Day one of the sim centre

Yesterday we made phenomenal progress on the simulation centre.  This facility is being established so that a wide range of learners in the health profession can have a place to rehearse technical skills, such as suturing, and complex team dynamic, such as managing maternal hemorrhage, without practicing on patients.  There will be capacity to teach nurses how to set up a table of surgical instruments, medical students how to insert IV lines, and residents how to manage a patient after severe trauma. 

The centre is a free standing building with two bright, well-ventilated rooms.  We had an important meeting yesterday with the Dean of the Faculty of Medicine, the new Medical Director of the simulation centre, the Head of Anesthesia, and a staff anesthesiologist.  Peter, Jon, Michelle and I wanted the place to look at good as possible before the meeting.  We got up early and scurried around the centre unpacking the many bags of donated supplies Jon and Michelle had brought from Halifax and all the equipment from the SAFE Course.  Then we ran to Nakumatt (the local Superstore plus) where Michelle bought a refrigerator with money donated by her soccer team for the sim centre.  This will be essential for storing animal parts used in teaching skills.  After a quick coffee at Bourbon Café we returned for the 10 AM meeting to a centre that looked remarkably transformed already.

We have been waiting a long time for the official appointment of Dr. Georges as the Medical Director of the Centre.  This has delayed spending the money I received from the simulation grant.  Therefore the space has not been painted and the cabinets have not been built.  During our meeting the Dean got on his cell phone and in fifteen minutes we had a couple of workers taking measurements for all the renovations. 

After a fabulously successful first day on the simulation program, Peter and I headed off to the market to load up on mangos, papayas, pineapples, passion fruits and cheese (all the essentials for life).  There was a lively cooking session with four of us packing into our tiny kitchen.  My good friend, Steven, joined us for dinner and shared many of his insights on justice and reconciliation.  He will be taking many of our team to visit the church in Nyamata on Sunday.

Peter writing a welcome poster in Kinyarwanda

Set up for skills and sim

Michelle adjusting a mannequin

Drs. Georges and Patrick after a very successful meeting

Check out this time lapse of sim centre set up:

http://www.youtube.com/watch?v=-wjYjYo79Mk&feature=youtu.be

in the back of beyond

We've just returned from what is possibly the hardest thing I've ever done physically.  We cycled from Gisenyi to Kibuye over two days.  This was 100 km total but most of it was up and down steep rocky trails.  The second day was nearly 10 hours of cycling.  We saw remote parts of Rwanda with friendly people and spectacular landscape.  These photos cannot possibly do it justice.  We are ever so grateful for Tom at Rwanda Cycle Adventures and his two porters Mansuet and Twisiere.  Tom has been working extensively with the local people along the trail to help with their ability to receive cycle tourists and also to have meal and accommodation options.  Our first night was at the Kinunu coffee washing station.  It is a little bit of paradise with mangos, papaya, pineapples, oranges, and lots of fabulous coffee! Both days we had dramatic thunder and lightening - fortunately the first day it was in the evening when we were cozy but on day two our last ride was in the rain with sunscreen washing into our eyes and one more rocky hill...

We could barely move when we arrived in Kibuye last night but fortunately we were staying at a very comfortable hotel with lovely hot showers.  

Shores of Lake Kivu

Banana plants and Lake Kivu

Fishing boats

We are back in Kigali, safe and sound, and ready to get down to work on the sim centre.  Jon and Peter have joined our group. More to come.

With our fabulous porter

Just outside Gisenyi

Fishing boats

Children enjoying the beach where we stopped for lunch on day one

Beautiful Lake Kivu

Are we there yet?  How many more hills???

I should have used more sunscreen

Our first day was hilly

The second day was more hilly, and much farther!!

Michelle enjoying Rwanda

Michelle is smiling all the time and very happy to be 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… 

Michelle, still gorgeous after 30 hours of travel

The simulation centre - lots of work to do!

Entrance to simulation centre on the grounds of CHUK

smooth sailing for day one

The second SAFE Obstetric Anesthesia Course started yesterday.  The first day ran much more smoothly than last week.  We know what is needed and are ready.  The participants have been incredible: 100% of people who were supposed to come last week arrived, fully participated in the course, and completed course evaluations. Again, 100% scheduled for the second week have arrived. 

The participants and faculty have been very happy with the program.  Initially people are shy but soon jump into role-playing and skills demonstrations in scenarios. 

The faculty and participants have greatly enjoyed meeting colleagues from around Rwanda.  These personal connections are so valuable and will form the basis of the Anesthesia Practice Network.

Preparing materials for SAFE Course round 2

Gaston practicing "giving an interactive presentation" in the Training of Trainers Course

Angela demonstrates the Universal Anesthesia Machine

Adolphe and Alex practice difficult intubation facilitated by bougie

The Calm before the Storm--TAKE TWO

I had a nice relaxing weekend in Kigali in order to prepare myself for Round 2 of the SAFE Course.  I decided not to go to Gisenyi with Patty and Megan as I wanted some time to regroup and relax before gearing up for this week.

