Dr. Livingston returns to Rwanda (2nd edition)

VAST Refresher Course 1 – Wednesday, January 9, 2019

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

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

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

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.

Anesthesia in Rwanda – a learner’s perspective

A month in Kigali has flown by, and I am already thinking about when I can go back. Through my transitional internship program, I had the chance to observe the practice of anesthesia in Rwanda and see the educational collaboration of CASIEF & HRH with the University of Rwanda first hand. There are 4 referral-level, teaching hospitals of Rwanda, 3 in Kigali, and another in Huye (Butare) in the southern part of the country, a 3.5 hour drive from Kigali. While most of my time was spent at CHUK – the largest public hospital in the country, I also visited King Faisal – a private hospital, and the Rwandan Military Hospital, each with its unique atmospheres.

The affiliated medical school at The University of Rwanda has its own residency program, which started in the mid 2000’s. Enrollment has been steadily increasing, more exponentially since about 2011, and today there are 30 residents total divided among the 3 years. In Rwanda, after graduating medical school (which is 6 years, immediately after high school), one is required to do 1-2 years of general practice, working as a family medicine physician in a rural district hospital, often as the sole provider. Only after completing this can one then apply for specialty training. For anesthesia, this consists of 3 clinical anesthesia years, much like in the States. (Next year, the training program will be extended to 4 years; concurrently, there is some talk of doing away with the mandatory service prior to specialty training.)

Each Monday all the residents from all 4 hospital sites convene at CHUK for didactics, led by the CASIEF & HRH volunteer anesthesiologists. The residents are split into Foundations (CA-1’s) and Core (CA-2’s and CA-3’s) for small group sessions in the morning, followed by a case presentation and other interactive lessons in the afternoon, often related to simulation or ultrasound. When I was there, the residents were prepping for their end of the year exams, so they were all eager to hone down core concepts. For me, this month was an excellent introduction to anesthesia and I found it very helpful learning with the Foundations group. The rest of the week, I would spend time in the operating rooms and the intensive care unit, where I was paired with a CA-3 Rwandan resident. At CHUK, there is one attending, with one to two senior residents (but usually only one) overseeing the 6 main operating rooms, each of which has a CA-1 or non-physician anesthetist (NPA, equivalent of a CRNA in the US) assigned. There was a separate team of residents for the 2 operating rooms in the maternity ward.

 

The breadth of cases in the main OR was quite impressive: all kinds of pediatrics (and only one peds surgeon), neurosurgery and orthopedics (mostly trauma, including late presenting trauma), urology, gastrointestinal/general, and ENT. While I had visited district and referral hospitals in other sub-Saharan countries, these in Kigali were much more advanced and well-equipped. It was a refreshing experience seeing the successful delivery of a relatively higher level of medical care. There were a several interesting and difficult airway cases, including a child with a large laryngeal papilloma, who ultimately needed an emergent tracheostomy after multiple failed intubations; luckily, communication was excellent among all the teams, and the ENT surgeon was already scrubbed and standing by while we were trying to get the airway.

There is one communal tea room, where everyone (nurses, doctors, technicians, cleaning staff, etc.) can mingle and grab a cup of tea or snack when there is down time. The next case would start…whenever it would start. That could range from 15 minutes to 1hr+ depending on the presence of the proper personnel, equipment, or the patient.

At King Faisal, I spent most of my time in the ICU. This hospital is well-equipped and privately funded. You talk to any non-medical expatriate living in Kigali and this is the hospital they will know. Many of the doctors are foreign-trained. I happened to be there the day of multidisciplinary ICU grand rounds. We all stood in a large circle in the ICU – about 30 people including anesthesia, surgery, internal medicine, and ENT residents (that particular day’s case was about a goiter). It was led by a neurosurgery attending, so his residents were there as well. There was even a cardiology attending (one of twelve cardiologists in the country!). The neurosurgeon posed clinical questions about the case and went around the circle asking each of the residents. No powerpoint slideshow or paper handouts, just good old fashioned verbal communication.

