Dr. Livingston returns to Rwanda (5th edition)

Resident Academic Day: Humility and Obstetric Hemorrhage – Tuesday, January 22, 2019 (from Patty)

Yesterday we completed our final Academic Day with the Rwandan residents here in Kigali. It’s been a tremendous honour to spend time with this passionate group of people, who despite incredible odds, are persevering at delivering high quality anesthesia care. I’ve never met a more engaged, enthusiastic group during a teaching session, and our various approaches to teaching were heartily welcomed. A highlight is always Anesthesia Jeopardy, where trivia relevant to the week’s teaching is covered, complete with cheers and (many!) jeers from the opposing team. It’s an understatement to say that they residents “really” get into it.

This week’s topic was obstetric hemorrhage – an important topic to cover in a country where maternal mortality remains at 210/100,000 live births (compared to just 7 in Canada), and postpartum hemorrhage (PPH) remains a significant cause of morbidity and mortality. Throughout my time here, I’ve striven to understand some of the causes at the heart of the issue.

Following medical school, graduates work as General Practitioners (GPs) in rural hospitals; there, they are responsible for all manner of obstetric care, including Caesarian sections, amongst other routine medical and surgical care. Formally trained Obstetricians are not readily available (there is a severe shortage across the country) and when these GPs run into issues with PPH or massive obstetric hemorrhage, they are often left to deal on their own. Add to that the incredibly limited supply of blood available for transfusion and stock-outs of common medications used to treat hemorrhage, and you have a perfect storm of factors leading to unnecessary loss of life.

In Kigali and Butare, two larger cities where the majority of anesthesia residents in Rwanda train, doctors receive patients transferred in from these rural District Hospitals for further management. Often these patients are still actively bleeding and are in a critical state. Yesterday, one resident discussed at length how she had spent much of the day and night last week dealing with one massive obstetric hemorrhage case after the next – something that would be unheard of in Canada. The cases that the resident described represent some of the worst PPH a Western physician may see in their careers, and here we have residents trying to manage these patients in challenging, under-resourced settings with only limited backup.

The irony was not lost on me that our Academic Day was spent teaching residents about a topic they have far more experience in dealing with than I ever will (hopefully!). What’s amazing is that the group was so interested in hearing about “my own” experiences and what I would do in their situation – coming from a major tertiary care hospital in downtown Toronto, seemingly endless resources and assistance is available when I need it. That’s not, nor will it likely be the case here anytime soon. The more time I spend in Rwanda, the more I realize how important it is to tailor our teaching to the clinical context in which we are working. While there may be gold standard treatments and buckets of evidence demonstrating one approach over another, we must think creatively how that may apply in different environments. At the end of the day, I couldn’t help but think that it was truly I that received the bulk of the education.

Hiking Nyungwe Forest – Wednesday, January 23, 2019 (from Patty)

From our time in Kigali, to our visits throughout the countryside, and the countless small hamlets whose jostling for space earns Rwanda the title of Africa’s most densely populated country, it is clear that this place is old. Rwanda’s roots run deep. The people, the language, the culture have shaped and been shaped by this place for time beyond measure. As a Canadian of European descent, the sentiment is almost foreign. This sense of agelessness thrums strongest in Nyungwe.

Nyungwe National Forest covers nearly 1,000 square kilometres in Rwanda’s south west. It encompasses the largest expanse of montane rainforest in Africa and may well be Africa’s oldest rainforest. It is the source of both the Nile and Congo river and provides Rwanda with more than 80% of its freshwater. It is home to 13 primate species and 300 species of bird, many found no where else. Its importance can’t be overstated.

Needless the say, we were very excited to arrive and explore! We arrived late at night, driving a winding road through utter darkness and at times torrential rain. Feeling small in the face of such a primordial expanse was a feeling that would only grow over our time in Nyungwe. The next morning dawned bright and clear as we set out on a 10km hike. Amidst foggy vistas were heard the distant calls of one of the resident chimpanzee troupes. We had the chance to walk amongst waterfalls, towering ferns, and mahogany forests. The photos below hardly do the experience justice. The day finished with yet more torrential rain but it was no hardship as we were by then cosily settled into our guest lodge for the evening.

Our second day in Nyungwe saw us once again trekking into the wilderness but this time with a specific goal in mind – a sighting of the rare black and white colobus monkey. As was the theme of the entire weekend, we were not disappointed. We saw a troupe of nearly 40 of the monkeys within short measure! Amongst them also were at least two newborns, completely white unlike their mature black and white coloured counterparts.

Nyungwe is vast. Clearly our own experiences, incredible though they were, barely scratched the surface of this ancient place. Rwanda has made the preservation and protection of this place a high priority, that its woods and their inhabitants be protected from destructive incursion. Long may it stay that way.

People Moving – Wednesday, January 23, 2019 (from Patty)

When I first came to Rwanda in 2008, there were few private cars. Most roads were dirt, there were few sidewalks, no street lights and pedestrians had to navigate their way over mounds and around pits. Now much of Kigali is paved with sidewalks and good street lighting. Private car ownership is growing, with a resultant deterioration in air quality.

But Rwanda is always innovating. I read in the local newspaper today of plans to install a cable-car network in Kigali. The study designers argue this will move people efficiently and will reduce greenhouse emissions, noise pollution and collisions. Furthermore, the study recommends transportation corridors for pedestrians and cyclists. Wow! This visionary thinking is what is helping transform a tiny landlocked African country into a significant regional player. Could we please have efficient public transportation and corridors for pedestrians and cyclists in Halifax?

Meanwhile, we make do with other transport options.

Excuse me. Come again? – Thursday, January 24, 2019 (from Jon)

Being a geographically small country, Rwanda is linguistically (and culturally) very homogeneous. Day to day most Rwandans speak Kinyarwanda, but due to Rwanda’s French colonial past, most Rwandans grew up also speaking French. Elementary school instruction for most of the country’s independent history was in French. However, in 2009 Rwanda intentionally became a member of the commonwealth and the official academic language became English in schools and colleges. This means that most Rwandans are fluent in Kinyarwanda, and at a somewhat lesser extend English and French.

That being said, many of the difficulties in communication are most complicated than simple linguistic misunderstanding. Let me give you a few examples.

While staying at the Gisakura guest house, we decided to plan the rest of the weekend and upcoming week. I turned on my computer and noticed a Gisakura wifi network. I walked to the desk to ask for the password.
Somewhat timidly I ask, “Excuse me, can you tell me the wifi password?”
The desk clerk replies, “I don’t think the wifi is working very well right now…” looking down at the unplugged wifi router sitting on her desk.
I, not realizing this – in retrospect very obvious non-verbal que – persist. “Well, I see the wifi network on my computer. Can you give me the password to try?”
The clerk again looks at the very obviously unplugged router with a very long pause and a slightly confused look on her face… then reaches for a piece of paper and writes down the password – I imagine deciding that it is just easier to avoid conflict by quietly leaving with the router for the night rather than to argue with this somewhat slow muzungu. By the time I realized that the password supplied was not going to solve the problem, I also decide that just using a cellular hotspot was easier than arguing about the wifi.

