Comic Time Out

Not every comic is meant to be funny. While the Scottish city of Dundee’s classic troublemaker Dennis the Menace always lunged for the elbow, one of its newer residents has gone for the incision.

01_Handiwork title

Handiwork: surgery in sequential art, by Emmanouil Kapazoglou, adapts the comic strip format to tell a serious story that is both strange and familiar.

It follows a typical operation on a typical day for a surgical team at the Tayside NHS Trust. Through the prism of the World Health Organization (WHO) Surgical Safety Checklist, we’re taken on a step-by-step journey of the pulse points and timeframes of a surgical procedure.

02a_Huddle

Scroll slowly. The panels, as with any comic strip or the boxes on the Checklist itself, can only succeed in linear, deliberate steps.

Handiwork_cartoon strip

First through the photographs and then through illustrations of those real life images, past the swinging doors and under the hot lights.

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Watch as the seeming chaos of masked faces and machines reveals its tightly-rehearsed order – and the team’s intense focus on the safety of the one person not expected to play a role, the reason they’re all here: the patient, lying insensate on a table in the middle of the room. 03b_Huddle

You’re completing your masters in Medical Art at the Duncan of Jordanstone College of Art and Design, but this still seems like an unusual subject! What led you to the comic strip and the operating room?

04a_Transport_photoComics are so important in medical education. They have a visual impact and a strong message, but they’re also a helpful generalisation – they can expand the experience of an individual into human experience regardless of gender, age, nationality etc.

They can also speak to the non-medical community, and I was interested to see how they could translate what goes on in an operating room. I wanted to capture the teamwork necessary for a successful surgery. 04b_Transport_paint

What surprised you about the operating room?

How calm it was. Medical dramas on TV make it seem stressful – what a misrepresentation. The OR was such a calm place.

Why did you choose the Checklist?

I wanted to show something constant, and the Checklist is the backbone of how surgery happens nowadays.  I was very surprised to find out how recently it was introduced – and how difficult it is to change certain patterns of behaviour when people have learned to be kings in their theatres.

07a_Surgery

Did you see it have an impact?

Seemingly small things, like an allergy not noted down – that could have been catastrophic, but the Checklist caught it. The simple communication it allows between the theatre staff, between the anaesthetist and the ward nurse – there’s a human life on the line, it’s essential. 08_Recovery

Did you feel like patients were in safe hands?

The teamwork at Ninewells is inspiring. There’s no place for egoism or career advancement in that room – everything happens for the safety of the patient.

It’s a powerful thing.

Yes, I find that very moving. The vulnerability of the patient under anaesthesia – it’s a person at their most vulnerable, unconscious and surrounded by so many people.

To find that calm mood, and all these people working together – it’s very tender in a way.

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Has it changed the way you think about surgery around the world?

I was looking on the Lifebox website and I was shocked – I never thought that lack of oximetry was an issue in so many countries.

You show the Checklist twice, once in photos and once in paint – why is that?

After the second viewing we thought that the pictures might be too intense for someone about to undergo surgery. The drawings are a simplification, and even though they’re the same scenes, people seem to prefer them. There are lots of things you don’t want to know before the operation – other than that you are going to be safe.

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They’re very vivid!

I used an impressionistic technique called speed painting where you set a timer, start painting and as soon as the timer goes off, you stop. It makes you keep only the most important aspects of the scene.

How did you relate to the Checklist it as a non-medic?

05b_lightsChecklists happen everywhere. It’s this methodology, a frame of mind behind a sequence of events that shows how teamwork is realised. I used to work as a production assistant at dance festivals – without a checklist we’d never be able to have a performance.

I found the surgical pause particularly poetic. A moment’s thought, everybody stops – it’s like this breath that a performer takes when they go on stage. The lights, the audience, the safety protocol – it’s no joke that the operating room is also called a theatre! 05c_lights

 

All photos copyright 2014 Emmanouil Kapazoglou, University of Dundee

A two-way street

You can cite the right statistics. You can read the New York Times over morning coffee. But stepping up to the operating room table while the sweat drips off your forehead?

As colleagues in low-resource settings know, that’s when unsafe surgery gets personal.

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Just ask Steve Brosnan and Corinna Matt, consultants from the Luton & Dunstable University Hospital in the U.K. who spent three months at the University Teaching Hospital (UTH) in Lusaka, Zambia.

