The Long and Winding Road (to surgical safety)

Ethiopia is enormous.  It spans more than 1.1 million square kilometers as the birds fly, and even further as the roads drive.  They are slow and treacherous, and “100 km is not as we know it – it is about 6 hours away,” explained a visiting UK doctor recently.

The road from Gondar to Lalibela – beautiful but long.
(c) Hailebet

If you can’t get to hospital, you can’t get an emergency caesarian section, or life-saving surgery after a road traffic accident.  If supplies or engineers can’t reach the hospital, drugs will run out and equipment will break.  Healthcare providers are forced to make terrible choices between treatment and unsafe care:

“I am a junior anesthesiology professional who works in a district hospital,” Abayehu Haile wrote to us recently.  “It is found 455km away from the capital city of Ethiopia.  Even though it is a district hospital, it serves more than 500,000 people living in four surrounding districts.

“In this hospital there are so many challenges to work because of resource limitation.  Pulse oximetry is the heartbeat for my work. But the only oximeter we had was always on and off in its function.  It was really hard to work with this monitoring and to have safe surgery, but I had no choice – as an anesthetist I am striving to save life as much as I can.

Pre-operative monitoring – mother and oximeter – at the Black Lion Hospital

“It was not easy to say ”this monitoring needs maintenance” and stop work.  Most of our patients can’t go to Jimma University Hospital, which is found 75km from this town. They don’t have enough money to pay for further transport and their only choice when we said no was to go back to their home with pain. So as a professional it was difficult to cancel cases because of monitoring and am sure you can understand how many challenges were there.”

The logistics of arranging and arriving at a training workshop are significant – but get it right, and the impact will be felt for miles around.

So we were thrilled to hear that Operation Smile, an international charity that provides free cleft palate surgery in low-resource settings, was planning an education workshop in the southwest city of Jimma in March of this year. Action stations…

Training at Jimma University Teaching Hospital

We worked closely with the Ethiopian Association of Anaesthesiologists (ESA) to make sure that anaesthesia providers from all around Jimma were able to attend the workshop; we got generous permission from the Ethiopian Ministry of Health to import oximeters without customs charge; we strategized with Operation Smile to find space for the Lifebox training workshop in their packed schedule, and in early February we shipped 31 oximeters to their office in Addis Ababa.  The Operation Smile team whisked them out of the airport and southwest to Jimma, 300 km away, and…smile!

Pulse oximeter recipients at the Lifebox training course run by Operation Smile in Jimma, March 2012

More important than the pictures, of course, is what happens once the cameras are off.

The rare opportunity for anaesthesia providers to meet gave them an opportunity to swap stories with the only other people who really understand the day-to-day realities of their work.  “When we shared ideas, I observed that every professional was facing challenges,” said Abayehu.

Meanwhile, the training and equipment make an immediate difference: attendees returned home with the monitoring they needed for their surgical patients, and a better understanding of how systems like the World Health Organization’s Surgical Safety Checklist can make a life-saving difference to their patients and practice.

But the path to surgical safety can be longer and lumpier than the road to Jimma.  We’re not done teaching and learning from our colleagues.  Dr Zoe Smith, a British doctor,  recently arrived at the University Hospital, where she’ll be working as an Operation Smile visiting lecturer for the next few months.  She’s following up on the Lifebox pulse oximeters and helping to implement the WHO Surgical Safety Checklist, and we can’t wait to tell you how well it’s going so far – but you’ll have to wait till next time.

She’s already put up some road signs.

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Making It 0 in the Empire State of the South!

Back in May, we got a tantalizing email from Dr Faye Evans, assistant professor in the Department of Anesthesiology at Emory University School of Medicine, about the upcoming Georgia Society of Anesthesiologists (GSA) meeting.

“Any chance you could come?  It is in July, on a beautiful lake in Georgia…”

Emory medical residents, led by Melissa Rader, Lyndsay Fry and Andrea Dillard, were preparing to launch a GSA campaign for Lifebox, introducing Make It 0 and encouraging members to support their anaesthetic colleagues working in low-resource settings.