The following morning, we enter the Nyungwe park office to be greeted by a friendly park ranger. “Good morning. You are welcome!” he says gesturing to a single chair. I look at the chair and the other three people with me and decide to stand. We all shake hands and exchange pleasantries. Now with all four of us standing near the desk he more emphatically says, “Please, have a seat” again gesturing to the single chair. I decide he really wants at least one of us to sit down so I sit. Proudly he explains “We have many activities in the park: monkey tracking, hikes, nature walks, the waterfall hike, the canopy trail.” Given that we came solidly unprepared and really open to any outdoor park related activity, we attempt to clarify our options.
Chris offers “I hear there are some packages for the trails. Is that true?”
“Yes, sir. You can enjoy many trails with the package. There is a package for short trails and a package for long trails.” A long pause clears the fresh mountain air.
Chris tries “which trails are included in the package.”
The ranger helpful says “the waterfall trail leaves from here at 9am.”
“So, the waterfall hike is included?”
“Sorry, no, sir. The waterfall hike is an additional fee.”
“Oh” Long pause while recalculating… “So, can we do the waterfall hike in the morning and then go on some other hikes in the afternoon?”
“Sorry, sorry. As you can see (gesturing to his watch reading 9am on the dot) you have missed the waterfall hike today”
Being that we had no firm plan, we were undaunted at this point. “Ok, that’s fine.”
“Thank you, sir.” Smiling
“Can we go monkey tracking?”
“Very good. We have 13 different species of monkeys here in the park!”
I break in at this point. “Great! How many Colobus monkeys are there?”
The guard looks up and appears to be counting in his head, responding after some time “37.”
“Ok, when can we see the colobus monkeys?”
“Tracking for colobus leaves 8, 10, (thoughtful pause) 1 and 3.”
“Great. Can we go at 10?”
“Yes, sir. May I please have your passports.”
We hand them over and begin to chat while he carefully writes down our information. Then we he is almost done registering us, he says “The ranger tells me the colobus monkeys in the trees now. They may be somehow difficult to see now. Maybe it’s better not to go now”
Now admitted becoming disappointed and somewhat comedically frustrated, “Ok, fine. Can we go on a nature hike?”
“No problem, sir. They leave from the Uwinka office. You can register for them there.”
“They can’t use the information you have here”
“No sir”
Now trying forcefully to remain upbeat, “Ok. Thank you for your help. Do they accept visa cards at the Uwinka office?”
“Yes, sir. Only visa.”
Upon arriving at the Uwinka office (13 windy mountain road kilometers away), the ranger there informs us that they only take cash.

This kind of miscommunication and misunderstanding is endemic in global health work either in or outside of the operating room. It plagues our ability to be effective and the fault does not clearly sit with one person or group of people. It can be at times comical or mildly frustrating, but at worst it can lead to conflict, destruction of long fostered relationships and even medical error resulting in harm. The most concerning aspect is that Canadian and (even more so) Rwandan culture tends toward being polite, overlooking perceived minor missteps. This means that miscommunication can go unnoticed until too late. The answer is likely that miscommunication decreases gradually as we understand each other’s culture, the words we use, our verbal ticks, and we strength our relationships between people. We can improve things but miscommunication will remain an ever present reality of working cross culturally.

Visit Dr. Livingston’s blog at < https://simcentreopening.blogspot.com/ > to see the original posts, including photos.

Dr. Livingston returns to Rwanda (4th edition)

First time at CHUK and the Sim Center – Friday, January 18, 2019 (from Mary)

Rwanda has taken possession of me. Until last Saturday night I had never set foot on African soil. I knew in my heart that I would come here one day, this was made a certainty when, several years ago, Gaston, with his guileless look, said “Mary, when are you coming to Rwanda?” My response, at the time was “When you and Patty can use me best, I will come”.

As it turns out the first International Rwandan Pain Conference was the occasion chosen. I will tell you about that wildly successful event in the next “from Mary” blog. First I want to share some stories from CHUK and the Sim Centre. I was delighted to join the team (on this occasion Patty, Jon, Stephen and Chris) for Monday teaching at the Sim Center. It was a privilege to meet the residents and to discuss difficult cases under the avocado tree outside of the Sim center. The cases were complex but the tools are here to manage them. There are not as many drug options in Rwanda but there is a basic pharmaceutical suite (acetaminophen, morphine, tramadol, amitriptyline, gabapentin, ketamine and lidocaine) which used creatively can assist with most problems. It was interesting to me to learn that serious burn injuries in babies and cesarian section pain are big issues here. It was especially fun to co-lead with Patty, an opportunity we do not get when in Canada.

I was very impressed when Magnus, the psychologist, arrived under the avocado tree. Here I have to digress for a minute to tell you that in the morning I was very fortunate to meet Dr. Lisine Tuyisenge, consultant pediatrician and Director of all Medical services at CHUK (pronounced “say-ash-u-ka”) (University Teaching Hospital Kigali). On this particular day Dr. Lisine was also serving in an acting capacity for her boss so there were people bringing in important looking documents for her review and sign as we met. Lisine is the local lead for the Microresearch project that our very own Dr.Noni MacDonald and collaborators are facilitating in Eastern Africa. Lisine connected me with Magnus as he is on the pain committee at CHUK and we are aiming to get pain teams involved with the micro research initiative (www.microresearch.ca) which is all about helping develop research projects to find sustainable solutions for local health care problems. Lisine sent Magnus over to the Sim Center and as he strode up the hill to join us under the avocado tree all the residents reached out to shake his hand and greet him warmly and he greeted them all by name in return. After Magnus left I asked the residents how they all knew Magnus so well. I was curious because, in Canada, the Anesthesia residents do not necessarily know the psychologists. They said that Magnus did a lot of work with them in the ICU. I thought Psychologists in the ICU! … how wonderful, I said Canada has a lot to learn from Rwanda! Spoiler alert: this is not the only thing we can learn from Rwanda.

Meanwhile, inside the Sim centre it was fun to see Jon lying on the stretcher with one of the trainees using the ultrasound (there were 4 working ultrasound machines!) to identify what I assume were vascular and neural structures in Jon’s axilla. Jon with head turned toward the monitor was instructing and acting as patient all at the same time, well done Jon! Stephen did a great job summing things up for the group and commending them for their hard work. Chris, who is also here for the first time, from Toronto, was an integral member of the team and it all came together as if this crew had worked together a hundred times. The residents were engaged, enthusiastic and the place was full of positive energy. I was impressed to see this Sim Center that I had heard so much about and so proud of Patty and the team. We also had the chance to meet Claudine one of the residents who will be coming to Halifax soon.

If I could share with you… – Friday, January 18, 2019 (from Patty)

We can send words and photos but I would also send you:

  • the smell of fertile earth mixed with aromas of eucalyptus trees
  • gentle breezes through leafy Kigali
  • the taste of a perfectly ripe avocado, mango, pineapple, banana, passion fruit
  • strong African gingery tea when one’s caffeine levels have reached rock bottom
  • Africancanadianization, that wonderful phrase developed by Paulin that speaks to the magic that happens when the best of our Rwandan and Canadian cultures merge
  • the lightbulb moments when learners understand
  • the smiles, always the smiles
  • friendship, is it ever this good?
  • cinnamon ice cream at Inzozi Nziza
  • green terraced hills with misty mountains beyond

I send you this and more.

Zero Pain and ice cream – Friday, January 18, 2019 (from Mary)

We had a beautiful 3 hour drive across Southwest Rwanda to Butare where the conference took place. We were pleasantly surprised that our accommodation at the Maison Sifa was situated on a hillside with an incredible view and was within a 10-minute walk to the conference venue. The word “walk” does not do the experience justice. It was a walk through gardens and sunflower fields with European style stone walls covered with flowers and cobblestone streets with birds singing all around and yes this was in the middle of deepest Africa, not that far from the origin of the Nile which Chris, Stephen and Jon may find this coming weekend.

Our first stop after we checked in to our Mansion (whoops did I say Mansion, I meant to say Maison) was to have lunch at one of Patty’s favorite spots the Inzozi Nziza, a cooperative run by women. Here we met up with Dave who had been on site for a week helping to get things organized. “Lunch” does not capture the experience. We ordered Tacos with avocados (some with egg). What we received were full plate sized scrumptious, thick, slightly crusty crepes with super tasty avocado filling spilling out onto the plate, just straight up slightly salted avocado mashup. Rwandan avocados are the best!