Teaching the WHO Surgical Safety Checklist at Kibagabaga

This morning I accompanied Angela Enright and Sarah Kessler (from Lifebox) to Kibagabaga to help with some Surgical Safety Checklist Training. For those of you who are not aware, Kibagabaga is a district hospital in Kigali and has been selected as a the site to pilot the surgical safety checklist in Rwanda.  Sophie Reshamwalla (from Lifebox) and Beth Riviello have spent endless hours at this hospital teaching the staff about the importance of the checklist and working on local implementation. The process has not been easy but I am confident they will be successful.

Angela Enright with the Rwandan Anesthesia Residents on academic day

After leaving Kibagabaga, we stopped by CHUK so that Angela could visit. She had not been back to CHUK in several years and was eager to see all of the changes.  She was quite impressed with the new operating rooms and all that had been accomplished over the past 5 years. I had the privilege of introducing her to the anesthesia residents at academic day.  Without her initiative and efforts, anesthesia in Rwanda would not be where it is today.   She is actually one of the founders of the Rwandan Anesthesia Residency program.

There is no problem that a nice cup of tea will not solve.

Simulation using  the Universal Anesthesia Machine (UAM)

This afternoon, we arrived back in Rwamagana at our home away from home "The Dereva Hotel" to start our preparations for this week's SAFE Course.   Now that we had one course under our belt, we know what we need to do to get organized.  Despite a new crew of local faculty and participants, we are confident that this course will be even more successful than last week's.

Stay tuned.....

by the shores of Lake Kivu

Faye has already given a great description of the SAFE Course.  As difficult as it was to keep it all together, the course ran smoothly and many people commented that they had never attended such a well-organized program.  They did not think it was possible to teach without power points, so were surprised they could learn so much by interactive teaching and learning.  One woman told me, “I used to think anesthesia was boring but now I want to read and learn”. 

Megan and I traveled to Gisenyi this weekend for a much needed break. She had been in Rwanda for nearly a week and had only see the inside of the Dereva Hotel.  We traveled with my son, Alex, and Emmy.  Emmy is our supreme driver and friend.  He gave Megan some background on the land of a thousand hills.  There has been plenty of rain recently, so the countryside is brilliant green.   Each year the roads are better than the previous year.  Now there are highway signs!  The country looks great.

The four of us had lunch at by the beach at the Serena hotel and relaxed.  Then Megan and I went to Paradis Malahide but Alex and Emmy traveled back to Ruhengeri so Alex could visit the gorillas the next day.  We rested by the water and watched the fishing boats heading out for a night of fishing on Lake Kivu.  The men sing as they paddle out.  That evening we had dinner by the fire pit in the lodge and watched a performance by a group of highly energetic traditional Rwandan dancers.  The drummer was seriously talented. 

 

After a delicious breakfast on the shores of Lake Kivu, Megan and I travelled back to Kigali and spent the afternoon at the Serena Hotel revising plans for the SAFE Course this week. Sender, our surgical friend from McGill, arrived yesterday.  Our big group gathered again for a fine dinner at Khana Khazana.  Today it’s back to work at the Dereva Hotel in Rwamagana…

The Inaugural SAFE Obstetrical Anesthesia Course in Rwanda: We Did It !!!

It is hard to believe it,  but the inaugural SAFE Obstetrical Anesthesia Course in Rwanda is now officially over.  I apologize for not having blogged sooner,  but this week has been a big blur.  Everyday was packed full of teaching, workshops, planning for the next day, and just talking with our fellow Rwandan anesthesia colleagues about how to improve the quality and safety of anesthesia in Rwanda.  After over a year of planning, I can't believe we pulled it off.  It is truly amazing and would have been impossible without everyone's hard work and commitment.

I thought I might give a brief summary of the week.  Monday night the participants arrived at the Dereva Hotel in Rwamagana.  Despite visiting the hotel last year, I was somewhat apprehensive of the hotel's ability to host the course and whether they could pull it off.  Realistically it was our best option.  I was pleasantly surprised...  the hotel was incredibly accommodating and the service by the staff far exceeded my expectations.  Everyone was incredibly kind and eager to help.  It was great!

Tuesday,  the day was devoted to a train-the-trainer course for 12 participants who had been selected as future SAFE Course trainers and the remaining 50 or so participants participated in Building Safe Teams which focused on communication and  teamwork skills.

Teaching Surgical Airway skills

Neonatal resuscitation with neo Natalie

Simulating Maternal Trauma

Wednesday started the official SAFE Course.   We began the day with a pretest (both obstetrical anesthesia knowledge and skills). The day was then divided into a few didactic lectures that would last approximately 30 minutes, and the remainder of the day was built around small group workshops with 6-8 individuals.  Topics included obstetrical anesthesia issues such as: spinal anesthesia (how to improve your blocks), benefits of spinal anesthesia, rapid sequence induction, surgical cricothyroidotomy, hemorrhage, preeclampsia, neonatal resuscitation etc.   The workshops were either a discussion, development of a skill, or working through a scenario with a discussion to follow.