During my last week, I also visited the Rwandan Military Hospital, and was struck by their military-speed efficiency. While the first case began an hour after its designated start time (not uncommon in Rwanda), the room turnover for the subsequent cases was done with lightning speed. Just when the first patient settled and stabilized in the PACU, it was time to bring in the next one. I was also expecting the patients to be mostly older men, but this hospital actually serves the general public as well, and they do all kinds of cases including pediatrics and OB.

Being a PGY-1 was a challenging yet exciting experience. Most foreign residents visiting Rwanda were there to teach and offer their clinical expertise. There’s a bit of an expectation of any ‘mzungu’ at the hospital that you are there to impart your wisdom and help improve current practices. While I was comfortable adjusting an insulin regimen or diuresing someone with CHF after 10 months doing mostly internal medicine rotations, I had very little experience as an anesthesia provider. It was a preview of all the exciting things ahead, and a humbling reminder that I was about to embark on ‘intern year 2.0’. Still, some interesting differences in practice have stuck with me, like the regular use of halothane or just funny semantics like calling it propoket rather than ketofol. Overall, this month got me super pumped to know that I am finally about to start learning and practicing my chosen specialty.

Another thing I was impressed by was the strength and organization of the residency program and the collaboration with CASIEF/HRH. Each year, two Rwandan residents are chosen to rotate at hospitals in the US and Canada, all with the support (including financial) of the University of Rwanda and the Ministry of Health. Anesthesiology is becoming a more and more popular specialty choice in Rwanda, I think in part due to this strong partnership. The profession grew from only one anesthesiologist in the entire country after the genocide in 1994 to over ten new anesthesiologists minted each year, with many pursuing subspecialty training as well. The current group of residents are part of the new wave of anesthesiologists, and have the insight and numbers to direct what their field will look like. They are bright and see the unique position they are in. Down the line, the plan is to wind down foreign support so there can be a permanently self-sustaining training program in Rwanda. I am optimistic it will be a success.

Yuanting Zha
Incoming CA-1 resident at Brigham and Women’s Hospital in July 2018

Posts about Rwanda on Marriage-Motherhood-Medicine Blog

Due to the NOTSS course, the academic day for anesthesia residents was moved from Monday to Tuesday morning. We spent another fantastic morning with the residents teaching each other and engaging in passionate discussions over the best way to do difficult cases. After the half day was finished, Margaret and I were picked up for our drive to Butare.

Butare (now named Huye) is in the Southern province and it takes about 2.5 hours to get there. It was the original intellectual seat of Rwanda – the university was founded there and the other main University Teaching Hospital (CHUB) is located there. While in Butare we stayed with the wonderful family of one of the anesthesiologists (who happened to be in Halifax of all places, so I did not get to meet him). It was lovely to stay in a home with children and puppies and gardens and a wonderful host. It was a short trip to Butare due to the NOTSS course and the Good Friday holiday. But it was very worthwhile.

Read more about Sally’s time in Rwanda on the Marriage-Motherhood-Medicine blog.

Congratulations to Dr. Gaston Nyirigara

We would like to congratulate Dr. Gaston Nyirigara a Rwanda colleague with the 2018 IASP (international Association for the Study of Pain) award of excellence in pain research and management in developing countries. Dr. Nyirigara has always been close with CASIEF and Queen’s pain research and management program. Once again congratulations.

I would like to summarize and describe key features for why Gaston received this award. “Intensely involved in clinical pain management in Rwanda, as well as a devoted teacher across the country. Committed to developing a network of pain management services across the country. Received one scholarship for training in Canada. Strong clinical care, patient advocacy and mentoring/education during clinical shifts. Very strong letter of support (mentioned by 2 reviewers). Established and leads Acute Pain Management Team, and this pain care program is the first of its kind in Rwanda. Hard-working and with a clear mission. Obtained support/funding to establish a Quality Improvement Strategy for pain care suggesting a plan to monitor the quality of care provided.”

