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After several months of planning, we are on the cusp of launching VAST in India. VAST is being piloted in Hyderabad, Telangana. It has been enabled by the organisation behind the scenes by Dr Gita Nath, the welcome by the team at the Care Institute of Health Sciences (CIHS) and the support of the WFSA.

We are hoping that the upcoming course will reflect VAST’s adaptability to different cultural and medical contexts, be of value to the course participants and help build the VAST Network of facilitators, as well as build capacity for simulation-based education more broadly.

Looking forward to reporting back on how the course goes!

Our team was invited to deliver the VAST in Addis Ababa, Ethiopia for a mixed group of anesthesia residents, NPAs, surgical trainees and nurses. This course stems from the ongoing link between CASIEF and anaesthesia training in Ethiopia. We had planned a two-day facilitator course, to prepare local leaders to run future courses, before launching into the VAST Course itself. We were delighted to find the local team had gathered the necessary equipment and arranged a bright, cheery space in the hospital simulation centre for the course.

We quickly recognized that we were working with a talented group of trainee facilitators: three strong women anesthesia department leaders (Mahder, Fetiya and Mahelet) and a senior resident (Destaalem). Before long, we were functioning as a well-practiced team and ready for the course proper.

The course participants had no experience with simulation other than using task trainers for skill acquisition. They were initially very quiet, and our team started wondering how the rest of the course would unfold. We did our best to create a supportive environment, used demonstration as much as needed, and encouraged translation to Amharic to be sure everyone understood. The inbuilt flexibility of simulation and the VAST scenario design was a great help. Soon people bought into the role-play and debriefings. Scenarios increased in complexity and on day three we saw some excellent performance in complex situations. Participant feedback was exceptional with many requests for “more often”, “include more of the team”, and “come again”.

 

Please see below a sample of the some of the comments and reflections on the course:

  • You have a great ability to make things easy, simple to understand
  • I am sure I will not forget most vital events, as they are imprinted in my memory
  • Non-technical skills will help the staff to do technical skills effectively
  • Please train other senior consultants and residents to change tradition which can also be continued by local trainers
  • It was interesting. Thank you for your time and energy. I hope you will come up with more training for us.

 

With 2018 behind us, it is with great excitement that the VAST team are looking forward to the opportunities and challenges that 2019 will present:

VAST Rwanda:

  • Non-technical skills study: With the support of a Dalhousie University research grantwe have been studying the impact of the course on non-technical skills. The initial measurements were made in August and September during the first four VAST Courses. We are currently inviting course participants back for a refresher course and to complete final performance measurements. We eagerly look forward to being able to synthesise the results from the trial.
  • Follow the exploits of Dr Livingston and her team of volunteers at http://simcentreopening.blogspot.com
  • VAST Simulation curriculum: The current Global Health Fellow at Dalhousie University (Dr Dave Rawson) is working closely with Dr Livingston and colleagues in Rwanda to develop a year-long simulation curriculum for first year anaesthesia trainees. The curriculum is an extrapolation of the VAST Course and utilises consistent principles of simulation-based education.

VAST expansion:

  • We are thrilled at the opportunity to potentially deliver VAST across a range of new settings during 2019
  • Current sites in the planning stages of delivery include Ethiopia, India, Fiji, Tanzania, Yukon
  • Stay tuned for updates as they unfold.

Thank you to all involved in the most recent VAST Course in Prince George, British Columbia. This is a fantastic moment for the team behind VAST, seeing it delivered in a drastically different setting. Please read Dr Patty Livingston’s reflections on the course. 

Prince George in November: crisp air, snow-covered ground crunching underfoot, evergreens, bright red berries and unique light – soft, almost mystical, with dramatic pinks and blues in the late afternoon. Nighttime moose encounters are a threat to drivers, who choose robust high-set trucks for safety.

Prince George is a hub for northern British Columbia. Fourteen years ago, the University of British Columbia established the Prince George medical school campus with the goal of preparing future doctors to serve in rural and northern communities. Previously, students trained in Vancouver and accustom to the big city context they rarely returned to the north. Now they learn in a setting that reflects the local needs. Trainees are often placed for extended periods in communities further afield, in small family practices in the interior and north. It was a rare and pleasant surprise to hear learners say their career aspiration is rural family medicine. We have come to Prince George to teach the Vital Anesthesia Simulation Training (VAST) Course.

