Due to the NOTSS course, the academic day for anesthesia residents was moved from Monday to Tuesday morning. We spent another fantastic morning with the residents teaching each other and engaging in passionate discussions over the best way to do difficult cases. After the half day was finished, Margaret and I were picked up for our drive to Butare.

Butare (now named Huye) is in the Southern province and it takes about 2.5 hours to get there. It was the original intellectual seat of Rwanda – the university was founded there and the other main University Teaching Hospital (CHUB) is located there. While in Butare we stayed with the wonderful family of one of the anesthesiologists (who happened to be in Halifax of all places, so I did not get to meet him).  It was lovely to stay in a home with children and puppies and gardens and a wonderful host. It was a short trip to Butare due to the NOTSS course and the Good Friday holiday. But it was very worthwhile.

We had the opportunity to work the residents currently on rotation in Butare and also to meet Dr. I – the first and one of only 2 pediatric anesthesiologists in Rwanda (a third will be joining the team in the summer).

On our first morning, the resident was doing a pediatric case – a 9 month old for a routine procedure. He had an excellent plan and back up plan. Unfortunately, things did not go as planned and we ended up struggling for over an hour to keep the patient’s oxygen saturation up and stabilize him for the surgery. It was very stressful as I still don’t have a full grasp of the equipment here and I am always wondering in the back of my head if there is something I don’t about this  machine or this place that is causing the problem! We called Dr. I to come and help but he was running a code somewhere else in the hospital! We finally managed to get the patient on the right track. Upon review, we can only assume the patient had a cold that hadn’t declared itself and definitely a component of reactive airway disease. But this was a much more dire situation than I would normally experience at home. Many things may have contributed: perhaps malnutrition played a role, perhaps the pre-op assessment hadn’t elicited important details, and perhaps the anesthetic we chose based on the available resources wasn’t the best choice.

It was yet another sobering experience for me. The patient did well – he tolerated our anesthetic and recovered well, although it was a lengthy recovery. But I am wondering why I have seen and heard of so many adverse events in pediatric patients here. It is true there is a high proportion of pediatric patients, but the anesthesia residents have strong skills and good plans.

Is it possible our most vulnerable patients are more susceptible to the extra challenges that anesthesia in a variable context imposes. And if this is so, how can we improve our care?