After lunch we headed to CHUB (“Say-ash-u-bay”) the University teaching hospital of Butare. Here we met Wilson who took us to the pediatrics and general surgery wards and showed us the measures of pain posters on the walls of these units. They included the faces of pain scales along with further detail in a very user-friendly format. Most importantly these posters were prominently displayed and are guiding practice.

Dave then led us to the potential site of a future Sim Center to be located at CHUB. En route we were entertained by a very playful group of monkeys. Of course us Mzungus all stopped to take photos. The possible site for the Sim Center has definite potential. After our tour we all agreed an ice cream stop back at Inzozi Nziza was needed. After some coffee ice cream with cookies crumbled on top (for photo of this delicious treat see Patty’s earlier blog entry) several of us went to the museum to learn about the history of Rwandan culture, farming and beekeeping, housing and traditions. I was amazed to see how the bee hives actually look like long skinny baskets, hung in a sideways fashion. Rwandan honey is excellent, it is slightly darker and thicker and more flavorful than Canadian honey. I have been testing a lot of it.

The First International Rwandan Pain Conference 2019 – Saturday, January 19, 2019 (from Mary)

Gaston and the conference organizing committee had done such a great job of getting the word out that 250 people registered and the conference had to be moved to a larger venue. Health care professionals from across the nation were present and it was an interprofessional mix. There was a participant from Uganda and our very own Dr. Rediet was there from Ethiopia. Rediet joined our group in Kigali and we have adopted her. Rediet is an amazing young anesthesiologist who works at the main teaching hospital in Addis Ababa and Patty and some of the team will be joining Rediet in Addis to teach the VAST course after this conference. Rediet has boundless energy, a full time anesthesia practice, 3 children and a wonderful vision for improving the management of pain in Ethiopia. Patty and I are already scheming ways to get Rediet to Halifax for a preceptorship. The Anesthesia Department Head at CHUB, Dr. Theogene was one of the speakers and stayed throughout the conference. The Director General of CHUB and a representative from the Ministry of Health were there as well. In other words this conference had the support of decision makers at all levels. The representative from the Ministry stayed for the entire conference!

The participants were very engaged. I was especially impressed when the groups at my workshop on Pain Research 101 came up with 25 excellent research questions within 30 minutes. Our 4 group facilitators Eugene, Joseph, Stephen and Chris, all recruited with little or no notice, did an excellent job. When a sudden downpour made it almost impossible to hear each other the groups just moved in closer, almost touching heads like a rugby scrum. Our goal was to interest participants in sending a pain research team to the next micro-research workshop and there were at least 20 who indicated they would be interested!

Gaston, who had sprained his ankle just this week went from crutches when he met us at Inzozi Nziza on Tuesday afternoon to beautiful Italian shoes with no crutches on Thursday morning and barely a limp. Gaston was the consummate host. It was a delight for me to see the transformation from trainee to inspiring leader, articulate and elegant. I have to say that I had a similar feeling watching Jon who did excellent presentations on chronic post-surgical pain and regional analgesia! Somehow from his small carry-on luggage emerged a perfectly pressed suit and 2 different business shirts. Rwandan men dress for the occasion in beautiful suits, shirts and ties and Jon did us proud. I had the chance to meet many of the participants and in every case they were optimistic and enthusiastic for change and inspired to bring what they had learned back to their own communities.

But I can’t forget the medical students. The medical students were with us for the entire 2 days of the conference. They took who took care of the registration desk and anything else needed. They were so great. The women even wore some traditional dress and all together they were quite sensational (photo below).

The second International Rwandan Pain conference is already being planned and I have no doubt that momentum will continue to build. Congratulations on a wildly successful event to Gaston and all involved !!

Visit Dr. Livingston’s blog at < https://simcentreopening.blogspot.com/ > to see the original posts, including photos.

Dr. Livingston returns to Rwanda (3rd edition)

Connections – Wednesday, January 16, 2019 (from Patty)

The best part of global health work is bringing likeminded people together. Then the magic happens. Rediet, an Ethiopian anesthesiologist, has come to learn about how Gaston set up the effective pain management program in Butare. She is hoping to implement a similar program in Addis Abba. Mary, pain specialist from Halifax, has been supporting Gaston for years and now she has bonded with Rediet. It is so rewarding to be part of this exciting network.

Gaston and the Butare team have done a marvellous job of organizing the first pain conference in Rwanda. There are 230 people attending – a mixed group of health professionals from around Rwanda (plus some visiting Canadians and Rediet from Ethiopia).

We were warmly welcomed by medical students in traditional Rwandan dress. Gaston had prepared beautiful conference packages for the attendees.

We heard a range of perspectives today with a good discussion about barriers to pain management in this context. One I hadn’t anticipated was a religious view that suffering pain is God’s will. I gave two short presentations with the key messages being that pain is complex, touches many aspects of a person’s being and treatments must be comprehensive. I encouraged everyone to remember non-pharmacologic options (working with patient expectations, listening, distraction for kids, physical modalities etc.).

Jon co-taught a regional anesthesia workshop with Alain, a Rwandan resident and expert in regional anesthesia. It was a pleasure to see how Alain has matured into the role of confident and skillful teacher.

At one time, anesthesia was the least desirable specialty. Alain was recently on the selection committee for new anesthesia residents. The tides have turned and now they pick the best. Indeed, they were not able to offer places to many of the applicants. This is truly a success story.

We have been busy working but found time yesterday to visit one of my favourite sandwich shops, Inzozi Nziza, run by a women’s drumming cooperative. Superb cinnamon ice cream with cookie crumbles was a hit with our team.

The pain conference continues tomorrow and then we have a VAST Butare refresher course. I hope we can squeeze in one more visit to Inzozi Nziza.

Suffering through pain in Rwanda – Wednesday, January 16, 2019 (from Chris)

The first day of the inaugural Rwandan “Zero Pain Conference” kicked off this morning in the beautiful town of Butare, nearly 3 hours drive from Kigali. The two day conference brings together MDs, non-physician anesthetists, physiotherapists, psychologists, researchers and many others interested in pain management. Delegates will have the opportunity to hear from experts in the field of pain medicine, and learn about novel ways to tackle pain both in and out of hospital, with the goal of reaching a “Zero Pain” Rwandan state – a lofty goal, but one that may benefit thousands while striving to reach it.

Since arriving here last week I’ve heard many times that Rwandans are expected to suffer through pain – whether that be labour and child birth, post-surgical, traumatic, or chronic type pain. The relationship to pain here is unlike any that I have experienced elsewhere. Many feel that pain is something that is meant to be endured, and that in time this may actually lead oneself to become stronger spiritually, physically and psychologically. Many Rwandans are deeply religious and feel that suffering through pain may allow them to become closer to faith. As such, most patients in hospital here do not complain of pain, and would not think to speak with their healthcare team if they felt that the pain regime prescribed to them was inadequate. Chronic pain, in particular, is not a well-known nor discussed topic, and there are currently only fledging programs hoping to change this.

Access to medications to treat pain are limited by stock-outs, and outpatients who must purchase their only prescriptions often lack the funds to do so. Fentanyl, morphine and ketamine are *usually* available, but these medications are not frequently prescribed on patient discharge, leaving post-surgical patients with limited options to manage their pain upon returning home. It is clear that stigma still exists around the use of these medications for pain management, and given the lack of multimodel analgesia options available, patients are not just accepting of suffering, but are in fact forced to suffer.

The concept of opioid addiction is complex, and sometimes poorly understood by patients and even their healthcare providers around the world, and that is no different here in Rwanda. Throughout this mornings discussions, the myths around opioid dependence, tolerance and addiction have begun to be broken down. Moving forward, patients and their doctors need to understand that one not need suffer in agony from acute pain purely to avoid the small possibility of dependence or tolerance. Opioids should not be feared, particularly if other options continue to be so limited. Frequent assessment and iterative treatment of pain is essential to ensure that patients do not suffer needlessly, and to prevent the development of chronic post-surgical and post-traumatic pain.