Simulation-based health professional education is widespread in high-resource settings, but it typically requires expensive mannequins, a simulation laboratory and technical expertise to run the equipment. The innovation of VAST is to create high quality, authentic clinical scenarios with simple technology, minimal equipment and human actors. The scenarios feel quite real and require learners to respond accordingly. Course participants manage commonly encountered clinical situations (e.g., urgent laparotomy, obstetrics, pediatrics, trauma, pain management) and learn non-technical skills for effective team working. Through simple portable methods, VAST creates an immersive, emotionally charged environment where participants have good “buy in” or credibility. The course is designed to be inter-professional and scalable to learners through fundamental, intermediate and advance levels of many scenarios. After running four VAST Courses in both rural and urban Rwanda, we were eager to explore a completely different context.

Our teaching group comprises Angela (an anesthesiologist and expert who has taught multiple courses around the world, including the recent VAST Course in Nyagatare, Rwanda), Lisa (global health coordinator), Julian (Prince George anesthesiologist and lead for the CASIEF Ethiopia program) and me (Patty, VAST co-author, teacher of VAST in Rwanda and former CASIEF Rwanda program lead). Our goal in offering VAST in Prince George is two-fold: to test VAST in a semi-rural Canadian context and to prepare Julian for facilitating the VAST Course in Addis Abba, Ethiopia in January.

The simulation centre in Prince George is well equipped and the staff are helpful. We had brought the core printed materials: course manuals, handbooks for participants, scenario role-play instruction cards, patient documentation (e.g., vital sign observation charts, anesthesia records, progress notes) and photographs of pathology to be discovered during patient examination. The Prince George simulation centre provided the remainder of the materials and a few simple mannequins. We spent the first two days setting up our workspace and running through scenarios to help Julian become familiar with VAST Course facilitation. This was useful for all of us and essentially offered a dress rehearsal before the learners arrived.

Angela and I had previously experienced VAST in a remote district hospital in Rwanda where the challenges were many: participants had to travel hours in the rain to arrive, people had little capacity in English, a hotel venue with abundant ambient noise and learners with no prior simulation experience. In contrast, Prince George was easy. The attendees included one anesthesiologist, one anesthesia assistant and four medical students. They arrived on time, fluent in English, with previous simulation experience and a high level of training. We quickly discovered that we could offer the intermediate and advanced levels of many scenarios. Because of everyone’s schedules, we condensed the course to two days rather than the usual three-day course. Despite this, we needed to omit little because the learning was smooth and efficient.

The course was received with great enthusiasm and appreciation. Indeed, the learners commented that interacting with simulated patients created much more buy in than they had previously experienced with expensive plastic mannequins. Credibility was such that we nearly had to stop one of them from intubating a colleague!

At the post-course dinner, kindly hosted by Julian and his wife, the learners asked to be involved in future VAST Courses and suggested specific communities they thought would be ideal. One medical student from Yukon thought there would be great value for the course in northern Canada. Others thought the course should be included widely in training programs and run for general practitioners. Our team left Prince George inspired by the value of this course in Canada and keen to implement it widely in both teaching hospitals and more remote settings.

 

Dr Patty Livingston’s reflections on VAST Nyagatare, Rwanda (27-29 August 2018):

Nyagatare is a small town in a remote corner of eastern Rwanda, north of Akagera Park, the savannah wildlife reserve. We had arrived at the venue (Nyagatare Diplomat Hotel) the afternoon prior to the course in two jam-packed cars with mannequins, our VAST bins (supplies) and the facilitation team, after driving 100 km of “African massage road” (bumpy and under construction). The massage road followed a somewhat shorter drive on the main highway to reach Rwamagana in the Eastern Province.

Because of geographical isolation, the health care challenges found in low-resource settings are compounded in this region. The VAST Course was designed to bring the benefits of active experiential simulation-based learning – mainstream for health care education in well-resourced settings – to health providers who work with limited resources, often in geographic isolation. Indeed, if the VAST Course can work in Nyagatare, if can probably work anywhere.

Dr. Christian, the Rwanda VAST Course Director, asked the regional hospital director generals to select 13 local anesthesia providers, nurses and midwives to attend this first of four VAST Courses we are currently offering. The facilitator team included Christian (Rwandan anesthesiologist), Eugene (senior Rwandan anesthesia resident), Laurence (Rwandan simulation centre coordinator), Sara (Canadian research facilitator), Dave (Australian anesthesiologist on a global health fellowship at Dalhousie University), Angela (Canadian anesthesiologist and global health leader) and myself, Patty (Canadian anesthesiologist and longtime friend of Rwanda).

