End of Tour Report of Visit to University Hospitals in Both Kigali and Butare

6:20 PM 3/20/2007

End of Tour Report of visit to University Hospitals in both Kigali and Butare (Finucane).

To: Drs Angela Enright and Dr.Phil Bridenbaugh

Date of Arrival January 6th and date of Departure February 20th 2007

Introduction:

It was an honor and privilege to be given the opportunity to work in Kigali and Butare at the university hospitals. The staff and residents that I worked with were very pleasant and co-operative and were very keen to learn. Rwanda is a beautiful country and the people are very hard working and pleasant and treat visitors with great respect.

Operating room issues at CHUK

Seeing that there were few residents to teach in the OR I decided to take a close look at what was happening in the OR. I attended morning rounds most mornings and then went into the OR to help when needed and there were many occasions when it was needed. The morning rounds could be improved quite a bit perhaps even if we had a blackboard in the pre-op room. I did give some short presentations in English and I also provided a handout for their files. The quality of the assessments carried out by the nurse anesthetists (NA) was questionable because most patients were assigned ASA 1 status regardless of their state of health and many of these patients were seriously ill. Rarely was the Mallampati score greater than 1. Medications or allergies were rarely recorded on the file and we never knew the patients’ weight or height.

Operating room starts were very unpredictable. On Mondays only emergencies and occasional add-ons were done. On Tuesdays when the OR was supposed to be in full swing there were frequent delays and there were many different reasons for the delays. One day there was a power failure; another day there was oxygen failure. One day the surgeons would not operate because they had not been paid. One morning there were no sterile drapes available.

One of the most efficient parts of the operation at CHUK was the ability to get the patient to the OR. Each morning I would do a tour of the OR and almost without fail patients were in the operating room before 07.30 however the skin was rarely cut before 08.30 on any morning.

There were 4 OR.s in CHUK and there was another OR in the pediatric area where ENT procedures were performed. The average number of cases we did in a day would be about 15 between the 5 ORs. Many of these cases were children. The most common operation was fractured femur. We did a fair amount of ENT and gynecology and of course quite a lot of general surgery. Surgery for gastric outlet obstruction was also a common procedure. The reasons for this disease were not understood but one of the surgeons indicated that the incidence had increased since the Genocide. The Genocide has become a reference point for many happenings in Rwanda not surprisingly.

The anesthesia equipment was a problem, starting with the machines. The Glostavent machine is a great idea in theory but there are lots of problems with it. The engineer from England (Richard Tully) was there when I was there and overhauled most of the machines and did some good in-servicing. There are still of problems with the OMV vaporizer. There were several anecdotal reports of too much and too little halothane being delivered to patients especially during induction. It is well known that the output from vaporizers is increased at high altitude and the altitude in Kigali is around 9000 feet. I personally observed problems anesthetizing children during gas inductions. Even after 10 minutes of 4 % Halothane children were still responding to venipuncture. The OMV vaporizer is really designed for field anesthesia and if we are to continue to use them we need to be able to analyze how much halothane is being delivered. I suspect that with increased flow the output of these vaporizers would drop dramatically and perhaps the cases of overdose were related to high intraoperative ambient temperature when lower flows were being used. The low pressure alarm on the ventilator is a real problem and it goes off all the time and is very aggravating. The Glostavent machine does not allow one to apply PEEP and there is no bag on the machine which is quite disconcerting. I understand that Diamedica is working on a new and improved variation of the OMV and indeed I believe that they are updating many other features of the machine and that the new version of the machine will have a bag. We desperately need a reliable vaporizer.

The monitoring equipment in the OR is sadly lacking. We had only one functioning ET CO2 monitor when I was there. There were many days when I was informed that there was no monitoring at all in some of the rooms except manual blood pressure measuring devices. There is no blood pressure measuring equipment for children. This is a major problem that needs to be addressed urgently especially when we do not know how much vapor we are delivering,

I observed many different anesthesia techniques during my time here. One of the most frequently used techniques was heavy sedation with diazepam immediately preoperatively. Patients received up to 10 mg of diazepam immediately before induction. I have tried to stop this practice but only time will tell how the NAs will respond. The anesthetists do not seem to be aware of the respiratory depressant effects of diazepam and they were very surprised when I informed of the half life of diazepam in healthy young volunteers (20-40 hours). I did a morning rounds on the benzodiazepines. On the opposite end of the scale they use morphine very sparingly in the OR and seem to think that if fentanyl was used there was no need for morphine at all. Patients are charged for every item that is used in a case including the cost of drugs, IV equipment, halothane, etc. I actually tallied up how much a patient would be charged for items used when I was in Butare. The total cost was $33.00 US for a 1.5 hour operation done using an LMA with oxygen and halothane, therefore I would estimate that an hour of anesthesia costs about $20.00 US and patients are expected to pay these costs. This may explain the next problem I observed.

I noticed that from time to time an NA would be asked if he/she had any morphine and if so they would pass that morphine in a syringe that had been used on at least one other patient in that room. This happened a number of times and I asked Judy Nevett if this was happening in the Recovery Room and she concurred that it was. We then obtained WHO literature on Safe Injection Techniques and informed Dr.Panjat about this and then informed all of the nurse anesthetists about the problem and asked then not to do this anymore. To my knowledge this practice has ceased in Kigali. This also happens in Butare. On my most recent visit there I observed the same practice. I did not get a chance to inform Dr.Jeanne about this problem on my recent visit.