With the growing community of pain practitioners here in Rwanda, this country is set up to drastically alter the Rwanda experience (and indeed expectation) of pain and suffering. In discussions with the conference delegates today, it’s clear that a wave of change is upon the country – more and more healthcare workers are interested in learning about the pathophysiology, pharmacologic, and importantly non-pharmacologic ways to treat pain. We must continue to support these efforts moving forward, and while we may never see a Rwanda with zero pain, we can certainly strive for amelioration of the suffering that is so pervasive today.

Rwandan Pain Conference: From need to opportunity – Thursday, January 17, 2019 (from Stephen)

This week finds our team in the beautiful Butare (Huye). Long the academic hub of the country, the city’s highland setting provides for cooler breezes and more temperate weather than frenetic Kigali. The contemplative weather plays welcome host to this week’s latest adventure: the first ever international pain conference held in Rwanda.

Another achievement in the long collaboration between CASIEF and the Rwandan anaesthesia residency programme, the ZeroPain conference has been organized in its entirety through local expertise. Pain experts among our team, Drs. Mary, Patty, and Jon, stand as equals amongst other local and international invitees to deliver locally tailored content and solicit ideas on future research needs. ZeroPain is truly a coming of age for the Butare Pain Team and their ability to chart their own course as they set out to conquer unrecognized and untreated pain in Rwanda.

With topics from safety in regional anaesthesia, to empowering nurse led recognition of pain, locally informed pain pharmacology, to the vast potential of micro-research, the conference has had broad appeal. Equally broad has been its reach! In polling the audience, we discovered that the conference is playing host to nurses, physiotherapists, social workers, non-physician anaesthetists, residents and staff anaesthetists, and researchers!

In reflecting on the accomplishment this conference represents, I feel something needs be said about the dedication of the attendees themselves. Despite a very busy conference schedule (grueling might actually be more apt), the attendees were unflagging in their attention. While my concentration drifted, the attendees were busy scribbling notes; there was hardly a distracted cell phone scrawl to be seen. The need for a paradigm shift towards the recognition and treatment of pain in stoic Rwanda is desperate; if the indefatigable attention of the conference attendees is any indication, the appetite for change is clearly equal to the task.

Familiar and foreign – Friday, January 18, 2019 (from Jon)

The moment I step off the plane the warmth and humidity settle on my skin as I smell the slightly smoky air of a major city which is at the same time fresh – infused with eucalyptus. The tactile and olfactory essence of this place immediately takes me back to the last time I was here. Even though I anxiously wait for my bags to appear on the carousel, the knowledge that there is a friend waiting for me outside settles my nerves. The drive from the airport is relaxed. Christophe and I catch up on the last few years as I gaze out the window at the galaxy of lights running through the valley and up the hills.

Although the apartment is new (and beautiful), I quickly reorient to the city and landmarks. The remainder of the weekend – aside from sleeping – is sent visiting favorite restaurants, coffee shops, and bars. The downtown core feels comfortable, my pace slows to match the locals and the heat – except for when I cross the street, timing my stride to the meet the gaps between motos and cars. Our good friend Emmy comes to pick me up for a chat over a Mutzig at the famed Guma Guma bar in Nyamirambo just under the old apartment.

Returning to Rwanda gets easier every time. It’s a unique experience for me to visit another country where we know so many friends. The Dal Health Office and Anesthesia and CASIEF have created an amazing interconnected group of people. There is a completely different feeling when you’ve known local staff for years, met their families, hosted them in your home, and been hosted by them in their home. All plans and discussions start with the background of mutual respect and a shared history. This obviously changes how priorities are set and plans are executed.

Even in minor ways these relationships make things easier. If I’m lost, I’m a whatsapp message away from someone to pick me up. If I need a favour, someone is there and happy to help. We are supplied with advice about transport, restaurants, tourism, and avoiding problems in general. In short, the experience of Rwanda is increasingly comfortable. Yet, it remains an enigma.

Culture underlies everything we do. Despite our experience and interpretation by our friends, we have misunderstandings and missteps. Even Patty on her 14th trip to Rwanda emphasizes that she’ll likely never fully understand the intricacies of the culture here. We try our best, but we will never replace the knowledge of our Rwandan colleagues.

Visit Dr. Livingston’s blog at < https://simcentreopening.blogspot.com/ > to see the original posts, including photos.

Bethune Round Table 2019 Call for Abstracts

CNIS Bethune Round Table in Global Surgery
June 6 – 9, 2019
Edmonton, Alberta, Canada

The call for abstracts is now open!

The 2019 theme is Ethics in Global Surgery. As the field of global surgery develops, it is important that ethical concerns remain at the forefront of its advancement. We encourage abstracts pertaining to the theme, but abstracts covering all topics in global surgery are welcome for submission.

Scholarship for Selected Abstracts

If your abstract is accepted, you may qualify for a scholarship to cover travel costs if you are clinician practicing in a low or middle-income country.


January 31, 2019: Abstract deadline if applying for travel scholarship
February 28, 2019: Final abstract deadline

For full abstract submission details and to submit your abstract, visit: https://bethuneroundtable.com/.

To submit your abstract, click here.

To register for the conference, click here.

Dr. Livingston returns to Rwanda (2nd edition)

VAST Refresher Course 1 – Wednesday, January 9, 2019 (from Patty)

We have been running the Vital Anesthesia Simulation Training (VAST) Course, a 3 day course that focusses on clinical practices and non-technical skills (e.g., team working, task coordination, prioritization) to improve peri-operative safety (https://vastcourse.org). The course was developed and implemented last year. We have been studying the impact of the course on non-technical skills. The initial measurements were made in August and September during the first four VAST Courses. Yesterday, we invited half of the course participants back for a refresher course and to complete the final performance measurements. The remaining participants will return on Jan 18.

I won’t comment too much on the details of the study other than to say we have been looking at performance of non-technical skills in short simulated scenarios before, immediately after and 5 months after the course. It was delightful to see the course participants again and to hear about their experiences and changes they have been able to make after returning to their home hospitals. It gives one hope that the VAST Course is a valuable direction for our efforts.

After a busy day of testing and hearing stories from the participants, we had a relaxing swim at the Serena Hotel and a lovely dinner at one of my favourite restaurants (Khana Khazana). Dave, Chris and Stephen are great companions. They work hard and are always keen to jump into whatever tasks need to be done. All of them have a delightful sense of humour (although too darn many puns from Stephen) so we’ve had plenty of light moments as well.

We will be getting away soon for our first weekend adventure. The guys are going gorilla trekking in Uganda on Friday. I will finish a few meetings in Kigali on Friday and meet them Friday evening at the Africa Rising Cycling Centre on Friday evening. We have a bike ride planned for Saturday before going to Lake Kivu on Saturday evening. Then back to Kigali on Sunday to get ready for another busy work week.

We send our best wishes from Rwanda, where it is green, fragrant, moist and warm. My companions have promised to post a few messages as well.

Cycling in the hills of Rwanda – Sunday, January 13, 2019 (from Stephen)

We are now one week into our visit to Rwanda and as I consider possible topics for my first reflection, I am stunned at the volume of experiences I have enjoyed in even this short time. Saturday morning, I awoke to find myself in the Africa Rising Cycling Club. We had ahead of us a 44km cycling trip that Patty promised us wouldn’t be too arduous. Knowing the cycling accomplishments of Patty and the CASIEF volunteers before me, I was nonetheless nervous. In my fretting, I was amazed to discover the many ways this trip itself represents the progression of a cycle.

