to do more and take more responsibility during the procedures. It's
nice when you start to get to know to people working in the OR, and
Dr. Alfred, a second year resident in anesthesia, has been very
welcoming and generous with his teaching.
The ORs here are somewhere in between what I've seen at the national
hospital in Muhimbili and the ORs at Ifakara, in terms of equipment
and resources available. There are still things that I see in theatre
that make me cringe, but in general they're doing a pretty good job.
Beyond resource differences, the biggest change for me is in patient
autonomy. The doctoring here is behind the times in allowing the
patient to make their own decisions and is thus very paternalistic:
Doctor knows best. Unfortunately this manifests as a feeling that
doctors don't need to tell patients what the procedure is going to be
or what to expect during and afterwards, or even when they're going to
stick a needle in someone's back. Maybe these are luxuries in our
country? There must be some evidence out there that we achieve better
outcomes if we treat our patients as a member of the health care team
instead of a child who doesn't know any better. The nice thing is that
the training that the anesthesia residents are receiving is starting
to change this attitude.
CASIEF is Canada's Anesthesia society, and they've been sending staff
anesthetists and Canadian residents over to Rwanda to teach for the
past 5 years. During and after the genocide in 2005, only a single
anesthetist remained in Rwanda (I got to work with her for a day:
wonderful woman. The strength she must have is mind boggling). CASIEF
is trying to help by training Rwandan residents to the degree that
they will be able to take on the teaching themselves and become
self-sufficient. I think it is an exemplary program because it follows
the old "Teach a man to fish" adage. When my training is complete,
CASIEF's is the type of program with which I'd like to be involved.
I was lucky enough to see the program in action on Thursday
when Roger, a staff anesthetist from Australia, and Rob, a 4th year
resident at Dalhousie, came down to Butare for two days of teaching. I
had known that Rob was going to be there at the same time and had
briefly met him prior to departing, so it was nice to see a familiar
face half way around the world. They spent the morning in the OR with
the residents doing clinical teaching, the afternoon doing a short
didactic session and then a webcast seminar on pain. I was glad to see
the quality of teaching that CASIEF is putting together and also to
chat about the experience in the hospitals frankly and honestly with
people who share my frame of reference.
Just a couple of short anecdotes: On Wednesday, a little girl of 7
was brought into the OR for a repair of a broken forearm. They sat her
up on the table and starting getting everything ready for the surgery.
However, the anesthetists don't like to put the patient asleep until
they see the surgeon in the room and being the first case of the day,
we were waiting for about 30 minutes that morning (fairly typical wait
time). The little girl was just sitting on the table in the OR,
waiting for her surgery and no one was really talking to her. I pulled
out my pad of paper and a pen and started drawing animals for her. She
came back by drawing a house and a person and then oddly the 5 vowels.
The segue was apparently lost in translation, but we also covered
numbers up to twenty in English, which she was clearly quite proud of.
Dr. Alfred got in on the action and made a latex glove balloon person
to play with. Hopefully it helped take her mind off the scary room and
the throng of doctors with masks on for a few minutes. The nurses were
clearly amused.
On Thursday the surgery was to insert a big metal rod in someone's
fractured femur. The problem was that the rod they had was too long
for the woman's femur, so instead of scratching the surgery, as they
would in Canada no doubt, the large scrub nurse, dressed in sterile
gown and gloves, grabbed a massive pair of bolt cutters and started
going to town on this rod. Then he got out a hammer and started
wailing on the cut end of the rod so that it wasn't as sharp. It was
quite the sight to behold, but far better I think than for the
patient, who was awake with spinal anesthesia but unable to see the
spectacle. I can only imagine what she thought was going on, hearing
the massive crashes of a blacksmith's hammer in the OR.
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