Improving Anesthesia in Rwanda, with Passion and Patience

Emily Nelson visits one of the wards at Butaro Hospital, Rwanda.

Barefoot farming injuries and falls from avocado trees quickly became part of the clinical landscape for Emily Nelson, MD, when she left the Brigham for Butaro Hospital in rural Rwanda.

An attending anesthesiologist at BWH, Nelson discussed her experiences at the "Brigham Global Anesthesia Hour" on March 6. Nelson and husband Josh Lamb, MD, an orthopedic surgeon at Beth Israel Deaconess Medical Center, spent October 2011-October 2012 with Partners In Health working at Butaro Hospital, located in northern Rwanda by the Ugandan border. Rwanda has a critical shortage of healthcare providers--the entire country has only 13 anesthesiologists, in contrast with more than 140 at BWH alone, and rates of avoidable anesthesia-related deaths are 100 to 1000 times higher in developing countries such as Rwanda. 

Working at Butaro Hospital was an exciting way for Nelson to learn about a new part of the world as well as give back to it. "I didn't know exactly what my role would be," said Nelson.  "I was taught that to be most effective in global health, one should watch and listen and adopt the role most needed by local care providers."

At Butaro, Nelson's projects included creating a system to ensure oxygen availability and teaching nurses about monitoring patients for post-surgical complications.  "Some of these projects may seem quite basic, or like projects that could be accomplished in a few days," Nelson said. "That's what I thought, until I tried to start implementing them!"

Among Nelson's most well-received projects was introducing nerve blocks, which involve injecting a local anesthetic near a nerve in order to eliminate feeling in a particular part of the body. Nerve blocks quickly became a popular form of anesthesia at Butaro. Nelson found patients often had a fear of general anesthesia and concerns that their limbs would be amputated or they would pass away while they were unconscious. Being conscious during an operation reduced their fear. Nerve blocks also allowed patients to continue breathing unassisted, so clinicians at Butaro did not have to place breathing tubes or manage the patient's breathing, making regional anesthesia safer in this setting.

One of Emily Nelson’s goals was to teach new anesthesia techniques to local clinicians.

When Nelson first arrived, one project she contemplated was providing pain relief for childbirth. But she ultimately abandoned the idea after observing that Rwandan women in labor were very stoic, and patients and health care providers she spoke with showed little interest in this service. An important lesson Nelson learned during her time at Butaro was to focus her energy on projects local staff identified as priorities, as this ensured support and increased the likelihood of success.

"Health care professionals can do great work on short-term projects," said Nelson. "I feel like I am a much better anesthesiologist after my time in Rwanda. I came home with better clinical skills in areas like physical exams and resuscitation, and being in such a different environment encouraged me to develop my creativity and flexibility. I gained a new perspective on death and dying thanks to my Rwandan colleagues, and I deeply admire the care they provided to patients.  There are people all over the world with no access to life-saving surgical procedures.  I am fortunate I had the opportunity to help, and thankful for everything I learned while I was in Rwanda."