Transitions

 Stage one complete and stage two begins!  The first key goal of this trip has been met. With my two colleagues representing the Royal College of Surgeons of Edinburgh, we successfully delivered two Basic Surgical Skills (BSS) courses in Rwanda over the past week, and I am now in Chitokoloki, Zambia. 

Each course ran over a busy 2-day period, and we trained a total of 36 junior surgeons. One of the consequences of COVID for surgical trainees has been that face-to-face training and conferences have been difficult or impossible to access, so some were accessing this course after a few years of previous surgical experience. Others were receiving these key principles near the beginning of their career journey. 

Participants and faculty celebrate the completion of the BSS course (1 of 2)

Our BSS course begins with the basics of surgical techniques: gowning, gloving and handling instruments. As one of our Rwandan faculty said to our students, surgeons have great responsibility in being the only profession given knife blades and permission to do harm with them! In days gone by, surgeons had little option but to learn and make their mistakes on patients. These days, simulation has a much more important role in the curriculum and the BSS in particular was established as a joint endeavour by the UK's Royal Colleges of Surgeons in 1994. In the UK, this course is typically taken by doctors in their first 2 years post-graduation and is a prelude to a surgical career. In Rwanda, surgeons typically start their formal training with significant experience, and when we started coming to Rwanda we wondered how relevant this basic training would be.

Back in 2016, we decided to formally explore these questions, and undertook a research study on the course*. We found that our course participants had completed an estimated average of 150 Caesarian sections before receiving their Basic Surgical Skills training. This was an anticipated finding since all new doctors in Rwanda are expected to be competent in this procedure. Despite this, our study found that before the course, only 47% of participants were forming hand-tied knots correctly, improving to 88% after the course. A number of other aspects of good practice in wound closure were found to be lacking and were significantly improved by the 2 days of intense tuition and practice. Confidence levels were also significantly boosted by the course and the trainee rated it as highly relevant to them.

After the building blocks of knotting and instrument handling are achieved, we rapidly move on to applying those skills in specific scenarios: skin closure, cyst and skin lesion excision, wound debridement, tendon repair, abdominal opening and closure, vascular patch repair and bowel anastomosis (joining two ends together). We also teach key emergency skills such as chest drain insertion and cricothyroidotomy (incision to create an airway at the front of the neck). This requires a huge amount of equipment and simulation material, including animal tissue (pigs and chickens!). The University of Rwanda has a well-equipped Simulation Centre in the site of the University Hospital of Kigali (CHUK) where our visiting team has also contributed equipment over the years. 

Lots of pre-course preparation required! Faculty working together to create one of our simulations

Back in 2015, David Sedgwick and I personally drove with our Rwandan colleague Dr Georges Ntakiyiruta to find the pigs and arrange their slaughter, then the faculty had to continually keep up with all the rapid changes in materal while also teaching the course. This year, we were very pleased to have the support of Mercy Kamukama from the Rwanda Surgical Society, who procured our animal tissues alongside other responsibilities. Dr Lynsey Forbes, Skill Centre Manager at the Royal College of Surgeons of Edinburgh worked alongside her Rwandan colleague Viviane to prepare and process our materials, which made a huge difference. The trainees were delighted to receive such intense supervision and progressed very well.

Lynsey and Viviane prove an excellent team!

We thoroughly enjoyed our time in Kigali and were sustained by friendship and lots of good food. Our guest house hosts provided a fresh fruit cocktail every morning that was a highlight: fresh pineapple, tree tomato, passion fruit, banana and papaya was washed down with some of Rwanda's delicious coffee. There were opportunities to link up with old friends from previous visits and on Sunday, enjoy fellowship at the St Etienne (Anglican) Cathedral where we were blessed by a warm welcome, vibrant music, and some excellent Bible teaching.

Kigali at night

 

Enjoying an outdoor breakfast together at Good News Guesthouse

During our stay, news came through of the death of HM The Queen. It felt a bit strange to process such a momentous transition point in British life while in the heat of Africa, but we were able to access updates, and watch the first speech of King Charles III. Our Rwandan friends were kind in passing on their condolences and in keeping with other Commonwealth countries, flags were at half-mast. The death of a 96 year old lady should not be a surprise, but after 70 years of one monarch, the change still comes as a shock. Immediately, passports are out of date (they begin "Her Britannic Majesty's Secretary of State...") and one seemingly unchanging feature of life is gone. I've joined many around the world in praying for her family and giving thanks for a long life of love and service, sustained by her own sincere Christian faith which she spoke about so clearly.

 

My arrival into Lusaka, Zambia was straightforward, and it was good to re-connect with Chitokoloki's pilot Chris Brundage. I had anticipated sharing a flight back to Chitokoloki (Chit) with Chris but since paperwork delays grounded Chit's light aircraft, I took a commercial flight up to Solwezi, the city of North-Western Province, and the journey continued by road. One of the long-term missionary workers, Steven Wallace, was kind enough to drive a nearly 1000km round trip yesterday to pick me up! It is good to be back but feeling very strange to be here without Jess.
 

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* For those who want to check out the article, it was published as: "The Basic Surgical Skills Course in Sub-Saharan Africa: An Observational Study of Effectiveness. Fergusson SJ, Sedgwick DM, Ntakiyiruta G, Ntirenganya F. World J Surg. 2017. DOI 10.1007/s00268-017-4274-2."