International Women’s Day – making safe surgery and anaesthesia happen

It’s late on a Monday and l’ve been scrolling through my Twitter feed for the past hour. I don’t normally spend this much time on one Twitter session but it’s almost as if I’m reading a book that I just can’t put down! The reason for this: it’s the night after International Women’s Day. March 8th, a date that has become increasingly important on my calendar over the last few years.

For me, this one day in the year is symbolic of a global effort to recognise and celebrate the achievements of women and girls all over the world, and to shine a light on the injustices they continue to face. And since joining Lifebox Foundation as a Communications Assistant in January, I’ve learned about a new one: unsafe surgery.

For the first time in history you’re more likely to be killed by a surgically treatable condition than a communicable disease, but in low resource settings surgery can be a challenge to access and desperately unsafe.  And all too often, women bear the brunt.

Social media has become a powerful tool for sharing these experiences.  And across great distances, it mobilises us all, encourages us to advocate for change. Sometimes it begins with just one story.

Carolina Haylock Loor - IWD2015

So when my colleague Sarah and I were planning our social media campaign for International Women’s Day this year, we really wanted to share the stories of some of the colleagues we work with around the world.  Women whose stories, from the forefront of the global crisis in unsafe surgery, show change in action.

I’m still new to the world of a surgery and anaesthesia, but I quickly saw why this year’s IWD theme, ‘Make it Happen,’ is so fitting.  Unsafe surgery is a global crisis, and our colleagues around the world aren’t waiting to be told to fix it.  They’re busy taking action.

Take Dr Ronke Desalu who works as a consultant anaesthetist at Lagos University Teaching Hospital. “I work in a 770 bed teaching hospital,” she explained, “and along with some colleagues was instrumental in establishing the use of the WHO Surgical safety checklist in my hospital.”

Ronke Desalu- IWD2015

This essential checklist has been proven to reduce surgical complications and mortality by 40 percent.

Or Dr Sandra de Iziquierdo from Guatemala, who told us that this year she aims to “introduce the use of pulse oximeters in five public hospitals with the highest maternal mortality rates.”

Sandra de Izquierdo - IWD2015

Distribution of pulse oximeters, training and education is a crucial part our work here at Lifebox – this robust tool means that anaesthesia providers in low-resource settings can confidently monitor their patients’ oxygen and blood saturation levels during surgical procedures.

Over the last two weeks our Twitter and Facebook pages have been bursting with action, with ambition, with compassion and with the voices of women at the forefront of safer surgical care in their communities.  There is so much work for them to do.

Kayser Enneking - IWD2015

What l have learnt over the last month at Lifebox is that it is not simply a matter of whether people in low-resource settings have access to surgery, but whether they will even survive it. Anaesthesia is up to 1,000 times more dangerous in low-resource countries than in high-recourse ones. Unsafe surgery is a global crisis that not only affects patients and their families but it also has implications for the doctors, health workers and medical teams who attend to them.

As I sat there scrolling, tweet after tweet, the resounding message about gender equality I took away is this – we must do more.  But then I thought about that day a few weeks back, when we emailed our colleagues to ask, ‘what are you doing right now to make surgery and anaesthesia safer?’  The answers came back so suddenly, so powerfully, so engaged.  These women are already working to make it happen.

Who are these brilliant individuals, advocating for global surgery at home and on the world stage?  Click here to find out!

Happy International Women’s Day.  Here’s to our safe surgery and anaesthesia champions!

Anna

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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.

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

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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.

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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.

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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…

Blantyre_workshop_August 2014_team photo

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.

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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.

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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! IMG_6322

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.”

map_malawi_pointsThis 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.

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

 

 

 

 

 

 

 

 

A two-way street

You can cite the right statistics. You can read the New York Times over morning coffee. But stepping up to the operating room table while the sweat drips off your forehead?

As colleagues in low-resource settings know, that’s when unsafe surgery gets personal.

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Just ask Steve Brosnan and Corinna Matt, consultants from the Luton & Dunstable University Hospital in the U.K. who spent three months at the University Teaching Hospital (UTH) in Lusaka, Zambia.

“The complete lack of 20ml syringes isn’t much of an issue,” Steve wrote to his department. “What is more of an issue is the search needed to find basic airway equipment and a properly working suction. The theatre oxygen supply is an exercise in patience, and constant vigilance is required.”

But as last year’s under-appreciated report from the All-Party Parliamentary Group on Global Health points out, there’s a mutual benefit to overseas volunteering.

Improving Health at Home and Abroad builds its case around a globalised reality: “We are now all connected and interconnected at every level: facing the same risks from pandemics and non-communicable diseases, relying on the same health networks, and sharing the same commitments to international development.”

When challenges faced by operating room teams across continents vary so wildly, everyone has something to give and something to learn.

In the classroom__UHT 2014_Zambia

The APPG report focuses on three recommendations: spreading good practice, creating a movement and providing the right environment to sustain success.

Steve and Corinna were involved with a number of projects that are doing just that!

