It has now been 14 days since I returned from Africa where I spent 4 weeks teaching in Rwanda and 1 week recovering on Safari in Kenya.
Firstly it was probably the greatest holiday of my life, I saw rain forests, savanna, chimps, gorillas, lions, more types of antelopes than I ever thought possible, giraffes, zebras and hippos. I also got to stay in some fantastic hotels (and some not so fantastic). I also lived in Kigali in an apartment, so had a chance to live amongst the Rwandans. We bought food in the local markets, ate in a local restaurant, walked everywhere and drank the local beer in the local bars. On that alone the trip was a success.
Why do I feel so disillusioned and somewhat unworthy?
At the end of the genocide, there was only one certified anaesthesiologist left in Rwanda. That doesn't mean that patients having surgery in Rwanda were biting bullets; anaesthesia was presumably performed by nurses, technicians, surgeons and doctors with little or no anaesthetic training. A call for help went out to which Canadian (and some American) anaesthesiologists responded. The problem with training specialist anaesthesiologists in Rwanda and other developing countries is that it was necessary to send them overseas to Belgium or France to get the specialty training. Of course once they got their overseas specialist credentials, very few of them really wanted to come back to a country where they would have to work harder for much less money. It was decided that the country needed to develop a local training program to meet the needs of the country which would produced well trained consultants but consultants whose certification had no value in France, Belgium or other desirable places. To help with this goal, a Canadian anaesthesiologist +/- a resident would go down to Rwanda each month to teach formally and in the operating room. In addition each Rwandan trainee would get 6 months of training in Canada.
Now I am not one of those people who did all kinds of overseas volunteer work or electives in third world countries in medical school. While early on in my career I flirted with working overseas, life and children intervened. 5 years ago out of the blue, I got invited to accompany a mission to Ecuador to do total joints and it was like I rediscovered medicine again. I went 4 more times and am going again next January.
Much has been written pro and con about the benefits of international aid and most of what I have read is strongly coloured by the political bias of the writer unfortunately. After one trip to Africa, I don't claim to be an expert on the continent nor do I have any solutions to its problems (stopping selling them weapons would be a good start?). I have always been a believer that it is better to teach a man to fish than to give him a fish and so this Rwandan mission appealed to me for that reason. I had also met with people who had been there and at the last CAS Meeting I attended an exceptionally enthusiastic presentation on the program. I was a little nervous but I thought that I was stepping into a well-oiled machine that was producing results.
Just prior to the meeting I attended the Global Outreach Course which I have previously blogged about. I was really impressed with the mantra of doing the best you can with the resources that you have and looked forward to learning about that.
What I actually found:
Currently there are two larger teaching hospitals in Rwanda, CHUK in Kigali and CHUB in Butare (where the medical school is). Surgery is also done in about 30 district hospitals and in a private hospital in Kigali which I will discuss below. Anaesthesia is for the most part provided by anaesthesia technicians. These are well trained with good airway management skills and are also able to do spinals. For the most part they work unsupervised. There are specialist anaesthesiologists, 2 at CHUK and 4 at CHUB. There is a residency training program with junior residents at CHUB and senior residents at CHUK. The idea is supposed to be that the more difficult cases will be done in part by the physicians while the techs do everything else. This model of technicians supervised by consultants is one that should work well and is roughly similar to the situation with CRNAs in parts of the US. I never actually found out who does the anaesthetics in the district hospitals, I suspect it is mostly techs.
I observed a number of problems almost immediately.
1. Lack of professionalism. The two staff anaesthesiologists at CHUK never attended morning report or arrived late. One of them only showed up in the OR twice during the days I was at CHUK, his side-kick was not much better. The residents were only marginally better, they were almost always late for morning report and for the OR. Some days no physician showed up to the OR at all. This but me in a bad position, my rules of engagement was that I was there to supervise residents and not to give anaesthetics. Frequently on ethical grounds I was forced to give the anaesthetic when the techs found the case difficult (they had fairly good judgement in this respect). This meant I did a number of neonatal cases. (They really are just small adults). More often I just ended up standing around waiting for a resident to show up.