We weren’t able to join them, but judging from their success, they didn’t need us!

Over the weekend, the Resident Component of the GSA raised $7000 for Lifebox, enough to send more than 25 oximeters and training to anaesthesia providers in operating rooms where they are most needed.

The students organized a fundraising raffle that included chances to win everything from zoo membership to a professional photography session, and high roller donors who bought $250 tickets – the cost of a Lifebox pulse oximeter – were eligible for even grander prizes.

Left to right: Andrea Dillard, Faye Evans, Melissa Rader, Lyndsay Fry

Just like the Lifebox pulse oximeter needs an education component to make a sustainable difference, the residents felt that Lifebox donors who understood the importance of universal pulse oximetry and safe surgery were the ones who’d have the power to make the greatest change.  The fundraiser was an opportunity to inform GSA members about the Lifebox mission: saving lives by improving the safety and quality of surgical care in low-resource countries.

“Many of the anesthesiologists at this meeting were not aware that there were millions of patients around the world undergoing general anesthesia without pulse oximetry monitoring,” said Fry. “Our goal is to expand interest in ensuring patient safety in operating rooms worldwide.”

We’re overjoyed that the GSA is joining other state societies, including Alabama, California and Massachusetts, in strengthening global patient advocacy through Lifebox fundraising and education. Thank you to everyone involved!  (We really wish we had been there.)

Vanderbilting bridges: from Tennessee to Kenya

Members of the Department of Anesthesiology at Vanderbilt University School of Medicine, Tennessee, don’t need to be told about the critical state of anaesthesia in low-resource settings – lack of providers, scarcity of the right drugs and equipment, the shocking mortality statistics  – thanks to the Vanderbilt International Anesthesia (VIA) programme, many have seen it for themselves.

Check out the video on the VIA home page, which focuses on Vanderbilt’s relationship with the Kijabe Hospital, in Kenya.  Panning down crowded hospital corridors, the images are stark and the voices are shocked.

“What do you do with a girl that needs a caesarean section?” VIA director Dr Mark Newton recalls asking a clinician at the hospital. “He said rather nonchalantly, ‘she just dies.’

“She just dies.”

But things are changing.  Kijabe Hospital sees 10,000 cases a year: that’s a lot of medical provision, and a lot of opportunity to teach. Newton splits his time between paediatric anaesthesia at Vanderbilt and chief anethesiologist duties at Kijabe, where he has developed a nurse anesthesia training programme.  Training nurses to deliver anesthesia is particularly important for rural areas, where lack of anesthetic provision is a constant crisis.   He’s assisted by Kenyan faculty, and medical staff from Vanderbilt who visit Kijabe (and a number of other sites in low-resource settings worldwide) to train, educate and learn.

The American Medical Association Foundation (AMA) took notice of Vanderbilt’s work and Newton’s travel schedule – in February they awarded him an Excellence in Medicine Award.  As well as the grand title, this award came with a cash prize, and Lifebox was thrilled when Newton asked to spend his award on pulse oximeters for Kenya!

“We can directly save lives with a mere $250 pulse oximeter which is designed for the rugged environment of Africa,” Newton told the AMA Foundation Quarterly last month.

10 oximeters touched down briefly in the U.S., before setting of for East Africa, where they are already hard at work – but this is only the beginning…

The Department of Anesthesiology will soon begin a fundraising drive to purchase additional pulse oximeters.  “Our target for the 2012-2013 academic year is to purchase a minimum of 200,” explained Dr Newton.  “Our graduating Kenyan Registered Nurse Anesthetists can then take these devices with them to use as they provide medical care throughout their careers.”

Vanderbilt Anesthesiology Chair Warren Sandberg, and residents Drs. Joseph Schlesinger, Brett Campbell, Jace Perkerson, and Justin Wright with some of the first pulse oximeters to be sent to Kijabe, Kenya, for use in the field.

“We are thrilled at Lifebox to be working with Vanderbilt University to provide pulse oximeters and essential training to anaesthesia providers in Kenya,” said Lifebox chairman, Dr Atul Gawande.  “They face critical gaps in resources and knowledge, and this work will save lives.”