NYSORA NEWSLETTER, MAY 2010

Teaching Regional Anesthesia and Pain Management in Rwanda, East Africa

Problem Based Learning Discussions

An abstract was presented by Doctor Rhit Mittal and Zaher Daoud

Juan-Francisco Asenjo and Eding Mvilongo
McGill University, Montreal Qc Canada

Rwanda, a recent addition to the East African Community, is a lovely country located in the east-central region of the African continent. It is bordered by Uganda in the north, the Democratic Republic of Congo in the west, Tanzania in the east, and Burundi in the south. Once a Belgian colony, before its independence in 1962, Rwanda has a high percentage of francophone people, along with Kinyarwanda, the indigenous official language, despite the switch to English as the second official language in 2007. Its land area, covering only 26,338 squared kilometers, makes Rwanda slightly smaller than the State of Maryland. There are roughly 10.5 million people living in Rwanda (July '09), making this country the most densely populated in Africa. The per capita income is $US 1000/year. By comparison, the world average yearly income is around $US 10,400/year, while in the United States, yearly income hovers around $US 47,000. The health care system is public, but a few private, non-surgical ambulatory facilities recently opened their doors in the capital, Kigali. There are only 8 trained anesthesiologists permanently based in Rwanda (!). They are distributed among three main hospitals to serve the entire population: the Centre Hospitalier Universitaire de Kigali (CHUK), the King Faisal Hospital in Kigali (KFH), and the Centre Hospitalier Universitaire de Butare (CHUB) in the city of Huye. Most of these anesthesiologists are expatriates from Uganda, India, and Burundi, with the balance consisting of Rwandans trained in Belgium or France. Although there are smaller county hospitals around the country (dispensaires), where C-sections and minor surgical procedures are performed, both general and neuraxial anesthesia are provided by technicians in those institutions. Rwanda's sole medical school is located in Huye, the second city in importance after Kigali.

The Canadian Anesthesia Society International Educational Fund (CASIEF), supported by the World Federation of Societies of Anesthesia, collaborated with the Rwandan Ministry of Health and the National University of Rwanda to implement a formal residency training program in Anesthesiology in 2005. Residents are chosen in a national competition and, upon selection, must sign a written commitment to serve the public health care system in Rwanda for 5 years after completion of their specialization. The Program Director is a young, French-trained Rwandan anesthesiologist (Dr. Theo), who is based in Huye, the headquarters city of the National University of Rwanda. As it stands, one North-American volunteer faculty member, often accompanied by a resident from his or her home institution, is sent by the CASIEF every month for four weeks to help out with resident training. Moreover, as the first generation of Rwandan anesthesiology residents is about to graduate after 4 years of training, a special agreement was reached to allow them to further their training experience by working in a Canadian university-affiliated Anesthesia Department for 6 months.

My tour of duty was in October 2009, and I was lucky to have working with me a star PGY4 resident from our program, Eding "Sandrine" Mvilongo. Our mission was to teach regional anesthesia and some pain management fundamentals to the local anesthesiology residents. Preparations began months in advance: reading material sent by Doctors Franco Carli and Patricia Livingston, who are in charge of coordinating the Rwanda mission; talking to other volunteers that preceded us here; organizing lectures; and obtaining vaccinations against pretty much every bug likely to be found in that part of Africa! Traveling to Kigali from North America is a rather long journey (best case scenario about 20 hours), since there are no direct flights to the central east-African continent from the United States or Canada. So this trip first brought me to Turkey to visit Dr Artikoglu, a former fellow in Regional Anesthesia in my department; from there, I travelled to Nairobi to catch a connecting flight to Kigali. In spite of my untimely arrival at 4 AM due to a delay in Nairobi, Doctor Antoine, a local PGY3, was waiting for me at the Kigali airport with a friendly smile. I must mention that dawn breaks at around 5:30 AM every day of the year because of the country's proximity to the equatorial line, causing the city to be on the move... by 6 AM! My welcoming party took me to the apartment set up for visiting professors; it is located in the oldest and somewhat humble neighborhood of Nyamirambo in Kigali. The apartment is Spartan by Western standards, but provides what is needed to live and work: a small kitchen, living and dining areas, three individual bedrooms and, of course, a television (only one channel), and internet access (a bit slow-w-w-w-w). Power outages are frequent and hot, properly pressurized water for showering is a commodity available only sporadically… but no complaints here!

