We are proud to share this wonderful video with you from one of CASEIF’s major partners

Every year around 290,000 women die due to complications in pregnancy and childbirth. 90% of these deaths are preventable.

Can you imagine facing difficulties during birth in an environment where access to safe anaesthesia and surgery is limited? Happy Birth Days is an insight into everyday childbirth in Tanzania, and into the Safer Anaesthesia From Education (SAFE) obstetric anaesthesia course which brings Tanzanian anaesthesia providers together for training on how to address the major causes of maternal mortality and give the safest possible care.

Happy Birth Days defines access to safe anaesthesia and surgery, not as a luxury, but as a basic human right – with the potential to save the lives of hundreds of thousands of mothers and babies around the world.

Dylan’s Story – Association of Anesthesiologists of Uganda Meeting

ethiopia-rwanda-meetingI spend part of last week in Kampala for the Association of Anesthesiologists of Uganda’s 3rd annual scientific meeting with Paulin, the chair here in Rwanda. It was fantastic to see so many attendees there for the meeting if this thriving society. An active society of anesthesia can make a huge contribution to training, setting national standards for anesthesia care, promoting research and scholarship and other forms of collaboration. What I saw at the AAU meeting is something to aspire to for the relatively dormant Rwandan Society of Anesthesiologists.

Delegates had come from the US, Kenya, Ethiopia, Rwanda, and Tanzania. In particular, I was lucky to find Dr Mahelet Tadesse, the vice-chair of the Department of Anesthesia at Black Lion Hospital where CASIEF has a partnership. She was there with 2 of her colleagues and we met with Paulin so that we could make the most of the opportunity if these two programs learning from each other. Some challenges are the same – the need to scale up human resources for anesthesia quickly with few local faculty. Other challenges are different, like the relationship between physician and non-physician anesthesia providers, and I think there’s great scope for South-South collaboration between programs like this. I’m planning to visit Addis early 2018 to get to know the program there, and I think it would be of value to bring Pauin, if possible. Mahelet and her colleagues expressed an interest in visiting and learning from the Rwanda program. It would be great to make that work.

In the evening I managed to catch up with some old and some new friends. The AAU had a Gala dinner with some quite amazing dancing typical of various regions of Uganda, Burundi and Rwanda. We were invited to get up and join.



You’re never too young to advocate for improved access to safe surgical and anesthesia care!


Jacob Bray’s Time in Rwanda as a Resident

During my final year of residency, I was afforded the opportunity to travel to Rwanda for international work. This was my first time in Africa and my first international medical experience. As I have always anticipated integrating international work into my future practice, I thought this was a perfect opportunity for me to get my feet wet (even though my wife was 30 weeks pregnant at the time).

On September 10th, I and two other physicians from the University of Virginia landed in Kigali. As part of the CASIEF program, our one-month assignment involved training and teaching the local anesthesia residents. We planned to stay for 1 month rotating between different hospitals throughout the country, giving weekly lectures, and providing clinical instruction in the operating room. Jet lagged and with a blood caffeine level that would rival a cup of espresso, we walked over to the Kigali teaching hospital (CHUK) from the CASIEF apartment in the Nyamirambo district of Kigali. Later we learned Emmy (the CASIEF driver) nicknamed our district “Vagas Nyamirambo” as this area is somewhat the heart of Kigali, never sleeping and in constant motion.  Our first day in CHUK was spent meeting the residents and giving our first day of lectures. I was both impressed with the fundamental knowledge and engagement of the residents during my stay. They seemed to have an unquenchable curiosity, firing questions during lections and in the ORs.

As we moved out of the classroom and into the OR, I think I learned as much from the residents and how they practice as they did from me. One thing I had to learn was how to adapt my teaching to their environment and resources. It took me a week or so to realize that teaching them about a medicine we at UVA would typically use in a specific situation did them no good if they did not possess that medicine. It began to make more sense to focus on how to optimize and leverage the tools they had at their disposal to improve patient care in their setting. One example was when I began discussing assessment of volume status in a patient using PPV or SVV when they do not have access to arterial catheters. We later learned that they actually had an abundance of portable ultrasounds, and we began to teach them how to assess the IVC for volume status. I think the largest and most lasting impact we made was spending two weeks teaching nothing but transthoracic cardiac ultrasound. We spent multiple days in the sim center teaching basic TTE views and IVC assessment for volume status. The moment I realized we made a lasting impact came a day prior to our departure when their chief resident Joseph showed us a TTE he performed in the ICU. He was able to diagnose the patient with severe right heart failure which was initially not suspected. Empowering the residents to use the technology available to them to make clinical diagnoses  and helping them to improve their clinical decision making was what I found most rewarding about our trip.

