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.

Deadlines:

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.

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!

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

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.

 

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

DEAR CAS MEMBERS AND CASIEF SUPPORTERS:

It 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.