Putting anaesthesia on the map

This is a map of where to find fish in Lake Malawi. The 3 million year old basin lapping against the ‘The Warm Heart of Africa”s eastern border has a unique biodiversity of cold-blooded residents.

Screenshot 2014-09-17 17.14.55

This is a map of the voter breakdown during Malawi’s fourth multi-party election, in 1993.

Screenshot 2014-09-27 17.26.40

And this is a map showing the start point of every patient arriving for surgery at the Fistula Care Centre in the capital city, Lilongwe: hundreds of women from dark corners of small rooms in rural villages across the country, living with the permanent incontinence of obstetric fistula. Usually in isolation, locked out of society mourning their baby, their dignity, their place in society.

IMG_6239

Maps can teach you a lot of different things, but of course it depends what you’re looking for.

In the last month Lifebox has joined two trips to Malawi, plotting a route directly towards the country’s anaesthesia providers.  Without them the fish will keep jumping and the politicians will keep campaigning – but victims of road traffic accidents will never be stitched up, fistula women will never be dry, and mothers in obstructed labour will continue to struggle and tear and lose their babies and join these neglected ranks.

Unfortunately it wouldn’t take long to put them on the map: there are just a few hundred clinical anaesthetic officers in Malawi, and fewer than five Malawian medical anaesthetists for a population of 16.4 million.  (Compared with more than 10,000 for a population of 64 million in the U.K.)

A small group of visiting medical anaesthetists effectively doubles the country statistics.

IMG_6167

In August, Lifebox trustee Dr Isabeau Walker travelled with long-time Lifebox friend and president of the College of Anaesthetists of Ireland Dr Ellen O’Sullivan to Queen Elizabeth Central Hospital in Blantyre, in the south of the country.

They were working with Cyril Goddia, who heads the hospital’s Anaesthesia Clinical Officer training programme.  A survey he undertook last year with Gradian Health Systems revealed a significant pulse oximetry gap.  So we set about a project to close it.

Some anaesthesia colleagues travelled 10 hours to get to Blantyre, from small rural hospitals across the region. They were working without pulse oximeters, or having to share one between two to four theatres.  Basic monitoring was a finger on the pulse and an eye on the colour of the patient’s lips…

Blantyre_workshop_August 2014_team photo

Thanks to the Cycling Surgeons, who took on hill and dale and puncture in the name of safer surgery, to the College of Anaesthetists of Ireland (COI) who led the faculty alongside our Malawian colleagues, we were able to donate 100 pulse oximeters and deliver training to 80 anaesthesia providers and 20 clinical officer surgeons.

“Thousands of lives will be safer as a result of all your efforts,” Dr Walker reported back.  Of the photo from the course – “The smiles say it all!”

Two weeks later we were back in the north, at Kamuzu Central Hospital with ACTS – the African Conference Team led by Dr Keith Thomson. This three-day conference (in the ‘Warm Heart of the Warm Heart’, according to Fanny Mtambo, who supports the UNC Project-Malawi) was an opportunity to improve practice in an area of anaesthetic care that makes up almost 80% of emergency cases: obstetrics.

IMG_6400

Think about surgery and (much like toast in a toaster) who comes to mind – the surgeon. But think again about an operation at its most basic level – scalpel rending skin – and imagine it without anaesthesia. It’s the difference between modern medicine and torture, but it’s often overlooked.

IMG_6420

This workshop, with support from the Gloag Foundation and UNC, was an opportunity to support the skills, the concerns and the community spirit of a group who know more than any other that something needs to be clear:

“There is no surgery without anaesthesia.”

Explained William Banda,  a medical anaesthetist working at Kamuzu: “You can train 100 surgeons – but there will be no operation.”

This shouldn’t be news – but since the message is still lacking, we’re delighted to see that it was! IMG_6322

MBC TV, the main television station in Malawi, sent two journalists and a camera to the conference, to meet the delegates and shine a lens on the vital role of anaesthesia in safe motherhood.  It’s possible that they zoomed in on more than expected – a visit to the maternity ward moved quickly from theory to practice – and a gown, mask and a brightly beeping corner of an operating room as a baby was born by emergency C-section.

“Bringing life into this world is an exciting experience,” narrates the journalist, “but at times it can be life-threatening…However there is no surgery without anaesthesia, as anaesthetists play a crucial role in an operation.”

The report was screened twice in 24 hours.  What was the response?

“We didn’t know, they say,” explained Marie. “We didn’t know you needed all this to deliver, to survive.”

map_malawi_pointsThis is a map of how far delegates at the Lifebox pulse oximetry workshop travelled to get to Blantyre – making the long journey by crowded bus, by bike, from all over the southern region.  They came to learn about safer surgery, and take an oximeter back to keep their patients safer.

There are so many more maps we need – where pulse oximeters and training are urgently needed next.  Where women wait for fistula repair surgery – or soon will, if they can’t get to a hospital.  Where safe surgery is taking place – and where we support the equipment and training to make it evem safer, so that providers and families aren’t forced to make terrible choices to do their jobs or save the people they love.

IMG_6338

Till then we’ll be leaving the fish to mind their own business.

 

 

 

 

 

 

 

 

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.

02b_Huddle

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.

05a_lights

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.

07b_Surgery

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.

UTH_Lowri Bowen_Zambia2014

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 in rural natal:

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…

View original 4,967 more words

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.

because

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.

Auditorium_MSFSci

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