I am ever grateful to the Rwanda residents, hospital staff, and anesthesia attendings for welcoming my colleagues and I with open arms. Living and working in Rwanda is an experience that I will forever remember and cherish. I look forward to maintaining connections with the people I met and collaborating with them in the future. .

Dylan’s Story – Clinical Leadership Course

leadership courseI’ve spent most of last week working on a leadership course here at CHUK, with Lisa Kelly, the COO of a large UK hospital (University Hospitals Coventry and Warwickshire NHS Trust). “INSPIRE through Clinical Leadership” is a work in progress. Lisa was in Lusaka with the University of Zambia anesthesia residency program for a year 2012-13. During that time she included leadership and management skills as part of the curriculum. Unfortunately when she left, there was no obvious replacement to teach these skills to out residents, so we’ve been working on putting the material in a course that could be delivered over 3-4 days. The idea is that the course would be run one week, and that participants with leadership experience would be selected for a train the trainers day. The following week the new local faculty could ruin the course themselves. We’ve run two pilots of the course in Lusaka, last year and in February this year, generously funded by the Tropical Health and Education Trust. This week was our first pilot in a different context – Rwanda – to see how generalizable the material is, and refine further. This time the course was supported by CASIEF.

breakout groupsI think that the course went really well. It’s very interactive and based on reflection, sekf-awareness and understanding key concepts. We covered an introduction to leadership and leadership styles, the patient experience, personal influence and managing a team, project management and performance management. Some parts were quite different due to cultural issues – in particular the scenario we had to work through conflict resolution didn’t really work in the very conflict averse Rwandan context. Back to the drawing board with that one. Language also slowed things down. English is the language of instruction here at the University of Rwanda, but in reality it’s usually people’s 2nd or 3rd language after Kinyarwanda and French. We just had to reduce the amount of content, trying to get the key points across. I think we may have to translate some material – e.g. self assessments – for next time.

Dr. Livingston gets her certificateWe got great feedback from the participants. I feel that leadership skills are so important here in Rwanda, where it’s so important to lead change in healthcare to improve patient outcomes. Lisa will be back early next year for a second pilot – and I hope the course material will be ready for dissemination soon after that.

Dylan’s Story – World Anesthesia Day in Rwanda

Muraho. Fantastic turnout for a social lunch for World Anesthesia Day yesterday. I think that this day goes unnoticed for most of us in Canada. At CHEO we order in baked good to the coffee room at the slighted provocation but I don’t think that this day has ever prompted a cake. We’re lucky to be able to take anesthesia, and our colleagues, for granted. In Kigali this was both a serious, but a joyful celebration. Anesthesia in Rwanda used to be one of the least popular specialties for post-graduate education, now it’s #1 – with 12 recruits this year, it’s more than any other program at the University of Rwanda. See more celebration of this day across the world by following the #CountMeIn hashtag.

Dr. Dylan Bould’s Story – Settling In

This is my second visit to Rwanda, but my first trip was very short and I’ve been getting my bearings as we’ve sorted out the many logistical hurdles of finding a car, house, moving in, getting the kids started in school, visa, medical licensure, and starting work. We’re starting to settle in now, and even have our first visitor come to stay this weekend.

First impressions are good! This is reverse innovation waiting to happen: traffic lights that count down the seconds until the lights change. Would love for these to come to Ontario.

Some things are organized a little differently than expected. The map above is of Kiyovu, as you can see a fairly green part of Kigali where I’m fortunate to live and work, and where the children go to school at Ecole Belge. All the roads winding around this area, and the rest of the city, are named with two letters (according to which part of town you’re in), a number then “street”, “road” or “avenue”. I’ve not worked out yet whether this makes things more or less confusing.

A 4×4 ambulance sounds like a great idea for rural terrains. It’s also essential to have a solid transmission even to pull out of the steep driveway of our home. Rwanda is undersold as the Land of 1000 Hills – it’s all hills.

