Going back to Ghana

The 70,000 global pulse oximeter gap keeps us busy. Not a day goes by without a Lifebox oximeter winging its way across earth and sea and sky to anaesthesia providers in the most remote hospitals worldwide, delivering life-saving surgery without this life-saving equipment.

But some days the skies are heavier than others!

In October 2013, we sent a donation of 320 pulse oximeters to Ghana, to support safer monitoring across every government OR and recovery setting.

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Lifebox is a small team, and countrywide programme like this stand on the shoulders of giants. We had incredible partners – the Ghana Association of Nurse Anaesthetists (GANA) and Ghana Health Service (GHS), and well-named champions: Dr Thomas Anabah, consultant anaesthetist and intensivist at Tamale in the northern region of Ghana, and Dr Malvena Stuart Taylor, consultant anaesthetist at Southampton University Hospital (and G.A.S. Partnership colleague, which has strong educational and training links with the Upper East Region of Ghana).

We joined forces at GANA’s 10th Biennial National Conference in Koforidua. 167 nurse anaesthetists attended workshops in oximeter maintenance, hypoxia guidelines, logbooks for ongoing learning and the WHO Surgical Safety Checklist – where this all began.

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Lives are saved by the anaesthesia provider who understands the physiology and the utility of oxygen monitoring, not the inanimate machine – so training is an essential component of any Lifebox distribution project.

GANA training conference_Ghana_2013 (2)“There is no doubt in my mind the positive impact such training that we have been privileged to provide will be vital to the safety of patients in Ghana,” wrote Malvena, following the conference.

“I say this with confidence, based on the observation of impact I can already see in those hospitals in UER who received a pulse oximeter over a year ago.”

Several months later – it was time to find out.

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Shane Patrick Moran, a final year medical student – born in Ghana and excited to get back – spent several weeks visiting hospitals in the Upper East Region. The aim was monitoring and evaluation, but not the coldly remote and modelled method – in person, face to face.

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He was able to give the pulse oximetry needs assessment multiple choice questionnaire – used to indicate knowledge improvement and retention at Lifebox training – to 50 nurse anaesthetists.

Results showed widespread understanding of the principles of pulse oximetry, while comparison of a few test scores from those who’d completed them back in Koforidua showed knowledge was holding nicely steady. Comments regarding the educational DVD which comes with each oximeter (and is also available online) were overwhelmingly positive.

Speaking of comments – we were able to catch up with Paddy directly!  Let’s switch to Q&A mode…

Professionally speaking, what were your biggest lessons learned on this trip?

Experience of conducting research in a low-resource setting and the challenges which can arise.  I learnt that no amount of prior planning can account for all eventualities.  A fuel strike, communication issues, missing paperwork, and a minor medical emergency all affected the data collection phase.  I especially learnt that the data and records which we take for granted in UK hospitals can be hard to come by in low-resource settings.  As a result, data collection was a more complicated task than I’d anticipated.

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And personally?

My research would not have been possible without the incredible kindness of my Ghanaian hosts.  Their enthusiasm and warmth has stayed with me on returning to the UK.  Our visit to sit astride live crocodiles at Paga is another experience I won’t forget!

Having been born in Ghana, the project also gave me an excuse to revisit for the first time.  My Ghanaian name ‘Kwabena‘ (meaning Tuesday-born) was a source of great amusement to my friends out there. 

What did you find to be successful – and what needs more work?

My project findings met expectations, in so far as the Lifebox donation improved understanding of pulse oximetry and the WHO Surgical Safety Checklist amongst anaesthesia providers.

However, I found that a lack of checklist training for other theatre staff, including surgeons, meant the WHO checklist is hardly ever used in practice.  It was revealing to hear one surgeon explain that the checklist is not used because “we are very busy and need to look after the patient first”.  Therefore education needs to extend to all professionals involved in surgery if they are to routinely engage with checklists.

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What are the specific challenges anaesthesia providers face in Ghana?

At every hospital I visited in Upper East Region, the caseload far exceeded capacity.  With one doctor per 40,000 people, the demand for healthcare is huge and unrelenting.  The poverty and geographic isolation of Upper East Region makes it hard to recruit doctors from more populous parts of Ghana in the south.  The anaesthesia providers have a vast workload in conditions of extreme professional isolation.  I came away with huge admiration for their professionalism in such a difficult working environment.

OLYMPUS DIGITAL CAMERA Any surprises?

OLYMPUS DIGITAL CAMERAA memorable moment came during a group teaching session for anaesthesia providers from across the region.  After encouraging everyone to share a tricky case where things had not gone as planned, we found that roughly half the room had experienced critical events with the same drug in the same type of obstetric case.  It was the first time they had shared their experiences, and by engaging with each other they discussed how to avoid the same scenario in future.

Opportunities for this type of reflective practice are few, but improving with help from Lifebox and the G.A.S. partnership (between Ghana Health Service and University Hospital Southampton).

What do you think has been the biggest impact of the Lifebox education and distribution work?

Ghana_oximeter on finger2_Paddy Moran_UER follow up 2014The biggest impact of the Lifebox education and distribution project in Ghana has been to equip every theatre in Upper East Region with pulse oximeters, while ensuring correct interpretation of low SpO2 by clinicians who use oximetry.  My project found all anaesthesia providers recognised low saturations and knew how to respond.  I also believe the Lifebox anaesthesia logbook is crucial to improving patient safety.

Since the training, anaesthesia providers have recorded critical events in their logbooks, allowing for reflective practice and professional development.  Lack of engagement with the WHO checklist is the main area where I feel the continuing efforts of Lifebox are still needed.

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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.

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

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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.

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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.

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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…

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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.

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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.

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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.

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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.

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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.

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

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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.

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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.

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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!

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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.

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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.

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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…

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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.

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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.”

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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…

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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…

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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.

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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.

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