Comic Time Out

Not every comic is meant to be funny. While the Scottish city of Dundee’s classic troublemaker Dennis the Menace always lunged for the elbow, one of its newer residents has gone for the incision.

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Handiwork: surgery in sequential art, by Emmanouil Kapazoglou, adapts the comic strip format to tell a serious story that is both strange and familiar.

It follows a typical operation on a typical day for a surgical team at the Tayside NHS Trust. Through the prism of the World Health Organization (WHO) Surgical Safety Checklist, we’re taken on a step-by-step journey of the pulse points and timeframes of a surgical procedure.


Scroll slowly. The panels, as with any comic strip or the boxes on the Checklist itself, can only succeed in linear, deliberate steps.

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First through the photographs and then through illustrations of those real life images, past the swinging doors and under the hot lights.


Watch as the seeming chaos of masked faces and machines reveals its tightly-rehearsed order – and the team’s intense focus on the safety of the one person not expected to play a role, the reason they’re all here: the patient, lying insensate on a table in the middle of the room. 03b_Huddle

You’re completing your masters in Medical Art at the Duncan of Jordanstone College of Art and Design, but this still seems like an unusual subject! What led you to the comic strip and the operating room?

04a_Transport_photoComics are so important in medical education. They have a visual impact and a strong message, but they’re also a helpful generalisation – they can expand the experience of an individual into human experience regardless of gender, age, nationality etc.

They can also speak to the non-medical community, and I was interested to see how they could translate what goes on in an operating room. I wanted to capture the teamwork necessary for a successful surgery. 04b_Transport_paint

What surprised you about the operating room?

How calm it was. Medical dramas on TV make it seem stressful – what a misrepresentation. The OR was such a calm place.

Why did you choose the Checklist?

I wanted to show something constant, and the Checklist is the backbone of how surgery happens nowadays.  I was very surprised to find out how recently it was introduced – and how difficult it is to change certain patterns of behaviour when people have learned to be kings in their theatres.


Did you see it have an impact?

Seemingly small things, like an allergy not noted down – that could have been catastrophic, but the Checklist caught it. The simple communication it allows between the theatre staff, between the anaesthetist and the ward nurse – there’s a human life on the line, it’s essential. 08_Recovery

Did you feel like patients were in safe hands?

The teamwork at Ninewells is inspiring. There’s no place for egoism or career advancement in that room – everything happens for the safety of the patient.

It’s a powerful thing.

Yes, I find that very moving. The vulnerability of the patient under anaesthesia – it’s a person at their most vulnerable, unconscious and surrounded by so many people.

To find that calm mood, and all these people working together – it’s very tender in a way.


Has it changed the way you think about surgery around the world?

I was looking on the Lifebox website and I was shocked – I never thought that lack of oximetry was an issue in so many countries.

You show the Checklist twice, once in photos and once in paint – why is that?

After the second viewing we thought that the pictures might be too intense for someone about to undergo surgery. The drawings are a simplification, and even though they’re the same scenes, people seem to prefer them. There are lots of things you don’t want to know before the operation – other than that you are going to be safe.


They’re very vivid!

I used an impressionistic technique called speed painting where you set a timer, start painting and as soon as the timer goes off, you stop. It makes you keep only the most important aspects of the scene.

How did you relate to the Checklist it as a non-medic?

05b_lightsChecklists happen everywhere. It’s this methodology, a frame of mind behind a sequence of events that shows how teamwork is realised. I used to work as a production assistant at dance festivals – without a checklist we’d never be able to have a performance.

I found the surgical pause particularly poetic. A moment’s thought, everybody stops – it’s like this breath that a performer takes when they go on stage. The lights, the audience, the safety protocol – it’s no joke that the operating room is also called a theatre! 05c_lights


All photos copyright 2014 Emmanouil Kapazoglou, University of Dundee


East in the desert

Last week a man called Robert Neighbour used a miniature bottle of cognac from an Air France flight to fix the jammed up vaporizer of a drawover anaesthesia machine.  (That’s not really central to the story, but we just thought you might like to know.)

Robert (above right) is the director of Diamedica, a manufacturer of anaesthesia equipment fit for purpose in low-resource settings.  He recently returned from Chad, in central Africa, where he took a Lifebox pulse oximeter to leave alongside the Glostavent anaesthesia machine he went to install.

He sent us an update after his return:

A few hours by car from Sudan in the east, south from the Libyan border in the north, sits Abéché, in eastern Chad, 900 kilometres from the capital N’Djamena.

It is hot and dry, with temperatures reading into the 50°s(C) and humidity in single figures. The terrain is largely desert, the rains never came last year and are not due until later this year.

The Sudanese region close by is still an area of some conflict and following the earlier situation in Libya the border is still closed to many vital commodities. Additionally, in common with neighbouring Mali, Chad has see thousands of returning soldiers who were members of Gaddafi’s foreign army. They have returned without funds or jobs to go to, and many have returned with their weapons often leading to violent local conflicts.

Abéché Regional Hospital, with approximately 150 beds has to deal with many cases of knife and gunshot wounds, the inevitable results of those conflicts, as well as the usual surgical needs of such a location.

The theatre block has three ORs, a recovery area, and a corridor for waiting pre-op.  The hospital has no piped gases and no oxygen cylinders.  Nor does it have a reliable water supply at present with sterilization being carried out using a simple pressure cooker.

I saw three pulse oximeters while I was there.  One was non-functional, the other two were unreliable.  I believe that they were badly affected by the heat and that the probes were of poor design.  They had one patient monitor, that I examined, with ECG and capnography (no pulse oximetry function).  The WHO Checklist is not used.

There are no Chadian physician anaesthetist in the country at present.


Road traffic accidents in Uganda are frequent and brutal.  Two years ago, the anaesthesia community at Mulago Regional Referral Hospital, the largest in the country, lost several of its own when a minibus carrying anaesthetic SHOs to a funeral was swiped off the side of the road.

Treatable injuries became fatal ones: the same infuriating story we heard many accounts of over the next few weeks. No drugs; no staff; no electricity; no efficient transport.

“In a country that has only 0.6 anaesthetic providers per 100,000 population (unlike the UK which has 20) this is a huge blow,” wrote Dr Sarah Hodges, Head of Department of Anaesthesia at the CoRSU Rehabilitation Hospital in Kisubi.

The World Health Organziation, which launched a Decade of Action for Road Safety in May, estimates that road traffic accidents will be the fifth leading cause of death by 2030.

As we crammed into a mutatu, cab, for the 300km journey down to Mbarara, suitcases strapped to the roof, squaring up to oncoming traffic and picking up speed along torn up and dusty roads, it was easy to believe.

Improvements in infrastructure over the last few years have certainly made cross-country journeys easier, but thunderstorms on the Monday before our training course began had swamped potholes and slowed travel.  The participants, stationed in hospitals and health centres as far north as Abel, by the border with South Sudan and west, across the Rwenzori Mountains, travelled hundreds of kilometres to get to Mbarara in the south.

Many who had left their posts before dawn were still arriving, wet and tired, the following morning.

This is Khasitsi Khalayi – a 40 year old anaesthetic officer at a Health Center 4 in the Mbale district, in Eastern Uganda.

“Since here are so many patients – sometimes you have shortages, sometimes you are alone – of drugs, of materials, staff.  Sometimes because of these shortages you are overworked, and patients are many.  You encounter some problems,” she explained.

Khasitsi left her home the day before, traveling by bus to Kampala where she boarded another bus to Mbarara, arriving at 2am.  She got on a boda boda, a motorcycle, and met Dr Stephen Ttendo at the University.

“He said I should not miss the pulse oximetry session.”