Workshop_flyer_UHT 2014_ZambiaThey taught trainees on the MMed physician anaesthesia programme, supported by the Zambia UK Health Workforce Alliance, THET and DFID. The aim is to build high-level anaesthetic capacity across the country – as vital a priority as increasing the number of surgeons, but not always given the same attention.

They helped to run a SAFE Obstetric Anaesthesia Course (like the ones in Uganda and Rwanda), developed by our co-founder the AAGBI and supported by THET, training non-physician anaesthetists in managing the leading causes of maternal death in low-resource settings.

And they worked with Zambian colleagues and Lifebox friend/long-term UTH faculty Dr Dave Snell to deliver the first phase of a country-wide oximeter and safer surgery rollout!

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Even at UTH, the largest hospital and a referral centre for the entire country, this takes planning.  We started in November.

For expected items – a to-do list, a budget, a venue; and for unpredictable items, say, customs clearance negotiations for a 50kg shipment of pulse oximeters…

Ready for teaching_UHT 2014_Zambia

…so that, come February when the delegates arrived, things were ready to go.  More than 40 from all over the region were welcomed by the faculty, by the Dean of the Medical School and by the Permanent Secretary to the Minister of Health.

The workshop was a great success. Corinna reports that everyone, from the nurses through to the trainee surgeons, now knows how important the oximeter is.  They listen for the beep and the falling pitch, taking evasive action as soon as a patient’s saturation dips.   The MMed anaesthesia trainees are bringing safety out into the recovery areas, sitting with post-surgical patients as they write up case notes.

St Francis Katete_Zambia_Lifebox in OR_2012

There’s another course planned for October in Livingstone, and two more next year. By the time the courses are finished, every anaesthetic clinical officer in Zambia will have training and access to essential oxygen monitoring.

These are big numbers, just ripe for a big political speech.

But that’s not what the Permanent Secretary did.

“Instead of making a long speech, he got all of the delegates to stand up introduce themselves, saying where they were from,” explained Steve. “It was only then that I realised that a lot of delegates had come a long way to be taught by us.”

Zambia delegate map

As we said at the top – and as Steve and Corinna, who started off with three months sabbatical and now can’t imagine not being part of the next three courses, will tell you – unsafe surgery gets real personal, real fast.

And that’s why we know that it’s going to change.

The crew__UHT 2014_Zambia

 

 

 

 

Change we can believe in

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

Airport contraband

(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.

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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.

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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!

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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.

Patty Livingstone
Faye Evans

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 1 participants

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

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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.

Lifebox oximeters for donation

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?)

Registration

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.

Honestly, people in love.  

They glow.  And they’re so happy all the time.

(c) This Sweet Love Photography

We might just find it annoying, if people in love weren’t so beautifully generous in their joy!

Three happy couples, six friends of Lifebox, have taken a day that is supposed to be all about them and made it about the difference they can make to other people, by putting the Lifebox surgical safety mission on their wedding registry.

“Your presence, love, and support are the most meaningful gifts we could ever hope to receive,” wrote University of California, San Francisco anesthesiology resident Kirsten Rhee, and her fiancé-now-husband Rob Steffner.  And of course they meant it, but…

“…if you do choose to give, one option is to donate on our behalf to Lifebox. The global surgical and perioperative burden of disease is too often neglected by the international public health community. However, Lifebox is one organization that we believe is making significant in-roads by supporting creative and sustainable solutions to a problem that does not get the exposure or support that it deserves.”

Kristen Dowling and Austin Enright, an American business major and a Canadian medic felt the same way.

“We look at it like this,” explained Kristen (avert your eyes from the glow).  “We’ve all had times in our lives when things are good, and we’ve all had times in our lives when things aren’t.  We’re so fortunate to have an amazing support system to celebrate with us in the good and help out in the bad.  At this time of celebration, we thought it would be great to share our support system with those that are in need.”

Louise Finch, a British anaesthetist, has seen that need first hand.  She was part of the very first Lifebox training and distribution workshop in Uganda, July 2011, and spent three months criss-crossing the country at rickety speed to ensure that all 80 recipients of Lifebox pulse oximeters were successfully using the machines six months later.

“Louise has first hand experience of how much the anaesthetic providers value these oximeters and the huge impact they have on patient safety,” wrote her fiance, Andy Bates.  “When we started planning our wedding we realised that we had everything we needed but that some of our friends and family might still want to give something to mark the occasion. We thought that making our guests aware of Lifebox offered a positive solution.”

All of us at Lifebox are touched, grateful and frankly giddy that at such a personal time in their lives, these couples are entrusting us to mark the occasion by making a direct difference to the quality and safety of patient lives worldwide.  Without getting mushy, we think that’s a fine testament to love.

A mother watches her child, prepped for surgery and safely monitored, at a hospital in Ethiopia.

“I can’t imagine knowing that your child (family member/friend) is sick and instead of hoping that the surgery works, you also have to hope that the surgery is safe,” said Kristen.  “Lifebox, through their extensive research and amazing reach within the medical community, helps to make surgeries safer.  It’s as simple as that.”

Participants at a Lifebox workshop in Mbarara, Uganda last year

Thank you from all of us at Lifebox.  And congratulations!