Dr. Livingston’s blog

Saturday, January 7, 2017

preparing for the residents

It’s been a quiet Saturday, as I prepare for a busy month and the arrival of Kitt and Kyle tomorrow afternoon.  Christophe has stocked our fruit and vegetable supply from the local market and bought a selection of Rwandan beer. We’ve started a slight teaching exchange of English for Kinyarwanda. Sadly, my Kinyarwanda vocabulary remains stuck at about 20 words, and even that might be an exaggeration.

Kigali has implemented a program of closing the road between the city centre and the airport one Sunday each month so that people can get more exercise. Great idea! Christophe and I are going to check it out tomorrow morning.

Although there is now wifi in the apartment (yay) it does not seem to be strong enough to post photos. Stay tuned. I’ll do my best to ramp in up when my companions come.












Thursday, January 12, 2017


I first met Paulin in November 2008 when he was chief resident. He showed great potential as a future leader. Today he is program director and acting head of anesthesia. He brings incredible energy to our mutual vision of creating an excellent anesthesia department.

We spent an office day together working on multiple projects: planning clinical and academic teaching for September this year when there will be 30 residents in the program, teacher assignments, simulation curriculum, education for non-physician anesthetists, improving pain management in Rwanda, working for better maternal safety, collaborative research projects and Paulin’s own career path. It was a rich and rewarding discussion. I feel so fortunate to have a friend like Paulin.

Needless to say, we had to fuel this productive day with a little coffee from Bourbon Café.








Monday, January 16, 2017

Rain in Rwanda

From Patty (written on Monday):
There has been no rain in Rwanda for a month but the skies opened today and the rain pelted down on the mental roof of the simulation centre in the middle of academic day. It was acoustically impossible for our class to continue as a whole, so we broke up into group work. The residents worked in pairs to explore problems and solutions to safe anesthesia care in Rwanda.  Fortunately, the rain stopped in time for a rewarding discussion of their ideas.

Kyle did the bulk of our morning teaching.  We had an enthusiastic Jeopardy session, once again.  It was great having Angela and Ruth to help with teaching today.  We ran three afternoon simulation stations, with Angela doing a stellar job at neonatal resuscitation.

From Kyle:

After a busy weekend, it was a bit of a shift to get back to business. Monday is the residents’ academic full day though, so we got up and got ready.

Today’s topic was on hypertensive diseases of pregnancy: mostly preeclampsia and eclampsia, as well as the related HELLP syndrome. A somewhat nuanced topic, it is important to review as these conditions are one of the leading causes of morbidity and mortality in pregnant women. This is particularly true in Subsaharan Africa, where the incidence of hypertension, an important risk factor for this disease, is especially high in women of childbearing age.

We all put a lot of energy into today’s session and were not disappointed, as the residents were generally very well-prepared. We completed a solid review of the diagnosis and management of each condition, made anesthetic plans for several hypothetical cases, and played a predictably rousing game of jeopardy.

We also participated in the residents’ weekly problem rounds and then had a quick lunch meeting with Eugene and Alcade, residents who will be joining us in Halifax for several months later this year. Action items identified included coats, boots, and a primer on how much less terrifying it is to cross a street in Halifax.

In the afternoon we took the residents through several simulation sessions, prominently featuring Patty as a distracted nurse, Kitt as a mom-to-be with a bad headache, and Ruth and Angela using music and other fun to review neonatal resuscitation. I even got to channel one of our PGY-1 sim mentors: “so, how did that scenario make you feel?”

We finished our very full day with a session on needs assessments and advocacy. We took a very simple, issue-based approach to deficiencies the residents have identified in their system, with problem solving and goal-setting to determine solutions. Many of the residents are very motivated to make changes here, and are clearly striving to improve the system in which they hope to someday practice. They definitely face greater challenges learning here than Kitt and I do at home.
















It also rained for the first time since we got here! A torrential downpour for about 20 minutes, and then sun again. I’m not sure it was enough to solidify my increasingly tenuous morning shower privileges… I hope for everyone else’s sake that it does!