Dr. Nyirigara also gave a Grand Rounds presentation for the Department of Anesthesia, Pain Management and Perioperative Medicine at Dalhousie University, March 21, 2018. That talk is available below.

Adam on VAST (from the Sim Centre Opening blog)

It’s alive…It’s alive!

Victor Frankenstein recounts how he “infused a spark of being into the lifeless thing at his feet”. The idea for the VAST Course sprouted in July 2017 and for months, it existed only on my hard drive. Without the enthusiasm and support of the team around me, there is no doubt that VAST would still be a lifeless entity. With the financial support of CASIEF and Dalhousie University, we were able to commit to piloting the course in Rwanda in January. In late December, the series of subfolders and files materialised into a set of tangible printed materials, resources and VAST paraphernalia. The great unknown was how all of this would transform into a 3-day simulation course.

We were off to an auspicious start. The first thing our eyes were drawn to at the Rwanda Military Hospital (RMH) Simulation Centre was an expansive banner heralding the piloting of the VAST Course. The months of meticulous preparation, testing, refinement and co-ordination were over and it was time to launch the first of three pilot courses. Throughout VAST, we focus a lot of attention on anaesthetists’ non-technical skills. Our team had to draw heavily on these same set of skills to effectively launch this project.

Team working
In the months leading up to the VAST Course, Patty had on several occasions referred to us (Michelle, Christian, Patty and I) as the ‘dream team’. My initial concern was to wonder I if had to settle for the role of the “Hick from French Lick” aka Larry Bird. Come game time, despite having never worked before together in this capacity, we functioned like a well-oiled machine. The first pilot course was underway and we were running two parallel groups through the various components of the course. Michelle behind the scenes, setting up rooms, Patty and Christian riffing off each other in debriefing sessions and I taking the helm of facilitating and debriefing the other group. It wasn’t long however before the line-up of the dream team was to get some fresh faces.

Stewart was certainly a prized recruit to the team. After a quick ‘pre-season’, namely the VAST Facilitator Course, Stew held a firm place in the starting five. In fact, by pilot week three, he was the front runner for MVP, having to step his responsibilities when other key players were out due to illness and a late season trade to the Butare Black Mambas. Rotating strongly off the bench we also had an injection of talent from our trainee facilitators. With some on-going coaching from the side-lines, these ‘trainee’ members of the team were soon more than pulling their weight, running and debriefing sessions following the VAST playbook. More on the surprise recruit, Laurence, later.

No team can function without an extensive support network. Daily buffets at both RMH and CHUK hospitals kept our energy levels high. The team transport was dutifully and punctually conducted by Alphonse. Christophe at the CASIEF apartment was working overtime ensuring our team uniforms (scrubs) were cleaned and pressed ready for game time each day. In all of this, like in any well-functioning team, there was a real sense of camaraderie and common understanding that developed amongst the team members.

Task management
There is a lot of focus in VAST on managing complex tasks, particularly on how to assess and organise available resources. Day 1 of the first week of the VAST Course is now a bit of a blur. The unknown of the mechanics of the running the course were playing out in front of us. Fortunately, we had the invaluable resource of Michelle to draw on. With Michelle at the helm co-ordinating set up and changeover between scenarios, the rest of us were able to focus on the other tasks of session delivery and mentorship of the trainee facilitators.

Decision making
Many of the decisions regarding course logistics and design had been set in stone months in advance. There was opportunity however for some on the fly experimentation with order of sessions, timings of breaks and finer details of how some sessions were to be conducted. This helped to maximise our short period of time with participants and to promote a favourable learning environment.