The first morning got off to a rough start. Distances required to travel and heavy rain left us with only one participant arriving on time. We also quickly realized that language would be a far greater challenge than we had experienced during the pilot courses in Kigali. The Nyagatare participants spoke Kinyarwanda and many have limited French or English. Simulation courses depend on communication, so clearly we had a problem. Fortunately, Christian, Eugene and Laurence were able to translate but by lunch we running behind schedule. Additional challenges had to do with noise. A boisterous neighboring shop was playing loud music and there was a political campaign complete with megaphone blasting from the campaign truck. The whole notion of running this course seemed impossible.

Over lunch on day one, the faculty had an emergency meeting to figure out how to salvage the situation. We decided to repeat the demonstration (faculty-led) scenario to model role-play in simulation. We adapted some of the discussions to include more role-play. The Rwandan facilitators ran debriefings in Kinyarwanda or translated for those of us who spoke English. We spoke slowly. The hotel manager asked the shop to turn down the volume and the political campaign moved on. The participants began to engage in simulation and day one finished on a better note than it had started.

Christian spoke with the participants about punctuality and, happily, days two and three started on time with the full group. The participants became more comfortable with simulation, role-play and debriefing. The VAST Course emphasizes application of non-technical skills in common scenarios found in low-resource settings. We attempted to address content knowledge by using pathology frequent in this context, providing simple preparation reading and asking course participants to answer a set of questions before the course. During the course, key content for scenario performance is provided through interactive discussions before it arises in scenarios. For example, day two is all about obstetric anesthesia care and maternal emergencies. The day starts with group work to answer questions on the medical management of cases that arise the rest of the day in scenarios. We found it worked well for Eugene to use the prepared slides as a guide for himself but to run the case discussion with some demonstration (e.g. how to used left lateral tilt) and use of a flipchart to record answers to questions.

We continued in this way through days two and three with scenarios, demonstrations, translation and repeating scenarios when needed. Christian led the final course synthesis in Kinyarwanda. The Rwandan facilitators provided feedback that the participants had found the course valuable. One participant said, “I am transformed”. They asked for the course to be repeated often and to include more of their colleagues. Christian said the participants would leave the course as different people.

The VAST Course in Nyagatare forms part of 4 courses being run consecutively in Rwanda over August / September. An incorporated research project is evaluating VAST’s ability to improve participants’ non-technical skills. The Nyagatare course is also being followed by a facilitator course at the Rwanda Military Hospital, developing Rwandan anaesthesia providers skills in simulation delivery.

VAST v1.0 is about to launch…first stop is Nyagatare District, Rwanda. Thanks to a research grant from Dalhousie University, we have some shiny new equipment and an all-star team ready to deliver VAST Courses over the next two weeks.

The Nyagatare courses will be followed up by VAST Butare, mid-way through September.

There will be more to follow, with some of the team’s reflections on the Courses as they unfold. A massive thankyou to all that have helped with getting this over the line.

Associated with these upcoming courses, we are extremely excited to be formally evaluating VAST’s impact on anaesthetists non-technical skills (ANTS). Assessment of ANTS will be made pre- and post-Course as well as repeat assessment at 4-6 months following the Course. To our knowledge, this will be the first attempt to assess the non-technical skills retention following a training initiative in a low-resource setting.

Best of luck to the research team.

 

A lot has happened since the pilot VAST Courses earlier this year…

Some significant changes have been made to the Course and its associated Facilitator Course, stemming from facilitator reflections and participant feedback on the pilots. VAST v1.0 is now ready for delivery, with its associated Facilitator Course revamped and to be delivered over 2 days.

The VAST research team, which includes members from the Dalhousie University and the University of Rwanda, has been successful in their application for a Dalhousie Anaesthesia research grant. An evaluation into VAST’s ability to improve anaesthesia providers’ non-technical skills and the degree to which that improvement can be sustained over time will be conducted over several months in Rwanda during 2018/19.

Four VAST Courses are planned for Rwanda over August / September, with two associated Facilitator Courses. We can’t wait to deliver VAST v1.0 and further build the VAST Network of simulation facilitators. Early planning is also underway for Course delivery in underserved areas of Canada. We have been spreading the word, giving presentations at the Bethune Roundtable in Toronto as well as at the Global Health Discussion Series and Department of Anaesthesia grand-rounds in Halifax.

