The Family Way

Tired of fighting a balance between work and home life?

Talk to Félicité Mukeshimana.  She’s an anaesthesia technician at a district hospital in Ruhango, a province in the south of Rwanda.


Félicité and Fiona in their finery

Félicité has two daughters – the first aged five, and the second, Fiona, two-months old and of course still nursing.  Nursing before the morning lecture.  Nursing at lunchtime.  Nursing in the evening during the dinner ceremony to celebrate the end of the first SAFE course last week.

They traveled together more than 100 miles by winding road from home to Rwamagana, Félicité in front and Fiona in back, surveying the world from her tightly bound sling.

Ruhango to Ramagana

“It’s important for us to be together and its important for me to be on the course,” Félicité explained, settling in to nurse.

They’re not the only traveling duo.  Several mothers and babies have checked in over the last ten days, and several pregnant women too.

Consolee Mukamugema_pregnanat at SAFE course

Consolee, an anaesthesia technician from Kibagabaga Hospital is glowing! But a four-day intensive training course is hardly putting your feet up

Félicité is the only person at her hospital with formal training in delivering anaesthesia.  There are some nurses who have learned how to step in at a pinch, but as the technician, Félicité ultimately bears responsibility for anaesthetizing, resuscitating and relieving pain for every single patient that comes to the door.

There are about 160 anaesthesia technicians in Rwanda, graduates of a three year training programme.  Medical anaesthetists are far fewer, and mainly to be found in the teaching hospitals and urban areas.  Technicians generally go to work in the rural hospitals, where they may be the only trained anaesthesia provider in the district.

They’re seeing late-presenting, complex cases, and these in droves – 38,000 emergency c-sections in 2011 and climbing.  Obstetrics is the single biggest caseload, and inevitably presents the bulk of complications.

Guheka_low res

The traditional guheka style of carrying babies is both practical and snug as a bug in a rug

Continuing education is essential. But education opportunities for anaesthesia technicians in Rwanda come around every – come to think of it, when was the last time you saw a blue moon?

And if a basic training course is rare, an opportunity like the SAFE Course and Lifebox training – four intensive days of practical work and relevant theory, addressing every possible complication, crisis and skill required to deliver safer obstetric anaesthesia, not to mention the distribution of essential equipment and CPD credits – well that’s never happened here before.

With all the logistics, time and financial support required, it’s not immediately clear when it will happen next.

So Félicité and her colleagues don’t have much choice: if they attend the training, their babies are coming too.

“I was a hospital nurse, but I trained as an anaesthesia technician so that I could help the surgeon to keep the patient safe, without pain,” Félicité told us, rocking the bundle in her arms. “I wanted to reduce pain.”

Fiona_lower res


Her daughter has the most perfect little rosebud baby mouth, and it’s mewling softly.  She’s been so quite all day, but she’s tired, she’s hungry, and it’s late.

The SAFE course is too good an opportunity to miss – but you know, we know, Félicité knows – good grief, it really isn’t easy.


Change we can believe in

Did you know that in 2006 the Rwandan government banned plastic bags in the capital city of Kigali?

Airport contraband

(Spot the rookie at the airport, sheepishly jettisoning contraband.)

Today the grass, unpocked with litter, is buena vista green. Thanks to the civic and environmental efforts of the last few years, Kigali is one of the cleanest cities you could hope to visit.


Another fact about Rwanda in 2006: did you know that at the time there was just one single medical anaesthetist, Dr. Jeanne D’Arc Uwambazimana, in the entire country?

Today, there are 20.

Thanks to a collaborative, empathetic and energetic partnership between the National University of Rwanda (NUR), the Kigali Health Institute (KHI) and the Canadian Anesthesiologists’ Society International Education Foundation (CAS IEF), an anaesthesia residency programme was set up. The Rwanda Society of Anaesthesiologists (RSA) has  now been formally acknowledged by the government as an official organization, with an important role to play in the ongoing improvement of Rwandan healthcare.

Anaesthesia residents

Anaesthesia residents are training in Rwanda for the first time

Such dramatic changes, in such a short amount of time – it’s easy to invest them with symbolism.  A city in healing from the appalling atrocities that took over its streets; a profession long-marginalized that has raised its profile twenty-fold.

But forget symbolism and consider practical impact: this beautiful city that people are pleased and proud to live in; those countless lives that have been saved through increased access to safe anaesthesia.

Certainly surgery is still a critical healthcare concern in Rwanda, but it’s a damn sight better than it was ten years ago.  And it’s against this optimistic background that #SAFERwanda came to town!

knowledge test

There are so many exceptional organizations and individuals involved in delivering this rigorous programme, that they really need their own background stories told.

Luckily, Lifebox can fill you in here.

Patty Livingstone
Faye Evans

And here!

Drs Patty Livingstone, left, and Faye Evans, right (who you might remember from her role in the Georgia Society of Anesthesiologists’ runaway-success Make It 0 campaign for Lifebox) have been blogging about their work in getting  the SAFE Course up and running in Rwanda since they arrived in the country several weeks ago.