“The complete lack of 20ml syringes isn’t much of an issue,” Steve wrote to his department. “What is more of an issue is the search needed to find basic airway equipment and a properly working suction. The theatre oxygen supply is an exercise in patience, and constant vigilance is required.”

But as last year’s under-appreciated report from the All-Party Parliamentary Group on Global Health points out, there’s a mutual benefit to overseas volunteering.

Improving Health at Home and Abroad builds its case around a globalised reality: “We are now all connected and interconnected at every level: facing the same risks from pandemics and non-communicable diseases, relying on the same health networks, and sharing the same commitments to international development.”

When challenges faced by operating room teams across continents vary so wildly, everyone has something to give and something to learn.

In the classroom__UHT 2014_Zambia

The APPG report focuses on three recommendations: spreading good practice, creating a movement and providing the right environment to sustain success.

Steve and Corinna were involved with a number of projects that are doing just that!

Workshop_flyer_UHT 2014_ZambiaThey taught trainees on the MMed physician anaesthesia programme, supported by the Zambia UK Health Workforce Alliance, THET and DFID. The aim is to build high-level anaesthetic capacity across the country – as vital a priority as increasing the number of surgeons, but not always given the same attention.

They helped to run a SAFE Obstetric Anaesthesia Course (like the ones in Uganda and Rwanda), developed by our co-founder the AAGBI and supported by THET, training non-physician anaesthetists in managing the leading causes of maternal death in low-resource settings.

And they worked with Zambian colleagues and Lifebox friend/long-term UTH faculty Dr Dave Snell to deliver the first phase of a country-wide oximeter and safer surgery rollout!

Receiving oximeters__UHT 2014_Zambia

Even at UTH, the largest hospital and a referral centre for the entire country, this takes planning.  We started in November.

For expected items – a to-do list, a budget, a venue; and for unpredictable items, say, customs clearance negotiations for a 50kg shipment of pulse oximeters…

Ready for teaching_UHT 2014_Zambia

…so that, come February when the delegates arrived, things were ready to go.  More than 40 from all over the region were welcomed by the faculty, by the Dean of the Medical School and by the Permanent Secretary to the Minister of Health.

The workshop was a great success. Corinna reports that everyone, from the nurses through to the trainee surgeons, now knows how important the oximeter is.  They listen for the beep and the falling pitch, taking evasive action as soon as a patient’s saturation dips.   The MMed anaesthesia trainees are bringing safety out into the recovery areas, sitting with post-surgical patients as they write up case notes.

St Francis Katete_Zambia_Lifebox in OR_2012

There’s another course planned for October in Livingstone, and two more next year. By the time the courses are finished, every anaesthetic clinical officer in Zambia will have training and access to essential oxygen monitoring.

These are big numbers, just ripe for a big political speech.

But that’s not what the Permanent Secretary did.

“Instead of making a long speech, he got all of the delegates to stand up introduce themselves, saying where they were from,” explained Steve. “It was only then that I realised that a lot of delegates had come a long way to be taught by us.”

Zambia delegate map

As we said at the top – and as Steve and Corinna, who started off with three months sabbatical and now can’t imagine not being part of the next three courses, will tell you – unsafe surgery gets real personal, real fast.

And that’s why we know that it’s going to change.

The crew__UHT 2014_Zambia

 

 

 

 

The Box of Life

Originally posted on Born in Uganda:

I first met Nick about a month ago. He’s an anesthetist from the UK working in Hoima in northern Uganda. He has been part of a project that donated some anaesthetic equipment to rural hospitals in Uganda about 3 years ago, and was about to embark on a journey around the south west to follow them up. He needed an assistant and extended the invitation my way. He said it was going to be a great adventure. I trusted him and so with very little information to hand I said yes, a habit that has taken to me to some extraordinary places in my life, both good and bad, but always interesting.

A pulse oximeter measures the heart rate and the amount of oxygen in a person’s blood. It’s a routine piece of equipment used in the west and you’ll know it by the painless finger clip. Rural hospitals in…

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What’s it like to volunteer at Lifebox?