All patients must be extubated before leaving the OR. That takes a long time especially after 8 or 10 mgs of diazepam followed by a general anesthetic. The other problem we encountered in Kigali is that there is no neostigmine or other type of reversal agent and there will be none for 6 months. The only non-depolarizing NMB available is vecuronium. We are also short of naloxone and none of these drugs will be available for at least 6 months. There is a nerve stimulator available and even though we were told not to teach the NA anything that was not sustainable, I found that the nerve stimulator was very useful especially when patients were apneic at the end of the case. The NAs. blamed either the NMB or morphine if used when patients were not breathing at the end of a case and never considered that diazepam could be contributing in any way.

The turnover of the rooms was a bit of a problem because of the techniques used. However no one seemed very concerned about the turnover. There was never any pressure from any quarter to speed things up.

Judy Nevett has really focused on the problems in the recovery room but I would like to reinforce what Judy has said. The surveillance in PARR is negligible at best. There is no room and there is little if any monitoring. There were several examples of patients lying in pools of blood overnight only to be discovered in extremis the following morning. We had a recent example of that the last day I was there. A young man had had a laparotomy the previous night and was bleeding from the drainage site. When we saw him in the morning he was in hypovolemic shock with no recordable blood pressure. Fortunately we were able to resuscitate him. The nurse had called for help during the night shift but no one came. The anesthesia residents, when on call, cover ICU and Emergency as the well as the OR. This is a problem. No one seems to watch what happens in the PARR. Patients are dropped off there overnight and nothing happens until we get in the following morning. If you need an ICU bed at any time for an OR patient your chances are slim to none. Most of the patients in ICU are in extremis and the only way you get a bed is if someone dies. There were at least three anesthetic deaths whilst I was there, two of them in children. One child had a respiratory arrest following a dressing of a 15% burn. The other child died during a bronchoscopy for a FB removal, this was a one year old child. I tried to get the nurses to present the problem cases but they were very reluctant to do so.

There are no assignments of cases to the staff anesthesiologists but there is enough work to keep 3 anesthesiologists very busy most days. It was not clear what was expected of the volunteers in the OR. There was no question in my mind that the additional help provided by volunteers was needed and greatly appreciated but we need to be fully aware of the boundaries and what is expected of us.

Policies and Procedures and Committee structure

There are no Policies and Procedures in the OR at CHUK and I didn’t get a chance to review CHUB but I expect it is the same there. A recent Accrediting body from South Africa reviewed CHUK and the score they received was 26/100 and several critical areas were cited (copy enclosed) They desperately need Policies and Procedures especially when anesthesia is administered by non-MD providers who are for the most part unsupervised during the off-duty hours. I have drafted a beginning Policy and Procedure document which I have given to Dr.Panjat (appendix enclosed) and he is going to add to this document. There is an urgent need to form an OR committee to allow us to address the various deficiencies on an on-going basis. The current structure allows each group to work in isolation with little or no communication among the groups about problems that have far reaching effects on all parties involved (Anesthesia, Nursing, Surgery and Ancillary personnel)

Safety Issues

If the problems I observed in Kigali occurred in North America these ORs would be closed. It is not safe to give an anesthetic here. We do not have adequate monitoring to safely provide anesthesia for the patients. Even when monitoring equipment is available the NAs do not react to abnormal values. On several occasions I observed saturations well below critical values and the NAs did not seem concerned nor did they call for help. The reason the anesthetists do not respond to these problems is that they obviously are not aware of the implications of a low saturation and other issues. This is a reflection of inadequate training and not in any way related to a lack of interest on their part. Right main stem intubations occurred very frequently in the ORs especially in children. We do not have confidence in our anesthesia equipment. We have no idea how much halothane is being delivered to the patients.

In the time that I was there (6 weeks) two large tanks of oxygen fell in the operating room narrowly missing one of the nurses on one occasion and damaging a Glostavent machine on the other occasion. If either of those tanks ruptured it is likely that there would have been a fatality.

The anesthesia gases are not being scavenged. The Sharps buckets are hard to find and when found are usually loaded and never seem to be emptied. You will find unguarded needles on the floor in the operating and recovery room. Needles are used to vent the IV bags and are constantly falling on the floor. This system needs to be changed. The staff do not consistently make efforts to protect themselves or the patients against blood borne diseases. They do not always wear gloves when starting IVs or when performing airway management.

Hypothermia is a significant problem because of the high incidence of trauma yet there is no way of warming patients or indeed of monitoring hypothermia.

Pain relief

There is no concerted effort to provide pain relief for patients post-operatively. When the nurse anesthetist drops a patient off in Recovery, what ever pain relief that patient received in the OR is likely the only pain relief they will receive post-operativly. Ketamine could be used much more effectively as an analgesic in this setting and the combination of Ketamine and regional anesthesia would be very successful.

Regional Anesthesia

Regional Anesthesia is something to be promoted here mainly because of the lack of analgesia provided during all phases of anesthesia. I think we should make a concerted effort to perform peripheral nerve blocks on patients who are amenable to that therapy even when the patient is undergoing general anesthesia. A number of the procedures are not suitable for regional anesthesia alone but most patients will benefit from the analgesia obtained from a peripheral nerve block. I would like to suggest that we should adopt this approach routinely in future. I tried to do a Bier block on a patient in CHUK only to discover that they had no reliable tourniquet.