One key decision that was suggested to us early on by Dr Paulin was the inclusion of Laurence, the sim centre co-ordinator from CHUK hospital. Laurence joined Michelle from the beginning of the first week of pilot courses, shadowing her every move and learning from the best. By the start of the second week of courses, Laurence was setting up stations and preparing the rooms for subsequent scenarios. Come week 3, Michelle was back in Canada and Laurence stepped up to the plate to independently run the ‘back of house’. An unexpected highlight was to watch Laurence spring to action on academic following the completion of the VAST Course pilots. Patty had tasked the residents with designing their own simulation scenario and within moments Laurence had the equipment set up in the same systematic manner in which we organise the gear for the VAST Course. This is just one example of what we have now seen as some of the ripple effect of the VAST Course…positive implications that are extend beyond our initial set of objectives.

Situational awareness
Language posed one of the key challenges to conducting these pilot courses. Whilst English is the official language in Rwanda, there is a transition from French and ubiquitous use of Kinyarwanda. Our participant group was also not uniform in their level of English. Being aware of this dilemma was of crucial importance. As much as possible, we encouraged Christian to deliver his sessions in French/Kinyarwanda. For the rest of us, it was important to take the time to meter our pace of speech, allow for translation and explanation amongst the group. It will be important that once the course materials are finalised post pilot, that we make the effort to translate resources and as much as is feasible, deliver of the program in a more ‘comfortable’ language.

It is still a little hard to come to terms with what has been achieved over months leading up to the piloting the VAST Course and subsequent course delivery. Certainly, there have been lots of lessons learned. Components of the course can be tweaked, elements that we should dedicate more attention to and some less effective components that can be pared back. In essence however, we are chalking down the previous few weeks as a great success. There is an encouraging amount of local support and endorsement of the project moving forward from both official channels and from participant feedback. The next exciting steps will involve refinement of the course and conducting formal evaluation of future courses delivered. I wholeheartedly thank everyone that has been involved to date with this project and I certainly look forward to the future of VAST in Rwanda and beyond.

There are also a number of photos in the original post at https://simcentreopening.blogspot.ca/2018/01/adam-on-vast-worth-wait.html.

Emotions January 29, 2018

Life in Rwanda is vivid and at times an emotional roller coaster. There is such joy in teaching breakthroughs, friendly greetings and warm welcomes.

There are also moments of feeling frustrated and down. My team abandoned me this weekend to go to Akagera Park (the safari in eastern Rwanda). I had to print the quiz for teaching and finish off some preparation for academic day. I got caught in a downpour and drenched my sandals in mud.

Then I had a really bad night in Nyamirambo…

This is from my SOS email:

At 6:10 AM on Sunday morning the music is still blasting from the bar across the street. Despite ear plugs, a fan turned up high and sleeping pills, I’ve slept poorly and been awake since 4:00 AM. The booming music is relentless and the mattress has a deep valley in the middle.
The water has been off all night. This is not because of drought – it’s rained every day. It is because the landlord shuts the water off to save the pump. So, I flush the toilet by pouring water from a bucket into the bowl. I wash my face with stagnant water from the bucket.
We had two power outages yesterday evening. These continue frequently.
I contemplate moving out for the last three nights but I’ve spent thousands of dollars already this month with no income. I guess it’ll just be three more nights of sleeping in the bar.

Okay. It was not a good moment. Dylan and Chil have adopted me and I am spending my last few nights in comfort in Kiyovu.

As we get close to the end of our time in Rwanda, it always strikes me how strange the whole notion of time really is. Each day here is so rich and different that it feels as though we’ve been in Rwanda for six months. It seems ages ago that we were on Lake Kivu.

As always, I’ve had a great team.

Allison promises to write a post about Akagera and Adam promises to write a post. Stay tuned.

xo
Patty

Allison’s reflections, January 28, 2018

This week has resulted in a fair amount of reflection. It makes sense to interpret and process situations based on your own cultural values and beliefs – it’s human nature. That being said, viewing a developing country through a North American lens is exhausting. It’s incredibly useful to take a step back.