“In every aspect of life, the phrase ‘the more you learn, the more you realise how little you know’ seems to ring true – yet in the context of volunteering with Lifebox on my gap year, it has never felt more apt. I came to the office vaguely conscious of my naivety: fresh from sixth form, the notion of working in global health was appealing and, eagerly armed with my copies of “Half the Sky” and “Mountains Beyond Mountains”, I was keen to learn.

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Nearly six months down the line, while my knowledge has increased, I’m also increasingly aware of my limited understanding of global health’s huge economic, social and political facets. My eyes have been opened to the challenges of trying to make a difference, although I’m sure I’ve yet to fully appreciate the scale of these challenges.

Each week I’ve been lucky enough to see behind the scenes of an international charity – the nuts and bolts of an organisation successfully delivering equipment and education to remote hospitals around the world, all conducted from a small office in central London.

Communicable diseases – HIV/AIDS, TB, malaria – tend to get a lot of media coverage, while non-communicable diseases and the global surgery crisis are rarely given attention. I was unaware of unsafe surgery’s significance for billions of individuals around the world until I started to volunteer with Lifebox; a position many of the general public are still in. Considering the magnitude of the problem, it is a travesty global surgery doesn’t receive more coverage.

Shift in burden of disease

Lifebox has exposed me to the virtual global health community, and seeing what people are thinking, saying, and then actively going and doing, is really inspiring. Social media is undoubtedly a useful tool for raising awareness and making connections, and it has been great seeing the likes of Facebook and Twitter being used for something other than posting selfies and pictures of cats (lovely though they are).

Papua New Guinea_surgical team with oximeter

I’ve volunteered with Lifebox through a busy few months – 8th March was International Women’s Day, which saw the wider launch of Lifebox’s “MAKE IT 0®” campaign, and I felt privileged to overhear some of the interviews taking place, interviews which went on to build the striking online compilation of real women’s experiences with surgery. An equal privilege was being able to help out at Lifebox Day, an exciting event in January which saw the gathering of many motivational safe surgery advocates, sharing their experiences of practice in low resource areas and ideas for how to move forward.

Mozambique_questions from the audience

Volunteering with Lifebox has been such a valuable, inspiring experience for me. I start medical school in September and really hope to pursue this area of healthcare further – the option to intercalate with a BSc in Global Health is definitely looking appealing at the moment. While there is still an appalling disparity in access to safe surgery globally, the determination of passionate individuals fighting for change is promising; one thing I’ve definitely learned is that there really is infinite possibility for progress.”

Oximeters make a difference on Make A Gif

Robyn Evans spent six months as a volunteer with Lifebox Foundation. She is currently volunteering with Orion and will be starting medical school later this year.

Hej hej E.S.A!

Travel broadens the mind, and the European Society of Anaesthesiology (ESA) gives us a reason to travel!

Lifebox a ParisTheir conference sets up shop in a different European city each year. In 2012 we put our best bisou forward making introductions in Paris

…last year we said hola to old acquaintances in Barcelona, and this year…

Barcelona_ESA view

 

 

 

Hej!  Welcome to Stockholm.

Bjorn welcomes you

More than 5000 anaesthetists spent a busy week under bright northern hemisphere summer skies, hopping islands and a broad scientific programme covering what looked like every aspect of anaesthesia.

Of course there’s one we’re interested in above all others: global.  Do we really understand the challenges facing colleagues delivering anaesthesia in low-resource settings, and what can the community do to help?  Because as Dr Wayne Morris showed at the WFSA‘s  symposium on global quality and patient safety – the world is not a balanced place to practice or receive safe surgery.

In fact, when you plot it to scale on a map, it looks utterly absurd.

Physician scale world map

Of course a lot of ESA members are all too aware, from their own work in low-resource settings, or from their daily practice.  So the conference was a great opportunity to talk face to face about the wheres and whats and whos and hows.

ESA lineup1.jpg  From Australia to America to Lebanon…

ESA lineup2.jpg

Tanzania to Tunisia to Egypt…

ESA lineup4.jpg…Switzerland to Turkey to our Swedish hosts, the charge to make surgery safer is going global!

And it’s taking effect.  We were thrilled when ESA told us that they would be donating 100 pulse oximeters for hospitals in member countries where access to safe monitoring is more of a challenge than you might think.

ESA-Uzbekistan-first handover

Smile!  For the handover of the first oximeter from ESA to representatives from the Uzbekistan Society of Anaesthesiology and Intensive Care – and the beginning of a life-saving collaboration.