One of the most striking things I noticed on arrival at CHUK, the main teaching hospital in Kigali, is the scaling up of training here, even since my last visit in January 2017. Three essential things need to happen for a training program to be able to scale up a safe anesthesia workforce: good recruitment, high quality training and finally retention of graduates in the workforce. Recruitment into anesthesia had long been a problem for this program, and the intake from 2006 to 2014 was 2, 0, 2, 4, 3, 2, 5, 0 and 2 residents, a total of 20. The intake from 2015 to 2017 was 10, 9 and 12, a total of 31 in just 3 years, more than quadrupling the annual intake. The room was packed on Monday for the 07:00 debrief of the previous nights cases. We know well of the dire lack of human resources for anesthesia and surgical care globally. Eugene, one of the senior residents, told me today “there is no problem without a solution”. It was fantastic to see the room packed with part of the solution to this particular problem. Although it’s too early for the increase in recruitment to have resulted in increased graduates, it feels like Rwanda is on the cusp of some profound changes to anesthesia and perioperative care.

Another change is in scope. I’m in Rwanda with the HRH (Human Resources for Health) program, and I’m twinned with Dr Paulin Ruhato. Paulin is now the chair of the Department of Anesthesia, Critical Care and Emergency Medicine. In addition to the anesthesia Masters program (for which Paulin is also program director), there’s also 25 residents in the Masters program in Emergency Medicine and 3 visiting HRH faculty to support this, 2 in emergency and one in critical care. There seems to be HRH faculty in almost every specialty, often here for many years. As Paulin’s twin, I’m the associate chair and associate program director – my job is to work with him and support him in the goal to make the department and training program entirely self-sustaining, without requiring external support. Globally emergency medicine is as underdeveloped, if not more underdeveloped as anesthesia. It’s fantastic to see changes on this scale being supported by such a large program, and a privilege to be part of it.

Dylan’s Story – Pre-Departure

We’re now T-7 days from our departure from Ottawa to Kigali. I’ll be working with the “HRH” (Human Resources for Health) program, now beginning it’s 6th year. It’s a very large US program, which has aimed to rapidly increase the numbers of healthcare workers across specialties and professions in Rwanda. Critically, it aims to increase capacity for Rwandans to train these healthcare professionals  – the hope is that at the end of year 7, Rwanda will be in a good position to manage without the program. I’m also the Chair of CASIEF (the Canadian Anesthesia Society International Education Foundation), which has been working in a partnership with the University of Rwanda and American Society of Anesthesiologists, and over the last 11 years has created an anesthesia training program from nothing. After the genocide, there was only one physician anesthesiologist in the country; now there is a university training program with a chair, a program director and as many as 10 residents starting each year. It’s definitely time for Rwandan anesthesia to transition to independence from external support and it’s my main goal to support that transition. To work on this, I’ll be “twinned” with Paulin Ruhato, the chair of the department of anesthesia, and also with a new program director for the residency program. I hope to be in Kigali for 11 months.

I’ve been travelling a lot for global health work in recent years, spending around 25% of the year outside Canada. It’s been an amazing privilege to do this work, but has been hard on my wife, Chilombo, and my three girls (twins Namwezi and Wamaka, 8 and Mwamba, 5) and I’ve really missed them when way from Ottawa. One of the really exciting things about this next year is that we’re all going together as a family. I’m really looking forward to exploring a new country with them and I think it’s going to be a great and educational experience for the kids. Every major move is quite stressful, and I can’t say that thing have been easy. In particular, there has been a lot of uncertainly. My sub-contract with the University of Ottawa, who are paying me for the year, was only signed yesterday. The contract between Brigham and the University of Ottawa, so that Ottawa can recover those funds, has not even been sent on to us here in Ottawa yet, and may still take some weeks. It was only a few days ago that the Memorandum Of Understanding between Rwanda and Harvard even arrived in Boston. So it’s all been quite last minute (apparently it’s like this every year), but things feel like they are finally coming together: flights were booked last week; this Monday we found out that the twins had made it into the same school as Mwamba having been on the waiting list; our house in almost boxed up and into storage, with the property on the market for rental. There’s still a lot of work to do, and we all have things and people to say “goodbye” to but increasingly I just feel like I want to get on with it now, I can’t wait for my feet to be on the ground in Kigali.

