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.

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

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.

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.

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…

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.

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.

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! 

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.”

This 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.

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

 

 

 

 

 

 

 

 

Change we can believe in

Did you know that in 2006 the Rwandan government banned plastic bags in the capital city of Kigali?

(Spot the rookie at the airport, sheepishly jettisoning contraband.)

Today the grass, unpocked with litter, is buena vista green. Thanks to the civic and environmental efforts of the last few years, Kigali is one of the cleanest cities you could hope to visit.

Another fact about Rwanda in 2006: did you know that at the time there was just one single medical anaesthetist, Dr. Jeanne D’Arc Uwambazimana, in the entire country?

Today, there are 20.

Thanks to a collaborative, empathetic and energetic partnership between the National University of Rwanda (NUR), the Kigali Health Institute (KHI) and the Canadian Anesthesiologists’ Society International Education Foundation (CAS IEF), an anaesthesia residency programme was set up. The Rwanda Society of Anaesthesiologists (RSA) has  now been formally acknowledged by the government as an official organization, with an important role to play in the ongoing improvement of Rwandan healthcare.

Anaesthesia residents are training in Rwanda for the first time

Such dramatic changes, in such a short amount of time – it’s easy to invest them with symbolism.  A city in healing from the appalling atrocities that took over its streets; a profession long-marginalized that has raised its profile twenty-fold.

But forget symbolism and consider practical impact: this beautiful city that people are pleased and proud to live in; those countless lives that have been saved through increased access to safe anaesthesia.

Certainly surgery is still a critical healthcare concern in Rwanda, but it’s a damn sight better than it was ten years ago.  And it’s against this optimistic background that #SAFERwanda came to town!

There are so many exceptional organizations and individuals involved in delivering this rigorous programme, that they really need their own background stories told.

Luckily, Lifebox can fill you in here.

And here!

Drs Patty Livingstone, left, and Faye Evans, right (who you might remember from her role in the Georgia Society of Anesthesiologists’ runaway-success Make It 0 campaign for Lifebox) have been blogging about their work in getting  the SAFE Course up and running in Rwanda since they arrived in the country several weeks ago.

It’s a great behind-the-scenes insight into hosting a course like this.  (Step one: begin more than a year ago.)

Week one participants at the SAFE Course in Rwamagana

But the whirlwind really picked up speed (cc: “The Calm Before the Storm“) last Monday, with the arrival of 55 anaesthesia techs, residents and consultants from 13 district hospitals across the country.

Also on the guest list: two Universal Anaesthesia Machines (UAM) donated by Gradian Health Systems…

Sun sets, electricity fails – the UAM keeps working

…and 90 Lifebox pulse oximeters, part of an incredible 250 units donated by members of CAS to Rwanda.  That’s enough oximeter for distribution to every single operating room and recovery setting at the district hospitals currently delivering surgery without this essential monitoring.

The road to safe anaesthesia is paved with pulse oximeters

So the first SAFE Course thundered by, four days of well-ordered breakfast, equipment training, communication, reflection, pre-test, lunch, airway assessment, cricothyroidotomoy, reflection, lunch, simulation, post-test, neonatal resuscitation, ruptured uterus, questions, cord prolapse, malaria, etc, English, French, Kinyarwandan, dinner, birdsong, and breakfast again.

And here we are, Tuesday morning, and ready for round two…

The second group of anaesthesia providers began arriving last night, fired up by reports from their friends who attended last week. (“Not boring!” – what higher praise?)

It’s exciting to think about the first group, back at work and scattered around the country.

This morning they’re checking their anaesthetic machines and charging their pulse oximeters.  Hopefully they feel a little more prepared for whatever obstetric emergency rolls through the door next, and energized to know that their colleagues in anaesthesia worldwide are proud to stand with them – in symbol, and in practice.

A bad day and a good day

You might know (because we told you.  A couple of times.  We told quite a few people) that back in February, Lifebox was in the Solomon Star, the leading newspaper of the Solomon Islands.

Thanks to generous donors from the Department of Anaesthesia at Christchurch Hospital  in New Zealand, a physician-owned anesthetic machine company, and the Australian Society of Anaesthetists (ASA), Lifebox was able to send 13 pulse oximeters to the National Referral Hospital in Honiara, Guadalcanal.

By the by (it’ll all come together!), did we mention that the best thing about the WCA was putting faces, voices, characters and handshakes to the names that once seemed so far away?

For instance, Dr Bata Anigafutu from the Solomon Islands, who was instrumental in coordinating the oximeters:

Bata originally trained as a surgeon, but the civil war of the late 1990s changed a lot of things.  The anaesthetist at his hospital left because of the troubles, and, smiling wryly, Bata explained that he “was pushed to the head of the table.”

He’s an anaesthetist now, not a surgeon (cheers from the WCA crowd – totally biased) – one of just three qualified physician anaesthetists amongst the thousand islands, with three more in training.

The first time he really thought about the importance of pulse oximetry was during his residency in neighbouring Bougainville, Papua New Guinea.

“We had a case, a 20 year-old girl, where the nurse anaesthetist, with no pulse oximeter, did the intubation. Supposedly. Twenty minutes in to the operation, the surgeon noticed that the blood was dark.  We checked the patient – it had been an oesophageal intubation [when the tube goes into the oesophagus, instead of the trachea].  It took a while to see that the patient had arrested.”

The girl died.  Bata remembers the horror of the case clearly – and the traumatized nurse anaesthetist, whose error had not been caught.

Pulse oximeters keep patients safely monitored, but they also protect the anaesthesia provider.  In well-resourced hospitals, equipment and tools like the WHO Surgical Safety Checklist, cushion the risk that a simple mistake will go unnoticed and kill someone.  In low-resource settings, the absence of safety precautions can be harrowing.

That was one day he remembered.

Another was the day the oximeters arrived.   Bata first heard about the global oximetry project in 2005, and had been working towards this for some time.

The head of his department went to pick up the oximeters, he explained.”  We opened them.  We got to appreciate [them].  There was local TV, media – people really appreciated it…”