Because, as Dr Isabeau Walker pointed out in her panel presentation about Lifebox, the journey so far and the miles yet to go: making surgery safer is an enormous challenge, but one that’s already underway.

With your help we’re making a difference, and you don’t have to take our word for it.

Oximeters make a difference on Make A Gif

make animated gifs like this at MakeAGif

The humanity in humanitarian

This year the MSF Scientific Day opened with a question that could have shut the whole thing down.

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But what else could they do?  It’s the 20th anniversary of the Rwandan Genocide, when MSF concluded that “you can’t stop genocide with doctors.”   The current situation in Central African Republic (CAR), Syria and Somalia is devastating, with MSF losing colleagues and in some cases having to pull back for the first time in 22 years.

How do you stand in these shadows and talk about humanitarian aid without asking the question: how far has it really moved since then?

“Collectively we need to do better,” said Vickie Hawkins, General Director of MSF UK.  “We need to find new methods.”

New methods, and age-old priorities.  If last year’s conference put the spotlight on measurement (from Hans Rosling‘s great table height) the focus this year seemed to be on the faces and the hearts behind it.

Jennifer Learning

Keynote speaker Jennifer Leaning, director of the FXB Center for Health and Human Rights in Boston, gave a powerful talk about the role of evidence in humanitarian decision-making, challenging the audience to put humanity at the centre of it.

“Respecting their biography is as important as the immediate healthcare you can provide,” she said, of her experience working with refugees.  “And prepare for this work to last a lifetime.  The point is not to keep people alive, but to help them live.”

With presentations on subjects ranging from “health services for survivors of sexual and gender-based violence in Papua New Guinea” to “tech solutions for understanding the who, what and where of the needs of populations in crisis,” panelists regularly concluding with thanks to their colleagues still on the ground and more than 2000 viewers watching online across 108 countries, there was a strong sense of wanting to make the day more than an echo chamber for clean data.

Global audience_MSFsci

Because publications in size 12 font may keep the stories straight, but there’s a lot more to be said – and learned – from breaking silos.

Ulcer_MSFsciTake the Buruli ulcer, an infectious disease that can damage right through to the bone, and is present in countries where HIV is prevalent.  How do the two conditions interact? How does this shape international guidelines?

Why were hiccups more frequent during hospital stay for Bundibugyo Ebola virus than self-reported at admission?  What do we learn when we distinguish between food security and nutrition security?

Nothing is in a vacuum, and again and again we put our hope in the equation that the more questions we ask, the better our questions get, and the closer we get to answers.

Like a late-breaking session on how to deal with the current Ebola outbreak, the 6th (or 4th) largest on record.

“What’s the problem?” asked panelist Armand Sprecher, devil’s advocaliciously.  “This is Ebola, we’ve done this before.”

Well, he explained – you need the treatment centres, and the outreach to go find patients and bring them back. You need to trace how they got sick and who they’ve been in contact with, and follow up with those contacts for two days.  You need to bury your dead safely, undertake health promotion in the community, engage with local providers so they can identify suspect cases, participate not obstruct…

Ebola in Guinea_MSFSci

“Epidemics,” said the German polymath Rudolf Virchow “resemble great warning signs.”  He was talking about the typhus outbreak in 1948, but Jennifer Learning quoted him in her keynote, marvelling, as she has done before, at the prescience and the relevance.

“War, plague and famine condition each other, and we don’t know any period in world history where they did not appear in more or less large measure either simultaneously or following each other.”

Stockout_MSFsciNothing in a vacuum.  Which means that epidemics aren’t just outbreaks of disease – they’re indicators, breakdowns of systems, epidemics of lost control, as Marc Biot found in his baseline survey monitoring drug stock outs of HIV medicines in South Africa.

An acute crisis in the Eastern Cape in late 2013 caused one of the depot systems to collapse entirely.

“We had to find out if it was a single case or an outbreak,” he explained, of the systematic research that has resulted in joint consultation and the first public-private partnership to create a national Stop Stock Outs Project.

Philipp du Cros, head of MSF’s research arm the Manson Unit, stood up to bring the day to a close. The only way to conclude a day of so much information and controlled emotion was with a recapitulation – and a reaffirming.

