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.


Ethiopia blog

An anesthesiology resident in Ethiopia:  My experience at Tikur Anbessa (Black Lion) Hospital

Karim Mohamed PGY5 

In April 2017, I departed on a 4-week teaching elective with the Toronto Addis Ababa Academic Collaboration (TAAAC) and the Canadian Anesthesiologists’ Society International Education Foundation (CAS IEF).  In this report, I hope to describe my time in this beautiful country, the impact it had on my life, and what I hope for the future of the collaboration.


Since its inception in 1996 CAS IEF has been active in improving and making available safe anesthesia in low and middle-income countries (LMIC).  The philosophy of the organization has been to develop self-sustaining programs that are suitable to a country’s needs.  Through collaborations with educational institutions, governmental agencies, and anesthesia providers, the organization has been successful in supporting anesthesia initiatives in Guyana, Rwanda, Zambia, Burkina Faso, and Ethiopia.

The fact of the matter is that five billion (yes, five BILLION!) people lack access to safe surgical care.  This results in more people succumbing to surgical disease annually than HIV, TB, and malaria combined!  CAS IEF realizes the need for safe and appropriate anesthesia services in the provision of these surgeries. CAS IEF has put together a skilled, and experienced board of trustees working to meet the organization’s objective.

About Ethiopia

Ethiopia is a country with a fascinating history and proud people.  Land-locked, nestled in the Horn of Africa, Ethiopia has some incredible archeological, historical, and cultural sights.  With a population of nearly 100 million, it is the most populous land-locked country in the world, and second most populous in Africa.  Many archeologists believe that some of the first modern humans originated in Ethiopia, before making their way to the Middle east.

The country has a complex religious history with approximately two-thirds of its inhabitants being Christian and a large proportion of remainder being Muslim.  Religious influences can be seen throughout the country and generally people of both faiths live in peace.

Ethiopia has largely been a monarchy for most of it’s history.  Ethiopian’s are proud to announce that it is the only African nation to defeat a colonial power during the 19th-century, and some claim it has never truly been under outside control.  In 1974, the government fell to a military communist group backed by the Soviet Union. They remained in power until the revolution of 1991 when the current governmental party took control, and has maintained it’s position since.

Ethiopia’s economy is largely supported by agricultural exports, the most important of which is coffee.  The coffee bean originates from Ethiopia, and it is an important part of the country’s culture, and economic identity.  The next time you are enjoying that brew in the lounge, remember that Ethiopia is responsible for introducing the world to this delicious drink!

My experience

I was lucky enough to share my experience in Ethiopia with Dr. Sophia Lane, a fourth-year anesthesiology resident at the University of Toronto.  There were two attending physicians who were part of the teaching mission, Dr. Neil Adhikari, a staff critical care physician at Sunnybrook Hospital in Toronto; and Dr. Jason McVicar, a staff Anesthesiologist at The Ottawa Hospital.

Having spent some time in Africa before, I thought I knew what to expect when I first arrived in Addis, however I was in for quite a surprise.  The city itself was extremely busy, there were people everywhere, and the air pollution was bordering on intolerable.  I remember thinking that the building architecture clearly had a Soviet influence, likely from the communist era of the 70s.  It was warm, but not hot.  Addis is quite high in elevation, and as there are no large bodies of water around, humidity was not really an issue.  Addis Ababa University had put us up at a government hotel called The Ghion in the heart of downtown Addis. The hotel has a very prominent place in local culture, with many weddings being held there in the summer.

The hospital was a brisk, pick-pocket ridden, 20-minute walk away.  Attempting to weave around morning traffic, avoiding the random 10-foot holes in the ground; appropriately named “death-holes” by Sophia, and protecting any valuables was our morning routine.  The hospital itself was associated with the University and was quite large with at least three different buildings.  A quick tour revealed that there was an MRI, CT, a very busy ER, OB ward, a rehab centre, and a separate building for administration and lecture halls.  Every morning the anesthesiology group would meet for Morning Report.  Here we would hear about any cases performed overnight, pre-anesthetic evaluations for the cases of the day, and a brief handover of the ICU.  There were many rotating residents from orthopedics, general surgery, and neurosurgery.  After Morning Report, the residents would disperse to their respective assignments (OR or ICU), and then return after rounds for teaching 3 days of the week.