One year ago, VAST was pre-conceptual. Now, the Course is fully developed, has undergone refinement and is ready for widespread dissemination. A huge thank you to everyone that has been involved in the project to date. The support, encouragement and wisdom of innumerable people have been instrumental in shaping VAST into what it is. The future is bright – June 2018

Victor Frankenstein recounts how he “infused a spark of being into the lifeless thing at his feet”. The idea for the VAST Course sprouted in July 2017 and for months, it existed only on my hard drive. Without the enthusiasm and support of the team around me, there is no doubt that VAST would still be a lifeless entity. With the financial support of CASIEF and Dalhousie University, we were able to commit to piloting the course in Rwanda in January. In late December, the series of subfolders and files materialised into a set of tangible printed materials, resources and VAST paraphernalia. The great unknown was how all of this would transform into a 3-day simulation course.

We were off to an auspicious start. The first thing our eyes were drawn to at the Rwanda Military Hospital (RMH) Simulation Centre was an expansive banner heralding the piloting of the VAST Course. The months of meticulous preparation, testing, refinement and co-ordination were over and it was time to launch the first of three pilot courses. Throughout VAST, we focus a lot of attention on anaesthetists’ non-technical skills. Our team had to draw heavily on these same set of skills to effectively launch this project.

 

Team working
In the months leading up to the VAST Course, Patty had on several occasions referred to us (Michelle, Christian, Patty and I) as the ‘dream team’. My initial concern was to wonder if had to settle for the role of the “Hick from French Lick” aka Larry Bird. Come game time, despite never having together before worked in this capacity, we functioned like a well-oiled machine. The first pilot course was underway and we were running two parallel groups through the various components of the course. Michelle behind the scenes, setting up rooms, Patty and Christian riffing off each other in debriefing sessions and I taking the helm of facilitating and debriefing the other group. It wasn’t long however before the line-up of the dream team was to get some fresh faces.

Stewart was certainly a prized recruit to the team. After a quick ‘pre-season’, namely the VAST Facilitator Course, Stew held a firm place in the starting five. In fact, by pilot week three, he was the front runner for MVP, having to step his responsibilities when other key players were out due to illness and a late season trade to the Butare Black Mambas. Rotating strongly off the bench we also had an injection of talent from our trainee facilitators. With some ongoing coaching from the side-lines, these ‘trainee’ members of the team were soon more than pulling their weight, running and debriefing sessions following the VAST playbook. More on the surprise recruit, Laurence, later.

No team can function without an extensive support network. Daily buffets at both RMH and CHUK hospitals kept our energy levels high. The team transport was dutifully and punctually conducted by Alphonse. Christophe at the CASIEF apartment was working overtime ensuring our team uniforms (scrubs) were cleaned and pressed ready for game time each day. In all of this, like in any well-functioning team, there was a real sense of camaraderie and common understanding that developed amongst the team members.

Task management
There is a lot of focus in VAST on managing complex tasks, particularly on how to assess and organise available resources. Day 1 of the first week of the VAST Course is now a bit of a blur. The unknown of the mechanics of the running the course were playing out in front of us. Fortunately, we had the invaluable resource of Michelle to draw on. With Michelle at the helm co-ordinating set up and changeover between scenarios, the rest of us were able to focus on the other tasks of session delivery and mentorship of the trainee facilitators.

Decision making
Many of the decisions regarding course logistics and design had been set in stone months in advance. There was opportunity however for some on the fly experimentation with order of sessions, timings of breaks and finer details of how some sessions were to be conducted. This helped to maximise our short period of time with participants and to promote a favourable learning environment.

One key decision that was suggested to us early on by Dr Paulin was the inclusion of Laurence, the sim centre co-ordinator from CHUK hospital. Laurence joined Michelle from early on in the first week of pilot courses, shadowing her every move and learning from the best. By the start of the second week of courses, Laurence was setting up stations and preparing the rooms for subsequent scenarios. Come week 3, Michelle was back in Canada and Laurence stepped up to the plate to independently run the ‘back of house’. An unexpected highlight was to watch Laurence spring to action on academic following the completion of the VAST Course pilots. Patty had tasked the residents with designing their own simulation scenario and within moments Laurence had the equipment set up in the same systematic manner in which we organise the gear for the VAST Course. This is just one example of what we have now seen as some of the ripple effect of the VAST Course…positive implications that are extend beyond our initial set of objectives.