For myself, this Rwandan visit represents the expression of what drew me to medicine in the first place. In my first week of medical school, with Patty as my case tutor, I recall her prodding us to consider what we could contribute to the global work of medicine. I now find myself in Kigali taking my first, imperfect attempts at teaching fellow residents. I have so much farther to go in my own learning, but I couldn’t escape the feeling that the arc of my own cycle is turning.

Setting out from Africa Rising, likewise palpable was the sense that this place represented the changing of a season for Rwanda too. I wouldn’t claim to understand the nuance of history, but the optimism of this cycle centre was inspiring. As we prepared for our own modest cycling trip, the Rwandan national cycling team played host to the Nigerian national team and trained with a goal no less ambitious than winning the Africa Cup. Having previously captured bronze and silver, their sights were set squarely on the gold for 2019. The momentum of the Rwandan cycling team truly captured something of the spirit of Rwanda itself. Indeed, the Rwandan team finished their +200km race from Ruhengeri to Kigali and back before we finished our own modest trip.

In its own way, CASIEF’s sustained partnership in Rwanda is witnessing the completion of its cycle. The accomplishments and talent on display every day in our interactions with the Rwandan residents speaks to their dedication as well as the coordinated work of many, many CASIEF volunteers before me. From the Simulation Centre, to curriculum renewal, and to the many relationships I myself have built with visiting Rwandan residents in Halifax, the work of this programme runs deep. As CASIEF ponders its next steps in Rwanda, the sentiment that CASIEF’s own cycle is turning is unmistakable.

Like my visit to Rwanda itself, our own cycling trip exceeded all expectations. Flanked by small crowds of curious children, we cycled the beautiful volcanic terrain to a waiting lunch on Ruhondo Island. The pictures below fail to do the vistas justice. As we finally settle back into our apartment in Kigali, I’m excited to consider what our next week has in store.

Gorillas in the Mist – Sunday, January 13, 2019 (from Chris)

Growing up, “Gorillas in the Mist” played in our household on a near bi-weekly basis. I know the plot (and most of the dialogue!) by hear, and my first inkling that I might one day spend my life travelling from country to country, continent to continent came from imagining myself in Dian’s shoes, immersing myself in a new land and culture while in pursuit of a greater cause. Mountain Gorillas have always had such a incredible appeal – so like us: intelligent, playful, family-oriented. When I first committed to spending a month volunteering with CASEIF, I knew that I just simply had to make time (and money!) to make the dream come true.

And so this past weekend I was giddy with excitement when I, along with Dave and Stephen, hopped in a car and began the trek to Mgahinga National Park in Uganda to sit in silence with a family of 9 gorillas for a single hour. We chose to visit the gorillas in Uganda, rather than our adopted home for the month, primarily because of the (significantly) reduced cost and the increased availability of permits – Uganda being only a burgeoning spot to visit these majestic apes. Mgahinga, at just 13 square kilometres is the smallest national park in Uganda, and one of two parks in the country where the Mountain Gorilla can be viewed.

After a relatively painless border crossing near Kisoro, Uganda, we spent a sleepless night in an expectantly dingy border town hotel before embarking on our journey. Early the next morning, we drove up a steep, winding and badly pot-holed road to the park entrance, where we would begin the 2.5 hour trek up the mountain. Or journey through vines, thickets, and patches of sting nettles was worth the sweat and sore muscles.

The first thing you notice when visiting gorillas is the sound – grunting, chewing, vines and leaves falling as the gorillas grab hold of their favourite plants. The next thing you notice, the smell: musty, dank, earthy, mixed with a sweaty pungency and a hint of excrement. Never mind all of the that, my first site of a wild, adolescent male silverback was one that I will never forget. Laying in a pile of crushed leaves, almost gingerly lifting his head to observe his observers, before flopping backwards to get comfy again. Of course, the photos do no justice.

Over the next hour my fellow trekkers and I had the sublime experience of watching this small family, 9 of the mere 900 or so Mountain Gorillas left on this planet. I watched as the babies of the group (two 2-year olds) play, eat and cling to their mothers as they roamed the forest in search of food and entertainment. More than once I scurried back as one of the four silverbacks pushed their way past us, gently but intimidatingly so. And perhaps most emotionally, I watched the 8-year-old female who was suffering from a hand injury after recently being caught in a poacher’s trap – it’s unclear at this time if the damage will be temporary or not, only time will tell.

In the early 1980’s the population of Mountain Gorillas was nearly extinct – found in just three countries that have had more than a fair share of political and civil turmoil, it’s amazing that a population of just 254 (in 1981) has now exceeded 900. It has been no easy task, and the work of countless conservationists, including the venerable Dr. Fossey, are to be thanked. While it is not an easy nor particularly affordable activity, the money that is raised continues to ensure the protection of these beautiful creatures, and for me that makes it worth it.

The work that CASIEF does here in Rwanda, while incredibly valuable, places volunteers in challenging situations with long hours, but the opportunity to take a few moments to fulfil a childhood dream adds so much to the overall experience. The Mountain Gorillas are so much a part of the country’s national identity, and I’m so thankful to have had the opportunity to experience them firsthand – and you should too!

Visit Dr. Livingston’s blog at < https://simcentreopening.blogspot.com/ > to see the original posts, including photos.

Dr. Livingston returns to Rwanda

Returning to my second home – Thursday, January 3, 2019 (from Patty)

In the wee hours tomorrow morning, I will begin the long journey back to Rwanda. This will be my last month-long visit as a CASIEF volunteer, although no doubt I will return for shorter visits and to help with specific programs.

The CASIEF-Rwanda program started in 2006, when there were only a few anesthesiologists in the the country. There are now 18 anesthesiologists and another 40 residents in training. With collaboration among partners in Rwanda, Canada, the USA, Australia, New Zealand and Scotland, great strides have been made in the past 12 years. This has included building an anesthesia training curriculum, establishing a multi-disciplinary simulation centre, training over 150 non-physician anesthetists (who provide most anesthesia care away from the urban centres) in SAFE Obstetric anesthesia, implementing a pain management program in Butare (the vast majority of this done by Dr Gaston, who has received international recognition for his accomplishments) and development of the Vital Anesthesia Simulation Training (VAST) Course (a 3-day course of essential anesthesia practices and non-technical skills designed for low-resource settings: https://vastcourse.org). This has come from the hard work of many dedicated individuals; it has been a pleasure to collaborate with all of them. Anesthesia in Rwanda has gone from being one of the least desired specialties to one where the best applicants are selected. The residents are well-qualified and committed to building an excellent anesthesia department. Former residents are now the leaders. I feel fortunate to have been involved in this work.

As usual, I have a big team coming and a long “to do” list. The team this year will be Dave (Dal global health fellow), Stephen (Dal anesthesia resident), Chris (Toronto anesthesia resident and the Lucky Iron Fish developer https://www.youtube.com/watch?v=0Lf6glgKt3Q), Mary (pain specialist who will come for a week for a pain conference) and Jon (Dal regional anesthesia fellow who has made a few previous teaching visits to Rwanda). In addition to the Monday academic program and OR teaching, we will follow up on a research evaluation of the VAST Course and present at the first pain management conference to be held in Rwanda (organized by Gaston). After three weeks in Rwanda, we will travel to Addis Abba, Ethiopia, where CASIEF has started a new partnership for anesthesia resident education. In Ethiopia, we will run a VAST Facilitator Course, so that Ethiopian anesthesiologists can teach VAST in the future, and also teach a VAST Course. I’ve never been anywhere in Africa other than Rwanda (not counting Nairobi airport) so it will be interesting to visit Addis Abba.

I won’t be arriving in Kigali until late Saturday afternoon and it always takes a while to get up and running. Please look for the next blog post early next week. I am grateful to all of you who follow the blog and offer your support.

