Counting to save lives

In less than two minutes, Christine Nanyanzi can convince you that the WHO Surgical Safety Checklist is a vital tool for saving lives – and that its absence from the operating room can kill.

 “Last week a mother came to my facility,” the 40-year old clinical anaesthetic officer explained, as we wandered around the Mbarara University of Science and Technology campus, looking for a quiet place to talk.

The afternoon training session was starting soon and most of the participants were sat on the balcony overlooking the main road into Mbarara – talking over the mechanical gutturals of passing motorbikes and digesting stacked plates of matooke (steamed bananas), ugali (maize), goat stew and groundnut sauce.

Leaning against the ground floor wall, she told us about the mother, who’d had a caesarean section at a district hospital three months ago.  She’d reported back three times since with severe abdominal pain and discharge from the wound.

A scan showed a mass, which was dismissed as scar tissue following the surgery.

“She came to us and our gynaecologist said, let’s see what this mass is,” said Christine.  “Let’s do an exploratory laparoscopy.”

“We found a big mop left in her abdomen from the c-section.”

A mop is a large swab, about 12 inches in diameter, often used instead of suction in low-resource hospitals during operations – they can be washed and reused repeatedly. The mop had become completely embedded in the woman’s small gut and colon.

Christine and the surgical team tried to separate the mop, but it was a complex procedure.

“Afterwards she was very sick – wasted, pathetic-looking, like a kid of five years.  After eight hours, she died.”

One of the last steps on the Surgical Safety Checklist, to be carried out before the patient leaves the operating room is:

Completion of Instrument, sponge and needle counts.

“If they had done the Checklist…” said Christine, quietly, shaking her head.

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Expecting

Pauline Agwang, 34, is the only anaesthetic officer at her facility in Eastern Uganda.

Away for just four days during the Lifebox training and annual meeting of the Uganda Society of Anaesthesia, she eats lunch with her left hand and fields phone calls about her recovering patients with her right.

In between, she tells stories of patients she has saved, and lost – and how a pulse oximeter would help.

“It’s very necessary – especially with caesarean section mothers, who bleed a lot – most of our c-sections are emergencies, with the mothers already in a bad state.”

Pauline’s hospital was designed to fit 100 beds, but today it holds more than 200: rows of patients line the floor, bringing their own blankets or buying mats from the stalls that spore in front of the building.  With so few other resources, the early warning provided by a pulse oximeter is a powerful one: it can pre-empt a life-threatening loss of blood or oxygen in the operating room.  And so often, as we heard again and again during our stay, there is no blood, there is no oxygen to give.

Pauline went home with one of the Lifebox pulse oximeters.  For us who had gotten to know her a little, it was a small personal relief as well as professional satisfaction: when we met her in July she was 28 weeks pregnant.  “I will deliver in the very hospital I am working in,” she explained, smiling.  “For us in Africa, you work till you deliver!”

“What am I going to do?”

Philip Ongom’s  old pulse oximeter finally stopped working last February during an emergency caesarian section.

Ask him about that moment and the anaesthetic officer, who has worked at a district hospital in Western Uganda for six years, remembers every detail with agitated clarity.

“[The mother] had had eight pregnancies and five miscarriages – she needed this baby,” he said.

Unaffordable cost, dangerous transport and a tradition of home births mean that women in Uganda are largely reluctant to plan for delivery in a hospital.  Often when they do arrive, their condition has long since deteriorated from ‘at risk’ to ‘critical’.

“She came late – the transport was a problem for her – and by the time she arrived, she had a ruptured uterus.  But fortunately when we opened her up, we found the baby was alive.”

While the surgeon prepared to operate, Philip put the pulse oximeter on the woman’s finger, and waited for a reading.  Nothing picked up.

“I thought, maybe it was fitting – or her cold hands had interfered with it.  At first I didn’t know it was a complete breakdown.  I thought, maybe her heart has stopped.”

“I tried to detach it from the main system, and tried it on myself.  It was the same.  Then I called my assistant.”

“I thought, my God, this is a machine that made my work easier and safer for my patient – what am I going to do?

Now my work will be difficult.  Now it will really suffer.”

Thanks to your support, Lifebox was able to give Philip a brand new pulse oximetry package.  Sensitive to changes in blood oxygen levels of just 1%, the Lifebox oximeter will allow him to focus on his patients without the dreadful anxiety of knowing they could desaturate at any moment without warning.  Non-invasive and portable, the oximeter will be used on hundreds of patients over the next few years, and it will, without question, save lives.