I strongly feel that partnerships like HRH and CASIEF are an essential part of the solution to the global crisis in global anesthesia and surgery. The recent Lancet Commission on Global Surgery established that 5 billion people in the world lack access to safe, timely and affordable surgical care. Scaling up is needed, so it’s great to have the opportunity to be part of such a large program. I’ve also been fortunate in having some excellent support at home. The Department of Anesthesiology and Pain Medicine at the Children’s Hospital of Eastern Ontario voted unanimously to approve 11 months leave of absence, so I still have a job to come back to next summer! This has resulted in significant inconveniences for my home department, including having to train someone to do pediatric cardiac cases. The University of Ottawa has been amazingly supportive, especially the Vice-Dean Paul Bragg, who went above and beyond to work on contract issues – the combination of a lot of bureaucracy and uncertainty could easily have killed my involvement in this project without this kind of strong support. We’re also lucky to have such great neighbours who’ve been really helpful with moving and storing our stuff.

Greetings from Burkina Faso!

Greetings from Burkina Faso!

It is with great excitement that we see the fruits of CASIEF led and supported SAFE-course in Burkina Faso flourish. CASIEF led SAFE train-the-trainers programs in 2015 has enabled further education within the country. Dr. Ki’s team announced two successful local SAFE-Paeds courses* held in April and May 2017 in Ouagadougou. Attendees were the first group of nurses specialized in anesthesiology.

All attendees were nurses from the Charles De Gaulle Pediatric Hospital. The SAFE-Peds course used a small group education style with 13 people per group. The team received lots of positive feedbacks on this model of teaching, which includes active discussions and hand on practices rather than the traditional didactic only learning.

The team had 5 trainers: 3 completed the SAFE-Peds training of trainers course last year in Cotonou, Benin. The other 2 trainers were pediatric anesthesia practitioners currently enrolled in the training of trainers course, which made them great helpers.

Next step for the team is to continue running the SAFE-Peds courses in other parts of the country. For that, the team is actively recruiting and training trainers to keep the momentum.

The Safer Anesthesia from Education (SAFE) courses aim to improve care through teaching of anesthesia providers around the globe. The SAFE-OB and SAFE-Paeds course have been utilized in many parts of the world. Furthermore the SAFE paradigm aims to train trainers locally to implement a sustainable teaching cycle. https://www.youtube.com/watch?v=t_QebNMh4VA




Rwandan resident experience at the Canadian Anesthesiologists’ Society (CAS) Annual Meeting

Eugene Tuyishime, Department of Anesthesia, Critical Care and Emergency Medicine, University of Rwanda

 During my elective rotation at Dalhousie University, I attended the CAS conference, in Niagara Falls in June 2017. The conference theme was Competence By Design – The Future of Education and Assessment in Anesthesiology – From Residency to Retirement. Participants were exposed to cutting edge anesthesiology research, best practice, and hands-on learning experiences. In addition, there was an opportunity to connect with some of the brightest minds in the profession and to learn of new innovations, research and technology.

I participated in the sessions on current update on cardiovascular risk stratification in non-cardiac surgery, airway management, labor analgesia, education and simulation in anesthesia, and global anesthesia.

I learned that anesthesia practice should have evidence-based practice guidelines. Currently, there are no practice guidelines in Rwanda. After attending the CAS meeting, I am motivated to contribute to a plan to develop guidelines in a Rwandan National Surgical Obstetrical Anesthesia Plan. It is my hope that with guidelines and advocacy, the level of anesthesia practice can be improved, with the goal of achieving the Lancet Commission on Global Surgery indicators for accessible, safe, and affordable surgery and anesthesia by 2030.

In addition to the use of guidelines, I observed the commitment of anesthesiologists to the improvement of resident education, such as the development of competency-based medical education. This approach may be introduced in Rwanda residency program in the near future. Finally, I met with wonderful people in the Canadian Anesthesiologists’ Society International Education Foundation (CASIEF). These people are inspired to contribute to global anesthesia safety.

In the CAS 2017 annual meeting, I was exposed to the recent evidence in anesthesia research and practice, the dedication of anesthesiologists to excellent resident education, and the commitment of CASIEF to improving anesthesia practice in low-income settings. In my context, the Rwanda Society of Anesthesiologists can apply these lessons by developing guidelines of anesthesia practice, supporting resident education, and being more involved in global health activities.