The teaching program consists of lectures and daily clinical activities, which take place in the hospitals where the residents rotate, both in Kigali and Huye. Mondays were spent at the CHUK, where the workday started at around 7AM, with a group discussion with the anesthesia technicians about their pre-operative assessments of the patients scheduled to have surgery during the upcoming session. The rest of the day was spent doing clinical teaching pertaining to the ongoing cases in the operating room. Tuesdays' clinical action took place at the King Faisal Hospital (KFH), where senior residents work in the ICU and the Anesthesia Department. The operating list of this private hospital encompasses a great variety of cases, except cardiac surgery and transplants. For instance, on the last scheduled day of my mission, I was involved with the anesthesia for the separation of co-joined twins. Wednesdays were formal lecture days; we got together with all the anesthesiology residents and the Program Director at the CHUK. Of note: since not everyone was based in Kigali, some of the PGY1 residents and Dr. Theo did the 5-hr round-trip commute from Huye every week. The morning session was broken into two seminars on a regional anesthesia topic, one of which was presented by a local resident and the other by my colleague resident. After lunch, I would give one or two talks to cover as much regional anesthesia and pain management concepts as possible, with a "not-too-complicated-keep-it-simple" approach. Discussions, clinical teaching, and lectures were conducted in both French and English because this program, taught in English, is challenging for the Rwandans who still struggle to master the English language. Thursdays were spent at the KFH and Fridays at the CHUK; a variation of this schedule occurred on the second and third weeks of the mission, when we travelled to Huye to work on these two days with the PGY1 residents based there. In all centers, a typical workday would end around 2PM, after which times cases from the emergency list would be started.

We found a nerve stimulator, some block needles, bupivacaine, and lidocaine in every hospital. There was even hyperbaric bupivacaine for spinal anesthesia in one of the institutions. We taught the residents single-shot peripheral nerve blocks, keeping it as simple as possible by focusing on one technique for the brachial plexus (infraclavicular approach) and the lumbar plexus (fascia iliac approach) blocks. Femoral, sciatic (infragluteal approach), ilio-inguinal, penile, and facial blocks were also covered. We demonstrated the insertion of lumbar epidurals at the KFH and the CHUB, and of thoracic epidurals at the CHUB. A consultation to assess a patient with chronic low back pain was also organized at the latter institution.

The working conditions in anesthesia are quite rough in Rwanda. Healthcare technology seriously lags behind in the country, when compared to the information technology sector growth over the last few years. For example, there are 100,000 children with access to computers and the internet in public primary schools because the country is fully wired with a fiber optic network. By contrast, hospital facilities and standards of care need urgent updating to ensure decreases in the prevailing high mortality and morbidity rates. For instance, some of the hospitals did not have supplies of succinylcholine, neostigmine, fentanyl, propofol, or even disposable endotracheal tubes. This is a serious pitfall considering the high prevalence of AIDS, which is due, in part, to the atrocities that happened during the 1994 genocide. Equipment is antiquated throughout the country although, while in Kigali, we witnessed a donation from Medtronic. The company provided the CHUK with six new anesthesia workstations. For the first time, residents and technicians were able to see end-tidal CO2 tracings and monitor trends. Maintenance of a sterile environment in the operating room is an ongoing battle. The absence of air exchange or air conditioning systems in the OR prompts the staff members to open windows to allow for some air circulation. As a result, flies and other insects are frequently found contaminating the surgical field, instruments, and the wound. On the other hand, hypothermia is rarely a concern and patients can almost always be managed with spontaneous ventilation.

Rwanda is truly an amazing country. People are nice and polite; even police officers will stop your car with a smile and check documents with a pleasant non-threatening attitude! The crime rate is very low and people walk the streets at all times of the day confidently. Some interesting facts: plastic bags were banned in 2005 to keep the country clean and decrease pollution; there are no fire departments except at the airport; it is forbidden to eat or drink in public areas; everybody must always wear footwear; and solicitation of any kind is forbidden. Cities are very clean (especially by North American standards) and President Paul Kagame leads by the example when he turns up once a month with the rest of the population to help clean his neighborhood. Rwanda has multiple, well-tended national parks where we saw giraffes, hippos, elephants, monkeys, gorillas, and many other animals in their natural habitat.

Rwanda, the Land of the Thousand Hills, is a great nation, which will benefit enormously from its collaboration with CASIEF to provide anesthesiology training to its new doctors. It was an unbelievable opportunity and a privilege to teach the anesthesiology residents and in turn, discover new realities, create new bonds with extraordinary individuals and colleagues, and explore the Heart of Africa.