Our first two weeks were in the ICU with Dr. Adhikari.  The ICU was split into medical and surgical. The anesthesiologists are in charge of the surgical ICU as well as performing any invasive lines, or airway management on the medical side.  For most of the two weeks, there were approximately 8 patients admitted to the surgical ICU, with 6 or them being ventilated.  It became immediately apparent that resources were going to be an issue, as we expected.  Some examples of resource deficiencies that were first encountered in the ICU include:  little to no opioid or sedation options available in the hospital, suction machines were shared among patients and catheters were often hard to come by, ventilators did not have humified circuits, IV cannulas were in short supply, and there were no infusion pumps.  With all that being said, I must say that the medical staff were very good at working with what they had.  Providing care in a setting with an abundance of resources is something we take for granted back here in Canada.  The residents were very creative in how they allocated resources, while still providing the best patient care possible.

The patient population in Ethiopia was vastly different from what we normally see in Canada.  Admitting a patient over 55 was extremely rare, probably because the life expectancy is 58 years.  Unfortunately, by the time patients presented to hospital, they were usually extremely unwell. A large number of obstetric patients were admitted with severe eclampsia or post-partum hemorrhage due to the lack of ante-natal care.  During our time in ICU we observed cases that we only read about in Canada; and the distribution of chronic disease to acute was excessively biased to the later.  Overall during our time in the ICU, there were many areas of improvement that we identified and attempted to address during our academic lecture sessions.  Some of the teaching topics included:  appropriate ventilation weaning strategies, sedation and analgesia in the ICU, oxygen delivery devices, a review of research methodology in the ICU, and a brief guide on the use of ultrasound for central line insertion.

After the two weeks in the ICU, we were joined by Dr. Jason McVicar, and we transitioned from the ICU to the OR.  There were 6 ORs in the main building, and an additional three in a separate building that were dedicated to orthopedic surgery.  The ORs and ICU were staffed by 4 staff anesthesiologists, and so they were spread very thin.  Most of the anesthesia care was provided by nurse anesthetists, along with the occasional junior resident assigned to their room.  Junior residents received clinical teaching from the nurse anesthetists; while the academic classroom sessions were run by other residents and moderated by a staff anesthesiologist.

The academic teaching sessions that were scheduled ranged in topics from basic airway management, to the peri-operative use of beta-blockers in patients.  Many of the lectures utilized Powerpoint, and were sourced from reference texts including Miller and Barash.  Additional resources included the WFSA tutorials of the week, and other online lecture presentations.  During our stay, we supplemented many of the already scheduled talks with presentations that we felt would be relevant and beneficial to the practice we witnessed.  The residents were very keen to learn, their knowledge base in medicine was very impressive.

The residents were very shy the first few sessions, and contrary to what we observe in Ottawa, they were very reluctant to participate in any interactive dialogue during lectures.  I suspect this is because they were comfortable with a didactic style of teaching, and it came to them as a little bit of a surprise that we wanted them involved.  A few days in, that had changed and they were eager to provide answers to any discussion questions.  Some of the topics that we discussed included:  acid-base analysis, anesthesia machine check, basics of the anesthesia machine, ATLS in hemorrhagic shock, basic ECG interpretation, comparison of general and regional anesthesia, a primer on opioids, spinal anesthesia, and a number of oral-exam style trouble rounds targeted to the senior residents.

What I learnt from the academic sessions was that the residents were eager for knowledge, and often what they lacked was an expert being able to prepare complex material into a format that is understandable and engaging.  As hard as it was to prepare all the lectures in the evenings, it was well worth the look on the residents faces when they truly learned something.  An example of this was during our anesthesia machine talk, the residents were surprised to hear that the APL valve did not need to be closed once the machine was switched to the mechanical ventilator.  They were truly convinced through dogma that it needed to be closed for the ventilator to work.  When we explained the circuit diagrams to them, and it became clear that the APL had no impact on the ventilator, the residents were keen to show the anesthetists in the OR the next day.  Something that is not easy to read about in a textbook, that becomes routine practice, really does need an expert to dispel the dogma.