Somewhere over the Atlantic Ocean – Sunday, January 6, 2019 (from Patty)

Chris was the only member of my team on the same flights to Rwanda, although we met just departing Toronto.

Somewhere over the Atlantic Ocean a few hours into the flight, an overhead call was made seeking medical assistance. I have been on many flights where these calls are made and typically someone is a bit lightheaded or has had too much to drink. This one was different. Chris, two other health care providers and I (with help from the flight attendants) ran a full code for about 45 minutes, using as much as we found in the meager medical kit and the defibrillator. Unfortunately, the patient did not survive. It was a very sad situation and for many reasons the conditions for the resuscitation attempt were poor.

The travel this time had a connection in Addis Abba, Ethiopia. Since we will spend our final week there, this routing made sense. My previous flights over Africa have been nighttime so it was great to see the landscape from the air, as we flew in the afternoon from Addis Abba to Kigali (via Bujumbura, Burundi). Addis appears relatively flat with some surrounding hills. As we flew further south over the Great Rift Valley, the terrain changed from dry brown to lush green hills. We flew over Lake Victoria – it’s huge! Burundi and Rwanda have similar landscape but Burundi is sparsely populated and has few roads. Rwanda is one of the most densely populated countries in the world at 230 people per sq. km. It is quite apparent from the air.

We arrived in Kigali Saturday afternoon with enough time and energy to get phones working, change money and have dinner on a leafy terrace

Stephen arrived at 2:00 AM today (Sunday) minus luggage…

We’ve spent the day getting ready for academic day tomorrow. There are 11 new PGYs but we won’t meet them tomorrow. We will have a group of about 20 residents and have made some lively teaching plans. Good night, stay tuned.

Lively teaching day – Monday, January 7, 2019 (from Patty)

Academic day. The residents received questions to be answered from their preparation reading the week before. They sent their answers to us in advance so we can look for areas of misunderstanding. Each week, one Rwandan resident is assigned to be the resident teacher so I prepared the program for yesterday along with her. This helps the residents build teaching skills.

The topic for yesterday was obstetric anesthesia and analgesia. We had an action packed day. The morning session included a review of the homework questions with emphasis on clear, concise answers. Then we had a pro-con debate on establishing a labour epidural service in their hospital. This encouraged the residents to move beyond book knowledge and to think critically about their working environment. After that, we broke the residents into four teams to sequence cards of all the anesthesia actions required from receiving a call for an emergency general cesarean section to delivery of the neonate (thanks for the idea, Amélie). We regrouped to critique and refine the sequencing and then our teaching team ran a demonstration scenario of exactly these events. We let the residents know they would be be asked to role-play this same scenario in simulation in the afternoon. Our morning session ended with a lively game of Jeopardy (always popular) complete with prizes.

In the afternoon, we ran three stations and broke the residents into small groups to rotate through the stations. This included the cesarean general anesthesia induction from the morning, an epidural station and spinal station.

The day was utterly satisfying. One cannot imagine a keener group of learners. They remained enthusiastic and engaged throughout the day.

I have been coming to Rwanda for ten years. When I started there were 8 residents and no designated teaching space. We had to move from one borrowed teaching area to another, often to be displaced by another group. There were no materials for teaching and certainly there was no simulation. Teaching was with powerpoint lectures. The residents struggled with English, so communication was challenging. The curriculum was four page topic list with volunteers choosing a topic to teach from the list.

Today there are 40 residents who have a full academic day each week in a simulation centre with a classroom and sim lab. There is a one year curriculum for foundations (first year residents) and a two year curriculum for core (second and third year residents). Fourth year residents are involved in teaching. We are currently working on a one-year simulation-based curriculum for the first year residents to supplement the academic curriculum. Teaching methods have moved from passive to active. The residents communicate well in English.

The graduates of the CASIEF-Rwanda program are now in leadership positions (university head of anesthesia, hospital anesthesia heads, program director). Reflecting on the situation, I believe CASIEF has now accomplished its original goal of building a sustainable anesthesia training program in Rwanda. There is still a need for support, particularly for subspecialty areas (e.g., pain management, regional anesthesia) but the core elements are in place and anesthesia is thriving.

It has been a pleasure to share this experience with Dave, Chris and Stephen. They have promised to write a few posts as well.

Visit Dr. Livingston’s blog at < https://simcentreopening.blogspot.com/ > to see the original posts, including photos.

CASIEF Featured in CAS Anesthesia News


CAS_AnesthesiaNews_2018-12-33-4_CASIEFIt has been an incredible year for CASIEF with great success in all our respective programs. CASIEF runs through the amazing generosity of Canadian anesthesiologists and we would like to thank you for your donations that allow us to work on improving the capacity for safe anesthesia care in some of the poorest countries in the world.

In previous years, we have had very successful fundraising drives, including for Lifebox, and in 2019 we would like to set a new target for our goals in Ethiopia. Ethiopia is at a crossroads for anesthesia. The government seems committed to increasing the numbers of residents and residency programs, and there is a huge number of learners, probably 100 residents in Addis Ababa alone next year. There are, however, very few local teachers. We feel that if we can provide support to scale up anesthesia training in Ethiopia, there can be a big change over the next five to six years. We plan to collaborate with partners in the US to work together on scaling up anesthesia training in Ethiopia. We want to send more volunteers, and we would like to fund some volunteers for longer (6 – 12 month) visits. We would like to get Ethiopian residents and fellows to Canada for training that they can’t get in-country. We would also like to provide administrative support in scaling up the residency program nationally and supporting local leaders in achieving this. Our fundraising goal is to raise $100,000 by June 2019. Many of you already give generously, and we would like to ask you to consider giving more to this particular cause. Many anesthesiologists prefer to make larger donations in the form of securities or stocks and, if you are considering this, please contact us at info@casief.ca.

We would like to apply the successful model we have used in Rwanda to Ethiopia, but the training gap in Ethiopia is on a completely different scale. Please help us to work with our partners in Ethiopia and the US to make the same impact on Ethiopian anesthesia that we have made in Rwanda. If you are thinking of volunteering, please contact Julian.Barnbrook@casief.ca for further information, or sign up here.

Lastly, we are excited to announce the annual CASIEF dinner will be located at an interesting venue in Calgary. More information to come in the new year — we hope to see you there.

Prince George BC welcomes the first Canadian VAST Course

Thank you to all involved in the most recent VAST Course in Prince George, British Columbia. This is a fantastic moment for the team behind VAST, seeing it delivered in a drastically different setting. Please read Dr Patty Livingston’s reflections on the course.

Prince George in November: crisp air, snow-covered ground crunching underfoot, evergreens, bright red berries and unique light – soft, almost mystical, with dramatic pinks and blues in the late afternoon. Nighttime moose encounters are a threat to drivers, who choose robust high-set trucks for safety.

Prince George is a hub for northern British Columbia. Fourteen years ago, the University of British Columbia established the Prince George medical school campus with the goal of preparing future doctors to serve in rural and northern communities. Previously, students trained in Vancouver and accustom to the big city context they rarely returned to the north. Now they learn in a setting that reflects the local needs. Trainees are often placed for extended periods in communities further afield, in small family practices in the interior and north. It was a rare and pleasant surprise to hear learners say their career aspiration is rural family medicine. We have come to Prince George to teach the Vital Anesthesia Simulation Training (VAST) Course.

Simulation-based health professional education is widespread in high-resource settings, but it typically requires expensive mannequins, a simulation laboratory and technical expertise to run the equipment. The innovation of VAST is to create high quality, authentic clinical scenarios with simple technology, minimal equipment and human actors. The scenarios feel quite real and require learners to respond accordingly. Course participants manage commonly encountered clinical situations (e.g., urgent laparotomy, obstetrics, pediatrics, trauma, pain management) and learn non-technical skills for effective team working. Through simple portable methods, VAST creates an immersive, emotionally charged environment where participants have good “buy in” or credibility. The course is designed to be inter-professional and scalable to learners through fundamental, intermediate and advance levels of many scenarios. After running four VAST Courses in both rural and urban Rwanda, we were eager to explore a completely different context.