The word doctor comes from the Latin word docere, meaning to teach. NWAC Dubai 2010 obviously takes this deeper meaning seriously. The NWAC's mission is education. The primary teaching mode used is the didactic model where research, facts, techniques and tools are presented by experts. The presenter and the audience then contemplate these things together moving as a group towards a deeper understanding. This is an honored and effective teaching method that reaches back to the beginning of teaching itself. We all remember "See one, do one, teach one". This approach, as effective as it is, does not fill every learning need. Medicine and anesthesia are complex and deep and require multiple modalities to address our learning and teaching needs. The faculty of NWAC Dubai 2010 realizes this and uses several approaches, tailoring each to its best use. Problem Based Learning Discussions (PBLDs) are an excellent example of a different classical learning approach being used here at NWAC Dubai 2010 and that is the dialectic model. Also referred to as the Socratic Method, it is a relentless search for better practices through questioning and discussion. The PBLD groups are small and their size and structure allows them to delve into the details and the deeper implications of a particular situation or problem.

We were able to sit in on a PBLD with NWAC Dubai 2010 faculty member Doctor Kristie Osteen playing the role of Socrates. There were seven people in the group including Dr. Osteen, an ideal number for the purpose. The subject was "Anesthesia for Patients Having Cataract Surgery – What Can Go Wrong?" This is an important line of inquiry considering the rising rates of cataract surgeries. The normal risks of anesthesia coupled with technical advances that make the surgeries themselves quicker, can lead to new problems that need to be examined. We'll use this PBLD as an example throughout our examination of the PLBD learning process.

Let us start with the PBLD structure. A group is convened under a particular subject or line of inquiry. The facilitator presents a case study. The rest of the group reviews the case study and then the questions begin, "If you were treating this patient with this drug, what are the post operative implications?" and so on. By examining the scenario from different angles information is revealed about the problem being discussed. For instance in this PBLD it was revealed that a common practice in the USA (the use of a 2% lidocaine gel) is not being done at all in much of the developed world. The questioning leads the group into new directions. A group member may find their assumptions challenged. This will force them to re-evaluate their treatments and common responses to situations. Though sometimes uncomfortable, this is extremely valuable. A fresh perspective is difficult to cultivate in a busy practice. For Dr. Osteen this is one of the greatest benefits to this learning approach. It makes us look anew at the challenges we face every day. It was clearly invigorating for those participating.

The whole group began to drop its guard as the result of joining in this mutual examination. Things then took a turn into richer territory as they each shared the full depth of their experiences. Now instead of a lecture where a teacher with 30 years of experience is explaining a situation, you had the combined experience of seven people (with a total of 100 years of experience or more) exploring a scenario together. In this PBLD there were techniques for stabilizing patients, GA vs. RA and the use of different drugs weighed and explored and shared amongst the participants. Through this experience each individual became enriched by the experiences of the whole group. Dr. Osteen believes that this is the true purpose of the PBLDs, the free exchange of experience and ideas for the benefit of all the participants; for instance an important moment in this PBLD was when a participant asked if anyone had tried a particular approach to patient stabilization which she had been considering. The other members of the group and the facilitator weighed in with responses, examining the merits or pitfalls of the potential anesthetic technique. That was information and a discussion which that participant really desired and the group benefitted from looking at a situation from a new viewpoint. These moments are when the PBLD dialectic approach to learning can really shine.

Dr. Osteen has suggestions for those that would like to get the most from PBLD learning opportunities. For participants she suggests studying any advance materials provided by the facilitator. At a minimum write down and bring questions with you and if you would like to go the extra mile email them to the facilitator in advance of the program. Be unafraid to question and participate; the idea is to share experiences. Her suggestions for facilitators are to prepare a topic and present it to the participants with any relevant material well in advance of the PBLD. Adapt your preparation if you get new information about the participants needs prior to the event. She also suggests that you be fluid and adaptable. Keep engaging the group even if they aren't talkative at first, they signed up because they wanted to be there. Don't be slavish to the title or case study. For instance, in this PBLD a participant had a question about a procedure not covered in the title, but it was clearly relevant and a valuable portion of the session. You never know where the discussion may lead or what discoveries might be made along the way. Lastly, remember the conversation need not end when the time runs out. It can easily continue through email, forums or other means.

