Steppe-by-Steppe: Safer Surgery in Mongolia

The Make It 0 campaign is global, but it works on a very neighbourly basis!  It’s great to see colleagues from high and low-resource setting countries working together to deliver training and equipment where it’s needed.  Most recently, the Australian and New Zealand College of Anaesthetists (ANZCA), the Australian Society of Anaesthetists (ASA) and the Mongolian Society of Anesthesiologists (MSA) delivered the first Lifebox training and distribution project in Mongolia.  

Dr Simon Hendel, an Australian anaesthetist who wrote about Lifebox last year for the Global Health Gateway (click to read ‘Making It Zero in the Real World‘), was Our Man in Mongolia and kindly sent in this report…

Mongolia view

Being largely ignorant of Mongolia and its history prior to going there, my notions of the country were no more formed than clichéd ideas of Chinggis Khaan merged somehow with years of Soviet occupation. I had prepared myself for boiled mutton fat washed down with homemade vodka for breakfast lunch and dinner. I couldn’t have been more wrong.

It’s an exciting time for Mongolia and not only for anaesthetists. Sandwiched between Russia and China and rich in mineral resources, Mongolia is in the throws of an economic and social boom, driven largely by the mining industry. This boom has seen vast sums of money injected into the country particularly in the capital, Ulaanbaatar. Whether this injection is good or bad is not for me to say, but it is resulting in massive changes in Mongolia.High end Mongolia

Boutique stores like Louis Vuitton, Hugo Boss and Ermegildo Zegna line potholed roads and the city’s population of urban poor. Like many booms in developing countries, one effect is to highlight the enormous disparity between the haves and the have-nots. Nowhere is that disparity clearer than in the provinces, where providing safe surgical services to the dispersed population remains very difficult.

Which is why it was such a privilege to work with my Mongolian and Australian colleagues to launch Lifebox in Mongolia and see true enthusiasm for making surgery safer.

Dr Ariunbold_Arkhangai Province_Dr Simond Hendel_Mongolia

We met in the Mongolian Society of Anaesthetists’ headquarters – a single room in a block of leased offices, quite fittingly flanked by tech startups. Representative anesthesiologists from each of the 21 provinces and 5 from hospitals in Ulaanbaatar eagerly took their seats around the central meeting table.

Mongolia training workshop 2Led by the president and immediate-past-president of the Mongolian Society of Anesthesiologists, the education sessions reinforced the essentials of pulse oximetry and oxygenation. Together, we interrogated the oximeters and practiced our action plans for low sats.

Mongolia training workshop 3

The day was fun and energetic and concluded with the distribution of an oximeter to each of the attendees. The ASA and ANZCA donated 100 oximeters jointly – 26 were distributed on the day and the remainder will be allocated by the MSA.

Dr Ganbold Lundeg_MSA president centre_Dr Simon Hendel left_Dr David Pescod 3rd from left_Mongolia

I’m an anaesthetist from a place where oximeters are taken completely for granted, expected by all to be accurate and available. It was humbling to work with colleagues who saw the life-saving value of this piece of equipment. I hope I’m not blasé about the “beep-beep” sound in every single theatre, recovery cubicle and ICU bed when I go home.

Mongolia on the road

Before and after

“To make people count, we first need to be able to count people,” said then WHO Director General Lee Jong-Wook in 2003/last week on the excellent Guardian Global Development Professionals Network.

If only ‘counting people’ was as easy as 1,2,3.  Good data gathering takes planning, it takes money, and it takes time you really don’t have at a busy hospital in a low-resource setting country.

Theatre list_Guinea

So it can be difficult to measure the impact of a programme, something programme people hate.  It’s not about vanity – it’s fundamental to know that an intervention is happening in the right place, with the right people, and that it will be needed, wanted, effective.  (Otherwise there’s a good chance that it is about vanity.)

That’s why data is so powerful.  It’s easy enough to vaguely imagine that access to surgery in Sierra Leone, a country ranked 177 out of 187 on the UN Development Index is ‘bad’ – but how bad, exactly?

Specifics spur action like nothing else; after all, it wasn’t just a ‘pretty face’ that launched a thousand ships, it was one face in particular.

Tired_Guinea

Thanks to a door-to-door study by Surgeons OverSeas (SOS) in Sierra Leone, we know that about 25% of the population has a surgical condition that needs attending, and 25% of deaths in the preceding year might have been averted by timely surgical care.

The study, explained one of the authors Dr Adam Kushner, is a first step toward mobilizing the World Health Organization, the U.S. government, foreign governments, and others in the global health community to address this dire need.

Now, you might remember Dr Eva Hanciles-Roberts, one of five medically-qualified anaesthetists in Sierra Leone, who came to visit us in the Lifebox London office last year, in dazzling colours that ignored the rain, and told us about the equipment issues – including high-tech monitors without batteries to make them switch on – she and her team faced.

Dr Eva Manciles-Robert demonstrates the pulse oximeter (in colour-coordinated style)

Dr Eva Manciles-Robert demonstrates the pulse oximeter (in colour-coordinated style)

That March, we worked with her to deliver training to the country’s 60 nurse anaesthetists at Connaught Hospital in Freetown.  Eva helped us distribute enough pulse oximeters to ensure that there was one in every hospital.

But what difference did it make?  Was the monitoring situation so very ‘bad’ before?

It so happens that in 2011, a British medical student called Hareth Bader flew out to Freetown to spend his elective placement exploring the level of intraoperative monitoring available at Connaught Hospital.  He used the Lifebox logbooks to record operation type, anaesthesia used and availability of blood pressure and oximetry during operations.