Woon Cho  our official timekeeper!

Thursday and Friday were more of the same with the day starting at 8:00 and concluding around 5:00  At the completion of the course we had the participants repeat the skills and knowledge test.  It was amazing to see all that they had learned.  I had the opportunity to  teach neonatal resuscitation and run the skills test in neonatal resuscitation.  It was great to see how much their knowledge and skills improved with the workshops.

The course concluded Friday evening with a wonderful banquet celebration.  Every participant and trainer received a course certificate.  In addition, delegates were given lifeboxes to bring back to their district hospitals.  At the end of the SAFE Obstetrical Anesthesia Course, we will have successfully distributed lifeboxes to every operating room in 20 of the 45 district hospitals.

The week has just been amazing!  Looking forward to a little R&R this weekend before starting all over again on monday for the second round.

xo

Our youngest participant

a passion for learning

Today was the third day of the SAFE Course.  Each week we are training twelve anesthesia residents or technicians in teaching methods.  The trainers had a one-day course at the beginning and have been paired with faculty members for all the small group sessions.  Each session is run four times with a different group of participants, so the trainers keep taking more responsibility for the session. They are bright and keen to teach.  It has been completely inspiring to watch them jump into teaching with such enthusiasm.   They truly rise to the occasion. 

Many people have commented on how wonderful it is to meet colleagues from around Rwanda.  Some people work in very isolated settings.  One technician told me that she has no help in providing anesthesia.  If she needs cricoid pressure for intubation, she has to ask one of the cleaners. 

We’ve had very positive feedback on the course.  One of the teachers commented that he expected to find people sleeping after lunch but instead saw everyone engaged with the program.  It helps so much that most of the sessions are outdoors in fresh air.

Dr. Enright running a scenario

This is the supreme gazebo.

Benjamin teaching about sepsis.

No Powerpoints....No Problem

After over 1 year of preparation, it was an amazing first day.  The first day of the course was really a prelude to the SAFE course. 12 participants participated in a train-the-trainers course which focused on skills to be a better teacher and the remainder of the group participated in “ Building Safe Teams.”  The buzz word for the day was  “communication.”  How do you communicate better with your students, anesthesia colleagues, and colleagues in the operating room.  Topics included such things as Non-technical skills, an Introduction to the WHO Surgical Safety Checklist, the Universal Anesthesia Machine, Life Box Pulse Oximetry and more.

Week 1 SAFE Course Participants

Since the majority of the participants prefer french as their primary language, discussions were conducted in French, English, Kinyarwanda, or some combination of the three.  For those of you wondering about my language skills, English is definitely my preferred language so I clearly had some help.

Sophie from Lifebox explaining the WHO Surgical Safety  Checklist

Despite all the preparation and three different projectors, we were unable to display our slides for our WHO Surgical  Safety checklist presentation (there were only a few) but it just didn’t matter.  Willy, one of the local Rwandan faculty, moderated the session and it was absolutely amazing.   He did a brief overview of the importance of the Checklist in patient safety and we then demonstrated how to perform the checklist by acting out various scenarios . It was quite humorous but also very effective. The audience really enjoyed it and asked great questions. 

Much of the equipment I brought over from the US including the mannequins, ambu bags, and criocothyroidotomy trainers are finally going to good use.  A special thanks to all who donated.  I am very appreciative of everyone who has donated their time and energy into developing this course.  It is hard to believe it is actually happening.  Very exciting….

2 broken projectors.  The 3rd one sort of worked:)

Cricothyroidotomy from Synatomy. Very lifelike!

The day finished with what turned into a 2 1/2  hour discussion with several of the participants about the Anesthetic considerations for Cleft Lip an Palate surgery.    Smile Train asked me if I could provide some additional training in this area for some select individuals from these four district  hospitals.   A special thanks to Paulin who helped me give this lecture as 1/2 of our audience spoke English and the other 1/2 only french.   From their questions, I realized how fortunate I am to have the resources available at home to take care of my patients.  Despite their excellent knowledge, the lack of anesthetic equipment and medications makes caring for children in Rwanda incredibly challenging.

Stay tuned for Day 2 but really the first day of the SAFE Obstetrical Anesthesia Course…..It is going to be another crazy day

we ran on time!

Today was the first day of the SAFE Course.  After one year of planning, we finally launched the baby.  It exceeded expectations.  We have a great facility at the Dereva Hotel.  It is a peaceful setting where the only outside sounds are from birds.  Most of the sessions are outdoors in gazebos, so there's lots of fresh air and light.  Even though we had little time for the Rwandan and visiting faculties to prepare together, we still managed to adapt to what was required.  

The whole day has involved lots of hands on, interactive teaching.  We've been running scenarios with role-play and teaching hands on skills.

Megan, who works with me in Halifax, has been a stellar course coordinator.  Who would have believed that we could run on time?? Megan has had to deal with many unexpected events, such as participants showing up with young children.   

We are all exhausted and working full out, so this will be brief.