A break from our routines, combined with these varied opportunities to teach and learn in new settings, is perhaps one of the most valuable things that NWAC provides. Why is time away from our practices so important? Renowned management consultant Nancy Duarte made the following observation during an interview in the MIT Sloane Management Review, "We live and work in environments that want us to utilize all of our resources, to not waste space, time or talent by leaving them unused. But what happens when you use things to 100% of their capacity? When a desk is 100% covered with papers, it is no longer a useful surface. When people are kept busy 100% of the time, there is no time available to generate new ideas". Take advantage of opportunities to learn and teach and change your routine through PBLDs, it's time well spent. This antidote to routine will be continued at NWAC Rome 2011.

Let's take a look back at an abstract presented during the 8th annual NYSORA Symposium this past December. Doctor Zaher Daoud and Doctor Rohit Mital presented an abstract that won the silver medal in the poster competition. We interviewed them and found the following fascinating story behind the abstract.

It started like many other days for Doctors Zaher Daoud, Rohit Mittal and their team. A 76 year old woman was in for a voluntary hip replacement. She had hypertension, type II diabetes and mild peripheral neuropathy. All things of concern, but nothing the team hadn't faced many times in their practice. After the patient was prepped for surgery Doctor Daoud performed an intrathecal block and then he began a right posterior lumbar plexus block at the L4-L5 level. He always leaves his PNS needle open to the air during insertion in case a vessel is inadvertently punctured. Such was the case this day, but as the puncture was immediately obvious, the needle was withdrawn and a new location chosen. The block went smoothly and the perineural catheter was left in place. The patient was rolled over on her back once full anesthetic effect was reached. About 25 minutes after the block was performed the external hip stabilizers were placed on the patient. The stabilizers were tightened firmly around the patient to immobilize the field of operation. As this was done the patient quickly became unresponsive to verbal commands. Extreme bradycardia showed clearly on the ECG and that progressed into a brief asystole and a loss of cardiac output. It wasn't a normal morning anymore!

An immediate presumptive diagnosis of local anesthesia toxicity (LAT) was made. All hospitals in the UK have an intralipid rescue kit in every operating theater and a protocol for its use. The team was prepared and instantly began resuscitation. The resuscitation protocol included the administration of 50 ml of a 20% intralipid bolus. This initial dosage was followed with a 450 ml infusion. The patient's condition stabilized in a little over 5 minutes. She regained consciousness and 4 hours later was sitting up enjoying a cup of tea and chatting with the staff. Four weeks later she would have her hip replacement surgery without any incident.

That is a short exciting story with a happy ending, from near death to stable in 5 minutes; from near death to a cup of tea in 4 hours. Most would have breathed a sigh of relief, congratulated themselves on being prepared and left it there. However, doctors Daoud and Mittal were curious and they couldn't let it go while there was still something to be learned. What had happened? Why were there no symptoms of LAT until 25 minutes after the block? What was the route the anesthetic followed?

After much reflection and investigation they concluded that there was a clear cascade of events. First a vessel was punctured during the psoas block before a new location was chosen and the block successfully placed. Second, the dosage of anesthesia was 10% over the upper limit of effective dose (normal procedure in most cases). Third, this surgery requires the patient to be moved around; the blocks are performed while the patient is on their side, then they are moved to their back for surgery. While there was no route for LAT with the patient in one position, there might be a route in another position. Once the patient is in position for surgery she must be firmly secured with hip stabilizers. The hip stabilizers provided the fourth and final clue. The Doctors surmise the application of the hip stabilizers raised the intra-compartmental pressure. The raised pressure caused the entry of an unpredictable amount of local anesthetic into the intravascular compartment through the previous wound. This explained the delayed onset of LAT.

Then they asked what could be done differently. How can this be avoided? Doctors Daoud and Mittal believe that the dosage should be reduced in instances where raised intra-compartmental pressure is expected. The idea that if X is the upper limit of effective dose then X + 10% provides a margin of surety ignores the heightened potential for LAT in such scenarios. Reducing the dose below the upper limit of the effective dose (or lower) is their recommendation. They would like to study the effects of intra-compartmental pressure on nerve blocks. More and more hip replacements are being performed, so the answer to that question has implications for all doctors and patients involved. The question now is how does one craft a valid study within the bounds of ethics? Doctor Daoud can be reached at zaher.daoud@cddft.nhs.uk and he welcomes comments, questions and ideas.