It’s a great behind-the-scenes insight into hosting a course like this.  (Step one: begin more than a year ago.)

Week 1 participants

Week one participants at the SAFE Course in Rwamagana

But the whirlwind really picked up speed (cc: “The Calm Before the Storm“) last Monday, with the arrival of 55 anaesthesia techs, residents and consultants from 13 district hospitals across the country.

Also on the guest list: two Universal Anaesthesia Machines (UAM) donated by Gradian Health Systems


Sun sets, electricity fails – the UAM keeps working

…and 90 Lifebox pulse oximeters, part of an incredible 250 units donated by members of CAS to Rwanda.  That’s enough oximeter for distribution to every single operating room and recovery setting at the district hospitals currently delivering surgery without this essential monitoring.

Lifebox oximeters for donation

The road to safe anaesthesia is paved with pulse oximeters

So the first SAFE Course thundered by, four days of well-ordered breakfast, equipment training, communication, reflection, pre-test, lunch, airway assessment, cricothyroidotomoy, reflection, lunch, simulation, post-test, neonatal resuscitation, ruptured uterus, questions, cord prolapse, malaria, etc, English, French, Kinyarwandan, dinner, birdsong, and breakfast again.

And here we are, Tuesday morning, and ready for round two…

The second group of anaesthesia providers began arriving last night, fired up by reports from their friends who attended last week. (“Not boring!” – what higher praise?)


It’s exciting to think about the first group, back at work and scattered around the country.

This morning they’re checking their anaesthetic machines and charging their pulse oximeters.  Hopefully they feel a little more prepared for whatever obstetric emergency rolls through the door next, and energized to know that their colleagues in anaesthesia worldwide are proud to stand with them – in symbol, and in practice.

Riddle me this:

What do you call an operation that saves two lives at once?

A caesarean section.

No need to be witty when you’re one of the greatest surgical priorities for healthcare in low-resource settings.  An emergency c-section is the most common major procedure in Sub-Saharan Africa: in Rwanda, for example, 2011 saw more than 38,000 urgently undertaken, as opposed to less than 2000 planned.

Safely deliver a struggling baby from a mother, locked in obstructed labour for days and deadly weary, and with one operation you’ve pulled two lives back from certain brink.

Safe delivery_Good News Hospital_Madagascar

Safe delivery at the Good News Hospital in Madagascar

But those are the good stories – the truth is, carrying a baby to term and making it to the door of a hospital is still no guarantee of safe delivery.  Lack of resources, training and support can make surgery in low-resource settings dangerous, particularly in the rural areas – and that’s before you factor in complex resuscitations, post partum haemorrhage, and conditions far more advanced than would ever be seen in a hospital in a high-resource setting.

In Sub-Saharan Africa, “most deaths are avoidable and one-third are attributable to anaesthesia.” (Dyer, Reed, & James, 2010.)

Simply put, the operation that should save the mother and baby may become the very thing that needlessly ends it.

neonatal probe_baby foot

Neonatal monitoring at the University Teaching Hospital of Kigali, Rwanda

Today marks another landmark on the road to changing this reality.

In Rwamangana, Rwanda, more than 60 anaesthesia providers have just finished the first day’s sessions – this very minute, in fact (the Lifebox blog has never felt so live!) – of day 1 at the SAFE Obstetrical Anaesthesia course.

SAFE snapshot

Led by faculty from the Rwanda Society of Anesthetists (RSA) and the Canadian Anesthesiologists’ Society International Education Foundation (CAS IEF), the course is supported by the Rwanda Ministry of Health and the World Federation of Societies of Anaesthesiologists (WFSA).  It is designed to make a long term impact on the safety and quality of obstetric anaesthesia care.

Over the next few days attendees will develop their skills in obstetric anaesthesia, everything from routine procedures to resuscitation and crisis management.

They’ll flex and strengthen their capacity for teamwork in the operating room through the ‘Building SAFE Teams’ curriculum – confident communication and teamwork being essential for a safe OR, as we well know from the WHO Surgical Safety Checklist.

They’ll get training in how to use Gradian Health Systems’ Universal Anaesthesia Machine (UAM), which is specially designed for use in low-resource settings by a team that knows the importance of safe anaesthesia in safe obstetric care (see Gradian’s recent post on the subject at Every Mother Counts).

And they’ll leave with Lifebox pulse oximeters – enough, in fact, for every OR in the whole country!  Last year CAS led a Make It 0 campaign that succeeded beyond our wildest dreams (combined and totaled).   They raised funds for more than 250 oximeters for Rwanda, and we’ll be distributing them at the training course this week.

That’s right – we!  Lifebox is thrilled to be joining the team, and over the next few weeks we’ll be sharing photos, tweets (#SAFERwanda), blog posts and more.  The course repeats next week with another group of anaesthesia providers – so stand by…