Situational awareness
Language posed one of the key challenges to conducting these pilot courses. Whilst English is the official language in Rwanda, there is a transition from French and ubiquitous use of Kinyarwanda. Our participant group was also not uniform in their level of English. Being aware of this dilemma was of crucial importance. As much as possible, we encouraged Christian to deliver his sessions in French/Kinyarwanda. For the rest of us, it was important to take the time to meter our pace of speech, allow for translation and explanation amongst the group. It will be important that once the course materials are finalised post pilot, that we make the effort to translate resources and as much as is feasible, deliver of the program in a more ‘comfortable’ language.

It is still hard to come to terms with what has been achieved over the months leading up to and piloting the VAST Course. Certainly, there have been lots of lessons learned. Components of the course can be tweaked, elements that we should dedicate more attention to and some less effective components that can be pared back. In essence however, we are chalking down the previous few weeks as a great success. There is an encouraging amount of local support and endorsement of the project moving forward from both official channels and from participant feedback. The next exciting steps will involve refinement of the course and conducting formal evaluation of future courses delivered. I wholeheartedly thank everyone that has been involved to date with this project and am certainly looking forward to the future of VAST in Rwanda and beyond – January 2018

Who knew it would lead to this… Prior to starting my Global Health Fellowship at Dalhousie University, I had no fixed idea what my year would entail. The months of preparation and paperwork gave me a sense of my commitments in Canada, but the specific focus of my fellowship was yet to be determined.

Fortuitously, flint struck steel in the week that I arrived in Halifax. The Chair of the Department of Anaesthesia in Rwanda, Dr Paulin Ruhato was in town. My supervisor, Dr Patty Livingston, Dr Ruhato and I were discussing the plan for my fellowship. A spark of an idea was formed …why not expand on the success of simulation based education in Rwanda and develop a simulation program focusing on the most essential aspects of safe anaesthesia delivery in low-resource settings. This was it!

Dr Livingston and I partnered with Dr Christian Mukwesi from the Rwanda Military Hospital to rework and refine this initial idea. We also had to ensure that simulation based education was something that anaesthesia providers in our target audience were receptive to. Through a comprehensive survey, we canvased opinion across anaesthesia providers in Rwanda, enquiring about experience with simulation, thoughts on its utility, interest in a new simulation program, requests for subject matter as well as barriers and enablers for participation. There was an overwhelmingly positive reaction to the idea.

Buoyed by this response, a proposal for the Vital Anaesthesia Simulation Training (VAST) Course was developed; a 3-day simulation based program focusing on both technical and non-technical skills. The case-mix chosen was reflective of common presentations seen at a district hospital in resource-limited settings, focussing on obstetrics, paediatrics, trauma, general surgery as well as neonatal resuscitation, pain and airway management. We strove to develop a program of utility to anaesthesia providers of all levels and that is complimentary to existing programs such as SAFE Obstetrics/Paediatrics, Essential Pain Management, Primary Trauma Care and Helping Babies Breathe.

Satisfied that the initial workings promoted the ability to deliver safe anaesthesia for the Bellwether procedures as well as reflecting the needs expressed in our survey, we sought further consultation. The course outline was sent for comment to anaesthesia providers in resource-limited settings beyond Rwanda and to experts in the field of global health. Additionally, we collaborated with the team at the Scottish Centre for Simulation and Clinical Human Factors to hone our frameworks for simulation delivery and debriefing.

Various aspects of the course have been ‘tested’ on anaesthesia residents both in Halifax and in Kigali. The pilot of the VAST Course in January will be the maiden run of the course in its entirety. We are also conducting VAST Facilitator courses (train-the-trainer) and are excited for the potential of building a network of Rwandan simulation facilitators. The VAST Course pilot is supported by the Rwanda Society of Anaesthesiologists, the University of Rwanda and the World Federation of Societies of Anaesthesiologists. We are extremely grateful to the Canadian Anesthesiologists’ Society International Education Foundation and Dalhousie University for their financial and logistical support.

In Canada, the final preparations and packing are currently underway for those of us that are travelling to Rwanda. I am extremely excited to transition from course development to delivery. No doubt there will be extensive lessons to be learnt and refinements to me made. The wealth of support and encouragement that has been afforded to me and towards this program has been remarkable. In this moment of reflection, I want to thank everyone who has been involved to help get the VAST Course ready for piloting and I can’t wait to report back on how it goes – December 2017