduate in the summer of 2010.

Canadian Anesthesiologists are asked to volunteer to spend a month teaching Anesthesia to the Rwandan residents. The aim is to have a Canadian Anesthesiologist continuously on site in Rwanda to supervise the program. I volunteered for the month of September 2009. Since I was informed that many of the patients are infants and children, and since I have not done any pediatric anesthesia for many years, I was fortunate to be able to convince Rob Kriz, one of our excellent U of T PGY5 residents, to accompany me and to keep me out of trouble (which he did on a regular basis). My airfare was paid by the CAS-IEF and Rob’s was subsidized by the U of T Department of Anesthesia and by The Hospital for Sick Children. Our accommodation was a 3 bedroom apartment provided by the Rwandan Ministry of Health.

The teaching of Anesthesia in the Rwanda program is essentially similar to a Canadian program. We spent 4 days/week in the OR 1:1 hands-on supervising/teaching the residents. One day/week was academic with lectures, seminars and trouble rounds. We found their residents generally have an acceptable level of book knowledge, which they get from close reading of a North American anesthesia text (Lange), that they are given. However, at all levels the technical skills of their residents are not adequate. One PGY4 resident had done a total of 10 epidurals and the other had done none. The few Rwandan Anesthesia attending staff (there are now 11 in the country) are too over-stretched to spend adequate time supervising their own residents (one anesthesia staff may have to cover up to 8 ORs with nurse-anesthetists and residents).

The anesthesia equipment and drugs are probably similar to most third world ORs, a mixture of what would have been available in Canada in 1950-60s. Some hospitals do not have piped gases so they use oxygen concentrators. Pulse oximetry is often (but not always) available and the same is true for other standard monitors, except end-tidal CO2 and expired gases which are never available. Also there are no transducers for invasive lines. The piece of equipment I missed most was reliable suction. Even an average intubation becomes an adventure when there are secretions and the suction doesn’t work.

We rotated between the three teaching hospitals in the two major cities: two hospitals in Kigali, the capital, and one in Butare, the University City 2/12 hours by road to the south. The Centre Hopital Universite de Kigali is a public hospital with 8 ORs, the King Faisal, a private hospital in Kigali, has 4 ORs and the Centre Hospital Universite de Butare, public, has 4 ORs.

As advertised we did a lot of pediatrics, often neonates: pyloric stenosis, imperforate anus, hernias, etc. Also, lots of trauma: vehicle-vehicle and vehicle-pedestrian and burns. Almost anything that can be done with a spinal is done with a spinal: lower GI, GU, lower limb orthopedics and C-sections. Some days one or more of the standard drugs (pentothal, ketamine, halothane, succinylcholine and pancuronium) were not available and the elective OR lists were cancelled. But the emergencies still have to be done so figuring out a general anesthetic can be quite challenging.

They tried their best to find some thoracic cases for me since that is my area of interest. I took some donated double-lumen tubes since they had run out, and which they plan to reuse. However, their types of thoracic cases are not what we see at the TGH. They see very little lung cancer, but they do major decortications for tuberculosis, neonates with T-E fistulas and other acquired and congenital thoracic problems. The cancer cases we did were mostly palliative procedures for major head and neck or abdominal tumors.

My wife, Rusty Stewart came with us. She is an ex-banker and spent part of her time auditing micro-loans for World Vision. She wrote a blog while we were there (www.rustystewartrwanda.wordpress.com) and posted some more photos which are still available on the web. Our children joined us for the last week and enjoyed the visit since there are several interesting tourism attractions in Rwanda, particularly the mountain gorillas.

I am grateful to Linda Flockhart, the head nurse in the CVICU, for the donation of several outdated pulse oximeter probes that were much needed. Also to Patricia Murphy for the loan/donation of her personal portable pulse oximeter. I found that it was a very rewarding experience and it makes me appreciate the equipment, drugs and monitors that we use routinely and that have made anesthesia so safe in the past 20-30 years. The goal of the program is to produce a critical mass of Rwandan Anesthesiologists (50+) in the next 12 years so that Rwanda can become self-sufficient in training their own Anesthesiologists. The CAS-IEF is looking for volunteers. Contact the program coordinator Franco Carli in Montreal (franco.carli@mcgill.ca), or talk to me if you are interested.