“The challenges are long-term,” he reminded the audience, “and it’s a double challenge in this abnormal condition – how can we be better, when we’re also in retreat?  Which are the questions that are going to have the highest impact?  Which are the methodologies?  How can activism, the outrage at a problem, provoke us to do a study that provokes us to more activism?”

The difficult questions need answering, and the imperatives bear repeating.

“Jennifer reminded us that it starts with dignity, the empathy for the humanitarian act.  That it’s not just about keeping people alive.  It’s about helping them to live.”

In memory_MSFsci

A life-affirming measurement

Maybe we’re biased, but we feel a real affinity with the colour yellow.

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Spot the Lifebox

So we were predisposed to like Rotary, and that’s before you factor in the amazing work they’ve been helping us with over the last year!

As we wrote in the April issue of Rotary Today (you can read a copy here), Rotarians around the world from Yorkshire to Benin have been rolling up their sleeves to help us make surgery safer in low-resource countries.

In the last year, with their help, we’ve been able to supply many more pulse oximeters and training programmes to healthcare workers in low-resource settings.

Of course we know we’re not the only ones who have been busy.  Last year in Harrogate we learned about the amazing global range of projects that Rotary clubs lead. So this year we followed the wheel to Birmingham, and the 89th Annual Rotary International Great Britain and Ireland (RIBI) Conference – to share our news, and catch up with members, projects and old friends!

RIBI 89th Conference

Like Dr Carl Heidelmeyer, our regular friendly face of the Rotary Club of Portishead -

RIBI 2014 Heidelmeyer

and Jane Palmer from Mercy Ships (a double meeting, with a Lifebox/Mercy Ships reunion also underway that weekend in the Congo!)

RIBI 2014_Mercy Ships

Our booth looked a little lonely at first – but they don’t call it the House of Friendship for nothing…

Sure enough, we were soon joined by new friends Barbara and Lindsay Bashford, whose son Tom Bashford was a medical VSO volunteer in Ethiopia two years ago.

Is surgery in low-resource settings really so unsafe? Tom recalls a nurse asking him for advice on “how to wake up patients who have not recovered from their anaesthetic after one or two days” – patients who, he knew, would never properly ‘wake up’ and recover from the permanent damage they’d sustained during the operation, caused by loss of oxygen.

He worked with the surgical team at a hospital to introduce the WHO Surgical Safety Checklist, the life-saving communications tool that is a vital component of Lifebox programmes.

And later that year Barbara and Lindsay’s club, the Rotary Club of Market Drayton, raised funds to send pulse oximeters to him at the hospital – ensuring that future patients would be more safely monitored.

Before they knew it, passing Rotarians were finding themselves monitored too.

Suspicious at first…

RIBI_suspicious at first…they soon realised, as the oximeter probe clipped onto their finger and – breathless pause – began to beep reassuringly…

RIBI 2014_suspicious no more

…that this was “a very life-affirming measurement!” (as Lindsay Bashford poetically put it.)

Soon everyone wanted to know their blood oxygen saturation.

RIBI_sats testing.jpg

Pulse oximetry isn’t just life-affirming – it’s life-saving.  A pulse oximeter is the most important piece of monitoring equipment in modern anaesthesia, essential for making it safe (risk of death from anaesthesia in the U.K.: 1 in 200,000) rather than desperately unsafe (risk of death from anaesthesia in West Africa: as high as 1 in 133).

But it’s missing from more that 70,000 operating rooms worldwide and so every day, essential operations – emergency Caesarean sections, trauma repair – take place with the surgical team effectively flying blind.

Lifebox distributes this vital equipment to hospitals in need, and in the last three years we’ve sent out more than 7000 across 90 countries.  But for the first time in history, more people are dying from surgically-treatable conditions than from infectious diseases. Global surgery is in crisis.

We love the Rotary attitude to getting things done – practical and effective.  “We asked what they wanted, needed,” explained David Pope, of the Rotary Club of Abindon Vesper’s work in Uganda, Kenya and Tanzania – real evidence of Rotary’s motto, ‘Service above Self’.

In the week after the RIBI conference, two academic papers were published – one showing the dangers of anaesthesia in low-resource countries, and one showing the long-term impact of Lifebox distribution and training.  There has never been a more important time to be practical and effective when it comes to global surgery.

Please get involved – it’s life-affirming for everyone!

Lindsay Bashford