Our teaching group comprises Angela (an anesthesiologist and expert who has taught multiple courses around the world, including the recent VAST Course in Nyagatare, Rwanda), Lisa (global health coordinator), Julian (Prince George anesthesiologist and lead for the CASIEF Ethiopia program) and me (Patty, VAST co-author, teacher of VAST in Rwanda and former CASIEF Rwanda program lead). Our goal in offering VAST in Prince George is two-fold: to test VAST in a semi-rural Canadian context and to prepare Julian for facilitating the VAST Course in Addis Abba, Ethiopia in January.

The simulation centre in Prince George is well equipped and the staff are helpful. We had brought the core printed materials: course manuals, handbooks for participants, scenario role-play instruction cards, patient documentation (e.g., vital sign observation charts, anesthesia records, progress notes) and photographs of pathology to be discovered during patient examination. The Prince George simulation centre provided the remainder of the materials and a few simple mannequins. We spent the first two days setting up our workspace and running through scenarios to help Julian become familiar with VAST Course facilitation. This was useful for all of us and essentially offered a dress rehearsal before the learners arrived.

Angela and I had previously experienced VAST in a remote district hospital in Rwanda where the challenges were many: participants had to travel hours in the rain to arrive, people had little capacity in English, a hotel venue with abundant ambient noise and learners with no prior simulation experience. In contrast, Prince George was easy. The attendees included one anesthesiologist, one anesthesia assistant and four medical students. They arrived on time, fluent in English, with previous simulation experience and a high level of training. We quickly discovered that we could offer the intermediate and advanced levels of many scenarios. Because of everyone’s schedules, we condensed the course to two days rather than the usual three-day course. Despite this, we needed to omit little because the learning was smooth and efficient.

The course was received with great enthusiasm and appreciation. Indeed, the learners commented that interacting with simulated patients created much more buy in than they had previously experienced with expensive plastic mannequins. Credibility was such that we nearly had to stop one of them from intubating a colleague!

At the post-course dinner, kindly hosted by Julian and his wife, the learners asked to be involved in future VAST Courses and suggested specific communities they thought would be ideal. One medical student from Yukon thought there would be great value for the course in northern Canada. Others thought the course should be included widely in training programs and run for general practitioners. Our team left Prince George inspired by the value of this course in Canada and keen to implement it widely in both teaching hospitals and more remote settings.


Accompaniment by the anesthesiologist

Alan Chu, MSc MD FRCPC

Sustainability, capacity-building, and buy-in.  Integration with the public health system.  Education, interprofessional collaboration, and government support for anesthesia infrastructure.  Although I was disappointed to learn that CASIEF’s legacy-worthy Rwanda project was winding down, its latest pickup in Guyana has great promise!

I have participated in many overseas missions, always small standalone projects, predominantly focused on care provision.  Care provision in Bolivia, Kenya, Haiti post-2010 quake; high-needs settings with minimal infrastructure and, in the case of Haiti, almost complete lack of government capacity.  With training in global health delivery focused on upstream and systemic solutions, I could not help feeling frustrated by organizations with great ideas but impatience with follow-through.

CASIEF’s current project in Guyana is a partnership with the University of Guyana in its capital city of Georgetown, at the country’s lone tertiary care hospital and sole academic centre for postgraduate training.  This is a vibrant community of physicians with training from all parts of the world and where many of the consultant educators are from Canada’s own McMaster University.  Indeed, McMaster has been instrumental in the development of nearly all residency training programs in Guyana, including general surgery, orthopedic surgery, pediatrics, psychiatry, and of course anesthesia.

Are you a senior anesthetist who has developed some wisdom in professional relationship-building and have a few good teaching scripts?  This is the project for you.  Most physicians doing this type of work fit this demographic: practicing physician, married with no children at home, late-career, with a good income.[1]

That being said, a refreshing aspect of the medical community at the Georgetown Public is that it is a youthful group.  The overseas volunteers were mostly early- and mid-career physicians, all with lots of energy.  The thoracic surgeon was a young fellow who hoped to develop a local thoracics training program using his recent residency and fellowship experience in North America and the UK.

These people are fascinating and inspiring.  I met not one but two ex-pat Guyanese who grew up in my own hometown of Toronto, and have returned to contribute to their country.  One precocious young office manager speaks only in inspirational sayings; his bumper sticker reads “Your attitude determines your altitude!”.  There are also several Canadian and U.S. physicians who maintain adjunct positions with the University of Guyana, some of whom leave the comfort of their homes to return frequently or stay for long stretches.

The anesthesia staff are an eclectic group, mostly mid-career, and clearly engaged in the ongoing development of this residency program.  They also contribute to the training of medical students and nurse anesthetists.  Dr. Alex Harvey is both Program Director for the anesthesia program and Head of the Institute of Health Sciences Education (akin to our PGME department).  She is a Jamaican-trained anesthesiologist and the only staff who provides cardiac anesthesia care for the open-heart team that visits every few months.  The sound of Spanish flows throughout the ORs as four were trained in Cuba, similar to a good portion of their surgical colleagues.  Some are not particularly academically inclined, having thrived in their environments because of their pragmatism, but they all are both engaged and engaging.  Hearing their varied and worldly stories is humbling and inspiring, a balance of acceptance of the realities of life and the empowerment that comes from taking it by the horns.


“Safe Anesthesia & Surgery Saves Lives” is CASIEF’s motto[2] and while this may seem a daunting political task, there is much that individuals can contribute!  The single greatest task for Canadian anesthesiologists is to build relationships with Guyanese physicians and staff.  It is this accompaniment that is the backbone support for the development of contemporary anesthesia professionalism, with its focus on patient safety and the relief of pain and suffering.

There's an element of mystery, of openness, in accompaniment: I'll go with you and support you on your journey wherever it leads. I'll keep you company and share your fate for a while. And by ‘a while,’ I don't mean a little while.” – Paul Farmer, 2011 Harvard commencement address

The role of bilateral partnership became evident one day quite early in my stay.  It was an important national holiday and I had plans to attend the Diwali parade with some friends.  What unfolded however was far from a celebration, it was catastrophic.  We found our Guyanese friend’s father unresponsive at the bottom of his stairs and, after learning there was no ambulance available, proceeded to perform forty-five minutes of basic life support in the back of his vehicle as he raced to the hospital, dodging countless potholes, struggling to understand what was happening on this most holy of days.  Back at the visitors’ residence an hour later, far away from my usual debrief supports and quite shaken, I was surprised when Dr. Harvey appeared at my doorstep.  We sat and chatted for a good while and I felt more at home than I have on any other mission.  What a display of accompaniment, and of partnership.  I can no longer assume that the privileged are accompanying the poor for when I needed support it was quite the opposite.  Despite the heavy workload and trying circumstances of Georgetown, here was yet another case in which Dr. Harvey did not hesitate to simply do what was required given the situation before her, much as each of us do in our daily work.  In many ways, we are the same, and we walk this journey together while building the relationships that are the foundation of all global health work.

With rare exceptions, all of your most important achievements on this planet will come from working with others—or, in a word, partnership.”  -- Paul Farmer, 2013, To Repair the World.

How is your emotional intelligence?  Are you able to reflect on your role, privilege, and power, and recognize how and why you are reacting to circumstances as they unfold?  It is often the same people who do not get thrown by countertransference from challenging patients who are well-suited to this work, clinicians who can take a step back while still showing up.