The time that we were not in academic teaching sessions in the classroom, we spent observing and teaching in the OR.  Often Sophia and I would go into a room each and provide teaching to junior residents as well as to the anesthetists during cases.  Anesthesia practice varied greatly in the ORs.  Many times, patients were genuinely in danger of serious complications due to the practice of the anesthetist, or anesthesiologist, and it was very difficult to not step in immediately and assume care.  We really had to try to orient the provider to fix the situation and offer some teaching.  Many of the surgeries were performed under neuraxial technique, although the failure rate of spinals was quite high.  The most striking area for improvement was summed up well by Dr. McVicar during our many debriefs with the residents.  Despite the lack of resources, the largest improvement that could be made in their practice was being prepared for unanticipated events.  Anesthetic machine checks were never completed, and suction was not available during a couple of aspiration episodes.  Oxygen to the anesthesia machine was provided via large pressurized tank, and once during the OR, the oxygen tank depleted and it took 10 minutes to have it changed. During that time, there was no way to provide volatile anesthesia or mechanically ventilate the patient, IV boluses of ketamine and propofol were used until the tank could be changed.  Simply checking the tank in the morning would have eliminated this potentially dangerous event.

The surgical safety checklist was treated as a chore, and something that just needed to be completed; it was not used as a conversation between the entire team.  Often a nurse would just pull a resident to the side and complete it between each other in the corner without anyone else listening.  One consequence of this was a spinal anesthetic being administered for a hip surgery, only to later discover that the surgery was planned for 6 hours.  Despite all this, the residents were very open to listening to our feedback and were engaged in debrief sessions that we had after each case.  I was happy to see that the first-year residents had checked their machines everyday after we had given the machine check lecture.

On call, there was no staff coverage and second and third year residents were often expected to manage the 6-week-old infant with ischemic gut going for a laparotomy. Inevitably a number of these cases did not go well, resulting in patient mortality or morbidity.  There was little to no realization that staff should be available for complex cases such as this overnight.

Overall, I must say that the experience in Ethiopia was eye-opening and very humbling.  The people were incredibly welcoming, and appreciative of any teaching that we were willing to provide.  I do hope that we left some knowledge with the residents that will shape their future practice.  The fact of the matter is that there is a lot of room for improvement.  Patient safety initiatives, quality improvement, medical education, and communication are all terms that we take for granted here in Canada; but my short time there made me realise how very important these are to the practice of anesthesiology.  CAS IEF will need a strong continued presence to develop a core of well trained anesthesiologists in Ethiopia.

I went to Ethiopia hoping to determine if a future in Global Health was indeed for me.  My time there confirmed that it is.  I additionally wanted to leave an impression on some of the residents there, and to become a contact with who they could communicate.  Overall my time in Ethiopia will forever change my outlook on medical education.  I have come to realise that not having a new endotracheal tube for every patient, or sevoflurane, or even opioids, usually is not the cause of a poor outcome.  However, not having a competent, well trained anesthesia care provider often is.  This is what I hope future CAS IEF missions continue to focus on, and I hope to be there when I can to support this lofty, but ever important goal.


Figure 1:  The food was plentiful and delicious.  The flatbread, called Injera is used to pick up the variety of vegetarian and meat thick curries.  Remember to only use your right hand while eating!


Figure 2:  Dr. Jason McVicar pointing out relevant anatomy for an ultrasound guided supraclavicular block with the first year residents, this picture was taken just minutes before the power went out!


Figure 3:  Lalibela is a town in northern Ethiopia, best known for its distinctive rock-cut churches.  The pictured church here dates back to the 12th century.


Figure 4:  A stunning view from a-top a hill in Lalibela.


Figure 5:  The first year residents with Dr. Jason McVicar and Dr. Sophia Lane on our last day.