Finally, with our work done, we had a quick debrief over tea and a celebratory dinner at Heaven, one of Patty’s favourite restaurants. Tomorrow she and Angela meet with the minister of health, while Kitt and I head back to the hospital and get started on next week’s material. The fun never stops here in Kigali.



Botswana Combined Critical Care Anesthesia Opportunity!

Funded Combined Critical Care Anesthesia opportunity in Botswana. If interested please read and reach out to attached contact.





Beth Israel in Boston has a longstanding partnership with a district hospital in Botswana whereby we fund a full-time internal medicine and full-time Obgyn attending and residents do rotations. I respect the program a lot – they were very careful initially to not go in to “steal data” and publish, and to listen to the local / national agenda. They have now made some incredible strides in medical education and patient care, and are linked into the national MOH planning process. They are just now starting to write up experience and support local research projects.

The IM and OB person on the ground have expressed a desperate need for an ICU physician, as the ICU is well-resourced but not well-staffed. We need someone who will do well personally and clinically, and who can commit a minimum of a year but preferably be open to longer.

I also think its a great opportunity for a global health anesthesiologist who wants to be on the ground. I am committed to supporting from afar as someone who has experience in a similar setting, and I have a curriculum from Rwanda that can be used as desired for the ICU. This position is funded by Beth Israel.


Beth: bethriviello@gmail.com

“Heading back to my second home” says Dr. Livingston

Monday, January 2, 2017

Heading back to my second home

It’s been a nearly perfect January day in Halifax – sun, blue sky, no wind, no ice, and 2 degrees.  The city is relatively quiet, as people squeak out one more day of holiday.
In two days, I will be heading back to Rwanda, my second home, for another month of teaching. My companions are two senior residents, Kitt and Kyle. Amélie, who was with me in January 2015, will join us for a week.  Ruth, with whom I have developed the Teaching and Learning Course for Medical Professionals, will join us to teach the course in Rwanda. It will be lively.
The big gap this year is Michelle, who has made multiple visits to help with the simulation program and nurse education. She needs to take a year off but has made me promise to hug everyone she knows. Rwanda is full of people who love Michelle, so I could be busy.
For years, the anesthesia residency program in Rwanda struggled to recruit candidates but this has changed dramatically in the past two years.  There are now 21 residents in the program.  This is a great success but also daunting. My Rwandan colleagues and I will need to work on logistics for this group and anticipate a possible intake of another 10 residents later this year. A good problem to have!
In addition to classroom and operating room teaching, Kitt, Kyle and I are planning a full program of simulated scenarios for each Monday afternoon. Simulation provides a great chance for the residents apply their skills in real time without risk to patients.
We are looking forward to offering the Essential Pain Management Course in Butare. This practical, multidisciplinary course teaches fundamental skills in pain management.  It has been offered in over 40 countries around the world.
My philosophy is that we should travel with a full teaching toolbox but be prepared to pull out what is needed at the time.  Precise but flexible.
There will be a gap in posts until I arrive in Rwanda on Friday.  Best wishes to everyone. Thank you for all your support.  I look forward to sharing our adventures.


Knowledge is Power
Google predicted the winner of the 2016 US presidential election way before any journalist. They had an heuristic algorithm based on the searches of users of google and social media. I don’t know how it worked but I’m sure it accounted for error, bias, and variability. It would have weighed the good results from the bad. Google has a lot of data and they know how to analyze it for their purposes. They can sift through the good and the bad and rank the information that they gather. The same is true for medical studies. Some will be more reliable and more influential than others. Tomorrow we will have the first Anesthesia Journal Club in Guyana. We will be discussing the : Difficult Airway Society Guidelines for unanticipated difficult intubation and seeing if they apply to the situations here in Guyana.