The hidden costs of help

The most commonly cited reason for doing overseas work is “to help” or “to do something good”[3], but some missions exhibit a much higher help-to-harm ratio!  Consider that the average physician cost for each short-term mission is $11,000[4].  What could local governments do with the annual spending by visiting physicians alone?  Think of the local costs of visiting missions: garbage, local resource use/waste, even lost employment time in some cases.  Think too of the potential for harm: inappropriate management in the presence of undetected comorbidities; postoperative complication management out of scope or beyond the resources of local personnel; psychological impact of exposure to colonial approaches or views; and Canadian medical trainees providing care beyond their level of training.  It is reasonable to admit that much overseas work suffers from physicians’ “pursuit of self-efficacy”, from various forms of medical tourism, and from other suboptimal motivations that perhaps may not justify its high price tag.[5],[6],[7]

It cannot be understated that the risk of harm remains of paramount importance to all overseas work.  A comment like “What?!  You don’t have that here?!  Well, how can you even do this work??  That is not safe!” will certainly make it harder for the subsequent CASIEF volunteer to achieve the goals of this collaborative project.  In fact, much subtler comments have ended relationships.

Thinking about bringing a resident with you?  Do it!  But be smart and cautious, please.

It requires a lot of interpersonal work for you and for them, especially if you believe some of what I have highlighted about the risk of harm and the importance of relationship-building.  Think of all your possible reservations and anxieties about your upcoming work.  Then imagine a sleep-deprived, always multi-tasking, relatively inexperienced resident contemplating these issues!

In my experience, the best way to incorporate a learner into the mission is to begin with pre-departure training that requires them to reflect on what aspects will be the most challenging for them personally and professionally.  Some description of the historical context of overseas work might help them develop a sense of privilege at being involved in this work; at being a guest of colleagues who are allowing themselves to be vulnerable.  There is literature on what should go into such pre-departure training, but in my view working through the ethics is vital[8].  Precepted missions (in which a Canadian anesthesiologist accompanies a Canadian trainee) are most appropriate for inexperienced residents or students, and the Guyana project is perfectly structured for this.  Plan ahead for your post-return debriefing and do not skimp, schedule multiple follow-up meetings.

I tell my residents something akin to: “This is hard work.  I’ve done this a lot and it is still hard for me.  But incredibly rewarding and a ton of fun.  You will be using all of your senses in overdrive, all day every day, and this is exhausting.  Strive to achieve the same principles as you would at home – patient safety, alleviate suffering, optimize patient outcomes.  Assessing your patients for disease severity and stability will require curiosity and thoughtfulness.  When developing anesthetic plans, consider how our context might affect patient outcomes.  Finally, contemplate what kind of global citizen you would like to be, and when you talk to anybody chose each word carefully to reflect that ideal.”

The doctor, not yet thirty, had been schooled for scarcity and failure, even as I’d been schooled for plenty and success … Working in that clinic had lowered his expectations about what was possible when it came to providing health care to those living in poverty … I’ve since learned that the great majority of global public health experts and others who seek to attack poverty are hostages to similar failures of imagination … How does this story relate to you? First, try to counter failures of imagination … Second point: as you seek to imagine or reimagine solutions to the greatest problems of our time, harness the power of partnership.”  – Paul Farmer, 2013, To Repair the World.

The CASIEF Guyana project is a great place for creative relationship-building.  I made a clinical blunder early on that resulted in a patient requiring a bedside chest tube; as I made the rounds apologizing and discussing the case with various staff, the intensivist roundly congratulated me for inadvertently unmasking the patient’s moderate-sized hemothorax and securing definitive care!  Early in the second week, after treading lightly and getting to know our colleagues and context, we routinely had a large audience of staff and residents in the regional block area looking on and getting involved.  In fact, I might even have imagined that surgeons were thankful that some cases at risk of being canceled could be deemed safe with the use of regional anesthesia or after surface ultrasound assessment.  I learned from my colleagues here that relationships can withstand clinical hiccups and that you never know how things will turn out.

I also had the opportunity to attend M&M rounds, which occurs about once monthly and is attended by all members and residents of the combined Department of Anesthesia and Intensive Care.  The case discussed was a patient who was incompletely optimized and delayed by an anesthesia trainee but subsequently approved by the staff consultant.  This was only after the surgical team had sequentially contacted progressively higher rungs on the ladder until somebody finally acquiesced.  The patient proceeded to arrest on the OR table under the care of the most junior anesthesia care provider on service (a nurse anesthetist) after a code run by the general surgeon.  With some rudimentary understanding of cultural and professional norms, I had some sense of the main issues at play and whispered some thoughts into the ear of the department head, who nodded in agreement.  To my astonishment, he then stood and asked me to address the department – what a heart-racing and humbling invitation that was!  This was what leadership courses call a “crucial conversation”.  The department head nodded supportively throughout, but this was also my last day, so my sincere apologies to subsequent volunteers if they have had to deal with any fallout I may have caused!

One day I was approach by a Guyanese colleague who asked, “So, how do our residents compare to yours?”  Awkward conversation ensued as I had not anticipated this question and I imagined completing an EPA assessment for a resident here.  In retrospect, I wish I had said that our residents are trained for our context and yours must be for yours.  The principles remain the same – safe patient care that also alleviates suffering and optimizes patient outcomes.  Our residents would struggle to accomplish that here.  My hope is that Dr. Harvey and the rest of our colleagues in Guyana, do not receive this message first from reading this newsletter, but rather from a collegial dinner on the balcony overlooking some mango trees, taking in the warm air and faint sounds of bhangra music.  And that those future conversations are replete with imagination.

[1] Caldron PHImpens APavlova MGroot W. 2016. BMC Health Serv Res. Dec 7;16(1):682. Demographic profile of physician participants in short-term medical missions.

[2] https://casief.ca

[3] Caldron PHImpens APavlova MGroot W. 2017. Int J Health Plann Manage. Jan 12. Why do they care? Narratives of physician volunteers on motivations for participation in short-term medical missions abroad.

[4] Caldron PHImpens APavlova MGroot W. 2016. Global Health. Aug 22;12(1):45.Economic assessment of US physician participation in short-term medical missions.

[5] Farmer, Paul. Personal communication, October 4, 2014.

[6] Philpott, J. 2010. Training for a Global State of Mind. Virtual Mentor American Medical Association Journal of Ethics March, Volume 12, Number 3: 231-236.

[7] Arya AN & Evert J. 2018. Global Health Experiential Education: From Theory to Practice. Routledge, New York.

[8] Pinto AD & Upshur REG. 2013. An Introduction to Global Health Ethics. Routledge, New York.

U of T Anesthesia Sports & BBQ Day

On Saturday September 8th, 2018 the University of Toronto held their 2nd Annual Department of Anesthesia Sports & BBQ Day. The event works to bring together staff and trainees and their families for some fun, friendly competition. This year we were honoured to be chosen as the selected charity and we were delighted that together the members of the Toronto anesthesia community raised $5,500 for CASIEF to support the development of anesthesia training programs in low resource countries.

total of 195 staff, fellows, residents, and administrative staff from the Department of Anesthesia and their respective families attended the event. We had fantastic weather and it a true pleasure to see everyone in matching hospital team t-shirts, cheer their teams, compete in fun games, laugh, and enjoy the comeradery.

There was representation from Toronto General, Toronto Western, Mount Sinai, SickKids, Sunnybrook, St. Michael's, Michael Garron, and St. Joseph's. Congratulations to the Toronto General team for winning the sports tournament and fundraising competition - they took home the champion’s trophy (named 'The Laryngoscope') this year. 

Thank you, University of Toronto, for all of your kind support!

Event Organizers

Team Pic – Michael Garron

Team Pic – Sinai

Team Pic – St. Michael’s

Team Pic – Sunnybrook

Team Pic – TGH