Teaching

Our teaching comes in many forms here in Rwanda. Each day begins with Morning Report from 7-8am. We start with handover of the previous night's cases on call, then review one or two interesting cases that are planned for the operating room that day. For example, today we had a case of a 5 month old infant girl who has pretty much been vomiting since birth. She weighs only 2.5 kg and is severely malnourished. She has been diagnosed with achalasia, a thickening of the muscle around the esophagus, basically squeezing it almost closed. The surgery will be to cut out some of the thickened muscle (myomectomy). Patty and I lead the discussion, and the residents (3 or 4 of them) and the anesthetic techs (maybe 20 of them) suggest various concerns that can be identified about the case, come up with a problem list, then we review the anesthetic considerations of a pertinent part of the case, such as general considerations for pediatric anesthesia. Finally, we come up with a plan.

The difficult cases are often booked first, so after this discussion everyone disperses to their various operating rooms. These cases generally go much more smoothly than I expect, because each aspect of the anesthetic is carefully planned, and all members of the team are

on the same page as to what we're doing. Morning report is an important part of our teaching here because it involves both the anesthesia technicians as well as the residents and local staff anesthesiologists. It also keeps us on our toes, because the topic of the day could be anything under the sun, and we not only have to identify the important teaching points, but also come up with a discussion of the anesthetic considerations without any preparation!

One day a week is devoted to an academic day with the residents. Both Patty and I give an lecture on a pre-arranged topic (we are doing endocrine diseases this month), a resident gives a presentation, and we finish with a case discussion. We try to make these as interactive as possible, with lots of questions, and lots of diagrams of various physiological mechanisms.

On Tuesday afternoons we give talks to the anesthetic technician students. This is a 3-year program out of high school that trains technicians to provide anesthesia care for 80-90% of surgeries in Rwanda. There is an extreme shortage of anesthesiologists - only 11 for 9 million people. The training that the technicians receive is largely based on practical skills, with very little discussion of the physiology and pharmacology that guides our practice. They have a few guest lectures per year from the anesthesiologists at CHUK, the main public tertiary care hospital in Rwanda, but the anesthesiologists are so overworked that they rarely have time.

We are doing a 3-session talk to pain management - they anatomy and physiology of pain mechanisms, diagnosis, treatment, etc. We are trying to identify barriers to good

treatment in Rwanda, where they don't even have oral morphine. Cancer patients have no access to chemo or radiotherapy, and are left to die slowly at home with no pain medication beyond ibuprofen and tylenol. The concept of palliative care here needs a great deal of improvement.

We very much enjoy teaching the anesthesia tech students: they are keen, attentive, and ask interested questions. Also, they are very grateful for any extra teaching provided.

But all is not sunshine and roses here in Rwanda. The residents in all specialties, not just anesthesia, have not been paid in 2 months. Something with the government, although I'm not sure what. Most of them have families, with up to 4 children - I'm don't know how they are able to manage.