SAFE in Rwanda: it's a wrap, now to the hills

The second SAFE Course has finished. The second week ran more smoothly than the first after a few alterations based on the experience of week one. Most session were run in outdoor gazebos. This proved to be an excellent setting with lively bird sounds throughout the day, a light breeze, and bright daylight. Fortunately, there was no rain until the last day when, just before the post-course skills test, it came down in bucket loads. After waiting out the rain, we were able to complete the final test before the participants regrouped to write “commitment to change” forms to identify clinical practice changes they hope to make based on new learning from the SAFE course.

Most of the course comprised a variety of small group stations where the participants are engaged in discussion, skills teaching, and simulated scenarios using mannequins or a participant role-playing as patient. There was enough equipment to provide authenticity to the scenarios. Participants worked as teams to manage situations such as emergency general cesarean section, ruptured uterus, or post-partum sepsis from retained products of conception. They employed anesthesia knowledge and skills as well as non-technical skills such as systematic preparation, communication and team working. The course participants had to role-play as anesthesia provider, assistant, or surgeon. A faculty member, who was assisted by one or two trainers, conducted each session; trainers are anesthesia residents and senior technicians, who had been identified by the local staff as having leadership capability. We ran a training of trainers course the first day and then mentored the trainers during the small group sessions so they were able to run the final session independently.

Planning and preparation for the SAFE Course has taken up much of the past year. It is easy to ask if all this hard work is worthwhile. The last day of the course, I had an experience that confirmed the need for this program. One participant had struggled with managing a scenario that required resuscitation of a sick patient. She had been unable to intubate and did not recognize that the intubation was esophageal. When this session was over I stepped away for a bit but when I returned I found our trainer was working with that participant to teach her intubation. It turns out the participant was trained on the job (no formal anesthesia teaching) and had never been taught how to intubate. She practices anesthesia in a district hospital. The trainer recognized the problem and taught the participant how to intubate on the mannequin. The learner had a huge sense of accomplishment when she performed the skill correctly.

This situation is an example of both the need for anesthesia skills and the value in training trainers as local champions for promoting safe anesthesia practice. It also illustrates the value of active, hands on learning. If we had conducted these sessions as lectures, how would we have found out and corrected deficiencies?

We cannot hope to have solved anesthesia problems in Rwanda with one course but we have begun a journey that involves working together for a common goal. Anesthesia providers have met colleagues from around the country. They had a chance to discuss common challenges they face – lack of equipment, relations with surgeons, and isolation were frequently mentioned. The next step is to implement the anesthesia practice network, which is a system of mentorship to continue to support the anesthesia providers who work in district hospitals.

Megan and I had to leave the course yesterday afternoon in order to transport all the equipment to the simulation centre and for Megan to catch the evening flight back to Halifax. It was too bad to miss the final banquet for the course.

The past few weeks have been entirely dedicated to the SAFE Course but now it is time to shift gears and work with colleagues in Rwanda to establish a simulation centre for teaching clinical skills and team training.

Michelle, who runs the skills teaching centre in Halifax, arrived safely last night. She will be sharing her vast experience with our local partners to help create the sim centre. Before we get to work on Wednesday, Michelle, Faye and I are going to treat ourselves to a three-day cycle expedition from Gisenyi to Kibuye. “Treat” may be the wrong term as this is route entirely consists of hills…