Telemedicine Program Gives U.S. Doctors Glimpse of Care in Rwanda—and Vice Versa

Typical OR in Rwanda.

The patient was in terrible shape. She had been stabbed by her husband in the neck and had lost her voice, indicating the knife had gone through her airway. Air was rushing the wound. The biggest concern for the anesthesiologist on duty was to find a way to secure the woman’s airway during surgery, knowing that placing a breathing tube down her throat might worsen the injury.
But this wasn’t Europe or North America. It was Rwanda. It took the patient three days to get to the hospital because she lived so far away. And there was no fiber-optic endoscope to perform intubation and to examine her vocal cords. The hospital did not even have a range of anesthetics at hand—only halothane.
This summer, Marcel Durieux, MD, PhD, and a group of anesthesia residents at the University of Virginia (UVA) sat quietly around a rectangular table in a windowless conference room, listening to anesthesia residents in Rwanda describe the patient—part of a new program in which residents on either side of the globe schedule monthly teleconferences to consult on difficult cases.

The program, which began about eight months ago, helps both groups of doctors, said Dr. Durieux, professor of

anesthesiology at UVA, in Charlottesville. Medical residents in the United States learn creative ways to deal with cases without the latest tools of modern medicine, and Rwandan residents obtain additional training.

“The whole country has 11 anesthesiologists, and it’s just not enough to train more residents,” Dr. Durieux told Anesthesiology News. “It’s difficult for us to understand how isolated physicians in developing countries tend to work. You may not have Internet access; you cannot go to conferences; you cannot subscribe to journals.”

Residents in the United States, on the other hand, constantly are learning from cases and encountering new tools and practices. “Anything we can do to break that isolation [Rwandan doctors face], to exchange ideas and discuss complex cases, both sides will learn from,” Dr. Durieux said.

Although the UVA telemedicine program performs distance medicine for rural Virginia and other locations, Dr. Durieux said it is the first anesthesiology telemedicine program for Africa. The group patterned it after a similar program set up by UVA surgeons.

 Alternating Perspectives

During the calls, both sides take turns. One month, Rwandan doctors present a case; the following month, it’s the U.S. residents’ turn. They try to pick cases that might happen in Rwanda and include technology the doctors might one day have access to. For instance, earlier this year, the American team described a closed head injury they managed using an arterial line, IVs and a computed tomography scan. Clinicians reviewed how they dealt with a patient experiencing increased intracranial pressure, indicating bleeding inside the brain. “They may not be able to do all this now, but at least it gets them thinking about what they would do if more money becomes available, and their system gets upgraded,” Dr. Durieux said.

But international residents have a few resources doctors here don’t, noted Jennifer O’Flaherty, MD, MPH, associate professor of anesthesiology and pediatrics at Dartmouth-Hitchcock Medical Center, in Lebanon, N.H. For instance, many other countries have IV tramadol and IV acetaminophen, which are rare in the United States. “I don’t know of any similar programs” that enable anesthesiologists from other countries to discuss cases they managed with local resources, added Dr. O’Flaherty, who is not involved in the telemedicine effort but works with Dr. Durieux on a separate project to boost Rwanda’s capacity to train residents, including in anesthesiology (http://hrhconsortium.moh.gov.rw/​).

Indeed, although learning about new technologies and treatment options is helpful, the real benefit of the meeting comes from revisiting previous cases and decisions, said Julia Weinkauf, MD, a faculty member in the Department of Anesthesiology in the UVA Health System, who helped set up the telemedicine program. “The experience of verbalizing and even defending your rationale for a certain treatment plan is very valuable for any trainee, and the Rwandan residents don’t get this opportunity in many other areas of their training,” Dr. Weinkauf told Anesthesiology News.

Rwandan students have plenty of printed materials to learn from, added Dr. Weinkauf, who also is on the faculty of the Department of Anesthesia in the University Central Hospital of Kigali, in Rwanda. When international doctors and teachers give lectures and workshops, they frequently leave behind PowerPoint files, books, articles and other resources. “But what they need most is guidance and mentoring on how to become adult learners and mature, critically thinking, academic physicians,” she said.

But those are skills that every doctor needs to cultivate, so the Rwandan residents try to present cases they know their U.S. colleagues will benefit from, as well, Dr. Weinkauf said. The wounded trachea case, for instance: “Such a case is very infrequently seen in the United States, so it provoked some interesting discussion.”
Indeed, the U.S. residents asked many questions about the patient with the tracheal injury. “Each conference is scheduled for one hour, but in reality every single one has run over because there’s too much to talk about,” Dr. Durieux said. Would it be safe to attempt intubating the patient, or should she undergo an awake tracheostomy? What vascular access did you have? What fluids and blood products would you want to have available? In the end, the patient did have a tracheostomy, and was found to have esophageal damage as well. Fortunately, she survived.

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