Ray Towey is –

Ray Towey is a patient man.

Ray Towey

(c) African Mission

In 2010 we sent him our first pulse oximeter. Lifebox wasn’t even Lifebox back then – it was the Global Pulse Oximetry Project, fresh from a worldwide tendering process led by WHO and the WFSA for an ideal monitor to thrive in low-resource settings.

We were perched on a desk in a third floor room at the AAGBI in London, figuring out what to do next.

Sure, we had our oximeter – robust, intuitive, with an education package, rechargeable batteries and a bright yellow glow – but no clear ordering system, no troubleshooting guide – and no proven plan for delivery.

Ghana_oximeter on finger2_Paddy Moran_UER follow up 2014

If we had a hope of closing even one Operating Room’s pulse oximetry gap (let alone the gap in 77,000), we needed to design and test our systems beyond reproach.

Ray Towey understood.

(c) CAGS

A British anaesthetist, he’d been working in Africa for more than 20 years – first in Tanzania and then in northern Uganda.

He took one of the first modern hospital pulse oximeters in his rucksack to St Mary’s Lacor in Gulu, a large church hospital, back in the 1980’s. It cost about £2000.

1980s oximeter

Biox II oximeter from 1985 – weighing approximately 25 pounds. (c PFT History)

“I started anaesthesia in 1968 – I’m old enough to remember giving it before oximetry. And in poor countries, people were dying from hypoxia before we noticed, particularly people with dark skin. So when the oximeter came, we knew we couldn’t do without it. First we carried one, then another,” he told us.

At St Mary’s, the majority of cases are surgical. Traumatic head injuries – often from motorbike accidents – multi organ problems – post-operative care.

Motorcycles-hospital-corridor

How valuable is the oximeter?

“People die when you don’t have one in the operating room,” he explained, sitting forward on the couch during a visit to the AAGBI. “And we give inappropriate oxygen therapy when we don’t have the oximeter in the neonatal unit.”

People die, that is, from conditions that would be treated and discharged as a matter of routine in Western Europe. They die from treatments that are supposed to save them, because the safety mechanisms aren’t in place.

As a medical professional – seeing this, knowing this – how do you move between worlds and not break down?

Ray Towey is an activist.

IMG_6258“I’ve been very active in the peace movement in the U.K. I was in jail in the 1980’s, active in the CND doing protest and resistance – the obscenity of nuclear weapons, what a waste of life and energy.

I never learned to live with the indifference of my culture. But I live with that as – a dissident. So as a dissident I’m doing my best to make the changes here. And as a healthworker.”

He took action at St Mary’s. Working with colleagues in the OR, in the ICU. Today the hospital hasn’t had a death on the operating room table in current students’ memory. They’re saving patients who would never be saved without their teamwork and systems. The challenge remains to reduce complications in the post-operative period. But that knowledge, that teamwork – that makes it worthwhile.

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Ray Towey is a humane man.

“When I lose a patient it hurts very much. And sometimes when you lose a patient in some particular situation – especially when they’re young – it hurts a lot.

I walk through the waiting room of the intensive care unit in Gulu about five times a day. And because I know a certain percentage are going to die, sometimes I can’t look them in the eye.”

Tired_Guinea

Ray offered to help us test our system. In late 2010 we shared the specifications of our oximeter and spare probes.

Check.

We developed instructions to use and test our procurement system, and Ray placed the first trial order online.

How to buy

Check.

Our manufacturer dispatched the equipment via regular postal service and –

Silence.

it didn’t arrive. Not the first week, or the second. Or the first month, or the second.

road to Aber hosp_Uganda_2011

Thanks to Ray we had our answer and our system. Since 2010 all Lifebox oximeters have been shipped by courier service. It’s a bit more expensive, but it’s the only way to guarantee that our equipment arrives in the hands of the people who use it, and on the fingers of the patients who need it, as soon as possible.

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We sent a new shipment to Ray.

“The concept of giving an anaesthetic without an oximeter is like not wearing shoes on the streets of central London,” he explained. “It’s just inconceivable that anyone would want to do that.

With more than 8,300 oximeters distributed to 90 countries around the world since, we haven’t lost a package.

In the spring of 2011 we got an email from Ray, and a photo.

“We used one of the oximeters on a sick neonate which is a big test. It did a good job for us. I think its got excellent software and was a good choice.”

Baby_and oximeter_Ray Towey_Uganda_2011

P.S. Not wishing to do injustice to the postal service or the value of every donation – believe it or not, the first shipment arrived! Three months later, surfacing in the Post Office in Kampala. But we still use a courier service – 77,000 operating rooms around the world have already waited long enough.

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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.

GANA training conference_Ghana_2013 (8)

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.

Ghana_Paddy and NAs_Paddy Moran_UER follow up 2014

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.

Ghana Health Service_Bongo Hospital_Paddy Moran_UER follow up 2014

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.

Ghana_OR__Paddy Moran_UER follow up 2014

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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