World Health Organization – World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Full text available from SpringerLink < https://doi.org/10.1007/s12630-018-1111-5 >.
Save the date.
10th Annual Anesthesia for Global Outreach Course,
Friday, October 26, 2018 7:15 AM – Sunday, October 28, 2018 5:00 PM
Due to the NOTSS course, the academic day for anesthesia residents was moved from Monday to Tuesday morning. We spent another fantastic morning with the residents teaching each other and engaging in passionate discussions over the best way to do difficult cases. After the half day was finished, Margaret and I were picked up for our drive to Butare.
Butare (now named Huye) is in the Southern province and it takes about 2.5 hours to get there. It was the original intellectual seat of Rwanda – the university was founded there and the other main University Teaching Hospital (CHUB) is located there. While in Butare we stayed with the wonderful family of one of the anesthesiologists (who happened to be in Halifax of all places, so I did not get to meet him). It was lovely to stay in a home with children and puppies and gardens and a wonderful host. It was a short trip to Butare due to the NOTSS course and the Good Friday holiday. But it was very worthwhile.
We would like to congratulate Dr. Gaston Nyirigara a Rwanda colleague with the 2018 IASP (international Association for the Study of Pain) award of excellence in pain research and management in developing countries. Dr. Nyirigara has always been close with CASIEF and Queen’s pain research and management program. Once again congratulations.
I would like to summarize and describe key features for why Gaston received this award. “Intensely involved in clinical pain management in Rwanda, as well as a devoted teacher across the country. Committed to developing a network of pain management services across the country. Received one scholarship for training in Canada. Strong clinical care, patient advocacy and mentoring/education during clinical shifts. Very strong letter of support (mentioned by 2 reviewers). Established and leads Acute Pain Management Team, and this pain care program is the first of its kind in Rwanda. Hard-working and with a clear mission. Obtained support/funding to establish a Quality Improvement Strategy for pain care suggesting a plan to monitor the quality of care provided.”
Dr. Nyirigara also gave a Grand Rounds presentation for the Department of Anesthesia, Pain Management and Perioperative Medicine at Dalhousie University, March 21, 2018. That talk is available below.
In April of 2017 I travelled to Addis Ababa, Ethiopia as part of the Canadian Anesthesiologists’ Society International Education Foundation (CASIEF) partnership with the Toronto Addis Ababa Academic Collaboration (TAAAC). These organizations are partnered with the Tik ur Anbessa (Black Lion) Hospital in Addis to support a physician-anesthesiologist residency training program in teaching trips that are scheduled for 3 months per annum. There is a massive shortage of anesthesiologists in Ethiopia and thus an even greater scarcity of those with time to teach residents. I had been interested in participating in this initiative since my first year of residency and now, approaching the end of my 4th year, felt I was ready for the challenge of going to teach in an environment very different from the one I was training in. I suspected that in addition to teaching, I would also learn a lot about other ways to provide anesthesia, especially when resources are limited.
Our trip was a 4-week mission for myself and Karim Mohamed, another 4th year resident, who is based in Ottawa. For the first 2 weeks we worked in the intensive care unit (ICU) with Neill Adhikari, an Intensivist from the University of Toronto associated with TAAAC. For the following 2 weeks we worked in the operating rooms (ORs) with Jason McVicar, a regional anesthesiologist associated with CASIEF from the University of Ottawa.
My first memories of our trip are of walking the streets of Addis. Our daily trek to the hospital would take us along a busy main road crowded with a cacophony of people and cars. Blue mini-buses zip past, each with its own herald, shouting out its destination. A hodgepodge of shops line the streets, and a few beggars sit along the road. In some ways, this scene is reminiscent of downtown Toronto. I recall one woman sitting at a major intersection on a raggedy blanket. Her prosthetic leg sits upright in front of her, a silent behest.
We make our way down this street, picking our way toward the hospital. Half the sidewalks are being redone and there are piles of rubble everywhere, underlying red sand peeping through. The street is one of juxtaposition: there are massive glass-coated skyscrapers under construction with bamboo scaffolding lining their sides and workers buzzing about. From behind these gleaming new structures I catch glimpses of shacks patched together from concrete bricks and plastic cast-offs, without obvious electrical wiring or plumbing.
We climb a steep hill and the hospital comes into view. It too is under construction – older square buildings of concrete with many rowed square windows are being blended together with newer, lighter structures. The inside of the main wing we work in, which houses the ORs and the ICU, reminds me of Canadian schools built in the 1960s. Staircases are made of many-speckled stone steps with concrete landings, and the walls are painted a dull yellow. The ORs have been recently renovated – they are large and bright with big windows spanning the walls. The anesthetic machines are also new – Chinese-made and relatively familiar looking. The ICU has also recently been expanded – it consists of a surgical ICU staffed by an anesthesiologist and a medical ICU staffed by a respirologist-intensivist. The ICU has ventilators and a single (occasionally broken) x-ray machine, but no arterial-blood gas (ABG) analyzers or readily available infusion pumps.
On our first day we met with our Ethiopian colleagues and further discussed the plan for the month. Our work would consist of a mix of didactic lessons, hands-on teaching sessions and clinical teaching via rounds in the ICU or time in the OR. The residents had a teaching schedule with pre-planned topics that they presented on that they wanted us to attend to help lead discussions on the presentation content after the talks. They also had a variety of topics they wanted us to give further lectures and practical sessions on, including regional anesthesia and the anesthetic gas machines.
