Rwanda is home to more than 12.3 million people. With almost 30 anesthesiologists for the whole country, majority of the anesthesia is provided by nurse anesthetists. Majority of the anesthesiologists work in the main referral and teaching hospitals (about 4 facilities) in Rwanda.  The nurse anesthesia training started in 1997 as an advance diploma course. Since then training opportunities for nurse anesthetists have been upgraded to Bachelor of Science level. The nurse anesthetists work in fifty hospitals across Rwanda, providing safe anesthesia for all surgical cases including pediatric and geriatric cases. These non-physician anesthetists work independently mainly in rural facilities where the staffing levels for anesthetists remain low. This insufficient number of trained anesthetists remains a significant barrier to safe surgery and the well-being of the non-physician anesthetists working in those locations. Burnout is a common occurrence.

“Investing in scaling up the training opportunities and quality of training for non-physician anesthetists will be extremely beneficial to the patients and to the country. Patients in rural areas depend on NPAs. Training them will not only enhance safe anesthesia but expand access to surgical services to patients where they need it most! We also need to develop strong research skills and practice for NPAs. We need data to inform efforts to improve our practice”

 Jean Damascene Gasasira

Gilles E. Rwibuka MSc. President ATSARPS

The Kenya Registered Nurse Anesthetists (KRNA) Chapter is hosting the 1st Pan African Nurse Anesthetists Conference (PANAC 2020) in June 2020. To promote diversity and multi-country representation at this event, the KRNA chapter is building bridges with like-minded associations on the continent. One such organization is Agora des Techniciens Supérieurs Anesthésistes Réanimateurs pour la Promotion de la Santé or ATSARPS, in short from Burundi, East Africa. This organization is led by Gilles Eloi Rwibuka, MSc. He provided some feedback on the practice of anesthesia in his country 

KRNA: What does anesthesia practice look like in your country? 

Gilles: Anaesthesia practice in Burundi is dominated by NPAs (Non-Physician Anesthetists) providing more than 95% of the services. We have only 7 physician anesthesiologists[1] with an estimated 600-800 NPAs who practice independently.

KRNA: How do non-physician anesthetists get trained in your country? 

Gilles: Anesthesia education for NPAs is a three-year (previously a 4-year program changed to meet the 2012 BMD system) Bachelor of Sciences degree in Anesthesia and Resuscitation. Entry to this program is open to candidates who have more than 50% in both High School and State Certification exams. There are currently no postgraduate programs in Burundi. ATSARPS is working to start one. They are exploring various options including training models from the IFNA Master Curriculum program, Association of Anesthetists (formerly AAGBI), and Bahir Dar (Ethiopia) Master Curriculum program. This work is being done in partnership with the Burundi Ministry of Higher Education and the Ministry of Health

KRNA: What challenges do you face in your practice? 

Gilles: Several challenges exist. One is the lack of recognition of anesthesia as a great domain of interest compared to other medical specialties by those interested in pursuing a career in health. Anesthetists also lack adequate equipment; items like defibrillators are missing in many hospitals, especially in the OR which puts patient safety at risk. They have a 50% chance of survival when they need resuscitation; I mean it is either a non-shockable rhythm “50%” (CPR) or a shockable rhythm “50%”. This is a big issue in Burundi.

KRNA: What is the highlight of your practice so far?

Gilles: Being able to complete my BSc in Anesthesia and Resuscitation and practice anesthesia as part of the surgical team. In anesthesia practice, there may be a simple procedure requiring anesthesia but there is never simple anesthesia. An example is a case I had during my training; an OR nurse was going to perform a tooth extraction (considered as a simple procedure) on an adult male patient of ±40 years old. The nurse used lidocaine as an anesthetic. At that point, he was alone with no assistant or a senior surgeon. Shortly after the injection, the patient developed acute toxicity to lidocaine, where his neurological and cardiovascular systems both showed signs of acute depressions. The OR nurse panicked at that moment, and fortunately, I was entering the OR when the signs were developing. (As for a reminder, the patient would have developed seizures, arrhythmia leading to cardiac arrest and eventually to death if nothing was done properly and timely.)

The ABCD approach I studied in the anesthesia academic program helped me manage the case by ensuring airways patency (A) and oxygen was given (B), the OR nurse taking an IV line at the same time (C), a blood sample was taken and IV fluids given. The level of consciousness was assessed (D), the patient was on the U of the AVPU rapid scoring system, accompanied by signs of seizures. The rapidly available drug to protect his nervous system was Valium which was given, and the seizures stopped. On exposure (E), there were no findings. The patient was placed into the HDU (high dependency unit) after stabilization. He remained there for 16 hours and was discharged after full recovery of all his capacities.

After that case, I was glad I was able to use what I had learned in anesthesia to save a life. This case, and many like it, have deepened my focus in studying anesthesia and develop my skills to provide safe anesthesia for all.

[1] WFSA Workforce survey conducted in 2015/16 found that there were only 6 anesthesiologists and 328 non-physician anesthetists in Burundi serving a population of ten million citizens