Someone recently said to me that the people I meet probably think ‘oh, what does she know…she’s just going back to her privileged life in Canada.’ Interestingly, this hasn’t been my experience at all. If anything, I think it illustrates the ‘North American’ lens concept – we tend to think our way is the better (best) way and then project this view on to other situations. The people in Rwanda are happy. They’re happy despite their history, despite their poverty, despite what we perceive as a ‘lack of.’ And it’s key to recognize that.

This inevitably brings up the more versus less debate. Canada is a culture of more; Rwanda is a culture of less. Our children have iPads and video games; these children have sticks and tires. We have excessive amounts of processed and imported food; they have small amounts of locally grown food. We strive for more stuff; they are content with very little. These values are clearly reflected in the dichotomy of our pace of life. We rush from one thing to the next and take great pride in being busy; they savour a more relaxed way of life. The relationship between expectations and happiness is, undoubtedly, a major player here. This has been a wonderful opportunity to reflect on my own expectations and how they impact the way I interpret the events of my life.

I love the concept of ‘maximizers versus satisficers.’ Briefly, maximizers must always make the absolute best decision and often worry if there’s another, better option available; whereas satisficers are content with the first option that meets their criteria. Generally speaking, I think Canadian culture is about maximizing and Rwandan culture is about satisficing. Perhaps we each need to adopt a little more of one another’s approach in our daily lives!

The exposure I’ve had to the people and culture in Rwanda through home visits has been life-changing. This week, I felt quite emotionally overwhelmed. I’ve seen poverty like never before, and living conditions that are such a complete departure from anything we could imagine in Canada. I’ve seen patients who are sick in ways that we never encounter at home, and who lack access to the basic standards of treatment. I’ve felt frustrated at my inability to effectively communicate with and understand the patients as a result of the language barrier. I’ve felt inadequate in my ability to help. I’ve felt perplexed, and sad, and discouraged.

That being said, I’ve also met many incredible, resilient, beautiful people. I’ve been welcomed into homes with a single chair that they enthusiastically offer to me. I’ve witnessed unimaginable stoicism in the face of inadequate pain control.  I’ve seen families rallying together to provide care like nothing I’ve ever experienced at home. I’ve gotten hugs and handshakes and many warm wishes. I’ve felt inspired, and grateful, and forever changed for the better.

This rollercoaster is a gift. I feel forever tied to the people of Rwanda; they’ve touched a part of my heart I didn’t realize was there.

The nurse, Peace, translated, and we spent most of the visit laughing. This patient said,

 “(in Rwanda) we are sick, we are poor, but we are fine.”

 

Thursday, January 25, 2018

There was torrential rain last night so this morning the air was clear and fresh as we arrived on the tidy grounds of the Butare Hospital campus.
Allie and I made pain management ward rounds again with another team member, Emmanuel. It is heartwarming to see the skill and care with which the pain team operates. They are knowledgeable and compassionate. We rounded today on the obstetrical ward. There were 6 postpartum women in one room with their neonates but the atmosphere was calm and serene. One woman had twins!
We were reminded once again of how risky pregnancy and delivery is in this setting. One lady had an eclamptic seizure a few days ago and was just recovering. Another middle aged woman had had multiple C-sections. Despite the challenges, it was obvious that patient care is improving.
Allie had to borrow Gaston’s spare lab coat for rounds, so we had to Dr. Gastons.

 

 

Following ward rounds, we had a highly productive meeting with the hospital leaders. They are committed to palliative care, a chronic pain outpatient service, and delivery of the VAST Course in Butare. We left the meeting feeling quite elated. As we were leaving, Gaston introduced us to a 92 year old ENT surgeon who continued to practice well into his late 80s. He was actually the very first student at the University of Rwanda (student number 001). There is an inspiring piece about his work ethic:
http://allafrica.com/stories/201603010145.html
Prof Venant Ntabomvura, a Rwandan leggend
Allie and I celebrated a great morning with lunch at Inzozi Nziza. She got coffee ice cream with cookies and sprinkles topping.