Last summer, Jill Lanahan, MD, of the BWH Department of Anesthesiology, Perioperative and Pain Medicine, departed for Rwanda to train residents at King Faisal Hospital in the country’s capital, Kigali, for one year. The outreach is part of the Human Resources for Health Program, a collaborative, seven-year project between the Rwandan government, BWH, Harvard Medical School and more than 20 other academic institutions in the U.S.
BWH Bulletin recently interviewed Lanahan to hear about her experiences abroad.
How would you describe your time in Rwanda so far?
JL: I could not have anticipated how well-received I would be in Rwanda’s medical community. We have formed a multidisciplinary team of medical students, resident physicians, surgeons and anesthesiologists, with the goals of improving pain control for women in labor and for patients undergoing orthopaedic procedures. Pain is often undertreated in these settings, and by maximizing what we can do preoperatively and intraoperatively, I believe we can have a significant impact on postoperative pain control and patient satisfaction.
What are some of the challenges around providing anesthesia care in a setting with limited resources?
JL: Now more than ever, I realize how much I take for granted back home. For example, I never have to worry about not having a medicine that I need to safely provide anesthesia.
Treatment of pain with intravenous opioids never occurs on the wards here due to safety concerns caused by the lack of sufficient monitoring equipment. The use of local anesthetics, especially one called bupivacaine, has been essential to our project. We have developed protocols for injection of this drug by surgeons and anesthesiologists for select procedures. Recently, however, we had a month-long bupivacaine shortage. During that time, we were unable to offer regional anesthesia because any small amount we had left had to be saved for mothers undergoing cesarean sections.
In addition, many patients do not have the proper nutrition to heal. In Rwanda, food is not part of medical care, and patients’ families are required to supply it. For various reasons, families are often unable to do so. A project at the Centre Hospitalier Universitaire de Butare called “Growing Health” is trying to tackle this problem by cultivating a small farm on hospital land to grow food for patients. The crops they grow provide patients with two nutritious meals a day. Unfortunately, though, the farm can only produce enough food for about a third of the patients.
What kind of training have you helped provide?
JL: Last month, the hospital had a visit from Team Heart, a multidisciplinary team from the U.S. that promotes sustainability and excellence in cardiac care. It was an amazing experience for two second-year anesthesia residents, Servent Izabayo, MD, and Gerald Kirenga, MD, and me. BWH anesthesiologists Danny Muehlschlegel, MD, MMSc, and Martin Zammert, MD, along with BWH residents Jeffrey McLaren, MD, and Matt Swisher, MD, welcomed Servent and Gerald to their team.
The week consisted of complex heart surgeries, mostly valve operations in children and adults with rheumatic heart disease, which is rare in the U.S. The team truly went above and beyond by teaching our residents skills and imparting knowledge that will be used to provide anesthesia for complex cases throughout their careers.
Is there a need for training in others areas?
JL: Patient safety and communication are two areas where significant improvement is needed. At least two, if not three, languages are spoken during every procedure: Kinyarwanda, French and English. Also, the culture tends to be hierarchical, and there is a reluctance to question anyone higher in the chain of command, even if there may be an error.
Specific to anesthesiology, the vast majority of anesthesia care in the country is provided by technicians whose highest degree is a high school diploma, with minimal or no physician oversight. This is quite a different model from BWH, where every case is closely supervised.
Another struggle in anesthesia has been physician recruitment and retention. In recent years, some of the most promising doctors have gone to work for nongovernmental organizations, which are able to offer higher salaries.
Although I am looking forward to rejoining my colleagues at the BWH in August, it will be hard to leave Rwanda. It has been a privilege to teach the residents and care for patients. Hopefully, I’ll have an opportunity to return soon.