When the residents did show up, they mostly just stood around and watched the techs do the case. Despite 4 weeks of nagging there was never any effect to set up the room, draw up emergency drugs or actually make any plan beyond fentanyl thio sux which seemed to be the only induction sequence the residents knew (with the occasional substitution of ketamine for thio). The technical skills of the senior residents were well below what I would expect from a junior resident in Canada because they never did anything.
This was a problem that seemed limited to CHUK. CHUB in Butare ran much like a teaching hospital in Canada with the 4 staff anaesthesiologist and residents working as a team with the technicians.
2. Equipment. I trained on Boyle machines and I am not overly anal about monitoring (except for SaO2). I wasn't expecting to see the equipment we expect in a Canadian OR. CHUK actually had newer machines and monitors. I suspect they were donated. These were supplemented by Glostavent machines. The problem was of course that most of the monitors didn't have working cables so that often there were 3 different monitors in a room in order to get SaO2, EKG and BP and techs were constantly shuffling monitors and cables between rooms. The machines while new were connected to disposable tubing that was been reused and was heavily patched. Most rooms had nothing resembling an anaesthetic cart, before every case there was a flurry of bringing in equipment and drugs. When I sharply asked a resident why he hadn't got a laryngoscope ready, I was told that there were only 3 working handles in the OR and that a handle would arrive just in time. In obstetrics one suction was shared between the two rooms; a second non-working suction was parked against the wall, nobody had bothered sending it out to be fixed. I never saw an oxygen cylinder on any machine which is a concern because I had been warned that the central oxygen supply had failed in the past.
Now I accept that a developing country like Rwanda may not have the resources that Canada has, however most of the above deficiencies are not that expensive. What was lacking was leadership from the consultant anaesthesiologists who unfortunately rarely showed in the operating room.
3. Dysfunctional OR. It has been my observation that dysfunctional ORs make for bad teaching environments. The OR at CHUK is one of the few ORs in the world that actually needs more rather than less administration.
4. Techs vs. Physicians. As I mentioned the techs for the most part did a very good job. Which made we wonder, what exactly is the plan for anaesthesia in the country. Clearly there is not going to be a physician-only model in the near future or ever which makes me wonder if we really need to be training as many anaesthesiologists as we were training.
5. Training doctors to work overseas. One of the reason that there were only 2 physicians at CHUK was that 3 people were doing subspecialty training overseas. I was told that one of them had no intention of returning and it was doubtful whether the other 2 would. Great I thought. We are giving their training program the Canadian Seal of Approval so that they can get jobs in Belgium.
6. Lack of QI process. Early on we noticed that we were getting a huge number of obstetrical horrendomas. For example I knew of at least 4 Caesarian hysterectomies during the 4 weeks I was there. One of the anaes. was shocked when I told him I had only even done one. We had a number of cases of obstetrical sepsis and/or hemorrhage transferred in. When we raised the issue of why are we not discussing these cases to find out why they are happening and can we prevent future occurrences, this was met with blank stares.
I was asked to make a report at the end of my mission. I waited for over week because I thought I might be more positive however I mostly sent in a report outlining what I have discussed above. Quite quickly the two people in charge of the program emailed me back, to explain that they too had encountered the same problems, that they had raised them with local people and had gotten nowhere. It was suggested that we needed to just keep on plugging.
The question is then, aside from a nice partially subsidized, otherwise tax deductible African vacation, what the hell are we doing taking 4 weeks away from our practices and our family. And of course the answer is: a nice partially subsidized, otherwise tax deductible African vacation which nobody wants to jeopardize. That and of course the warm fuzzy feeling of having volunteered in a developing country.
By the end of the month, I was basically showing up for morning report, going to the OR to see if there was a resident who actually wanted to taught and then bugging out to the comfort of the pool at the Serena Hotel where for $200 you can buy a month's membership. It was only after I left that I had the revelation that probably every doctor before me had done just that, gone to the pool, gone sightseeing or golfed (one of the doctors from Canada raved about the Kigali golf course to me).
As we left the country to fly to Kenya, I had never felt so worthless in my life. I felt that I had accomplished nothing in the 4 weeks; that this must have been due to some character flaw as so many doctors have apparently found the mission professionally rewarding. Then of course the above revelation occurred and I felt a little better.
But I probably will return. Africa has this kind of hold on you.