Almost every physician in this country has a smartphone. The residents rely on them for communication to contact consultants and resources in the hospital. There is no overhead paging system, no front desk with an OR clerk, let alone a phone in the OR. Over the past couple of weeks I have been able to show them how to access medical information that is reliable and peer reviewed. The residents and students are hungry for knowledge and want to practice evidence based medicine that is tailored for their patients. Access to this knowledge is expensive through commercial sites, but if you look hard in the Global Anesthesia sphere you can find free access through sites like the World Federation Societies of Anesthesia, Global Health Delivery and Open Anesthesia. Information on the internet is plentiful but not always reliable or accurate. The goal of the Journal Club is to foster a culture of critical appraisal so these physicians can tailor the best therapies for their patients.

Pillows and blankets for a comfortable sleep
November 13, 2016

A pillow is a small comfort that we take for granted in Canada and we definitely need a blanket to stay warm when we sleep. Sometimes its a luxury in the OR. Well I’m sure they could find them if I asked but it might be an interesting discussion with the hospital CEO: “The visiting doctor says we have to buy pillows and blankets instead of antibiotics and pain medications”.

Why are these small creature comforts so important to have in the OR? The pillow helps position the patients head and neck for endotracheal intubation, lining up the visual axis from the mouth to the larynx. Without good positioning the junior trainee will struggle with the airway and not recognize why. Blankets keep the patients warm which is important for infection control and drug metabolism in the body. My take home message about global health: You don’t need to donate the pillows and blankets to make an impact: teach proper positioning and maneuvers for airway management and thermoregulation.

My first week at Georgetown Public Hospital Corporation is over. It has been a busy yet fulfilling week. I am at the major teaching hospital and referral centre for all of Guyana. The buck stops here for patient care. This is a country with limited resources. The population is not big, about 750,000. From an anesthesiologist’s perspective, there seem to be enough consultants, residents and trainees at the teaching hospital. The rest of the country is a different story but more of that later.

Dr. Alexandra Harvey, the anesthesia residency program director, brought forth a vision to train nurse anesthetists and anesthesiologists in 2008. The first residents will graduate this year. The training is free and the residents have a commitment to provide a number of years of service when they graduate. The residents do a 4 month rotation at McMaster University in their final year before sitting for their exams and there will be an external Canadian examiner. My role with CASIEF (Canadian Anesthesia Society International Education Foundation) is mentor and teach these residents the skills they need to provide safe anesthesia with the resources they have.

A long with clinical teaching in the OR around specific anesthesia issues, I have had the privilege of using new teaching modules developed for University of Ottawa anesthesia residents in our new competency based residency program. The modules are based around a clinical scenario. Instead of a dry talk at the end of the day, case based learning engages the residents and provides a practical context for the information the acquire and consolidate.

The concepts that they learn plus or minus the pillow will help them, for as William Shakespeare said in Hamlet: “For some must watch, while some must sleep So runs the world away”

The Journey Begins: By Dr. Nikhil Rastogi

I’ve had a passion for global health and outreach since an elective in medical school over 30 years ago. Since then I have come across ethical and social issues such as accessibility to care, sustainability, and quality of care disparities. Those challenges still persist but are navigable.

The bottom line is that I believe that safe surgical and anesthesia care is a basic human right. The way to get there is through partnerships. With this in mind I am excited to start out on my anesthesia education adventure. My national organization, the Canadian Anesthesia Society has long had an International Education Foundation: CASIEF, that has a successful track record in countries such as Nepal, Rwanda, Ethiopia. They are sending me on a newly established partnership with the Georgetown Public Hospital Corporation, the main teaching hospital in Guyana. Guyana has only a handful of anesthesiologists and has recently established a residency program. Our new partnership has already seen a resident come for training in Canada. Weekly teaching session are broadcast for didactic teaching. My role will be to mentor and teach in their operating rooms. But first there will be so much to learn.

Every medical system is complex and has unwritten rules and hierarchies so this will take some getting used to.


We want to announce that Drs. Walton & Rastogi are one of the first volunteers with CASIEF in Guyana. We are extremely excited about the future of this partnership. Pease follow their experience on our Guyana blog.