“Appropriate monitoring of patients is compulsory during surgery and something we take for granted in the United Kingdom,” he told us later, echoing Eva.  And the data.

Of the 46 operations he logged, 43% had no oximeter available, and 23% only intermittent availability – and this at the country’s teaching hospital, in the capital city.

“Surgery continues to be practiced with inadequate monitoring in Sierra Leone, with intraoperative complications such as cardiac arrests and poor early recognition of problems,” he wrote.

Hareth had taken a pulse oximeter, donated by the AAGBI, and after introduction he reported that 100% of the next round of operations he logged were being monitored with continuous pulse oximetry. (You can see the poster presentation from the AAGBI’s GAT Conference here.)

“If mortality is to improve, oximetry must be more readily available.”

Training at Connaught2

c/o Hareth Bader

A year down the line, and Eva, who is in regular contact with the anaesthesia providers she trained, can tell us what a difference more ready access to pulse oximetry and the Lifebox training workshop is making.

“Complex surgery is still referred to Freetown,” she told the British Medical Journal “But nurse anaesthetists who work outside the capital report they now carry out their work with more confidence.”

And all of the donated oximeters are still in place.  She counted.

SLANA_oximetry_recipients

Man v machine

From Silicon Valley to Mount Sinai they’re arguing over what the future of medicine needs more: doctors or algorithms.  Both sides should visit a rural district hospital in Tanzania and agree to shake hands, because the answer is clear: you need more of both.

This is Haydom Lutheran Hospital, 300km from Arusha in northern Tanzania, as seen from the air.

It’s an impressive site, as a referral hospital for more than 2 million people needs to be.

Haydom Lutheran Hospital | Haydom, Mbulu, Manyara, Tanzania

(c) Haydom Lutheran Hospital – http://www.haydom.com/?page_id=26

But you don’t travel all this way just to lark around with the birds, so let’s take a look at life on the ground.  

Haydom Lutheran Hospital_main reception building

(c) Haydom Lutheran Hospital – http://www.haydom.com/?page_id=26

Originally set up by a Norwegian civil society organisation, the hospital is now run by a local church.   More than 2000 major and 2000 minor surgeries  each year – and 600 c-sections – keep the 5 operating theatres busy, and the hospital vital to the community.

Baby IC | Haydom Lutheran Hospital

(c) Haydom Lutheran Hospital – http://www.haydom.com/?page_id=26

Now, we know that safe surgery is hard enough in the best conditions – operating without the right equipment “is nearly impossible,” as Professor Norbert de Bruijn found out as a surgical volunteer at Haydom earlier this year.

He began fundraising for a particular piece of equipment: a Glostavent anaesthesia machine specially designed for use in a low-resource setting, made by Diamedica in the UK.

They’re easy to use and simple to maintain – just like the pulse oximeter from Lifebox, which our friend Robert Neighbour, director of Diamedica, kindly delivered earlier this year when he went to Haydom to set up the three new machines!

Diamedica visit

You might remember Robert, front centre, from his visit to Chad last year – and the impressive incident with the biomedical engineering and the congac (see link above)

So, now we’ve got our feet on the ground – what exactly does a ‘day in the life’ of an oximeter look like?

Karoline Linde can tell you.  She sent an email from Haydom after just another busy day, walking us through the surgical wing and putting all debates about man v machine on hold…

“In Theatre 5 I followed an operation removing a prostate, where they only used spinal anaesthesia, and the anaesthesia nurse, Gabriel, monitored the patient manually,” she recounted.

Haydom_oximter on finger

“At one point he saw that the blood pressure was dropping, and so he goes to Theatre 3 next door to get the oximeter.

‘The great thing about these pulse oximeters is that they are portable, so in case we see that the patients vital signs are deteriorating we can get the oximeter and check,’ he explains.”

“Gabriel takes the oximeter back to Theatre 3 where anaesthesia nurse Malisha puts the probe on a 35 year old women undergoing surgical revision of a complicated fracture.  Malisha will be using the Glostavent to give general anaesthesia.  ‘The Lifebox pulse oximeters are very good, especially for monitoring children’ says Malisha.”

From Malisha in Theatre 3, to Gabriel in Theatre 5, back to Malisha in 3 – ask an age-appropriate doctor in the Europe or North America and they’ll tell you that’s how it used to be when pulse oximeters were first introduced in the 1980s.  Anaesthetists would race into work, review patients, and stake their claim for who was more vulnerable, who was more deserving of the oximeter.

As though some people deserve safer surgery more than others.

We know they don’t.  So we provided more oximeters, and we trained more people how to use them.  And we made anaesthesia safer.

SONY DSC

We need to do the same thing in low-resource setting countries, where patients just as deserving, and providers just as devoted, are struggling for safe care in the face of immense risk.

The staff at Haydom do an incredible job, and they shouldn’t have to juggle equipment to get the job done.  We know how to make anaesthesia safer – we just need support to do it.

Thanks to Lifebox donors, we’re thrilled to say that we’re now able to send more oximeters to Haydom, so that soon, oximeters won’t have to travel between theatre to spot check patients.

What we don’t need to do is argue about it. Healthcare workers – equipment – training – we know for a fact that there’s so much more to be done.

Maternity Ward 2 | Haydom Lutheran Hospital

(c) Haydom Lutheran Hospital – http://www.haydom.com/?attachment_id=719