Our first 2 weeks in the ICU were an eye-opening experience for me. I constantly felt grateful for the tools and resources we had available to us in the ICUs I was used to working in at home. I also felt acutely aware of the amount of waste that occurred at home and learned a lot from the nurses working in the unit about resource allocation and protection. The denizens of the ICU were also very different than what I was used to: it was rare to meet a patient older than forty and many of the conditions we witnessed were ones that we either never saw in Canada or had progressed to a degree that would occur only rarely at home. I distinctly recall the young woman in fulminant heart failure because of the fatal combination of advanced rheumatic heart disease and pregnancy. Or the patient with intractable raised intracranial pressure who needed a correctly sized ventricular-peritoneal shunt. I also recall the challenge of diagnosing and treating what appeared to be severe acute respiratory distress syndrome (ARDS) using only lung ultrasound and a pulse oximeter. Our Ethiopian colleagues recognised and were frustrated by these resource limitations — and still cared for their patients with smart adaptations. We tried to focus our rounds on practical information in the context of their current working environment, while incorporating teaching on arriving technologies, such as interpreting ABGs (a blood gas machine was on order) or ultrasound-guided vascular access, as the unit had recently acquired an ultrasound machine. Meanwhile, in addition to teaching, Dr. Adhikari provided the residents with research studies that had been done in low and middle income countries (LMICs) which would be more relevant to their practice, rather than the ones that much of our practice at home was based on.
I was continually impressed by the depth of general medical knowledge of the residents I met and the detail with which they researched the presentations they gave to their peers. The educational challenges facing the program were even greater than in previous years as the government had recently expand the residency program and doubled the number of residents it took on that year as compared to past years. While long term this strategy would increase access to anesthesiologist-provided care, in the short-term it was making it even more challenging to find adequate learning opportunities for all the new residents. The residents were acutely aware of this and keen to seize every opportunity – they reminded us more than once of sessions they felt were particularly important we cover in our month and stayed extra late when we did give a hands-on session on the anesthetic machines, asking astute questions and clarifying points of confusion. Similarly, the residents went through extra steps to arrange regional anesthesia practice when Dr. McVicar was there, given his expertise in the area. They sought out patients and trundled ultrasound machines from the main operating rooms to the separate orthopedic hospital. After performing blocks on patients, they stayed late to do further ultrasound practice on each other to reinforce the ultrasound anatomy.
Our time in Addis was busy and challenging, and just as we were getting used to the system, our month was coming to a close. In discussing with Karim, we found we would recommend certain things to others considering a trip, and that we ourselves plan to do when we return. Firstly, communication with the residents was often done through informal channels or via one of the staff. To ensure that all information is relayed, we would request an email list for the residents and communicate to the group directly that way. This would help eliminate some of the issues we had around scheduling teaching sessions and ensuring that everyone is aware of logistical details. Having this list in advance of our trip would also have allowed us to prepare teaching sessions that fit their learning needs, rather than assessing needs and preparing material as we went along. We would also liaise more closely with the administrative staff about the scheduling of teaching sessions as we often encountered room double-bookings and last-minute changes. Finally, creating a form of ‘handover’ between ourselves and the next group, either from Canada or another international partner involved in anesthesiology education (University of Bergen, Norway and Seattle Alliance Outreach) to ensure continuity and avoid overlap would help improve sustainability of our efforts. We felt very grateful to be able to participate in this initiative and get to know so many amazing people in Addis. We look forward to continuing our teaching efforts there!
There is always room for improvement in pain management for all patients throughout the world. It was Dr. Dorette Husbands, a final year anesthesia resident at the Georgetown Public Hospital Corporation, who approached us for help with her Master’s Thesis. She noticed that the nurses in the post anesthesia recovery room did not have a pain assessment tool, and that large doses of opioids were given to patients intravenously without knowing if the pain was severe or not. Other patients appeared to be undertreated. She proposed a quality assurance project to improve the quality of care for acute pain management in recovery room patients.
This is where we got involved helping to collect data. After quietly observing nurses care for 30 patients, today we began our intervention and introduced a combined visual analogue scale and Baker-Wong faces scale, along with an intense education session, teaching nurses to titrate opioids, and use multimodal therapy. Below nurses are taking a pretest to evaluate pain knowledge and barriers against treatment.
After the course, the nurses enthusiastically sprang into action and one nurse told me that instead of giving 7.5 mg of IV morphine to a patient, she used the pain assessment tool and gave 2.5 mg instead. The patient’s pain was relieved and he was not overly somnolent. He was discharged from PACU one half hour later.
Now for the next step. Tomorrow and Wednesday pain talks will be given to the entire anesthesia department, and hopefully this will lead to the creation of PACU standing orders for pain. Of course it is one step at a time. We are hoping the next set of volunteers will become involved in data collection post-intervention, and continue with pain education throughout the hospital.
2018 CASIEF Gala Dinner
Sunday, June 17, 2018.
Auberge Saint-Gabriel, 426 Rue Saint-Gabriel, Montreal
Reception 18:30, Dinner & Speaker 19:00 – 22:00
Dr. Dan Poenaru – Guest Speaker
Dr. Poenaru is a Canadian pediatric surgeon who has dedicated his life to treating needy children throughout eastern Africa. Motivated “by the enormous needs of African children,” not only those of Kenya, but also the numerous Somali refugees entering the country, Dr Poenaru opened a surgical practice in Kijabe, Kenya. Throughout his career, he has treated patients through civil war and in refugee camps, exposing himself to tremendous personal risk. Dr Poenaru is the recipient of the 2014 Teasdale-Corti Humanitarian Award of the Royal College of Physicians and Surgeons of Canada and the 2015 ACS/Pfizer Surgical Humanitarianism Award of the American College of Surgeons.
To learn more about our speaker:
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.
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.
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.
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.
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.
There are also a number of photos in the original post at https://simcentreopening.blogspot.ca/2018/01/adam-on-vast-worth-wait.html.